Fall 2013 TRIAD: Volume 24, Number 4

triad FALL 2013

VOLUME 24 ISSUE 4

THE AWARD WINNING JOURNAL OF THE MICHIGAN OSTEOPATHIC ASSOCIATION

WOMEN’S HEALTH IN THIS ISSUE:

• Specialists

Identify Top Women’s Health Issues

• Breast

Cancer Risks, Detection and treatment

• Affordable

Care Act (ACA) Essential Health Benefits

TRIAD, fall 2013

1

We reward loyalty. We applaud dedication. We believe doctors deserve more than a little gratitude. We do what no other insurer does. We proudly present the Tribute® Plan. We go way beyond dividends. We reward years spent practicing good medicine. We salute a great career. We give a standing ovation. We are your biggest fans. We are The Doctors Company.

Richard E. Anderson, MD, FACP Chairman and CEO, The Doctors Company

You deserve more than a little gratitude for a career spent practicing good medicine. That’s why The Doctors Company created the Tribute Plan. This one-of-a-kind benefit provides our long-term members with a significant financial reward when they leave medicine. How significant? Think “new car.” Or maybe “vacation home.” Now that’s a fitting tribute. The Michigan State Medical Society exclusively endorses our medical malpractice insurance program, and we are a preferred partner of the Michigan Osteopathic Association. To learn more about our program benefits, call our East Lansing office at (800) 748-0465 or visit www.thedoctors.com/tribute.

Exclusively endorsed by

www.thedoctors.com 2

TRIAD, fall 2013

TA B L E O F C O N T E N T S

FEATURES 12

Top Women’s Health Issues

16

Breast Cancer Risks, Detection and Treatment

18

Affordable Care Act: Essential Health Benefits

7

DEPARTMENTS

12

ACA

5

Editor’s Notebook

6

President’s Page

7

D.O. Spotlight

8

AMOA News

9

Student Spotlight

10

Legislative Update

11

Intern-Resident Prospective: Vitamin D Deficiency and Pregnancy

21

The Practice Manager

22

Dean’s Column

18

Advertiser index Association Benefits Company................................................4 Health Law Partners PC........................................................24 Kerr Russell..........................................................................17 Keystone Pharmacy..............................................................23 MSU Communications PR Department.................................23

Pinkus Dermatopathology Laboratory..................................17 Premier MRI CT...................................................................20 The Doctors Company...........................................................2 Wachler & Associates PC.....................................................20

TRIAD, fall 2013

3

4

TRIAD, fall 2013

e di t or’s no t ebook

A

s the holidays are nearing and we are reminded of what really matters in life, we turn your attention to women’s health issues. Arguably, the women in our lives are the glue that holds us together. It’s our wives, mothers, grandmothers, sisters and aunts who, in general, take care of us. But, the question remains, who is taking care of them?

by JOHN SEALEY, D.O.

Our cover story highlights the top five health issues women face today: heart disease, breast cancer, osteoporosis, depression and auto-immune disease. We bring you the latest in terms of treatment and diagnoses, what’s on the horizon and what non-specialists can do. Below are some highlights of what our members had to say about each health issue.

Laila Shehadeh, D.O. tackles both heart disease and osteoporosis. Dr. Shehadeh reminds us that more “women than men die of heart disease every year” and “nearly 80 percent” of those diagnosed with osteoporosis “are women.”

On Depression, Katherine Jawor, D.O., a psychiatrist in Muskegon, says “Women experience immense and frequent changes in family and life situations… Supporting these changes is a top concern when you consider the economy of women.”

“Breast cancer accounts for nearly a quarter of all cancer diagnoses, 14 percent of all cancer deaths and is the second leading cause of cancer death in women,” says Jason Beckrow, D.O., FACOI. John Tower, D.O. says “Autoimmune diseases are much more common in women, particularly in women of child bearing years. There are about 23 million Americans affected by autoimmune diseases many of those who are women.”

A common theme throughout is encouraging all physicians to maintain the osteopathic principles which include working in partnership with your patients by finding out their family medical history, educating the patient(s) on health issues and paying attention to their bodies.

Our intern/resident perspective also brings to life vitamin D deficiency and pregnancy. In her article, Dr. Shania Seibles explains “The best time to approach prevention of adverse maternal and fetal outcomes [due to vitamin D deficiency] during pregnancy is prior to pregnancy... patients who are considering pregnancy should be counseled and screened more thoroughly.”

Should you have any questions regarding these issues, I encourage you to reach out to the osteopathic physician authors who were interviewed within these articles.

John Sealey, D.O. is TRIAD Co-Editor-In-Chief and a member of the MOA Board of Trustees. He can be reached at driverjws@aol.com.

TRIAD, fall 2013

5

P R E S ID E N T ’ S P A G E

A

Osteopathic medicine is such a huge part of our lives and who we are. We have worked hard to be able to heal with our hands, hearts and minds. However, that ability can sometimes turn into an obstacle. The burden of being a physician is that you never stop being a physician.

There are many things that keep me up at night, which include: the increased complexity of regulatory oversight, coding and billing, physician shortages, documentation requests, changes due to the Affordable Care Act, and the list goes on and on. One thing I know for certain, especially as the President of the Michigan Osteopathic Association (MOA): the MOA is here for you.

by MICHAEL D. WEISS, D.O.

Our association exists for one reason: to help our member physicians succeed. Your membership of the MOA helps to advance our profession and each other. Each of you provide the tools needed to offer top-notch educational programs, discounted insurance, experiences with payers, advocacy and much more. More importantly, your membership shows your commitment to promoting and preserving osteopathic medicine. Together we can do so much more than we could otherwise. There is strength in numbers.

As you receive your membership renewal statements, I’m reminded that my own membership allows me to: • Build my knowledge and keep it current, including full access to every MOA publication.

• Share my perspective and make a difference. I am involved in the work that matters to me and my profession.

• Gain expert support to help my practice and my career.

• Enjoy savings on insurance, financial services, medical supplies, legal advice and much more.

We also work on your behalf to protect your professional interests in the legislative, regulatory and public policy arenas on issues that can affect you, your practice and, ultimately, your career.

By providing our policymakers with information, resources and recommendations, the MOA represents the osteopathic community while protecting the public interest, and promotes public awareness and confidence in the integrity and competence of osteopathic physicians.

Over the past year, we’ve: • Supported pro-physician candidates through the Michigan Osteopathic Political Action Committee (MOPAC).

• Worked with policymakers on the development of a universal prior authorization form to make it more efficient for usage.

• Joined the coalition to expand Medicaid to nearly 470,000 Michigan residents over the next several years.

• Continued to urge our policymakers against expanding scope of practice, preserving your years of education and training.

As you renew or consider your membership to the MOA, I strongly encourage you to take the next step and support MOPAC. I want to thank you for your commitment to your patients and the osteopathic community. I look forward to working with you as we prepare for the future of health care.

MOA President Michael D. Weiss, D.O. is in private practice in obstetrics and gynecology and serves as the director of the Women’s Wellness Institute in Rochester Hills. He may be reached at doctorstork@sbcglobal.net.

6

TRIAD, fall 2013

D.O. SPOTLIGHT julie sherbin-sher, d.o.

Julie Sherbin-Sher, D.O. grew up immersed in the osteopathic philosophy.

“My exposure as a child was only through osteopathy, as my father is an osteopathic otolaryngologist. I agreed with the osteopathic principles and practice. I felt treating the body as a whole, especially with diet and nutrition, would be very beneficial for my patients,” she says.

julie sherbinsher, d.o.

In college at Michigan State University (MSU), she studied art to balance pre-med classes and had been conflicted over which way to proceed. She remembers back to Psychology 101 at MSU, which opened her eyes to the field of behavioral health.

“I decided to take the more helpful and medically challenging path,” she recalls. Sherbin-Sher graduated from MSU in 1993 with a Bachelor of Fine Arts in three-dimensional art. She went directly to the University of Medicine & Bioscience in Kansas City, Missouri and decided to continue her career as an osteopathic physician. She felt that being in psychiatry as an osteopathic physician would further her interest in holistic mental health.

After graduating in 1997, Sherbin-Sher did her osteopathic psychiatric residency at Henry Ford Hospital. She worked in private practice for approximately four years, where she says she learned a lot about managing patients in a quicker environment.

“I’m an only child and both my parents are from Michigan, so I decided to stay here. I have since met my husband from Bloomfield Hills and we have three beautiful girls. I’ve always called Michigan my home,” she explains.

Sherbin-Sher currently works for an indigent clinic in New Baltimore. She also trains students from multiple universities in her office. Additionally, she is on staff at McLaren Macomb, Beaumont Hospital in Troy, and Henry Ford Hospital.

Fun for Sherbin-Sher is going out with her husband and meeting new and interesting people, as well as traveling.

As an osteopathic physician, she discusses plant-based holistic nutrition, regular exercise and other lifestyle changes that will positively impact her patient’s lives.

Of the latest in her job as a psychiatric osteopathic physician, she says: “Psychiatry is a very academic and challenging area. There are many new modalities that are arising in the field such as transcranial magnetic stimulation (TMS), brain scanning and genetic testing. There’s also been talk of improved reimbursements through insurance companies.”

Sherbin-Sher carries the legacy of growing up in an osteopathic household proudly, weaving it into her own life as an osteopathic professional.

“I am a very proud and happy osteopathic physician. Helping other people with the direct approach of psychotherapy, diet and nutrition is the best and most fulfilling job,” she says.

Julie Sherbin-Sher, D.O. is board certified by the American Osteopathic Board of Neurology & Psychiatry. She specializes in psychiatry and is clinically interested in anxiety and mood disorders.

TRIAD, fall 2013

7

AMOA NEWS

B

by Veronica Gracia-Wing

FROM THE AMOA PRESIDENT

by Dana Borenitsch

eing one of the advocates—as we hope your spouse is—gives us another responsibility to be “doing” something we believe in. As your spouse, we are your support, the backbone of the profession.

Out of the outrageous number of things your wife does in a given day, I bet you can count on one hand the things she does for herself. She is usually the “go to” person for your family. If it needs doing, she does it; if she sees a need, she does it; helping someone, she’s there; along with the grocery shopping, cooking, cleaning, nursemaid, chauffeur, gardener, counselor, encourager and a “fixer” of whatever needs fixing.

She does an insurmountable number of things for everyone. Many times she is the most important person in the world to so many! Because of this you need to be sure she is taking care of herself! In her busy world, is she seeing her doctor or her specialist regularly? (I’m guilty of not doing this.) Her annual checkups, vaccines, scans, etc.; is she watching what she eats?

Exercising? (Guilty again.)

If she’s too busy to take care of herself, who will our families be able to depend on and get unconditional love from if she’s not around? You also can only do so much in a given day.

You may be parents of small children and she may even be trying to balance a career on top of that. She needs to TRY to take the time to be sure she gets her checkups, and so should you. YOU ARE BOTH PRICELESS! We believe and prioritize the health and well being of our patients, immediate and extended families, friends, and even pets. We need to do the same for our spouses and ourselves!

We have all been created for a special purpose that only we have been designed to do.

So we need to stay healthy to fulfill our divinely orchestrated mission. I believe our purpose is to be a blessing as we serve others, believing in the various groups we’re involved in and giving it our “all”. We need to do everything in our power to be the best and healthiest we can be.

We are priceless in God’s eyes, to those we love and who love us.

S TAY H E A LT H Y !

Dana Borenitsch is the president of Advocates for the Michigan Osteopathic Association. She can be reached at dborenitsch@hotmail.com.

8

TRIAD, fall 2013

STUDENT SPOTLIGHT

by Veronica Gracia-Wing

W

hen Sister Mary Lisa Renfer was applying to medical school, she looked at both allopathic and osteopathic schools.

“The more I learned, the more I was drawn to osteopathy. I appreciate the way that osteopathic medicine emphasizes communication and treating the whole person, as well as the power of physical touch. There is something so unique in the way that we can interact with each other person to person,” she explains.

SISTER MARY LISA RENFER

A great draw for her towards osteopathic medicine was the emphasis on building trust with patients. She was also drawn to the possibility of using Osteopathic Manipulative Medicine (OMM) in a clinic setting, as she understood it to help so many with chronic pain issues for patients that have turned from one medication to another without success.

Renfer grew up as the second of seven children around southeast Michigan, mostly in Plymouth.

Faith became the center of her life at a young age. It was when she was in middle school that she first thought about becoming a nun. In high school and college she became involved in various service experiences, hoping to fill that desire to serve.

“This desire lead me to pursue pre-medical studies when I began college at Franciscan University of Steubenville in Ohio, in the hope of someday helping to alleviate the suffering of others,” she says.

She met the Religious Sisters of Mercy of Alma, Michigan in June of 2009, the summer after her junior year of college. A unique aspect of the community was their commitment to higher education in order to be of greater service to those in need. She knew she had found what she had been looking for - she joined the community on September 8, 2009. She was given the new name of Sister Mary Lisa when she became a novice in 2010, named after Saint Elizabeth of Hungary, a young woman from the Middle Ages who spent her life in service of the poor and the sick.

“After two years at our Motherhouse in Alma, I was sent to our convent in DeWitt, Michigan to apply to medical school and begin my senior year at Michigan State University. I was delighted to be accepted to the College of Osteopathic Medicine at MSU and began my medical studies the next year,” Renfer recalls.

The emphasis on treating each patient as a whole person is very important to Renfer.

“Throughout our curriculum we keep coming back to that main concept. I have found that it helps us not only as we begin to have patient encounters in the clinic setting, but also in the way that we interact with each other as a class. I have never felt like we were working against each other as a medical school class, but instead that we are helping one another throughout the process, and I think that this is part of the D.O. experience,” she says.

She has also greatly enjoyed learning OMM and working at the Student OMM Clinic.

“The people who come to the clinic often have many problems they have been dealing with for years, and it is a privilege to be able to connect with them and offer even some relief both in the OMM treatment and in the conversations that we have during their time with us.”

As a religious sister, Renfer goes where she is sent, so there is always an adventure and mystery to her future. At this time, it is her hope and that of her community that she will pursue obstetrics and gynecology as a specialty, with a focus on fertility awareness methods of family planning.

On why service is integral to her life, she says: “Service is important to me because it reminds me that my life is not given to me for me alone. The gifts that I have and the joys that I experience do not reach their full potential unless I give of myself for others.”

Sister Mary Lisa Renfer is a second year student at Michigan State University College of Osteopathic Medicine TRIAD, fall 2013

9

L E G I S L ATI V E U P DAT E

T

by KEVIN MCKINNEY

he Legislature faces some tough issues that have been short of reaching any progress for some time. The first issue and number one priority for Governor Snyder is improving the funding for the transportation infrastructure in Michigan – both roads/bridges and public transit. The task of raising more than a billion dollars in new revenue to fix our crumbling road and bridges has been a daunting task and a heavy political lift. Despite the Governor’s willingness to put forward his own plan, which he most recently abandoned, to increase the gas tax and car registration fees as primary funding mechanisms, there has been very little support in the legislature. And, while there is more interest in increasing the sales tax and placing it on the statewide ballot for voter approval, the politics do not line up very well to get the necessary two thirds legislative super majorities in both chambers. Even with legislative leadership holding quiet conversations with the governor in hopes of finding some compromise, there is the looming 2014 November elections that will be on everyone’s mind as they contemplate such unpopular measures to support.

If the road funding issue cannot be resolved this fall, its only hope may be in the lame duck session in December of 2014.

Equally controversial and perhaps even more contentious is the issue of Michigan’s Auto NoFault system and ways to make reforms that will preserve the system. Auto insurers have been unsuccessful in attempts this session to move House Bill (HB) 4612. This bill would place limits on the lifetime medical and rehabilitation benefit, create significant barriers for access to care with little lasting – only one year – premium reduction for the policy holders. The bill, in its current form, continues to struggle on the House floor with almost twenty House Republicans joining the House Democratic caucus in opposition. The latest response from the auto insurers has been the recent introduction of HB 4959, which would allow those eligible for Medicare to opt out of the Personal Injury Protection (PIP) benefit. While on first blush the policy sounds attractive, quick analysis between the two different coverages of Medicare and Auto No-Fault shows the vast difference in benefits and the diminution of coverage if HB 4959 should pass. The Coalition Protecting Auto No-Fault (CPAN) continues to oppose these changes being pushed by the insurers as they will push more liability onto taxpayers and dramatically reduced benefits.

I anticipate that this issue will rage on in the Legislature during the fall session and, if not resolved, will also wait until the lame duck session.

Senate Bill (SB) 2, the APRN scope of practice expansion proposal, is still pending on the Senate floor and remains unclear if and when there will be vote on the measure. It may well be pushed into a larger discussion with a yet to be introduced measure by Senator Jim Marleau, who is the chair of the Senate Health Policy Committee. His measure takes a boarder view of the healthcare workforce issue. The Michigan Osteopathic Association’s (MOA) Council of Government Affairs (CGA) has established a small workgroup to review Senator Marleau’s bill draft in detail and will report to both CGA and the MOA Board of Trustees in the coming weeks. The workgroup will determine if the proposed policy actually addresses the current issues of access to care in the underserved areas of Michigan.

Kevin McKinney handles the MOA’s Governmental Affairs and He may be reached at kevin@mckinneyandassociates.net 10

TRIAD, fall 2013

Additional policy issues the MOA supports: • Immunization Waiver Exemptions Working in partnership with the other physician organizations and local health departments to address the recent spike of immunization waiver exemptions in Michigan. Some data is high enough to impact the “herd immunity” in certain counties. A public awareness campaign and, perhaps, a legislative response may be part of the plan.

• Anaphylaxis Two bills addressing anaphylaxis (HBs 4352-4353) requires school districts to have non-patient specific auto epinephrine injectors in the school buildings and providing civil immunity for those prescribers/dispenser and school personnel in administering epipens.

• Marketing Healthcare Services HBs 4875-77 which deal with healthcare services being marketed and offered as a benefit even with significant co-pays and high deductibles will get a hearing in the House Health Policy Committee.

• Specialty Tier Formulary A policy to address the increasing use by insurers of a Specialty Tier formulary in requiring high co-insurance for certain specialty drugs will be introduced and hopefully carefully examined. The MOA will continue to work with several patient advocacy groups on this issue in hopes of providing some relief to patients suffering from certain chronic diseases who are unable to afford their medications.

While the fall agenda is always subject to change, there is full expectation anything that may be controversial will likely be taken up during this fall session, ending in mid-December – or it may get pushed to late next year during lame duck. The MOA will continue to work with other stakeholders on these issues and provide you with the knowledge and information needed to be effective communicators with your own legislators. Through the MOA’s communications, the use of the D.O. Connect (http://mi-osteopathic.org/DOConnect) and the strong activities of the Michigan Osteopathic Political Action Committee (MOPAC), Michigan’s osteopathic physicians will continue to succeed in being a valued and credible voice in the legislative and political process. I encourage you to visit http://mi-osteopathic.org/TakeAction often which will allow you to communicate with your legislators on these issues and more.

F E AT U R E

Vitamin D Deficiency and Pregnancy: What Can You Do? by shania seibles, D.O., JD

Vitamin D deficiency has long been thought to be common among pregnant women and has been shown to be associated with an increased risk of preeclampsia, gestational diabetes mellitus, and/or pre-term birth. The best time to approach prevention of adverse maternal and fetal outcomes during pregnancy is prior to conception. Optimization of individual health status should always be a priority, however, patients who are considering pregnancy should be counseled and screened more thoroughly.

As primary care providers in the state of Michigan, patients are seen every day for routine care or sick visits and these are excellent opportunities for screening for Vitamin D deficiency since all of our patients are considered at higher than normal risk. Vitamin D status can be assessed by measuring serum 25-OH-D levels which can be added to other routine health maintenance laboratory studies. Generally, a serum level of at least 32 ng/mL or 80 nmol/L is considered adequate. Most prenatal vitamins contain Vitamin D, however, only in amounts around 400 IU per tablet. If a patient is identified as having a deficiency, it is safe to administer 1,000-2,000 IU daily, and up to 4,000 IU daily during pregnancy or lactation are thought to be safe.

Even though Vitamin D deficiency has been shown to be associated with adverse maternal and fetal outcomes during pregnancy, there is no current evidence suggesting that we should use Vitamin D supplementation to prevent these outcomes. Additionally, there are no evidence-based recommendations for routine administration of Vitamin D during pregnancy beyond that included in the prenatal vitamin.

At this time, I believe that all reproductive aged women in Michigan should be screened for Vitamin D deficiency and treated if deficiency is evident. This will help to optimize maternal health status once pregnancy is achieved. If pregnancy has already been achieved, Vitamin D status should be assessed with the initial prenatal laboratory panel and treated when present. Hopefully, the current research on Vitamin D and its effects on pregnancy will provide more insight to is role in adverse maternal and fetal outcomes.

REFERENCES: 1. Vitamin D: Screening and Supplementation During Pregnancy.

Committee Opinion No. 495. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011; 118:197-8.

2. WHO. Guideline: Vitamin D Supplementation in Pregnant Women.

Geneva, World Health Organization, 2012.

TRIAD, fall 2013

11

A Look At the Top Concerns In

WOMEN’S HEALTH

By VERONICA GRACIA-WING

In this important issue of TRIAD,

OSTEOPOROSIS

we turn to the specialists to

Laila Shehadeh, D.O. | Henry Ford Macomb Gynecology Clinical professor for MSUCOM

gain an understanding of the top concerns in women’s health.

We interviewed members of the Michigan Osteopathic Association who addressed what colleagues identified as the top five concerns in women’s health: osteoporosis, heart disease, autoimmune disease, depression and breast cancer.

Here’s what they had to say.

Why is osteoporosis a top concern in women's health?

Osteoporosis is a major public health threat for 44 million Americans—nearly 80 percent of whom are women. Women spend 1/3 of their life menopausal when estrogen is depleted and the risk for fractures increases greatly. Before the Women’s Health Study in 2002 many women took hormone replacement therapy as they entered menopause, which protected them against developing osteoporosis. As women stopped using hormones they were left with the risks of bone thinning and bone fragility leading to osteoporotic fractures. Once a patient suffers a vertebral fracture, which typically occurs first, they have a two to three fold increase of a hip fracture, which may lead to their loss of independence and post-surgical risks.

According to the National Institutes of Health more than 1.5 million osteoporosisrelated fractures occur annually in the United States. Although vertebral fractures are the most common single site of fractures, non-vertebral fractures are more common than vertebral fractures as a whole. The most common sites of non-vertebral fracture include-hip (approximately 300,000 fractures annually), wrist (approximately 250,000 fractures annually) and other sites (300,000 fractures annually). Studies show patients who experience a vertebral fracture have a 19 percent chance of another fracture within the first year following said fracture.

What is the latest in osteoporosis treatment?

Bisphosphonates such as Fosamax, Actonel, Atelvia, Boniva, Zoledronic Acid (Reclast or Zometa) are the mainstays of osteoporosis medicines today. Evista is an option if a patient can’t tolerate bisphosphonates. Other treatments include parathyroid medications such as Forteo, monoclonal antibody drugs such as Prolia (Denosumab), Calcitonin and Estrogen.

How can D.O.s help?

• Recommend at least 1,500 mg of calcium and 1,000 units of vitamin D per day • Advise weight bearing exercises, smoking cessation and decreasing alcohol intake 12

TRIAD, fall 2013

F E AT U R E What else should we know about osteoporosis?

Osteoporosis is an epidemic. The National Osteoporosis Foundation guidelines recommend that postmenopausal women and men aged greater than 50 years should be considered for pharmacologic treatment to reduce fracture risk if they have: • Hip or vertebral fracture • T score < -2.5 by central DXA at the femoral neck or spine • Low bone mass and 10 year probability of hip fracture >3% • Ten year probability of any major osteoporosis-related fracture > 20% based on the U.S. adapted World Health Organization algorithm

HEART DISEASE Laila Shehadeh, D.O. | Henry Ford Macomb Gynecology Clinical professor for MSUCOM

Why is heart disease a top concern in women's health?

How can D.O.s help?

Although heart disease is often thought of as a problem for men, more women than men die of heart disease each year. The mortality is higher in women because heart disease symptoms in women can be different from symptoms in men. Every 90 seconds a woman has a heart attack in the United States. Before menopause women are protected from heart disease by estrogen, but as soon as menopause hits, risks become the same.

Educate patients on the things women can do to reduce risk of heart disease:

Symptoms are more subtle in women than in men: it’s not that crushing chest pain men experience because women tend to have blockages not only in their main arteries, but also in the smaller arteries that supply blood to the heart—called small vessel heart disease or microvascular disease. Other symptoms may include neck, shoulder, upper back or abdominal discomfort; shortness of breath; nausea or vomiting; sweating; lightheadedness or dizziness; and unusual fatigue. Because of these vague symptoms for women they may show up in the emergency room after a heart attack has occurred.

• Quit smoking or don’t start smoking.

Heart disease risk factors include high cholesterol, high blood pressure, diabetes and obesity. Other factors are metabolic syndrome (combination of fat around the abdomen), high blood pressure, high blood sugar and high triglyceride, which have a much greater impact on women than men.

• Women under the age of 65 who have a family history of heart disease should pay particularly close attention to the heart disease risk factors.

Women of all ages should take heart disease seriously since it’s the number one killer of women in the United States.

Mental stress and depression affect women’s hearts more than men’s. Depression makes it difficult to maintain a healthy lifestyle and follow recommended treatment.

Smoking is a greater risk factor for heart disease in women than in men. Low levels of estrogen after menopause pose a significant risk factor for developing cardiovascular disease in the smaller blood vessels.

• Exercise 30 to 60 minutes a day on most days of the week.

• Maintain a healthy weight.

• Eat a diet low in saturated fat, cholesterol and salt.

• Be compliant with medication regimens that are prescribed by your doctor.

• See your doctor on a regular basis.

What is the latest in heart disease treatment?

Statins, beta-blockers and aspirin.

What things are on the horizon?

Minimally invasive procedures and more research on heart disease in the female population. The focus is shifting to prevention as opposed to treatment.

TRIAD, fall 2013

13

DEPRESSION/ MENTAL HEALTH Katherine Jawor, D.O. Community Mental Health of Muskegon

AUTOIMMUNE DISEASE John E Tower, D.O., FACOI President and Medical Director of Arthritis Physicians LLC Chief of Rheumatology Beaumont Health System-Troy

Why is osteoporosis a top concern in women’s health?

Autoimmune diseases are much more common in women, particularly in women of child bearing years. There are about 23 million Americans affected by autoimmune diseases many of those who are women. There are about 80 different types of autoimmune disease. Some are organ specific, where others can affect many organs.

It is important that people realize that autoimmune diseases can be mild or more severe.

What is the latest in autoimmune disease treatment?

In more severe conditions, there is more targeted therapy that reduces the triggering part of the immune system. This represents a new form of therapies that are available in the last 10 to 15 years, specifically for Rheumatoid Arthritis (RA) and most recently Lupus. These therapies block the trigger that stimulates the autoimmune disease to create this misdirected inflammatory response producing symptoms of arthritis and many other symptoms that may be the effect the autoimmune response.

There is a great deal of ongoing interest and research being done in the areas of targeted therapy. Additionally, we have long had knowledge of the link to hormonal changes in the body. For instance, some conditions get better in pregnancy. Unfortunately it is still unclear as to how the positive effect occurs whereas in other situations hormonal changes may accentuate symptoms.

Another area in of interest is the genetic link and “susceptibility” to autoimmune disease that runs in families.

Pine Rest Christian Mental Health Services

Why is depression a top concern in women’s health?

Women experience immense and frequent changes in family and life situations. They suddenly find themselves in roles of having to care for children, as a single parent or with a partner, and aging parents. Supporting these changes is a top concern when you consider the economy of women.

What is the latest in depression treatment?

Treatment is two-pronged: psychotherapy, where patients can talk about the stressors causing depression, and medications, antidepressants and anti-psychotics (for depressions that are resistant).

As D.O.s, we, of course, look at the whole person, trying to understand any medical issues that might exacerbate mental health challenges. We also look to the potential causes of mental health issues, whether it’s a thyroid concern or family dynamics.

What things are on the horizon?

Electroconvulsive treatments (ECT) for the very resistant depression. Transcranial magnetic stimulation (TMS) is a less invasive alternative to ECT.

Finally, an increased understanding of the effect of chronic inflammation has on the acceleration of atherosclerosis in women with autoimmune disease.

There is also exciting new research where saliva tests are taken and analyzed to see what category of anti-depressants a patient would be a good candidate to use.

How can D.O.s help?

How can D.O.s help?

Primary care physicians can be very helpful in the earlier screening for cardiovascular diseases as well as autoimmune disease in their female patients.

Primary care physicians can recommend therapy, understanding that medications aren’t the only option when addressing mental health concerns. They can also look at stressors in the patient’s life to see what might be contributing.

What else should we know?

Depression is rather common. Help is out there for the any one of us that become depressed.

14

TRIAD, fall 2013

F E AT U R E

BREAST CANCER Jason R. Beckrow, D.O., FACOI Founder, Lighthouse Oncology Medical Director, Hospice at Home

Why is breast cancer a top concern in women’s health?

The impact of breast cancer is omnipresent and a significant women’s health priority.

For women born in the United States, one out of every eight will face a breast cancer diagnosis in her lifetime. Breast cancer accounts for nearly a quarter of all cancer diagnoses, 14 percent of all cancer deaths and is the second leading cause of cancer death in women. It is estimated that 242,000 women in the U.S. will be diagnosed with invasive breast cancer, and 40,030 women will die from the disease in 2013.

What is the latest in terms of treatment?

Advances in breast cancer therapeutics have been leading the way forward for decades, starting with advances in surgical techniques leading to breast conserving surgical strategies and limited field radiation. Targeted therapy in cancer care grew out of targeting the estrogen receptor with medications such as Tamoxifen followed by aromatase inhibition and Her-II receptor blockade.

We are now moving into the molecular era both for therapeutics and diagnostics.

We routinely employ a 21-gene analysis for risk stratification and treatment decision making for women with hormone receptor positive breast cancer.

What things are on the horizon?

Future research will continue to seek highly tuned targeted and molecular therapies especially triple negative and pre-menopausal breast cancer. On the diagnostic side, improvements in breast imaging modalities as well as genetic markers will continue to evolve and shape our treatment paradigms.

MOA’s commitment Women are much more than our patients. They are our mothers, daughters and sisters. They are caretakers and leaders. They are our friends and colleagues. The health of the women in our lives, both personal and professional, is vital to a thriving community.

The Michigan Osteopathic Asso-

How can D.O.s help?

ciation is committed to providing

Primary care physicians have always been and will always be the foundation of medical care. Patients who are lucky enough to have established a trusting relationship with their primary care doctor will have an added layer of support and an advisor to turn to, especially when difficult treatment decisions must be made.

the best for women by staying on the leading edge of care.

What else should we know?

In addition to the best quality medical therapeutics and biologic understanding of cancer and carcinogenesis, the ideal physician will also understand the incredible emotional, spiritual, social and existential concerns that a majority of our patients will experience. The emerging field of Supportive Oncology, which is the intersection of medical oncology and non-hospice palliative care, is growing to serve this multifactorial need.

Osteopathic physicians have valued the care of the “whole” patient since our inception and are ideally suited to lead this important initiative.

TRIAD, fall 2013

15

were in their first year of menopause.

Physicians should discuss with these patients the option of ordering a digital mammogram.

keeping breast cancer risks at forefront can lead to early detection and treatment By jacqueline ross, phd, rn | senior clinical analyst department of safety, the doctors company

T

he grim reality is that one in eight women will be diagnosed with breast cancer over a lifetime. Breast cancer is second only to lung cancer in causing cancer deaths among women, with 220,000 newly diagnosed cases and 40,000 deaths each year in the United States. Fortunately death rates from breast cancer have been declining since 1990s due to early detection, screening and increased awareness.

because women with these genes have a high probability of contracting breast and ovarian cancer. A woman who has a sister, mother, or daughter who had breast cancer -- especially if cancer was in both breasts, was pre-menopausal, or occurred in more than one firstdegree relative -- is two or three times more likely to develop breast cancer.

Physicians should encourage individuals with this history to consider genetic counseling.

Although the causes of breast cancer are not well known, some risk factors are understood. The majority of women with breast cancer have no direct family history of breast cancer. The chance of getting breast cancer increases with age. Two-thirds of women diagnosed with breast cancer are ages 50 and older. Most of the rest are ages 39 to 49, with a much lower number of younger women also diagnosed. Some other risk factors related to breast cancer include being female, radiation exposure, never being pregnant, having your first child after the age of 35, beginning menopause after 55, postmenopausal hormone therapy, never having breast fed, obesity, drinking more than one alcoholic beverage a day, and having dense breast tissue which can mask the presence of a cancerous tumor.

Occasionally malpractice issues may arise related to breast cancer. In examining the last six years of closed claims data from The Doctors Company involving breast cancer claims, most cases involved a diagnosis-related failure (92%) and multiple specialties (radiologists, gynecologists, general surgeons, pathologists, family medicine & internal medicine).

As with any risk factor, some of these can be controlled, but many cannot.

For example, hereditary factors cannot be controlled. The BRCA1 and BRCA2 gene mutations account for about 20 to 25 percent of hereditary breast cancers and about 5 to 10 percent of all breast cancers. Much has been done in regards to genetics research, specifically regarding identification of the BRCA genes 16

TRIAD, fall 2013

Thirty percent of the cases included a misinterpretation of diagnostic test, such a mammogram, according to an analysis of factors leading to claims. This contributing factor primarily involves the specialty of radiology. Research has shown that screening mammograms may miss 10-20% of breast cancers. A study in the New England Journal of Medicine compared traditional mammograms to digital mammograms.

The digital mammogram is stored in a computer, can be manipulated better for visibility and clarity, has a lower average lower radiation dosage, but is more costly. The findings showed that digital mammograms were superior to traditional mammograms for three groups of women: those under 50 years old, those with dense breasts (a risk factor in breast cancer), and those who were premenopausal or who

Some patients may be confused about when to begin screening mammography because recommendations vary.

The American Cancer Society and the Susan G. Komen Foundation recommend that women over 40 get annual mammograms, whereas the U.S. Preventative Task Force recommends screening mammograms should begin at 50, and younger patients should discuss with their physicians when to initiate screening mammography.

Mammograms are more apt to be diagnostic as women age, because the breast becomes less dense with aging which increases the sensitivity of mammography.

Another issue seen in almost 30% of the breast cancer claims was a delay in ordering diagnostic tests, like mammograms or breast biopsies. A general surgeon may have thought a breast lump was a cyst and recommended waiting rather than getting a biopsy when in fact the lump was a breast tumor. In one case, a family practice physician thought a 38-year-old patient had fibrocystic disease and did not need mammography or referral. The tests were delayed and her breast cancer progressed. Breast cancer can only be excluded by biopsy.

Breast cancer remains a major concern for women and their families. Communication between providers and patients is vital. Physicians should work closely with their patients to obtain a comprehensive history because many risk factors for breast cancer are known. Screening continues to improve outcomes. Early diagnosis and treatment are essential to promote patient safety and reduce risks.

Contributed by The Doctors Company.

For more patient safety articles and practice tips, visit their website at: www.thedoctors.com/patientsafety.

The guidelines suggested in the article at left are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each health care provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

YOUR PATIENTS EXPECT THE HIGHEST STANDARD-OF-CARE FROM YOU. You should expect the same from your dermatopathology laboratory.

As a member of your healthcare team, Pinkus Dermatopathology Laboratory offers the reliability, convenience, expertise and accessibility you and your patients deserve.

• Over 60 years experience in delivering excellence in dermatopathology • Board-certified dermatopathologists read every case,

with over 2 million cases analyzed • 99.7% of results reported in one business day • Consultations with a dermatopathologist 7am-5pm Monday-Friday • Affordable and reliable analysis of dermatological specimens

Pinkus is proud to serve physicians and patients nationwide.

Isn’t it time you chose Pinkus Laboratory?

EXPERT INTERPRETATION | RAPID RESULTS | EXPERIENCE YOU CAN RELY ON toll free 800.746.5870 | www.pinkuslab.com 1314 N. MACOMB STREET, P.O. BOX 360, MONROE, MI 48161 | 32669 WEST WARREN, SUITE 10, GARDEN CITY, MI 48135

Patients trust doctors.

Doctors trust Kerr Russell.

A successful medical practice requires more than talented physicians and a desire to heal.

Let Kerr Russell provide the legal insight needed to manage and grow your practice.

PRACTICE FORMATION • TAX MATTERS • PURCHASE, SALE AND LEASING OF REAL ESTATE • EMPLOYMENT CONTRACTS PRACTICE PURCHASES AND SALES • MALPRACTICE AND ALL OTHER COMMERCIAL LITIGATION • MEDICAL STAFF PRIVILEGE MATTERS STARK LAW, ANTI-KICK BACK, FRAUD AND ABUSE AND OTHER REGULATORY MATTERS • LICENSING MATTERS

T R U S T E D

P A R T N E R S

One Detroit Center 500 Woodward Avenue | Suite 2500 Detroit, Michigan 48226-3427 tel (313) 961-0200 Please contact Daniel J. Schulte or Patrick Haddad dschulte@kerr-russell.com phaddad@kerr-russell.com

W W W.K E R R - RUSS E LL .CO M

Established 1874 TRIAD, fall 2013

17

association

benefits

company

Services, Savings, Solutions, Simplicity

“THE ESSENTIALS” The MOA Insurance Team (MIT) portfolio of insurance offers the following products and services:

D

HEALTH BENEFITS UNDER THE U AFFORDABLE CARE ACT U

Michigan Osteopathic Association

Free COBRA Administration

H.S.A.’s (Health Savings Accounts) H.R.A.’s (Health Reimbursement By peggyArrangements) a. leiby F.S.A.’s (Flexible Spending Accounts)

T

U

Premium Only Plans – at no cost

U

Medical, Dental, Vision (Group & Individual) All Carriers!

U

Life Insurance, Long Term Care, Short/Long Term Disability (Group & Individual)

Support the team that supports the MOA!

he Affordable Care compliant Act Plan Descriptions U Legally 1. Summary Ambulatory Patient Services– (ACA) makes a about numbereligibility ask Care you receive without being admitted to a hospital—for example,

Our team of changes to private at a clinic, physician’s office or same-day surgery center. for Medicare eligible’s U Plan options health insurance plans. approach focuses One important protecWho benefits? In 2008, 74% of U.S. adults had at least one ambulatory care visit.

on partnering tion is the establishmentContact of a package of today for a no obligation quote Julie “Essential Health Benefits” which must more 2. Emergency Services with you and and/or to learn about how the MIT can help be covered beginning in 2014.

Care for conditions which, if not immediately treated, could lead to

you meet your professional insurance goals.

your staff

This protection will allow people to serious disability or death. to provide know exactly which health benefits are 248.359.6489 or to the Centers for Disease Control and Prevention (CDC),

Who benefits? According 21% of included in insurance plans and make customized ext.

167 1.800.782.0712 adults visited an emergency room in 2009. The average ER visit cost $1,265 in 2008. sure that services most people will need solutions to all at some point in their lives are available.

The following summary gives a brief definition of the 10 “Essential Health Benefits” (EHB) and, when available, the percentage of people who have a need for the care and the average cost to an individual. Unless otherwise noted, data are from the Medical Expenditure Panel www.

Survey (MEPS), large-scale surveys of individuals, medical providers, and employers. (While the data presented is several years old, it is used as it provides a nationwide view of cost information, which can vary widely by region.)

18

TRIAD, fall 2013

3. Hospitalization insurance and board, care Care you receive as a patient in a hospital, such as roomyour from doctors and nurses, and tests and drugs administered during your stay. needs.

Who benefits? The CDC estimates 8% of people spent at least one night in a hospital in 2010.

Based on 2009 national data from the Agency for Healthcare Research and Quality (AHRQ), the average hospital stay was 4.6 days and the average cost was $9,173.

association-benefits .com 4. Maternity and Newborn Care

Care provided to women during pregnancy and during and after labor; care for newly born children

Who benefits? About 4 million babies are born each year in the U.S. The average cost for an uncomplicated pregnancy and delivery at a hospital is about $7,600 (in 2004 dollars).

F E AT U R E

5. Mental Health and Substance Use Disorder Service (including behavioral health treatment)

Care to evaluate, diagnose and treat mental health and substance abuse issues.

Who benefits? The average annual cost to treat someone with a mental health or substance abuse issue was $1,531 in 2007.

6. Prescription drugs

Drugs prescribed by a doctor to treat an acute illness, like an infection, or an ongoing condition, like high blood pressure.

Who benefits? According to the CDC, 48% of people reported using at least one prescription in the previous month in 2008. People using one or more prescriptions in 2004 spent an average of $1,037.

7. Rehabilitative and habilitative services and devices

Services and devices to help people with injuries, disabilities or chronic conditions gain or recover mental and physical skills.

Who benefits? he range of care is diverse: fitting someone with an artificial limb, helping a child with a development disability participate at school, treating an athletic with a sports injury, helping a stroke victim regain speech skills and more. Looking only at Medicare beneficiaries in 2000 and considering only outpatient therapy services, 8.6% of people received care, and the average cost per person was $581.

8. Laboratory services

Testing blood, tissues, etc. from a patient to help a doctor diagnose a medical condition and monitor the effectiveness of treatment.

Who benefits? The American Clinical Laboratory Association estimates that lab tests enter into 70% of medical decisions, but account for less than 3% of health care spending.

While the ACA requires coverage for each of these categories, the law does not define the specific services that must be covered or the amount, duration, or scope of services. The HHS Secretary will define the specific benefits within each of these categories.

The ACAâ&#x20AC;&#x2122;s requirement that essential health benefits be covered without annual dollar caps will provide patients with more health benefits and a lesser financial burden. Millions of people will benefit from coverage of these essential services.

Americans have been waiting a long time for substantial coverage of services that are essential to their health. The requirement that plans cover these essential health benefits offers a pathway to comprehensive health insurance for all Americans.

9. Preventive and wellness services and chronic disease management

Preventive or wellness services include routine physicals, screening, and immunizations. Chronic disease management is an integrated approach to manage an ongoing condition, like asthma or diabetes.

Who benefits? According to a 2010 MetLife study, 45% of employer-provided benefit packages include a wellness program and a quarter include a disease-management program. MetLifeâ&#x20AC;&#x2122;s 2009 study reported 57% of employees participated when a program was available to them. Employers usually offer these programs at no cost to employees, in hopes that the programs will reduce their healthcare cost over time. Wellness program providers often quote a savings of $3 for every $1 invested.

10. Pediatric services (including dental and vision care)

The other nine essential benefits, but provided to kids. Of course, the mix of services and common conditions treated are quite different for different age groups.

TRIAD, fall 2013

19

MRI available at:

CT available at:

CT available at:

29275 Northwestern Hwy., Suite 175 Southfield, MI 48034

44200 Woodward Ave., Suite 112 Pontiac, MI 48341

46325 W. Twelve Mile, Suite 100 Novi, MI 48377

Premier

MRI CT

20

TRIAD, fall 2013

t he p r a c t i ce m a n a ge r

W

omen face many roles in the ever-changing, modern world that we live in. Many play more than one part, maintaining a career, a family or both. From the young to the elderly we often neglect the health issues that men also have to deal with, including the numerous additional risk factors that are brought on by simply just being a woman.

by mimi owens

All of our patients must maintain good health habits – preventive care, exercise and diet. Women need to stay current on their health screenings for early cancer detection. With the pressures of reproductive health information and Pap smears starting in early womanhood, a woman’s annual trips to the doctor start much earlier than their male counterparts. Breast cancer screenings are ordered for all of our patients over 40. Patients aged 50 and over are given Fecal Occult Blood Test (FOBT) kits and sent for colorectal or sigmoid examinations. As a woman’s age increases, comes a decrease in hormones and osteoporosis bone density testing is done to evaluate bone fracture risk. Fibromyalgia is on the rise and has been proven to be more prevalent in women.

An increase in hypertension and cardiac risk factors just add to a long list of worries every woman faces, not to mention her regular every day struggles In a fast paced stressful world many of our patients are so overwhelmed with caring for others that they sometimes tend to forget to care for themselves. Regular screenings and mental health awareness are critical elements to staying healthy. We must strive to develop ways to address female mental health as well as their physical well being.

As a woman and practice manager, I understand the additional health challenges that women face. Stress affects many women differently and, often, women mask their emotions, whether to try and be strong and play the “super woman” role or in shame of their feelings sometimes even by self medicating. Many of our female patients face similar issues yet react differently. Hormones, stress levels and family support may play a part in the reaction to emotional distress and depression. Eating disorders such as anorexia and bulimia go undetected until it is, sometimes, too late.

Communication is the key. As health care professionals we have to train our staff to develop a trustworthy approach in communication with our patients to give them the comfort to share their stories. Suggesting exercise, yoga and group activities, as well as therapy with or without antidepressants, have been proven to turn a person’s whole well being around. mimi owens can be reached at driverjws@aol.com.

TRIAD, fall 2013

21

DEAN’S COLUMN ADDRESSING MORTALITY AMONG POOR WHITE WOMEN IS IMPORTANT FOR ALL As a husband, a father of daughters and a physician, I am personally and professionally concerned about women’s health. So when I read articles like the one in “American Prospect” magazine focusing on how white women who have not graduated from high school are dying, on average, five years earlier than their peers a generation ago (http://bit.ly/15hzA0w), I’m troubled.

by William Strampel, D.O.

This is not an isolated story. In an article from the “Journal of Health and Social Behavior,” researchers noted a growing gap between the mortality rates among less-educated white women and those with more than a high school education. The authors looked at social-psychological, economic and health behaviors and found possible links between increased mortality and factors like whether women were smokers, were not educated beyond high school and did not have access to desirable employment. The correlations were not definitive on the reasons why the disparity exists.

It seems that in study after study the findings are the same, but no one seems to be able to adequately explain why they are occurring or how we can address them. We know that for all Americans that lifestyle factors like smoking and lack of exercise contribute to serious chronic conditions and a shortened life span, but why are mortality rates increasing more significantly among poor white women? Are they more socially isolated than their African American or Hispanic sisters? Does geography play a role? Are they more likely to abuse controlled or illegal substances? Does education play a greater role than among other demographic groups?

It’s true that more definitive answers to questions like these can be used to shape policies and develop aggressive education and action steps, but this is an issue that can’t wait for the future.

We need to do more to help low-income white women and other underserved audiences get access to health care before they are critically ill. They need to be able to find treatment in places other than their local emergency room.

I’m pleased that this issue of “Triad” is adding to the conversation and information available about women’s health. It’s a critical dialogue that we must continue. It’s also important that scientists at institutions like Michigan State University keep investigating why the mortality disparity exists and what we can do to reduce or eliminate it.

I’m also very proud that the MSU College of Osteopathic Medicine has a long history of providing access to health care for many underserved audiences, including poor white women. It’s at the very core of our mission and our profession and it will continue to be an important focus of our service efforts.

It’s critical that we continue to work to provide better medical care for all and to discover the answers to questions about how we can improve life expectancy for the women in everyone’s lives.

William Strampel, D.O., is Dean of the Michigan State University College of Osteopathic Medicine. He can be reached at pat.grauer@hc.msu.edu.

22

TRIAD, fall 2013

TRIAD Staff John W. Sealey, D.O. & Craig Glines, D.O., Editors-in-Chief William Strampel, D.O., Contributing Editors Kris T. Nicholoff, Executive Director Lisa M. Neufer, Director of Administration Kevin M. McFatridge, Manager of Communications Cyndi Earles, Director, MOA Service Corporation Shelly M. Madden, Manager of Membership Marc A. Staley, Manager of Finance Wendy Batchelor, Manager of Physician Advocacy Carl Mischka, Advertising Representative Keystone Millbrook, Layout and Cover Design 2013–2014 Board of Trustees Michael D. Weiss, D.O., President Myral R. Robbins, D.O., President-Elect Robert G.G. Piccinini, D.O., dFACN, Secretary/Treasurer Edward J. Canfield, D.O., Immediate Past President Kurt C. Anderson, D.O., Past President Lawrence J. Abramson, D.O., MPH, & Bruce A. Wolf, D.O., Department of Insurance Lawrence L. Prokop, D.O. & Chaun Gandolfo, Department of Public Affairs John W. Sealey, D.O. & Craig Glines., D.O., MSBA, FACOOG, Department of Education Jeffrey Postlewaite, D.O. & Jasper Yung, D.O., Department of Membership

WE’RE DOING WHAT

WE DO BEST IN THE PLACES WE’RE

NEEDED MOST. Celebrating our 4,324 Spartan alumni, 3,200 volunteer clinical faculty, and 42 partner hospitals

College of Osteopathic Medicine

www.com.msu.edu

The osteopathic profession in Michigan is made up of osteopathic physicians, osteopathic hospitals and an osteopathic medical school. This TRIAD stands together to serve our patients and one another. TRIAD, the official journal of the Michigan Osteopathic Association, serves Michigan’s osteopathic community, including its osteopathic physicians, hospitals, medical school and patients.

The Michigan Osteopathic Association will not accept responsibility for statements made or opinions expressed by any contributor or any article or feature published in TRIAD. The views expressed are those of the writer, and not necessarily official positions of MOA. TRIAD reserves the right to accept or reject advertising. The acceptance of an advertisement from another health institution or practitioner does not indicate an endorsement by MOA. TRIAD (ISSN 1046-4948; USPS 301-150) is published quarterly by the Michigan Osteopathic Association, 2445 Woodlake Circle, Okemos, MI 48864. Periodical postage paid at Okemos, MI 48864 and other post offices.

Subscription rate: $50 per year for non-members. All correspondence should be addressed to: Communications Department, Michigan Osteopathic Association, 2445 Woodlake Circle, Okemos, MI 48864. Phone: 517.347.1555. Fax: 517.347.1566. Website: www.mi-osteopathic.org. Email: moa@mi-osteopathic.org.

POSTMASTER: send address changes to TRIAD, 2445 Woodlake Circle, Okemos, MI 48864. ©2013 Michigan Osteopathic Association TRIAD, fall 2013

23

24

TRIAD, fall 2013