Arizona Physician Spring 2023

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27 Physicians across Arizona
their views on graduate medical education Preparing Tomorrow’s Doctors Priya Radhakrishnan, MD, Chief Academic Officer at HonorHealth, discusses GME today and the future of residency programs SPRING 2023 A PUBLICATION OF THE MARICOPA COUNTY MEDICAL SOCIETY
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Editor-In-Chief

John McElligott, MPH, CPH

Managing Editor Edward Araujo

Creative Design

Randi Karabin, KarabinCreative.com

Cover & Featured Articles

Photography Ben Scolaro, scolarodesign.com

Advertising ads@arizonaphysician.com

Maricopa County Medical Society Board Members

President

Zaid Fadul, MD, FS, FAAFP

President-Elect

Jane Lyons, MD

Treasurer

Vishal Verma, MD, MBA

Secretary

Ann Cheri Foxx-Leach, MD, D.ABA

Directors

Kishlay Anand, MD, MS

Jay Arora, MD, MBA

David Carfagno, DO, CAQSM

Anchit Mehrotra, MD

Ruchir Patel, MD, FACP

Rahul S. Rishi, DO, FAAAAI, FACAAI

Karyne Vinales, MD

Resident & Fellow Director Krishna Pulivarthi, MD

Medical Student Director

Tapanga Parham-Horton, MS

10 GME Formulas and Funding Continue to Hold Arizona Back Learn why Arizona is slated to be around 2,000 residency slots short of where it should be by 2030. 14 The Creighton View on GME Creighton University’s Dr. Jaya Raj shares insights into the Creighton University Arizona Health Education Alliance. 26 In Depth: Valleywise Health Dr. Michael White of Valleywise Health shares Valleywise’s role in graduate medical education. CONTENTS 4 | From the MCMS Board President 6 | From the Editor-in-Chief 7 | MCMS Partner Program 8 | Briefs 22 | What Arizona Docs are Saying 30 | Legal Corner 32 | How To 34 | Physician Spotlight IN EVERY ISSUE 18 COVER STORY Priya Radhakrishnan, MD, Chief Academic Officer at HonorHealth discusses how she helps prepare the next generation of physicians.
VOLUME 5 • ISSUE 1 Digital & Social Media arizonaphysician.com ArizonaPhysician @AZPhysician @AZ_Physician M i c h a e l W h i t e , M D , M B A , on Leading at Valleywise L o r i K e m p e r , D O , on GME at Midwestern J a s o n B e s t e , M D , & S a r a B e s t e , M D , on Global Health C h e c k o u t t h e l a t e s t & u p c o m i n g p o d c a s t e p i s o d e s : @arizonaphy ic an com/podcast Listen to the latest episode:

Evolving Residency Programs to Meet Where Physicians Work

Residency, much like boot camp, is the best experience you would never want to repeat. When I was a resident, we didn’t have work hour limits and virtual medicine was still nascent. We worked with Coumadin or Heparin only and several facilities we rotated through were still using paper charting systems. Medicine and all the work options available have grown by leaps and bounds. Training for tomorrow’s reality is an evermoving target that must constantly be aimed at if we want to be relevant.

It is said that change is truly the only constant in life. With that in mind, the question becomes how to anticipate and prepare for the ever-evolving challenges of the practice landscape. Residency programs already incorporate ACGME standards when it comes to the number of procedures and patient encounters. Residency programs must make efforts to incorporate the different practice settings in which medicine now takes place as well as the different tools available to physicians.

The virtual medicine landscape is quite diverse, with many areas of focus and practice. This begins with simple urgent care telemedicine and can be as complex as the “hospital at home” healthcare model pioneered in Massachusetts. Remote patient monitoring equipment is being incorporated in all forms of health care delivery, from smart watches that record EKGs to the Oura ring that monitors and tracks sleep metrics. Residents need exposure to incorporating these new tools into their practice as well as experience operating in virtual practice settings.

The one thing I realized (that incidentally no one warned me about) was that the hardest part of my career was life after

residency. Suddenly every decision was my own with no backup. In most cases, I was in an isolated practice environment with no colleagues to curbside easily. New practice techniques were coming along seemingly every week, but I no longer had the “malpractice free” forum. I ultimately found resources and support when I joined my county medical society. They hosted social engagements and relevant CME events, and helped to connect me with like-minded physicians who had already traveled down the path I was about to embark upon.

The challenges of a good GME program are timeless and summed up in one sentence: How do we best prepare tomorrow’s doctors today? The answers may change, but the core truth remains. Every physician needs to take charge of their own training and seek out rather than shy away from new techniques. And we must all continually hold ourselves accountable for the work that we do and the efforts that we make. In the end, we lay down in the beds that we ourselves make.

Respectfully,

Dr. Zaid Fadul's focus in medicine has been on improving patient outcomes and building better care delivery systems. He is Board Certified in Family Medicine and Addiction Medicine. He also has the privilege of serving in the US Air Force Reserve as a Flight Surgeon, where his training is focused on Occupation and Aerospace Medicine. He currently serves as the Chief Medical Officer for Steady Hand Medical and the President of the Maricopa County Medical Society. Dr. Fadul has traveled extensively as a photographer and is proficient in Spanish and conversational Arabic. His proudest moments come as a father of three with a loving and supportive wife.

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FROM THE MCMS BOARD PRESIDENT
Interested in getting involved with MCMS? Reach me at mcms@mcmsonline.com
To learn more: DementiaCampus@hov.org (602) 767-8300

ACanadian physician, Dr. Osler created the first residency program and is considered the first to train medical students in bedside clinical care.

Sir Osler’s legacy is alive in Arizona today. We have six medical schools and many residency programs for graduate medical education. Over 100 years after the passing of Dr. Osler, scores of physicians are training the next generation of physicians in the Grand Canyon State.

GME TODAY

We are incredibly thankful to Jaya M. Raj, MD, FACP, for her view of the Internal Medicine residency program run by the Creighton University School of Medicine-Phoenix. Dr. Raj says the Creighton experience is unique because, “our residents care for a large portion of the medically underserved population in Phoenix in at least three different settings and healthcare systems.”

Brian Powell of the Flinn Foundation returns with a piece about how formulas for federal funding prevent Arizona from growing its residency programs to meet current and future patient demands. He writes, “A vote in Congress more than a quarter century ago continues to financially haunt Arizona with each passing year and makes it nearly impossible for the fast-growing state to catch up and end its physician shortage—one of the worst in the nation.”

We go in depth with Michael White, MD, Executive Vice President and Chief Clinical Officer of Valleywise Health, to discuss the public health system and its role in GME. Dr. White says, “As the state’s only public teaching hospital and safety net system of care, Valleywise Health is truly the foundation for a healthy Maricopa County.”

In What Arizona Docs Are Saying, most survey respondents believe GME programs are producing qualified physicians. About 93% of physicians believe Arizona needs to increase its residency slots and 96% want the federal government to pay for them. We received a wide range of suggestions for improving GME programs for the future. Check it out.

Felipe R. Perez, MD, FAAFP, goes under the spotlight. As Director of the Family Medicine Residency Program at El Rio Health in Tucson, Dr. Perez shares what motivates him and what it takes to become an attending physician.

DR. PRIYA RADHAKRISHNAN

Priya Radhakrishnan, MD, met with Managing Editor Edward Araujo to discuss her journey from medical school in Keralta, India, to building 14 GME programs as the Chief Academic Officer and Vice President of Health Equity at HonorHealth. In addition to clinical competencies, Edward writes that Dr. Radhakrishnan believes the medical education community is preparing residents for the rigors of a career in medicine. That requires financial information, guiding residents on dietary habits and physical fitness, and pushing them to develop support networks.

When it comes to the future of residency programs, Dr. Radhakrishnan would like to see fewer demographic disparities between the physician workforce and patients they serve. Such an outcome requires, among many other actions, better STEM education for underrepresented students.

Edward’s article about Dr. Radhakrishnan covers more ground, including ways to retain physicians trained in Arizona and innovative funding models. What’s clear is that Dr. Radhakrishnan is the right person to be leading the charge for HonorHealth.

VALUABLE ARTICLES

Attorney Jonathon Morrison of Frazer Ryan Goldberg & Arnold writes about tax strategies when considering a sale or merger of private practices with larger groups, private equity, or hospital systems.

Ryan Naylor, CEO/Founder of VIVAHR, shares tips for avoiding hiring pitfalls. Common mistakes to avoid include a bad job title, insufficient information about the role, and hiding your company’s mission or organizational culture. Contact us at info@arizonaphysician.com with any comments or suggestions.

Enjoy the magazine.

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Not an MCMS member? Visit mcmsonline.com/join or call us at (602) 252-2015. FROM THE EDITOR-IN-CHIEF
“HE WHO STUDIES MEDICINE WITHOUT BOOKS SAILS AN UNCHARTED SEA, BUT HE WHO STUDIES MEDICINE WITHOUT PATIENTS DOES NOT GO TO SEA AT ALL.”
—Sir William Osler, MD

PREFERRED PARTNER

WHAT IS THE PARTNER PROGRAM

Maricopa County Medical Society’s Partner Program is designed to introduce select companies to our members. MCMS strives to facilitate physician growth in all areas of their life and practice. As we work to support our members, we think there are excellent opportunities to work closely with business partners that can facilitate that growth.

Learn more at mcmsonline.com/ partner-program

MAKE HEALTHCARE COMPLIANCE EASY.

MCMS hears it. We understand the administrative aspects of medicine can be overwhelming and diverts precious time you’d rather be caring for patients. Our partner MedTrainer provides an all-in-one healthcare compliance software allowing you to stay on top of compliance requirements specific to your organization.

Three Core Products

LEARNING | MedTrainer is your best solution to comply with state and regulatory standards. Staff can access the MedTrainer learning library from any phone or computer. The library has over 500 courses designed to keep your staff well informed with the latest information.

COFFEE NOT CUTTING IT?

Stop waking up early or staying late to catch up on administrative paperwork. Get more done in less time with medtrainer.

Medtrainer credentialing customers report saving 2 hours a week on tasks

Medtrainer learning customers report saving 4 hours a week on employee onboarding

Medtrainer compliance customers report saving 6 hours a week on tasks

Source: 2022 MedTrainer customer survey (results are averaged)

CREDENTIALING | Enrollments can be a time-intensive process that takes away from other essential work and slows down internal processes. Streamline the continuous task of credentialing in one platform, including primary source verifications and background checks.

COMPLIANCE | The Medtrainer cloud-based compliance management system makes compliance as easy as possible, so you can get more done in less time. Automation and next-level organization mean you avoid fines, experience fewer errors, and have more time for other work. primary source verifications and background checks.

Health Trends in 2023

The team at Cleveland Clinic predicts these trends in the healthcare market.

TONERS | Dermatologists say modern toners have more skinfriendly ingredients that boost collagen, exfoliate, and retain moisture. The latter would help in the desert.

Upcoming Events You Don’t Want to Miss

MARICOPA COUNTY FAIR |

April 12-16 | Wear some sunscreen and stay hydrated while you explore this fair with your loved ones! Livestock shows, agriculture and youth exhibits, midway rides and live entertainment are among the attractions. Located at Arizona State Fairgrounds, 1826 W. McDowell Rd., Phoenix AZ 85007.

PAT’S RUN | April 15 | Thousands of runners and walkers participate in this annual 4.2-mile run/walk honoring late football star Pat Tillman. The race, which also includes a .42-mile kids’ run, winds through downtown Tempe and finishes on the 42-yard line of the ASU stadium, paying tribute to Tillman’s jersey number from his college days. Located at the ASU Sun Devil Stadium.

ARIZONA TIKI OASIS | April 27-30 |

Wear your most festive aloha wear to this event! Every year, the Arizona Tiki Oasis visits the Hotel Valley Ho in Scottsdale. You will find food and drink tastings, art and music for tiki enthusiasts across the

state. The event is the companion event to the highly regarded Tiki Oasis Festival in San Diego. The Hotel Valley Ho is located at 6850 E. Main St., Scottsdale.

JARABE MEXICANO & BALLET

FOLKLORICO QUETZALLI |

April 14 | Jarabe Mexicano invites you to experience a Latin getaway night! This musical celebration of eclectic musical genres and diverse communities is accentuated and intensified by the beautiful, colorful Mexican folk dancing of Ballet Folklorico Quetzalli-AZ. This is an evening of music for the whole family! It’ll be at the Chandler Center for the Arts, 250 N. Arizona Ave.

SPRING TRAINING BASEBALL |

Feb 24-March 27 | Come support your Arizona Diamondbacks or your native city’s baseball team! The weather gets warmer during the Spring… but not too warm like it does during the summer. No better way to spend your rest days than to catch up with some live baseball!

EXERCISE SNACKS | Busy physician schedules prevent many docs from getting the recommended 150 minutes of exercise each week. Try more bite-sized workouts of 15 minutes twice a day during the weekdays and a longer workout over the weekend.

HEALTH COACHES | Some people need a little push, someone to guide them. Consider hiring someone who offers a mix of in-person, phone calls, and video chats to help you with exercise, diet, reducing stress, and adequate sleep.

CBT-I | Cognitive behavior therapy also applies to insomnia. The technique helps you to determine why you’re tossing in bed.

SET BOUNDARIES | Learn to say no to anything that makes you uncomfortable. Recognize gaslighting and don’t allow others to disrespect you. Also, take time for yourself and protect that private time.

BRIEFS NEWS AND NOTES FROM THE FIELD
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Coffee, Coffee, Coffee…

5 GREAT COFFEE PLACES IN PHOENIX

CORTADO COFFEE

ROASTERY | cortadophoenix.com | is independently owned and operated two location coffee shop that features freshly roasted single-origin and unique blends of coffee. From Americanos to Espressos, Cortado has it all and even tasty healthy sandwiches.

COPPERSTAR | copperstarcoffee.com | this Melrose District staple has a great community vibe and offers a carhop drive-thru if you can’t hang out. “Great Coffee, Delicious Food, Creative People.”

FIRST DRAFT AT CHANGING HANDS | firstdraftbookbar.com | a bar in a bookstore doesn’t do this coffee spot justice. Enjoy a hot mug of coffee while reading an interesting book or grab a beer while a performance is going on. You will enjoy the experience.

XANADU COFFEE CO. | xanaducoffee.com | a coffee shop by the people, for the people. This eclectic little shop welcomes everyone with open arms and tasty hot or cold coffee.

PRESS COFFEE | presscoffee.com | started in 2008, this specialty coffee shop is committed to remaining quality driven and community focused. Press roasts fresh, high quality in-house coffee every day.

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Continue to Hold Arizona Back

GME Formulas Funding and A

rizona medical leaders are in a seemingly endless struggle to expand residency and fellowship positions at hospitals and health centers around the state.

A vote in Congress more than a quarter century ago continues to financially haunt Arizona with each passing year and makes it nearly impossible for the fast-growing state to catch up and end its physician shortage—one of the worst in the nation.

The problem worsened with Arizona’s budget crisis at the onset of the Great Recession, and in 2010, the state eliminated all direct state funding for GME.

But over the last several years there have been some wins.

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BASED ON CURRENT PROJECTIONS, THE STATE WILL BE 2,000 RESIDENCY SLOTS SHORT OF WHERE IT SHOULD BE BY 2030.

Arizona has substantially increased the number of medical-school graduates—the state has gone from one to six medical schools in less than 30 years—and found creative ways to tap into uncapped Medicaid funding to dramatically increase residency opportunities. And following the years of austerity, there’s been new direct investment from the state to help expand hospital residency programs.

The number of GME slots in Arizona in allopathic and osteopathic training programs has increased from 1,262 in 2007 to 2,191 in 2022. This coincides with the dramatic increase in the number of medical-school graduates with the opening of the University of Arizona College of Medicine-Phoenix as well as the Arizona campuses of the Mayo Clinic Alix School of Medicine and Creighton University School of Medicine.

Still, despite GME programs expanding, and 95% of available residency training positions filled, the reality is the state still falls well short of what is needed for primary care and key specialties, according to physicians and policy experts who work in graduate medical education.

Dr. Daniel Derksen, director of the Arizona Center for Rural Health at the University of Arizona, said that based on current projections, the state will be 2,000 residency slots short of where it should be by 2030.

“This won’t get addressed by piecemeal alteration,” Derksen said. “We need to take bold steps in Arizona to expand the number of GME slots based on our very rapid population growth over the last two decades.”

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Dr. Cheryl O’Malley, associate dean of GME at the University of Arizona College of Medicine-Phoenix, said: “GME is a big investment without short-term solutions. That is why there is this urgency. If we don’t act quickly, it will take that much longer for these physicians to get into the workforce.”

AN UPHILL BATTLE

Arizona was a different place in the mid1990s, with just one medical school—the University of Arizona College of Medicine in Tucson—and about 3 million fewer people.

And yet, more than 25 years later, the formula for the largest distribution of GME federal funding through Medicare has not been updated to reflect Arizona’s current population.

The Balanced Budget Act of 1997 locked in the per-capita distribution of funds from the Centers for Medicare and Medicaid Services. The formula that accounts for about two-thirds of federal GME funding in the United States to this day remains based on the population of the United States in 1996, with an exception for new hospital programs. This has penalized states such as Arizona, while states such as New York have a disproportionate number of slots despite a slow-growing or declining population.

“You can imagine that not many FTEs were allocated to Arizona in 1996,” said Dr. Shakaib Rehman, associate chief of staff for education at Phoenix VA Health Care Systems, which sponsors more than 170 GME positions.

Rehman also serves as chair of the American College of Physicians advocacy committee and invites physicians to become involved with policymaking.

“ACP has been raising this issue for many years, but we need to have other organized medicine join the efforts and change this unfair formula.

“Health care is not just practicing medicine but also influencing policymaking. Otherwise, bad policies will cause problems for physicians and patients,” he added.

THE IMPACT OF MATCH DAY

According to the Association of American Medical Colleges, 55% of the individuals who completed residency training between

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…55% OF THE INDIVIDUALS WHO COMPLETED RESIDENCY TRAINING BETWEEN 2012 THROUGH 2021 ARE PRACTICING IN THE STATE WHERE THEY DID THEIR TRAINING.

2012 through 2021 are practicing in the state where they did their training.

O’Malley, whose school has about 350 residents and fellows across its approximately 30 programs, said for those graduating from an Arizona medical school, then completing their residency at an Arizona hospital, there’s an approximately 75% chance that the physician will stay and practice here.

Derksen said statistics show for residents training in a community heath center or rural area, the likelihood they will remain and practice in that region is high.

One example of such a program is North Country HealthCare in Flagstaff, which in 2020 started an accredited family-medicine residency program with a community health center as the sponsoring institution.

The cost to fund a residency is high, with training typically lasting between three and seven years. The estimated direct GME expenses per resident per year is $132,583, plus indirect expenses of $124,267, according to 2022 figures provided by the Arizona Health Care Cost Containment System, or AHCCCS.

This spring, AHCCCS anticipates making $381.3 million in GME payments to hospitals for the 2022 academic year. This portion of payments uses a voluntary match provided by local political subdivisions such as Arizona’s public universities and local, tribal, and county governments, according to ACHHHS.

Since 2015, AHCCCS has been allowed to pass on a greater Medicaid payment to

Arizona hospitals, which identify and secure a funding partner. GME funding for Arizona hospitals increased by more than $100 million between 2015 and 2016 alone, and the figure has continued to increase.

In late 2022, AHCCCS made $13.8 million in GME payments to hospitals for the 2022 academic year, comprised of a general-fund state match and a federal match, according to the state agency.

Heather Carter, a former state legislator and current executive vice president of Greater Phoenix Leadership, who has worked in health policy at both Arizona State University and the University of Arizona, said the legislature did not revisit direct funding of GME after the Great Recession until a bill she sponsored passed in 2019.

She suggests the continuing education of policymakers.

“People don’t naturally know what GME is unless you or a family member studied to be a doctor and did a residency and worked in a hospital system, and most people serving in the legislature have zero experience,” Carter said. “There is a tremendous need to just educate. They are not going to invest in something they do not understand.” ■

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View Creighton The on GME

In 2017, an alliance was formed to strengthen and expand graduate medical education in Arizona. Creighton University, Dignity Health St. Joseph’s Hospital and Medical Center, Valleywise Health and District Medical Group joined together in the Creighton University Arizona Health Education Alliance. The Alliance provides learners with essential patient-care experience in prominent missionfocused Phoenix facilities. Together, we are training the next generation of physicians and health care providers. With hands-on experience and a commitment to caring for a diverse community, we’re increasing the number of compassionate health care professionals in the region. As we move forward, we’re guided by a spirit of service learning and a commitment to community.

THERE ARE MORE THAN 320 RESIDENTS AND FELLOWS CURRENTLY TRAINING AT MEMBER INSTITUTIONS.

SIZE AND SHAPE

There are more than 320 residents and fellows currently training at member institutions. We have 16 residencies and fellowship programs. Residency programs include emergency medicine, family medicine, internal medicine, obstetrics and gynecology, podiatry, psychiatry, radiology-diagnostic, and surgery. Fellowship programs include child and adolescent psychiatry, emergency medicine ultrasound, gastroenterology, global women’s health, healthcare disparities, hospice and palliative medicine, surgical critical care and burn, and women’s imaging.

Creighton University has a strong commitment to increasing the diversity of the healthcare workforce, promoting an equitable and inclusive environment,

and fostering a sense of belonging among all its residents, students, and faculty. The Internal Medicine program has made it a top priority to recruit students with diverse backgrounds, experiences, cultures, and perspectives. Our residents and faculty come from all over the country and from many different areas of the world. We place a heavy emphasis on recruiting residents from groups which are traditionally underrepresented in medicine in order to better meet the needs of our diverse patient population. Currently, 46% of our categorical Internal Medicine residents identify as women and 27% identify as Black or African American, Hispanic/ LatinX, or Native American.

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GME TEAM

There are multiple supporting resources the Creighton Alliance provides. These include academic support (e.g., interviews and board exam prep), scholarly activity and research, faculty development for our physician and healthcare faculty, wellness, and the GME program.

BREADTH AND DEPTH OF TRAINING

Internal Medicine (IM) is a broad medical specialty which encompasses Ambulatory Internal Medicine, Hospital Medicine, and a wide array of subspecialties. Our residency is 36 months in length, during which residents spend at least 12 months on the general inpatient wards, 3-6 months in the medical intensive care unit, and 10 months in the ambulatory setting. They also rotate through all the subspecialties of Internal Medicine, including Cardiology, Pulmonology, Hematology and Oncology, Gastroenterology, Infectious Disease, Endocrinology, Nephrology, Allergy, Addiction Medicine, Geriatrics,

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Learn more about the Creighton GME program at creighton.edu/arizona-health/residencies-fellowships/.
Our residency is 36 months in length, during which residents spend at least 12 months on the general inpatient wards, 3-6 months in the medical intensive care unit, and 10 months in the ambulatory setting.

and Rheumatology. At the completion of residency, trainees are eligible for board certification in Internal Medicine. Physicians who wish to subspecialize must complete anywhere from 1-6 additional years in fellowship training.

UNIQUENESS

Our IM Residency Program has a total of 85 residents in the program: 26 categorical residents per year plus 7 preliminary interns. Residents rotate at both St. Joseph’s Hospital and Valleywise Health Medical Center, thus gaining a broad exposure to a diverse patient population with a wide range of pathology. They also rotate to the St. Vincent de Paul Clinic, which provides free medical care to uninsured patients. Thus, our residents care for a large portion of the medically underserved population in Phoenix in at least three different settings and healthcare systems. This is a core value of Creighton, a Jesuit institution, which is dedicated to the care of the whole person and service to others.

WHAT MAKES IM RESIDENTS SUCCESSFUL

Excellent interpersonal and communication skills are essential. The ability to relate to and communicate effectively, respectfully, and collaboratively with people who have different viewpoints, backgrounds, and areas of expertise is essential. The most successful residents are great team players. They are also self-reflective and are constantly striving to improve their knowledge and skills.

INCORPORATING MEDTECH

Medical technology is changing rapidly. Point of care ultrasound (POCUS) is one of the most exciting and useful technical advances in medicine. Our residents receive hands-on training in bedside POCUS to aid in more rapid, accurate diagnosis of common acute conditions such as pneumothorax, heart failure, and deep venous thrombosis.

OBSTACLES FOR ATTENDING PHYSICIANS

Physicians work long hours, cope with stressful situations, and juggle many responsibilities. Teaching faculty have additional roles and responsibilities on top of their clinical duties. They must be knowledgeable about adult learning theory and pedagogy. They must strike a balance between experiential and didactic teaching and provide residents with supervision while granting them autonomy. These are skills which are not necessarily taught in medical school. They are acquired with time and dedicated practice.

Physicians who teach residents and students find it incredibly rewarding. It is a pleasure and a privilege to watch them grow into compassionate and clinically outstanding physicians who will shape the future of U.S. healthcare.

WHERE THEY GO NEXT

Over the past 3 years, roughly 575 of our residents become hospitalists, 6% choose a career in Primary Care, and 37% subspecialize. Our residents have matched into highly competitive fellowships in Cardiology, Pulmonary and Critical Care Medicine, Gastroenterology, Hematology and Oncology, and Rheumatology, to name just a few. Approximately 43% of our internal medicine graduates stay and practice in Arizona. Many have stayed and joined our faculty at Creighton.

IM residency programs feed into all the subspecialties mentioned above. The Internal Medicine program at the Creighton Alliance has its own IM fellowships in Gastroenterology, Hospice & Palliative Care, and a newly approved program in Cardiology.

WHAT THE FUTURE HOLDS

The landscape of medicine and healthcare is constantly changing, and medical education must evolve to meet the needs of our patients and our community. In addition to educating residents about new diagnostic tests, treatment strategies, and technologies, we need to educate them about medical ethics, the business of medicine, the science of healthcare delivery systems, social determinants of health and healthcare disparities, social justice and public policy. We must teach them to be clinicians, scientists, healers, advocates, teachers, and leaders. ■

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Doctors Preparing

Tomorrow’s

Priya Radhakrishnan, MD

Finding joy daily in all that you do may seem hard for most people. Yet, Dr. Radhakrishnan’s contagious and never-ending smile even while discussing even the toughest subjects will make you a believer. She remains a happy person whether helping patients, peers, or the young physicians she’s helping to shape.

Priya Radhakrishnan, MD, is multi-talented and compassionate of others. Her journey in medicine began humbly in Kerala, on the southeastern tip of India. Her father, who always wanted to become a doctor but never got the opportunity, pushed all his children to achieve his goal. Priya succeeded.

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DEVELOPING A LOVE FOR MEDICINE

In India, young physician hopefuls must pass the difficult Entrance Test for Medical School right after high school. During the subsequent five years of undergraduate medical education, Dr. Radhakrishnan, “developed a passion for medicine and what it can do to help people.” At Calicut University, now known as Government Medical College in Kozhikode, Kerala, she met the man who became her husband while she completed her undergraduate medical studies. After passing another entrance exam for postgraduate medical education in India, she began her MD in Pathology.

Dr. Radhakrishnan passed another gate on her journey by completing the United States Medical Licensing Examination (USMLE). She would go on and have the options of either internal medicine or pathology residencies. She interviewed for both and found that pathology was missing one powerful component, that of human interaction. She decided on internal medicine. With her residency in New York, her husband received a fellowship in Chicago. Having a young family, she was fortunate to transfer as a third-year resident in Evanston, Illinois.

TAKING ON MULTIPLE ROLES

Dr. Radhakrishnan wears multiple hats. She is Chief Academic Officer and Vice President of Health Equity at HonorHealth, outgoing Governor of the American College of Physicians, Arizona Chapter and Professor at the University of Arizona College of Medicine, Phoenix. In addition to helping to shape the next generation of physicians, she continues to see patients. “I think, particularly in medicine, it’s important to have that connection. I love seeing patients and healthcare delivery,” says Dr. Radhakrishnan.

When John C. Lincoln Health Network and Scottsdale Healthcare merged in March 2015, Dr. Radhakrishnan became the Chief Academic Officer of the new entity called HonorHealth. The locally owned, nonprofit, integrated health system has 6 hospitals, 70 primary and specialty care clinics, a cancer care network, research, and

community services. In her role, Dr. Radhakrishnan has crafted the system’s GME as the Designated Institutional Official. Since its inception, HonorHealth has grown to 14 GME programs that will have graduated 126 residents as of June 2023. From residency programs in Internal Medicine, Family Medicine, General Surgery and Physician Medicine & Rehabilitation to fellowship programs in Addiction Medicine, Clinical Informatics, Cardiovascular Disease, Electrophysiology, to Hospice and Palliative Medicine, it makes Dr. Radhakrishnan smile. Today’s HonorHealth GME programs coincide with the GME needs she helped map out.

GME IN ARIZONA TODAY

Since its inception in 1965, the Centers for Medicare and Medicaid Services (CMS) has been the largest funder of graduate medical education. Federal investments in GME occur through various programs that support physician workforce development. Unfortunately, CMS has not increased GME slots to keep up with demand states Dr. Radhakrishnan. This year, for example, CMS funded 200 additional slots which is way too low for the entire country, let alone in Arizona.

Medicare is the largest funder of GME in Arizona, accounting for around 90% or $459 million of total support, according to the University of Arizona’s Center for Rural Health. Based on 2018 figures, according to the Association of American Medical Colleges, there are 19 teaching hospitals and 1457 residents in Arizona. Since 1997, a cap has been placed on Medicare-supported residency programs. Some additional residency slots have been added but hospitals do not receive Medicare payments for those trainees. That means hospitals must fund the remaining percentage of slots.

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“Arizona ranks 42 out of 50 states for primary care and 31 out of 50 for actively practicing physicians per the Arizona Primary Care Physician Workforce Report.”

On the Personal Side with Priya Radhakrishnan, MD

Q: If you could describe yourself in one word, what would that be?

A: That would be maverick, someone who wants to achieve what has not yet been achieved.

Q: Do you have family? Pets?

A: My husband is Dr. Rajiv Poduval who is a nephrologist and the CEO of Panoramic Health. We have a daughter, Aditi who works for a tech startup after graduating from Stanford. We also have a dog Bowie, who is a chill Chow Chow mix.

Q: Do you have a hidden talent most people would not know about you?

A: I am a closet poet.

Q: What career would you have been doing if you were not a physician?

A: An anthropologist.

Q: What book are you reading now, or recently?

A: “And Every Morning the Way Home Gets Longer and Longer” by Fredrik Backman

Q: What is your favorite food?

A: I love Indian food.

Q: What is your favorite local restaurant?

A: Green House, it is very consistent.

Q: What is your favorite activity outside of medicine?

A: Traveling

“Arizona ranks 42 out of 50 states for primary care and 31 out of 50 for actively practicing physicians per the Arizona Primary Care Physician Workforce Report,” says Dr. Radhakrishnan. She says, “COVID-19 caused a huge exodus and premature retirements, so the current pool of physicians is even smaller.” Of residents and fellows per 100,000 population, Arizona ranks 37 out of 50. Having too few residency slots for the population served leads to medical school graduates leaving the state. Building personal and professional relationships and becoming ingrained in the local culture tends to keep residents close to where they train. GME slots should parallel medical school graduates to ensure most if not all Arizona trained physicians stay. Residents like the Grand Canyon State. Per Dr. Radhakrishnan, Arizona ranks 17 out of 50 in post-GME retention. Having more residency slots would translate to physicians making Arizona their home to practice medicine.

Dr. Radhakrishnan acknowledges Arizona now has a larger and stronger base from which to grow its future residents unlike in the past. Until 1995, Arizona had only one medical school in Tucson. There are now five medical schools in Maricopa County. The bottleneck to match with coveted residency slots has become tighter.

PRODUCING THE PHYSICIANS ARIZONA NEEDS

Are GME programs doing what’s needed to produce qualified physicians? Dr. Radhakrishnan states, “lots of work needs to be done.” The landmark Flexner Report of 1910 had a century-long impact on graduate medical education. Many aspects of modern American GME come from this competency-based report. It was widely hailed as the standard until the early 2000s, when physicians began to realize the damage, it had created through the closing of several historically black university medical programs, widening the gap between white and nonwhite students going into medicine. For Arizona, there is a gap in the number of American Indian physicians serving its uniquely high proportion of federally recognized tribal members.

20 n ARIZONA
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PHYSICIAN
Read more about the current state of GME according to Dr. Radhakrishnan at
arizonaphysician.com/priya-radhakrishnan-md

Progress is being made in some areas. Dr. Radhakrishnan believes that today’s medical education community is doing a great job across the board to ensure that residents are well equipped for the rigors of working in medicine. That includes teaching residents about financial information, dietary habits, physical fitness, support networks and the need for stronger mentor-mentee relationships. A silver lining of the COVID-19 pandemic is that it helped residents to learn how to care for each other. That would help them gain more compassion for their patients.

THE FUTURE FOR RESIDENCY PROGRAMS

In an ideal world, we would want federal and state governments to invest more in the sustainability of GME, states Dr. Radhakrishnan. “Currently there are federal and state policies for funding GME, but that hasn’t always been the case” says Dr. Radhakrishnan. States like Arizona in the past have eliminated GME funding or greatly reduced the money dedicated to GME. She remembers when that resulted in attrition and the closure of many residency slots. Her hope is that we don’t go back to those days.

Dr. Radhakrishnan hopes that a better understanding of healthcare workforce needs in a growing Arizona will help to shape policy priorities and increase residency slots. She would like to see greater emphasis on eliminating the demographic disparities between the physician workforce and the populations they serve.

The future of residency programs is also tied to retention. There are ways to entice physicians to stay in Arizona. One is loan repayment, since many physicians are saddled with large amounts of school loans. Second, residents should have a voice at the workplace when it comes to the profession they will be joining. That includes being heard when it comes to employee policies and advocacy at the county and state levels. A third way is continuing to help these young physicians through organized medicine in areas such as policy advocacy and mental health wellbeing.

FINAL THOUGHTS ON GME

Ultimately, new innovative funding models should be put together by both government and private funders to ensure GME is prioritized and keeps up with medical school graduation rates. That will ensure Arizona isn’t losing topflight new physicians to other states that better prioritize the retention of residents. Our booming population in Arizona includes a vast younger and older population that will likely have a much higher need to access healthcare in both urban and rural settings. Dr. Radhakrishnan’s work will continue to highlight the need for prioritizing GME as a tool to keep physicians in Arizona and to ensure patients are getting the care they need. Patients will be able to select physicians to help them with their healthcare needs in the surrounding areas in which they live. ■

21 ARIZONAPHYSICIAN.COM

What DOCS Arizona are Saying

On a scale of 0 to 10, indicate how well GME programs are producing qualified physicians. Zero equals unqualified and 10 equals very qualified.

Average = 7.4

Local government 37 % Private entities 52%
Read more about what Arizona Docs are Saying when it comes to graduate medical education at arizonaphysician.com/docs-gme
Arizona
GME programs? Who should fund GME programs? Yes 93% No 7 % Federal government 96% State government 74%
22 n ARIZONA PHYSICIAN MAGAZINE
Does
need to increase its residency slots at

Why or why not is more diversity needed among residents?

I believe there is adequate diversity in candidates trained in American schools. —Burt Feuerstein, MD

I was one of them in the early 1980s. By today’s standards there was open and overt discrimination from staff and “colleagues.” There are great candidates all over the world. They bring a lot of experience having had to already do one year of rotating internship before getting their MD degree.

More physicians versus mid-level providers would be appreciated. —Amy Guzek, MD

International medical school graduates are highly motivated and are very often highly educated. Our need in the state is so great that we should not be biased against international graduates when we are allowing osteopathic students who are far less qualified to work. —Yazmin Amin, MD

Too many US graduates need residency spots. —Palak Patel, MD IMGs are highly qualified and can assist our patients if their English is good. —Gary A. Smith, MD

I believe residency positions should be provided to US graduates before IMG graduates. —Katherine Mitzel, DO

There is a big gap of physicians needed for the near future with our aging population and rapid expansion of business in Arizona. —Alvin G. Wong, MD

Residency spots should be given based on merit and qualifications. Many IMGs are highly qualified and skilled. Several are also bilingual, which only increases diversity to reach out to a broader population. —Shazia A. Malik, MD

Acceptance of medical graduates should be based on qualifications, not on minority status. International graduates should be considered only if there are not enough qualified US graduates. —Karen Kennedy, MD I first think we should open enough spots for all US medical graduates, and we likely would still need more doctors at that point. —Jane Lyons, MD

International medical graduates bring different perspectives on how things can be done.

—Cheryl O’Malley, MD

I believe there are still many US grads needing residency slots. —Suganya Karuppana, MD

To increase the number of physicians in the state. Of course, these IMG should be considered if they are strong, competitive and competent applicants.

Only if they are qualified by school, grades, and recommendations. —Paul Baranko, MD

State capacity needs to match state production and it does not. —Frederic Schwartz, DO

Right now, there are some US trained graduates who do not place into a residency. While we need to solve this problem first, if there are still open slots, then well qualified IMGs should be taken into residency programs. —Ronnie Dowling, MD

US grads should be given preference in US residency slots, but the projected shortages of docs demand that residency outputs improve. If IMGs are required to fill the workforce need, then they should be offered positions. —Robert Cravens, Jr, MD

It creates healthy competition. Sometimes students and residents built within the system become lax or don’t see a diversity of opinion. —Avtar

There is a glut of graduates from Arizona schools who are much more likely to stay and fill the need in the state of Arizona and who are not able to get into programs in the state. —Lori Kemper, DO

23 ARIZONAPHYSICIAN.COM

Share any suggestions for improving GME programs for the future.

More work on evaluating data and clinical trials. Emphasis on personal patient follow up.

Allow associate physician training paths for unmatched MD and DO students versus allowing NPs and PAs to “practice medicine” with less appropriate education and training. —Amy

Integrating hospital systems to allow for greater variability of resident experience, i.e., university, community, and public hospitals along with public access clinics to assist the indigent and underserved populations. —Gary

Many are unaware of opportunities in Arizona. I think the GME programs should support outreach and help recruit the best candidates to our state.

There should be more medical schools and larger class sizes to produce the physicians needed to treat the growing population of Arizona. —Karen Kennedy, MD ACGME stresses more on didactic lectures which is counterproductive. Residents get better grasp of medicine with practical training. —Nadeem

The ACGME has undertaken a project to look at modifying program requirements in each specialty to match what future practice looks like. This includes growth of abilities to lead teams to ensure that they can function at the level of their training to provide the most access for patients. This is a challenge for physicians and practices to adjust to because it means letting go of some of the traditional responsibilities to transition to a fully functioning multi-disciplinary team and physicians being responsible for a larger number of patients. —Cheryl

Incentivize and prioritize primary care residency.

Indicate whether more DIVERSITY is needed among residents in the following categories: Should Arizona allow more international medical graduates into its residency programs? Race No more | 26% A little more | 33% Much more | 41% Religion No more | 42% A little more | 39% Much more | 19% Yes 58% Age No more | 42% A little more | 54% Much more | 4% Disability No more | 33% A little more | 45% Much more | 22% Sex / Gender Identity No more | 33% A little more | 45% Much more | 22% Socioeconomic Status No more | 26% A little more | 30% Much more | 44% No 42% 24 n ARIZONA PHYSICIAN MAGAZINE

Increase the numbers of residency spots, more rural exposure, simulations, more research opportunities. —Joanna Kowalik, MD

Having more full-time faculty running the programs and subspecialties, competitive salaries for teaching staff. —Paul Baranko, MD

More primary care slot allocation and support.

Teaching physicians need to be paid a reasonable stipend for residency/GME training.

I’ve been practicing for 49 years and find that some of the younger physicians don’t do very thorough physical exams. They rely on labs and imaging to treat their patients. Most physicians now stand in the room with their backs to the patients and they don’t seem to connect.

Official paid training for faculty. Faculty should be given time to grow and maintain their credentials. A faculty GME track as a roadmap would be nice. —Avtar

We need to expand the number of residents per residency program and the number of internal medicine/family medicine residencies in Arizona. Also, we need to expand the number of spots for internal medicine fellowships, because we are losing high-quality graduates to other states. —Alvin

GME programs can improve by taking third year students from a diversity of colleges (especially in those hospitals that are financially supported by tax dollars). Additionally, students from D.O. programs should be considered based on their osteopathic credentials and not be expected to jump through additional hoops (such as requiring them to take USMLE).

Get more funding from state, local and private.

Learn more about the participating physicians

Burt Feuerstein, MD, PhD University of Arizona, College of Medicine —Phoenix

WEB | phoenixmed.arizona.edu

Antonio “Sergio” Torloni, MD, MS Banner MD Anderson Cancer Center

WEB | bannerhealth.com

Amy Guzek, MD Hip Kids Pediatrics

WEB | hipkidspediatrics.com

Yasmin Amin, MD National Partners in Healthcare

WEB | nphllc.com

Sarah Patel, MD Sonoran Sleep Center

WEB | Sonoransleep.com

Palak Patel, MD Arkai Anesthesia

Gary A. Smith, MD, MMM, FAAFP Public Safety Wellness Center

Katherine Mitzel, DO, FACEP University of Arizona, College of Medicine—Phoenix

WEB | phoenixmed.arizona.edu

Shazia A. Malik, MD Valley Urogynecology Associates WEB | Valleyurogynecology.com

Karen Kennedy, MD Northwest Clinic for Children

WEB | nwcchildren.com

Charles Finch, DO Emergency Medicine

WEB | honorhealth.com

Jane Lyons, MD Dignity Health, St Joseph’s Hospital

WEB | dignityhealth.com

Cheryl O’Malley, MD University of Arizona, College of Medicine – Phoenix

WEB | phoenixmed.arizona.edu

Read more about what Arizona Docs are Saying when it comes to graduate medical education at arizonaphysician.com/docs-gme

Marie Gronley, MD Scottsdale Mental Healthcare, PC

WEB | Psychiatristscottsdale.com

Suganya Karuppana, MD Valle Del Sol

WEB | Valledelsol.com

Joanna Kowalik, MD, MPH District Medical Group

WEB | Dmgaz.org

Paul Baranko, MD Retired

Frederic Schwartz, DO, FACOFP AT Still University

WEB | Atsu.edu

Ronnie Dowling, MD White Mountain Surgical Specialists

Nadeem Shabbir, MD

Banner Neuroscience

WEB | Bannerhealth.com

Robert Cravens, Jr, MD Tucson ENT

WEB | Tucsonent.com

George Sibley, MD OptumCare

WEB | Optum.com

Avtar Singh, MD

Phoenix VA Health Care System

WEB | Va.gov/phoenix-health-care

Mark Zubriski, MD, PhD

Phoenix VA Health Care System

WEB | Va.gov/phoenix-health-care

Alvin Wong, MD

Phoenix VA Health Care System

WEB | Va.gov/phoenix-health-care

Lori Kemper, DO, MS, FACOFP Midwestern University

WEB | Midwestern.edu

Shakaib Rehman, MD, CSH, FACP, FACH

Phoenix VA Health Care System

WEB | Va.gov/phoenix-health-care

25 ARIZONAPHYSICIAN.COM

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Valleywise Health

We sat down with Michael White, MD, Executive Vice President, and Chief Clinical Officer of Valleywise Health, to discuss the public hospital system and its role in graduate medical education.

ARIZONA PHYSICIAN: What makes Valleywise Health stand out from other hospitals in Arizona?

DR. MICHAEL WHITE: As the state’s only public teaching hospital and safety net system of care, Valleywise Health is truly the foundation for a healthy Maricopa County. Since Valleywise Health first began serving the community in 1877, we have continually reinvented ourselves to meet Maricopa County’s evolving medical needs.

You may know Valleywise Health as one of the nation’s best and busiest burn centers. But there’s another side to us. The side that cares for those challenged by severe mental illness through three behavioral health facilities and innovative mental health programs.

We also provide primary and specialty care through 12 Federally Qualified Health Centers (FQHCs) throughout Maricopa County.

A
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CONVERSATION WITH
IN

AP: Please describe funding sources and the recent proposition approved by voters.

DR. MICHAEL WHITE (Pictured to the right): As a safety net hospital system, Valleywise Health relies on public support and a range of state and federal programs, including AHCCCS, Arizona’s Medicaid program.

In 2020, more than 64 percent of voters in Maricopa County approved a proposition to renew the annual property owner tax assessment that supplements our operational budget. The annual assessment levy equals about 12% of our revenues.

In 2014, Maricopa County voters overwhelmingly approved Proposition 480, which really set the stage for the transformation of our health care system. That measure stemmed from a 15-member citizens’ bond committee, which recommended a $935 million bond measure to fund multiple construction and renovation projects.

AP: Valleywise has grown over the past ten years. Where and why?

DR. MICHAEL WHITE: The approval for Proposition 480 allowed us to begin a “Care Reimagined” process, which included a comprehensive demographic study to identify the medical and behavioral health needs of Maricopa County. The result is an expansion of our Community Health Centers:

 South Phoenix/Laveen, opened August 2020

 South Central (includes resident training), opened September 2020

 North Phoenix, opened November 2020

 Peoria, opened January 2021

 West Maryvale, opened November 2021

 Mesa, opened January 2022

The opportunity to buy the Maryvale Hospital allowed us to quickly upgrade and open a 192-bed inpatient behavioral health hospital, filling a long-standing critical need within the community. In addition, the Emergency Department was updated and reopened to the entire community.

The most visible project remains construction of a new Valleywise Health Medical Center. Once completed in October, the 10-story, 673,000-square-foot tower will include 233 private patient rooms, a dedicated floor for the Arizona Burn Center, 10 operating rooms, two interventional radiology areas, two catheterization labs, a dedicated procedural floor and rooftop and ground-level helipads.

27 ARIZONAPHYSICIAN.COM
Learn more about Valleywise Health by visiting arizonaphysician.com/Valleywise
“Everyone who leaves here knows where they’re going next. We don’t have anybody that is floating.”

AP: How many and what types of health professionals are working at Valleywise today?

DR. MICHAEL WHITE: Valleywise Health has about 4,000 employees and our District Medical Group partners provide about 400 physicians and advanced practice clinicians across a wide range of specialties. We have 13 Graduate Medical Education programs ranging from emergency medicine, all primary care specialties, to psychiatry in partnership with the Creighton University Arizona Health Education Alliance. Additionally, we have fellowship programs in child psychiatry, gastroenterology and others. We train all the health professions that require certification from radiation technology to respiratory therapy to nurses and physicians.

AP: Which other organizations are in the health education alliance and what role does Valleywise play?

DR. MICHAEL WHITE: Valleywise Health is a core member of the Alliance, which includes Creighton University, Dignity Health St. Joseph’s Hospital and Medical Center and District Medical Group. We’re one of the founding members who came together to increase the number of physicians who not only train in Arizona but hopefully will remain here to serve our communities. When we created the Alliance, the goal was to bring additional learners using physician training first but then to increase that halo to cover all health care professionals so we can meet the demands of a rapidly growing population. It’s an exciting opportunity to play a major role in the training of new generations of physicians and other health care professionals.

AP: What types of research can residents conduct through Valleywise?

DR. MICHAEL WHITE: We have a number of research mentors in all the of the specialties. Much of research we do is focused on quality and patient safety as well as improvement. With our focus on training and education, our learners are continually asking important questions on how we can better care for our patients and utilizing the data we have to improve outcomes. We also are participating in multi-center clinical trials which include pharmaceutical and device research.

AP: Which reasons do residents offer for why they chose Valleywise to train?

DR. MICHAEL WHITE: Everyone who trains at Valleywise Health through the Creighton University Arizona Health Alliance is really drawn to our mission. We’re here to provide exceptional care to an underserved patient population, and our residents understand and recognize they have an immense opportunity to give back with their unique skills while they further hone those skills.

AP: Which reasons do residents offer for why they chose not to train at Valleywise?

DR. MICHAEL WHITE: Most individuals, when they choose a residency training program, will want to continue their careers in that geographical area. They want to be closer to home, to parents, to their support systems. That’s usually the chief reason why people decide not to do their training with us.

n ARIZONA PHYSICIAN MAGAZINE 28 IN DEPTH
PHOTOGRAPHY COURTESY OF VALLEYWISE HEALTH

AP: What knowledge, skills, or abilities does your team seek in residents?

DR. MICHAEL WHITE: We seek residents who are dedicated to our unique patient population and want to further their careers with lifelong learning. Medicine is a calling, and we are interested in providing individuals the opportunity to grow their skills through improving their knowledge while focused on outcomes of our patients. Additionally, we want to see individuals that are able to build teams, collaborate with their peers and form relationships with their patients.

AP: Do you get any feedback from employers about the quality of residents completing the program?

DR. MICHAEL WHITE: As part of a residency training program, one of your obligations is to survey graduates as well as their employers in the first year after graduation. The responses are largely positive. The way I evaluate this is how many residents don’t have an opportunity when they graduate from their programs. Everyone who leaves here knows where they’re going next. We don’t have anybody that is floating—people get to go largely where they would like to go to either practice or further their training.

AP: In which areas are improvements needed?

DR. MICHAEL WHITE: We always look for opportunities to continue to increase our patients base so we continue to have an increased number of opportunities for our residents. Any patient contact can be a valuable learning experience.

AP: Does Valleywise support any increases in funding or legislative changes needed for residency programs in Arizona?

DR. MICHAEL WHITE: We have always supported the expansion of Graduate Medical Education programs. ■

FOUNDED IN 1877 4,000 EMPLOYEES 400 PHYSICIANS AND ADVANCED PRACTICE CLINICIANS 1 MEDICAL CENTER 1 EMERGENCY FACILITY 2 COMPREHENSIVE HEALTH CENTERS 9 COMMUNITY HEALTH CENTERS 3 BEHAVIORAL HEALTH CENTERS VALLEYWISE HEALTH By the Numbers Connect with Valleywise Health at valleywisehealth.org
Interested in having your medical practice/hospital showcased in Arizona Physician? Let us know at info@arizonaphysician.com

Selling Your Medical Practice?

OPTIMIZE THE SALE WITH THIS TRIPLE TAX-ADVANTAGED STRATEGY

Amidst continued volatility in the medical industry, the state of Arizona is experiencing increased consolidation in the health sector.

As a growing number of medical practices merge with larger medical groups or sell to hospitals, many physicians are left with a critical quandary: How can the physician selling her practice not only maximize the profit from the sale, but also preserve and protect the wealth and continue her legacy after the sale?

After all, capital taxes from the sale (which are often the largest expense of the transaction, swiftly eroding profitability) can damper what should otherwise be the rewarding culmination of years of hard work. Then, whatever is left still remains subject to risk from creditors and lawsuits, as well as federal estate tax at death.

By utilizing a savvy tax planning strategy known as an “Optimized Charitable Lead Annuity

Trust” (OCLAT), the physician can save up to 30% of the taxes from the sale, remain in full control of investing the contributed funds (much like a self-directed IRA), fund charitable causes in furth-erance of her legacy, and transfer to heirs (or receive back) significant wealth in the future—a quintessential win-win.

Specifically:

 The physician receives a federal and state income tax deduction equal to the amount contributed to the OCLAT, subject to a 30% AGI limitation (i.e. a physician selling his practice for $10M may contribute up to $3M to the OCLAT, reducing taxable income from $10M to $7M);

 The assets contributed to the OCLAT are exempt from the physician’s personal creditors, lawsuits, and bankruptcy (and future divorce if the OCLAT is funded while single);

 After the required charitable payments are made, the assets remaining inside the OCLAT

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Learn more about what you should know before selling your medical practice by visiting arizonaphysician.com/selling-med-practice LEGAL CORNER

account should be 2-5 times the amount of the initial contribution (assuming a conservative 5-7% investment rate of return) which assets may be transferred back to the physician (free of income taxes) or transferred to the physician’s heirs (free of income taxes and free of the 40% gift/estate tax).

For instance, consider Dr. Smith, a philanthropic surgeon selling her practice in 2023 for $5M and paying taxes at the top income tax bracket (roughly 50% when accounting for state and federal taxes).

Dr. Smith opens a self-managed OCLAT account at her bank and transfers $1M of assets (stocks, bonds, digital currency, etc.) into the OCLAT account. The transfer of $1M to the OCLAT unlocks an immediate $1M income tax deduction, saving her roughly $500,000 in taxes on her 2023 tax return.

Over the charitable term selected by Dr. Smith (let’s assume 30 years), Dr. Smith will invest the $1M inside the OCLAT, and will also be required to make annual donations to her

favorite charities. The required donation amount is set by the IRS based on interest rates in effect at the time of funding. These rates are currently at a historically low level, making the OCLAT even more advantageous. In this way, the trust will simultaneously bolster Dr. Smith’s philanthropic legacy and compound her investments.

At year 30, after Dr. Smith has donated about $2.5M from the OCLAT account, there will be about $5M remaining (assuming a 7.5% annual rate of return). This amount may be transferred back to Dr. Smith (income tax-free) and/or she may elect to transfer all or a portion of the $5M to her children (income tax-free and without the 40% gift tax).

Alternatively, rather than wait until year 30 (especially if the investments have performed exceptionally well in a so-called “home-run CLAT”), Dr. Smith may choose to prepay the $2.5M donations and access the remaining OCLAT assets ahead of schedule.

OCLATs perform so well that some physicians opt to execute them even without selling their practice. For example, one large local medical group had surgeons (who capped out on their 401(k)s and profit sharing plans) that were looking for an additional, more powerful retirement account option. Rather than being limited to the conventional retirement account’s ~$60,000 yearly contributions, the surgeons could fund an OCLAT account with up to 30% of their annual income, regardless of how much they made, every single year. And, unlike other retirement plans, there are no income taxes or gift/estate taxes when OCLAT assets are paid out at the end of the charitable term (compared to assets from a traditional retirement account, which will be subject to 40-50% ordinary income tax and a 40% estate tax upon death— effectively a ~70% tax).

After decades of devoted care for patients and their families, physicians deserve to enjoy the fruits of their labor in retirement—and to know their families are taken care of. For physicians with charitable intentions who are looking for additional income tax options, the OCLAT is perhaps the best way to divert tax dollars to medical foundations and health nonprofits, all while building a robust nest egg and a meaningful tax-efficient legacy. ■

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Avoid Hiring Pitfalls When Hiring Medical Staff

Common mistakes and things to consider in 2023

Hiring the right medical staff is essential for any healthcare organization to maintain a quality standard of care. However, making the wrong hiring decisions can have disastrous consequences, leading to decreased patient satisfaction and financial loss. Therefore it’s essential to take all necessary steps to avoid making costly mistakes when recruiting medical personnel. Doing so will help ensure your organization continues providing the highest quality care for patients. Here’s what you need to know about avoiding hiring mistakes in the medical field.

COMMON HIRING MISTAKES WHEN HIRING MEDICAL STAFF

BAD JOB TITLE | Tailoring a job title to attract many applicants is crucial to successful recruitment. With the right words, you can draw the attention of potential candidates and showcase your company as a desirable employer.

Here are some tips on how to make sure that your job title stands out from the rest:

Keep it short and simple | Long and complicated job titles can be off-putting to potential applicants. They can also appear intimidating or confusing. Keep the title concise, and ensure it reflects what you’re looking for.

Leverage industry buzzwords | Include those keywords in the title if the job requires specific skills or knowledge. It will help it to show up in relevant searches and attract those with the right experience level.

Create a functional job title | As you craft your job posting, consider the title that resonates with those searching for the position. When designing the job titles, stick to simple keywords that accurately describe the post. Save any fun puns or out-of-the-box terms for employees’ business cards and Linkedin profiles!

INSUFFICIENT INFORMATION | When you set out to hire for a specific role, it’s essential providing potential applicants with enough information about the job. That way, they can make an informed decision on whether or not to apply and have realistic expectations of what the job entails. Providing precise details

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Learn more about how to avoid hiring pitfalls at your medical practice by visiting arizonaphysician.com/avoiding-hiring-pitfalls
HOW TO

about the job is vital for avoiding confusion or misunderstanding between the employer and the employee. Give candidates a thorough overview of duties, skills needed, working hours, and other relevant information to give them insights into what they can expect. Speak to the values and culture of your company as well—this will help applicants determine if it’s an environment in which they’ll thrive.

HIDING YOUR COMPANY | Hiding crucial information from potential employees needs to be corrected for several reasons. It can lead to a lack of trust between the organization and its candidates. If applicants feel that their questions about the company’s mission and organizational culture are being intentionally avoided, they will likely view this as a red flag. This feeling of distrust can also carry over into the job itself since employees may sense that their employers are not being honest or transparent with them. At the end of the day, honesty matters. Be open when hiring new employees. Not only will this lead to more trust within the organization, but it will also create a better candidate experience for those who do apply. Being transparent about company information and expectations from the start will go a long way toward finding the right people for the job.

THINGS TO CONSIDER WHEN HIRING MEDICAL WORKERS IN 2023

SOFT SKILLS | When hiring medical workers, it is essential to consider their hard skills, such as technical knowledge and expertise, and soft skills. Soft skills are essential components in a medical worker’s overall success and can significantly impact patient care quality. These skills help ensure medical workers can deliver effective care with compassion, manage challenging patient needs, and create meaningful relationships with other healthcare professionals. Soft skills are also essential for helping medical workers remain up-to-date on the latest medical advancements. These skills also help them communicate effectively with colleagues and patients and develop better approaches to wellness management. Focusing on soft skills during the hiring process sets medical staff up for success. It ensures that employers bring on board individuals who will contribute positively to the larger healthcare environment.

COMPANY CULTURE | Whether you’re a small business or a large corporation, hiring the right people for your team is essential for success. That’s why it’s vital to always keep company culture in mind during the recruitment

process. Company culture isn’t just about having an office with fun decor and relaxed dress codes—it’s the attitudes, values, and beliefs defining your company. Finding recruits who share these is vital to building a successful team that works hard, communicates well, and supports each other. When you hire someone who has the skills and complements your culture, it helps create an environment of trust and respect—something which can drive your business to new heights. Research shows that when employees feel like they belong, there is a boost in job satisfaction and productivity. So, remember to consider company culture when you’re looking for new recruits— it’s essential for creating a workplace that brings out the best in your team!

PURPOSE | When it comes to hiring, it’s important to give job seekers purpose. A purpose-driven individual is far more likely to be successful in their job, and that helps your company reach its goals. Giving candidates a sense of purpose can also help them feel more connected to the team and become enthusiastic about their work. Jobseekers who understand the bigger picture of their role are more likely to be loyal and motivated. They also have greater clarity on what needs to be done, which leads to better performance. When job seekers know that their work has a purpose and is meaningful, they feel far more valued and respected by their employers. This can increase productivity and morale in the workplace, leading to greater success for the company.

SCORECARDS | When hiring in the medical field, utilizing candidate scorecards can be especially beneficial. As a part of structured hiring, not only are scorecards a great way to measure and track the success of potential new employees accurately, but they also help employers make sure they hire someone well-qualified and capable of handling the job. Scorecards provide an objective overview that employers can use to ensure they make the right hiring decision. It also allows employers to easily compare potential candidates and better understand applicants’ qualifications. Additionally, scorecards are an essential tool for employers when it comes to staying compliant with any industry regulations or standards that may be in place. ■

33 ARIZONAPHYSICIAN.COM

PHYSICIAN SPOTLIGHT

Felipe R Perez, MD, FAAFP on teaching residents at El Rio Health

Q: What motivates you to train residents in family medicine?

A: When I completed my family medicine residency training, I never envisioned myself teaching residents. My goal was to serve the community by providing care at a Federally Qualified Health Center (FQHC), but teaching was not part of my career plans. About three years into my career as a family medicine physician, I was asked if I would mentor a medical student during their pre-clinical years. I hesitated at first because I didn’t feel qualified to teach medical students, let alone residents! But I finally agreed. I remember my first mentee. His name was Mohammad.

For the first few weeks I felt nervous because I was not sure if I was doing a good job as an attending physician. Over time, however, I learned my insecurities about teaching were completely unfounded. I was surprised to discover how easy and enjoyable it was to share my passion about caring for patients and the community. This newfound passion motivated me to increase my teaching commitment. I learned how teaching can enhance job satisfaction by providing me with a sense of added purpose, which in turn improved my overall sense of well-being. Combining my passion for medicine and teaching took my career in a new direction and led me to eventually start Arizona’s first teaching health center to train family medicine residents in an FQHC.

Q: What does it take to become an attending physician?

A: Any physician passionate about patient care and interested in sharing their passion can become an attending physician. People often think attending physicians need special training or teaching experience to become an educator, but that’s not necessarily true. In many cases, attendings physicians begin their teaching career by mentoring a student for a few hours per week. As they gain more experience, they might increase their teaching commitment and even seek out faculty development opportunities.

Q: Is it what you expected?

A: No. It was much better than I expected. In fact, it changed the direction of my career. I am grateful to have discovered the synergy of both teaching and taking care of patients.

Q: Which improvements are needed in GME? Maybe they’re structural, funding, policy, etc.

A: We need to address the primary care physician shortage in Arizona. We currently have a large disparity in access to care in rural and underserved communities. Although there have been recent improvements to address the shortage, we still have a significant challenge ahead of us. One possible solution is to focus more state initiatives on training and incentivizing FQHCs and rural health centers that provide recognition and support to attending physicians who teach. This is important because there is strong evidence that physicians often stay to practice medicine where they were trained.

Q: Please share a funny moment as an attending.

A: One time I helped a resident physician replace his car’s radiator in the clinic parking lot. It got a lot of laughs from the staff. ■

34 n ARIZONA PHYSICIAN MAGAZINE
FELIPE R PEREZ,
Arizona Physician Magazine 326 E Coronado Rd, Suite 101 Phoenix, AZ 85004 (602) 417-2303 information@arizonaphysician.com Medical Professional Liability Coverage That Puts YOU First As a physician-founded and directed mutual Mutual Insurance Company of Arizona® To Learn more or request a quote at 800-681-1840 or info.mica-insurance.com/mcms

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