Cap Scan - April 2016

APRIL EDITION, VOLUME 2016, NO. 4

CMS TRIVIA BUFFS LEAP INTO THE NEW YEAR

The first ever Connect the Docs Leap Year Trivia Night on February 29th at

Beef ‘O’ Brady’s was a leaping success! We had 45 people enjoying the food,

drinks, trivia, and overall fun atmosphere. CMS President, Dr. J. Daniell Rackley

did a great job as the emcee. Team PF5 (Dr. Gregory Perry’s family) came in first

place with Team Frogger (Alliance members, Amy Pagano and Cynara Miller and their families)

as a close second. We thank Michael Davino with Waddell & Reed Financial Advisors for sponsoring

this event.

Thank you to all of the participants!

CONTINUED ON PAGE 4

CAPITAL MEDICAL SOCIETY 2016 MEETINGS CALENDAR April 11, 2016 Connect the Docs Happy Hour 5:30 pm – 7:30 pm Food Glorious Food 1950 Thomasville Road

April 19, 2016 CMS Membership & CME Meeting New Screening, Evaluation, and Treatment Options for Lung Cancer Jeffery Snyder, M.D., Capital Regional Medical Center Heart & Lung Surgical Associates 6:00 pm Maguire Center for Lifelong Learning at Westminster Oaks

April 23, 2016 Connect the Docs Family Fun Day Picnic 11:00 am – 2:00 pm Maclay Gardens ($6 entrance fee)

BOARD OF GOVERNORS J. Daniell Rackley, M.D., President Tracey Hellgren, M.D., President-Elect David Dixon, D.O., Secretary/Treasurer Joshua Somerset, M.D., Immediate Past-President Christie Alexander, M.D. Shelby Blank, M.D. Hien Guyer, CMS Alliance President Rohan Joseph, M.D. Shakra Junejo, M.D. Maribel Lockwood, M.D. Paresh Patel, M.D. Gregory Perry, M.D. Ernesto Umaña, M.D. Kenneth Whithaus, M.D. Pam Wilson, Executive Director Family Medicine Resident Todd Hewitt, M.D. Internal Medicine Residents Sura Jermanus, M.D./Jose “Tony” Martinez, D.O.

PUBLICATION INTERIM EDITOR Frank Skilling, M.D.

MANAGING EDITOR Shannon Boyle

GRAPHIC DESIGN Gandy Printers

EDITOR EMERITUS Charles E. Moore, M.D.

ARE YOU INTERESTED IN WRITING AN ARTICLE FOR CAP SCAN? Please contact Shannon Boyle at sboyle@capmed.org. All articles submitted will be reviewed by your peers prior to publishing.

Cap Scan is published during the first week of each month and is the official publication of the Capital Medical Society. Advertising in Cap Scan does not imply approval or endorsement by the Capital Medical Society. The opinions expressed are those of the individual authors and do not necessarily reflect the official policies of the Capital Medical Society.

I N T H I S I SS U E :

MISSION: TO PROMOTE THE PRACTICE OF MEDICINE FOR THE ULTIMATE BENEFIT OF THE PATIENT. (850) 877-9018 Fax: (850) 878-0218 www.capmed.org

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CMS Member Announcements …

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2016 CMS Meetings Calendar …

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CMS Connect the Docs Happy Hour …

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CMS Lunch and Learn …

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Reflections from the Interim Editor …

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CMS Connect the Docs Family Fun Day Picnic …

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Viewpoint …

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FSU COM Student Pathography …

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Practice Management …

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Medical Writing …

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CMS Foundation …

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CMS Foundation: We Care Network …

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Medical/Legal …

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HAPPY BIRTHDAY! {APRIL BIRTHDAYS}

Amy Reimer Neal, M.D. – 3rd

Edward Forster, M.D. – 15th

Duncan Postma, M.D. – 4th

Stephen Mnookin, M.D. – 15th

Michael Ford, M.D. – 5th

Stephanie Lee, M.D. – 18th

Randy Reese, M.D. – 7th

Wendy Somerset, M.D. – 18th

Barbara Jaeger, M.D. – 8th

Barbara Demby Abrams, M.D. – 20th

Jesse Judelle, M.D. – 9th

William Placilla, M.D. – 20th

Ronald Hartsfield, M.D. – 10th

R. James Mabry, M.D. – 21st

Vikki McKinnie, M.D. – 10th

Jana Bures-Forsthoefel, M.D. – 24th

Edward Jackson, M.D. – 12th

James Davenport, M.D. – 25th

Mansukhlal Padalia, M.D. – 12th

Mary Swain, M.D. – 25th

Charles Cooper, M.D. – 13th

Clifton Bailey, M.D. – 27th

J. Anthony Giralt, M.D. – 13th

Farhat Khairallah, M.D. – 29th

Louis St. Petery, M.D. – 14th

Julian Hurt, M.D. – 30th

HAPPY BIRTHDAY! WE ARE SO GLAD YOU WERE BORN!

If you are a member of the Capital Medical Society and would like a copy of the Minutes from the Board of Governors meeting, please call the CMS office.

Thank you.

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CMS Trivia Buffs Leap into the New Year …

CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION

DID WE MISS YOUR BIRTHDAY? IF SO, PLEASE EMAIL ROSALIE CARLIN AT RCARLIN@CAPMED.ORG!

CMS MEMBER ANNOUNCEMENTS

PROFESSIONAL NOTES Christie Alexander, M.D. (right) with FSU College of Medicine served as the House of Representatives ‘Doctor of the Day’ on February 23, 2016 by legislative sponsor, Representative Michelle Rehwinkel Vasilinda.

Since its inception in the 1960s, the ‘Doctor of the Day’ program has delivered medical care to the members of the Florida Legislature and all legislative employees. Every year, the physicians of Florida have provided this important voluntary public service each day of the Regular Session.

Barbara Williams, M.D. with Patients First served as the House of Representatives ‘Doctor of the Day’ on February 15, 2016 by legislative sponsor, Representative Michelle Rehwinkel Vasilinda. Physicians from across the state also come to Tallahassee during the Legislative Session to testify on behalf of pro-medicine bills, and to speak against those that are detrimental to patients and physicians.

The ‘Doctor of the Day’ program is a means to interact closely with lawmakers during session and provide them with care while they are away from their home districts.

Thank you for your service, Dr. Alexander and Dr. Williams!

CMS Members: If you receive accolades, please let us know so we can include you in this section!

Email the details to Shannon Boyle at sboyle@capmed.org.

BABY ANNOUNCEMENT Austin David Castillo was born on February 9, 2016 to David Castillo, M.D. and Nicole Castillo, M.P.T. Austin was 20 1/2 inches and 7 lbs. 15 ounces.

FSU Football Class of 2034.

Congratulations, Dr. and Mrs. Castillo!

CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION 3

CMS CONNECT THE DOCS LEAP YEAR TRIVIA NIGHT

CMS TRIVIA BUFFS LEAP INTO THE NEW YEAR (continued from page 1)

Alan Null, CDFA & Michael Davino, CFP® (850) 300-7059

A special thank you to our host and sponsor for this event:

CAPITAL MEDICAL SOCIETY 2016 MEETINGS CALENDAR (continued from page 1)

May 10, 2016 *Change of date* CMS Membership & CME Meeting Medical Use and Risks of Radiation Sergio Ginaldi, M.D., Radiology Associates of Tallahassee 6:00 pm Maguire Center for Lifelong Learning at Westminster Oaks May/June 2016 CMS Doctor/Son Banquet Time & Location: TBA August/September 2016 CMS Meet the Candidates Forum Time & Location: TBA September 20, 2016 CMS Membership & CME Meeting Palliative Care and Decision Making from Chemo Patients to End of Life Monica Williams-Murphy, M.D., Huntsville Hospital, author of “It’s OK to Die” and J. Brian Sheedy, M.D., TMH Palliative Care Consultation 6:00 pm Maguire Center for Lifelong Learning at Westminster Oaks 4

CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION

October 18, 2016 CMS Membership & CME Meeting Domestic Violence and Human Trafficking – 2-Hour Required CME Terry Coonan, J.D., Executive Director at FSU Center for the Advancement of Human Rights and Suzanne Harrison, M.D., Associate Professor and Education Director, Family Medicine, FSU College of Medicine 6:00 pm Maguire Center for Lifelong Learning at Westminster Oaks November 15, 2016 CMS Membership & CME Meeting Periodontal Disease and Systemic Disease William Baldock, D.D.S., Capital Periodontal Associates and Spencer Gilleon, M.D., Tallahassee Ear, Nose & Throat-Head & Neck Surgery 6:00 pm Maguire Center for Lifelong Learning at Westminster Oaks December 1, 2016 CMS Foundation Holiday Auction 6:30 pm FSU University Center Club

CMS CONNECT THE DOCS HAPPY HOUR

Join your colleagues for a Happy Hour Monday, April 11, 2016 • 5:30 pm – 7:30 pm Food Glorious Food • 1950 Thomasville Road Hors d’oeuvres and first beverage provided by our sponsor:

Please RSVP by April 7 to Rosalie Carlin at (850) 877-9018 or rcarlin@capmed.org.

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CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION

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CMS LUNCH AND LEARN

CAPITAL MEDICAL SOCIETY LUNCH AND LEARN SEMINARS On February 17th, J. Scott Fenstermaker, RHU, Managing Owner, Strategic Benefits Group, gave an excellent program on the Affordable Care Act. You can reach Mr. Fenstermaker at (850) 422-9600 or scott.fenstermaker@sbgbenefits.com.

Thomas Howell Ferguson, P.A., CPA’s sponsored the February 17th Lunch and Learn. Brian Walgamott and Kavisha McCranie were in attendance as representatives of Thomas Howell Ferguson, P.A., CPA’s. You can reach Mr. Walgamott and Ms. McCranie at (850) 668-8100 or bwalgamott@ thf-cpa.com or kmccranie@thf-cpa.com.

Seminars are held at the Capital Health Plan on Governors Square Blvd. and we thank them for providing this lovely venue.

Mark Your Calendars for the Remaining Spring 2016 Lunch and Learn Seminars April 20, 2016 Legislative Session and How It Impacts Your Practice This presentation will include a legislative update with an emphasis on issues that will impact physicians’ practice of medicine in the ever-changing world of health care.

Speaker: Jarrod Fowler, MHA, Director of Payment Advocacy, Florida Medical Association Sponsor: Michael Davino, CFP, Waddell & Reed, Inc., Financial Advisors May 18, 2016 Beyond Meaningful Use Though Meaningful Use and CMS’ EHR Incentive program is not over, the healthcare landscape continues to shift with practices facing new mandates to keep up and opportunities to evolve. This session will touch on the following: • The most pressing challenges in Meaningful Use today • What may be on the horizon • Best practices for long-term success • How the lessons of Meaningful Use benefit practices engaged in value-based reimbursement • IHI’s Triple Aim and why it matters • How Meaningful Use ties into Medical Home models • Defining Care Transformation Speaker: Diane Gaddis, CPHIMS, FHIMSS, BSMP, President/CEO, The Center for the Advancement of Health IT Sponsor: Liz Thiele, TMH Federal Credit Union Time: 12 Noon to 1:30 PM (Seminars start at 12:30 PM) Place: CHP Auditorium, 2nd Floor, 1491 Governors Square Blvd.

Cost: $10 per person, per seminar For more information or to register, call Rosalie Carlin at 877-9018.

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CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION

REFLECTIONS FROM THE INTERIM EDITOR

WHITE COAT, SMALL SHOULDERS

By Frank Skilling, M.D. White coats have come to symbolize the medical profession as black gowns symbolized university students in medieval times.

When I was a medical student in the early 1970s, we were required to wear short white jackets, white trousers, dress shirts and ties while on our clinical rotations. The status of someone on the wards was immediately discernible: only attending physicians wore long white coats. Only surgical residents were allowed to wear scrub suits under their white jackets. Cardiology fellows all wore white shirts with conservative ties under their jackets. And so it went down the clinical pecking order. No one would think of going without a jacket on rounds lest they be judged a civilian merely tagging along. Since virtually all the nurses were women, and all wore white caps, it was a safe bet that any male in a short white coat was a lowly medical student of undetermined class rank.

Fourth year students had minimal status, and third year students had even less.

Isaac Newton remarked that his purported brilliance as a scholar was merely because as a scientist he had been able to stand on the shoulders of giants. Few of us can know the influence of teachers past who have provided us with the platforms that we now take for granted. Henry James said that to be a teacher is to achieve a form of immortality because teachers never know whom they will influence in the future.

This fine thread of professor to student recently became more visible to me when I received a letter from Dr. James Geissinger, a retired neurosurgeon in Tallahassee, who enclosed a photo of two of his surgical mentors with Dr. Elizabeth Crosby, the neuro-anatomist who wrote the definitive treatise on the anatomy of the mammalian brain. Dr. Geissinger commented that he considered her text so important that he read it from cover to cover four times during his training! Geissinger was an extraordinary neurosurgeon who, along with his partner Dr. Frank Davis, was a stalwart in the medical community and provided superb neurosurgical care to his patients for many years before his untimely retirement after

contracting hepatitis C from exposure to a patient’s blood.

Today, more than 20 years after his retirement, I still see patients whose vision and lives he saved. One of them is now a young woman who was diagnosed with hydrocephalus (“water on the brain”) as an infant and who was doomed to a life of blindness, total brain failure, and an early demise had he not intervened.

Her father has relayed to me that once the diagnosis was made, Dr. Geissinger immediately placed a ventricular shunt in her brain to remove the excess fluid. She has lived an extraordinarily normal life, and the shunt worked well until ten years ago when it malfunctioned, causing headaches and papilledema (swelling of the optic nerves). The shunt was replaced then and she was restored to a headache-free normal existence.

Geissinger’s photo shows the diminutive Dr. Crosby as she points out anatomical findings of a brain section to the two neurosurgeons.

As I mentioned in a previous article about her, Dr. Crosby’s knowledge of neuro-anatomy was so profound that she was often invited into the operating room to direct the neurosurgeons who needed her guidance in an era before CT and MRI scans. No one present at the time of the photo could guess that her shoulders would provide the platform that allowed Dr. Geissinger to save the life of my patient decades later. Although Newton may figuratively have stood on the shoulders of giants who preceded him, Dr. Geissinger also perched on the shoulders of a tiny figure in a white lab coat who directed his hands a generation later. CMS CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION 7

CMS CONNECT THE DOCS FAMILY FUN DAY PICNIC

The Capital Medical Society and Capital Medical Society Alliance invite you and your family to the Family Fun Day Picnic Saturday, April 23, 2016 11am - 2pm Maclay Gardens State Park • 3540 Thomasville Road $6.00 entrance fee**

“Stella” the Food Truck and Street Chefs will serve delicious food plus we’ll have lots of family fun activities!

Come on out and enjoy the day with your colleagues and their families!

Please RSVP by April 15 to Rosalie Carlin at (850) 877-9018 or rcarlin@capmed.org.

Food and drinks provided by: 8

CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION

VIEWPOINT

NO REGRETS

By Jason Oberste, M.D. Interim Editor’s Note: Battlefields have provided medical advances for centuries. Our combat units in Afghanistan have close medical support from military physicians and surgeons. Dr. Jason Oberste, an orthopedist at Tallahassee Orthopedic Clinic, tells his story in this brief article about one of the surgical teams that deployed with US ground forces in Afghanistan. Operating on casualties essentially on the front lines of combat is fraught with hazard, and the tension is made even worse when the team is striving to save its own members.

Afghanistan, Winter 2009

base was the surgical team.

physician stateside.

0230

We were a special operations surgical team, SOST. Our mission was to be embedded with small covert teams in “destinations unknown” throughout the worst places in the world.

We were there as a safety net, in case our operators were injured.

I sat half asleep with a radio in my lap…waiting.

It was like many other nights that we had an “alert.” Earlier this night, we had sat outside staring at a comet that was lighting up a perfectly clear Afghan sky, overlooking the mountains, with many more stars than were ever visible in the half illuminated skies back home. No lights allowed here.

We called it “light discipline.”

No need to give the enemy any lit up targets to shoot.

There were usually thirty of us on this base: special operators and our medical team. We spent our days preparing, practicing, and planning out missions.

We also played cards, swapped music, watched movies, shot weapons, grilled crappy food, and discussed home together.

We were family. Our lifeline to the world was a dirt airstrip and a satellite link.

Tonight, all that was left on the

We were all highly trained in our medical specialties. Our team consisted of 2 surgeons (Orthopedics and General Surgery), an Emergency Medicine physician, a Nurse Anesthetist, and a surgical technician. We were all aware of the risks that this team would face. We were all volunteers and had been selected.

The team was also highly trained in the requirements of special operations. This included: weapons training, air commando school, survival/ evasion/resistance/escape, international terrorism, as well as months of field training.

In four years, I had spent over 16 months deployed, and at least another 8 months in military training. All while practicing as a military

This was my fourth overseas tour with this team…

Our operators had NEVER been injured.

0245 At this point, only the 5 surgical members were left behind to guard the base. The gates were closed. The lights were off.

The weapons were loaded. The operators were on a mission.

The transport team had been activated to pick up casualties from “troops in contact.”

I was manning the radio, but there was little chatter. We had done this many times. It was becoming somewhat routine.

Usually, we would bring in Taliban or civilian casualties, occasionally a coalition soldier from another country. We would patch them up and obtain information that may be useful in future mission planning.

CONTINUED ON NEXT PAGE

CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION 9

VIEWPOINT

We had not heard from our transport team since they had left in the Blackhawk helicopter.

dental extractions, mole removal, cyst excision, even circumcisions.

I could hear the helicopter returning. This is a rhythm that will be forever etched into my memory. Even today, when I hear a helicopter at the hospital, my adrenal glands squeeze and my heart quickens.

I never would have envisioned this when I signed up to join the military at the age of 21. I had joined the Air Force on a HPSP (Health Professions Scholarship Program) contract. In return for full tuition, books, and a living allowance during medical school, I owed four years of obligation after training. After medical school, I was selected for a military orthopedic residency in San Antonio.

When all of my training was complete, my wife and I had been in the US military for nine years.

0300 The door to our makeshift trauma bay moves with the draft from the chopper.

The trauma bay/operating room is a shack. We have stocked it with cinder block and wooden shelves. We have a spartan array of medical equipment. Essentially enough to stabilize a small mass casualty without resupply. We had headlamps, minor surgical sets, some hand tools for fracture repair, and very simple anesthesia equipment for airway management.

We were trained to be dropped from a helicopter with our 5 bags and to be ready for surgery within 15 minutes.

In 4 deployments, I had done about 50 surgeries. Mostly minor gunshot wounds, shrapnel injuries, some amputations. I had also done over 100 small surgical procedures as a gesture of goodwill in small villages and rural communities throughout the world. These included

For my 4 years of obligation, I applied for the Special Operations position at Air Force Special Operations Command (AFSOC) at Hurlburt Field in Fort Walton Beach, Florida. I was selected and trained for this mission.

This was my last deployment. I had been to El Salvador, Qatar, Southeast Asia, Philippines, and now Afghanistan.

Afghanistan is the end of the earth. Don’t ever go there.

0310 The swing doors burst open!

My critical care nurse, Ricky, the transport commander, stumbles through the entry. His

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Dr. Oberste in Afghanistan in Winter 2009.

body armor is half fastened. His beard is full of the gray dust that is a constant nuisance. Typically a stoic, calming presence on our team; he looks rattled.

His pupils are dilated and his eyebrows are raised…

“It’s our guys!”

0311 Stretcher after stretcher burst through the doors with my operators/friends lying with ripped uniforms, bloodstained bandages, and tired eyes.

The surgical team immediately responds to triage and address each of our injured comrades.

Following the stretchers, my anesthesiologist, a Westpoint and Harvard Med grad and collegiate swimmer, limps into the trauma bay. He was with

VIEWPOINT

our operators on this mission as close medical support. His eyes are swollen shut, his hair is singed, and he bumps into me at the door. He has obviously sustained a massive facial injury.

Our anesthesiologist sustained a C3 spinal burst fracture, maxilla fracture and closed head injury.

Our CRNA performed all anesthesia that morning.

We laid him on a stretcher, placed an IV, and immediately intubated our anesthesiologist.

Each of our teammates were stabilized and loaded on a C-130 transport plane that arrived at 0900. They each were reassessed in Bagram, Afghanistan that afternoon, then transported to Germany the following day. Later that week they were at Bethesda Naval Hospital in Maryland.

0312-0900

All survived.

We triaged and operated on six of OUR team members that morning. Not Taliban. Not foreign coalition soldiers. Not civilians.

0930

“Where do you need me Obi?” “Eric, I need you to just sit down.”

I slowly walked to our chow hall and sat down alone…and cried.

4 years of college…4 years of medical school…5 years of residency…4 years of deployment…

Every minute of those years for this moment.

No Regrets!

CMS

I stood alone and watched the C-130 take off and disappear over the mountains.

Their Humvee had rolled over an IED that was made of 2 antitank mines and a 40 mm mortar. The vehicle had been blown into the air and onto a mud hut. All 6 men were in that Humvee.

Two other vehicles in the convoy were not destroyed and called in medical support and secured the area.

Injuries included: open abdominal shrapnel wound, bilateral ankle/talus fractures, open acetabular fracture, closed humerus fracture, open scrotum, open pelvis fracture, and knee dislocation.

The destroyed Humvee in Afghanistan.

CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION 11

FSU COM STUDENT PATHOGRAPHY

FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE – STUDENT PATHOGRAPHY (Student essay on one of their patients from their rotation. All patient names are fictitious.)

Life is a cycle; a constant flow of ebb and flow, of rest and rigor. I wish I could have another chance but it’s too late for me now. My body now rests in Sunset Cemetery in Columbus, Georgia.

To explain how I got to the end of my life, I will share with you my story.

My name is Joel Nicholson and I was born in Tifton, GA, USA in 1965. My mother Evita, was an assistant principal and my father Jack was a football coach. They raised my three brothers, sister, and I in Tifton. Our only language was English growing up. My family would be considered African-American or called black by society. I don’t like to use the term black so much, as I have always thought that black people and all people were much more than a color. That being said, make no mistake, I am still proud to be black. It has always been a very pertinent detail in my life that as a so-called black man, I had to move and choose differently than others. There were certain places and people I knew to avoid so that I wouldn’t find myself in a situation I didn’t want to be in.

I didn’t go outside much growing up or during my adult life. Major reason being, my insecurity about the way people would look at me for being fat and black. Those who knew me, including myself, would consider me a friendly introvert.

I am a lover of fine cuisine and a student of Eastern cultures. I am also an avid sports fan, but I usually didn’t participate in them because I wasn’t good enough. College football was definitely my favorite sport, and I am a Georgia Bulldog through and through. Growing up in a post-civil rights era in the South motivated 12

CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION

me to want to learn more and go to college.

My parents encouraged us all, my siblings and I, to do so. Throughout my entire life I have valued education and I have always tried to learn something new even when not in school. After high school I went to Georgia State College for a short time; for financial reasons I had to leave. While my time at Georgia State was short it opened my eyes up to things outside of my world in Georgia. It inspired me to be more mindful of world happenings. Unfortunately, I couldn’t pursue my personal and academic goals because of the systematic roadblocks I frequently encountered on my life journey.

Following my stint at Georgia State, I migrated up to New Jersey where I worked for Johnson and Johnson Company for 14 years. After losing my job, I had to move back down to South Georgia. Unable to support myself, I moved in with my Uncle Al. At that point in my life I was still able to get around on my own and do for myself. If I could’ve changed anything it would’ve definitely been to get rid of all this weight that has me feeling trapped inside. I didn’t want my life to end that way, obese and paraplegic. It’s been about five years ago now, when I was moving some furniture and moved too quickly when I felt a severe back pain that eventually led to me being functionally paraplegic.

Most people judged me immediately with their eyes; I grew very used to that look. Many times it comes with disdain. Most thought my being fat was all my fault and/or they pitied the state I was in. I had to learn to live with the fact that I was in

FSU COM STUDENT PATHOGRAPHY

morbid condition. That I was wheelchair bound and considered morbidly obese. It is a ‘tough pill to swallow’; when all you want to do is be able to stand up and pee on your own or get in and out of bed without assistance, and you can’t! I had an extensive medical history which included; Retinal detachment that led to blindness in my left eye; a history of a spinal cord abscess that complicated my back injury and led to my paraplegic state; severe obstructive sleep apnea that made me tired all the time; Neurogenic bladder with an indwelling Foley catheter that led to cyclical UTI’s and hospitalizations; HTN with intermittently labile HTN; DM Type II, uncontrolled; Chronic Kidney disease stage 4 secondary to HTN and DM; Diabetic Gastro paresis; GERD and PUD; Coagulopathy; Congestive Heart Failure; Hx of Ischemic Stroke; Hx of DVT; and of course Morbid Obesity with a BMI of 60, I was over 350 lbs. I wish I didn’t have to live like that but I was still proud to be living.

too late for me. I also remember him dropping in on me from time to time during my cyclical hospitalizations to chat.

I shared with him my want for him to be a symbol for our people, for all people. To be someone who spoke truth at all times and would help prevent people from experiencing life the way I knew it. I wish I came to know the truths we chatted about and shared, earlier in my life, but I am glad I got to know them at all. While he was away in Florida on a rotation I was hospitalized one last time. This time I didn’t make it out of that hospital alive.

I had respiratory failure complicated by my coagulopathy, obesity, diabetes, and heart failure.

I felt like I lost my humanity connected to all those machines; unable to talk; tubes coming in and out of all my orifices. The sensation of suffocating overwhelmed me and I ended up passing due to an acute pulmonary embolus. My Life flow was obstructed and now I rest in rigor mortis.

There were only a few people in the healthcare field that I felt comfortable speaking to.

Joel’s intelligence, infectious smile, his engaging Reason being was because I never felt a sense sense of humor, and his warmness toward all of judgment from them. I’ll mention two; my beings have had a profound impact and made care taker Susan and a student doctor I met this him an invaluable part of my Life. I will cherish year. I really enjoy my interactions with that his memory. young doctor. I remember the day I met him at my primary care physician Dr. D’s office. Dr. - Adam Baptiste D asked if his student could interview me and follow me throughout the year. He was very cordial with me and genuinely interested in who I was as a person. We had a long conversation where I told him everything I’ve told y’all Dennis A. Fried, M.D., J.D. so far and more. It was the most time that anyone Licensing, Discipline &Peer Review Defense in the healthcare field for All Medical Professionals in Florida had ever spent with me and it felt like he actually Free Initial Consultation cared and wanted me to Blanchard, Merriam, Adel & Kirkland, P.A. get better. He was genuine 4 S.E. Broadway Street, and made me feel special.

Ocala, FL 34471 I remember being excited by his enthusiasm, but 352-732-7218 www.bmaklaw.com I knew it was probably CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION 13

PRACTICE MANAGEMENT

CONNECTING COMMUNITIES THROUGH HEALTH INFORMATION TECHNOLOGY Connecting health care providers across communities increases coordinated care and better patient outcomes. The Agency for Health Care Administration (Agency) supports these connections by promoting the use of health information technology (health IT) throughout the state of Florida.

The Agency manages the Florida Health Information Exchange (Florida HIE), which enables the secure statewide exchange of health information between health care providers and administers the Medicaid Electronic Health Record (EHR) Incentive Program funded by the U.S. Centers for Medicare and Medicaid Services (CMS).

The Medicaid EHR Incentive Program encourages eligible providers (EPs) to adopt and meaningfully use certified electronic health record technology to support the exchange of health information. This year is the last year that EPs can begin participation in the program and take advantage of the incentive payments offered (totaling $63,750 over the course of six years).

The benefits of EHR utilization are extensive. Patients can become more engaged in their health care through patient portals, and providers can more easily document information and coordinate with one another. This exchange of information promotes measurable improved care delivery and performance, leading to improved patient outcomes.

In order to participate in the Medicaid EHR incentive program, providers must be a non-hospital based physician, dentist, advanced registered nurse practitioner (ARNP), certified nurse midwife, or Physician Assistant (under certain circumstances). Participants must have 30% Medicaid volume, 20% if they are Pediatricians.

Providers can begin the program by simply adopting, implementing, or upgrading to certified electronic health record technology. In years that follow, participants begin documenting specified measures to demonstrate the meaningful use of their EHR technology. As part of meeting these measures, providers must be able to transfer patient information from their EHR to other providers electronically when there is a transition of care.

One way to achieve this measure is through use of the Direct Messaging Service offered by the Florida Health Information Exchange (Florida HIE).

The Direct Messaging service provides health care professionals with a secure, encrypted, HIPAAcompliant way to securely exchange messages and health information via email. The Florida HIE’s Direct Messaging service is nationally accredited by Direct Trust. This accreditation provides the ability for providers, vendors, and organizations to exchange information across a very large community of entities meeting these standards. Users of this service include health care providers, health plans, and health care agencies. This web-

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based service has no software to download and can be integrated with electronic health records and health information or used as a stand-alone mailbox.

In addition to the Direct Messaging Service, the Florida HIE promotes exchange through a Patient Look-Up (PLU) query service. The service enables providers (with patient consent) in participating health care organizations to query one another for medical records.

PLU provides comprehensive patient data from many sources, allowing practitioners to make more informed decisions about patient care. PLU operates without a centralized database, providing the security of local control with the utility of statewide exchange.

In addition, PLU provides access to the national eHealth Exchange gateway. There is currently funding from the CMS to assist organizations with initial participation costs. For providers who do not have the technical infrastructure to directly connect to the PLU network, this funding can help them join one of the existing partner organizations - a lighter implementation while still receiving all of the benefits of the state connections.

Better care coordination is achieved through the inclusion of every facet of a patient’s health care team. The Event Notification Service (ENS) provides health plans and accountable care organizations (ACOs) with timely alerts on their members’ health

PRACTICE MANAGEMENT

HEED THOSE EHR ALERTS

care encounters. With over 200 hospitals securely sending admit-discharge-transfer (ADT) feeds to the service, health plans and ACO subscribers are able to provide this information to primary care providers to ensure that patients are receiving the best and most appropriate follow up care. Supporting the reduction of hospital readmission and non-urgent use of emergency departments, ENS works to keep all members of a patient’s health care team up to date on the patient’s care needs and health status.

By closing the gaps in information availability, the use of EHR and HIE systems build a stronger and more knowledgeable network between all levels of the health care continuum. Health care professionals are encouraged to access and utilize Health IT. A number of funding opportunities are available to help to help providers adopt EHR technology and communities of care to connect to HIE services.

Contributed by the Agency for Health Care Administration (AHCA).

To learn more about Florida HIE services, please visit www.florida-hie. net, or email flhii@ahca.myflorida. com. For more information on EHR incentive program requirements and how you can participate, visit the website at www.ahca.myflorida. com/medicaidehr, or email MedicaidHIT@ahca.myflorida.com for assistance.

By Jacqueline Ross, PhD, RN, Senior Clinical Analyst, Department of Patient Safety and Risk Management, and Susan Shepard, MSN, RN, Director, Patient Safety and Risk Management Education Patient harm caused at least in part by the use of electronic health records (EHRs)—or e iatrogenesis—emerged as a factor in a closed claims study conducted

by The Doctors Company. The study of 71 claims closed by The Doctors Company between 2007 and 2013 revealed that 65 percent involved EHR-related user issues, and 42 percent identified system technology design risk factors.

Some claims included both user issues and system technology design risk factors.

The ECRI Institute (formerly Emergency Care Research Institute) recognized alarm hazards as the number one IT-related problem in 2015. Alarm hazards occur not only with physiologic monitoring systems,1 but also with alarm-generating devices, such as EHRs. Unfortunately, human factors may prevent healthcare providers from responding appropriately or using the alarms that are readily available to them.

EHRs have multiple benefits— from improved patient outcomes and improved care coordination to practice efficiency and cost savings. However, inappropriate use of or ignoring EHR alarms/ alerts has been connected to patient harm. On the issue of over-alerting (systems generating too many alerts), Dr. Tejal K. Gandhi, president and CEO of the National Patient Safety Foundation, noted “most studies

have found that only 20 percent of alerts are actually accepted,” so an important alert could be missed.

She added that studies have shown that reducing the number of alerts “by streamlining the ones that you decide to alert on, by tiering, to only interrupt for things that have a certain amount of significance, you can actually reduce the number of interruptions significantly.”2 E-health data come from external sources, such as websites or through health information exchanges (hospital charts, consultant reports, and laboratory and radiology reports). Doctors also have access to data through e-prescribing community medication histories—which can expose them to liability for potential interactions with drugs prescribed by other clinicians.

For example: Dr. A renews a medication, and his e-prescribing program sends an alert advising him that the medication could interact with another medication the patient is taking. He has not prescribed that drug, so his office staff will have to contact the patient to identify who has prescribed it, and then Dr. A will have to contact Dr. X to “negotiate” which drug will be discontinued or changed. If failure to take action results in patient injury from a drug-drug interaction, Dr. A may be liable.3 Drug-drug interaction lists are often so comprehensive and CONTINUED ON NEXT PAGE

CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION 15

PRACTICE MANAGEMENT

generate alerts with such frequency that they can become disruptive and annoying. Doctors may develop “alert fatigue” and ignore, override, or disable them. However, if it can be shown that following an alert would have prevented an adverse patient event, the physician may be found liable for failing to respond.4 Optimized, clinically meaningful drugdrug interaction lists that focus on a smaller set of interactions most frequently associated with harm or expert consensus lists may address this problem.

However, EHR vendors may resist eliminating the low-risk warnings, fearing that doing so could increase their liability.

The following two claims illustrate some of the issues surrounding alerts and human factors.

uncontrolled bleeding from the fistula, and the patient exsanguinated and expired. Experts were critical that there was no EHR high-risk medication alert.

Medication reconciliation might have prevented this error.

Strategies for Reducing Alert Hazards • Understand alarm fatigue. When caregivers become overwhelmed, distracted, or desensitized to an alarm or an alert, determine the most important alarms, and work with your vendor to ensure that unnecessary alarms or alerts are not built into your system.5 • Determine if alerts are appropriately configured so that alert conditions are not missed or ignored.6

Claim One An elderly female saw an otolaryngologist for ear/ nose complaints. The physician intended to order Flonase nasal spray. The patient filled the prescription and took it as directed. Ten days later, she went to the ER for dizziness. Two weeks after that, the pharmacy sent a refill to the physician at his request. It was for Flomax—a medication prescribed for enlarged prostate—which has a side effect of hypotension.

When ordering the prescription, the physician had typed “FLO” in the medication order screen. The EHR automatched Flomax, and the physician selected it without realizing the mistake. Flomax is not FDA-approved for females. There was no EHR Drug Alert available for gender. To prevent this type of mistake, the provider should have reviewed the prescription with the patient and read what was ordered. By writing the indication for the medication on the prescription, the pharmacist would have been alerted that the medication was not appropriate to the condition being treated.

Claim Two A dialysis patient was transferred to a skilled nursing facility. There was an active hospital transfer order for Lovenox. A physician evaluated the patient on admission but made no comment about the Lovenox order. During the first dialysis treatment, there was active bleeding at the fistula site. The anticoagulant heparin had not been given. The nursing staff did not inform the physician of the bleeding.

During the second dialysis treatment, there was 16

CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION

• Assess your EHR for frequent drug-drug interaction alerts, which have been shown to lead to alert fatigue that can cause the alerts to be disregarded, ignored, or disabled. Work with your EHR vendor to use key data elements to design EHR alerts for high-risk drug-to-drug interactions. The result will be more meaningful alerts that are less likely to be ignored or disabled, thus avoiding a possible error.

• Be aware that clicking through drug-to-drug therapeutic duplicates or drug/allergy alerts with little review can be interpreted to mean that the physician ignored the safety alerts.

• Read the alerts. EHRs record how much time is spent reviewing information. If the time is very brief and there is a negative patient outcome, the physician could be perceived as sloppy or hurried.

• Don’t turn off alerts. If a hospital-employed physician and hospital turn off alerts that could have avoided a patient problem, the hospital and physician may both be found liable.

• Always document why a clinical decision support (CDS) prompt was overridden. CDS may conflict with a medical specialty’s clinical standards of care or practice guidelines or with the information in FDA-approved drug labels.7

PRACTICE MANAGEMENT

Alerts are a necessary safety mechanism when used, heeded, and configured appropriately for your practice. Check your alerts to make sure they provide adequate information and are not overly burdensome to your practice.

References 1. ECRI Institute. Top 10 health technology hazards for 2015: a report from health devices. November 2014. www.ecri.org/2015hazards. Accessed July 1, 2015.

2. Texas Medical Institute of Technology. Webinar transcript: Ambulatory patient safety issues— opportunities for improvement. http://www. safetyleaders.org/downloads/WebinarTranscript_ August2013.pdf. August 15, 2013.

3. Troxel D. Electronic health record malpractice risks. The Doctors Company. Available at: http://www.thedoctors. com/KnowledgeCenter/PatientSafety/articles/ Electronic-Health-Record-Malpractice-Risks. Accessed July 1, 2015.

4. Ibid.

5. Lacker C. Physiologic Alarm Management. Pennsylvania Patient Safety Advisory. 2011 Sep;8(3)105-8.

6. ECRI Institute. Top 10 health technology hazards for 2015: a report from health devices. November 2014. www.ecri.org/2015hazards. Accessed July 1, 2015.

7. Russ AL, Zillich AJ, McManus MS, Doebbeling BN, Saleem JJ. Prescribers’ interactions with medication alerts at the point of prescribing: a multi-method, in situ investigation of the human-computer interaction. Int J Med Inform. 2012 Apr;81(4):232-243.

Reprinted with permission. ©2016 The Doctors Company (www.thedoctors.com). This article originally appeared in The Doctor’s Advocate, fourth quarter 2015.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.

The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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17

MEDICAL WRITING

THE DECLINE AND FALL OF MEDICAL WRITING

By Richard Gunderman, M.D., PhD and James Lynch, M.D. George Orwell said, “If people cannot write well, they cannot think well, and if they cannot think well, others will do their thinking for them.” If Orwell was right, the profession of medicine and the patients it cares for could be in big trouble. As a result of ongoing changes in healthcare, today’s medical students and residents are being asked to write much less than in the past, with a predictable decline in the quality of what they produce. This, in turn, threatens the quality of patient care.

Recently one of our medical students, a very bright young man, submitted his first patient write-up. He had spent several hours interviewing the patient, performing a physical exam, and recording his findings. Inspecting his work, we told him, “This is not good medical writing. What you have produced is not a note fit for a patient’s chart but a series of bullet points.” He replied, “But that’s how I think — I think in bullet points. Why should I write any differently?”

He had a point. He and many — perhaps most — of his colleagues really do think in bullet points. Raised on a steady diet of terse emails, abbreviation-laden text messages, and telegraphic tweets, their routine modes of written communication exhibit a clipped, disjointed quality. Too often, isolated impressions tumble forth one over another, with very little in the way of a coherent, sustained theme to bind them together.

The decline in medical writing has other sources, such as the widespread use of PowerPoint in education. When nearly every medical school lecture is formatted in bullet points, why should students suppose that they are expected to produce anything different? The same approach is found among many textbooks, which often eschew the use of complete sentences. Another factor promoting bullet-point thinking is the ubiquitous replacement of essays by multiple-choice tests.

Yet we believe there is an even more pervasive force behind the declining quality of writing in medicine.

It is the medical record itself, which has moved from handwritten pages in loose-leaf binders to electronic forms and templates. Instead of telling a patient’s story in prose, today’s medical learners are required merely to tick boxes, review auto-populated forms, 18

CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION

and copy and paste chunks of text from one entry to another.

Not only are medical students less frequently required to compose integrated narratives, but they are also devoting less time to confirming the elements they do record. At first, pasting blocks of text seems to provide a welcome short cut, but it soon becomes a new norm, with erosive effects for both the accuracy of the medical record and the veracity of the physician. When students don’t formulate their own ideas, critical thinking and analysis inevitably suffer.

The driver in this dumbing down of the medical record is not primarily the best interests of patients — making medical records more user-friendly, knowledge-rich, and useful in patient care. Instead, it is coding and billing. Medical practices, hospitals, and health systems are loath to “leave money on the table,” and so they require physicians to enter health information in ways that maximize its value as a commodity.

The length of entries in patients’ charts has grown exponentially. Why? If something is left out, payment may be denied. Yet the quantity of medical knowledge has not increased. Truly valuable information is diluted by formulaic drivel, making it more difficult to locate what the health professional really needs to know. Many colleagues have commented that, in today’s medical record, the care of the patient too often seems an afterthought.

The days when making entries in the medical record challenged young doctors to synthesize and integrate what they were learning about their patients are fast fading from memory. Even if all the information really is captured — and for reasons we outline below, we doubt that it is — it is unlikely to be fully understood and acted on. First it must first be formulated into a coherent narrative, a story that weaves together the biology and the biography of the patient.

Such integration makes a difference. A woman being treated for cancer had a history of asthma and abnormal heart rhythms. The oncologist reviewing her record asked if her episodes of dysrhythmia were associated with the use of her inhaler, which delivers

MEDICAL WRITING

a drug that stimulates the heart. Once she modified her use of the inhaler, the heart problems went away.

Her pulmonologist and her cardiologist never wrote a comprehensive note, and as a result, they never put two and two together.

Today’s doctors in training are too often functioning as data entry specialists, no longer eliciting, recording, or understanding the patient’s story. We forget that really first-rate medicine resembles creative writing.

When the patient’s story is fragmented into ticked boxes, auto-populated fields, and pasted chunks of verbiage, key elements remain unintegrated, inconsistencies go uncorrected, and opportunities to tie things together are missed.

It is not just a matter of reducing medical errors.

Getting the full story is equally crucial in caring for the patient as a person. In another case, a student emerged from an encounter with an elderly cancer patient and gave a competent bullet-point style account of what he had learned. He had dutifully gathered all the information required by the template on his tablet computer, including even sensitive matters such as sexual history and end-of-life care.

What was completely missing from the student’s account, however, was any sense of who the patient was, what kind of life he had led, and what he hoped for from his care. Such information is not part of any quality metric, nor is it needed to code and bill accurately for the encounter. From some points of view, such information might be branded mere chitchat, nothing more than pleasantries exchanged to prevent patients from thinking their doctor sees them as a disease and nothing more.

But there is far more to it than this. The attending physician returned with the student and spent an additional 15 minutes with the patient. During this time, he learned that the patient holds a PhD in a foreign language and had spent decades in the intelligence service. Early in his career, he had been captured and tortured before finally being liberated.

Undeterred, he returned to the intelligence service and met a woman fleeing persecution, whom he later married.

In the course of this conversation, both the medical student and the attending physician gained a deeper understanding of the patient, with important implications for his care. Yet they also learned some

fascinating things about a world they had never encountered before. More notably, toward the end of the conversation, the patient’s wife reached over and took the attending physician’s hand in her own, saying, “My husband has seen many doctors, but you are the first one to ask questions about his life. I just wanted to thank you for treating him as a person.”

Why did the attending physician get this information?

Not because he was populating a field on a computer screen, but because he was genuinely interested in the patient. If he knew the story better, he would be able to take better care of the patient.

We are not suggesting that physicians who trained before the era of the electronic health record were all great writers. We are simply concerned about what will happen if writing continues to sink beneath the horizon of medical training. How will medical students learn to think critically and know when to diverge from established algorithms? How will they grasp the vital role that knowing the patient’s story should play in medical practice?

Such questions are beginning to receive attention.

The reformatted Medical College Admissions Test now includes a section on critical analysis and reading skills. Some medical schools are challenging applicants to write reflective essays, and the same thing is occurring when graduating students apply to residency programs. Some schools have also developed programs in narrative medicine. But more efforts are needed, and they cannot be confined to medical schools.

To be sure, medicine is a science, and it is also an important form of economic activity. Both depend on data, and today’s doctors are generating such data by the gigabyte. But medicine is also an art, and the artful side of medicine lives not by data but by narratives. Patient management may be driven by data, but it is often the story more than anything else determines how well the patient is cared for.

Reprinted with permission. Richard Gunderman is Chancellor’s Professor, Schools of Medicine, Liberal Arts, and Philanthropy, Indiana University, Indianapolis, IN. James Lynch is dean of admissions, University of Florida College of Medicine, Gainesville, FL.

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CMS FOUNDATION

The Impact of Private Support: Capital Medical Society Foundation’s community of donors strategically help fulfill its mission “to support the charitable efforts of physicians and others, increase access to healthcare, promote education and serve the community’s health needs through innovative projects that are exemplary, affordable and dignified.”

• Access to healthcare is increased through gifts to We Care Network and the We Care Network Endowment Fund. $64 million in donated specialty medical and dental care has been provided to low income, uninsured patients since the program was created in 1992. Gifts support the salaries and benefits of the case management team who coordinate donated care.

• To provide incentives to keep medical students trained at FSU College of Medicine in the Big Bend after completion of their residencies and help meet the growing demand for physicians in Florida, gifts to the Scholarship Fund provide scholarships to FSU College of Medicine students who have expressed an interest in returning to the Big Bend to practice after completion of their residencies. $50,000 was distributed to seven medical students in 2015.

DONATE TO THE CMS FOUNDATION

WE THANK OUR DONORS We thank the following people who made a donation to the CMS Foundation this past month: We Care Network Florida Blue Foundation – for 2015-2016 Dental and Medical Services in Gadsden County Your gifts to Capital Medical Society Foundation transform lives in the Big Bend.

• Gifts to Capital Medical Society Foundation help provide operational resources for Capital Medical Society Foundation, including building maintenance, computer upgrades, as well as, modest grants to area non-profits whose programs improve access to health care for the underserved. In 2014, CMSF was able to repave its parking lot after 17 years, install a front door security and intercom system to improve the safety of staff, and purchase a new computer server. $11,000 in grants were awarded for Big Bend Hospice’s Bereavement Services Program, Elder Care’s In-Home Services Program, and FSU College of Medicine’s Chapman Community Health Program were awarded in 2015.

Gifts to Honor and In Memoriam: You can make a donation to the CMS Foundation in memory of someone who has passed away or in honor of someone, such as a fellow physician, you hold in high esteem or has taken care of you or your family. CMS Foundation will send an acknowledgement letter to those you memorialize and honor.

How to Give: Through the generosity of donors, funds have been created in order to establish financial stability to meet our mission. You can donate at any time to one of CMS Foundation’s current funds: 1) Capital Medical Society Foundation-area of greatest need 2) The Capital Medical Society Foundation Endowment 3) We Care Network 4) We Care Network Endowment 5) Scholarship Fund Checks should be made payable to the CMS Foundation and indicate on the memo line of your check to which designation you would like to donate. Bring your check to the CMS Office or mail it: Capital Medical Society ~ 1204 Miccosukee Road ~ Tallahassee, FL 32308.

If you would like to discuss a gift of appreciated securities, an insurance policy, designation of retirement plan assets, estate gift, or multi-year pledge, please contact: Pam Wilson, Executive Director pwilson@capmed.org or (850) 877-9018

20 CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION

CMS FOUNDATION: WE CARE NETWORK

THANK YOU To our CMS members and We Care partners who saw new patients for the We Care Network in February 2016.

Your generosity and support of the We Care Network makes a difference.

Physicians Kalil Al-Nassir, M.D. Greg Albright, D.O. J. Galt Allee, M.D. Aaron Appiah, M.D. Wayne Batchelor, M.D. Camille Blake, D.O. Robert Bradford, M.D. Tim Broeseker, M.D. Viet Bui, M.D. Ashton Byington, M.D. Carlos Campo, M.D. Joseph Camps, M.D. Michael Cavallaro, M.D. Gilbert Chandler, M.D. William Dixon, IV, M.D. Mark Fahey, M.D. Michael Ford, M.D. Akash Ghai, M.D. Spencer Gilleon, M.D. Sergio Ginaldi, M.D. Gian-Carlo Giove, M.D. W. Harris Green, M.D. Aaron Guyer, M.D. Celeste Hart, M.D. Robert Hoyne, M.D. Iman Imanirad, M.D. Marc Inglese, M.D. Barbara Jaeger, M.D. Simha Jagadeesh, M.D. Floyd Jaggears, M.D. John Katopodis, M.D. Farhat Khairallah, M.D. Maribel Lockwood, M.D. Michael Mangan, M.D. Gary McManama, D.D.S. T. Adam Oliver, M.D. Steven Ostrov, M.D. Praful Patel, M.D. Timothy Paulk, M.D. Michael Pentaleri, M.D. Duncan Postma, M.D.

J. Daniell Rackley, M.D. Stephen Richardson, M.D. Andres Rodriguez, M.D. Karen Russell, M.D. L. Stephen Sarbeck, M.D. Gadi Silberman, M.D. Jeannine Silberman, M.D. Robert Snider, M.D. Bob Soni, M.D. Mary Swain, M.D. Timothy Sweeney, M.D. John Thabes, M.D. Jean Paul Tran, M.D. Tony Weaver, M.D. Dale Wickstrum, M.D. William Yaakob, M.D. Daniel Yang, M.D. Samuel Yu, M.D. Dentists Eric Amundson, D.D.S. William T. Baldock, D.D.S. JP Bastien, D.M.D. Steven Bryan, D.M.D. Darrh Bryant, D.M.D. Susan Byrne, D.M.D. David Cardman, D.M.D. Walter Colón, D.M.D. Brittney Craig, D.M.D. John S. Dozier, D.M.D. Michael Hartley, D.M.D. William McFatter, D.D.S. E. Lynn McLarty, D.D.S. Jim McSoley, D.M.D. Lawrence Pijut, D.M.D. Frank Swerdzewski, D.D.S. James Sykes, D.M.D. Jay Walton, D.D.S. Lawrence Weaver, D.D.S. Ed Zapert, D.M.D. Facilities Affordable Dentures Anesthesiology Associates Beachton Denture Clinic Capital Regional Medical Center Dermatology Associates Desloge Home Oxygen Leon County Dental Clinic Pathology Associates Radiology Associates Seven Hills Surgery Center Southeastern Surgery Center Tallahassee Diagnostic Imaging Tallahassee Endoscopy Center Tallahassee Health Imaging Tallahassee Memorial HealthCare Tallahassee Orthopedic and Sports Physical Therapy Tallahassee Outpatient Surgery Center TMH Family Medicine Residency Program Women’s Imaging Center

The We Care Network strongly encourages our volunteer physicians and dentists to send their value of donated services to us. The value of donated services is important for us to share with our funders and the community.

Also, up to five hours per biennium of CE Credit may be fulfilled by performing pro bono medical and dental services to We Care Network patients, if we have received documentation of value of services. You can send your value of donated services via fax to Rosemary Evans at (850) 2010085 or mail to 1204 Miccosukee Road, Tallahassee, FL, 32308. Thank you!

Please contact Rosemary Evans at revans@capmed.org or 201-0130 if you are a We Care volunteer and you provided volunteer specialty care in the month of February 2016 and your name was omitted.

We thank our referring providers from February 2016: Eboni Allen, ARNP Anne Ananga, ARNP Aaron Appiah, M.D. Arvind Bakhru, M.D. William Baldock, D.D.S. Marie Becker, M.D. Viralkumar Bhanderi, M.D. Jonna Bradley, ARNP Sherry Bramblett, ARNP Daniel Breivogel, ARNP Alexander Brickler, III, M.D. Acquinonette Bryant, M.D. Kendall Campbell, M.D. Lysmar Carrion-Dinguis, M.D. George Cohen, M.D. Sheryl Cowan, ARNP Marilyn Cox, M.D. David Dixon, D.O. Julia Drude, M.D. Susan Dunbar, ARNP Shirley English, ARNP Cynthia Evans, ARNP Mark Fahey, M.D. Sharron Foster, M.D. Benjamin Fragale, D.D.S. Alexander Franz, M.D. Anneka Gaffney, ARNP Spencer Gilleon, M.D. Judy Griffin, ARNP Muhanad Hasan, M.D. Hantz Hercule, M.D. Dwight Hooper, M.D. James Hunt, D.O. Hank Hutchinson, M.D. Iman Imanirad, M.D.

Amit Jain, M.D. John Katopodis, M.D. Charles Kent, M.D. Howard Kessler, M.D. Elaine Larkins, ARNP Esaias Lee, M.D. Stephanie Lee, M.D. Michael Mangan, M.D. Damon McMillan, M.D. John Ness, M.D. Rose Origa, ARNP Paresh Patel, M.D. Lisa Perkins, ARNP Marlaine Registe, ARNP Charlie Richardson, M.D. Jose Rodriguez, M.D. Tim Ruark, M.D. Karen Russell, M.D. David Saint, M.D. Tamara Sealy, M.D. Gadi Silberman, M.D. Robert Snyder, M.D. Alanna Steaple, ARNP Nina Sumlar, M.D. Mary Swain, M.D. Tallahassee VA Clinic Scott Tetreault, M.D. Marianne Towler, ARNP Dwanna Ward-Boahen, ARNP Franklin Watson, D.D.S. Ed Zapert, D.M.D. Donald Zorn, M.D. Richard Zorn, M.D.

DURING THE MONTH OF FEBRUARY, THE WE CARE NETWORK: RECEIVED 150 REFERRALS, WITH 89 PATIENTS NEW TO THE PROGRAM

SCHEDULED 96 APPOINTMENTS WITH VOLUNTEER PHYSICIANS AND DENTISTS

$114,006 IN DONATED CARE WAS REPORTED BY WE CARE VOLUNTEERS

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21

MEDICAL/LEGAL

SMILE! THE DOCTOR IS ON CAMERA: THE PROS AND CONS OF RECORDING OFFICE VISITS AND PROCEDURES

By Rich Cahill, Vice President and Associate General Counsel, The Doctors Company “Doctor, can I record our conversation today?”

Have you ever heard that question from a patient or a patient’s family member? The issue of allowing patients to record their appointments requires balancing potential privacy and liability risks with the potential benefits of improved patient recollection of instructions and treatment adherence.

It’s typically not the best course to allow patients to record the appointment. The recording devices could be disruptive and could be potentially intimidating to physicians and staff. In addition, these recordings— unlike the electronic health record—can be altered or manipulated to create an inaccurate portrayal of what actually occurred. These recordings can also easily be streamed or posted online, raising the issue of patient and staff privacy and HIPAA compliance. In addition, recording the visit may inhibit the flow of information between the doctor and patient.

Patients may be less likely to be open about sensitive health issues because of the fear that the recording might be listened to by an outside party.

If a patient records a visit without the doctor’s permission, that can result in a loss of trust, which is the basis of a strong physician-patient relationship.

Only about a dozen states nationwide prohibit electronic recordings done without the explicit consent of all participants in the encounter. It is important to know the specific laws concerning recordings in the jurisdiction where you practice.

Regardless, it is recommended that patients be advised unequivocally that digital recordings by handheld devices such as smartphones are prohibited on the premises in order to protect the privacy of other 22 CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION

patients and staff in compliance with federal and state privacy laws.

Post this notice clearly on your practice website, in the conditions of treatment signed by the patient at the outset of the relationship, and as office signage near the reception window. Suspected violations should be handled immediately. If this policy is violated, meet with the patient in a confidential setting to discuss the issue and reiterate the office policy. Depending on the circumstances and the status of the patient’s current episode of care, advise the patient that further violations may result in termination of the physicianpatient relationship.

If patients ask to record the visit, encourage them instead to take notes or to have a trusted family member or friend join them for the office visit to help take notes, remember information, and ask questions.

Doctors can also encourage patients to be engaged in the conversation with “Ask Me 3,” a program that promotes clear communication through these three main questions: 1. What is my main problem?

2. What do I need to do?

3. Why is it important for me to do this?

Doctors should also ask patients to repeat back the information shared, and then correct any misunderstandings. _________ Contributed by The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/ patientsafety.

MEDICAL/LEGAL

ACHIEVING THE WRONG GOAL: RETIREMENT PLANNING FOR THE 21ST CENTURY I thoroughly enjoy mountain climbing as a hobby of mine. There are gorgeous landscapes to be seen, rigorous physical endeavors to conquer, detailed planning to account for, a team of professionals you must rely upon with your life, and a journey that’s never the same for anyone, even if they’re on the same climb.

As you plan to enter retirement and live off the assets you’ve accumulated, the journey is very similar to climbing a rigorous mountain. You might want to travel to see beautiful landscapes, have goals you want to conquer, definite details you must account for with your finances, hopefully a team of professionals you trust with your financial life, and although you are entering this journey with 10,000 other people every day, no person’s trip is the same as another.

However, while the similarities are striking, there is one distinct difference when talking with those that plan for the mountain climb and those that plan for retirement. What exactly are they planning for?

Mountain climbers know; but do individuals or even their financial advisors?

Think about this question: What’s the most important part of climbing a mountain?

Most people, many of whom haven’t climbed mountains before, think of the peak and answer, “Getting to the summit!” Now, if you asked any professional climber, they’ll tell you that is the wrong goal.

The right goal of any climb is to get home safely.

With retirement, the right goal isn’t building up enough money, it is not running out of money with an undetermined lifespan. The question is then, how can we set ourselves up for success for the right goal in retirement, and put ourselves in the best position to not run out of money?

One school of thought came out many years ago.

Some people got together and proposed the “4% Rule.” The idea is that you can pull out 4% of your portfolio, adjusted for inflation, and be in an above

90% success rate for not running out of money in a 25-30 year retirement. This idea has established itself as a great rule of thumb for people trying to plan their retirement. The danger, though, is that this rule no longer holds true.

Recently, Dr. Wade Pfau, Ph.D., CFA, a Professor of Retirement Income at The American College, and other economists have pointed out that the 4% Rule no longer provides a high success rate of not running out of money. This is due to changes in technology and the financial services industry, lack of pension plans, and longer lifespans. For reference, please check out Dr. Pfau’s white paper, “Optimizing Retirement Income by Combining Actuarial Science and Investments.”

Economists now believe a “safe” distribution rate is between 2.5%-2.7%. Put this into perspective: For every $1 million of capital you have, you can spend between $25,000 and $27,000, adjusted for inflation, annually. If this seems awfully inefficient, your feelings are not without merit.

This is where actuarial science, as Dr. Pfau illustrates, helps create efficiencies for the right goal in retirement planning. If planned for carefully, we can move the needle on that distribution rate using the same science that insurance companies have used for 200+ years.

In today’s financial environment, it’s no longer “investments vs. annuities vs. insurance.” Just as the successful Coca-Cola said a few years back, it’s the power of “and.”

As mentioned in the beginning, each person’s journey is highly individualized, even on the same trip as someone else. As always, work with your professional advisor(s) and tailor your plan for you.

There is no silver bullet that will work for everyone in every situation. Ask your advisor(s) to lay out your distribution plan, even if you’re in your mid-30s.

That’s the right retirement goal for which to aim.

Contributed by Tyler Huston, CFP®, AEP®, CLU®, ChFC®, CASL®, Pyxis Advisors, 850-629-7220 or THuston@financialguide.com.

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