MI MEDICINE | SEP-OCT 2019

THE OFFICIAL MAGAZINE OF THE MICHIGAN STATE MEDICAL SOCIETY » VOL. 118 / NO. 5

September / October 2019

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FEATURES & CONTENTS September / October 2019

08

One Snarky Comment Too Many JODI SCHAFER, SPHR, SHRM-SCP

10

October is Liver Awareness Month MDHHS

12

MSMS Billing & Coding Resources STACIE SAYLOR, CPC, CPB

24

Challenges of Cultural Diversity in Health Care: Protect Your Patients and Yourself SUSAN SHEPARD, MSN, RN

COLUMNS 04 President's Perspective

FEATURE

16

MOHAMMED A. ARSIWALA, MD

06 Ask Our Lawyer

DANIEL J. SCHULTE, MSMS LEGAL COUNSEL

DEPARTMENTS 14 In Memoriam 23 Welcome New Members 28 MSMS Educational Courses

Celebrating Women in Medicine

BY NICK DELEEUW FOR THE MICHIGAN STATE MEDICAL SOCIETY

In September, the Michigan State Medical Society joins the American Medical Association in observing its annual Women in Medicine Month.

Read the article beginning on page 16.

STAY CONNECTED!

SEPTEMBER / OCTOBER 2019 |

michigan MEDICINE® 3

perspective

MICHIGAN MEDICINE® VOL. 118 / NO. 5 Chief Executive Officer JULIE L. NOVAK Managing Editor KEVIN MCFATRIDGE KMcFatridge@msms.org Marketing & Sales Manager TRISHA KEAST TKeast@msms.org Publication Design STACIA LOVE, REZÜBERANT! INC. rezuberant.com Printing FORESIGHT GROUP staceyt@foresightgroup.net Publication Office Michigan Medicine® 120 West Saginaw Street East Lansing, MI 48823 517-337-1351

Celebrating

WOMEN IN MEDICINE

www.msms.org All communications on articles, news, exchanges and advertising should be sent to above address, ATT: Trisha Keast.

Postmaster: Address Changes Michigan Medicine® Trisha Keast 120 West Saginaw Street East Lansing, MI 48823

Michigan Medicine®, the official magazine of the Michigan State Medical Society (MSMS), is dedicated to providing useful information to Michigan physicians about actions of the Michigan State Medical Society and contemporary issues, with special emphasis on socio-economics, legislation and news about medicine in Michigan.

The MSMS Committee on Publications is the editorial board of Michigan Medicine® and advises the editors in the conduct and policy of the magazine, subject to the policies of the MSMS Board of Directors.

Neither the editor nor the state medical society will accept responsibility for statements made or opinions expressed by any contributor in any article or feature published in the pages of the journal. The views expressed are those of the writer and not necessarily official positions of the society. Michigan Medicine® reserves the right to accept or reject advertising copy.

Products and services advertised in Michigan Medicine® are neither endorsed nor warranteed

by MSMS, with the exception of a few.

Michigan Medicine® (ISSN 0026-2293) is the official magazine of the Michigan State Medical Society, published under the direction of the Publications Committee. In 2019 it is published in January/February, March/April, May/ June, July/August, September/October and November/December. Periodical postage paid at East Lansing, Michigan and at additional mailing offices. Yearly subscription rate, $110.

Single copies, $10. Printed in USA. ©2019 Michigan State Medical Society

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Helene Brooke Taussig, MD

Anita Avery, MD

By Mohammed A. Arsiwala, MD, MSMS President

®

Colleagues, This month, the Michigan State Medical Society stands with the American Medical Association to celebrate Women in Medicine Month. As part of that celebration, we are proud to bring you a special edition of Michigan Medicine® recognizing the tremendous leadership accomplishments of just a few of the women leading health care across Michigan in the 21st century.

Their contributions to patient care and the development and practice of the highest quality medicine – and the contributions of thousands of other Michigan women leading in practices, academia, research, and physician organizations – echoes throughout our history.

From Elizabeth Blackwell, who in 1849 became the first woman in the nation to earn a medical degree, to Doctor Helene Brooke Taussig who in the early 20th century became the first woman to lead the American Heart Association and Doctor Anita Avery, the first female Chair of the Michigan State Medical Society’s Board of Directors, women in medicine are daily impacting the practice and development of medicine and leading the charge in state houses and our nation’s capital to improve health care policy.

MOHAMMED A. ARSIWALA, MD MSMS PRESIDENT

In this edition of Michigan Medicine®, we highlight just a few of the dynamic achievements Michigan women have made in the broad development of physician leadership. You will also hear from Michigan women who are delivering results for their patients while advancing patient care. Our cover article highlights and examines leadership development and what next important steps lie before us on the road to one common goal; to support the growth of all young physicians in all stages of their medical career.

Michigan women are revolutionizing patient care, redefining leadership, and leading large healthcare organizations. This September, and every day of the year, we celebrate their lasting contributions to medicine and their immense impact on our leadership, education and community.

Sincerely,

Mohammed A. Arsiwala, MD MSMS President

michiganMEDICINE® SEPTEMBER JANUARY / OCTOBER / FEBRUARY 2019 2019 | |michigan MEDICINE®

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ASK OUR LAWYER

Responding to and What to Expect in a Licensing Investigation

By Daniel J. Schulte, JD, MSMS Legal Counsel

I received a letter in the mail from the Bureau of Professional Licensing within the Michigan

Department of Licensing and Regulatory Affairs (“LARA”). It states I am the subject of an investigation

by LARA regarding a possible violation of the Michigan Public Health Code (the “Code”). I am being requested to set up an appointment with an investigator to discuss the possible violations and for the gathering of information. This has never happened to me before. Can you explain the process?

T

his letter is the beginning of what will be a long process. The Code authorizes LARA to investigate activities related to the practice of a health profession by a licensee. This typically occurs after LARA receives notice of a potential violation of the Code or allegations that one or more grounds for disciplinary action exist. This could arise due to LARA receiving an allegation (anyone may submit an allegation that a licensee has violated the Code), malpractice settlements, awards or judgements (three or more in a five year period or any number totaling more than $200,000 in a five year period) or a failure to renew your license timely, obtain required continuing medical education or other technical violations of the Code.

You should have an attorney represent you in this process. Your attorney should contact LARA’s investigator and schedule an in-person meeting with you and your attorney to discuss the allegations being investigated, to provide requested documentation, etc. Deciding exactly what to discuss and what documentation to produce are decisions to be made in consultation with your attorney. You

may produce medical records. The Code provides that the physician-patient privilege does not apply in an investigation

by LARA acting within the scope of its authorization. This provision is generally enforceable under HIPAA. Following the meeting, the investigator may or may not request that you provide additional documents or other information and may or may not request a follow-up interview with you. LARA may also retain an expert to render a professional opinion regarding whether or not your conduct is consistent with the applicable standard of care or otherwise violates the Code. Once the investigation is complete, the investigator will prepare a written report which will be submitted to the Board of Medicine which will be used by it to determine whether or not there has been a violation of the Code. The time required for LARA to complete its investigation and for the board to make its decision may take up to 4-6 months after your meeting with the investigator.

If the board determines there has been no substantiated violation of the Code you will receive written notice from

LARA that its investigation has concluded and the file has been closed.

If the board determines there has been a violation of the Code, LARA will proceed to file an administrative complaint.

If an administrative complaint is filed, you must file an answer within 30 days.

You will then have an opportunity to request a compliance conference at which you and your attorney will meet with a representative of the board and attempt to negotiate a settlement. If no settlement is reached your case will proceed to a hearing before an administrative law judge. The judge will make determinations of fact and propose a decision to the board. The board then must decide whether to accept the decision of the administrative law judge. Sanctions against your license (suspension, revocation, probation, fine, etc.), if any, are imposed only by the board. The board’s decision can be appealed to the Michigan Court of Appeals.

DANIEL J. SCHULTE, JD, MSMS LEGAL COUNSEL IS A MEMBER AND MANAGING PARTNER OF KERR RUSSELL

SEPTEMBER / OCTOBER 2019 |

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ASK HUMAN RESOURCES

One Snarky Comment Too Many

By Jodi Schafer, SPHR, SHRM-SCP, Human Resources Management Services, LLC

Q:

I messed up. Last month in a moment of anger, I fired my nurse. She had been getting on my nerves.

She had a snarky attitude, and had made one sarcastic comment too many. I have had a number of discussions with her about the comments that I felt undermined me, but she did not change her ways. During a morning meeting, she made another snarky comment. I don’t remember what she said, I just know I was mad. She was shocked, as I was, when I told her to leave and that she was terminated. Unfortunately, this exchange happened in front of the entire staff.

Although I am glad I fired her, I do wish I handled it better.

My reaction has frightened my other employees who are now concerned that they could be next in line to bear my wrath.

What can I do to assure them that this action was not a typical occurrence, but rather a onetime event?

I also recently received a request from a doctor I know, asking me for a reference on her. This ex-employee was good otherwise, but her mouth would prevent me from giving her a positive reference. Yet, I don’t want to get in the way of her getting a new job. How should I handle it?

CODE OF CONDUCT

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“People tend to remember the one bad thing that occurred rather than the 39 good things you did. Keep trying, count to ten, remain calm and don’t let anyone push your buttons.”

“Losing it” at the workplace does little for your reputation as a manager, as you found out. I agree that your actions may lead other employees to be concerned about the way you may treat them. There are a few things you can do to influence the staff’s opinion of you, and actions speak louder than words. The most important thing to do now is to let the dust settle and go out of your way to treat your employees professionally and respectfully.

If your staff did not see anything wrong with her comments, you are going to have more difficulty.

the situation that has already occurred, it will reinforce your desire for a cooperative, positive, supportive workplace.

With this, you have a document that can be used to hold employees accountable for the behavior and communication style you expect. Those who are not understanding or complying with this policy can be coached up or counseled out – in a measured, appropriate (private) fashion.

The policy statement is only part of this solution though. You have to show your staff that the behavior you exhibited was

Actions speak louder than words! Three steps you can take: 1.

Let the dust settle and go out of your way to treat your employees professionally and respectfully.

2.

Review (or add to your employee handbook) the code of conduct and professional communication expectations for your office.

3.

Show your staff that the behavior you exhibited was an exception rather then a rule.

You may have some policy guidance for code of conduct and professional communication expectations for your office in your employee handbook. If you don’t have a handbook, or your handbook is missing this section, now is a good time to add it in. While it won’t do much for

them that you aren’t prone to spontaneous terminations. People tend to remember the one bad thing that occurred rather than the 39 good things you did.

Keep trying, count to ten, remain calm and don’t let anyone push your buttons.

As far as the reference is concerned, I would ask for a signed authorization from the ex-employee with a “hold harmless” clause and retain a copy of it in your files. Then let the prospective employer lead with their questions. Do not answer questions unless the behavior has been documented in the employee’s file. Only answer the questions asked and do not expand on them. Most people do not ask specific questions. Instead they will ask a broad question like, “What kind of employee was she?” Answer the question in general terms, focusing on her work skills rather than her snarky ways. If asked why she is no longer working for you, be honest, but stick to the facts. Rather than saying “I lost it” when she made yet another snarky comment, instead say that you had difficulty with her communication style and she was no longer a good fit for your office.

an exception rather then a rule. This is done through your actions, and your actions alone. No matter how much you tell them and they agree and say they understand, this little “losing it” episode will remain in their memories for years to come. From now on you need to show

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MDHHS UPDATE

October is Liver Awareness Month Michigan Department of Health and Human Services

The liver is one of the largest organs in the body and is essential for digesting food and ridding the body of toxic substances. Over time, continuous damage to the liver can result in scarring (cirrhosis) which can lead to liver failure or even death.

O

ver 42,000 new cases of liver cancer will be diagnosed and over 30,000 people will die from liver disease in the United States in 2019, according to the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) Program (source: https://seer.cancer.gov/statfacts/html/livibd.html).

Over 42,000 new cases of liver cancer will be diagnosed and over 30,000 people will die from liver disease in the United States in 2019.

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Liver Awareness Month was established to encourage people to identify potential risks and signs of liver cancer and to learn how to prevent liver disease. Liver disease can be inherited (genetics) or caused by other factors that damage the liver including chronic infection with hepatitis B virus (HBV) or chronic hepatitis C virus (HCV), excessive use of alcohol or obesity. Early detection of liver cancer may be difficult because there is no recommended screening for liver cancer based on the American Cancer Society (source: https:// www.cancer.org/cancer/liver-cancer.html).

Over 65% of liver cancers are related to chronic HBV and HCV infections. There is no vaccine to prevent HCV, however there are effective treatments for those who are chronically infected. HBV is preventable. Hepatitis B vaccine is recommended starting at birth and for all children, regardless of risk factor, to prevent infection later in life. Adults at risk or even those who just want to be protected from getting HBV should also get the hepatitis B vaccine. Along with the hepatitis B vaccine, all children 12 months of age or older, regardless of risk, and adults at risk or

| SEPTEMBER / OCTOBER 2019

Over 65% of liver cancers

are related to chronic HBV and HCV infections. those who want to be protected from the hepatitis A virus (HAV) should also get the hepatitis A vaccine. For more information regarding viral hepatitis, visit www.michigan.gov/hepatitis. For more information regarding hepatitis A and B vaccines contact your doctor, local health department or go to: www.michigan.gov/immunize.

Michigan has an ongoing HAV outbreak and although cases have slowed, the national numbers are still rising and include states surrounding Michigan. Individuals are at a higher risk for developing HAV if they have chronic liver disease, including cirrhosis of the liver, HBV or HCV. To prevent liver disease, people need to avoid risky behaviors and make healthy lifestyle choices. For more information about liver cancer and prevention, go to www. cancer.org/cancer/liver-cancer.html.

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HEALTH CARE DELIVERY

MSMS Billing & Coding Resources

By Stacie Saylor, CPC, CPB Manager, Reimbursement Advocacy, The Michigan State Medical Society

MSMS has many practice resources available for no cost to members on topics such as legal and regulatory, HIT, practice management and reimbursement. The MSMS website includes an abundance of relevant and valuable resources for billing and coding.

W

ithin the Health Care Delivery section, new articles and webinars have been added on medical necessity. As Medicare and third-party payers recognize medical necessity as a critical factor in determining claims payment, practices indicated a need for supplementary information relating to documenting medical necessity.

Payers are increasingly reviewing E&M services and looking for documentation

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that supports the level of service. They are looking for documentation that proves that the services (levels billed) were appropriate for the reasons/conditions and complexity of the patient encounter. “Medical Necessity� is terminology created by the insurance industry and used by commercial and federal programs to clarify how they will pay for services. For therapeutic and diagnostic services, this is often a matter of the payer assigning a payable diagnosis they have determined that supports their policies and decisions to cover the service. As expected diagnosis coding plays a key role in supporting medical necessity for all services and along with appropriate documentation should support the level of E&M billed.

New articles and webinars on medical necessity on the MSMS website…

Visit www.msms.org/billingandcoding for access to these resources: How Medical Necessity Fits into E/M Leveling MDM vs. Medical Necessity: The Debate Continues Even More MDM vs. Medical Necessity Medical Necessity vs. MDM: We Have a Winner Medical Necessity: Why It Matters, Ways to Demonstrate It Evaluation and Management Services Guide CMS Internet-Only Manual (IOMs) Free Webinar on “Understanding Medical Necessity”

Visit www.msms.org/ondemandwebinars for these FREE webinars.

Medical Necessity – Tips to Prove It Webinar Billing 101 Claim Appeals Credentialing Reading Remittance Advice Tips and Tricks on Working Rejections

SEPTEMBER / OCTOBER 2019 |

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IN MEMORIAM Physician, Philanthropist, MSMS Board Member

Bassam Nasr, MD

Bassam Hani Nasr, MD, passed away on Tuesday, July 16, 2019, after a short illness. Doctor Nasr, a well-known Gastroenterologist in Port Huron, has lived with his family in St. Clair County for more than 30 years. He grew up in Lebanon and came to the United States to fulfill the American Dream through hard work.

With his vision, Doctor Nasr co-founded Physician Healthcare Network 25 years ago and has been the president since its inception. He brought access to various areas of medicine to this community. Over the years he had employed hundreds throughout the network and cared for so many. His contributions to the community are significant, and his leadership has touched thousands of lives.

He believed in philanthropy and gave back to the community through various generous contributions to organizations such as Blue Water Hospice, SC4, and the Community Foundation, to name a few.

Doctor Nasr was very involved with the Michigan State Medical Society. He served as a member of the MSMS Board of Directors from 2008 until the time of his passing in 2019. He held various positions throughout his time on the board, including District Director for District 7, Finance Committee Chair, and Board Secretary. He was elected to the Michigan Delegation to the American Medical Association in 2010 as an Alternate Delegate and moved to the role of Delegate in 2018. Doctor Nasr was appointed to the MSMS Foundation in 2016 and became President in 2018.

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| SEPTEMBER / OCTOBER 2019

MEMBERS OF THE MICHIGAN STATE MEDICAL SOCIETY REMEMBER THEIR COLLEAGUES WHO HAVE DIED.

ANWAR GHUZNAVI, MD WAYNE COUNTY 7/10/19

EDWARD LARSEN, MD WAYNE COUNTY 6/5/19

BYRON SCHOOLFIELD, MD GENESEE COUNTY 7/18/19

ROBERT ANDERSON, MD WASHTENAW COUNTY 7/24/19

JAMES WILKINS, MD JACKSON COUNTY 6/2/19

BASSAM NASR, MD, MBA ST CLAIR COUNTY 7/16/19

ROBERT JANKE, MD KALAMAZOO ACADEMY OF MEDICINE 6/5/19

TO MAKE A GIFT OR BEQUEST: CONTACT REBECCA BLAKE, DIRECTOR, MSMS FOUNDATION CALL 517-336-5729 OR EMAIL RBLAKE@MSMS.ORG

Physician

with independent primary care practice in Grand Rapids, MI

Opportunity Available Answer Health, a Physician Organization supporting independent physicians in West Michigan, has an opportunity available for a primary care physician within an established, independent Internal Medicine Practice located in Grand Rapids, Michigan. The practice has provided exceptional care to a large patient base for over 50 years.

STAY CONNECTED!

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Currently, five providers provide patient care in a family-oriented, caring, and team-based environment. The team includes physicians, mid-level providers, embedded care manager with CDE, social worker and pharmacist, medical assistant for each physician, and experienced administrative and support staff.

Eligible candidates are board certified in internal medicine, family medicine, or internal medicine/pediatrics and have experience in providing patient-centered and evidence-based care within the primary care setting. This position is full-time with competitive salary and benefits including 401K, health and life insurance, paid time off, and an ownership opportunity after one-year employment.

If interested, please email your Curriculum Vitae (CV) to Answer Health Physician Organization at info@answerhealth.com. If you have questions, please call Answer Health Physician Organization at 616-552-1500.

SEPTEMBER / OCTOBER 2019 |

michigan MEDICINE® 15

FEATURE

WOMEN IN MEDICINE WE HAVE SEEN THE FUTURE OF MEDICINE, AND IT IS FEMALE. This September, the Michigan State Medical Society joins the American Medical Association in observing its annual Women in Medicine Month. And this year, there’s plenty to celebrate.

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“It’s important that physicians reflect the diversity that we see in our patients—which includes women and minorities and individuals from all walks of life.”

LAUREN B. SMITH, MD

SEPTEMBER / OCTOBER 2019 |

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Here in Michigan, more than 14,000 highly qualified, expert, effective and compassionate health care providers—who happen to be women—are revolutionizing patient care, physician leadership, and public policy. That’s nearly 40 percent of the state’s professionally active physician workforce.

The Michigan State Medical Society’s Board Chair is a woman, as is its chief executive officer. Its immediate past president is a woman. Five members of the Society’s Board of Directors are women.

The president of the American Medical Association is a woman. The president of the Michigan chapter of the American Academy of Pediatrics and both the president and the chairman of the board for the Michigan Academy of Family Physicians are women. Two of the three state departments most connected to health care and health care policy in Michigan, the Department of Insurance and Financial Services and the Department of Licensing and Regulatory Affairs, are led by women.

Each represents a tremendous accomplishment by a tremendously accomplished professional, but for every exciting development that takes place in the halls of power, thousands happen in research labs, study halls, exam rooms and operating suites across the state.

Private practice, physician organizations, business, academia and more—for Michigan women in medicine, leadership anywhere is possible, and they’re proving it daily.

At the same time, unique challenges remain for women leaders in health care, many trend lines aren’t where one would hope or expect, and there’s real work left to be done.

SUCCESSES:

Different Paths to Different Destinations

L

ast fall, the public’s attention was dominated by a fascinating trend in national, state and local politics—the mass ascendency of women to seats of power across the country. It was quickly dubbed the “pink wave” by pundits and the media, and it continues to shape our shared future.

The percentage of physicians who are women has grown 43 percent over the last decade, 42,000 women are currently enrolled in medical school and, perhaps most significantly, almost 61 percent of physicians under 35 years of age are women, according to AthenaHealth.

The trend is important to recognize for many reasons, not insignificantly for its size and seemingly sudden onset. The sheer volume of women assuming new leadership positions was historic and unprecedented—but it’s a trend line that’s only starting to catch up to those in health care.

But it’s possible one of the most significant areas of meaningful growth isn’t measured by the number of medical doctorates being earned, but the leadership women are bringing to decision-making boards, institutions, and other medical disciplines.

Those arenas remain those in which the most work is yet to be done—but they’re also where the most exciting transformations already are well underway.

Indeed, our nation has come a long way since 1849, when Elizabeth Blackwell became the first woman in the U.S. to earn a medical degree. Even one hundred years after that accomplishment, women made up only six percent of the physician workforce. Today, that number is greater than 36 percent across the U.S.

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Melanie Manary, MD, FACP, MBA says expanding leadership roles for women may be a sign of shifts in societal expectations and a growing “sweet spot” for many of the top women pioneers working in medicine today.

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“Men have lots of responsibility for families, but even in the 80s and 90s it was often the mom [bearing most of the responsibility at home],” said Doctor Manary. “When my father was sick it was me mostly [responsible to care for him]. [You’d be] driving to the hospital in the middle of the night and admitting patients, then you’d drive back home and pack your kids’ lunches before going back to bed.

“Now, years later, there is this sweet spot.

It’s great. We have hospitalists and now we get to our fifties and say, wow, I don’t have to make lunches or worry about what time people are coming home.”

Many of today’s senior female physicians are able to leverage their growing freedom—along with their age, health, and breadth of experience—to add value to the field of health care in new ways.

LEADERSHIP:

Building a Business

S “There is this 'sweet spot.‘ A time in a woman’s life when there are less home responsibilities, you are still young and you’ve gained experience in your field and confidence in your abilities.”

MELANIE MANARY, MD, FACP, MBA

LEADERSHIP:

Physicians Organizations

D

octor Manary, a physician in private practice, hasn’t just seized opportunities that have come her way—she’s created them for herself.

For her, that means serving as the Petoskey/ Northern Area medical director for the Northern Physicians Organization, as a member of NPO’s Board of Directors, and on its quality committee. It also meant returning to school mid-career to pursue a master’s degree in business administration.

“There is a time in a woman’s life when there are less home responsibilities, you are still young and you’ve gained experience in your field and confidence in your abilities. You have lots of energy to learn and expand your role,” Doctor Manary said. “That’s why I think there are a lot of women who are middle aged, kind of coming in because they’ve already honed their organizational and multitasking skills and can jump right into it.”

Of course, not every woman’s story is the same, and not every journey to leadership emanates from a sweet spot.

andy Dettmann, MD, DABAM, FASAM is the president-elect of the Kent County Medical Society and the founder of the Dettmann Center in Grand Rapids, where she helps patients overcome opioid and alcohol addiction. She’s employed full time by Mercy Health as their first addiction medicine specialist, and a nationally recognized expert on addiction treatment. That wasn’t always the case.

A 1987 graduate of the Michigan State University College of Human Medicine, Dettmann was a respected physician in the state’s second largest city before becoming disabled in 2004. Her health deteriorated to the point that in 2011 she was essentially on hospice care.

“My board certifications in both emergency medicine and pediatric emergency medicine expired, as well as my license to practice medicine,” said Doctor Dettmann.

“However, with the help of community, a change in my family situation, and God’s grace, I started to get better. In 2011, I was homeless, eating at shelters, and relearning simple math, with an anoxic brain injury and significant psychopathology from the abuse I had endured.”

That was hardly the end of her story.

“I got my medical license reinstated in 2012 and became acutely aware of the escalating opioid epidemic and decided to practice addiction medicine,” Doctor Dettmann said. “Since that time I have become board-certified by the American Board of Addiction Medicine and the American Board of Preventive Medicine.”

Since reclaiming her license to practice, Doctor Dettmann has made it her life’s work to care for and protect the rights of marginalized residents who’ve been “shamed, blamed, and even punished in our society for their diseases.”

No wonder they’re literally writing a book about her miraculous journey.

Doctor Dettmann hasn’t just earned the right to practice medicine—twice—she’s built a business on the frontlines of the state’s most significant public health crisis that puts patients first.

“I have learned to listen to the wisdom of Eleanor Roosevelt, that ‘you must do the thing that you think you cannot,’ and ‘do what you feel in your heart is right— for you will be criticized anyway,’” said Doctor Dettmann. “I follow Jesus, not societal norms.”

(CONTINUED ON PAGE 20)

“I have learned to listen to the wisdom of Eleanor Roosevelt, that ‘you must do the thing that you think you cannot,’ and ‘ do what you feel in your heart is right— for you will be criticized anyway.‘ I follow Jesus, not societal norms.”

SANDY DETTMANN, MD, DABAM, FASAM

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LEADERSHIP:

Academia

L

auren B. Smith, MD, is a Professor of Pathology at the University of Michigan and, like Doctor Dettmann and Doctor Manary, she has pursued and excelled in a variety of leadership roles outside the exam room.

“I decided to go into medicine after working in a genetics lab that studies bipolar disorder at the University of California, San Francisco” said Doctor Smith. “I realized then how many interesting areas of medicine exist. This was where my interest in ethics began, when I worked on a study addressing the stigma and decision-making involved in genetic testing.”

Six years after finishing her undergraduate degree she returned to the University of Michigan to pursue medical school. She completed her residency and fellowship and continued her work in medical ethics. She now serves as Section Head of Hematopathology and as the Director of the University’s Ethics Path of Excellence program in the medical school. She is also one of seven clinical Ethicists at the University of Michigan.

Doctor Smith is also a former Chair of the Michigan State Medical Society’s Ethics Committee, helping the state’s largest physician organization navigate medical ethics as knowledge expands, science develops, and public discourse evolves. She continues to chair the annual MSMS Bioethics Conference.

She’s worked hard to earn every opportunity, but still counts herself lucky to hold leadership positions that often go to men in other fields. “There are more subtle forms of sexism out there, and we still need to advocate for women’s rights,” Doctor Smith cautions.

For every success there remains a challenge.

Not all of the numbers are glowing.

CHALLENGES:

Leadership Gaps, Attitudes and Expectations

A

ccording to the AMA, among women who self-identified as holding a leadership position, fewer than 10 percent reported being a department chair, CEO, or CMO.

“I decided to go into medicine after working in a genetics lab that studies bipolar disorder at the University of California, San Francisco.

I realized then how many interesting areas of medicine exist.

LAUREN B. SMITH, MD

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Examples in academic leadership like Doctor Smith aren’t hard to find, but they’re still not the norm. In fact, female representation in medical academia continues to lag the successes experienced in other areas of medicine.

A 2017 study published in the Journal of the American Medical Association found that: Female physicians in academia remain less likely than their male counterparts to have reached the rank of full professor, Start-up funding packages to help launch faculty careers were nearly twice as high for men as for women, and Salaries for female physicians in academia were eight percent lower than for men in the same field.

An analysis by the Department of Surgery at the University of Michigan reports that despite women making up roughly half of the nation’s working surgeons, only 19 percent of associate professors, 10 percent of full professors and fewer than five percent of department chairs in surgery are women.

Perhaps more alarming, the U of M experts examined current data and trend lines and report that at the current pace, it will take over 100 years to attain gender parity in these fields.

Sameen Ansari is a third year medical student at the Oakland University William Beaumont School of Medicine, and a member of the Michigan State Medical Society’s board of directors. She straddles a line between the next generation of physicians, and today’s crop of health care leaders.

She says that any observance recognizing women in medicine should celebrate the successes, but keep in mind the road left to travel.

“We’ve made a lot of progress, and representation of women in medical schools is improving, but there’s a lot of work left to do as far as women being recognized as leaders in medicine,” said Ansari.

CHALLENGES:

Diversity and Patient Outcomes

A “We’ve made a lot of progress, and representation of women in medical schools is improving, but there’s a lot of work left to do as far as women being recognized as leaders in medicine.”

SAMEEN ASARI, MEDICAL STUDENT

Ansari tells a story that’s too familiar to most female physicians—that of entering a patient’s room alongside men serving in other non-physician roles and watching the patient address the men as the primary care givers.

“For me, I just politely correct people,” Ansari said. “We all have implicit bias. By being vocal and speaking about it without worrying about what others assume about you, that’s how we open the dialogue and move past this.”

Doctor Manary, the northern Michigan ACO leader, embraced similar experiences as challenges, and turned them into an MBA. “When a hospital group first purchased the hospital where I worked, there were meetings about being employed physicians,” Doctor Manary recounts. “At one meeting someone came up to me and patted me on the shoulder and said ‘Melanie, we’re going to take care of you.’ That day I went home and looked up going to business school. I said, ‘I think I’m going to take care of myself.’”

After graduating from business school, she earned a leadership position in her physician organization and a group practice.

s the numbers swing towards more inclusive representation among physicians, and women like Ansari, Doctor Smith, Doctor Dettmann and Doctor Manary have claimed more leadership posts, the biggest winners may just be Michigan patients.

Studies have shown that female physicians may provide an overall better quality of care for patients with type two diabetes, may produce lower mortality rates among heart patients, and, according to a much-discussed study of 1.5 million hospitalized Medicare patients conducted by researchers from Harvard, patients treated by female physicians are slightly less likely to die or be readmitted to the hospital over a 30-day period.

It shouldn’t be any surprise that academic research points to strengths in the leadership of female physicians. It also points to some of the potential best practices associated with better outcomes.

Female primary care physicians, for instance, were found to engage in more patient-centered communication and to have longer visits with patients than their male colleagues, according to one study.

Another found that, in a random sample, female physicians reported systemically counseling patients more than did male physicians. An analysis by researchers at Johns Hopkins Bloomberg School of Public Health cited studies showing women spent, on average, about 10 percent more time per visit with their patients.

“Hopefully, the ideal physician, whether a man or a woman, is extremely caring, conscientious, and empathetic toward his or her patients,” says Doctor Smith, the U of M physician and Ethicist. “It’s important that physicians reflect the diversity that we see in our patients—which includes women and minorities and individuals from all walks of life.”

Conclusion The successes of today’s women in medicine are worth celebrating. Each of those successes shines brighter when examined against the backdrop of medicine’s past. Even more exciting, the statistics and trends tell us our best days are still in front of us.

“Progress would be slower if there wasn’t action,” said Ansari. “Consciously choosing women leaders who are fully competent and qualified, and elevating them to be in positions of leadership is a real way to make a difference. Once women see themselves represented in certain arenas, they’ll see that as a space which is open and welcoming to them.”

Doctor Dettmann says progress happens when women pursue their goals, and don’t let anything stop them. “Barriers are completely invisible to me and I’d say that has worked out very well for me! My [approach]—stay on my path and do what I think is right!”

SEPTEMBER / OCTOBER 2019 |

michigan MEDICINE® 21

22 michigan MEDICINE®

| SEPTEMBER / OCTOBER 2019

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michigan MEDICINE® 23

Challenges of Cultural Diversity in Healthcare: Protect Your Patients and Yourself Susan Shepard, MSN, RN, Senior Director, Patient Safety and Risk Management Education, The Doctors Company

P

hysicians are increasingly faced with providing care to a multicultural society complicated by literacy issues. Ensuring safe and quality healthcare for all patients requires physicians to understand how each patient’s socio-cultural background affects his or her health beliefs and behavior.

Case Examples: Consider the following scenarios: A married 32-year-old Middle Eastern female with uterine fibroids presented at the office of a gynecologist. After years of infertility and pain, a hysterectomy was recommended. She spoke English moderately well but with a heavy accent. Offers of an interpreter were declined, including translation of the surgical consent form. Eight weeks post-hysterectomy, the patient asked the physician how soon she could expect to become pregnant.

An elderly female Asian patient was noncommunicative with the physicians and staff during the first three days of her hospitalization. She would not maintain eye contact or talk, even when an interpreter was provided. Communication regarding the patient’s care or concerns would occur only when a male family member was present. The staff and physicians—concerned with privacy issues—generally spoke with the patient when family members were not present. After several days of delayed treatment because consent for a necessary but non-emergent surgery could not be obtained from the patient, a visiting chaplain of the same nationality explained the cultural requirement that a male be present for a female’s care.

24 michigan MEDICINE®

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Contributed by The Doctors Company

thedoctors.com

Addressing the Problem The Doctors Company’s closed claims studies have shown that inadequate provider-patient communication is a frequent contributing factor to patient noncompliance, poor patient outcomes, and litigation. Effective provider-patient communication leads to an increase in patient satisfaction, better compliance, and improved outcomes. In multicultural and minority populations, the issue of communication may play an even larger role because of behavioral, cognitive, linguistic, contextual, and cultural barriers that preclude effective patient-provider communication. Research has shown that services for minorities can be improved by removing language and cultural barriers.

When cultures and languages clash, physicians are unable to deliver the care they have been trained to provide. Culturally competent care depends on resolving systemic and individual cultural differences that can create conflicts and misunderstandings. If the provider is unable to elicit patient information and negotiate appropriate care, negative health consequences may occur.

How can physicians easily acquire and maintain the skills to provide culturally responsive and appropriate care to the increasingly diverse population of patients in the United States? Traditionally, training in cross-cultural medicine has focused on providing a list of common health beliefs, behaviors, and key “dos and don’ts.” This approach does not take into account acculturation and socioeconomic status and can lead to stereotyping.

An alternative approach, proposed by Drs. Joseph R Betancourt, Alexander R Green, and J. Emilio Carrillo, helps physicians

elicit a patient’s beliefs and preferences in order to identify and deal with the patient’s concepts, concerns, and expectations. This communication model is called ESFT (Explanatory model of health and illness, Social and environmental factors, Fears and concerns, and Therapeutic contracting).

Case Example Consider this scenario with an example of the ESFT approach: A 62-year-old Dominican patient presented with hypertension. In the past two years, she had been seen by several physicians, had multiple tests to rule out any underlying etiology, and tried a variety of medications to control her blood pressure. Despite these efforts, her blood pressure remained poorly controlled. The patient, whose primary language was Spanish, had limited English skills but refused an interpreter at all clinic appointments. It appeared that the patient was non-adherent with taking the antihypertension medicine, taking it only periodically when she felt tense or stressed.

Further inquiry by the physician revealed that the patient was illiterate and did not understand the complex medication regimen she had been given.

The physician was able to explore the patient’s explanatory model for hypertension using the ESFT approach. The patient strongly believed that her hypertension was episodic and related to stress.

She didn’t take her daily antihypertension medication because it didn’t fit her explanatory model. The physician was able to reach a compromise by explaining that, although her blood pressure goes up during stressful times, her arteries are under stress all the time, even though she didn’t feel it.

Taking medications daily would relieve the arterial stress but would not help with her

emotionally stressful episodes. The physician was able to negotiate with the patient to add relaxation techniques to her daily routine.

12%

OF THE ADULT POPULATION HAS THE SKILLS TO NAVIGATE AND UNDERSTAND OUR COMPLEX HEALTH SYSTEMS— SKILLS REDUCED BY STRESS AND ILLNESS.

Health Literacy The Doctors Company supports the Agency for Healthcare Research and Quality (AHRQ) interventions to reduce the complexity of healthcare, increase patient understanding of health information, and enhance support for patients of all health literacy levels.

Studies have shown that people from all age, race, income, and education levels are challenged by an inability to obtain, process, and understand basic health information and services needed to make appropriate health decisions and to follow instructions for treatment. AHRQ has found that only 12 percent of the adult population has the skills to navigate and understand our complex health systems— skills reduced by stress and illness. We encourage you to explore the AHRQ Health Literacy Universal Precautions Toolkit.

(CONTINUED ON PAGE 26)

SEPTEMBER / OCTOBER 2019 |

michigan MEDICINE® 25

Challenges of Cultural Diversity in Healthcare: Protecting Your Patients and Yourself (CONTINUED FROM PAGE 25)

Steps You Can Take

Explain to patients who refuse interpreter services that it is very important to the patient’s care and safety that you and the patient/family member understand each other. Suggest a referral to a physician who speaks the patient’s primary language. Be sure to document in the medical record the patient’s refusal and your explanation of the risks and benefits of an interpreter.

Evaluate any personal attitudes, beliefs, biases, and behaviors that may influence your care of patients.

Conduct a self-assessment: Cultural and Linguistic Competence Health Practitioner Assessment available from the Georgetown University National Center for Cultural Competence.

Use a communication model such as ESFT or LEARN: • Listen to the patient’s perception of the problem.

• Explain your perception of the problem.

• Acknowledge and discuss differences and similarities.

• Recommend treatment.

• Negotiate treatment.

Ask the patient or interpreter to repeat back what you said during the informed consent process, during the discussion of the treatment plan, or after any patient educational session with you or your staff. The repeat-back process is a very effective way to determine the extent of the patient’s understanding.

Use “Ask Me 3,” a tool that identifies three simple questions all physicians should be ready to answer—regardless of whether the patient asks. More information is available in our article, “Rx for Patient Safety: Ask Me 3,” and “Ask Me 3: Good Questions for Your Good Health” on the Institute for Healthcare Improvement’s website.

Use language services for your limited English proficiency (LEP) patients.

• Partner with your health plans and hospitals to identify written and oral language services.

• Find out your state requirements. In some states, Medicaid plans may call for providing language access.

26 michigan MEDICINE®

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Improve cultural competence: • Recognize that culture extends beyond skin color.

• Find out each patient’s cultural background.

• Determine your cultural effectiveness.

• Conduct culturally sensitive evaluations.

• Elicit patient expectations and preferences.

• Understand how your cultural identity affects your practice.

Obtain more information from these useful websites: • U.S. Department of Health and Human Services, Office of Minority Health, National Standards for Culturally and Linguistically Appropriate Services (CLAS) • U.S. Department of Health and Human Services, Think Cultural Health, A Physician’s Practical Guide to Culturally Competent Care • Agency for Healthcare Research and Quality, What Is Cultural and Linguistic Competence?

• Health Resources and Services Administration, Culture, Language, and Health Literacy Resources

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

Reprinted with permission. ©2019 The Doctors Company (thedoctors.com).

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TheHLP.com [284.996.8510] SEPTEMBER / OCTOBER 2019 |

michigan MEDICINE® 27

Educational Offerings MSMS On-Demand Webinars Webinars Offering CME: Balancing Pain Management and Prescription Medication Abuse: Chronic Pain and Addiction*

Webinars at No Cost to Members: Billing 101

CDL-Medical Examiner Course

Balancing Pain Management and Prescription Medication Abuse: Chronic Pain and Addiction*

Human Trafficking*

Claim Appeals

Medical Ethics – Conscientious Objection among Physicians*

Credentialing

Preparing for the Medicare Physician Value-Based Payment Modifier

Health Care Providers' Role in Screening and Counseling for Interpersonal and Domestic Violence: Dilemmas and Opportunities

Pain and Symptom Management Series*

HEDIS Best Practices

Opioid Town Hall (new in 2019) *

In Search of Joy in Practice: Innovations in Patient Centered Care

Pain and Opioid Management*

Legalities and Practicalities of HIT - Cyber Security: Issues and Liability Coverage

The CDC Guidelines* The Current Epidemic and Standards of Care* Treatment of Opioid Dependence* The Role of the Laboratory in Toxicology and Drug Testing*

Coding and Billing Webinars: Access to Medicare Changes to E&M Codes for 2019 and other Coding Updates Billing 101 Claim Appeals Complete Coding Updates for 2018 Credentialing Managing Accounts Receivable Reading Remittance Advice Tips and Tricks on Working Rejections

Legalities and Practicalities of HIT - Engaging Patients on Their Own Turf: Using Websites and Social Media MAPS Update and Opportunities* Michigan Automated Prescription System Update* Reading Remittance Advice Section 1557: Anti-Discrimination Obligations Sexual Misconduct – Prevention and Reporting (new in 2019) Update on Chronic Fatigue Syndrome Part 1: Clinical Diagnostic Criteria for Chronic Fatigue Syndrome/CFS now called Myalgic Encephalomyelitis or ME/CFS (new in 2019) Update on Chronic Fatigue Syndrome Part 2: Uniting Compassion, Attention and Innovation to treat ME/CFS (new in 2019) Prescribing Legislation* Tips and Tricks on Working Rejections *Fulfills Board of Medicine Requirement.

Visit msms.org/OnDemand for the complete listing of On-Demand Webinars.

28 michigan MEDICINE®

| SEPTEMBER / OCTOBER 2019

MSMS Board of Directors Disclosures Upcoming Educational Conferences 2019 MSMS Annual Scientific Meeting Morning, afternoon and evening clinical courses available.

Date: Tuesday, October 22 - Saturday, October 26 Location: Sheraton Detroit Novi Hotel, Novi

House of Delegates Resolution 25-13 states that: “MSMS annually provide Michigan physicians with a list of all officers, officials, candidates and staff who receive money as salary or non-patient care compensation from Blue Cross Blue Shield of Michigan (BCBSM) or any other insurer, medical product company or its affiliates annually in Michigan Medicine.”

Following are the disclosures of the MSMS Board of Directors, officers and staff.

Sameen Ansari – None

Intended for: Physicians and all other health care professionals

Mohammed A. Arsiwala, MD – None

Register: Online at msms.org/eo

Anita R. Avery, MD*

Contact: Marianne Ben-Hamza 517/336-7581 or mbenhamza@msms.org

A Day of Board of Medicine Renewal Requirements Date: Friday, November 1

Robert H. Blotter, MD – None Paul D. Bozyk, MD – None T. Jann Caison-Sorey, MD, MSA, MBA – Medical Director, Chronic Conditions and Care Transitions to Home Programs, BCBSM Adrian J. Christie, MD – None Betty S. Chu, MD, MBA – None Sandro K. Cinti, MD – None Talat Danish, MD, MPH, FAAP*

Location: Holiday Inn, Ann Arbor

James M. Feeley, MD*

Intended for: Physicians and all other health care professionals.

Amit Ghose, MD – None

Register: Online at msms.org/eo Contact: Beth Elliott at 517/336-5789 or belliott@msms.org

James D. Grant, MD* Theodore B. Jones, MD – None Larry R. Junck, MD – None Mark C. Komorowski, MD – None Nita M. Kulkarni, MD – None

23rd Annual Conference on Bioethics Date: Saturday, November 2

P. Dileep Kumar, MD – None Samuel J. Mackenzie, MD, PhD – None Mark E. Meyer, MD – None

Location: Holiday Inn, Ann Arbor

S. “Bobby” Mukkamala, MD – None

Intended for: Physicians, bioethicists, residents, students, other health care

Donald R. Peven, MD – None

professionals, and all individuals interested in bioethical issues.

Michael J. Redinger, MD – None Richard C. Schultz, MD – None

Register: Online at msms.org/eo

John J. H. Schwarz, MD – None

Contact: Beth Elliott at 517/336-5789 or belliott@msms.org.

Herbert C. Smitherman, Jr., MD, MPH*

REGISTER TODAY! Register online at msms.org/eo

or call the MSMS Registrar at 517-336-7581.

James H. Sondheimer, MD – None F. Remington Sprague, MD – Board of Directors, BCBSM Brian R. Stork, MD – None J. Mark Tuthill, MD – None Thomas J. Veverka, MD – None John A. Waters, MD – None Phillip G. Wise, MD – None * Did not disclose by print deadline

ADVOCACY

Five Reasons to

BACK the PAC The Michigan Doctors’ Political Action Committee (MDPAC) builds and maintains strong relationships with lawmakers, as well as candidates running for political office.

As the face of physicians, MDPAC bring medical knowledge into

Activate your political voice!

The Michigan Doctors’ Political Action Committee (MDPAC) is the political arm of the Michigan State Medical Society.

It is a bipartisan political action committee made up of physicians, their families, residents, medical students and others interested in making a positive contribution to the medical profession through the political process. MDPAC supports pro-medicine candidates running for political office in Michigan.

Physician engagement is essential to the success of a pro-medicine legislature. Current and potential lawmakers want and need to hear from professionals in the field of medicine. Through MDPAC, you will activate your voice on the things most important to Michigan physicians.

discussions with political decision makers.

For more than three decades, MDPAC has mounted successful lobbying efforts on behalf of physicians.

For example... MDPAC protects and strengthens tort reform, stopped the physician’s tax, and has

helped to stop the expansion of a non-physician’s scope of practice.

MDPAC has power, prestige and respect! If you wake your sleeping giant, MDPAC could make rapid, positive change for physicians and patients. It could ease administrative pressures with the current prior authorization process, save you money

and time on your Maintenance of Certification, and advance public health issues.

Trial lawyers, insurance companies, and other political opponents raise massive sums of money.

Medicine’s friends, through MDPAC, must dig deeper to raise equivalent or greater amounts of funds to advance Michigan

physician’s agenda.

Get started today at MDPAC.org

The current political landscape is uncertain.

Only through a well-funded, unified voice will physicians and their patients’ interests be heard.

MDPAC is that voice.

Get your voice heard by contributing today at MDPAC.org

16 michigan MEDICINE

30 michigan MEDICINE®

| JULY / AUGUST 2017

| SEPTEMBER / OCTOBER 2019

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