Michigan Medicine, Volume 116, No. 6

THE OFFICIAL MAGAZINE OF THE MICHIGAN STATE MEDICAL SOCIETY » VOL. 116 / NO. 6

November / December 2017

The Prescription for Job Satisfaction ALSO INSIDE

HPV Vaccine Rates

Page 8

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FEATURES & CONTENTS November / December 2017

12

Physicians Can Be at Risk When Homebound Patients Refuse Help

BY ROBIN DIAMOND, MSN, JD, RN Contributed by The Doctors Company

20

HIT Corner: Team Documentation Helps Tackle EHR Burnout

BY SARA BERG, SENIOR STAFF WRITER, AMA

COLUMNS 04 President's Perspective

BY CHERYL GIBSON FOUNTAIN, MD

06 Ask Our Lawyer

BY DANIEL J. SCHULTE, JD

08 MDHHS Update

BY JACKIE CHANDLER, MS

14 Ask Human Resources

BY JODI SCHAFER, SPHR, SHRM-SCP

28 WealthCare Advisors

Christopher Dehlin, MD

COVER STORY

15

BY JIM NIEDZINSKI, AIF®

DEPARTMENTS 07 Welcome New Members 23 In Memoriam 24 MSMS Medical Opportunities 30 MSMS Educational Courses

The Prescription for Job Satisfaction

BY JOSEPH BECSEY FOR THE MICHIGAN STATE MEDICAL SOCIETY

Why is it that physicians everywhere are becoming increasingly frustrated with their chosen profession? Surprisingly, the answer is not complicated: recognizing the signs of physician burnout and being proactive about finding solutions that work for them. (Story on page 15.)

STAY CONNECTED!

NOV / DEC 2017 |

michigan MEDICINE 3

perspective

MICHIGAN MEDICINE® Chief Executive Officer JULIE L. NOVAK Managing Editor KEVIN MCFATRIDGE KMcFatridge@msms.org Marketing & Sales Manager TRISHA KEAST TKeast@msms.org

The end of the year lends itself well to reflection.

Graphic Design STACIA LOVE, REZÜBERANT! INC. rezuberantdesign@gmail.com

The act of turning over an old calendar for a new one

COVER & PHOTOS OF CHRISTOPHER DEHLIN, MD LUKE ANTHONY PHOTOGRAPHY lukeanthonyphoto.com

begs individuals and organizations alike to consider

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Michigan Medicine®, the official magazine of the Michigan State Medical Society (MSMS), is dedicated to providing useful information to Michigan physicians about actions of the Michigan State Medical Society and contemporary issues, with special emphasis on socio-economics, legislation and news about medicine in Michigan.

The MSMS Committee on Publications is the editorial board of Michigan Medicine and advises the editors in the conduct and policy of the magazine, subject to the policies of the MSMS Board of Directors.

Neither the editor nor the state medical society will accept responsibility for statements made or opinions expressed by any contributor in any article or feature published in the pages of the journal. The views expressed are those of the writer and not necessarily official positions of the society. Michigan Medicine reserves the right to accept or reject advertising copy.

Products and services advertised in Michigan Medicine are neither endorsed nor warranteed

by MSMS, with the exception of a few.

Michigan Medicine (ISSN 0026-2293) is the official magazine of the Michigan State Medical Society, published under the direction of the Publications Committee. In 2017 it is published in January/February, March/April, May/ June, July/August, September/October and November/December. Periodical postage paid at East Lansing, Michigan and at additional mailing offices. Yearly subscription rate, $110.

Single copies, $10. Printed in USA. ©2017 Michigan State Medical Society

4 michigan MEDICINE | NOV / DEC 2017

the previous twelve months and take stock of where they presently stand.

Michigan Medicine® is no different than most in this regard.

By Cheryl Gibson Fountain, MD, Michigan State Medical Society President

®

R

eflecting on the issues we have highlighted over this past year, it’s easy to see that the world of Medicine continues to change at a rapid pace, and no part of our medical system has gone untouched. From complex regulatory changes and reporting tools to new models of care and an ever-evolving patient-physician relationship, change is afoot in every aspect of the practice of medicine. Even the process of how physicians code, bill, and the manner in which they’re reimbursed is in flux.

It’s easy to lose site of the actual physician amidst all this change, but we have to collectively recognize the hazard in that sort of negligence. Physicians are bearing the brunt of the burden associated with a rapidly evolving medical system, and it’s clear to see that it is taking its toll.

That’s important, and it deserves its own highlight.

CHERYL GIBSON FOUNTAIN, MD, MSMS PRESIDENT

Physicians across the country are increasingly feeling burnt-out in their chosen profession, and that has far-reaching consequences for everyone. Burnout is directly linked with several undesirable outcomes affecting both physicians and the patients they treat.

Higher physician turnover, higher medical error rates, lower quality of care, lower patient satisfaction and even physician suicide – these are the very real consequences of physician burnout.

And the long-term implications are problematic as well. In a medical system already facing a physician shortage and struggling to manage an influx of previously uninsured patients, the question of who will meet the looming needs of an aging population become difficult to answer in the face of growing dissatisfaction among physicians across the country.

The problem obviously needs attention in a serious way, and a systemic fix should be the ultimate goal, but that does not preclude frustrated physicians from taking action to rediscover the joy in the practice of medicine. The good news is there is plenty physicians can do, both in their practice and their personal life, to reconnect to the pleasure that comes in treating patients, and there are a myriad of tools and resources available to help.

This edition of Michigan Medicine focuses on physician satisfaction— or more appropriately the lack thereof—and what can be done to rejuvenate it.

The Michigan State Medical Society is proud be one of those resources, and it is my hope that this issue of Michigan Medicine® will help elevate the importance of physician wellbeing and serve as a starting point for any members who have recognized the need to take action in that regard in their own lives.

The practice of medicine can and should be fulfilling. We help people. We save lives.

There’s little in this world intrinsically better for the soul than that. We owe it to ourselves to remember, celebrate, and protect that unique virtue that only comes with being a physician as we move into 2018 and beyond.

NOV / DEC 2017 |

michigan MEDICINE 5

ASK OUR LAWYER

Video/Audio Recording of Procedures

By Daniel J. Schulte, JD, Michigan State Medical Society Legal Counsel

Q: A patient’s wife asked if she could remain with her husband in the ER while I examined him and treated his injury. The husband said that this was fine with him.

The wife stood in the corner behind the nurse and I who were focused on performing a procedure. When we were finished I turned to let the wife know we were finished and all went well and discovered she was making a video of the procedure with her iPhone. She never asked for permission to make the video and no one provided consent.

Can a video legally be made under these circumstances?

Do I have any legal recourse?

This video recording was made illegally. Section 539d of Michigan’s Penal Code provides: “(1) Except as otherwise provided in this Section, a person shall not do either of the following: (a) Install, place, or use in any private place, without the consent of the person or persons entitled to privacy in that place, any device for observing, recording, transmitting, photographing, or eavesdropping upon the sounds or events in that place. (b) Distribute, disseminate, or transmit for access by any other person a recording, photograph, or visual image the person knows or has reason to know was obtained in violation of this section.

(3) A person who violates or attempts to violate this section is guilty of a crime as follows: (a) For a violation or attempted violation of subsection (1)(a): (i) Except as provided in subparagraph (ii), the person is guilty of a felony punishable by imprisonment for not more than 2 years or a fine of not more than $2,000.00, or both. (ii) If the person was previously convicted of violating or attempting to violate this section, the person is guilty of a felony punishable by imprisonment for not more than 5 years or a fine of not more than $5,000.00, or both. (b) For a violation or attempted violation of subsection (1)(b), the person is guilty of a felony punishable by imprisonment for not more than 5 years or a fine of not more than $5,000.00, or both.”

It was illegal for this patient’s wife to use her iPhone to make this video. The space in the ER where treatment is provided to patients is a “private place”. I assume there are signs posted prohibiting cell phone use, curtains dividing the treatment areas and other steps have been taken maintain privacy in this area. Both patients and the health care professionals working there are entitled to and expect privacy in the ER. Any distribution, dissemination or transmission of this video is also illegal. This is either a 2 year or 5 year felony with fines of $2,000.00 or $5,000.00 depending on whether the patient’s wife has been convicted of making illegal videos in the past. You or the hospital should put the patient and his wife on notice that the video was made illegally and that it should be destroyed. You may or may not want to file a police report to put the authorities on notice of this illegal act.

Audio recordings of patient encounters are becoming more and more frequent. Patients can easily record a conversation with their phone and the recording may assist in the care of the patient in cases where the physician’s instructions are complicated.

A recording also helps a caregiver at home that cannot make the appointment. The law requires that all parties to the conversation have knowledge of the recording and consent to it being made.

DANIEL J. SCHULTE, JD, MSMS LEGAL COUNSEL IS A MEMBER AND MANAGING PARTNER OF KERR RUSSELL

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Welcome New Members Chippewa/Mackinac

Kalamazoo

Oakland

Shiawassee

Catherine Wilkerson, MD, MPH

David Karr, DO Keith Mulder, MD Vincent Pagano, MD Andrew Schulz, MD Adam Schwabauer, DO

Casey Darrah, MD

Oscar Macal, MD

Kenneth Eichenbaum, MD

Antonio Santiago-Agostini, MD

Genesee Rachel Ford, MD Tarek Haykal, MD Karen Moses, MD

Kent

Andrea Pacheco Arias, MD

Navneet Mander, MD Shawna Pierce, MD Valerie Shavell, MD Mili Thakur, MD Jeremy Veenema, DO David Weatherly, MD

Vinu Perinjelil, MD Mey Yip, MD Omari Young, MD

Gratiot Shaun Moon, DO

Paul Sheng, MD

Ingham Jackson Timothy Ekpo, DO

Iram Mirza, MD

Rajasekhar Jagarlamudi, MD

Mark Rosner, MD

Ari Kriswari, MD Nabeel Obeid, MD Richard Swartz, MD

Gregory Casey, MD

Saginaw

Paul Corsello, MD Brian Fedoronko, MD

Branden Yaldou, MD

Marina Ananich, MD

Stephen Berger, MD Collin Deal Houssaye, DO

Ryan Palacio, MD

Marquette

Rhonda Todd, MD

Kylene Willsey, MD Alexandra Norcott, MD

Kaitlyn Matz, DO

Michael Banka, MD Dustin Miller, MD

Jacob Trapp, DO

Julie Kado, MD Tamer Mahmoud, MD, PhD

Jeffrey Karr, MD

Muskegon

Ciprian Gradinaru, MD

Washtenaw Syed Ahmad, MD

Out of State

Livingston

Amit Sachdev, MD

Brian Gietzen, MD Amy Jacobson, MD

Robert Nettleman, MD

Wayne

Benjamin Schoener, DO

James Boutrous, MD

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A successful practice requires more than talented individuals and a desire to heal.

Let Kerr Russell provide the legal insight needed to manage and grow your business.

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NOV / DEC 2017 |

michigan MEDICINE 7

MDHHS UPDATE

Statewide Efforts Have Measurably Increased HPV Vaccine Rates

By Jackie Chandler, MS, Outreach Coordinator, Michigan Department of Health and Human Services, Division of Immunization

W

hile adolescent vaccination coverage continues to improve in Michigan and across the nation, considerable opportunity remains to prevent

human papillomavirus (HPV)-associated cancers. Cancers caused by HPV include those of the cervix, vulva, vagina, penis, and anus. HPV infection can also cause oropharyngeal cancer—this cancer affects the back of the throat, including the base of the tongue and the tonsils. The HPV vaccine is an effective tool against cancer.

To place this in perspective, research indicates HPV vaccine can prevent nearly 28,500 new cancer cases each year.1 Furthermore, a study in Sweden demonstrated the importance of vaccinating earlier.2 Vaccine effectiveness prevented genital warts in: 93 percent of girls vaccinated between the ages of 10 through 13 years.

In response to strong research findings, the Advisory Committee on Immunization Practices recommends that adolescents aged 11 through 12 years receive two doses of HPV vaccine at least six months apart to get the best protection against genital warts and cancers caused by HPV infections3:

48 percent of women vaccinated between the ages of 20 through 22 years.

• The first dose is routinely recommended at age 11 through 12 years, but the vaccine may be administered as early as age 9 years.

21 percent of women vaccinated between the ages of 23 through 26 years.

• The second dose of the vaccine should be administered 6 to 12 months after the first dose.

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• Vaccination with the two-dose series can be started at age 9 and through age 14.

• Adolescents aged 9 through 14 years who have already received two doses of HPV vaccine less than 5 months apart, will require a third dose.

Note: If the HPV vaccine series is initiated at ages 15 through 26 years, then three doses of HPV vaccine are needed to best protect against cancer-causing HPV infections. Three doses are also recommended for persons with weakened immune systems aged 9 through 26 years.

Since the introduction of HPV vaccine in 2006 for females and in 2011 for males, coverage has increased gradually for females and more rapidly for males. However, HPV vaccine coverage has not reached the levels of other vaccines routinely recommended for adolescents like tetanus, diphtheria and acellular pertussis vaccine (Tdap) or meningococcal conjugate vaccine (MenACWY). Most parents nationally, 60.4 percent, are getting the first dose of HPV vaccine for their child4. According to the Michigan Care Improvement Registry (MCIR), 57.6 percent of adolescents aged 13 to 17 years have received at least one

dose of HPV vaccine. Completion of the vaccine series persists at a lower rate: only 46.1 percent of females and 39.2 percent of males have all their recommended HPV vaccinations.5 Increasing protection against HPVassociated cancers is a top priority for the State of Michigan and the United States.

Efforts across the state are producing promising results. Since 2006 when HPV was licensed, the percent of doses administered to 11 and 12 year olds in Michigan has increased from 17.1 percent HPV – CONTINUED ON PAGE 10

NOV / DEC 2017 |

michigan MEDICINE 9

HPV – CONTINUED FROM PAGE 9

to 48.2 percent in 2017.6 Getting the first dose at a young age is critical for maximizing HPV vaccine effectiveness, where there is a greater immune response and less exposure to infection.

The Michigan Department of Health and Human Services (MDHHS) uses an evidence-based strategy to impact HPV vaccine uptake: overdue notifications.

Overdue notifications are used to inform parents, via letter, email, or text, that vaccinations are late.7 Since the end of 2014, MDHHS has been conducting statewide, mail-based notifications using the MCIR. Most recently, in July 2017, letters were mailed to the parents of all adolescents aged 12 through 14 years who were overdue for their final dose of HPV vaccine. An evaluation of prior overdue notifications with this age group has shown that about 6 percent more adolescents will complete the HPV series within 60 days of notification compared to those who were not notified.

In addition to the statewide overdue notifications, MDHHS is partnering with a number of provider offices to strengthen adolescent AFIX activities. AFIX is a quality improvement (QI) process that is proven to increase immunization coverage levels.8 A few of the QI strategies that are recommended include: • Routinely measure a clinic’s adolescent immunization coverage and share the results with staff.

• Schedule the next vaccination visit before the patient(s) leave the office.

• Consistently recommend and simultaneously administer Tdap, MenACWY, influenza, and HPV vaccines at age 11 through 12 years (recommend the same way and the same day).

• Every three months, providers participating in the adolescent AFIX project are given a report card that highlights their coverage levels for initiation and for completion of HPV, Tdap and meningococcal vaccines for patients aged 11 through 17 years.

All health care providers have the power to prevent HPV-associated cancers!

Your recommendation is a critical factor in whether your patients get the vaccines they need. Every year that adolescents are not vaccinated represents another year they risk being exposed to cancer-causing infections. If your team needs a refresher on HPV recommendations or adolescent immunizations, MDHHS offers free immunization modules.

For more visit www.michigan.gov/immunize, click on Health Care Professionals/Providers, and look under Provider Education Resources for Immunization Education Opportunities for Health Care Personnel.

REFERENCES: Viens LJ, Henley SJ, Watson M, et al. (2016). Human papillomavirus–associated cancers — United States, 2008–2012. MMWR Morb Mortal Wkly Rep 65(26), 661–666.

Leval et al. (2013). Quadrivalent human papillomavirus vaccine effectiveness: A Swedish national cohort study. J Natl Cancer Inst 105(7), 469–474.

Meites E, Kempe A, Markowitz LE. (2016). Use of a 2-dose schedule for human papillomavirus vaccination — Updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep 65(49), 1405–1408.

Walker TY, Elam-Evans LD, Singleton JA, et al. (2017).

National, regional, state, and selected local area vaccination coverage among adolescents aged 13–17 years — United States, 2016. MMWR Morb Mortal Wkly Rep 66(33), 874–882.

MDHHS. (2017). HPV vaccination rates in Michigan, MCIR data as of August 2017, children aged 13-17 years. Unpublished data.

MDHHS. (2017). Percent HPV Initiation Age by Calendar Year, Michigan Care Improvement Registry Data, 2006-2017. Unpublished data.

Community Preventive Services Task Force. (2017).

Vaccination Programs: Client Reminder and Recall Systems. Retrieved August 28, 2017, from https:// www.thecommunityguide.org/ Centers for Disease Control and Prevention (CDC).

(2017). AFIX (Assessment, Feedback, Incentives, and eXchange). Retrieved August 28, 2017, from https:// www.cdc.gov/vaccines/programs/AFIX

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michigan MEDICINE 11

Physicians Can Be at Risk When Homebound Patients Refuse Help

By Robin Diamond, MSN, JD, RN, Senior Vice President of Patient Safety and Risk Management, The Doctors Company

More than ever, physicians are focusing on treatment plans that include the kind of care patients need at home. However, physicians face potential liability when patients refuse help that is offered or neglect to follow up as instructed.

If

a patient sues, even a verdict in favor of the physician does not negate the time, expense, and emotional impact of a lawsuit. Consider this example:

A 67-year-old male with a history of obesity, hypertension, hypercholesterol, atrial fibrillation and cardiovascular disease had seen the same physician for 20 years. During one hospitalization, the patient was put on the blood thinner Coumadin. The physician and the discharge nurse both educated the patient and his wife about the risks of Coumadin use and the importance of having blood work done every month.

Nevertheless, the patient did not keep the first appointment for the monthly blood test (INR). The physician’s staff called to schedule a follow-up visit, but the patient did not return the call. Two days following the call, the patient fell at home. His wife took him to the emergency department, where she told the staff that she had been unable to drive him to his appointment for blood work, but she had made sure

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he took his Coumadin as prescribed.

The patient’s INR was extremely elevated with a reading of 8.8 The patient was diagnosed with a bilateral subdural hematoma and underwent a bilateral craniotomy. He was discharged to home but due to problems with his coordination and confusion, he visited the emergency department several more times over the next few months.

The patient sued for malpractice, claiming the physician failed to properly manage the medication regimen and failed to monitor blood levels, resulting in the fall, subsequent injury, and poor recovery. He also claimed the doctor failed to warn him of the risk of bleeding from the Coumadin.

The case went to trial. Because of the doctor’s thorough documentation, the jury agreed that he had properly educated the patient and made the right resources available to monitor the effects of the Coumadin. The jury found that the patient’s failure to schedule his lab appoint-

ments and follow-up appointment caused the injury and, therefore, found in favor of the physician.

While this patient failed to follow physician instructions, other homebound patients simply refuse any help. A recent study found that between 6% and 28% of patients eligible for home healthcare refuse these services and similar trends are seen with other types of assistance for patients at home. Patients often say they are managing just fine and don’t need help, while others don’t want strangers in their homes or they worry about the cost of co-pays for home care. That means some patients are not getting the follow-up and supportive care that the doctor outlined in the care plan. And when patient doesn’t follow up, it can put the physician at risk.

Patient behaviors were contributing factors in 25% of internal medicine closed claims studied by The Doctors Company. Of these factors, noncompliance with the treatment plan was the most

common, accounting for 9% of internal medicine claims. This was followed by 7% of claims resulting from patients failing to make a follow-up appointment or referral, and 4% of claims resulting from patients failing to take medications as prescribed.

The potential malpractice risks to physicians are increasing as more care is moved from a healthcare setting to the patient’s home. The following are tips to reduce risks when treating homebound patients:

Conduct a risk analysis to determine how likely the patient is to comply with instructions.

Consider the following: patient’s age,

Document that: The patient received proper discharge instructions.

Resources were made available to overcome compliance challenges.

The physician or practice made a good-faith effort to follow up and intervene if the patient was not in compliance.

Schedule a follow-up appointment before the patient leaves the office.

Give the patient contact information for community home-health resources.

Educate the patient about why community resources are provided and draw a distinction between what is and is not offered.

Patient reluctance to follow the discharge plan is often caused by lack of

ability to drive, socioeconomic status,

understanding about what type of follow-up care is needed. Taking time to

whether patient lives alone, and history

document patient discussions gives homecare providers valuable information

of failing to comply with appointments or

to ensure patients are following the plan—and will also demonstrate,

medication instructions.

in the event of a lawsuit, the high quality of care provided.

Reprinted with permission. ©2017 The Doctors Company (www.thedoctors.com).

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michigan MEDICINE 13

ASK HUMAN RESOURCES

Addressing Office Politics: Tactics and Expert Opinions

By Jodi Schafer, SPHR

Q

An employee of mine (Employee A) invited a few coworkers to a get-together at her home a few weeks back. One of the employees (Employee B) who was not invited found out about it and was upset about being ‘snubbed’. There has been tension between these two employees before, but now Employee B is giving Employee A the silent treatment as punishment. Normally I wouldn’t get involved in a situation like this, but the lack of communication between these two employees is starting to impact the entire office. Things are so cold between them that I actually had a patient ask me what their issue was. Help!

Office politics can be tricky. On the one hand, you don’t want to feed into it, but on the other hand ignoring the problem hasn’t proven successful. What’s a leader to do? Well, I’ll describe some of the ways previous clients have tried to address this problem, along with my expert opinion about the effectiveness of each approach.

Tactic #1 – Written Warning Write-up Employee A because her decision to only invite some of the office to her get-together was not conducive to a positive work environment. Purposely excluding some of her coworkers is clearly a violation of your Code of Conduct policy, which requires teamwork, collaboration and open communication. Employee A’s actions caused a great deal of harm and stress in the workplace, so to ensure this doesn’t happen again in the future, disciplinary action should be taken.

Expert Opinion: Employee A should not be disciplined since she did

not violate a policy. She has every right to invite who she wants to her house for a personal function. The problem is Employee B not speaking to Employee A, which is impacting performance and is a requirement of the job.

Tactic #2 – Town Hall Meeting Hold a meeting to discuss this problem with the entire staff and facilitate a resolution between the two individuals at the center of it all, Employees A and B. This will allow all of the employees an opportunity to discuss the situation and clear the air. The focus will be on finding a solution rather than placing blame, so as not to hurt any more feelings.

Expert Opinion: A full staff meeting does nothing to resolve the problem. The only people who should know what is going on are the people involved, Employees A and B. When you bring in the whole team you’re breaking confidentiality. You’re likely to embarrass the employees involved and confuse the staff who are not.

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Tactic #3 – Work it Out or Else Put Employee A and B together in a room alone so they can work it. These are adults who need to learn to resolve their own issues. You don’t have time for this childishness. If they can’t work it out then they won’t be working for you anymore. You need to send a message that this type of behavior won’t be tolerated in your practice.

Expert Opinion: If the two of them could work this out on their

own they would have done it by now. There is too much emotion involved for the conversation to remain positive and professional. If these are otherwise good employees then firing them would be like cutting off your nose to spite your face. You lose in the end either way.

Tactic #4 – Facilitated Meeting As much as you’d like for these two employees to resolve this issue on their own, it’s clear that is not going to happen. Speak to Employee A and B individually first and then bring them together. Facilitate a meeting that focuses on the need to work together as a team. Employee A has the right to invite who she wants to her parties and Employee B must understand that the workplace is not conducive to behaviors such as the silent treatment.

Expert Opinion: This is the best option. If you start by speaking

with each person individually you have an opportunity to get each employee’s side of the story and they can say their peace.

Most employees just want to know that they have been heard and that you are listening. After they’ve dealt with the emotional side of it, you can bring them together and focus on the need to communicate in order to get their jobs done. Develop a plan and expectations for future behavior and then hold each employee accountable to it.

FEATURE STORY

The Prescription for Job Satisfaction “When I grow up, I want to be a doctor.”

W

hile maybe not quite as popular as “astronaut,” or “superhero,” there’s

no question that “doctor” is always on the short-list of dream professions for elementary school-aged children. Why it enjoys such enduring popularity is impossible to nail down but it’s not hard to offer a conjecture.

Children have simple, altruistic dreams, and even at a very young age it’s plain to see that physicians serve to help people.

It’s no wonder so many young children express an interest in doing the same.

And these children have the right idea. Medicine is a noble, prestigious profession, and most who chose to pursue it as a career do so because they want to make a positive difference in people’s lives. And whether it persists from an early age or develops later in life, becoming a physician is likely the true dream of most who pursue the training given the incredible amount of time, money and effort required to earn the distinction.

CONTINED ON PAGE 16

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michigan MEDICINE 15

S

o why it is that physicians everywhere are becoming increasingly frustrated with their chosen profession? A profession that on the surface seems as though it should provide an ample supply of joy and self-fulfillment.

Surprisingly, the answer is not complicated. Physicians feel they are losing control of the environment in which they practice.

With each passing year, physicians find themselves allocating more and more time to staying on top of never-ending regulatory changes and skyrocketing documentation requirements, and it’s coming at the cost of what’s really important – spending quality time with their patients. The bottom line: the prevailing model of care is burning out physicians far too quickly and far too frequently.

What is complicated is the solution. There’s no magic wand to be waved when it comes to helping frustrated physicians rediscover joy in the practice of medicine -the problem is too big, too complex and too systemic. However, there are steps, both professionally and personally, practitioners can take that can make a big difference in the effort to reconnect to the joy in delivering care.

Physician burnout is now a full-blown epidemic in the United States with far reaching consequences for practitioners, patients and the medical system as a whole. For some, addressing the problem can be as simple as making a few organizational tweaks, while others are finding success with more aggressive, outside-the-box approaches to the problem. The key for practitioners everywhere is recognizing the signs of burnout and being proactive.

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Burnout—where to start?

Fortunately, there are resources for those struggling with burnout. And for physicians who are unsure of where to even start, the Michigan State Medical Society (MSMS) and the American Medical Association (AMA) are great places to turn.

MSMS and AMA recognized the severity of the physician burnout problem many years ago and has been making efforts to combat it ever since. That’s where Christine Sinsky, MD, FACP, comes in.

Doctor Sinsky is an internist at Medical Associates Clinic and Health Plans in Dubuque, Iowa, and she also serves as Vice President of Professional Satisfaction at the AMA – a role for which she is uniquely qualified.

“About seven years into practice, I came to the realization that I was going to need organize my work differently if I hoped to continue practicing medicine,” said Doctor Sinsky. “After reflecting on both the wants of my patients and my wants as a practitioner, I realized there was a lot of overlap, and that empowered me to reengineer my practice in a way that was more manageable and enjoyable for me while still providing my patients with the kind of quality care and attention they expect and deserve.”

Doctor Sinsky is now doing her best to help other physicians make the same kind of changes as the point person for StepsForward, a growing AMA initiative providing doctors with strategies to improve clinical workflows and efficiencies within their practice.

Launched in June 2015, the StepsForward initiative was born out of past research conducted by AMA-RAND identifying both the primary drivers of, and obstacles to, physician satisfaction. Unsurprisingly, the ability to provide high quality care was identified as the largest contributing factor to physicians’ sense of professional satisfaction, while impediments to providing that quality care were recognized as significant stressors for practitioners.

Today, the program provides physicians with access to nearly 50 modules offering practical and actionable guidance on how to reengineer their practice to run more efficiently and effectively.

“StepsForward is a great place to start for any physician struggling with burnout. There’s just so much that can be done in terms of process improvements and workflow adjustments within a practice to improve the situation. Making just a few simple operational changes, such as instituting pre-visit laboratory testing or synchronizing prescription renewals, can dramatically improve the efficiency of a practice, which saves time and that

“After reflecting on both the wants of my patients and my wants as a practitioner, I realized there was a lot of overlap, and that empowered me to reengineer my practice in a way that was more manageable and enjoyable for me while still providing my patients with the kind of quality care and attention they expect and deserve.”

—Christine Sinsky, MD, FACP

StepsForward is a growing AMA initiative providing doctors with strategies to improve clinical workflows and efficiencies within their practice.

leaves everyone – physicians, support staff and patients – happier. Process excellence should always be the goal. ”

And StepsForward makes it easy for those who have no idea of where to start. Before starting the modules, physicians are encouraged to first fill out a practice assessment questionnaire. The exercise provides physicians the opportunity to reflect on the operations of their practice, and the responses generate suggestions on what modules physicians should consider in order to maximize the benefits of the program.

Rapid Cycle Process Improvement in Action One does not need to go far to find physicians benefiting from intense focus on process excellence.

After years spent practicing in an environment that prevented them from addressing the barriers they recognized to providing great care, Michigan physicians Christopher Dehlin, MD, and his wife, fellow practitioner, Jennifer Dehlin, MD, made the bold the decision to open their own practice and immediately set out to do things differently where they live in Marquette.

The edict driving their new practice, Singletrack Health, is simple – everyone can and should be engaged in the process to improve the delivery of quality care.

“Happy patients and happy physicians go hand in hand,” said Doctor Dehlin. “The key to getting there is having the whole staff engaged in the effort to identify all the little things we can change that would make the day run smoother. When your whole staff is empowered in that effort, everyone is happier.”

To facilitate that rapid cycle process improvement, Singletrack Health holds weekly staff meetings where team members are encouraged to offer suggestions and raise concerns that are heard, and can be immediately acted upon, by the practice’s decision makers.

The system enables the practice to quickly address any inefficient or frustrating aspects of their care processes, and that has allowed everyone, including Doctor Dehlin, to devote more time to the kind of things they want to be doing.

The results have been remarkable. In just one year, strong focus on communication and collaboration amongst the staff and constant emphasis on identifying ways in which the Singletrack Health team can work smarter and more efficiently has yielded amazing results in terms of both patient and staff satisfaction.

“It’s pretty incredible when you think about it because what we’re doing isn’t that revolutionary,” said Doctor Dehlin. “We’re taking care of the same people, in the same town, with mostly the same staff, but it’s just so much more enjoyable now, and that really just boils down to the philosophy of how we’re taking care of these patients and engaging our staff. There’s nothing extra special about us or what we’re doing, we just truly focus everyday on making things run better.”

Doctor Dehlin’s advice for other doctors suffering from burnout is to get proactive about addressing it.

“Burnout doesn’t come from working hard, it comes from how big the difference is between what you are doing and what you want to be doing,” said Doctor Dehlin. “The more closely you can align those two things, the happier you’ll be. And to do that, you need to first reflect on what it is you want, and then take steps to make it happen.

There will always be a stressful component to the work we do as physicians, but there are so many opportunities for rejuvenation when you actually feel like you’re doing a great job.”

The edict driving Singletrack Health, is simple – everyone can and should be engaged in the process to improve the delivery of quality care.

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“Happy patients and happy physicians go hand in hand,” said Doctor Dehlin. “The key to getting there is having the whole staff engaged in the effort to identify all the little things we can change that would make the day run smoother. When your whole staff is empowered in that effort, everyone is happier.”

—Christopher Dehlin, MD

Beyond the Practice: Addressing the Personal Component of Burnout Addressing the bureaucratic burdens that come with practicing medicine should provide tremendous relief for most physicians suffering from burnout. However, according to Doctor Sinsky, there is also a personal component that needs to be recognized when it comes to physician wellness and satisfaction.

“From what I’ve observed, 80 percent of burnout is related to organizational factors, and a lot of that can be addressed by simply focusing on process improvements,” said Doctor Sinsky. “However, the other 20 percent is determined by individual factors, and it’s important that physicians are aware of that personal component of burnout and takes their own steps to address it.”

On this front, Doctor Sinsky recommends all physicians adopt the practice of mindfulness training and take steps to aggressively protect their work-life balance – two things that are often easier said than done, but important nonetheless.

“It’s easy to put off administering self-care as a physician,” said Doctor Sinsky. “We’re often so predisposed to take on ‘one more thing,’ and then ‘one more thing’ after that, until there’s just no time left to take care of ourselves. But we need to fight that instinct because that’s typically how burnout begins – when it feels like there’s no time left for the things we enjoy in life.”

To combat this feeling, Doctor Sinsky recommends endeavoring to intentionally leave the problems of work at work and the problems of home at home, which helps in the effort to be fully present and engaged in both settings. Letting everything else fall away, allowing oneself to fully engage with the patient in the room can make a real difference for physicians struggling to find meaning and happiness in their work.

Taking just a few minutes a day for reflection can also do a world of good. Pause from time to time and ask oneself “Why did I originally decide to pursue medicine? What aspect of my practice do

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I find the most meaningful? What is it that I ultimately want out of my career? What do I want out of my personal life?” Breaking momentarily to internally ask and answer these kinds of questions from time to time can help center and rejuvenate physicians who have lost their sense of what’s great about practicing medicine.

“Joy in the practice of medicine isn’t just possible, it should be expected,” said Sinsky. “It’s tough to name a profession that takes on more meaningful work. Physicians heal people - there’s so much room for joy in that service. As physicians, we just need to do our best to create an environment that enables us to stay connected to the meaningful aspect of what we do – providing quality care to the patients who need us.”

Leaving the System Behind Some physicians are taking measures much more drastic than process improvement and the practice of mindfulness to rediscover the satisfaction they know medicine can provide.

Not that long ago, Chad Savage, MD, of Brighton, MI was facing down the very real consequences of burnout. Years spent working for a hospital-employed, insurance-based practice seeing over 3,000 patients began taking its toll far too early in Doctor Savage’s career.

“Despite the fact that it felt like I was working 24 hours a day 7 days a week, it got to the point where I wasn’t able to see as many patients as I had previously been seeing because I just kept getting more and more bogged down by all the bureaucratic stuff that gets in the way of patient care,” said Doctor Savage. “The system just became so overly burdensome. I knew I had to do something different.”

Doctor Savage’s solution: direct primary care.

Doctor Savage opened a new practice, YourChoice Direct Care, and adopted the direct primary care model, allowing him to cut the middleman entirely. His patients pay a monthly membership, which entitles them to unlimited office visits, annual wellness exams, discounted lab work, basic office procedures, and 24/7/365 telemedicine access - no insurance, no red tape.

The move has done wonders.

“I don’t know how else to describe it, but I really do feel lighter now,” said Doctor Savage. “What I do now is almost exclusively patient care, and I’m able to so freely move throughout my day providing that. It’s so freeing to be able to simply do what you need to do for your patients without first jumping through a bunch of hoops to complete what’s often a simple task.”

While still unfamiliar to many, Doctor Savage thinks the direct care model is definitely a way forward for a medical system in need of serious reform.

“Most people go into medicine with no false illusions about it being an easy job. But there is an expectation that the toughness is going to be the practice of medicine,” said Doctor Savage. “It’s the unexpected burden that comes with all the bureaucratic activity

“We should work in a system that facilitates good care by eliminating the obstacles to it, and the direct primary care model is very conducive to that.”

—Chad Savage, MD

that has really sucked the joy out of the practice of medicine for most. There’s no reason, especially with primary care, why there needs to be an army of middlemen between us and our patients, especially when that army often serves to steer and corrupt physician behavior. We should work in a system that facilitates good care by eliminating the obstacles to it, and the direct primary care model is very conducive to that.”

The Bottom Line Is there a “best” answer when it comes to coping with physician burnout? No, probably not, but it’s plain to see that physicians everywhere are devising individualized solutions that do work.

And there is a common denominator. Every physician that has managed to rediscover the happiness that can be found in the practice of medicine all took a proactive step toward reviving it.

Physicians feeling frustrated need to work toward solutions that align with their needs and circumstances, and that takes reflection and research. Reflection comes in one’s own time, but the Michigan State Medical Society can help members with the research component. The on-demand webinar titled “In Search of Joy in Practice” and past Michigan Medicine articles on the topic of physician burnout are excellent places to start.

And starting is the most important part.

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HIT CORNER

Team Documentation Helps Tackle EHR Burnout

By Sara Berg, Senior Staff Writer, AMA

Two of the most frequent complaints about electronic health records (EHRs) echoed by physicians are that they hinder face-to-face interaction with patients and require physicians to become data entry experts.

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Christine Sinsky, MD, a practicing internist and Vice President of Professional Satisfaction at the American Medical Association (AMA) was quoted in a recent AMA Wire® story about how the impact of EHRs and increasing requirements and regulations have fundamentally changed the nature of a physician’s work: “Work previously done by other team members has been shifted to the physician in the EHR,” said Dr. Sinsky. “Tasks that may have earlier required a matter of

seconds, now may each take one to two minutes. Add this up over the thousands of individual tasks each day and it wasn’t surprising that I and other physicians began to wonder if we were spending more time caring for the computer than caring for the patient.”

The amount of time spent by physicians interacting with EHRs was the topic of a recent study published in September in Annals of Family Medicine. Doctor Sinsky is one of the study’s co-authors along with

researchers from the AMA and the University of Wisconsin’s medical school and engineering department. The study, which followed the EHR interactions from 142 family physicians in a single health care system in southern Wisconsin over a threeyear period, found that each weekday, physicians spent an average of 5.9 hours out of an 11.4-hour workday working in the EHR.

The breakdown was as follows: 4.5 hours during clinic times and 1.4 hours after work.

44 percent of the total EHR usage time was spent on clerical and administrative tasks such as documentation, order entry, billing and coding and system security.

About one-third of the time was spent on medical care EHR tasks such as chart reviews and problem lists.

24 percent of the time was spent on inbox management.

It was noted that “a big chunk of the administrative work family physicians and other doctors do on EHRs could be properly delegated to other members of the practice team.” The study’s authors noted that there are some solutions that can be implemented to help cut stress and burnout related to EHR systems.

These solutions include: Proactive planned care Team-based care that includes expanded rooming protocols, standing orders and panel management.

Sharing of clerical tasks including documentation, order entry and prescription management.

Verbal communication and shared inbox work.

Improved team function.

“The most powerful intervention to increase direct clinical face time with patients is advanced team-based care where the physician is paired with a stable team of two or three clinical assistants,” said Dr. Sinsky. “In this model, one of the clinical assistants provides in-room support during the patient visit, performing real-time information retrieval, visit note documentation and pending of orders.”

“Together, this care team is able to efficiently provide access and care to patients who need to be seen, close preventive and chronic-illness care gaps in a standardized manner and—because the medical assistant or nurse was in the room during the appointment— can also provide more robust between visit care,” she added.

The AMA, through the STEPS Forward™ initiative, has interactive 24/7 online practice modules available to assist physicians and their practices implement team-based care strategies to address common EHR challenges such as team documentation and inbox management. The goal of STEPS

Forward™ is to offer physician-developed strategies “that allow physicians and their staff to thrive in the evolving health care environment by working smarter, not harder.”

Team Documentation Module Team documentation, also referred to as “scribing,” is a process where staff assist with documenting visit notes, entering orders and referrals and queuing up prescriptions in real-time while in the exam room with the physician and the patient.

By implementing a team documentation process, physicians can delegate medical recordkeeping tasks that will allow them to focus more on the patient and deliver quality care during patient visits. This model is intended to help practices learn how to effectively implement the team documentation process including assessing their current documentation process, designing an efficient workflow, delegating administrative tasks to appropriate staff, and managing post-implementation process improvements.

EHR In-Basket Restructuring for Improved Efficiency Module When the physician’s in-basket becomes the default destination for most forms of communication in the office, it creates a burden that can be difficult to effectively manage. The physician is then faced with spending long hours before and after clinic to complete “between visit” clerical work.

However, most in-basket messages in many practices do not need to be routed to the physician. This module is designed to help practices think critically about messages being routed to the physician, guide practices to establish a centralized team in-basket, and suggest ways to empower team members to contribute in a meaningful way to in-basket management.

To view these and other STEPS Forward™ modules visit http://www.ama-assn.org/ ama/ama-wire/blog/STEPS_Forward/1.

ACKNOWLEDGEMENT – MSMS thanks the American Medical Association and the AMA Wire® for the content of this article. Excerpts taken from Family doctors spend 86 minutes of “pajama time” with EHRs nightly, September 11, 2017, Sara Berg, Senior Staff Writer, AMA Wire®.

NOV / DEC 2017 |

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IN MEMORIAM

Former MSMS Executive Director Warren Tryloff Has Died Warren F. Tryloff, former Executive Director and longtime friend of the Michigan State Medical Society, passed away on August 21, 2017 at the age of 95. Tryloff will be remembered as one of the most influential leaders of MSMS, whose inspiring work helped expand the organization into what it is today.

In the beginning of his career with the Michigan State Medical Society, Tryloff worked closely with MSMS’s first executive director, William J. Burns. He was highly involved with the selection and building of MSMS’s present headquarters in East Lansing, designed by world renowned architect Minoru Yamaskai. Tryloff’s early influence on MSMS is still felt today in other areas as well, as he was instrumental in realigning the MSMS board size and structure along with splitting the House of Delegates from the annual scientific meeting.

In 1970, Tryloff was appointed to serve as the Executive Director of the Michigan State Medical Society. Some of his most recognized achievements during his tenure include his involvement in creating the Michigan Physicians Mutual Liability Company in 1977, an organization that eventually became The Doctors Company, along with passing comprehensive Tort Reform and starting MSMS’s pension protection program, a member benefit that is still in effect today.

OBITUARY

WARREN F. TRYLOFF

WARREN F. TRYLOFF 1922 - 2017

William Madigan, MSMS Executive Director from 1987 to 2005, remembers Tryloff as a great leader and a man that was easy to work with.

“Much of his style is permanently ingrained at MSMS and in all the leaders and staff who came after him to one degree or another,” said Madigan. “He set the direction and let his staff run and flourish.

His staff and physician members loved his style and strength, which made the Michigan State Medical Society so effective and welcoming.

Under Tryloff’s strong leadership, MSMS revamped Michigan Medicine magazine— it became the first socioeconomic medical association magazine in the AMA federation. Prior to this, Michigan Medicine was a scientific journal.

“Warren’s was the consummate planner and organizer. Prior to every Board meeting and House of Delegates sessions, staff and leadership would hold pre-meeting and post-meeting sessions to assess successes and/or failures,” said Madigan.

“Early on it was what we now know today as continuous quality improvement.”

Tryloff served as Executive Director from 1970 to 1984, at which time he retired and ended his 32-year long career with MSMS.

Warren Tryloff leaves three daughters, Robin, Molly and Maggie, and five grandchildren residing in Evanston, Illinois.

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Warren F. Tryloff, 95, died peacefully on August 21, 2017, at McGaw Care Center in Evanston, Illinois. He was widely admired for his leadership, wisdom, and grace, and will be deeply missed by all who knew and loved him. Mr. Tryloff was born in Mount Clemens, Michigan, on January 24, 1922.

He studied business at Michigan State University, and joined the Army Air Force in World War II. He was a bombardier with the 8th Air Force, was shot down and held a prisoner of war in Germany, and was discharged a first lieutenant. After his marriage to Nancy Iske of Hamilton, Ohio, the couple moved to East Lansing, Michigan, where he began his medical association career. In 1985, he retired as chief staff executive of the Michigan State Medical Society after 32 years of service to the organization. He is survived by daughters Robin Tryloff, Molly Niespodziewanski, and Margaret Flores; granddaughters Emily Streetman, Catherine Niespodziewanski, Nora Flores, and Lilia Flores; and nephews Jerry and Paul Tryloff. He was preceded in death by his wife Nancy, sister Harriet, and brother Duane. A funeral service will be held on Saturday, August 26, 2017, at 2:30 p.m. at Elliott Chapel at Westminster Place, 3131 Simpson Street (access off of Golf Road) in Evanston, Illinois. Donations may be made to Alice Lloyd College, 100 Purpose Road, Pippa Passes, Kentucky 41844, or the Geneva Foundation of Presbyterian Homes, 3200 Grant Street, Evanston, Il 60201.

Published in Lansing State Journal from Aug. 25 to Aug. 27, 2017.

In Memoriam

MEMBERS OF THE MICHIGAN STATE MEDICAL SOCIETY REMEMBER THEIR COLLEAGUES WHO HAVE DIED.

x

DALE ROBERT DREW, MD OAKLAND COUNTY MEDICAL SOCIETY 9/1/17

We’ve designed 14,960 websites.

DAVID A. BRINTON, MD OAKLAND COUNTY MEDICAL SOCIETY 9/7/17 EDUARDO T. BERMUDEZ, MD SAGINAW COUNTY MEDICAL SOCIETY 9/14/17 JOHN GEORGE KLEMM HARVEY, MD MUSKEGON COUNTY MEDICAL SOCIETY 8/22/17 PETER E. MIKELENS, MD GENESEE COUNTY MEDICAL SOCIETY 8/9/17 WARREN F TRYLOFF 8/22/17

And we only reached that number because physicians like you trust us to help them succeed.

Call (888) 536-5537 or visit Officite.com/Nov/MSMS for a free consultation and two months free website hosting.

x TO MAKE GIFT OR BEQUEST TO THE MSMS FOUNDATION CONTACT: REBECCA BLAKE, DIRECTOR, MSMS FOUNDATION PHONE 517-336-5729

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michigan MEDICINE 23

MSMS Medical Opportunities msms.medopps.org

msms.medopps.org

Family Health Care Outpatient Urgent Care Opportunity in Health Center, PA/NP Baldwin, MI Medical Opportunities ID # 11935

Family Health Care Internal Med and Family Med Opportunity in River Country, MD/DO White Cloud, MI Medical Opportunities ID # 11743 We’re looking for a patient-centered physician to join our outpatient health center facility in White Cloud, MI, just outside of Big Rapids and close to beautiful Lake Michigan. Practice Medicine the way it was meant to be with limited productivity expectations and no hospital rotations. Flexible schedule and a dedicated care team complete with a scribe.

As the only medical practice in Lake County, we are looking to expand services to an urgent care setting with 2-3 midlevel providers on weekly bases.

Northwest Michigan Health Services, Inc.

Why Family Health Care?

Call Rotation (PHONE ONLY) 1:11

FHC was the first community health center in Michigan and the third in the nation.

No Hospital Rotations

FHC has and continues to play a vital role in the “one-stop-shopping” concept for health care services.

We are accredited by the Accreditation Association for Ambulatory Health Care (AAAHC) and National Committee for Quality Assurance (NCQA).

We are also certified as a Patient Centered Medical Home (PCMH).

Progressive practice model including EHR (NextGen).

Outpatient Practice Directed by a board of directors composed of community members and patients Direct and immediate return of patient satisfaction Patients truly respect and appreciate our Physicians Patient Centered Organization Model Active retention and provider burnout reduction plan of action Progressive, Non-profit, Group Practice, and privately owned

What we provide our Physicians: 4 or 5 Day Work Week

Eligible for $25,000 in TAX FREE loan repayment per year for up to 8 years.

Henry Ford Health System Sleep Medicine Physician, MD/DO Novi, MI

Federal Malpractice Coverage (No Cost to you)

Medical Opportunities ID # 126890

Experienced Mid-levels within your team

The Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine is expanding and has a need for a Sleep Medicine Physician for our Henry Ford Columbus (Novi) & Taylor Medical Centers.

Scribe 1.5 Medical Assistants RN Case Manager Behavioral Health Therapist Clinical Pharmacist to assist with Medication review, interactions, and education Excellent Equipment and Trial of new products (within reason) Much more!

Henry Ford Health System Division Head, Hematology/Oncology, MD/DO Detroit, MI Medical Opportunities ID # 12689 Henry Ford Health System is seeking a passionate leader for the Division of Hematology-Oncology.

This leader will provide oversight for the Hematology-Oncology Division within the Department of Medicine for Henry Ford Medical Group. The Division Head must have a solid academic background and an unwavering desire to build a robust research enterprise in areas such as clinical trials, precision medicine, and population health.

Reporting to the System Medical Director, Henry Ford Cancer Institute and the Chair, Department of Medicine, the Division Head of Hematology/Oncology will provide oversight for the Hematology/Oncology (HemOnc) Division within the Department of Medicine for Henry Ford Medical Group (HFMG) and will be a senior

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leader providing insight and guidance to the Henry Ford Cancer Institute (HFCI) Clinical Council with a focus on System HemOnc Growth Strategy.

Further, the Division Head serves in a physician leadership role over the Bone Marrow Transplant Program. The incumbent also partners extensively with the HFCI administrative dyad partners in all five of HFCI’s markets to ensure continuity and quality outcomes while pursuing growth opportunities for HemOnc and infusion services.

The Division Head should have a strong academic background and be prepared to build a strong research enterprise in areas such as clinical trials, precision medicine, and population health. The Division Head is also responsible for advancing the medical education mission and ensuring a robust, innovative fellowship program and an environment of scholarly inquiry.

Our Academic Center is actively recruiting a Sleep Medicine Specialist with background in pulmonary/critical care, neurology, psychiatry or otorhinolaryngology to join our team. Our ACGME approved fellowship trains 3 physicians yearly and educates multiple trainees from our residency and fellowship programs. Our three AASM accredited sleep laboratories count with a total of 12 beds, providing over 5000 outpatient visits, close to 3000 polysomnograms annually and 1500 home sleep studies. Three PhDs are responsible for the conduct of NIH and pharmaceutical studies, with international recognition for work in insomnia, circadian disorders, sleep apnea, sleep and pain, sleep pharmacology, and sleep therapies. The ideal candidate would supplement current clinical and research endeavors.

Henry Ford Health System Medical Director, MD/DO Detroit, MI Medical Opportunities ID # 12691 Henry Ford Health System seeks a Precision Medicine Program - Medical Director.

Under the direction of the Medical Director, Henry Ford Cancer Institute (HFCI), and the Division Head, Henry Ford Medical Group (HFMG) Hematology/Oncology, the Medical Director,

MSMS Medical Opportunities has been connecting physicians with employers since 1944.

It is a nonprofit program through the Michigan Health Council designed to simplify your job search by posting jobs that match your practice preferences. Learn more at msms.medopps.org.

Precision Medicine Program (PMP), provides overall clinical management of the system wide program, which encompasses clinical leadership, program/business development, strategic planning, regulatory compliance, research and education, and other administrative roles in the department. The Medical Director will be expected to work alongside the Director, PMP to develop, implement, monitor, and lead an innovative vision in creating a nationally recognized Precision Medicine Department. This position requires the full understanding and active participation in fulfilling the mission of HFHS and the HFCI. It is expected the physician demonstrates behavior consistent with the core values and supports the HFHS and HFCI strategic plan.

The Medical Director will also act as a Liaison between HFCI’s Precision Medicine Program and the HFMG Hematology/Oncology Division. The incumbent will also serve a leading role in HFCI System-wide Clinical Research management and administration, partnering with existing Phase I physician leadership and the HFCI Clinical Trials Office (CTO) team.

This is a high profile position within both PMP and the HFCI research arm. The incumbent in this position will possess a deep understanding of multifaceted matrixed cancer organizations and exude and employ an emotionally intelligent approach to dyad leadership with his/her PMP Administrative Director counterpart. The incumbent demonstrates an exceptional level of integrity, judgment, trust and confidentiality; and presents a balanced perspective across all stakeholders.

Henry Ford Allegiance Health Pediatrics Opportunity, MD/DO Jackson, MI Medical Opportunities ID # 8925 Pediatrician Hospitalist Henry Ford Allegiance Health located in Jackson, Michigan is seeking board certified or eligible Pediatric Hospitalists to join our experienced team. One full time or several part-time or per diem positions are available. Enjoy excellent worklife balance with flexible scheduling. The affiliation gives Henry Ford Allegiance Health greater access to new state-of-the-art technologies and data driven care models, and enable physicians and other clinicians from both systems to work together to develop innovative approaches to patient care. It will also help Henry Ford Allegiance Health expand its services strategically, and have better access to capital funding. By working together with HFHS, Henry Ford Allegiance Health

can become more efficient, generating additional funds from Allegiance’s operations, that will stay in the Jackson community. We are adding a new innovation center (adding State of Art Simulation & Research Labs) Fall 2017, to a new Patient Surgical Tower that will add 66 private rooms, Fall 2018.

Competitive salary package Allegiance Health recently became the newest member of the Henry Ford Medical Group EPIC EMR is currently being implemented as part of the partnership 12-hour shifts Average of 11 or 12 shifts per month for full time position Nights, weekends and holidays shared equally 9 bed Level II NICU caring for infants 32 weeks gestation and above where you work closely with NNPs support Other responsibilities; include high risk delivery attendance, normal newborn care, inpatient pediatric care, Emergency Department consultation, and Pediatric Rapid Response team coverage In house OB Hospitalists Opportunities for teaching residents in Family Medicine, Psychiatry, Traditional Internship and Emergency Medicine, as well as Michigan State University medical students that rotate on inpatient pediatrics

Henry Ford Allegiance Health Rheumatology, MD/DO Jackson, MI Medical Opportunities ID # 1007 Henry Ford Allegiance Health seeks a fourth BE/ BC Rheumatologist to join well-established and reputable practice (20 years). See the following: Current board-certified Rheumatologists see an average of 24 patients/day and are scheduling new patients up to 6 months out.

Office equipped with 8 exam rooms and fully staffed with 2 LPN’s, office manager and receptionist / medical assistant / medical biller.

Limited call of 1:4.

We offer a very competitive salary, productivity bonus and signing bonus.

Paid benefits include: medical, dental, short and long term disability, life insurance, pension and 403b plan, four weeks vacation, one week CME. Recruitment Incentives include paid interview expenses, moving expenses, malpractice insurance, student loan repayment up to $50K, a $30K relocation stipend if you purchase a home in Jackson County.EEO/AA

Henry Ford Allegiance Health Employed ENT Opportunity, MD/DO Jackson, MI Medical Opportunities ID # 9888 Henry Ford Allegiance Health is seeking to employ a BE/BC, general Otolaryngologist to join two board-certified otolaryngologists in a wellestablished and thriving, broad-based practice offering an immediate patient base.

Common procedures include: Audiogram, Adult Ear Tubes, Biopsy of Skin and Oral lesions, Cauterization of nose bleeds, Cerumen removal, Frenulectomy (tongue tie), Nasal Endoscopy and Laryngoscopy, Removal of Ear and Nasal Foreign Bodies. Stateof-the-art microscopes and audio booths in office.

EMR: EPIC being installed August 5, 2017.

We partnered with Henry Ford Health Systems on April 1, 2016, who just passed their 100 years of service. How many companies can say they have survived 100 years of successful business.

Allegiance Health is entering their 99th year. This is very exciting for Henry Ford Allegiance Health and our community.

The affiliation gives Henry Ford Allegiance Health greater access to new state-of-the-art technologies and data driven care models, and enable physicians and other clinicians from both systems to work together to develop innovative approaches to patient care. It will also help Henry Ford Allegiance Health expand its services strategically, and have better access to capital funding. By working together with HFHS, Henry Ford Allegiance Health can become more efficient, generating additional funds from Allegiance’s operations, that will stay in the Jackson community. We are constructing a new innovation center (adding State of Art Simulation & Research Labs) Fall 2017, a Surgical Patient Tower that will add 66 private rooms, Fall 2018.

Henry Ford Allegiance Health Neurologist, MD/DO Jackson, MI Medical Opportunities ID # 12101 Henry Ford Allegiance Health is seeking BC/BE Neurologist to join a reputable practice with 2.75 outpatient providers, 1 nurse practitioner and 1.75 inpatient neurology hospitalist.

The Neurology Hospitalists cover 44 of 52 weeks, and the eight weeks remaining are split among four (one private practice) providers. The Hospitalist is the feeder system for follow up care for our outpatient Neurologist.

MED OPS – CONTINUED ON PAGE 26

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MED OPS – CONTINUED FROM PAGE 25 7 exam rooms 2 medical office supports (hiring for a 3rd who will be part time) 4 MAs 1 NP rounds inpatient Perform EMGs in the office Botox injections, research and med trials are being done by one of the providers Benefits, Compensation & Incentives The compensation package includes a base salary with bonus opportunity, malpractice and health insurance, CME, PTO, and a 403(b). Henry Ford Allegiance Health also provides a housing incentive to any physician that relocates his/ her primary residence to Jackson County within the first year, student loan forgiveness, moving allowance, and a signing bonus.

Henry Ford Allegiance Health Psychiatry: Core Faculty / Substance / Geriatrics, MD/DO Jackson, MI Medical Opportunities ID # 11775 The faculties are clinical psychiatrist responsible for supervision of the psychiatry residents and other trainees on psychiatry rotations. We have opportunities focusing on substance abuse, and geriatrics as well.

Henry Ford Allegiance Health Palliative Hospice Medical Director, MD/DO Jackson, MI

Northwest Michigan Health Services, Inc. Family Medicine, NP Manistee, MI

Medical Opportunities ID # 3899

Medical Opportunities ID # 11964

Join a very reputable, well-established (2002) and rapidly expanding employed group practice.

Currently 1-1/2 board-certified geriatricians/ hospice & palliative medicine, 4-NPs, 1-RN, 1-MA, 1-LMSW and clinical support staff. Allegiance Senior Health Center is an outpatient clinic which offers primary geriatric care, comprehensive geriatric assessment, home care, inpatient and outpatient palliative care as well as coverage for our freestanding Hospice Residence and our Inhome Hospice Program.

Northwest Michigan Health Services, Inc. is opening a new clinic in Manistee, MI and is seeking a full-time Nurse Practitioner. Northwest Michigan Health Services, Inc. is a Federally Qualified Health Center, offering primary medical, general dentistry and behavioral health services for all ages in a community health setting.

Practice Info -Hours are M-F, 8-5p -No acute care or skilled nursing home involvement -Patient volume varies averaging 10-18 patients/ day per provider -Palliative care certification/experience is a plus -Primary call 1:4 with backup call for midlevels.

Ability to work independently

All incoming calls are triaged via RN staffed messaging service.

We offer a competitive compensation package with full benefits including: full health, dental, life and retirement benefits. Excellent recruitment incentives include: signing bonus, student loan repayment, $30K relocation incentive, CME time & allowance, paid moving expenses and more.

We are redesigning behavioral health in our community and need to be sure candidates are interested in helping to build a ‘new’ academic program. Program is focusing on population health management, integration.

Henry Ford Allegiance Health Adult Psychiatry, MD/DO Jackson, MI

Clinical duties include a combination of inpatient, outpatient, and consult liaison work in psychiatric service and will include participation in research.

Core Faculty will model professionalism, collaboration and teamwork with staff and other health professionals. The faculties are expected to engage in any or all areas of scholarship – discovery, teaching, integration, and application.

Faculty members will contribute to the advancement of the discipline of Psychiatry as demonstrated by peer-reviewed funding; publication of original research or review articles in peer reviewed journals, or chapters in textbooks; publication or presentation of case reports or clinical series at local, regional, or national professional and scientific society meetings; or, participation in national committees or educational organizations.

Opportunity for Adult Psychiatry

Administrative All faculty members will participate in some administrative activities as a function of other elements of the job (e.g., leading curriculum committees or task-forces, organizing education, QI teams, etc.) While the Program Director has primary responsibility for administration of the residency, the faculty will participate in resident and faculty or staff recruitment activities, program evaluation, accreditation work, as delegated.

We have a full service for Behavioral Health.

Come live, work and play in the beautiful South Central Michigan. Jackson is a family oriented community with excellent schools, is in close proximity with two Big Ten Universities and provides affordable housing. Our four-season climate provides the perfect formula for unlimited year-round recreational activities.

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Medical Opportunities ID # 12692 Behavioral Health Outpatient (Geriatrics, Child/Adolescent, Adult) Partial day programs (Intensive outpatient program)

Qualifications Licensed Nurse Practitioner in the State of Michigan

Community Health Experience preferred Northwest Michigan Health Services, Inc. is an Equal Opportunity Employer and offers a competitive wage and benefit package.

Pine Rest Christian Mental Health Services Psychiatry Opportunity, MD/DO Grand Rapids, MI Medical Opportunities ID # 6808 Pine Rest is now hiring for Psychiatry! We have opportunities to join our medical staff team of over 80 board certified psychiatrists in our 225+ bed inpatient hospital or in one of our 19 outpatient clinics throughout West Michigan.

Pine Rest is one of the largest free-standing behavioral health providers in the U.S. A nonprofit organization founded in 1910, its comprehensive behavioral health center is located on a 200 acre campus in beautiful Grand Rapids, Michigan and has a network of 19 outpatient offices in Michigan and Iowa, providing individualized and group therapy for people of all ages. Depending on the severity of needs, Pine Rest offers inpatient hospitalization, partial hospitalization, outpatient counseling (through our clinic network), residential & community services, and consultation liaison.

Inpatient Adult/Geri unit

Crisis Assistance

St. John River District Hospital Family Medicine, Ob/Gyn, Urgent Care, MD/DO East China Township, MI

Addiction recovery center

Medical Opportunities ID #12683

Neuropsychology (only neuropsychology service in Jackson county)

Substance Abuse Services We are looking to redesign our behavioral health department now that we are growing.

St. John River District has openings in: Family Medicine-Full-time, Outpatient Only Solo practice located in Algonac-located in St. Clair County Seeking two family medicine physicians for practice in East China to join a team of 5 physicians Obstetrics and Gynecology Seeking a full-time physician to replace a retiring physician in East China Urgent Care Part time and contingent openings in St. Clair, Michigan

Practices for Sale Center for Ethics and Humanities in the Life Sciences

College of Human Medicine

Clinical Ethics Consultation Services Helping health professionals optimize the delivery of ethically sound care.

Clinical Ethics Consultation Training Workshops Develop and enhance your clinical ethics consultation skills in an interactive small-group environment.

For detailed information visit bioethics.msu.edu clinical.ethics@hc.msu.edu (517) 355-7550

Rochester Hills Walk in Clinic Reasonable monthly rent, successful business, current Physician is looking at going back into Industrial Medicine. History of over 1 million dollar gross.

Very nice insurance mix, mostly internal medicine practice is up for best offer since the plan is to sell by June.

Dearborn – General Practice Semi Retired Physician has a 2-3 day practice 20-30 patients per week, $20,000 for practice or free when you lease or buy building.

Jackson – Well Established Practice, Mostly Medicare Nice 2700sq.ft building, large parking lot, favorable location. Good insurance mix, equipment. Will offer terms of all kinds on this $425-500K grossing business with good loyal patients. Conservatively operated for years.

Reasonable offer for business, $160K building on land contract.

ENT with mostly Allergy Patients, Westland

Hearing aid tenant in building, small general medicine tenant, buy practice (asking $25K) and rent on short or long term agreement, very reasonable rates. Plenty of room and parking.

White Lake Primary Care Practice On busy corner of M-59. Grosses $700,000 - $800,000 a year. Doctor has medical conditions needs to sell. Good insurance mix. Plenty of parking, nice facility, a must see if you are looking to expand your practice. Asking $200,000.

Pediatrics in Westland near Canton 30 years, high volume, yes it does a big gross. A Pediatrician Physician can work into the practice and take over EARN and purchase transaction.

Only a Boarded Pediatrician, potential to earn substantial income.

Call Joe for details, Cell: 248-240-2141.

The Good Doctor Suddenly Died St. Clair Shores near 9 Mile, 2500 sq.ft. clinic, 4 exam rooms, 180 active Internal Medicine Patients Medicare Patients. The heirs wish to make a win win deal for you. All the equipment including vascular/doppler/echo/ UltraSound. Call and ask about this one!

Looking for Part time/Full time Work as a Provider?

Different locations available. Call Joe Zrenchik.

Joe Zrenchik, Broker 248-240-2141 (cell) • 734-808-0147 (eFax) bestdoctors@yahoo.com 248-919-0037(office) www.michiganmedicalpractices.com Thinking about retirement, relocation or expansion of your medical practice? We have buyers and sellers for primary care, internal medicine and cardiology practices.

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WEALTHCARE ADVISORS

Year-End Tax Planning Strategies

By Jim Niedzinski, AIF®, Wealth Advisor

D

id you know that according to the Tax Foundation, the average American pays more in taxes than for food,

clothing, and housing combined? Given the hustle and bustle that comes with the season, be sure to make time to connect with your tax and financial professionals to evaluate any year-end tax planning opportunities.

Here are some year-end tax planning strategies to consider.

Family Evaluate and potentially increase your withholding of state and federal taxes to help you avoid estimated tax underpayment penalties.

Determine whether you can shift income to family members who are in lower tax brackets to minimize overall taxes. The “kiddie tax” rules apply to: 1. those under age 18 2. those age 18 whose earned income doesn’t exceed one-half of their support 3. those age 19 to 23 who are full-time students and whose earned income doesn’t exceed one-half of their support Consider making gifts of up to $14,000 per person—a federal tax-free gift, under the annual gift tax exclusion. You can give up to this amount to as many people as you would like. Gift assets that are likely to appreciate significantly for optimal income tax savings.

Review if there are ways to minimize the income tax on social security and Medicare benefits by lowering income below the applicable threshold amounts.

Business Owners Accelerate expenses in the current year to lower your tax bill—such as repair work and the purchase of supplies and equipment.

Consider paying fourth quarter taxes before December 31, 2017 rather than waiting until January 15, 2018.

If you have significant business losses this year, it may be possible for you to apply them to the prior year’s returns to receive a net operating loss carryback refund. If you had significant income in prior years, you should maximize the current year’s losses by deferring income if possible.

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CONTACT A WEALTHCARE ADVISOR OR YOUR TAX PROFESSIONAL TO DETERMINE THE APPROPRIATE STRATEGIES FOR YOU.

Personal Residence / Real Estate

Retirement Account Management

Consider making your January 2018 mortgage payment in December 2017 so that you can deduct the accrued interest.

REVIEW ROTH CONVERSION STRATEGIES

Selling a primary residence? Confirm if you qualify to exclude all, or part of, the capital gains of the sale from federal income tax. If you meet the requirements, you can exclude up to $250,000 ($500,000 for married couples filing jointly). Generally, you can exclude the gain only if you used the home as your principal residence for at least two out of the five years preceding the sale. In addition, you can generally use this exemption only once every two years. However, if you don’t meet these requirements, you may still be able to qualify for a reduced exclusion if you meet the relevant conditions.

Selling an investment property? Consider structuring the sale of investment property as an installment sale to defer gains to later years.

Maximize the tax benefits you derive from your second home by modifying your personal use of the property in accordance with applicable tax guidelines.

Funding RETIREMENT PLAN FUNDING

Are you 70½? Make sure that you have satisfied your required minimum distribution by December 31, 2017.

Company stock in your 401(k) plan?

Evaluate if a Net Unrealized Appreciation strategy can be used.

INVESTMENT PORTFOLIO

Low tax rate today with expectation of high tax rate in the future?

Consider gain harvesting.

High tax rate today? Consider loss harvesting.

Important Deadlines:

» October 16 The last day to contribute to a SEP or Keogh retirement plan if an extension was filed for tax year 2016.

The last day to re-characterize a Roth Conversion from tax year 2016.

» December 31 Establishing and funding a Solo 401(k) for 2017

DONATE

Consider a qualified charitable distribution from IRA assets.

Consider establishing a donor advised fund.

Consider donating highly

Complete 2017 contributions to Employer Sponsored 401k plans Correct any excess contributions to IRAs and qualified plans.

appreciated stock in lieu of cash.

Consider a charitable remainder trust.

Maximize your pre-tax retirement plan contributions. At a minimum, contribute the necessary amount needed to maximize any employer match available to you.

Consider contributing to a Roth IRA or Traditional IRA. Set up a retirement plan for yourself, if you are a self-employed taxpayer.

COLLEGE FUNDING Consider contributing to a 529 College Savings Plan or an Education IRA.

JIM NIEDZINSKI, AIF®, HAS OVER 15 YEARS OF WEALTH MANAGEMENT EXPERIENCE. HE SPECIALIZES IN ADVISING CLIENTS WITH COMPLEX FINANCIAL SITUATIONS, SUCH AS THOSE INVOLVING PRIVATELY HELD BUSINESSES, EXECUTIVE COMPEN-SATION PACKAGES, AND ESTATE TAX LIABILITIES. PRIOR TO JOINING PLANNING ALTERNATIVES, JIM WAS CO-FOUNDER AND MANAGING PARTNER OF THE CAPSTONE GROUP, LLC, WHICH PROVIDED WEALTH MANAGEMENT SERVICES TO HIGH NET WORTH FAMILIES. JIM EARNED A BA DEGREE FROM THE UNIVERSITY OF MICHIGAN, ANN ARBOR AND HOLDS THE ACCREDITED INVESTMENT FIDUCIARY® (AIF®) CREDENTIAL.

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2017 - 2018 Educational Courses MSMS On-Demand Webinars: Educational Conferences CME When You Want It! REGISTER TODAY! Balancing Pain Management and Prescription Medication Abuse Billing 101 The CDC Guidelines* CDL – Medical Examiner Course Choosing Wisely Part 1: Stewards of Our Health Care Resources Choosing Wisely Part 2: Change Strategies to Implement Choosing Wisely Claim Appeals Compliance in the Office Conscientious Objection Among Physicians* Credentialing From Physician to Physician Leader Health Care Providers’ Role in Screening and Counseling for Interpersonal

and Domestic Violence: Dilemmas and Opportunities HEDIS Best Practices HIPAA Security and Meaningful Use Compliance Human Trafficking* ICD-10 (2017) and Routine Waiver of Copays ICD-10: What We Have Learned & What We Need to Know In Search of Joy in Practice: Innovations in Patient Centered Care Inter-professionalism: Cultivating Collaboration Legalities and Practicalities of HIT – Cyber Security: Issues and Liability Coverage – Engaging Patients on Their Own Turf: Using Websites and Society Media MACRA Webinar Series Managing Accounts Receivable Michigan Automated Prescription System (MAPS) Update* Opioids and Michigan’s Compensation Webinar Pain and Symptom Management* Patient Portals as a Tool for Patient Engagement Physician On-line Rating and Reviews: Do’s and Don’ts Preparing for the Medicare Physician Value-Based Payment Modifier Reading Remittance Advice The Role of the Laboratory in Toxicology and Drug Testing* Section 1557: Anti-Discrimination Obligations Understanding and Preventing Identity Theft in Your Practice Tips and Tricks on Working Rejections Treatment of Opioid Dependence* What’s New in Labor and Employment Law Year-End Wrap Up *Fulfills Board of Medicine Requirement

21st Annual Conference on Bioethics

Visit www.msms.org/OnDemand for complete listing of On-Demand Webinars.

Register online at msms.org/eo or call the MSMS Registrar at 517-336-7581.

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Date: Saturday, November 11 Time: 9:00 am – 4:30 pm Location: Sheraton Detroit Hotel, Ann Arbor Intended for: Physicians, bioethicists, residents, students, other health care professionals, and all individuals interested in bioethical issues Contact: Caryl Markzon at 517-336-5755 or cmarkzon@msms.org.

Practical Guidance for Health Care Compliance Date: Wednesday, December 6 Time: 10:00 am – 3:00 pm Location: MSMS Headquarters, East Lansing Intended for: Physicians, PO Administrators, practice consultants, office administrators, students, other health care professionals.

Contact: Caryl Markzon 517-336-7575 or cmarkzon@msms.org

2018 Spring Scientific Meeting Morning, afternoon and evening clinical courses available Date: Thursday, May 17 and Friday, May 18 Location: DoubleTree Hotel, Dearborn Note: Continental breakfast and lunch will be provided Intended for: Physicians and all other health care professionals Contact: Marianne Ben-Hamza 517-336-7581 or mbenhamza@msms.org

153rd MSMS Annual Scientific Meeting Morning, afternoon and evening clinical courses available Date: Wednesday, October 24 - Saturday, October 27 Location: Sheraton Detroit Novi Hotel, Novi Note: Continental breakfast and lunch will be provided.

Intended for: Physicians and all other health care professionals Contact: Marianne Ben-Hamza 517-336-7581 or mbenhamza@msms.org

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