contents
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helping patients take charge of their chronic illnesses: Partnering in self-management within our communities through living healthy workshops
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WCPM update
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madness in greek tragedy fast forwarded to the 21st century
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the battle for what’s right for our patients
WAKE COUNTY PHYSICIAN | 1
contributors
WCPM
January 2015
Publisher Wake County Medical Society Editor Paul Harrison Wake County Medical Society Officers and Executive Council
2015 President | Andrew Wu, MD Secretary | Robert Munt, MD Treasurer | Robert Munt, MD Past President | Patty Pearce, MD Founding Editor | Assad Meymandi, MD, PhD, DLFAPA
Council Terry Brenneman, MD Members Maggie Burkhead, MD Warner L. Hall, MD Ken Holt, MD Assad Meymandi, MD, PhD, DLFAPA Robert Munt, MD Patricia Pearce, MD Derek Schroder, MD Michael Thomas, MD Brad Wasserman, MD Andrew Wu, MD WCMS Barb Savage Alliance Karen Albright CoPresidents
L. Jarrett Barnhill, MD
is a professor of Psychiatry at the UNC School of Medicine and the director of the Developmental Neuropharmacology Clinic within the Department of Psychiatry. He is a Distinguished Fellow in the American Psychiatric Association and Fellow in the American Academy of Child and Adolescent Psychiatry.
Barbara Beirne James, MSW
Barbara Beirne James graduated from East Carolina University with her Masters in Social Work. Barbara currently serves as a Living Healthy Coordinator for Community Care of Wake and Johnston Counties. In her role, Barbara leads efforts to expand the Living Healthy program which is a series of evidence-based workshops that focus on chronic disease, diabetes, and chronic pain self-management.
Robert W. Seligson
Wake County Medical Society 2500 Blue Ridge Road, Suite 330 Raleigh, NC 27607 Phone: 919.792.3644 Fax: 919.510.9162 dearp@wakedocs.org www.wakedocs.org
“The Wake County Physician Magazine is an instrument of the Wake County Medical Society; however, the views expressed are not necessarily the opinion of the Editorial Board or the Society.� 2 | JANUARY 2015
For the last 20 years, Robert W. Seligson has served as Executive Vice President, CEO of the North Carolina Medical Society, the largest and oldest professional association in the state, representing nearly 13,000 physicians and physician assistants throughout North Carolina. He also serves as CEO of the North Carolina Medical Society Foundation, the philanthropic arm of the Medical Society.
Wake County Physician Magazine (WCPM) is a publication for and by the members of the Wake County Medical Society. WCPM is a quarterly publication and is digitately published January, July, April, and October. All submissions including ads, bio’s, photo’s and camera ready art work for the WCPM should be directed to: Tina Frost Graphic Editor WCPM tina@tinafrost.com 919.671.3963
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he Wake County Medical Society is inviting its members to write articles for upcoming issues of the Wake County Physician Magazine. Wake County Medical Society members wishing to write an article for publication are asked to submit a brief five sentence proposal. Proposed article summaries could focus on your first person accounts of the personal side of practicing medicine (e.g., a patient overcoming all odds and achieving a positive outcome, experience with grief/ overcoming grief, your best day practicing medicine, or care management success stories, etc.) or any other human interest story that might appeal to our readership- keeping in mind that anything resembling promotion of a current practice or practitioner, or taking a political stance would not be useable, with the final say on such matters resting with the editorial board. Please email your brief proposal to Paul Harrison, editor, by March 1, 2015 at pharrison@ wakedocs.org. The plan is to begin publishing member articles in the January 2015 issue, which will be posted on our website. Thanks!”
Photographs or illustrations: Submit as high resolution 5” x 7” or 8” x 10” glossy prints or a digital JPEG or TIF file at 300 DPI no larger than 2” x 3” unless the artwork is for the cover. Please include names of individuals or subject matter for each image submitted. Contributing author bio’s and photo requirements: Submit a recent 3” x 5” or 5” x 7” black and white or color photo (snapshots are suitable) along with your submission for publication or a digital JPEG or TIF file at 300 DPI no larger than 2” x 3”. All photos will be returned to the author. Include a brief bio along with your practice name, specialty, special honors or any positions on boards, etc. Please limit the length of your bio to 3 or 4 lines. Ad Rates and Specifications: Full Page $800 1/2 Page $400 1/4 Page $200
WAKE COUNTY PHYSICIAN | 3
Helping patients take charge of their chronic illnesses: Partnering in self-management within our communities through Living Healthy workshops
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By Barbara Beirne James, MSW
hronic disease can take a serious toll on people’s lives. Symptoms such as pain, physical limitations, and poor emotional health can compromise the quality of daily life. It can be challenging for individuals suffering from one or more chronic diseases to follow through on recommendations for basic lifestyle changes. In addition to the healthcare that individuals living with chronic conditions receive from their medical provider, effective chronic disease management
involves people and caregivers who perform consistent actions such as taking medication on time, regularly checking blood pressure and blood glucose levels, eating right, and engaging in physical activity. While individuals make decisions and engage in behaviors that affect their health, research shows that they differ greatly in their level of skill and confidence of being able to do so. Dr. Kate Lorig and her team at Stanford University’s School of Medicine Patient
Education Center have proven that individuals can be prepared to take a greater role in managing their health by involving them in efforts to increase knowledge, skills, and confidence to manage their chronic conditions. Stanford University’s School of Medicine offers evidence-based selfmanagement programs that include the Living Healthy Chronic Disease Self-Management Program (CDSMP), Diabetes SelfManagement Program (DSMP), Chronic Pain SelfManagement Program [continued on page 11]
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Amy Wood Pasquini, Development Director, Our State Magazine, was the speaker at the Wake County Medical Society 2015 annual dinner on December 4, 2014. Eighty five members and guests were present to hear Amy’s entertaining and humorous talk about her 17 years delightful experience with Our State Magazine. Amy is also the Executive Producer of Content for “Our State,” a tentime, Emmy Award winning, television show produced by UNC-TV. She is the producer of many Our State travel weekends including the Best of Our State and Learn & Live Weekends. Born in Atlanta, Wood grew up in North Carolina. She obtained her BA in journalism from Georgia State University. She is the author of two books “Life Between Azalea Festivals,” and “White Bred, A Prodigal Jaunt Through the Suburban South” in addition to many articles for Our State. She lives in High Point with her husband John Pasquini where they enjoy sampling pimento cheese recipes from around the state. Amy concluded her talk by singing the Butter Bean Song, along with heartfelt audience participation.
Andrew Wu, MD, WCMS 2015 president and Amy Wood Pasquini, Development Director, Our State Magazine
Andrew Wu, MD, and a radiologist with Wake Radiology was sworn in as the 2015 Wake County Medical Society President at the November 11, 2014 WCMS Executive Council meeting, by outgoing WCMS President Patty Pearce, MD. Dr. Wu presented Dr. Pearce with a plaque to recognize her year of leadership with the Society. Dr. Wu expressed the desire to increase the relevance of the Society to its members by establishing and developing an effective legislative committee whose primary goal would focus on advocacy on behalf of the Wake County Physician community. Andrew Wu, MD, incoming WCMS 2015 President thanks Patty Pearce, MD, outgoing WCMS 2012 WCMS President WAKE COUNTY PHYSICIAN | 5
Madness in Greek Tragedy Fast Forwarded to the 21st Century By L. Jarrett Barnhill, MD
M
adness as expressed in ancient literature does not rise to DSM-5 or ICD-10 standards. Even though the beliefs and behaviors of many characters in Greek tragedies seem very odd, it is presumptuous to assume that we can reliably diagnose mental illness. After all these characterizations were never intended as biographies or psychiatric case studies. Yet we can glean insights into issues that continue to plague modern humanity. But in the long run, there may be more in their art than clinical acumen. To paraphrase Hamlet: there is more in a creative work than is dreamt in our nosology. . In our limited sample of Greek tragedy, we observed the juxtaposition of folk beliefs, mythology, social values and ancient ideals of the Homeric warrior class and the effects of culture change. The emergence of Hippocratic medicine/philosophy breathed new life into this process. The Hippocratics tried to disentangle medical disorders from folk beliefs and supernatural causes. They introduced empiricism and rational materialism into medical philosophy. Yet their ideas ran counter to most beliefs and practices of “men and women on the street�. Today their ideas about balance of humors and heat flow to the brain in mental disorders sound anachronistic especially. But metaphorically, this line of reasoning loosely parallels some of our ideas about imbalances in neurotransmitter networks, [continued on page 11]
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The Battle for What’s Right for Our Patients By Robert W. Seligson
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L
ooking over the annals of human history, it is undeniatten in the dustbin of human history. In down the custo Now that the 2014 mid-term elections are behind us and we are looking ahead to the North Carolina legislative longsession, one thing is clear –physicians and physician assistants in this state need to stand together to do what’s right when it comes to caring for North Carolina’s most vulnerable patients. We are bracing for a political battle as the General Assembly debates which path to take to reform North Carolina’s Medicaid program. Many in the legislature believe the best approach is to contract with outside corporate managed care companies to run North Carolina Medicaid. The North Carolina Medical Society (NCMS) favors an alternative that puts doctors – not corporations – in the driver’s seat when it comes for caring for their patients. For nearly two years, since Governor McCrory first solicited input from all stakeholders on the best way to reform the system, the NCMS has consistently and forcefully offered alternatives that are value based and physician led. Fortunately, through our ongoing discussions with key stakeholders, over the past two years, some in the legislature, the Governor and his administration have come to see that the model we endorse is more likely to
promote true reform of the health care system, lower costs, improve quality and, most importantly, put patient care where it belongs – in the hands of the clinicians. Why is this such an urgent and important issue? If you see Medicaid patients in North Carolina – and admirably, 87 percent of North Carolina physicians do – your reimbursement rates may have been reduced by up to 4 percent starting this month (January 2015). This rate reduction is the result of a budget passed by our General Assembly in response to a Medicaid program that they perceived as “broken.” We agree that the system needs reform, but certainly not on the backs of physicians or, more critically, by potentially reducing access to care for our citizens. With so many new regulatory and financial hurdles facing physicians these days, rate reductions bring them closer to the tipping point beyond which they will not be able to accept more Medicaid patients. With talk of expanding Medicaid at some time in the future, the state needs to work with physicians to ensure adequate coverage and listen to what doctors think would best serve their patients. The NCMS has been working on many fronts to inform those in the health care community as well as policymakers about the physician-led accountable care initiatives currently underway throughout
North Carolina. The Toward Accountable Care Consortium and Initiative, under the auspices of the NCMS, has nearly 40 members and has produced 16 toolkits thus far that serve as resources for primary care and specialty physicians on what Accountable Care may mean for them. Back in March 2013, we submitted our response to the state’s request for information. You may read that original document on our website (www. ncmedsoc.org).The NCMS has helped convince the NC Department of Health and Human Services that this accountable approach is financially sustainable, addresses the needs of the “whole person,” through care collaboration and promotes better health outcomes for lower cost. Our goals have always been similar, only the method of achieving them has differed. One needs only look at successful ACOs throughout our state – Cornerstone Health Care in High Point, Wilmington Health, Triad Health Care Network in Greensboro, Coastal Carolina in New Bern, to name a few – to see that physicians are gaining experience with this type of care, and seeing initial success. The infrastructure already exists through these ACOs and the Community Care of North Carolina networks, making it an easier [continued on page 12]
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Healthy living continued from page 4]
(CPSMP), and Tomando Control de su Salud (CDSMP in Spanish). These workshops assist participants to build skills that break the symptom cycle in management of multiple chronic illnesses. They are designed to help participants gain confidence, self-efficacy, and skills to better manage their chronic conditions and lead happier and healthier lives. Topics include nutrition, exercise, communication, decision making, problem solving, and action planning which contribute towards healthy behavioral change. Selfmanagement coaches participants to become full members of their healthcare team by empowering them to take an active role in managing their chronic illnesses. These programs help participants make lifestyle choices and changes, adhere to prescribed medical treatments, and become 10 | JANUARY 2015
educated, responsible and informed patients. Living Healthy workshops are small, highly interactive groups that encourage interaction, mutual problemsolving, and support for participants. Each workshop is a series of six-week long classes that meet once each week for 2 ½ hours and are facilitated by a pair of leaders, one or both of whom are non-health professionals with a chronic disease themselves. Research has demonstrated the positive impact of these programs on self-reported symptoms of fatigue, depression, physical activity, communication with physician, self-efficacy for self-management, and use of hospital, emergency department (ED) and office visit services. According to the Stanford research, improvements in symptoms, behaviors, health and utilization have been shown to persist up to two years after workshop completion (1). Feedback from participants who took these workshops support the research findings evidenced by the following testimonials: • “They taught us to focus on what we can do and not on what we can’t do.” • “The pain doesn’t go away, but you learn to manage the pain instead of the pain managing you.” • “Now I can work better with my doctor to manage
my symptoms.” • “I know the things to do, this helps my motivation to get it done.” • “The progress is due to the positive class support.” For the last three years, Community Care of Wake and Johnston Counties (CCWJC) has been dedicated to making selfmanagement an integral part of health within its communities and a priority health care outcome. CCWJC offers Living Healthy workshops, free of charge to participants, through a collaboration of community partnerships and in a variety of settings in Wake and Johnston counties. For more information regarding Living Healthy workshops or to offer a workshop at your practice or in your community, please visit our website at (http:// www.ccwjc.com/living_ healthy.asp) or contact us directly: • Barbara Beirne James – bjames@wakedocs.org, (919) 819-6862 • Travis Battle - tbattle@ wakedocs.org, (919) 3026228 § References: (1) Ory MG, Ahn SN, Jiang L, Lorig K, Ritter P, Laurent DL, Whitelaw N, Smith ML: National Study of Chronic Disease Self-Management: Six Month Outcome Findings. J Aging Health: 2013, 25:1258.
Madness from Greek Tragedy continued from page 6]
epigenetics and models of etiology. One effect of culture change involves the generation of cognitive dissonances (conflicting beliefs and values). In the Athens of the 5th century BCE, there were cognitive dissonances about the roles of supernatural agents (gods), free will, and fate. The poet/ playwrights used these dissonances to create plots that involved irresolvable conflicts between the demands of the polis (city-state) and family. Nietzsche provided another- the balances between Apollonian reason and Dionysian passions. Although the later Socratics emphasized self-knowledge, few tragic characters seem focused on self-reflection and analysis. We know nothing of Ajax as a child but are aware of his obsessive need to avenge his humiliation. By modern standards, this level of humiliation and loss of status might be sufficient to trigger severe depression complete with a mocking, deprecatory hallucinations (the goddess Athena). For us, his suicide is linked to this mental state, especially his collapse into deeply engrained beliefs in a warrior code that
preached about suicide as an honorable death over living in shame. But can we reliably diagnose Ajax? Does his suicide resemble that associated with the bushido code among Samurai warriors that persisted among soldiers through World War II? Our means of clinical diagnoses rely upon a different set of cultural values that do not routinely accept suicide as a means of saving face. For many of us the Athenian perspective requires suspending our belief system. Oedipus was a man of reason who confidently tried to escape fate. Yet it was his blindness to real sense of self and the limits of reason that lead to his demise. Modern readers wonder why Oedipus couldn’t connect the dots. After all he was a riddle-solver. The real question for us is “what did Oedipus know and when did he know it”? It seems that reason clouded his awareness that he was the unknown perpetrator of several heinous crimes. Once he learned of his patricide, he knew its consequences -the Furies would drive him mad. Freud argued that his incestuous relationship with his mother that drove Oedipus to blind himself
(symbolic castration). But for a Greek audience the pledge to destroy the man who caused of the plague sealed his fate. The trigger event for the plague was the rash action of Oedipus. He murdered his father Laius; married his mother and begat his halfsiblings. His incest was an outgrowth of incomplete about his origins and who he really was. But the Furies punished patricide, not incest. Yet Oedipus collapsed when he lost his most valued asset: his identity as a rational man who was supremely capable as a leader. Thus his motives were mixed. Today we ask how his blindness provide new and deeper insights or can what we don’t know harm us. Medea is no easier. A modern Forensic assessment might focus the facts: she was an abandoned wife and distraught and desperate mother who murdered her children. A careful reading of the play tells us there was more than madness in this tragedy. To an Athenian audience, Medea was a marginalized, husbandless, barbarian woman living in their profoundly xenophobic, exclusivist, misogynous society. She [continued on page 12]
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The Battle continued from page 9]
transition than superimposing an outside
entity to care for Medicaid patients. Because of our strong advocacy for the accountable care model of reform, we have powerful allies as we enter the long-session. We will need to educate new legislators and reinforce our message with those who still believe that handing the system over to outside companies is an easy solution to financial predictability. We need your voice and your support in our upcoming battle on behalf of your patients and our state’s most vulnerable citizens. Please join the nearly 13,000 other physicians and physician assistants who are members of the NCMS to make sure your voice is heard when legislators are making the decisions that will affect your patients and your livelihood. The NCMS has a proven track record of success – witness our tort reform victory in 2011. Over the course of our 164-year history we have always stood for the health of our patients and the state of North Carolina. Please join us at this crucial time to preserve what is best for our citizens. § Madness from Greek Tragedy continued from page 11]
defied Greek sex role stereotypes by acting as a Homeric warrior. By play’s end Euripides throws another curve ball- Medea’s escape as a goddess (deus ex machina). To understand this shocker, we need to explore Euripides portrayals of the gods. They were in part manifestations of natural forces and human passions. Some critics suggest that Medea was also a pre-Olympian- an ancient mother/ earth goddess who demanded child sacrifice in order to insure fertility and successful crops. Others link Medea to the Peloponnesian War, making her brutality a powerful reminder of ruthless passions and unrestrained fury of warfare. War resulted in the sacrifice of thousands of sons to another goddess- honor and glory. So who is mad? In our world we define madness in terms of measurable, quantifiable, statistically analyzable clinical syndromes. But poets 12 | JANUARY 2015
create tragic characters that cannot be reduced in this fashion. Historically, Greek philosophy blended dialogue with music in a combination that infused with reason and a search for self-knowledge (Apollonian) contrasted with passion and loss of self in a way that defies verbal description (Dionysian). Today modern authors still struggle with the limitation of words as a means of evoking deeper emotional experiences. Our awareness of this shortcoming threatens the very nature of literature as a mode of self-expression. Today we would attempt to answer these questions by consulting scientists to explain both the disorders and acts of creation. We are vexed by poets who still struggle with the voice inside the whirlwind. Perhaps this irresolvable conundrum explains the longevity of drama and keeps psychoanalysts busy. §
The Wake County Medical Society (WCMS) is a 501 (c) 6 nonprofit organization that serves the licensed physicians and physician assistants of Wake County. Chartered in 1903 by the North Carolina Medical Society.
CURRENT PROGRAMS Project Access - A physician-led volunteer medical specialty service program for the poor, uninsured men, women, and children of Wake County. Community Care of Wake and Johnston Counties CCWJC has created private and public partnerships to improve performance with disease management initiatives such as asthma and diabetes for ACCESS Medicaid recipients. CapitalCare Collaborative - The CCC program is a membership of safety net providers working corroboratively to develop initiatives to improve the health of the region’s medically underserved such as asthma and diabetes for Medicaid and Medicare recipients.
Become a Member of Wake County Medical Society and help support the indigent care and community service programs of the Society. WHY JOIN
BENEFITS OF MEMBERSHIP
Membership in the Wake County Medical Society is one of the most important and effective ways for physicians, collectively, to be part of the solution to our many health care challenges. A strong, vibrant Society will always have the ear of legislators because they respect the fact that doctors are uniquely qualified to help form health policies that work as intended. It’s heartening to know the vast majority of Wake County physicians, more than 700 to date, have chosen to become members of the Wake County Medical Society.
HOW TO JOIN To become a member of the Wake County Medical Society contact Deborah Earp, Membership Manager at dearp@ wakedocs.org or by phone at 919.792.3644 A portion of your dues supports to the volunteer and service programs of WCMS. Membership is also available for PA’s. There is even an opportunity for your spouse to get involved by joining the Wake County Medical Society Alliance.
WCMS MISSION To serve and represent the interests of our physicians; to promote the health of all people in Wake County; and to uphold the highest ethical practice of medicine.
Service Programs - The spirit of volunteerism is strong in Wake County. Hundreds of local physicians volunteer to help our indigent. The Society coordinates several programs that allow low income individuals access to volunteer doctors and to special case management services for children with diabetes, sickle cell anemia or asthma. Publications - Members receive the peerreviewed The Wake County Physician Magazine four times a year, and we keep you informed regularly via pertinent emails. The magazine focuses on local health care issues in Wake County, the Wake County Medical Society and the WCMS Alliance, a companion organization composed of physician spouses and significant others. Socializing with your physician colleagues - Many physicians feel too busy to do anything except work long hours caring for patients. But, the WCMS provides an opportunity for physicians to nourish relationships through social interaction with one another at our dinner meetings featuring prominent speakers and at other events. Finally, joining the WCMS is plain and simple the right thing to do - Physicians and the community benefit from our membership and our leadership in local affairs.
JOIN TODAY!
Are you interested in becoming a Wake County Medical Society member? Simply visit our website at www.wakedocs.org and complete the online application or contact us by phone at 919.792.3644.
A portion of your dues joining the Wake County contributes to the volunteer Medical Society Alliance. and service programs of WCMS. Membership is also available for PA’s. There is even an opportunity for your spouse to get involved by
JOIN TODAY!