Round up 6 2014

Page 1

To learn more visit www.mcmsonline.com

PRESIDENT’S PAGE: The majority of physicians are now opting for employment, and most physicians trained today will expect to be employed. The ratio of employed physicians to those in private/solo practice will continue to rise. This concerns Dr. Miriam Anand as she worries about the continued deterioration of the physician voice. Page 6

PUBLIC HEALTH: Drug poisonings have become the leading cause of unintentional mortality in the United States, and opioids have been the class of drugs most frequently involved in the fatalities. Dr. John Middaugh proposes comprehensive action for this drug poisoning epidemic. Page 24

round-up Volume 60 • June 2014

Providing news and information for the medical community since 1955.

EMPLOYMENT:

Dr. Anthony Yeung – educating the next generation of physicians to be competitive in a new era of healthcare. Page Page 18 18 LEGAL – ANATOMY OF A BOARD COMPLAINT: Chances are if you practice medicine long enough, you will have a board complaint filed against you at some point in your career. When you receive that letter, it will be a disturbing experience, and most likely a source of anxiety and anger. Dr. Steven Perlmutter, JD, provides his unique perspective on how physicians can handle that dreaded letter - if you ever receive one in the mail. Page 32 PROFESSIONAL DEVELOPMENT – PHYSICIANS CREATING THEIR FUTURE: The transparency called for under the ACA will reveal a great deal of information, which provides impetus for fixing problems that need to be repaired. Dr. Howard Lang believes physicians in small and medium practices need to create their own future by coming together and sharing data and analytics so they can better coordinate care at lower costs. Page 38

PERSONNEL – DOCUMENTATION, A LEGAL RX FOR A SUCCESSFUL EMPLOYMENT RELATIONSHIP: The omission of proper employment documentation can lead to personnel disputes. Stacy Gabriel’s article serves as a general guide on how and what to document in an employment setting. Page 42 MCMS IS WORKING FOR YOU – NOT JUST ANY PHYSICIAN REFERRAL SERVICE WILL DO. CALL THE EXPERTS. CALL MCMS: Did you know we have a FREE Physician Referral Service? It’s a perk of membership! Learn more about the program, how you can update your information, or sign-up. Page 46 VIEWPOINT – TRIVIA: One of Dr. Rudi Kirschner’s world-famous vignettes; samples from his “this and that” non-taxing trivia folder. Page 53






round-up Features

6 12

18 23 24 28 32 36 38 42 46 53

june 2014

president’s page

Employed or self-employed, we all share a similar goal.

from the executive director Random thoughts.

practice spotlight: anthony yeung, md

Educating the next generation of physicians to be competitive in a new era of healthcare.

in the community

APCA’s ninth annual “Taste of Asia” fundraising banquet.

public health

Comprehensive action for drug poisoning epidemic.

employment — finance

Managing cash flow from multiple employment incomes.

employment — legal

Anatomy of a board complaint.

member happenings

Celebrating our members’ achievements.

employment — professional development Physicians creating their future.

employment — personnel

Documentation: a legal prescription for a successful employment relationship.

mcms at work for you

Not just any physician referral service will do. Call the experts. Call MCMS.

viewpoint Trivia.

In every issue

Patient Education Handout ......................................9 Letters to the Editor................................................16 MCMS New Members ..........................................17

In Memoriam..........................................................49 Marketplace ............................................................54 MCMS April Board Minutes ................................56

4 • Round-up • A monthly publication of the Maricopa County Medical Society • June 2014


On the cover: Dr. Anthony Yeung holding the FDA approved multi-channel spine endoscope, the Yeung Endoscopic Spine System (YESS™). This procedure is used to treat herniated, protruded, extruded, or degenerative discs, and spinal stenosis in the lumbar spine. Cover photo courtesy of Mike Paulson, Paulson Photo/Graphic.

Round-up staff

Board of Directors

2012-2014 Tanja Gunsberger, DO Jennifer Hartmark-Hill, MD Kelly Hsu, MD Susan Whitely, MD

Editor-in-Chief Miriam K. Anand, MD Editor Jay Conyers, PhD

Advertising Candice Scheibel

Production Candice Scheibel Karen Hellwig

MCMS 2014 officers

President Miriam K. Anand, MD President-Elect Ryan Stratford, MD Vice President Elizabeth McConnell, MD Secretary Suzanne A. Sisley, MD Treasurer Mark R. Wallace, MD Immediate Past-President Daniel Lieberman, MD

Board of Censors

Nathan Laufer, MD Chair Daniel Lieberman, MD Michael R. Mills, MD, MPH Ryan Stratford, MD Thomas E. McCauley, MD James R. Meador, Jr., MD Anthony T. Yeung, MD

2013-2015 Adam M. Brodsky, MD John L. Couvaras, MD Steven R. Kassman, MD Robert J. Standerfer, MD 2014-2016 Lee Ann Kelley, MD Richard Manch, MD May Mohty, MD Anita Murcko, MD

Advertising Info. To obtain information on advertising in Round-up, contact MCMS.

phone: 602-252-2015 advertising@mcmsonline.com

Postmaster

Send address changes to: Round-up, 326 E. Coronado Rd., Phoenix, AZ 85004 www.mcmsonline.com

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The opinions expressed in the Round-up are those of the individual authors and not necessarily of the Maricopa County Medical Society. Advertising is subject to editorial board approval. All rights reserved. Copyright 2014.©

Round-up (USPS 020-150) is published monthly by the Maricopa County Medical Society, 326 E. Coronado, Phoenix, AZ 85004. Volume 60, No. 6, June 2014.

Periodicals postage paid at Phoenix, Arizona. Subscription rate: One year - $36.

The MCMS was established in 1892 as a not-for-profit physician association in Maricopa County, Phoenix, Arizona. We represent over 2,600 members, which include MDs, DOs, medical students, residents, healthcare administrators, medical educators, and more.

The Mission of the MCMS is to promote excellence in the quality of care and the health of the community, and to represent and serve its members by acting as a strong, collective physician voice.

In fulfilling this Mission, the Society will initiate, respond to, and implement efforts through which professionalism in medicine is enhanced; the ethics of medicine are fostered and preserved; the patient’s rights and choice are supported; and quality practice of medicine is preserved.

Through these actions, members will have their current and future needs met in a manner that they cannot effectively undertake or achieve individually.

June 2014 • A monthly publication of the Maricopa County Medical Society • Round-up • 5


president’s page

Employed or self-employed, we all share a similar goal. Miriam K. Anand, MD President

C

hange has been a prevailing theme of some of my earlier editorials and our profession has had a lot of changes imposed on us in recent years, with this year certainly being no exception. As mentioned earlier, however, change is really nothing new to medicine and some changes have been much more gradual. As opposed to prior decades, the majority of physicians are now opting for employment and it is estimated that two thirds of physicians today are employed. Younger physicians are more likely to choose employment over practice ownership. Given the ever-increasing burdens of running a practice, which I alluded to in my April editorial, this should really come as no surprise. 6 • Round-up • A monthly publication of the Maricopa County Medical Society • June 2014


president’s page As a private practitioner, I can imagine that employment would offer a number of advantages. You can leave work at the office, as long as you’re not on call. You can enjoy vacation and time away from work without worrying (or maybe even being aware) of how it will affect the bottom line. Staffing headaches are not yours to worry about and neither are the costs of running the practice. Billing and dealing with insurance companies are generally someone else’s concern. The grass does seem greener.

A recent Medscape survey showed that employed and self-employed physicians showed equal overall satisfaction, although self-employed doctors were somewhat more satisfied with their current practice situation than their employed counterparts. The same survey also showed that those who made the switch from employment to selfemployment showed greater satisfaction than those who did the opposite, but the latter group reported having a better work-life balance. While many of the employed physicians worked for smaller or large group practices, c. 49% of employed physicians work for a hospital or a practice owned by a hospital.

The Medscape survey showed that employed physicians felt that their opinions and feedback were not important to the employing organization and this may account for the slightly lower satisfaction rates. Most of us are likely familiar with the recent scandal at the Phoenix VA. Many may also be familiar with the story of Dr. Katherine Mitchell, a second physician to come forward publically about her concerns regarding patient care at the VA. In a written statement, she said, “I have seen what happens to employees who speak up for patient safety and welfare within the system…devastation of professional careers is usually the end result.” It is extremely disheartening that physicians can be punished for expressing concerns about patient care and one can only wonder if it happens in other systems as well.

It is said that most physicians being trained today will expect to be employed, so more likely than not the ratio of employed physicians to those in private practice will continue to rise. This worries me for the future of our profession, not because I am concerned about my own position as a self-employed physician, but because I worry about the continued deterioration of the physician voice. As I

June 2014 • A monthly publication of the Maricopa County Medical Society • Round-up • 7


president’s page

mentioned in a previous article, employed physicians (with the exception of those in administrative roles) seem to have a layer of separation from pending and proposed changes that affect how we provide care to our patients.

Medical Society (MCMS) allows those concerns to be channeled through a unified voice.

Sadly, however, membership in organizations such as ours is low in comparison to the number of practicing Despite this, a recent study co-sponsored by the RAND physicians in the county. Those outside of medicine who Corporation and the AMA found that physician satisfaction wish to impose further rules and regulations on us, such as legislators and insurance companies, continue to take advantage of this lack of unity, resulting in the current climate we are all now practicing in. It is the mission of the MCMS to act “We want to be able to represent all physicians, both as a strong, collective voice for employed and self-employed, but we need to learn physicians and to work in a manner to preserve the quality of medicine. more about the particular issues faced specifically by

We want to be able to represent all physicians, both employed and self-employed, but we need to learn more about the particular issues faced specifically by employed physicians. If you are employed, please let us know about the concerns you have and please encourage your colleagues to join the MCMS. As part of our efforts to provide services to our members, physicians negotiating with prospective employers will be able to take advantage of reduced fees for consultation with an employment lawyer as a membership benefit. We want to be able to expand the benefits that we can provide for our members and be able to include more benefits for employed members, but we need to hear from you. ru

employed physicians. If you are employed, please let us know about the concerns you have and please encourage your colleagues to join the MCMS…” – Miriam Anand, MD

has been shown to be related to providing high quality care to patients. Employed or not, physicians are all burdened with the stress of practicing in the current climate, in which more and more barriers to providing good care seem to pop up with regularity. Self-employed physicians may have slightly more leeway in making direct changes to improve patient care in their own practices, but employed physicians need a forum for their voices to be heard.

Currently these forums seem to be social media or friends and colleagues. Some of you may be familiar with KevinMD.com, a website started by Kevin Pho, MD that is self-described as a site that “shares the stories and insight of the many who intersect with our healthcare system, but are rarely heard from.” This site often provides very relevant articles from those “on the front lines,” so to speak, and trigger very interesting threads of discussion. While these outlets may be useful for venting our frustrations, they do little to actually change what is happening in medicine. Membership in organizations such as the Maricopa County

Dr. Miriam Anand is an Allergy and Immunology specialist practicing in Tempe. She is the Maricopa County Medical Society’s 120th President, and has been a MCMS member since 1998. Contact her by email at manand@mcmsonline.com.

8 • Round-up • A monthly publication of the Maricopa County Medical Society • June 2014


Compliments of the:

Free Physician Referral service: Call: 602.252.2844 mcmsonline.com/provider search

Why does my doctor run late and what can I do about it? Why does my doctor run late?

There are many reasons that may cause your doctor to run behind. Unfortunately, changes have occurred to our healthcare system over the past couple of decades that are beyond the doctor’s control. These changes are related to legislative and insurance regulations imposed upon physicians. They have created a situation where physicians have less time to spend with the patient and schedules are often tight even under the best of circumstances. Some reasons why your doctor may run late are:

• There is an emergency with another patient that the doctor needs to address first. • A patient scheduled before you has a complicated medical history or has trouble describing his/her medical issues clearly and concisely.

• One or more patients scheduled before you arrived late, causing the doctor to run late for the rest of the day.

What can you do to have your visit go as smoothly as possible?

• Give the exact reason for your visit when you schedule the appointment. The length of the appointment time may be based on the problem for which you are being seen. The examination room may also need to be set up for certain procedures/treatments based on your medical issues. Each new medical problem raised during the visit triggers a new set of questions that the physician must ask and could lead to delays.

• If you are asked to arrive early to fill out forms, please do so. The office is trying to streamline the check-in process so that they can have you ready to see the physician at your scheduled time. The forms often provide the physician with important health information that may help shorten your visit.

• Ask the scheduler how long you should anticipate being in the office. You can also ask for an appointment time that increases the likelihood of being seen at your appointment time. (For example, the doctor is most likely to be on time for the first appointment of the morning or just after lunch.)

• Leave ample time after your office visit before any other appointments or responsibilities that you have. Be aware that there may be unanticipated tests or procedures, depending on your medical issues, which may require extra time. Politely let the staff know at the beginning of your visit if you have another appointment or responsibility and what time you need to leave. Again, plan ahead and leave plenty of time between appointments.


• Come prepared. You will be asked to provide certain information at most physician visits. Having this information with you and readily available will help streamline the process. This includes insurance information (and cards), employment information, emergency contact information and information regarding your personal medical history. The general medical information that your doctor will want to know is listed below.

• The main reason for your office visit. Is it for a specific symptom or symptoms? If so, then be prepared to answer the following questions for each issue: – When did it start? Is it always present or just sometimes?

– What is the symptom like? (For example, if it’s pain, is it steady, throbbing, or like a sharp stabbing?) – Is it mild, moderate or severe?

– What makes it worse? Is there anything that makes it better? – What types of treatment have you already tried?

For the following items, keep a list of this information on your computer and update it regularly. Print it out for your appointment. Be sure to bring the most recent information with the date it was last updated on the form.

• What medications are you taking? What is the dose and how often do you take it? Or bring the actual bottles with the labels containing the name and dose of the medication and the directions.

• What medications are you allergic to? What type of reaction did you have?

• What other medical conditions do you have or have you had any new medical issues since your last visit?

• What surgeries have you had in the past? Anything new since your last visit?

Other things to consider

It is understandable that it can be frustrating to have to wait. It’s important to realize that most physicians and medical offices do not make you wait because they are disrespectful of your time, but often run behind due to matters beyond their control. Some doctors may routinely run behind, but, as the patient, weigh this against the quality of care that you are getting.

If you know that your doctor runs behind, but are happy with the care you receive, you may wish to bring things to do while waiting. Remember to bring games, books, or toys for the kids, if needed. You may also consider bringing something to do if you are visiting an office for the first time and don’t know if there will be a wait or not. The information provided on this handout is for general educational purposes only. It is not intended to be used as a substitute for medical advice from your healthcare provider. You should not use information from this article to diagnose a health problem, condition, illness or disease. Any concerns or questions you have about your health or the health of your family should be discussed with your physician. Please note that medical information is constantly changing. Therefore some information may be out of date.



from the executive director

Random Thoughts...

I

Jay Conyers, PhD

’m not a doctor. For nearly a decade, however, I was constantly explaining myself to others who thought, because of my job, that I was. So much so that I became all too comfortable using the familiar catchphrase from a character, Dr. Cliff Warner, on the soap opera All My Children, who helped millions of Americans “play doctor at home” when he plugged for Vicks cough syrup in their commercial by stating, “I’m not a doctor, but I play one on TV.”

From 2003-2011, I was on the faculty at the University of Texas Medical School at Houston, having held positions in cardiology, biomedical engineering, and surgery. My patients were small and furry. They didn’t complain. They didn’t have choices. They weren’t empowered. Yet they were well represented by a tough-as-nails Institutional Animal Care and Use Committee (IACUC) board who,

in my mind, viewed their care as equal to that of their human counterparts.

Intentionally fed high fat diets, these patients of mine would eventually develop diffused aortic plaques, which our laboratory would try to detect using iodinated molecular imaging agents designed using biocompatible nanoparticles. Our ultimate goal was to develop a “silver bullet” capable of not only homing in on lipid-rich atherosclerotic lesions prior to the onset of clinical symptoms, but also delivering a therapeutic payload directly at the site of rupture-prone regions within the coronary vasculature. While it sounded rather straightforward, in vivo imaging of a diseased mouse aorta, with a sub-millimeter vascular wall thickness, proved difficult. As a PhD-level chemist trained to manipulate nanoscale carbon allotropes to

12 • Round-up • A monthly publication of the Maricopa County Medical Society • June 2014


from the executive director appear “welcomed” in biological environments, I perhaps oversimplified the difficulty in attaching vascular recognition molecules to carbon nanotubes, loading them with iodine for CT contrast enhancement, and embedding therapeutic agents that would be precisely released at disease site. Sounds simple, right? Fortunately, we were successful in funding this research, and it proved to be a vital resource for the medical school. Each year, we would welcome medical students into our lab as they fulfilled their research requirements. I also took on undergrads (hoping to strengthen their medical school application), a few high school students (from the Michael E. DeBakey High School for Health Professions), and even a few residents interested in careers in academic medicine.

I often thought, “How did I get this job, and who was crazy enough to hire me?” Fortunately for me, I was lucky enough to cross paths with a forward-thinking physician who saw value in scientists and physicians working together. When I first met Ward “Trip” Casscells, MD in late 2002, I knew I was in the presence of someone who respected my degree as much as I respected his. We’d sit around for hours and design experiments, talk about how chemistry could intersect medicine, and how we would build programs in Houston that would be the envy of others. Somehow these conversations led to my first (and only) job as an assistant professor. He gave me a chance when I likely didn’t deserve one. I owe him my career, to be certain.

were two years into a sizable grant from the Department of Defense for developing a disaster response program for trauma and terrorism. And that was only one of three large programs we were running at the time. During his one year away from the university, I somehow managed to keep the ship afloat. I learned the essentials of management and leadership (through trial and error, with emphasis on error). I figured out how to channel humility and leave hubris at the door. Prior to trading in his white coat for a combat helmet and fatigues, Trip often said to me, “Nothing worthwhile is ever given. It’s only earned.”

Fast forward to now, and much has changed for me and Trip since he first transitioned from civilian to soldier. For him, he went on to become Assistant Secretary of Defense for Health Affairs, overseeing a $42 billion healthcare enterprise at the Pentagon. He became a role model for countless doctors, soldiers, and public servants.

Unfortunately, he lost his battle with cancer in October 2012. For me, I was lucky enough to help him launch a modestly successful healthcare consulting firm once he stepped away from public service, and I used that experience to land in my current position as Executive Director of the Society. How fortunate am I to have had the opportunity to learn from such an innovative person who saw value in others?

Soon after joining the faculty under Trip’s tutelage, I learned that his credibility was even more than I had imagined. His father was a pioneering surgeon who had published the first paper on arthroscopic surgery in 1971 (J Bone Joint Surg Am. 1971 Mar; 53(2):287-98). He was a highly successful medical entrepreneur who founded a company in the 1990s (Volcano Corp.) that still develops precision-guided medical devices for the diagnosis and treatment of peripheral vascular disease.

In 2006, Trip joined the Army, at age 54. Seriously. At the time, he and I

June 2014 • A monthly publication of the Maricopa County Medical Society • Round-up • 13


from the executive director

“I’m nearly two-thirds of the way through my first year (of, hopefully, many) here at the Society, and I am often thinking of how I can use my lessons learned to help me better represent your needs as members of our organization. What did I learn? What can I do to help advance the voice of physicians? What I can do to make your lives easier?”

— Jay Conyers, PhD

What I learned from Trip was immeasurable. He taught me how to see the best in others, and how to understand the importance of access to healthcare in energizing a society. We ensured that this was part of our work, our mission, our purpose. Much of what we did in our consultancy was focused on medical diplomacy, or medical stability operations (as it’s referred to in the military). We helped engage communities in conflict in improving access to care. It’s amazing to see how the hearts and minds of communities less fortunate than ours can be won over when you give them access to care that we, here in the U.S.A., otherwise take for granted.

I’m nearly two-thirds of the way through my first year (of hopefully, many) here at the Society, and I am often thinking of how I can use my lessons learned to help me better represent your needs as members of our organization. What did I learn? What can I do to help advance the voice of physicians? What I can do to make your lives easier?

If there’s one thing I learned prior to joining this organization, it’s that providing people with high-quality, affordable care can solve many ailments in our society. Many of you may not agree, but countless political differences, territorial conflicts, employment disputes, and economic disparities can often be somewhat quelled through better access to care. To do so, however, we need a strong physician voice that can speak to the needs, and wants, of the people. Physicians have often developed intuitive

relationships with their patients, and have a keen understanding of what they want and need. But if physicians are always worrying about their patients, then whose looking out for the physicians? That’s our job. We have a dedicated staff that works tirelessly to refine the value proposition that the Society has to offer its members. We have room for improvement, but we’re turning over every rock to see where there is an unaddressed need. We’re here to serve.

We understand the importance of the physician community, and the impact it can have on our society. It’s the same everywhere. From Maricopa County, and throughout Arizona. Even greater nationally, and perhaps even more so on a global landscape. One of my favorite memories of Trip was from when he was questioned during his first budget presentation. Soon after assuming the “medical” helm at the Pentagon, he endured his first hearing in front of the House Armed Services Committee. After presenting his budget, which included a more than $3 billion increase from the prior year, he was told by the Committee, “Healthcare is not the tip of the spear. It you insist on this budget, you may have to resign.” In his reply, Trip stated, “Sir, we are not the tip. Health is the muscle, brain, and heart behind the spear.”

As physicians, my belief is that you, too, serve the same role. You’re the muscle, brain, and heart behind our nation’s efforts to care for its citizens. Let us here at the Society fight for you, as a unified physician voice, so that you can focus on helping those in need. ru Jay Conyers, PhD is the Executive Director for the MCMS and CEO of the Medical Society Business Services.

He has prior experience as a healthcare executive and also served on the faculty at the University of Texas Health Science Center at Houston. He can be reached at 602-251-2361 or jconyers@mcmsonline.com.

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letters to the editor Dear Editor:

I was very glad to see a feature article on the use of new and innovative technologies impacting patient care, empowerment, and engagement (Murcko, A.C., Grando, A.: “Information Technologies for Patient Empowerment,” Round-up, 60:32-37, 2014). New patientcentered technology has the potential to significantly improve our patients’ access to thier records and to higherquality medical information, and ultimately will result in patients who can make better-informed medical decisions for themselves.

their notes that way. Considering this, one way my practice has tried to help patients is to video record my discussions with my patients and then provide them access to the video as a means to review my advice and instructions, a service we call “The Medical Memory.”

Our research into the impact this has on our patients is ongoing, but Anita C. Murcko MD, FACP, with Adela Grando, PhD our preliminary results have been very positive: over 65% of patients reported better understanding and recall of my advice, and between 35% and 55% of patients reported feeling more at ease and less anxHowever, in the discussion of ious about their neurosurgical probsome of these advancements, the lems. Many comments about the report only briefly glances over the underlying fundamental need to improve patient video system indicated that patients were using the personunderstanding and literacy, not simply access. If a patient alized discussion to be able to start a dialogue about their cannot read and understand the notes we type into our problems and treatment options with friends and family. electronic medical records, what use is giving them more I strongly believe that future discussions of patient access to those notes? Indeed, at the recent American engagement and empowerment should include a commitTelemedicine Association 2014 Annual Conference in ment to identifying ways of making that information underBaltimore, MD, no fewer than five of the presentations standable to anyone. The use of technology to achieve more included some comment about patients being unable to open access to information is great, but would be better if recall between 40% and 80% of information presented to we examined the root of the patient empowerment problem: them, that half of the information retained was misrelimited comprehension and understanding. membered anyway, or that as many as 30% of patients in one study were non-compliant with written instructions Sincerely, attributed to poor health literacy. Dr. Randall W. Porter, MCMS member since 2001 Doctors are taught throughout their training to speak in Andrew J. Meeusen, MA a way patients can understand them, but they do not write Barrow Neurological Institute What’s old is new...providing and delivering personalized care by educating, engaging, empowering and partnering with our patients is what we learned in medical school and strive to do each day. So what’s new? A lot.

The Internet, patient portals, e-tool apps and social media have transformed the patient-physician relationship. Many patients now come to us having already explored treatment options, risks benefits and expected outcomes.

Weekly we read or hear about a new study o extols the clinical virtues and financial benefit vated patient , of Meaningful Use , accountabl mentations, shared decision-making experim centered medical home (PCMH) initiatives an health imperatives . The evidence is clear: pe actively involved in their health and healthcar outcomes and lower costs.

The Robert Wood Johnson Foundation p introduces the new buzzwords. (also known as “patient activation”) genera

32 • Round-up • A monthly publication of the Maricopa County Medical Society • May 2014

CONNECT with your Society. Letters and electronic correspondence will become the property of Round-up, which assumes permission to publish and edit as necessary. Email: Editor: Miriam Anand, MD, manand@mcmsonline.com Managing Editor: Jay Conyers, PhD, jconyers@mcmsonline.com Fax: 602-256-2749 Write: Round-up, 326 E. Coronado Rd., Ste. 101, Phoenix, AZ 85004 Click: www.mcmsonline.com/contact 16 • Round-up • A monthly publication of the Maricopa County Medical Society • June 2014

What are your thoughts?

Email. Fax. Write. Click.


new MCMS members There’s no place like the Maricopa County Medical Society. Welcome Home! MCMS would like to recognize our new members for helping us become a stronger, more unified, voice for our community’s physicians. Please reach out to one or more of our new members and welcome them aboard, and share with them your insight into how the Society can be of service. GREGORY DODARO Medical Student

Medical School: Creighton University School of Medicine

KATHERINE PETERSON, MD Resident — OBGYN

Medical School: University of Washington, Seattle, WA Residency: Banner Good Samaritan Medical Center, Phoenix, AZ

NATASA VOJVODIC, DO Resident – Family Medicine

Medical School: Lincoln Memorial University — DeBusk College of Osteopathic Medicine, Harrogate, TN Residency: Scottsdale Healthcare, Scottsdale, AZ ANTHONY KUNER, MD Internal Medicine Diagnostic Radiology

Fellowship: Barrow Neurological Institute Internship: Maricopa Medical Center Residency: Integris Baptist Medical Center. Medical School: St. Louis University Currently completing Fellowship in Phoenix.

CHELSEA MCGARVEY, MD Internship — Internal Medicine

Medical School: University of Arizona College of Medicine, Phoenix, AZ Internship: Mayo Clinic Arizona JEFF MUELLER, MD Anesthesiology

Medical School: Washington University School of Medicine, St. Louis, MO Internship: Mayo School of Graduate Education, Rochester, MN Residency: Mayo School of Graduate Education, Rochester, MN Practice: Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ 85054 Website: www.mayoclinic.org Phone: 480.342.1800 SHANNON M. PETERS, MD Anesthesiology/Pediatric Anesthesiology

Medical School: University of North Dakota School of Medicine Residencies: Sandford Medical Center, Fargo, ND and Mayo Medical Center, Rochester, MN Practice: Valley Anesthesiology Consultants, 1850 N. Central Ave, Suite 1600, Phoenix, AZ 85004 Website: www.valley.md Phone: 602.262.8900

THOMAS PALILLA, MD Anesthesiology

Medical School: American University of the Caribbean Residencies: Shadyside Hospital and Medical Center, Pittsburgh, PA and Hahnemann University Hospital, Philadelphia, PA Practice: Anesthesia Medical Professionals, 17505 N. 79th Ave., Suite 409, Glendale, AZ 85308 Website: www.anesthesiamedpro.com Phone: 602.584.9985 JOSEPH H. WORISCHECK Urology

Medical School: St. Louis University School of Medicine,

St. Louis, MO Residency: St. Louis University Hospitals Practice: SW Urologic Specialists, 6007 E. Baseline Rd. #105, Gilbert, AZ 85234 Website: www.swurologic.com Phone: 480.897.2727

June 2014 • A monthly publication of the Maricopa County Medical Society • Round-up • 17


practice spotlight

Educating the Next Generation of Physicians to be Competitive in a New Era of Healthcare

A

Susan Parker

nthony T. Yeung, MD understands how to keep patient care his top priority as the tides are changing in the way that healthcare is delivered. Changes in medical technology, advancements that challenge previous “gold standards,” and evolving “best practices” illustrate the ever-changing landscape in medicine.

Patients are demanding less invasive options, and payers want to control costs. The result is new quality initiatives, changes in delivery models, and the need for physician education on less invasive, more cost effective treatment options. The next generation of physicians will need this training to be competitive in the new era of healthcare or find employment to insulate themselves from having to deal with the ever demanding complexities of practicing medicine. Innovation can keep physicians choosing to stay in private practice rather than becoming employees of hospitals or healthcare systems.

In this issue of Round-up, get to know Dr. Yeung; what motivated him to become a physician, his practice philosophy and treatment beliefs, and why he believes that physicians need to continue to band together as a collective voice by joining organizations such as the Maricopa County Medical Society (MCMS).

The beginning.

The impetus for Dr. Yeung to become a physician was a mentor in Tucson, Dr. Jack Klein, who helped Dr. Yeung’s

Anthony T. Yeung, MD

family when they escaped from Communist China in 1949. It was serendipitous that his mother was born in the U.S. and had sisters who lived in Arizona.

With his mother’s fortitude and her philosophy to “turn it around in one generation,” Anthony Yeung decided to emulate Dr. Klein by becoming a physician so he too could use his knowledge and skills to help people.

His motivation to focus on minimally invasive spine surgery stemmed from Dr. Yeung’s own experience caring for his mother after another surgeon did her back surgery, while he was still a resident. She was worse after her surgery. He thought there had to be a better way. So in the 1990s, Dr. Yeung took the concept of the knee scope

18 • Round-up • A monthly publication of the Maricopa County Medical Society • June 2014


practice spotlight and brought it to the spine, using a transforaminal approach and visualized endoscopic instrumentation he pioneered allowing for a less invasive, equally effective approach for spine surgery.

When asked his practice philosophy, Dr. Yeung says, “I am focused on what is best for my patients as opposed to what the payer will approve. I believe in physician autonomy and patient choice.” — Susan Parker

Marrying laser technology and the endoscope, Dr. Yeung developed a FDA approved multi-channel spine endoscope that allows surgeons to visualize foraminal and intradiscal anatomy and selectively remove the degenerative and extruded portions of a herniated nucleus contributing to back and leg pain.

The sleek 2.7 mm operating channel scope uses a keyhole incision to access the damaged disc, dilating rather than cutting muscle and tissue, resulting in less tissue destruction, no need for general anesthesia, and a quicker recovery. This procedure is used to treat herniated, protruded, extruded, or degenerative discs, and spinal stenosis in the lumbar spine. “Endoscopic foraminal spine surgery offers the least invasive surgical solution to visualizing and treating the pain generators without burning any bridges for traditional more invasive procedures that have higher surgical morbidity,” comments Dr. Yeung. Patients appreciate his philosophy to “refuse to fuse” as their initial surgical option.

Dr. Kelly Hsu describes him like this, “Dr. Anthony Yeung’s professional success comes from being a true visionary with high goals, a unique ability to solve problems, and the determination to get the job done. He is a great leader because he always leads by example and persistently convinces those around him to dig a little deeper and reach a little farther. Dr. Anthony Yeung is famous for mentoring younger physicians and is generous with those who are making an honest effort to help themselves. He is a straight shooter who confidently speaks

the simple truth for the betterment of friends, colleagues, and patients.”

Practice and treatment philosophy.

The art of practicing medicine has changed over the years; economic circumstances in the practice of medicine have forced physicians to work in environments where they practice their art, but resign to be controlled by the payers. Some even embrace it. But, in Dr. Yeung’s opinion, medicine will always be an art based on science. “The

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June 2014 • A monthly publication of the Maricopa County Medical Society • Round-up • 19


practice spotlight to what the payer will approve. I believe in physician autonomy and patient choice.” He believes economics, rather than patient satisfaction, guides payers and their paid consultants.

Dr. Yeung’s treatment philosophy is to provide patients with what he would recommend for his own family, and he practices what he preaches. When he recently herniated a disc in his own back, Dr. Yeung had his son, Christopher Yeung, MD, perform the Yeung Endoscopic Spine Surgery on him, without hesitation. The surgery was a success.

Educating the next generation of physicians through philanthropy.

left to right: Drs. Anthony and Christopher Yeung science guides us, but the art of medicine is what separates the good or superior from the average.”

When asked his practice philosophy, Dr. Yeung says, “I am focused on what is best for my patients as opposed

Hospitals are once again buying physician practices, including practices owned by seasoned physicians who just don’t want to deal with the business of practicing medicine anymore. In a private practice, innovation creates more options for physicians than selling to a hospital for survival. By embracing innovation, physicians can remain in private practice by virtue of their performance. They can assemble a “dream team” which rises to the top 10% of their specialty in both expertise and delivery of medical or surgical care. Resourceful physicians have the ability to remain independent, yet still contribute to patient care by bringing innovation and collaboration to mainstream medicine. That is why Dr. Yeung decided to help the University of New Mexico (UNM) with his donation to create the Anthony T. and Eileen K. Yeung Center for Endoscopic Spine Surgery. Dr. Howard Yonas, Chairman of the Department of Neurosurgery at UNM explained, “Because we have a very cohesive multi-disciplinary group in our spine program, it is clear that each part of the breadth of Dr. Yeung’s work will be embraced by all members of the team.” The multi-disciplinary team at UNM hopes to validate minimally invasive spinal surgery with prospective IRB approved comparison studies in an academic setting using strict IRB guidelines.

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practice spotlight

Q & A with Dr. Anthony Yeung

Q: Why did you decide to become a physician?

A: I was always interested in the healing arts as I was influenced by and deeply grateful for a Physician in Tucson, Dr Jack Klein. Being a physician was the best way for me to emulate him by using my knowledge and skills to help others. It is an incredible feeling when that occurs on a regular basis, to hear from the people I was able to help years and decades later, telling me what my help meant to them.

Q: What “personalizes” you as to how you promote the profession of medicine?

A: I believe in fighting for physician autonomy in order to facilitate patient choice and have never deviated from that position.

Q: Why did you choose to start your own practice?

A: It is always difficult to get a group of surgeons with different skill sets, work ethics, and outlook on the direction of medicine to agree on the structure of their group practice. While I was grateful for the 10 years with my former group, I was growing apart from the group’s direction and internal policies, and I felt it was time to adapt to the future direction of healthcare. That was minimally invasive spine, which none of my previous partners embraced in the 1980’s.

Q: What drove you to create the Anthony T. and Eileen K. Yeung Center for Endoscopic Spine Surgery at UNM?

A: It hit me one day that it would take forever for me to pass on my work without the help of a medical school and teaching institution. The Dean of my Alma Matter, the University of New Mexico, contacted me, then the Chief of Neurosurgery spoke to me about his vision to provide care to a mostly indigent population in New Mexico. His vision matched my own and was the motivation for me to get involved.

June 2014 • A monthly publication of the Maricopa County Medical Society • Round-up • 21


practice spotlight “Every patient who comes to us is evaluated by a multi-disciplinary team,” said Dr. J. Fred Harrington, Assistant Professor of Neurosurgery and Director of the new endoscopic spine surgery center. The team includes orthopedic spine surgeons, neurosurgeons, physiatrists, internal medicine, family practice, psychology, pharmacy, occupational therapy, and chiropractic medicine.

Past President of MCMS, Dr. Nathan Laufer added, “Tony is a superb physician, innovator, and entrepreneur who has never forgotten his humble roots. He is a man of passion and conviction, but most importantly, has shared his success with those less fortunate and with his alma mater.”

Additionally, Dr. Yeung hosts and trains surgeons who travel from around the world to Phoenix to attend his quarterly meetings and cadaver labs. Most months, Dr. Yeung also travels to other countries to train spine surgeons so all patients globally have access to this procedure. In fact, he and Dr. Sandford Roth, a retired Rheumatologist and MCMS member since 1966, have both spent time in China teaching at the Beijing Medical School, which is how their friendship began.

Dr. Roth said, “It was a lifetime experience for me to become a mentor to Professor Wu, an orthopedic total joint surgeon specializing in joint replacement, and have the opportunity to work with Dr. Tony Yeung, who also served as a Visiting Professor. Dr. Yeung was just presented a Lifetime Achievement Award by the Asian Pacific Community in Action (APCA) at their annual fundraiser in May, as he continues this legacy relationship between Phoenix and China.” (Editor note: please see page 23 for photos of the APCA event).

The importance of organized medicine.

Dr. Yeung, an active member of the MCMS since 1978 and President in 1995, strongly believes it is important that physicians get involved in professional physician organizations such as the MCMS.

He notes, “During my presidency, I focused on patient autonomy and patient choice. That is being taken away from physicians by payers hoping to direct us by controlling reimbursement. In fact, it was when private practice physicians banded together to protect the interests of physicians and their patients that the MCMS was formed. We should continue that legacy by uniting as a common voice to protect the physician-patient relationship, and ensure patients have access to innovative treatments with the best outcomes.”

Dr. Yeung believes the Society is needed now more than ever, as autonomy and private practice are changing rapidly, where doctors will no longer be able to treat patients individually, but as population and disease entities.

He concludes, “Clearly, changes in healthcare will continue, but we must find ways to keep patient care the top priority, protect physician autonomy, and protect the physicianpatient relationship. We do not want to treat patients with calculators. For new physicians in a cost-conscious medical environment, this is more critical now than ever.” ru Photos courtesy of Desert Institute for Spine Care (DISC) and Paulson Photo/Graphic. To learn more about DISC visit http://www.sciatica.com. Mike Paulson offers MCMS members a 10% discount. He can be reached at 602-230-1550 or photo@paulson.com. Susan Parker is the Director of Business Development at DISC. Her career includes biologic and medical device sales, including regional, national, and international sales and marketing for Fortune 100 companies. Contact her at 602-944-2900 or sparker@sciatica.com.

“The MCMS is the only organization where independent physicians can unite and have a collective voice. Physicians should become more collegial and support the common cause as a group,” said Dr. Yeung.

22 • Round-up • A monthly publication of the Maricopa County Medical Society • June 2014


in the community

APCA 9th Annual “Taste of Asia” Fundraising Banquet left to right: Miriam K. Anand, MD; Suresh Anand, MD; Kenja Hassan

On the evening of May 10, 2014, the Asian Pacific Community in Action (APCA) honored St. Luke’s Health Initiative, Dr. Anthony Yeung, and Josefina “Jo” Barone, MBA, RN, for their contributions to improving the health and lives of countless Arizonans.

Dr. Yeung, former President a long-time member of the MCMS, was the recipient of a APCA Lifetime Achievement Award. Dr. Kelly Hsu, also a MCMS member, APCA Founder and board member, was Chair of the event.

left to right: Kelly Hsu, MD; Manish Amin, MD; Yasmin Amin, MD

Dr. Yeung accepting his award.

The 9th annual Taste of Asia fundraising banquet was held at the Doubletree Paradise Valley Resort, and included a talent showcase, silent auction, and Asian hors d’oeuvres. Local Asian and Pacific Islander community members, governmental officials, and healthcare providers were in attendance.

Asian Pacific Community in Action is as a grassroots non-profit agency created to ensure culturally responsive health information and health services for low-income Asian Americans and Pacific Islanders in the greater Phoenix metropolitan area. Established in 2002, APCA remains the only organization in Arizona that provides comprehensive health services specifically for these communities. APCA also serves refugees from Asia and other continents. APCA’s mission is to provide services, advocacy and education for diverse communities resulting in a healthier and more empowered population overall.

left to right: Christopher Yeung, MD; Kimberly Yeung-Yue, MD; Anthony Yeung, MD; Eileen Yeung; Kathy Nakagawa, PhD; Kelly Hsu, MD

To learn more, visit http://www.apcaaz.org

Photos courtesy of Mike Paulson, Paulson Photo/Graphic. Mike can be reached at photo@paulson.com

June 2014 • A monthly publication of the Maricopa County Medical Society • Round-up • 23


public health

Comprehensive Action for Drug Poisoning Epidemic John Middaugh, MD

T

he inappropriate use and abuse of prescription drugs is a serious public health problem.1 The use of psychotropic drugs (antipsychotics, antidepressants, and stimulants) by adult Americans increased 22% from 2001 to 2010.2 Opioid prescriptions increased by more than 300% between 1999 and 2010.3 There are estimated to be over 100 million Americans who suffer from chronic pain.4

Drug poisonings have become the leading cause of unintentional injury mortality in the United States, and the large majority of these fatalities have been caused by prescription drugs.5 Opioid prescription drugs have been the class of drugs most frequently involved in unintentional drug poisoning fatalities.6 The large majority of unintentional prescription drug fatalities due to opioids and a large proportion of opioid-related unintentional fatalities have had the presence of other psychoactive prescription drugs, especially benzodiazepines, sedatives, stimulants, and anti-depressants.7

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public health National surveillance has documented that these categories of fatalities have doubled over the past decade, that the rates of fatalities have increased most dramatically among women, and that men between the ages of 35–55 years have the highest rates of unintentional opioid-related fatalities.1,7 Use of prescribed opioids has dramatically increased among pregnant women enrolled in Medicaid during the past five years, and there were large regional differences, for example, 41.6 percent of pregnant women in Utah were prescribed opioids compared to 9.5 percent in Oregon.8 Existing public health, medical, pharmaceutical and law enforcement databases are inadequate to track this iatrogenic epidemic and provide detailed information about risk factors that can be used to target effective interventions.9-11

Solutions to this epidemic are complex and will not be easily discovered and implemented. The State of Arizona has launched a multi-systemic effort to reduce prescription drug misuse and abuse in Arizona, the Prescription Drug

Misuse and Abuse Initiative, to characterize the epidemic and work with multiple stake-holders to develop solutions.12 Physicians and other health care providers are at the heart of the problem and hold the keys to its control.

There exists an important opportunity for Arizona physicians to take ownership of the problem and be at the forefront of its solution. Among the immediate steps to respond are those adopted by the Arizona Medical Association at its annual meeting on May 30-31: • The Arizona Medical Association (ArMA) participate in the Arizona Prescription Drug Misuse and Abuse Initiative and urge the Arizona Legislature and the Arizona Executive Branch to adequately fund efforts to control this preventable epidemic. • The ArMA encourages the Committee on Public Health to survey and continuously monitor the Continuing Medical Education (CME) marketplace for high quality CME regarding the use and management of controlled substances.

June 2014 • A monthly publication of the Maricopa County Medical Society • Round-up • 25


public health • The ArMA encourages all licensed prescribers of controlled substances to enroll and use appropriately the Arizona Controlled Substances Prescription Monitoring Program. • The ArMA endorses the ongoing efforts by the Arizona Department of Health to develop Opioid Prescribing Guidelines.13, 14

In addition, there are other important opportunities to effectively address the epidemic.

Physicians should advocate for and support efforts to improve surveillance to monitor and characterize this epidemic. Opportunities exist to learn from data that are being collected by the Medical Examiner, Board of Pharmacy, State Vital Records, and Emergency Room and Hospital Visits.

The Arizona Department of Health and medical organizations can encourage the chain pharmacies in Arizona to replicate the work of CVS Caremark as published in the September 2013 New England Journal of Medicine3, and to establish an ongoing surveillance system using existing prescription data to monitor controlled substances use by patients and provider prescribing practices in Arizona. ru John Middaugh, MD is a Public Health Consultant and retired Epidemiologist. His previous positions include Director, Division of Community Health and Chief Health Officer for the Southern Nevada Health District.

He joined MCMS upon re-location to Arizona in 2014. He can be reached at jpmidd@cox.net.

References:

1. Kirschner N., Ginsburg J., Sulmasy L.S., for the Health Policy Committee of the American College of Physicians. Position Paper. Prescription Drug Abuse: Executive Summary of a Policy Position Paper from the American College of Physicians, plus Appendix. Ann. Intern. Med. 2014; 160: 198-200.

2. Smith, B.L. Inappropriate Prescribing. American Psychological Association. 2012; 43: 36-39. www.apa.org/monitors/2012/06/prescribing.aspx

3. Betses, M. and Brennan, T., Abusive Prescribing of Controlled Substances — A Pharmacy View. N. Engl. J. Med. 2013; 369:989-991.

4. Institute of Medicine (IOM) of the National Academy of Sciences (NAS). Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research. Washington, D.C., National Academies Press, 2011.

5. Hall, A.J., Logan, J.E., Toblin, R.L., Kaplan, J.A., et al., Patterns of Abuse Among Unintentional Pharmaceutical Overdose Fatalities. JAMA 2008; 30: 2613-2620.

6. Webster, L.R., Cochella, S., Dasqupta, N., Fakata, K.L., et al., An Analysis of the Root Causes for Opioid-Related Overdose Deaths in the United States. Pain Medicine 2011;12:S26-S35.

7. Feng, J. and Middaugh, J.P., Poisoning deaths in Southern Nevada. 2013;2: 1-31. Southern Nevada Health District. Las Vegas, NV, 89127.

8. Saint Louis, Catherine. Surge in Narcotic Prescriptions for Pregnant Women. The New York Times. April 13, 2014.

9. Shacter A., Poisonings Among Arizona Residents, 2010. Injury Prevention Program. Bureau of Women’s and Children’s Health. Arizona Department of Health Services. 2011. 10. Webster, L.R. and Dasqupta, N., Obtaining Adequate Data to Determine Causes of OpioidRelated Overdose Deaths. Pain Medicine, 2011;12: S86-S92.

11. Goldberger, B.A., Maxwell, J.C., Campbell, A., and Wilford, B.B. Uniform Standards and Case Definition for Classifying Opioid-Related Deaths: Recommendations by a SAMHSA Consensus Panel. Journal of Addictive Diseases, 2013; 32: 231-243.

12. Prescription Drug Misuse and Abuse Initiative. Arizona Criminal Justice Commission and Governor’s Office for Children, Youth, and Families. 2012. www.aacjc.gov/acjc.web/rx/default.aspy 13. Arizona Prescription Prescribing Guidelines. Arizona Department of Health Services. 2013.

14. England, B., Opioid Prescribing Guidelines Coming. Round-Up. Maricopa County Medical Society. 2014; 60: 12-14.

26 • Round-up • A monthly publication of the Maricopa County Medical Society • June 2014


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employment — finance

Managing Cash Flow from Multiple Employment Incomes Mike McCann, CFP®, AIF® Case Study:

Many physicians, especially those who are members of specialty partnerships, receive two types of income. One is a traditional salary or hourly wage received for direct patient care and is addressed from an income-tax-standpoint with W2 withholdings. The second might be self-employment income or profit-sharing distributions based on the net profitability of the group; this may be distributed annually or throughout the year, and it is treated differently with regard to taxes.

The Challenge:

Managing multiple sources of income can be complicated, and individuals often don’t differentiate the incomes in their financial planning, either from a tax standpoint or in retirement planning. Because their cash flow is often inconsistent, many people believe they can’t consistently carry out any financial planning.

The Strategy:

Inconsistency of cash flow is actually a key factor that makes financial planning all the more necessary. Ongoing review and planning of their situation can help bring a level of financial stability that in turn helps bring peace of mind. 28 • Round-up • A monthly publication of the Maricopa County Medical Society • June 2014


employment — finance One challenge to managing multiple income sources is that some physicians may view their partnership distribution each year as a windfall and end up not saving or not planning with that money. Conversely, they may get discouraged in a given year if there is no profit-sharing distributions from the partnership, and they were counting on that income. Finding a balance and managing the proper lifestyle to the variable income helps both in the short term and long term.

In his book, Personal Success, Brian Tracy wrote that successful people “tend to have fluid, flexible, adaptive minds.” When it comes to financial success, this amounts to creating a personal financial plan that is fluid, flexible and adaptive. One’s planning and investment strategy should focus on allocating income and assets in a balanced way to best manage risk and generate needed income — today, tomorrow and in the future. Each of the following perspectives brings something important to the overall personal financial plan: Short-term perspective (one to five years): Investments in this vantage point are lower-risk and intended to help provide for current income needs. These funds help you make the most of life, one day at a time. Mid-term perspective (five to 10 years): Investments with moderate risk are utilized to

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Long-term perspective (10 to 15 years): Higher-risk investments with higher long-term growth potential will help meet far-away goals such as retirement, college for the kids or that dream vacation. Funds in this vantage point provide stability for the future. They are hands-off in the short-term, and that’s okay because short- and mid-term needs are already covered.

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June 2014 • A monthly publication of the Maricopa County Medical Society • Round-up • 29


employment — finance One way to be flexible is to prioritize goals. While most people’s goals may be similar — investing for retirement or college, buying a new home or vehicle, paying down debt, saving up for a dream vacation — each goal may have a different rank depending upon one’s age, income, dreams and priorities. Which goals will be funded first with the reliable income? Which will be funded last (or less), in the event the variable income does not meet expectations in a given year? Creating flexibility within the financial plan helps to ease the discomfort of inconsistencies in cash flow from year to year.

Retirement savings are a key planning concern for most people. Because of their earning potential, physicians are often the target of creative marketing and overly-complicated retirement planning recommendations, especially from the insurance and pension professions. A simpler solution often can work just as well. It may be a matter of setting up a one-person retirement account, such as a 401k or Sep IRA. Other solutions may simply be paying down debt or doing after-tax savings as part of the retirement plan.

The Action Plan: The key to remember is that everyone’s situation, and therefore solution, will be a little bit different. Working with a Certified Financial Planner practitioner to create a comprehensive personal plan can be the first step in managing multiple employment income sources. Periodic review, adjustments and fine-tuning of that plan and your investments will help foster peace of mind and maintain a path of ongoing financial stability. ru Mike McCann is an investment advisor and founder of Perspective Financial Services, LLC, a preferred partner with the MCMS for more than a decade. He offers a 20 percent members-only discount to MCMS physicians.

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30 • Round-up • A monthly publication of the Maricopa County Medical Society • June 2014



employment — legal

Anatomy of a Board Complaint Steven B. Perlmutter, MD, JD

C

hances are if you practice medicine long enough, you will have a board complaint filed against you at some point in your career. When you receive that letter, it will be a disturbing experience. A board complaint ranks high among the sources of anxiety and anger, perhaps only second to IRS letters and medical malpractice claims.

Of all those in healthcare-related fields, physicians have the most emotionality about board complaints. Doctors take these complaints personally, and who can blame them? A doctor spends the majority of his or her time and energy

creating favorable outcomes for patients. A complaint by a patient or another physician is a personal affront. It is an attack against one’s integrity. Moreover, it is an attack against your license, your privilege to practice medicine, your livelihood, and your future.

Board complaints are sometimes a thinly veiled test balloon floated by a plaintiff’s medical malpractice attorney. If the board sides with the injured party against the physician, there is a strong impetus to file a medical malpractice claim. After all, if a board comprised of mostly doctors thinks you are negligent, won’t a jury come to the same conclusion?

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employment — legal There is good news about board complaints. Not all is doom and gloom. The vast majority of board complaints will be dismissed at an early stage, soon after the charges have been answered. Of the complaints that ultimately come in front of the board, most of them are dismissed. Even if the board finds fault with your actions, the case is usually settled with a nondisciplinary letter of concern and perhaps a continuing education requirement. Only a minority of cases go on to censure, probation, suspension, and revocation of a license. Nonetheless, the best scenario is to get out of the case quickly. Most professionals with experience in front of healthcare licensing boards agree that the presence of an attorney has a salutary effect on the outcome of the case.

or not you will continue to practice medicine. And while you are under no obligation to obtain legal representation and can appear on your own behalf (“pro se”), it is not advisable. Some legal scholars suggest that the right to proceed pro se is akin to

allowing the defendant to waive his right to a fair trial1. Self-representation may provide one with a clear opportunity to shoot oneself in the foot2. Even the U.S. Supreme Court has opined that, “a pro se defense is usually a bad defense 3.”

Although numerous articles have been written about the “five” steps or “ten” steps to take or not take upon receiving a board complaint, I have attempted to write this article from the perspective of one who is both an attorney and physician. I have had board complaints. I have defended them by myself and with the help of an attorney. If I had to do it over again, I would never answer a board complaint without an attorney. And chances are that your professional liability policy has a provision that requires the insurer to pay for legal counsel if a board complaint should arise.

My best advice is this: hire an attorney to represent you before you respond to a board complaint. Abraham Lincoln once said, “A person who represents himself has a fool for a client.” A Medical or Osteopathic Board proceeding may not seem like much on the surface, but it is a legal proceeding that can determine whether

June 2014 • A monthly publication of the Maricopa County Medical Society • Round-up • 33


employment — legal 2. Prepare a concise, complete, and persuasive response.

“Physicians are trained in empiricism and the scientific method, not in persuasion. Your response to a complaint is different. You are not writing to the board as an objective, uninvolved party. This is not grand rounds or a curbside consultation. You are writing to try to persuade the board that you are right…” — Steven Perlmutter, MD, JD

However, for those physicians who have the intestinal fortitude to proceed on their own, here are some principles that should be considered before and during the process of answering a complaint. But first, the usual disclaimers. This information: (1) does not constitute legal advice; (2) does not create an attorney-client relationship; and (3) may not apply to your specific circumstances. In other words, caveat emptor. 1. Respond in a timely fashion.

Some physicians get the letter (or email) and file it in a drawer somewhere.

It is as though hiding the complaint will make it go away. That is akin to hiding a basal cell carcinoma with a Band-Aid and thinking it will go away. In fact, it makes it worse. Every complaint has a deadline for the filing of an answer, and it may be as short as 14 days. If an answer is not filed promptly, you now have a second problem. Failure to respond may be deemed to be unprofessional conduct in itself. So make sure your response is in by the deadline. If you are unable to comply with the deadline, ask the board for an extension. It will usually be granted.

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Complaints often reference that elusive term, standard of care. Standard of care is the degree of care, skill, and learning expected of a reasonable, prudent physician in Arizona in the same or similar circumstances. Standard of care complaints typically involve one of four scenarios: (1) you didn’t act when you should have; (2) you acted when you shouldn’t have; (3) you did the wrong thing; or (4) you did the right thing but in a negligent or reckless manner. The purpose of your answer to the complaint is to explain how your actions were reasonable and rational, to wit, in compliance with the standard of care.

Physicians are used to being complete and concise on histories and physicals, operative reports, and hospital notes. It is also necessary to apply these skills to prose. For example, imagine the complaint concerns a complicated eye surgery with a poor result (a topic I know something about). My response would discuss my initial visit with the patient and all the visits up to the time the decision to have surgery was made. I would detail the preoperative examination and my discussion of the risks, benefits, and alternatives of the procedure. The surgical complication that occurred during the procedure would be explained. My response would detail the postoperative care — how I managed the complications and any referrals made. Then, I would go to the medical literature and pull articles that discussed the prevalence of the complication and how it should be managed. In summary, my response would show that what I did was proper in all respects.

34 • Round-up • A monthly publication of the Maricopa County Medical Society • June 2014


employment — legal Physicians are trained in empiricism and the scientific method, not in persuasion. Your response to a complaint is different. You are not writing to the board as an objective, uninvolved party. This is not grand rounds or a curbside consultation. You are writing to try to persuade the board that you are right — you took the correct action or you did the proper evaluation or the complication that occurred will happen to every surgeon sooner or later. You need to be credible, convincing, and compelling.

At the same time, you must be honest. If you made a mistake, it is usually better to admit it than try to hide it. Boards look at dishonesty and arrogance with disfavor. However, the way that the mistake is framed linguistically may have a significant impact on how it is viewed. In other words, the language used to explain a circumstance can have a dramatic effect on each board member. How do you describe an eight ounce glass with only four ounces of water in it? Whether you refer to the glass as “half empty” or as “half full” can make all the difference in whether the adjudicator accepts your point of view. 3. Don’t respond when you are angry or unprepared.

As part of the investigation into the complaint, you will be asked to provide your medical records and a narrative response. At some point, you may also be interviewed by board staff or questioned by board members in an open, public forum. It is important that you respond to board staff and board members with courtesy and dignity at all times. Keep in mind that these people did not bring the complaint to your doorstep. They are just doing their jobs. It will not help your case to be rude or critical. It will hurt it.

Another tendency that physicians exhibit is to blame the complainant. While the complainant may have created his or her problem, it is seldom beneficial for the doctor to recriminate or censure the patient. It is better to explain how the complainant is incorrect, either based on facts or misperceptions.

Preparedness is essential. Just as you would not go into an exam room or an operating room without being prepared, neither should you speak to an investigator or draft a response without contemplation, deliberation, and a thorough knowledge of the facts. Responses such as “I don’t know” or “I don’t remember” will be discounted if you had the opportunity to review the records and know the answers. On the other hand, it is not prudent to speculate. Consider that every word you write or say will be recorded

and analyzed. As they say in the crime shows, anything you say can and will be used against you. 4. Never alter your medical records.

Never, alter your medical records. It is both a legal and ethical violation. Someone will figure it out, and you will lose the case. There may be a copy of the records somewhere else. If you use paper records, your handwriting may change or you may use a different pen. The ink can be dated. The difference in the pressure on the page may be ascertainable. Computerized records are replete with metadata. In other words, you will not outsmart individuals specially trained to find altered records. If it is determined that you have altered the record, you lose automatically. You will lose all credibility, and no one will believe anything you say. Always take the high road. In summary, if you are confronted with a board complaint, take it seriously but remain optimistic. Retaining an attorney is generally a good idea. Check with your professional liability insurer. If you decide to handle the complaint on your own, respond in a timely fashion. Make the response concise but complete and persuasive. Remain calm and courteous. Be prepared. Chances are that the complaint will just be a blip in a long and productive career. ru

1. See United States v. Farhad, 190 F.3d 1097, 1106-07 (9th Cir. 1999).

2. Decker, The Sixth Amendment Right to Shoot Oneself in the Foot: An Assessment of the Guarantee of Self-Representation Twenty Years after Faretta, 6 SETON HALL CONST. L. J. 483, 598 (1996).

3. Martinez v. Court of Appeal of Cal., Fourth Appellate Dist., 528 U.S. 152 (2000)

Steven B. Perlmutter, MD, JD began his clinical practice in Ophthalmology in Arizona in 1985. After 25 years of medical practice, he retired to attend law school graduating with honors from the Sandra Day O’Connor College of Law at Arizona State University in 2011. To learn more call 480-346-1212 or visit http://boardcomplaint.com.

June 2014 • A monthly publication of the Maricopa County Medical Society • Round-up • 35


member happenings Endowed Professorship in honor of David Goldfarb, MD

The C.R. Bard Foundation has made a significant commitment to The Johns Hopkins University to establish an endowed professorship in honor of David Goldfarb, MD, MCMS member since 1977.

The endowment is to recognize his outstanding commitment to the development and invention of ePTFE vascular grafts, which has led directly to saving countless lives and improving the quality of life for millions of patients throughout the world.

In Academic Medicine, endowed professorships are coveted and prestigious positions. They afford academic freedom and flexibility and are thus an important institutional strategy for advancing the frontiers of research and improving patient care. Endowed professorships enable the recruitment of world-class physicians and scientists to academic institutions and also allow these organizations to better support and retain their most talented faculty.

Bard’s contribution has enabled the Johns Hopkins Department of Surgery to establish “The David Goldfarb, MD Endowed Professorship in Vascular Surgery.” This professorship will provide protected time for a vascular surgeon to spend in the laboratory to investigate new and novel approaches to vascular surgery. The establishment of this endowment honors the legacy of trailblazers in the field and supports the next generation of researchers positioned to make major breakthroughs in the area of vascular surgery. ru

Richard Heuser, MD, presented at the EuroPCR, May 20-23

Richard Heuser, MD, Chief of Cardiology at St. Luke’s Medical Center and MCMS member since 1994, spoke at EuroPCR, the largest and most prestigious annual course in interventional cardiology in Europe.

EuroPCR, held May 20-23, is the official annual course of the European Association of Percutaneous Cardiovascular Interventions (EAPCI), and attracted more than 12,000 delegates in interventional cardiovascular medicine from around the world. The conference highlighted different treatment options, the latest techniques, updates and breakthrough science in the field of cardiology. Dr. Heuser is one of the few Americans, and the only Arizonan, invited to present at this esteemed conference. He lectured on two devices developed right here in Arizona — the Verve Medical device and PRODIGY ™ Support Catheter.

The Prodigy Support catheter is a revolutionary tool used during angioplasty to lessen the risk of damage to the vessel wall. The device was FDA approved in January, and has since been used on half a dozen patients at St. Luke’s Medical Center. The Verve device is a nonvascular system used to lower blood pressure in people who are resistant to medication. It’s currently being evaluated in a clinical trial in India. ru

Are you moving on up to the East, West, North or South-side? Or moved in a different direction worth noting? Have you recently taken on a new role at your practice, clinic or hospital? Recognized for excellence in delivering care? Accepted a new position within our community? Have you completed a new training or certification? Recently retired?

New job? Retiring? Receive an award? Speak at a conference?

Share your news!

If so, we want to know! Please share with us your recent professional achievements, and we will share them with the rest of our members and readers in our “Member Happenings” profile. Email your news to mcms@mcmsonline.com 36 • Round-up • A monthly publication of the Maricopa County Medical Society • June 2014


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employment — professional development

Physicians Creating Their Future Howard L. Lang, MD

This is the beginning of an era where healthcare is a right, not a privilege. The transparency called for under the Affordable Care Act will reveal a great deal of information which provides impetus for fixing problems that need to be fixed. Physicians will be provided with substantial clinical analytics which will show what care people are getting. Is it on a timely basis and are they getting the care they need? Is there a way for the Maricopa County Medical Society to work with the membership to find a way for small and medium practices to have the same level of integration, as is done in large groups and hospitals. Can it be done without consolidation and without driving prices up? It seems to me that what is needed is to find a way for small practices to bind together, share data and analytics so they can better coordinate care at lower costs.

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employment — professional development First of all, we must change the way we talk and think. To many pessimists, everything is irrevocably messed up, things will not change, and you know that “this” or “that” is going to happen. This is what is called the “default future.” They live as if that future is preordained. The default future consists of our expectations, fears, hopes and predictions; all of which are ultimately based on our past

experiences. They live in their default future, unaware that by doing so they are creating it. Consider what could be created if we all worked together in a new way.

Before anything new can happen, we need to make space by doing the linguistic equivalent of clearing out closets. We can discuss what is holding us back and what can be done about it. We must look into the collective blind

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employment — professional development spots (the unsaid and unaware) so that issues are moved from the background to the foreground. Giving voice to the unsaid creates space.

Creating that space will allow for future based language, also called “generative language,” which has the power to create new futures, to create a new vision and to eliminate the blinders that are preventing people from seeing possibilities. A declared future is not a dream or a hope, but a future to which you commit yourself. • Medical organizations need leaders, not managers. Leaders create conversations composed of future based language to create futures that didn’t previously exist. • If I wanted to co-create a future with others, who would I need to involve?

• In what manner and in what way would I need to listen to them?

• How, and in what way, would I be willing to give up controlling a direction so a new future would arise? There are questions to ask and be answered:

• What are we doing and why are we doing it? • Why are we doing it this way?

• Does what you do in your work correspond to what you believe about your work?

“We must create a future that will restore physicians’ professional and economic viability. Restoration of these will bring the restoration of our professional identity. With the return of our professional identity will come peace of mind. Peace of mind produces right values, right values produce right thoughts, and right thoughts produce right actions.” — Howard L. Lang, MD • Is the medicine you are practicing congruent with the medicine you want to be practicing? • If not, why not? What will you do about it?

As Abraham Lincoln said, “the dogmas of the quiet past are inadequate to the stormy present.” We must not let the fear of the unknown prevent us from shaping our own future.

The Maricopa County Medical Society...giving back through public health outreach initiatives, education, and mentoring.

Join us as we continue our work toward positive change.

Membership information: call: 602.252.2015 • click: www.MCMSonline.com

I believe we must become the architects of change in order to develop physician organizations that preserve the integrity of physicians and that allows them to preserve the physician-patient relationship.

What do I mean by “organization?” An organization is an aggregation of resources that satisfy the interests of the people within the organization. The organization exists because the people involved in it perceive that their behavior within the organization is the best way to fulfill their personal values. The power of the individuals within the organization is the ability to tap into the organization’s resources to service their values. The reason for the existence of an organization such as

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employment — professional development the Maricopa County Medical Society (MCMS) is to create the power necessary to promote its members’ common purpose. Change comes from power and power comes from organization. Meaningful policy follows power.

When individuals with patient-centered values aggregate, all become powerful and will more readily accept change in what they help create. The aggregation of the personal values will drive the mission statement of the organization. In my opinion some of those personal values include clinical authority; a core belief in the fiduciary responsibility in the physician-patient relationship; a core belief that the physician is not a fungible commodity and will not require a core “dump” of their professional values.

Ralph Waldo Emerson asked, “why do we go dragging around the ‘corpse’ of memory?” We must bring the past for judgment into the thousand-eyed present and live ever in the light of a new day.

We must create a future that will restore physicians’ professional and economic viability. Restoration of these will bring the restoration of our professional identity. With the return of our professional identity will come peace of mind. Peace of mind produces right values, right values produce right thoughts, and right thoughts produce right actions.

We cannot escape our history and we should not escape our future. What we must do now is to create that future — and get there first. From a sign on the wall of a church in England: • A vision without a task is but a dream.

• A task without a vision is drudgery.

• A vision and a task are the hope of the world. ru

Howard L. Lang, MD, is a retired OB/GYN residing in Scottsdale. He is a Past-President of the California Medical Association, Past Chair of the American Medical Association Medical Staff Section, and a member of the MCMS since 2007. He can be reached at drhlang@aol.com.

To get MCMS moving on the right track, I believe the Board should: 1) enlarge the Board to include a student, resident and employed physician; and 2) form a Relevancy Task Force. This Task Force would evaluate the functioning of the MCMS by bringing in members and non-members to an open meeting to discuss what they require, and how the Society can meet members’ legislative, legal, and economic needs. Additionally, what is the Society’s relationship to the Arizona Medical Association in areas such as resolutions to the House of Delegates? Does it satisfy the independent needs of the MCMS?

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employment — personnel

Documentation: A Legal Prescription for a Successful Employment Relationship Stacy Gabriel, JD

In the medical profession, timely and accurate medical record-keeping is an essential component of successful patient care. Conversely, deficient medical recordkeeping can derail the best-laid treatment plan. So important is proper documentation to the medical profession that an entire cottage industry has sprung up to facilitate the transition from paper to electronic medical records. While the lack of proper documentation in the employment context may not have the same dire consequences as in the medical context, this omission is the root cause of most employment disputes and the medical profession is by no means immune from such disputes. In fact, physicians and medical groups that employ physicians can be among the most delinquent when it comes to failing to properly document. As a consequence, physicians and medical practices often get embroiled in personnel disputes that could have been easily avoided through proper documentation. This article will provide a general guide about how and what to document in an employment setting.

How to Document

This may seem like a simplistic point to cover. After all, physicians are highly educated professionals who are trained on the mechanics of meticulous record keeping. While that may be true as to medical records, many in the medical field are not as conscientious when it comes to documenting personnel matters. Instead, I often hear my physician clients say they verbally addressed a point that is now the subject of a dispute, but didn’t feel the need to put it in writing. When faced with this all-too-common scenario, my standard response is, “If it’s not documented, it didn’t happen!” 42 • Round-up • A monthly publication of the Maricopa County Medical Society • June 2014


employment — personnel When it comes to personnel matters, documentation means, at a minimum: • Drafting a document that describes the subject or issue being communicated. The document can take the form of a memo, letter, email or any other form of written communication; • The document should be dated and the author should be identified;

• The document should be written so it makes sense to a third party audience. Avoid excessive acronyms, first names only, or vague references to events without context. Specify the date(s) when the event being described occurred; • If there is backup documentation to support or provide context to the issues raised in the document (e.g. sales data, financial statements, attendance records), consider attaching the backup support to the document;

• The document should be delivered to the employee in question contemporaneous to the event. Sticking the document in a drawer or a supervisor’s file, but not sharing the document with the employee, is tantamount to not documenting at all; • In a potentially adversarial situation (such as a discipline or termination), it is advisable to have a witness to the delivery of the document; preferably someone who will be viewed as non-threatening and objective to the employee in question;

• In most cases, the employee who is issued the document should acknowledge that he/she received the document by signing it and should be given a copy of the signed document. If the employee refuses to sign, a notation should be made on the document specifying the date it was delivered and that the employee refused to sign; • If the document is of a critical nature, a space should be provided for the employee to write a rebuttal;

• The document should be filed in a personnel file or some other central location easily accessible to the Human Resources (HR) representative, or management responsible for HR matters;

• The document should be maintained for the duration of the employment relationship, and several years thereafter; and • The document should not be circulated beyond the employee in question, your counsel, HR or key members of management who have a need to be apprised of the situation.

What should be documented?

There are certain critical aspects of the employment relationship that should be documented. Those include: The Formation of the Employment Relationship

Perhaps no other aspect of the employment relationship is neglected as much as the terms of hire; perhaps because the parties are in the “honeymoon” period and everyone’s guard is down. However, a miscommunication over the terms of employment routinely becomes the subject of later conflict. It is essential that parties to an employment relationship delineate in writing: the job/role the employee is expected to perform; the duration of the employment term (if it is for a fixed period of time); that the relationship is at-will (meaning it can be terminated by either party for any reason and at any time); the wages the employee will earn; work schedule and location; whether the employee is exempt (salaried) or non-exempt (hourly) after that determination is made in compliance with federal wage and hour laws; whether the employee is eligible for bonuses or incentive compensation (see the following section for further discussion on compensation plans); any benefits to which the employee is eligible; and any other unique aspects of the employment relationship (e.g., sign-on bonus or payment of relocation, malpractice, CME and other professional-related expenses). In most instances, these terms can be memorialized in an offer letter that should be signed by the employee. However, when it comes to key hires, the prospective employee may insist the terms be memorialized in an employment agreement that entitles the employee to severance if he or she is terminated without cause. Such agreements require careful scrutiny and should be vetted by an experienced employment law attorney. Compensation Plans

Whether contained in the offer letter, employment agreement, or a separate document, it is essential that an

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employment — personnel employee’s compensation terms be clearly specified. Ambiguity regarding how a bonus/incentive payment is earned, when it is to be paid, whether it is subject to any offsets or deductions, and whether it is owed if the employee leaves before the payment is scheduled to be made can become the subject of hotly debated and expensive legal disputes. Care in drafting proper language up front will greatly reduce the risk of problems arising down the road. Restrictive Covenant Obligations

In Arizona, non-compete agreements as applied to physicians are strongly disfavored. However, even in the physician context, non-competes are not, per se, unenforceable. Also, courts are more receptive to enforcing other forms of restrictive covenants, such as non-disclosure/confidentiality obligations and patient or employee non-solicitation/non-interference provisions. If an employer wants to restrict an employee’s ability to engage in certain competitive activities post-employment, those restrictions must be documented either in the offer letter, employment agreement or a separate document. Careful consideration needs to be given to the duration and geographic scope of the restrictions, and whether to provide monetary consideration for binding an employee to a covenant beyond an initial job offer or continued employment. Consulting with legal counsel at the drafting phase, or to review and potentially update existing agreements to bring them into line with developments in the law, is highly advisable. Personnel Policies and Procedures

A prudent employer will communicate its workplace rules and expectations in writing to its staff upon hire, oftentimes in an employee handbook. This gives employees the opportunity to conform their behavior to the employer’s expectations and provides the foundation to dispense disciplinary action upon non-compliance. While not every workplace scenario must be reduced to a policy, there are a handful of essential personnel policies that every employer should implement. Those include: antiharassment and discrimination; FMLA (if the employer has over 50 employees within 75-mile radius); substance abuse testing and prevention; proper use of internal communication systems; attendance; paid time off; dress code; and conflict of interest.

Performance Feedback

Employees should be advised in writing when they are doing a good or bad job. Silence will be interpreted as sign of satisfactory performance. Performance reviews are a vehicle to give an employee an honest assessment of whether they are meeting an employer’s expectations. While delivering a negative review can be uncomfortable, it is never a good idea to “sugar coat” a review. That favorable review will become exhibit number one in a later wrongful termination or discrimination claim made by a disgruntled employee. If an employee violates a workplace rule or is not performing up to an employer’s expectations, written corrective action should be issued following the “How to Document” rules discussed above. Separation Agreements

If the employment relationship ends, it may be appropriate to memorialize the terms of departure in a separation agreement. Most frequently, a separation agreement is used when the employer has decided to pay the departing employee severance or provide some other benefit in exchange for releasing any known or unknown claims against the employer. A separation agreement can also be used to reinforce an existing, or introduce a new, restrictive covenant obligation on the departing employee. The separation terms will vary widely based on the unique facts and circumstances of each departure. Counsel should be consulted.

While not every employer-employee interaction needs to be documented (and indeed over- documentation can stifle a healthy working relationship), there are certain personnel events, such as the ones described in this article, that should be reduced to writing to set expectations and avoid conflict. It bears repeating: “If it’s not documented, it didn’t happen!” ru Stacy Gabriel is the founder and managing member of a law firm focused on employment law matters. She regularly advises and represents both medical practices and physicians in negotiating employment contracts, drafting personnel policies, and resolving workplace disputes. She can be reached at stacy@gabrielashworth.com.

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mcms — at work for you

Not just any physician referral service will do. Call the experts. Call the MCMS.

Candice Scheibel

For a patient trying to find the right physician, not just any doctor will do. Some are not only searching for someone for their own medical needs, but also for family members in need of care. Whether they need a routine checkup or require highly-specialized medical care, it needs to be someone that the patient and/or their family feel comfortable with. Someone with the right credentials. Someone they can trust.

Calling their health plan may not always be the best solution - getting stuck in a call cue or automated attendant system is not a fun way to spend time. And the member services or customer care staff may not always have the physician’s best interest at heart. They are there to promote the plan, not the physicians.

To aid the community and help attract patients to our physician members, the Society offers a free telephone and web-based physician referral service to connect the patient with a physician that best meets their medical needs.

When an individual calls or emails the Society, MCMS membership staff asks for the type of physician or specialty, city of residence, and any other demographic information needed to identify the appropriate physician. (Upon request of the caller, we will also provide educational information and board certification(s), gender, and languages spoken.) The MCMS representative will then enter the data in e-Society, the Society’s proprietary Customer Relationship Manager (CRM), and the results will populate a list of physician that meet the entered criteria. MCMS physician members whose profiles best match the search criteria will appear at the top, narrowing down to physicians who only have several properties that “match” the request. Each time a search is performed the referrals will shuffle as to give all those who participate in the program an equal opportunity to receive a referral. MCMS provides as many choices as the caller requests.

Totals for web and phone are kept on a monthly, quarterly, year-to-date and last year basis in the physician’s profile. The final selection of a physician is up to the patient based on their needs and preferences. Calls are answered during Society business hours, Monday through Friday, 8 am –5 pm. Unanswered calls are sent directly to voicemail and returned the following business day.

The referral service is manned by MCMS staff that is knowledgeable about all the physicians in the program and understands the doctor/patient bond. It is operated for Maricopa County Medical Society actively practicing members whose membership is in good standing, are residency-trained, board-eligible or certified, and licensed to practice medicine in the state of Arizona. There is no charge to MCMS members or to the caller/web user for this service.

New, qualifying MCMS members are asked at the time of enrollment if they would like to receive referrals. Those who check yes need to complete a series of questions such as their education, specialties and board certifications, areas of interest, languages spoken, additional offices, and gender. This information is entered into e-Society within three business days. As soon as a dues payment is recorded in the member’s account, the profile is “turned on” and the physician’s information is active in our referral system and online search. Updates and/or review of existing profiles can be requested at any time by calling the MCMS Membership staff at 602-252-2015 or emailing us at mcms@mcmsonline.com. Updates are reflected within one business day and online within 48 hours. To review your current profile,

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mcms — at work for you go to www.mcmsonline.com/providersearch and enter your last name. For those members receiving referrals, in order to refer the appropriate patients to your practice, we need to have up-to-date biographical information on you in order to match consumer needs with your expertise. Please call or email us. We will work with you or your designated contact person to update your profile. Looking towards the future, plans to build on the existing service to provide additional member value include: • Keeping our referring physicians and their patients informed. Sending MCMS members a follow-up email to let them know we successfully referred to them. Included in the email will be the caller’s contact and/or demographic information your office needs to follow-up with the caller.

• Enhancing the online user experience. Plans to enhance the physician/provider search on mcmsonline.com include a physician map search, a map view – ability to see search results pinned on the map, a cleaner look and feel, and more.

• Improving the user experience. Building upon existing infrastructure, we will include additional information for callers such as the insurance accepted by physician members and hours of operations for the office/clinic/appointments.

Whether you are a new physician interested in building your practice, or an experienced physician looking to grow your practice, MCMS can connect you to patients in need of your particular expertise.

If you are not currently signed up to receive FREE patient referrals, isn’t it time? Call MCMS at 602-252-2015 or email mcms@mcmsonline.com to get signed up. ru Candice Scheibel is the Director of Communications for the MCMS, overseeing marketing, membership and the production of Round-up. She has worked in healthcare marketing for over 15 years, including leading marketing/communications efforts for two start-up health plans. Email her cscheibel@mcmsonline.com.

Referral Line Fast Facts Phone number: 602-252-2844 Website: mcmsonline.com/providersearch Email: mcms@mcmsonline.com MCMS Membership value is in the numbers: • MCMS provided 12,224 physician referrals in 2013. (Web and telephonic included in totals). • This breaks down to 1018 referrals per month, 235 referrals a week, annually. Top 10 Specialty Referrals: • Internal Medicine: 1626 • Family Medicine: 1033 • Gastroenterology: 1029 • Orthopedic Surgery: 872 • Ophthalmology: 552 • Psychiatry: 541 • ObGYN: 531 • Cardiology*: 410 • Dermatology: 374 • Urology: 296 Cost: The average dollar amount for a regular office visit to a PCP under the CPT code 99213 is $75 (allowed amount) for an office visit (Medicare fee schedule is $72). Three referrals through the MCMS telephone and web-based service = $250 (active annual dues membership). *Includes Cardiovascular Disease and Interventional Cardiology.


Did you know MCMS has a FREE patient referral line? As a service to the community, MCMS offers free physician referrals through our telephonic service or online provider search.

If you are a member and not receiving patient referrals, contact MCMS to get signed up, today! 602.252.2015 mcms@mcmsonline.com Maricopa County Medical Society physician members: Keeping Arizona families healthy for 122 years, and counting.


in memoriam A life that touches others goes on forever.

Thank you for your contributions to the medical profession. You will be missed. In Memory of Howard Lawrence, MD

I shall be restless all day if I do not write about my friend Dr. Howard Lawrence and tell you a little about him.

He was a plastic and reconstructive surgeon and the best. When I had a burn patient, Howard would place skin grafts that would rehabilitate quickly. Many could not afford medical services, but Howard saw to the need and looked for recompense later if at all. It never Howard appeared to be a concern. There were Lawrence, MD babies with Hare Lip and Cleft Palates that came to his attention. All were given his services without stint or withholding regardless of ability to pay.

I had an occasional patient with an enormous ventral hernia that required a graft of some sort in its repair. Either a man-made substance such as Stainless Steel Mesh, Dacron or similar, or a Free Cutis Graft from the patient. The latter was best in my hands since there was no tissue reaction to it. In order to obtain this graft, a split-thickness graft must be cut with a Dermatome, left attached at one end, the remaining thickness of skin removed, all fat cleaned, the graft placed and the split-thickness graft replaced on the donor site. Howard was there to accomplish this which was in his field and performed superbly.

Howard and I were invited along with Dr. John Eisenbeiss, a Neuro-Surgeon and Dr. Bud Moore, an Obstetrician-Gynecologist to present a Seminar in Mazatlan, Mexico, which we did.

We took our sons fishing to Canyon Lake when they were quite small and slept out.

I loved that man and believe everybody that knew him did. He was 98 years of age. A kind, gentle man. A friend, a Colleague. A Physician. He died Saturday the 24th of May. Are there any like him? How I hope they did not throw away the mold. Paul (B. Jarrett, MD)

Robert Caldwell Drye, MD, age 86, died of natural causes on April 28, 2014. He was born in Brooklyn, New York, the son of John W. Drye, Jr. and Loraine (Caldwell) Drye. He was educated at Exeter Academy and MIT, and graduated from New York University School of Medicine in 1951. He married Vivian Nevue in Chicago, Illinois on September 10, 1955.

Dr. Drye served in the U.S. Army Reserve Medical Corps beginning in 1951, with the 11th Airborne from 1953 to 1955, and with the Illinois National Guard until 1967, retiring with the rank of Lieutenant Colonel. He was the Director of Residency Training at the Illinois State Psychiatric Institute prior to moving to California. He practice Psychiatry in Carmel and Seaside between 1970 and 1987, living in Carmel from 1970 to 1986, and Monterey until 1988.

He is preceded in death by his wife Vivian in 1979. He is survived by his sister, Anne of Shelburne, VT; seven children, 18 grandchildren, five great-grandchildren, and several nieces and nephews. He is also survived by his companion of 21 years, Neria Ryder.

Robert Forrest Easley, MD, age

90, died in Phoenix, Arizona, on April 28, 2014. Born in Mesa, Arizona, on August 27, 1923, he was the youngest child of Bedford Forrest Easley and Margaret “Madge” Francis (Turpen) Easley.

He attended Mesa High School where he was an Eagle Scout, a drummer in the marching band, and a runner on the track team. Earning both a track and math scholarship, Bob attended Arizona State Teacher’s College (ASU) for two years where he participated in track, Lambda Phi Epsilon fraternity, and student government as a sophomore class officer. He was preparing to become a teacher until the summer of 1943 when attending college went on hold to serve his country in WWII. While in the Army, Dr. Easley made a major life decision to pursue a career as a doctor instead of a teacher, and he hoped to finish college and

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in memoriam attend medical school on the GI Bill after his discharge. He accomplished this by briefly attending Phoenix College, finishing his Bachelor’s degree on a fast track at the University of Denver, and completing medical school at the University of Utah in only three years.

Also after returning home from the Army, Dr. Easley met Betty Jean Hendrix. Their long-distance courtship continued while he was in medical school and Betty Jean attended Arizona State College to become a teacher. In June of 1950, just after their respective graduations, they married and moved to Louisiana where he completed his medical residency and Betty Jean taught Kindergarten. In 1952, they moved to the small town of Glendale, Arizona, where Dr. Easley joined a medical practice with Dr. Phillip Rice. The medical practice grew over the years, and he enjoyed a long and rewarding career as a general practitioner, lovingly known as “Dr. Bob” to scores of friends and neighbors. He became an involved civic leader and was very active in the Glendale Rotary Club and at First Christian Church in Phoenix, where he served as an elder. On December 31, 1989, he retired from medicine, and continued his involvement in the community and enjoyed social activities with their many dear friends in Glendale.

His parents, brothers Bert, J.B., and Willis, and his wife Betty Jean (Hendrix) Easley have preceded him in death. He was a loving husband, father, uncle, and “Papa,” and is survived by his children, Brian Forrest Easley; Janet Kay Easley Prouty (and husband Tod); and Kevin Robert Easley; his six granddaughters, Kendra Jean Prouty, Rebecca Easley, Bethany Jean Easley, Lauren Margaret Easley, Alixandra Forrest Easley, and Andrea Easley; and several nieces and nephews.

Robert F. Crawford, MD, age 85,

passed away peacefully, surrounded by his family on April 28, 2014, following a long and courageous battle with vascular dementia. Dr. Crawford was born on February 18, 1929 in Thomasville, Georgia to John and Mary Crawford. He attended Emory University and graduated with his medical degree in 1954, and was a member of Alpha Omega Alpha. He completed his internship at the University of Pennsylvania, Philadelphia. In Philadelphia Dr. Crawford met Louise McLaughlin, RN during his internship, and they were married in San Francisco on

October 1, 1956. His military service included serving with the United States Naval Reserves as a Medical Officer on the USS Onslow. He was honorably discharged as a reserve officer with the rank of Lieutenant (JG) Medical Corps, USNR.

In 1960 Dr. Crawford and Louise moved to Phoenix to join Herman Lipow, MD at the Pediatric Clinic on Thomas Road and 48th Street. The practice later grew to include Leonard Wright, MD, David Folkestad, MD, David Alexander, MD, and Susan Apley, MD. For almost 30 years he cared for both children and their concerned parents.

Dr. Crawford was also active in the medical community. He served as a member of the Board of Directors of the Maricopa County Medical Society, and later as Treasurer. He also served as Vice President of the Maricopa Foundation for Medical Care (now the Arizona Foundation for Medical Care). Dr. Crawford was active as Chair of the Department of Pediatrics at both Good Samaritan Hospital from 1972-1975 and St. Joseph’s Hospital and Medical Center from 1982-1983.

In addition to being a pediatrician, Dr. Crawford devoted a great deal of time supporting the Mutual Insurance Company of Arizona (MICA) in an effort to offer equitable medical malpractice insurance to all physicians in the state. In 1984 he became First Vice President and then President from 1988-1995; and later became MICA’s Chairman of the Board in 1989 when he retired from his pediatric practice and continued leading MICA until 2004. His beloved wife of 49 years, Louise, parents John and Mary, brothers Allen and Jack, and son James Crawford preceded Bob in death. Survived by his sons Robert and Edward; daughter Margaret (Peggy); and grandchildren Hannah, Sarah, Jonathan and Nicholas.

Clifford J. Harris, Jr., MD, age 85,

beloved husband, father, grandfather, physician, and community leader died December 17, 2013 in the arms of his family in Mesa, Arizona. Dr. Harris grew up in Chicago, the son of Clifford John Sr. and Rita Acker Harris; he had one sister, Dale. He met his wife Carol May Katt at Presbyterian Hospital where he studied medicine and she studied nursing. He graduated from University of Illinois Medical School in 1954, and then completed four

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in memoriam years of training in Internal Medicine and Hematology. After his residency, Dr. and Mrs. Harris lived in Izmir, Turkey with their three children, where he served two years in the U.S. Air Force. Their young family ventured into surrounding countries to explore history and culture. They moved to Mesa in 1961, where Dr. Harris established a private practice, caring for many grateful patients. In 1968, with the idea of having patients paying to stay well, he cofounded ABC HMO, which was the first HMO in Arizona and later became part of CIGNA Healthcare of Arizona.

Dr. Harris cared for his community’s health by volunteering weekly at Maricopa County hospital and serving on numerous hospital boards and local boards such as Mesa United Way and East Valley Cultural Alliance. He was recognized as Mesa Man of the Year in 1992. In his retirement, he worked tirelessly to make Mesa and the state of Arizona smoke free in public places. Dr. Harris had Alzheimer’s disease which he and Carol faced head on by participating in research studies at Banner Alzheimer’s Institute. As his final contribution, he donated his remains to further the research of Alzheimer’s disease.

Dr. Harris is survived by his loving family: wife, Carol Katt Harris FNP; children: Clifford W. Harris, JD, MBA; Coralee H. McKay, MD; Kathleen Katt, MD; Kenneth Harris, MBA; Kurtis Harris, PE; Carolyn Harris, MA; Kevin Harris, JD; and Kristeen Harris, MEd; in-laws: Barbara, Cindy, Julie Harris, and Vicente Abril; and 11 grandchildren: Andrea, Clifton, Alexander, Trevor, Brandon, Carter and Abel Harris; Justin and Carlee McKay; and Wesley and Tara Bratt.

James Cruse Zemer, MD, age 81,

passed away peacefully on Thursday, May 8, 2014, with family by his side. He was born in Toledo, Ohio in 1933 and raised in Fostoria, Ohio, and attended both undergraduate and medical school at the Ohio State University. He was a member of Alpha Tau Omega fraternity, and Phi Chi medical fraternity. At Ohio State, Dr. Zemer met a redheaded nurse named Rachel. They married in 1959, moved to Phoenix in 1962 and had an adventure-filled, devoted and loving life together.

year career. He was in private practice during most of his career and was a staff member at numerous Valley hospitals, including St Joseph’s Hospital, Good Samaritan, and St. Luke’s. Later in his career he joined Valley Anesthesia, and was a contractor and consultant to the VA Medical Center’s Surgical Department before retiring in 2006.

He was a Diplomat of the American Board of Anesthesiology, and a Fellow of the American College of Anesthesiology. Dr. Zemer was also active in many professional medical societies. He was a member of the American Society of Anesthesiologists and the American Medical Association, and he served as President of both the Arizona and the Maricopa County Societies of Anesthesiology. He was particularly devoted to the Sisters of Mercy and St. Joseph’s Hospital, beginning first as an Intern, and later serving in various leadership roles. He also served as Chairman of St. Joseph’s Board of Directors, being the first non-Catholic and first layperson to hold this position.

Dr. Zemer is survived by his wife, Rachel; his two children, Jeff (Tracey) and Sara (Jeremy); five grandchildren, Mollie, Zack and Jake Zemer; Ben and Sophie Young; and numerous nieces, nephews, and extended family members. He was preceded in death by his parents, Hudson and Bernice; his brother, Jack; sister-in-law, Pat; his sister, Janice, and brother-in-law, Lou.

Stephen Milliner, MD,

age 63, passed away on April 20, 2014 with his family by his side, after a long and bravely fought battle with multiple Myeloma. He loved his family, friends, his profession and the game of golf.

Dr. Milliner was born in South Africa and immigrated to the United States where he completed his residency at Duke University Medical Center. He was dedicated to his practice as a pediatric orthopedic surgeon and he was admired by his peers. He is survived by his devoted wife Melanie and three sons Sean, Mike and Jake. ru

Dr. Zemer joined practice with Harvey Brown, MD to create Phoenix Anesthesiology Group and enjoyed a 44

June 2014 • A monthly publication of the Maricopa County Medical Society • Round-up • 51


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viewpoint

Trivia

Rudi Kirschner, MD

Just to be safe I have always kept a few vignettes neatly filed in my desk in case I can not come up with a new ideaof-the-month. You noticed the “neatly filed” phrase of course. The emphasis is on the neatly; a sign of compulsiveness. We could not have made it through medical school if we were not compulsive, some of course more so than others. I happen to belong to the “more-so” group. Everything is neatly filed and labeled except for one manila folder which is labeled “this and that.” Within this folder however sub-sections are devoted to various items and I would like to share some of these.

It would almost be heresy if at least one of these sub-sections were not devoted to the law. Then there is a subsection, i.e. weighty and not so weighty.

The law loves Latin – it gives it that sophistication, which of course it sorely needs, so lets borrow from it. • Primum non-nocere – first do no harm.

• Aegrescit medendo – the remedy is worse than the disease.

• Nemo liber est qui servit corpori – no one is free who is slave to his body. • And then the legal admonition to the physicians; medice, cura ta ipsum – physicians heal thyself.

And then the not so weighty:

Judge:You are charged with habitual drunkenness. Have you anything to say in your defense? Defendant: Habitual thirstiness.

Counselor: She had three children, right? Witness: Yes. Counselor: How many were boys? Witness: None. Counselor: Were there any girls?

A few headlines from our journalist friends: • March planned for next August. • Blind Bishop appointed to See.

• Patient at Death door – Doctor pulls him through.

With some reticence but obviously not enough, let us leave the law and look at the church, surely a courageous step. These are actual announcements: • Don’t let worry kill you. Let the Church help.

• Wednesday, the ladies liturgy society will meet. Mrs. Jones, will sing “Put Me In My Little Bed” accompanied by the Pastor.

• Weight Watchers will meet at 7 pm at the First Presbyterian Church. Please use the large double doors at the side entrance. • Thursday night – potluck supper. Prayer and medication to follow.

And being a Senior Citizen, a few personal observations:

• I am very good at opening childproof caps with a hammer. • I am realizing that aging is not for wimps.

• I am sure they are making adults much younger these days and when did they let kids become doctors? • Remember … inside every older person is a younger person wondering what the heck happened. To those of you who can not relate … just wait!!

This is in my “this and that” file and I hope you enjoyed this non-taxing trivia. ru Dr. Rudi Kirschner is a retired Family Practice physician. He has been a member of the MCMS since 1959 and a contributing author to Round-up for many years. He can be reached at rkirschnermd@cox.net.

June 2014 • A monthly publication of the Maricopa County Medical Society • Round-up • 53


marketplace

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54 • Round-up • A monthly publication of the Maricopa County Medical Society • June 2014


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June 2014 • A monthly publication of the Maricopa County Medical Society • Round-up • 55


mcms april board minutes The Maricopa County Medical Society

BOARD OF DIRECTOR’S MEETING April 14, 2014 • 6 pm ATTENDEES

Board Members: Drs. Miriam Anand, Elizabeth McConnell, Suzanne Sisley, John Couvaras, Kelly Hsu, Steve Kassman, Lee Ann Kelley, and May Mohty were all present. Participating by phone: Drs. Ryan Stratford, Mark Wallace, Jennifer Hartmark-Hill, Anita Murcko; MCMS Staff: Jay Conyers. At 6:09 pm, meeting called to order by Dr. Anand.

WELCOME

Dr. Anand welcomed the Board and asked for any old business. No old business items were brought to the discussion. CONSENT AGENDA

Dr. Anand summarized the Consent Agenda, containing the March minutes and membership report for March 2014. The Consent Agenda was approved. PENSION PLAN UPDATE

Jay updated the Board on the status of closing out the Plan, and the process for finalizing the paperwork with the Pension Benefit Guarantee Corporation (PBGC).

ArMA HOUSE OF DELEGATES

Dr. Anand discussed the House of Delegates meeting held by the Arizona Medical Association, scheduled this year for May 30 and 31. The five delegates for the Society were announced, and will include Drs. Mark Wallace, Sue Sisley, Adam Brodsky, Elizabeth McConnell, and Jennifer Hartmark-Hill. Dr. Anand pointed out the need for the Board to vote on resolutions at the next Board meeting.

Dr. Anand discussed possible resolutions that could be submitted through the Society, specifically explaining regulation of e-cigarettes as a possible resolution for the Society. Dr. Murcko suggested the Board consider a resolution around electronic prior authorizations. Dr. Anand

conveyed to the Board the need to vote on our ArMA House of Delegates Director at the next Board meeting, prior to the House of Delegates meeting. MEMBERSHIP

Dr. Couvaras briefly discussed a recent meeting he and Jay had in which they discussed the Society’s need to increase membership. He turned the discussion over to Jay, who walked the Board through a presentation that outlined the Society’s value proposition, approaches to recruitment and retention, and ways to change what it is the Society offers to its member physicians.

The Board discussed the different needs of self-employed physicians compared to those employed by the hospitals. It was recognized that these two groups have different sets of needs. FINANCIAL REPORT

Jay presented a slide showing a breakdown of the profitability of the Society and individual business units for the month of March. He highlighted certain revenue centers and costs for the business units, comparing actual to budgeted. The Board approved the March 2014 financials, as presented. ARIZONA MEDICAL BOARD

Jay briefly updated the Board on the medical board licensing opportunity, pointing out that both bills, SB1380 and SB1381, had been approved by the legislature and were awaiting the Governor’s signature. NEW BUSINESS

Dr. Hsu invited everyone to a fundraiser event being organized by the Asian Pacific Community-in-Action. The event was held May 10 and honored Dr. Tony Yeung, a former Society president and current member. ADJOURNMENT

Dr. Anand adjourned the meeting at 7:36 pm. ru

56 • Round-up • A monthly publication of the Maricopa County Medical Society • June 2014