Oklahoma DO July/August 2014 by Oklahoma Osteopathic Association

The Journal of the Oklahoma Osteopathic Association

OKLAHOMA D.O.

May/June 2013 July/August 2014

Volume 79, No. 2

Volume 79, No. 1

Oklahoma D.O.

Oklahoma D.O. | July / August 2014

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Robert S. Juhasz, DO 2014-2015 AOA President

WE KNOW OKLAHOMA HEALTHCARE

Oklahoma D.O. PAGE 2

AT PLICO, WE ARE HONORED TO

“THROUGH THE PLICO BIOMEDICAL ETHICS FUND,

INVEST IN OSTEOPATHIC EDUCATION

PLICO PROVIDES A WONDERFUL RESOURCE

AND COMMITTED TO PROTECTING

FOR OUR COLLEGE OF OSTEOPATHIC MEDICINE.

YOU THROUGHOUT YOUR CAREER

YOUR CONTINUED SUPPORT ALLOWS FOR THE

IN MEDICINE.

APPOINTMENT OF AN ADJUNCT PROFESSOR TO

CALL US TODAY AND BEGIN

THE MANY ETHICAL ISSUES SURROUNDING THE

EXPERIENCING THE DIFFERENCE

PRACTICE OF MEDICINE AND MEDICAL RESEARCH.”

DIRECT INSTRUCTIONAL ACTIVITIES RELATED TO

THAT COMES WITH LOCAL SERVICE

— KIRK JEWELL, PRESIDENT, OKLAHOMA STATE

AND TRUSTED EXPERTISE.

UNIVERSITY FOUNDATION

405.815.4800 | PLICO.COM FINANCIAL STABILIT Y RATING ® OF A, EXCEPTIONAL

Oklahoma D.O. | July / August 2014

The Journal of the Oklahoma Osteopathic Association

OKLAHOMA D.O.

May/June 2013 May/June 2012 July/August May/June2014 014

January 2012

Volume 79, No. 2

Lynette C. McLain, Editor Lany Milner, Associate Editor

OOA Officers: Michael K. Cooper, DO, FACOFP, President (Northeastern District) C. Michael Ogle, DO, President-Elect (Northwest District) Gabriel M. Pitman, DO, Vice President (South Central District) Bret S. Langerman, DO, Past President (South Central District) OOA Trustees: Kenneth E. Calabrese, DO, FACOI (Tulsa District) Dale Derby, DO (Tulsa District) Melissa A. Gastorf, DO, FACOFP (Southeastern District) Timothy J. Moser, DO, FACOFP (South Central District) Richard W. Schafer, DO, FACOFP (Tulsa District) Christopher A. Shearer, DO, FACOI (Northwest District) Kayse M. Shrum, DO, FACOP (Tulsa District) Ronald S. Stevens, DO (Eastern District) OOA Central Office Staff: Lynette C. McLain, Executive Director Lany Milner, Director of Operations and Education Matt Harney, MBA, Director of Advocacy and Legislation Marie Kadavy, Director of Communications and Membership Jessica Hansen, Special Projects Coordinator Lisa Creson, Administrative Assistant

The Oklahoma D.O. is published monthly from the Oklahoma Osteopathic Association Central Office: 4848 N. Lincoln Blvd., Oklahoma City, OK 73105-3335. Lany Milner, Graphic Designer and Associate Editor Copy deadline is the 10th of the month preceding publication. Advertising copy deadline is the 15th of the month preceding publication.

Oklahoma D.O. | July / August 2014

2014 Post Trip Information

“Inaugural Address” provided by Robert S. Juhasz, DO, 2014-2015 AOA President

Oklahoma Delegation Recap

AACOM Statement on AOA HOD Vote to Support Single CME Accreditation System

“What’s the Difference?” editorial provided by JoAnn Ryan, DO& Harriet H. Shaw, DO

2015 Winter CME Seminar Program

2015 Winter CME Seminar Registration Form

“Food Poisoning: Your Guide to Prevention” provided by the American Osteopathic Association

29 “Hepatotoxic Injury in a HIV Positive Patient on Emtricitabine/ Rilpivirine/Tenofovir Therapy” 32 “In patients with skin tags, when should removal of the tags be considered compared with watchful waiting?” 34

“OSU’s Operation Orange: Introducing Oklahoma High School Students to Medicine” Courtesy of OSU Center for Health Sciences

July Birthdays

August Birthdays

What DO’s Need To Know

Bureau News

In Memoriam

47 Classifieds

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The OOA Website is located at www.okosteo.org

“President’s Message” provided by Michael K. Cooper, DO, FACOFP, 2014-2015 President

Oklahoma D.O.

For more information: 405.528.4848 or 800.522.8379 Fax: 405.528.6102 E-mail: ooa@okosteo.org

michael k. cooper, DO, FACOFP President 2014 â&#x20AC;&#x201C; 2015 oklahoma osteopathic association

I would like to thank the membership of the OOA for placing trust in me as the 2014-2015 president. I would also like to thank you many friends and colleagues who came to the inauguration banquet, some of whom came from quite a long distance. If you missed the banquet, you missed a really great time. I cannot remember a better planned banquet from top to bottom. The OOA staff did an excellent job in putting together not only the banquet but also the whole annual convention.

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And now back to our own practices. It is easy to lose the energy and excitement of the annual convention when you are juggling a large patient load and meaningful use. But there is an easy way to keep your enthusiasm and your energy for osteopathic medicine high - mentor a student. When you mentor a student, you remember just why you went to osteopathic medical school. You don't have to give formal lectures. They already get hours of didactics and formal education. A student will learn much from you by just observing the way you practice your particular type of osteopathic medicine. Just show these doctors-in-training how to be an osteopathic physician. In return, they will remind you of the wide-eyed first experiences you had when you were a medical student. Apprenticeship is an integral part of medical education. The apprenticeship is also mandatory in order to ensure our osteopathic culture.

Board of Trustees has voted not to take a position on this issue. Many are concerned that we will lose our identity and uniqueness. But this will only happen if we allow it to happen. We cannot allow anyone or anything else to control our identity or our future. Regardless of what lies ahead for our profession, we can still be in control of our future. Fostering our osteopathic culture with each other and our students is the way to maintain our culture. I urge you to get involved in your district and go to district meetings. Matt Harney, OOA staff member, is organizing another round of district meetings for the smaller districts. Your participation is vital to the longevity of the osteopathic profession. Most importantly, mentor a student. Mentoring a student will pay it forward. Then it should not matter which residency tract a graduate chooses. I would also like to personally invite you and your family to the OOA Post AOA Convention Trip from Oct. 29- Nov. 1, 2014. We are going to The Tanque Verde Ranch in Tucson, Ariz., which offers a variety of activities for the whole family. Information is available through the OOA office and travel is being arranged by Bentley Hedges Travel. DO OK

Our profession now faces its most significant challenge in recent history, the proposed merger of osteopathic and allopathic graduate medical education accreditation. This issue has certainly polarized our membership. But whether you are for or against this issue, some type of change is coming. It has to change. Sixty percent of osteopathic medical graduates must enter an allopathic residency because there are only enough osteopathic residency positions to absorb about 40 percent of osteopathic medical graduates. This is because our profession has expanded seats in osteopathic medical schools far faster than residency positions. By not changing in some manner, 60 percent of our graduates are at risk of not obtaining any graduate medical education position. The current plan for this merger is still under negotiation. There are many questions yet to be answered and no definitive agreement has been signed at this time. Because of this, the OOA

This article was written prior to attending the AOA House of Delegates meeting. Oklahoma D.O. | July / August 2014

Oklahoma Osteopathic Association Post OMED Convention Trip

TUCSOn Tanque Verde Ranch Oct. 29 - Nov. 1, 2014

Join Dr. Michael and Diane Cooper on a four-day post OMED convention getaway Oct. 29-Nov. 1, 2014, at Tucson, Ariz. Tanque Verde Ranch. The ranch stables approximately 180 horses and features activities that run the spectrum of outdoor excitement. You can enjoy riding on a walking trail, loping trail or on a breakfast trail ride. If horses are not your preference, you can partake in mountain biking, hiking, nature walks, fishing, tennis or just relaxing poolside. The resort offers indoor and outdoor pools, five tennis courts, an exercise room, large indoor and outdoor whirlpool spas, and basketball or fishing equipment. For an additional fee, championship golf is nearby or a soothing massage and/or body treatment may be scheduled at the La Sonora Spa. You will enjoy a buffet lunch on Wednesday, Oct. 29, at the resort and dinner at the highly popular Cowboy Cookout with live western entertainment in the Cottonwood Grove. The dinner offers grilled steak and chicken with all the assorted side dishes.

Enjoy a breakfast ride on Thursday or other activities such as golf or spa. Breakfast is served 7:00 a.m. to 9:30 a.m. A buffet lunch will be served on Thursday and Friday from 12:00 p.m. to 1:30 p.m. Dinner will be served at the resort from 5:30 p.m. to 8:00 p.m. Trip Price Includes: • Three nights accommodations at Tanque Verde Ranch, including hotel taxes and three meals daily, including the Cowboy Cookout and Thursday breakfast trail ride. • 3 hours of CME available • Access to any and all regularly scheduled ranch activities • Wi-Fi available in all guest rooms and throughout the resort • Coordination by Travel Leaders/Bentley Hedges Travel Not Included: Alcoholic beverages / Individualized airfare to Seattle and return from Tucson or roundtrip to Tucson / Roundtrip Transfers from Tucson airport to Resort / Harmony with Horses, Sunset Trail Rides (available upon request)

Visit tanqueverderanch.com to learn more about the resort’s activities and accommodations. • • •

• •

Terms and Conditions A valid photo ID is required for travel. Names on air ticket and birth date must be the same as on the passenger identification.

All payments are non-refundable. **Optional Trip Protection Insurance is available. Trip Cancellation, Trip Interruption, Missed Connection $250, Trip Delay up to $750, Medical Expense $25,000, Emergency Medical Transportation $250,000; Baggage and Personal Effects $1,000, Baggage Delay $250, Accidental Death and Dismemberment $25,000. Cancellation must be for a covered reason for insurance to be in effect. Details for purchase will be provided with receipt of deposit. Oklahoma D.O. | July / August 2014

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Air travel arrangements can be made from your home city to Seattle and return from Tucson to your home city. A flight from Seattle to Tucson is approximately $160. For those attending the Post Trip only, air arrangements on flights of your choice can be made to Tucson to meet with other participants. Bentley Hedges Travel will waive customary $30 fee per airline ticket for this event and will coordinate arrival and departure needs for airport transportation to the Ranch.

Oklahoma D.O.

Three night package: $950 - per person, double occupancy $1,325 - single occupancy $525 - per child (3 to 11 yrs) sharing with 2 adults Four night package: $1,225 - per person, double occupancy $700 - per child (3 to 11 yrs) sharing with 2 adults

Inaugural Address

by Robert S. Juhasz, DO, July 19, 2014

Provided by the American Osteopathic Association

I am so incredibly proud and humbled to be your AOA president at this historic time for our profession. I want to thank Bill Burke for his great work as Master of Ceremonies and Father Fred for being able to share this day with us.

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I would not have made it here without the amazing support of so many people, but particularly, my family. You had a chance to be introduced to my children and their spouses and significant others and got a glimpse of my beautiful grandchildren in the video my future DOs, what you might not have known was that we have a new addition to our clan, Eleanor Anna Youdath, my fourth grandchild. I just want to let each of them know how proud I am of them, at this moment, and what a blessing they and their families are in my life. Now, I would like to ask the love of my life my wife, Donna, to please join me on stage for a few moments. Donna is my confidante and my companion on the journey of life. She has been Mrs. Donna or Mom to our crew since we blended our families together in 1992. Thank you, Donna, for all of your love and support and for all that you do for all of us and for the blessing you are to all that you meet. I want to tell you about a book I have been reading that really resonates with me as a DO. In “Start With Why,” Simon Sinek makes the point that every company, every organization and I would say each of us

must ask this question of ourselves. What is your “Why?” In other words, Why do you exist? What gives you purpose and passion? What makes you get up excited to get going every morning? As health care continues to evolve in this country, now more than ever we must ask ourselves this simple, yet very important question: What is our “Why?” In the Charter of The American School of Osteopathy, back in 1897, Andrew Taylor Still stated our purpose: "The object of this corporation is to establish a College of Osteopathy, the design of which is to improve our present system of surgery, obstetrics and the treatment of diseases generally, and place the same on a more rational and sci entific basis.” You see, our “Why” has always been to improve care for the people whom we are privileged to serve. “Why?” It is such an important question for us as a profession and for each of us as individuals and as DOs. Why did you become a DO? For me, as you saw in the video, my time at Brentwood Hospital played a pivotal role in my decision. I saw how the DOs treated their patients, and I saw how ALL Oklahoma D.O. | July / August 2014

of the staff treated each other as family. It’s here where I learned about diversity, working together with a team of people of different colors, creeds and backgrounds for one great purpose to take great care of patients. Last September, I returned to what was Brentwood Hospital, as president of what is now South Pointe Hospital, and I can tell you that our caregivers still live out their “why” every day!

Steve and Elizabeth Juhasz, married at age 38 and had Oklahoma D.O. | July / August 2014

He left Hungary on Christmas Eve, 1944, when the Nazis had occupied the village where his family lived. Knowing that the Russians would invade overnight, he knew that he had to make a choice to stay with his family and be locked behind what would become the iron curtain, or to leave to seek new opportunities in a new land. He met his family in the wine cellars of the basilica and his mother and father encouraged him to go. He bid them and his younger brother and two sisters goodbye, never to see most of them again. He was 31 years old.

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Rediscovering my "Why" got me thinking about those who influenced my decision to enter the profession and who continue to impact me today.

My dad came from a beautiful village named Esztergom, on the Danube River, in Hungary. All of the kings of that country had been crowned in the basilica that sits high on a hill there. He built bridges as a Hungarian soldier, before World War II, and became a police officer.

Oklahoma D.O.

In coming back to where my osteopathic journey started, I have refound my "Why". To educate great osteopathic students and residents, take great care of patients with a great group of caregivers and improve the health of the communities that we serve.

me and my brother when they were 40 and 44 a feat unto itself in their day.

He set out on a journey to come to the United States which would keep him waiting in Czechoslovakian and German Red Cross Camps for seven years until he could get his chance to come to the United States. He had his chances to go to Australia or South America, but he chose to wait to come to the USA. He loved this country. He instilled in my brother and me what it meant to be an American citizen. To work hard, to be the best that you can be, to take care of your family and your neighbors, and to never forget where your strength comes from. Thank you Dad for giving me the gifts of perseverance and resilience!

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My mother was a wonderful woman with a big, kind heart and a fervent faith she shared with my brother and me. Having been the second oldest of eight brothers and a sister, she helped raise her siblings while my grandfather worked in a gunpowder factory and my grandmother tended to their small farm.

My mother taught me about the love of our Lord, about faith and how to pray, which has been such a tremendous gift throughout the years. She was also a selfless servant leader who taught me to listen and be patient, which has been invaluable in my relationship with my wife and family, in caring for patients as well as being able to care for and lead others. Thank you Mom for the gifts of patience, listening and faith!

My professional mentors greatly influenced my decision to enter our profession. I became a DO because of people like my chief, Bob DeRue, DO, a cardiologist. Bob taught me to take care of people, not problems. He taught me that all of us will be patients sooner or later and that we must learn something every day. Once we stop learning, we should stop. Many of my mentors taught me that we could improve health care for every one of our patients if we did this simple thing: treat them the way that we would want ourselves or our families to be treated. I am so grateful for people like Marcie Oliva and John Strosnider, who saw promise in a scrappy first-generation kid and pushed him forward. Their encouragement has made a huge difference to me. Today, I want you to think about the people who helped you answer your “Why” and recognize them as the Unsung Heroes, Guardians or Champions of the Profession. Thank you, Norm for establishing such a worthy pro-

gram and for your painstaking leadership this past year. John Becher and I will continue to work to meet the goals that you set for us. You know when you hang out with Norm you learn many things. One is you should be prepared to eat well and bring an appetite—Anthony Bourdain has nothing on you, my friend. And two when you’re a surfer, sometimes you have to paddle hard to catch a wave, and sometimes you get the opportunity to ride it. Thank you, Norm, for all of your hard paddlin’ this year! Oklahoma D.O. | July / August 2014

We’ve been talking about our “why,” the personal purpose that drives each one of us. But to have an even greater impact as a profession, we need to work together to answer four significant questions: • Who are we? • How do we teach? • What do we do? and • What difference do we make?

philosophy, practice and science of osteopathic medicine with a dedication to lifelong learning and mentorship.

The evolving health care environment is seeking solutions. As the osteopathic medical profession we can provide these solutions.

Some of you have heard me say, “You cannot not teach.” In other words whatever you’re doing, good or bad, is being watched and you are always a mentor — whether you know it or not.

So who are we?

We are DOs. We use the skill of touch to diagnose and to treat according to tenets set forth by Andrew Taylor Still. We get to know our patients as people and care for the whole person—body, mind and spirit. We know that the body has an amazing ability to heal and regulate itself. We understand that structure presupposes function if you want things to get to where they need to go, you have to be sure there is nothing in the way. And when we plan a treatment for our patients, it incorporates all of our unique tools into that plan of care.

When I met with students last fall at OMED, they said that when they didn't see DOs practicing osteopathically, that they felt that many of us had “broken our osteopathic promise.”

Many of the students who matriculate to our osteopathic medical schools were accepted at allopathic schools, but they chose to become DOs because they believe we care for patients in a different way. They were inspired by our “Why.” We need to keep our promise to these students and our patients and demonstrate the type of care we provide in all of our work.

What do we do?

In a study published in last December's Journal of the American Osteopathic Association researchers found

“ I ask you now to join me as we move confidently

forward together firmly rooted in our heritage...our "Why." Going forward boldly to reach for the stars, to improve all medical care through the shining light of osteopathic medicine!! ”

Oklahoma D.O. | July / August 2014

Why?

Most likely because, in our first week of school, we begin to learn osteopathic manipulative diagnosis and treatment. Developing this skill relies on our hands, to

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We train in many settings, from solo practices to the most prestigious academic medical centers; in teaching health centers and community hospitals. We train alongside our MD colleagues across the country, whether in a solo practice in an underserved community, or in a military hospital in Afghanistan. Much of the teaching we do is in small groups or using one-onone-preceptor based training. We train our residents to become our future faculty, to perpetuate the education,

that while empathy declined among third-and fourthyear allopathic and osteopathic medical students, it declined less so in the osteopathic medical students. When comparing the two groups of students, the one statistically significant difference between them was touch.

Oklahoma D.O.

How do we teach?

diagnose and treat, and to become comfortable with appropriate touch. Could this make a difference in how we provide care to our patients throughout our careers, whether we continue to incorporate OMM in our practices or not? Could it be that we are unique in how we care for our patients?

What difference do we make?

We do have something special to offer, and I would submit that we not only have the privilege, but the responsibility to offer the kind of care that we know can help people. We know patients benefit from our care. Now we must prove it. We must show that it is unique, that it makes a difference and is cost effective. We can do this through research, a key pillar of our Strategic Plan. Today, I’m challenging the colleges of osteopathic medicine, the state and specialty societies, the research institutes and all of you to work together as we develop the infrastructure to improve our research efforts and publications. If I had to describe our research environment right now, I would say it’s much like resuscitating a patient. When it comes to publishing major collaborative osteopathic research, it’s like running to a code. We run in and there is no pulse. We begin CPR. We hook up the AED and defibrillate thump! Every once in a while we have a major work published the low back pain study, the otitis media study, the MOPSE study, the empathy study. We get a zap of energy. We see QRS complexes cross the screen for a short period of time. We say, "Hot damn!" with excitement! Then we go flat line and we wait to do it all over again, whenever the next big study is published.

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I AM HERE TO TELL YA...WE NEED A PULSE! To jump-start our efforts, I’m appointing a task force to work with internal and external collaborative partners to develop strategies to fund and implement a research network infrastructure and grantsmanship that sets the stage for a steady stream of research. Through this collaboration, we will work towards the goal of publishing scholarly osteopathic research in the JAOA and other major journals at least every month. I have often said “The best awareness campaign is through well published research.” Our communications team at the AOA will have a pipeline of articles that will bring

greater understanding and awareness around the world about DOs and osteopathic medicine about the four vital questions we’ve been talking about today and give them the tools that they need to create the awareness that you have been asking for, another significant part of our Strategic Plan. The answers will not only help others have a better understanding of the profession but will also help the osteopathic family see that we continue to be relevant, especially to the growing number of younger DOs. I’d like to address this segment of members—our younger DOs—for a moment. This meeting, our organization and much of what we do is for you. We’re all about strengthening the profession by creating opportunities for you and training you to be our future leaders. We’re about creating the right partnerships and pathways that expand our ability to influence the practice of medicine and health policy. The Single GME Accreditation system is one strategy to do that but so is increasing OGME, investing in research, strengthening our policy efforts, and optimizing our management and governance structure in such a way that we can reinvest any savings in improved services to you. We will continue to strengthen those member services that provide you value and are relevant to your needs in a rapidly changing health care environment, and help you find joy in the work you do. We want you to be proud to be a member of the AOA! We are also working to collaborate with our state and specialty affiliates, to partner with and promote innovative programs like the ACOI’s Phoenix Physician and Leadership Training Programs. While there has been debate surrounding the agreement for the single GME accreditation system a primary goal has been to preserve access for DOs in all residency and fellowship programs. By doing so, we have the responsibility to develop osteopathically focused ACGME programs for DO residents in all of the specialties in which we train. As we move forward with the single accreditation system, we will now have our osteopathic standards, including NMM/OMM, codified in the largest GME accreditation system in the world! We will be a part of the governance of this new system with DOs serving to bring our influence to improve graduate medical education at all levels. We will continue to advocate for our excellent AOA-certified DO educators to serve as faculty and program directors in all ACGME training programs if they meet the standards on a level playing field. Oklahoma D.O. | July / August 2014

As I said when I represented the profession at the ACGME Board meeting last month, I would hold our AOA-certified faculty up as some of the best medical educators in the world!! We had said early on when we agreed to move forward with an agreement with AACOM and ACGME that this was "the end of the beginning” and now we are moving forward united!! United in the opportunity to share our “Why” with all medical educators and the public in ALL GME programs. These are exciting times for us as a profession. It’s an honor to serve as your president. I’m extremely proud to be part of this profession, part of this association, which will continue to be the professional home for all physicians who practice osteopathically. We know we cannot cling to the past while we are to working to create the future. We have two choices. One-we can just talk about seizing the opportunities that change has brought us and let ourselves be carried along into obscurity as a quaint anachronistic system of care. Or we can embrace the changes and realize the dream of Dr. Andrew Taylor Still…to make good on the vision of the old doctor and be the original health system reform he envisioned more than 140 years ago!

sibility! I know the AOA trustees know that this is our finest hour! One hundred years from now when the 218th President of the American Osteopathic Association gives this address, he or she will be able to speak about this moment in their history, about how we met the challenges before us, about how we seized the opportunities before us and how we improved care of patients throughout the world by improving all medical care through our leadership and the contributions of the unique education, philosophy, practice and science of osteopathic medicine. This is our “Why”… I ask you now to join me as we move confidently forward together firmly rooted in our heritage...our "Why." Going forward boldly to reach for the stars, to improve all medical care through the shining light of osteopathic medicine!!

The choice is clear!

When we articulate our answers, there is no doubt that every person would want the care provided by a DO.

Oklahoma D.O. | July / August 2014

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Now I ask for your help and your commitment to take the vision of a pioneer doctor and the work of so many, who have nurtured and sustained the osteopathic profession he founded and share it far and wide. I know we are up to the task that we will embrace our respon-

Oklahoma D.O.

We must now seize the opportunity before us. We must study our educational models, our philosophy, our practice and further the science of osteopathic medicine. We must demonstrate the difference our practice makes so that we will have the tools to share our message with our medical colleagues, policy makers and all who seek better care of patients through our healing influence. We must embrace our responsibility to let all of medicine and the world know: • Who we are • How we teach • What we do and • What difference it makes to the patients we are privileged to serve

2014

OKLAHOMA DELEGATION REPORT

written by Matt W. Harney, MBA

“

I think we put our head in the lion’s mouth and it's pretty scary. On the other hand, the guy that does it at the circus usually gets away with it. Now that it's done we need to all cooperate to make it work or we might get our head bit off. -Kenneth E. Calabrese, DO

”

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The American Osteopathic Association convened for the 2014 House of Delegates at the Fairmont Hotel in Chicago July 17-20, 2014. The House of Delegates (HOD) brought together osteopathic physicians from every state to discuss resolutions and approve national leadership. The HOD also included several reference committee and bureau meetings, which provided tremendous input on resolutions and other essential items of business. The AOA House of Delegates includes 473 delegates representing state societies as well as another 33 delegates from specialty organizations such as ACOFP (American College of Osteopathic Family Physicians), ACOEP (American College of Osteopathic Emergency Physicians), AOCR (American Osteopathic College of Radiology), and AOASM (American Osteopathic Academy of Sports Medicine) among many others. Every state receives one delegate automatically. Other state delegate positions are allocated based on the state’s AOA members as a proportion of national

AOA membership. These allocations are calculated every year. The District of Columbia and members of the military are also considered divisional societies along with the 50 states. This year, Oklahoma received 17 of 506 total delegates, effectively constituting more than 3% of the national delegation. Only Michigan (55), Pennsylvania (48), Florida (41), Ohio (34), California (29), New York (25), New Jersey (23), and Texas (20) had more delegates, making Oklahoma the 9th largest contingent. None of these eight states has a population larger than that of Oklahoma, speaking to the robust proportion of osteopathic physicians in our state. These figures include student delegates (of which Oklahoma had one). Oklahoma also had 12 alternate delegates in attendance. The House of Delegates meets annually in July to elect officers and discuss and formalize a wide range of organizational policies regarding program directors, osteopathic culture, diversity, medical education, and accreditation, among other topics. Oklahoma D.O. | July / August 2014

Oklahoma D.O.

Clearly, the most important, contentious and far-reaching issue facing the osteopathic profession this HOD was the resolution for single GME accreditation.

PAGE 13 photos provided by the american osteopathic association Oklahoma D.O. | July / August 2014

Thursday, July 17 The Credentials Committee and Bureau on Socioeconomic Affairs got things kicked off on the 17th with noon meetings. The Bureau of State Government Affairs, Council of Building, Committee on Rules & Order, and Bureau of State Affiliate Concerns also met Thursday. The AOA also provided two opportunities for delegates to review the MOU (Memorandum of Understanding) for the Single Accreditation System. The strictly-guarded viewing sessions were held 2:30-4:00p.m. and 9:30-10:30p.m. Only delegates and executive directors were allowed to view the MOU. No pictures of photocopies of the document were allowed, and every viewer received a uniquely numbered copy which was to be returned upon one’s exit from the viewing session. The Oklahoma delegation met Thursday evening to discuss various resolutions and housekeeping items and to provide a general overview for the following three days. Following the delegation meeting, all Oklahoma delegates and alternates attended the UFOS (United Federation of Osteopathic Societies) meeting. UFOS is a coalition that includes 42 (of generally the smallest) states, Washington D.C., and the Military. The federation was established to ensure these smaller states had a balanced role in the AOA’s policies and leadership. Oklahoma is one of the largest state delegations within UFOS. Donald J. Krpan, DO, is the chair of UFOS.

Oklahoma D.O. PAGE 14

Following a welcome and introductions, the federation moved forward with business. Candidates interested in being considered for an AOA Board of Trustees position as a UFOS nominee provided remarks in front of the entire federation. Layne E. Subera, DO, and Trudy J. Milner, DO, proudly represented Oklahoma as candidates. The single GME accreditation resolution was also discussed at this meeting. Outgoing AOA President Norman E. Vinn, DO, started this discussion by admitting there seemed to be uncertainty regarding single GME accreditation, but asked the question, “under our current system, what happens to the osteopathicness of our programs?” Dr. Vinn went on to say, “We’ve been studying the possibility of the merger for two years. Now we need to begin the process and see how it evolves. There are options for us to pull out.” Regarding the assertion the AOA Board of Trustees went beyond its authority in signing the MOU, he said, “we made a governance decision that’s technically within the purview of the Board.” Also joining Dr. Vinn was Boyd R. Buser, DO, who also serves on the AOA Board of Trustees. Dr. Buser was a central character in advocating for single accreditation, which has also been referred to as the “single pathway” and “unified accreditation” among other monikers. Dr. Vinn report-

ed Dr. Buser had made 90 conference calls and presentations regarding the MOU in the last 3 months. Before opening the floor to questions, Dr. Vinn stated the MOU and single accreditation is a “very nuanced discussion with many moving parts.” Several questions were asked including specifics regarding the ACGME bylaws as well as the ability of the new Board to protect the osteopathic profession. One California delegate stated, “I don’t get the motivation for this!” before asking about the prospects for specialty and fellowship slots being reserved only for osteopathic physicians. Oklahoma delegate and OOA Trustee Gabriel M. Pitman, DO, asked about residency program directors. Dr. Pitman indicated program directors from Oklahoma have expressed opposition mentioning that it appeared many programs wouldn’t be allowed to continue under new guidelines. Dr. Buser answered, “Programs will not be closed solely on the basis of size. RRCs (Residency Review Committees) can approve credentials of program directors. Some do not have ABMS (American Board of Medical Specialties) certification. Our basic standard is to receive AOA Board certification.” He continued by saying each program could appoint a co-director who is ABMS certified. “If a program can meet every single standard but the ABMS certification and it’s rejected, we’ll shine a light on that and it will be adjudicated.” Dr. Pitman followed up by asking if the nonclinical hours requirement can be modified. Dr. Buser replied that is decided by specialty and will be decided through the residency review committee process. After the question-and-answer period closed, UFOS moved to support single GME accreditation as a whole. Oklahoma was one of nine states within the UFOS caucus that successfully moved to be exempt from this unanimous support. Oklahoma Chair David F. Hitzeman, DO, made the motion on behalf of the delegation. Several very small states were absent, but the remaining states decided to support single accreditation. Nationally, osteopathic colleges graduate just more than 5,000 students per year. However, only about 3,000 osteopathic resident slots are currently available. Due to the work of many, Oklahoma does not face this problem. Oklahoma State University College of Osteopathic Medicine, Oklahoma’s only osteopathic university, graduates 115 students per year and has approximately 130 residents slots available counting all specialties and fellowships. In other words, Oklahoma is a national leader in successfully developing funded residency positions for its students. Oklahoma D.O. | July / August 2014

Oklahoma D.O. | July / August 2014

The morning session also featured time for questions and answers in front of the entire HOD regarding the single accreditation system. Dr. Buser fielded questions while Vice Speaker of the AOA House of Delegates David L. Broder, DO, of New York presided.

PAGE 15

AOA Executive Director & CEO Adrienne White-Faines, MPA, shared remarks on her first full year at the helm of the national association. Mrs. White-Faines announced the AOA ended the fiscal year with a $1 million surplus despite a $3 mil-

lion deficit being projected at the start of the fiscal year. WhiteFaines also touted a burgeoning profession, as 60percent of practicing DOs are under the age of 45. This does not include the 22,000 osteopathic medical students nationwide. She also shared the AOAâ&#x20AC;&#x2122;s three-year strategic plan, which will be used to develop its long-term plan. The strategic plan focuses on member engagement and revenue reliance, practice service delivery, research alignment, and continued collaboration and partnership development.

Oklahoma D.O.

Friday, July 18 Friday kicked off the first day of the full House of Delegates business, with Oklahoma delegates wearing matching blue ties and scarves featuring the Oklahoma Osteopathic Association logo. Several reports were provided that morning to the full House, alternate delegates and staff. Also, several reference committees met that afternoon including the Ad Hoc Committee, Committee on Constitution & Bylaws, Committee on Education, Committee on Professional Affairs, Committee on Public Affairs, Committee on Resolutions, Joint/Board House Budget Review, and the Special Reference Committee on Single Accreditation System.

Other fun facts from the morning session: • The AOA has $27.5 million in reserves • The AOA has net assets of more than $43 million (plus the Chicago building that hous es the AOA Headquarters is underestimated by nearly $15 million). • Mark A. Baker, DO, of Texas serves as chair of the Strategic Planning Committee and announced operational metrics for the AOA that include a goal of at least 10 new residency program leads per year. That evening the entire Oklahoma delegation enjoyed dinner at Benny’s Chop House. Spouses were invited to attend. Also attending were all five students from Oklahoma who were in attendance at the HOD. They included second-year students Brittany Cross, Bob Aran, Taylor Craft, and Alex Smith, as well as third-year student at OSU-COM Matthew Smith. The evening kicked off with a short reception that transitioned to dinner. Oklahoma Osteopathic Association President Michael K. Cooper, DO, provided welcoming remarks for what was undoubtedly going to be a spirited weekend for the House of Delegates. Following dinner, delegates were encouraged to attend Oklahoma’s hospitality suite which enhances delegation camaraderie but also provides networking opportunities with delegates from other states.

Oklahoma D.O. PAGE 16

Saturday, July 19 July 19, 2014, will prove to be a historic day for osteopathic medicine. OOA President Dr. Cooper and delegation Chair Dr. Hitzeman called a special meeting for 6:45 a.m. to discuss its position on single GME accreditation in advance of the full meeting and vote by the HOD. The House of Delegates convened at 7:30 a.m. for the nominations to the AOA Board of Directors and other leadership positions for the following year. The morning session continued with a report for the AOIA Political Action Committee and the role it plays in congressional elections. The PAC supports pro-physician candidates of both political parties for the House and Senate. PAC support is determined by a candidate questionnaire among other factors. The Oklahoma delegation yet again was proud to have 100% delegation participation (including alternate delegates) and submitted $6,600 in contributions to the AIOA PAC. Next up was the A.T. Still Memorial Lecture by William D. Strampel, DO. Dr. Strampel serves as Dean of the College of Osteopathic Medicine at Michigan State University and specializes in pulmonology and critical care. In his remarks, Dr. Strampel referred to the underdeveloped understanding of medicine in the days before Dr. Still.

Many physicians who pre-dated Dr. Still gave patients arsenic, opium, lead, mercury, or alcohol to cure their ills. However, A.T. Still, MD, DO, was a “disruptive innovator” whose new way of thinking challenged the status quo. Dr. Strampel drew parallels between the trailblazing courage of a rural Midwesterner doctor (Dr. Still) and the unique opportunity to address challenges facing DOs today. Dr. Strampel asked the delegates to consider, “What would A.T. Still do if he were around today?” Dr. Strampel closed by stating, “We should build on the solid foundation Still set down as a history of innovation and dedication to medicine. We, this profession, have changed the face of American medicine.” The House of Delegates then took up what was considered by some to be the most important issue in decades—single GME accreditation. At the outset, it was announced that 75 minutes of debate would be allowed. Rules were announced regarding timing and process before the floor was opened to debate. ACOFP (American College of Osteopathic Family Physicians) President Carol L. Henwood, DO, proposed the ACOFP Resolution H-812, effectively creating many protections for the single accreditation proposal submitted by the AOA Board of Trustees in the form of Resolution H-800. The essence of the amendatory ACOFP resolution (submitted with the support of the ACOP, AOASM, AOAPRM, AOCD, AOCOPM, AOCP, AOSRD, as well as the state associations in Iowa, Nevada, New Jersey, and New York) is as follows: OOA Trustee and delegate Ronald S. Stevens, DO, was one of several physicians who spoke in favor of H-812. After approximately 25 minutes of debate, a delegate rose and called the question. This effectively forced an up-ordown vote on the amendatory language. The amendment failed to receive a two-thirds vote and died. The House then moved forward with debate on H-800. Viewpoints were expressed both in support and opposition to the measure. The primary concerns dealt with ensuring osteopathic distinctiveness, the uncertainty surrounding the RRC process, the viability of maintaining small programs, new requirements for program directors, ACGME progress reports from the AOA, and the influence (or lack thereof ) of the new ACGME Board positions reserved for DOs. With 23 minutes of debate still remaining, the question was called. The resolution passed with several Oklahoma delegates voting in opposition to the measure. Therefore, the single GME accreditation was passed. The resolution outlined the process, format, and timeline for transition to a single, unified GME accreditation system. Following passage of the H-800, delegates took a short break and then continued review of resolutions. At noon, the House adjourned for the House of Delegates Annual Awards Luncheon. At the luncheon, the Oklahoma State Oklahoma D.O. | July / August 2014

University College of Osteopathic Medicine received the Strategic Team Award and Recognition (STAR). The President and Provost of OSU Center for Health Sciences and Dean of OSU-COM Kayse M. Shrum, DO, accepted the award on behalf of the college. Following the awards luncheon, the House continued discussion on a host of resolutions. At 4 p.m., incoming AOA President Robert S. Juhasz, DO, was sworn in by outgoing President Norman E. Vinn, DO, and gave his Inaugural Address. Dr. Juhasz is an AOA board-certified internist and president of Cleveland Clinic’s South Pointe Hospital in Warrensville Heights, Ohio. Dr. Juhasz graduated from the Kansas City (Missouri) University of Medicine and Biosciences’ College of Osteopathic Medicine and completed his residency at what is now South Pointe Hospital. Dr. Juhasz has been named a “Top Doc” by Cleveland Magazine and was awarded the Phillips Medal of Public Service by OU-HCOM. He also is an honorary alumnus at OUHCOM and received the Ohio Osteopathic Association Trustee Award. Dr. Juhasz is the 118th president of the American Osteopathic Association.

oklahoma delegation

d E L E g A T E S

Sunday, July 20 The House of Delegates spent Sunday morning continuing its discussion and review of resolutions. One resolution of particular noteworthiness was H-345, submitted by the Ohio Osteopathic Association. The successful resolution seeks to promote opportunities for medical students to document and practice order entry in electronic medical records (EMR) at facilities where osteopathic medical students are trained. The resolution noted that only 64 percent of medical school programs allowed students to use their EMR and only two-thirds of those programs permitted students to document and write notes in those records.

Oklahoma D.O. | July / August 2014

Kenneth E. Calabrese, DO Thomas J. Carlile, DO Joseph R. Schlecht, DO William J. Pettit, DO James P. Riemer, DO Gordon P. Laird, DO Christopher A. Shearer, DO Justin S. Sparkes, DO Tammie L. Koehler, DO H. Zane DeLaughter, DO John F. Rice, DO Ray E. Stowers, DO Jonathan B. Stone, DO B. Eric Blackwell, DO Jason L. Hill, DO Dale Derby, DO Bob Aran, OMS-II PAGE 17

bit.ly/1p5YgCk

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Oklahoma D.O.

for a complete list of all the 2014 resolutions with the actions from the house visit:

A L T E R N A T E S

1 Michael K. Cooper, DO, Chairman of Delegation 2 C. Michael Ogle, DO, Vice Chairman of Delegation 3 David F. Hitzeman, DO 4 Layne E. Subera, DO 5 Bret S. Langerman, DO 6 Stanley E. Grogg, DO 7 Gabriel M. Pitman, DO 8 Dennis J. Carter, DO 9 LeRoy E. Young, DO 10 Duane G. Koehler, DO 11 Scott S. Cyrus, DO 12 Kayse M. Shrum, DO 13 Melissa A. Gastorf, DO 14 Timothy J. Moser, DO 15 Trudy J. Milner, DO 16 Ronald S. Stevens, DO 17 Brittany Cross, OMS-II

in their own words Delegates

What did you like most about the AOA House of Delegates (HOD) experience? “A chance to give direction, through our delegation, to the AOA.” -Kenneth E. Calabrese, DO “Representing Oklahoma DO's” -Ronald S. Stevens, DO “As a student representative and Oklahoma delegate at the 2014 AOA House of Delegates, I liked being able to express the opinions and concerns of students in my state and being able to vote on the issues presented to the House.” -Brittany Cross, OMS-II

“I really enjoyed the interaction with my peers and being able to actively advocate for our profession.” -Jason L. Hill, DO “Potential for direct input into decisions on policy and effect the direction of the osteopathic profession and the ability to renew old acquaintances and make new contacts with leaders of the profession from around the country.” -David F. Hitzeman, DO

“I really enjoyed hearing all the different points of view from so many brilliant people. I've always been impressed with our osteopathic leadership and it was great to be a part of such an important weekend. While not everyone had the same opinion on the single accreditation, everyone had a unique and well thought-out argument. Knowing that we have so many bright people looking at all sides of the single accreditation gave me a ton of confidence about the future of medicine.” -Bob Aran, OMS-II

Oklahoma D.O. PAGE 18

What makes the AOA House of Delegates meeting important? “This is where all the states can come under one roof and represent their peers on a national level. The policies made here affect all osteopathic physicians. The HOD is the platform for all states and national councils to come together and direct the way our profession moves forward.” “Ability to demonstrate the leadership abilities of individual members -Bob Aran, OMS-II of the delegation and the state association by active involvement in AOA policy decisions, as well as, direct involvement in the political “This meeting is THE opportunity for membership process of the AOA. Ability for direct conversations with present and to give directions/bind the Board of Trustees (through future leaders of the profession that facilitates Oklahoma members Resolutions) to the membership’s will.” involvement on the Bureaus, Councils and Committees of the AOA. -Ronald S. Stevens, DO Opportunity for Oklahoma members to be involved in the process to determine AOA Board of Trustee positions. Making personal contacts and building relationships with past, present and future leaders enhances Oklahoma’s ability to continue to be an effective participant “The AOA House of Delegates gives each state, specialty orgaand leader in our profession at the national level.” nization, residents and students an opportunity to influence -David F. Hitzeman, DO the policies of the AOA. As the legislative body for the AOA, the House of Delegates is important because the policies set by “Peer networking and a chance to voice our ideas the House will directly affect osteopathic physicians and the and concerns with the board.” profession as a whole.” -Jason L. Hill, DO -Brittany Cross, OMS-II Oklahoma D.O. | July / August 2014

What are your thoughts on the HOD decision to begin the transition to single GME accreditation? “Disappointed, concerned that this decision is the first step in unification of all post-graduate education.” -Jason L. Hill, DO “I am in favor of the final resolution after the amendments were added to ensure timely feedback on the progression of the process; the annual reports to the HOD is critical and will allow continued input by the entire profession and allows for withdrawal if it appears the profession as a separate entity is in jeopardy. The need for our profession to be able to provide post-doctoral training opportunities for all of our graduates is critical and accessibility to ACGME programs is necessary. I believe that change is always difficult and the concerns of our specialty societies and affiliates are well understood by our leaders and osteopathic interests will be best served by being part of the process, ie. ‘at the table,’ during the transition period. I have known the majority of those who have negotiated thus far and am confident of their commitment to maintaining the Osteopathic Profession and its core principles while dealing with this important and complex issue.” -David F. Hitzeman, DO

“I am excited for the future and the HOD's decision to move forward with single GME accreditation. This move secures our students’ option to continue our osteopathic training through residency and still enter any fellowship in the country. It also unites the allopathic and osteopathic schools to spearhead the future of GME as a team. While not all the questions about single accreditation have been answered, I am fully confident the leaders I meet at the HOD and the future student leaders I know from around the country will lead us into a bright future. Osteopathic physicians have historically been determined advocates for patients' wellbeing and in promoting our principles. Single GME accreditation is the next step our profession is taking to champion our cause, and I am very optimistic about our future.” -Bob Aran, OMS-II

“I was against the final resolution as I felt it would be harmful to what we have accomplished in the way of residency creation and some of our current residencies. However, since this was a democratically accomplished decision, I see my role as working within this new resolution to find ways of minimizing the damage and exploiting the possibilities.” -Ronald S. Stevens, DO

PAGE 19

Oklahoma D.O. | July / August 2014

“My thoughts on the unified GME accreditation are that this transition will benefit the osteopathic profession. Having a single standardized system will ensure that each GME program consistently prepares competent physicians. Furthermore, because the unique practices and principles of the osteopathic profession will remain intact, this will allow osteopathic medicine to continue to thrive and further contribute to health care in the United States.” -Brittany Cross, OMS-II

Oklahoma D.O.

“I think we put our head in the lion’s mouth and it's pretty scary. On the other hand, the guy that does it at the circus usually gets away with it. Now that it's done we need to all cooperate to make it work or we might get our head bit off.” -Kenneth E. Calabrese, DO

Oklahoma D.O. PAGE 20

Oklahoma D.O. | July / August 2014

AACOM STATEMENT on AOA HOUSE OF DELEGATES VOTE TO

SUPPORT SINGLE CME ACCREDITATION SYSTEM

Delegates representing the nation’s more than 104,000 osteopathic physicians (DOs) and osteopathic medical students voted Saturday to support a decision by the American Osteopathic Association (AOA) Board of Trustees to pursue a new, single accreditation system for graduate medical education (GME). This decision clears the way for DO and MD granting medical schools, hospitals, and community health centers to develop a single standard for residency program training. Graduating students from DO or MD schools can now become board-eligible, practicing physicians in the United States through a single accrediting system. “The outstanding work of the leaders of the osteopathic profession and osteopathic medical education, as well as the tireless commitment of student organizations around the country, all made it possible to develop this landmark proposal and move it forward to final passage,” said Dr. Stephen C. Shannon, President, American Association of Colleges of Osteopathic Medicine (AACOM). “As we now move into implementation of single GME accreditation, future generations of physicians will be empowered to use the principles and practice of osteopathic medicine to meet the challenges of a changing healthcare system.” This historic vote during the annual meeting of the AOA House of Delegates comes after an announcement in February that AACOM, the AOA, and the Accreditation Council for Graduate Medical Education (ACGME) reached an agreement to work together to prepare future generations of physicians. When fully implemented in July 2020, the new system will allow graduates of U.S. DO and MD medical schools to complete their residency and/or fellowship education in ACGME-accredited programs and demonstrate achievement of common milestones and competencies. AACOM strongly believes the public will benefit from a single standardized system to evaluate the effectiveness of GME programs for producing competent physicians. Through osteopathic-focused residency programs, the new GME accreditation system will recognize the unique principles and practices of the osteopathic medical profession and its contributions to health care in the United States.

Oklahoma D.O. | July / August 2014

PAGE 21

AACOM was founded in 1898 to support and assist the nation's osteopathic medical schools, and to serve as a unifying voice for osteopathic medical education. AACOM’s mission is to promote excellence in osteopathic medical education, in research and in service, and to foster innovation and quality among osteopathic medical colleges to improve the health of the American public.

Oklahoma D.O.

About AACOM The American Association of Colleges of Osteopathic Medicine (AACOM) represents the 30 accredited colleges of osteopathic medicine in the United States. These colleges are accredited to deliver instruction at 42 teaching locations in 28 states. In the 2013-14 academic year these colleges are educating over 23,000 future physicians – more than 20 percent of US medical students. Six of the colleges are public and 24 are private institutions.

d.O.

What’s the difference? By JoAnn Ryan, DO, Emeritus Associate Professor, Oklahoma State University College of Osteopathic Medicine & Harriet H. Shaw, DO Professor, Oklahoma State University, College of Osteopathic Medicine

What do patients say when asked: “What is the difference between an MD and a DO?” We’ve heard that DO’s are caring, holistic, empathetic, open to alternative treatments, more hands on, use manipulation, and the like.

Oklahoma D.O. PAGE 22

But even osteopathic physicians are often vague about the difference. At a recent meeting with prominent DO’s, the answer was “OMM is not the only difference between DO’s and MD’s…….” leaving that awkward silence, as if they couldn’t quite articulate what explains the difference. In view of the proposed changes in graduate medical education, it seems important for us to elucidate the differences. Our conclusion based on discussion, and some research, is that the behavioral differences between the two professions is directed by the osteopathic tenets. Consider each of the tenet and their attendant behaviors: The body is a unit; the person is a unit of body, mind, and spirit. This concept compels the physician to take a broader view than the chief complaint, and enter into patient centered communication; listening, observing body language, seeking to understand cultural implications, and making the patient a partner in their treatment plan. The body is capable of self-regulation, self-healing, and health maintenance. This tenant focuses the osteopathic physician on opportunities to grow the health within an individual. Andrew Taylor Still, MD, DO, said, “Anyone can find disease, it’s the osteopathic physician’s job to find health.” Growing the individual’s health requires an individualized plan for improved nutrition, exercise, weight optimization, stress management and other “lifestyle” issues. Structure and function are reciprocally interrelated. While not the only difference, OMM (osteopathic manipula-

tive medicine) is the most obvious and acknowledged. In her “Core Competency Curriculum,” Lisa A. DeStefano, DO, chair of the Department of Osteopathic Manipulative Medicine at the Michigan State University College of Osteopathic Medicine says that “A. T. Still’s writings did little to describe osteopathic manipulative technique, instead focusing on the meticulous study of normal anatomy and physiology, with particular focus on the autonomic nervous system, lymphatic system, and vascular circulation. …However, the role of OMM is clearly defined by the respect we have for normalizing physiological function in our patients.” Our goal is to affect the physiology, not just describe it. Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function. When DO’s give the tenets priority in their thought processes and treatment planning, they are engaging in the unique work of the osteopathic physician. So yes, there is a difference between DO’s and MD’s, and no, it is not just OMM. It is rooted in the osteopathic philosophy and principles of our tenets. Of course other professions demonstrate these principles in some ways, and, not all DO’s demonstrate all of the behaviors all the time. But, as a professional group, these tenets are our guidelines. Even though we may not be able to recite them word for word, we live by them and our patients recognize us by the behaviors they incite. We can support the concept of unified graduate medical education certification. But, in view of these significant differences we believe that osteopathic medicine must be preserved as a separate and unique profession. As part of that preservation, the program directors of all osteopathic programs must be osteopathically trained physicians. Oklahoma D.O. | July / August 2014

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Oklahoma D.O.

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Oklahoma D.O. | July / August 2014 OK_OsteoSoc_full_1c_7'375x9'75.indd 1

3/28/11 11:05 AM

8:00 am – Noon

Exhibits Open

8:00 – 9:00 am “Update on Sexually Transmitted Infections” Bryan C. Roehl, DO, FACOOG (certified obstetrics & gynecology, Ada, OK) 9:00 – 10:00 am “Regional Response to a Bioterrorism Event in Oklahoma” Justin W. Fairless, DO, NRP, FACEP, FAAEM (certified emergency medicine, Tulsa, OK) 10:00 – 11:00 am “Got FEVER? Woes of International Travel” Arthur G. Wallace Jr., DO (certified emergency medicine, Tulsa, OK) 11:00 am – Noon “Radiation Events - What You Need to Know” David E. Hogan, DO (certified emergency medicine, Oklahoma City, OK)

program chair

Friday – January 30, 2015 Noon – 6:00 pm

Registration

2:00 – 6:00 pm

Exhibits Open

2:00 – 3:00 pm “Venomous Snakebites in Oklahoma & Their Management” Boyd D. Burns, DO, FACEP, FAAEM (certified emergency medicine, Tulsa, OK) 3:00 – 4:00 pm “Inhalational Insults” Daniel A. Nader, DO, FACCP (certified internal medicine, pulmonary medicine & critical care medicine, Tulsa, OK)

Oklahoma D.O. PAGE 24

4:00 – 5:00 pm

“Sepsis Update” Billy R. Bryan, DO, FACOEP, FACEP (certified emergency medicine, Oklahoma City, OK)

Noon – 2:00 pm Lunch Lecture-Legislative Update 2:00 – 3:00 pm “K2 and Bath Salts” Timothy A. Soult, DO, FACEP (certified emergency medicine, Oklahoma City, OK) Proper Prescribing Lecture – Sign-In Required for Credit 3:00 – 5:00 pm Risk Management Course – Sign-In Required for Credit Brenda Wehrle, BS, LHRM, CPHRM (Senior Risk Management Consultant, Brentwood, TN) 5:00 – 6:30 pm

Mentor Mentee Reception

Sunday – February 1, 2015 7:00 am

Registration & Continental Breakfast

8:00 – 9:00 am

“The Hypertensive Thugs of Pregnancy" Joseph R. Johnson, DO, FACOOG (certified obstetric & gynecological surgery, Tulsa, OK)

9:00 – 10:00 am

"Stuck on You...Tick Born Disease" Shelly R. Zimmerman, DO (certified emergency medicine, Oklahoma City, OK)

10:00 – 11:00 am “Bioterrorism in the 21st Century: A Brief History and Lessons Learned From Armed Forces Around the World” Guy W. Sneed, DO, FACOOG (certified obstetric & gynecologoical surgery, Tulsa, OK)

5:00 – 6:00 pm “Vaccine Voodoo…. Just Get it Done” Stanley E. Grogg, DO, FACOP (certified pediatrician, 11:00 am – Noon “Orthopedic Evaluation of Bone & Joint Infections & Tulsa, OK) Treatment” 6:00 –7:00 pm OOA Past Presidents and District Presidents M. Sean O’Brien, DO (certified orthopedic surgery, Meeting Oklahoma City, OK) 6:00 – 7:00 pm

OOA New Physicians Meeting

Saturday – January 31, 2015 7:00 am

Registration & Continental Breakfast

8:00 – 9:30 am

Bureau on CME Meeting Oklahoma D.O. | July / August 2014

On or Before 1/23/15 After 1/23/2015 q DO Member Registration* $340 $365 q DO Member Saturday Proper Prescribing & Risk Management Registration $180 $205 q Retired DO Member Registration* $80 $105 q DO Nonmember Registration* $840 $865 q Nonmember Saturday Only Registration $680 $705 q MD/Non-Physician Clinician Registration* $340 $365 q Student, Intern, Resident, Spouse, Guest Registration free free *Includes: Proper Prescribing Course, 2 Continental Breakfasts & Saturday Luncheon

REGISTRATION INFORMATION Registrant Name (please print): ____________________________________________________________________________ please indicate: qPhysician qIntern qResident qOMS-I q OMS-II q OMS-III q OMS-IV Preferred First Name to Appear on Name Badge: _______________________________________________________________ Other Professional/Guest: _________________________________________________________________________________

PAYMENT INFORMATION

q Check Enclosed

q VISA/MASTERCARD

q DISCOVER

q AMERICAN EXPRESS

Credit Card No.: _____________________________________ Card Exp. Date: ________ 3 Digit CID Number: ___________ Billing Address: __________________________________________________________________________________________ City: _______________________________________________ State: _____________ Zip: ___________________________ Preferred Telephone: (_______)_____________________________ Email address: ____________________________________

ONLY Electronic syllabus is available for this meeting. Please bring appropriate viewing device.

Mail Registration Form & Payment to: OOA at 4848 North Lincoln Boulevard, Oklahoma City, OK 73105-3335 or Fax to 405-528-6102.

Oklahoma D.O. | July / August 2014

PAGE 25

Requests for refunds must be received before January 23, 2015, and a $25 service fee will be charged.

Oklahoma D.O.

Signature: _______________________________________________________________________________________________

American Osteopathic Association Health For the Whole Family

“Food Poisoning: Your Guide to Prevention” Signs and Symptoms

Are signs of food poisoning immediate? “Not always,” says Dr. Caudle. “Symptoms may start anywhere from a few hours or days after eating foods contaminated with harmful bacteria, such as salmonella, which is found in contaminated raw meat, eggs or dairy products,” she continues. While symptoms vary due to the type of bacterial contamination, according to Dr. Caudle, sufferers can expect to experience one or more common symptoms like nausea, vomiting, diarrhea, fever, and abdominal pain and cramps. While most symptoms are mild and can be treated at home, Dr. Caudle recommends seeking medical attention if you begin experiencing these severe symptoms: • Frequent episodes of vomiting or vomiting blood • Severe diarrhea for more than three days • Blood in bowel movements • Severe abdominal cramping

Oklahoma D.O. PAGE 26

• Temperature higher than 101.5 F Every year, millions of people experience symptoms related to food poisoning. Typically, symptoms are mild; however, in some instances they can escalate and lead to complications such as paralysis, kidney failure and even death. With symptoms ranging from mild to severe, often it is difficult to recognize the signs. So, how can you know for sure if your illness is just a minor digestive issue or a case of food poisoning? Jennifer Caudle, DO, an osteopathic family physician from Philadelphia, discusses the signs of food poisoning and provides food safety tips to keep you healthy.

• Dehydration signaled by excessive thirst, dry mouth, little or no urination, severe weakness, dizziness or lightheadedness • Difficulty speaking • Trouble swallowing • Double vision • Muscle weakness that progresses downward Food poisoning symptoms often begin to improve on their own within 48 hours. Dr. Caudle recommends visiting your physician for treatment if your symptoms Oklahoma D.O. | July / August 2014

Preventive medicine is just one aspect of care osteopathic physicians (DOs) provide. DOs are fully licensed to prescribe medicine and practice in all specialty areas, including surgery. DOs are trained to consider the health of the whole person and use their hands to help diagnose and treat their patients.

linger or escalate. She also stresses paying close attention to high-risk groups such as infants, older adults, and people with suppressed immune systems for signs of severe dehydration, as they may need to be hospitalized in order to receive intravenous fluids.

Steps to a Smooth Recovery

Food poisoning symptoms can be unbearable. However, there are a few things that you can do to improve your comfort level and prevent dehydration while you recover. Dr. Caudle recommends: • Sucking on ice chips, taking small frequent sips of water, or drinking clear soda or broths. Drinking plenty of fluids is important to avoid dehydration. • Easing back into eating by gradually adding bland, easy-to-digest foods like soda crackers, toast, gelatin, bananas and rice into your diet. • Avoiding certain foods and substances, such as dairy products, caffeine, alcohol, nicotine and fatty or highly seasoned foods, until you feel better. • Getting plenty of rest.

• Use hot, soapy water to wash the utensils, cutting board and other surfaces you use. • Keep raw meat, poultry, fish and shellfish away from other foods in order to prevent cross-contamination. • Immerse and rinse fruits, vegetables and prepackaged salad leaves before eating. • Use a food thermometer to cook foods to a safe temperature. • Refrigerate or freeze perishable foods within two hours of purchasing them. • Thaw foods safely by defrosting them in the refrigerator, in the microwave using the "defrost" or "50% power" setting, or by running cold water over them. • Thawing food on the kitchen counter should be avoided, as food left at room temperature too long may contain bacteria or toxins that can't be destroyed by cooking.

Food for Thought

• Wash your hands well and often with warm,

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“Generally, implementing food safety guidelines and practicing safe hygiene and sound judgment about uncertain foods is the key to reducing your food poisoning risk and maintaining good health,” says Dr. Caudle. “If Tips to Prevent Food Contamination and you aren't sure if a food has been prepared, served Poisoning While there is no guaranteed method to prevent food or stored safely, discard it,” she advises. “Trust your poisoning, there are a few key steps that you can take to instincts. If there is any type of doubt about your food, just throw it out.” DO reduce your risk. Dr. Caudle suggests that you:

Oklahoma D.O.

• Avoiding anti-diarrheal medications (unless pre- scribed by your physician), as drugs intended to treat diarrhea may slow elimination of bacteria or toxins from your system and may make your condition worse.

soapy water before and after handling or preparing food.

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CENTER FOR HEALTH SCIENCES Mousumi Som, DO, FACOI Assistant Professor of Medicine Department of Internal Medicine

Hepatotoxic Injury in a HIV Positive Patient on Emtricitabine/Rilpivirine/ Tenofovir Therapy Celeste Boeckman, DO Internal Medicine Resident Oklahoma State University Medical Center Mousumi Som, DO, MS Internal Medicine Program Director Oklahoma State University Medical Center Jeffrey S. Stroup, PharmD, BCPS Associate Professor of Medicine Oklahoma State University Medical Center Introduction The use of antiretroviral medications in the treatment of Human Immunodeficiency Virus (HIV) has demonstrated a decrease in transmission rate, the occurrence of opportunistic infections, and mortality (1,2). Antiretroviral therapy has been shown to reduce the amount of HIV-1 copies in genital secretions, which likely reduces transmission rates (1). An increase in the estimated survival rate has also been shown through improvement in CD4 T-cell counts and immune function (3).

Patient willingness and compliance should be considered, and the treatment regimen should be tailored to patient convenience and tolerability. In addition, every effort should be made to reduce the likelihood of drug toxicity (6). Although there are benefits to antiretroviral therapy, adverse side effects must be taken into consideration. Complications include: bone, cardiovascular, renal, and neurologic disease. One well known complication is hepatotoxicity. Guidelines recommend routine laboratory evaluation when patients are on treatment. An elevation in liver enzymes has been a guide for the diagnosis of hepatotoxicity. The severity of hepatotoxicity ranges from fulminant hepatic failure to the absence of symptoms. There are many confounding

factors that make the diagnosis of hepatotoxic injury difficult to establish and further work up must be performed (3,7). Case Presentation A 23 year old Hispanic female with a history of HIV presented with an initial CD4 count of 420 and an undetectable viral load. She had been taking emtricitabine/rilpivirine/ tenofovir three months prior and on a routine complete metabolic panel was found to have an elevated ALT and AST at 95 and 69 respectively with a normal bilirubin and alkaline phosphatase. At that time, it was thought to be related to emtricitabine/rilpivirine/tenofovir and the medication was discontinued. Monthly complete metabolic panels showed a peak in her transaminases with an ALT of 448 and an AST of 354 three months after discontinuation of the emtricitabine/rilpivirine/tenofovir therapy. In the fourth month her ALT and AST began to decline to 161 and 272 respectively. At month sixth, her ALT and AST continued to decline and stabilize at 160 and 112. A thorough history was performed. An accurate medication list was obtained which only included emtricitabine/rilpivirine/tenofovir and a once a day multivitamin. She was asked about alcohol or illicit drug use for which she denied. She stated she was in a monogamous relationship. No significant family history related to liver disease was documented. She denied recent travel and had not been outside of the United States for the past 10 years. Review of systems was negative for abdominal pain, diarrhea, melanotic stools, fatigue, pruritus, weight loss or gain, and sore throat. Physical exam showed a well-nourished female who appeared to be her stated age. There was no evidence of scleral icterus or jaundice. Her abdominal exam was negative for tenderness to palpation, hepatomegaly or splenomegaly. Bowel sounds were detect-

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(2). Patients presenting with acute HIV syndrome and an AIDS defining illness should also be offered treatment (2,4). For example, trials have demonstrated that when patients with a CD4 count below 50 who presented with tuberculosis (TB) meningitis had improved AIDS- free survival when antiviral treatment was offered within the first 2 weeks of TB treatment (2). Patients with concomitant hepatitis B or C infection, when treatment is indicated, should be offered treatment. Hepatitis C has become the most common cause of morbidity and mortality in HIV-HCV coinfected patients. Patients have an accelerated rate of fibrosis progression, a higher incidence of liver cirrhosis and end-stage liver disease, and development of hepatocellular carcinoma at a younger age. Treatment has assisted in avoidance of a further increase in liver-related morbidity and mortality in the HIV population (5). If patients develop HIV-associated nephropathy they should also be offered treatment as it has been shown to improve survival and overall kidney function (2).

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Approximately 10% of patients manifest a fulminant course of immunologic and clinical deterioration after primary infection. Recommendations from the Centers for Disease Control and Prevention (CDC) are to offer all HIV positive patients regardless of their CD4 count treatment with antiretroviral medications once a diagnosis has been made (1,2). In addition, there are several other conditions in which therapy should be encouraged. Pregnant patients should be offered therapy as it is effective in preventing transmission to the infant

Oklahoma State University Center for Health Sciences College of Osteopathic Medicine 1111 West 17th Street Tulsa, Oklahoma 74107-1998

ed in all four quadrants. No ascites or fluid wave was noted. There was no evidence of spider nevi, palmar erythema, or caput medusa. Laboratory was performed to evaluate for causes of potential liver disease. They are represented in table 1. A right upper quadrant ultrasound was performed which did not demonstrate any acute abnormalities. As there were no other significant abnormalities found, a gastrointestinal consultation was placed for potential liver biopsy. A liver biopsy demonstrated that the patient had portal inflammation and hepatic steatosis.

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Physical exam and laboratory help establish the diagnosis. Viral hepatitis may present with fever, nausea, vomiting, and fatigue. Physical exam may demonstrate ascites, scleral icterus, asterixis, and jaundice. Patients will have positive virologic markers. Some patients will have an elevated INR, bilirubin, and ALT/AST. Patients with autoimmune hepatitis may have positive titers for antinuclear antibody, smooth-muscle antibody, or liver-kidney microsomal antibody. P-ANCA is positive in primary sclerosing cholangitis and anti-mitochondrial is positive in primary biliary cirrhosis. Hemochromatosis presents with an elevated serum ferritin, iron saturation, and iron level. Some patients may present with jaundice and pancreatitis. A hereditary marker includes mutation of the HFE gene. Plasma ceruloplasmin and urinary cooper are helpful in the diagnosis of Wilson’s disease which can also present with a Kayser Fleischer ring on physical exam. An alpha-1 antitrypsin level should be checked for Alpha-1 antitrypsin deficiency. Alpha-Fetoprotein levels

Further diagnostic evaluation via ultrasound and percutaneous liver biopsy is helpful. Ultrasound can be performed to detect patency of the portal vein, hepatic artery, and hepatic veins. It can help identify dilation in the intrahepatic and extrahepatic biliary tree and also demonstrate gallstones or any space occupying lesions. Liver biopsy is helpful in diagnosis and in assessing disease severity. Drug induced hepatitis secondary to antiretroviral therapy has been associated with steatohepatitis and hepatocellular necrosis shown by biopsy (3,6). Medication regimens for HIV usually include: 2 nucleoside reverse transcriptase inhibitors (NRTI) with a nonnucleoside reverse transcriptase inhibitor (NNRTI), or a ritonavir boosted protease inhibitor (PI), integrase strand transfer inhibitor, or agents that block the CC chemokine re-

ceptor 5 (2). Complera® contains 2 NRTIs (emtrictabine/tenofovir) and a NNRTI (rilpivirine) (6). NRTIs function by inhibiting the nucleoside reverse transcriptase enzymes. They include abacavir, lamivudine, emtricitabine, zidovudine, didanosine, stavudine, tenofovir, and zalcitabine. NRTIs are typically associated with a low incidence of hepatotoxicity and found in only about 5-6% of users. However, treatment with zidovudine, didanosine, and stavudine has been linked to hepatotoxicity. Elevation in hepatic enzymes has also been associated with patients co-infected with hepatitis C and being treated with tenofovir, lamivudine, or ribavirin. Elevation was shown to occur between 3 to 13 months of initiation of treatment and was secondary to mitochondrial DNA polymerase dysfunction causing lactic acidosis. Mitochondrial toxicity has been associated with accumulation of microvesicular steatosis. These patients will have complaints of nausea, vomiting, abdominal pain, and

Lab

Results

Range

ANCA Panel Antimyeloperoxidase Antiproteinase Atypical pANCA Cytoplasmic Perinuclear Ceruloplasmin Epstein Barr DNA Quant Ferritin Iron Iron Saturation TIBC HgbA1C Liver - Kidney Microsomal Antibody Actin Smooth Muscle Antibody RPR Cholesterol HDL Triglycerides TSH Beta Hcg INR

< .9 < 3.5 < 1:20 < 1:20 < 1:20 26.3 Negative 262 119 31 380 5.7 3.6 14 NR 137 54 123 1.710 Negative 1.0

(0-9) (0-3.5) < 1:20 < 1:20 < 1:20 (15-30) Negative (30-400) (40-155) (15-55) (250-450) (4.8-5.6) (0-20) (0-19) NR 0-199 >40 0-149 (.450-4.5) Negative 0.8-1.2

Table 1

Discussion As mentioned above, treatment with antiretroviral therapy can cause hepatotoxicity. When hepatotoxicity occurs an extensive differential diagnosis must be investigated. The differential diagnosis would include: viral hepatitis (Hepatitis A,B,C,D,E), autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis, Wilson’s disease, nonalcoholic steatohepatitis (NASH), alpha-1 antitrypsin disease, alcoholic liver disease, hemochromatosis, hepatocellular carcinoma, and drug induced liver disease (6).

are helpful in the diagnosis of hepatocellular carcinoma (6).

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distention. Hyperlactatemia was shown to be reversible with discontinuation of the medication (3). NNRTIs that demonstrate hepatotoxicity will typically do so in the first 12 weeks of initiation. Known NNRTIs that cause hepatotoxicity are nevirapine and efavirenz. The incidence ranges from 2-20% of users (3). It has been suggested that efavirenz causes hepatotoxicity by mitochrondrial dysfunction. The mechanism differs from NRTIs in that efavirenz does not affect mitochrondrial DNA polymerase. It has been suggested that direct toxicity occurs secondary to an increased expression of the metallothionein 2A gene which is involved in the regulation of reactive oxygen species (8). Nevirapine and efavirenz have also been associated with a hypersensitivity reaction that occurs within the first 4-6 weeks with a second peak seen 6 to 12 months later. This is thought to be due to an idiosyncratic reaction where liver toxicity could occur at any time. Individuals with HLA-DRB*0101 may also be at greater risk of a hypersensitivity reaction and hepatotoxicity. Gender has also been associated as a risk factor and women with CD4 cell counts higher than 250 have experienced fulminant hepatic failure second-

ary to nevirapine. Patients coinfected with hepatitis C also are considered to have an independent risk factor for hepatotoxicity with treatment of nevirapine and efavirenz (3). Rilpivirine is another medication that has shown to be associated with hepatotoxicity. In the THRIVE study, rilpivirine was evaluated compared to efavirenz and demonstrated similar rates of hepatotoxicity (9). In contrast, the ECHO trial demonstrated that rilpivirine demonstrated significantly lower rates of the hepatotoxicity (10). PIs have also been linked to hepatotoxicity with an incidence between 3-20% of users. The exact mechanism is unknown. Indinavir and atazanavir have been noted to cause isolated hyperbilirubinemia in 6-40% of patients by inhibiting UDPglucuronosyltransferase. A significant risk factor for PI related hepatoxicity is coinfection with Hepatitis B and C. Nelfinavir, ritonavir, saquinavir, and indinavir have been shown to cause elevated hepatic enzymes in patients with coinfection. Other risk factors include the use of cocaine and alcohol while on treatment with a PI. The mechanism of toxicity from PIs has been theorized to be secondary to a metabolic

alteration in cytochrome P450 in conjunction with underlying hepatic disease (3). Conclusion The use of antiretroviral medications has demonstrated a reduction in transmission and overall mortality. However, many adverse side effects have resulted with treatment. Once a patient begins to demonstrate signs or symptoms of hepatotoxicity, antiretroviral therapy should be discontinued and serial liver enzymes should be monitored. Once there is resolution of enzyme elevation, antiretroviral therapy should be resumed excluding the offending agent. If the patientâ&#x20AC;&#x2122;s liver enzyme elevation occurs within less than 3 months of therapy, nevirapine, efavirenz, and abacavir should be avoided. If the elevation occurs after 6 months of therapy then regimens containing didanosine, zidovudine, and stavudine should be avoided. Patients should also attempt to reduce risk factors that contribute to the elevation of liver enzymes which include: excess alcohol consumption, intravenous drug abuse which increases risk of exposure to viral hepatitis, and unnecessary over the counter medications. DO OK

References 1. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011; 365: 493-505. 2. Thompson MA, Aberg JA, Hoy JF, et al. Antiretroviral treatment of adult HIV infection. JAMA. 2012; 308: 387-402. 3. Jain MK. Drug-induced liver injury associated with HIV medications. Clin Liver Dis. 2007; 11: 615-39.

4. Kitahata MM, Gange SJ, Abraham AG, et al. Effect of early versus deferred antiretroviral therapy for HIV on survival. N Engl J Med. 2009; 360: 1815-1826.

5. Payer BA, Reiberger T, Breitenecker F, et al. The risk of infections in HIV-HCV coinfected patients during antiviral therapy with pegIFN and RBV. J Infect. 2012; (65: 142-149. 6. Pratt DS, Kaplan MM. Evaluation of abnormal liver-enzyme results in asymptomatic patients. N Engl J Med. 2000; 342:1266.

8. Gomez-Sucerquia LJ, Blas-Garcia A, Cabrera M, Esplugues J, Apotolova N. Profile of stress and toxicity gene expression in human hepatic cells treated with efavirenz. Antiviral Res. 2012; 94: 232-41.

9. Cohen CJ, Andrade-Villanueva J, Clotet B, et al. Rilpivirine versus efavirenz with two background nucleoside or nucleotide reverse transcriptase inhibitors in treatment-naive adults infected with HIV-1 (THRIVE): a phase 3, randomised, non-inferiority trial. Lancet. 2011; 378: 229-237. 10. Surgers L, Lacombe K. Hepatoxicity of new antiretrovirals: a systemic review. Clin Res Hepatol Gastroenterol. 2013; 37: 126-133.

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7. Nunez M. Hepatotoxicity of antiretrovirals: incidence, mechanisms, and management. J Hepatol. 2006; 44: S132-139.

Tabitha Danley DO, Faculty Mentor Department of Family Medicine

St. Anthony Family Medicine Residency 1000 N. Lee Oklahoma City, OK 73101

Erin Balzer DO, OGME-2, author

Clinical Question: In patients with skin tags, when should removal of the tags be considered compared with watchful waiting? Answer: Skin tags should be removed if there is concern for other disease process. Otherwise they can be removed at patient request for cosmetic purposes or comfort. Level of Evidence for the Answer: C Search Terms: skin tags, acrochordons, fibroma mole, fibroepithelial polyps Date Search was Conducted: November 2013 Inclusion and Exclusion Criteria: Inclusion Criteria: Any article, document or material pertaining to skin tags or treatment of skin tags or acrochordons Exclusion Criteria: none

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Summary of the Issues: Skin tags, also known as fibroma moles, or acrochordons, are outgrowths of normal skin tissue usually on narrow stalks. They have an overall prevalence of 46% in the general population, 25% of adults, with 59% of people having one present by the age of seventy.1 The increased incidence with age appears to peak at around age 50, at which point it levels off.1

Certain populations may be more prone to skin tags. A familial tendency in skin tag lesions has been noted. In Crohnâ&#x20AC;&#x2122;s disease, perianal skin tags may be common. Hormone fluctuations may increase frequency, such as in the second trimester of pregnancy, and then regression may occur postpartum.2 They also appear more commonly in association with impaired carbohydrate metabolism, such as in diabetes.2 Factors affecting growth include epidermal growth factor, alpha tissue growth factor, and also infection with human papilloma virus. 2 While it was previously thought patients with skin tags would correlate to having increased colon polyps, studies at this time have not established an association.3 Areas of increased friction are more common sites for skin tags; such as axilla, inguinal, and neck regions, with axilla being most common. Forty-eight percent of skin tags were located in the axilla region.1 These can also be areas of irritation for the patient, resulting in a desire for removal. In deciding on removal of an acrochordon, you need to diagnose it first. Diagnosis is based on clinical appearance. On exam, acrochordons are soft, small, pedunculated, flesh colored or hyperpigmented skin growths, typically 2-5mm in size.2 On the neck and axilla, they are usually small, furrowed papules. On the trunk, they may be larger, more pedunculated or nevus-like. Skin tags may be present as a single lesion or found in groupings.4

They are more common in women and obese people, and located most frequently in the axilla and neck region or other areas of increased friction. People with multiple tags typically have no more than three in each location.1 Although benign, skin tags become symptomatic if they begin to catch on clothes or jewelry or rubbing on other areas of skin. They may also become irritated, pruritic or inflamed.2 Because of this and cosmetic purposes, many patients request to have these tags removed. The decision then has to be made whether to remove the tag or simply observe.

Possible differential diagnoses of acrochordons include neurofibroma, pedunculated dermal nevus, nodular exophytic melanoma, and warts.1,2,4 To differentiate during exam, keep in mind that neurofibromas are larger and firmer typically, although some skin tags can grow to be large. Pedunculated dermal nevi may require a histological exam to differentiate.2 If you are unsure of the diagnosis, or if the tag is having unexpected changes in appearance, biopsy or excision should be performed. If a true skin tag is biopsied, results will show acanthotic, flattened or frond-like epithelium with papillary-like dermis, and loose collagen with dilated capillary and lymph vessels.2 If determined to be benign, but the growth is bothersome to the patient, simple removal may be performed. Banik and Lubach sampled 137 soft fibromas from 12 patients in their study and all were histologically typical.1

Summary of the Evidence: There are no randomized control studies or review articles available that have evaluated removal of skin tags versus watchful waiting. Banik and Lubach conducted a study published in 1987 to assess localization and frequency of skin tags. Seven hundred and fifty patients were examined. Twenty-five percent of males and 21% of females were found to be skin tag carriers. Seventy-one percent of the patients had no more than three skin tags.1

What are the options for removal once the decision has been made to remove a skin tag rather than watching to see if it resolves on its own? Excision by scissor, or shave excision, radiofrequency loop, cryosurgery, electrodesiccation are all valid options.2,3 On occasion, the tag may become twisted on itself, cutting off blood supply and falling off on its own.2 There are no review studies discussing the recommended method of removal, so physician preference, location, or size may be the deciding factor for removal method.

Oklahoma D.O. | July / August 2014

Conclusion: In conclusion, when a diagnosis of benign skin tag (or acrochordon) can be confirmed based mainly on clinical presentation, removal versus watchful waiting is solely a preference choice. If the patient desires removal and there is no concern for complications or other diagnosis, cryotherapy, excision or electrodessication can be performed. This is typically done to improve patient symptoms such as discomfort or irritation or for cosmetic reasons.

Reference List: 1. Benik R, Luback, D. Skin tags: localization and frequen- cies according to sex and age. Dermatologica 1987; 174(4):180 2. Usatine R, Smith M, Chumley H, Mayeaux E. Skin Tag. Ch. 157 In: Color Atlas of Family Medicine, 2nd ed. China. The McGraw-Hill Company. 2013: http://access- medicine.mhmedical.com.ezproxy.chs.okstate.edu/content. aspx?bookid=685&Sectionid=45361220 (Accessed on 11/25/2013)

3. Habif T. Benign Skin Tumors. Ch. 20 In: Clinical Derma- tology, 5th ed. China. Elsevier (Mosby) 2010:784

4. Goldstein B, Goldstein A. Overview of benign lesions of the skin. August 2013. (Accessed 12/5/2013 on uptodate. com)

When you need it. ProAssurance.com

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Medical professional liability insurance specialists providing a single-source solution

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Introducing Oklahoma High School Students to Medicine

OSU’s Operation Orange Courtesy of OSU Center for Health Sciences

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“

It also helps them see that medicine is a viable career option, even if they live in a rural area.

”

An Operation Orange participant in Weatherford practices intubation.

Oklahoma D.O. | July / August 2014

Cherokee Nation Chief Bill John Baker and OSU-CHS President Kayse M. Shrum, DO watch an Operation Orange participant practice CPR in Tahlequah.

Several hundred Oklahoma high school students experience a day in the life of a medical student at Operation Orange summer camps across the state hosted by Oklahoma State University Center for Health Sciences. The camps are an initiative of OSUCHS President Kayse M. Shrum, DO, to expose Oklahoma high school students to a career as a physician.

During the camps, attendees participated in a number of activities that physicians learn during their training. The campers tested suturing skills, studied anatomy with a human heart, lungs and brain, practiced intubation, learned about CPR and listened to simulations of breath sounds, the digestive tract and heart beats. DO OK

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The OSU College of Osteopathic Medicine has made a concerted effort to meet with students while they’re still in high school. Faculty and current medical students provide guidance and mentorship to the Operation Orange students to encourage their interest in medicine and prepare them for the rigors of medical school.

“The camps are a fun way to connect with these students and for them to better understand what they will learn in medical school,” said Shrum. “It also helps them see that medicine is a viable career option, even if they live in a rural area.”

Oklahoma D.O.

“These camps are an opportunity for us to take the OSU College of Osteopathic Medicine on the road and get these students excited about medicine,” said Shrum. “We have met with many students who had never thought about being a physician because there is not a doctor in their hometown or thought it was out of reach.”

Five camps were offered at partner institutions in June, including Southeastern Oklahoma State University in Durant, Southwestern Oklahoma State University in Weatherford, Cherokee Nation W.W. Hastings Technology and Education Center in Tahlequah, University of Central Oklahoma in Edmond and the main OSU campus in Stillwater.

y l u Jbirthdays 1st Aunna C. Herbst, DO Fei-Ling Yeh, DO Juliana Bizzell, DO Kenan L. Kirkendall, DO Natasha R. Knowlton, DO R. Randy Hunt, DO Montgomery L. Roberts, DO Jenney Qin, DO 2nd Jean-Maria C. Langley, DO 3rd Monica S. Kidwell, DO

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4th John C. Loose, DO Lea M. Wolfe, DO Tony R. Hill, DO John W. Patterson, DO Aliyeah Ayadpoor, DO 6th Karl A. Kuipers, DO Bradley M. Short, DO Thomas A. Jones, DO David F. Hitzeman, DO Donald L. Riley, DO Jack L. Morgan, DO Brian A. Levings, DO

7th Angela D. Bolz, DO Heather R. Tipsword, DO Brent C. Nossaman, DO Nicole B. Washington, DO D. Scott Dycus, DO M. Shane Hull, DO Stephanie A. Meissen, DO L. Todd Olsen, DO Michael J. Museousky, DO 8th M. Elaine Ramos, DO Damon L. Baker, DO Heath A. VanDeLinder, DO Yancy J. Galutia, DO Chelsey D. Gilbertson, DO 9th Colbi M. Smithton, DO Michael C. Breedlove, DO Jeffrey R. Jones, DO Lisa R. Waterman, DO Tyree L. Seals, DO Andrew Michael Eaton, DO Linden S. Cowley, DO 10th Benjamin Fore, DO Cynthia K. Wilkett, DO Douglas B. Coffman, DO

James M. Rebik, DO P. Lynn Elethorp, DO Jeanne Heyser-Easterly, DO 11th Jon Trent Hamilton, DO Bryan L. Dalton, DO Samantha C. Moery, DO Parker L. Simon, DO Raeanne Lambert, DO Stephanie K. Barnhart, DO 12th James M. Fitzgerald, DO H. Nathan Claver, DO 14th Andrea E. McEachern, DO Mark E. Melton, DO Janna K. Burkus, DO 15th Andrea M. Adams, DO Brian A. Chalkin, DO Troy L. Harden, DO Esther Elizabeth B. Walker, DO Richard D. Allen, DO Patrick G. Livingston, DO Stevan E. Lahr, DO 16th Cindy S. Wright, DO Jimmie D. McAdams, DO William R. Kennedy, DO Thomas E. Franklin, DO 17th John Buck Hill, DO Sommer M. Parschauer, DO

Oklahoma D.O. | July / August 2014

18th Larry Burch, DO Gilbert M. Rogers, DO Bryan C. Roehl, DO Christopher A. Taylor, DO

24th Stephanie A. Parker, DO Jozef Dzurilla, DO

19th Stephanie L. Carner, DO Charles A. Rodman, DO Derek Scott Johnson, DO

25th Joshuan Hicks, DO Jason R. Graham, DO Lori Gore-Green, DO LeRoy E. Young, DO Laura V. Swant, DO

20th Glen H. Bailey, DO Charles F. Harvey, DO David W. Asher, DO Derek R. Holmes, DO Pamela A. Jarrett, DO

26th Elizabeth A. Cordes, DO Ben F. Cheek, DO Gerald D. Rana, DO Scott S. Carpenter, DO Steven P. Medeiros, DO

21st Corby W. Smithton, DO Jules L. Merenda, DO John S. Marouk, DO

27th Ryan W. Schafer, DO Lorri J. Dobbins, DO Robert C. Gaston, DO Terry R. Gerard II, DO Ryan P. Sullivan, DO

22nd Steven C. Wang, DO Katie B. Dalton, DO Stacy L. Noland, DO Joshua Medved, DO Vincenzo Galati, DO Joanne Chinnici, DO

28th Dina G. Azadi, DO 30th J. Harley Galusha, DO Bob L. Weeks, DO Gary K. Augter, DO Ronald F. Distefano, DO Scott E. Dellinger, DO Matthew B. Rudolph, DO

Oklahoma D.O.

23rd Dennis E. Blankenship, DO Gavin V. Gardner, DO Michael T. Cain, DO Pamela B. Ghezzi, DO Audrey M. Stanton, DO Nick L. Carroll, DO

31st A. John Geiger, DO Christopher C. Thurman, DO Eric W. Metheny, DO Hampton W. Anderson, DO

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1st Joseph L. Adams, III., DO Jessica Booth, DO Jack Doran Butler, DO Paul E. Weathers, DO Richard G. Wood, DO George E. Erbacher, DO, FAOCR Thomas B. Leahey, DO

Gary M. Freeman, DO Jacob A. Moore, DO

2nd David B. Austerman, DO Carrie A. Harp-Wetz, DO Jerry C. Childs, DO Rory C. Dunham, DO Stephanie D. Burleson, DO Carol K. Anderson, DO

9th Charles A. DeJohn, DO Julie M. King, DO David E. Hogan, DO, MPH

3rd Laura L. Arrowsmith, DO Chelsea Galutia, DO Scott S. Cyrus, DO H. Dwight Hardy, DO James E. Burleson, DO Johnny O. Johnson, DO Stephen A. Back, DO 4th Jay Brent Wheeler, DO John W. Hallford, DO Judy A. Distefano, DO Kevin Sue Weibel, DO Scarlett Custer, DO

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5th Carolyn J. Steele, DO W. Wes McFarland, DO Jonathan M. Knox, DO Ruth M. Thompson, DO 6th Daniel A. Nader, DO Danny C. Smith, DO Jason L. Hill, DO Jeffrey S. Krantz, DO Timothy Talbot Tye, DO 7th Brian W. Cook, DO Donn R. Turner, DO Fred M. Ingram, DO

8th David R. Kerr, DO Jacob C. Carman, DO Leslie S. Little, DO Tara J. Claussen, DO

10th Bobby L. Elliott, DO Lisa Owens, DO Latricia G. Arnold, DO 11th Barney E. Blue, DO Kevin D. Carter, DO Phillip R. Berry, DO Ralph B. Coffman, DO C. Michael Johnson, DO 12th Leslie M. Hamlett, DO 13th Gary W. Cannon, DO Jackie L. Neel, DO Sammy J. Worrall, DO Daniel P. Kite, DO 14th Jeremy Ray Smola, DO Kristalyn K. Gallagher, DO 15th Jennifer R. Ferrell, DO Joseph M. Coffman, DO David T. Dotson, DO Mark Andrew Keuchel, DO 16th Bobby C. Kang, DO Annie Hyon, DO Harold Blankenship, DO Kimberly Sorensen, DO

Walter Everett Kelley, DO 17th Jeffrey R. Morris, DO 18th Michael L. Oliver, DO 19th Brandon A. Conkling, DO S. Emilee Wood, DO John S. Moore, DO Sheila M. Taber, DO Ted Kaltenbach, Jr., DO 20th C. David DeJarnett, DO Anthony Economou, DO Jason M. Crouch, DO 21st Ethel Vasquez-Harmon, DO Paul Engelman, DO 22nd Aaron P. Wilcox, DO Bryan S. Simms, DO Dominic J. Totani, DO Dana Terrell, DO 23rd Donald T. Brock, DO Katherine D. Cook, DO Jon T. Maxwell, DO 24th Clayton W. Flanary, DO Charles P. W. Crowell, III., DO Gregory J. Dennis, DO G. Jason Hunt, DO Matthew E. Stiger, DO Victoria S. Chain, DO 25th Brad A. Liston, DO Barry S. Rodgers, DO Rita Westenhaver, DO Kevin B. Lane, DO Richard G. Allen, DO Oklahoma D.O. | July / August 2014

26th Richard A. Hastings II, DO Gary L. Postelwait, DO James M. Brown, DO Laura Black-Wicks, DO Colby Dale Mayo, DO Randall D. Behrmann, DO Stephen L. Sutton, DO 27th Jay A. Clemens, DO, MPH Joan E. Stewart, DO Michael K. Cooper, DO Michael G. Stone, DO

28th J. Scott Clark, DO Randall Colin Wetz, DO Rhonda L. Casey, DO Thomas D. Schneider, DO 29th Cecil A. Cook, DO Jequita D. Snyder, DO

31st Jerry J. Cole, DO William R. Anderson, DO Brooks B. Zimmerman, DO Tracy L. Langford, DO Stephanie Bryan, DO Steven P. Sanders, DO

30th Thomas J. Carlile, DO Gary D. Lovell, DO

birthdays

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Oklahoma D.O. | July / August 2014

What DO’s Need To

KNOW

CMS initiative helps people make the most of their new health coverage “From Coverage to Care” outreach to engage doctors and new patients

The Centers for Medicare & Medicaid Services (CMS) launched a national initiative “From Coverage to Care” (C2C), which is designed to help answer questions that people may have about their new health coverage, to help them make the most of their new benefits, including taking full advantage of primary care and preventive services. It also seeks to give health care providers the tools they need to promote patient engagement. “Helping to ensure that new health care consumers know about the benefits available through their coverage, and how to use it appropriately to obtain primary care and preventive services is essential to improving the health of the nation and reducing health care costs,” said Dr. Cara V. James, director of the CMS Office of Minority Health. Dr. James noted that, “to achieve these goals, we need to make sure that people who are newly covered know that their coverage can help them stay healthy, not just help them get better if they get sick.” C2C will be an ongoing project. As more and more people obtain coverage, there will be a continuous need to ensure that people have answers to questions they might have about their new coverage and are appropriately connected to the health care system to help them live long, healthy lives. This launch also marks the release of the new Roadmap to Better Care and a Healthier You, http://marketplace.cms.gov/help-us/ c2c-roadmap.pdf?linkId=8267630, which includes 8 steps to help consumers and health care providers be informed about the diverse benefits available through their coverage and how to use it appropriately to access to primary care and preventive services. Among other things, the “Roadmap” contains information on health care coverage terms, the differences between primary care and emergency care, and the cost differences of decisions to seek care in- and out-of-network, where applicable to the consumer’s health plan.

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More information about C2C and other helpful resources, including a 10-part video series, to help those with new health care coverage make the most of their coverage, and raise awareness about the importance of getting routine primary care and regular preventive care are available at: http://marketplace.cms.gov/c2c. People with related questions about the C2C initiative should write to Coveragetocare@cms.hhs.gov

IRS Announces Issuance of Two Affordable Care Act Electronic Publications

The IRS announced the issuance of two electronic publications containing information for individuals and families about the Affordable Care Act (ACA). These one-page publications are available on the IRS website and can be used by individuals, tax professionals, health care professionals and other stakeholders for educational and outreach purposes. Publication 5152, Report changes to the Marketplace as they happen…, discusses the importance of reporting changes in circumstances, such as family size and income changes that can affect the Premium Tax Credit, to the health insurance Marketplace. Reporting changes can help individuals and families avoid getting too much or too little in advance credit payments. Publication 5156, Facts about the Individual Shared Responsibility Provision, discusses what individuals need to know regarding health insurance coverage and taxes. Oklahoma D.O. | July / August 2014

These two publications will supplement several earlier IRS ACA flyers: • Publication 5120 (English) and Publication 5120SP (Spanish) – Facts about the Premium Tax Credit (Flyer) • Publication 5121 (English) and Publication 5121SP (Spanish) – Facts about the Premium Tax Credit (Tri-fold Bro- chure) • Publication 5093 –Health Care Law Online Resources More Information Find out more about these and other tax-related provisions of the health care law at IRS.gov/aca. Subscribe to IRS Tax Tips to get easy-to-read tips via e-mail from the IRS.

10.3 million gained health coverage during the Marketplace’s first annual open enrollment period

Health and Human Services Secretary Sylvia M. Burwell announced the release of a new study, published in the New England Journal of Medicine, estimating that 10.3 million uninsured adults gained health care coverage following the first open enrollment period in the Health Insurance Marketplace. The report examines trends in insurance before and after the open enrollment period and finds greater gains among those states that expanded their Medicaid programs under the Affordable Care Act. “We are committed to providing every American with access to quality, affordable health services and this study reaffirms that the Affordable Care Act has set us on a path toward achieving that goal,” said Secretary Burwell. “This study also reaffirms that expanding Medicaid under the Affordable Care Act is important for coverage, as well as a good deal for states. To date, 26 states plus D.C. have moved forward with Medicaid expansion. We’re hopeful remaining states will come on board and we look forward to working closely with them.” According to the authors’ findings, the uninsured rate for adults ages 18 to 64 fell from 21 percent in September 2013 to 16.3 percent in April 2014. After taking into account economic factors and pre-existing trends, this corresponded to a 5.2 percentagepoint change, or 10.3 million adults gaining coverage. The decline in the uninsured was significant for all age, race/ethnicity, and gender groups, with the largest changes occurring among Latinos, blacks, and adults ages 18-34 – groups the Administration targeted for outreach during open enrollment. Coverage gains were concentrated among low-income adults in states expanding Medicaid and among individuals in the income range eligible for Marketplace subsidies. The study finds a 5.1 percentage point reduction in the uninsured rate associated with Medicaid expansion, while in states that have not expanded their Medicaid programs, the change in the uninsured rate among low-income adult populations was not statistically significant. The study also looks at access to care, and finds that within the first six months of gaining coverage, more adults (approximately 4.4 million) reported having a personal doctor and fewer (approximately 5.3 million) experienced difficulties paying for medical care. The study does not include data from before 2012, as coverage was changing rapidly during this period. This means the results do not include the more than 3 million young adults who gained health insurance coverage through their parents’ plans.

To read the article visit: http://www.nejm.org/doi/full/10.1056/NEJMsr1406753

Health and Human Services Secretary Sylvia M. Burwell announced that consumers have saved a total of $9 billion on their health insurance premiums since 2011 as a result of the Affordable Care Act. Oklahoma D.O. | July / August 2014

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Consumers have saved a total of $9 billion on premiums Health care law will return to families an average refund of $80 each this year

Oklahoma D.O.

The analysis builds on previous studies by reviewing a larger sample size and taking into account changes in the economy and pre-existing trends in insurance coverage. Using survey data from the Gallup-Healthways Well-Being Index for January 1, 2012, through June 30, 2014, the authors analyzed changes in the uninsured rate over time. This is also the first study to associate reductions in the uninsured rate with state-level statistics on enrollment in the Marketplaces and Medicaid under the Affordable Care Act, as described in HHS enrollment reports, and to assess the impact of the improved coverage on access to care.

Created through the law, the 80/20 rule, also known as the Medical Loss Ratio (MLR) rule, requires insurers to spend at least 80 percent of premium dollars on patient care and quality improvement activities. If insurers spend an excessive amount on profits and red tape, they owe a refund back to consumers. “We are pleased that the Affordable Care Act continues to provide Americans better value for their premium dollars,” said Secretary Burwell. “We are continuing our work on building a sustainable long-term system, and provisions such as the 80/20 rule are providing Americans with immediate savings and helping to bring transparency and accountability to the insurance market over the long term.” An HHS report released today shows that last year alone, consumers nationwide saved $3.8 billion up front on their premiums as insurance companies operated more efficiently. Additionally, consumers nationwide will save $330 million in refunds, with 6.8 million consumers due to receive an average refund benefit of $80 per family. This standard and other Affordable Care Act standards contributed to consumers saving approximately $4.1 billion on premiums in 2013, for a total of $9 billion in savings since the MLR program’s inception. The report shows that since the rule took effect, more insurers year over year are meeting the 80/20 standard by spending more of the premium dollars they collect on patient care and quality, and not red tape and bonuses. If an insurer did not spend enough premium dollars on patient care and quality improvement, they must pay refunds to consumers in one of the following ways: • a refund check in the mail; • a lump-sum reimbursement to the same account that was used to pay the premium; • a reduction in their future premiums; or • if the consumer bought insurance through their employer, their employer must provide one of the above options, or apply the refund in another manner that benefits its employees, such as more generous benefits. The 80/20 rule, along with other standards such as the required review of proposed premium increases, is one of many reforms created under the health law helping to slow premium growth and moderate premium rates. Combined with the savings consumers are receiving from tax credits on the Marketplace and the new market reforms, including the prohibition of pre-existing condition exclusions and charging women more for insurance than men, the 80/20 rule helps ensure every American has access to quality, affordable health insurance. To access the report released today, visit: http://www.cms.gov/cciio/Resources/Forms-Reports-and-Other-Resources/index. html#Medical Loss Ratio

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For more information on MLR, visit: http://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/Medical-Loss-Ratio.html

Oklahoma Standard Authorization to Use or Share Protected Health Information (PHI) Instructions Revised forms and instructions approved by the Oklahoma State Board of Health are now available. • Complete Patient Name, Date of Birth, Medical Record # and Social Security # (Medical Record # and Social Security # are not required); • Insert the name of the person or organization disclosing the PHI; • Insert the name and address of the person or organization receiving the PHI; • Check the appropriate box(es) for the information to be shared and/or check the “other” box and insert the information to be shared; • Check the appropriate box for the purpose for sharing the PHI and/or check the “other” box and insert the purpose; • If the Authorization expiration date is different than one year from the date of signature and the desire is to have the expiration date to occur at the occurrence of an event, insert the occurrence of the event for an expiration date; • The patient or Legal Representative must sign and date the Authorization • If a Legal Representative signs the Authorization, a description must be inserted in the appropriate space; • If the expiration date of the Authorization is longer than one year from the date of signature or no event is indicated, insert an expiration date. Oklahoma D.O. | July / August 2014

OKLAHOMA STANDARD AUTHORIZATION TO USE OR SHARE PROTECTED HEALTH INFORMATION (PHI) Patient Name:_________________________________

Medical Record #:____________________________

Date of Birth:___________________________________

Social Security #:_____________________________

I hereby authorize _______________________________________________________________________________ Name of Person/Organization Disclosing PHI to release the following information to ________________________________________________________________ Name and Address of Person/Organization Receiving PHI Information to be shared:

□ Psychotherapy Notes (if checking this box, no other boxes may be checked) □ Entire Medical Record □ Billing Information for____________________________________ □Mental Health Records □ Substance Abuse Records □ Medical information compiled between___________ and ___________ □ Other:______________________________________________________________________________ The information may be disclosed for the following purpose(s) only:

□ Insurance □ Continued Treatment □ Legal □ At my or my representative’s request □ Other:______________________________________________________________________________

I understand that by voluntarily signing this authorization: • I authorize the use or disclosure of my PHI as described above for the purpose(s) listed. • I have the right to withdraw permission for the release of my information. If I sign this authorization to use or disclose information, I can revoke this authorization at any time. The revocation must be made in writing to the person/organization disclosing the information and will not affect information that has already been used or disclosed. • I have the right to receive a copy of this authorization. • I understand that unless the purpose of this authorization is to determine payment of a claim for benefits, signing this authorization will not affect my eligibility for benefits, treatment, enrollment or payment of claims. • My medical information may indicate that I have a communicable and/or non-communicable disease which may include, but is not limited to diseases such as hepatitis, syphilis, gonorrhea or HIV or AIDS and/or may indicate that I have or have been treated for psychological or psychiatric conditions or substance abuse. • I understand I may change this authorization at any time by writing to the person/organization disclosing my PHI. • I understand I cannot restrict information that may have already been shared based on this authorization. • Information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer be protected by the Privacy Regulation. Unless revoked or otherwise indicated, this authorization’s automatic expiration date will be one year from the date of my signature or upon the occurrence of the following event:____________________________________________________ _________________________________________________________________________________________________

________________________________________________ Description of Legal Representative’s Authority

_____________________________________________ Expiration date (if longer than one year from date of signature or no event is indicated)

Oklahoma State Department of Health Community and Family Health Services/ Administration

Oklahoma D.O. | July / August 2014

HIPAA Document - retain for a minimum of 6 years

ODH 206 August 2014

PAGE 43

_____________________________________________ Date

Oklahoma D.O.

________________________________________________ Signature of Patient or Legal Representative

Dear Friend of OFMQ: Healthcare is evolving and OFMQ is evolving with it. That's why I'm eager to share exciting news with you firsthand about emerging opportunities occurring at OFMQ. In light of the Centers for Medicare & Medicaid Services QIO program changes, we are expanding our consulting service lines in the areas of quality improvement, information technology, health information technology, long-term care, care review and analytics to better serve healthcare providers and our fellow Oklahomans. Since 1972, OFMQ has experienced a rich history of success and demonstrated strong leadership across various healthcare settings, collaborative projects and national initiatives. Using a unique mix of clinical and technical expertise, our hands-on approach to healthcare consulting services and our dedication to providing support statewide will continue. How does this impact you and your organization? You can expect our reputation for integrity, expertise, quality and collaboration that you have experienced in the past to be ongoing hallmarks of our service in future endeavors. We will also be offering our services through different contracting opportunities, some commercial, some through grants and contracts.

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We remain your trusted advisor and fully committed to advancing healthcare quality and improving lives across our state. It's an honor to serve you and we look forward to assisting you in providing quality healthcare services that meets your business needs. To utilize our services, visit www.ofmq.com to explore opportunities for OFMQ to assist you. Thank you for your continued loyalty and interest in working with OFMQ. As we transition into the future, let's continue joining together to embark upon new ways for improving Oklahoma's healthcare standards. Sincerely, Gregg Koehn, CPA President and Chief Executive Officer, OFMQ

Oklahoma D.O. | July / August 2014

OOA

Bureau News: 2014-2015 OOA DUES STATEMENTS We truly appreciate your membership and would be honored to serve you another year. Beginning in September, you will receive renewal notices at your home and office addresses. To receive uninterrupted member benefits and continue your support of the only organization in Oklahoma that lobbies at the Capitol on behalf of osteopathic physicians and students, renew by Nov. 1, 2014. As always, life members, retired physicians, residents and students receive free membership. If you have any questions, please call Marie Kadavy, director of communications and membership, at 405-5284848 or 800-522-8379.

Bureau on Membership The OOA Board of Trustees welcomes the following new members to the OOA family! Erica D. Dearman, DO Family Medicine Oklahoma City, OK

Chadwick B. Ross, DO Emergency Medicine Ponca City, OK

Arthur Douglas Beacham III, DO Anesthesiology Oklahoma City, OK

Tiffany D. Dupree, DO OB/GYN Elk City, OK

Ryan P. Sullivan, DO Emergency Medicine Vian, OK

Best Chen, DO Family Medicine Enid, OK

Erin Powers Kinney, DO Emergency Medicine Oklahoma City, OK

Miguel A. Tovar, DO OB/GYN Chickasha, OK

Tessa L. Chesher, DO Child Psychiatry Tulsa, OK

Nick T. Reynolds, DO Family Medicine Durant, OK

Keely W. Wheeler, DO Psychiatry Tulsa, OK

Oklahoma D.O.

Courtney B. Atchley, DO Pediatrics Oklahoma City, OK

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Oklahoma D.O. | July / August 2014

memoriam

WiILLIAM B. GEB, DO William B. Geb, DO, passed on June 19, 2014. Dr. Geb was born on April 12, 1925, in Ponca City, Okla. He graduated from Oklahoma City University and later, from Kansas University College of Osteopathic Medicine. He began his career as a family physician in Spiro, Okla. After 10 years of serving that community, he moved to Oklahoma City and established a practice in Del City for a number of years. A portion of that time, he served as Chief of Staff at Hillcrest Hospital. Dr. Geb also served as a part-time medical examiner for the State of Oklahoma. Dr. Geb was an active member of the Oklahoma Osteopathic Association and a life member of the association. In the later years of his career, he served at Tinker Air Force Base as a physician in industrial occupational medicine until his retirement in 1993. While working at Tinker Air Force Base, he received awards, including the Air Force Logistics Command Distinguished Civil Service Award. During his retirement, Dr. Geb enjoyed his membership at the Beacon Club and socializing with numerous friends such as Drs. Joseph Corn and Thomas Carlile. Also, he enjoyed studying finance and economics. Dr. Geb is survived by his nieces, Kathryn Ghazal, of Midwest City, Okla.; Elizabeth Richards and Joyce Lynn Geb, of Oklahoma City; nephew, John Geb, of Ventura, Cali.; grandniece, Laura Geb, of Beaverton, Ore.; and grandnephews, Mark Ghazal, of Midwest City; and Dr. David Geb, of Boulder, Colo.

Contributing

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n OEFOM Memorials n

Pam Ortloff Don and Lynette McLain Dr. Joseph and Judy Schlecht Dr. Thomas and Glenda Carlile Dr. Harvey and Barbara Drapkin Dr. Dennis and Sheri Carter Dr. Richard and Beverly Schafer Dr. Thomas and Glenda Carlile Dr. David and Rita Hitzeman Dr. David and Rita Hitzeman Dr. Thomas and Glenda Carlile

In Memory of

Anna Jane McCuistion Anna Jane McCuistion Anna Jane McCuistion William B. Geb, DO William B. Geb, DO Jimmie Lou Morgan Nicewander Margaret Koro Dorene Hillman Nancy Ann Baylor Thomas M. Luce Charles Pratt

JEFFREY S. JENNINGS, DO Dr. Jeffrey S. Jennings, 52, left this Earth from his home on Friday, July 4. Dr. Jennings was born to Tom Wilson Jr. and Shirl Rea on July 13, 1961, in Okmulgee. He attended grade school and high school in Okmulgee, where he was a successful scholar and star athlete. He attended the University of Oklahoma, where he was a proud member of the Sigma Alpha Epsilon fraternity. After college, he went on to the Oklahoma State University College of Osteopathic Medicine, graduated four years later, and went on to complete a residency in radiology. He was a radiologist all across the state and was loved by many patients and co-workers. Dr. Jennings married his wife, Lori (White) Jennings on Oct. 21, 1989. They lived a beautiful and strong 25 years together and had three children: Sydney, 21; Jacob, 18; and Graham, 17. He was a die-hard Sooner fan, loved to go golfing, enjoyed reading Stephen King novels, and listening to classic rock music. More than anything else, he enjoyed being surrounded by family, and watching his children grow up, all with Lori by his side. Dr. Jennings is preceded in death by his great-grandparents, Mr. and Mrs. Claude Eubanks; his grandparents, Mr. and Mrs. Wallace Crawford; and his father-in-law, Don White. He is survived by his parents, Mr. and Mrs. Bruce Rea; his wife, Lori; and children, Sydney with fiancĂŠ Micheal, Jacob, and Graham. He is also survived and missed by a host of other friends and family.

Oklahoma D.O. | July / August 2014

Classified Advertising OFFICE BUILDING FOR SALE: 6501 S. Western, OKC, OK 73139. Over 1 1/2 acres total size, 10,000 sq ft building divided into 3 doctors offices. 1200 sq foot private office upstairs with private bathroom and shower. 2 double sided fireplaces, over a dozen chandeliers, rough wood cathedral ceilings. Alarm and phone system in place, double glass doors in entrance, back patio with separate storage building. Larger office is fully equipped with exam tables, Pap table, chairs, medical instruments, QBC (CBC) machine, autoclave, medical supplies, and much more. For information contact: Captain David Simpson at (405) 820-5360. CLINIC FOR SALE: By owner. Fully equipped: LAB, XRAY, EKG. Well established clinic, near Integris Southwest Medical Center is available for sale. Clinic is well equipped and is ideal for one or more physician practice as well as a variety of specialties. Clinic has: waiting room with refrigerated water cooler, wheelchair accessible restroom, reception and staff work stations, Nurses station, 5 - 7 exam rooms with sinks and running water, large multipurpose procedure room, 3 private offices with built-in bookcases, (One Office with 3/4 Bath), additional staff and patient restrooms, large upstairs (currently used for storage) and variety of other medical equipment. Misys Medical Software. Large Parking Lot. “Must See Inside” the all steel building located at 2716 S.W. 44th St. in OKC to appreciate the effort placed upon providing convenient and up to date medical care. PRICE IS NEGOTIABLE. Doctor prefers to sell, but would consider leasing. If interested, please call: Evelyn Francis at (405) 249-6945.

DOCTORS WANTED: to perform physical exams for Social Security Disability. DO’s, MD’s, residents and retired. Set your own days and hours. Quality Medical Clinic-OKC, in business for 16 years. Call Jim or JoAnne at 405-632-5151. PHYSICIAN NEEDED: The practice of Terry L. Nickels, DO is currently seeking a part-time Family Physician with OMT Skills to help cover the office. If interested please contact Dr. Terry Nickels at (405) 301-6813. FAMILY, URGENT CARE, AND EMERGENCY PRACTITIONERS – IMMEDIATE OPPORTUNITIES for FT/ PT and temp positions. Oklahoma physician owned placement company is hiring now. Offering top wage, flexible schedules, paid malpractice and travel expenses. Call Rachelle at 877-377-3627 or send CV to rwindholz@oklahomaoncall. com

Oklahoma D.O.

IMMEDIATE OKLAHOMA OPPORTUNITY with largest family medicine clinic in Muskogee, Ok. Excellent opportunity to assume a practice that is up and running. Senior physician of four physician group leaving to pursue new career opportunities. 2,000 active patients need a physician. Two physicians currently practice OB. Surgical OB experience a plus. On site x-ray and CLIA certified lab. Nursing and support staff in place. Income guarantee. Be your own boss, work hard and practice family medicine in its historical tradition with respect and loyalty of small town patients. Contact Evan Cole, DO, 918-869-2456, ecoledo@yahoo.com, Brad McIntosh, MD, 918-869-7356, drbamc@yahoo.com Jason Dansby, MD, 918-869-7387, jasonddansby@yahoo.com or Judy Oliver, RN, practice administrator, 918-869-7357. (leave a message if temporarily unavailable) Find us on the web at www.mfpclinic.com.

STAFF PHYSICIAN NEEDED: The Oklahoma Department of Corrections is seeking applicants for Staff Physician at our correctional facilities statewide. The state of Oklahoma offers a competitive salary and benefits package which includes health, dental, life and disability insurance, vision care, retirement plan, paid vacation, sick days, holidays and malpractice insurance coverage. For more information and a complete application packet contact: Becky Raines 2901 N. Classen Blvd., Suite 200 Oklahoma City, OK 73106-5438 (405) 962-6185 FAX (405) 962-6170 e-mail: braines@doc.state.ok.us

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Oklahoma D.O. | July / August 2014

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Oklahoma D.O. PAGE 48

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