Michigan Medicine, Volume 115, No. 3 by Michigan State Medical Society

A W A R D - W I N N I N G

M A G A Z I N E

O F

T H E

M I C H I G A N

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M E D I C A L

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www.msms.org

May / June 2016 • Volume 115 • No. 3

Tough Conversations ALSO IN THIS ISSUE • Covenant-Not-To-Compete Issues in Employment Contracts: 8

• STOP-THINK-CONNECT: Preventing Ransomware Attacks: 12

• Enhancing Communication Improves Patient Satisfaction and Reduces Risks: 26

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Chief Executive Officer JULIE L. NOVAK

Managing Editor May / June 2016 • Volume 115 • No. 3

COVER STORY

Approaches and Solutions to Tough Conversations By Veronica Gracia-Wing for MSMS

FEATURES

Enhancing Communication Improves Patient Satisfaction and Reduces Risks By Pamela Willis, BSN, JD, RN, CPHRM (Contributed by The Doctors Company)

COLUMNS

President’s Perspective

By David M. Krhovsky, MD Impact the Future by Advocating Together

Immediate Past President’s Message

By Rose M. Ramirez, MD Vaccines, Birth Control Pills, and Physician Well-Being

Ask Our Lawyer

By Daniel J. Schulte, JD Covenant-Not-To-Compete Issues in Employment Contracts

MDHHS Update

Rosemary F. Franklin, B.S., MDHHS Division of Immunization Back-to-School Is Around the Corner: Are All Your Patients Up to Date on Needed Vaccines?

HIT Corner

By George Goble, Chief Information Security Officer McLaren Health System STOP - THINK - CONNECT Preventing Ransomware Attacks

KEVIN MCFATRIDGE EMAIL: KMCFATRIDGE@MSMS.ORG

Publication Office Michigan State Medical Society 120 West Saginaw Street, East Lansing, MI 48823 517-337-1351 www.msms.org All communications on articles, news, exchanges and classified advertising should be sent to the above address, attn: Kevin McFatridge.

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Postmaster: Address Changes Michigan Medicine Hannah Dingwell 120 West Saginaw Street, East Lansing, MI 48823 Michigan Medicine, the official magazine of the Michigan State Medical Society (MSMS), is dedicated to providing useful information to Michigan physicians about actions of the Michigan State Medical Society and contemporary issues, with special emphasis on socio-economics, legislation and news about medicine in Michigan. The MSMS Committee on Publications is the editorial board of Michigan Medicine and advises the editors in the conduct and policy of the magazine, subject to the policies of the MSMS Board of Directors.

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WealthCare Advisors CORRECTION In Michigan Medicine’s March/April feature titled “Rural Practices: Founded in Family and Community,” Jonathan Pasko, MD, was mistakenly referred to as John Pasko, MD. The Michigan State Medical Society and Michigan Medicine sincerely apologize for the error and inconvenience.

Neither the editor nor the state medical society will accept responsibility for statements made or opinions expressed by any contributor in any article or feature published in the pages of the journal. The views expressed are those of the writer and not necessarily official positions of the society. Michigan Medicine reserves the right to accept or reject advertising copy. Products and services advertised in Michigan Medicine are neither endorsed nor warranteed by MSMS, with the exception of a few. Michigan Medicine (ISSN 0026-2293) is the official magazine of the Michigan State Medical Society, published under the direction of the Publications Committee. In 2016 it is published in January/February, March/April, May/June, July/August, September/October and November/December. Periodical postage paid at East Lansing, Michigan and at additional mailing offices. Yearly subscription rate, $110. Single copies, $10. Printed in USA.

The mission of the Michigan State Medical Society is to promote a health care environment which supports physicians in caring for and enhancing the health of Michigan citizens through science, quality and ethics in the practice of medicine.

P R E S I D E N T ’ S

P E R S P E C T I V E

Impact the Future by Advocating Together BY DAVID M. KRHOVSKY, MD

he medical profession is ever-changing, bringing along new

challenges for physicians to navigate and build a better world. As a member of the Michigan State Medical Society and your president, I’m prepared to address and meet these changes and challenges with fresh eyes.

As a young physician, I became active in my county medical society, as well as my state specialty society. These experiences taught me the importance of our unified voice, and led to even deeper involvement. Eventually, I joined the MSMS board, which has now culminated in my new role as president. I believe our organization needs continued leadership to provide support to its members and that’s what I plan to do. As president, I will be working with MSMS staff and our board chair and vice chair to steer the direction of the Society over the coming years. It is important to keep in mind that MSMS is led by no one individual, but is a true team effort of staff, leadership and the House of Delegates.

I hope to inspire others while continuing my journey as a lifelong learner, collaborating and listening to my peers.

“A can-do attitude and a positive perspective can lead us to achieve our agreed upon goals.” A can-do attitude and a positive perspective can lead us to achieve our agreed upon goals. As directed by the membership through the House of Delegates, we will focus on advocacy, membership issues and the financial health of MSMS. Of course, we must never lose sight of our “why,” namely, our commitment to provide the best care possible to as many of our citizens as possible. After all, at the end of the day, it’s all about our patients. Many physicians, me included, challenge the status quo and strive to encourage others to embrace the changes in health care. By working together to tackle issues—old and new—our profession can thrive.

MICHIGAN MEDICINE

I encourage you to get involved in this network of physicians. Seek out new members and get involved in committees. Become an inspiration to those around you, and become an ambassador of MSMS. You and your peers can become true advocates as well as accomplished physicians. As a group we can tackle and solve issues with a greater impact than we can moving forward individually. Again, I bring up inspiration. It’s important to me that we as physicians continue to find inspiration in our work—whether that’s through sharing our accomplishments internally or discussing our triumphs outside of the doctor’s office. As a profession, health care is tough and we’ve all had to become incredibly strong individuals. It is working and discussing through issues that divide us that the real strength comes from. I believe we will succeed in providing quality care for our patients while also serving as a support system for one another. Together we can affect real positive change in not only our profession, but throughout the world—taking Michigan health care to the next level. I’d like to thank Rose Ramirez, MD for her service and commitment as our outgoing president. Her leadership and strength inspire me to continue her work in honoring the past while looking to the future. I plan to use my position to serve as an advocate and a voice for Michigan health care. Doctor Krhovsky, a Grand Rapids anesthesiologist, is president of the Michigan State Medical Society May / June 2016

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IMMEDIATE PAST PRESIDENT ’S MESSAGE

Vaccines, Birth Control Pills and Physician Well-Being BY ROSE M. RAMIREZ, MD

his issue of Michigan Medicine highlights some of the difficult conversations and situations we may be challenged with in our professional lives. When I think about how

to navigate many of these conundrums, I focus on how I want my family to be treated and how I want to be treated by my colleagues. Showing respect for others, whether they are patients or our staff, is one criteria of a great physician. When we show fairness and consistency and equanimity in our daily work, this builds trust– an essential ingredient in the arsenal of a true healer. When I began my year as president of the Michigan State Medical Society, I was thinking about the ongoing issues around affordability of health care and the need to better address end-of-life care. I was also very happy to be celebrating the 150th year of our Michigan branch of the American Medical Association. Now, as the year has come to a close, I feel great gratitude for the honor and privilege to have served as your 150th MSMS president. We have had the wonderful opportunity to practice our profession in a time of great change, however much work remains to be done. I want to highlight some important history, and remind those serving with me and after me, that I see some priorities we need to address. I offer my ongoing commitment to the care of our patients and to the well-being of our physicians. The dramatic increase in life expectancy in the United States during the 20th century ranks as one of society's greatest achievements. In 1900, for every 1,000 babies born, about 100 died before reaching age one. More women died during childbirth and the average life expectancy in the U.S.

was less than age 50. Now, fewer than six in 1,000 babies born in the U.S. die before age one and we need to push that number lower. The average life expectancy for men and women in 2015 is 76 and 82, respectively. Physicians have certainly contributed to the lengthening of the lifespan and improved quality of life in many ways. A short list would include the development of vaccines and the discovery of penicillin. Surgeries have become much safer due to anesthesia and antisepsis. Cardiac care, the discovery of insulin and radiologic imaging add to the list. Our public health systems deserve a lot of credit for the wide distribution of vaccines. Much of the increase in lifespan is also due to advanced public health, including clean water and improved sanitation. I hesitate to mention this in light of the recent crisis with lead-contaminated water in Flint, Mich., yet it highlights the critical importance of clean and safe water. As a woman, I want to highlight two things that occurred in the 20th century in the U.S. that gave women a stronger voice MICHIGAN MEDICINE

and more control over our lives. The 19th Amendment to the U.S. Constitution was ratified on Aug. 18, 1920 and women gained the right to vote. In 1965, the Supreme Court ruled that it was unconstitutional for the government to prohibit married couples from using birth control. In 1972, the Supreme Court legalized birth control for all, regardless of marital status. Now, the high numbers of women graduating from medical school and contributing to our profession is the norm. The late 20th and early 21st centuries brought rapid advancements in technology. Information technology has given us the tools to gather and analyze data in a way that has challenged us to our limits. Scientific technology has given us new medications, new treatments, new devices and much higher costs for health care. Public expectations have become very high and it is very difficult to say to a patient, "There is nothing more we can offer at this time." Our population has gotten older and the costs of care at the very end of life have skyrocketed. In spite of this, death has not become optional. Our American culture is one of avoiding talk of death. It's almost as if, “we don't talk about it, it may not happen." I'm thankful that we are seeing conversations about death becoming more common. People who are nearing death often want to acknowledge it and make their wishes known. Families cope better after the loss of a loved one when they know and can try to fulfill the wishes of their dying family member. MSMS has been working with others across our state to address end-oflife care and to normalize the conversations regarding death. May / June 2016

Physician Burnout As I conclude, the one other issue I would like to highlight is physician burnout. In the December 2015 issue of the Mayo Clinic Proceedings, a study of ‘Changes in burnout and satisfaction with work-life balance in physicians and the general U.S. working population between 2011 and 2014’ concluded, “Burnout and satisfaction with work-life balance in U.S. physicians worsened from 2011 to 2014. More than half of U.S. physicians are experiencing professional burnout.” The rapid increase in technology and our shift to an information society add to this increase in burnout. I think the movement toward hospital employment of physicians and the accompanying loss of autonomy also contribute. It’s clear that technology has been a double- edged sword. Information technology has helped us to have data at our finger-

tips when caring for patients, working toward transparency and gathering information on quality that will enable us to improve population health. Just as most patients want face-to-face time with their physician, the human touch element is shrinking as we feel more pressure to manage and record the volumes of data we generate. We keep trying to work faster and smarter, yet this comes at a cost—impaired physicians, alcohol and drug abuse, premature retirement, patient harm and so forth.

we need to take care of ourselves. We need to prioritize time with our family, get enough sleep and work toward a better balance of the things that bring meaning to our lives. MSMS is the largest physician organization in our state. We need to support the work done by this great organization on behalf of patients and physicians. Physician well-being needs to be at the top of the list if we want to continue to be the best!

When physicians are not at their best, quality suffers. You have undoubtedly heard the proverb, “Physician, heal thyself.” This refers to the readiness and ability of a physician to care for patients when the physician is not taking care of their own physical and mental health. Before we can do our best for our patients,

Doctor Ramirez, a Kent County family physician, is immediate past president of the Michigan State Medical Society

Welcome New MSMS Members! Sarah Allgeier, MD, Washtenaw

Sai Dukkipati, MD, Genesee

Ran Lee, MD, Washtenaw

Rami Salameh, MD, Genesee

Ahmed Alomari, MD, Washtenaw

Yuan Feng, MD, Washtenaw

Simon Lee, MD, Washtenaw

Sindhu Samba, MD, Washtenaw Peter Sassalos, MD, Washtenaw

Aviva Alpert, MD, Washtenaw

Dustin Fleck, MD, Washtenaw

Michael Little, MD, Macomb

Lauriane Auvergne, MD, Washtenaw

Karl Freydl, DO, Washtenaw

Andrew Lohse, MD, Washtenaw

Elizabeth Secord, MD, Oakland

Lara Azzi, MD, Oakland

Crystal Gardner-Martin, MD, Livingston

Jose Lozano Garcia, MD, Washtenaw

Fad Shihadeh, MD, Washtenaw Christa Siebenburgen, MD, Washtenaw

David Baehren, MD, Hillsdale

Benjamin Garmezy, MD, Washtenaw

David Lustig, DO, Oakland

Steven Bartek, MD, Washtenaw

Amit Gupta, MD, Washtenaw

Aiman Mahmood, MD, Washtenaw

Erica Stevens, DO, Kent

Monica Benedikt, MD, Washtenaw

Angela Gupta, DO, Washtenaw

Matthew Manry, MD, Washtenaw

Garth Strohbehn, MD, Washtenaw

Gregory Bennett, DO, Washtenaw

Joseph Holicki, DO, Branch

David Manthei, MD, Washtenaw

Samuel Talsma, MD, Washtenaw

Vashali Bhargava, MD, Oakland

Meghan Horn, MD, Washtenaw

Gregory McBride, DO, Northern

Pooja Tangri, MD, Oakland

Zeeshaan Bhatti, MD, Washtenaw

Danielle Horne, MD, Washtenaw

Orlena Merritt-Davis, MD, Oakland

Theophilus Ulinfun, DO, Wayne

Elizabeth Block, MD, Washtenaw

Daniel Horner, MD, Washtenaw

David Miller, MD, Washtenaw

Fred Van Alstine, MD, Shiawassee

Kristopher Brenner, DO, Kent

Jeffrey Jacob, MD, Oakland

Todd Miyake, MD, Washtenaw

Ahsan Wahab, MD, Genesee

Laura Brown, MD, Monroe

Gaurav Katta, MD, Washtenaw

Subhan Mohammed, MD, Genesee

Danielle Welch, MD, Wayne

Kristine Cece, MD, Washtenaw

Kashif Khan, MD, Washtenaw

Pawel Mroz, MD, Washtenaw

Angela Weyand, MD, Washtenaw Loren Wise, MD, Northern

Brian Chen, MD, Washtenaw

Neil Khanna, MD, Washtenaw

Samyukta Mullangi, MD, Washtenaw

Elizabeth Constance, MD, Washtenaw

Hannah King, MD, Washtenaw

Niket Nathani, MD, Washtenaw

Eanas Yassa, MD, Kent

Naomi Cook, MD, Livingston (lives in Livingston, works in Washtenaw)

Matthew Kittle, DO, Washtenaw

Ogechukwu Ndum, MD, Washtenaw

Michael Yee, MD, Washtenaw

Mark Korenke, MD, Washtenaw

Joseph Nelson, MD, Washtenaw

Robert Yin, MD, Delta

Halley Crissman, MD, MPH, Washtenaw

Travis Kruger, MD, Washtenaw

Komalben Parmar, MD, Genesee

Rachel Young, DO, Genesee Kim Yu, MD, Oakland

Anshu Dalela, MD, Oakland

Daniel Larach, MD, Washtenaw

Megan Pesch, MD, Washtenaw

Michelle Debbink, MD, Washtenaw

Sophia Larson, MD, Washtenaw

Laura Peterson, MD, Washtenaw

Jeremiah DeWitt, DO, Kent

Christy Le, MD, Washtenaw

Tyler Policht, MD, Washtenaw

Steven Dudick, MD, Wayne

Matthew Lee, MD, Washtenaw

Swapnil Rath, MD, Washtenaw

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A S K

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L AW Y E R

Covenant-Not-To-Compete Issues in Employment Contracts BY DANIEL J. SCHULTE, JD, MSMS LEGAL COUNSEL QUESTIONS:

A potential employer has offered me an employment agreement containing a covenant-not-to-compete. The employer is a large group practice with two offices. Can the covenant-not-to-compete prohibit me from starting or joining a medical practice near either office? How do I know if the ten mile radius will be enforced against me? The agreement states that if I breach the covenant-not-to-compete I will automatically be liable and must pay the employer liquidated damages of $40,000. Is such a penalty enforceable? ANSWERS: Can The Covenant-Not-To-Compete Apply To Two Offices When The Employee Primarily Works At Only One? Yes. Courts looking at these types of restrictions have held that if they are expressly provided for in the employment agreement they can be enforced. If you believe that the employer’s competitive interests are adequately protected without the geographic radius encompassing both offices you should negotiate this up front because you will likely not be able to argue it following a termination of the employment agreement.

Is A Ten Mile Radius From Each Practice Location Enforceable? Probably. Michigan’s Antitrust Reform Act, MCL 445.771 et seq. and many Michigan court decisions have established a commonly understood rule that a covenant-not-to-compete will be deemed reasonable if tailored to protect an employer’s reasonable competitive business interests and the protection provided to the employer in terms of the covenant-not-to-compete’s duration, geographic scope and the type of employment or line of business prohibited are expressly provided for in an agreement and are “reasonable”. In a medical practice setting, a covenant-not-to-compete can reasonably protect against unfair competition 8

from the departing employee resulting from the loss of patients following the departing employee to a new practice location. The courts have also recognized as reasonable the protection of the employer’s investment in the training of the employee and protecting the employer’s patient lists. The reasonableness of a specific geographic restriction will depend on the facts and circumstances of each case. However, the courts have routinely confirmed the reasonableness of a common approach to determining a reasonable geographic restriction to be used in medical practice covenant-not-to-compete agreements. This method involves determining where the medical practice’s patients are located and basing the geographic restriction on that particular area.

Is A Covenant-Not-To-Compete Unenforceable If It Violates A Professional Code of Ethics? No. The Michigan Court of Appeals has held that a covenant not to compete in an employment agreement is enforceable even when it violates the American Medical Association’s Principles of Medical Ethics. The same would be true if complying with a covenant not to compete would violate the ethical rules of another organization the employee belongs to. MICHIGAN MEDICINE

Will A Penalty Clause Be Enforced? No, but a liquidated damage clause may be. A liquidated damages provision will be enforced if the amount is reasonable in relation to the possible injury suffered by the employer upon the employee’s breach of the covenant-not-to-compete. Liquidated damage amounts that are “unconscionable” or “excessive” and therefore are merely penalties will not be enforced. The amount of a liquidated damages provision in a medical practice covenant-not-to-compete must bear some reasonable relation to the expected loss of patient revenue arising from the employee’s breach of the covenantnot-to-compete. Damages in breaches of covenant not to compete cases in physician employment agreement cases are typically capable of reasonable determination – they equal the profit lost on post termination patient encounters with the breaching physician. Therefore, there is rarely a need for a liquidated damages provision in this context. Daniel Schulte, JD, MSMS Legal Counsel, is a member of Kerr Russell Attorneys and Counselors

May / June 2016

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M D H H S

U P D AT E

Back-to-School Is Around the Corner: Are All Your Patients Up-to-Date on Needed Vaccines? ROSEMARY F. FRANKLIN, B.S., MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES, DIVISION OF IMMUNIZATION It’s not too early to start thinking about the next school year. Soon, your office will be filling up with children who will be starting school in the fall as well as returning students. Use these office visits as a chance to get your patients up-todate on all recommended vaccines. Every time a child or adolescent arrives at your office – whether for a preventative or sick visit – it is an opportunity to immunize that patient with needed vaccines. Sometimes parents may come into your office and only want the vaccines required for school entry.1 Please take time to talk to these parents about the importance of immunizing their children, including adolescents, according to the recommended schedule.2 The American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), the Society for Adolescent Medicine (SAM), and other professional medical organizations recommend that providers vaccinate based on current Advisory Committee on Immunization Practices (ACIP) recommendations. In following the ACIP recommendations, Michigan's school immunization requirements will be met. Many children in Michigan have not received all the recommended vaccines, leaving them vulnerable to vaccinepreventable diseases.3 Influenza, HPV, and 10

hepatitis A vaccines are recommended by the ACIP, and yet they are not required by Michigan schools. Does that mean that they are not as important as those vaccines required by schools? Absolutely not – these vaccines are every bit as important as the others. The ACIP recommends that all teens and pre-teens (boys and girls) receive the HPV vaccine series. Flu vaccine is recommended every year for everyone 6 months of age and older. Two doses of hepatitis A separated by six months are also recommended. The Michigan Department of Health and Human Services (MDHHS) urges immunization providers to give the most comprehensive protection to patients by following the ACIP recommendations. While state requirements are usually related to state mandates for day care and school entry, following the ACIP recommendations is considered the standard of care. Even though you may talk with all your parents about the importance of following the recommended schedule, some of them may not be convinced. Under a rule change that went into effect on January 1, 2015, parents who request a non-medical waiver for school or childcare required vaccines must be referred to their local health department for a waiver education appointment. During the appointment, parents will have the opportunity to discuss their vaccine concerns and receive education from a county health department staff member about the benefits of vaccination and the risks of vaccine-preventable diseases before claiming the waiver. MICHIGAN MEDICINE

Educational resources are available to provider offices, including free immunization education sessions through the MDHHS Immunization Nurse Education program and the Physician Peer Education Project on Immunization. The education sessions through both of these programs are approved for continuing medical education credit.4 Informational brochures about immunization topics are available free of charge from the Michigan Department of Health and Human Services. A variety of brochures is available, and can be ordered online at www.healthymichigan.com. As children and adolescents come in to your office over the summer, be sure to take the opportunity to assess for needed vaccines. Back-to-school check-ups and sports physicals are an ideal time to make sure all of your school-aged children and adolescents are fully vaccinated. Use these summer appointments to help alleviate the fall rush and assure all your patients are up to date before school starts. ENDNOTES 1 Michigan requirements for school and childcare attendance: http://1.usa.gov/1QXRXOu 2 Recommended immunization schedules for all ages: http://www.cdc.gov/vaccines/ 3 Immunization coverage rates by counties, Michigan County Immunization Report Cards: www.michigan.gov/immunize - click on Local Health Departments. 4 Educational Resources: http://www.aimtoolkit.org/health-care/ education-training.php May / June 2016

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H I T

CO R N E R

STOP - THINK - CONNECT Preventing Ransomware Attacks BY GEORGE GOBLE, CHIEF INFORMATION SECURITY OFFICER, MCLAREN HEALTH SYSTEM

ansomware is hitting the health care scene with a vengeance. Based on recent media reports, it appears that these attacks against hospitals and medical practices are becoming commonplace. There have been at least eight incidents revealed in recent weeks whereby cyber-attackers

basically hold computer systems hostage by encrypting data and then demanding a ransom to decrypt it. In the recently publicized case of Hollywood Presbyterian Medical Center, services were down for a week. The resulting payout was $17,000 to restore its systems and administrative functions.

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May / June 2016

What is Ransomware? Ransomware is a specialized type of phishing attack. Both ransomware and phishing scams generally rely on some form of false pretense to gain a person's trust and then convince them to do something they shouldn't - such as click, download, and enter data. The email typically contains a message requiring the unsuspecting user’s immediate response - in hopes that they reply. Some sample subject lines include: • The attached invoice needs your immediate attention • A problem with your bank account access requires you to verify access information

Would you be able identify a phishing attack? See how your skills rate by taking the self-test available at: http://www.contentverification.com/phishing/quiz/index.html

What to do if you receive a Ransomware / Phishing email DO NOT CLICK ON ANY LINKS OR ATTACHMENTS! Immediately notify the appropriate people in your organization including, as applicable: • Your Information Security Officer or Privacy Officer

• A friend has sent you an eCard

• Your information technology (IT) help desk

With Ransomware, when the user clicks on the link or attachment, a virus is launched that encrypts the user’s data files. The attacker then sends an email asking for money or “ransom” in exchange for the decryption keys.

• Your IT vendor or consultant

How to identify Ransomware / Phishing emails Did you know that 91% of successful data breaches started with a phishing attach? Some phishing red flags include: • Misspellings, poor grammar • Web Site address (URLs) that use a variation in spelling or a different domain. Malicious websites may look identical to a legitimate site • Requests to enter IDs and passwords online

What happens if you become a victim of Ransomware? Immediately call the appropriate people in your organization including, as applicable: • Your Information Security Officer or Privacy Officer

What can you do to prevent Ransomware? The installation and maintenance of anti-virus software, firewalls, and email filters to reduce some of this traffic is critical. Additionally, backup all your data, perform regular system backups, test to ensure that the backup process works, and store data off the network. Train all employees on the importance of information security, how to avoid becoming a victim of ransomware, and the steps to follow if they have concerns about a suspicious email, link or message. Remain vigilant—cyber-attackers are highly motivated and these schemes are getting more and more sophisticated.

• Your information technology (IT) help desk

Other helpful resources:

• Your IT vendor or consultant

• http://www.michigan.gov/cybersecurity/ 0,4557,7-217-51788---,00.html

• Immediately change your passwords • Change your password on any account for which you use the same password

• https://www.dhs.gov/stopthinkconnect • https://www.onguardonline.gov

STOP – THINK – CONNECT

• Requests for urgent and immediate action

The next time you receive an email and get that gut feeling that something

Actions to Take:

is not quite right – STOP.

• Pay close attention to the sender of the email and to whom you are replying. • Before hitting SEND, verify the TO address

Take another look and THINK – why would this person want me to do this? Who is this person and do I really trust what they are asking me to do?

• Do not click on links in an email, instead type the link address in a browser

Perform due diligence to CONNECT that the requestor or request is legitimate.

• Avoid downloading any unknown software

Only if you are 100% comfortable should you click on any link.

• Never allow a third party to remotely access a computer if the caller's authenticity cannot be verified

If you have any doubt, follow the steps outlined above.

George Goble is the Chief Information Security Officer (CISO) with McLaren Health System. He has over 23 years of experience delivering information security for both profit and nonprofit organizations, and across multiple industries including health care, manufacturing, retail, finance, and consulting. Volume 115 • No. 3

MICHIGAN MEDICINE

How do I talk about … » Noncompliance? » Patient termination? » Patient satisfaction quality scores? » Drug diversion? » Disagreements with colleagues? » End-of-life care?

MICHIGAN MEDICINE

May / June 2016

Tough Conversations

hysicians are increasingly called upon to engage in meaningful communication, both with patients and colleagues. With more and more demands and what seems like not enough hours in the day, how can we ensure the toughest of conversations are productive for everyone involved? Difficult, emotional conversations are a regular part of the physician’s day – read on to learn from your colleagues and other professionals about their tried and true approaches to tough conversations.

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What advice do you have as it relates to patient noncompliance? This has been a very challenging question throughout time. I encourage students and residents to identify what is important to patients, what motivates them. When you try to find out what connects with the patient and offer feedback in a non-dictatorial way, you can have a greater impact on their care. Offering incremental steps for change is also an important approach.

Pino D. Colone, MD, FACEP » Emergency Department Service Chief, Henry Ford West Bloomfield Hospital

For example, if I’m working with a morbidly obese teenager, I might talk to them about the importance of controlling their blood sugar as it relates to things like impotence. For incremental change, we’ll talk about reducing eating fast food from five days a week to cutting down to three. Just telling them to stop the noncompliance isn’t helpful. You’ve got to figure out what their priorities are and avoid setting them up for failure.

How do you use and incorporate patient satisfaction quality scores? An ever increasingly important question … Surveys have their limitations and the response rate isn’t always great, but we always try to use feedback for improvement. As part of the leadership that reviews and is held accountable for that data, I also hold my staff accountable for the results. We use the data in our regular staff meetings, focusing in on the patient experiences as opposed to the score itself. I find that when you look at the experience first, the score will follow. Typically we’ll talk about what the scores are for the month, exploring the why behind the scores. It’s an opportunity to make positive experiences for your staff and patients.

How do you address patient drug diversion? This is a problem that has been growing in Michigan, and has hit us harder than in many other states. I believe the drug diversion trend stems from the late ‘90s concept of pain being the fifth vital sign, and the Federal government encouraging physicians to be more aggressive in the treatment of pain. This has, in part, led to the epidemic of overprescribing and the everyday problem of drug abuse. I encourage my physicians and physician assistants to use the Michigan Automated Prescription Sys16

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tem and address the patient directly. We’ll often offer a non-narcotic alternative, and, if the patient is willing, refer them to a drug treatment on the spot at a facility on our hospital campus.

How do you approach end-of-life care conversations as an emergency medicine physician? Unfortunately it’s an all too familiar conversation. So many times a critically ill patient has not had the discussion with other providers or family members about their wishes for end-of-life care. In the emergency room, we address particular concerns they might have, as well as understanding with specificity the level of intervention they’re willing to accept. We need to help patients understand what their options are and what each of those options mean. The time to have these kinds of conversations is not when something dramatic happens, but when patients can have an understanding of the situation. Throughout all of these conversations, we want to ensure we’re respecting patient wishes and approach the matter in a kind and caring way, emphasizing that our primary concern is their well-being. If you don’t focus on patient well-being, then you run the risk of alienating a patient, compromising the dynamic and increasing your risk of noncompliance.

What is your advice on how to handle a situation where you see a colleague not performing their best? The shadow you cast can take many forms. I believe in leading by example and come in to the ER positive and approachable, which fosters an environment of the same mood and tone. This helps in the understanding that if there is a decision to be made, and my staff doesn’t agree, that ultimately the decision is mine. They respect that. I want every conversation to be educational. I’m always open to collaboration and believe all relationships are founded in communication. We work together to build a solid foundation of communication, collaboration and cooperation. To do that, I address situations and behaviors directly. We leave little room for mixed messages or the perception that not performing well is acceptable. May / June 2016

My preference is one-on-one, situational coaching. If it’s a procedure or management issue, we can talk about Continuing Medical Education and the vast resources available to them. If it’s interpersonal interactions, we talk about what the specific behavior was and why it happened. We set up the expectations together so they have frame of reference for the future. If it turns out to be an ongoing conversation, then we’d talk about a performance improvement plan. Depending on the issue, management becomes more and more formal, but the overwhelming majority are individual conversations.

How do you handle conversations about the all too common issue of physicians not taking care of their own health and wellness? I also handle this directly, even though I think it’s probably easier to ignore. I have a good read of people and can sense a change in baseline mood or how they’re interacting with others. I’ll express my concern to the individual and offer them the opportunity to open up. I let them know that I am a resource for them, and acknowledge that I’m seeing something out of character. I believe in a healthy work-life balance and professional satisfaction. We spend a lot of time at work, so if I can improve satisfaction on this front, I will do it. I will often advocate for an individual or the department, and report back what the results of those discussions were, which helps builds creditability and validates concerns. It’s important to me to take a genuine interest in my staff’s families and make it more than just about work. It’s impossible to completely separate our two lives, so being satisfied at work is a very important measure. I want my people to be happy. I make the time as I’m working clinically, walking through departments and touching base. This takes interest and motivation, but not a lot of time. If something is important enough, you make the time whether it’s five minutes or an hour. Leading by example and casting a positive shadow encourages others to do the same. The smallest interaction is going to have a lasting impact. Volume 115 • No. 3

“Throughout all of these conversations, we want to ensure we’re respecting patient wishes and approach the matter in a kind and caring way, emphasizing that our primary concern is their well-being.”

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Why and how do you terminate a patient relationship? I most typically terminate because of patient drug abuse; specifically those who are doctor shopping for pain medication. I have never discontinued care because of noncompliance. For those patients who we’ve identified using the MAPS, we’ll have a sit-down conversation to show them the evidence, and clearly let them know that we are unable to help them.

How do you approach conversations about end-of-life care as a hospice provider?

Edward Christy, MD, CMD, FACP, FAAHPM, AGSF, MBA » Medical Director, Heart to Heart Hospice, Durand Rehabilitation Center, Shiawassee Medical Care Center, Genesee Care Center, Medilodge of Montrose, Whitehills Convalescent Center

What steps do you take when a patient doesn’t comply with orders? This matter needs serious improvement, because it is too easy for patients to not comply and slip through the cracks of care. I see this as a major system failure that makes patient noncompliance too common. As physicians, we prescribe medicine and then forget about everything else. I’m just as guilty as anyone, forgetting about things like exercise and diet. But we simply don’t have enough people in the office to follow up with patients closely on the little things.

“I try to make these conversations as relaxed as possible. The care plan and goals are the focus during subsequent conversations to avoid confusion.”

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I collect as much information about the patient as possible. I will find out what the patient knows about the disease. So much of the time the patient has not had anyone put together everything that is going wrong. First I try talking with one person, moving to the next of kin if the patient is unable to have this conversation. That information is then brought to the next sit-down conversation. At this second sit down with the patient and any family, we collect goals of treatment and goals of care, identifying what those goals are together to create a care plan. During these conversations, I strive to validate the opinions of everyone present and listen actively. After all this, I put a plan in place and explain what the possibilities are related to each care element and what the joint expectations are. I try to make these conversations as relaxed as possible. The care plan and goals are the focus during subsequent conversations to avoid confusion.

What is your advice on how to handle a situation where you see a colleague not performing their best? In these matters, I try to collect as much data as possible, identifying exact details and dates associated with the incident. After this, I’ll sit down to lunch or dinner with a colleague to discuss what happened. It’s important to me to try to understand the “why” from my colleague’s point of view before we discuss what went wrong. After getting input, I’ll then explain a different perception of the situation so we can find a solution together. May / June 2016

How do you handle matters where you don’t necessarily agree with a colleague?

Robert Jackson, MD » Family Physician, Western Wing Physicians, Allen Park » Medical Director, Medical Advantage Group, East Lansing

I think physicians have a hard time pointing fingers at one another. You want to make sure you’re right before saying someone is wrong. I think it’s hard to judge things with minimal information, so I go into those conversations with calmness, great empathy for everyone and data. When you go into those conversations with solid data and mutual interest in helping each other do better, the outcome is better. It isn’t always easy. With data you can show what may be lacking. Address what you know and what you don’t in these conversations. It’s a priority to get a colleague to improve performance rather than have a patient irreparably harmed and a physician unable to provide good medical care. With tough conversations, I suggest we look for solutions rather than accusations. Anyone who has had performance issues

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at work can appreciate that kind of process. You need to be fair to the physician, the community and to the patients they’re seeing.

How do you handle conversations about the all too common issue of physicians not taking care of their own wellness? To be honest, sometimes it’s hard for me to see if others aren’t taking that all-important time for themselves. If I do, I talk with them about needing to find joy in what we’re doing as physicians and helping them identify ways to find a work-life balance. Physicians may work a lot of hours, but we have the ability to do a lot that’s extraordinarily meaningful and fills our hearts. It’s important that we’re honest about that. If you see hints of a colleague struggling with balancing their professional and personal lives, you’ve got to have those conversations based in figuring out how to improve it, and help them change their situation. (continued on next page)

and/or damage the relationship with people we have to work with daily in stressful and intense environments. It’s important to have these kinds of conversations, because this is about relationship building with one another that strengthens team building and health care delivery. It is how we build potential in our teams and ourselves.

Sandy Carter, MBA, PhD » Professional Certified Coach, The Center for Physician Leadership Coaching

It is through our conversations that we build trust and create transparent cultures that reduce redundancies and errors and improve quality.

When people perceive a sense of safety they can take risks to innovate, create, contribute, challenge and celebrate with one another. Research suggests improving patient safety is connected to improving trust, communication, teamwork and learning from past mistakes which requires in part, dealing with messier situations that make people feel vulnerable. Physicians can frame tough conversations for productive outcomes by starting from within.

Sandy’s tips to approaching challenging conversations: 1. Mindset – Stay engaged in a learning state of mind. Don’t expect to be perfect. Mastering difficult conversations requires practice, patience and a willingness to fail, learn and get better. It is about experimenting through baby steps, reflecting and integrating knowledge and evolving confidence and wisdom over time. 2. Reflection – Before your difficult conversation, give yourself time and space to ask some important questions: what would be an ideal outcome? What do you hope to accomplish? Ask - what is really going on for me?

often see physicians when they are at the edge of their skill set – skills such as emotional intelligence, understanding their strengths or vulnerabilities haven’t traditionally been taught in their educational or training programs. Physicians may lack confidence in dealing with conflict and interpersonal communication skills, such as how to deliver feedback and being empathic with one another. They may also feel stuck and externalize the problem, feeling overreactive and victimized. This is no surprise as traditional training focuses on rigor and often disconnects from vulnerability. Having these conversations requires practice and a willingness to fail. This is challenging for physicians who have been sued or shamed for failing and can associate danger with failing. Honest and authentic conversations invite us to be vulnerable. Physicians’ environments are stressful with time constraints, large workloads, etc. and it becomes easy to rationalize and put things off that we anticipate will be hard. Tough conversations are risky because we can’t be sure of the outcome. If we attempt a conversation and it doesn’t go as intended or hoped, we can feel rejected, attacked or misunderstood. We could even hurt others

3. Be completely honest with yourself! Examine your personal beliefs and assumptions. What feelings and emotions are activated in you? We all have habitual behaviors and conditioning that creates blind spots – what might you be contributing to the issue? 4. Mindfulness – Be present! Take time to choose the right time and place to have the conversation where there will be minimum distractions. If possible, don’t look at your cell phone, read your texts, glance at charts or test results. These distractions may make you feel more comfortable, but they will prevent you from attending fully to the situation at hand. 5. Be empathetic – Think about how you would want to be treated and place yourself in their shoes. What might they be feeling and how can you help them to feel as safe as possible for a respectful dialogue to take place? 6. Identify big picture outcomes, as opposed to problems – You’ll want to place focus on where you’re going and not where you are. Reframe negative thinking to sustainable positive outcomes. 7. Educate yourself – Dealing with conflict is a natural part of relationships and working with a coach and/or reading and developing skills in this area will serve you well for the longterm. There are a number of good books and articles on the topic: “Difficult Conversations: How to Discuss What Matters;”“Crucial Conversations: Tools for Talking When Stakes are High.” 8. Take purposeful action – Empower yourself by following through on tough conversations. Do your best to stay present, engaged and lead with integrity – learn from your experiences and build on them through practice, practice and more practice! 9. Celebrate – Working through tough relationships can be deeply satisfying and meaningful. When you master new skills such as being mindful, empathic and focusing on positive outcomes, a person can more effectively deal with complexity and relationship challenges. Your confidence can increase, and one has a sense of empowerment and engagement; which enhances happiness, resiliency and well-being.

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May / June 2016

www.MSMSInsurance.org

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Eliminates the need for you or your practice to contact insurers for billing purposes; Has direct access to the insurer’s systems to add, terminate or change a subscriber’s information within 24 hours, which removes the administrative burden from you and your staff; Will research claims inquiries and benefit questions for you or the subscriber, which will eliminate the frustration of contacting a complex customer service center; and, Handles all COBRA administration for groups with more than 20 employees, free of charge, thus removing another administrative burden.

You always get more with MSMS Physicians Insurance Agency because we focus on you.

For more information or to request a quote for affordable, high-quality health insurance, please connect with Beth at 877/742-2758 or belliott@msms.org. Volume 115 • No. 3

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PERSPECTIVE: END-OF-LIFE CARE AND ADVANCE CARE PLANNING Carolyn Stramecki » Director, Honoring Healthcare Choices - Michigan Understanding the core strength of advance care planning and how it is to be utilized, is vastly different from the tasks that can be marked off with a checkmark at the onset of a patient encounter. Be a part of the care process. ACP is not the equivalent of a traditional code status conversation or determination. Rather, it is a process of communication that should occur throughout a person’s lifespan with regularity and at times with spontaneity. This process of communication assists individuals in understanding their own choices for future health care; allows the person to reflect on his/her values; allows them time to discuss with their providers, caregivers, family, patient advocate and loved ones; and may involve choosing a patient advocate.

ACP is not intended to be a part of prognostication; of giving news, good or bad. It uses various communication techniques, shared decision-making and evidence based language to illicit treatment options that align with the person’s self-identified acceptable goals of care. Providers are often not afforded the time based on business models to respectfully hold these conversations. The reality of the constraints put upon them as revenue generators leaves little opportunity to effectively provide this service without assistance. Having a skilled, certified facilitator to conduct the time-consuming pieces of the ACP conversation can be of great benefit to a provider. The facilitator (typically a social worker, nurse or clergy), can spend time with the patient, patient advocate and loved ones over multiple sessions, which may result in the completion of an advance directive, a Michigan Physician Orders for Scope of Treatment form, or, if warranted, an out-of-hospital Do Not Resuscitate form.

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The role of providers in the ACP process is to: • Provide the patient with information about the diagnosis and prognosis prior to a scheduled ACP facilitation. • Introduce the topic of ACP as a standard of care and suggest the patient have a conversation. Remind the patient and family that to offer the good care that is desired, it needs to be discussed and shared. • Trust in the partnership formed with certified facilitators. • Answer questions and clarify information as a follow-up to facilitation as needed. • Acknowledge the hopes of the person and identify those that clinically can be supported. • Verify and sign medical orders (MI-POST, DNR form) if created. • Review with patients regularly. • Ask for the information when treating a patient. • Perspective: Honest and authentic approaches to tough conversations

May / June 2016

Recruiting is hard work. We can help! MSMS Medical Opportunities connects Physicians and other health providers with Michigan’s health care employers. • •

Physician profiles and job searches are free, quick and effective. Job posting memberships begin at $500.

msms.medopps.org For membership information or to schedule a demo of MSMS Medical Opportunities, contact us at 800/479-1666 or recruitment@mhc.org.

Serving healthcare providers for over 30 years

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CO M PA N Y

Enhancing Communication Improves Patient Satisfaction and Reduces Risks BY PAMELA WILLIS, BSN, JD, RN, CPHRM (CONTRIBUTED BY THE DOCTORS COMPANY)

Communication and satisfaction with the patient-physician relationship are potent predictors of whether patients decide to file medical malpractice claims. Adopting appropriate communication techniques and informed consent processes are important steps for physicians in decreasing the likelihood of medical malpractice claims and increasing positive patient outcomes.

“T

here are many aspects of our medical practice that we can’t control as much as we would like in our efforts to reduce the risk of malpractice accusations,” said Srinivas “Bobby” Mukkamala, MD, an otolaryngologist in Flint, Michigan, and vice chair of the Michigan State Medical Society Board of Directors. “But there is one thing we can do, even with our busy schedules: Improve communication with our patients. While our face is often buried in our laptop screen wondering why a page won’t load or why our entire note just got wiped out, it’s easy to overlook key points in our conversations with our patients. Even when those conversations start to feel routine, we need to remember to fully engage with each patient.”

providers and the patient or family. These deficiencies included poor provider-patient rapport, inadequate informed consent, ineffective education, language barriers, low literacy (reading below fifth grade level), and low patient health literacy (the inability to read, understand, and act on health information). Communication deficiencies among providers were cited in 45 percent of cases. These included misunderstood orders, poor handoff, and poor professional rapport. Telephone, e-mail, and fax communication deficiencies occurred in 5 percent of cases, with Internet and telemedicine cited in 1 percent of cases.

Communication Deficiencies

Successful Communication Techniques

In The Doctors Company’s 2007 to 2015 (second quarter) closed claim review, communication deficiencies were noted as a significant risk management issue in 23 percent of all malpractice claims. While communication was rarely the only factor, 60 percent of these cases involved communication deficiencies between healthcare

A major barrier to provider-patient communication is how little information patients remember when they leave a provider’s office. Patients forget 80 percent of the information they are told and inaccurately remember an additional 10 percent. That leaves patients with just 10 percent of the information remembered correctly.1

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May / June 2016

TECHNIQUES TO IMPROVE PATIENTS’ UNDERSTANDING: • • • • • • • • • •

Involve the patient’s family members in education and follow-up instructions. Use educational videos, pamphlets, and classes. Have staff members reinforce teaching after provider visits. Speak slowly, use plain language, limit information, and repeat often. Continue to reinforce teaching regularly at subsequent visits. Use “Ask Me 3,” a tool in which patients are encouraged to ask, “What is my main problem?” “What do I need to do?” and “Why is it important for me to do this?” Avoid yes/no questions like “Do you understand?” in favor of open-ended questions like “What questions can I answer for you?” Use “teach back” techniques such as “Just so I know I have explained it correctly, can you repeat the instructions back to me?” Listen carefully for at least two minutes before interrupting a patient. Be personally available to patients for discussion and assessment of understanding of informed consent, then document the discussion and have the form signed.

Additional Techniques Providers Can Adopt: • Introduce yourself to patients with name and specialty—especially in the hospital, where so many care providers are coming in and out of a patient’s room daily. • Greet everyone in the room with eye contact. • Avoid technical terminology and medical jargon—if you must use it, explain it well. • Tell patients what to expect—how long a test, procedure, and recovery will take. This decreases anxiety due to the unknown. • Encourage written questions and the use of an “Ask Your Doctor” notepad. Volume 115 • No. 3

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“After you go through your routine and have said everything you think is necessary, it is helpful to pause, look up, and ask patients if they understand the risks and benefits of the treatment plan,” Dr. Mukkamala said. “Then be sure to document that discussion.” Dr. Mukkamala also noted that the other aspect that often falls through the cracks is effective telephone communication with patients. “Our EMRs have messaging functions, so documentation of what the patient called about and our response is not nearly as haphazard as the old sticky notes in the charts. There is still, however, an opportunity to be more thorough in our electronic charting. Ask your staff to document the call back to the patient and chart that the concerns were addressed, if you don’t have time to do that documentation yourself.” ENDNOTES 1

Patient Safety & Quality Healthcare, May/June 2006, N. Baum, MD

Pamela Willis is a patient safety risk manager for The Doctors Company. For more patient safety articles and practice tips please visit www.thedoctors.com/patientsafety. 25

2016 Education Offerings

ON-DEMAND WEBINARS: Education When You Want It!

2016 BILLING AND CODING COURSES

 Physician Executive Development Programs: • Health Care Law for Physicians in ACOs • Medicaid Issues and Trends: Outlook for 2014 and Beyond • In Search of Joy in Practice: Innovations in Patient Centered Care • From Physician to Physician Leader • Inter-Professionalism: Cultivating Collaboration • Financial Information Analysis, Budget Development and Monitoring

PHYSICIAN ASSISTANT AND NURSE PRACTITIONER SERVICES: INCIDENT TO, SPLIT SHARED AND OTHER COMPLIANCE ISSUES

 Choosing Wisely  Balancing Pain Management and Prescription Medication Abuse: Chronic Pain and Addiction  CDL-Medical Examiner Course  Legalities and Practicalities of HIT including: • Cyber Security: Issues & Liability Coverage • Engaging Patients on Their Own Turf: Using Websites and Social Media  Summary of the Affordable Care Act  HIPAA Security Rule  End of Life Concerns and Considerations  What’s New in Labor and Employment Law  Preparing for the Medicare Physician Value-Based Payment Modifier  Understanding and Preventing Identity Theft in Your Practice  Stepping Up to Stage 2  Physician On-line Rating and Reviews: Do’s and Don’ts  Patient Portals as a Tool for Patient Engagement  Health Care Providers’ Role in Screening and Counseling for Interpersonal and Domestic Violence: Dilemmas and Opportunities  Opioids & Michigan Workers’ Compensation

Date: Wed., May 4 and Thurs., October 27 Time: 9:00 am to 4:00 pm Location: MSMS Headquarters, East Lansing

BILLING 101

Date: Thurs., May 19 and Wed., October 26 Time: 9:00 am to 4:00 pm Location: MSMS Headquarters, East Lansing

COMPLETE CODING UPDATES FOR 2016

Date: December 8, 2016 Time: 1:00 - 4:00 pm Location: MSMS Headquarters, East Lansing

NEW! MSMS/MMBA BILLING WEBINAR SERIES – AT NOON ON THE THIRD WEDNESDAY OF EACH MONTH

• Managing Accounts Receivable Wednesday, May 18 • Reading Remittance Advice Wednesday, June 15 • Working Rejections Wednesday, July 20 • Appeals Wednesday, August 17 • Compliance Wednesday, September 21 • ICD-10 for 2017 & Routine Waiver of Co-pays Wednesday, October 19 • Year-End Wrap Up Wednesday, November 16 • MSMS Legal Alerts Wednesday, December 21

Visit www.msms.org/eo for complete listing of On-Demand Webinars.

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MSMS LUNCH-N-LEARN Grab a lunch, click the link, and join us! These FREE, short, interactive, online updates are designed to explore key policy issues impacting physicians in Michigan. Beyond presentation, insights are solicited from participants and interaction is encouraged.

UPCOMING WEBINARS • MI’s Standardized Behavioral Health Consent Process Wednesday, May 25 • HEDIS Best Practices Wednesday, June 22 • Human Trafficking Overview and CPS Protocols Wednesday, July 20 • Health Information Technology Wednesday, August 10 • End-of-Life Care Wednesday, August 31 • Direct Primary Care Wednesday, September 14 • Heath Information Technology Wednesday, October 19 • The Importance of Medical Documentation Wednesday, November 9 • Human Trafficking Part 2: What to look for in Patients and Other Guidelines for Physicians Wednesday, December 7

For more information and to register for upcoming webinars, follow this link:

www.msms.org/Education/ UpcomingWebinars.aspx

May / June 2016

EDUCATIONAL CONFERENCES – Visit www.msms.org/eo for complete listing of Educational Conferences. COMPLIANCE ESSENTIALS FOR EVERYDAY PRACTICE - NORTHERN MICHIGAN

SPRING SCIENTIFIC MEETING Morning, afternoon and evening clinical courses available.

Date: Fri., May 13, 2016 Time: 9:00 am to 4:00 pm Location: Hotel Indigo, Traverse City Intended for: Physicians, PO Administrators, Practice Consultants, Office Administrators and all other health care professionals. Note: Continental breakfast & lunch provided Contact: Caryl Markzon 517-336-7575 or cmarkzon@msms.org

151ST MSMS ANNUAL SCIENTIFIC MEETING

Date: Thurs., May 19 and Fri., May 20

Morning, afternoon and evening clinical courses available.

Location: Somerset Inn, Troy

Date: Tues., October 25 – Sat., October 29

Intended for: Physicians and all other health care professionals

Location: Sheraton, Novi

Note: Continental breakfast & lunch provided Contact: Marianne Ben-Hamza 517-336-7581 or mbenhamza@msms.org

Intended for: Physicians and all other health care professionals Note: Continental breakfast & lunch provided Contact: Marianne Ben-Hamza 517-336-7581 or mbenhamza@msms.org

ANNUAL JOSEPH S. MOORE, MD, CONFERENCE ON MATERNAL AND PERINATAL HEALTH

YOUR PRACTICE, YOUR MONEY – OPTIMIZE YOUR FINANCIAL HEALTH

20TH CONFERENCE ON BIOETHICS

Date: Wed., September 21

Date/Time: Fri., November 13, 5:30 to 8:00 pm

Time: 9:00 am to 4:00 pm

Date/Time: Sat., November 14, 9:00 to 5:00 pm

Date: Thurs., May 19

Location: Troy Sheraton, Troy

Location: Hotel Indigo, Traverse City

Time: 9:00 am to 4:15 pm

Intended for: Physicians, PO Administrators, Practice Consultants, Office Administrators and all other health care professionals.

Intended for: Physicians, bioethicists, residents, students, other health care professionals, and all individuals interested in bioethical issues

Note: Continental breakfast & lunch provided

Contact: Caryl Markzon 517-336-7575 or cmarkzon@msms.org

Location: Somerset Inn, Troy Intended for: Physicians, nurses, residents, students, and all other health care professionals working with women and infants. Note: Continental breakfast & lunch provided Contact: Marianne Ben-Hamza 517-336-7581 or mbenhamza@msms.org

FOUR WAYS TO REGISTER

1 Register online at www.msms.org 2 Fax your completed registration form to (517) 336-5797 3 Phone MSMS Registrar at 517/336-7581 4 Mail: MSMS Foundation, 120 W. Saginaw, East Lansing, MI 48823

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T H E

M A R K E T P L A C E

Would You Like To Place A Classified Ad? The rate for classified advertising in Michigan Medicine, including both print and online versions, is $1.60 per word, with a minimum of $65.00. All ads must be prepaid. Text for classified advertisements and advertising fees should be received no later than the first of the month proceeding the month of publication. All submitted ads must be typed. No handwritten or dictated ads will be accepted. To place an ad, please call Carl Mischka at 888-666-1491 or email carl@mischka.us.

PHYSICIAN WANTED - LANSING Seeking progressive complete health physician in the greater Lansing area who understands the relationship between oral and systemic health. Complete Health Dentist interested in partnering in treatment and co-referral of our patients. Familiarity with the Bale/Doneen method is a plus.

Please call 517-332-8665 or e-mailmydentist@ameritech.net.

Working Together With You to Maximize the Financial Health of Your Practice Services Tailored to Your Specific Needs: • Full Billing Services • Credentialing Services • Business Planning • Electronic Health Records

• Accounts Receivable Recovery Services • New Practice Start-Up • Flexible Practice Management Software Options

All Medical Specialties Welcome PH: 248-478-5234 • FAX: 248-478-5307 www.elitemedicalbill.com We Are Your Medical Reimbursement Specialists 28

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May / June 2016

Family Practices n Allen Park: Retired Orthopedic Surgeon offering turn key operation. Full PT Lab, receive patient files, lots of potential for a very low price asking $50,000. n East Pointe Primary Care: Near I94 and Kelly Road. 3 Exam rooms, 2 year old practice. Asking $60,000 includes equipment/goodwill and transition. Real estate available. n Farmington Hills: Long established Internal Medicine Practice, 10 Mile/ Middlebelt area. Free standing building, 5 exam rooms, lab, x-ray. Very close to Botsford, St. Maryâ&#x20AC;&#x2122;s, and Providence Novi. Asking $175,000 for practice. n Garden City Internal Med Practice: Long established, majority of patients Medicare. Fully equipped, grossing in excess of $200,000 annually. Asking $70,000. n Mexican Town Detroit: 20 year old Primary Care Clinic. Staff is fluent in multiple languages. Seller financing available, priced to sell, work as you pay terms. Never in 25 years have I had the opportunity to offer more flexible terms. Price reduced to $589,000 for everything including real estate. n Lincoln Park: Walk-in clinic. Very visible, long established, seeing approximately 40 patients daily. Approx. gross income $800,000. Asking $250,000 for practice and $350,000 for real estate. n Podiatry Practices Detroit: 2 locations, very successful, grossing in excess of $600,000 annually. Fully equipped. Asking $300,000 for both locations. Real estate available. n Westside Detroit, Primary Care Practice: Established 2005, grossing in excess of $500,000 annually. Fully equipped. Asking $200,000 owner wants to retire.

Medical Buildings For Sale or Lease n Pontiac: Large professional medical building. Three story, suites 5005,000 sq. ft. Across from hospital, acres of parking. VERY REASONABLE rates/terms or buy building for $250,000. n West Side Detroit: 8,000 square feet, multi suites, fully leased. $60,000 positive cash flow excellent. Brick, single story asking $500,000 or lease for $1.00 square foot plus utilities.

For more details contact our practice specialist at Union Realty:

Joe Zrenchik, Broker 248-240-2141 (cell) joezrenchik@yahoo.com 248-919-0037 (office) Thinking about retirement, relocation or expansion of your medical practice? We have buyers and sellers for primary care, internal medicine and cardiology practices.

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Stock Volatility – What’s An Investor to Do? BY NICOLE GOPOIAN, JD, CFP®

any investors believe that by analyzing the right information, using the best tools and listening to the brightest experts, we can know which investments will be “winners” and which will be “losers.” Experience is a powerful teacher. Those of us who have experienced volatile markets know that outsmarting the market over the long term is virtually impossible. The events that move the markets are those that have not yet happened. And no one knows the events of the future – no one.

When the markets are falling, our brain senses fear and we feel the compulsion to do something. We seek an expert who will tell us the right thing to do. The problem is that no one has a crystal ball. The fact of the matter is that our ability to make short term predictions is flawed. So what are we to do during a volatile stock market?

Stay the Course Making decisions based on emotions is like kryptonite to an investor. The media consumes our daily lives and sometimes it seems impossible to escape the gloom and doom messages. This constant negative messaging creates a sense of fear, and that fear can drive us to sell stocks when their value is low – often at the worst possible time. This destroys our portfolio value over the long term. Nicole Gopoian, JD, CFP® is an advisor at WealthCare Advisors, LLC – an MSMS joint venture.

Remember, the stock market has averaged an annual return of over 10% since good record keeping began in the 1920s. But this return was not to be achieved without discomfort. It’s been a reward to those of us who have been willing to wait out the bad times – sometimes months or even years. MICHIGAN MEDICINE

Develop and Update a Financial Plan It’s easier to stay the course – particularly to tolerate the bad times – when we have a plan in place. The plan identifies our goals and clarifies the best path to achieve them. It also provides insights on how to align our investment strategy with our goals and the level of risk that we’re comfortable taking. If the stock market volatility is giving you angst, now would be a great time to develop or update your plan. We will see exactly where you’re at on the path to achieving your goals. If need be, it will allow us to make the necessary adjustments to get you back on track. This peace of mind will keep us from making emotional decisions when it comes to our investments.

Diversify At times, it may make sense for us to lean more one way or another toward asset classes when it comes to investing in the stock market, but it’s important to always hold a mix of asset classes that do not respond the same way to similar kinds of risks. We don’t know which asset class will perform best from year to year. But we do know that having a mix of asset classes will decrease volatility and create a smoother ride over time. We’re also likely to experience a higher compound return, providing better financial outcomes and a higher likelihood of achieving our goals. There are a variety of factors that can cause major market corrections (i.e., tech bubble, mortgage crisis, recession, etc.), but the tools to survive stock market volatility are the same: Stay the Course, Develop a Financial Plan and Diversify. May / June 2016

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