TRIAD
The Award-winning Journal of the Michigan Osteopathic Association
Winter 2011, Volume 22, Number 1
Health Care Ethics: Black, White & Shades of Gray
In This Issue: • Ethical Dilemmas 101 • Islamic Osteopathic Medical Students Speak About the Misconceptions That They Encounter & Work to Combat • Medical Spotlight: Endovascular Treatment of Carotid Artery Disease • HealthFlex: An MOA Core Grant-Winning Program
contents features
Page 12 Ethical Dilemmas 101: Understanding the Core Principles of Ethics and Their Application by Elizabeth Petsche, Visiting Assistant Professor, Michigan State University College of Osteopathic Medicine
TRIAD
The Award-winning Journal of the Michigan Osteopathic Association
Winter 2011, Volume 21, Number 4
Health Care Ethics: Black, White & Shades of Gray
IN THIS ISSUE: • Ethical Dilemmas 101 • Islamic Osteopathic Medical Students Speak About the Misconceptions That They Encounter & Work to Combat • Medical Spotlight: Endovascular Treatment of Carotid Artery Disease • HealthFlex: An MOA Core Grant-Winning Program
Medical ethics serve as a moral guidepost for health care providers as to what is right, wrong and how to negotiate your way through issues that fall somewhere between. This overview offers insight into the core principles of ethics and how to apply them. Page 16 Endovascular Treatment of Carotid Artery Disease by Bipinchandra B. Patel, D.O. and John W. Sealey, D.O., F.A.C.O.S. A brief overview of endovascular carotid artery stent placement, a procedure whose positive results are helping to prevent strokes. Page 19 Personal Accounts, Insights and Perspectives from Members of the Islamic Medical Student Association by Craig Reed, Public Relations, Michigan State University College of Osteopathic Medicine Members of the Islamic Medical Student Association share their thoughts, views, and personal experiences of living in the post - 9/11 world and the misconceptions and prejudices that have intensified as a result.
Winter 2011
Page 28 D.O.s Making a Difference Northern Michigan’s Thomas Allum, D.O., Blazed a Trail and Bridges the Miles with His Osteopathic Care by Cheri Rugh MOA member Thomas Allum, D.O., reflects on his uphill battle to gain respect and acceptance for osteopathic medicine upon moving to northern Michigan more than 40 years ago. Page 30 MOA Board of Trustee Profile: Draion Burch, D.O. by Cheri Rugh As one of three newly elected MOA Board members, medical resident Draion Burch, D.O., shares a few details on his background, the path that led him to osteopathic medicine and what he sees in his future. Page 32 Is Your Liability Insurer a Safe Choice? by Laura A. Kline, CIC, CPCU, Vice President, The Doctors Company/American Physicians A review of the three types of insurance companies and how not understanding the difference in these types of insurance companies can put you and your practice at risk. Page 34 Association Benefits Works With the Blues to Offer New Plan Designs for 2011
departments
Page 26 MOA Core Grant Recipient: Alcona Health Center HealthFlex Program Works Both the Brain and Body by Cheri Rugh
7 Editor’s Notebook
The MOA awards Core grants to those who are taking steps to host health-related events that embody osteopathic values. Read how MOA Core Grant Winner Alcona Health Center, under the guidance of Donald Spaeth, D.O., has developed a series of geriatric patientfocused health education and physical movement classes called HealthFlex.
37 MSUCOM Student News
9 President’s Page 11 AMOA News 35 Dean’s Column
39 Intern Resident Column 41 Practice Manager’s Column 45 The Last Word
TRIAD, Winter 2011 3
TRIAD
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.
Winter 2011; Volume 22, Number 1
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 under the direction of the MOA Editorial Committee. The committee develops policies regarding the content, advertising and format of all MOA publications. TRIAD is published quarterly. Periodical postage paid at Okemos, MI 48864 and other post offices. Subscription rate: $50 per year for non-members (includes UPDATE newsletter). 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 E-mail: moa@mi-osteopathic.org POSTMASTER: send address changes to TRIAD, 2445 Woodlake Circle, Okemos, MI 48864. ©2011 Michigan Osteopathic Association 4 TRIAD, Winter 2011
TRIAD Staff Editors-in-Chief Draion Burch, D.O. John Sealey, D.O. Managing Editor Cheri Rugh Contributing Editors John Bodell, D.O. Vance Powell, D.O. William Strampel, D.O.
Executive Director Director of Administration Manager of Communications Director, MOA Service Corp. Manager of Membership Advertising Representative Layout and Cover Design
Kris T. Nicholoff Lisa Neufer Ryan Knott Cindy Earles Shelly M. Madden Gretchen Christensen Ellen Weeks, Village Press, Inc.
2009-2010 Michigan Osteopathic Association Board of Trustees
President President-Elect Immediate Past President Secretary-Treasurer
George Sawabini, D.O. Kurt Anderson, D.O. Donna Moyer, D.O. Robert Piccinini, D.O.
Trustees Draion Burch, D.O. & John Sealey, D.O. Department of Continuing Education Edward Canfield, D.O. & Lawrence Prokop, D.O. Department of Insurance Craig Magnatta, D.O. Department of Judiciary and Ethics Lawrence Abramson, D.O. & Myral Robbins, D.O. Department of Membership Donna Moyer, D.O. Department of Professional Affairs Shane Sergent, Student & Michael Weiss, D.O. Department of Public Affairs
POH Regional Medical Center combines the holistic heritage of osteopathic medicine with progressive medical education programs and practical patient care experiences. We Offer: n Medical Student Electives in Numerous Specialties and Subspecialties n Traditional Rotating and Specialty Internships n 17 Residency Programs
editor’s notebook
by Draion M. Burch, D.O., Co-Editor-in-Chief
M
Draion Burch, D.O., is a resident in the Department of Obstetrics and Gynecology with St. John Providence Health System Osteopathic Division. He is also a new member of the MOA Board of Trustees and shares the responsibility of Editor-inChief of TRIAD with John Sealey, D.O.
edical ethics has been a concern since medicine was first institutionalized. Historically, taking the Hippocratic Oath was sufficient for osteopathic physicians, but now modern advancements in medicine and changes in society have produced controversial topics not easily defined as right or wrong. Practicing health care professionals and medical educators need ongoing collaborations to establish ethical guidelines when controversial topics arise. Consequently, there are few areas of medicine that have not encountered an ethical issue. Medical ethics must be carefully examined from all viewpoints. Answers are not easily obtained. While some may consider medical ethics to only apply to physician-centered patient care, there are growing concerns about the ethics of health care as a whole and in a clinical setting such as a hospital or office. Others consider ethics dealing with the development and research practices surrounding new reproductive technologies and organ distribution paramount. For the new physician the ethics of interactions in social media or with pharmaceutical and surgical companies may be of concern. These issues, and many more, will engulf our medical community. As an osteopathic physician, are you informed about the ethical concerns facing your medical community? As the voice of the Michigan osteopathic community, TRIAD’s collection of articles provides an environment that focuses on the issues most important to you. This month’s TRIAD tackles medical ethics. The lead article titled “Ethical Dilemmas 101” explores the different forms and facets of medical ethics and illustrates that every situation is as unique as the patients we treat. My fellow co-editor-in-chief John Sealey, D.O., shares his cardiovascular medical expertise in the article titled “Endovascular Treatment in Carotid Artery Disease,” while the article “Personal Accounts, Insights and Perspectives from Members of the Islamic Medical Student Association” looks at the social biases experienced by Islamic medical students. Rounding out this issue are features on the MOA Core Grant winning program HealthFlex, American Physician’s advice on “Is Your Liability Insurer a Safe Choice?,” and a profile on one of your newest board members – me! As the co-editor-in-chief, I invite you to embrace the TRIAD. Our goal is to produce a publication that meets your needs, so feel free to forward any questions, comments or suggestions about any of our MOA publications. To contact the MOA, call (800) 657-1556 or email moa@mi-osteopathic.org. m
TRIAD, Winter 2011 7
president’s page by George Sawabini, D.O., President
C
George Sawabini, D.O., President of the MOA
oncerns about medical ethics date back to antiquity, with the work of the Greek physician Hippocrates. The Hippocratic Oath used to be taken by all medical graduates, and was the standard basis of ethical conduct for a long time. Medical graduates no longer automatically swear to the Hippocratic Oath. The field of ethics (or moral) philosophy involves systematizing, defending and recommending concepts of right and wrong behavior. Philosophers today usually divide ethical theories into three main subject areas, one being applied ethics, which deals with controversial everyday issues. Medical ethics is a field within the applied ethics division. Medical ethics concentrates on the outcomes that can be achieved in specific clinical situations, it has been defined as a discipline/methodology for considering the implications of medical technology/treatment and what ought to be. The medical profession is one of the few professions that publish a formal code of ethics. Medical ethics has also been described as beginning where the area of the law ends. Good ethics is like good health. We have a fair idea what it is, but it is hard to define. We define good health by taking a medical history, performing a physical examination, and measuring certain standard parameters. In a similar fashion medical ethics utilizes mainly four principals as the parameters. The principals are used in different tools to analyze each presenting clinical situation to offer the best solution. Ethical decisions are very subjective and vary depending upon religion, customs, mores and traditions of society. There is no universal standard of ethical conduct. What is considered right may vary among individuals, cultures, nations and religions. In the United States we are governed by western ethics based on Jewish, Roman Catholic and Protestant beliefs. The principal topics in contemporary medical ethics boil down to three things: 1. The physician’s responsibility relative to the patient. 2. The physician’s responsibility to other physicians. 3. The physician’s responsibility to other medical institutions (professional associations, health care institutions and insurance companies), and society at large. At one time medical experts (physicians) were the best suited to make medical ethical decisions. However in today’s environment, being a skilled medical expert does not auto matically guarantee that the physician is an expert in medical ethics. The field is getting more complex, the health environment is constantly changing, and the technological advances are arriving at a faster pace. When moral values are in conflict the result is an ethical dilemma. Many ethical conflicts can be traced to the lack of effective communications. Currently, health care ethics has evolved into an interdisciplinary field. Rising medical costs, and the scarcity of resources pose a dilemma to the practitioners of medicine. The complexity of technical considerations in the delivery of health care governed by law, regulated by the government and cost contained by the insurance companies is a very large and ever expanding field. The medical ethics field is now, more than ever, in need of involvement from all the stakeholders – patients, the public, the legal system, philosophers, ethicists, and the health care professionals. It is these same stakeholders that must work together to resolve the many ethical conflicts and dilemmas that emerge in the constantly changing and evolving science of caring for patients. m TRIAD, Winter 2011 9
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amoa president’s news by Gloria Ferris, President, AMOA
W
hen I think of ethics, I can still remember my ethics teacher from way back when I was a student nurse. Ethics was defined as the rules of conduct recognized in respect to a particular profession and the six values usually discussed included autonomy, beneficence, non-malfeasance, justice, dignity, truthfulness and honesty. These six values are further complicated in the practice of medicine by scientific discovery and invention. A physician’s basis for ethical practice of medicine begins in childhood. The moral philosophy by which he/she is raised instills the individual’s perception of right and wrong. The educators prepare the medical student by providing the information and by their good example. They must be doing it well, we members of the Advocates for the Michigan Osteopathic Association (AMOA) are very impressed with the students and young physicians’ standards of integrity, professionalism and confidentiality. When reviewing 2010, the AMOA completed several projects. Among the highlights are the AMOA’s provision of a computer flash drive for each new Michigan State University College of Osteopathic Medicine (MSUCOM) student. AMOA co-hosted the new student barbeque held in partnership with the Michigan Osteopathic Association (MOA) and MSUCOM. Several AMOA members were onsite at the MOA headquarters to welcome students and we raffled off a Meijer gift card. We did the same for new students at the MSUCOM Detroit and Macomb campuses. Just before the holidays, we conducted our Tree of Peace project which allowed members and supporters of the osteopathic profession to donate to the AMOA in memory of past friends and relatives. Each participant received a keepsake ornament in recognition of their donation and another ornament was used to decorate the tree at the MOA head quarters to represent their support of the AMOA. Both the decorated tree and sentiment behind it were beautiful! AMOA has continued to work hard to increase membership, trying to reach out to areas that have not been represented before. Special thanks to Salina Holley for organizing an Intern and Resident Advocates Association at Henry Ford Wyandotte, a step in the right direction to increased involvement from a new group. To learn more about the AMOA, its initiatives and to sign up for membership, visit the MOA website at www.mi-osteopathic.org, click on the physician section and select the committees, groups and organizations link, or contact AMOA Membership Coordinator Pam Kolinski at kolinski@comcast.net. m
TRIAD, Winter 2011 11
I
magine yourself in one of these situations:
1 Robert, an elderly gentleman and widower, is brought into the emergency room while you are on duty. He is your patient, and after a multitude of tests and evaluations, it becomes clear to you that Robert is in a vegetative state and any medical intervention would be futile in allowing Robert to regain consciousness. Upon the formulation of your diagnosis you share your findings with Robert’s family, who cannot agree upon the proper course of action to take with respect to their loved one. Two of Robert’s children wish to maintain palliative care for their father, his youngest child wishes to allow for Robert to be taken off of life support, and his siblings wish to seek a second opinion. Robert completed no advance care directives and no information regarding Robert’s wishes for end-of-life care is found within his chart. What do you do?
Ethical Dilemmas 101:
Understanding the Core Principles of Ethics and Their Application by Elizabeth Petsche, Visiting Assistant Professor, Michigan State University College of Osteopathic Medicine 12 TRIAD, Winter 2011
2 You are performing a routine examination on Amanda, a 17-year-old female, who has been a patient of yours for the past 15 years. During the course of the examination, you find that Amanda is HIV positive. Amanda is in a long-term, committed relationship with a man who has recently become her fiancé, and they are planning on getting married on her 18 th birthday. Amanda pleads with you to maintain her confidentiality with respect to this issue. She does not want her fiancé or her parents to know about the fact that she is HIV positive. Upon conclusion of the examination, Amanda’s mother calls your office to inquire about Amanda’s health. What do you do?
Every day physicians face situations that challenge them ethically, personally, and professionally. The cases above are examples of some of those situations. Although not all physicians will respond to these situations in the same way, all physicians can use the same core ethical principles when determining what course of action to take. Ethics is a set of moral standards and behaviors that govern an individual’s interactions with other individuals within our society. Ethics are used to determine what is right or wrong and what moral standards should guide our conduct. Unfortunately, unlike some other aspects of the practice of medicine, situations that require the applica tion of ethical principles regularly consist of scenarios in which no clearly defined correct answer exists. Physicians routinely find themselves in situations where there is no “correct” answer, and a treatment plan must be made based upon equally undesirable options. No clearly defined test has been established to determine which unde sirable options should be chosen when faced with an ethical dilemma. However, this does not mean that health care providers are destined to wander aim lessly amid the turmoil and uncertainty; there are tools available to assist in the resolution of ethical dilemmas. There are several guiding principles that should be considered and evalu ated when faced with a challenging situation. These principles include: nonmaleficence, beneficence, auto nomy, and justice.1 • When faced with a decision that appears to be unwinnable, remem ber your first ethical obligation is to first do no harm, also known as nonmaleficence. Harm is understood as the infliction of bodily injury upon another, and as the imposition of setbacks to any significant interests held by another. The second principle is beneficence. As a health care • provider you have an obligation to provide a benefit to others and to take actions that promote your patient’s best interests. • The third principle is autonomy. There has been a shift in the culture of medicine over the last several decades and patient autonomy is emphasized and valued over the prior culture of physician paternalism. Patients must be treated in a manner that provides them with the opportunity to make informed decisions regarding their own health care and also their participation in medical research. • The final principle is justice. Justice does not require that all persons be treated the same, but it does require that no person be treated more favorably than another. It promotes the equitable distribution of benefits and burdens to all individuals.
The difficulty and ambiguity of the application of these principles is demonstrated in both of the scenarios above. In the case of Robert, without more evidence or additional facts to know what decision Robert would have made regarding his condition, a physician will not be able to honor his wishes (i.e. respect his autonomy). What is clear, based upon the information currently available, is the fact that Robert’s situation is perceived as futile and will not improve regardless of the care or treat ment given, making it difficult to adhere to the ethical principle of beneficence. Simultaneously, members of Robert’s family wish for the continuance of care and for the further gathering of opinions. If the wishes of these family members are honored, it may be possible to prolong their time with Robert, and taking that time away from these loved ones may cause them harm, potentially violating the principle of nonmaleficence. In the case of Amanda, a minor who has been diagnosed with HIV, she does not wish for her fiancé or her family to know of her diagnosis. The ethical principle of autonomy suggests that Amanda’s wishes should be honored and respected. Unfortu nately, the decision becomes compli cated for a number of reasons. First, Amanda is a minor and, therefore, her ability to be treated autonomously may be compromised as she is legally presumed to be incompetent and may be unable to make decisions regarding her own health care. Second, Amanda is in a long-term committed relation ship with a man who will become her husband in the very near future, and maintaining the confidentiality of Amanda’s disease may cause severe and immediate harm to her fiancé. Therefore, allowing Amanda to keep this secret from her fiancé may indirectly cause her physician to violate another of the ethical principles, nonmaleficence, as it is possible that her fiancé may contract the HIV disease from Amanda. Regardless of whether the situation resembles that of Robert, is more like that of Amanda, or is completely different (as ethical dilemmas will appear in an expansive variety of forms), there are approaches and methods that may be used when attempting to make that “correct” decision. One potential method is to follow a methodical and fact-specific analysis.2 Begin by reviewing your case and clearly defining the issues that are preventing you from establishing a treatment plan. After you are able to clearly articulate the complicating issues of your patient’s case, identify the facts that are hindering your ability to make a decision and also those facts that might provide support for making one decision over another. Remind yourself to whom or to what you owe an obligation. Do you owe a duty to your patient, your patient’s family, your institution, or to someone else? Then evaluate all of these things – the ➤ TRIAD, Winter 2011 13
issues, the facts and your obligations – and decide, based upon this analysis, which of the options should be chosen. Justify this decision to your patients and to those entities to which you determined you owed an obligation. After you have made your decision, analyze it to determine if it was in fact ethical. One potential test that has been suggested to validate the ethical status of a decision has three steps.3 First, determine if the decision you have made is legal and/or in accordance with institutional policy. Second, determine if your decision promotes a situation where as many people win as possible. Third – this is a self-reflective step – consider how you would feel about yourself if you were to read about your decision in an article or in the paper.
Despite the sometimes difficult and fact-specific nature of these ethical dilemmas, physicians are not completely alone when facing them. First, remember if you are uncer tain about what action to take, seek clarity from your patients and their family if possible. Speak with them. Try to truly understand their expectations and attitudes about the current situation. There are times that a conversation with these individuals may make one of your options more pala table. During these conversations it will be important for you to examine your own personal ideals, to tolerate the uncertainty that is associated with that examination, and to maintain your integrity while respecting the opinions of others. Second, review the American Osteopathic Association’s (AOA) code of ethics. This code provides osteopathic physicians with guidance by outlining the professional and ethical responsibilities that osteopathic physicians have to their patients, their society and their profession.Third, if speaking with your patient or reviewing the AOA’s code of ethics does not provide additional clarity, remember you have support systems in place. Seek advice and guidance from your facility’s ethics committee, your direct supervisor, a hospital chaplain, or legal counsel. Any of these resources may be able to provide you with the support or insight that is necessary to make an appropriate decision. While it is clear that ethical dilemmas take many forms, and often lack a clearly defined correct answer, they are not impossible to navigate. Remember the core principles of ethics and apply them. First, do no harm; then provide a benefit to others. Remember that your patient has the right to make decisions that impact their well-being, and to always practice medicine in a judicial manner. The appli cation of these principles may be difficult, but speaking with your patient or their family may provide the insight necessary to make the “correct” decision. If not, there are other support systems available that may prove helpful, and, like ethical dilemmas, these support systems take a variety of different forms. Do not hesitate to turn to others for help or to seek out a second opinion. m Endnotes:
1 Each of the four principles described was found in: McWay,
2
3
14 TRIAD, Winter 2011
Dana. Legal and Ethical Aspects of Health Information Management. 3rd ed. Clifton Park, NY: Cengage Learning, 2009. 95-98. The process described was outlined in: McWay, Dana. Legal and Ethical Aspects of Health Information Management. 3rd ed. Clifton Park, NY: Cengage Learning, 2009. 116. The test described was outlined in: Lewis, Marcia, and Carol Tamparo. Medical Law, Ethics, and Bioethics for the Health Professions. 6th ed. Philadelphia, PA: F.A. Davis Co., 2007. 9.
Endovascular Treatment of
Carotid Artery Disease
by Bipinchandra B. Patel, D.O. and John W. Sealey, D.O., F.A.C.O.S.
A
ccording to the CDC, stroke is the third leading cause of death in the United States. With an incidence of 1.5 deaths per thousand, it is the most common and
disabling neurologic disorder in the elderly population1. The gold standard in the past for carotid artery stenosis was carotid endarterectomy, first described in the 1950s by Scott, DeBakey, and Cooley. In 1980, Kerber et al reported percutaneous balloon angioplasty as an option for carotid artery stenosis. Although angioplasty was successful, there were drawbacks to the procedure including vessel wall recoil, angiographic evident intimal dissection, and plaque dislodgement with particulate embolization. The latest endovascular treatment for carotid artery stenosis is endovascular carotid artery stent placement with cerebral protection devices 2. The Carotid Revascularization Endarterectomy Versus Stent Trial (CREST) is the first trial to compare carotid artery stent placement with cerebral protection devices versus carotid endarterectomy. Many other trials were done prior to the CREST trial, but all had flaws. The CREST study was funded by the National Institutes of 16 TRIAD, Winter 2011
Health and created in the late 1990’s, starting in 2000 and ending in 2008 after 2,500 patients were enrolled. Patients were randomized equally to include sympto matic patients with a carotid bifurcation stenosis ≥ 50 percent on angiography, ≥70 percent on ultrasonography, or ≥ 70 percent on computed tomographic angiography or magnetic resonance angiography. In 2005, the study was changed to include asymptomatic patients with carotid artery stenosis. The patients had to have an ultrasonography with 50-69 percent stenosis. The patients then had to have a more detailed test to confirm diagnosis such as: ≥ 60% by angiography, ≥ 70 percent on ultrasonography, 80 percent on computed tomographic angiography, or magnetic resonance angiography. As a standard of care, the interventionists and surgeons enrolled in the study had to have the qualifications and experience in the placement of carotid stents. The study showed that both procedures are equivalent in major perioperative morbidity and mortality as well as longterm stroke prevention. The most common perioperative morbidity in stent placement was stroke (most of them being minor). Perioperative morbidity in carotid endarter ectomy was myocardial infarction. In the long term, both procedures were equivalent in stroke prevention 3. Who is eligible for carotid artery stent placement? Currently there is no consensus to determine the right patient for carotid artery stent placement, but generally patients’ comorbidities determine the better candidates for the placement versus surgery. Patients with a history
of pulmonary disease, post radiation for head and neck cancer patients, and patients with restenosis after endarterectomy are candidates for stent placement 3. The operating room plays an important role in successful stent placement. The operating table should be radiolucent making sure all the wires are clear of the femoral artery, iliac artery, aorta and the neck. Placement of an extra table at the foot of the operating table helps to keep the catheters and guide wires sterile and “in line” with the patient. The patient needs to be prepped in a sterile fashion by first shaving the groin area of any hair and then cleaning the skin with antiseptic solution. The main operator is on one side and the screen directly opposite the operator. Anesthesia is at the head of the bed monitoring blood pressure and cardiac rhythm. The procedure is done under local anesthesia so that patient can be monitored continuously for neurological deficits. Patients are given aspirin 75mg and Plavix 300mg on the day before surgery. At the start of the procedure, patient is given 1mg/kg of heparin and continued for 48 hours post surgery 4. There are four approaches to gaining access to the carotid artery. First is the direct percutaneous access to the carotid artery. The main indication for this access is for tandem lesions involving the intrathoracic portion of the common carotid artery. The second approach is accessing the brachial artery. The main risk of this access is injury to the median nerve. This access is most useful when access is denied via femoral artery. The third approach is the radial artery if low profile equipment is available. The femoral artery is the most common approach to accessing the arterial system 4. One of the key instruments that allow us to stent a carotid artery is the Cerebral Protective Device (CPD). When stenting was first performed, there was a high risk of emboli that could cause an ischemic stroke. CPD’s help prevent these strokes. There are several different kinds that protect the brain from emboli that originate from the plaque. The PercuSurge Guardwire System, made by Medtronic, is a guide wire with a balloon on the tip. Once the wire is placed in the internal carotid artery, the balloon is inflated and stops the emboli. A suction device is then placed over the wire to remove the emboli prior to deflating the balloon. Parodi Anti-Emboli System is based on the principle of reverse flow. This system allows the inflation of one balloon in the external carotid artery and the common carotid artery. This allows the reversal of flow in the internal carotid artery. The blood and emboli flow through the catheter into a filter. Once the blood is filtered, the blood is returned into the patient’s vein. EPI Filter Wire EZ is a guide wire that has a basket to collect the emboli. Once the stent is placed, the basket is withdrawn into the sheath. The sheath is then removed 4. The first carotid stents manufactured were of the balloon-expandable stent-crushing type. This method led to cerebral flow impairment. The complication of this stent led to the development of a self-expanding stent.
The stent is composed of one of two types of material. One is the cobalt alloy stent called the Carotid Wallstent made by Boston Scientific. This is a self-expanding stent that relies on its spring-like action to expand as the sheath is pulled back during deployment. All other stents on the market are composed of nickel-titanium alloy (nitinol). This stent is laser cut from a nitinol tube that has thermal expansion properties. At room temperature these stents are compact, but when exposed to temperatures above 32.2°C the stent expands to a preformed shape. The nitinol stents can be further classified as open cell versus closed cell. The difference is the number of bridges that connect each hoop of the stent. The more bridges between the hoops the more rigid the stent and therefore termed the closed cell. Open cell stents are more flexible because they have less bridging between the hoops. The different types of stent give the interventionist an opportunity to select the appropriate stent for the appropriate anatomy. The more tortuous the anatomy of the carotid artery, the more flexible (open-cell) the stent needs to be. Currently there are conical shaped stents available for better adapta tion to the vessel wall. As the lumen narrows from the common carotid artery to the internal carotid artery, the conical stents accommodate for this change in lumen5. Strokes associated with carotid artery stenting are most common in the early post-procedural phase. When selecting the stent, the interventionist has to determine if the plaque has a high emboligenic property. A lesion with a gray-scale median of less than 25 has a higher chance of embolization. These plaques have a higher content of lipids and fats. Conversely, a lesion with a gray-scale median greater than 25 has a higher content of fibrous scar tissue and calcium. The latter lesion is less likely to embolize. The interventionist is likely to use a closed-cell stent for an emboligenic plaque as the extra bridging holds on to the plaque better. This limits the possibility of stroke 5. In summary, just the mention of having a carotid stent placement is not as simple as it sounds. Successful stent placement is multifactorial. Stent, CPD, and patient all play a role in the success of stent placement. Carotid stent placement is not an option to replace medical or surgical therapy for carotid stenosis but rather another tool for the treatment of carotid stenosis. m References:
1 Rosamond W, Flegal K, et al. Heart Disease and Stroke Statistics-2008
2
3 4
5
Update: A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2008; 117:e25-146 Mark Wholey MD and Michael Wholey MBA, MD. History and Current Status of Endovascular Management of Extracranial Carotid and Supra-Aortic Vessels. Journal of Endovascular Therapy. 2004; 11(Suppl II) II-43-II-61. Rita Coram, MD and Alex Abou-Chebl MD. A Summary of the CREST Trial. Endovascular. October 2010: 45-48. John Hallet MD, Joseph Mills MD, Jonathan Earnshaw MD, Jim Reekers MD, and Thom Rooke MD. Comprehensive Vascular and Endovascular Surgery. 2nd Edition. 2009; 630-646. Marc Bosiers, MD; Koen Deloose, MD; Jürgen Verbist, MD; Patrick Peeters, MD. Carotid Artery Stenting: Which Stent for Which Lesion? Vascular. 2005;13(4):205-210. TRIAD, Winter 2011 17
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Contact Information:
POH Regional Medical Center Department of Medical Education
248.338.5392
18   TRIAD, Winter 2011
Personal Accounts, Insights and Perspectives from Members of the Islamic Medical Student Association by Craig Reed, Public Relations, Michigan State University College of Osteopathic Medicine
O
n the ninth anniversary of the 9/11 tragedy,
“Our members go to the Islamic Center all the time as a community,” second-year MSUCOM medical student members of the Islamic Center in East Mussop Mohammad, president of IMSA said. “A lot of Lansing, Michigan, found on their doorstep people that go there are from different places like Detroit, Chicago or Ontario. It is a common place for all of us, a copy of the Koran, torn and burned. For a place where we can better ourselves. It’s humiliating members of the Michigan State University College of for the entire world for something like this to happen. Any book that is burned, it’s disappointing, let alone a book Osteopathic Medicine’s (MSUCOM) Islamic Medical that people use to guide their lives. The Koran has a lot Student Association (IMSA), the incident has sparked of overlap with the Bible and the Torah. These books are a lot of dialogue. trying to bring humanity together for the common good.” “I’m sad someone would disrespect God because it is our belief that the Koran is the word of God,” secondAs an (osteopathic) medical student you can see the year student Altamash Iftikhar, co-vice president for IMSA said. “It talks about Jesus,Abraham and Moses and impact you make through medicine, I don’t think any is the only scripture with an entire chapter on Mary. If other profession can make such impact. a Christian, for example, were to read the Koran, they would see how revered Jesus is in our faith.” ➤
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TRIAD, Winter 2011 19
Devone Almansour and MSUCOM’s Islamic Medical Student Association member Ayman Founas work with a patient while in the Dominican Republic on a medical mission trip.
The incident has fostered a variety of reactions. It in stigated several violent protests overseas. Closer to home, the neighbors of the Islamic Center helped collect the loose pages from the damaged Koran which the wind had blown throughout the neighborhood. Other expressions of solidarity with Muslim neighbors were seen as well. “I had gone home to Flint that weekend,” Aishah Aslam, secretary for IMSA said. “On the Friday after the incident, an older lady came to the mosques in Flint after we finished our prayers. You could tell she was nervous and had something to say, so we asked her to address everyone at the front of the room. She said ‘I want you to know that this whole thing with the Koran burning is not a representation of my faith, Christianity.’ Everybody listened to her and came up afterwards to give her hugs. It really touched us that she came to say that. There are people who would be too intimidated to come in, let alone come in and accept our invitation to address everyone.” “Things like this will happen,” commented Mohammad about the incident.“We can’t be surprised by these things. There are so many people in the world. There’s no telling what might have triggered this man to do this.” “The fact that he eventually turned himself in is a good sign,” said Aslam.“Maybe he felt some regret for his actions and this can be an opportunity to correct some of his misunderstanding about Islam.” 20 TRIAD, Winter 2011
Climate Change Living in post-9/11 America has meant a lot of changes for followers of Islam. Before the tragedy, little attention was given by others to their faith. After the incident, they have faced a higher level of scrutiny and in some cases intolerance. “We’re seeing a resurgence of Islamophobia these days. We saw similar things after 9/11,” second-year Ul-Hassan Jawad, co-vice president for IMSA, said. “ It’s quite alarm ing. We have the ongoing mosque issue in New York City and the pastor in Florida who wanted to burn the Koran — little things here and there which in some cases have been used for political purposes which have led to inci dences like the burning of the Koran in East Lansing.” “If a man goes into a building and kills eight people, that’s what the media reports:‘Man kills eight.’ If a Muslim does something, right away they call it terrorism. Every time you look at the news and see the link they are making between Muslims and terrorism, you’re going to believe Muslims are bad people,” said Altamash. “We as Muslims have to deal with the backlash of ignorance. After 9/11, my mother and sister who wear the headscarves had people yelling at them and tell them to ‘go back where you came from.’ I was born and raised in Chicago. My sister was born and raised in Chicago. My father is an orthopedist who has practiced in Chicago for 36 years. It’s sad. At times I do not feel welcomed in my own country.”
Handling the negative reac tions on the street brings most IMSA members back to their religious roots for guidance. “I was just reading a verse that when someone does something bad to you, you should respond with something good. That is part of the philosophy behind Islam by — no matter what crazy things might happen. In Islam, we’re supposed to control our anger, and learn how to deal with it,” said Aslam. “Our last messenger, Mohammad, said the strongest person isn’t the person who is physically the strongest, but is the one who is able to control his anger,” Mohammad said.
Myth Busting As a student organization IMSA funnels a lot of its time and energy into demystifying Islam for others. “We have different programs on campus, like our annual Fast-a-thon which coincides with Ramadan when Muslims fast from sunrise to sunset each day. It is a chance for non-Muslims to experience what we experience,” Jawad said. “We’re here to clear any of the misconceptions that anyone has about Islam. Our events are a way to show people what Islam is really about.”
MSUCOM’s Islamic Medical Student Association members Ayman Founas and Mussop Mohammad (pictured left to right with Karim Saleeby) take a well deserved break from seeing patients during a 2010 mission trip to the Dominican Republic.
Organized events aren’t the only times Jawad and other members of IMSA edu cate their peers. “In Islam, the way we show our religion is through our actions. Be good to our neighbors. Be kind to others. This type of edu cation is one of those things we try to do everyday,” Jawad said. “When we have events, we try to convey to our participants that if they have any questions or thoughts to bounce off of me, go ahead. Don’t think that it’s too personal. I want people to ask me questions so I can clarify misconceptions. If you don’t ask me, then there’s no way to help clear up misunderstandings about Islam,” Aslam said. One common misconception is the meaning behind a Muslim woman covering her head. “The reason why I wear a headscarf is because God mandated it, said Aslam. “I’m worshipping God by ➤
TRIAD, Winter 2011 21
wearing this. We obey God and then we look for reasons why this obligation exists: Whether it’s for preserving modesty, or having people interact with me without think ing about how I look, but simply treat me as a person.” I feel a lot of benefit comes from wearing this in terms of interacting with people and etiquette. It helps with focus. Muslim women around the world may have different reasons why they wear it or do not wear it, and how they wear it or if they do. Everyone will have their own personal ideas whether cultural or otherwise.” “A nun dresses modestly and no one says anything, but a Muslim woman covers herself in modestly and some
people believe she is oppressed,” Iftikhar said. “Mary is always depicted as having herself covered in modesty.” “When we decide to wear this, it infuses into every part of our life,” Aslam continued. “When I go into a hos pital, I have to think about ‘what I should wear.’ I have to think about what I should wear because I need to be able to scrub up for surgery.”
Medicinal Purpose
Hand in hand with their faith being a part of their every day life, so too has the desire to help and heal others been present for many IMSA members since their childhood. “My dad is my role model,” Iftikhar said. “I’ve wanted to be in medicine all my life. The earliest memories I have is sitting on my father’s lap and watching videotapes of surgery with him. I just thought it was the coolest stuff even though I had no real idea what was going on. I was just fasci nated. I also got to see the impact my Celebrating 25 years father made on people’s lives. People of serving healthcare providers would stop him in the street all the time to thank him for helping them or a family member. During the war in Bosnia, my father and a couple of other Muslim physicians did free surgery for several Bosnians. He also went to Pakistan through Doctors Without Borders to treat people there. People from the village he helped, they will still save up money just to call him and say “hi” because they remember all the good things he did. I hope to be one-quarter the man and physician he is.” “I came into medicine for similar reasons,” Aslam added. “My mom is in the medical field and my father is an engineer. The doctors in our community have done so much for our community. They practically built the mosques and the community in Flint. Seeing how much they have been able to do, that has been inspiring.” “Going into medicine was a perfect fit for me,” Mohammad said.“My dad is a physician in oncology over at Wayne State University. I wanted to be part of a profession where I could be there for my community and raise my kids when I have them. Our religion says if you heal one person, it is like healing all of mankind. Regardless of where you end up practicing medicine, you know you’re going to be helping people.” m
22 TRIAD, Winter 2011
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Grant Recipi Alcona Health Center Program HealthFlex Works Both the Brain and Body by Cheri Rugh
P
hysically at-risk senior members of Alcona and Health Center’s Lincoln facility and its HealthFlex Iosco counties and the surrounding areas now program is the only facility within a 35-mile radius that have a chance to participate in a series of health can serve as an exercise facility. The center services education and physical movement classes offered over 1,200 clients each year. by Alcona Health Center’s Lincoln site, under the guidance Currently, HealthFlex participants are patients of of Donald Spaeth, D.O. The classes are offered in the Alcona Health Center Lincoln site, most as a result eight-week cycles and target geriatric patients with health of a recommendation from their health care provider, concerns that include diabetes and chronic pain. “Simple but word has spread and now community members changes in activity have a large impact on feelings of are asking to participate. In the pilot cycle of the well being,” Dr. Spaeth said. program, held fall of 2010, the The program, named HealthFlex, participant group averaged The HealthFlex Program is the recipient of an MOA Core 72 years of age with a body mass Grant which is given to programs incorporates the mind/body/spirit index of close to 30 and with that support primary care and prehigh incidence of hypertension, concept by using diet, vention – the core of good health. hypercholesterolemia and some HealthFlex evolved from a com with diabetes. “Our program activity and behavior toward munity event held during National combines professional instrucimproving overall wellness, Health Center Week back in 2008. tions in dietetics, exercise and life“We put on a demonstration of difstyle changes, to provide a catalyst Donald Spaeth, D.O., said. ferent types of exercise available in for improving health behaviors,” our community and it was attended Dr. Spaeth said. exclusively by those over 55 years The nuts and bolts of the of age,” explained KiAnn Kruttlin, HealthFlex program include a a certified physician’s assistant with participant questionnaire both the center. “This spurred us on to put at the beginning of the program together some sort of formal health and at the program’s completion education and exercise program (to monitor progress) and weekly targeted to meet the unique needs group meetings that include both of the senior age group.” Topics educational and physical compocovered during each program cycle nents. The educational component include nutrition, techniques for incorporates presentations from dealing with chronic pain as well guest speakers such as a behavior as physical training to improve therapist on making positive health balance and muscle tone. changes and techniques for living “Patients, especially those in with pain and from a certified rural and underserved areas, need diabetes educator on nutrition. to have programs made available “During the educational part of to them. Many residents have the meeting we discuss barriers not been exposed to alternative to practicing healthy habits and approaches to wellness, they tend give alternatives to those barriers to do what their parents and grandand we encourage group memparents did,” Dr. Spaeth said. The bers to give solutions to the HealthFlex program is perfectly ‘excuses’ for not practicing matched with the area, as Alcona wellness,” Kruttlin said.
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26 TRIAD, Winter 2011
ient Pictured are members of the HealthFlex program as well as a photo of Donald Spaeth, D.O., Alcona Health Center, who oversees the HealthFlex program.
The physical component provides for 40 minutes of exercise with an emphasis on eye/hand activities, balance, yoga and Tai Chi. “We are thrilled to have received the MOA Core Grant because that funding will be used to purchase exercise equipment such as free weights that will allow us to move our participants to the next, more intense exercise level,” Kruttlin said. “So many of our seniors have health problems that make them feel they cannot exercise, we are excited to help
O
them find out they can do so much!” “In my mind, the HealthFlex program embodies the osteopathic principals of osteopathic medicine. It offers the participants an oppor tunity to learn how the mind/body/spirit interact and new methods of improving their life,” Dr. Spaeth said. “It also has a domino effect because those that have been involved tell their friends and family so the changes in one person’s lifestyle impact others.” m
About MOA Core Grants
ne of the unique tenets of osteopathic medicine is a commitment to primary care and prevention — the core of good health. In 2007, the MOA created a program to assist those osteopathic physicians who are taking the initiative to host health programs or clinics that embody these osteopathic values. In October, the association awarded three MOA Core Grants from a pool of extremely qualified applicants. The MOA will highlight each of the Core Grant recipients in a TRIAD article over the coming year. The program highlighted in this issue – HealthFlex offered by Alcona Health Center – can be implemented on a small budget, but with far-reaching effects. For additional information on this program, contact KiAnn Kruttlin at kkruttlin@alconahc.org. For a list of 2010 MOA Core Grant recipients, visit the MOA website at www.mi-osteopathic.org, and look for another Core Grant feature story in the Summer issue of TRIAD.
TRIAD, Winter 2011 27
D.O.s Making a Difference Northern Michigan’s Thomas Allum, D.O., Blazed a Trail and Bridges the Miles with His Osteopathic Care “The future will present more challenges for rural
osteopathic physicians – the closure of hospitals, the influx of midlevel providers, government regulation and the difficulty of networking, but if we focus our efforts on patients and their satisfaction we will succeed.
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– Thomas Allum, D.O.
by Cheri Rugh
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OA member Thomas Allum, D.O., of Rogers City, has been a rural physician in northern Michigan for more than 40 years. Currently employed with Northern Michigan Regional Hospital at its Rogers City location and formerly the medical director of the Rogers City Medical Group, Dr. Allum is no stranger to the unique circumstances to which a rural physician must adapt to. “Isolation is the biggest threat. We have tried to network with regional experts, both M.D. and D.O., so that we do not feel isolated and to ensure we have access to the latest ideas on disease management,” Dr. Allum explained. “Continuing Medical Education is especially important, it helps to keep us up to speed on the latest trends as they impact our rural location.” Dr. Allum’s journey to the practice of osteopathic medicine in northern Michigan involved much more than the miles on the road it took to get there. “When I first came to northeastern Michigan in 1970 I was only the second D.O. ever to practice here, the first had received no cooperation from the other local doctors and hospital and had only lasted six months.” Things took a turn in 1970 when the local hospital was in desperate straits with only one remaining surgeon for its 50-bed hospital and 50-bed extended care facility. “My partner Jack McNeil, D.O., and I arrived and had to prove ourselves to everyone” Dr. Allum said. 28 TRIAD, Winter 2011
Fortunately for Dr. Allum and Dr. McNeil, their medical training and preparation had been superb and they were able to handle the patient load that quickly grew. “We were immediately put to work delivering up to 30 babies per month, covering the ER, assisting in surgery, designing and building an ICU, and a hundred other things!” Over time, the two D.O.s were able to convince their M.D. counterparts of their medical skills and were able to achieve parity and ultimately were fully accepted as colleagues in the practice and business of medicine. “What is funny to me is that while there was a lot of bias, discrimination and ignorance about our training and our profession amongst the establishment, our local patients had no biases,” Dr. Allum said. “They needed care and we could provide it. We were able to use our training to care for the entire town and to gain the support of almost everyone. We kept our focus on quality care and patient satisfaction. We melded into the community. We updated the practices and training for the hospital staff. We were successful.” While his geographical location presents distinct barriers such as lengthy travel times for appointments, etc, Dr. Allum emphasizes that the practice of osteopathic medicine is the same as it is everywhere. “I work with local partners and regional experts to try and provide the same quality and access to care that one could get
in a larger community. It just requires extra work and coordination by our staff.” No matter where he practices medicine, Dr. Allum strives to provide the compassionate care he was trained to give. “I just do what I was trained to do by my old mentors,” Dr. Allum said. “‘Try your best to help your patients in their time of trouble and don’t do any harm’ were lessons drummed into me and they are lessons I have never forgotten.” Dr. Allum’s personal work ethic is to treat every one of his patients as a “special” patient where he interacts with them as if they were a member of his own family. “My staff also realizes that every patient is special, so we really work as a team to go above and beyond with every patient.” A graduate of the Chicago College of Osteopathy, Dr.Allum’s exposure to osteopathic medicine came at a much earlier point in his life – his birth! “I was born at the old Detroit Osteopathic Hospital (DOH) in 1942 and I always saw an osteopathic physi cian when I was a youngster.” Dr. Allum returned to DOH for his medical school senior year externship before finishing his training to be a general practi tioner. “Osteopathic Medicine was in my blood and general practice was the way to go in those days, it offered a chance to do a bit of everything from obstetrics to surgery to OMT and counseling.” Even after practicing medicine for more than 40 years, Dr. Allum finds joy in his time with patients. “Every morning is exciting as you never know what the person in the next examination room has as a challenge for you.” Whether it be long-time patients, whom Dr. Allum compares to being like family members (“we go through life together facing each new challenge as it arises trying to get the best quality of life”), or new patients whom he likens to an unopened Christmas present (“you just can’t wait to get at it and find out what surprises they have), he works to understand the patient’s anxiety, fear, concern and hopes.“When I am working to treat a patient I always try to
follow through with them and their families to be sure they understand all that has happened to them, what to expect in the future and to ensure that nothing has been overlooked.” As much as things change they also stay the same and those words ring true for Dr. Allum as he reflects back on his years of practicing osteopathic medicine. “I try to remember what the ‘old guys’ taught me: keep the patient the center of focus, train young physicians in the skills of treating the whole person, and finally, be eternally grateful to our predecessors in this great profession.” m
TRIAD, Winter 2011 29
profile MOA Board Trustee
. Draion M. Burch, D.O. by Cheri Rugh The MOA TRIAD is pleased to publish this question-and-answer feature on new MOA Board Trustee Resident Representative Draion Burch, D.O. To date, each active member of the MOA Board has been featured in a past issue of TRIAD as a form of introduction and background. Here is brief look at the background, credentials and osteopathic views of Dr. Burch, what drew him to the profession and what fuels his ongoing commitment to it. Where were you born? Ocean Springs, Mississippi Any memorable experiences you would like to share regarding your childhood/adolescence? “My most memorable childhood moment was when I was failed in the first grade and my parents were told that my reading skills were not at the same level as my classmates. Because of this I had to attend summer school to remediate. By third grade, I was promoted to the gifted and talented class. I now have dedicated my life to education. This life situation inspired me to start a nonprofit organization called Project S.T.A.R. (Success Through Achievement in Reading). This organization helps elementary children develop better reading and writing skills while reiterating how these much needed skills will further enhance their quality of life.” Visit the website at www.projectstarmi.com for more information. When did you decide to become a doctor (a D.O. specifically) and how did you come to this decision? “My parents once told me that I always wanted to be a doctor since I was a child — age eight to be exact. Whenever I played ‘hospital’ with my cousins, I always wanted to be the doctor, to be the one who helped people recover from their ailments. As I grew older I struggled with the decision on the type of physician I wanted to become. My childhood physician was a D.O. and he encouraged to learn more about osteopathic medicine. I shadowed D.O.’s to learn about the pro fession, read books about osteopathic medicine, visited osteopathic medical schools, and joined an osteopathic pre-med interest group. The more I was exposed to osteopathic medicine, the easier it was to define the type of physician I desired to become.” Where did you attend college? I attended Xavier University of New Orleans, Louisiana, the only historically black Catholic university nationally known for preparing students to be physicians and I graduated in Chemistry. 30 TRIAD, Winter 2011
Where did you attend medical school? I attended The Ohio University College of Osteopathic Medicine (OU-COM) in Athens, OH. “I was first attracted to OU-COM because of the college’s Center of Excellence for Multicultural Medicine. I saw that OU-COM was invested in training minority students to become superior clinicians, researchers, and leaders in academia and health policy.” Where are you working during your residency? I am currently at St. John Providence Health System Osteopathic Division Macomb-Oakland Hospital, Macomb Center; Obstetrics and Gynecology Chief Resident. “Caring for women through the physical transitions of their lives, from adolescence through menopause and beyond, is essential. Advocating for women’s health allows me to engage in preventative medicine and practice continuity of care. The diversity in practicing OB/GYN enthralls me; this field offers a fusion of surgery and medicine, as well as manual procedures. Due to intrusive procedures and the intimate nature of women’s health care, the patient-physician relationship is special and must be cultivated with open communication and trust. Women must be empowered to take charge of their health.” Any experiences you would like to share regarding your life? One of my most memorable moments before medical school was when I taught ninth grade chemistry at a math and science school in New Orleans. “I wasn’t ready to go to medical school yet. I needed some real-life experiences and I got them. I had students who were pregnant, HIV-positive; I had a student commit suicide. From this experience, I learned that life is precious and everyday one has to live up to their full potential. I love to teach, it is truly my passion. Of all the awards that I have received thus far, the most rewarding was when I was voted Teacher of the Year.” Another memorable moment in residency was when I met the U.S. Surgeon General.This moment helped me realign my life goals.
Do you participate on any committees or outside involvements on a professional level? At the state level, I am a member of the MOA Board of Trustees as the resident representative. In addition, I am the chair of the MOA Intern Resident Committee and vice chair of the MOA Department of Continuing Educa tion, which includes the MOA Editorial Committee, MOA IT Committee and the MOA Education Committee. I have served as a delegate to the MOA House of Delegates for three years and I am a Governor’s Club member of Michigan Osteopathic Political Action Committee. Nationally, I am a member of the American Osteopathic Association’s Board of Trustees as the resident representative while also serving as chair of the AOA Council of Interns and Residents and as a member of the AOA Bureau of Conventions, AOA Mentor of the Year Selection Committee and as a delegate to the AOA House of Delegates for three years, and I am a member of the Resident’s Roundtable for the Osteopathic Political Action Committee. I also serve on the American College of Osteopathic Obstetricians and Gynecologists (ACOOG) Board of Trustees and as a member of their ACOOG Historian Committee and CME Committee as well as Vice President of the National Osteopathic Medical Association. “I am passionate about advocating for the osteopathic profession and empowering our community to be committed to the principles of osteopathic medicine.”
mentors came with varied characteristics — they were highly educated/uneducated, younger/older, professional/non-professional, and male/female. One of the main ingredients I valued in my mentors was their ability to help me mold my aspirations. My mentors had the expertise I admired, the character istics I wanted to emulate, as well as the willingness to share their time — time for me to observe, model, learn and practice. My mentors were role models who challenged me to improve through professional and personal growth. Regardless of my success, I always benefited from the guidance of a mentor. My mentors consist of academicians, clinicians, researchers, teachers and administrators. I like to think of combining all of their skills and characteristics to see myself in the future. I set a standard of “that’s what I want to be like,” when I put together my mentoring team. 3. Journal daily. I write things in my journal, and then I look back to see what I was thinking a month ago. I like to see if I’m on track. It gives me the oppor tunity to readjust my strategy. 4. Every time I get an opportunity to develop profes sionally, I just do it. I never know what door it might open. Every person that comes into my path is someone I look at and say “What can this person teach me that is not obvious in this moment?” m
What inspired you to serve as a board member? I wanted the osteopathic residents in Michigan to have a voice. Michigan has the largest number of postdoctoral trainees in the country. George Northrup once said “The future of osteopathic medicine is not in the hands of those who oppose us, but rather in the hands of those who believe in it the most.” Hobbies/areas of interest: I enjoy mentoring and teaching medical students and residents. I also enjoy reviewing manuscripts for journals and reviewing grants. On the other hand, I enjoy working out and listening to all genres of music. Any words of wisdom to share with fellow D.O.s? 1. Set goals and reach them. I write my goals, and I look at the short term ones every day, and then weekly, and monthly. I produce benchmarks to gauge my progress. It is like a road map that leads me to the next place. Effective organizational skills are very important to me. Before I go to bed, I look at my schedule for the next day to anticipate problems and opportunities. I developed five, 10 and 20 year plans. 2. Find a mentor to help you with every stage of your life. Mentors became an integral component of my career plan. I developed mentors throughout life, and they enlightened my pursuit of personal goals. Even as a child, I looked toward my parents, teachers, and friends to show me the way. My TRIAD, Winter 2011 31
Is Your Liability Insurer a Safe Choice? How not understanding the three types of insurance companies can put you and your practice at risk by Laura A. Kline, CIC, CPCU, Vice President, The Doctors Company/American Physicians
O
ver the past six months, there have been some disturbing developments with regard to Universal International Insurance, Ltd. (also affiliated with New Millenium, Ltd.), a Bermuda-based medical malpractice insurer. According to an Aug. 24, 2010, article in “Michigan Lawyers Weekly,” physicians who have purchased medical liability coverage from the company should be very concerned. In at least two instances, as of the date of the article, the company failed to pay settlements on behalf of their policyholders. As a result, judgments have been entered against the physicians involved in the claims. On Oct. 20, 2010, Novi police found the owner of the insurance company, Detroit-area attorney Nicholas Ianni Jr., dead of multiple gunshot wounds. According to a Detroit Free Press article on Nov. 29, Ianni’s killing remains a mystery. Universal/New Millenium is a Tier 2 excess and surplus lines insurer. As such, they are not regulated by any state or federal entity and doctors who have purchased coverage from the company have little recourse in the event of a claims-related or other dispute. In addition, insureds of their company do not qualify for protection under Michigan’s Guaranty Association. Physicians must understand the differences between the following types of insurance companies operating in Michigan:
m Admitted Insurers – Strict Regulation and Solvency Requirements Admitted insurers are both regulated and author ized, which means they are subject to financial oversight and market conduct regulation by the Michigan Office of Financial and Insurance Regulation (OFIR). Purchasing insurance from an admitted carrier ensures your coverage is legitimate and the company has adequate financial resources to pay claims. In addition, admitted companies qualify for protection under Michigan’s Property and Casualty Guaranty Association. If there is a coverage dispute or the insurance company becomes insolvent, the Guaranty Association will intercede to protect the interests of policyholders and pay claims. m Excess and Surplus Insurers – Little or No Regulation and Minimal Solvency Requirements Physicians sometimes seek coverage through an excess and surplus (E&S) carrier if they are unable to obtain it from a traditional admitted insurance company, usually due to a poor loss history, licensing or disciplinary issues, or because they perform high-risk procedures. In most states, consumers who want to buy insurance from an E&S carrier have to first be rejected by an admitted company. However, unlike other states, Michigan law has a unique and unusual provision that allows consumers to purchase directly from either tier of the E&S market without first attempt ing to secure coverage in the admitted market.
Admitted Insurers
Tier 1 Excess & Surplus Lines Insurers
Tier 2 Excess & Surplus Lines Insurers
Traditional insurance companies that are intended to be the primary source of coverage for most risks.
Intended to be used for hard to insure risks that have been turned down by the traditional market.
Intended to be used when coverage is not available in the admitted or Tier 1 markets.
Highly regulated.
Minimal regulatory oversight.
Not regulated by any state or federal entity.
32 TRIAD, Winter 2011
This means that physicians in Michigan who purchase E&S coverage may be at increased risk of ending up with inadequate insurance protection. This risk runs the gamut from becoming the victim of outright insurance fraud to obtaining a policy from a company that offers an attractive premium but does not have adequate financial resources to pay claims. m Bottom Line – Experience and Financial Stability are Critical Medical liability insurance is a specialty line that most insurers avoid because it requires specialized knowledge and expertise. It is not uncommon for inexperienced carriers to face financial hardship due to a lack of assets compounded by ineffective underwriting and pricing. You should be able to rely on your insurance agent to provide comprehensive information and assist you in making an informed decision. If you are working with someone who does not represent any of Michigan’s well-known admitted carriers, they may not have the experience or expertise to look out for your best interests. Securing liability coverage through a reputable agent is important to ensure adequate protection for you and your medical practice. m
Sidebar:
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or detailed information about the level of protection offered by the different types of medical liability insurers in Michigan, as well as examples in each of the three categories, visit the MOA website at www.mi-osteopathic.org to select the Physicians Tools and Resources tab followed by the Tools for Providers tab and click on Liability Insurance. To determine if a company is an admitted insurer, a search feature is available on the OFIR website at: http://www.cis.state.mi.us/fis/ind_srch/ins_comp/ insurance_company_criteria.asp. Scroll to the bottom of the page and enter the insurance company’s name to conduct a search. You can also contact OFIR with questions at (517) 373-0220, (877) 999-6442, or via e-mail at ofir-info@michgan.gov. All information reported to and by OFIR is available to the general public upon request.
The Doctors Company/American Physicians is the exclusively preferred professional liability insurer of the Michigan Osteopathic Association. For information about the company, visit their website at www.thedoctors.com.
TRIAD, Winter 2011 33
Association Benefits Works With The Blues to Offer New Plan Designs for 2011
W
ith the new year, many employers are looking for cost effective ways to manage employee benefits expenses. Blue Cross Blue Shield of Michigan continues to address those specific needs of the employer and seek a more competitive position throughout Michigan. The latest effort begins with a host of changes that took effect January 1, 2011, designed to offer employer groups an oppor tunity to better manage increasing health care cost trends. New Medical Plan Designs Available January 1, 2011, are Blue Cross Blue Shield of Michigan’s (BCBSM) new Simply Blue PPO, Simply Blue HRA, and Simply Blue HSA plans. These new plans allow employers to gradually move to new comprehensive benefit designs for increased cost-savings opportunities while maintaining the coverage their employees need. A summary of these plans is below. Simply Blue PPO This PPO plan is competitively priced and provides employees with the benefits they want. Multiple deductible and copay plan options Preventive care covered at 100 percent 20 percent in-network coinsurance 40 percent out-of-network coinsurance Cost-sharing feature supports cost-effective use of services Simply Blue HRA The Simply Blue PPO plan can be paired with a health reimbursement arrangement to provide flexibility to help employees cover out-of-pocket health expenses.
34 TRIAD, Winter 2011
Multiple deductible and copay plan options Preventive care provided at 100 percent Can also be paired with a Flexible Spending Account (FSA) Fund through the Blues HRA or FSA partner or other administrator The account, if funded and owned by the employer, allows the employer to choose which qualified medical expenses are covered Simply Blue HSA The Simply Blue PPO plans are IRS-compliant to be paired with a health savings account offering employees a tax advantage and encouraging them to take responsibility of their health care dollars. Multiple high-deductible and coinsurance plan options Pharmacy is integrated with medical deductible Preventive care covered at 100 percent Fund through Healthy Blue Choices HSA with no start-up or administrative fees or use another financial institution’s HSA Employees are able to save for current or future health care expenses Employer or employee can contribute pre-tax dollars The employee owns the account More Access All of the plans feature the BCBSM provider network, so employees have coordinated care and unmatched access to physicians, specialists and hospitals throughout the state, nation and world. BlueHealthConnection Employees are provided with comprehensive wellness and care
management through BlueHealthConnect. This unique program includes an online health assessment and coaching programs, 24/7 nurse line and health improvement programs including Quit the Nic, chronic condition management and case management. Valuable Web Resources Employees have the convenience of viewing their account, benefit and claims information online anytime. They also can find and compare the cost and quality of doctors, hospitals and drug treatment options based on the criteria that is important to them with Healthcare Advisor, a suite of online tools designed to assist with health care decision-making and encourage patients to take greater control of their health. Healthcare Advisor is powered by WebMD. Member Discounts Employees can save money on healthy products and services with Healthy Blue Xtras and Blue365 savings programs. This includes healthy products and services they use every day from companies across Michigan and the United States. Association Benefits Company has provided MOA members and their staff benefits consulting services for more than 20 years. As a licensed independent agency, we provide employers with benefit solutions including life, health, dental, long term care and disability. We can provide clients with competitive quotes from a variety of carriers. For additional information call MOA at (800) 657-1556, or contact the Association Benefits dedicated MOA representative, Julie Watson (248) 359-6489 or julie@association-benefits.com. m
dean’s column by William Strampel, D.O., MSUCOM Dean
I can do no other than be reverent before everything that is called life. I can do no other than to have compassion for all that is called life. That is the beginning and foundation of all ethics.
Y
William Strampel, D.O., is dean of the Michigan State University College of Osteopathic Medicine.
– Albert Schweitzer, 1875-1965
our patient is hemorrhaging internally and refuses a transfusion. A family surrounds the bed of a comatose man, arguing about whether to terminate life support. The U.S. Congress intervenes in a decision about a woman in a long-term vegetative state. What is the common element? The application of medical ethics. This concept called “ethics,” especially for physicians, is often viewed as a system that constrains us, a system in which we must color within proscribed lines using proscribed hues. Yet, for me, doing what is medically ethical is often much more like painting a watercolor with a team: there are only vague forms to follow, the edges are blurred, we must often work quickly, there’s little chance to correct any mistakes, and our vision for the outcome invariably clashes with those of our co-painters. In short, studying ethics is clean and pure and allows a certain sense of self-righteousness. Doing what’s ethical, on the other hand, is often a messy business. And, in my opinion, it should be. Physicians must struggle not only with these questions in monitoring and adapting their own behavior, but they have the concomitant privilege and burden, in a climate of life and death decisions, to work with others in wrestling with questions of ethics. This conundrum about doing what is good goes all the way back to the creation of the word “ethics,” first used in Aristotle’s Ta Ethika. Aristotle noted how Socrates was the first to take theoretical philosophy and apply it to practical human questions. How do we choose what is good? How do we live that out in our lives? First, we must know our own values, and when necessary,“Physician, heal thyself.” Before we can ever approach the application of ethics in medicine, we must understand what we believe, what we value, what principles guide our personal and professional lives. This process, like any lifelong learning, must be continuous, as new knowledge, new techniques, new multiculturalism, new societal constraints, and new opportunities require refining – and in some cases full redefinition – of our ethical systems. Second, we must develop the discipline to live by our values, day in and day out. This is important in honing our ethical skills, and in serving as role models of ethical behavior for our families, our patients, our professional colleagues and our communities. Third, we must know our patients. We are tinkering with their bodies and their lives, and decisions need to be driven by their values. We need to educate ourselves about cultural norms of major segments of our patient population so we’re not blindsided at a crisis point. Part of our responsibility as doctors, I believe, is to encourage our patients to be prepared to make difficult medical choices for themselves and their families in ethical ways. Ultimately, they hold the trump. Fourth, we must be willing to seek help when the ethical path is not clear. Query a trusted colleague. Put together a multidisciplinary team to review the situation. Test your assumptions against the views of others you respect. Examine, examine, examine. Finally, if your values and your patient’s are so dissonant that you do not feel you could serve them without compromising yourself, you still owe them your care. If you must recuse yourself, do it respectfully, offering a clear explanation, and provide a referral for them if at all possible. Ethical snarls can occur in almost any medical venue among any group of people. It’s important to remember that the worst way to untangle a conundrum is to have each person pulling tighter on his or her own thread. Ethical, well-intentioned, informed decision-making – always with the highest calling for good – is a GPS on a ship seeking an unmarked port in the blackest of nights. m TRIAD, Winter 2011 35
msucom student news
A
by Max Kaiser, MSUCOM Class of 2013
s osteopathic physicians, we pride ourselves on our unique approach to patient care. Often called “caring for the whole patient,” osteopathic physicians strive to look beyond the medical diagnosis to incorporate forces outside of science that may impact our patients’ conditions. However, one aspect of osteopathic medicine that needs further refine ment is our consideration of some under-recognized, yet common, ethical situations. Even as a second-year medical student, I have experienced multiple instances of ethical quandaries. I’m not talking about larger medical issues that we as a society are still grappling with, I’m referring to issues that affect all physicians on a daily basis. To maintain the high level of care that we espouse, we need to be aware of these dilemmas and ensure that we possess the proper tools to evaluate these instances to continue to provide care of which we can be proud. The most well-known of these dilemmas lies in our interactions with pharmaceutical companies. From my own personal experience, and from the medical literature, most medical students and physicians see these interactions as necessary and free of undue influence.1 Unfortunately, the data suggests that the information provided by pharma ceutical representatives may not be completely accurate 2 and that the more interactions doctors have with repre sentatives, the more samples received, and the more meals consumed, the more that prescription habits are adversely affected.3 These interactions also concern patients, as they can change patients’ views of our profession and lead them to fear our possibly biased prescribing habits.4 Though these issues are obviously complicated (i.e., does the influence of free samples outweigh their utility,) it’s important to acknowledge these forces and be prepared to discuss and defend our decisions. END NOTES: 1 Gilbert, D. (2006, April 16). I’m O.K., You’re Biased.
The New York Times, p. 12. 2 Katz, D., Caplan, A. L., & Merz, J. F. (2003). All Gifts Large and Small. The American Journal of Bioethics, 39-46. 3 Adair, R. F., & Holmgren, L. R. (2005). Do Drug Samples
Influence Resident Prescribing Behavior? A Randomized Trial. The American Journal of Medicine, 881-884. Caudill, T. S., Johnson, M. S., Rich, E. C., & McKinney, W. P. (1996). Physicians, pharmaceutical sales repre sentatives, and the cost of prescribing. Archives of Family Medicine. Haayer, F. (1982). Rational Prescribing and sources of information. Social Science Medicine, 2017-2023. Chew, L., O’Young, T. S., Hazlet, T. K., Bradley, K. A., Maynard, C., & Lessler, D. S. (2000). A Physician Survey of the Effect of Drug Sample Availability on Physicians’ Behavior. The Journal of General Internal Medicine, 478-83.
A second ethical concern relates to professionalism – a concept we often espouse to avoid ethical concerns. There are many articles attempting to define profession alism5, but it is often a nebulous concept that we use to confer respect upon our profession, and to imply our authority over medicine. In some cases these ideals have led us down problematic paths. For example, our white coats – what started out as a connection to our scientific roots 6 – has become a potential barrier to effective com munication with our patients 7. In other ways, have we taken “professionalism” too far? Do we need to hide common activities, such as drinking alcohol, from our patients? Are we less respected if we wear jeans? Have we begun to conflate our pride and status with what is best for our patients? These are questions that only we can answer personally, but we must first be willing to identify them as quandaries before we can seek personal answers. Finally, self-referral and direct sale of items to patients are also ethically problematic. Though Stark Laws 8 aim to curtail these practices, they are not all-encompassing. Unfortunately, self referral has been shown to increase unnecessary referrals and health care costs 9. This practice, along with direct sales, endangers the vital trust of our patients 10. However, such services may be admissible, such as when a physician provides services to a community that may otherwise not exist. Again, we must be cognizant of the affect of our decisions and how they may affect patient care. Though I’ve only touched upon a few ethical concepts that I see as under-discussed, I hope I’ve awakened our collective interest in examining how we practice medicine, and how ethics may play a role in delivering the exceptional care that we as osteopathic physicians pride ourselves on. m
Fugh-Berman, A., & Ahari, S. (2007). Following the Script: How Drug Reps Make Friends and Influence Doctors. PLoS Medicine, 0621-0625. 4 Gibbons, R. V., Landry, F. J., Blouch, D. L., Jones,
D. L., Williams, F. K., Lucey, C. R., & Kroenke, K. (1998). A Comparison of Physicians’ and Patients’ Attitudes Toward Pharmaceutical Industry Gifts. The Journal of General Internal Medicine, 151-154. 5 Cruess, S. R., (2006). Professionalism and Medicine’s
Social Contract with Society. Clinical Orthopaedics and Related Research, 170-176. Swick, H. M. (2000). Toward a Normative Definition of Medical Professionalism. Academic Medicine, 612-616. 6 Blumhagen, D. W. (1979). The Doctor’s White Coat:
The Image of the Physician in Modern America. Annals of Internal Medicine, 111-116.
8 Starklaw.org 9 Hillman, B. J., Joseph, C. A., Mabry, M. R., Sunshine, J. H.,
Kennedy, S.D., & Noether, M. (1990). Frequency and costs of diagnostic imagain in office practice – a comparison of self-referring and radiologist-referring physicians. New England Journal of Medicine, 1604-1608. Litt, A. W., Ryan, D. R., Batista, D., Perry, K. N., Lewis, R. S., & Sunshine, J. H. (2005). Relative procedure intensity with self-referral and radiologist referral: extremity radiography. Radiology, 142-147. 10 Ogbugo, P., Fleischer, A. B., Brodell, R. T., Bhalla, G.,
Draelos, Z.D., & Feldman, S. R. (2001). Physicians’ and Patient’s Perspectives on Office-Based Dispensing: The Central Role of the Physician-Patient Relationship. Archives of Dermatology, 151-154.
7 Van Der Weyden, M. B. (2001). White Coats and the Medical
Profession: Time to Rediscover the Symbol of our Purpose and our Pride. The Medical Journal of Australia, 324-325.
TRIAD, Winter 2011 37
Experience the benefits of
membership • Legislative Advocacy • Quality CME • Group Medical & Dental Insurance • MOA BUSINESS MEMBER Discounts
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We value your membership! Have you renewed your MOA membership for 2011? If not time is running out! Don’t let your membership benefits lapse! Call MOA Manager of Membership Shelly Madden at 1-800-657-1556 and renew your membership TODAY!
moa intern resident perspectives by Joel M. Post, D.O.
Medical Ethics Informed Consent: A Resident’s Perspective
I
nformed consent is a legally binding process based on patient autonomy. According to medical ethicist Ronald Munson, it requires “deliberation before decision making.”1 It can be broken down into the “informed” part and the “consent” part. Valid informed consent must be obtained by an attending physician and should be based on a dynamic communi cation between the treating physician (not the physician’s assistant or resident) and the patient. According to the American Medical Association (AMA) the following should be discussed in layperson’s terms prior to obtaining consent: 2 c The
patient’s diagnosis, if known;
c The
nature and purpose of a proposed treatment or procedure;
c The
risks and benefits of a proposed treatment or procedure;
c Alternatives
(regardless of their cost or the extent to which the treatment options are covered by health insurance);
c The
risks and benefits of the alternative treatment or procedure; and
c The
risks and benefits of not receiving or undergoing a treatment or procedure.
The “informed” part of the informed consent is both an ethical and legal requirement in all 50 states and the “consent” part relies on an individual making a voluntary decision. Generally one must be competent in order to act voluntarily. There are plenty of “gray” areas with regards to legal competency, but in general there are special circumstances regarding patients that can’t make decisions for themselves, minors, and emergency situations in which treatment can be rendered without informed consent. Also adding to the complexity is the fact that valid informed consent within a teaching institution entails more than the six points outlined by the AMA. Not directly stated in the list above is informing the patient that a resident physician may be performing part
or all of the named procedure under supervision. Most teaching institutions have written this into the consent to surgery preoperative documents. At my training institution, it is mentioned on line two of the surgical consent,“My doctor may have other doctors assist or do part of the procedure(s).” I have had many patients ask me if I will be performing the surgery when I interview them in the preoperative area. My answers have varied over my three years of surgical training. “I just assist” seemed like a safe reply. Surgeon and writer Atul Gawande, M.D., dives right into this conundrum in his book “Complications: A Surgeon’s Notes on an Imperfect Science.” He poses the question,“Do we ever tell patients that because we are still new at something, their risks will inevitably be higher ... given the stakes, who in their right mind would agree to be practiced upon?” 4 In the orthopaedic ethics literature, two leading authors Capozzi and Rhodes are quite forthright when it comes to patients being properly informed saying, “those who are inadequately informed of risks (including resident involvement) cannot give informed consent.” 4 As Munson points out, informed consent is much more than an agreement; it is a process that requires deliber ation over information that must be understood. In a surgical teaching institution this requires that the patient be adequately informed that a resident may perform part of the surgical procedure. Maybe next time a patient asks me if I will be assisting with their surgery, I will ensure that they are adequately informed before I respond! m
END NOTES: 1 Munson, Ronald. Intervention and Reflection: Basic Issues in Medical
Ethics, 7th ed. Belmont, CA: Thompson, 2004 2 http://www.ama-assn.org/ 3 Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect
Science. New York: Picador, 2002 4 Capozzi, James D. and Rosamond Rhodes. J Bone Joint Surg Am. 2000;
82:1356
TRIAD, Winter 2011 39
MOA Membership Directory Moves
Online Exclusively PHYSICIANS
OFFICE MANAGER
PUBLIC
A
s an MOA member, your dues dollars should bring you the most “bang for your buck.” In 2011, you will find that extra “bang” as we are no longer publishing a printed MOA Membership Directory. Instead, the MOA Membership Directory will be available exclusively on the MOA website, under the members only tab. This move to an online membership directory offers multiple benefits to our members: 1. The online directory is continually updated, offering the most accurate information available. 2. An online membership directory is more accessible; if you are able to log on to a computer you are able to access this directory from anywhere. 3. The cost of providing and maintaining an online membership directory is minimal, saving the association thousands of dollars in staff preparation time as well as the cost of design, print and postage.
How to Use the MOA
Online Membership Directory 1 Go to the MOA website at www.mi-osteopathic.org. v 2 Click on the Physicians tab. v 3 Click on Member Login found at the top of v the left column. 4 Enter your login and password *. v 5 Click on Search for Members. v 6 Enter search information. v (To narrow your search to include just Physicians or
Office Managers click the Membership Type box and select your desired type.)
Search by: name specialty (select the question mark for a list of specialty codes) city county state or a combination of any. 7 Click on the Search button. v 8 View results of your search. v 9 For detailed contact information for an MOA member, v click on the eyeball icon under View Contact Info heading.
* If you don’t have your
member login or password select the “click here” button to have them emailed to you.
40 TRIAD, Winter 2011
Michigan Osteopathic Association
Members of the 2009-10 MOA Editorial Committee decided to move the directory from a printed publication to a more timely, cost-effective online directory. It’s one of the many ways we’re working to ensure you’re getting the best benefits through the best use of your membership dollars. For easy access the MOA Membership Directory Online, visit the MOA website at www. mi-osteopathic.org and follow the step-by-step directions provided here to login. m
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practice manager’s column by Todd Sperl, Managing Partner, Lean Fox Solutions, LLC
O
Improving the Patient Experience: An Editorial Reenactment
n a daily basis practice managers are expected to manage costs, improve physician and staff satisfaction, and find ways to keep patients happy. To address patient satisfaction, practice managers pour over the latest survey results looking for trends in the data. However, most survey results are dated and hard to interpret. To get real-time feedback, practice managers have begun inviting patients to serve on their process improvement teams. The following discussion highlights how and why the voice of the customer can assist in improving patient satisfaction and along the way transform your practice. Voice of the Customer While the hostess escorts them to their table, Andrea’s phone vibrates to let her know she has a message. She checks the message “oh good” she says to herself. “Good news?” Michelle asks. “ Kind of, I now have more time for lunch. My doctor is running late, his office just texted to let me know.” Just as Michelle blurted out “You’re kidding, your physician did what?” Tammy arrived to complete the lunch trio. “Sorry I’m late. Traffic was horrible. We better hurry up and order, I know Andrea has an appointment soon.” “Not anymore,” says Michelle, “the physician office just tweeted her letting her know that they are running behind.” “He didn’t tweet me,” replied Andrea, “although the office is looking into that, his office simply sent me a text letting me know that he was running behind by 30 minutes.” “I wish my doctor would let me know when she was late” Tammy said. “Mine too” chirped Michelle. “I had to wait two hours at the doctor’s office last week which made me late for picking up the kids from school. To make matters worse, I heard the staff talking and they knew earlier in the day that the doctor was over committed.” “See I told you my physician office was awesome. It runs like a well oiled machine!”As the ladies ordered lunch, Andrea began telling them why. About 12 months ago, my physician realized that they were offering “old-fashioned service” to their patients – service that is now too time-consuming, that sends patient wait times soaring and patient satisfaction dropping. In response they sent out a letter asking patients for feed back. I completed their survey and I mentioned things like appointment scheduling delays, long waits in the lobby, the office looked disorganized, and staff rudeness. After completing the survey, they asked me to participate
in several brain-storming sessions focused on improving the patient experience. Being diabetic I probably visit the office more than most patients, so I have seen the improvements first hand. Ten Ways to Transform Your Practice Let me see if I can remember all the try-storming we have done so far. “The what?” asked Michelle and Tammy. “Try-Storming is the name of the process they followed to make changes in the office; it follows the theory of if at first you don’t succeed, try, try, again. When confronted with a problem or opportunity, you simply try a solution, measure the success, adjust and try again. Instead of coming up with the perfect solution, we try-stormed different ideas continuing to move forward,” Andrea said. Here are some of the improvements so far: 1 Daily Huddles. To ensure patient needs are met and that patients flow smoothly through their visit, every morning the staff briefly “huddles” to review the upcoming day. This informal review of the day’s visits allows the staff to make any last minute adjustments. 2 Organizing and Standardizing Exam Rooms. Now the same supplies and inventory are in each room. This leads to fewer interruptions to the flow of patient care. In the past, when my doctor left the room for equipment or supplies it seemed like it took him forever to return. Now each exam room is identical so all providers can use any exam room, increasing flexibility of room use. 3 Synchronization of the Patient, Provider, and Information. As a patient, this one was difficult for me to understand, but I learned there are many things that go on behind the scene to make each patient visit successful. The staff worked on organizing multiple processes so I’m in the exam room ready for the provider just a few minutes before the provider is ready to see me. 4 Cross-Training the Staff. After some discussion, our focus group agreed that the ability of the clinic to respond to unexpected events was critical. The office team needed to be well trained and flexible. For example, check-in and check-out staff were cross-trained and now can fill in for each other. 5 Reduced Interruptions. Interruptions create unnecessary variation in the flow of tasks, disrupt the coordination of work among staff, and contributed to patients waiting for services or treatment. For example, when a provider is interrupted during a patient visit to talk ➤
c c
c
c
c
TRIAD, Winter 2011 41
practice manager’s column continued to a different patient, another physician or to discuss a lab result, this can result in a longer visit for the patient. “That happens during my office visits all the time” said Tammy. To decrease these common types of interruptions, we established telephone call policies to mitigate interruptions by phone. 6 Improved Call Center. The office introduced standardized phone-based triage so patients’ questions can be answered as efficiently as possible. This also improved appointment scheduling.
c
Patient Reminders. This one was my idea. c7 Electronic We added “e-minders” to increase patient appointment commitment and medical practice recommendations. For example, if the patient provides the office with their cell number or email they will receive reminders about upcoming appointments. “I would love that. Are you saying everything would be managed electronically?” asked Michelle. “Yes, as much as possible. You can even accept appointments using Microsoft Outlook software,” said Andrea. 8 Patient Experience Summary. At the end of each visit the patient is provided with a one page summary of what the provider discussed during the visit, like medications, lab results, etc. Initially, they printed it out and handed it to you. Now some have opted to have it sent directly to their home email address.
c
Visit or Doing Today’s c9 Same-Day Work Today. Few appointments are accepted in advance; patients call in the morning and are assigned a time slot for later in the day. The call center starts accepting and triaging calls at 7 a.m. Patients are assigned 15-minute time slots on a first-call, first-serve basis. Traditional appointments are still scheduled, usually for annual physicals or patients who need regular follow-ups. Now instead of going to an urgent care center (or the hospital emergency center), I can see a provider who knows me and my medical history. 10 Courtesy Shuttle. We found that some patients were missing appoint ments because they couldn’t get a ride. Now patients receive transportation to and from primary care visits, specialist visits, physical therapy, and to non-emergency hospital visits as well. The seniors love this service!
c
“Wow they really are listening to the voice of the customer. Some of those solutions sound expensive and difficult to do,” Tammy said. “Yes and no. Rome wasn’t built in a day and neither was this improved patient experience. They have been at this for over a year now. All of these changes allow the staff more time to provide better patient care. Now my visits are shorter, but my time with my doctor is longer! Hey, our lunch is here. We better eat or I will really be late for my appointment” Andrea said. m 42 TRIAD, Winter 2011
44 TRIAD, Winter 2011
the last word R. Taylor Scott, D.O., Co-Chair, MOA Education Committee
A
s current co-chair of the MOA Education Committee, I was asked to comment in this Last Word regarding some of the considerations and issues regarding ethics and continuing medical education (CME). While there are growing concerns about potential ethics of the sponsor ship and financial support of CME in many professional associations, there is also a rich history of varied support for many venues for this education. As was recently mentioned at the Osteopathic Leadership Conference in Las Vegas, there is compelling evidence that CME improves the quality of care across multiple specialties. Yet at the same time, there have been a number of concerns raised in multiple reports regarding questions of reporting participation and financial support of CME programs.1 The Institute of Medicine, in it’s 2009 report “Conflict of Interest in Medical Research, Education and Practice,” states “CME has become far too reliant on industry funding and that such funding tends to promote a narrow focus on products and to neglect the provision of a broader education of alternative strategies for managing health conditions and other important issues such as commu nication and prevention.” 2 In the United States there are more than 30,000 sponsored activities each year with over half a billion dollars in support from commercial companies.1 It has been reported that between 1998 and 2007 the industry funding of accredited CME rose by more than 300 percent.1 While CME may be viewed as having issues of sponsorship ethics and industry funding, there is an important function served by this continuing education for advancement of skills and knowledge. According to D.J. Rogers, the secretary for the American Osteopathic Association’s (AOA) Council on Continuing Medical Education (CCME), CME is defined as referring to a specific form of continuing education that helps medical professionals learn about new and developing areas in their fields of expertise to help them retain, develop and enhance their knowledge, ability, and professional performance. 3 CME activities may consist of live events, written publications, online programs, and audio, video, or other electronic presentations. 3 CCME has reported that in 2009, 71.4 percent of all AOA members had a CME requirement that had to be met in the cycle ending in December 2009. 3 CME is an important component of state medical licensure as well. In Michigan, the requirements for
license renewal are 150 hours of credit over three years – 60 hours must be AOA Category 1 credit; 90 hours must be Category 2 credit (there are four Categories of CME credits granted by the AOA; 1-osteopathic, 1A-formal, 1B-less formal, and 2-non-osteopathic, 2A-formal, 2B-less formal). There are certain exemptions from this CME requirement such as students, residents, military members who are involved in significant military operations and others. 3 The current guidelines for the 2010-2012 CME cycle is available on the AOA website at http://www.osteopathic.org/inside-aoa/development/ continuing-medical-education/pages/cme-guide.aspx. With these facts in mind, we can certainly see not only the importance of CME but the requirements as well. With the use of CME to facilitate the ongoing improvement and enhancement of physicians quality of patient care there is a certain potential for tainting the perception of professionalism with regard to conflict of interest and financial influence. This potential should make all of us reflect and examine our own participation in CME not only with regards to support and funding, but in documentation of participation and “seat time”. The trust our patients put in physicians relies on our profession doing it’s best to honor that trust and to maintain the best practices in ethical conduct from the individual practitioner to local, state and national organizations. Thus the justification for maintaining continuous medical education relies on the expectation for enhancement of patient care in the most professional and ethical of environments. And so, for me, the privilege of providing care for my patients considers their expectation that my CME is accomplished under the most ethical of conditions. At your MOA, this is what we all not only continuously strive for, but absolutely expect. And that’s my last word. m
References: 1 Morris, L Taitsman JK (December 2009) “The Agenda for Continuing
Medical Education – Limiting Industry’s Influence”. N.Eng.J.Med, 361(25): 2478-82. 2 Institute of Medicine, Conflict of Interest in Medical Research, Education,
and Practice. Washington, D.C., National Academies Press, 2009. 3 Rodgers, DJ (March 2010) “AOA Continuing Medial Education”, JAOA,
110(3): 168-182.
TRIAD, Winter 2011 45
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EMPLOYMENT OPPORTUNITIES Physicians needed to do histories and physicals. Two sites available: one in Detroit and one in Warren. Very flexible schedule: work as many shifts as you want or as little as once a week and/or make your own hours (even after your usual 9-5 day is okay). Please contact Susan Stroia for details at 248-217-0029 or email me at suestroia@yahoo.com. Immediate Opening! Growing Family Practice Office with multiple locations is seeking a full time physician to join our staff. With locations in Madison Heights, and Southgate, we are looking for a talented provider interested in providing quality care to our patients. All can didates must be Board-certified, eligible Family Medicine Physician. This is a Full time position. Provider will see approx. 35 patients per day. Must meet and maintain high patient satisfaction and productivity standards. Some shared call schedule, by phone only. Some hospital work also expected. Expected to work some non-traditional hours, to include possible evenings and rotating Saturday schedule. Competitive Salary and Benefit Package. Please contact Susan Stroia at 248-217-0029 or email suestroia@yahoo.com. Independent internal medicine practice in Flint Michigan is seeking physicians to join our group. We have a very busy hospitalist practice with some office. We offer competitive salary and bonus along with a complete benefit package. Please send inquiries to: tshep59@yahoo.com or fax to 810-720-6075. REAL ESTATE MEDICAL SUITES AVAILABLE: Professional building with outstanding location on North Woodward near 11 Mile has 700 square feet with two exam rooms and 4,400 square feet on Nine Mile in Oak Park with 12 exam rooms available immediately. Can be divided to suit your needs. Reasonable rent. Contact: (248) 548-0880 or jeffrey@brodskyrealty.com.
46 TRIAD, Winter 2011
American Osteopathic Association............................................... 5 Basha Diagnostics.......................................................................... 33 Blue Cross Blue Shield of Michigan.............................................. 15 Colonial Valley Software, Inc......................................................... 14 Ghabi Kaspo, D.D.S....................................................................... 29 Health Law Partners...................................................................... 42 Lean Fox Solutions........................................................................ 40 Med-Share Diagnostics.................................................... Back Cover Medical Informatics Solutions....................................................... 10 Michigan Beef Industry Commission............................................ 18 MOA Insurance Team (MIT)...................................... 24-25 (center) MSU College of Osteopathic Medicine, Pr Dept.......................... 18 Physician Assistant Solutions......................................................... 10 Physicians Health Plan.................................................................. 10 Pinkus Dermatopathology Lab...................................................... 8 PNC Financial................................................................................ 23 POH Regional Medical Center.......................................................... 6 POH Regional Medical Center, Dept. of Medical Education.......... 18 Survey Vitals solution, powered by 9g Enterprises... Inside Back Cover The Doctors Company........................................... Inside Front Cover Wachler & Associates, P.C............................................................... 22
Statement of Ownership, Management and Quarterly Circulation of
TRIAD Magazine Publisher: Michigan Osteopathic Association Service Corp. 2445 Woodlake Circle, Okemos, MI 48864 Headquarters & Office of Publication: Michigan Osteopathic Association Service Corp. 2445 Woodlake Circle, Okemos, MI 48864 Co-Editors: Draion Burch, D.O. & John Sealey, D.O. Managing Editor: Cheri Rugh Circulation: Average no. copies each issue during preceding 12 months: A. Total copies printed (Net press run), 4,700; B. Paid circulation: 1. Mail subscriptions, 4,748; 2. In-county subscriptions, 0; 3. Sales through dealers, 0; 4. Other classes, 0; C. Total paid circulation, 4,748; D. Free distribution, 120; E. Free distribution outside mail, 60; F. Total free distribution, 180; G. Total distribution (Sum of C and F), 4,928; H. Copies not distributed, 75; I. Total (Sum of G and H), 5,003; Percent paid circulation, 96.3. Single issue nearest filing date: A. Total copies printed (Net press run), 5,450; B. Paid circulation: 1. Mail subscriptions, 5,450; 2. In-county subscriptions, 0; 3. Sales through dealers, 0; 4. Other classes, 0; C. Total paid circulation, 5,330; D. Free distribution, 30; E. Free distribution outside mail, 20; F. Total free distribution, 50; G. Total distribution (Sum of C and F), 5,380; H. Copies not distributed, 75; I. Total (Sum of G and H), 5,455; Percent paid circulation, 99. Cheri Rugh, Managing Editor