Round-up Magazine, July 2016 by Maricopa County Medical Society (MCMS)

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Round-up July 2016

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July 2016 | Volume 62 | Number 7 Round-up (USPS 020-150) is published 12 times per year by the Maricopa County Medical Society, 326 E. Coronado Rd., Phoenix, AZ 85004. Round-up is a publication of the Maricopa County Medical Society (MCMS). Submissions, including advertisements, are welcome for review and approval by our editorial staff at roundup@mcmsonline.com. All solicited and unsolicited written materials and photos submitted to Round-up will be treated as unconditionally and irrevocably assigned to and the property of MCMS and may be used at MCMS’ sole discretion for publication and copyright purposes and use in any publication, website or brochure. MCMS accepts no responsibility for the loss of or damage to material submitted, including photographs or artwork. Submissions will not be returned. The opinions expressed in Round-up are those of the individual authors and not necessarily of MCMS. Round-up reserves the right to refuse certain submissions and advertising and is not liable for the authors’ or advertisers’ claims and/or errors. Round-up considers its sources reliable and verifies as much data as possible, but is not responsible for inaccuracies or content. Readers rely on this information at their own risk and are advised to seek independent legal, financial or other independent advice regarding the content of any submission. No part of this magazine may be reproduced or transmitted in any form or by any means without written permission by the publisher. All rights are reserved.

ROUND-UP

PUBLISHED MONTHLY BY THE MARICOPA COUNTY MEDICAL SOCIETY

July 2016 | Volume 62 | Number 7

4 7 9 11 13 19

Letters To The Editor

What’s Inside President’s Page Medical Education

To Fight The Zika Pandemic, Learn From Ebola

By Ranu S. Dhillon, Robert Glatter and Devabhaktuni Srikrishna

A Delicate Balance:

Should Expert Witnesses Enjoy Absolute Immunity for False or Unfounded Testimony? By J. Alexander Dattilo

Better Healthcare at Lower Costs

By Senator William Frist, M.D.

Member Profile

Change for the better? A look at medical education with Linda Lau, MD By Dominique Perkins

Alcohol Abuse Common Among Med Students, Study Finds By Health Daily News

Should Doctors-In-Training Work Fewer Hours? By Dhruv Khullar

33 38

College Kids, With Kids

By Jamie Merisotis and Anne Marie Slaughter

Top 11 Ways Physicians Can Get the Most Out of CME on a Budget By Janet Kidd Stewart

Social Media and the Patient-Physician Relationship By Himaja Gaddipati

42 43

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Letters To The Editor Dear Dr. Brodsky,

Whenever Round-up shows up in my office, I almost invariably thumb though it to see if there is an article by Rudi Kirschner, MD, as I have known him for many years and really enjoy his writing. If there is none, I usually do not look at most of it if it does not pertain to my practice. Fortunately, my secretary spends more time on the magazine than I and she brought me the May, 2016 issue with the article, “How to Discourage a Physician,” by Dr. Richard Gunderman. I laughed so hard I nearly cried. I enjoyed this more than any article I have ever seen in Round-up. This was the best written article I have ever read in your magazine and only wish that it could be printed in every major magazine and read by our politicians, our insurance executives and of course our hospital CEOs. I appreciate Dr. Gunerman’s humor and insightful discussion of the problems facing medicine today. Hopefully I will see more of his articles in the future. — Howard H. Johnston, M.D.

Dear Dr. Brodsky,

The University of Arizona College of Medicine – Phoenix has matured into a first-rate medical school since the initial class in 2004. Dean Stuart Flynn and Jacqueline Chadwick, Vice Dean of Academic Affairs, provided outstanding leadership that made this possible with a dedicated faculty and administrative staff. For those of you who do not know, Dean Flynn recently resigned because of the lack of autonomy that he was granted that was necessary for the growth of the medical school. He did not leave, as implied in some articles, because he was looking to do so. On the contrary, he dedicated his heart and soul to the growth of the medical school and was anxious to continue on with his efforts. Following Dean Flynn’s resignation were six other senior-level deans of the medical school. These included the vice dean of academic affairs, associate dean of student affairs, associate dean of admissions and recruitment and interim director of diversity and inclusion, associate dean of faculty affairs, and deputy dean of finance and administration. 4

Round-up July 2016

These resignations are a significant loss to the medical school and the state of Arizona. The House of Delegates of ArMA passed a resolution urging the Arizona Board of Regents (ABOR) to conduct an immediate independent investigation of this. It is indeed a sad event for the medical school, the city of Phoenix, and the state of Arizona. — Robert E. Kravetz, MD, FACP, MACG

Dear Dr. Brodsky,

It was my pleasure to chat with your Executive Director, Dr. Jay Conyers, last month concerning the announcement about the InfantSEE program, which appeared in the Society’s May e-newsletter. I am concerned about the promotion of this program, as the position of the Arizona Ophthalmological Society (AOS), of which I am the current president, has been that optometrists generally lack the proper training to perform eye exams in infants. The InfantSEE Program was first introduced nationally by the American Optometric Association and sponsored by Vistakon/Johnson & Johnson, which offers free initial eye exams to 6- to 12-month old infants. The AOS is concerned about the effectiveness of this screening program, as well as the minimal training and experience with infants that optometrists receive. The high success rate of screening for ophthalmic pathology in children and infants through Primary Care MDs is well documented, whereas the sensitivity and specificity of exams through InfantSEE are not known. Independent research at Vanderbilt University found 35% of children seen by Tennessee optometrists were prescribed glasses despite having no amblyogenic factors. The authors of the study extrapolated data to the U.S. population and estimated that a single mandatory eye exam would cost over $135 million a year in unnecessary spectacles. Additionally, most optometrists recruited for the InfantSEE program do not routinely examine infants. Instead, they are being offered a one-day course to teach skills that ophthalmologists (i.e., eye MDs) learn in residency. This training deficiency may explain a growing national trend, in which myriad anecdotal cases suggest incorrect diagnoses and mismanagement of patients in the InfantSEE program.

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Letters To The Editor As eye MDs, we are committed to improving the ease with which children’s eye problems are detected. The cost-effective approach taken by ophthalmologists is recommended by the American Association of Pediatrics (AAP), the American Academy of Ophthalmology (AAO), and the American Association for Pediatric Ophthalmology and Strabismus (AAPOS). My organization would happily offer further insight if the Society were interested in taking a position on a program that we view as potentially harmful to infants and children. Regards, Charlie Schaffer, MD President, Arizona Ophthalmological Society

Dear Dr. Brodsky,

The generous gift provided by the Maricopa County Medical Society and the MICA Medical Foundation in support of scholarships is an investment in tomorrow’s health care leaders. We appreciate your commitment to our students, our future doctors, so they have access to a high quality medical education no matter their financial situation. Nothing we do to enhance our learning community will matter if students can’t afford the opportunities we offer. Scholarships allow our institution to attract the finest students, many of whom might not otherwise be able to afford to nurture their talents without the benefit of financial assistance. We have seen a steady increase in the need for scholarship aid as tuition costs continue to increase and outpace family income and federal tuition assistance; your gifts bridge this financial gap. Many of our donors agree that assisting these students is one of the most rewarding investments they will ever make. You are building a pipeline of talented health professionals who will ensure the future health of our communities and address the challenges of health care. Thank you again. Sincerely, Kenneth S. Ramos, MD, PhD Interim Dean, UA College of Medicine – Phoenix Associate Vice President, Precision Health Sciences Director, Center for Applied Genetics and Genomic Medicine 6

Round-up July 2016

Got something to Say? Share? Celebrate?

We want to hear from you! We are excited to reinstate the Letters to the Editor section of our publication. Did a survey topic make you think? An article make you chuckle? Or maybe you had a great time at one of our events! If something you read stood out to you, send us a note telling us what you think! Each month we will select a few letters to share. In addition to what you think of our magazine, we’d also love to hear about you! Graduations, publications, big birthdays, promotions or new jobs, we want to hear about the moments in your life worth noting, so that we can celebrate life’s accomplishments alongside you. Share with us via mail, email, or on social media (you can find us on Facebook, Twitter, LinkedIn & Instagram). As ever, we are always on the lookout for members with a strong voice and unique perspective to contribute Round-up articles. If you are a Society member and would like to be considered for upcoming author opportunities, let us know! Here in the Maricopa County Medical Society, we think yours are the stories worth telling. Thank you for letting Round-up be a part of that. Contact us at roundup@mcmsonline.com Or mail letters to: Maricopa County Medical Society Attn: Round-up Editor 326 East Coronado Rd Suite 101 Phoenix, AZ 85004

What’s Inside E

ducation for a physician is a necessary evil. It doesn’t end at medical school, and it doesn’t end at the completion of a residency program. For many, it continues on in the form of an internship or fellowship, depending on the specialty, and for most, it continues until retirement through continuing medical education (CME). Only physicians practicing solely in the states in Colorado and Montana enjoy no required CME, and those in New York have limited requirements related to infection control.

Largely, CME tends to average roughly 20-30 hours per year, depending on the state’s licensing cycle, and a growing number now include specialty requirements such as pain management, geriatrics, domestic violence, and infectious diseases transmission, among others. Here in Arizona, allopathic physicians are required to complete 40 hours every two years, whereas osteopathic physicians must complete 20 each year, with no fewer than 12 hours of Category 1-A. Other than the legal field, not many professions require continuing education to the extent that physicians must meet to maintain licensure. As if medical school and residency weren’t enough! The state of Arizona now has more than 2,200 students enrolled in allopathic or osteopathic medical school programs. When the Mayo Medical School welcomes its first class of medical students in 2017, we will have six schools training tomorrow’s physicians here in Arizona. But how does it all break down? The University of Arizona has nearly 720 medical students, with nearly one-third (253, to be exact) at the Phoenix campus. A.T. Still and Midwestern make up the bulk of the number, with 431 and 1,000, respectively. Creighton supports 84 students here in Phoenix, comprised exclusively of 3rd and 4th year students. A year from now, Mayo will welcome 50 new students. With all the news about our physician shortage here in Arizona, will the addition of a

sixth medical school help us bridge the gap between how many physicians we have and how many we need? No one knows the answer, but many suggest the real problem lies in the shortage of residency slots. I’ve heard conflicting reports on how many physicians Arizona needs to support our growing population, but the number that continually comes up is half. That’s right, half, which means our state has half as many residency slots as it actually needs. Just a few months ago, 508 residency slots were open here in Arizona, with 471 slots reported by the National Residency Matching Program and another 37 by the American Osteopathic Association. Of these, only 20 remain unfilled. Looking at the physician break down, DO graduates secured 95 of the available slots, with MD graduates grabbing the other 393.

Jay Conyers, PhD EXECUTIVE DIRECTOR

jconyers@msmsonline.com 602.251.2361

At first glance, the numbers suggest that we almost have enough residency slots for all graduates each year. With roughly 2,200 students, an estimated 550 medical students graduate each year and seek out residency programs. Unfortunately, only about half of students graduating from Arizona-based medical schools end up matching here. That means a high percentage of students who train in Arizona complete their residency elsewhere. Why is this important? Because the majority of residents practice within the state the complete their residency, not where they completed medical school. That doesn’t bode well for our state. With the 7th highest growth rate among states from 2010 to 2015, Arizona is headed on a trajectory where our population growth far outpaces our state’s increase in the total number of physicians. This is a big issue that our state will have to address eventually, hopefully sooner rather than later. So this month, we profile a physician in the trenches of medical education. Linda Lau, DO, directs the family practice residency program for Mountain Vista mcmsonline.com/round-up

What’s Inside Medical Center in Mesa, and serves on the faculty at Midwestern University. We bring you a great summary article by Janet Kidd Stewart on how you can get more bang for your CME buck, as well as Midwestern University’s winning essay, submitted by Himaja Gaddipati, for the student scholarship program sponsored jointly by the medical society and the MICA Foundation. We also have an opinion piece by Sen. Bill Frist, MD, who offers his thoughts on how communities can reduce their healthcare costs without compromising quality of care. A number of other great articles are also in this issue, and we hope you enjoy reading each of them! Next month, we shift gears and focus on the Affordable Care Act, and the implications the landmark legislation has had on our nation. It’s surely been a mixed bag of results, and perhaps even more so here in Arizona. With most payers leaving the exchange this year or next, who knows where the uninsured and underinsured will look

for coverage going forward. As our profile, we will be looking at the work being done by Steven Herman, MD, a forensic psychiatrist new to Arizona. It should be a great issue, so we hope to hear from you after reading it! We hope you enjoy this issue of Round-up. You’ve all put your blood, sweat, and tears into your journey to being a physician, and hope you’re all doing what you to set out to do. Many of you are discouraged by how medicine has changed, largely at the hands of state and federal oversight. Some have jumped ship and retired early, or made a career change out of frustration. Many are considering it. Stay the course, your patients need you. “You don’t train someone for all of those years of medical school and residency, particularly people who want to help others optimize their physical and psychological health, and then have them run a claims-processing operation for insurance companies.” – Malcolm Gladwell

You’re Invited!

Join us for the Maricopa County Medical Society’s

Health Policy Forum

Thursday, September 22, 2016 6:00 - 8:30 pm MCMS Courtyard 326 E. Coronado Rd. Phoenix, AZ 85004

Come join your colleagues for an interactive Q&A with Arizona’s leading policy experts. Featured Panelists:

Rep. Heather Carter (LD-15) Arizona State House of Representatives Chairperson of House Health Committee

Sen. Katie Hobbs (LD-24)

Arizona State Senate Minority Leader Senate Health and Human Services Committee

Ms. Christina Corieri

Arizona Governor’s Office Health and Human services Policy Advisor

Moderator:

Pele Fischer, JD Space is limited! Reserve your spot and submit a question for the event. Sponsored by long-time Society partner

Arizona Medical Association Vice President of Policy and Political Affairs

RSVP TODAY! mcmsonline.com

Round-up July 2016

President’s Page I

t is true that many university health care systems are in difficult financial straits and several have found it necessary in recent years to partner with private health networks in order to make ends meet. Realistically, we as a society must recognize the societal benefit of academic medicine and find a way to pay for it. Universities have from their inception been focused on independent research and the furthering of the limits of human knowledge, in addition to teaching, raising and mentoring the next generation of academics (as well as teaching general studies to the masses). Central to the concept of the university is a feature not found in any other venture - that of the tenured professor, who, unencumbered by having to reapply for a job every year and not beholden to any special interest, may exercise true academic freedom and independence. Clearly, universities have to be financially viable, but the culture of the institution was and is one of unbridled academic freedom rather than one of increasing shareholder value, maximizing revenue-over-expenses, or profiteering. When universities partner with private institutions, whether for-profit or not-for-profit, we must be careful not to contaminate that culture of independent knowledge, research, and academic pursuit. Because the benefits of academic medicine may be deemed a public good, it is not entirely clear that privatizing university medical centers is the correct way forward. Or perhaps if it is, we should be very careful to have safeguards in place to maintain independent and scientifically based academic standards and research capabilities. In our own backyard, the recent acquisition/merger of the University of Arizona Medical Center, including the University of Arizona Medical School, with Banner Health has resulted in some consternation among both local private physicians as well as among the academic leaders

of the Medical School. While it is not within the scope of this article to discuss these developments in detail, there is one quirk related to the acquisition which caught my eye. In many State University systems, the Medical School Hospital is named for the State University, thereby indicating its allegiance to both treating patients from that state and training the next generation of physicians for that state. For example, in Minnesota, there is the University of Minnesota Medical Center. In Illinois, there is the University of Illinois Hospital and Health Sciences System. In Michigan, there is the University of Michigan Medical Center. In Wisconsin, there is the University of Wisconsin University Hospital. In Texas, there is the University of Texas Health Science Center. In Pennsylvania, there is the Hospital of the University of Pennsylvania. In Washington, there is the University of Washington Medical Center. In Arizona, there is…..Banner University? The name of our State - Arizona - doesn’t even appear in the name of the State University Medical School’s hospital. It’s just Banner University Medical Center (with it’s Phoenix campus and it’s Tucson campus). As if to say that we are treating patients from and training the next generation of physicians for the State of Banner. Separately, as I was contemplating our roles as physicians and teachers, I was reminded of an unsettling experience I had recently. I was called to the Emergency Department to evaluate an unstable hypotensive patient having chest pain who had not been taking his usual medications (for a history of prior heart attack and heart failure) and who had required intubation due to severe hypotension. He was described by the Emergency Department physician as having had a “hypotensive code arrest.” The patient was treated with appropriate medications and showed subsequent improvement in his clinical condition. What caught my attention about this case was fact that the

Adam Brodsky, MD, MMM

MCMS PRESIDENT 2016 abrodsky@msmsonline.com 602.307.0070

Dr. Brodsky specializes in Interventional Cardiology He joined MCMS in 2005. Contact Information: Heart & Vascular Center of Arizona 1331 N. 7th Street Suite 375 Phoenix, AZ 85006 http://heartcenteraz.com

mcmsonline.com/round-up

President’s Page patient had been at that same hospital only two weeks earlier. In fact, during the previous admission he had been noted to have been out of his cardiac medications due to his recent move from out of state. What was interesting to me was that he was admitted as an “observation” admission, had an exercise stress test ordered, but had no consults placed to cardiology. The patient ended up leaving against medical advice the next day before the stress test could be completed, but the patient never saw a cardiologist during the approximately 15 hour “observation” admission. Would it not have made sense for this patient who has a chronic cardiac issue, who is new to the state, and who has run out of his lifesaving medications, to at least have been given the opportunity to establish a relationship with a cardiologist so that patient could then follow up in the outpatient setting, thereby hopefully avoiding a future admission? Instead, the patient had no follow up, was again on no medications, and ended up being readmitted within two weeks, this time in a “hypotensive code arrest.” What bothers me about this case is not the medical outcome - we all know these things can happen. What bothers me is that according to the medical system we have created, the initial admission for this patient was a “success.” It was a success because by avoiding

Round-up July 2016

unnecessary consults, the patient was able to be discharged from the “observation” unit in a timely fashion, and the timelines of “observation” discharges is a top item on the health care system’s “dashboard.” In contrast, stopping to think that this particular patient, having just moved from another state, having a chronic, severe cardiac condition, and having no medications and no established local doctor, may have benefited from a face-to-face meeting with a local doctor who could see that patient in an office setting a few days later to establish a long term relationship, is not on the health care system’s “dashboard.” We need to teach our medical students, residents, and fellows, and indeed perhaps even ourselves, that following the guidelines does not absolve us of the ethical responsibility each of us has to our individual patients, regardless of what any administrator’s “electronic dashboard” shows or doesn’t show.

TO FIGHT THE ZIKA PANDEMIC, LEARN FROM EBOLA BY RANU S. DHILLON, ROBERT GLATTER AND DEVABHAKTUNI SRIKRISHNA

n Feb. 1, the World Health Organization declared the Zika virus an international public health emergency. Though not yet confirmed, Zika is suspected of causing microcephaly — babies born with small heads and abnormal brain development — and paralysis in adults. The virus is “spreading explosively” throughout South and Central America with cases confirmed in more than 20 countries. The WHO anticipates that up to 4 million people could become infected by the end of the year and, with large numbers of travelers in and out of the region, Zika could spread to other parts of the world. Just over a year ago, we faced a similar challenge when Ebola was spiraling out of control. At the time, two of us (Ranu and Devabhaktuni) were asked by the pres-

ident of Guinea, one of the three most affected countries, to help develop a national strategy to contain the epidemic. Based on our experience fighting Ebola, we propose a four-pronged strategy for containing Zika. Just like Ebola, there is no vaccine or cure for Zika. Stopping this pandemic will require disrupting its “chains of transmission.” For Ebola, which is transmitted through bodily fluids, this meant implementing a response that identified newly infected people at the first sign of illness and then quarantined them before they infected others. Controlling Zika, which is transmitted by mosquitoes and apparently through sex, might logically require eliminating mosquitoes in areas where the virus is present and immediately isolating infected people, especially from pregnant women. This can be done by ensuring people use mcmsonline.com/round-up

mosquito repellents and sleep under insecticide-treated bed nets (similar to those that have helped achieve dramatic declines in malaria in Africa) and by eliminating conditions where mosquitoes thrive, including standing water and outdoor debris. However, because 80% of infected people show no signs of illness and others have nonspecific symptoms like fever and body aches, it’s hard to know who has Zika and, therefore, pinpoint areas where these interventions need to be targeted. Right now, affected countries are identifying local hot spots by looking for places where there are unusually high rates of babies born with microcephaly — essentially, only after severe damage has already been done. Some countries are currently trying to contain Zika by broadly recommending that all women avoid becoming pregnant and that communities take precautions against mosquitoes. But implementing these measures across entire countries will require mass distribution of both birth-control and mosquito-control material. These approaches will only be partially effective. Therefore, alongside such broad-brush efforts, a more nuanced four-pronged response is needed.

1. Pinpoint Hot Spots With Widespread Testing

In areas where Zika may be present, all patients with symptoms that could signify infection should be screened by blood testing so that hot spots can be quickly detected. This approach would benefit from the accelerated development of easy-to-use, point-of-care diagnostics for Zika. Similar to Ebola, Zika diagnosis currently requires polymerase chain reaction (PCR), a laboratory-based test that needs special equipment and personnel. One of the major failures during the Ebola epidemic was the inability to quickly validate and deploy rapid diagnostic tests (RDTs) that could have been used by non-specialized health workers to diagnose Ebola within minutes with just a finger prick. This would have allowed Ebola cases to be detected earlier and transmission to be curbed more quickly. Developing a similar test for Zika should be an immediate priority. Meanwhile, existing labs at regional and sub-regional hospitals should be equipped to carry out Zika diagnosis by PCR so surveillance of the virus’ spread can begin immediately.

2. Implement Targeted Control Measures

With information on where Zika transmission is happening, mosquito control and isolation interventions can be implemented. Bed nets and repellant should be distributed to all households; environmental conditions conducive to mosquito breeding should be addressed; and people diagnosed with Zika should be kept away from pregnant women. Many of the countries currently affected by Zika have relatively stronger health systems. In Brazil, the most heavily affected country, for example, there is already a network of local clinics linked to community health workers who go from household to household to ad12

Round-up July 2016

dress health issues. These local health systems should pivot toward epidemic control and search out potential cases of Zika while providing counseling to pregnant women to minimize their risk of infection.

3. Prevent Widespread Transmission

At the start of the West African Ebola epidemic, the virus was clustered within a few local communities and, as in the two-dozen Ebola outbreaks before it, could have been confined and brought to a quick end. However, once Ebola eluded early response efforts and spawned an epidemic of local outbreaks, it became a global crisis. Zika has already become fairly widespread. But every effort should be made to try to pin the virus down in its current locations and stop it from reaching new geographies. Once a hot spot is identified, people traveling out of the area should be tested at diagnostic checkpoints.

4. Integrate Research with Immediate Action

With Ebola, we tried to manage the epidemic even while many critical questions about the virus remained unanswered. Despite thousands of cases and over two years of fighting the epidemic, we still did not learn as much as we should have about Ebola because of an inability to conduct research alongside efforts to manage the epidemic. With Zika, we may have even more knowledge blind spots that need to be quickly understood if the pandemic is to be contained. Does Zika actually cause microcephaly and paralysis as is suspected? If so, is everyone vulnerable or only people with certain characteristics? Amid the chaos of the Ebola epidemic, a clear-sighted approach to disrupting the “chain of transmission” tamed runaway growth. We must heed the lessons from the Ebola crisis and employ a systematic strategy to combat Zika.

RANU S. DHILLION, M.D. Ranu S. Dhillion, M.D., is an advisor to the president of New Guinea and the country’s National Ebola Coordination Cell. He is in the division of global health equity at Brigham and Women’s Hospital and Harvard Medical School, and is a senior health advisor at Columbia University’s Earth Institute.

ROBERT GLATTER, M.D. Robert Glatter, M.D., is an assistant professor of emergency medicine at Northwell Health’s Lenox Hill Hospital. He is editor at large at medscape Emergency and chief editor at Medscape Consult.

DEVABHAKTUNI SRIKRISHNA Devabhaktuni Srikrishna is the founder of Patient Knowhow, which curates patient educational content on YouTube. Previously, he was founder and chief technology officer of Tropos Networks, which was acquired by ABB Group. © 2016 Harvard Business School Publishing Corp. Distributed by The New York Times Syndicate

A Delicate Balance:

Should Expert Witnesses Enjoy Absolute Immunity for False or Unfounded Testimony? BY J. ALEXANDER DATTILO

Introduction. Since the powdered wig era, witnesses have enjoyed immunity from liability for statements made in connection with litigated matters. In recent years, there has been an active discussion of the pros and cons of this immunity rule; in 2013, the Maricopa County Medical Society was asked to support a proposed bill that would have limited the immunity, allowing suits against witnesses whose testimony was given in bad faith, or with malice. This article discusses the history of the immunity rule and the current state of the law in Arizona; addresses the unfortunate and unavoidable consequences of the rule; summarizes one of the remedies that have been proposed to alleviate those unfortunate consequences; and provides an admittedly biased view of whether and how the proposed remedy might be worse than the disease. Regarding bias, I spent many years representing physicians in medical malpractice cases. During that time, I deposed and cross-examined a great many adverse witnesses. It was my opinion that some of those wit-

nesses offered testimony that was, at best, unsupported by any valid scientific or factual basis, and at worst, intentionally misleading and dishonest. Despite those experiences, it is my bias that the current immunity rule is, on balance, better than any of the proposed alternatives.

How we got here. Since the beginning of the English jurisprudence system, attorneys have been “absolutely immune from civil liability for statements or conduct that may have injured, offended, or otherwise damaged an opposing party during the litigation process.”1 This rule reflects an awareness that losers in litigation often are sore losers, and that allowing them to file lawsuits against the adverse attorney might lead to an endless proliferation of lawsuits.2

1 T. Leigh Anenson, Absolute Immunity from Civil Liability: Lessons for Litigation Lawyers, 31 Pepp. L. Rev. 4 ( 2004) 2 “Lawsuits filed against litigation lawyers by their clients’ adversaries pri-

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The immunity protection was extended to witnesses in judicial proceedings, based on a theory that “the judicial process is an arena of open conflict, and in virtually every case, there is, if not always a winner, at least one loser. It is inevitable that many of those who lose will pin the blame on…witnesses and will bring suit against them in an effort to relitigate the underlying conflict.”3 The immunity protects statements made in judicial and quasi-judicial proceedings (e.g., arbitration),4 and it applies both to testimony given in proceedings, and to reports, consultations and other support provided in connection with those proceedings.5 The immunity rule is applied in federal court proceedings,6 and in proceedings under state law in Arizona. In Arizona, the policy reason behind the rule was stated as follows: In the area of absolute privileges one of the most common is that involving the participant in judicial proceedings. The socially important interests promoted by the absolute privilege in this area include the fearless prosecution and defense of claims which leads to complete exposure of pertinent information for a tribunal’s disposition…. The privilege protects judges, parties, lawyers, witnesses and jurors. The defense is absolute in that the speaker’s motive, purpose or reasonableness in uttering a false statement do not affect the defense. 7 As reflected in the above quote, the immunity is very broad and “absolute.” Consequently, a witness who gives false testimony is immune from civil liability to the person who is the object of that testimony;8 this is true even if the witness knows the testimony is false, or acts in reckless disregard of the truth or falsity of the testimony. The immunity is available to expert witnesses9 as well as fact witnesses, and it insulates witnesses from liability for all types of civil claims, e.g., defamation, breach of the right of privacy, interference with contract, fraud, and intentional infliction of emotional distress.10

Does “absolute immunity” facilitate false testimony? Given the breadth and depth of the immunity for tesmarily seek vengeance.” Id. 3 Mitchell v Forsyth, 472 US 511 (1985). 4 Advanced Cardiac Specialists, Chartered v Tri-City Cardiology Consultants, P.C., 222 Ariz. 383 (App. 2010) 5 Darragh v. Superior Court, 183 Ariz. 79 (App.1995) 6 Briscoe v. LaHue, 460 U.S. 325, 330-31 (1982). 7 Green Acres Trust v. London, 141 Ariz. 609 (1984). 8 There is a developing body of law that permits lawsuits against “friendly” expert witnesses, i.e., claims brought against expert witnesses by the party that retained the witness. McCahey, JP, Should Expert Witnesses Receive Witness Immunity?, ABA Section of Litigation, Commercial and Business Litigation, Fall, 2006. This type of “witness malpractice” claim is outside the scope of this article. 9 McCahey, fn. 8, supra. 10 T. Leigh Anenson, fn. 1., supra.

Round-up July 2016

timony, some have argued that the application of the immunity to expert witnesses allows those witnesses to “assassinate character for profit.”11 The perception that false expert testimony is offered with impunity may be particularly acute in medical malpractice actions, where expert testimony is almost always necessary.12 Almost invariably, in these cases there are (at least) two expert witnesses, one called by the plaintiff’s attorney and one by the defense attorney; even more invariably, the testimony of each expert witness on direct examination aligns remarkably well with the position of the party that solicited and paid for the expert’s testimony. Is this a remarkable coincidence; an honest difference of opinion between subject matter experts; or, perhaps, the result of false or fraudulent testimony? There is no question that the immunity available to expert and other witnesses has the potential to encourage false or groundless testimony, and to allow witnesses to make statements or engage in activities that can damage litigants, and the litigation system. Sir John Dalberg-Acton famously observed that “absolute power corrupts absolutely.” If that is true, it seems likely that absolute immunity creates a risk that the litigation process can be corrupted. The continued existence of the absolute immunity reflects an awareness of that risk, however, and a determination that the benefits of the immunity outweigh the risks. As a result, a plaintiff’s expert in a malpractice case is insulated from liability for his or her disparaging statements about the physician defendant, “even at the expense of uncompensated harm to [the physician’s] reputation.”13 As a corollary, however, the immunity also provides protection to a defense expert who testifies, in effect, that a claimant is exaggerating or fabricating his or her injuries.

A proposed remedy. Several years ago, there was a movement in Arizona to adopt a statute that would limit the immunity available to witnesses in medical malpractice actions. Basically, the change would have provided immunity only if the witness acted “in good faith and without malice.”14 In theory, it might seem hard to imagine why such a change would be objectionable: why should a witness who testifies in bad faith, or with malice, be immune from liability for that testimony?

Is the remedy worse than the disease? As is the case in all debates about policy issues, the answer is, it depends on your point of view. On the “pro” side, some believe the proposed change would 11 McDowell, CM, Authorizing the Expert Witness to Assassinate Character for Profit: A Reexamination of the Testimonial Immunity of the Expert Witness, 28 U. Mem. L. Rev. 239 (Fall, 1997) 12 Bal, BS, The Expert Witness in Medical Malpractice Litigation, Clin Orthop Relat Res. 2009 Feb; 467(2): 383–391. 13 Green Acres Trust, supra, fn. 7, at 612-13. 14 SB 1453, 2013.

have positive effects, because it would allow anyone who felt that an adverse expert witness’s testimony was offered in bad faith15 or with malice16 to prove that assertion and recover damages if they were able to do so. More broadly, others might feel that the proposed change would have a deterrent effect, instilling caution in prospective witnesses, and giving them a reason to adhere more closely to accepted medical and scientific orthodoxy.17 On the “con” side, allowing dissatisfied litigants to sue their adversaries’ expert witnesses could deter many well-intentioned and highly qualified experts from testifying in litigation.18 Since the elimination of absolute immunity would apply to defense witnesses, as well as plaintiffs’ witnesses, the deterrent effect might make it difficult for defendants’ attorneys

15 Many court decisions and legal articles reference the concepts of “good faith” and “bad faith,” but few seem obligated to provide a meaningful definition of what those terms means. See, e.g., McDowell, CM, supra, at fn. 11, and Advanced Cardiac Specialists, fn. 4, supra. Perhaps good faith, like many other vague and abstract concepts, is in the eye of the beholder. 16 In the traditional defamation context, a defendant’s statements arise from malice when “the defendant makes a statement knowing its falsity or actually entertaining doubts about its truth.” Godbehere v. Phoenix Newspapers, Inc., 162 Ariz. 335 (1989) 17 Interestingly, one commentator has suggested that “the potential of personal liability and the need for liability insurance may deter all but the expert who is a professional witness from accepting an engagement as an expert witness.” McCahey, supra, at fn. 8. Under this view, eliminating the absolute immunity for expert witnesses might dissuade all but the most resolute (and, perhaps, financially motivated) experts from serving as witnesses. 18 Id.

to find qualified experts. One other potential disadvantage to elimination of absolute immunity relates to an aspect of legal procedure. Under the current state of the law, cases against expert witnesses who claim the right to absolute immunity can be dismissed by the trial judge, who decides the issue in the pretrial stage, as “a matter of law.”19 Where the application of the immunity depends on questions relating to good faith or malice, if the claimant can produce any evidence showing that a witness lacked good faith, or acted with malice, the right to immunity becomes a “question of fact,” which must be decided by a jury after a trial on the merits.20 Regardless of the likely outcome of such a trial, few physicians who have been through a jury trial would willingly engage in conduct that would subject them to another one. Consequently, the threat of involvement in litigation could dissuade thoughtful, risk averse physicians from offering well-grounded opinion testimony.

How prevalent is the disease? Before expending time, energy and political capital trying to address the problem of false and unfounded testimony, it might be helpful to consider the incidence and severity of the problem. I have found no data on 19 Green Acres Trust, supra, fn. 7, at 616. 20 Advanced Cardiac Specialists, fn. 4, supra. In this case, the appellate court held that since the plaintiff produced no evidence showing that the defendant had acted in bad faith, or with malice, the case could be dismissed without a trial.

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While horror stories about aberrant jury verdicts get a lot of press coverage, they are the exception, rather than the rule. Jurors are pretty good at separating fact from fiction, and that is one reason why physicians prevail in the vast majority of cases that go to trial. this subject. My only input is from personal experience, which includes twenty plus years representing physician defendants and/or their professional liability insurers. Based on that experience, I believe that testimony that is completely lacking in medical or scientific support is rare. If that experience is consistent with reality, it may be the result of several factors that inhibit the introduction of flawed testimony. One of those factors is economic reality. While horror stories about aberrant jury verdicts get a lot of press coverage, they are the exception, rather than the rule. Jurors are pretty good at separating fact from fiction, and that is one reason why physicians prevail in the vast majority of cases that go to trial. A plaintiff’s attorney who invests the significant sums of money necessary to bring a medical malpractice case to trial cannot expect to profit on a contingency fee case if the case is build on flawed expert testimony. In addition, if an expert’s testimony is sufficiently flawed, trial judges now have greater authority to preclude the jury from hearing the testimony. One rule designed to reduce the introduction of unfounded testimony is statutory: A.R.S. §2-2601, et seq., requires plaintiffs in almost all medical malpractice cases to obtain a supporting affidavit from a qualified expert witness as a condition of filing suit. Another limitation on expert testimony was adopted by the Arizona Supreme Court; in 2010, the Court adopted a rule of evidence that requires trial judges to determine that expert testimony meets certain rigorous standards

Round-up July 2016

before allowing the jury to hear the evidence.21 As a result of these changes and other factors,22 skilled plaintiffs’ attorneys are very discriminating about the cases they take, and few of them want to invest their time and money in cases built on unfounded opinion testimony.

Are there other possible remedies? Another factor physicians should consider in deciding whether to make an effort to eliminate absolute immunity for expert witnesses is the availability of other possible remedies against unfounded testimony. Potential weapons against such testimony include effective cross-examination of such witnesses; contempt or perjury proceedings against the offending witness; and possible licensing board actions.23 Each of these weapons has potential, but the most intriguing and promising mechanism for dealing with unfounded expert testimony comes directly from physicians themselves: the creation of peer review and sanction processes implemented by professional associations. In 1983, the American Association of Neurological Surgeons was the first professional medical association to establish a process for reviewing the expert testimony of its members, and imposing sanctions on those members who offer testimony that violates standards established by the Association. In 2001, the Federal Court of Appeals for the Seventh Circuit upheld the dismissal of a lawsuit filed against AANS by a physician whose membership had been suspended for what the court called “irresponsible testimony.”24 While these professional associations are not immune from liability for the actions they take against their members,25 eighteen other societies have implemented processes for peer reviewing their members’ testimony,26 and courts have permitted the associations to discipline their members as long as the associations “act in good faith27 and do not violate public policy.”28

21 The Court adopted a revised Rule of Evidence, 702, Testimony by Expert Witnesses, which adopted what is called the Daubert standard, which is articulated as follows: “A witness who is qualified as an expert by knowledge, skill, experience, training, or education may testify in the form of an opinion or otherwise if: (a) the expert’s scientific, technical, or other specialized knowledge will help the trier of fact to understand the evidence or to determine a fact in issue; (b) the testimony is based on sufficient facts or data; (c) the testimony is the product of reliable principles and methods; and (d) the expert has reliably applied the principles and methods to the facts of the case.” 22 In addition, these plaintiffs’ attorneys know that many physicians have professional liability insurance policies that allow them to preclude a settlement if the physician believes the case is frivolous. They also know that most of the professional liability insurance carriers vigorously defend frivolous cases, and not so frivolous cases. 23 Bal, BS, fn. 12, supra. 24 Austin v American Association of Neurological Surgeons, 253 F.3d 967 (7th Cir. 2001). 25 Medical societies’ authority to discipline expert witnesses faces challenge, amednews.com, posted June 25, 2012. 26 Bal, BS, fn. 12, supra. 27 There is that undefined phrase again. 28 Bal, BS, fn. 12, supra, citing Turner JA, Going after the ‘‘hired guns’’:

Conclusion. One more thing physicians might consider in deciding whether absolute immunity for expert witnesses is a good thing or bad is the position taken by the one group that always benefits from increased litigation, lawyers. Complaints to licensing authorities are somewhat analogous to expert testimony in professional liability lawsuits, in that in each circumstance, someone is accusing a professional of negligence or other misconduct. While individuals who file complaints against physicians enjoy only a qualified immunity,29 a person who files a Bar complaint against an Arizona attorney enjoys absolute immunity.30 It is interesting that attorneys, who as a group would stand to benefit the most from the increased litigation that might flow from elimination of absolute immunity, and who certainly have nothing to gain by enis improper expert witness testimony unprofessional conduct or the negligent practice of medicine? Pepp L Rev. 2006;33:275–310. 29 Regarding complaints about allopathic physicians, A.R.S. §32-1451 A provides in part as follows: “Any person or entity that reports or provides information to the board in good faith [that phrase again] is not subject to an action for civil damages.” Regarding osteopathic physicians, see A.R.S. §32-1855.03, which also incorporates the “good faith” limitation. 30 Drummond v. Stahl, 127 Ariz. 122 (App. 1980) (“In our opinion, public policy and legal precedent compel us to adopt the position that there is an absolute privilege extended to anyone who files a complaint with the State Bar alleging unethical conduct by an attorney.”)

couraging frivolous Bar complaints, operate in a system in which individuals who make those complaints enjoy complete immunity. It may be that attorneys have concluded that the risk of an occasional frivolous complaint is outweighed by the benefits of the free expression of criticism. If attorneys prefer a system in which unfettered criticism is preferred over increased litigation, physicians might want to consider where their interests lie.

J. ALEXANDER DATTILO J. Alexander Dattilo is an associate in the Phoenix, Arizona law firm of Milligan Lawless, P.C. Alex’s practice focuses on labor and employment, healthcare litigation, and general commercial litigation, including representation of physician practices, individual physicians and other healthcare providers in employment disputes, shareholder disputes, practice breakups and related matters. Alex is a member of the Arizona Association of Health Care Lawyers and the Board of Directors of the Maricopa County Bar Association. He obtained his law degree from the University of Arizona, James E. Rogers College of Law, and is licensed to practice in Arizona and Pennsylvania.

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Round-up July 2016

Better Healthcare at Lower Costs BY SENATOR WILLIAM FRIST, M.D.

am a surgeon. I like to cut, and sew, and fix. I like to keep things simple. So my central organizing thesis is this: Health care delivery today fails because of a massive misallocation of resources toward the goal of a patient’s health. We overuse, underuse, and misuse existing resources. We overuse health services, driven in part by a fee-forservice payment model.

Aspire & A Better Way to Die

First, in America people don’t die the way they want to. They too often die chaotically and uncomfortably, with huge costs to the patient and the system. There are too many hospitalizations, too many trips at 2 AM to the emergency room, too many painful side effects from medicines, too much discomfort.

We misuse our existing resources - doctors, facilities, medicines — by neglecting evidence-based medicine.

But it doesn’t have to be that way. A company named Aspire Health is showing us the way. Two years ago, a group of us founded the palliative care company Aspire Health to strike right at the heart of this end-of-life chaos and waste.

This can be fixed. These are exciting times; we will see more innovation in health service delivery in the next three years than we have in all the history of modern health care delivery.

Aspire took the successful, decade-old model of inpatient, brick-and-mortar palliative care and modernized and transformed it using IT and specialized teams, moving it exclusively to the outpatient and post-acute space.

Let me give two examples, and then toss out a challenge.

Aspire is pioneering the way, taking this new model to national scale, now in 13 states and 36 cities working

We underuse prevention services and techniques.

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with 14 insurers, including many of you in the room. It has definitively given better results for much less cost. How? 1. It focuses on not just physical care, but on emotional, on spiritual, and on mental health as well. 2. It focuses on not just the patient, but the family and caregivers. 3. It delivers care not just with any doctor, but a specially-trained, palliative care doctor and a tightly-knit team of a palliative-trained nurse practitioner, social worker, registered nurse and chaplain.

Access: Aspire patients have 24/7 access to a physician or nurse practitioner. Patients and their families always have someone to call in a crisis. They don’t have to go to the emergency room. Technology: The system is built on powerful IT-managed caregiver workflows, which ensure that the patient always has the right person, at the right place, at the right time. The outcomes speak for themselves. For 12,000 endof-life patients we found: •

Higher satisfaction for both patient and family

It’s highly specialized care — highly individualized for the patient at the end of life — and delivered in the home with intense attention to social determinants and environment.

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Fewer hospitalizations (60% reduction), but more patient contacts in smarter settings (home)

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Round-up July 2016

Today, narrow networks rule the day. Wait times for primary doctors continue to rise. Emergency visits are going up with expanded coverage. And rural hospitals are closing. But today’s technology can radically improve convenient and timely access to expert physicians. Telehealth is one of the few solutions that increases the capacity of the system by improving access to care while driving down costs.

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Imagine for a moment, it’s 10:30 at night and your child is suffering from a high fever or some other nonemergency illness. You either anxiously wait until the next morning to try to track down a doctor (good luck), or more likely you get in a car, drive 45 minutes to the emergency room, wait an hour, see a nurse or doctor in or out of network, and drive back home 5 hours later ending up with a $1400 bill from the hospital! Or… within 10 minutes you reach a board certified doctor by phone or video, licensed in your state, who has an average of 8 years of clinical experience. At a cost of $45 out of pocket. Yes, a full 50% of the more than 1.5 million doctor visits Teladoc has had to date occur on nights, weekends, and holidays, when doctors’ offices are closed, and the ER or Urgent Care Center is the only alternative.

Technology-enabled, remotely-delivered care provides equal outcomes delivered much more quickly and conveniently, yet at much much lower price. The purpose is not to replace the primary care doctor but to fill the gaping holes — to improve access and deliver quality care when and where it is needed for a fraction of the cost. Every payer and system in this room will grow its reliance on telemedicine. Willis Towers Watson says that within a year and a half, over 80% of large employers will offer a telemedicine benefit. How do you decide whom to partner with? First, you must insist upon quality measures. Telemedicine has a low barrier of entry — it can get dumbed down quickly by inferior doctors — but a high barrier to scale. Second, look for high patient engagement. Telehealth is an empty promise without active patient engagement. Without engagement and use by the patient, the value, and cost savings, will never be realized. With the value of telemedicine so obvious, what has been the biggest barrier to more widespread adoption? To date it has been the resistance of some state medical societies who hold on to antiquated models of practice delivery. This is rapidly changing as quality and cost data so powerfully demonstrate the effectiveness and safety of remotely delivered, evidence-based medicine.

The Challenge Imagine yourself in my 12th floor conference room in Nashville across from the park three days ago. 15 people are gathered around the table including the CEOs of the five largest employers in Nashville, the four largest health care companies — big public companies like HCA, Emdeon, Change — and representatives from the more than 120 nonprofits and churches in Nashville who have some interest in improving health. It was the inaugural board meeting of NashvilleHealth, a new, county-wide collaborative that has come together to do a simple thing: Take the aggregate population health measures of Nashville, as reported by the Robert Wood Johnson Foundation — which are poor — and make them the best in the state. And then outperform our peer cities of Charlotte, Austin, Raleigh-Durham, and Cincinnati, all of whom are beating us badly now. Our goal is to create a culture of health, to make the healthy choice the easy choice, and to focus on the social determinants of where and how we learn, live, work, play and pray. Our discussion centered on a real example of how we REALLY improve health. Smoking rates in Tennessee are 23%, which means we have 110,000 smokers in Nashville. If we take that down to the national average of 15% or 70,000, that means we have 40,000 fewer smokers within 5 years. We have the knowledge and the proven tools today to do that. We didn’t five years ago.

WILLIAM FRIST, M.D., SENATOR Senator William Frist, M.D. is a nationally-acclaimed heart and lung transplant surgeon, former U.S. Senate Majority Leader, and chairman of the Executive Board of the health service private equity firm Cressey & Company. He is actively engaged in the business as well as the medical, humanitarian, and philanthropic communities. He is chairman of both Hope Through Healing Hands, which focuses on maternal and child health and global poverty, and SCORE, a statewide collaborative education reform organization that has helped propel Tennessee to prominence as a K12 education reform state.

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Round-up July 2016

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Change for the better? A look at medical education with

Linda Lau, MD

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BY DOMINIQUE PERKINS

e have watched the world of medicine and health care delivery change dramatically over the years. Electronic health records, innovative medical technologies, increased regulations and reporting needs, and the constant struggle for complete compensation have altered the course of physician life in what seems to be a permanent shift. It only makes sense that the way we train up and coming physicians would undergo similar alteration. Our featured physician this month holds a front-row seat to these changes. Linda Lau, MD, is a long-time privately practicing family physician, and recently program director of a residency program in East Mesa. Two resimcmsonline.com/round-up

dents have graduated from the program so far, and both have passed their Board exams and secured jobs after graduating. Round-up had the chance to sit down with Lau and discuss her love of family practice, her experience sharing that love with her residents, and her views on the continually morphing task of training and preparing the next generation of doctors for a medical atmosphere that bears little resemblance to the one so many remember.

The Changing World of Medical Education “Over the last decade, there’s been positive changes in medical school learning due to technology,” Lau said. E-books, Youtube videos on medical procedures, question banks and practice tests for Board preparation, and other web resources have changed the way curriculum is presented, absorbed, and put into practice. Everything is so accessible. There are even 3D anatomy models to aid in visualizing and understanding the body. “One of the nice advantages of being on Midwestern faculty is having access to their library’s website,” Lau said. “They have paid subscriptions to many great resources like Dynamed, Prescriber’s Letter, Up to Date, Visual Dx, Essential Evidence Plus and much more. That itself is enough incentive to sign up and teach students!” 24

Round-up July 2016

Midwestern University is the academic sponsor of Lau’s residency program, and she says they have been amazing to work with, in particular Dr. Shulman and Lilia Wilson. “They are so supportive,” she said. “They are extremely knowledgeable with all the regulations and academic requirements in residency training. They are vital to our program’s success.” Midwestern University also has simulation labs to teach and assess students’ ability with clinical encounters using mock patients. “It’s pretty awesome to see all these developments,” she said. Over the last three years, Lau said they have selected many Midwestern medical students for their residency programs. “They are strong, well-prepared students,” she said. “As residents, their clinical performances are solid; their OMT skills are impressive.

Unifying Accreditation In addition to the modifications in medical education brought about by ever-changing technologies and software programs, residency programs are undergoing a change.

In 2014, the Accreditation Council for Graduate Medical Education (ACGME), American Osteopathic Association (AOA), and American Association of Colleges of Osteopathic Medicine (AACOM) agreed to a single accreditation system for graduate medical programs. This merger will take place over several years, taking full effect in 2020.

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This change will place graduates from allopathic and osteopathic medical schools in unified residency and fellowship programs. “I believe the merger will be a positive change,” Lau said. Consistency and uniformity in training standards, as well as ACGME’s enormous resources and extensive history and experiences will bring a great advantage to training physicians. AOA programs can still maintain their osteopathic distinction so that osteopathic manipulation therapy skills can continue to develop and become proficient during residency. And being able to share best practice and teaching tips is always beneficial. “One thing I’ve learned as a new program director is that you don’t need to reinvent the wheel. Somebody has already done most of the work,” she said. “As clinicians and educators, we can learn from each other and sharpen each other’s skills to make positive and better changes.”

Aiming for Work-Life Balance

With the constantly mounting challenges and requirements today’s physicians are facing, more and more are opting for employment instead of moving into private practice. Many claim that a desire for an easier work-life balance is behind this. “I do sense that young physicians today value a balanced work life,” Lau agrees. “If you look at studies regarding the millennial generation, you will see that they value family, self-development, and jobs that support their passions and interest. Thus, they are more likely to change jobs to align with these values. “In a recent Medscape survey, physicians under 40 were twice as likely to be employed than selfemployed.” While the quest for better balance in work and family life is certainly understandable, Dr. Lau wonders what is being lost along the way. “One of my concerns is that with frequent employment changes and lack of commitment to an organization or medical practice, the longevity of patient relationships will suffer,” she said. “This is one of the most rewarding parts of family practice.”

In the past, privately practicing family physicians would hang their shingle, and then stay put as they built up a base of clients around them. If you don’t stick around long enough in a community, you won’t experience the various seasons of life patients and families go through. “I share this perspective with the residents to help them think through where they choose to practice after they finish residency,” she said. In private practice in particular, studies are showing that patients are increasingly complex, and family physicians need to manage and oversee these patients to ensure safety and quality of care. While some project that the role of mid-levels will expand to replace physicians in some instances, Lau believes that these studies regarding the increasing complexity of family care patients is evidence of the necessity of fully-trained physicians, despite the excellent and compassionate medical care mid-levels can contribute. “Physicians have more education and clinical training,” she said. “I believe that mid-level providers have a role in the patient-centered medical home model. However, I believe it’s the physician that leads the team of healthcare providers.”

The Enduring Role of the Medical Society Maintaining a work-life balance is certainly taxing on both time and energy. With such a struggle, some may wonder if organized medicine still has relevance in an atmosphere of so much competition. Should medical students and trainees get involved in medical societies while still in training? Or are their benefits limited only to actively practicing physicians? While time is certainly a challenge that can seem limiting, Lau feels that taking the time is still worth the effort. “Yes, it’s important to involve students and residents in medical societies,” she said. “Bringing awareness to residents regarding healthcare policies and community needs and activities is important.” In addition to keeping up to date on policy, public health, best practices, and opportunities for community involvement, organized medicine also provides openings for networking, mentorship, and additional training. Being a part of a larger professional collective contributes to higher standards and accountability. “Our residents are involved with Arizona chapter of AAFP and ACOFP,” Lau said.

Following Medicine and Warmer Weather Lau knew at a very young age that she wanted mcmsonline.com/round-up

Grove Family Medical for 15 years.

to be a physician. She always enjoyed science, and sincerely liked helping people. When she was accepted to Union College and Albany Medical’s 7-year accreditation program, it was affirmation of her long-held desire to become a physician.

“Being a family doctor for so many families in the Southeast Valley has been extremely rewarding and invaluable to me,” she said.

Lau graduated Magna Cum Laude with her bachelor’s in 1994, and from Albany Medical College in 1997.

“The trust, the shared stories, the long-term relationships and the appreciation from patients keep me going.”

When selecting her specialty, Lau was drawn to the diversity and versatility of family medicine, and returned home to complete her residency training at Beth Israel Medical Center in New York City. She particularly wanted to work with the poor and underserved.

“This is what I love most about family practice!”

After completing residency, Lau began practice on Staten Island, so that she could be close to home after her first child was born. Lau and her husband are very active outdoors, and had long hoped to move out west where they could take full advantage of enjoyable weather and outdoor activities. Lau and her husband enjoy playing tennis, mountain biking and swimming. “The weather in New York was so unpredictable,” she said. “After 9/11 occurred, we felt it was time to make a change. We saw the growth in Phoenix and were interested.”

Sharing 15 Years in Private Practice Lau has been privately practicing medicine at Desert

For the past three years, Lau has been the program director for a family practice residency at Mountain Vista Medical Center in East Mesa, and has had the opportunity to share her experience with family practice residents. “It’s been a privilege to share my wisdom, medical knowledge, and patient experiences with them,” she said. “They learn from me but I’ve grown so much as well. “ In Arizona, many talk about the physician shortage. And although not all agree, many attribute it to the lack of residency slots in AZ. “The physician shortage in Arizona is one of the reasons why Mountain Vista administration and physicians are committed to teaching and training medical students and residents.” The leadership team consists of Sandy Elcock, Michelle Dinsdale, Drs. Sciortino, Dinsdale, Saddouk, Lopez, and Ruben Ortiz. A lot of hard work has gone into creating and sustaining three residency programs at the hospital. In addition to the family medicine residency program, there is also one for Internal Medicine and Surgery. Previous studies have shown that medical students tend to stay in cities where they complete their residency programs. The more residency programs a city has, the better chance it has of retaining physicians. “Furthermore, I hope the state will offer more incentives to medical students choosing primary care to help with the enormous student loan debts that they accrue.”.

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DOMINIQUE PERKINS Dominique joined Maricopa County Medical Society’s staff in 2014, and is currently serving as the Communications Coordinator. She has a bachelor’s degree in Communications and Journalism, and over 6 years’ experience as a writer, editor, and social media strategist. Dominique also enjoys helping with Society events. Be sure to look for her the next time you attend! Dominique can be reached at dperkins@mcmsonline.com.

MEMBER PROFILE

Dr. Lau | On the Personal Side Describe yourself in one word. Hardworking

What is your favorite food, and favorite restaurant in the Valley? Sushi at Sushiya, Gilbert

What career would you be doing if you weren’t a physician?

Biology Teacher. My biology teacher introduced me to the seven year biomedical program at Union College.

What’s a hidden talent that you have that most wouldn’t know about you? Play the piano

Favorite Arizona sports team (college or pro)?

Used to be the Phoenix Suns but they are not doing so well.

Favorite activity outside of medicine?

Cooking, baking, traveling and being active at my church.

Family?

Happily married for 19 years. My husband owns a sign and printing business. We have 3 growing boys, ages 17, 14 and 10. They like to play basketball. We travel every summer for family vacation and explore new things. My faith and family keeps me from burning out as a physician.

Best movie you’ve seen in the last ten years? The Blind Side

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ALCOHOL ABUSE COMMON AMONG MED STUDENTS, STUDY FINDS B Y H E A LT H D A I LY N E W S

edical students may be more at risk for problem drinking, a new study says, citing burnout and school debt as two possible reasons why.

“Our findings clearly show there is reason for concern,” said study senior author Dr. Liselotte Dyrbye, an internist at the Mayo Clinic in Rochester, Minn. “We recommend institutions pursue a multifaceted solution to address related issues with burnout, the cost of medical education and alcohol abuse,” she said in a Mayo news release. While the study found an association between being a medical student and a higher risk of alcohol problems, it did not prove a cause-and-effect relationship. For the study, the researchers sent surveys to 12,500 medical students in the United States. About one-third responded. The researchers found that about 1,400 medical students reported alcohol abuse or dependence. That’s about a third of medical students who responded. By comparison, about 16 percent of people who aren’t in medical school have an alcohol abuse or dependence problem, the study said. Medical students had twice the rate of alcohol problems as surgeons, physicians and the general public, the study noted.

Round-up July 2016

The researchers found a strong link between burnout factors such as emotional exhaustion and problem drinking among medical students. Other significant factors included: younger age, not being married, and large educational debt, the researchers found. The average cost of medical school rose more than 200 percent from 1995 to 2014, the researchers pointed out. People graduating with a medical degree in 2014 had an average of $180,000 in educational debt, the researchers said. Study first author Eric Jackson, a medical student at Mayo Medical School, said he recommends wellness programs in medical schools. These programs could help identify what’s adding to the stress, as well as help to remove barriers to mental health services, he said. The findings were published online recently in the journal Academic Medicine.

SHOULD DOCTORS-IN-TRAINING WORK FEWER HOURS? BY DHRUV KHULLAR

ospital care is a 24-hour-a-day enterprise, but the question of which doctor should be there — and how long he or she should already have been there — is among the most controversial and unsettled in medicine. It’s a question that comes up almost daily among my peers, and my own feelings about the issue often depend on whether I’m trying to grasp details about a new patient or struggling to stay awake at the end of a very long shift. In 2003, at the genesis of the modern patient safety movement, the Accreditation Council for Graduate Medical Education mandated that residents work no more than 80 hours per week. In 2011, it limited individual shifts for first-year residents to 16 hours. Since then, research has been mixed on whether reducing the length of shifts or total number of hours worked has improved resident health, medical education or

patient outcomes. This year, two large national trials, known as iCompare and First, aim to shed new light on the issue. Researchers randomized first-year residents at internal medicine or general surgery programs across the country to work either 16-hour shifts, the current maximum, or longer shifts of 28 hours or more. Shortly after the iCompare trial began, two advocacy groups sent an open letter to the Office for Human Research Protections, calling the trial “unethical” and arguing that it exposes patients to dangerously sleep-deprived residents while exposing residents to a greater risk of car accidents, needlestick injuries and depression. These trials come at a critical time, amid mounting evidence of serious mental health concerns for medical trainees. A recent study found that almost one-third of mcmsonline.com/round-up

residents exhibit symptoms of depression; other studies show that almost 10% of fourth-year medical students and 5% of first-year residents admitted to having suicidal thoughts in the previous two weeks — with higher rates among minorities. And yet, it’s not clear whether more restrictive work hours will make things better for residents or patients. When residents work fewer hours, there are more patient “handoffs” — when a patient is transferred from one doctor to another. The process makes it more likely that important details are overlooked, and intimate familiarity with a patient’s recent clinical course is often left behind. And residents may not even be reporting their hours accurately. Whistleblower protections are lacking, and the penalty for work hour violations is loss of program accreditation, which could hurt the resident reporting the problem. In the face of uncertainty, we need more data — and we’re starting to get it. Results from the First trial, published on Tuesday, Feb. 2, found no significant differences in patient outcomes, resident satisfaction or educational quality when surgical trainees worked longer shifts. (Results from iCompare, which is looking at internal medicine residents, are expected in June.) But I worry about how to interpret the results of trials like these, and what positive or negative findings may mean for residency training discussions going forward. In a profession driven by evidence, data is useful. But

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it’s important to recognize data’s limitations. Many patient-care metrics we use to evaluate the impact of duty hour restrictions — mortality, procedural complications, adverse events, readmission rates — are crude. They might make sense for hospitals and health systems designed to increase efficiency and insulate patients from human fallibility. But they fail to capture the nuances of care delivered at the doctor-patient level. Good patient care is about more than surgical infection rates and medication errors. At the end of a long shift, am I the kind of doctor — and person — I want to be? Do I make time to sit with a suffering patient? Do I snap at a well-meaning colleague? Well-being is similarly difficult to study. Research suggests that one’s judgment of happiness and life satisfaction is surprisingly fickle. For example, people interviewed on sunny days report being more satisfied with their entire lives than those interviewed on rainy days. So if you ask me about my training program after a particularly bad 16-hour shift, I’m likely to rate it worse than during a particularly good 30-hour shift. Medical educators also worry that work hour restrictions force residents to see fewer patients and miss important educational experiences. At the same time, we allow residents to spend hours scheduling appointments, faxing medical records, gathering vital signs, obtaining prior authorization, and completing many other nonclinical tasks. We don’t learn to do these tasks in medical school; we shouldn’t be spending our time on them as residents. If we’re concerned about resident education, let’s focus on increasing quality time spent on direct patient care and educational activities. The right answer on how many hours residents should work may be more nuanced than we’ve been willing to accept. It isn’t the same today as it was 20 years ago, as the complexity of caring for patients and medical technology continue to evolve. It varies by subspecialty — discontinuity may have graver consequences for neurosurgery, say, than for radiology. And it hinges more on the character of work than the length of it — I’d spend twice as long at a patient’s bedside if I could spend half as long at a computer. Ultimately, the answer may be as philosophical as it is empirical. What kind of doctors do we want to be? What kind of doctors do patients want us to be? And does what we can’t measure still matter in a profession that’s now judged and motivated by what we can?

DHRUV KHULLAR Dhruv Khullar is a resident physician at Massachusetts General Hospital and Harvard Medical school.

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COLLEGE KIDS, WITH KIDS BY JAMIE MERISOTIS AND ANNE MARIE SLAUGHTER

n the last year or so, dozens of employers — from the Navy to Goldman Sachs — have begun offering or expanding benefits like paid family leave and job-sharing that enable parents to better balance work with family life. Slowly, America’s famously family-unfriendly workplace might finally be improving. But the only employees who really stand to benefit are white-collar ones. Since the 1960s, paid parental leave increased nearly five times for workers with a college degree, but it has only doubled for those with just a high school degree.

ing parents getting these quality jobs: a college degree. And colleges are doing far too little to help them.

There’s one big obstacle standing in the way of work-

Nearly half of student-parents attend community col-

There are 4.8 million undergraduates raising children — one-fourth of all postsecondary students. But more than half of these student-parents leave college without finishing after six years. Their lack of a degree essentially locks them out of jobs with benefits like on-site child care, paid leave and telecommuting that make it possible to be effective workers and parents.

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leges, and a quarter of them enroll at for-profit institutions. Some are lured to these institutions by their flexibility and affordability, but too many colleges fail to provide the support students need to graduate. The same is true for many at traditional four-year institutions. Kim Mitchell of Mantua, New Jersey, dropped out of college twice because it was impossible to balance schoolwork with a demanding software-trainer job and her role as lead parent to two children. “Your free time is your family time,” Ms. Mitchell, 46, said. “As a working mom, you feel guilty giving up any of that time with your little ones.” When her kids were teenagers, she enrolled for a final time in an online program. She completed her bachelor’s in 2014 and her master’s in June but now faces another challenge: paying off $47,000 in student loans while footing the bill for her kids’ college tuition. To make sure more student-parents complete their degrees when they first enroll, we must better meet their needs. This means ensuring they have adequate financial resources. Nearly six in 10 student-parents live at or below 200 percent of the federal poverty line — $48,600 a year for a family of four. A setback such as a broken-down car can make it all but impossible to work, attend school and provide child care. Hillary Clinton has proposed awarding up to a million stu-

dent-parents $1,500 per year for expenses like child care and transportation. This would help, but other changes are needed. Allowing students to receive aid in regular installments over the course of the school year — much as they would a paycheck — rather than up front enables parents to better manage the myriad expenses they face. And offering a small amount of support for unexpected expenses midyear — so-called emergency aid — would also help. Student-parents also need on-campus child care. Half of public four-year institutions and 45 percent of community colleges provide it, but those percentages have declined since 2003. This drop is driven partly by state and federal budget cuts for programs that support on-campus child care. Funding for one such federal program, Child Care Access Means Parents in School, decreased to an estimated $15 million in 2015 from $25 million in 2001. For Melissa Maher, a 43-year-old mother of three schoolage children in Bartlett, Tennessee, having school-break schedules that are misaligned with her children’s K-12 calendar adds to the costs that she and her husband face. This is one reason flexible alternatives to brick-and-mortar institutions are so important. Many of these programs track progress toward a degree not by time spent in classrooms, measured by credit hours, but by students’ actual learning, measured by competency or mastery. Institutions like Brandman University and Empire State College allow students to learn online, in-person or through a mix. (Full disclosure: Lumina Foundation, run by one of the writers, has given grant money to programs at these schools.) Schools that offer such competency-based online courses have to go through a complicated regulatory process for their students to receive federal financial aid. We need to streamline this process to make it easier for aid recipients to attend these flexible programs.

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By making these changes, we can help student-parents improve their prospects and our economy. Over the next decade, two-thirds of all jobs in the United States will require education beyond high school, yet only 45 percent of Americans have a degree or certificate — a gap we must fill to remain competitive. There’s perhaps never been greater momentum to establish a better work-life equilibrium in America. Just as we pressure employers to improve their benefits, we need to pressure colleges to help student parents succeed. JAMIE MERISOTIS Jamie Merisotis, the president of Lumina Foundation, is the author of “America Needs Talent: Attracting, Educating and Deploying the 21st-Century Workforce.”

ANNE-MARIE SLAUGHTER Anne-Marie Slaughter, the president of New America, is the author of “Unfinished Business: Women, Men, Work, Family.” © 2016 The New York Times. Distributed by The New York Times Syndicate.

Top 11 Ways Physicians Can Get the Most Out of CME on a Budget BY JANET KIDD STEWART

ontinuing education is taking on greater importance amid new quality measures, but it comes at a time when practices already are having to budget for pricey new electronic health record and technical upgrades called for under health reform. Getting the most bang for the buck when it comes to continuing medical education (CME) is critical. The pressures on physicians go beyond just keeping up with the pace of knowledge expansion. New requirements to demonstrate quality of care that can be documented and quantified, observers say, further drives up demand for CME. With the movement from volume to value it has become imperative for physicians to perform at a higher level, and CME will become even more important, says Michael Romano, MD, chief medical officer for Nebraska Health Network, a health system with 1,300 providers. Romano last year won an award from the Accreditation Council for Continuing Medical Education (ACCME) for his work on broad CME initiatives that

improved physician performance and patient care. In a 2011 paper for the American Clinical and Climatological Association, Peter Densen, MD, a professor at the University of Iowa, discussed estimates that the doubling time of medical knowledge fell from 50 years in 1950 to 3.5 years in 2010, with a forecast of just 73 days by 2020. Knowledge is expanding faster than our ability to assimilate and apply it effectively, Densen wrote. Clearly, simply adding more material and/or time to the curriculum will not be an effective coping strategy â&#x20AC;?fundamental change has become an imperative.â&#x20AC;?

1. New CME Can Be Lower Cost.

The good news from a financial perspective, say physicians and other CME experts: Some of the most effective learning opportunities are coming from lower cost, informal and often online channels. And even in the live world of medical conferences, there are ways to stretch a CME budget. mcmsonline.com/round-up

Rather than simply attending a specialty society’s annual conference, more physicians are participating in local, informal case presentations and online learning. When people used to say CME, “I would think of lecture halls, dark rooms and a sage on the stage, much the way I was educated in medical school, says Graham McMahon, MD, an internist and president and chief executive officer of ACCME in Chicago. “Now that’s anachronistic and there’s such a variety of approaches that are more engaging, interesting and accessible.” “Hospitals are boosting investments in continuing education as a way to satisfy quality initiatives, and physicians themselves are attending a much broader array of programming than they did even just a few years ago,” McMahon says. Rather than simply attending a specialty society’s annual conference, more physicians are participating in local, informal case presentations and online learning.

panies and healthcare industry entities. “It’s easier to sit in a chair and view slides than to engage in proactive case studies or learning groups,” he says. For some applications, however, newer and often cheaper methods can work better. The trick, experts say, is choosing which method is best for each continuing education opportunity.

3. Avoid Credit Shopping.

When training budgets are tight, it’s tempting to choose a CME course by picking the lowest-cost course per credit hour. Experts urge physicians to think about the actual value a given course generates, however. “The key to stretching the CME dollar is to be much more deliberative about choosing courses,” McMahon says. He recommends physicians avoid credit shopping, or basing course selection on the lowest cost per credit hour delivered. Instead, think about the ongoing education benefits of any CME opportunity. Repeated engagement with a subject over time can often drive much higher performance improvements than traditional one-off didactic lecture sessions, experts say.

4. Find the Gaps.

Another way to stretch the CME dollar is through self-assessment tools, typically online through individual specialty associations that can identify the most critical areas physicians need to improve. In other words, physicians should skip CME programs that simply reinforce knowledge they already have. “You want to identify gaps in yourself and then search for activities that plug that gap,” McMahon says.

2. Get Involved.

Finding true knowledge gaps can be tricky, however. While board certification exams often give physicians feedback on what questions were missed, for example, the length of time between exams (often a decade) make them impractical as an ongoing learning guide, notes Elizabeth Grace, MD, medical director for the Center for Personalized Education for Physicians in Denver, Colorado, which offers re-entry programs for physicians coming back to practice after a hiatus and those who have been placed in performance improvement programs. In addition, CME credit courses will often have a pre-test, but that is to demonstrate before-and-after knowledge on a very narrow topic, she says.

“My sense is that physicians really enjoy going to meetings for the social aspects,”says Daniel Carlat, MD, a psychiatrist in Newburyport, Massachusetts, and publisher of the Carlat CME Institute, which advocates for CME that is free of conflicts of interest from drug com-

Physicians are sometimes blind to the gaps in their own knowledge and skill base, she says. And the more deficient a physician is, the less likely he is to know he needs help. Physicians tend to choose CME programs that focus on content they already like and feel comfortable with, as opposed to where they see a real need, she says. However, that will change as more medical associations develop programs to assist with quality-based practice measures, she said.

“The currency of education today is not necessarily information exchange, but getting together to problem solve, develop cognitive skills or learn a specific new technique in a hands-on way,” McMahon says. “Rather than going back to the same conference every year, physicians are thinking about a specific skill they need to develop this year, and finding that activity or course that delivers that,” McMahon says. Clearly, lecture-style education taught at live conferences still has its place. Imparting new research information quickly is better suited to more didactic teaching styles, for example, and informal learning through face-to-face interaction with colleagues is still valuable, experts say.

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Competency-based education, with defined benchmarks for skill development, will make it easier for physicians to inventory their strengths and work on weaknesses, she says. She advocates educational programs that address topics of importance to physicians’ patient populations as a way to acquire skills that can be immediately put to use in practices and demonstrate value to payers.

5. Don’t Go All-In for Online.

Online education can certainly save costs on airfare, hotels and restaurants and evidence suggests younger physicians tend to prefer online to live meetings anyway but having the ability to engage in impromptu conversations around the buffet line can’t be overlooked as a way to boost the perceived value of attending a conference. “You want to balance online with peer learning,” McMahon says. “Both are valuable to a physician’s life-long education,” he says. The face-to-face interaction with colleagues from within a given specialty is still critical, and can help alleviate pent-up career stress, which can in turn prolong careers, says Romano, a family physician also certified in hospice and palliative care. What gets lost in the conversation [about online alternatives and budget shortfalls] is the collegial interaction with colleagues from the same specialty, and that’s a very important part of these activities. “As we deal with physician burnout, the ability to take a week, go to a vacation spot and unwind for a week is really helpful in avoiding some of these burnout issues, he says. That’s an investment worth making, he says.

6. One for the Team.

Increasingly, experts say, physicians are evaluating CME as it relates to an overall practice. Some of the newest courses, for example, involve teams of nurses, physician assistants, pharmacy professionals and doctors. Coursework centers on, among other things, how to function better as professionals. “This one will take awhile to develop, but everyone recognizes this is important,” Romano says. “More gatherings will begin to include the entire team.”

7. Skip the Conflicts.

There can be some sticker shock involved with maintenance of certification, so anytime you can make it do double-duty, that’s good. have dovetailed their offerings to serve both goals, experts say. “There can be some sticker shock involved with maintenance of certification, so anytime you can make it do double-duty, that’s good,” he says. The American Board of Internal Medicine and ACCME inked a deal in 2015 to streamline the process for using approved CME coursework as part of the MOC process. (A list of joint programs can be found at bit.ly/ABIM-ACCME-courses.) As part of that agreement, accredited CME providers can use a single, shared system for registering CME and MOC activities, among other areas of interoperability, the groups say. Another example is thinking about leveraging CME as a career advancement tool. “In talking with hospital CEOs about the value of CME, one thing we recognized is that CME is rarely used strategically,” says John Combes, MD, an internist and chief medical officer for the American Hospital Association. “There’ss a need to develop physician leaders and this is an activity to engage physicians and also get a benefit to organizations,” he says. In a 2014 report, “Continuing Education as a Strategic Resource,” the association said hospital-provided CME programs account for nearly 40% of credit hours offered. The report urged hospital associations to promote partnerships with medical societies and others on CME, another way to stretch dollars a practice commits to education.

Carlat advocates skipping conferences that are labeled as CME but are sponsored by drug or device makers, though industry-funded CME is rarer today than it was a few years ago, he says.

The association also advocates more accommodative policies on accepting project work and other non-traditional activities as CME, another form of double dipping that can lower overall CME costs for a given practice.

“A lower percentage of CME is financed by corporations, but it’s still an issue,” he says. Commercial funding accounted for 25% of CME investment in 2014, down from 37% in 2010, according to ACCME.

Replacing time-based credit with performance-based CME should be a key part of adapting new learning methods into physicians’ ongoing training, the report concludes, while acknowledging some practitioners’ concerns about loosening CME guidelines too much.

8. Double Dip.

Carlat also suggests taking advantage of CME that can also serve as part of a physician’s maintenance of certification (MOC) requirements. Increasingly, CME providers

9. Think Outcomes.

Looking forward, be aware that increasingly, CME may be measured more by outcomes than credit hours. As mcmsonline.com/round-up

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less formal gatherings for skill development become more popular, look for newer ways of measuring continuing education, experts say. “How do you quantify the learning that happens in these less formal engagements? We used to sign up for an activity, fill out an application and collect documentation of attendance. Now education is happening on the fly and it’s difficult to quantify,” Romano says. Looking at outcomes may be the best indicator, he says, though he acknowledges the dilemma that some outcomes measures take many years to come to fruition. Performance-based measures after CME occasion’s tracking, for example, a physician’s ordering of mammograms for over-50 patients is easier to quantify over a shorter period of time, he says. And practices can measure evidence-based processes of care that should result in good final outcomes, he says, such as physicians’ performance on keeping diabetic patients blood pressure and cholesterol under control.

10. Leverage Colleagues.

Joining with a few other local practices to tackle issues in a similar format to a grand rounds or a cancer care team review is another way to promote learning in a lower-cost environment. “The thing we found most useful is gathering physicians around one table to talk about activities,” Romano says. Physicians informally sharing opinions on treatment plans and discussing clinical cases are the most effective ways of learning, he says. “When you get a group together to talk about patient care, patients definitely benefit. The sharing of the clinical experience is one of the more powerful ways to do education, not to mention the cost savings involved when you can bring a larger group together to lower the administrative costs of the meeting,” he says. This can be done even in a more traditional, didactic conference environment, says McMahon. To boost the take-away value of these sessions, he says, consider digging in when a presenter pauses a lecture and asks the audience to pause and think of a case that relates to the topic, says McMahon. Those are great opportunities to turn to a peer and ask how they handled a case, he says.

When you get a group together to talk about patient care, patients definitely benefit. being able to ask about the subtleties among clinical colleagues.” He does expect nearly weeklong, multi-faceted meetings to constrict down to smaller workshop sessions targeted to engaging physicians on areas of specific expertise. Already, he says, physicians can extend the value of these sessions by being accountable for their own engagement. Asking questions at the end of presentations and sending follow-up emails to presenters after a conference with more detailed questions are all ways to boost what physicians take away, he says. “I’ve had attendees write me about specific patients after a conference where I have presented and have gladly and happily gotten back to them,” he says.

11. Go Outside the Norm.

“It’s important, also, to look for expertise at conferences that brings in knowledge that is a bit outside a physician’s core specialty,” Dorman says. “It might mean reaching out for activities that might be put on by other specialists. A pulmonologist might identify a weakness in expertise in certain aspects of kidney disease, for example, so maybe once every few years he might look for a session on that,” he says. The jury is in on CME in general, Dorman says, noting that CME has proven its value in moving the profession forward. But the issues involving how physicians can learn more and get increased value out of each opportunity are still on the table, he says. The present question is, “Can we learn more about which methods are cost effective under which circumstances? And, how can we be more effective?”

“It creates opportunities to become more self-aware and to be honest about not knowing an answer or struggling with a difficult issue,” he says, another way to get more value out of a conference rather than simply absorbing presented information. Traditional, presentation-based conferences still have value, argues Todd Dorman, MD, FCCM, associate dean for continuing medical education at Johns Hopkins University School of Medicine. Didactic education shouldn’t be seen as weak cousin, he says. “There’s still a role for live meetings because they provide networking, interacting with experts and

JANET KIDD STEWART Janet Kidd Stewart is a nationally syndicated columnist and freelance business writer. She regularly lends her deep understand of healthcare topics to contribute to Medical Economics regarding practice managements issues.

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Social Media and the Patient-Physician Relationship The Maricopa County Medical Society has teamed up with long-time supporter MICA Foundation to co-sponsor a scholarship for local medical students to write about emerging topics in healthcare. Thomas Esposito is our second of four total essay winners who will receive a $2,500 reward. BY: HIMAJA GADDIPATI

n 2014, a mysterious disease was responsible for a plight of deaths. Silently spreading on the borders of West Africa, the virus, later identified as Ebola, created panic all over the world. Between September 16th and October 6th, the word â&#x20AC;&#x153;Ebolaâ&#x20AC;? was tweeted

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10.5 million times [24]. Physicians worked to alleviate the communal frenzy by directing the Twitter community towards information published by the Center for Disease Control and Prevention (CDC) and sharing informative web links. U.S physicians tweeted about Ebo-

Student Essay la an average of 9.37 times, while the average user was found to tweet only 2.98 times. Interestingly, the social media trends of Ebola did not mimic virus outcomes. As the death toll rose, Ebola-related Twitter traffic declined. However, physicians maintained their social media presence well after public interest waned. In an effort to curb misinformation, the dialogue continued to highlight the medical community’s ability to manage this disease [2] [23]. This recent trend of events exemplifies the evolving role of physicians in the digital age. Widespread use of social media grants physicians with real-time access to community perceptions of disease. With this in hand, they are endowed with the responsibility of educating the masses, combating misinformation, and facilitating appropriate health behavior changes. Although the exact way this should be accomplished remains ambiguous, the differences in Twitter usage during the recent Ebola outbreak between the general community and physicians suggests a promising start. Spreading credible information, debunking myths, and alleviating fear are not novel goals. However, social media is reinventing the way this is achieved. By interacting on an open platform, we are placing physicians on equal ground with the community and fostering a more amiable patient-physician relationship. In doing so, we are creating a fundamental shift in the way patients and physicians are interacting at large. For decades, the traditional patient-physician model has followed a hierarchy. Rooted in a power differential defined by status and knowledge, healthcare delivery has followed a dominant physician, passive patient model. But even before the advent of social media, patients fared better when physicians promoted a more equitable partnership [17]. Patient activation, defined as the skills, knowledge and confidence that equips patients to become actively engaged in their health, is related to better health outcomes [16]. Patient activation is higher when patients feel they are engaging in a high quality interpersonal conversation and believe they are being treated fairly during the treatment process. Patient activation is also improved when physicians provide more support and contact outside of the office visit [1]. Social media has the potential to amplify these effects in a more efficient manner. With open access to infor-

mation, patients can now become empowered even before the doctor’s visit. An informed patient can facilitate a higher quality exchange of information as it allows the physician to focus their time on discussing treatment options, answering questions, and filling in gaps of knowledge. This is especially beneficial for patients with chronic illness or diseases that are more difficult to manage. By preemptively educating themselves, these patients experience a priming effect and are likely to have a better behavioral response to more complex or invasive procedures [13]. Today, many patients prefer a shared and participatory medical decision making process [6]; and physicians largely agree. Seventy-five percent of U.S physicians preferred a shared decision making process and did not feel that an informed patient was obtrusive [22]. Additionally, in about 50% of prescriptions written, patient input was considered. However, the ultimate prescribing behaviors of physicians did not change based on whether the patient was informed or not, suggesting that quality of care is not being compromised with patient input [21]. Although the informed patient can improve the patient-physician interaction, a misinformed patient could have a more profound negative effect. Peer-topeer healthcare is a growing source for patient support and information. In a 2011 survey, 23% of adults with a chronic illness and 15% of people without chronic illness reported going online to connect with someone with the same ailment [12]. This is not particularly new behavior, as conversations beginning with “my neighbor also experienced XYZ symptoms…” have always occurred during an office visit. Similarly, people with no medical training have often solicited medical advice to friends [25]. However, anecdotal advice now has the potential to spread faster and to a wider net of people. With the innumerable amount of blogs, forums, and websites, physicians often lag behind in these conversations [21]. When a patient approaches a physician expecting them to interpret this material, extra time must be invested to fully educate the patient. Additionally, the patient-physician relationship may be strained when a physician refuses a request for an inappropriate treatment. Physicians may feel that their authority is being questioned, while patients may feel they are being treated unfairly. These opinions in turn get promoted on forums where physician bashing is often the norm [25], creating a vicious cycle of ill suggestions.

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At its core, social media is a people-oriented platform, and so is medicine. Social media has the potential to demolish barriers and connect physicians with a wider demographic of patients. Perhaps the biggest challenge, however, is honoring what is arguably the crux of the patient-physician relationship: patient confidentiality. A study found that four-fifths of physicians and medical students were concerned about maintaining patient privacy on social networks, and were in wide disagreement about what is appropriate to post [8]. When asked if they thought social media could improve the patient-physician relationship, about 50% of respondents thought it could improve communication while the other 50% thought otherwise [4]. With no favorability in either direction, the social media pendulum could still swing either way. There is also wide disagreement on the etiquette of Facebook use with patients. Physicians practicing in primary care fields, such as family medicine, pediatrics, psychiatry and OBGYN, receive more friend requests from patients than physicians of other specialties. A majority of physicians did not think it was ethically appropriate to accept friend requests with a top concern being maintaining confidentiality. However, primary care physicians are also more likely to look up patients on Facebook [4] [14]. One case study describes how Facebook was used to contact a family member of a severely delirious patient [3]. While this yielded a positive outcome, it is still unclear whether this is ethically acceptable. 40

Round-up July 2016

Social media platforms are blurring professional and personal boundaries. But at this point in time, it is difficult to definitively delineate whether it is enhancing or hindering the patient-physician relationship. In the late 90s and early 2000s, the medical community had a similar discussion about email. While the convenience appealed to many, the volume of emails, and concerns of patient confidentiality clouded the true value of its utility [20]. By the mid-2000s, however, email etiquette became solidified and firewalls to protect patient privacy were established in hospitals everywhere. Now, email is widely accepted to be enhancing patient-physician communication [19]. In a similar vein, several recent studies support the use of texting between provider and patient to improve a variety of health outcomes [15] [11]. However, because standard text messages are not HIPAA compliant, secure messaging solutions, such as the Doc Halo app [10], are emerging. Social media is next on our agenda. Guidelines for social media use are already emerging in the literature [5] [9] [18], suggesting that we will be making similar progress. Although few concrete solutions currently exist, the general professional consensus acknowledges that social media use will only increase, and physicians must get involved in order to bend the curve towards benefiting their patients. At its core, social media is a people-oriented platform, and so is medicine. Social media has the potential to demolish barriers and connect physicians with a wider demographic of patients. As a worldwide community, we have already exemplified several positive trends of social media use. From the optimization of email in the workplace to the responsible use of Twitter during the Ebola epidemic, we have already shown evidence of being able to use technology productively. Based on these advances, we can anticipate the utility of social media platforms to become increasingly clear, and ultimately enhance the patient-physician relationship.

References

[1] Alexander, J. A., Hearld, L. R., Mittler, J. N., & Harvey, J. (2012). Patient-physician role relationships and patient activation among individuals with chronic illness. Health Serv Res, 47(3 Pt 1), 1201-1223. doi: 10.1111/j.1475-6773.2011.01354.x

Student Essay [2] Allen H. Ebola and the viral spread of information. http://www. bodyinmind.org/ebola-viral-spread-information/ Published November 4, 2014. Accessed February 28, 2016. [3] Ben-Yakov, M., & Snider, C. (2011). How Facebook saved our day! Acad Emerg Med, 18(11), 1217-1219. doi: 10.1111/j.15532712.2011.01199.x [4] Bosslet, G. T., Torke, A. M., Hickman, S. E., Terry, C. L., & Helft, P. R. (2011). The patient-doctor relationship and online social networks: results of a national survey. J Gen Intern Med, 26(10), 11681174. doi: 10.1007/s11606-011-1761-2 [5] Chauhan, Bindiya, & Janis Coffin DO, FAAFP. (2012). Social media and you: what every physician needs to know. The Journal of medical practice management: MPM, 28(3), 206. [6] Chewning, B., Bylund, C. L., Shah, B., Arora, N. K., Gueguen, J. A., & Makoul, G. (2012). Patient preferences for shared decisions: a systematic review. Patient Educ Couns, 86(1), 9-18. doi: 10.1016/j. pec.2011.02.004 [7] Chretien, K. C., & Kind, T. (2013). Social media and clinical care: ethical, professional, and social implications. Circulation, 127(13), 1413-1421. doi: 10.1161/CIRCULATIONAHA.112.128017 [8] Colbert, J. A., & Lehmann, L. S. (2015). Partnering with patients to realize the benefits of social media. Am J Obstet Gynecol, 212(3), 302-303, 302 e301. doi: 10.1016/j.ajog.2014.12.014 [9] Dauwe, P., Heller, J. B., Unger, J. G., Graham, D., & Rohrich, R. J. (2012). Social networks uncovered: 10 tips every plastic surgeon should know. Aesthet Surg J, 32(8), 1010-1015. doi: 10.1177/1090820X12462027 [10] Doc Halo app https://www.dochalo.com/ [11] Fischer, Henry H, Moore, Susan L, Ginosar, David, Davidson, Arthur J, Rice-Peterson, Cecilia M, Durfee, Michael J, . . . Steele, Andrew W. (2012). Care by cell phone: text messaging for chronic disease management. The American journal of managed care, 18(2), e42-47.

ijsu.2006.01.005 [18] Kind, T., Patel, P. D., Lie, D., & Chretien, K. C. (2014). Twelve tips for using social media as a medical educator. Med Teach, 36(4), 284-290. doi: 10.3109/0142159X.2013.852167 [19] Leong, Shou Ling, Gingrich, Dennis, Lewis, Peter R, Mauger, David T, & George, John H. (2005). Enhancing doctor-patient communication using email: a pilot study. The Journal of the American Board of Family Practice, 18(3), 180-188. [20] Lewis, M. A., & Dicker, A. P. (2015). Social Media and Oncology: The Past, Present, and Future of Electronic Communication Between Physician and Patient. Semin Oncol, 42(5), 764-771. doi: 10.1053/j. seminoncol.2015.07.005 [21] Moick, Martina, & Terlutter, Ralf. (2011). Physicians’ motives for professional internet use and differences in attitudes toward the internet-informed patient, physician-patient communication, and prescribing behavior. Medicine 2.0, 1(2), e2-e2. [22] Murray, E., Pollack, L., White, M., & Lo, B. (2007). Clinical decision-making: physicians’ preferences and experiences. BMC Fam Pract, 8, 10. doi: 10.1186/1471-2296-8-10 [23] Satterthwaite B. Physicians Turn to Social Media to Calm Ebola Frenzy http://mdigitallife.com/tag/social-media-insights/ Published October 27th, 2014. Accessed February 28, 2016. [24] Stone A. This Map Shows How Discussion of Ebola is Spreading. The Huffington Post. http://www.huffingtonpost.com/2014/10/08/ebola-spread-across-twitter_n_5947570.html Published October 8, 2014. Accessed February 28, 2016. [25] Yunker, A. C. (2015). Intrusion of Social Media into the Patient-Physician Relationship. J Minim Invasive Gynecol. doi: 10.1016/j. jmig.2015.11.014

[12] Fox S. Peer-to-peer healthcare. Pew Internet & American Life Project. http://pewinternet.org/Reports/2011/P2PHealthcare.aspx Published February 28, 2011. Accessed February 28, 2016 [13] Gerber, Ben S., & Eiser, Arnold R. (2001). The Patient-Physician Relationship in the Internet Age: Future Prospects and the Research Agenda. Journal of Medical Internet Research, 3(2), e15. doi: 10.2196/ jmir.3.2.e15 [14] Ginory, Almari, Sabatier, Laura Mayol, & Eth, Spencer. (2012). Addressing therapeutic boundaries in social networking. Psychiatry, 75(1), 40-48. [15] Hall, A. K., Cole-Lewis, H., & Bernhardt, J. M. (2015). Mobile text messaging for health: a systematic review of reviews. Annu Rev Public Health, 36, 393-415. doi: 10.1146/annurev-publhealth-031914-122855 [16] Hibbard, J. H., & Greene, J. (2013). What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. Health Aff (Millwood), 32(2), 207-214. doi: 10.1377/ hlthaff.2012.1061 [17] Kaba, R., & Sooriakumaran, P. (2007). The evolution of the doctor-patient relationship. Int J Surg, 5(1), 57-65. doi: 10.1016/j.

HIMAJA GADDIPATI Hima is currently a second year medical student at Midwestern University. She completed her undergraduate degree in Neuroscience at UCLA, and holds a Master’s degree in Cancer and Reproductive Biology from Johns Hopkins University. She has a strong interest in public health initiatives, and hopes to serve disadvantaged communities globally in future years.

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In Memoriam Richard A. Snider, MD Richard A Snider, MD, 71, of Sun Lakes, AZ passed away on July 10, 2016. He was born in Toledo, Ohio to Ruth Roper Snider and John Wrede Snider.

THIS ISSUEâ&#x20AC;&#x2122;S ADVERTISERS COX Business................................................................ 2 Plaza Companies ......................................................... 3

He is survived by his beloved wife of 35 years, Sharon, daughters: Merideth R Hamilton (Mike); Andrea B Cook (Tim); Erin Hartman (Aaron); stepdaughter, Lori J Hinojosa (Rudy); stepson Ron Leth and 10 wonderful grandchildren. He also is survived by two sisters from Toledo: SuAnn Snider and Katherine Stover and half-sister Debby Hartman from Phoenix.

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He was preceded in death by his brother, John T Snider.

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He was so proud of his family and loved his children and grandchildren so much. His children and family will miss his caring ways and his smile. He especially loved going on cruises with family. He also enjoyed fishing and golfing.

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Dick was a graduate of DeVilbiss High School in Toledo, Ohio and earned his BS from Earlham College in Indiana. He then went on to The Ohio State University Medical School and received his MD in Internal Medicine.

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As a young man he was always kind and caring and that never changed throughout his life. Dick had a 12 year medical practice in Maumee, Ohio before falling in love with Arizona and starting his medical practice in Ahwatukee, Phoenix in 1986. Throughout his 35 years of medical practice he was on numerous hospital committees and boards. He loved his patients and was dedicated to giving them the best care possible. Dickâ&#x20AC;&#x2122;s Family wishes to thank the caregivers and care home for their wonderful caring treatment of him in the last stages of his life.

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