November 2016 | Physician Magazine by Los Angeles County Medical Association

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helping hands LOCAL LEADERS MAKING A DIFFERENCE IN LA HEALTHCARE

NOVEMBER 2016

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NOV EM B ER 2016 | TA B LE OF CONT ENT S

Volume 147 Issue 11

COVER STORY 10 Helping Hands | Local Leaders Making a Difference in LA Healthcare

FEATURE

What’s Next on Your Career Path?

After spending years in medical school and completing a residency program, and for some a fellowship program in a subspecialty, doctors face the challenge of managing their careers so that they reach their full potential. Some doctors are rethinking the traditional career path altogether, while others are looking for ways to combine medicine with a special interest.

ON THE INSIDE 4 President’s Letter | Vito Imbasciani, MD 6 CMA’s House of Delegates | Gustavo Friederichsen 7 LACMA Physician Spotlight | Richard E. Horowitz, MD 8 LACMA Partner Spotlight | JNT Tek & IMAT Solutions

Physician Magazine (ISSN 1533-9254) is published monthly by LACMA Services Inc. (a subsidiary of the Los Angeles County Medical Association) at 801 S. Grand Avenue, Suite 425, Los Angeles, CA 90017. Periodicals Postage Paid at Los Angeles, California, and at additional mailing offices. Volume 143, No. 04 Copyright ©2012 by LACMA Services Inc. All rights reserved. Reproduction in whole or in part without written permission is prohibited. POSTMASTER: Send address changes to Physician Magazine,801 S. Grand Avenue, Suite 425, Los Angeles, CA 90017. Advertising rates and information sent upon request.

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EDITOR

Sheri Carr 858.226.7647 | sheri@physiciansnewsnetwork.com ADVERTISING SALES

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Christina Correia 213.226.0325 | christinac@lacmanet.org Dari Pebdani 858.231.1231 | dpebdani@gmail.com David H. Aizuss, MD Troy Elander, MD Thomas Horowitz, DO Robert J. Rogers, MD

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cal Association is a professional association representing

as well as medical students, interns and residents. For more than 100 years, LACMA has

PRESIDENT

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IMMEDIATE PAST PRESIDENT

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been at the forefront of current medicine, ensuring that its members are represented in the areas of public policy, government relations and community relations. Through its advocacy efforts in both Los Angeles County and with the statewide California Medical Association, your physician leaders and staff strive toward a common goal— that you might spend more time treating your patients and less time worrying about the challenges of managing a practice.

Vito Imbasciani, MD William Averill, MD C. Freeman, MD Sion Roy, MD Peter Richman, MD

RESIDENT/FELLOW COUNCILOR

CMA TRUSTEE

COUNCILOR – DISTRICT 2

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Jerry Abraham, MD David Aizuss, MD Emil Avanes, MD Erik Berg, MD Robert Bitonte, MD Stephanie Booth, MD Amanda de la Cerda Troy Elander, MD Samuel Fink, MD Hector Flores, MD Sidney Gold, MD Stephanie Hall, MD Po-Yin Samuel Huang, MD David Hopp, MD Marvin Kaplan, MD Kambiz Kosari, MD Jeffery Lee, MD Paul Liu, MD Maria Lymberis, MD Ashish Parekh, MD Jinha Park, MD Anantjit Singh, MD Stacy Songco Heather Silverman, MD Diana Shiba, MD Nhat Tran, MD Omer Deen, MD Theressia Washington, MD

LACMA’s Board of Directors consists of a group of 30 dedicated physicians who are working hard to uphold your rights and the rights of your patients. They always welcome hearing your comments and concerns. You can contact them by emailing or calling Lisa Le, Director of Governance, at lisa@lacmanet.org or 213-226-0304.

SUBSCRIPTIONS Members of the Los Angeles County Medical Association: Physician Magazine is a benefit of your membership. Additional copies and back issues: $3 each. Nonmember subscriptions: $39 per year. Single copies: $5. To order or renew a subscription, make your check payable to Physician Magazine, 801 S. Grand Avenue, Suite 425, Los Angeles, CA 90017. To inform us of a delivery problem, call 213-683-9900. Acceptance of advertising in Physician Magazine in no way constitutes approval or endorsement by LACMA Services Inc. The Los Angeles County Medical Association reserves the right to reject any advertising. Opinions expressed by authors are their own and not necessarily those of Physician Magazine, LACMA Services Inc. or the Los Angeles County Medical Association. Physician Magazine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. PM is not responsible for unsolicited manuscripts.

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P RES IDEN T ’S LET T ER | VIT O IM B AS C IANI, M D

An Early Report on the CMA’s House of Delegates

“The clear consensus was to ask the CMA to advocate for replacing the present [Maintenance of Certification] system with one that is more practice-specific.”

Hundreds of physicians from all over California convened in Sacramento over the October 15-16 weekend for California Medical Association’s annual House of Delegates meeting. Organized both geographically and by mode of practice (hospital-based, solo and small practice groups; larger groups; administrative and organized medical staff physicians), this was the first meeting to be conducted under new rules for the conduct of the House established by the Board of Trustees over the last two years. Instead of debating hundreds of isolated, discrete, often unrelated resolutions, the new system concentrated on in-depth education and debate on six large topics. On each topic, prior to the debate, a presentation was made by an expert in the field, and earned CME credit for all attendees. The first topic was likely uppermost in the minds of many physicians: the impact of MACRA on everyone’s practice. CMA VP Elizabeth McNeil gave a lengthy explanation of the mode of practice-specific components of MACRA: the Merit-Based Incentive Payment System (MIPS) for small and solo practice groups, and Advanced Payment Models (APMs) for larger physician groups. She also reviewed the last-minute final regulations that were published by CMS the preceding day. These new regulations will have a positive effect on small and solo practices, so it is imperative that these physicians, if they have not already done so, review the new requirements of the Quality Payment Program. This can be done at www.qpp.cms.gov. Among other kinds of relief, it lowers the patient threshold for mandatory participation (<$30,000 in Medicare billing or fewer than 100 Medicare Part B patients). The CMA promised to continue educating physicians about MACRA and to provide tools to help physicians prepare and successfully report. It also pledges to urge CMS to make significant changes to MIPS and APM. The second topic—a fix to the “family glitch” by pursuing a 1332 Waiver for California to the Affordable Care Act—was thoroughly debated. By expanding the subsidy income eligibility, the family glitch would be eliminated, making health plans more affordable for many families whose income makes them currently ineligible for subsidies. The discussion on opioid prescribing and pain management was led by a panel of three physicians in emergency and addiction medicine. It ranged broadly and settled on recommendations to create an advisory committee to evaluate the CURES database; to ask that pharmacists and dispensing physicians be required to submit data in real time (for Schedule II-IV drugs); to facilitate interstate sharing with other prescription drug monitoring programs, including the U.S. Deptartment of Veterans Affairs and the Indian Health Services; to require a law that a valid search warrant be obtained by any law enforcement agent to access and use CURES; and to transition CURES out of the Department of Justice and to a health-related department. It also recommended that no specific practice guidelines or parameters be established by legislation. The next topic included a presentation and debate on physician burnout, including among young physicians, residents and medical students. The CMA promised to develop toolkits for accessing resources for use by component societies and physician practices. Maintenance of Certification was hotly debated after a presentation by the executive director of the American Board of Medical Specialties, Lois Nora, MD, and the head of the competing National Board of Physicians, Paul Teirstein, MD. The clear consensus was to ask the CMA to advocate for replacing the present system with one that is more practice-specific and is more cognizant of the time and cost involved in meeting present requirements. Finally, Karen Smith, MD, director of the California Department of Public Health, gave a comprehensive update on state efforts to shore up the health of all citizens by concentrating on local activities aimed at pervasive chronic diseases. In addition to talking about obesity, tobacco use, pain, behavioral health, violence and infectious diseases, a long discussion ensued over whether or not to include the effects of climate change. At times, the sessions resembled the sausage-making process that Otto von Bismarck warned us not to look at. But the product, and the collegial involvement of physicians from all over California that produced it, should make each of us proud. It’s important that there are doctors who are committed to serving the larger House of Medicine in addition to their own patients.

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November marks the end of the election season and the beginning of the holiday season. Say goodbye to campaign ads and hello to gift ideas— as if our physician members don’t have enough to contend with. This brings up a topic that needs to be addressed—physician burnout.

“My message is brief this month to give you time to reflect on what’s important, namely, you. If you need help, resources and assurance, we are here.”

At the recent CMA House of Delegates (HOD), which I encourage every physician to attend, we heard from experts on burnout. It’s at near-epidemic levels, and yet it’s barely talked about. Until now. CMA and LACMA, along with our colleagues across the state and country, are looking for ways to combat this problem, and there might be a remedy in sight. Volunteering or activism— spending less time on data entry and more time helping others or with friends and family—is one antidote worth talking about, but it’s not the cure-all. In this issue you will learn about other physicians making a difference in their communities. Some are working on the front lines of homelessness, while others step out of their clinics, practices and groups to walk for a cause, raise awareness for patients in need or help fellow physicians in crisis. It’s all about community, and it starts with all of us, each of us looking at ourselves and asking, “What can I do to help my community?” As one physician said at HOD, “By volunteering or helping someone else, the life you change just might be yours.” In other words, burnout is complex and has many faces, causes and characteristics. How physicians manage burnout is critical to survival because it impacts health, mental health, relationships and, yes, patient care. My message is brief this month to give you time to reflect on what’s important, namely, you. If you need help, resources and assurance, we are here. We offer tips on work-life balance, provided by expert Shuli Suman, who has concluded that work-life balance doesn’t really exist. But there is a way to find fulfillment, authenticity and joy in personal and professional life. Learn more with the webinar on the LACMA Blog. Look for future talks, events and articles from LACMA on the topic of well-being. If you have ideas, suggestions or thoughts on ways LACMA can help members cope, manage and thrive, I’m here to listen and will constantly look for ways to help each and every one of our members.

Gustavo Friederichsen Chief Executive Officer

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LACMA Physician Spotlight:

Richard E. Horowitz, MD A T L A C M A T H E R E ’ S B E E N a lot of talk lately about new programs, new partners and new members. But it’s important to us to also recognize the physicians who have been part of LACMA over many years. surveyed colleagues on daily practice and training and gave With that in mind, we’d like to take a moment to honor numerous talks on these subjects on a local and national Dr. Richard E. Horowitz. Dr. Horowitz was certified in level. He considers his book “Laboratory Administration for anatomic and clinical pathology in 1963. Early on, he was an Pathologists” (co-authored by Elizabeth Wagar, MD) to be his attending pathologist at Los Angeles County General Hospital magnum opus. and taught at Keck School of Medicine of the University of Dr. Naritoku said that Dr. Horowitz is recognized as a Southern California (USC), an affiliation that would last towering figure in the pathology world by all who benefited throughout his career. from his generosity in teaching, mentoring and professional Dr. Horowitz became director of laboratories at Saint associations. We’d like to thank Dr. Horowitz for his decades Joseph Hospital in Burbank in the 1960s and remained of service and leadership in the medical community in Los there for 30 years. At the same time, he continued to teach Angeles and nationwide. at UCLA, USC and the Wadsworth Veterans Administration Hospital until just a few years ago. He has also served on the Board of Directors and as president of the College of American Pathologists. With his many accomplishments and associations, it’s difficult to know which best represent the full breadth of Dr. Horowitz’s professional life. His colleague, Wesley Naritoku, MD, professor at Keck School of Medicine MEDICAL PRACTICE PURCHASES, SALES AND MERGERS of USC said, “If you mention Dr. Horowitz in any circle of pathologists, they will know his name.” Now retired, Dr. Horowitz is well known for his excellence in his work in the lab. Dr. Naritoku shared that Dr. Horowitz’s “organ recitals” were highly regarded among the residents who witnessed his diagnostic skill. Residents who worked with Dr. Assisting physicians with Horowitz have been commended for legal issues for over three decades. the quality of their training. A true teacher and scientist, Dr. Fenton Law Group, LLP 1990 South Bundy Drive Horowitz spent his career asking Suite 777 “How can we improve things?” This Los Angeles, CA 90025 The brand physicians trust led to his seminal work on laboratory 310.444.5244 www.fentonlawgroup.com management. He brought pathologists together to share best practices,

MEDICAL BOARD HOSPITAL STAFF F R A U D / A B U S E MEDI-CAL/M E D I C A R E

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LACMA Partner Spotlight:

JNT Tek

IT for Solo and Small Practices SOMETIMES THE MOST EFFECTIVE IT SOLUTIONS involve just simple common sense. When

Emil Avanes, MD, was working with Dave Bader at JNT Tek to set up a new system in his office, Bader suggested that he install docks for the tablets they were using at the nurses stations and place them in multiple locations around the office. That way the tablets would stay charged and would sync records consistently. Obvious? Yes, but Dr. Avanes (President, LACMA District 2) admits he hadn’t thought of setting up the extra docking areas.

Of course not all IT is this simple. In working with solo and small physician practices, Bader has some tricks up his sleeve that help with billing, CRM, scheduling, security, HIPAA compliance and more. Now more than ever, doctors need to see themselves as business owners along with the other professional hats they wear. Bader knows that IT support is one way doctors keep their businesses efficient and profitable. When computers are sluggish, workflow can slow to a crawl. This isn’t just frustrating; it cuts into billable hours and backs up the day’s appointments for physicians and staff. Bader’s job is to address why the system isn’t running smoothly. He’s got his diagnostic checklist. Have you added computers that may have a newer version of the operating system? Are all computers across the office standardized? Is your backup system functioning? Are all licenses updated? Is your firewall updated? Small and solo practitioners aren’t likely to have

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a full-time IT person on site. The good news is that a company like JNT Tek is working closely with LACMA to offer services targeted specifically for our physicians. As MACRA changes roll out and the new reporting becomes a reality, your ability to meet the requirements and succeed will depend in part on EHR — not just how diligent you are, but how good and efficient your overall system is. We’ve been sharing info on MACRA and the value of your LACMA membership. Take advantage of JNT Tek’s special offer and get a free assessment of your office system. JNT Tek is offering consulting, management and project-based services tailored specifically for physicians. If you have a question you’d like to ask the expert, feel free to send it over to deborah@lacmanet.org and we’ll publish the answer. To take advantage of the free assessment for LACMA members, you can email Dave Bader at dave@jnttek.com.

LACMA Partner Spotlight:

IMAT Solutions Advancing Healthcare Through Data

MATT HOFFMAN WAS A DOCTOR before he crossed over into the world of EHRs, information

exchanges and technology to find his calling. Physician Magazine recently spoke with Dr. Hoffman, now medical director at IMAT Solutions, and other key players at IMAT to get a better understanding of what the people at IMAT actually do, how they help doctors make decisions on patient care based on all of the most up-to-date data.

They describe what they do in good detail, but it’s complicated at first glance: IMAT Solutions is a new, disruptive medical data management and decision support company. Wait! Keep reading. It makes a lot of sense when you break this out into everyday language, consider the challenges you have with your EHR and learn more about their services. “The problem with healthcare isn’t that there isn’t enough data. There’s no lack of data. The problem is that there’s too much data coming in from multiple formats and sources. For the first time, there’s a solution to look at all the data and see what is happening with a patient or group and make decisions in real time,” said IMAT CEO Kurt Garbe. Let’s say you’re seeing a patient and you’re planning to prescribe a medication. You check the correct boxes on your tablet, and make your notes. Here’s where IMAT enters the picture to make life easier. Before you send the script, you check for patient information outside your EMR with IMAT. Turns out another physician on the patient’s care team had prescribed a medication that would likely cause a reaction. This gives you the insight into the care the patient is receiving outside your office. You and your staff now have access to all the patient records within the network. You’ll be able to access the original documents from across the patient’s care team, and all the data will be available in a standardized format. What that means is that even unstructured data such as discharge summaries, radiology reports and lab reports will be pulled together and easily accessible. Everyone will see the data the same way, no matter what system they use, so labs aren’t speaking a

different language from your office anymore. And this all happens lightning fast so you maximize care and the amount of time you can spend with each patient. Working with 35,000 healthcare professionals means they’re processing tens of millions of records daily for almost 30 million patients overall. Working with IMAT allows you to pull quality metrics, create a centralized view of a patient’s records and make use of standardized data and common reports. The analytic capabilities are also well-developed and continuing to evolve to put the right patient data at the point of care delivery. Dr. Hoffman stressed the evolving nature of the analytics of their services. It’s early in the process still, but the plan is that data capture and analysis will lead to better patient care by being able to predict when patients are at risk. Anticipating patients’ needs with a predictive model would mean that patients could receive preventative information as well as care and avert a medical crisis. At IMAT they understand the challenges physicians are still facing with EHR, reporting and reimbursement. Dr. Hoffman said that they are working hard to develop tools that let doctors focus more on care and less on check boxes. He said to hang in there because the benefits of being able to standardize data and get a good, comprehensive picture of clinic visits and patients’ records will make a difference not just in quality reporting, but in stress levels for physicians. Visit imatsolutions.com/ to find out more about IMAT Solutions. Mention that you’re a LACMA member and get first-class treatment.

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HELPING HANDS F O R T H I S I S S U E O F P H Y S I C I A N M A G A Z I N E we wanted to look at who is making a difference in LA healthcare and decided to look at more than just our phenomenal doctors and highlight the work of a couple of policy makers. At LACMA, weâ&#x20AC;&#x2122;re meeting with local, city and state officials not only to hear about the bills theyâ&#x20AC;&#x2122;re authoring and sponsoring, but to share the issues our physicians care about most. Please meet California Assemblymember Mark Gipson and Congresswoman Judy Chu.

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Assemblymember Mark Gipson represents the 64th District in Los Angeles. His district runs through South LA and into South Bay, covering areas such as Carson, Compton, Watts and parts of Long Beach. The Assemblymember has been in office since 2014. Healthcare concerns from constituents help shape the focus for Assemblymember Gipson. He’s been vocal on issues concerning hepatitis C, authoring bills on screening and certification for licensed counselors. He worked on AB 444 concerning standardization of epidural equipment in alignment with the International Organization for Standardization. He’s worked to encourage more people to get colonoscopies. HIV testing, homelessness and affordable housing are other issues he’s tackled while representing Angelenos. Recently, he served at an informational hearing on infectious disease, specifically the spread of hepatitis B and C in California. The results of that hearing are due soon. Judy Chu represents California’s 27th District in the U.S. House of Representatives. This district covers the San Gabriel Foothills area and cities such as Alhambra, Pasadena and Monterey Park. Congresswoman Chu is the first Chinese-American woman elected to the U.S. Congress. While she’s supported many issues around healthcare, part of her legacy may come from opening a Veterans Healthcare Clinic in the San Gabriel Valley. Currently, vets seeking treatment have to travel to clinics in downtown LA, West LA or even Long Beach. Rep. Chu is working with the city of Pasadena to find a place to house a community clinic for vets. Depending on space allowances, the clinic could provide primary care as well as mental health services and address women’s healthcare needs. The Greater LA Veterans Administration will ultimately oversee the community clinic, but the San Gabriel Valley area has 45,000 vets to serve. When Rep. Chu met with LACMA CEO Gustavo Friederichsen and Government Affairs Consultant Luis Ayala recently they discussed LACMA’s renewed commitment to public health issues and advocacy. Rep. Chu’s office is looking forward to working with LACMA as the organization pivots to issues affecting communities on a local level. They discussed climate change, gun violence, clean water, drought, underserved communities and veterans’ issues. These meetings with government officials give LACMA yet another view into the diversity of Los Angeles and the issues that define our communities. Talking with physicians, their staff, leaders in healthcare policy and government officials is just one of the ways we’re taking the pulse of the city and moving LACMA forward.

Jeff Penso, MD, and Walk

with a Doc

It’s not hard to find studies extolling the virtues of walking, community and regular healthcare. Walk with a Doc is an organization that puts all of these together. Dr. Jeff Penso (LACMA District 5) is a pediatrician who has been leading walks for the past three years. The concept of Walk with a Doc is brilliantly simple: Anyone who wants to walk shows up at the appointed time and place wearing comfortable shoes. The attending physician gives a short health talk, everyone stretches a little, and then they walk. Dr. Penso said that some people ask him medical questions and mostly he agrees with their doctors. Dr. Penso usually talks about preventative measures like nutrition, diet and exercise but has given information on timely topics like the Zika virus as well. He started working with Walk with a Doc after someone at LACMA told him about it. In turn, LACMA helps sponsor the walks with Dr. Penso in Culver City. Dr. Penso said that one of the benefits of the walks is that participants get to see doctors as people and accessible. It breaks down barriers. He’s also had people he’s known for a long time come to walk, and that’s part of what’s fun for him — not knowing who will show up each month. You can join in and Walk with a Doc at 9 a.m. every third Saturday of the month at City Hall in Culver City, either as an expert or walker. To find out about more opportunities to join in, go to the website at www.walkwithadoc.org. N OV E M B ER 2016 | W W W. P H Y S I C I A N S N E W S N E T W O R K .C O M 11

Natalie Nevins, DO To address the medical needs of Los Angeles’ most vulnerable populations, Care Harbor, an annual event, has provided thousands of residents free healthcare. This year, Care Harbor will run from Jan. 20 to 22, 2017, but its chief medical officer, Natalie Nevins, DO, is busy all year. She’s hands-on, involved in everything having to do with medical services for the three-day event. Dr. Nevins shared that one of her goals for the event is to make sure that the people seeking services have access to aftercare. Through partnerships with community clinics, everyone who comes to Care Harbor leaves with

a free or low-cost follow-up appointment. Dr. Nevins is an Air Force veteran. She serves as director of clinical education for Western University of Health Sciences. Along with her practice and work on Care Harbor, she is CEO of AD+World Health, a nonprofit for humanitarian aid. In other words, she doesn’t sleep a lot. Dr. Nevins’ vision is larger than an annual event offering free services. She’d love to see physicians volunteering time throughout the year — for a half day once a month or once a quarter. The key is to match doctors with community clinics where they can go in regularly to help. She said that one of the benefits of LACMA helping to coordinate physicians volunteering for Care Harbor is that the residents and students have that level of service modeled for them. They see that service and community are part of what makes being a physician rewarding. Thank you, Dr. Nevins, for all that you do for the community.

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All Hands on Deck at

Care Harbor Can you help? The team at Care Harbor is looking for doctors from all specialties as well as dentists and eye doctors to participate. Care Harbor will run Jan. 20 to 22, 2017, at The Reef in downtown LA. Care Harbor brings together physicians, nurses, physician assistants, mental health providers, dentists, nutritionists, students, residents and more for this oneof-a-kind healthcare event in Los Angeles. Thousands of LA residents who are uninsured, underinsured or at risk have benefited from the chance to receive healthcare services during the free clinic. People from LA Care will be onsite to enroll patients who qualify for Medi-Cal. Education about issues such as nutrition, smoking cessation, disaster prep and health screenings will be available. The Department of Mental Health will be on hand to provide support; at past Care Harbor events, patients who were suffering from domestic violence or other forms of abuse were able to get immediate help. The Department of Public Health will provide vaccines and HIV testing. Providing clinic services, education, screenings, follow-up and preventative strategies goes toward the goal that “those who pass through Care Harbor today will not need to return tomorrow.” We’d love to send a big contingent of LACMA doctors down to Care Harbor. Come out for a half day, full day or what works with your schedule. Don’t miss out on this amazing chance for community outreach, connection with other physicians and a profound reminder of what makes the practice of medicine much more than just a job. You can find more information at the Care Harbor website, www.careharbor.org, or contact deborah@ lacmanet.org with questions or to sign up.

What Sparks Community Involvement? Talking with Daniel Borenstein, MD LACMA recently launched its first initiative with LACMACares. The program partners LACMACares with Uber to provide rides for retired physicians and physicians in need. The idea for the Uber-LACMACares partnership came out of a conversation between Dr. Daniel Borenstein and LACMA CEO Gustavo Friederichsen. Over a District 5 luncheon, Dr. Borenstein shared that there were retired doctors who were missing out on meetings they used to attend because they weren’t able to drive anymore and couldn’t always find a ride. As a psychiatrist, he knows that social activities play an important role in the lives of retired people. Friederichsen made the leap to pull in Uber to provide rides. The result is the first program through LACMACares. Noticing what’s needed may seem obvious in talking about community service, but it requires being an active part of the community. From there, getting to the right person, making introductions and connecting people are crucial. When he was on staff at UCLA, Dr. Borenstein saw trainees struggling with emotional issues while completing their training. He mentioned this to a friend who was a lawyer at the Ahmanson Foundation. Through this conversation, the foundation ended up funding a grant that allowed UCLA trainees in the psychiatry program to receive improved mental health support at no charge. For Dr. Borenstein, involvement in organizations such as LACMA, the California Medical Association and the American Psychological Association has led to personal and professional relationships that have allowed him to help get things done, connect people and make a difference. “I like these projects where I can find ways to be helpful,” said Dr. Borenstein. What sparks your community involvement?

Need a ride? LACMACares has teamed up with Uber to provide rides to retired physicians and those in need. Keep this info handy! It couldn’t be simpler to book an Uber ride with LACMA:

1. 2.

(213) 226-0393

Call us at or email us at membership@lacmanet.org. We’ll handle the rest,

at no cost to you.

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By Marion Webb

A F T E R S P E N D I N G Y E A R S I N M E D I C A L S C H O O L and completing a residency program, and for some a fellowship program in a subspecialty, doctors face the challenge of managing their careers so that they reach their full potential. Some doctors are rethinking the traditional career path altogether, while others are looking for ways to combine medicine with a special interest.

In this November issue, we provide physicians with career development inspiration and with ideas and resources to help them make the most of their current position or explore new opportunities.

Career Dissatisfaction According to a recent Physicians Foundation survey of over 17,000 physicians nationwide, doctors continue to struggle to maintain morale, adapt to changing delivery and payment models and provide patients with reasonable access to care. The “2016 Survey of America’s Physicians: Practice Patterns and Perspectives” reports that 80% of doctors report being overextended or at capacity, with no time to see more patients. The level of dissatisfaction is driving nearly half of physicians surveyed to rethink their current situation, with 48% of doctors, up 5% from 2014, planning to cut back on hours, retire, take a non-clinical job, switch to “concierge” medicine or take steps to limit patient access to their practices. 1 4 P H Y S I C I A N M A G A Z I N E | N OV E M B ER 2016

Resources for Exploring New Opportunities In the book “Do You Feel Like You Wasted All That Training?,” Michael J. McLaughlin, MD, tells of his journey of leaving his plastic surgery practice after four years at the age of 36 to enter the field of medical communications. Dr. McLaughlin wrote that while the number of physicians working as consultants in non-clinical jobs continues to rise, with companies in the pharmaceutical, communications, insurance, legal, public health, investment, publishing and creative industries having a constant need for such expertise, most physicians aren’t aware that these non-clinical options even exist. “There is a large unmet need for cross-pollination of ideas and ideas within the non-clinical area,” he wrote. In 2004, he founded Physician Renaissance Network, a resource for doctors with non-clinical jobs and interests to explore options. For more information, visit prnresource.com.

In another book, titled “Physicians’ Pathways to Non-Traditional Careers and Leadership Opportunities,” edited by Richard D. Urman, MD, and Jesse M. Ehrenfeld, MD, more than 30 physicians tell of their careers and opportunities in areas other than traditional clinical medicine. In the Foreword, Karen Antman, MD, provost of the Boston University Medical Campus and dean of the School of Medicine, said that the experiences of these physicians “considerably broaden career options and leadership opportunities for physicians and provide a wider framework for physicians to take leadership roles in health policy and delivery.” In the book “Physicians in Transition: Doctors Who Successfully Reinvented Themselves,” by Richard F. Fernandez, MD, Michelle Mudge-Riley, DO, writes in that book’s Foreword that readers will be introduced to doctors who felt “lost, trapped, exhausted, sick, guilty, and frightened,” and though they may not have understood these feelings or what caused them, they faced the problem head on to overcome them. “Most of these doctors don’t feel like they have done anything extraordinary or that they have now found their ‘perfect job,’ but each has demonstrated the courage to take the first step towards personal and professional satisfaction and fulfillment,” the author wrote. One doctor, however, said that while Google may offer literally thousands of potential answers to alternative careers for physicians, finding one’s true passion is more of a matter of soulsearching rather than Internet surfing. In her blog post, Evgenia Galinskaya, MD, a physician turned physician career consultant, offered these five reasons for why lists of alternative careers are actually not helpful. 1. One size doesn’t fit all, and trying to force a fit that may work for others doesn’t mean it’ll work for you. 2. Doctors may overlook what they are truly passionate about in their career choices. She cited as examples Harry Hill, Graham Chapman and other physicians who became actors. 3. Lists can be demotivating when nothing jumps out. 4. Choosing another career just to get away from medicine can have damaging effects on one’s mental and physical health if it isn’t the right career. 5. Trusting others isn’t always the answer to what works best for you. Dr. Galinskaya finds that the real answer takes contemplation and careful evaluation, starting with self-discovery and selfassessment, exploring options and opportunities, and then narrowing down the options and implementing a plan to get there.

New Skills For doctors who are passionate about their career but feel that they lack expertise in running a successful practice, gaining new skills and certifications may be the best prescription, according to Rosario Ortega, physician advocate for the Los Angeles County Medical Association (LACMA).

Ortega said that medical school prepares doctors for becoming great practitioners but many physicians lack the business skills they need to successfully run their own practices or a group practice. “You can be a great physician, but if you don’t manage your office effectively, you can’t make money,” Ortega said. “Even if you hire a third party to manage your office, you should have a general understanding of what to do.” An office manager certification course, which typically runs six to eight weeks, can provide a general understanding of billing codes, managing employees, and other key skills doctors need to run a small business. Taking courses in small business, advertising, guerrilla marketing and social media are all critical to running a successful business. “Learning how to use the Internet and position yourself online through marketing is really key,” Ortega said. Today’s tech-savvy consumers, especially younger people with families, will turn to the Internet to find a physician of their choice. Doctors who aren’t listed by name only but provide information about their educational background and overall philosophy and have earned positive reviews from happy patients are more competitive in the marketplace.

Online Education/ Resources Christian Fox, MD, professor of clinical emergency medicine at the University of California, Irvine, School of Medicine and a frequent speaker at medical conferences, feels that the Internet is the wave of the future for continuing education. Traditionally, doctors attended medical conferences to earn their continuing medical education (CME) credits, but the Internet has gained significant market share. “We are seeing less attendance at conferences because everyone is turning to the Internet for continuing formal education,” Dr. Fox said. The American Medical Association (AMA) also has developed several online tools to help physicians prepare for transitioning to pending Medicare payment and delivery changes under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The online MACRA tool (https://apps.ama-assn.org/pme/#/ education/value-based-care) is an interactive tool that offers initial assessments to physicians to determine how their practices will be impacted by MACRA. AMA President Andrew Gurman, MD, said the tool will give physicians and their staff a brief assessment and relevant educational and actionable resources. “Once physicians and medical practice administrators fill out the online questionnaire, they will receive guidance for participating in the MACRA payment model that is best for them,” he said during a conference call with healthcare industry experts on Oct. 5. He added that the tool is free. AMA plans to continually update the payment model evaluator tool to respond to regulatory changes and to keep practices up-to-date throughout the new payment and care delivery reform process. In addition, AMA launched a ReachMD podcast series titled “Inside Medicare’s New Payment System” (https://reachmd.com/ programs/inside-medicares-new-payment-system/) featuring Andy Slavitt, CMS acting administrator, Gurman, AMA staff experts and others to help physicians be informed on upcoming Medicare changes.

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Professional Degree/ Certification Courses

Continuing Medical Education

Leah Vriesman, a professor and director of executive education programs in health policy and management at University of California, Los Angeles (UCLA), agreed with Dr. Fox, however, that some learning is still more beneficial in a classroom setting. Professional students, including doctors, who pursue a master’s degree in public health, or MPH, at UCLA learn in a classroom setting for several reasons. “We put an emphasis on management and policy,” Vriesman said. “You can’t do that if you’re not a good communicator and don’t build a network.” UCLA’s 21-month-long program is geared toward the working professional, including doctors (about 25%), policymakers and lawyers. The curriculum consists of a three-term sequence of academic coursework, followed by a summer fieldwork placement of at least 10 weeks, and a final three terms of further academic coursework. Classes cover topics such as biostatistics, finance, ethics and law. Vriesman said the program offers doctors a path for career advancement, ranging in classes for those requiring business skills and the regulatory know-how to start their own practice to others wanting to position themselves for leadership roles. The contacts made within the cohorts often lead to job opportunities before students graduate, she noted. For doctors who want to change healthcare for the better and become physician leaders, Mark Hertling, a retired three-star U.S. Army general and former tank commander, developed what some would consider a battle plan to help doctors grow as leaders. Hertling had no experience in healthcare management until his retirement from the military in 2013 when he was hired as senior vice president at Florida Hospital in Orlando to develop better leadership skills among physicians at the hospital. In his book “Growing Physician Leaders: Empowering Doctors to Improve Our Healthcare,” Hertling outlined how in 2014 he instituted a physician leadership development course applying military principles to the medical practice, according to a report published by Medpage Today. His course, eight five-hour sessions, is now in its third year and as of the end of October has graduated 250 students in classes of 50 persons each. Many of the graduates have been placed in formal and informal leadership positions. One of the course assignments focused on asking a subordinate, a peer and a supervisor about what made it challenging for each of them to deal with a doctor and to give suggestions for improvements, Medpage Today reported. After three years, the answers were typically the same, including the doctor not delegating enough and the doctor feeling that he or she is smarter than others and never taking advice. The answers should be enlightening, Hertling was quoted as saying, because “by seeing ourselves, we could correct ourselves. The problem with healthcare today is that it doesn’t see itself for what it is doing.” The reality today is that of 6,500 hospitals in the United States, only about 250 are run by doctors, he noted.

For every newly minted doctor, simply getting to see more patients at the bedside is key to becoming an accurate physician, which takes time, Dr. Fox noted. Doctors also need to focus on their CME training, which differs in every state. In California, all general internists and family physicians who have a patient population of which more than 25% are 65 years of age or older must complete at least 20% of all mandatory continuing education hours in geriatric medicine or the care of older patients, according to the California Medical Board website. All physicians and doctors also must complete 12 credit hours in pain management, according to the report. CME training is increasingly moving to mobile devices and smartphones. According to a study that surveyed 971 physicians across a variety of specialties — conducted by ON24, a virtual communication vendor with headquarters in San Francisco, and MedDataGroup, an interactive content and database marketing services company in Topsfield, Mass. — 84% of the doctors surveyed currently prefer attending CME events online. The AMA offers CME courses online arranged by topic or format and Webinars at www.ama-assn.org/ama/pub/ education-careers/continuing-medical-education.page. Medical schools, including the University of California, Irvine, and UCLA, also offer CME coursework. UCLA’s Office of Continuing Medical Education (www.cma.ucla.edu) lists about 60 courses each year.

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Social Networks and Apps Doctors are now turning increasingly to their iPads and smartphones to stay up-to-date with clinical work. “Every specialty has their own website,” Dr. Fox said. “As an emergency room physician, I turn to www.uptodate.com and www.pubmed.com to find answers.” Sermo (www.sermo.com) is a website that offers physicians a way to network with “highly intellectual people and a live community of doctors.” It also allows doctors to explore job opportunities, share clinical information, do case studies, and earn honoraria while having their voices heard, according to published reports. The site is exclusive to doctors and also allows doctors to interact with drug experts, participate in forums with members of Congress and get involved in numerous other ways. Ozmosis.org is another network for “verified U.S. physicians” only and similar to Sermo, though less established. Dr. Fox said he’s a fan of www.sonosim.com, an online ultrasound training program he feels is remarkably lifelike. “That kind of technology can cut down on hours one needs to spend in the classroom,” he noted. As someone who spends a lot of time with medical students and residents, Dr. Fox observed that younger students are attached to their iPads and embrace digital technology, including apps.

“I’m the first to admit that we have a textbook shelf in the ER that hasn’t been used in two years,” Dr. Fox noted. One of the reasons is that several textbooks are now readily available as apps. Apps can provide doctors with instant up-to-date information on therapies and other clinical data, which, in turn, allows doctors to make treatment decisions much quicker than ever before. Another popular app is PubMed on Tap, an application for the iPhone, iPod Touch and iPad, which lets doctors search for PubMed and PubMed Central while on the go. For drug information on the go, Dr. Fox recommended Micromedex and Epocrates Rx, which can be downloaded on Android phones for free.

mentoring programs and networking events to help them connect with the county’s top doctors and influencers.

Attitude A positive attitude may not be at the top of the list for future success, but Dr. Fox feels it’s a character trait that all revered doctors seem to have in common. “When I look around the hospital and look at people, I admire those with a consistent reputation,” he said. “Everyone trusts them, loves them; they are reasonable and honest and upbeat people who have a positive and can-do attitude.”

Organizations

Mentors The human connection, however, is critical for career advancement, and mentors can provide the help doctors need at the very early stages of career development and networking. Dr. Fox said for medical students who want to do well on their exams, reaching out to their professors is key to gaining knowledge and expertise. In addition, “It really can advance their career with letters of recommendations, providing a reference and opportunities to conduct research and publish papers,” Dr. Fox said. For young doctors in Los Angeles County, LACMA provides

Finally, to advance in their careers, doctors need to shake a lot of hands. Joining organizations like LACMA opens the door to meetings with top doctors in their respective fields, Dr. Fox said. It is especially important for young doctors to belong to LACMA, Ortega noted. “Many doctors join specialty organizations, but you need to join the county physicians organization and actively participate in the networking events and district planning meetings,” Ortega said. “It’s not enough to put your profile on the Internet. You need to shake hands and take advantage of people like me who help young physicians all the time.”

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Things You Should Know About

MACRA

What Is MACRA? MACRA proposes three major changes to Medicare reimbursements. First, it ends the sustainable growth rate (SGR) formula that would significantly reduce payments. Second, it establishes a new framework to reward physicians based on performance and health outcomes rather than volume alone. Third, it aims to combine the existing quality reporting programs and a new program (Practice Improvement) into one streamlined system called the Merit-Based Incentive Payment System (MIPS). MACRA establishes an annual physician fee schedule update of 0.5% from 2016 to 2019. Thereafter, physician fee schedules will remain at 2019 levels through 2025. There will be an incentive based on quality measures that will increase or decrease overall payments starting in 2019.

How Will Physicians Get Paid Under the Merit-Based Incentive Payment System (MIPS)? MIPS will include the Physician Quality Reporting System, the Value-based Payment Modifier Program, the Medicare Electronic Health Record (EHR) Incentive Program and the new Practice Improvement Program for eligible providers. Payment adjustments will be contingent on four major categories: quality, resource use, clinical practice improvement and meaningful use of EHRs. Physician performance in each category will be compiled into a composite performance score that will determine their payment adjustment and whether the physician will incur a bonus or a penalty. Providers who score 70 or higher will become eligible for a performance adjustment.

Which Payment System Should My Practice Pick? Providers wonâ&#x20AC;&#x2122;t be given the opportunity to choose between the advanced Alternative Payment Model (APM) and Merit-based Incentive Payment System (MIPS). Rather, providers will qualify for one or the other based upon performance results.

Solo and Small Practices. Solo and small practices will be subject to MIPS unless they are in the first year of their practice, see less than 100 Medicare patients, bill Medicare less than $10,000 per year or are in a qualified Alternative Payment Model. Until they qualify, small practices can seek technical assistance from CMS through their regional extension center, if needed.

Transitional Support Is Available. The Centers for Medicare and Medicaid Services (CMS) recognizes that MACRA will affect clinical staffing and workflow from a financial and technical standpoint. Thus, CMS has included a budget for transitional costs that includes $100 million for technical assistance over a span of five years to encourage participation, 29 practice transformation networks to provide support to physicians making the transition towards MACRA compliance and 10 support networks for specialty providers as a forum for best practices where small practices can discuss, track and share best practices on their transition path.

What You Can Do Today. Moving to a new reimbursement model requires planning and organization with regard to your organizationâ&#x20AC;&#x2122;s technology roadmap. First, start with understanding what new technological capabilities will be required to operate in accordance with MACRA. Then, get associated with the payment system your practice or medical group qualifies for. CMS has indicated that it is willing to continue listening to physicians to ease the transition. In the best interest of physicians, the Los Angeles County Medical Association (LACMA), California Medical Association, and American Medical Association continue to work for modifications and simplification. Look for updates from LACMA on social media and in your email inbox.

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