Michigan Medicine®, Volume 121, No. 3

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May / June 2022



WHOSE INTERESTS does your malpractice insurer have at heart? does your malpractice insurer have at heart?

Yet another medical liability insurer has transitioned from focusing on doctors Yet Yet another another medical medical liability liability insurer insurer has has transitioned transitioned from from focusing focusing on on doctors doctors to focusing on Wall Street. This leaves you with an important question to ask: to to focusing focusing on on Wall Wall Street. Street. This This leaves leaves you you with with an an important important question question to to ask: ask: Do you want an insurer that’s driven by investors? Or do you want an insurer Do Do you you want want an an insurer insurer that’s that’s driven driven by by investors? investors? Or Or do do you you want want an an insurer insurer that’s driven to serve you—one that’s already paid $120 million in awards to that’s that’s driven driven to to serve serve you—one you—one that’s that’s already already paid paid $120 $120 million million in in awards awards to to its members when they retire from the practice of medicine? its its members members when when they they retire retire from from the the practice practice of of medicine? medicine? Join us and discover why delivering the best imaginable service and Join Join us us and and discover discover why why delivering delivering the the best best imaginable imaginable service service and and unrivaled rewards is at the core of who we are. unrivaled unrivaled rewards rewards is is at at the the core core of of who who we we are. are. Endorsed by Endorsed Endorsed by by

p resident 's Dear friends and colleagues, It is a thrill for me to offer my greetings in this message, which is my first as the newly-inaugurated President of the Michigan State Medical Society. It is a professional honor and a personal privilege for me to help guide this organization over the next year. I thank you for your trust and ask for your continued support of and involvement in MSMS, because we have a lot of important work to do. A key part of this work includes advocacy in the halls of government on behalf of our patients and our profession, and the feature article in this edition of Michigan Medicine focuses on the urgent need for us to be heard, both individually and collectively. Once again, an all-too-familiar push to expand the scope of practice for non-physicians is being discussed in the Michigan Legislature. Most recently, we saw this with the effort to remove physician supervision from anesthesia care in Michigan. Now, new legislation has been introduced allowing nurse practitioners to practice independently. As physicians, we know that this is not best the approach to take if we are serious as a state about providing quality, safe, accessible and affordable care for patients. In fact, Doctor Martha Gray, an Ann Arbor primary care physician quoted later in this edition, says it very well. “Public policy in Michigan should acknowledge, respect, and protect Michigan’s patient-centered, physician-led health care model,” she tells us. “It’s what patients want and what patients deserve.” Advocating for this physician-led health care model is the top public policy priority for MSMS. It is why we have led the creation of Michigan for Advancing Collaborative Care Teams (MIACCT), a diverse coalition of health care providers you will learn more about in this issue. MIACCT is working together to inform policy makers about the importance of physician-led care. It remains important that physicians across our state engage with their lawmakers to protect and promote the policies that best serve our patients. Working together, our voices can help bring about the important, sensible policy changes our patients need and deserve.


“It remains important that physicians across our state engage with their lawmakers to protect and promote the policies that best serve our patients. Working together, our voices can help bring about the important, sensible policy changes our patients need and deserve.”

We have a lot to accomplish together in the weeks and months ahead. I am excited to be working on your behalf for this next year as MSMS President, and look forward to our future collaboration..

Sincerely, Thomas J. Veverka, MD, FACS MSMS President

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12 The Fight to Preserve the Physician-led Care Team For many years, the Michigan Legislature has, like its peers in many other U.S. states, wrestled with issues related to the safe practice of medicine and the appropriate scope of practice for non-physicians working in the health care field. (Story begins on page 12.)

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Hiring a Physician Assistant DANIEL J. SCHULTE, J.D


MSMS Education: Live, Virtual and On-Demand Webinars MICHIGAN STATE MEDICAL SOCIETY

MICHIGAN MEDICINE® VOL. 121 / NO. 3 Chief Executive Officer JULIE L. NOVAK Managing Editor KEVIN MCFATRIDGE KMcFatridge@msms.org Publication Design STACIA LOVE, REZUBERANT! INC. rezudesign.com Printing FORESIGHT GROUP staceyt@foresightgroup.net


Employees on Military Leave JODI SCHAFER, SPHR, SHRM-SCP


Telephone Communication for Healthcare Providers: Safety Strategies NICOLE FRANKLIN, MS, CPHRM


May is Hepatitis Awareness Month and May 19th is Hepatitis Testing Day




Publication Office Michigan Medicine® PO BOX 950 East Lansing, MI 48826 517-337-1351 www.msms.org All communications on articles, news, exchanges and advertising should be sent to above address, ATT: Kevin McFatridge. Postmaster: Address Changes Michigan Medicine® Kevin McFatridge PO BOX 950 East Lansing, MI 48826

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 2022 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. ©2022 Michigan State Medical Society

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Hiring a Physician Assistant By Daniel J. Schulte, J.D., MSMS Legal Counsel


I have run a small group practice for many years.

We can no longer keep up with the demands of seeing every patient every time they come into the office. Hiring a physician assistant or two seems to be what many similar practices have done to keep up. What are the delegation and supervision requirements applicable to having physician assistants work in the office? Is there a limit on how many PAs we can hire/supervise?


everal Michigan laws applicable to the practice of physician assistants were changed in 2017. Those effect of those changes was a shift from PAs being regulated pursuant to the delegation and supervision provisions of Michigan’s Public Health Code to now being required to practice pursuant to the terms of a practice agreement with a physician. There are no specific limits on the number of practice agreements a participating physician may have in place with PAs at the same time. Your group practice must appoint a “participating physician” who will enter into a practice agreement with each PA the group hires. The practice agreement must contain the following provisions: A process between the PA and participating physician for communication, availability, and decision making when providing medical treatment to a patient. The process must utilize the knowledge and skills of the PA and participating physician based on their education, training, and experience. A protocol for designating an alternative physician for consultation in situations in which the participating physician is not available for consultation.

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The signature of the PA and the participating physician. A termination provision that allows the PA or participating physician to terminate the practice agreement by

providing written notice at least thirty (30) days before the date of termination. The duties and responsibilities of the PA and participating physician. The practice agreement shall not include as a duty or responsibility of the PA or participating physician an act, task, or function that the PA or participating physician is not qualified to perform by education, training, or experience and that is not within the scope of the license held by the PA or participating physician.

A PA is prohibited from performing acts, tasks or functions to determine the refractive state of a human eye or to treat refractive anomalies of the human eye, or both. Likewise, a PA shall not determine the spectacle or contact lens prescription specifications required to treat refractive anomalies of the human eye or determine modification of spectacle or contact lens prescription specifications, or both. A PA may, however, perform routine visual screening or testing, postoperative care, or assistance in

the care of medical diseases of the eye under a practice agreement. You should consult with your malpractice insurer and make sure any necessary changes are made to your policy to ensure that you have coverage for the services provided by the PAs you hire. You should assume that the changes to the law regarding PA practice do not change your practice’s liability exposure for claims arising from services provided by your PAs. Generally, a PA who is a party to a practice agreement may prescribe a drug in accordance with both the authority granted in the practice agreement and those procedures and protocols for the prescription established by rule of Michigan Department of Licensing and Regulatory Affairs. If a PA prescribes a drug, the PA’s name shall be used, recorded, or otherwise indicated in connection with that prescription. If a PA prescribes a drug that is included in schedules 2 to 5, the PA will need to have a Michigan controlled substances license and DEA registration. When writing controlled substance prescriptions, the PA’s DEA registration number shall be used, recorded, or otherwise indicated in connection with that prescription. MSMS has a comprehensive legal alert addressing the requirements applicable to employing PAs which include FAQs, forms, and other materials you may find helpful. These materials can be accessed at: http://MSMS.org/ Alerts.

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Employees on Military Leave By Jodi Schafer, SPHR, SHRM-SCP HRM Services | www.WorkWithHRM.com


I have an employee who is in the National Guard, and they have just told me that they are being deployed to support an emergency situation in another state. They are not sure how long they will be gone. While I support their service, it will be extremely hard for our small practice to cover their position when they are gone. What are my options?


hank goodness there are people such as your employee who

are willing to serve in the National Guard, the reserves, and other military branches so that we can have adequate support for emergencies. With that said, it is understandable that an employee’s unexpected leave can create hardship on employers.

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Without legal protection, employees who also serve in the military may not have a job when they return. For this reason, there are two federal laws - the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) and the Family and Medical Leave Act (FMLA) that apply to military leave and military family leave. Both Acts provide eligible employees the right to, at minimum, unpaid leave, during their deployment and certain rights for re-employment upon their return. FMLA, which was amended in 2008 to include military family leave entitlements, only applies to employers with at least 50 employees within a 75-mile radius. Specific employee eligibility requirements that can be found at the Department of Labor’s website https://www.dol.gov/general/topic/ benefits-leave/fmla. However, you said you are a small practice, so we’ll focus primarily on the other federal law, USERRA, for the purposes of this article.

USERRA applies to all employers, regardless of size, and to all regular employees, regardless of position, length of service or full-or part-time status. The law requires employers to provide leaves of absence and to re-employ workers who enter military service while employed. It applies to members of the uniformed services, including reservists, and National Guard members for training, periods of active military service (whether voluntary or involuntary) and funeral honors duty, as well as for time spent being examined to determine fitness to perform such service. So, the answer is, you must re-employ the employee when they return from service. However, you may hire temporary employees, reassign work to other employees, and of course, hire additional employees to fill the void while they are on leave. The type of position the returning employee is entitled to depends on the duration of the military service. Commonly, for

service of 90 days or less, the employee is entitled to return to the same position or the position he/she/they would have attained if they had not taken leave. The returning employee is entitled to all pay increases, seniority increases and other benefits that would have been earned during their time of absence.

According to USERRA, there are three exceptions for the employer related to re-employment:

For employees returning from leaves longer than 90 days, employers may place them into positions that closely resemble the job an employee would have held or attained in terms of seniority, status and pay.

• The employment was for a brief, nonrecurring period with no reasonable expectation that such employment would continue indefinitely or for a significant period.

• The employer's circumstances have changed as to make such re-employment impossible or unreasonable. • Re-employment would impose an undue hardship on the employer.

“Without legal protection, employees who also serve in the military may not have a job when they return. For this reason, there are two federal laws … that apply to military leave and military family leave.”

There are also specific eligibility requirements that employees must meet for re-employment such as providing notice of leave (employers must accept verbal notice and may not require supporting documentation), being released from service under honorable conditions, and not exceeding five years of military leave, not including annual training and monthly drills. We strongly recommend that you have a policy related to military leave in your employee handbook. This helps everyone better understand and follow the law. Also, do not forget that you are required to post notice about USERRA in a place where employee notices are normally placed – https://www.dol.gov/agencies/vets/programs/userra/poster.

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May is Hepatitis Awareness Month [ AND MAY 19TH IS HEPATITIS TESTING DAY ] By Sarah de Ruiter, BSN, RN, MA, Immunization Nurse Educator Michigan Department of Health and Human Services, Division of Immunization


enters for Disease Control and Prevention (CDC) and MDHHS would like to bring awareness to viral hepatitis. Hepatitis is a disease that affects the liver. A person may have a flu-like illness or experience a quick onset of symptoms.

Symptoms may include fever, headache, malaise, anorexia, nausea, vomiting, diarrhea, abdominal pain, or dark urine. However, people do not often show any symptoms and without a blood test they may never know they are infected with hepatitis. Millions of Americans are living with chronic hepatitis and may not know it but can still infect others. Knowing the facts will help protect others.

Hepatitis A Virus Hepatitis A virus (HAV) is an acute illness often with a discrete onset of symptoms. HAV infection is widely underreported and is estimated that approximately 25,000 people are infected annually. HAV is transmitted through fecal-oral route. This can happen through: • Close person-to-person contact with infected person

At increased risk for HAV:

At increased risk for severe HAV:

• International travelers

• People with chronic liver disease

• Men who have sex with men

• People with HIV

• People who use injection or non-injection drugs

Hand washing and hepatitis A vaccination are key in preventing infection.

• People with occupational risk of exposure

For more information, go to: www.cdc.gov/hepatitis/hav/havfaq.htm or www.michigan.gov/hepatitis

• Sexual contact with infected person

• Close personal contact with an international adoptee

• Ingestion of contaminated food/water

• Experiencing homelessness

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Hepatitis B Virus

The hepB vaccine is recommended for:

Hepatitis B Virus (HBV) is an acute or chronic illness. Over 860,000 people are living with HBV in the U.S. and over 1,600 people die every year due to the complications of having HBV. HBV is most commonly transmitted sexually or at birth from mother-tochild. HBV is transmitted through percutaneous (punctures of the skin) and through mucosal contact with infectious blood or body fluids. This can happen through:

• All infants • Unvaccinated children under 19 years of age • Adults 19 through 59 years of age • Adults 60 years and older with risk factors for HBV The following may also receive hepB vaccination: • Adults 60 years and older without known risk factors for HBV

• Birth to an infected person

For more information, go to the MMWR, Universal Hepatitis B Vaccination in Adults Aged 19-59 Years: Updated Recommendations of the Advisory Committee on Immunization Practices – United States, 2022: www.cdc.gov/mmwr/volumes/71/ wr/mm7113a1.htm?s_cid=mm7113a1_w

• Contact with blood or contaminated body fluids of an infected person

Hepatitis C Virus

• Having sex with an infected partner • Injection-drug use or by sharing needles, syringes, or drug-preparation equipment

• Exposures to needle sticks or sharp instruments • Sharing razors, toothbrushes, nail clippers, glucose monitoring equipment (anything that contains contaminated blood or body fluids) The best way to prevent the spread of HBV is to be fully vaccinated with hepatitis B (hepB) vaccine. All babies need hepB vaccine within 24 hours of birth to have a safety net of protection. Babies born to an HBV infected person need hepB vaccine and hepB immune globulin (HBIG) within 12 hours of life, a complete hepB vaccine series and post-vaccination serologic testing. For more information, go to: www.cdc. gov/hepatitis/hbv/hbvfaq.htm or www. michigan.gov/hepatitisB

Hepatitis C virus (HCV) is an acute or chronic illness. Over 3.5 million people are chronically infected in the U.S. HCV is most commonly transmitted through blood exposures. This can happen through: • Sharing drug injection or preparation equipment • Birth to an infected person • Health care exposures • Sex with an infected person (not common, more common among men who have sex with men) • Unregulated tattoos/body piercings • Sharing personal items (razors, toothbrushes, nail clippers, glucose monitors) • Blood transfusions and organ transplants

“The best way to prevent the spread of HCV is avoid sharing or reusing needles, syringes, or any other drug preparation equipment. Do not share personal items and do not get tattoos or body piercings from an unlicensed facility.”

The best way to prevent the spread of HCV is avoid sharing or reusing needles, syringes, or any other drug preparation equipment. Do not share personal items and do not get tattoos or body piercings from an unlicensed facility. Current treatments can cure most people of HCV in 8 – 12 weeks. MDHHS launched the We Treat Hep C Initiative in April 2021 to increase access to HCV treatment for Michigan Medicaid and Healthy Michigan Plan beneficiaries. Below are the changes: • Prior authorization removed for MAVYRET® • Sobriety and prescriber criteria removed • Any prescriber with prescriptive authority can treat HCV. MDHHS has implemented complimentary HCV consultation programs to help providers feel more confident treating patients with HCV.

For more information, go to: www.cdc.gov/ hepatitis/hcv/hepatitiscoverview, www. michigan.gov/hepatitis or www.Michigan. gov/WeTreatHepC

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Patti loved bowling night, and that was before she knew bowling helped save her life.


atti (a pseudonym to guard the patient’s privacy) was a patient of Martha Gray, MD, an Ann Arbor-based independent primary care physician. One day, Patti called Doctor Gray’s office to complain. “Patti told me, ‘I still have this earache and the treatment the nurse gave me just isn’t working,’” Doctor Gray remembers. “So I began asking more questions. Patti said every time she went bowling she would get an earache. It was only when she bowled, but it was troubling. She called my office earlier and spoke to one of the nurses, but the treatment my nurse recommended just wasn’t working.”

As Doctor Gray would later explain, she knew Patti didn’t have what would be typically known as an earache. “Adults don’t get earaches,” she said. When Patti would go bowling, the lifting and the rolling of the heavy ball was creating pressure in her ears and neck. Doctor Gray, a 40-year physician and leader within the Washtenaw County Medical Society, knew that what felt like an earache to Patti was the onset of angina, a condition marked by severe pain in the chest, often also spreading to the shoulders, arms, and neck, caused by an inadequate blood supply to the heart. “I didn’t look in her ears,” Doctor Gray recounts. “I ordered an EKG.”

The EKG showed blockage in Patti’s coronary artery, and Patti was taken to the emergency room for treatment. Doctor Gray has other stories, too. Stories of patients misdiagnosed by well-meaning and caring nurses whose training and experience hadn’t prepared them for the situation or condition presented. “Nurses are critically important to the delivery of health care,” Doctor Gray says. “They have been a vital part of my practice and the treatment and care of our patients. But doctors and nurses are different. We have different training, different experiences, different roles and different responsibilities.” CONTINUED ON PAGE 14

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Unsupervised Practice for Nurse Practitioners “Independent practice” is a nurse practitioner’s (NP) ability to provide treatment without required supervision from a physician. A NP who works in a state that has granted unsupervised practice—and, so far, Michigan is not one of these states—can assess, diagnose, interpret images and treat a patient, as well as prescribe medication, in the same way physicians do. For many years, the Michigan Legislature has, like its peers in many other U.S. states, wrestled with issues related to the safe practice of medicine and the appropriate scope of practice for non-physicians working in the health care field. Just last year, the Legislature endured a contentious and deeply controversial debate over legislation to allow nurse anesthetists to administer anesthesia without the supervision of a physician. Long a priority for nurse anesthetists in Michigan, lawmakers in 2021 took up and passed a compromise version of House Bill 4359 after months of tense negotiations and advocacy by the physician community in opposition to the bill as originally introduced. “Scope of practice debates are not new,” says Kate Dorsey, manager of state and federal government relations for the Michigan State Medical Society (MSMS). “Our experience with HB 4359 is an important reminder that our job as advocates for patients and good public policy never ends, and that while the legislation did ultimately pass, it was the relentless involvement of the physician community that brought needed changes to the final bill.” And that involvement from physicians remains critically important.

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On October 6, 2021—just three months after Governor Gretchen Whitmer signed HB 4359— Senator Rick Outman (R-Six Lakes) introduced controversial legislation continuing the push for scope of practice expansion in Michigan. Senate Bill 680 would allow for full unsupervised practice for NPs, including prescribing authority of opioids and other medications. The bill was referred to the Senate Committee on Health Policy and Human Services where it has yet to receive a public hearing. “By allowing increased scope expansions, lawmakers are allowing forprofit entities to shape our health care system – regardless of what patients want – while also reducing patient choice in who provides their care,” says Rose Ramirez, MD, a Grand Rapids family physician and past president of the Michigan State Medical Society. “Patient-centered, physician-led care is the best way to increase health care access without compromising patient safety or quality of care, and that is why limiting legislation like this is the top priority for MSMS.”

Michigan for Advancing Collaborative Care Teams Coming off the contentious legislative fight over physician supervision of anesthesia care and looking ahead to the anticipated introduction of legislation allowing for the unsupervised practice for NPs, physician and staff leaders of the MSMS knew more work was needed to communicate to the public and to lawmakers about the negative health implications resulting from scope of practice expansions. MSMS was not alone, however, in understanding this need. Dozens of organizations representing a diversity

of health care providers saw the real threat to care posed by these public policy proposals, and these organizations came together to advocate for their patients. Under the leadership of MSMS, and at the same time Senate Bill 680 was being introduced in the Michigan Senate, Michigan for Advancing Collaborative Care Teams, or MiACCT, was formed. MiACCT is a coalition of health care providers united and committed to growing, strengthening, and preserving the physician-led health care team patients rely on for care. "Physicians spend over a decade of their lives pursuing intense training in order to acquire the necessary knowledge and skills to treat patients. Physician-led healthcare results in effective, safe medical care at lower cost to the patient, as it has been shown to decrease unnecessary medical visits, lab work and radiology examinations." says Leah Davis, DO, a radiologist from Traverse City. “All of these groups came together as part of the MiACTT coalition to educate patients and advocate for public policies that protect this proven health care model.” Since its formation in the fall of 2021, more than 30 health provider organizations have joined MiACCT, including the American College of Physicians, American College of Surgeons – Michigan Chapter, Michigan Academy of Family Physicians, Michigan Psychiatric Society, Michigan Radiological Society, Susan G. Komen, and ten Michigan county medical societies. In recent months, representatives from these groups have been meeting with lawmakers to answer questions, address claims made by proponents of SB 680 and share information about

differences in training and education between physicians and NPs. “Coalitions like MiACTT are critically important as we work to inform both lawmakers and the public,” Dorsey says. “Given the recent landscape on issues like this, we need a robust response from a diverse and broad coalition to show lawmakers why scope issues are such a problem. MiACTT is helping to fill that role.”

Rhetoric v. Research As MiACTT, its member organizations, and MSMS staff are meeting with public officials on issues related to scope of practice and Senate Bill 680, a common theme has emerged. According to Dorsey, advocates for the unsupervised practice of NPs point to a shortage of medical professionals in Michigan and a lack of access to care for patients, especially in more rural part of the state. “Proponents of scope expansion always point to addressing a lack of access to care,” Dorsey says. “But the research just doesn’t support the rhetoric.” 2020 data from the American Medical Association compared access to care in states that allow full unsupervised practice for NPs against those states that do not. The census of practicing physicians and NPs in each state shows that NPs did not choose to locate and practice in rural and underserved areas once unsupervised practice was permitted. In fact, research showed the opposite to be true. Not surprisingly, both primary care physicians and NPs practice medicine in and around population centers. Comparing states like Oregon and Minnesota, which permit unsupervised practice, to Michigan, which does not,

demonstrates no significant difference in the decisions of NPs to locate and see patients in areas of the state where access to care is a challenge. “Access to care is a legitimate public policy concern,” Doctor Gray says. “States that have permitted unsupervised practice, however, have shown that it doesn’t actually address the concern.” In addition to state data on access, recent studies have shown that extending unsupervised practice has led to a lessening in the quality of care, risks to patient safety, and an increase in health care costs. For example, a 2020 study in the Journal of General Internal Medicine conducted a retrospective cross-sectional analysis to determine the opioid-prescribing patterns of physicians, NPs and physician assistants (PAs) who worked in primary care and prescribed at least 50 prescriptions. Based on the analysis, the study found 6.3 percent of NPs and 8.4 percent of PAs prescribed opioids to more than 50 percent of their patients compared to just 1.3 percent of physicians. They also found NPs and PAs in states with unsupervised prescription authority for schedule II opioids were 20 times more likely to overprescribe opioids than NPs and PAs in states with restricted prescription authority. Notably, the study also found from 2013 to 2017, when almost every medical specialty decreased opioid prescribing, NPs and PAs significantly increased opioid prescribing.

Given the recent landscape on issues like this, we need a robust response from a diverse and broad coalition to show lawmakers why scope issues are such a problem. MiACTT is helping to fill that role.”

Public opinion research also points to the clear preferences of patients to maintain a physician’s role in their


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care. In fact, polling by the American Medical Association showed that 95 percent of voters in the United States believe that physicians “should be involved in medical diagnosis and treatment.” Polling in Michigan shows the same. A survey conducted in 2021 by the non-partisan polling firm, EPIC MRA, asked Michigan voters “if nurse practitioners were able to have the full practice authority proposed, and if you, other family members or loved ones needed health care services, would you prefer to have it provided by a physician or a nurse practitioner?” Sixty-two percent of people polled answered that they would prefer a physician, 13 percent said they would prefer a NP.

Patient-centered, physician-led care

public policy if physicians don’t get involved and speak out,” she says.

When a person watches as a loved one heads into a serious medical procedure, his or her thoughts aren’t primarily on how the operation will be conducted, but when that loved one will be home again—safe, healthy, and healing.

Dorsey puts an even finer point on it. “This is priority number one for MSMS.”

“That’s human nature,” Doctor Ramirez says. “That’s at the core of patient care—fixing serious problems, healing people, and returning loved ones to their homes and families.” According to Doctor Ramirez, patientcentered, physician-led care is the best care and state policy should protect it. “And right now, that proven, tested, and trusted model of physician-led care that patients rely on and expect is at risk of being undermined by bad

She encourages physicians to get involved, contribute to the Medical Doctors’ Political Action Committee and utilize the MSMS Action Center to contact their lawmakers about the issue of expanded scope of practice. “In our conversations with lawmakers, we are finding them to be open to conversation and hearing our concerns,” Dorsey says. “They look at the difference in training, in education, and in experience. They see the real potential for problems with the expansion of prescribing authority, especially when it comes to opioids, and they get it. But we have to keep at it.”

Convergence — Detroit From Above by Brian Day

Trusted Advisors to Michigan Physicians

A successful practice requires physicians focused on treating Apatients. successful practiceto requires physicians focused on treating patients. As counsel the MSMS community for over 70 years, As to the MSMS community years, we know how to wecounsel know how to help physicians. Letfor usover help70 you protect, help physicians. Letyour us help you protect, manage, and grow your practice. manage, and grow practice.

kerr-russell.com Daniel J. Schulte, dschulte@kerr-russell.com | Patrick J. Haddad, phaddad@kerr-russell.com | Kathleen A. Westfall, kwestfall@kerr-russell.com

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24/7 The phone rang in the middle of the night, and of course Doctor Gray answered it. “We are all on call for our patients 24/7,” Doctor Gray says. “If you're my patient and you call me in the middle of the night, I’ll answer.” This time it was the patient from earlier in the day who had visited with a nurse complaining of a sore back. Now, the patient couldn’t sleep. The pain had spread to under her right rib and shoulder. Doctor Gray asked her a few more questions and then told her to make a middle of the night trip to the emergency room. “You have acute appendicitis, and it has likely ruptured,” Doctor Gray recalls. “You have to go to the ER now.” An hour later, the attending emergency room physician called Doctor Gray to share that her patient’s appendix had in fact ruptured, that she was heading into surgery and would be all right. “Nurses are a vital partner in caring for and treating patients, and I have relied on them for decades in my practice,” Doctor Gray says. “My education and training as a physician have prepared me for my leadership role on each patient’s health care team, just as nurses rely on the education and training they have received.” “It is important to recognize that these experiences are different and that these experiences depend on each other for the benefit of patients,” Doctor Gray continues. “Public policy in Michigan should acknowledge, respect, and protect Michigan’s patient-centered, physician-led health care model. It’s what patients want and what patients deserve.”

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MSMS EDUCATION: LIVE, VIRTUAL, ON-DEMAND WEBINARS The MSMS Foundation has a library of on-demand webinars available, many of which are free, making it easy for physicians to participate at their convenience to meet their educational needs.

Webinars that Meet Board of Medicine Requirements: A Day of Board of Medicine Renewal Requirements Human Trafficking Medical Ethics – Conscientious Objection among Physicians Medical Ethics – Confidentiality: An Ethical Review Medical Ethics – Decision Making Capability Medical Ethics – Eliminating Disparities in Health Care What Can You Do? Medical Ethics – Just Caring: Physicians and Non-Adherent Patients

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Medical Ethics – Racial Disparities in Maternal Morbidity and Mortality: A Persisting Crisis Medical Ethics – Reclaiming the Borders of Medicine: Futility, Non-Beneficial Treatment, and Physician Autonomy Pain and Symptom Management – Naloxone Prescribing Pain and Symptom Management – Balancing Pain Treatment and Legal Responsibilities

To register or to view full course details, please visit: msms.org/OnDemandWebinars

Grand Rounds Series

Other Webinars:

A Review of COVID-19 Variants

2021 ASM – Cardio-Oncology: Enhancing the Cardiac Care of the Cancer Patient

Changes to Michigan’s Auto No-Fault Act for Physicians

2021 ASM – Updates in Endocrinology

Coronavirus Relief – Overview and Updates

2021 ASM – Update in Infectious Disease

CURES Act – What is Information Blocking and How Do I Comply?

2021 ASM – Updates in Otolaryngology

Cyber Preparedness & Response for Medical Practices

2021 SSM – Contemporary Management of Nephrolithiasis

Domestic Violence and Sexual Assault (Intimate Partner Violence)

2021 SSM – Neuroscience: Central Nervous System and Neuromuscular Junction Inflammatory Disorders

Federal Information Blocking Rules Harm Reduction in Practice and Policy Strategies Henry Ford Health System COVID-19 Requirement for Employees MDHHS Update from New Director Elizabeth Hertel Navigating the No Surprises Act Recovery Audit Contractor (RAC) Region 1 Sharing Clinical Notes With Patients – A New Era of Transparency in Medicine Update on COVID-19 from Joneigh Khaldun, MD, Chief Medical Executive

Monday Night Medicine Series Creating a Manageable Cockpit for Clinicians 100% Virtual Collaborative Care for Behavioral Health Outcomes Practicing Wisely – Save 2 Hours Each Day AMA Strategic Plan to Advance Health Equity

2021 SSM – Updates in Allergy, Asthma and Immunology 2021 SSM – Updates in Dermatology 25th Annual Conference on Bioethics Health Care Providers' Role in Screening and Counseling for Interpersonal and Domestic Violence: Dilemmas and Opportunities HEDIS Best Practices In Search of Joy in Practice: Innovations in Patient Centered Care Integrating Pharmacists into Practice: The Missing Link for Comprehensive Medication Therapy Management Legalities and Practicalities of HIT - Cyber Security: Issues and Liability Coverage Legalities and Practicalities of HIT - Engaging Patients on Their Own Turf: Using Websites and Social Media Medical Marijuana Law Medical Necessity Tips on Documentation to Prove it

Implicit Bias and Racial Disparities

Non-Pharmacologic Management of Musculoskeletal Pain Syndromes

“Then when you know better, do better.” Next Steps in the Journey of Dismantling Systemic Racism Within Health Care and Beyond

Section 1557: Anti-Discrimination Obligations

A Team Based Approach Training Modules – • Module 1: How to Develop a Pharmacist-Physician Collaboration • Module 2: Medication Therapy Management Reimbursement and ROI

Update on Chronic Fatigue Syndrome Part 1: Clinical Diagnostic Criteria for Chronic Fatigue Syndrome/CFS now called Myalgic Encephalomyelitis or ME/CFS

• Module 3: Best Practices for Addressing Workflows, Resources, Challenges

Sexual Misconduct – Prevention and Reporting

Update on Chronic Fatigue Syndrome Part 2: Uniting Compassion, Attention and Innovation to treat ME/CFS

Once registered, you will receive an email within 15 minutes with links to watch the on-demand webinar and to complete the survey evaluation. Contact: Beth Elliott at 517/336-5789 or belliott@msms.org

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Grand Rounds Date(s): May 11, June 8, September14, October 5, November 9, and December 14, 2022 Time: 12:00 - 12:45 pm Location: Virtual Conference Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org

A Day of Board of Medicine Renewal Requirements Date: September 23, 2022 Time: 9:00 am – 4:00 pm Location: In-Person Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org

Practice Management

Annual Scientific Meeting

Date(s): May 11, June 8, September14, October 5, November 9, and December 14, 2022 Time: 12:00 – 12:45 pm Location: Virtual Conference Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org

Date: September 22, October 20-21, and November 17, 2022 Time: September and November 3:00- 6:00 pm, October 8:30 am - 4:30 pm Location: September and November Virtual Conference, October In-Person Intended for: Physicians and all other health care professionals Contact: Brenda Marenich at 517/336-7580 or bmarenich@msms.org

Monday Night Medicine

A Day of Board of Medicine Renewal Requirements

Date(s): October 3, and November 7, 2022 Time: 6:30 – 8:00 pm Location: Virtual Conference Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org

Date: November 4, 2022 Time: 9:00 am – 4:00 pm Location: In-Person Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org

Spring Scientific Meeting

24th Annual Conference on Bioethics

Date(s): May 12-13 and June 9-10, 2022

Date: November 5, 2022

Time: 8:00 – 11:00 am Location: Virtual Conference

Time: 8:45 am – 4:00 pm Location: In Person

Intended for: Physicians and all other health care professionals Contact: Brenda Marenich at 517/336-7580 or bmarenich@msms.org

Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org

Implicit Bias Series Date(s): June 10, July 8, August 12, September 9, October 14, November 11, and December 9 Time: 12:00 – 12:30 pm Location: Virtual Conference Intended for: Physicians and all other health care professionals Contact: Brenda Marenich at 517/336-7580 or bmarenich@msms.org

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For more information or to register, please visit: MSMS.org/EO Questions? Contact Beth Elliott: email belliott@msms.org or call 517/336-5789

Convenient access to specialists at


• Make appointments • Transfer patients • Consult with physicians • Get patient information



24 hour s a day, 7 days a w eek

Telephone Communication for Healthcare Providers: Safety Strategies Nicole Franklin, MS, CPHRM, Patient Safety Risk Manager II, The Doctors Company

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Contributed by The Doctors Company


The way we communicate has changed dramatically over the years. Even with the introduction of technology-based communications, such as social networking sites, telemedicine, and texting, the telephone call is still the most widely used communication tool between healthcare providers and patients. Telephone conversations can, however, present difficulties and may be inherently deceptive if both parties lack the ability to observe nonverbal communication (for example, facial expressions, eye contact, and gestures) that clarify and qualify what the voice is expressing.


hen casually or carelessly conducted, telephone communications can lead to diagnostic errors and misunderstandings that may culminate in professional malpractice claims.

Telephone Communication with Patients Creating comprehensive, clear guidelines for telephone encounters with patients is critical in mitigating risk. Establish practice guidelines and ensure that all office and clinical staff are trained on their roles in communicating with patients by telephone. Protect yourself from potential liability by following these general practices: Smile when greeting patients. Research has shown that people are able to tell if you are smiling by the tone of your voice. Warmly express to patients that you are happy to speak with them today. This inter-

action may be the first impression that a patient has of the practice or the staff, and it is a factor in patient satisfaction.

Speak to patients clearly and slowly, and enunciate carefully. Use easy-to-understand language that avoids medical terminology.

Triage and refer all critical calls to emergency services. Examples of critical calls include abdominal or chest pain, fever of unknown origin, high fever lasting more than 48 hours, convulsion, vaginal bleeding, head injury, dyspnea, casts that are too tight, visual alterations, and the onset of labor. For more information on this topic, read our article, “Telephone Triage and Medical Advice Protocols.”

Obtain the services of an interpreter if you encounter a language difficulty. Follow the Americans with Disabilities Act (ADA) requirements for patients using telephone auxiliary aids or services, including interpreters. For more information, see “ADA Requirements: Effective Communication.”

Obtain as much information as possible about the patient’s presenting complaint, medical and surgical history, current medications, and allergies to help you arrive at an accurate appraisal of the patient’s condition. Listen carefully and allow the caller both the time and opportunity to ask questions.

Avoid distractions, such as checking email or attending to other duties, when speaking with patients. Drowsiness, fatigue, or distraction on the part of either party can affect the ability to communicate effectively.

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Adhere to HIPAA rules and regulations to maintain patient privacy when communicating over the telephone, both inside and outside the office. Use a low voice when discussing protected health information, and implement reasonable safeguards to avoid disclosing information to others not involved in the patient’s care. Develop written protocols for front office/unlicensed personnel to help them respond to patient questions and concerns. An unlicensed individual cannot provide medical or dental advice. Clinical/licensed individuals answering patient calls cannot exceed their scope of practice. Prescribe or advise by telephone only when you have reviewed the patient’s allergies, medications, and medical and surgical history. If providing new instructions to the patient, such as changing a medication dosage, ensure understanding by asking the patient to repeat back the instructions to you. Document the patient’s understanding in the medical or dental record. For more information on this topic, read our article “Rx for Patient Safety: Use Ask Me 3 to Improve Patient Engagement and Communication.” Accept a third party’s description of a medical or dental condition only when you have confidence in that person’s competence to describe what he or she sees. If descriptions are unclear, the patient may require an office visit.

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Make prompt referrals if the patient’s call concerns a medical or dental problem that is outside your expertise. Proactively track the consultation and expected report, and follow up with the referred provider and patient. Confirm that pharmacists understand all dosages and instructions for drug prescriptions given by telephone. Spell out any similar drug names and use individual numbers for dosages, such as “five zero” for 50. Include the reason for the use of the drug. Insist that pharmacists repeat information back to you. Do the same with facility personnel who take your telephone orders. A safer approach is to use electronic prescribing or fax the medication order. Verify and document the patient’s adherence with telephone advice through a follow-up contact to ensure continuity of care.

“Confirm that pharmacists understand all dosages and instructions for drug prescriptions given by telephone ... A safer approach is to use electronic prescribing or fax the medication order.

Provider Cross-Coverage When you will be away from your own practice or covering for another provider, these additional strategies can help you avoid problems: Implement a communication process between cross-coverage providers. In several instances, a covering provider has been held completely responsible for damages resulting from a telephone misdiagnosis while the original provider was exonerated. Give a brief status report on your acute patients with notice of any anticipated patient calls when handing off care. Document all calls in the patient record. Brief the primary provider on all calls during your coverage period. Prescribe only the amount of medication the patient requires during the period you are covering for another provider. Pain medications and narcotics should be refilled or ordered only in small amounts and per state regulations.

Contributed by The Doctors Company


Documentation Disagreements about what was said during telephone conversations can be a major problem in professional malpractice cases. Follow these documentation processes to mitigate this risk: Document all patient telephone conversations in the medical or dental record—including those received and returned after hours. Include the date and time of each contact and when follow-up is completed.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

Record all details immediately about the information you received, what you advised, and the orders you gave. This action is especially important when a telephone call occurs after office hours or on a weekend. Implement an office process for calls received during office hours. Office staff should tell the caller when the provider is most likely to return the call. Include tracking and follow-up to ensure that the caller’s questions and problems are resolved and documented. Document a patient’s hospital medical record with telephone conversations about the hospitalized patient—including any conversations with nurses or other providers. Effective telephone communication and its documentation are vitally important in preventing and defending litigation. For additional risk reduction strategies see our telehealth resources and our article “Smartphones, Texts, and HIPAA: Strategies to Protect Patient Privacy.”

For further assistance, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.

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Delphine Colar, DO

Stephen Higgins, MD

Sarosh Anwar, MD

Liesel Zima, MD

Sigrid Messana, DO



Michael Mishkin, DO


Anirudh Penumetcha, DO

Brian Giersch, MD

Alan Rebenstock, MD


Denise Gribbin, MD

Douglas Saylor, MD

Emad Alkhankan, MD

Andrew Jameson, MD

Lodewijk VanHolsbeeck, MD

Nigel Bramwell, MD

Karen Leavitt, MD

Ahmed El-Sabbagh, MD


Foaz Kayali, MD


Kunal Bailoor, MD, HCE-C

Imad Modawi, MD

Douglas Kubek, DO

Steven Haase, MD

Seif Saeed, MD

Marie McDonald, MD

George Mashour, MD, PhD

Katherine Jean Yulo, MD




Amar Ahmed, MD

Ali Alateya, MD

Omer Alrawi, MD

Lubna Fatiwala, MD

Jessica Arden, MD

Evan Black, MD

Ashraf Hamza, MD

David Gordon, MD

Ryan Castro, DO

Dana Kabbani, MD

Zachary Hector-Word, MD

Steven Feldman, MD

Thomas Kelly, MD

Peter Kohler, MD

Samra Huda, MD

Lester Laddaran, MD

Mark Langlois, MD

Mohan Kaza, MD

Nasser Lakkis, MD

Shanley O'Brien, MD

Phillip Kucab, MD

Joshua Ruch, MD

Kirthi Lilley, MD

Phillip Levy, MD, MPH, FACEP, FAHA, FACC

Steven Schmidt, DO

Aleksey Mishulin, MD


Amina Pervaiz, MD Philip Ross, DO

Eric Haynes, DO

Ethan Sagher, MD

Judith Lin, MD

Shabeta Sahore, MD

James Venier, DO

Michael Staudt, MD

Richard Schubatis, MD Steven Soliman, DO Maryam Tahvildari, MD Obead Yaseen, MD

John Steele, MD Ramkrishna Surendran, MD Niluka Weerakoon, MD John Whapham, MD

Thank you for your ongoing support of organized medicine in Michigan.

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