Texas Family Physician, Q1 2018 by Texas Academy of Family Physicians

TEXAS FAMILY PHYSICIAN VOL. 69 NO. 1 2018

MATERNAL MORTALITY IN TEXAS Searching For Answers In The Data

PLUS: Chagas Disease Annual Session Highlights Failure To Diagnose Melanoma: Closed Claim Study

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INSIDE

TEXAS FAMILY PHYSICIAN VOL. 69 NO. 1 2018

Maternal mortality and morbidity in Texas

Since a report published in late 2016 showed Texas led the nation in a stark increase in maternal mortality, the health care community has been scrambling to understand what the data means and how we can solve the crisis. By Perdita Henry

Chagas disease on our doorstep

Most kissing bugs in Texas carry the parasite that causes Chagas disease. A member of TAFPâ&#x20AC;&#x2122;s Commission on Public Health, Clinical Affairs, and Research tells you what you need to know.

6 FROM YOUR PRESIDENT Something to chew on 8 AAFP NEWS Survey says FPs are warming up to value-based payment models. 9 PRACTICE MANAGEMENT New tools help you with MIPS. 10 MEMBER NEWS Plano network achieves URAC accreditation | Siy takes office at TCMS | San Antonio FP joins ACGME panel | TAFP officer wins seat on AAFP commission | Salud Sin Fronteras receives AAFP grant

By James A. Mobley, MD, MPH

12 YOUR ACADEMY Highlights from Annual Session

17 PUBLIC HEALTH Walk With a Doc

Failure to diagnose melanoma

The experts at TMLT are back again to help you brush up on your risk management strategies with a case study involving a family physician.

By TMLT Risk Management Department

30 PERSPECTIVE Tips for new FPs

Get CE today. Put it into practice tomorrow. P H Y S I C I A N S. Get free CME on the

go with Texas Health Steps Online Provider Education. All courses can be accessed 24/7 from your computer or mobile device. Choose from a wide range of topics with direct relevance to your practice, including many courses with ethics credit. Learn more at txhealthsteps.com.

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TEEN CONSENT AND CONFIDENTIALITY Learn about legal requirements and best practices for providing health services to adolescents.

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IMMUNIZATION Apply current immunization schedules and counsel families about how they can protect their childrenâ&#x20AC;&#x2122;s health.

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Accredited by the Texas Medical Association, UTHSCSA Dental School Office of Continuing Dental Education, American Nurses Credentialing Center, National Commission for Health Education Credentialing, Texas State Board of Social Worker Examiners, Accreditation Council of Pharmacy Education, Texas Academy of Nutrition and Dietetics, Texas Academy of Audiology, and International Board of Lactation Consultant Examiners. Continuing Education for multiple disciplines will be provided for these events.

PRESIDENT’S COLUMN

TEXAS FAMILY PHYSICIAN VOL. 69 NO. 1 2018

The Texas Academy of Family Physicians is the premier membership organization dedicated to uniting the family doctors of Texas through advocacy, education, and member services, and empowering them to provide a medical home for patients of all ages. TEXAS FAMILY PHYSICIAN is published quarterly by TAFP at 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Contact TFP at (512) 329-8666 or jnelson@tafp.org. OFFICERS president

Janet Hurley, MD

president-elect vice president treasurer

Rebecca Hart, MD

Amer Shakil, MD, MBA

Javier D. “Jake” Margo, Jr., MD

parliamentarian

Mary Nguyen, MD

immediate past president

Tricia Elliott, MD

EDITORIAL STAFF managing editor

Jonathan L. Nelson

associate editors

Perdita Henry and Jean Klewitz chief executive officer and executive vice president

Tom Banning chief operating officer

Kathy McCarthy, CAE

advertising sales associate

Michael Conwell CONTRIBUTING EDITORS James A. Mobley, MD, MPH Alyssa Molina, MD David Sabgir, MD TMF Quality Innovation Network TMLT Risk Management Department

SUBSCRIPTIONS To subscribe to TEXAS FAMILY PHYSICIAN, write to TAFP Department of Communications, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Subscriptions are $20 per year. Articles published in TEXAS FAMILY PHYSICIAN represent the opinions of the authors and do not necessarily reflect the policy or views of the Texas Academy of Family Physicians. The editors reserve the right to review and to accept or reject commentary and advertising deemed inappropriate. Publication of an advertisement is not to be considered an endorsement by the Texas Academy of Family Physicians of the product or service involved. LEGISLATIVE ADVERTISING Articles in TEXAS FAMILY PHYSICIAN that mention TAFP’s position on state legislation are defined as “legislative advertising,” according to Texas Govt. Code Ann. §305.027. The person who contracts with the printer to publish the legislative advertising is Tom Banning, CEO, TAFP, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. © 2018 Texas Academy of Family Physicians POSTMASTER Send address changes to TEXAS FAMILY PHYSICIAN, 12012 Technology Blvd., Ste. 200, Austin, TX 78727. 6

TEXAS FAMILY PHYSICIAN [No. 1] 2018

Chewing on a big fat wad of gum By Janet Hurley, MD TAFP President changes in health care have been fast and furious in the last several years. The advent of MACRA created the need to prepare for MIPS and APMs, and more robustly report on quality and cost. There is an ongoing desire for interoperability and EMR modifications requiring more “clicks” than we would like. Many physicians have added new types of team members to their practices, such as social workers, nurse navigators, or care coordinators to reach out to patients in new creative ways. Some of this has been good for patients, and some of it possibly not. Some days it feels like physicians are chewing a big fat wad of gum, and feeling choked. Early in 2017, I took a new position in my health system as medical director of population health. One goal of this department is to use care team members in new, creative ways to meet the educational and social needs of our patients. While it might be ideal for the physician to spend 45 minutes with each patient, addressing medical needs and providing counseling about mammograms, colonoscopies, smoking cessation, diabetes, congestive heart failure, and many other things is not a practical reality for most practices. Trying to fit all of that into a 15 minute visit will snuff out the most important reasons the patient came to the clinic in the first place. It is hard to move from a former “lone ranger” type of practice style to a

team style, where some of these duties are delegated. Hiring these team members costs money, and payers have not been quick to offer per-member per-month support. Being accountable for these processes without financial support to change is choking the joy out of primary care practices across the country. My population health department was chin-deep in care coordination, nurse navigation, behavioral health integration, ACO quality monitoring, cost monitoring, transition-of-care processes, value-based payer contracting, and other things when I took the position. Yet due to recent acquisitions made possible by a strategic partnership with a larger health system, our provider numbers doubled and our geographic footprint in our region tripled. We are now challenged to transition our population health processes to many other clinics, some of which have limited — if any — care coordination or nurse navigation processes, and have never measured quality nor been held accountable for quality or cost metrics. For me, that task is daunting. Our team has followed several strategies to improve this process.

Hiring these team members costs money, and payers have not been quick to offer per-member permonth support. Being accountable for these processes without financial support to change is choking the joy out of primary care practices across the country.

1. Educate. Educate. Educate. Provider education about the “why” of population health is essential for buy-in, and to reducing the risk that they will feel threatened.

TURN 15 MINUTES OF WAITING ROOM TIME INTO $170 OR MORE! THEO is a Wellness Screening for Every Medicare Pa�ent! THEO is a Prac�ce Management Tool for Medicare’s Annual Wellness Visit. It is the most eﬀec�ve way to perform a wellness screening, iden�fy gaps in preventa�ve services and bill for the Medicare Annual Wellness Visit. 2. Start small and celebrate wins. This is particularly true when our population health nurses help a patient with a social determinant of health. Often physicians feel frustrated when they are held accountable for poor quality outcomes on a non-compliant patient. We all win if our nurses help to identify the social problem and meet the need, so the patient can enjoy better health. 3. Leverage IT solutions whenever possible. Our organization has embedded clinical decision support tools into our EMR to make it easier for providers to do the right thing. This same EMR enables us to have high-quality, robust reporting tools to provide accurate and timely feedback to physicians. How can a small practice achieve these same goals without the financial benefits of a health system? One way is to start small and code smart. I heard a solo family physician tell a story about adding a social worker to her practice. The social worker covered her own salary by doing Medicare annual wellness visits and chronic care management billing. The social worker not only assisted with the social needs of these patients, but also could call patients with routine health reminders, or provide valuable counseling services for patients who simply needed a listening ear. The overall net financial cost was low, the patients were healthier, and the doctor was happier. This is one strategy to improve quality and reduce cost. Perhaps other practices could benefit from this small step toward helping their patients. Either way, health care in America is changing. As we transform our practices, patients will see the benefits. Doctors may even achieve and maintain high levels of joy in their practice. The task is daunting, yet we do not have to do it all at once. As with any large monstrous process, we must “chew” a small bit of it at a time.

BENEFITS OF THEO:

HOW THEO WORKS:

• Finds hidden risks

• Provide the THEO assessment to all your regularly scheduled Medicare pa�ents via an iPad.

• Promotes HCC RAF Codes to physicians • Recommends addi�onal covered services,

procedures, treatments (all billable events)

• Data collected for clinical measures and MACRA quality metrics (MIPS, APM)

• Allows your Prac�ce to properly document

& bill for the Medicare Annual Wellness Visit (codes G0438/G0439)

• The Medicare pa�ent performs this self-assessment (takes 10-15 minutes) while they are wai�ng to see their physician. • Generates all required Medicare Documenta�on. No Staﬀ or Physician �me required. • On the same claim, Medicare is billed for oﬃce visit PLUS Annual Wellness Visit. (up to $170 reimbursement)

Call (214) 605-4262 for more informa�on and to receive a discount for being a member of TAFP.

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AAFP NEWS

COMING SOON ON TAFP’S

CME SCHEDULE C. Frank Webber Lectureship & Interim Session April 13-14, 2018 Renaissance Austin Hotel Austin, Texas Texas Family Medicine Symposium June 8-10, 2018 La Cantera Hill Country Resort & Spa San Antonio, Texas Annual Session & Primary Care Summit Nov. 9-11, 2018 Nov. 7-8: Business meetings and preconference workshops

Sheraton Arlington Hotel and Arlington Convention Center Arlington, Texas 8

TEXAS FAMILY PHYSICIAN [No. 1] 2018

Study details growing acceptance of value-based payments among family physicians, but barriers still exist Follow up from 2015 study finds more family physicians transitioning into value-based payment models, but challenges remain By AAFP Staff fifty-four percent of family physicians indicate their practices participate in value-based payment models and half believe value-based payment models will encourage greater collaboration between primary care physicians and specialists. Those are among the key findings from a recent study on physician acceptance of value-based payment. The results are from a follow-up study conducted by AAFP and sponsored by Humana. The study found that more and more family physicians are embracing value-based payment models, which is reflected in IT, care coordination and other investments. According to the study, family physicians are: • Acknowledging a connection between quality and payment. Thirty-seven percent of value-based payments distributed within a family physician’s practice are based on achieving quality and/or outcome measures, an increase from 18 percent as reported in 2015. • Investing in care coordination as part of their approach to value-based payment models. Thirty-two percent of family physicians report that they provide ongoing care management/coordination services to all high-risk patients, an increase of 23 percent from 2015. » Forty-three percent cite hiring/hired care management and care coordinators, compared to 33 percent in 2015. • Earmarking more practice resources for value-based payment. Fifty-four percent of family physicians are in a practice that is updating or adding health IT infrastructure for data management and analysis to participate in value-based payment.

“Family physicians are doing the work to prepare for value-based care models,” said AAFP President Michael Munger, MD. “Our members are making changes at the practice level and making investments to prepare for the transition to value-based models that will support better care. However, major barriers still exist that are stifling progress. Among the most commonly noted are issues related to administrative burden like a lack of staff time, lack of standardization for reporting requirements and lack of data transparency. That’s why the AAFP is committed to working on administrative simplification for our members so they can focus more on caring for patients and less on dealing with paperwork. We appreciate Humana’s efforts to partner with us and support family physicians in this effort.” The same barriers to navigating and implementing value-based payment models that the AAFP and Humana identified two years ago are still prevalent: • Lack of staff time (90 percent). • Lack of transparency between payers and providers (78 percent). • Lack of standardization of performance measures (78 percent). • No uniform insurance company reports on performance (75 percent). Additionally, only 8 percent of family physicians agree with the statement “quality expectations are easy to meet in VBP models,” down from 13 percent in 2015. “The AAFP continues to be an invaluable partner in helping us listen to and better understand primary care physicians and the challenges they face,” said Roy A.

“The AAFP is committed to working on administrative simplification for our members so they can focus more on caring for patients and less on dealing with paperwork.” — Michael Munger, MD AAFP President

Remove the guesswork from MIPS with free online application By TMF Quality Innovation Network Beginning Jan. 1, 2018, clinicians who are eligible for the Merit-based Incentive Payment System can begin submitting their data to the Centers for Medicare and Medicaid Services for the MIPS 2017 performance year. CMS has contracted with TMF Health Quality Institute to help clinicians make a successful transition to MIPS. As part of this support, TMF offers clinicians free access to the TMF MIPS Toolbox, an online application for managing MIPS requirements, tracking progress and submitting data directly to CMS.

With the TMF MIPS Toolbox you can: Beveridge, MD, Humana’s chief medical officer. “While the study shows that more family physicians have adopted valuebased payments, there’s not much change in the way they see this model of care influencing what they care most about — their patients’ health, or their staffs’ morale and their practices’ performance.” He added that Humana is using these findings to create even greater urgency for its simplification efforts, including standardizing quality measures and reducing the number of them as well as increasing collaboration and transparency in sharing data and actionable insights. The 2017 Value-Based Payment Study was sent to 5,000 active members of the AAFP. A total of 482 surveys were returned, and 386 were evaluated after a screening process. As of September 30, 2017, Humana has 1.9 million individual Medicare Advantage members (out of 2.8 million total individual MA members) today who are cared for by approximately 51,500 primary care physicians, in more than 900 value-based relationships across 43 states and Puerto Rico. Humana has approximately 66 percent of Humana individual Medicare Advantage members in valuebased payment relationships. Humana’s total Medicare Advantage membership is approximately 3.3 million members, which includes members affiliated with providers in value-based and standard Medicare Advantage settings.

Choose measures to maximize MIPS scores. With the MIPS Toolbox, you can select performance measures for individual MIPS categories. Base score measures are preloaded in the application; other measures can be filtered by interest or specialty. You can create “what if” scenarios and estimate individual or group scores. Track progress. After identifying your measures, reporting period and submission method, you collect your performance data and enter numerators and denominators for each measure. For Improvement Activities and Advancing Care Information measures, you simply mark “complete” and “yes,” respectively. You can compare your performance to national benchmarks, calculate a projected final score, and track your progress through a user-friendly interactive dashboard. Submit data directly to CMS (optional). Clinicians can use the MIPS Toolbox to submit data for any MIPS-eligible measure. BizMed, which maintains the TMF MIPS Toolbox, has contracted with a national qualified registry to perform MIPS submissions to CMS. Clinicians who choose the full or partial participation option for MIPS in 2017 pay a $75 registry fee per eligible clinician. There is no registry fee for clinicians who choose the MIPS test option for 2017. Clinicians choosing the test option can submit Improvement Activities and/or Advancing Care Information measures; they cannot include quality measures in their submission.

Get started today Access your free TMF MIPS Toolbox account at www.bizmedtoolbox.com/TMF. Once you log in, online guides and “pro tips” will help you navigate the tool’s features and functionality. If you need assistance, your TMF quality improvement consultant is just a call, click or email away. • Submit a request for support form. • Call (844) 317-7609 or live chat with a consultant Monday through Friday, 8 a.m. - 5 p.m. CT. • Email QualityReporting@tmf.org (practices with 16 or more clinicians in Arkansas, Missouri, Oklahoma, Puerto Rico, and Texas). • Email QPP-SURS@tmf.org (practices with 15 or fewer clinicians in Arkansas, Colorado, Kansas, Louisiana, Mississippi, Missouri, Oklahoma, Puerto Rico, and Texas). For additional information and resources to support your transition to MIPS, visit https://www.tmf.org/qpp.

Source: AAFP Press Release, Nov. 29, 2017.

www.tafp.org

MEMBER NEWS Atlantic Health Partners Your flu & vaccine partner As you may know, Atlantic Health Partners is the nation’s leading vaccine buying group and works with many of our chapter members. Atlantic offers practices the most favorable terms for Sanofi and Seqirus flu products, and can help you best plan for flu season. In addition, Atlantic also offers our members the best pricing for the complete range of Sanofi and Merck vaccines, and provides these additional services: • Vaccine reimbursement support and advocacy • Incomparable and timely customer service • Medicare Part D Program so physicians can administer Shingles and Pertussis vaccines Joining Atlantic Health Partners will improve your ability to effectively and efficiently provide immunizations to your patients and strengthen your practice performance. We encourage you to contact Cindy or Jeff at (800) 741-2044 or info@atlantichealthpartners.com to see how your practice can benefit from their program.

✓ Frustrated by prior authorizations? ✓ Can’t verify insurance coverage for patients in your extendedhours practice?

Catalyst Health Network earns URAC accreditation in clinical integration plano-based catalyst health network has earned URAC accreditation in clinical integration. URAC is a leading independent accreditation body dedicated to helping health care organizations like Catalyst Health Network demonstrate a comprehensive commitment to quality care, improved processes, and better patient outcomes. “We are truly honored to not only receive the distinguished URAC accreditation in Clinical Integration, but also achieve a perfect score in the review process,” said TAFP member Christopher Crow, MD, president of Catalyst Health Network, in a December 2017 press statement. “We are extremely proud of our team and network for their dedication. This accreditation is a reflection of our commitment to transform the health and well-being of the communities we serve through the power of relationships.” Catalyst Health Network is only the fifth in the nation to earn URAC’s full accreditation in clinical integration. Catalyst is a clinically integrated network of primary

Siy named TCMS President The current TAFP Foundation President, Linda Siy, MD, has been installed as president of the Tarrant County Medical Society. Siy is also a past TAFP president and has served as chair of the TAFP Political Action Committee Board of Trustees.

If you are a Texas Medical Association member with a payer complaint, check out the

Nguyen appointed to AAFP commission

TMA HASSLE FACTOR LOG

Mary Nguyen, MD, was appointment to AAFP’s Commission on Membership and Member Services. She will serve a four-year term. She is TAFP’s current parliamentarian, she is a former president of the Alamo chapter of TAFP, and she has held the position of co-convener at AAFP’s National Conference of Constituency Leaders. Nguyen practices at Medina Valley Family Practice in Castroville where she frequently teaches and mentors medical students.

where you can file your grievance and help organized medicine build a case for action.

www.texmed.org/hassle 10

TEXAS FAMILY PHYSICIAN [No. 1] 2018

care physicians with 515 primary care providers, 140 office locations, 750,000 patients, and 70 care team members. The network is comprised solely of physician members and managed by StratiFi Health, a physician services and population health organization. According to the statement: “This accreditation allows Catalyst Health Network to continue striving to make a difference in patients’ lives, and the communities in which they serve by providing a path to reduced cost, improved experience and outcomes while building trust throughout the provider network.” “Accepting the responsibilities of becoming a clinically integrated organization, Catalyst Health Network shows it is committed to quality, coordinated services and care,” said URAC President and CEO Kylanne Green. “URAC is delighted to help Catalyst Health Network and others by providing them with an accreditation program that validates the quality of their services and helps them avoid regulatory concerns.”

Nadeau joins ACGME review committee Mark Nadeau, MD, of San Antonio, was appointed to the Accreditation Council for Graduate Medical Education’s Review Committee for Family Medicine. Nadeau is faculty at the University of Texas Health Science Center San Antonio and is a veteran of the U.S. Air Force.

Student-run clinic receives AAFP Foundation grant Salud Sin Fronteras, a student run free clinic in El Paso, was awarded over $24,000 from the AAFP Foundation. Charmaine Martin, MD, leads the clinic’s Longitudinal Primary Care Track, which is designed to provide valuable family medicine experience to medical students and expose them to the medically underserved community of migrant workers.

The Baylor Scott & White Scoliosis Center can help cure the suffering, embarrassment and worry that people living with scoliosis deal with every day. • Fellowship trained scoliosis surgeons • More than 4,000 surgeries performed • Cervical, thoracic and lumbar surgeries All services are not available at all locations. Physicians provide clinical services as members of the medical staff at one of Baylor Scott & White Health’s subsidiary, community or affiliated medical centers and do not provide clinical services as employees or agents of those medical centers, Baylor Health Care System, Scott & White Healthcare or Baylor Scott & White Health. ©2017 Baylor Scott & White Health. Scoliosis_89_2017 CE 11.17

Changing Scoliosis Care. For Life.®

MEMBER NEWS

Highlights from TAFP’s Annual Session • November 9-11, 2017 The committees, commissions and sections of the Texas Academy of Family Physicians met in Galveston and deliberated on many important items. Thanks to all the members who participated. Most commissions, committees and all sections are open to guests and meet twice a year at TAFP’s Interim and Annual Sessions. You can also request an appointment by submitting a “Make Your Mark” involvement form. Contact Juleah Williams at jwilliams@tafp.org with any questions. Here are a few of the highlights from the recent meeting. All the recommendations mentioned will be presented to the Board of Directors.

ADVOCATING FOR YOU AND YOUR PATIENTS The Commission on Health Care Services and Managed Care discussed the issue of measuring quality and made a recommendation that TAFP work within AAFP to encourage de-emphasizing linear models and move toward measurements that better reflect the complexity of family medicine. Richard Young, MD, demonstrated a new payment system he has designed called Sentire. An executive from Cigna discussed the company’s recent collaborative efforts to support primary care in valuebased contracts. The Commission on Legislative and Public Affairs discussed several legislative and policy topics including scope of practice, the state’s prescription drug monitoring program, the opioid crisis, telemedicine, free-standing emergency rooms, Medicaid physician payment rates, the 1115 Medicaid waiver and the likelihood of expanding Medicaid. They also discussed the current economic and political environment in Texas and what that means for the kinds of policies TAFP should pursue leading up to the 2019 Texas Legislature. TAFP will survey members on various legislative issues including acceptable trade-offs for Medicaid reforms. TAFP’s Political Action Committee was very active during Annual Session to raise money before the 2018 election cycle. TAFPPAC is a non-partisan political action committee that supports candidates 12

who demonstrate concern for issues important to family physicians and their patients. Board members made personal appeals to colleagues during the meeting and they secured 28 new donors — a record for TAFPPAC! WORKFORCE DEVELOPMENT The Board of Directors and the Commission on Academic Affairs watched a demonstration of a new practice management e-learning curriculum the Academy is developing. The online modules will be available for Texas residency programs to use to fulfill part of their ACGME practice management requirements. TAFP plans to launch the final version of the first three modules in April during Interim Session. The Commission on Academic Affairs discussed the Texas Family Medicine Preceptorship Program. State funding for the program was restored in 2016 for administration of the program and stipends for students. The number of preceptorships increased in the last two years and the commission members proposed ideas to improve the program going forward. The goal of the program is to provide an opportunity for first- and second-year medical students to experience family medicine outside the academic health center. Practicing physicians are needed to volunteer to serve as preceptors and medical students are encouraged to apply for the program. Generous stipends are available for students.

TEXAS FAMILY PHYSICIAN [No. 1] 2018

More than 40 students and 30 residents participated in the Resident and Student Track held on Saturday, November 11 to learn about medical malpractice, physician wellness, and caring for the underserved. Students participated in resident-lead procedure stations. TAFP also held a point-of-care ultrasound course just for residents on Friday, November 10.

that status since 1996. Staff and volunteers collaborate to plan and produce education for members and ensure compliance with all requirements. At Annual Session, the Commission on Continuing Professional Development and the CME Planning Committee worked on future educational offerings and discussed ABFM’s Maintenance of Certification.

MEMBER SERVICES AND RESOURCES IN DEVELOPMENT

PUBLIC HEALTH AND RESEARCH

The Section on Maternity Care and Rural Physicians discussed implementation of their new scholarship program. Scholarship applications will be accepted from medical students, residents and practicing physicians interested in attending AAFP’s Family-Centered Maternity Care Live Course. There is an opportunity for one recipient in each of the three categories to receive a $2,000 scholarship to cover registration, travel and lodging for the event. Contact Jean Klewitz at jklewitz@tafp.org for more information.

The Commission on Public Health, Clinical Affairs, and Research saw presentations from James Mobley, MD, on Chagas disease and Neelima Kale, MD, on teen pregnancy rates. The commission also reviewed a request to join the advisory board for STOP HCCHCV. Rita Schindeler-Trachta, MD, spoke to the group about intimate partner violence and asked the commission to recommend that TAFP declare IPV a problem of epidemic proportion.

The Leadership Development Committee met to review the Family Medicine Leadership Experience and shape the curriculum for the 2018 class. They also discussed ways to keep the alumni from the first two classes involved in TAFP. The new class will have their first session during TAFP’s Interim Session in April. TAFP Member Communities launched at the 2016 Annual Session and continued to grow in 2017. Five different groups met throughout the conference and all have enough interest to continue live gatherings in 2018. The five communities were Early Career Physicians, Direct Primary Care Physicians, Hospitalist and ER Physicians, IMG Physicians, and Solo and Small Group Physicians. Look for them at the next Interim or Annual Session you attend. They provide an opportunity for members to connect and learn from each other. TAFP is an ACCME-accredited provider of continuing medical education and has maintained

TAFP meetings are an opportunity to gather and participate in discussion on a variety of topics. Section meetings on maternity care, rural health and research are held during TAFP’s Interim and Annual Sessions. Section meetings are intended for any interested member to participate. The Section on Maternity Care and Rural Physicians discussed the new AAFP Family-Centered Maternity Care Live course scholarships, the loss of fellowships, and explored ways to get more students interested in obstetrics and rural practice. The Section on Research discussed creating a statewide primary care research network. They will continue exploring the feasibility of the project during future conference calls and section meetings. Since 2017, the section has held monthly conference calls to provide regular dialogue for research-interested physicians. To join these calls and interact with fellow researchers across the state, contact Perdita Henry at phenry@tafp.org.

ORGANIZATIONAL ISSUES The voting representatives on the Member Assembly elected these 2017-18 leaders: President-elect: Rebecca Hart, MD Vice President: Amer Shakil, MD Treasurer: Javier D. “Jake” Margo, Jr., MD Parliamentarian: Mary S. Nguyen, MD Delegate to AAFP: Linda Siy, MD Alternate Delegate to AAFP: Ashok Kumar, MD New Physician Director: Lawrence Gibbs, MD, MEd At-large Director: Terrance Hines, MD Special Constituencies Director: Lesca Hadley, MD

K N A R F . C ER B B E E R W C TU LE ILY FA M F O TS ✤ MY A DE RE S E N C A SP AS T E X SICI A N Y PH

S T IN U A NCE O F A S M IS E N A AX IMU R 8 ✿ AS ✤ M T S™ ✤ 1 0 , 2 , TE X DI E 4 1 R C I L 13 A U S T I N O R Y 1 R P G A L ✱ A CATE E T HO A PR M 17 A 2 DAYS OF CME. 1 DAY OUT OF THE OFFICE!

Resident Director: Samuel Mathis, MD Medical Student Director: Jason Johnston At the Annual Business and Awards Lunch, the membership approved bylaws amendments recommended and published in Texas Family Physician last year. These changes will alter the leadership structure of TAFP. The position of Vice President is being eliminated and the number and length of term for the At-Large Director positions will go from one elected each year for a three-year term to two elected each year for twoyear terms. These changes will go into effect during the 2018 Annual Session and Primary Care Summit.

THE TEX AS ACA DEM Y O F FA M I LY PH Y S I C I A N S presents:

2018 TEXAS FAMILY MEDICINE

JUNE 8-10, 2018

LA CANTERA HILL COUNTRY RESORT SAN ANTONIO, TEXAS

MEMBER HIGHLIGHTS Several members completed terms as committee or commission chair and they were thanked for their years of service:

Maximum of 24 AMA PRA Category 1 Credits™

Lesca Hadley, MD — Commission on Membership and Member Services Sam Wang, MD — Commission on Health Care Services and Managed Care

Want to know more about TAFP CME or to attend an event?

www.tafp.org/professional-development

Katharina Hathaway, MD — Section on Research

www.tafp.org

PUBLIC HEALTH

CHAGAS DISEASE ON OUR DOORSTEP GABRIEL L. HAMER

By James A. Mobley, MD, MPH

Kissing bugs or triatomine bugs

James A. Mobley, MD, MPH is a family physician practicing in Portland, Texas and a Fellow of the American Academy of Family Physicians. He is Health Authority for San Patricio County and the Medical Director for Texas A&M Healthy South Texas Initiative. The opinions expressed in the article are those of the author and do not necessarily represent the views of the Texas Academy of Family Physicians, the San Patricio County Department of Public Health, or Texas A&M Healthy South Texas. The author wishes to thank Kerry DuBose, RN; Rachel Curtis-Robles, PhD; Sarah Hamer, PhD, DVM; Thomas Cropper, DVM; and especially Marivell Garcia for their assistance in preparing this article. 14

TEXAS FAMILY PHYSICIAN [No. 1] 2018

n 2007, blood banks began testing donors for Chagas disease. If a donor tests positive for Chagas, that person is referred to a health care provider for further evaluation. Since Chagas is a disease primarily of Central and South America, Texas family physicians may have limited experience or knowledge of how to evaluate Chagas disease. The following true case illustrates a typical Chagas presentation. MARIVELL When Marivell was 17, her older brother died in an automobile accident. She decided to donate blood at her local blood bank to honor his memory. A few weeks later she received a letter from her blood bank informing her that she had tested positive for Chagas disease. The letter provided information on Chagas disease and advised her to see her family doctor for further evaluation and confirmation of the diagnosis. Chagas disease is a parasitic infection caused by Trypanosoma cruzi. It is spread through the feces of infected triatomines, also known as kissing bugs. When the kissing bug takes a blood meal, it defecates, potentially contaminating the wound with the Trypanosoma cruzi parasite. Kissing bugs are often found in poorly constructed and rural housing, typically living within mud walls and thatched roofs. They also may be found in brushy and forested environments emerging at night to feed. Chagas can also be transmitted by blood transfusion, organ transplantation, and congenitally. Chagas disease can also be spread by canines and other mammals orally. Oral spread can occur in animals that eat infected kissing bugs. Puppies in Texas have been found with kissing bugs in their mouths. Chagas is endemic throughout much of Central and South America. It is estimated that as many as 6 million people in Mexico, Central America, and South America have Chagas disease. In Texas, Chagas has been found in skunks, raccoons, and opossums. Persons living in the United States who

have migrated from endemic areas and U.S. residents who live in substandard housing are particularly vulnerable to the disease. Also, campers and other people who spend a lot of time in the outdoors may be at risk. It is estimated that there may be over 300,000 infected persons living in the United States, most of whom do not know they are infected. Pets, especially dogs, are also vulnerable to infection with T. cruzi. Marivell was born in Corpus Christi and has lived in the same house in Sinton, Texas all her life. She has never left the United States. “It seems that it is not unusual that a Chagas-positive individual in the U.S. cannot definitely pinpoint the exact source of infection,” says Dr. Rachel Curtis-Robles of the Texas A&M College of Veterinary Medicine. Marivell was referred by her family doctor to an infectious disease specialist who confirmed the diagnosis of Chagas. CHAGAS IN TEXAS In Texas, 60 to 65 percent of the triatomine bugs have tested positive for T. cruzi. Chagas is considered an endemic disease in dogs. In Texas from 2013 to 2014, 351 animal cases of Chagas disease were reported, mostly in dogs. These cases occurred in all geographic regions of the state. Locallyacquired human cases are still uncommon. From 2013 to 2014, 39 human cases of Chagas disease were reported. Twenty-four were acquired in another country, 12 were locally-acquired, and the location of acquisition was unknown for three. It is likely that many more cases of Chagas go unreported than those that are reported. Urban expansion has caused displacement of wildlife hosts in Texas resulting in a higher prevalence of domestic dogs as hosts. Thomas Cropper, DVM, has found Chagas in Air Force service dogs trained in San Antonio and kissing bugs have been found in the tents of Air Force trainees in the area. Of 33 kissing bugs collected at an Air Force training site in San Antonio, eight tested positive for human blood. Four out of eight tested positive for the Chagas parasite. In San Antonio, 66 percent of opossums, 32 percent of raccoons, and 26 percent of skunks tested positive for T. cruzi. SYMPTOMS OF CHAGAS DISEASE Chagas disease has an acute phase — lasting four to eight weeks — and a chronic phase. During the acute phase, most people

have no symptoms while some may experience flu-like symptoms. There may be fever or swelling around the site of inoculation. Rarely, acute infection may result in cardiomyopathy, encephalopathy, or meningitis. Romaña’s sign, infected swelling of the eyelid, is a marker of acute Chagas disease. The swelling is due to bug feces being accidentally rubbed into the eye or the bite wound. Following the acute phase, most infected people enter a chronic indeterminate asymptomatic state during which few or no parasites are found in the blood. Twenty to 30 percent of infected people will eventually develop symptoms. Symptoms include cardiomyopathy, cardiac arrhythmias, congestive heart failure, apical aneurysms with thrombus formation, and stroke. Also dilatation of portions of the gastrointestinal tract may occur, leading to bowel obstruction. Chagas has also been associated with megacolon and megaesophagus. EVALUATION OF BLOOD DONORS WHO TEST POSITIVE FOR CHAGAS A medical history, including possible exposures is key. The review of systems should focus on symptoms of chronic Chagas disease including palpitations, syncope, dizziness, congestive heart failure, symptoms compatible with thromboembolic phenomena, dysphagia, odynophagia, weight loss, and prolonged constipation. The evaluation should also include a physical examination and an electrocardiogram with a rhythm strip. Barium studies of the gastrointestinal tract may be considered. CHAGAS DISEASE DIAGNOSIS During the acute phase, the parasites may be found in blood smears by microscopic examination. Circulating parasite levels decrease rapidly within a few months and are undetectable during the chronic indeterminate phase. Diagnosis of chronic Chagas disease is made by serologic tests. Initial testing is done by commercial laboratories. If the test is positive, further testing will be done by the Texas Department of State Health Services and the Centers for Disease Control. Because a single test is not sufficiently sensitive or specific to make the diagnosis, a two-step protocol is used. The CDC uses an indirect fluorescent antibody test and an enzyme immuno assay. Consider the diagnosis of Chagas for unexplained heart failure or dysrhythmias

TEXAS COUNTIES WITH LOCALLY ACQUIRED HUMAN CHAGAS CASES, 2013-2015 ATASCOSA BEXAR BROOKS CAMERON

CORYELL FAYETTE JIM WELLS POLK

TRAVIS VICTORIA WILLACY

FOR MORE INFORMATION ON CHAGAS DISEASE Texas DSHS Infectious Disease Control Unit: Their Chagas Disease website is www.dshs.texas.gov/IDCU/disease/Chagas.doc. Contact them at (512) 7767676 or by email at feedback.IDCU@dshs.state.tx.us. The Centers for Disease Control and Prevention Chagas website is www.cdc. gov/parasites/chagas/. Questions regarding treatment should be directed to Parasitic Diseases Public Inquiries (404) 718-4745 or email chagas@cdc.gov. For more detailed information on evaluation and treatment, visit jamanetwork.com/journals/jama/fullarticle/209410 for free access to the article: Evaluation and Treatment of Chagas Disease in the United States: A Systematic Review (JAMA 2007: 298:2171-81) For more assistance visit Kissing Bugs and Chagas Disease in the U.S. Texas A&M Agriculture and Life Sciences website kissingbug.tamu.edu/. They will help with analysis of triatomine bugs collected in Texas.

especially in younger individuals and in unusual presentations of large and small bowel obstruction. If you suspect Chagas disease in a patient contact your local health department or the Texas Department of State Health Services Infectious Disease Control Unit for assistance. CHAGAS DISEASE TREATMENT Untreated Chagas infection is lifelong. There is no FDA approved treatment for Chagas disease. However two drugs, nifurtimox and benznidazole, are available for use under investigational protocols for compassionate treatment. They are available only through the CDC and there is no charge for these medications. The CDC recommends treatment for all people diagnosed with acute infection, congenital infection, or suppressed immune systems. All children with chronic infection should be treated and adults with chronic infection should be considered on a case-by-case basis. Side effects

are common and more frequent and severe with increased age. They include peripheral neuropathy, anorexia, nausea, vomiting, headache, and weight loss. Contraindications to treatment include severe hepatic or renal disease. Questions regarding treatment should be directed to the Department of State Health Services or the CDC Parasitic Diseases Public Inquiries. MARIVELL Marivell’s infectious disease doctor told her that the blood work showed she was in the ‘chronic’ phase. She was advised not to get pregnant and he treated her for six months. During her treatment, Marivell became nauseous, lost her appetite, vomited, and lost about 60 pounds. She did finish the course of the medication. Now 23, she is chronically tired, has little strength, and suffers from frequent body aches. She wonders if it will ever be safe for her to get pregnant and have a family. www.tafp.org

TEXAS FAMILY PHYSICIAN [No. 1] 2018

MATERNAL MORTALITY IN TEXAS Digging through the data for answers By Perdita Henry

A 2016 study published in the journal Obstetrics & Gynecology revealed a startling trend. Researchers found that maternal mortality and morbidity rates were rising all over the country but in Texas, the rates were much worse. The authors noted that historically, women only died at this rate during war, natural disasters, and severe economic upheaval. Since none of those things were taking place in the Lone Star state, researchers couldn’t say for sure why this increase was happening. From there, news outlets picked up the story. The Houston Chronicle reported that from 2011 to 2015, 537 Texas women died while pregnant or within 42 days of delivery, compared to 296 women who died from 2007 to 2010. This doubling of maternal deaths made Texas the most dangerous place to give birth in the developed world. The rise in maternal mortality and morbidity rates in Texas began around the same time as the Texas Legislature’s devastating cuts to family planning funds in 2011. You may remember the contentious legislative session and the many efforts to exclude Planned Parenthood from the state Medicaid program. When the Legislature adjourned, the Texas Medicaid waiver program known as the Women’s Health Program — which would have matched nine federal dollars to every one dollar spent by the state — was scrapped and 280,000 women who depended on the program were left in health care limbo. Women who already had limited access to health care services found themselves pushed out of a system that provided annual well-woman exams, access to contraceptives, and family planning education. In the numerous news articles about the maternal death rate, coverage often centered on whether the legislative cuts set us down this path. In July of 2016, the Texas Maternal Mortality and Morbidity Task Force released a report examining the deaths that occurred in Texas from 2011 to 2012. Their initial findings revealed that there was no single cause for the increase, rather there has been a perfect storm of challenges facing Texas women. Chronic health problems, mental and behavioral health issues, drug use — both legal and illegal — and a lack of access to health care before, during, and after birth have led to awful outcomes for families and communities across the state.

www.tafp.org

he task force found that black women are the most at-risk demographic, that Hispanic women have the lowest rates of diagnosed depression or mental health issues but the highest rates of postpartum suicide, and that the number of babies born in the Medicaid program addicted to opioids is rising. With this information in hand, the task force and their chair, Baylor College of Medicine obstetrician-gynecologist, Lisa Hollier, MD, continue to dig through the data, trying to identify causes and recommend changes needed to save Texas women. “I am really grateful that we have the opportunity to continue our detailed reviews of individual medical records for the women who have died,” Hollier says. “I think in those reviews we will really focus on causes and contributing factors. We will have an opportunity to identify the likelihood of prevention for a number of these deaths and what we could identify as potential solutions.” A perfect storm hits women’s health in Texas The task force found that chronic health conditions were responsible for a significant portion of maternal deaths during 2011 and 2012. These conditions were often accompanied and amplified by negative social determinants of health, exacerbating the stress on expectant mothers. “I think that the task force recognizes the importance of social determinates and that, in part, is one of the reasons we were pulling deaths from a full year after the end of pregnancy,” Hollier says. “We wanted to be sure we captured all of the relevant deaths that were potentially related to pregnancy.” Diabetes, hypertension, and obesity are common chronic conditions that are often aggravated by pregnancy. The task force looked at several issues influencing the increased rates of maternal mortality and identified cardiac events and hypertension/eclampsia as the first and third most common causes of death within one year of delivery. Of the women who died between 2011 and 2012, 20.6 percent of them died from some sort of cardiac event, while 11.1 percent died from hypertension/eclampsia. Mental health issues played a role in many maternal deaths. In their investigation, the task force found several missed opportunities to screen expectant mothers and refer them for mental health treatment. The National Institute of Mental Health notes that people

Percentage of Texas maternal deaths and births in 2011-2012 by mother’s race/ethnicity 2.6

5.8 30.8

White Black

48.1 60 28.8 40

Severe maternal morbidity (SMM) during pregnancyrelated hospitalization by race/ethnicity, 2012

11.4

Other 37.8

34.8

Texas births

Hispanic

Maternal deaths

Rate per 1,000 hospitalizations

Percentage of events by race/ethnicity

100

with depression have an increased risk of developing several chronic illnesses such as diabetes, cardiovascular disease, and stroke, and people with chronic illnesses have an increased risk for developing depression. In the data the task force reviewed, white women had the highest rates of diagnosed mental illness including depression and black women had the next highest rates. But in the data for Hispanic women, the task force found something curious. They had the lowest rates of diagnosed mental illness, but they accounted for the highest rates of maternal deaths by suicide. How much mental illness was going undetected and among whom? According to the report: “Factors affecting likelihood of diagnosis, such as access to care, access to medical home, provider or health care system factors, care seeking behaviors, or other issues may contribute to lower prevalence of diagnosis among non-whites.” Hollier says the task force identified significant missed opportunities for screening for behavior health problems and referral of women to treatment. “I would encourage my colleagues who are caring for pregnant and postpartum women to be sure they are screening these women for depression using a standardized instrument.” The American College of Obstetricians and Gynecologist recommends that screening happens at least once during the pregnancy and postpartum period, but Hollier says patients in her practice are screened three times: at the beginning of prenatal care, in the third trimester, and postpartum. “I would also recommend being aware of transitions in care and assisting women in those hand-offs — a hand-off from a family physician to an obstetrician during a pregnancy and then back to the family physician, or a hand-off from a pediatrician to an ob-gyn. We noticed those care transitions often put women at risk and so paying special attention to those care transitions would also be very important.” Drug overdose was the second leading cause of maternal deaths in Texas from 2011 to 2012, with opioids accounting for 11.6 percent of those deaths. This finding coincides with the rise of prescription drug abuse and overdoses around the country. Substance use disorder among pregnant women can be difficult to track. “Since opioids are the most commonly abused substances

Pregnancy-related stays with at least one SMM indicator

40 State average (27.7) 30

41.4

26.3

23.4

White

Black

Hispanic

26.5

Other

Source: Maternal Mortality and Morbidity Task Force and Department of State Health Services Joint Biennial Report, Texas DSHS, July, 2016

TEXAS FAMILY PHYSICIAN [No. 1] 2018

both in Texas and nationwide, a way to estimate the prevalence of substance use as a contributing factor to severe maternal morbidity may be to examine the rate of neonatal abstinence syndrome in newborns,” the report states. Neonatal abstinence syndrome is defined as a group of problems that occur in a newborn who was exposed to addictive opiate drugs while in the mother’s womb. In their analysis of NAS newborns, the task force found several prenatal substance abuse cases that likely would have remained undetected by medical professionals. Opioid NAS steadily increased from 2008 to 2012, which suggests that more pregnant women were using opioids. The task force also found that unless a pregnant woman suffered an overdose, had a history of drug addiction, or was treated for a mental health issue, her dependency would likely remain unknown and untreated. Out of the 19 women using Medicaid during their pregnancies who died of drug overdoses, 14 of them died 60 or more days post-delivery, after Medicaid coverage expires. “The Department of State Health Services will be partnering with the Alliance for Innovation on Maternal Health and will be implementing the newest AIM bundle on opioid dependence,” Hollier says. “This is great news. I think it will help us address the opioid problem here in Texas and care for the women who have opioid dependence.” So why are black women dying more often? The rising mortality and morbidity rate related to pregnancy is not unique to Texas. Almost every state in the U.S. has seen a rise in maternal mortality, but one of the glaring findings researchers continue to report is the degree to which black women are affected. The task force reported that while black women only accounted for 11.4 percent of Texas births in 2011 and 2012, they accounted for 28.8 percent of pregnancy-related deaths. We don’t know for certain why black women bear the greatest risk for maternal death, but evidence is mounting that the stress of being both black and female in America is perhaps most to blame. Dealing with racism day-to-day is stressful. Whether you are looking for a job, shopping in a department store, or simply driving down the street, black women often have to deal with the racial biases of people they encounter. Years of continuously navigating those types of interactions takes its toll.

Mortality risk at discharge from pregnancyrelated hospitalization by race/ethnicity, 2012

7.0

Risk of mortality at discharge pregnancy-related stays

6.0 1.9

5.0

State average (3.7)

4.0 3.0

1.3 1.0 4.4

2.0 1.0

2.4

1.0 2.0

White

Black

Hispanic

Extreme Major

2.8

Rates of hemorrhage and/or blood transfusion by race/ethnicity, 2012

Other

Rate per 1,000 hospitalizations

8.0

Arline Geronimus, a professor at the University of Michigan School of Public Health, has conducted extensive research on the ways the body is affected by continuous stress. She coined the term “weathering” to describe the cumulative impact of repeated experiences with social or economic adversity and political marginalization that may cause disproportionate physiological deterioration. “Weathering, causes a lot of different health vulnerabilities and increases susceptibility to infection, but also early onset of chronic diseases, in particular, hypertension and diabetes,” Geronimus told ProPublica. In 2009, researchers from the University of Southern California and Harvard published a study in Social Science & Medicine, focusing on the self-reported racism experiences of both U.S. and foreignborn pregnant black women. Their study revealed that “chronic exposure to racial prejudice and discrimination could ... contribute to physiological wear and tear, thereby increasing health risk.” In several articles exploring why black women face such high maternal morbidity and mortality rates, there are recurring instances of having to deal with projections from the medical professionals charged with caring for them. Being rushed through medical processes, having their symptoms and experiences downplayed, and having to deal with snide remarks and assumptions are just some of the examples women shared with reporters about their experiences on their journey to motherhood. Many black women must also endure the hardships of poverty, with its food insecurity, little to no access to regular health care, transportation difficulty, and the early onset of chronic health conditions. A growing body of evidence suggests black women are literally aging faster at a cellular level, and sometimes pregnancy is the straw that breaks the camel’s back. The task force found that black women are more likely to experience hemorrhage and blood transfusion than any other race or ethnic group in the state. “This is a multifactorial problem,” Hollier says. “African-American women may be more likely to have anemia. African-American women may be more likely to have uterine fibroids, which could contribute to menstrual blood loss, which could then contribute to both anemia before pregnancy and bleeding at the time of delivery. They may be less likely to access care and get treatment for their anemia. There are many different factors that contribute to

State average (16.9)

15 24.4 10

17.1 13.9

15.9

White

Black

Hispanic

Other

www.tafp.org

“This is a multifactorial problem. African-American women may be more likely to have anemia. African-American women may be more likely to have uterine fibroids, which could contribute to menstrual blood loss, which could then contribute to both anemia before pregnancy and bleeding at the time of delivery. They may be less likely to access care and get treatment for their anemia. There are many different factors that contribute to this. I imagine this is an area that will have an increase in study now that we have identified these particular disparities.” Lisa Hollier, MD Chair, Texas Maternal Mortality and Morbidity Task Force this. I imagine this is an area that will have an increase in study now that we have identified these particular disparities.” In the meantime, the task force wants increased provider education on the impact of health disparities in health outcomes and recommends the development and implementation of programs that assist women in becoming their own advocates. The 85th Legislature It took a few tries, but the Legislature did take action to address this crisis. Senate Bill 17 extended the life of the Maternal Mortality and Morbidity Task Force to 2023 and added a nurse specializing in labor and delivery and a physician specializing in critical care as members. It also expanded their duties. They will now review best practices and programs of other states, evaluate health conditions and factors that affect the most at-risk population, compare rates of pregnancy-related deaths based on the mother’s socioeconomic status, and make recommendations along with the Perinatal Advisory Council to help reduce pregnancy-related death. The measure also gave the task force additional support from Health and Human Services Commission and the Department of State Health Services. With the next legislative session scheduled for 2019, there is still much to be done and the House Committee on Public Health seems to understand that. Last fall, the committee received its interim charges from the Speaker of the House. Charge No. 1 reads: “Review state programs that provide women’s health services and recommend solutions to increase access to effective and timely care. During the review, identify services provided in each program, the number of providers and clients participating in the programs, and the enrollment and transition process between programs. Monitor the work of the Maternal Mortality and Morbidity Task Force and recommend solutions to reduce maternal deaths and morbidity. In addition, review the correlation between pre-term and low birth weight births and the use of alcohol and tobacco. Consider options to increase treatment options and deter usage of these substances.” 20

TEXAS FAMILY PHYSICIAN [No. 1] 2018

With more time and more resources being dedicated to uncovering the roots of the issue, it seems like the state is on the right path. In the end, the 2011 cuts to women’s health care certainly did not help an already vulnerable population. An increase in access to health care is necessary at every interval for women to make it through pregnancy and postpartum safely. As the task force continues to study the rise in maternal mortality and morbidity, there has been some progress. The Texas Collaborative for Healthy Mothers and Babies in collaboration with the Alliance for Innovation on Maternal Health has implemented maternal safety bundles, which will soon be available to physicians who practice obstetrics. Also, the Department of State Health Services will be participating with the Alliance for Innovation on Maternal Health to implement an AIM bundle on opioid dependence. If you would like to know more about the AIM bundles or would like more resources for yourself and your patients, check out The Council on Patient Safety in Women’s Health Care, www.safehealthcareforeveywomen.org. They offer several patient safety bundles ranging from mental health to assistance in reducing peripartum racial and ethnic disparities. If you are looking for assistance in keeping your patients from losing care soon after they deliver, check out Healthy Texas Women, www.healthytexaswomen.org. There you can access toolkits on postpartum depression and Long Acting Reversible Contraceptives and much more. You can also visit The Texas Collaborative for Healthy Mothers and Babies, www.tchmb.org, which offers resources to physicians and has a significant amount of resources available to expectant women and their partners. The road to reducing maternal mortality and morbidity is long and there is no single answer to correcting this devastating problem. Making it safer for women to begin or expand their families will take the awareness, the attention, and the time of everyone involved with bringing a child into the world.

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RISK MANAGEMENT

CLOSED CLAIM STUDY

Failure to diagnose melanoma By the TMLT Risk Management Department

This closed claim study is based on an actual malpractice claim from Texas Medical Liability Trust. This case illustrates how action or inaction on the part of the physicians led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physicians’ defensibility. This study has been modified to protect the privacy of the physicians and the patient.

keratosis was favored, the possibility of a regressive melanocytic neoplasm could not be excluded. The oncologist treated the patient for primary bladder melanoma and recommended surgery. A bladder resection with excision of the tumors was performed. Pathology slides revealed deep bladder muscle invasion with melanoma.

PRESENTATION

Two weeks later, the patient underwent an MRI that showed multiple brain lesions consistent with the melanoma diagnosis. Treatment was only marginally effective and the patient died.

A 48-year-old man came to his family physician requesting a refill for his allergy medication and an evaluation of a skin lesion on his back. The lesion had only recently appeared. The patient’s history was significant for Hodgkin’s disease that had remained in remission since treatment.

ALLEGATIONS

The physician’s documentation did not mention an exam or treatment of the lesion, but the patient was scheduled for a follow up visit.

PHYSICIAN ACTION The patient returned to the practice 11 days later. During this visit, the family physician documented a 2 cm seborrheic keratosis on his back and performed cryotherapy on the lesion. Nearly one month later, the patient sought treatment for sinus symptoms and requested a re-check of his “mole.” The patient encounter note did not include any reference to the lesion; however, billing records indicated that a repeat cryotherapy treatment was performed at this visit. The patient was treated over the next year at five visits, primarily for upper respiratory infections. A year after the initial diagnosis of the patient’s lesion, he returned to the practice with a chief complaint of hematuria. A urology work up revealed two large lesions in the bladder diagnosed as invasive malignant melanoma. Since a primary melanoma in the bladder is extremely rare, the oncologist ordered testing to determine the source of the patient’s primary melanoma. CT and PET scans failed to show any primary melanoma tumor. A pathologist/dermatologist reviewed the biopsy results of the lesion on the patient’s back previously treated by the family physician. He concluded that although a diagnosis of benign

A lawsuit was filed against the family physician. The allegations included: • failure to properly evaluate, diagnose, and treat the lesion; • failure to refer the patient to a dermatologist for evaluation of the lesion; • failure to perform a biopsy or obtain a pathological analysis of the lesion; and • failure to timely provide or order proper and immediate care and treatment.

LEGAL IMPLICATIONS A diagnosis of seborrheic keratosis was made at the visit in which the first cryotherapy was performed. The physical examination included the length of the lesion (2 cm). It was determined that this diagnosis was well within the scope of practice for a family physician. The defendant reasoned that since the lesion was a classic seborrheic keratosis, it was not necessary to document all the reasons that it was not a melanoma. The issue of whether the original lesion was a melanoma and thus the original site of the malignancy proved to be a battle between the expert witnesses. The plaintiffs’ experts reasoned that since primary malignant melanoma of the bladder is extremely rare — with only five to 10 documented cases in medical history — the probabilities strongly favored the conclusion that the urinary cancer represented a metastasis. www.tafp.org

The defense experts argued that if the bladder tumors metastasized from the skin lesion, the work-up by the oncologist would have shown positive results from the PET and CT scans and two resections of skin lesions. All results from the comprehensive testing to determine the source of the melanoma were negative, including negative findings for axilla or groin lymph node involvement. It was also stated that metastatic melanoma from an unknown site occurs in 1 to 15 percent of cases. A dermatopathologist involved in the subsequent work-up — who examined tissue later removed from the site of the treated lesion — concluded that he could not definitively state what type of lesion had previously been present and treated.

DISPOSITION Due to the weaknesses in the medical record documentation, the testimony of the pathologist, and the fact that the primary site of the melanoma could not be identified with certainty, the case was settled on behalf of the family physician.

RISK MANAGEMENT CONSIDERATIONS The absence of documentation about the lesion during the visit when the second cryotherapy treatment was performed created a weakness for the defense. All experts agreed that if cryotherapy is performed on any lesion, it should be documented. Upon questioning, the family physician could not recall the office visits or the reason he treated the patient’s lesion. When

Lane Aiena, MD Marian Allen, MD Adanna Amechi-Obigwe, MD Lee Hagar Bar-Eli, MD Justin Bartos, MD Joane Goforth Baumer, MD Stephen Benold, MD Henry Boehm, Jr., MD Lindsay Botsford, MD, MBA, CMQ Emily Briggs, MD, MPH Matthew Brimberry, MD John Carroll, MD Chinglin Lillian Chan, MD C Mark Chassay, MD Maria de Lourdes Coimbra, MD Douglas Curran, MD Richard David, MD Troy Fiesinger, MD Lewis Foxhall, MD

Melecia Fuentes, MD Kelly Gabler, MD Melissa Gerdes, MD Lisa Biry Glenn, MD Roland Goertz, MD, MBA Joseph Gonzalez, MD T. David Greer, MD Ajay Gupta, MD Natalia Gutierrez, MD Lesca Hadley, MD Suhaib Haq, MD Rebecca Hart, MD Clare Hawkins, MD, MSC John Haynes, MD Anne-Marie Herpin, MD Robert Hogue, MD Farron Hunt, MD Janet Hurley, MD Kara Kern, MD Kaparaboyna Ashok Kumar, MD

TEXAS FAMILY PHYSICIAN [No. 1] 2018

documentation in the medical record is absent or brief, the physician’s credibility and accuracy may be questioned. The Texas Administrative Code Section 165.1 defines the Texas Medical Board rules for medical record keeping. The documentation requirements for each patient encounter in maintaining an “adequate” medical record includes the reason for the encounter with relevant history, physical examination findings, an assessment, clinical impression or diagnosis, and plan of care. 1

1. Texas Medical Board Rules. Texas Administrative Code Title 22, Part 9, Chapter 165, Section 165.1. Available at http:// texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_ view=4&ti=22&pt=9&ch=165&rl=Y.

This closed claim study is published as an information and educational service. The information and opinions in this study should not be used or referred to as primary legal sources or construed as establishing medical standards of care for the purposes of litigation, including expert testimony. The standard of care is dependent upon the particular facts and circumstances of each individual case and no generalizations can be made that would apply to all cases. The information presented should be used as a resource, selected and adapted with the advice of your attorney. It is distributed with the understanding that neither Texas Medical Liability Trust nor its affiliates are engaged in rendering legal services.

James Lackey, MD C. Timothy Lambert, MD Don Lawrence, DO Eric Lee, MD Leah Raye Mabry, MD Javier Margo, MD Ronnie McMurry, MD Alyssa Molina, MD Dale Moquist, MD Graciela Moreno, MD Maria De Jesus Munoz, MD Nancy Naghavi, DO Mary Nguyen, MD John Ray, MD Katie Ray, MD David Schneider, MD Puja Anil Sehgal, MD Dan Sepdham, MD Amer Shakil, MD, MBA Kyle Sheets, MD

Linda Siy, MD Mary Anne de la Cruz Snyder, DO Mary Spalding, MD Joshua Splinter, MD Dana Sprute, MD, MPH Richard Stuntz, MD Erica Williams Swegler, MD Sheri Talley, MD James Terry, MD Lloyd Van Winkle, MD Elizabeth Wanner, MD Andrew Weary, MD Walter Wilkerson, MD Keith Wilkerson, MD Khalida Yasmin, MD Robert Youens, MD, MMM Richard A. Young, MD

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PUBLIC HEALTH

SEARCHING FOR BALANCE AND WALKING OUT THE SOLUTION By David Sabgir, MD

it was 11 years invested into medical training wasted. After doing my best for 11 years after college, I found myself totally ineffective at changing my patients’ behavior. We’d had wonderful heart-to-heart talks. These conversations were real, full of great intention, and essentially worthless. As my patients came back for their six- and 12-month follow-ups, I realized I had not done my job. Their heart disease, which I knew to be 82 percent preventable, was not interrupted. It was a runaway locomotive. They were still sedentary and they hadn’t lost a pound. As a matter of fact, they were up 3 pounds. The weather had been too hot. The weather had been too cold. They knew they had to “get out.” This frustration didn’t repeat itself with one patient or a dozen patients, this was hundreds becoming thousands of patients. I was ineffective despite long, emotional conversations. One day, that was it. I refused to play this charade for what I hope to be a 30-plus-year career of trying to help others. Now, I would make them say “no” to my face. I asked a patient in November 2004 if they would join me, my wife, and two little ones at the park for a walk. This was met with a

different response. There was a sparkle, a new level of connection between that patient and this physician. That was the day Walk With a Doc was born. Since that late fall day, my inevitable path to burnout ended and my life’s work balance began. That day was the beginning of a melding of my personal life and my medical practice, two things many doctors fight feverishly to keep apart. We are honored to share this program with thousands of other health care providers who have followed suit and we’re excited for more to join us. Walk With a Doc is a pop-off valve for us as physicians. It’s simply an hour of our week where we can meet patients on their terms and our terms. We meet in a park or a mall – winters can be harsh in Ohio – in comfortable clothes. We talk about the Buckeyes, laugh about Saturday Night Live or discuss potential dream vacations and we also chat about blood pressure, palpitations, or whether or not to take a statin. Most importantly, we talk while walking or rolling in the wheelchair. When I meet patients at the park, I have more than seven minutes to see a patient. At the park, I have as much time as we need, and we both love it. All 299 of our participating communities love it. www.tafp.org

WALK WITH A DOC Physicians are thanked way more than we should be for participating in Walk With a Doc but this program benefits us just as much as it does our patients. Every minute, every smile, every comment, and every pat on the back reminds us of why we went into medicine. We know 82 percent of cardiac disease is preventable if we exercise regularly, eat well, maintain a healthy weight, and don’t smoke. Our more than 6,800 Walk With a Doc events in 2016 arguably hit all four of those facts. Many ‘Walks’ provide fruits, healthy recipes, and sometimes even samples. The walking component goes a long way in addressing the physical activity component. Many doctors also know the endorphins released by walking activate the same receptors activated by nicotine, therefore cutting cravings. The opportunity to do this with patients is a gift. Over 600 Saturdays have come and gone since the program’s inception and I still hate to miss one. The good feelings of satisfaction and anticipation follow me into the office for the rest of the week. I now close every visit with either, “I would love for you to join me at Walk With a Doc on Saturday” or “It was great to meet your daughter this weekend.” Our chapters know they are going the extra mile for their patients. That brings a whole new level of camaraderie to their offices Monday through Friday. The office visits are shortened dramatically with our walk participants. “I think I told you everything on Saturday, David. I’m really doing great,” my patients say.

We stumbled upon something very special. This level of familiarity between patient and physician breaks down many important barriers. In the process of eliminating those barriers we show a vulnerability that sparks lifelong friendships. These friendships can go a long way in preventing burnout. Our health care leaders around the country embody the phrase “walking the walk.” As patients and as providers, we’re empowered by watching this needle move. We are watching it move away from sedentary lifestyles and loneliness and into a world of togetherness, hope, activity, and progress. It is why I refer to it as a life-work balance. Since that cold November day in 2004, I don’t feel like I’m working nearly as much. I feel like I’m living.

David Sabgir, MD, is a board-certified practicing cardiologist in Columbus, Ohio. He started Walk With a Doc to improve his patients’ quality of life. With 42 chapters, Texas now has more chapters than any state in the country. Walk with a Doc has been recognized by multiple U.S. Surgeon Generals, CNN Heroes, and the Robert Wood Johnson Foundation among others. Thanks to funding from the Texas Medical Association Foundation and with generous support from Texas Medical Association Insurance Trust and Prudential, Walk With a Doc is free to TMA members. They can be reached at (512) 370-1390 or contact@walkwithadoc.org.

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1 28 2018-CRS-TAFP-halfPg.indd TEXAS FAMILY PHYSICIAN [No. 1] 2018

12/1/17 3:05 PM

FOUNDATION FOCUS

2017 TAFP Foundation donors

Thank you to these 2017 TAFP Foundation donors, whose contributions fund scholarships for Texas medical students, family medicine research grants, and travel scholarships for residents to attend continuing professional development activities.

Jonathan Nelson ★ Mary S. Nguyen, MD Donald Nino, MD Elisabeth Noelke, MD ★ Paul Oliver, MD Linda Parker, MD

★ = TAFP Foundation monthly donor

John Partin, MD ★ H. David Pope, MD T. Dale Ragle, MD ★ John Richmond, MD

AbbVie

★ C. Mark Chassay, MD

★ Terrance Hines, MD

★ Shelley Roaten, MD

Texas Medical Association

Maria de Lourdes Coimbra, MD

Richard Hozdic, II, MD

Jeanette Robles-Suarez, MD

Texas Medical Liability Trust

Michael Cooper, MD

James Hrachovy, MD

Stephanie Roth, MD

Catalyst Health Network

★ Seth B. Cowan, MD

★ Farron Hunt, MD

Alex Salazar, MD

Texas Organization for Rural and Community Hospitals

Karl Crudo, MD

★ Janet Hurley, MD

Gerald Salinas, MD

John Cullen, MD

★ Jamal Islam, MD, MS

Kristi Salinas, MD

Baylor Scott and White Health

Douglas W. Curran, MD

Bruce Jacobson, MD

★ Sarah Samreen, MD

Kelsey Seybold Clinic

Richard T. David, MD

★ Brian Jones, MD

David Schneider, MD

Austin Regional Clinic

★ Chrisette Dharmagunaratne, MD

★ David Katerndahl, MD

★ Sandra Scurria, MD

★ Adanna Amechi-Obigwe, MD

★ Jorge Duchicela, MD

Christina Kelly, MD

Puja Sehgal, MD

Marian C. Allen, MD

Carolyn Eaton, MD

★ Shelley Kohlleppel, MD

★ Amer Shakil, MD, MBA

Dale Crawford Allison, MD

★ Bruce Echols, MD

★ Kaparaboyna Ashok Kumar, MD

★ Linda Siy, MD

★ Charles Anderson, MD

★ Tricia Elliott, MD

★ C. Tim Lambert, MD

Howard Smith, MD

★ IL Balkcom, IV, MD

★ Christopher Ewin, MD

★ Don Lawrence, DO

★ Mary Spalding, MD

★ Madhumita Banga, MD

★ Robert Ezell, MD

★ Eric Lee, MD

Joshua Splinter, MD

★ Tom Banning

★ Antonio Falcon, MD

Benjamin Leeah, MD

★ Charles Stern, MD

★ Lynda Barry, MD

★ Troy Fiesinger, MD

Joseph Long, MD

★ Sharon Stern, MD

★ Justin Bartos, MD

★ Aimee Flournoy, MD

Donald Lovering, MD

★ Donald Stillwagon, MD

Joane Goforth Baumer, MD

Linda Flower, MD

★ Leah Raye Mabry, MD

Richard Stuntz, MD

Celina Beltran, MD

Grant Fowler, MD

Joseph Mansen, MD

Erica W. Swegler, MD

★ Stephen Benold, MD

★ Lewis Foxhall, MD

★ Javier Margo, MD

★ Sheri J. Talley, MD

Peter Beshara, MD

★ Kelly Gabler, MD

James Martin, MD

James Terry, MD

Adrian Billings, MD, PhD

Oscar Garza, MD

★ Kathy McCarthy, CAE

Thuy Hanh Thi Trinh, MD, MBA

★ Henry Boehm, Jr., MD

Melissa Gerdes, MD

★ Mike McCrady, MD

★ Lloyd Van Winkle, MD

★ Teddy Boehm

★ Lisa Glenn, MD

Mark McKinnon, MD

David Vaughan, MD

Jessica Boldwill, MD

★ Roland Goertz, MD, MBA

★ Susan McMullen, MD

Francisco Vera Adames, MD

★ Lindsay Botsford, MD, MBA, CMQ

★ John Green, MD

Ronnie McMurry, MD

Andrew H. Weary, MD

★ Emily Briggs, MD, MPH

★ T. David Greer, MD

★ Jessica Miley

Sally Pyle Weaver, MD

★ Dennis Brown, MD

★ Ajay Gupta, MD

Li-Yu Mitchell, MD

John Weed, MD

Brian Byrd, MD

★ Natalia Gutierrez, MD

Roger Moore, MD

★ Jim White

Domingo Caparas, Jr., MD

★ Lesca Hadley, MD

Graciela Moreno, MD

★ Hugh Wilson, MD

John Carroll, MD

★ Suhaib Haq, MD

★ Dale Moquist, MD

Keith Wixtrom, MD

Anthony Catinella, MD, MPH

★ Rebecca Hart, MD

Thomas Mueller, MD

Elizabeth Yang, MD

Fernando Chacon, MD

Guoxiang He, MD

Bonnie Muncy, MD

★ Khalida Yasmin, MD

★ Chinglin Lillian Chan, MD

★ James M. Henderson, MD

★ Maria De Jesus Munoz, MD

★ Richard Young, MD

Marissa Charles, DO

Carmen Herrera, MD

James A. Murphy, MD

Robert Youens, MD, MMM

www.tafp.org

PERSPECTIVE

Transitioning from resident to new physician By Alyssa Molina, MD miserable at work, it’s very hard to be happy outside of when it comes to residents transitioning into practice, work. Get a feel for the people who work there. Make sure there are a few things I would stress. Know where you would you can spend time talking to the people already working like to be on the job continuum between autonomy and there, and if you can, try to have lunch or dinner with them. security. You could have a completely autonomous posiInteracting with them before you accept the position will tion. You own your own practice, you decide when you’re help you figure out if you’ll get along with them and if they opened, when you are closed, and what you do. While you’ll have helpful natures. have complete autonomy, you won’t have security. If you When you first get out of residency, you’re going to have are sick and you don’t come to work, you don’t get paid. At a lot of questions and you’re going to feel like you’re flailing. the other end of the spectrum, you have the security of During this transitional period, it’s very helpful to have an being employed by a practice. In that practice, they decide officemate you can ask questions to who how many patients you see, how many isn’t annoyed by your presence. Convacation days you get, and so on. There’s sider asking yourself these questions very little autonomy, but you have job about the position you are thinking of security. You always get a paycheck, and When you first get out taking: Will you have to compete for it doesn’t matter how many patients patients? Is the practice busy enough to you see. Most jobs are somewhere in the of residency, you’re handle another physician? Do they seem middle so, it’s important that you figure going to have a lot of excited to have you there? out for yourself, and your family, where I have a colleague who accepted a you are comfortable on the spectrum. questions and you’re job at a hospital. The hospital wanted Where I’m currently employed, I going to feel like you’re her there, but her officemate didn’t. She have a lot of autonomy. If I choose to flailing. It’s very helpful also had to compete for patients with take off, I just make sure I’m not on call her officemate and it made her miserand that someone’s covering the clinic. to have an officemate able. She ended up getting out of her I’m paid based on my productivity so you can ask questions contract early because of it. You need to there isn’t a certain number of days I have off each year. If I’m willing to to who isn’t annoyed by know these things before you sign on. It may seem obvious, but be sure take a smaller paycheck, I could take your presence. to read your contract. Make sure you off more days and still have a job when understand every piece of it. At the end I get back. Where I am on the conof the day, it doesn’t matter what was tinuum provides me with a base. They said, the only things that matter are do all the billing for me, so I don’t have what’s written. If you’re not comfortto worry about that. able with — or you don’t understand — your contract, hire Figure out where you’re comfortable on the security a contract attorney to make sure your interests are taken and autonomy scale, because being in the wrong place on care of. If things hit the fan, your contract is the only thing that scale can affect your happiness. People who need to be that matters. independent probably don’t want to work in a place where Now once you get into practice, know your limitations they have no say in who gets hired and what gets done. but be willing to stretch them a little. Be willing to ask People who thrive with that kind of autonomy might be for help, and make sure you put a system in place to ask miserable in that type of practice. If you need the security for help. I’m really blessed to work with Russell Thomas, of knowing how much money you’re making every month, Jr., DO, MPH, and Ray Cantu, MD. Both of them are very that you have good benefits, and that you have to see a knowledgeable, kind, and wise physicians. When I have certain number of patients, then you’d likely be drawn to a questions, I ask them. They give me good advice on how to practice that provides more security. It’s incredibly impormanage patients, where to look something up, and which tant to know yourself when picking a practice. specialists to trust. Knowing when to ask and figuring out Keep in mind, you’ll probably see the people you work whom to ask for help early is important because you’re with more than you see anybody else. Make sure you like going to need help at first, and that’s okay. You’re supposed the people you work with. It’s important to find a practice to need help at first. where your personality fits in with the culture. If you are

TEXAS FAMILY PHYSICIAN [No. 1] 2018

FAMILY MEDICINE FACULTY OPPORTUNITIES Houston, Texas

Baylor College of Medicine has opportunities for clinical faculty who are board certified/eligible in Family Medicine and interested in providing inpatient services. In addition to joining an outstanding group of faculty who are dedicated to the care of a variety of populations, our faculty enjoy opportunities to participate in academic activities including medical student education and resident education.

APPLY ONLINE: https://www.bcm.edu/careers

This position includes a faculty

FOR FURTHER INFORMATION CONTACT

appointment at a competitive salary with excellent benefits and the opportunity to join a distinguished institution.

ROGER J. ZOOROB, MD, MPH, FAAFP RICHARD M. KLEBERG SR. Professor and Chair DEPARTMENT OF FAMILY & COMMUNITY MEDICINE 3701 Kirby Drive, Suite 600 • Houston, TX 77098 Roger.Zoorob@bcm.edu • 713.798.2555 https://www.bcm.edu/departments/family-and-community-medicine/

APPLY ONLINE: https://www.bcm.edu/careers Position #: 89115, 159628, or 254183

Baylor College of Medicine is an Equal Opportunity/ Affirmative Action/Equal Access Employer

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By volunteering to precept a Texas medical student, you can open a door to a new world for the next generation of family doctors. QUESTIONS? Give us a call at (512) 329-8666 or send an email to Juleah Williams, jwilliams@tafp.org.

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