Winter 2014 TRIAD: Volume 25, Number 1

triad WINTER 2014 VOLUME 25 ISSUE 1

THE AWARD WINNING JOURNAL OF THE MICHIGAN OSTEOPATHIC ASSOCIATION

IN THIS ISSUE: • PHYSICIAN HEALTH LINKED TO QUALITY AND PATIENT SAFETY • WORKPLACE WELLNESS INTERVENTIONS • WELCOME TO MEDICARE vs ANNUAL WELLNESS COMPARISONS

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

FEATURES 16

Practicing What We Preach:

Exploring Physician Wellness and Burnout

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The Doctor’s Company:

Worksite Wellness Interventions

24

“Welcome to Medicare” vs Annual Wellness Visits:

What is Included?

16

DEPARTMENTS 20

24

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Editor’s Notebook

7

President’s Page

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D.O. Spotlight

10

Student Spotlight

12

Intern-Resident Spotlight

13

Legislative Update

29

AMOA News

30

Dean’s Column

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e di t or’s no t ebook

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craig glines, D.O.

s physicians, we put our patients’ health ahead of our own. We prioritize the health of others. It’s what we do and why we chose to work in health care.

But what about us — physicians? We must practice what we preach as physicians are important role models, not only for our patients and peers, but also for our families and communities. By not following our own advice, treatment and care, we jeopardize our influence in health promotion and disease prevention. Recent studies have shown that physicians who practice healthy behaviors for themselves are more likely to talk to their patients about these topics. It is imperative to recognize and support personal health at each stage of professional development, as medical students, residents, and practitioners.

In this issue of TRIAD, we are looking at physician’s health and wellness. From burnout and depression to personal health and self-awareness, we bring you tools you can use as part of your everyday life. For example: • Dr. Dike Drummond, a life and career strategist, defines burnout in three distinct symptoms and educates us on the Maslach Burnout Inventory tool; • Dr. Vincent Rimanelli, an emergency medicine physician, and Dr. Sylvia Mustonen, a family medicine practitioner, discusses the “whys of burnout” and how it’s connected to your own physician and mental health; • Dr. Robert Piccinini, talks about how to implement change once you’ve noticed the signs and impact; and, finally, • A list of tips from your colleagues on how to address and prevent stress and burnout.

I will end with a quote from Aristotle: “We are what we repeatedly do. Excellence, therefore, is not an act but a habit.” craig glines, d.o. is TRIAD Co-Editor-In-Chief and a member of the MOA Board of Trustees. he may be contacted at Craig.glines@oakwood.org.

“We are what we repeatedly do. Excellence, therefore, is not an act but a habit.” —aristotle

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P R E S ID E N T ’ S P A G E

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n a September 2013 article in The New York Times titled “Easing Doctor Burnout With Mindfulness”, Dr. Pauline Chen wrote about a patient, who from his regular doctor, received a clean bill of health. It seems, however, he felt as though his regular physician wasn’t “listening to everything [he] was trying to tell him.”

It seems, according to recent research, that burnout is common among physicians in the United States, with an estimate of 30% to 40% experiencing burnout.1

by MICHAEL D. WEISS, D.O.

It’s not necessarily surprising to me, however, how high the percentages are considering all of the changes we’ve seen in health care. From the Affordable Care and Protection Act to the ICD-10 implementation, it is a challenging time. But, as you read this edition of TRIAD, I ask that you think about why you became a physician.

It’s a noble profession… we work tirelessly to improve our patient’s physical and mental health and wellness. With the topic of this edition of TRIAD, I thought I would share with you the following from ListDose.com:

Top 10 Reasons Why Being A Doctor Is A Great Profession 10 No recession: Last I checked we are in higher demand today than we were yesterday!

9 Lots of options: With everything we know about the human body, there is much more we have left to learn!

8 Family health: It’s an advantage knowing you will be able to take care of your family.

7 Learning: It’s true. We go to school for many years, but we are fortunate enough to keep learning.

6 Respectable: I don’t know about you, but my credentials earns my instant respect.

5 Trusted: Because we are physicians, we almost instantly gain trust from our patients.

4 Successful: Being a physician has brought me a great deal of success… socially and economically.

3 Challenging: Nothing is more challenging than trying to find the best solution

in even the most intense moments.

2 Arrival of a new life: I have always been fascinated by how life is created.

Seeing this on a daily basis, instantly reminds me of how lucky I am.

1 Life saving: We save lives.

It’s important, what we do. I hope you remember that every minute of every day.

“Life is a process—just one thing after another. When you lose it, just start again.”

– Richard Carlson, Don’t Sweat the Small Stuff…and It’s All Small Stuff: Simple Ways to Keep the Little Things from Taking Over Your LIfe 1

The Journal of the American Medical Association, May 18, 2011, Physician Burnout

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.

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D.o. SPOTLIGHT

vincent rimanelli, D.O. – centered around prevention

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By VERONICA GRACIA-WING

Vincent rimanelli, d.o.

incent Rimanelli, D.O. was born to Italian immigrants in Detroit during the summer of 1965. His father was a tailor, a businessman who came to the U.S. to pursue his dream; the American dream.

“He was very successful and it was not because of education; he came to the U.S. with only a 4th grade education,” Dr. Rimanelli explains.

“My siblings and I learned that we had to hustle to be successful from his example and directives.”

Dr. Rimanelli, who worked with his father from the age of seven until heading to college, was the first to go to college and the first medical doctor in the family.

“My parents had no idea what osteopathy was, but quickly learned when the first table came back home on Christmas break,” he recalls.

College was Wayne State University followed by medical school at Des Moines University. Residency was in the Detroit area, naturally.

“As with so many people in medical school, I thought heavily on what it was I wanted to do as a resident and just what it was I wanted to be when I grew up,” he says.

Leaving his options open, Dr. Rimanelli combined his residency in internal medicine and emergency medicine. Midway through the five-year program, it became clear that emergency medicine was the path for him.

“I think, in part, the decision to do emergency medicine was because I could spend more time with family. I do love the rapid turn over and do not like to sit still. I like to stay busy,” he says.

He began moonlighting in Monroe for Monroe Emergency Physicians in 1994 and was offered a position at the Mercy Memorial Hospital emergency department in 1996 and never left.

“I met my wife at the hospital; home is here,” he says.

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Family is important to Dr. Rimanelli, as is setting an example for his team in Monroe. He strives to live a life centered around prevention, understanding that physicians have a unique looking glass into the future of the hows and whys of chronic illnesses.

“We know awareness of diet, sleep, activity and social interactions are the keys to a long, healthy lifespan,” rimanelli says.

Dr. Rimanelli translates that awareness into his own routine on a daily basis.

“I try to do a daily activity that recharges my spirit and soul. That may be something as simple as listening to music or reading, or visiting the sauna or playing racquetball,” he says.

Of the highly sought after work/life balance Dr. Rimanelli says the following: “I think overachieving in anything can deplete your energy level and eventually lead to burnout. As physicians, we’re taught very early on to wear many different hats. We’re superheroes, we’re workaholics and we’re lone rangers. We need to learn when and how to say no. That and having support at home and professionally are crucial to our stress levels.”

“As physicians, we’re taught very early on to wear many different hats. We’re superheroes, we’re workaholics and we’re lone rangers. We need to learn when and how to say no.”

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s t u d en t S P O T L I G H T

nicole saghy— FINDING A HEALTHY BALANCe

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By VERONICA GRACIA-WING

NICOLE SAGHY

ith her father’s passion for science and her mother’s clinical skills and love for helping people, Nicole Saghy is ready to make a difference in the lives of patients.

Saghy completed her undergraduate at the University of Michigan with a degree in neuroscience. While there, she worked in two research labs - one focused on behavioral and physiological research and the other was working at the University of Michigan Autism Communication Center.

“My first experience in the clinical world was after undergraduate in White Plains, N.Y. at the Center for Autism and the Developing Brain through Weill Cornell and Columbia at New York-Presbyterian Hospital,” she says.

Saghy credits her grandparents as her inspiration for following the path to becoming a D.O. Her grandfather worked as a therapist and her grandmother as an LPN. “At my grandfather’s funeral, a few of his clients told me stories of how he had saved their lives. My grandmother used to tell us stories of her work at the hospital,” she recalls. “In fact, it was my grandmother who first told me what a D.O. was. She spoke so highly of their ability to connect with and treat patients.”

She loved the idea of learning the philosophy behind healing and of osteopathic manipulative medicine. Saghy currently studies at Michigan State University College of Osteopathic Medicine and is looking forward to clerkship at Henry Ford Wyandotte.

An active student at MSUCOM, Saghy offers her service to Sigma Sigma Phi. “One of our chapter’s goals is to reach out to the community and educate them on the principles of osteopathic medicine,” she says. “Most recently, we visited an elementary school to answer their questions and show them what D.O.s do.”

As part of MSUCOM’s Community Integrated Medicine (CIM), Saghy participates in coordinating health fairs throughout Michigan to promote wellness and preventative medicine. In addition to taking every opportunity she can to help with her specialty decision-making process, she also values giving back to the community.

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“Everyone faces challenges in their lives and a helping hand can make all the difference. Right now I have the ability to give some of my time back to the community through helping at food banks and health fairs.”

“I find you can learn from most situations you’re in. through volunteering I can learn new skills from the organizations and from the people I’m working with.”

Saghy feels that her education at MSUCOM so far has made her very comfortable not only talking to patients, but also performing physical exams.

“It can be hard to get patient interaction in your first year of medical school, but the student organizations at MSUCOM make it easier. Osteopathic Manipulative Medicine is integral to being able to perform a physical exam and the OMM classes make me more comfortable palpating and knowing what I’m feeling. In our osteopathic patient care courses we’re often told about the power of touch and going through my first week of preceptorship I saw that it really does help build a rapport with patients,” she says.

“It is so important to find a happy and healthy work/life balance,” says Saghy.

“It is important for students to recognize what is working for them in balancing their life now so when changes occur in the the future, they have a baseline of what is important to them.”

She also says MSUCOM has provided her with some of the tools necessary to help her with the delicate balance that is life and medical school. She takes part in their Fit for Life program and values the osteopathic patient care course, which spends some time on how students can take care of their physical, mental, spiritual and emotional health.

“It is important for students to recognize what is working for them in balancing their life now so when changes occur in the the future, they have a baseline of what is important to them.”

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INTERN-RESIDENT SPOTLIGHT myles jen kin, d.o. – self-professed Adrenaline Junky

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By VERONICA GRACIA-WING

MYLES JEN KIN, D.O.

s a freshman at the University of California at Los Angeles, Myles Jen Kin landed a work-study job with the UCLA Police Department.

“I was 19 years old and working on a 911-only ambulance service; I loved my job and fell in love with emergency medical services,” he says.

His plan was to become a firefighter/paramedic with the Los Angeles city or county departments, but the more he was exposed to the medical side of EMS, the more he desired to expand his medical knowledge.

“During my junior year I had an interview with a local fire department,” he recalls. “It was on the same day as a chemistry midterm. I couldn’t reschedule the interview and my professor wouldn’t budge on the midterm date, so I was at a crossroads. Ultimately, I chose the midterm, which pushed me down the road to medical school.”

After receiving a degree in psychobiology from UCLA, Dr. Jen Kin attended Boston University and graduated with a degree in medical sciences.

Dr. Jen Kin credits his uncle, a D.O. board certified in internal medicine and psychiatry, with helping him further down the path of medical school and osteopathic medicine, specifically.

“He is a fantastic physician and had a profound influence on my medical career,” he says. “I actually didn’t know he was an osteopath until college; when I discovered that, I started to explore osteopathy.”

Dr. Jen Kin attended Lincoln Memorial University - DeBusk College of Osteopathic Medicine and is currently in residency at Genesys Regional Medical Center in emergency medicine. He is active in the American Academy of Emergency Medicine as a member on the national education committee and the vice president’s council. He is of further service as a mentor for the American College of Osteopathic Emergency Physicians and Emergency Medicine Residents’ Association.

“It’s a privilege to be where I am. I feel so fortunate to have been able to go through medical school and mentoring is a way for me to help pay that forward,” he says. “I relate easily with students, understanding their struggles with finances and time.”

Balance is one of the things Dr. Jen Kin tries to help students manage.

“Achieving a balance is a big priority for me. It’s difficult, but I’ve learned it’s all about making priorities and decisions. I sacrifice things like social activities, television and sometimes sleep to do the things I’ve decided are important to keep in my life,” he explains.

Ever into the adrenaline rush, Dr. Jen Kin enjoys participating in multi-sport racing, especially triathlons and is currently training for an Ironman.

“I’ve found something that I’ve stuck with, something that’s my go-to happy place, so to speak,” he says.

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

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by KEVIN MCKINNEY

s the 97th legislature returns for its second year of the two-year session, it remains a bit of an unknown as to its productivity and what issues and agendas will be pursued. Governor Snyder laid out his 2014 priorities to the legislature in his State of the State Address which was held in mid-January.

Likely both Republican Majorities in the Senate and House will also have caucus agenda’s they will push forward prior to the end of session. With 2014 being an election year, for not only the state-wide elected offices (Governor, Secretary of State and Attorney General, U.S. Senate), both the House and Senate, as well as many policymakers, many find themselves in contested primaries or targeted races in the general election. Usually, the political wisdom heading into an election year is to get the controversial issues addressed and out of the way early enough so that it is not on the minds of the electorate right before the elections.

I anticipate, based on many discussions with legislators that the current appetite of the legislature for any more “heavy lifting” on behalf of the Governor is over for this legislative cycle.

Caucus and individual priorities will get increased attention rather than tackling huge reform issues that will impact large constituencies. The current lingering and very contentious issues such as finding a new revenue source to fund the $1.2 billion infrastructure needs in this state (gas tax) or making significant changes to Michigan’s auto no-fault system, which are being pushed by the auto insurance industry, will most likely be pushed into the lame duck session after the general election in November, if addressed at all.

Besides getting the state budget adopted in late spring, most issues will need to be progressing through the legislative process by late April if there is reasonable expectation they will get through both legislative chambers this year. Once the state budget is adopted in late May/early June, I expect the legislature will recess for the summer only to return after the Labor Day holiday for a brief couple of weeks prior to recessing again until after the November election.

Depending on the outcome of the elections and whether there is a significant change in either chamber or in the Governor’s office will dictate the lame duck agenda.

(Legislative Update continues on page 10)

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

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LEGISLATIVE UPDATE (continue d ) health policy issues in process Your Michigan Osteopathic Association (MOA) continues to monitor and work on a number of health policy issues that are currently in

Code but it remains highly unlikely the committee will be weighing in on overall scope of practice issues between provider groups. The MOA will be working in concert with the Michigan State Medical Society (MSMS) in further research as to any regulatory or statutory modifications needed to strengthen the integrated health care team to improve access to care.

the process

Senate Bill 2:

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ith the recent passage of Senate Bill 2 in the Senate which provides for an expanded scope of practice for APRN’s the issue now resides in the House Health Policy Committee where its future is uncertain. MOA members responded to MOA’s action alert and successfully made more than 900 contacts to their respective House members raising policy concerns with the bill.

The larger effort to make changes to the health care work force that is embodied in Senate Bill 586 that is pending in the Senate Health Policy Committee will resume discussions with impacted providers but with the unfortunate passage of Senate Bill 2, Senate Bill 586 is at a disadvantage of re-opening the very contentious scope of practice debate during an election year. The Administration did established a Public Health Code Advisory Committee that has sought out from all stakeholders issues and recommendations for consideration for a re-codification of the Public health

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Immunizations: The MOA will also continue to work with other physician groups, health plans, local health departments and the Department of Community Health and the Centers for Disease Control and Prevention on ways to improve immunizations in our state. The MOA is concerned with the alarming rise in personal exemption waivers for child immunizations which now makes Michigan the fourth highest in the country.

A public awareness campaign as well as making sure parents are fully aware of the risks if they choose to exercise the philosophical waiver is being explored.

In certain counties where local health departments require parents to watch an educational video has significantly reduced the exemption waivers.

Co-Pays and Co-Insurance: The MOA will also continue to work with other stakeholders and patient advocacy groups to address the rising concerns patients are experiencing with health insurers with high co-pays and co-insurance requirements that have significantly impacted patients access certain medications – especially drugs on specialty tier formularies. This coverage issue is a concern with publically funded health coverage but now a growing concern with plans in the health exchanges and in the other commercial insurance markets.

Another policy issue of concern remains the required step therapies or more commonly called “fail first” requirements being mandated by insurers on prescription drugs.

Medical Marijuana: Safe access to medical marijuana legislation passed the House in December and will likely be taken up in the Senate this year. To provide further clarity to the Michigan Medical Marijuana Act and make sure registered medical marijuana patients have safe access to tested medicines, the House overwhelming passed two bills – House Bills 4271 and 5104 – to allow local communities to regulate and license provisioning centers and testing labs and to allow for non smokable forms of medical marijuana. Senate Bill 660 which would allow for a pharmaceutical grade medical marijuana to be cultivated and dispensed in local pharmacies if and only if, the federal government rescheduled it to a schedule 2 drug passed both chambers and has been sent on to the Governor.

Even though the 2014 elections are still several months away and the filing deadline for running for office is not until May, much attention has turned to the campaigns and the candidates.

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hile the Republicans currently hold a 59 to 51 majority, it is still possible for the House Minority Democrats to win a net gain of five seats to take over the majority from the Republicans. This election cycle will see approximately 29 seats (16 Republicans and 13 Democrats)

open due to term limits. Depending on candidate recruitment and fundraising will determine if there is a real chance for Democrats, especially in an off presidential election year, to be successful.

It is exciting to report, that the recent announcement of MOA’s immediate past president, Dr. Ned Canfield running as a Republican in the 84th District marks the first time (in recent memory), there has been an osteopathic physician running for the State House. I am sure there will be plenty more to report on Dr. Canfield’s upcoming campaign; however, to learn more about his campaign, please visit http://edwardcanfield.com.

In the Senate, Republicans hold a 26-12 majority and by almost all accounts will not lose the majority in the upcoming elections even though there are a number of targeted and open seats in play right now, especially if Democratic candidate recruitment is successful.

The Michigan Osteopathic Political Action Committee (MOPAC) will continue to monitor the upcoming candidates and campaigns and make well-informed decisions on contributions to those candidates that remain physician friendly and understand our legislative priorities and issues In the meantime, please continue protecting your profession by contributing to MOPAC. For more information and to donate, please visit: http://mi-osteopathic.org/JoinMOPAC

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practicing what we preach exploring physician wellness and burnout

By VERONICA GRACIA-WING

Burnout. A silent and alarmingly common physician experience.

Just look at Burnout.

A the research: Up to 60% of practicing

Burnout is linked to

A 2012 University of

physicians report symptoms

a lower quality of care,

Michigan study indicates

of burnout.

increased medical errors,

job stress and mental

patient dissatisfaction,

health issues contribute

1

Nearly half of all

lawsuits and a decrease

to a higher rate of

in the ability to express

physician suicide. Despite

empathy. Personal

high access to health care,

consequences run the

physicians are less likely

in three physicians

gamut: substance abuse,

to seek treatment.3

is experiencing burnout

accidents, health problems

at any given time.

and relationship issues.

third-year medical students report burnout.1 Approximately one

2

Krasner, MS, Epstein, RM, Beckman, H. Association of an Educational Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians. JAMA. 2009;302(12):1284-1293.

1

2

Shanafelt, TD. Enhancing Meaning in Work, A Prescription for Preventing Physician Burnout and Promoting Patient-Centered Care. JAMA. 2009:302(12):1338-1340.

3

https://www.uofmhealth.org/news/archive/201211/job-stress-and-mental-health-problems-contribute-higher

The state of physician wellness is troubling, to say the least.

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F E AT U R E

What is burnout?

Dike Drummond, MD, life and career strategist and founder of The Happy MD, a resource for physicians feeling stress and burnout offers the following.

"First we need to understand the difference between stress and burnout, which is the ability to recover in your time off. When a physician is not able to recover or recharge between call nights or days in the office, burnout begins," he says.

According to Dr. Drummond, three distinct symptoms define burnout: 1. Physical and emotional exhaustion.

2. Depersonalization.

3 Reduced sense of personal accomplishment.

The Maslach Burnout Inventory (MBI) is a tool to assess professional burnout based on the three scales above.

Developer Christina Maslach describes burnout as "…an erosion of the soul caused by a deterioration of one's values, dignity, spirit and will."

The whys of burnout We know what burnout is, so the next natural question is why?

essence of being a medical provider is jeopardized, when physicians can't do what it is they want to do at the core which is to help people - it's no wonder feelings of dissatisfaction and depression follow.

Sylvia Mustonen, D.O., a family medicine practitioner at Novia Care Clinic in Ft. Wayne Indiana believes job stress for physicians is a growing factor.

"We see things grow more and more complicated with the cumulative burden of regulations, the drive to see more people in less time and the constraints of EMR," she says. "Regulatory initiatives are making personal satisfaction take a dive."

Burnout is related to that loss of meaning and the feeling of losing a sense of control. Bogged down by records, politics, numbers, colleagues, administration and the institution, physicians are constantly over-tapping into their reserves. This is not to mention the emotional fatigue one experiences when helping others and relying on levels of compassion and empathy.

“regulatory initiatives are making personal satisfaction take a dive.”

—Sylvia Mustonen, D.O.

"Bottom line? Being a doctor is stressful," says Vincent Rimanelli, D.O., emergency medicine physician at Mercy Memorial Hospital in Macomb, Mich. "We're conditioned early on to believe that we need to be superheroes; emotionless workaholics who can do it all and all on our own."

Many physicians feel that delivering a high quality of care is compromised by regulatory obligations. When the TRIAD, Winter 2014

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"The physics of burnout isn't best explained by the commonly used battery analogy," says Dr. Drummond.

"When a battery runs out, the thing has to stop. Doctors never stop."

Instead, Dr. Drummond refers to an energetic bank account. Physicians can overdraw from this bank account, thus taking their energy levels below zero.

"You can't give what you haven't got," he says. "In training, we're told how to survive when we're less than zero and it becomes expected of us to operate as such. We've got to figure out a way to keep our energetic bank accounts in the positive so we have not only something to give to our patients, but to ourselves and our families."

Working in the relative isolation many physicians do can create higher susceptibility to depression and feelings of embarrassment in asking for help.

Often it's not the asking for help that's the most difficult part, but the acknowledgement that it's actually needed.

"Severely burned out physicians are the last to recognize they are burned out.

They feel isolated and compelled to never show weakness. They can't talk to their spouse or other doctors and finally get to a point where they try to figure it out on their own," says Dr. Drummond.

”Severely burned out physicians are the last to recognize they are burned out. They feel isolated and compelled to never show weakness.”

—Dike Drummond, M.D.

It's all connected Burnout and stress tends to compromise physical health as well as mental health. When stress levels rise, the tendency to eat poorly or shirk off exercise rises. Motivation wanes. Research indicates physicians who are overweight or obese are less likely to discuss weight loss with their patients.

"Professionally I can tell when a colleague is stressed," says Dr. Mustonen.

"Things start happening in documentation, their attendance drops and they become behind on work."

It's not a stretch to say physician health - physical and mental - has a direct impact on the quality of patient care delivered.

Where to start then?

What good is knowing all the signs and impacts if you can't implement change?

How can we avoid burnout and work toward the coveted work / life balance?

“Achieving the work / life balance means putting yourself as high of a priority as you do your patients.”

—Robert Piccinini, D.O., dFACN

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"Achieving the work / life balance means putting yourself as high of a priority as you do your patients," says Robert Piccinini, D.O. dFACN, a private practitioner with Associates in Psychiatry in Sterling Heights, Mich and secretary/treasurer for the Michigan Osteopathic Association. "Granted, we don't always get it right and sometimes we do need to put ourselves aside because of altruism."

"Change begins with precontemplation," says MaryJo Voelpel, D.O., FACOI, hematology and oncology specialist in Lake Orion, Mich. "If you bring about awareness of the issue through identification and the problems related, you have the opportunity to effect change."

Awareness is often met through mindfulness. Giving a task, small or large, undivided attention can relieve stress and help prevent burnout. Acknowledgement can lead to recovery.

More than anything, physicians with feelings of stress and burnout need to know they are not alone.

"If I see a colleague that's having a hard time, I'll often confide with them my own feelings of inadequacy," says Dr. Piccinini. "This can open a door for them to express their own feelings.

Feeling this way doesn't mean you're flawed, it means you're human."

Greater changes Physicians agree that change needs to occur not only on a personal level, but institutionally as well.

"The pressure is on doctors to be productive. Reviews are largely based on productivity and throughput, not quality care," says Dr. Mustonen. "We should be advocating for models that allow for more time with patients."

Dr. Mustonen additionally believes better professional support systems should be in place and that awareness of the challenges facing physicians must be addressed administratively. Dr. Voelpel is an advocate for offering wellness incentives and fitness plans in the workplace. Drummond is an advocate for forming wellness committees to support physician health.

The next generation of physicians being trained at Michigan State University College of Osteopathic Medicine has a unique resource in the Joy Initiative.

The program is designed to help medical students envision and incorporate happiness into their lives. Emotional resilience training and the development of the mindfulness mentioned above drive the initiative's focus.

MSCUCOM student, Nicole Saghy understands the value of incorporating this type of mindfulness early on in her medical career.

"In my opinion, this type of training cannot be stressed enough," she says.

"Work/life balance is something that is going to evolve for us as we move into clerkship, as we shift into internship, as we go into our residencies and as we practice as attendings. It is important for us as students to recognize what is working for us in balancing our lives now so when changes occur, we have a baseline of what is important to us."

Tips

from your colleagues on how to address and prevent stress and burnout:

• Breathe deeply.

• Exercise.

• Decrease stress through unburdening yourself with financial pressures.

• Recharge as often as Answering the call Dr. Drummond calls burnout not a problem, but a calling.

"It's a calling to do something about your life. It involves examining your life from work to personal to spiritual.

When you're examining and inventorying, give yourself permission to dream about how you'd like your life to look.

Write these things down and make a plan. Every destination has a map - plan out and honor yours," he offers.

If you recognize any of these struggles in yourself or a colleague, it may be difficult to start down the path of acknowledgement and implementation. Identify what is doable for you and believe in your peers when they tell you you are not alone. The ancient phrase is true: a journey of a thousand miles begins with a single step.

you can. Find whatever works for you.

• Delegate.

• Be thankful.

• Lead by example.

• Eat mindfully and healthfully.

• Quit smoking.

• Know and respect your own limitations.

• Learn the power of no.

• Seek simplicity.

• Create the space for health and wellness in your work environment.

The key is, you’re not alone. You don’t have to be a superhero.

As dedicated medical professionals, we’re all in this together!

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disconnect from malpractice risks by following these telephone triage tips

By Susan shepard, MSN, RN director, patient safety education the doctors company

M

iscommunication is one of the most common causes of adverse patient events in the physician’s office setting. Telephone triage, a critical part of the patient’s overall care and management, presents a significant area of liability exposure.

Implementing an effective telephone triage system can improve physicianpatient communication, confidence, service, satisfaction, and care. It can also reduce emergency medicine department (EMD) visits while ensuring that the patient has access to the appropriate level of care.

Telephone triage guidelines require accurate assessment without the benefit of a face-to-face encounter. For this reason, only licensed professional staff with appropriate training should provide assessments. Required qualifications and training should be clearly defined in the job descriptions of personnel who perform telephone triage.

Patients should be informed in writing about situations that are appropriate for telephone advice. Providing patients with examples of the types of problems likely to require an office or EMD visit will aid them in accessing the most appropriate care. Recommend a face-to-face encounter when a patient or a family member/caller seems overly anxious or dissatisfied with the advice given or if the patient believes the situation is urgent. Instruct patients to dial 911 in situations that involve (but are not limited to) allergic reactions, chest pain, eye injuries, burns, or shortness of breath/wheezing.

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F E AT U R E

To avoid some of the risks of telephone triage: 4 Develop policies and protocols for licensed professional staff to follow. These policies and protocols should:

— Require that licensed professional staff check with the doctor first if there is any doubt about proper instructions or advice.

— Instruct licensed professional staff not to give advice beyond their competence.

4 Develop written protocols for staff members who take initial calls but who are not RNs or mid-level practitioners. These written protocols should include specific examples of questions to ask the caller, such as:

— Whom am I speaking to? (Find out whether or not you are speaking with the patient.)

— What is the reason for your call? (Use the caller’s own words to describe the situation.)

— What medications are you taking? What are the dosages and frequency and how are they administered?

— Is there anything else you would like me to know?

susan shepard msn, rn

4 Outline the types of calls to either refer immediately to licensed professional staff or to schedule for an office appointment.

4 Instruct non-licensed office staff to never practice medicine over the phone.

4 Train all staff members to refer a call to the physician immediately if the patient has an urgent or emergent need.

4 Document all calls in which medical information or advice is provided. Documentation should include the date, time, patient’s name, name of caller/relationship to patient, complaint/concern/question, and advice given.

4 Document critical negative information that helped determine the advice that was provided. Examples: “mother stated the child has no fever, no lethargy, or neck stiffness” and “mother stated the child has a good appetite and is taking fluids.”

4 Establish a reasonable time frame in which non-urgent calls are expected to be returned.

If possible, build time into the physician’s schedule to return calls. Inform patients when they can expect a return call.

4 Review telephone procedures and protocols with staff periodically to ensure that inquiries are being appropriately managed.

4 Contributed by The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

Susan Shepard has a master’s degree in nursing administration, a master of arts degree in management, and a bachelor of science degree in nursing. She holds the rank of Colonel (retired) in the U.S. Air Force, Nurse Corps.

TRIAD, Winter 2014

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TRIAD, Winter 2014

New Study Finds Reduced Evening Snacking When Beef Is Consumed At Breakfast Recent research published in the American Journal of Clinical Nutrition suggests that eating a protein-rich breakfast, such as beef and eggs, boosts satiety and reduces hunger signals and brain activation responses involved with food cravings more than a typical ready-to-eat breakfast cereal. Study participants, overweight late adolescents who normally skip breakfast, experienced a significant reduction in unhealthy evening snacking following a protein-rich breakfast.

Lean beef is a complete high-quality protein that contains all the essential amino acids your body needs for optimal health. Even better, a 3-oz serving of lean beef is about 150 calories on average and provides more than 10 percent of the Daily Value for 10 essential nutrients. Lean beef is a perfect partner for fruits, vegetables and whole grains, so it’s easy to enjoy more high-quality protein in your diet.

• Leidy HJ, Ortinau LC, Douglas SM, Hoertel HA. Beneficial effects of a higher-protein breakfast on the appetitive, hormonal, and neural signals controlling energy intake regulation in overweight/obese “breakfast-skipping” late-adolescent girls. Am J Clin Nutr 2013; 97:677-88.

• U.S. Department of Agriculture, Agricultural Research Service, 2012. USDA Nutrient Database for Standard Reference, Release 25. Nutrient Data Laboratory homepage www.ars.usda.gov/ba/bhnrc/ndl.

Michigan Beef Industry Commission • www.mibeef.org TRIAD, Winter 2014

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There is sometimes confusion between the “Welcome to Medicare” visit and the ”Annual Wellness” visit. The following article clarifies the differences.

“welcome to medicare” and annual wellness visits

what is included?

Welcome to Medicare Services Checklist Obtain and record the patient’s medical and family history:

Welcome to Medicare Visit Benefits for the introductory Welcome to Medicare Visit are only available within the first 12 months following a patient’s enrollment in Medicare Part B. This benefit is limited one time.

The patient does not need to have had this visit to be covered for the yearly “Wellness” visits.

NOTE: Often the Welcome to Medicare Visit is referred to as the Initial Preventive Physical Examination (IPPE).

• Past medical and surgical history, including illnesses, hospital stays, operations, allergies, injuries and treatments.

• Use or exposure to medications and supplements, including calcium and vitamins • Medical events experienced by the patient’s immediate family, including parents, siblings and children, including diseases that may be hereditary or place the patient at increased medical risk.

Obtain and record a list of current healthcare providers and suppliers who are regularly involved in providing medical care to the patient Obtain and record the patient’s weight, height, body mass index (or waist circumference, if appropriate), blood pressure and other routine measurements as deemed appropriate, based on the individual’s medical and family history.

Detect and record evidence of any cognitive impairment that the patient may have by direct observation, with consideration of information obtained by way of patient interview or concerns raised by family members, friends, caretakers or others.

Review and record the patient’s potential risk factors for depression, including current or past experiences with depression or other mood disorders, using an appropriate screening instrument for persons without a current diagnosis of depression, which you as the provider, may select from various available screening questions or standardized questionnaires designed for this purpose and recognized by national professional medical organizations.

(Add a link to screening tool?)

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F E AT U R E

Review and record the patient’s functional ability and level of safety, based on direct observation or the use of appropriate screening question or a screening questionnaire, which the provider may select from various available screening questions or standardized questionnaires designed for this purpose and recognized by national professional medical organizations. This includes a minimum review or screening for hearing impairment, ability to perform daily activities of daily living, fall risk and home safety. nd recognized by national professional medical organizations. (Add a link to screening tool?)

Frequently Asked Questions: Welcome to Medicare Visit

Establish a written screening schedule, such as a checklist, for the next 5 to 10 years as appropriate, based on recommendations of the USPSTF and the Advisory Committee on Immunization Practices, and the patient’s health status, screening history and age-appropriate preventive services covered by Medicare. (Add link to checklist or screening schedule?)

come to Medicare Visit/IPPE is an introduction

Develop a list of risk factors and conditions for which primary, secondary or tertiary interventions are recommended or are underway, including any mental health conditions or any such risk factors or conditions that have been identified through the Welcome to Medicare Visit/IPPE and a list of treatment options and their associated risks and benefits.

Furnish personalized health advice to the patient and a referral, as appropriate, to health education or preventative counseling services or programs aimed at reducing identified risk factors and improving self management, or community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall prevention and nutrition.

Is the Welcome to Medicare Visit/ IPPE the same as a beneficiary’s yearly physical?

No, the Welcome to Medicare Visit/IPPE is not a “routine physician checkup’ that some seniors may receive every year or two from their physician. For a newly enrolled beneficiary, the Welto Medicare and covered benefits, and focuses on health promotion and disease prevention and detection to help beneficiaries stay well. Medicare does not cover routine physical examinations.

Are any clinical laboratory tests part of the Welcome to Medicare Visit/IPPE? No, the Welcome to Medicare Visit/IPPE does not include any clinical laboratory tests, but you may want to make referrals for such tests as part of the Welcome to Medicare Visit/IPPE, if appropriate.

Can the physician bill a separate Evaluation and Management (E/M) service at the same visit as the Welcome to Medicare Visit/IPPE?

“Voluntary advance care planning,” which means verbal or written information regarding the following areas:

Medicare may pay for a significant, separately

• A patient’s ability to prepare an advance directive in the case where an injury or illness causes the patient to be unable to make health care decisions.

(Current Procedural Terminology (CPT) codes

• Whether or not the physician is willing to follow the patient’s wishes as expressed in an advance directive.

identifiable, medically necessary E/M service 99201 – 99215) billed at the same visit as the Welcome to Medicare Visit/IPPE when billed with modifier – 25. That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury, or to improve the functioning of

(Article continues on page 22)

a malformed body member.

TRIAD, Winter 2014

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‘‘Welcome to medicare” and Annual WELLNESS VISITS – what is included?

(Continued from page 21)

The Annual Wellness Visit (AWV) Reminder: the patient does not need to have had a “Welcome to Medicare/IPPE” visit to be covered for yearly “Wellness” visits. Medicare covers the Annual Wellness Visit for beneficiaries who are no longer in the first 12 months of their first Part B coverage period. Please note the Annual Wellness Visit is a SEPARATE service from the Initial Preventive Physical Examination (IPPE, also known as the “Welcome to Medicare Preventive Visit”).

Frequently Asked Questions: Annual Wellness Visit Is the Annual Wellness Visit the same as a Medicare beneficiary’s yearly physical?

No, the Annual Wellness Visit is a preventive wellness visit and not a “routine physician checkup’ that some seniors may receive every year or two from

AWV Services Checklist An update of the list of current providers and suppliers who are regularly involved in providing medical care to the patient, as that list was developed for the first AWV providing personalized prevention plan services.

Measurement of the patient’s weight, height, body mass index (or waist circumference, if appropriate), blood pressure and other routine measurements as deemed appropriate, based on the individual’s medical and family history.

Detection of any cognitive impairment that the individual may have An update to both of the following: • The written screening schedule for the patient that was developed at the first AWV providing personalized prevention plan services.

• The list of risk factors and conditions for which primary, secondary or tertiary interventions are recommended or are underway for the patient – the list that was developed at the first AWV providing personalized prevention plan services.

Furnishing of personalized health advice to the patient and a referral, as appropriate, to health education or preventative counseling services or programs

their physician. Medicare does not cover routine physical examinations.

Are clinical laboratory tests included as a part of the Annual Wellness Visit?

No, the Annual Wellness Visit does not include any clinical laboratory tests, but you may want to make referrals for such tests as part of the Annual Wellness Visit, if appropriate.

Do deductible or coinsurance/ copayment apply for the Annual Wellness Visit?

No, coverage for the Annual Wellness Visit is provided as a Medicare Part B benefit. Medicare waves both the coinsurance or copayment and the Medicare Part B deductible for the Annual Wellness Visit.

Can the physician bill a separate Evaluation and Management (E/M) service at the same visit as the Annual Wellness Visit?

Medicare may pay for a significant, separately

“Voluntary advance care planning,” which means verbal or written information regarding the following areas:

identifiable, medically necessary E/M service (Cur-

A patient’s ability to prepare an advance directive in the case where an injury or illness causes the patient to be unable to make health care decisions.

– 99215) billed at the same visit as the Annual

Whether or not the physician is willing to follow the patient’s wishes as expressed in an advance directive.

treat the beneficiary’s illness or injury, or to improve

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rent Procedural Terminology (CPT) codes 99201 Wellness Visit when billed with modifier – 25. That portion of the visit must be medically necessary to the functioning of a malformed body member.

Diagnosis Codes: Welcome to Medicare Visit/IPPE You must report an ICD diagnosis code; however, CMS does not require a specific diagnosis code for the Welcome to Medicare Visit/IPPE. Therefore, you may choose any appropriate diagnosis code.

Use the following Healthcare Common Procedure Coding System (HCPCS) codes when filing claims for the Welcome to Medicare Visit/IPPE. Code Description G0402 Welcome to Medicare Visit/IPPE; face-to-face visit, services limited to

new beneficiary during the first

12 months of Medicare enrollment G0403 Electrocardiogram, routine ECG with 12 leads; performed as a screening for the Welcome to Medicare Visit/IPPE with interpretation and report G0404 Electrocardiogram, routine ECG with 12 leads; tracing only, without interpretation and report, performed as a screening for the Welcome to Medicare Visit/IPPE G0405 Electrocardiogram, routine ECG with 12 leads; interpretation and report only, performed as a screening for the Welcome to Medicare Visit/IPPE

Annual Wellness Visit You must report an ICD diagnosis code; however, CMS does not require a specific diagnosis code for the Annual Wellness Visit. Therefore, you may choose any appropriate diagnosis code.

Use the following Healthcare Common Procedure Coding System (HCPCS) codes when filing claims for the Annual Wellness Visit.

Code

Description

G0438 Annual wellness visit; includes a Personalized Prevention Plan of Service, initial visit G0439 Annual wellness visit, includes a Personalized Prevention Plan of Service, subsequent visit TRIAD, Winter 2014

27

Excellent Opportunity to acquire a CON Also For Sale: CT Phillips Scanner Unit has relatively new tube and is in excellent functioning condition.

If you are interested individually or as a group, please contact Carol at:

313.274.0991 x

Dearborn Foot Specialists Dr. Daniel Salama, DPM Medical & Surgical Foot Specialists 2200 Monroe, Dearborn, MI

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TRIAD, Winter 2014

AMOA NEWS

S

ince this specific TRIAD has to do with physician’s health and wellness, I want to briefly touch on this subject. The importance of YOU as health care individuals taking care of yourselves is imperative.

by Dana Borenitsch

Your primary concern is concentrating on the health of others. With your busy schedules, long hours, going to multiple locations daily, dealing with sickness and disease all day, what about yourself? Both adults in our household have experienced putting off check-ups for years and discussing symptoms and self-treating. It’s SO convenient to just write yourselves a prescription. What about any follow-up lab tests to see if any other internal side effects are going on? That is also often neglected.

What about your yearly medical check-up instead of just treating symptoms? When was the last time you had lab work, a heart evaluation, or a prostate exam? With all medical technology and treatment, the sooner you find out what is happening within your own body, and get treatment if necessary, the better the outcome for everyone concerned.

What about diet and exercise? There are so many scenarios that can happen to our bodies without us doing anything to cause it, but this is something we DO have control over.

There are many, many people depending on you, daily, loving you and want you to be around for a very long time, so PLEASE get yourself checked out! Take some time for yourself, go to a doctor. Not just a friend or colleague that will have a friendly chat instead of doing a good in depth examination.

God has created a fantastic body with every intricate part functioning in perfect harmony in most of the population. You are truly gifted as a physician to know and understand the intricacies of our bodies, to be able to have the trust of your patients to test and treat any ailments that come into your office.

Doctors, you know, and probably stress to your patients, the importance of preventive maintenance. Physicians should be a good example for their patients in getting preventive medical care .

Be the absolute BEST you can possibly be... You deserve it!

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

TRIAD, Winter 2014

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DEAN’S COLUMN

N

be a leader in life ear the end of 2013 A.T. Still, father of osteopathic medicine, was inducted into the Missouri Hall of Fame. His contributions to medicine, medical education and our profession are well documented and stand as a testament to one person’s power to change the world.

by William Strampel, D.O.

You might never get named to a hall of fame, have a medical school named in your honor, serve in the legislature or patent a machine, but in this issue that looks at physician health and wellness, I would encourage you to become a leader in your own life for your profession, your practice and your patients.

Have you stepped up to take on a role within your state professional organization, the MOA, within your specialization, or—pardon the moment of blatant self-promotion—your alma mater? It’s easy for us all to say that we’re too busy to help make our profession stronger or to pave the way for the next generation of physicians, but taking the time to serve in these volunteer roles pays off in many ways.

By sharing the work with others, you’ll prevent one person from being overburdened with commitments. By interacting with your peers you’ll make new connections who can be significant sounding boards, sources of inspiration or just plain great people. In giving back to the institution that granted you your undergraduate or medical degree (I’ll advocate the latter), you can reconnect with old friends, make new ones and learn more about the students of today who’ll be your colleagues tomorrow.

It’s also critically important that you show your patients, your team at work and your family that you are a leader by taking care of yourself in all aspects of health. Seek the help that you need for physical or emotional challenges and not only listen, but act on the information given. Sometimes we are tempted to bow to cultural norms that call on us to always be strong and to take on everything that life—and medicine—throws at us. But we also have to remember that sometimes it takes as much strength to admit we need help or advice as it does to bear our burdens.

By donning the white coat and taking the oath to serve you established yourself as a leader.

Don’t let the business of living and working strain your ability to do what you need to do for yourself and those around you.

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.

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AD V E RTI S E R I N D E X

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 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. ©2014 Michigan Osteopathic Association

Asociation Benefits Company............................................. 4 Brodsky Investment Company.......................................... 27 Dearborn Foot Clinic ...................................................... 28 Health Law Partners PC...................................................... 2 Kerr Russell...................................................................... 28 Lilly.................................................................................... 6 Michigan Beef Industry.................................................... 23 MSU Communications PR Department............................. 27 Pinkus Dermatopathology Laboratory.............................. 22 Premier MRI CT................................................................. 6 The Doctors Company..................................................... 32 Wachler & Associates PC................................................. 22

T riAd SPRING 2013 vOlUME 24 ISSUE 2

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SPECIAL CONVENTION PREVIEW G 2013 TRIAD, SPRIN

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For advertising inquiries, please contact Carl Mischka at 888.666.1491 or via email at cmischka@mi-osteopathic.org