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September / October 2016 • Volume 115 • No. 5
Solutions for Physician
ALSO IN THIS ISSUE 06 Providing Smartphones, Tablets, and Other Devices to Employees to Facilitate Information Flow
10 Online Learning Modules:
Helping to Manage Physician Burnout
18 CANDOR Toolkit: The Right Tools to Do the Right Thing After an Adverse Event
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Managing Editor September/October 2016 • Volume 115 • No. 5
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KEVIN MCFATRIDGE EMAIL: KMCFATRIDGE@MSMS.ORG
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Physicians Take On Burnout and Provide Solutions By Allie McLary for MSMS
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CANDOR Toolkit: The Right Tools to Do the Right Thing After an Adverse Event By Robin Diamond, MSN, JD, RN, Senior Vice President of Patient Safety and Risk Management, The Doctors Company
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President’s Perspective By David M. Krhovsky, MD Join the Conversation: Caring for the Caregiver
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By Jalyn Ingalls, MA, Influenza Epidemiologist, Michigan Department of Health and Human Services Division of Immunization Recommending the Flu Vaccine for the 2016-2017 Season: What You Should Know
State Medical Society (MSMS), is dedicated to providing
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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
HIT Corner Online Learning Modules: Helping to Manage Physician Burnout
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the conduct and policy of the magazine, subject to the policies of the MSMS Board of Directors. Neither the editor nor the state medical society will accept responsibility for statements made or opinions expressed
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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
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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.
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Join the Conversation: Caring for the Caregiver BY DAVID KRHOVSKY, MD This issue of Michigan Medicine focuses on a problem that greatly interests me, both personally and professionally — physician health and wellness. Within the past few years, there has been a resurgence in discussions surrounding stress and burnout, specifically how it relates to the health care profession.
caught in the crossfire as they strive to provide excellent service to both patients and the physicians they work for. Physicians can take the lead in transforming their practices into a healthy work culture.
and change that will demonstrate to a new generation of physicians how much their health and wellness matters along with the patient’s. We hope to establish healthy coping mechanisms as physicians navigate the ever-changing world of health care.
When I’m with my staff, I encourage lightheartedness, especially at the beginning of meetings, to lighten the mood and put people at ease. We interact socially when possible, and it’s important that they feel empowered to address issues that negatively affect their work life. Encouraging staff to strive for a healthy work-life balance directly correlates to the happiness and health of the practice in general.
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s the caregiver, it sometimes feels as though everyone wants something from you all the time. It’s important to understand and be aware that life is about far more than work. It’s too easy to let personal needs go unaddressed in order to serve others, and it’s a challenge that all physicians and their staff struggle with. We need to serve as leaders in our field and address burnout to establish ways of becoming an advocate for ourselves and our staff in this industry. Health care professionals are trained to be tough and work hard no matter how sick or fatigued they are. But in reality, sometimes life presents situations that physicians just can’t handle on their own. In the past, to admit needing a coping resource was often viewed as failure, but it’s time for physicians to get past that. Fortunately, hospitals and other institutions across the state are revitalizing their physician wellness committees in an effort to bring greater awareness to the problem. There are now resources undergoing development and promotion that are available to physicians who feel stress and burnout. By taking advantage of these resources, physicians will be better equipped to move on personally when life throws them a curve. Institutions like Spectrum Health are actively searching for solutions by creating and providing seminars that address burnout. But it’s more than just attending workshops. These institutions are taking a closer look at where burnout starts, and they are making changes to their onboarding and other processes to reflect these findings. It’s through ideas, conversation 4
But how do we do that?
How do we, as experienced physicians, serve as the example when we all feel that strong pull of responsibility, pressure and love that comes with our profession? The answer is both simple and complicated – make time for your own interests. It’s important to take the time outside of work to focus on tasks or hobbies you really enjoy. I enjoy reading, playing golf and spending time with my wife, kids and two grandsons. My family is my greatest treasure, and I learned a long time ago that simple things in life give me the greatest satisfaction. Find what works for you. A valued mentor once told me there are very few work-related tasks that can’t wait until tomorrow. Physicians serve as role models for their patients and peers. If we’re practicing healthy behaviors, then we’re more likely to have those conversations with our patients – and that means more than just the physical habits. Taking the time to center yourself and find the space or activity that allows for relaxation and down time is a great way to take a step back from your work and allow your mind a break. But the issue of burnout doesn’t only apply to physicians. Their staff also can get MICHIGAN MEDICINE
We know that employees who are cognizant and intentional about maintaining their own health and well-being will be much better equipped to give patients the best care possible, whether in the office or in the hospital. As leaders, we must recognize and encourage this. It is incumbent upon us to provide our teams with the necessary downtime during the work day to regroup and recover. Maintaining a balance between work and a personal life always will be a challenge for those working in health care. But by joining the conversation, sharing coping mechanisms and empowering peers and staff to find the solutions that work for them, we can prevent burnout from affecting our health care professionals. It’s our job to point the way forward and provide solutions that can endure through the changing landscape of health care.
Doctor Krhovsky, a Grand Rapids anesthesiologist, is president of the Michigan State Medical Society
September / October 2016
Save the Date 59TH ANNUAL ALLEN SILBERGLEIT, MD CLINIC DAY
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In the recently opened Education Center (located just inside the South Patient Tower) Continental Breakfast & Program: 7:15 a.m. – 12:30 p.m. Luncheon will immediately follow the program. For more information, contact Via Barias, Via.Barias@stjoeshealth.org or phone: 248-858-6017
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Providing Smartphones, Tablets and Other Devices to Employees to Facilitate Information Flow BY DANIEL J. SCHULTE, JD, MSMS LEGAL COUNSEL QUESTION:
ANSWER:
I have noticed lately that practices
There are many advantages to enabling your employees to access and transmit patient information from the palm of their hands. You are wise to consider the legal risks up front. There are two important legal considerations that you should address.
are providing smartphones, tablets and other devices to their employees. These devices are used to facilitate/increase the flow of patient information that more and more is in an electronic form. I am considering making the investment necessary to keep my practice up to date and to enable my employees to do their jobs more efficiently. I would like to know what I should be concerned with before I go any further.
The first is ownership of the patient record information. You should have a written policy reminding your employees that all patient record information is owned by the practice not the employee. The fact that the information is in an electronic form and a copy of the information resides on an electronic device does not mean it is no longer owned by the practice. Your employees should sign an acknowledgement that they understand and agree that whether a patient record is on paper in their briefcase or a PDF saved on a smartphone or tablet (and regardless of who owns the device) the information is owned by the practice and cannot be viewed, used, transferred, etc unless doing so is in the course of their employment duties. Your practice should be the owner of the devices that will be used by employees to store, view, transmit, etc patient record information. Your written policy should restrict the use of patient record information to only these devices and expressly prohibit employees from doing so on their personal devices. The second consideration is the security of the patient record information while it is stored and used by employees via mobile devices. HIPAA requires that, as a starting point, your practice conduct a risk assessment. This assessment should be documented in writing and identify the ways your patient record information could be taken/used inappropriately as a result of its availability on mobile devices. HIPAA next requires that your practice have a
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written policy addressing all the security risks identified by your assessment. The risk assessment and written policy will obviously vary practice to practice. However, most will contain certain critical policies:
• Mobile devices remain in the office unless they are removed for an employee to perform a job function. • An incident response plan dictating what to do if a breach of patient record information occurs. • An annual review/update of the risk assessment that takes into account and addresses any incidents that have occurred, new risks identified, breaches of the policies by employees, etc. • Encryption of patient record information when in transit. • Password management. • Active monitoring of who is accessing patient record information. Audits and enforcement actions related to HIPAA compliance are becoming more and more common. When they result from a reported breach (made by an upset patient, disgruntled employee or otherwise) of patient record information it is the lack of a risk assessment and/or written policies and not the breach itself that results in penalties being assessed. You must fully comply with HIPAA by conducting a risk assessment and adopting proper policies prior to providing mobile devices to your employees. Daniel Schulte, JD, MSMS Legal Counsel, is a member of Kerr Russell Attorneys and Counselors
September / October 2016
Volume 115 • No. 5
MICHIGAN MEDICINE
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M D H H S
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Recommending the Flu Vaccine for the 2016-2017 Season: What You Should Know BY JALYN INGALLS, MA, INFLUENZA EPIDEMIOLOGIST, MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES DIVISION OF IMMUNIZATION The Advisory Committee on Immunization Practices recommends that everyone aged 6 months and older receive an influenza vaccine during the 2016-2017 flu season, as the flu vaccine is the single best way to prevent the flu.
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n the 2014-2015 flu season, only 44.3 percent of people eligible for the flu vaccine in Michigan received the vaccine, with the following breakdown by age: 52.6 percent of children aged 6 months through 17 years, 35.7 percent of people aged 18 through 64 years, and 65.7 percent of people aged 65 years and older. Overall, flu vaccination rates in Michigan have been slowly trending upward for the past four influenza seasons but are still low in comparison to other states. In order to best protect their patients, it is important that physicians strongly recommend the flu vaccine to patients and also set an example by getting the flu vaccine for personal protection and to protect those around them.
At their June meeting, the Advisory Committee on Immunization Practices (ACIP) voted that live attenuated influenza vaccine (LAIV), also known as the nasal spray flu vaccine FluMist®, should not be used during the 2016-2017 flu season. ACIP still recommends that everyone aged 6
months and older receive the flu vaccine. This change in recommendation should not discourage the practice of recommending, stocking, and administering the annual flu vaccine. New research supported changing this recommendation. Data presented by the Centers for Disease Control and Prevention (CDC) showed that overall vaccine effectiveness for LAIV was 3 percent for children aged 2 through 17 years, whereas the inactivated influenza vaccine (IIV) was 63 percent effective. It is still unclear why LAIV was not as effective in preventing flu during the 2015-16 flu season, however officials will continue to research LAIV to determine why it was ineffective. This situation is an example of scientific research influencing new policies that improve public health responses and overall population health. Flu vaccines are monitored on an ongoing basis, and health officials are continually working to improve the effectiveness of these vaccines.
Patients who are concerned about the recommendations and are skeptical about getting their annual flu vaccine should still be encouraged to get the vaccine. These talking points can be used when recommending flu vaccines this upcoming fall: Research and data have shown that FluMist® was not as effective in preventing the flu, but the flu shot was effective in preventing the flu. This recommendation change is an example of using research to improve public health policy, and overall population health. Though FluMist® was ineffective, this is not a reason to skip getting an effective form of the flu vaccine. Some protection against the flu is better than no protection. We understand that shots can be scarier for patients than the nasal spray, especially for children, but the poke of a flu shot is much better than the pain that comes with the flu. There are strategies that can be used to ease the pain of receiving an injection. Encourage parents to sit down and hold the child during the injection, and possibly bring a toy to help distract the child. The parent may want to give their child something to look forward to after receiving the vaccine, such as a favorite meal or snack. Another distraction technique that can be helpful is to get the child to cough during the injection. You can also encourage parents to talk to their children about the positive aspects of shots. For example, parents can say “I know shots can hurt, but they are very helpful to you. Shots can help you from getting really sick.” Patients are much more likely to get vaccinated and have their children vaccinated when health care providers give a strong recommendation for vaccination. Please continue to protect patients from the flu by promoting, recommending, and administering flu vaccine.
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September / October 2016
Welcome New MSMS Members! Angela Collins, MD Genesee
Meghana Tipparthy, MD Genesee
Adam Asarch, MD Kent
Sharmistha Dev, MD Washtenaw
Charles Frank MD Genesee
Larry Ansari, MD Ingham
Nicholas Blank, MD Kent
Terence Joiner, MD Washtenaw
Diana Khalil, MD Genesee
Timur Baruti, MD Ingham
Michael Lacroce, MD Kent
Emily Shuman, MD Washtenaw
Mahin Khan, MD Genesee
Michael Coleman, Jr, MD Ingham
Stephen Macedo, MD Kent
Aubrey Allen, DO Wayne
Hafiz Khan, MD Genesee
Adam Burch, DO Jackson
Jarrad Utter, MD Kent
James Blessman, Jr, MD Wayne
Lakshmi Kollu, MD Genesee
Nishant Chaudhary, MD Jackson
Katherine Naber, DO Lapeer
Emily Boes, DO Wayne
Kiran Kommaraju, MD Genesee
Michele Johnson, DO Jackson
Sosa Kocheril, MD Livingston
John Iljas, DO Wayne
Shujing Lin, MD Genesee
Samantha Mishra, DO Jackson
Justin Grill, DO Muskegon
Mohammed Nayeem, MD Wayne
Vinisha Noti, MD Genesee
Miraflor Reyes-Ganzon, MD Jackson
Joshua Grant, MD Oakland
Yagnaram Ravichandran, MD Wayne
Lisa Ochoa, DO Genesee
Matthew Routh, DO Jackson
Nader Meri, MD Oakland
Felecia Williams MD, MBA Wayne
Prathapraju Poloju, MD Genesee
Benjamin Sulka, DO Jackson
Aaron Wood, DO Oakland
Stephanie Simon, DO Genesee
Michael Redinger, MD Kalamazoo
Evon Schexnaydre MD, FACOG Ottawa
Volume 115 • No. 5
MICHIGAN MEDICINE
OBITUARIES The members of the Michigan State Medical Society remember with respect their colleagues who have died. Victor Bloom, MD Wayne County Medical Society Died June 24, 2016 Jack L. Tromp, MD Barry County Medical Society Died June 27, 2016
w To make a gift or bequest to the MSMS Foundation, please contact: Rebecca Blake, Director 517-336-5729 | rblake@msms.org
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Online Learning Modules Helping to Manage Physician Burnout In June of 2015, the American Medical Association (AMA) launched an interactive 24/7 online practice transformation series designed to address administrative burdens that are leading to physician burnout. The AMA’s STEPS Forward™ initiative is designed to offer “innovative strategies that will allow physicians and their staff to thrive in the evolving health care environment by working smarter, not harder. Physicians looking to refocus their practice can turn to AMA STEPS Forward™ for proven, physician-developed strategies for confronting common challenges in busy medical practices and devoting more time to caring for patients.” As reported in the AMA Wire®, a 2013 AMA study with the RAND Corporation found that providing high-quality care was the primary driver of physicians’ professional satisfaction while obstacles to providing that care were found to be major sources of stress. The following observations from Christine Sinsky, MD, an internist in Dubuque, Iowa, and Vice President of Professional Satisfaction at the AMA reflect those findings, as well as the need for physician-developed practice transformation tools: “When I was a young physician, only a few years into my practice, I realized that if I was going to stay in practice and thrive, I needed to change the way I organized my work…I realized that I needed to spend much less time documenting the visit and chasing after results and find a way to spend more time really focused on the patient. Otherwise, I wasn’t going to be able to stay in practice.”
Current Featured Modules » Preparing your practice for value-based care » Pre-visit planning » Preventing physician burnout 10
Additionally, physicians who have used the AMA’s practice transformation series have reported positive changes. “Before, there wasn’t enough time in the office visit to get it all done,” one physician said. Another physician noted that using these solutions led to a rediscovery of the “beauty of reconnecting with my patients.” Currently, there are 35 educational modules, with more expected in the future. These modules are developed by physicians and categorized as follows: • Patient Care (11) • Workflow and Process (12) • Leading Change (4)
“Taking great care of our patients is why we get up in the morning—it is not to enter into this vortex of frustration,” Dr. Sinsky said. “We need to improve the efficiency of the practice, and by doing so, to create the time to do the work we know is most valuable.”
• Professional Well-Being (3) • Technology and Finance (5) Examples of topics covered by the AMA’s STEPS Forward™ collection of practice improvement modules include, but are not limited to: planning end-of-life decision with your patients, preparing your practice for value-based care, medication adherence, improving blood pressure control, adopting a patient pre-registration process, implementing a daily team huddle, team documentation, quality improvement using Plan-Do-Study-Act, preventing physician burnout, adopting telemedicine in practice, electronic health record implementation, and revenue cycle management. MICHIGAN MEDICINE
As previously mentioned, all of this can be done online and at a time that is convenient for the physicians and/or their staff. The modules can be accessed at www. STEPSforward.org. On the webpage for each module, physicians will find steps for implementation, case studies and downloadable tools and resources. Physicians completing the modules can also earn continuing medical education credit. Additional stories on the AMA’s STEPS Forward™ modules may be found at http:// msms.org/STEPSForward. The American Medical Association and the AMA Wire® contributed to this article. September / October 2016
Serving healthcare providers for over 30 years
Volume 115 • No. 5
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Solutions for Physician 12
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September / October 2016
Health care professionals carry an inordinate amount of responsibility, working every day to provide the highest quality of care to their patients. Starting as early as medical school, future physicians, nurses and administrators work around the clock to learn and put their caregiving expertise into practice. This hard work, pressure and stress can lead to burnout for physicians and their staff. Physicians are taking on the issue of burnout, voicing the importance of self care in an industry focused on helping others. By practicing healthy behaviors and coping mechanisms, physicians and their staff can more efficiently treat their patients and share those healthy habits. They’re speaking up about the symptoms and how to address burnout in a way that can stand the test of time and work for all generations of health care professionals. Volume 115 • No. 5
Marwan Abouljoud, MD, FACS, CPE, MMM Director of Henry Ford Transplant Institute Henry Ford Hospital (pictured at left)
How does burnout come about? I think the general issue of burnout typically begins when people start getting busy and sacrifice components in their lives that are important for them, such as self care, hobbies, etc. They lose the sense of reward and meaning. Specifically, in health care, physicians are working in a competitive market where they’re expected to always do good and keep up on the changes in health care. Many are working 60 to 70 hours a week while hearing what they need to do differently or better, instead of the great job they are currently doing. Things like sacrificing a social life, the perceptions of the world on health care providers and recovering from a hard day are pressures some physicians deal with well, but many don’t. Burnout isn’t just limited to physicians, it’s also present in nurses and other medical staff. Physicians shouldn’t just be hired for a job, but for a life-long career where they can advance and grow.
What are the symptoms of physician burnout? As a result of burnout, physicians fall on a scale of emotions starting with emotional exhaustion, moving to depersonalization and then finally losing their sense of personal accomplishment. These feelings create a disconnect between their care and their patients. Most physicians feeling burnout fall in the emotional exhaustion category, the precursor to depression. They are physically there, but not present. Loss of glory, feeling drained and experiencing a lack of drive, initiative and purpose are all signs of emotional exhaustion. MICHIGAN MEDICINE
In cases of depersonalization, physicians often refer to patients as a room number and describe a particular event in a very impersonal way. This detachment is often used as a coping mechanism in our profession, but a complete lack of empathy detracts from the care of the patient. It’s important for physicians to hold on to that sense of accomplishment, to feel like what they do is worth it. In an ever-changing world of treatments and technology, thank yous are few and far between. Maintaining that appreciation for what you do is an active exercise that needs to happen every day.
What behaviors can physician burnout lead to? When physicians are dealing with emotional exhaustion and depersonalization, they put up an emotional wall between them and the patient. Some of that is necessary in the medical profession, but when you build that wall so high, it can cause issues. When a physician’s quality of care declines, it has historically become a human resources issue, where they address the front-end behavior. We are now working to change the mindset and behavior of just sending the employee to HR and enacting an improvement plan to fix the problem. Instead, we train our physicians to be leaders and influencers who can confidently navigate crucial conversations, professionalism and business planning rather than turning to unacceptable behavior to cope with the stress of their profession.
How do you prevent burnout at Henry Ford Hospital? I like to think I’m not preventing burnout, but rather building a resilience to it. It’s important to be able to adjust in this changing world. I work with three or four generations of doctors, each with different schooling and training experiences. continued on page 14 13
With our younger doctors coming on board, the biggest anxiety is learning the system. We’ve adjusted the onboarding process to address the anxiety, introducing new employees to their peers six months prior and using those contacts to facilitate introductions, process explanations and more. At the other end of the scale, we’re developing a program that addresses those physicians transitioning into retirement. How can we evolve and let them serve in a different capacity, continuing to utilize the skills of those individuals without devaluing them? Our answer is to keep them as mentors and consultants. To address the depersonalization, we have a program with criteria on how to relate to a patient — how to develop empathy and connect with the patient as a human being. We’re building these programs out of effective communication and health care to provide a framework in building healthy habits.
John Billi, MD Associate Vice President for Medical Affairs University of Michigan
What does the change from Triple Aim to Quadruple Aim mean for physicians, and how does it address physician burnout?
The Triple Aim — enhancing physician experience, improving population health and reducing costs — are established goals to optimize health system performance. Recently, an additional aim was added to address physician burnout. Its focus is to improve the work life of health care providers, including clinicians and staff. There’s an increasing recognition on the cause of physician burnout, with them feeling under a lot of pressure because of the 14
pace of change and requirements to move to electronic records. According to a study conducted by the Mayo Clinic Proceedings, “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.”
my staff to come up with their own solutions, test them out and adjust if necessary.
Many feel as though they are victims of the circumstances they’re practicing in, with little control over their environment. Part of the process of moving someone from feeling like a victim of being overworked toward feeling like, “I can fix this, I can change things,” is to understand and design experiments to address these problems.
Where do physicians start in striving for a better work-life balance?
The way to accomplish the first three aims is through an engaged and empowered work force, including physicians and their staff. I feel that adding the fourth aim provides the means to accomplish the first three. If we have a satisfied, productive workforce — physicians, nurses, therapists and other office staff — they feel empowered to make change. They can think about ways to make the experience better for the patient and for the physician.
How do physicians address the new goal of improving work life for them and their staff? I’m a practitioner of lean thinking, or scientific problem solving. I don’t think the best way to solve this problem is by hiring efficiency consultants. This is about the physicians and their staff working together on identifying and solving the problems in their office — whether it’s inefficiency in office tasks or even getting your patient in the room on time. The key method we use is: 1) Go and see, 2) Ask why, 3) Show respect. Instead of assuming people aren’t trying to do a good job at work, understand there are barriers keeping staff from doing that work. I trust staff have the information to design experiments to make a patient’s experience or our processes better. This trust empowers MICHIGAN MEDICINE
More employee engagement results in a better working environment, with less stress and better efficiency in providing quality care to our patients.
It’s all about eliminating the frustrations and inefficient processes that exist in your job or office. While it’s important to take time with your family, conduct mindfulness and meditation to reduce stress, it’s also imperative to determine a process for coping with workload and other pressures. Start with the processes in place at your office. Work with your practice’s staff to determine what processes aren’t working or are taking an excessive amount of time. Are there ways to address those issues? It isn’t about errors or blame, but how the staff can design a better and more efficient way to accomplish tasks.
Christine A. Sinsky, MD, FACP Vice President, Professional Satisfaction, American Medical Association
How does acknowledging the health and wellness of physicians and staff affect a practice as a whole? Physicians and their care teams thrive when they are well-supported with the knowledge, tools, workflows and policies to do their work most effectively. When they can enjoy their work, patient care is better. When burnout is lower, then quality, safety and satisfaction is higher. Ironically, both burnout and its opposite — joy in practice — are contagious. By addressing the issues that are leading to stress and burnout in staff, ideas and solutions can catch on and spread. September / October 2016
Here's how other physicians center themselves and strive for that work-life balance: “Life is so busy and hectic both at work and at home. What really grounds me is yoga and meditation, leading me to deep levels of relaxation that I would otherwise struggle to find.”
What is the AMA STEPSforward™ program and what value does it offer physicians in regard to burnout in the health care profession?
—J. Mark Tuthill, MD
The goal of STEPSforward™ is to help physicians re-engineer their work so that it is more efficient and effective, thus more satisfying for the patient and for the team. The toolkits offer practical and actionable guidance, including checklists for expanded roles for nurses, calculators to estimate cost savings for a practice, tools to conduct successful team meetings and much more.
—S. Bobby Mukkamala, MD
There are videos of many of these innovations in action, so you can watch a team meeting, daily huddle, learn more about pre-visit planning or see how team documentation works in practice. The modules were created by physicians for physicians. They are written with expertise on the topic and reviewed by peers to provide a one-stop resource for physicians and their practices. Since STEPSforward™ launched in June 2015, more than 25,679 modules have been completed.
How can physicians incorporate the AMA STEPSforward™ in their practice? A good place to start is by filling out the practice assessment questionnaire online. It gives an opportunity to reflect on one’s current practice versus what is possible. Based on the responses, specific modules are recommended. It is often helpful to start with straightforward, relatively simple operational changes, such as instituting pre-visit laboratory testing and synchronized prescription renewals. Each of these strategies creates early wins and can save the practice 30-60 minutes of time per day. It is also helpful to hold team meetings so that medical assistants, nurses, reception staff and physicians can step aside and re-engineer the work to be more efficient and effecive, using the STEPSforward™ modules as a guide. Volume 115 • No. 5
“I try to stay balanced by being involved with activities that are completely non-medical in nature. Whether they are related to community events, social events or my hobbies, they all remind me that life is not 100 percent about my medical practice.”
“The best thing I’ve done is negotiate structured time off. The week off allows for decompression and I return the next week re-energized.” —Tom Veverka, MD, FACS
“I am extremely fortunate to have colleagues that I trust and respect. When I am not the guy on call, I can distance myself from work. My weekdays at work are highly structured to be predictable and productive. This allows me to plan free time to be with friends and family.” —Richard C. Schultz, MD
“I love activities in nature—biking, bird watching, hiking, kayaking and cross country skiing. Recently I’ve learned more about mindfulness, and my goal is to meditate 10 minutes almost every day.” —John E. Billi, MD “My satisfaction has always been a matter of appropriately prioritizing what’s important to me. I believe there is nothing more important than quality time spent with family. For me, satisfaction comes from focusing on the people you love, stayhing positive, helping others and appreciating the blessings in life.” —Pino D. Colone, MD
“Look at the big picture. By pursuing useful diversions—hobbies, exercise, relaxation and spending time with family and friends—physicians will remain healthy, extend their careers and get greater satisfaction from the practice of medicine.” —James C. Mitchiner, MD, MPH
“I have learned to say no. Instead of heaping more on an already full plate, I am delegating and looking for good results instead of perfect results. The parts of my professional life that bring me the most satisfaction are the relationships that have evolved over the past 20 years. The intellectual challenges of practicing medicine helped me set priorities. As I strive to find balance, I am consciously working to be more present in the moment.” —Rose M. Ramirez, MD “Care for yourself so you can serve others. Love your family, laugh, make time for fun, be curious, and try to get to heaven. In the end, no one will say you didn’t work enough.” —Joann Smith, MD MICHIGAN MEDICINE
15
MSMS Board of Directors Disclosures House of Delegates Resolution 25-13 states that “MSMS annually provide Michigan physicians with a list of all officers, officials, candidates and staff who receive money as salary or nonpatient care compensation from Blue Cross Blue Shield of Michigan (BCBSM) or any other insurer, medical product company or its affiliates annually in Michigan Medicine.” Following are the disclosures of the MSMS Board of Directors, officers and staff.
Tyler B. Andre, MD – None Mohammed A. Arsiwala, MD – None Anita R. Avery, MD – Outside physician reviewer, Priority Health John E. Billi, MD – None T. Jann Caison-Sorey, MD, MSA, MBA – Medical Director, Population-based Health Care Chronic Condition programs, BCBSM Adrian J. Christie, MD – None Betty S. Chu, MD, MBA – None Sandro K. Cinti, MD – None Craig T. Coccia, MD – Pino D. Colone, MD – None Stephen N. Dallas, MD, MA – None Amit Ghose, MD – None Cheryl Gibson Fountain, MD – None James D. Grant, MD – Board of Directors, Blue Cross Blue Shield of Michigan Bryan W. Huffman, MD – None Jeffrey E. Jacobs, MD – None Theodore B. Jones, MD – None
Mark C. Komorowski, MD – None David M. Krhovsky, MD – None James C. Mitchiner, MD, MPH – None S. “Bobby” Mukkamala, MD – None Bassam H. Nasr, MD, MBA – None Donald R. Peven, MD – None Rose M. Ramirez, MD – None James J. Rice, MD – None Richard C. Schultz, MD – None John J. H. Schwarz, MD – None M. Salim Siddiqui, MD – Varian Medical Systems, Palo Alto, CA Herbert C. Smitherman, Jr., MD, MPH – None James H. Sondheimer, MD – None F. Remington Sprague, MD – Board of Directors, Blue Cross Blue Shield of Michigan J. Mark Tuthill, MD – None Thomas J. Veverka, MD – None David T. Walsworth, MD, FAAFP – Blue Care Network Honoraria John A. Waters, MD – None
MANDATORY USPS STATEMENT OF OWNERSHIP, MANAGEMENT, AND CIRUCLATION 13. Publication Title
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8406
8540
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99.97%and99.97% Statement of Ownership, Management, Circulation (All Periodicals Publications Except Requester Publications)
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Sep/Oct 2016 in the ________________________ issue of this publication. 12. Tax Status (For completion by nonprofit organizations authorized to mail at nonprofit rates) (Check one) The purpose, function, and nonprofit status of this organization and the exempt status for federal income tax purposes:
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Has Not Changed During Preceding 12 Months Has Changed During Preceding 12 Months (Publisher must submit explanation of change with this statement) PS Form 3526, July 2014 [Page 1 of 4 (see instructions page 4)] PSN: 7530-01-000-9931
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PRIVACY NOTICE: See our privacy policy on www.usps.com.
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Digitally signed by Kevin M. McFatridge DN: cn=Kevin M. McFatridge, o=Michigan State Medical Society, ou=Marketing, Communications and Public Relations, email=kmcfatridge@msms.org, c=US Date: 2015.09.11 09:09:44 -04'00'
6/8/16
I certify that all information furnished on this form is true and complete. I understand that anyone who furnishes false or misleading information on this form or who omits material or information requested on the form may be subject to criminal sanctions (including fines and imprisonment) and/or civil sanctions (including civil penalties).
MICHIGAN MEDICINE
September / October 2016
2016 Education Offerings ON-DEMAND WEBINARS
BILLING AND CODING COURSES
EDUCATIONAL CONFERENCES
Visit www.msms.org/eo for complete listing of On-Demand Webinars.
For all billing and coding contact: Stacie Saylor at 517-336-5722 or ssaylor@msms.org
Visit www.msms.org/eo for a complete listing of Educational Conferences.
Physician Executive Development Programs:
NEW! MSMS/MMBA BILLING WEBINAR SERIES – NOON ON THIRD WEDNESDAY OF EACH MONTH
CARING FOR THE FINANCIAL HEALTH OF YOUR PRACTICE
• 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 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
• Compliance in the Office – 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
PHYSICIAN ASSISTANT AND NURSE PRACTITIONER SERVICES: INCIDENT TO, SPLIT SHARED AND OTHER COMPLIANCE ISSUES Date: Thurs., October 27 Time: 9:00 am to 4:00 pm Location: Sheraton Detroit, Novi Intended for: Physicians, billers/coders, and billing managers.
BILLING 101
Date: Wed., October 26 Time: 9:00 am to 4:00 pm Location: Sheraton Detroit, Novi Intended for: Physicians, billers/coders, billing mgrs.
COMPLETE CODING UPDATES FOR 2016 Date: December 8, 2016 Time: 1:00 - 4:00 pm Location: Sheraton Detroit, Novi Intended for: Physicians, billers/coders, billing mgrs.
Continental breakfast & lunch provided Date: Wed., September 21 Time: 9:00 am to 3:30 pm Location: Sheraton Detroit Novi Hotel, Novi Intended for: Physicians, PO Administrators, Practice Consultants, Office Administrators and all other health care professionals. Contact: Caryl Markzon 517-336-7575 or cmarkzon@msms.org
151ST ANNUAL MSMS SCIENTIFIC MEETING Morning, afternoon and evening clinical courses available. Continental breakfast & lunch provided Date: Wed.-Sat., October 26-29 Location: Sheraton Detroit Novi Hotel, Novi Intended for: Physicians/health care professionals Contact: Marianne Ben-Hamza 517-336-7581 or mbenhamza@msms.org
20TH CONFERENCE ON BIOETHICS Continental breakfast & lunch provided Date/Time: Sat., November 12, 9 to 4:30 pm Location: Sheraton Ann Arbor Hotel, Ann Arbor Intended for: Physicians, bioethicists, residents, students, other health care professionals, and all individuals interested in bioethical issues Contact: Caryl Markzon 517-336-7575 or cmarkzon@msms.org
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
Visit www.msms.org/eo for complete listing of On-Demand Webinars.
MSMS LUNCH-N-LEARN — Grab a lunch, click the link, and join us! • 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
Register online at msms.org/eo or call MSMS at 517-336-7581 for more information. Volume 115 • No. 5
MICHIGAN MEDICINE
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T H E
D O C TO R S
CO M PA N Y
CANDOR Toolkit: The Right Tools to Do the Right Thing After an Adverse Event BY ROBIN DIAMOND, MSN, JD, RN, SENIOR VICE PRESIDENT OF PATIENT SAFETY AND RISK MANAGEMENT, THE DOCTORS COMPANY
In the past, hospitals and physicians could appear cold and distant after adverse events. The fear of malpractice lawsuits created a culture in which physicians were expected to avoid most contact with a patient or family who might have reason to sue— and physicians certainly weren’t supposed to accept blame.
E
ven when a well-meaning physician wanted to acknowledge the tragedy and express concern, hospitals sometimes discouraged the conversation because they were afraid the doctor’s comments would implicate the hospital in a malpractice case. The actual effect of this way of thinking was just the opposite of what hospitals and doctors desired. Rather than shielding them from liability, patients and family members perceived this culture of silence as callous and uncaring, in some cases encouraging them to file lawsuits. That was then. Over the past decade the healthcare community has embraced the idea that saying “I’m sorry this happened,” or at least acknowledging that an unanticipated adverse event occurred with genuine sympathy and concern, can go a long way toward healing the relationship between the healthcare provider and patient. Physicians have moved progressively toward a culture that expects an adverse event—a medication error, for instance, or a death during routine surgery—to be followed by a full disclosure of the facts to the patient and family. Hospital administrators and physicians both can say they’re sorry for what happened and even acknowledge they made a mistake in some circumstances when a clear-cut error has occurred that could have been prevented.
18
This is not just the right thing to do; it also helps the hospital and physicians avoid malpractice litigation, especially the lawsuits motivated not by actual errors or substandard care but by patients and family members who were left angry and abandoned. Now we have not just the right idea, but the right way to execute it.
When Bad Things Happen to Good Doctors The Agency for Healthcare Research and Quality (AHRQ) developed the Communication and Optimal Resolution (CANDOR) Toolkit with the input of healthcare professionals who studied the different tools, policies, and procedures in use at various hospitals, including the disclosure resources offered by The Doctors Company. David B. Troxel, MD, medical director at The Doctors Company, served on the oversight committee, and I served on the technical advisory committee, which assessed expert input and lessons learned from AHRQ’s $23 million Patient Safety and Medical Liability grant initiative launched in 2009. The CANDOR Toolkit then was tested in 14 pilot hospitals across three U.S. health systems: Christiana Care in DelaMICHIGAN MEDICINE
ware, Dignity Health in California, and MedStar Health in the Baltimore/Washington, DC, metropolitan area. “CANDOR is one of the most important patient safety programs to be released in the last 10 to 15 years,” said David Mayer, MD, vice president of quality and safety at MedStar Health and one of the originators of the toolkit. “CANDOR promotes a culture of safety that focuses on organizational accountability; caring for the patient, family, and our caregivers; fair resolution when preventable harm occurs; and most importantly learning from every adverse event so our health systems are made safer.” This tool is just as useful for doctors as for hospitals. When a hospital is sued, physicians who were involved in the case will likely be named in the suit, whether they are employed by the hospital or not. Even though the CANDOR Toolkit is designed for hospitals, physicians should become aware of the valuable resources available to them in this toolkit, such as the videos that demonstrate how to have an effective disclosure conversation and tools that help doctors assess their own interpersonal communication skills. The toolkit facilitates communication between healthcare organizations, physicians, and patients while promoting a culture of safety, said John Morelli, MD, vice president of medical affairs at Dignity Health’s Mercy General Hospital in Sacramento, California. “The CANDOR Toolkit helps our caregivers improve how we rapidly communicate with patients and families when harm occurs. Consistent with our mission and values, we have September / October 2016
always communicated with compassion and empathy; however, the toolkit provides a framework to respond quickly and in a learned manner to patients and families while also offering support to our caregivers.”
CANDOR calls for a prompt response and specific actions after an adverse event. Within one hour, specially trained hospital staff should: Explain the facts, and what might still be unknown, to patients and family members. Contact the clinicians involved and offer assistance, because the stress and grief of the healthcare professionals can easily be over looked in these incidents.
possible. We also suggest they go to their hospital administration to find out what the hospital’s disclosure process is and how closely it follows the CANDOR plan, because a cooperative approach is ideal. Working in harmony with the hospital is easiest in a closed system, where the physician is employed and insured by the hospital. Even when the hospital and physician are in adversarial positions and limited in communication, both parties still can adhere to the best practices outlined in the CANDOR program. The philosophy and actions outlined in the CANDOR Toolkit can help hospitals and physicians avoid malpractice litigation, but even when the matter cannot be resolved and goes to trial, the fact that
the patient and doctor talked early on can make a huge difference in the outcome of the case. Patients tend to pursue litigation with a vengeance when they think the doctor doesn’t care, but they tend to be much more reasonable when they can see that the physician is a human being with emotions, regret, and sympathy for the patient. Contributed by The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/ patientsafety.
Immediately freeze the billing process to avoid further stressing the patient with a bill for the services that may have caused harm. CANDOR calls for the hospital to complete a thorough investigation within two months, keeping patients and relatives fully informed along the way. When the investigation is complete, the patient and family are provided with the findings and engaged in a discussion of how the healthcare organization will try to prevent similar adverse events in the future.
Encouraging Open Communication The investigation will not always find that the physician or other clinicians failed to meet the standard of care, and in those cases the patient and family members can still benefit from understanding what happened. In many cases, they will not sue despite their loss because they are satisfied that the hospital and physicians did their best and were forthcoming with information. The Doctors Company encourages physicians to disclose and speak to patients about unanticipated events as early as Volume 115 • No. 5
MICHIGAN MEDICINE
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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.
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 20
MICHIGAN MEDICINE
September / October 2016
Family Practices n 30+ years Royal Oak Family Practice
Over 1.2 million gross. 5 days a week, 8a to 4p, great insurance mix, great patient mix... virtually no HMO out of 8,000+ active patients. Aprox. 10% Pediatrics... One hired Physician will stay, owner will transition. It really takes 2 or 3 to best handle the practice. Real Estate with tenants available as well. Nice facility, parking, and neighborhood. Add evening or weekend hours, HMO insurances or Specialists to increase revenues. Call for more details.
n Internal Medicine Practice in Jackson (Beredo)
Long Established $ 500K gross solid Medicare practice in 2700+ sq.ft. building with large parking lot. Patients are by appointment, no Opiate seekers, room for 2 or more Physicians. Hospital follow up offers increased revenues. Asking $124,000 Real Estate offered with flexible terms including Land Contract.
n Pediatric Opportunity Downriver (Choudhury)
Pediatric practice doing 1.8 Million Gross offers a work while you buy opportunity. One Physician currently in practice will stay on as partner; it takes at least 2 to see all the Patients. If you are Board Certified this rare opportunity could be yours. Offered at $600,000 with Real Estate available.
n Pediatric Opportunity Westland/Canton or Inexpensive Suites (Duggal)
Another long established and successful practice doing $900,000+ solo, hard work but very lucrative and rewarding. Work as you BUY or whatever you have in mind. Lease or Buy the building. If you don’t wish to buy and are not a Pediatric specialist we have suites to rent CHEAP!
n Drastic Price Reduction on Family Practice, East Side (Khanna)
I now have offer a Family Practice and Building for less than the Building alone may be worth. If you are Primary Care, have association with St. John Hospital want your Own office and don’t have a lot to spend.
HOT Lease Deals! 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) • 734-808-0147 (eFax) joezrenchik@yahoo.com 248-919-0037 (office) www.michiganmedicalpractices.com Thinking about retirement, relocation or expansion of your medical practice? We have buyers and sellers for primary care, internal medicine and cardiology practices.
Volume 115 • No. 5
MICHIGAN MEDICINE
21
Brexit Update and Perspective BY NATHAN MERSEREAU, CFP®, PRESIDENT, WEALTHCARE ADVISORS
The Brexit vote (Britain’s decision to leave the European Union) was unexpected by experts. While uncertainty in financial markets is a common reality when investing, there are a few notable points surrounding this historic event: • Most politicians and businesses campaigned to keep Britain in the EU. • Polls leading up to the vote, while close, predicted Britain would remain in the EU. Voters decided by a 52% to 48% margin to leave. • The vote to leave the EU is non-binding on the UK government. Prime Minister David Cameron resigned and it is expected the next Prime Minister will honor the voters’ wishes. • Britain must now invoke a clause in the EU treaty to begin the process of leaving.
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EVENT FIRST DAY DECLINE FULL DECLINE
TIME TO RECOVER LOSSES
Japan earthquake
3/11/11
-6%
-16%
4 months
US debt ceiling debacle
8/1/11
-3%
-14%
3 months
European debt crisis
3/27/12
-3%
-11%
3 months
Source: Charles Schwab, Bloomberg data as of 6/23/16. Past performance is no guarantee of future results.
Since Britain is the first country to leave the EU, many procedures have not been tested. The process of leaving the EU is expected to take several years since various levels of negotiation will be required. Uncertainty will abound until negotiations are complete. Britain leaving the EU is another indication of voters who are unhappy with the status quo. Britain, like the US, is dealing with a number of economic issues. Other countries may consider a departure. This speculation can hinder economic investment and trade which in turn can create headwinds for global growth. How this unfolds is unknowable but we are positioned to weather it.
Perspective Unpredictable events cannot be foreseen. What is interesting and reassuring is that shocks have happened to the market numerous times in the past. Below you will see three such major shocks in recent history and what happened following each event. Since stock markets had not expected Brexit, short term uncertainty will continue to produce volatility, particularly in the European markets. The long term implications are also uncertain. It may take the next couple of years for Britain and the EU to work out new trade agreements. MICHIGAN MEDICINE
What’s an Investor to do? Smart investors maintain a diversified portfolio to deal with events just like this. This means holding a combination of stocks, bonds and alternative investments to spread out risk. While this concept seems basic, it is often ignored. The problem is that it’s boring. Many investors are impatient and they want to make money quickly. By chasing returns, they often buy stocks when they’re expensive and then abandon the holding in favor of chasing the next big thing. This cycle is harmful to investors and may prevent them from achieving their long term goals. The boring diversified approach is far sounder. What happens during a market cycle is always different but long term results are quite predictable – recovery for the disciplined investor and losses for those driven by emotions.
Nathan Mersereau, CFP® is President of WealthCare Advisors, LLC – an MSMS joint venture.
September / October 2016
Volume 115 • No. 5
MICHIGAN MEDICINE
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Advancing the practice of good medicine.
NOW AND FOREVER. We’re taking the mal out of malpractice insurance. However you practice in today’s ever-changing healthcare environment, we’ll be there for you with expert guidance, resources, and coverage. It’s not lip service. It’s in our DNA to continually evolve and support the practice of good medicine in every way. That’s malpractice insurance without the mal. Join us at thedoctors.com
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MICHIGAN MEDICINE
September / October 2016
8/16/16 11:23 AM