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A combined publication of the Arizona Medical Association, Maricopa County Medical Society, and Pima County Medical Society

March 2017

Women in Medicine: Your experiences pg. 19

Thriving in medicine: perspective from

Leigh Neumayer, MD pg. 23


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ARIZONA PHYSICIAN | March 2017


VOLUME 1, ISSUE 3 EDITOR-IN-CHIEF JAY CONYERS, PhD

jconyers@arizonaphysician.com

MANAGING EDITOR SHARLA HOOPER

shooper@arizonaphysician.com

ASSOCIATE MANAGING EDITOR DOMINIQUE PERKINS dperkins@arizonaphysician.com

PHOTOGRAPHY DENNY COLLINS

www.dennycollins.com

LAYOUT & PRINTING PRISMA

www.prismagraphic.com

Contents 23 Physician Profile

Collegiality and mentorship – thoughts on thriving as women in medicine in today’s world with Leigh Neumayer, MD.

ADVERTISING MANAGER BARB SPITZOCK

bspitzock@arizonaphysician.com

EDITORIAL BOARD GRETCHEN ALEXANDER, MD MICHAEL BUGOLA, MD JOHN COUVARAS, MD MICHAEL DEAN, MD TIMOTHY FAGAN, MD TABITHA MOE, MD ROBERT ORFORD, MD WILLIAM THOMPSON, MD JAREN TROST, MD

arizonaphysician.com twitter.com: /AZPhysician facebook: /ArizonaPhysician instagram.com: /azphysician

Features 14 16 19

Progress for Women in Medicine Slow Four Ways to Prioritize Women’s Health

28 30

Event Photos: Women in Surgery Mentorship Mixer Women in Medicine: What Physicians Think

Are Female Physicians Leaving Money on the (Operating Room) Table?

In This Issue 4 What’s Inside

38 Health on Tucson

6 Pima County Perspective

39 Community: End of Life Task Force

10 Congressional Corner with Rep. Tom O’Halleran 12 Policy Corner

41 Community: Live and Learn AZ 43 Arizona’s Bioscience Roadmap

35 Women Caring for Women March 2017 | arizonaphysician.com

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What’s Inside MARCH 2017

Jay Conyers, PhD

This variance in women’s speech does not make it girly, immature, whiny, cloying, annoying, or otherwise objectionable. It simply makes it the way half of the population tends to vocally project. And in medicine, as in all fields, it makes it worth listening to. Lara Devgan, MD, MPH

I

love this quote; it struck me when I first read it. Dr. Devgan, a New York-based plastic surgeon, wrote a thought-provoking piece for Doctor Blog that was later featured on KevinMD.com, the popular site sharing countless physician voices. Her article, “When women speak: Is there a gender bias in medicine?” examined how oration of female voices of authority are criticized for things their deliverers – women in positions of power – can’t necessarily control. She used terms like ‘upspeak’ and ‘vocal fry’ to describe the perception of many women’s voices when speaking publicly, including women physicians. Dr. Devgan’s assessment struck a chord with me. You see, I have a preteen daughter who is wickedly smart, but occasionally portrays a ‘dumbed down’ version of herself. I’ve seen it most when she’s amongst her friends, and primarily I chalk it up to ‘gender expectations’ in the classroom, and the pressure/influence of her male classmates – all hormones and false confidence covering up insecurities and a lack of social awareness. And it bothers me. I often wonder if I’ve done enough as a parent to empower my daughter to aim high, think big, and ignore anything she hears to suggest she can’t do anything she sets her mind to. While we don’t seem to have achieved gender-neutrality quite yet in medicine, we’re getting closer. Despite a past professional culture that once considered the rigorous training requirements too much for women, women are now inching closer to dominating a profession once held exclusive to those possessing the Y chromosome. Historically, many look to Dr. Elizabeth Blackwell, the first woman to obtain a medical degree in the U.S. Or to Dr. May Walker, the first known female surgeon in the U.S. Or

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ARIZONA PHYSICIAN | March 2017

to Dr. Barbara Ross-Lee, the first African-American woman to serve as a dean of a medical school. Today, half of all new doctors are female, and medical schools can claim that more women are enrolling than their male counterparts. Look it up, it’s true. More than 40% of all physicians in osteopathic practice, 60% of all practicing pediatricians, more than half of all practicing OBGYNs – all women. And the list does not end there. But what about pay? In 2008, newly-trained female physicians made a good $17,000 less than their male counterparts in New York. Surgeons? $44,000 less. Oncologists? Yep, there too, at the tune of $38,000. A 2016 study put the gender pay gap in family medicine at $15,000, but it jumped to $34,100 when looking at all specialties. What about academics? On average, female full Professors are paid at the same level as those male counterparts who are merely at an Associate Professor level.

Make no mistake, gender bias exists in medicine Few stories illustrate this as clearly as the recent case of Dr. Tamika Cross, a 4th-year OBGYN resident at the University of Texas Medical School in Houston. While on a non-stop Delta Airlines flight, returning from a wedding in her native Detroit, Michigan, Dr. Cross was alerted to a fellow passenger in need of medical attention. A few rows ahead of her sat a woman in distress as her husband slumped over unresponsive in the adjacent seat. As the passenger’s condition worsened, the flight attendant asked for any physicians on board to press the call button. Pressing her button, Dr. Cross began to get up and assist,


Our community health partner is Live and Learn, a Phoenix-based nonprofit helping women impacted by poverty and violence through career training in education and healthcare professions. And our legal section is a joint effort by Tucson-based healthcare lawyer Susan Goodman, and Dr. Lisa Soltani, medical director of Internal Medicine at El Rio Community Health Center. Together, they examine how women are caring for one another in the community. While you’re enjoying this issue, our teams are hard at work on the April issue, which will look at the opioid crisis. We’ll be profiling Dr. Patrick Hogan, co-founder of Arizona Pain Doctors and current President & CEO of the Arizona Society of Interventional Pain Physicians. We’ve got great content planned around the issue and hope you look forward to reading it! Jay Conyers, PhD, is the Editor-in-Chief for Arizona Physician and serves as Executive Director of the Maricopa County Medical Society.

Women in Medicine

but was stopped by the flight attendant, who said, “Oh no sweetie, put your hand down. We are looking for actual physicians or nurses.” Perplexed by the blatant discrimination, Dr. Cross persisted in her effort to assist. As the flight attendant actually considered that Dr. Cross might actually be a physician, she asked to see her credentials, and inquired as to what type of physician she was, and where she worked (never mind the fact that the passenger was still unresponsive). Desperate to help, Dr. Cross quickly rattled off answers to the senseless questions, hoping to finally get access to the man in need. But before the flight attendant would move out of Dr. Cross’ way, a ‘seasoned’ white male physician came from several rows back. The seemingly relieved flight attendant said to Dr. Cross, “Thanks for your help, but he can help us, and he has his credentials.” Did he show his credentials? According to Dr. Cross, he did not, nor would he have had time. But he fit the description of a doctor, the stereotype – white, male, middle aged. As for Dr. Cross? Well, she has to deal with at least three stereotypes: Dr. Cross is not only female, but she’s young. And black. If there’s any good that came of this incident, it’s that Delta changed its policy to no longer require doctors provide credentials before assisting passengers in distress. But what’s to prevent the next generation of female physicians from experiencing the same biases? In this issue, we take a look.

Look for quotes from our survey respondents throughout this issue of Arizona Physician Magazine.

So what’s inside? Arizona has some of the most accomplished women physicians in the nation, so we didn’t have to look far to find a remarkable physician to profile. We share the story of Dr. Leigh Neumayer, noted breast cancer surgeon and Chief of Surgery at the University of Arizona College of Medicine – Tucson. Recently elevated to the post of interim Vice President for Health Sciences, Dr. Neumayer has accomplished a lot at the helm of the surgery department, which has seen its NIH ranking move up 21 slots, to 29th in the nation. We have a great article by Dr. Elaine Siegfried examining how women have progressed in medicine over the years. Also included is an interesting piece looking at four ways hospitals, clinics, and physicians are prioritizing women’s health, authored by Aine Cryts. Karen Coyne looks at gender pay gaps in medicine and shares why she thinks women physicians seem to leave money on the table when negotiating compensation. As for our survey, we asked you about gender bias in medicine, and have a great summary showing how physicians feel about discrimination, pay disparities, and equal representation in specialty fields of medicine. In our policy section we look at numerous bills being tracked closely by physician groups this legislative session, and our congressional corner is penned by Rep. Tom O’Halleran (CD-1), who shares with us his thoughts on how Arizona would be impacted by an Affordable Care Act repeal.

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Pima County Perspective WOMEN IN MEDICINE: GENDER MAT TER S!

T

he number of women entering medical school is at an all-time high. This important trend is more than demographic justice; it is necessary to optimize patient satisfaction and care outcomes of patients. A recent study published in the Journal of the American Medical Association (JAMA) found mortality and readmission rates are significantly lower for Medicare patients treated by female physicians when compared to those treated by male physicians.1 Graduate medical education (GME) training is necessary in order to be clinically active and directly treat patients who can benefit from these potential gender-based differences. Yet, the percentage of women entering GME training programs has not kept up, especially in Arizona.

Gender differences in care As physicians, we all want the best possible care and outcomes for our patients. The authors of the JAMA study concluded that understanding why differences in care quality and practice patterns between men and women exist may provide valuable insights into improving quality of care for all patients, regardless of who provides the care. Previous studies have shown that female physicians are more likely to follow clinical guidelines, stick to evidence-based practice, and emphasize preventive care.2-4 Additionally, female physicians communicate with their patients differently than their male peers and provide more psychosocial counseling to their patients.5 It is critical that we make a concerted effort to identify which of these, if any, differential medical practices translate to better patient care and outcomes; once identified, we can employ them in all of our practices and add them into our standard medical education and training.

Higher percentage of women enrolling in medical schools in Arizona This year marked the largest number of women ever enrolling in medical schools across the U.S., according to the American Association of Medical Colleges. Nationally, enrollment is split fairly evenly between men and women 6

ARIZONA PHYSICIAN | March 2017

Charles B. Cairns, MD

(50.2% to 49.9%, respectively). At the University of Arizona College of Medicine – Tucson (COM-T), we exceed this national rate, as 54% of our medical students are female. This has not always been the case. In 1967 when the University of Arizona College of Medicine (UA COM) was founded in Tucson as the first medical school in Arizona, only 10% of the inaugural class were women. The percentage of women consistently grew over the first four decades with overall gender parity by 2006. In 2007, the University of Arizona College of Medicine – Phoenix (COM-P) opened its four-year medical education program as an expansion to the downtown Phoenix UA College of Medicine program. Graduate medical education is required for the transition from medical school to professional practice. Nationally, we still have difficulty in getting trained female physicians into practice. This problem is especially challenging in Arizona. There is a lower percentage of women enrolled in GME programs in Arizona (42%) at COM-T and COM-P sponsored GME programs compared to the percentage of women in GME programs nationally (46%). The reasons for this disparity are probably complex, but clearly GME program availability remains an issue in Arizona. The number of GME programs available to UA College of Medicine graduates from both the COM-T and COM-P is lower than in other states. In particular, there are a smaller number of GME positions in residency programs that are chosen predominantly by women, such as pediatrics and obstetrics/gynecology. As a result, we in Arizona are potentially losing more graduating women than men to other states for GME program training. Thus, we need to increase the number and size of GME programs in Arizona, especially those of particular interest to women.

Women in Academic Medicine The percentage of women who are full-time academic faculty, both nationally (38%) and at COM-T (38%), is even lower than those for medical school and GME programs. To address this trend, it is important that women, and all students, feel welcome, experience fair treatment, and have


strong mentors and role models to guide them through their careers. The COM-T has been pro-active in addressing these issues. In the late 1990s, the Women in Academic Medicine group was organized within the College to offer opportunities for education, mentoring and networking and to address issues affecting women in academic medicine. Its members spearheaded the Generating Respect for All in a Climate of Academic Excellence (GRACE) Project in 1999 to look into pay disparities as well as gender differences in rank, track and leadership within the College. The study was prompted, in part by a faculty survey that asked if men and women were treated equally. Among male faculty, 80% answered yes; yet only 30% of women said yes. The GRACE Project research committee, led by Anne Wright, PhD, and Kathryn Reed, MD, documented an 11-percent annual pay gap between male and female faculty members. The study also noted wide disparities in promotion and tenure, and the fact that no woman had ever been appointed department head.6 In response, Kenneth Ryan, MD, interim dean of the College in 2001, took action to reduce salary disparities for female faculty members.7 In April 2002, he appointed Tammie Bassford, MD, interim head of the Department of Family and Community Medicine – the first woman to head a department in the College’s history. He named her permanent head in January 2003. Today we have five women leading departments in COM-T: Kathryn Reed, MD, Chair of the Department of Obstetrics and Gynecology; Myra Muramoto, MD, MPH, Chair of Family & Community Medicine; Carol Gregorio, Chair of Cellular & Molecular Medicine; Leigh Neumayer, MD, Chair of the Department of Surgery; and Monica Kraft, MD, Chair of the Department of Medicine. Thus, 25% of our departments at COM-T are led by women, compared to 15% nationally. Given women lead the two largest departments (medicine and surgery), a remarkable 45% of our faculty are led by a female departmental chair. This progress extends to the COM-T Dean’s Office as well. When the College was founded in 1967, none of the deans were women. Currently, 45% of our COM-T deans are women, including our vice dean and senior associate deans for Research, Faculty Affairs and Administration. Our own published research has found that female physicians can have high levels of career satisfaction. We found that significant factors for career satisfaction included amount of recognition at work, career advancement, schedule flexibility, gender-equal opportunity for advancement, and gender-equal financial compensation.8 In order to assure gender-equal opportunities, there need to be policies and procedures in place to prevent and protect against harassment and discrimination. A JAMA-published study that came out last summer cited 30% of women in academic medicine experience sexual harassment at some point in their career.9 There are also reports that show persistent discrepancies in salaries, promotions and start-up packages between male and female faculty.10

A recently published article in the journal Lancet systematically reviewed the reasons for women’s choice or rejection of careers in academic medicine.11 The authors found that women are interested in teaching more than in research; participation in research can encourage women into academic medicine; women lack adequate mentors and role models; and women experience gender discrimination and bias. The authors suggest overcoming these barriers by providing a more enabling environment for women.11 Specialty colleagues of mine recently published an article12 that offered a number of sound practices that all medical and academic medicine leaders can use to shift the current system that often leaves women lagging behind, “in compensation and leadership opportunities and often shifted into less promotable positions and frequently given many administrative tasks that ‘lead to nowhere.”

In order to assure gender-equal opportunities, there need to be policies and procedures in place to prevent and protect against harassment and discrimination. They suggest: • Cultivate relationships with young female physicians and faculty members so they remain engaged. • Be transparent in compensation plans. • Provide detailed mentoring plans. • Provide appropriate role models at all stages of career and life. Additionally, they advise that we should “evaluate our process and our outcomes around recruitment, hiring and faculty development and be prepared to act if we uncover gender discrepancies in compensation, promotion, and leadership opportunities.”12 I completely agree! In summary, physician diversity – including gender – in medical school, GME training, community practice, and academic medicine is important. There is increasingly convincing evidence that gender matters for patient satisfaction and the care outcomes of our patients. As we celebrate the 50th anniversary of the founding of the UA College of Medicine – Tucson, we have to continue to invest in programs, including GME, to assure the success of physicians of all genders, especially given the gaps among women in Arizona. Dr. Cairns is the Assistant Vice President for Clinical Research and Clinical Trials at the University of Arizona Health Sciences, Dean of the University of Arizona College March 2017 | arizonaphysician.com

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References 1. Tsugawa Y, Jena AB, Figueroa JF, Orav EJ, Blumenthal DM, Jha AK: Comparison of Hospital Mortality and Readmission Rates for Medicare Patients Treated by Male vs Female Physicians. JAMA Intern Med. 2016 Dec 19. [Epub ahead of print] 2. Berthold HK, Gouni-Berthold I, Bestehorn KP, Böhm M, Krone W. Physician gender is associated with the quality of type 2 diabetes care. J Intern Med. 2008;264(4):340-350. 3. Baumhäkel M, Müller U, Böhm M. Influence of gender of physicians and patients on guideline-recommended treatment of chronic heart failure in a cross-sectional study. Eur J Heart Fail. 2009;11(3):299-303. 4. Lurie N, Slater J, McGovern P, Ekstrum J, Quam L, Margolis K. Preventive care for women: does the sex of the physician matter? N Engl J Med. 1993;329 (7):478-482. 5. Roter DL, Hall JA, Aoki Y. Physician gender effects in medical communication: a meta-analytic review. JAMA. 2002;288(6):756-764. 6. Wright AL, Schwindt LA, Bassford TL, Reyna VF, Shisslak CM, St Germain PA, Reed KL. Gender differences in academic advancement: patterns, causes, and potential solutions in one US College of Medicine. Acad Med. 2003 May;78(5):500-8.

Women in Medicine

of Medicine – Tucson, and a professor in the Department of Emergency Medicine at the UA College of Medicine – Tucson. He is an honors graduate of Dartmouth College and was a Holderness Medical Fellow at the University of North Carolina, where he received the Medical Faculty Award as the outstanding graduating medical student. He completed an emergency medicine residency and EMF Research Fellowship at the Harbor-UCLA Medical Center. Dr. Cairns is board-certified in emergency medicine, a fellow of the American College of Emergency Physicians and a fellow of the American Heart Association.

““In In medical school we were equally represented, and pretty similarly represented in anesthesia residency, and even my pediatric anesthesia fellowship, so I was surprised when I joined a private practice that I was the 7th woman in a group of 45! I’m not sure if there are more women in academia compared to private practice or if my group is just an outlier. Over the last few years we have recruited more women, but are still less than 25%.”

7. Wright AL, Ryan K, St Germain P, Schwindt L, Sager R, Reed KL. Compensation in academic medicine: progress toward gender equity. J Gen Intern Med. 2007 Oct;22(10):1398-402. 8. Clem KJ, Promes SB, Glickman SW, Shah A, Finkel MA, Pietrobon R, Cairns CB. Factors enhancing career satisfaction among female emergency physicians. Ann Emerg Med. 2008 Jun;51(6):723-728. 9. Jagsi R, Griffith KA, Jones R, Perumalswami CR, Ubel P, Stewart A. Sexual Harassment and Discrimination Experiences of Academic Medical Faculty. JAMA. 2016 May 17;315(19):2120-1. 10. Parks AL, Redberg RF. Women in Medicine and Patient Outcomes: Equal Rights for Better Work? JAMA Intern Med. 2016 Dec 19. [Epub ahead of print] 11. Edmunds LD, Ovseiko PV, Shepperd S, Greenhalgh T, Frith P, Roberts NW, Pololi LH, Buchan AM. Why do women choose or reject careers in academic medicine? A narrative review of empirical evidence. Lancet. 2016 Dec 10;388(10062):2948-2958. 12. D’Onofrio G, Baren JM. Advancement of Women in Emergency Medicine: New Strategies for Different Outcomes. Acad Emerg Med. 2016 Nov;23(11):1287-1289.

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Congressional Corner U.S. REPRESENTATIVE TOM O’HALLERAN

A

s a new member of Congress, a top priority is working across the aisle to protect access to healthcare, especially in Arizona’s rural communities. The future of the Affordable Care Act (ACA) continues to be one of the biggest concerns I hear from my constituents. Every day, my office is flooded with calls from patients, doctors, hospitals, and business owners who voice their opinion as Congress debates repealing the law. The ACA has brought improved access to care in rural communities, coverage for low-income and middle-income families, benefits for Native American tribes, preventative healthcare for women, and lower costs for seniors. These improvements are critical to my constituents. We cannot afford to roll these advances back. Rural communities are receiving a much-needed investment in care because of the ACA. From telemedicine to mobile clinics, pilot programs are expanding access to health services for Americans across the country. New programs like Teaching Health Centers are tackling provider shortage by offering medical residents more opportunities to train in rural areas, knowing that residents are more likely to stay and practice where they train. Medical facilities across rural Arizona rely on these programs to make their communities healthier. In addition to expanding access to care, the ACA has reduced prices for families and seniors. By closing the “Donut Hole” in Medicare Part D, the ACA has lowered out-of-pocket prescription costs. Since 2010, over 94,000 seniors in Arizona have saved over $470 million on prescription drugs, with an average beneficiary saving of $1,047 per year. Seniors now receive coverage for annual wellness visits, and the law eliminates cost sharing for recommended preventive services and screenings like breast and colon cancer. In 2015, 70% of Arizona seniors enrolled in Medicare Part B used at least one preventive service. These changes keep seniors healthy and lower costs to the taxpayer. The American Hospital Association has warned that a full ACA repeal without a replacement would have a disproportionately negative impact on rural hospitals and facilities. We cannot risk losing these medical facilities, the jobs they 10

ARIZONA PHYSICIAN | March 2017

create, or the critical access they provide to rural Arizonans. A repeal of the ACA would especially harm tribal communities. The ACA provides critical improvements and investments for American Indians and Alaska Natives, who have long faced wide health disparities and barriers to care. The law permanently reauthorized the Indian Health Care Improvement Act (IHCIA), the reauthorization of which had languished for over a decade. The IHCIA provides programs for mental and behavioral health treatment, expanded care for tribal veterans, reimbursements for patient travel costs, and funding for urban Indian health centers. A complete repeal of the ACA would endanger the progress we have made and undermine our commitment to First American communities. I recently had the honor to meet with Jeff Jeans, a Republican small-business owner from Sedona. At 49, Jeff’s life changed forever when he was suddenly diagnosed with cancer. Thanks to key ACA provisions, like guaranteed coverage for people with preexisting medical conditions, and no lifetime or annual insurance limits, he was able to get the treatment he needed to save his life. Jeff is now cancer-free, and he bravely shared his story on national television during a CNN town hall with Speaker Paul Ryan. Jeff’s courage to speak out reminds us all that we must work together to put good policy before politics. While repeal is not the answer, we must address the shortcomings of the ACA. I am committed to working with Republicans and Democrats to address them. For example, I support legislation to repeal the law’s medical device and health insurance taxes that disproportionately harm small businesses. We also need to address areas of our healthcare system that the ACA has not improved, such as price transparency, prescription drug prices, and long-term care. Tackling these issues head-on will lower the overall cost


We cannot go back to the days when insurance companies could deny coverage to sick children or patients with chronic health conditions like diabetes or cancer, or when women could be charged more for the same health coverage as men. fiscally responsible thing to do, but this is not a discussion of spreadsheets and numbers alone. We must remember that decisions made in Washington, D.C. impact families and businesses in Arizona and elsewhere.

Women in Medicine

of healthcare in America and incentivize innovation. We cannot go back to the days when insurance companies could deny coverage to sick children or patients with chronic health conditions like diabetes or cancer, or when women could be charged more for the same health coverage as men. We also cannot allow the investments made in the ACA to go unfunded, which would leave our rural communities without access to care. I am committed to working with our medical community – hospitals, doctors, clinics, patients, and advocates – to innovate and improve healthcare affordability for all families. Partisan politics should not get in the way of improving our healthcare system. Improving our healthcare system is the

““In In my opinion the biases are there, but are frequently subtle, so that calling them out carries the risk of making the female physician in question look petty.”

March 2017 | arizonaphysician.com

11


Policy Corner AZ BILLS IMPACTING PHYSICIANS & PATIENT CARE

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ction is unfolding at a brisk pace at the Capitol during the First Session of the 53rd Legislature in 2017. We’ve not seen a particularly large number of bills filed in the new session, but that is to be expected with a new freshman class and because of a House rule change to cut back on the use of so-called “vehicle” bills (for later striker amendments). Nearly 600 bills were introduced this session and the Arizona Medical Association (ArMA) is following approximately 150 related to health care. In this edition of Arizona Physician, we will share our process for determining a position on legislation and will highlight the high profile legislation we are actively engaged on this session.

How we determine our action on legislation The legislative work and advocacy by ArMA is driven by the policy set through the House of Delegates (HOD); the HOD is comprised wholly of physicians representing all areas of the state and specialty societies. The HOD meets annually and considers proposed policy and issue positions, and action items submitted in the form of resolutions. The resolutions are submitted by members and committees of ArMA, Maricopa County Medical Society, Pima County Medical Society, and individual physicians. Once the HOD has adopted a resolution, our Committee on Legislative & Government Affairs (L&G Committee) works with our advocacy team to determine what legislation is related to those issues; we then follow and engage as necessary on those bills throughout the session. In general, we review legislation related to all health care and practice management issues. We use our existing HOD-established policy and guidance from the L&G Committee to determine our approach to each legislation. The legislation we are seeing this year can be grouped in several categories: patient care and services, scope of practice, regulatory, and surprise billing.

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ARIZONA PHYSICIAN | March 2017

Pele Fischer, JD

Patient care and services ArMA, along with our dermatology and cancer advocates, are working on two important bills related to skin cancer. HB 2194, sponsored by Rep. Heather Carter (R-LD15), bans minor children from using indoor tanning facilities. HB 2134, also sponsored by Rep. Carter, removes the ban on children applying their own sunscreen in schools and camps. ArMA has been fully engaged and helping advocate for both of these bills. HB 2335, sponsored by Rep. Paul Boyer (R-LD20), seeks to decrease tobacco and nicotine addiction in Arizona by increasing the minimum purchasing age for tobacco products from 18 to 21 years old. ArMA, along with numerous other health focused advocacy groups, is supporting the legislation. SB 1080, sponsored by Sen. Barbara Fann (R-LD1), bans texting by teen drivers for the first six months of licensure. After years of unsuccessful attempts to address distracted driving, SB 1080 has some momentum. ArMA is supporting the legislation and we hope to see it across the finish line.

Scope of practice SB 1336, sponsored by Sen. Nancy Barto (R-LD15), makes changes to the statute regarding the scope of practice of Certified Registered Nurse Anesthetists (CRNA). This is a contentious issue and ArMA has been working closely with the Arizona Society of Anesthesiologists (AzSA), CRNA leadership and legislators to find an acceptable agreement on the definition of “presence” and “direction” for physicians and surgeons. ArMA will oppose the bill if an acceptable definition cannot be reached. SB 1269, sponsored by Sen. Barto, expands a pharmacist’s scope of practice to include: dispensing of emergency refills for certain medications; prescription and dispensing of tobacco cessation drug therapies (not Chantix and Zyban); and prescription and administration of oral fluoride varnish, if outlined requirements are met. ArMA has been working closely with physician advocacy groups to ensure that the legislation includes adequate requirements needed to protect


Regulatory HB 2195, sponsored by Rep. Carter, is the Arizona Medical Board’s (AMB) bill to make helpful changes to improve efficiencies with the licensing statutes for MDs – a bill ArMA supports and has been helping to shepherd through the process. SB 1028, sponsored by Sen. Barto, continues the Arizona Board of Osteopathic Examiners in Medicine and Surgery for eight years. ArMA, along with the Arizona Osteopathic Medical Association (AOMA), supports the bill. SB 1452, sponsored by Sen. Barto, makes changes to the health licensing board statutes, particularly related to what portions of a health professional licensee’s disciplinary records must be posted on the licensing board’s website for public availability. It states that all disciplinary and final non-disciplinary actions and orders against a licensee are to be posted on the board’s website. Importantly, however, letters of concern and advisory letters are not to be posted (they still will be available if a member of the public requests them). The bill makes several other changes to the health regulatory boards – most of which have previously been implemented by the AMB. SB 1439, sponsored by Sen. Barto, prohibits a person from discriminating against a health care entity because the health care entity does not provide, assist in providing or facilitate in providing any item or service that results in the death of an individual. It also permits a health care entity the right to civil action in superior court if the health care entity is subject to a discrimination violation. The wording of the bill is quite sweeping in scope, and ArMA is actively studying the bill’s impacts to determine whether a public position should be taken on this measure.

to the bill and there is still a lot work that needs to be done on both the policy and technical sides. ArMA is leading the effort to ensure that a reasonable solution is reached. Arizona has a lack of verifiable data regarding surprise billing; attempting to find appropriate and adequate solutions is always difficult when the extent of the problem and its root causes are unknown. SB 1321, sponsored by Sen. Sean Bowie (D-LD18) would require the Arizona Department of Insurance to produce a report on surprise billing. ArMA supports the legislation. A report from DOI could help provide data to better inform the policy discussions of surprise billing. If you are interested in learning more about any legislation, please feel free to contact Ingrid Garvey, igarvey@azmed.org. Pele Fischer, JD, is the Vice President of Policy & Political Affairs for the Arizona Medical Association.

Women in Medicine

patient safety and to not improperly override the physician patient relationship.

““In In previous positions, I found that my opinion/ comments weren’t taken as seriously as the ones of male colleagues. I also had trouble with relationships with nurses/MAs not responding to my requests as they would do for a male physician.”

Surprise billing While this policy issue is often touted as surprise billing by physicians, it is predominately a symptom of a much larger set of problems that have resulted from changes in healthcare insurance products including: • Narrow network plans • Lack of network adequacy and coordination standards • High deductible plans / lack of out-of-network coverage • Inaccurate and out of date physician directories These changes in health insurance have burdened patients in the form of unexpected and expensive out of pocket bills. There are several legislative measures attempting to address the issue. ArMA has been actively involved in stakeholder meetings investigating the issue of surprise billing and working to determine a solution that helps patients get surprise bills resolved, ensuring physicians receive fair and equitable payment, and that any solutions do not have unintended negative consequences for our healthcare market. SB 1441, sponsored by Sen. Debbie Lesko (R-LD21), would set up an arbitration process to settle disputes over surprise bills. To date there have already been numerous amendments

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Progress for Women in Medicine Slow, but Significant BY E L A I N E S I E G F R I E D, M D

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Women in Medicine

““II own my own practice mainly because I do not feel I was treated appropriately when I worked for a large group.”

M

y childhood was guided by Donna Reed and June Cleaver, but I came of age under the influence of Gloria Steinem and Betty Friedan, when women were clamoring for change. By the time I completed my training, almost half of my professional colleagues were female. So I am impatiently annoyed that in the year 2016 women have not been as equally represented among the leaders in our field. But change is never easy or fast. From a historic perspective, it’s been only about a half-dozen generations since women were even allowed to train in medicine (initially at a segregated institution). Opportunities for leadership have been even more recent. In 2016, 57% of college students are female but only 23% of all bachelor’s


and master’s level institutions employ female presidents. That figure is higher for community colleges and Ivy League universities.1 Women also continue to lag behind men as lead authors in top medical journals, although those numbers are improving.2

Professional organizations The American Dermatological Association (ADA) is dermatology’s founding, and most enduring, specialtyspecific organization. The ADA was established by 16 men in 1876, and membership has always been by peer-nomination. In 1925, a few years after Dr. Rose Hirschler became the first female US dermatologist,4 an ADA vote allowed women to attend their historical lectures and dinner. It was another quarter-century before Dr. Beatrice Kesten, who clearly deserved the recognition, became the first female ADA inductee.5 The American Board of Dermatology (ABD) was established in 1932 as a founding member of the American Board of Medical Specialties. Dr. Kesten became the first female director in 1953. The organization did not elect another woman until Barbara Gilchrest became a director in 1988. As of 2015, only ten of the 100 emeritus directors were women. However, the current ABD leadership includes eight women and 11 men. The American Academy of Dermatology (AAD) was founded in 1937 by 17 “founding fathers.” The inaugural meeting was held November 1938 in my hometown, St. Louis, Mo., and was attended by approximately 40% of the nearly 600 members.6 The AAD now represents more than 19,000 fellows; almost half are women. As of 1970, only one woman served on the AAD Board of Directors (June Carol Shafer, 1956-1958). The second, Dr. Margaret Ann Storkan, was elected in 1971 and became vice president two years later, when less than 10% of the more than 4,000 AAD members were women. During the next two decades, women made few leaderships inroads, despite support from male colleagues like Dr. Walter Shelly, who reportedly nominated several women to committees, but was often declined.3 It was not until 1992 that Dr. Wilma Bergfeld took office as the first woman president, after serving on the Board of Directors for 10 years. Since then, the AAD has been led by additional female presidents, vice presidents, secretary/treasurers, and board directors. The AAD also honors outstanding members as well as non-dermatologists, including a small minority of women: one of the 10 Distinguished Service Award recipients, one of the first 10 Gold Medal honorees, five of the 30 Master Dermatologists and two of the 26 Marion Sulzberger winners.7 Men have dominated the political world in almost all cultures. In 2016, 89% of the countries in the world are led by men. The dermatology academic political microcosm is similar. Among those who chair academic departments of Dermatology, I counted 17 women among the 117 programs listed by the AAMC.8 Notably progressive locations are my “Show Me” state, where all three departments are chaired by women, and Massachusetts, with three of four

programs being led by women. And two programs are chaired by a second generation female (Eastern Virginia and Boston University). A forum held at the March 2016 annual AAD meeting focused on “Closing the Gender Gap in Academic Dermatology and Dermatology Leadership: Problems and Solutions.” It included all-women faculty presentations on work-life balance, navigating the two career household, negotiating skills, and mentoring. It did not tackle the delicate and complex topic of pay discrepancy, which is greater for professionals. Is lack of female leadership the result of institutional sexism, or of women’s personal choice and skill set? Males and females have evolved over millennia to embrace different roles. Physical strength, a characteristically male trait, trumped all other leadership qualities until technological advances allowed appreciation of alternate leadership skills. So, as Dr. Walter Shelly noted,3 other female characteristics must be impacting our eligibility. One may be motivation to sit at the male-dominant table. I know of few women who aspire to climb to the top of an administrative bureaucracy or to build a large corporation. But technology has allowed growing interest and inquiry about the differences between male and female leadership, including advantageous feminine characteristics: compassion, organization, honesty, collaboration, task focus, and interest in mentoring. Change is slow, but steady. Many women have already achieved notable firsts: flying solo across the Atlantic, winning a Nobel Prize, and serving as mayors, senators and Prime Ministers. And one day a woman will be elected President of the United States. References: 1. https://www.eab.com/daily-briefing/2015/03/19/ one-quarter-of-presidents-are-women 2. http://www.pharmalive.com/women-lag-men-as-lead-authors-intop-medical-journals/?utm_campaign=shareaholic&utm_medium=email_this&utm_source=email 3. http://www.the-dermatologist.com/article/3646 4. Franca K, Ledon J, Savas J, Nouri K. Women in medicine and dermatology: history and advances. An Bras Dermatol. 2014; 89(1):182-3 5. http://www.amer-derm-assn.org/about.html 6. Hubler WR. Organizing American dermatology and the founding of the American Academy of Dermatology. J Am Acad Dermatol. 1988;18(4 Pt 2):783-5. 7. https://www.aad.org/Forms/Policies/Uploads/GP/GP%20-%20 Awards%20Policy.pdf 8. https://services.aamc.org/eras/erasstats/par/display8. cfm?NAV_ROW=PAR&SPEC_CD=080

Elaine Siegfried, MD is professor of pediatrics and dermatology, Saint Louis University Health Sciences Center, St. Louis, Mo. She also is a member of the Dermatology Times Editorial Advisory board and a co-medical editor. Copyrighted 2017. Advanstar. 127887:0217SH

March 2017 | arizonaphysician.com

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Four ways to prioritize women’s health BY AINE CRYTS

I

f you want women to prioritize their health, try to make it easier for them, says Kathryn Babich, MD, an obstetrician-gynecologist at Park Nicollet Health Services in St. Louis Park, Minnesota, who noticed that a lot of women weren’t coming in for their annual physicals. That meant these women – many of them young working women and women with children juggling careers – weren’t getting their blood tested, they weren’t getting mammograms and Pap smears, and they weren’t getting eye exams if they needed them. Park Nicollet’s solution was to ask clinical staff to sign up to work at the clinic on Saturday mornings. During this time, female patients have access to 13 different services, including mammography, wellness visits, eye exams, physical therapy, and mental health – all of which are co-located in the same health center. Babich laughs

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when she says that young women, in particular, often come in wearing their pajamas, but she’s just glad that they’re there. One great example of the positive effect of preventive health screening is the Pap test, she says. As recently as the 1940s, cervical cancer was a leading cause of death among women of childbearing age in the United States. After the introduction of the Pap test in the 1950s, the U.S. incidence of cervical cancer and death rates between 1955 and 1992 declined by more than 60%. From “all-in-one” healthcare appointments to coordinating women’s care for convenience, here are more ways providers and researchers say plans and providers can prioritize women’s health.


University of Pittsburgh Medical Center (UPMC) has taken a service-line approach to standardizing care across its hospitals that serve patients throughout Pennsylvania and parts of New York and Ohio, says Maribeth McLaughlin, RN, chief nursing officer and vice president of patient care services at Magee-Womens Hospital of UPMC. One area UPMC has focused on is reducing the rate of C-sections – and part of the health system’s success has involved building decision-support tools within the Electronic Health Record System (EHR) to guide clinicians based on national standards, she says. Reducing C-section rates is important because it reduces maternal mortality rates, but vaginal birth is just better for mothers and babies, McLaughlin says. Just as important are the discussions doctors have with pregnant mothers about their birth plans. In these conversations, clinicians need to discuss with women their wishes and expectations – and educate them about the fact that vaginal births lead to safer deliveries. Still, it’s important to talk to women about when their clinical team may need to deviate from the birth plan in order to provide the best outcome for the mother and her child, says McLaughlin. As a result of its pathways-focused approach, MageeWomens Hospital of UPMC’s repeat section deliveries rate is 16% better than the National Perinatal Information Center/ Quality Analytic Services (NPIC/QAS) benchmark, and the hospital’s vaginal birth after caesarian (VBAC) rate is 75% percent better than the NIPC/QAS benchmark. Cost is important here, too. A repeat caesarian section is 10% more costly than a VBAC, says a UPMC spokesperson.

2. Make healthcare guidance easy to understand Women around the country are working hard to manage work-life balance, and it can be difficult to get them to make preventive care a priority, says Babich. “Women are notorious for putting themselves at the bottom – whether they’re young, at midlife, or later in life,” she says. “They

Women in Medicine

1. Standardize care pathways for women’s health

““The The men in the office seem to take on medical responsibilities unnecessarily and without being asked, making it clear that it doesn’t seem as if the women in the office can or will take care of it. Meanwhile, a particular male colleague has made comments that the clinic should be kept clean because “there are enough women around,” referring to the providers, nurses and medical students.”

typically have children depending on them, a husband, and then work. All of this requires a lot of work. And a lot of the time, women just don’t come in for their preventative care and screenings,” she says. One way to encourage more preventive care is through patient education, says Babich, particularly among the newly insured who may be unaware of the types of preventative care services they need and are entitled to. Women need more guidance in order to stay healthy, Babich adds. One way providers can help is by educating women on how often they need to have their cholesterol tested, how often to come in for a Pap smear, how often to come in for a mammogram, and when they should get a colonoscopy, based on their family history, she says. And coordinating care for women is very helpful, says Babich. “Women are balancing everything, and they don’t have time to take three-and-a-half days out of their schedule for various appointments. If they’re moms, they don’t want to be dragging their kids into the physician’s office. That’s why we need to coordinate care – either with technology with the EHR or a dedicated women’s health center where they can get all their care in one place.”

3. Learn about treatment paths for endometriosis and other conditions If Jessica Shepherd, MD, an obstetrician-gynecologist and director of minimally invasive gynecology at the

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University of Illinois at Chicago, could ask payers for one thing, it would be this: Learn more about how health issues such as fibroids and endometriosis impact women’s lives. Insurance companies need to realize how much time women are taking off work as a result of fibroids and endometriosis, and a lot of this isn’t documented in their patient history. Still, payers require a great deal of documentation in order to reimburse for hysterectomies and myomectomies, she says. The fact is, if a woman is bleeding because of either of these conditions, she’s likely to take the day off from work, says Shepherd, who is also founder of “Her Viewpoint,” a web-based community for women’s health issues. Chances are, woman probably won’t go to the doctor’s office to be treated – and that means the occurrence isn’t being documented.

Women in Medicine

““IfIf you enter a patient’s room with a male PA or male NP or male RN the patients usually assume that the female physician is the nurse! One day that might change. Also women physicians are not supposed to get upset or angry or they will be labelled moody or some other label but male docs can throw a tantrum (as well as instruments) and still be loved by the staff.”

Endometriosis is a tough disease to diagnose and treat, she says. One of the successful treatments for endometriosis is to put women on birth control without placebo, which means women receive continuous hormones. In effect, those women are going through their pack of birth control pills more quickly than if they were taking placebo pills for a week. Despite that, many payers refuse at first to pay for the additional birth control pills.

4. Conduct research on conditions that impact women’s health With all the clinical trials and research done on heart disease, most of that research is based on how men experience the disease – and that informs how heart disease is treated in this country, says Alina Salganicoff, vice president and director of women’s health policy at the Henry J. Kaiser Family Foundation. She points out that the way heart disease manifests itself within women is different, even down to the way women’s blood vessels get blocked. “We know that sex is a very important determinant of how women experience health and outcomes, so we must pay for this research,” she says. Aine Cryts is a writer based in Boston. Copyrighted 2017. Advanstar. 127887:0217SH

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Are female physicians leaving money on the (operating room) table? BY KAREN COYNE, CFP(R)

T

he studies don’t lie. Female physicians – while representing nearly half of new medical school graduates – earn far less than their male counterparts. In 2013, the Journal of the American Medical Association reported a $56,000-a-year difference, while the U.S. Census Bureau same year found that female physicians received $140,036 per year compared to a $202,533 median income for men.

Why Women Doctors Earn Less The wage gap can be explained partly because women are more likely to take time off for family, choose lowerpaying specialties, and may work fewer hours than men.

But JAMA found that even within the same specialty and adjusted for working hours and seniority, male doctors took home $12,000 more per year. Over the course of a 30-year career, this disparity costs women doctors a whopping $350,000! So what is causing women to earn less? And what can be done about it?

1. Women need to become better negotiators. Women generally don’t feel comfortable asking for promotions or for more money from their employers, business partners or patients – and it could stem from a relative lack of confidence compared with their male peers. March 2017 | arizonaphysician.com

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more comfortable competing and taking career risks. As the vice chair of communications for the Association of Women Surgeons, she says that groups such as hers offer resources such as information on promotion and negotiation.

This issue is not unique to American women. Nikki Stamp, MD, a cardiothoracic surgeon in Sydney, Australia, explained how her lack of confidence undermined her negotiation for a higher-paying position: “I asked to be employed as a fellow … but [the hospital] was not willing to fund the position. I just accepted the vague explanation at face value.”

Women doctors tend to cluster in lower-paying specialties – and often work in lower-paying hospital settings–two factors that contribute significantly to the income gap. Women often eschew higher-paying specialties because of the time commitment. For example, women currently comprise just 14% of plastic surgeons despite growing numbers of women receiving training in this specialty. Why? Heather Furnas, MD, co-founder of Plastic Surgery Associates in Santa Rosa, California, explains: “The hours are long, the years of training are long, and it’s very difficult to have a child during the 15 or so years it takes to get through college, medical school, and training,” she says. “The money comes with potentially huge sacrifices … The training model is based on a man’s life, and there will need to be adjustments if women are to be able to have children as early as and as much as their male counterparts do.” Furnas’ observations point to a Catch-22 in medicine: The culture in higher-paying specialties won’t change until more women enter, but the existing culture prevents more women from entering. As with all decisions in life, women must consider potential trade-offs in choosing a demanding specialty. Many successful women doctors have had to ignore the naysayers (including the well-meaning advice of mentors, program directors, and even parents), and take risks, before ultimately achieving happiness in their (very demanding) fields.

“Just because woman are respected and valued much beyond what they were several decades ago, that does not mean that it is time to stop noticing the subtle discriminations and micro-aggressions to our gender. I would like to see more female leaders in our community, equal-pay, and an elimination of the inherent bias that several hold that men are “more competent” or more “fit” for a career in medicine. There are several specialties that do not have an equal ratio of male to female residents. We have to ask whether this is really due to lack of interest, or a larger aspect that discourages woman from entering those fields.”

Women in Medicine

In their recent book, The Confidence Code: The Science and Art of Self-Assurance – What Women Should Know, journalists Claire Shipman and Katty Kay reveal that even the most accomplished women routinely underestimate their value and ability, and are more risk-averse than their male counterparts. A pervasive lack of confidence often holds women back.

Passively accepting a “no” answer is a common mistake for novice negotiators. And women are especially vulnerable. Women routinely accept the first salary they’re offered – not knowing that it’s possible to negotiate for a higher one. One study showed that even with their first jobs, men are four times as likely as women to negotiate their starting salary. Men also make salary a priority. Male physicians, for instance, ranked “high pay” as their second-highest priority for job satisfaction while it ranked fourth for women. To their own detriment, women often mistakenly negotiate based on what they need – since they are often married to another professional – instead of what they are worth. Worse yet, women hesitate to apply for positions for which they are well qualified, because they feel unworthy or not ready. Stamp believes that doctors generally, and women doctors particularly, don’t develop the business or negotiating skills that could make them more financially independent. “One thing that works very much against women is that we do not talk about how much we earn,” she says. Heather Yeo, MD, a surgical oncologist at New YorkPresbyterian/Weill Cornell Medical Center, concurs. On the other hand, as a researcher she has had experience negotiating start-up packages. She’s observed that her male colleagues often negotiate for a higher stipend while she has opted to negotiate for perks that make her life easier – support in the form of a research assistant and statistician, for example – which to her are more valuable than money. So even when women in medicine are negotiating, they are asking for different things than their male peers. These choices contribute to the wage gap without telling the whole story. Either way, she contends that women need to become 20

ARIZONA PHYSICIAN | March 2017

2. Women doctors shouldn’t rule out higherpaying specialties and/or private practice.

3. Women can clock more billable hours and increase services-per-patient ratios Male doctors see more patients, on average, and provide more services per patient – which tends to increase their income. An astounding study of Medicare reimbursements by personal finance firm NerdWallet Health found “On average, male doctors are paid 88% more in annual Medicare reimbursements. Men make $118,782 per year from Medicare; women are paid $63,346. • Male physicians see 60% more patients. On average, women doctors treat 320 Medicare patients per year, while men treat 513 patients. • Male doctors make more money per patient treated. On average, they make 24% more treating each patient than female doctors do. • Male doctors perform more services per patient treated. To explore this, NerdWallet Health devised a metric to calculate a physician’s average “service volume” per patient. They found that male doctors billed Medicare, on average, for one more procedure per patient than female physicians (5.7 services performed per patient by male doctors vs. 4.7 services per patient by female doctors).


Prior research has shown that male doctors generally work more hours, which could increase their billings to Medicare. Men also dominate high-paying surgical fields; women make up less than 10% of Medicare physicians in surgical specialties like cardiac, orthopedic, and neurosurgery. Obviously, patients appreciate that their female doctors spend more time with them. But don’t assume that you have to sacrifice quality for quantity. Find ways to strike an efficient balance between patient care and your own bottom line.

4. Women can lobby for more transparency and engage in peer networking Women doctors can negotiate from a position of strength when they know what their peers earn. Greater transparency in income data could help reduce the pay gap. Currently, however, most doctors don’t know if they are being paid fairly since most institutions lack clear policies on how to determine salaries. Or worse, some institutions implement pay secrecy policies (which may be illegal). Networking among peers can help women close the awareness gap. Find a mentor who is familiar with your unique skill set and your goals and who can advocate for you. The American Medical Women’s Association is working to level the playing field for women in medicine through its Gender Equity Task Force. Its members educate and mentor women physicians and support networking through several events annually.

Conclusion Women – in medicine as in other fields – leave money on the table for a variety of reasons, often as they attempt to prioritize home and family, and make compatible career choices. But choosing to prioritize your family shouldn’t disadvantage you in negotiations. Under-valuing your worth is always short-sighted. A layoff, divorce, death, or disability can quickly thrust any woman into the job of primary breadwinner in the family. A woman’s worth shouldn’t go up or down based on her husband’s take-home pay. There are many reasons why a wage gap exists, and there are also actions women can take to help close it. Karen Coyne, CFP(R), is a strategic wealth advisor with Raymond James in Hagerstown, Maryland. With over 15 years of experience, she helps physicians make smart financial decisions so they can focus on what they do best. Email karen.coyne@raymondjames.com. Raymond James Financial Services Inc., Member FINRA/SIPC. Any opinions are those of Karen Coyne and not necessarily those of Raymond James. The information has been obtained from sources considered to be reliable, but we do not guarantee that the foregoing material is accurate or complete. Copyrighted 2017. Advanstar. 127887:0217SH

Women in Medicine

• This gap in service volume is true across specialties. Male doctors performed more services per patient than female doctors across nearly all specialties. In a specialty like pathology – where doctors infrequently provide services directly to patients – they found no variation in average service volume.

““II am frustrated that with the increase in women physicians in medical school, the specialties and leadership, there are still no formal policies on pregnancy in surgery residency. We have come a long way, but are still talking about the same things without any concrete action. With that, I still love my specialty and have been so lucky. I share my passion with my husband who is my colleague and support. I have three children and in 30 years things have “balanced out.” I work to live.”

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Collegiality and mentorship – thriving as women in medicine today WI T H

Leigh Neumayer, MD

Representative Heather Carter and Dr. Neumayer

BY DOMINIQUE PERKINS Article Photos by Denny Collins Photography

March 2017 | arizonaphysician.com

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Dr. Neumayer and her mother, Marge Neumayer

She also worked as a phlebotomist, and then began working as a nurse’s aide at a nursing home. “Figuring the work in a nursing home would expose me to many different and probably unpleasant smells I thought it would be a good test,” she said. Thoughtfully comparing her experience in working as an engineer with her job as a nurse’s aide, Neumayer found that while she was certainly capable of doing either job, she much preferred the nursing home work, and her decision was made. She went to Baylor College of Medicine, and enjoyed each of her rotations with a clear preference for surgery. She chose otolaryngology, and matched in a position at the University of California at San Francisco. While in San Francisco, she met and married her husband, who was also a surgical resident. They transferred together to the University of Arizona to complete residencies in general surgery. After completing her residency, Neumayer joined the faculty at the University of Arizona while her husband completed a vascular surgery residency, and then moved to the University of Utah in Salt Lake City while he completed a residency in cardiac surgery.

Salt Lake surgery

W

hen Leigh Neumayer, MD, told her father, a general surgeon in private practice for over 40 years, that she wanted to become a physician, he initially discouraged her. “He thought the environment was changing so much that it wasn’t going to be as fun or easy to be a doctor,” she said. This was in the late 1970s, and he may have had a point. The landscape of medicine certainly has changed. From practice guidelines that micro-manage a physician’s care decisions to the constant battle for reimbursement, one could argue there are many aspects of a doctor’s life that are neither fun nor easy. However, Neumayer still finds a great deal of joy in what she does, and seeks to pass that along to others.

Exploring options In addition to her father’s cautions, she had her own reservations to entering the medical field: her nose. “I have a very sensitive nose,” she said. “My concern was that the smells in medicine might be too much for me. I didn’t like visiting my grandpas in their nursing homes because of the strong smells.” To be sure she made the right decision for her, Neumayer considered her career options carefully, and put her interests to the test to see how she faired. She studied engineering in college, which allowed her to spend time working in both math and physics, which she thoroughly enjoyed. 24

ARIZONA PHYSICIAN | March 2017

Neumayer practiced in Salt Lake City for 22 years. She worked at the VA, where she held many positions including staff surgeon, and chief of surgery. As her interests and talents continued to expand, she began to work part time at the VA and part time with the University of Utah, where she started a general surgery practice including trauma care. Eventually she moved full-time to her work with the university, and focused her elective practice on breast disease, still participating in trauma call and service and staffing a new ICU in the Huntsman cancer hospital, and co-led multidisciplinary breast cancer clinical and research programs. In 2014, Neumayer was recruited back to the University of Arizona to lead the department of surgery. Beginning January 1 of this year, she was appointed interim Senior Vice President for Health Sciences. “I spend the majority of my time now in administration; however, [I] try to carve out some time for research and still do one day a week clinical, and take one to two nights of call a month,” she said.

Reaching out As a surgeon, Neumayer entered a field traditionally dominated by men. Currently, fewer than 20% of our nation’s more than 25,000 general surgeons are women. Neumayer remembers there being very few women in surgery when she completed medical school, but said that the presence or absence of women in the field did not impact her decision to pursue it. “I chose surgery because I love the field,” she said. However, once she was completing her residency, Neumayer did begin to notice that there weren’t very many like her.


Women in Medicine

“By then I was married (to another surgeon) and was wondering if there were women surgeons who were married to other surgeons and whether any of them had kids,” she said. She helped conduct a survey through the Association of Women Surgeons to find out, and made many contacts through her experience, all of whom she says are great colleagues and friends to this day. While many more women have joined the ranks of physicians and surgeons since Neumayer graduated from medical school, there are still specialties reported to have fewer than 10% of women in their fields (vascular surgery, interventional radiology, neurosurgery, interventional cardiology, urology, thoracic surgery, and orthopedic surgery). Whereas other specialties, such as OB/GYN and Pediatrics have a clear majority of women in their practice. We asked Neumayer why she thought this might be the case, and she felt it came mainly down exposure, and the availability of good role models. Because medical students are not required to have rotations in specialties such as vascular surgery and interventional radiology, few pursue them. And frequently only those who have had some exposure to the field before. The popularity of other practices may also be a question of exposure, Neumayer said, but she also pointed out that once you hit a sort of “critical mass” of women in a specialty, gender becomes a non-issue.

““There There was remarkable inequality during medical school, residency and the early years of practice, however, improvement has occurred over the years.”

“Interestingly, while the residencies are replete with women in those specialties, the number of women in leadership positions in OB/GYN and peds are still very low,” she said.

New roles As one of only a handful of female surgery department heads at an American medical school, Neumayer admits she does see herself as a role-model for other young female physicians considering a career in a male-dominated field, and tries to make herself available to mentor students, residents and faculty. “I think this is a very important part of what I do,” she said. “To me, being happy in what you are doing every day is the most important thing, so I try to empower and enable others to find what it is that makes them happy.”

Dr. Neumayer has a discussion with Scott Saleska, PhD, Associate Professor at UofA

March 2017 | arizonaphysician.com

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Neumayer said that in January of 2014 there were four departments of surgery at medical schools run by women, and by the end of 2016 that number had grown to 16. These 16 women have actively banded together to promote and support other women surgeons by holding a special leadership forum this spring. “This is so important to prepare women and give them more exposure to get them into these roles,” she said. Speaking of her own role as the newly-appointed interim Senior Vice President for Health Sciences at the University of Arizona, Neumayer said she sees the challenges presented by the role to be potential opportunities. As they search for a new university presidency as well as other high-profile positions, she said she hopes to engage all involved to create a shared vision for the university department of health sciences. She plans to spend a lot of time at both the Tucson and Phoenix campus, serving as a bridge between the two schools. Common programs and centers such as the University of Arizona Cancer Center and the precision grant provide a common thread of research that will serve to unite and support them. There has been much discussion throughout the last year about leadership changes in the Phoenix campus. Neumayer says the first priority will be to secure full accreditation. “Part and parcel to this is to complete the dean search,” she said. “Dr. Ken Ramos has been serving as the Interim Dean and has done an immense amount of work along with other leaders in the COM-P in preparation for the accreditation site visit.”

did not experience a salary gap with male surgeons was the VA, where salaries were lower across the board than at universities or in private practice. There have been some recent reports in the media noting the correlation between treatment successes of elderly patients when cared for by women physicians. Hospitalized elderly patients treated by female physicians had lower incidences of mortality and reduces readmission rates as compared to those treated by male physicians. When asked about the clinical implications of these findings, Neumayer noted that they seemed similar to studies that have shown improved outcomes when patients are cared for by providers of their same race or ethnicity, and perhaps it is tied to perceptions and comfort-level. “I believe we should identify best practices and work hard to implement them across diverse settings,” she said.

DOMINIQUE PERKINS Dominique is the Associate Managing Editor for Arizona Physician and serves as the Communications Coordinator for the Maricopa County Medical Society.

Increased equality Most medical schools have seen female enrollment dramatically increase over the past several decades, and women now make up at least half the student body at most institutions. Neumayer noted that while there may be more women around than there used to be, the biggest change she has witnessed is the number pf physicians who are currently married to other physicians. “This presents great problems when recruiting, because both spouses want a good job,” she said. When it comes to inequalities on the job, she said it all hinges on the beginning negotiations. Recent reports show that female physicians make on average 8% less than their male counterparts, and that first job really makes a difference. “My experience in the last two years is that women ask for less from the get-go,” Neumayer said. Neumayer referenced Evelyn Murphy, PhD, economist and founder of the WAGE Project, who has done extensive research and reports that for physicians starting out a lower salary can add up to as much as $2 million lost income over 20 years. “We won’t fix this gap until there is absolute attention paid to this both in the public and private sector,” she said. She also said the only place she has worked where she 26

ARIZONA PHYSICIAN | March 2017

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From left to right: Eileen Neumayer, Dr. Neumayer, Jim Neumayer, Marge Neumayer, and Ann Krieg

On the

personal side.. 1. Describe yourself in one word.

6. Favorite Arizona sports team (college or pro)?

2. What is your favorite food, and favorite restaurant in the Valley?

7. Favorite activity outside of medicine?

Optimistic.

I am someone who eats to live, not lives to eat so this is a tough question. My favorite restaurant is El Charro Cafe (downtown in Tucson), and favorite food is most things Mexican (assuming we aren’t including dessert).

3. What career would you be doing if you weren’t a physician?

Flight attendant (I think I would make a pretty good one, having been a waitress, a mom and a doctor!!).

4. What’s a hidden talent that you have that most wouldn’t know about you? I have a secret recipe for chocolate chip cookies. I baked a batch for each of my medical school classmates for their birthdays.

5. Best movie you’ve seen in the ten years?

U of A basketball team.

Playing golf or shopping.

8. Family?

I am married to a cardiac surgeon and we have three children. Ashleigh has just finished college, and is applying to medical school, Andrew is a junior at the Ross School of Business at the University of Michigan, and A.J. is a freshman at the University of Utah studying math and computer science. My dad who died about 2 years ago at age 92 was a surgeon. My mom who is 88 and still working (say hi to her if she is your cashier at Silver Lake Lodge at Deer Valley) was a medical technologist in her prior career. My oldest brother is a small business owner, and my other brother works for Lockheed Martin. They both live in Florida. My older sister is the chair of the department of Music at Utah State University, and my younger sister is a compliance guru for Pearson, and lives in Park City, UT.

I don’t watch many movies, so I will just go with Frozen. March 2017 | arizonaphysician.com

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Medical students enjoy a photo opportunity.

Association of Women Surgeons – Arizona Mixer On January 24th, the Arizona Chapter of the Association of Women Surgeons (AWS) hosted a mixer for Valley surgeons and medical students interested in careers in surgery. The event was held in the Maricopa County Medical Society (MCMS) courtyard, where women from around the Valley braved the cold weather for a fun evening getting to know one another. Mentoring was a primary theme, as established Valley surgeons spoke with local medical students about career tracks and work-life balance, among other topics.

Dr. Joan Kohr, breast/ general surgeon, leads a discussion on self care.

E V ENT PHOTOS BY DENN Y COLLINS PHOTOGR A PH Y

Local medical students and surgeons enjoy a conversation - while keeping close to the table heaters.

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ARIZONA PHYSICIAN | March 2017

The event was well-attended, and much-enjoyed.


Dr. Tanja Gunsberger, general surgeon and MCMS board member, welcomes the crowd.

Mindie Factor, President of the MCMS Alliance, enjoys enjoys mingling with other guests.

From left to right: Christine Gibson, Marissa Cutting, Morgan Keefe, Heather Kissel

Dr. Marybeth Schultheis, colorectal surgeon, speaking with (from left to right) Morgan Keefe, Heather Kissel, Juliana Cackovic, Christine Gibson, and Mckenzie Murdock.

March 2017 | arizonaphysician.com

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ARIZONA PHYSICIAN | March 2017

Women in Medicine

““Being Being a female cost me a year in medical school due to refusing a professor’s advances. That was in a century when they could get away with it.”


BY SHARLA HOOPER

W

omen physicians were interested in our survey! Our survey garnered a two-thirds majority of women respondents. Thank you to all the physicians who took the time to thoughtfully consider the presence of women in medicine leadership, and the biases encountered.

Women leadership in training & current environment

Women in Medicine: What Physicians Think

American Association of Medical Colleges (AAMC) data shows that in 1966, women accounted for 9.3% of the population matriculating from medical school; by 1990, that percentage had jumped to 38.5, and as of 2014 was 47.2. Over half of our respondents, 57.1%, reported having “few” women physician leaders in their training. While our survey did not collect ages of respondents, it is likely that our younger physicians are experiencing the outcome of a shift in the presence of women leaders in medicine; 24% of our respondents reported encountering an equal or majority of women physician leaders in their training. While 57.8% of both male and female respondents feel that women are now proportionately represented in physician leadership, there was a striking difference in how male and female respondents perceived the gender pay gap. Of female respondents, 69% believe that a gender pay gap for women still exists; of male respondents, 41.5% believe a gender pay gap for women still exists. A 2016 Journal of the American Medical Association (JAMA) study of sex differences in physician salary at academic institutions found that women physicians were making about $51,000 less than their male colleagues. After multivariate adjustments (specialties, time worked, patient volume), the gap grew closer but still felt short by about $19,000 annually. One of our respondents shared her personal experience of being offered $25,000 less than a male colleague: “I know exactly how much he made, because I was his fellow when he was a first year resident and we had maintained our friendship over the years. He started at that job straight out of fellowship with no prior experience. I was hired at the same job 1-2 years later when I had two fellowships under my belt and four years of practice! I was so mad, but instead of walking away, I negotiated for more money because I needed the job. Their final offer was still 10K short of what they offered him (he did not have to negotiate).” Sixty-six percent of our respondents felt that women are proportionately represented in primary care, and 75.3% felt that women are not proportionately represented in specialty care. Again, this is confirmed by a recent study of residents. An AAMC 2015 “Report on Residents” identified the top specialties among 86,439 residents in the graduate medical education class of 2013-2014; women continue to make up a larger percentage of residents in Family medicine (about March 2017 | arizonaphysician.com

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Gender

Medical practice

66.5%

environment

11.0% 12.9% 9.7%

SOLO PRACTITIONER

33.5%

SMALL GROUP (2-5 PHYSICIANS)

17.4%

EMPLOYED AT A HOSPITAL

Bias or inequality

experenced due to gender YES

70.8% 6.5%

NO

22.7%

NOT SURE

Women in leadership positions where you trained

17.5% 1.3%

34.4% 5.8%

women proportionally represented in primary care? YES

32

66.9% 15.6%

NO

NOT SURE

ARIZONA PHYSICIAN | March 2017

17.5%

NOT SURE

YES

FEW

women proportionally represented in leadership positions in your workplace?

NO DIFFERENCE

Do

57.1%

Are

Are

OTHER

59.1% .06%

for women vs. men physicians

gender pay gaps exist?

59.5% NO

24.2% 16.3%

EQUAL MEN AND WOMEN

MORE WOMEN

2.6% 30.3%

ADMINISTRATOR

balance

20.1%

3.9%

LARGE GROUP (6-20 PHYSICIANS)

Importance of work-life

NONE

NOT SURE

16.1%

MEDIUM GROUP (6-20 PHYSICIANS)

NOT SURE

YES

57.8% 11.7%

NO

30.5%

NOT SURE

women proportionally represented in specialty care? Are

YES

11.0% 13.6%

NO

75.3%

NOT SURE


58%), Psychiatry (about 57%), Pediatrics (about 75%), and Obstetrics/gynecology (about 85%).

Personal experiences of bias Of the 154 respondents to our inquiry, “Do you feel you have experienced any bias or inequality due to your gender in your medical training or practice?”, 109 responded “yes.” We followed this with an opportunity to comment and share any observed inequalities in treatment, promotion, or responsibility due to gender. The instances and observations described range from subtle to outright. Several respondents shared that female physicians often experience being called by their first names by, well, everyone – while male colleagues are consistently referred to deferentially by their professional title of “Doctor.” From a woman physician in a self-identified administrator position: “It is small, but in a room of professionals, paraprofessional, staff, a male Dr is called Dr. A female Dr is often called by her first name...really is evident, has been for 24 yrs.” And from a hospital-employed woman physician: “I have also found women are far too often referred to by our first names by other non-physician staff – nurses, techs, patients, drug/device reps – whereas our male counterparts are almost always assumed to be “Dr. So-and-So” whether they are actually a physician or not. This has happened to me personally in meetings and via email regularly.” There are generational differences reflected in the experiences of those who trained 30 years or more ago: “When I trained, women were either not accepted or rarely accepted into certain specialty training programs. When I started a solo practice in 1989, the ICU nurses said I had to get my orders co-signed by a male physician! I was also told the physician lounge was for males only!” Some bias comes from a less discussed source: patient bias towards the physician. “I didn’t really experience anything in residency or fellowship from other physicians, but patients often thought I was a nurse and I had to explain that I was a doctor. Even today, some older male patients speak to me as if they have to explain medicine to me.” Depending on setting/environment: “I have almost exclusively worked with men physicians. Only recently have women entered neurology practice in greater numbers. When I worked in a group there was no inequality. When I worked at the University there was definite inequality. Within physicians we’re not valued, treated equally, or paid equally.” Leadership growth limited to specialties with higher percentage of female physicians: “I find growing numbers of women in leadership positions within my field (OBGYN) only, and even then, not in equal proportions. I also think that the lack of bias/inequality in my training is because of my chosen specialty.”

Motherhood in medicine Several comments highlighted the conflict between training and family planning: “During interviews for

residency, I specifically was asked if I was planning to become pregnant during those years (which I believe was not a permitted question), and was told that at that institution that males were preferred for this reason.” One respondent shared that she had a fellowship denied because she was pregnant. A particularly extensive comment highlighted the differences in expectations of women physicians as mothers – and the biases perpetuated even by women physician leaders: “I have found women are not considered for extra-clinical opportunities (e.g. speaking engagements, trips) because organizers assume we are too busy with family commitments...Sadly, the concept of ‘work-life balance’ is lost on many, men and women, alike. In my personal experience, I have had several women in leadership positions opposed to things that could potentially make my work life easier. One of these women told us that because she personally struggled with finding good childcare previously in her career, she felt we were ‘getting off easy’ if we did not have the same struggles. Another woman in leadership said to me (after I had proposed coming back part-time for 6 months after maternity leave to get used to working with two little kids) that she didn’t support it because my colleagues may just get used to working without me; she went on to basically equate coming back after maternity leave to men coming back after having orthopedic surgery (shoulder/hip/knee repair) and that we shouldn’t discriminate against men by ‘favoring’ women with leave policies. This kind of mentality (from a woman, no less) greatly underestimates the stress and responsibility in addition to the profound physical changes a new mother feels after giving birth.” One medical student offered the following thought: “It is not all negative however. I know several really wonderful female physicians that I look up to and are great mentors. I feel supported by my school and in general most of the attendings and residents that I work with. But I do believe that there is still a lot of work to be done…” Resources Anupam, Olenski, Blumenthal. JAMA Intern Med. 2016;176(9):12941304. http://jamanetwork.com/journals/jamainternalmedicine/ article-abstract/2532788 Report on Residents (2015). AAMC. https://www.aamc.org/ data/421300/residentsreport.html The State of Women in Academic Medicine: The Pipeline and Pathways to Leadership, 2013-2014. AAMC. https://www.aamc.org/ members/gwims/statistics/

SHARLA HOOPER Sharla is the Managing Editor for Arizona Physician and serves as Associate Vice President of Communications and Accreditation for the Arizona Medical Association.

March 2017 | arizonaphysician.com

33


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ARIZONA PHYSICIAN | March 2017


Women Caring for Women

A

BY SUSAN GOODMAN

ccording to the 2015 State Physician Workforce Data Book 1, about one third of Arizona’s physicians are women. While some specialties don’t have enough female representation to report data on a percentage basis2, adult primary care statistics demonstrate women participating at roughly the same percentage rate as that of their overall workforce representation percentage. In Southern Arizona, we are fortunate to have many accomplished women physicians and other professionals on the front lines of primary care medicine. Certainly, as healthcare providers anticipate legislative and administrative changes to the health law and coverage landscapes, reflections on some of the good that has come from expanded access to care is relevant. El Rio Community Health Center is one provider in Southern Arizona that has been improving access to care and disease management. Notably, it is one of Arizona’s active participants in the national medical legal partnership demonstration project aimed at addressing larger social-determinates impacting health in our community. A recent New England Journal of Medicine short review and comment article entitled “Socioeconomic Status Predicts Mortality More Strongly Than Some Globally Recognized Risk Factors”, emphasizes the necessity for demonstration projects like the medical legal partnership.3 It reported that socioeconomic status was correlated to morbidity and early mortality, even after the data was adjusted

for the seven modifiable risk factors targeted by the World Health Organization (WHO) in their campaign to control non-communicable diseases. Risk factors included alcohol overuse, inactivity, smoking, hypertension, sodium intake, diabetes, and obesity. The article suggested that socioeconomic status should be targeted as a modifiable risk factor. In large measure, this broadened view of health determinates has been facilitated through the necessary initial step of increased access to care flowing from payment structure changes such as the Arizona Health Care Cost Containment System (AHCCS) expansion and enhanced coverage for preventative care. Dr. Lisa Soltani is one of the many female physician warriors in this battle to impact health outcomes in primary community healthcare. Dr. Soltani is a Duke-trained Internal Medicine physician who has authored some important reflections on the primary care benefits which have flowed from improved access to preventive services, and for women, contraception from the essential health benefits coverage expansion that came with the Patient Protection and Affordable Care and the Health Care and Education Reconciliation Acts.4

It is in herself she will find the strength she needs.

Some important excerpts from these articles include:5

On the topic of expanded access to preventive services without cost-sharing or deductible: As a primary care physician in one of the nation’s largest March 2017 | arizonaphysician.com

35


WOMEN ’S HEALTH C AR E COV E R AG E U N D E R T HE AC A 9.5 million Women have Healthcare Coverage | 55 million Women have access to: • Annual well women examination • Birth control coverage • Mammograms and cancer screening • Breast feeding support and supplies for new moms

• Screening and counseling for domestic and intimate partnership violence • Screening and treatment for sexually transmitted diseases • Maternity care as an essential health benefit

In addition, insurers are prohibited from charging higher insurance premiums for women. Source: Arizona Alliance for Community Health Centers Annual Report 2016

Community Health Centers, I witness daily the ravages of illnesses that could have been prevented with engagement of people earlier on in wellness and awareness of their own role in avoiding disease. A 2013 Kaiser Family Foundation Survey found that up to 50 percent of adults had put off a recommended preventive service within the previous year due to a concern about cost. This is despite the fact that many of them likely did have more access and coverage for that service—under the ACA—than they were aware. It takes time to re-educate a nation of people who have previously been flummoxed by the vagaries of piecemeal coverage. You don’t need wait to seek care only when you have a concerning symptom: you now have a right (and even a duty) to seek expert advice on how to remain healthy… In a second op-ed co-authored with Dr Ilana Addis, Associate Professor of OB/Gyn at the University of Arizona College of Medicine, on the importance of removing barriers to effective contraception: As women’s healthcare providers, we’ve seen contraception benefit our patients in numerous ways. The best way to prevent unwanted pregnancy is through access to proven contraception methods. Methods like the intrauterine device (IUD) or implants that deliver hormones have now been shown to be as effective as permanent sterilization at a fraction of the cost and effort through a simple office-based

36

ARIZONA PHYSICIAN | March 2017

Women in Medicine

““Women Women are rare in administrative positions, especially rare in policy creation positions.”

procedure. Evidence shows that these long-acting reversible contraceptives (LARCs) can be used safely in the entire continuum of child-bearing years, from adolescence to post-pregnancy, and in a much broader range of women than previously thought. In fact, for most people, there are now very few health reasons not to use these very safe and effective methods that are relatively inexpensive over the long term. Without the ACA, contraceptives—LARCs in particular—will be increasingly out of financial reach for many women. This is concerning given that the uninsured rate for women under the ACA dropped by more than one-third overall, and for women qualifying for Medicaid, by almost half. Further, the U.S. abortion rate has reached its lowest point since Roe v. Wade legalized abortion. While these decreases can’t be entirely attributed to the ACA’s contraceptive mandate or other programs that make access easier, we must be equally cautious to not disregard the impact of greater access to reliable contraception. To describe the current political climate as polarized would be an understatement. Whether you agree or disagree with Dr. Soltani’s assessment of the benefits of the ACA, what is most important is that physicians and other healthcare professionals/providers remain engaged and active in the rulemaking process – providing feedback to our lawmakers to take to Washington, D.C. and to address at the state level. Lisa Soltani MD MPH FACP is a primary care physician and medical director for Internal Medicine at El Rio Community Health Center. She received her medical degree at Duke University Medical Center and her MPH degree at University of Arizona. She is currently a fellow in the Public Voices OpEd Project.


Never doubt that a small group of thoughtful committed citizens can change the world; indeed, it’s the only thing that ever has. Margaret Mead

References: 1 :https://www.aamc.org/download/447148/data/arizonaprofile.pdf, accessed 2/15/2017. 2 In AAMC’s 2015 data, these specialties included: Interventional Cardiology, Neuro, Thoracic, and Vascular Surgery, and Vascular and Interventional Radiology. 3 By Bruce Soloway, MD reviewing Stringhini, S, et al., Lancet, January 31, 2017 at http://www.jwatch.org/na43414/2017/02/14/ socioeconomic-status-predicts-mortality-more-stronglysome?query=etoc_jwgenmed&jwd=000020004534&jspc=. 4 PPACA, 111 P.L. 148, 124 Stat. 119; HCERA, 111 P.L. 152, 124 Stat. 1029. Free access to the text of these laws is available at: https:// www.healthcare.gov/where-can-i-read-the-affordable-care-act/, accessed 2/15/2017. 5 Full articles are available at: http://www.huffingtonpost.com/ entry/you-should-save-preventive-services-so-preventiveservices_us_5876d892e4b086a337b6f642?; and, https://rewire. news/article/2017/01/18dont-gut-affordable-care-act-want-fewerunintended-pregnancies-abortions/. 6 410 U.S. 113, 93 S. Ct. 705 (U.S. 1973).

Women in Medicine

Susan Goodman RN JD is a health law compliance attorney at the firm of Mesch Clark Rothschild. She assists health care providers with legal needs grounded in operational compliance support. Her legal competence is augmented by her direct work experience in clinical, corporate, leadership, and operational health care roles.

““II had a fellowship denied because I was pregnant.”

HEALING HANDS. BIG HEARTS.

Big Thanks.

Blue Cross Blue Shield of Arizona values the contributions and efforts of Arizona physicians in caring for our members.

March 2017 | arizonaphysician.com

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Women Leading in Southern Arizona

T

wo of Southern Arizona’s important healthcare providers are led by women who began their health careers in nursing. Judy Rich is the CEO of Tucson Medical Center, a locally-governed nonprofit regional hospital that has been serving Tucson and surrounding areas for 70 years. Nancy Johnson is the CEO of El Rio Community Health Center, an organization with 11 campuses in Tucson providing for the medical needs of more than 95,000 adults and children. These two Southern Arizona organizations have joined forces to create HealthOn Tucson, a new innovative, integrated health and wellness nonprofit collaboration. As part of this joint venture, construction is underway for HealthOn Broadway, 1 W. Broadway Blvd. When open in March 2017, the 8,211 square-foot facility will provide state-of-the-art primary care, health education and wellness coaching to any community member. Accessible from the streetcar, the facility will be open Monday through Saturday, including evening hours. HealthOn Broadway will be staffed to accommodate up to 7,000 patient visits per year. This venture aims to keep the community healthy by offering an array of preventative health care education and wellness programs in addition to direct care. TMC has been working with the City of Tucson and Pima County about the needs of their employees and having a downtown health care option. “Our community is telling us that they want to access health care where they live and where they work,” said Judy Rich. “And it just made sense to partner with our colleagues at El Rio Health to bring this innovative concept to downtown Tucson.” Add this desire for closer access to the recent growth of downtown, and El Rio’s recent relocation of its administrative campus to the Manning House (in addition to its El Rio Congress clinic), and downtown became the natural choice for this first collaborative site. “We are transforming how primary care should be delivered through patient experience, innovation, efficiency and clinical outcomes,” said Nancy Johnson. “TMC and El Rio are committed to creating a unique, integrated health care model, which has not yet been seen in Tucson.”

Judy Rich, CEO Tucson Medical Center

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ARIZONA PHYSICIAN | March 2017

Nancy Johnson, CEO El Rio Community Health Center


End of Life Care in Arizona – Where Do We Go from Here? The Joint ArMA/AOMA Task Force on End of Life Issues

D was a 69-year-old male who developed renal cell carcinoma with lung and bone metastases at the time of diagnosis. He was treated with chemotherapy and radiation therapy with partial response and many complications, including serious, and ultimately intractable, pain. I visited every other week and we discussed life, death, and choices. He pursued chemotherapy and other efforts to extend life as long as possible, fully aware of the complications, and made the choice to endure them. He used his time well, but when he could no longer function, and pain was particularly difficult to manage, he enrolled in hospice and died peacefully shortly thereafter with family at his side, approximately two years from original diagnosis. His last question to his oncologist was, “Why didn’t you tell me it would be this bad?”

Ron Fischler, MD

D

espite his incurable illness and untimely death, Ron’s friend was fortunate compared to many Americans who succumb to life-limiting illnesses. He had a friend with medical expertise to help with the complex and confusing choices that patients face at the end of life; however, he died wishing he had better communication with his oncologist. He maintained a large degree of control over the type, amount and settings in which his care was provided, and ultimately died peacefully at home surrounded by loved ones. Sadly, many Americans experience circumstances where their choices for care at the end of life are unheard or overlooked and often end up dying with poorly controlled symptoms in hospitals or nursing homes. Why does this happen and what can we as physicians in Arizona do to improve end of life care for our patients? By the late twentieth century the impression that technology could stave off dying became very powerful and

to many in the medical establishment, death became equated with failure, rather than as a natural inevitable part of the life experience. Discussing death or providing a negative prognosis became virtually taboo under the false premise that providing honest information would destroy hope for both patients and their families. The American health care system remains heavily focused on sophisticated acute inpatient care and is woefully inadequate to address the needs of frail elderly patients with multiple chronic conditions who comprise a majority of those who die in the United States, particularly as the Baby Boomer generation ages. “As an Emergency Medicine physician, I am saddened at how many patients end up in the [Emergency Department] when they would be far more humanely served in a palliative or hospice care setting,” states Alan Molk, MD. A substantial percentage of Medicare spending continues to occur in the last six months of life, often on interventions March 2017 | arizonaphysician.com

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that provide little or no benefit, which is neither clinically appropriate nor financially sustainable. There are myriad reasons for this, including “perverse” financial incentives that favor more care, regardless of the chance of benefit; perceived legal risks for physicians who do not acquiesce to “do everything,” even when they believe such efforts are futile; avoidance of advance care planning; and lack of understanding by both patients and physicians alike of the role and benefits of palliative care and hospice and/or the availability of such services. Jud Tillinghast, MD, a retired critical care specialist reflects, “Addressing the difficult questions surrounding end of life is a daily problem in the ICU. I have seen family members divided and agitated, demanding aggressive care even if it only prolongs a patient’s suffering. We need more physicians (primary care, specialists, hospitalists and critical care) to communicate clearly and sensitively with patients facing a terminal condition, with assistance from the palliative care team, to help families honor the wishes of their loved ones and ideally to do this before a crisis occurs that results in the ICU admission.” Many of the deficiencies in end of life care in the United States, and possible solutions, were highlighted by the Institute of Medicine in its 2015 report, Dying in America. A key message for physicians was to initiate advance care planning discussions as early as possible for individuals with serious illness. This is a role that most physicians fail to address, most often citing lack of time, inadequate reimbursement and inadequate training. Furthermore, when they do conduct such discussions and prognosticate regarding survival, physicians tend to be overly optimistic and overestimate life expectancy in order to not decrease their patients’ hope, which may be well-intentioned but is usually counter-productive. Cottonwood cardiologist Bruce Peek, MD, states: “How we assist patients and their families during the dying process is just as important as how we assist them to prolong life. Educating patients and families regarding the nature and prognosis of their disease throughout the course of their illness, and eliciting their goals and preferences along the way is essential to what we do.” The increase in palliative care programs and the recent emergence of hospice and palliative medicine as a recognized medical specialty have been beneficial. “Palliative care is specialized supportive care for people with serious illnesses and is provided by a team of doctors, nurses and other specialists. Unlike hospice care which is indicated for patients with a life expectancy of 6 months or less, palliative Care is focused on providing comfort and appropriate at any stage of a patient’s illness to help with symptom management, address psychosocial and spiritual aspects of illness, and define and meet patients’ and families’ goals of care,” explains Stacie Pinderhughes, MD, Director of Palliative Care at Banner Health. “Numerous studies have demonstrated that the involvement of Palliative Care teams can increase patient and family satisfaction with their care and a landmark study in the New England Journal of Medicine demonstrated that Palliative Care services reduced the incidence of depression and actually prolonged survival 40

ARIZONA PHYSICIAN | March 2017

in patients with advanced lung cancer.” Still, major gaps in end of life care persist. Many patients today also want more options as they face the end of life. This has fueled efforts and passage in numerous states of so-called “Medical Aid in Dying” or “Death with Dignity” legislation that provides a legal framework for physicians to prescribe medications by which patients with terminal illness can end their lives. The Task Force on End of Life Care created by the Arizona Medical Association (ArMA) and the Arizona Osteopathic Medical Association (AOMA) is a multispecialty group of physicians from around Arizona. The mission of the Task Force is to assess the state of end of life care in Arizona and offer practical options to improve care for patients across our state. The group initially prioritized three areas:

1. Education. How can we provide effective, convenient

and accessible educational efforts for both physicians and the public, and to help physicians increase their skills in end of life care? We also want to determine the level of interest of primary physicians, hospitalists, and specialists in Arizona if such training were made available.

2. Access to Palliative Care. How can we assist to

increase the availability and accessibility to hospice and palliative care services for patients across Arizona, and to enable advance care planning to occur earlier when it may be more beneficial?

3. Policy. Assess Arizona physician attitudes regarding

Aid in Dying legislation and other end of life care issues which may be subject to legislative efforts.

The first goal of the Task Force is to gather as many physician views as possible on these issues. To that end, the Task Force will send a survey to as many Arizona physicians as possible. Your feedback will help us transform the care our patients receive at their most vulnerable time in life. As Carla Denham, MD, a psychiatrist and member of the Task Force, observed, “I was not really surprised to learn that conversations about death and dying are often rewarding to patients and their families, since they frequently help to reduce fear and clarify treatment goals. What was surprising was how those same conversations alleviated my own fears as well.” To learn more about the Task Force and its members, view article references, or to sign up for updates from the group, please visit www.azmed.org/general/custom. asp?page=endoflifecare. Paul E. Stander MD, MBA, FACP is Associate Chief of Staff for Geriatrics at the Phoenix VAMC and was Chief Medical Officer at Banner Good Samaritan and has worked with Hospice of the Valley for many years. He is Clinical Professor of Medicine at the University of Arizona - Phoenix College of Medicine. Ron Fischler, MD, is a pediatrician in Scottsdale who has developed a strong personal interest in end of life issues. He has held leadership roles at Scottsdale Healthcare and in the Arizona Academy of Pediatrics and Arizona Medical Association. He is an Associate Clinical Professor at the University of Arizona College of Medicine.


Live&Learn Hope... with an Action Plan

W

hen you think of a woman living in a transitional housing facility, do you find yourself picturing someone never able to break out of the cycle of poverty? “This is exactly why Live and Learn came into being,” says Katie Johnson, Director of the Phoenix-based non-profit. “Our agency is all about bringing back hope and empowering women towards independence. We are here to show there is a way out of poverty.” Started in 2012, Live and Learn believes that education and career training are the keys to ultimate economic stability for this population. “Our agency is committed to helping those impacted by poverty and violence by training them for high-demand jobs with good salaries,” says Ms. Johnson. “But we do more than that. We provide support along the journey. We become the cheerleaders for some amazing women who many times have never had a supportive person in their life before.” Many of the agency’s clients are referrals from transitional housing facilities, women who are trying hard to rebuild their lives from the ground up. “Life has thrown these women some curve-balls and things just haven’t turned out the way they had hoped they would,” says Ms. Johnson. “The thing that unites the women who become our clients is their true determination and drive to make a better life for themselves and their families. Women who are accepted into the Live and Learn program are full of potential and ambition, just waiting for opportunity, and some support. They are truly inspiring.” Live and Learn provides women with a structured pathway to economic independence, and stays with clients

for two years to follow their progress and success. The agency provides personalized career planning, sponsored education and training, mentoring and financial assistance to each participant. Live and Learn program staff provide individualized support to each client, guiding them through basic skill-building, career track training, all the way to job search strategy, and through post-placement challenges and adjustments. “For Live and Learn, success is measured by seeing clients complete training and education programs in areas with high employment demand and where there are opportunities for advancement with further experience and training,” says Ms. Johnson. “Our goal is to see women securing and keeping a job, along with developing a plan for continued education and training to truly reach a ‘livable wage’.” Careers in healthcare remain a focus area for Live and Learn. In 2016 the agency enrolled 26 women in various healthcare programs - ranging from Medical Assistant (MA), Medical Administrative Assistant (MAA), Phlebotomy, and Certified Nursing Assistant/Patient Care Tech (CNA/ PCT), through to Licensed Practical Nurse (LPN) and Registered Nurse (RN). Live and Learn has developed a strong partnership with PIMA Medical Institute, as well as Maricopa Community Colleges, to support our women working towards various certificate and degree programs in healthcare. Raquel T. was living in a transitional housing facility when she was referred to Live and Learn in 2015. A single mom of three, she had been a victim of homelessness for several years prior to hearing about the program. Today March 2017 | arizonaphysician.com

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Raquel will tell you proudly that she is a graduate of PIMA Medical Institute, having recently completed the Medical Assistant program where she graduated with Honors. “I have had many set-backs and struggles in life, but education has always been important to me,” says Raquel. “I wanted to be successful and support my family – I just didn’t see how it would be possible to return to college with all that I was facing in my life. It was a constant juggle making ends meet and I struggled with personal doubt and fear.” Raquel says Live and Learn made the difference because they believed in her. “Being part of this program has been such a benefit for me and for my family,” she says. “I continue to receive so much support and encouragement throughout this journey. Live and Learn has given me the tools to succeed. They encouraged me through every situation and helped me gain my confidence back and believe in myself again.”

Women in Medicine

““II think the wage gap is the most persistent inequality faced by women. I feel that the newer generations of doctors are more apt to treat female physicians more equally in the workplace.”

Raquel recently completed her MA externship and is excited to be searching for full-time employment in the field. “I have overcome so many barriers on this journey, and I see a brighter future just around the corner,” she says. Live and Learn is a life-changing program. Over 230 clients have graduated from career training programs with the agency since 2012. Over 95% of those women have been the first in their family to earn a high school diploma or GED; the first to train for a professional career and earn a certificate; the first to secure a job with possibility of advancement. “When women are moving towards financial stability, they are better able to address the needs of their family,” says Live and Learn’s Katie Johnson. “They are proving to themselves they are capable – and deserving – of a better life; and that education is key to their future, and that of their children also.” Live and Learn is always looking for new community partners to collaborate with to support their amazing clients. If you would like to find out more about the organization, please contact Katie Johnson at 480-888-6142 or kjohnson@ liveandlearnaz.org. Katie Johnson is the Executive Director of the Live and Learn Program. Born and raised in Sydney, Australia, Katie is a graduate of the University of Technology, Sydney. Katie joined Live and Learn in 2012 and was instrumental in implementing mentoring services and expanding career training opportunities for the agency.

For your commitment to our

MISSION, and our MEMBERS. STAT Transcription Accurate, On-Time Reports

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ARIZONA PHYSICIAN | March 2017

602.251.2363


BENEFITTING PHYSICIANS, PATIENTS, AND THE ECONOMY B Y B R I A N P O W E L L | F L I N N F O U N D AT I O N

A

rizona’s Bioscience Roadmap is a long-term strategic plan with a goal of increasing access for Arizonans to health innovations and improving outcomes while diversifying and strengthening the state’s economy. The plan has been beneficial to physicians and their patients throughout the state in many ways, including improved access to clinical trials – whether to try to extend the life of a pancreatic-cancer patient or to help find a cure to Alzheimer’s disease – enhanced research at the state’s universities and private institutions, and an increase in startup bioscience firms working to commercialize their discoveries. The Roadmap was commissioned in 2002 by the Phoenix-based Flinn Foundation, a nonprofit philanthropic organization, and updated in 2014 to guide the state through 2025. It is the longest-running, statewide, proactive bioscience plan in the nation. The Flinn Foundation, established in 1965 by leading cardiologist Robert S. Flinn and his wife Irene, directs the majority of its grantmaking to advancing the biosciences in Arizona and provides staffing support to the Roadmap and its Steering Committee.

Roadmap priorities The Roadmap is much more than a written document. Beyond its well-researched underpinnings, it is a dynamic, evolving action plan that is helping to galvanize bioscience interests across the state to follow a common vision. Its thesis of pursuing disciplines where Arizona has exceptional strengths has helped to establish Arizona’s status as one of the nation’s fastest-growing bioscience regions. Roadmap advocates are guided by a set of goals, strategies, and recommended action steps to advance the

bioscience sector and improve health outcomes through collaboration, and private and public investments. The biennial release of data collected by the research and strategy firm TEConomy Partners tracks the state’s progress. Of particular relevance to physicians, the Roadmap calls for increases in Arizona’s production of general practitioners and the number of graduate medical education slots, and the development of nationally-recognized healthcare delivery models. Other key priorities include improving science, technology, engineering, and mathematics (STEM) education, increased advocacy and education of policymakers, obtaining new research and infrastructure funding, and attracting risk capital. For instance, the Roadmap calls for the development of the healthcare and biomedical talent base by attracting and retaining top graduate students, doctoral and post-doctoral candidates and trainees, and physician-scientists who would develop Arizona-based research programs, including clinical research. One potential action step is for the Arizona Board of Regents to recommend establishment of doctoral and postdoctoral research fellowships and physician-scientist recruitment packages. Another key Roadmap strategy is to develop programs to educate health-care providers about how to offer patients access to precision-medicine treatments. Arizona, with strong university research groups and anchor independent institutions such as the Phoenix-based Translational Genomics Research Institute and the Tucson-based Critical Path Institute, is on the leading edge of precision medicine. Education programs could include a focus on physician training in molecular and precision medicine and the use of scientific and clinical data, and the pursuit of further March 2017 | arizonaphysician.com

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research while in clinical practice. Another potential action is to form consortia of physicians, scientists, and others involved in targeted disease focus areas. In addition, the Roadmap’s emphasis on creating a hospitable environment for bioscience entrepreneurs and firms is intended to lead to the commercialization of new devices and drugs that could prove to be beneficial to both the physician and the patient. Two pacesetters are Oro Valley-based diagnostics firm Ventana Medical Systems, Inc., founded by a University of Arizona pathologist, and W.L. Gore and Associates, whose medical-products division has headquarters in Flagstaff and another hub in Phoenix. Gore often tests newly developed stents, grafts, and other products at clinical sites in Arizona.

Steering committee This vision is being driven by the Arizona’s Bioscience Roadmap Steering Committee, which was created with the Roadmap to oversee the implementation of the plan and promote collaboration and partnerships. The committee meets quarterly and has more than 100 members, including several physicians, and promotes the interests of the biosciences, health care, physicians, universities, hospitals, researchers, and firms. The committee members are leaders in the private and public sectors in science, health care, business, academia, economic development, government, and policy. The chair of the Bioscience Roadmap Steering Committee is Ron Shoopman, president of the Southern Arizona Leadership Council and a member of the Arizona Board of Regents. Mark Slater, Vice President for Research at HonorHealth and Chief Executive for the HonorHealth Research Institute, is the vice chair. The institute accelerates precision-medicine therapies for cancer and cardiovascular disease through early-phase clinical research. Steering Committee members have advocated strongly for medical education, including the University of Arizona colleges of medicine in Tucson and Phoenix as well as the new Mayo Medical School, in partnership with Arizona State University, in Scottsdale. They have argued that in addition to educating the next generation of physicians, the medical schools are essential for attracting desired federal research grants.

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ARIZONA PHYSICIAN | March 2017

Women in Medicine

“Although women in leadership positions within the healthcare industry appears to be expanding, there is still an obvious discrepancy with male majority in subspecialties and academic medicine from what I have personally experienced. Women often have to adopt a “male mentality” in a sense to be respected in these roles; aka less nurturing, more paternalistic and dictatorial. With this said, I feel that leadership roles among female physicians is vastly improving however.”

Arizona Physician (USPS 020-150) is published 12 times per year. It is a combined publication of the Arizona Medical Association, Maricopa County Medical Society, and Pima County Medical Society, 326 E Coronado Rd., Phoenix, AZ 85004. Periodicals postage paid at Phoenix, AZ. Postmaster, send changes to: Arizona Physician, 326 E Coronado Rd., Phoenix, AZ 85004. No part of this magazine may be reproduced or transmitted in any form or by any means without written permission by the publisher. All rights reserved. Volume 1, Issue 3

Private-public partnerships The Roadmap recommends that state, county, and local governments play a role in the advancement of the biosciences. This includes funding research at the state’s universities and private institutions, as well as providing tax credits for research and development, and angel capital investments. Governments from northern to southern Arizona have invested in incubators and accelerators, which have provided lab and office space as well as critical resources to startup firms. The Roadmap also calls for strengthening STEM education at both the state and local level. This includes improving math and science in K-12 education, increasing the number of bioscience academies, and funding career and technical preparation programs. It also encourages private-public partnerships to address needed infrastructure investments such as research facilities, multi-tenant facilities, research park developments, and new biomedical anchors.

Economic benefits One of the Roadmap’s overarching goals is to create a more diverse economy in Arizona, which can help attract and retain talent, not only for those recruited to Arizona in the medical and bioscience industries, but also for spouses and partners seeking employment in the same area. Every other year, the Flinn Foundation reports data on the Roadmap’s benchmark goals. The most recent report, released in March 2016, included economic data from the previous year. Since the launch of the Roadmap in 2002, Arizona has seen large increases in bioscience jobs and wages, which is defined to include hospital employment. Jobs increased by 49% during this time, adding more than 36,700 for a total of 110,410. Wages for bioscience workers increased 50% to $61,823, well above the state’s private sector average. Data was also reported on university tech transfer, including startups, invention disclosures, patents, and licenses; National Institutes of Health grants and research-and-development expenditures; and bioscience venture-capital funding in Arizona. For more information about Arizona’s Bioscience Roadmap, visit www.flinn.org/roadmap.


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