NC Family Physician - Winter 2023

PRESIDENT’S MESSAGE

We are Unique Unicorns — that Actually Exist

CHAPTER AFFAIRS

April 9, 1948: The Birthdate of the NC Academy of Family Physicians

MEMBERSHIP & MEMBER SERVICES

“The Choose Your Own Adventure Path”: Wisdom from the 2022 NCAFP Distinguished Physician of the Year, Dr. Shannon Dowler

PUBLISHED BY

MOMS in Family Medicine

Navigating a Fulfilling Career and Family: Part II

PG. 26

PROFESSIONAL DEVELOPMENT

20 Accolades, Awards, and Achievements: The 2022 Winter Weekend Celebrated Champions of Family Medicine All Weekend Long

PRACTICE MANAGEMENT

28 Key Regulatory Considerations for Direct Pay and Concierge Models in Family Medicine

CONTRIBUTIONS

30 The Afghan Refugee Projects

DEPARTMENTS

President’s Message 4

Chapter Affairs 10

Membership 18

Professional Development 20 t 919.833.2110 • fax 919.833.1801 • ncafp.com

Managing Editor, Design & Production

Peter T. Graber, NCAFP Communications

Assistant Editor Kevin LaTorre, NCAFP Communications

NCAFP Foundation 24

Practice Management 28

Contributions 30

Have a news item we missed? NCAFP members may send news items to the NCAFP Communications Department for publishing consideration. Please email items to kevin@ncafp.com.

PRESIDENT’S MESSAGE to NCAFP Members

By Dr. Shauna Guthrie 2022–2023 NCAFP President

I am so honored to be here and have the opportunity to represent family physicians across the state in the role of president of the NCAFP for the next year.

I absolutely would not be here without my family both born and chosen. Some traveled halfway across the country, and others halfway across the state to share this moment with me. Your ongoing love, support of my cockamamie ideas, and ability to question me about my ideas in a way that only makes them better has only made me better. I also would not be here without the many mentors I have had physician and non. I don’t want to name names, because I don’t want to leave anyone out. But if you have received an email from me late at night after reading an article you wrote that struck my interest, or with a question about how to set up my own business, or with a stream

of consciousness email ending with “what do you think?” you’re on that list.

Giving this speech is one of the more intimidating things I’ve done in my life. Some of you sitting here remember some of the past talks of incoming presidents. I remember jumping to my feet and clapping, tears in my eyes, after hearing Rhett Brown or Tameika Howell speak. Well, you can put away your Kleenex, because this will not be that kind of talk. I’m an introvert from the Midwest (Kansas, the state that is flatter than a pancake and looks like a candy bar with a bite out of the corner), and we try not to stick out too much from those around us or stir up too much emotion in people.

But…I will share some stories and hopefully through these will help you get to know me a little better.

“We are

Dr. Guthrie being sworn-in as 2022-2023 NACFP President by AAFP Board Chair Dr. Sterling Ransone, Jr., as her Grandmother Diana Guthrie looks on.

2022-2023

NCAFP Board of Directors

Unicorns — that Actually exist”

Address of NCAFP President Dr. Shauna Guthrie

Executive Officers President Shauna Guthrie, MD, MPH

President-Elect Garett R. Franklin, MD

Secretary/Treasurer Mark McNeill, MD

Immediate Past President Dimitrios P. Hondros, MD

Executive Vice President Gregory K. Griggs, MPA, CAE

At-Large Directors

Joshua Carpenter, MD Lisa Cassidy-Vu, MD

Deanna Didiano, DO Nicole Johnson, MD, MPH Kelley Lawrence, MD, IBCLC, FABM Benjamin F. Simmons, MD

Patrick Williams, MD Courtland Winborne, MD

Academic Position

Margaret Helton, MD (UNC)

Resident Director Matthew Drake, MD (ECU)

Resident Director-Elect Morgan Parker, DO ()

Student Director Morgan Beamon (ECU)

Student Director-Elect

Akhila Boyina (Wake Forest)

Although we shared a love of medicine, I was not blessed with an amazing memory or the confidence to ski down double Black Diamonds with wild abandon like my grandfather, but I did inherit two other things from him. First, his loud, boisterous, old-man-style, often painful, sneezes. Every single sneeze seems to become a spectacle and there’s little I can do about it. Maybe don’t put away those Kleenexes just yet…on the upside, since COVID I have a little more control because who wants to be sneezing in their mask??

What I also inherited is his propensity to see the bright side of things, and learn from our trials and tribulations while turning them into entertaining stories to share with others. You would think one of the best things to ever happen to him was getting stranded without power on a cruise ship in the middle of the ocean on his way home from a trip to Antarctica.

I grew up on a farm, a scrawny tomboy, and my absolute least favorite

AAFP Delegates & Alternates

chore was carrying 50-pound prickly bales in the Midwest’s humid 102-plus-degree heat. I knew growing up that this was not the life for me. Thanks to the help of others, resilience, persistence, and frankly a significant amount of privilege, I live a very different life from that now. I did purposefully land in a rural area because that is where I can best utilize my training and skills, but I can live by my own schedule, have my own dog, raise chickens in town (I guess you can’t completely take the country out of the girl)…and students…this can be you some day…I can even buy namebrand cheese now!

Living in the country, it can be easy to be disconnected from politics, put my head down, and focus on caring for my patients. Whether we practice in a city or out in the sticks, a lack of advocacy for our patients and our profession can affect the lives of many. Food is health, housing is health, social support IS health. Working with legislators is sometimes icky business, but it’s necessary. And I’m proud that our elected officials know that when there is a question about how something affects the health of our communities, the NCAFP is one of the trusted groups they call. For issues of gun safety, abortion bans, or scope of practice, they can come to us to provide an evidence-based, patient-centered perspective while representing all our members across the state. The NCAFP will continue to fight these fights on your behalf — sometimes publicly and sometimes more privately. They will always protect evidence-based medical decision-making, informed patient autonomy, and the right of physicians to practice without fear of unnecessary legal ramifications. You can absolutely put your head down and see patients, that’s okay! But if there are issues that are important to you, get involved! It can be very refreshing to affect your community in a different way. Email Greg Griggs if you want to participate in a White Coat Wednesday, join a board committee, or if you aren’t sure how you can get involved, just tell him you would like to know more. He’ll get you involved, and you could be in my shoes before you know it.

Talking to our legislators can be intimidating, but I was once told that the scary feeling you get when doing something new (like getting involved with the NCAFP Board within your first year of practice in a new state) is called growth.

A neighbor used to say, “I learned something new, so it’s already a good day,” and I now also say this often. In the middle of 2020, I worked a weekend hospitalist shift. Since I left private practice for public health, I often did this for a weekend every couple months to keep up my skills, but hadn’t for several months because for some reason after March 2020, no one was taking vacations anymore. I was already a little intimidated – having spent the majority of my time understanding outpatient management, contact tracing, the latest on masking, and constantly changing

quarantine and isolation guidelines…I definitely felt like a resident again, going to my fellow hospitalists with my plan to get confirmation I wasn’t doing anything totally off the grid. I will always remember when I went to visit my first inpatient with COVID, ever, I walked confidently into the negative pressure anteroom, saw the PAPPR and associated equipment, and turned right back around. I hadn’t realized until that moment I didn’t have a clue how to properly put this thing on. I put one on once before COVID had even reached the U.S. It sure seemed easy with the rest of the nursing staff in our conference room!

I could have TOLD someone how to do it. I probably could’ve figured it out, but I also could’ve done it wrong but in that point in the pandemic the repercussions felt especially scary for myself and anyone I came in “close contact” with. So, instead of being a tough gal I opted for vulnerability. I snuck over to the nursing area where of course a whole group of nurses were chatting, and asked for help. Like any great nurse, my patient’s nurse didn’t bat an eye (or laugh at me), helped me get suited up, and sent me on my way. It was very humbling – some growth definitely happened that weekend. It didn’t hurt that the rest of the shift was not very memorable.

As family physicians, we are lifelong learners. And we have certainly had our fair share of learning in the past few years. Trying to decipher guidance about and then actually obtain proper PPE, reading scientific articles to be sure our advice to get the vaccine is the right choice for our patients – or just so we can argue with someone spreading misinformation online. As someone with no children of my own I spent an inordinate amount of time attending school board meetings with my boss and always had to come prepared with data, the latest community and school-based guidance, and ready to answer any questions someone asked with a straight face because they saw a Facebook post that they deemed reputable.

Physicians do not like to be vulnerable and ask for help, but that is one thing that helps us learn. We are willing to watch five YouTubes on how to inject an elbow rather than just ask our practice partner for a quick refresher. Before COVID stopped us in our tracks for a sniffle, we would work long shifts despite feeling like death because we didn’t want to let our team down. As an only child and a strong, independent woman and especially as a physician asking for help personally or professionally can be hard. But it can also keep you safe, and bring you closer to those around you, and make the day a better one, because you learned something.

All of us share the trauma of the past three years and I don’t want to discount that. But something we also share and can be proud of is the incredible amount of learning we did during this time, especially at the beginning. Information was changing faster than we could take it in, but we did it! And the NCAFP really stepped up during that time to provide frequent newsletter updates to keep us all on top of the changes. They knew that primary care medical providers, especially family physicians, are the key to having meaningful discussions with patients about getting vaccinated because we are their trusted medical advisors. And the NCAFP staff pushed – HARD – to remind state officials of the important role family physicians play in their patients’ care, and helped us get vaccines into our offices and into the continues on next page

Dr. Guthrie with Outgoing NCAFP President Dr. Dimitrios Hondros

arms of our patients.

Before my training, I had no idea of the importance of family physicians in healthcare and in their local communities. Despite my initial intentions, I’m not only a family physician but now have the honor of representing all of you.

The only thing I thought I was sure of when I started medical school was that I did not want to be a family physician. I had no great local role models in my small town like you often hear about. Honestly, I had very limited medical care at all growing up. What I did have was a part-time job in college as a medical assistant swabbing throats and drawing

eyes because my feedback usually revolved around wanting to know what happened to someone’s dog, did they ever get pregnant, were they able to go back to work, are they living with their uncle again? It became clear very early on that I needed a specialty with continuity. I really liked mental health, and I knew I liked working with people of all ages. And my hands are not the steady hands of a surgeon (plus my chlorhexidine allergy seemed like a sign). Meanwhile, I remember the moment I found this program called the New Hampshire Dartmouth Leadership Preventive Medicine Residency. It was a complete mouthful, but a real lightbulb went on for me. I was sitting in our small group computer lab and what drew my attention was not their

blood. From that perspective, Family Medicine looked so boring. Luckily, I was obviously wrong.

After undergrad at the University of Kansas, I went to Drexel University College of Medicine in Philadelphia and participated in a problem-based curriculum. Most of our learning was done using patient cases. When we finished the case, we would give feedback to improve the case for the next group, and the other members of my small group would roll their

unnecessarily-long name, but their master’s in public health focused on quality improvement. Now, keep in mind, this was 2005 – when quality improvement wasn’t a widely-used term, nor had it become a dirty word.

I have always been someone who liked seeing problems (often that others didn’t even see, or at the least didn’t want to deal with) and finding a solution. I have been told more than once that I don’t always have to rock the boat. To

which I respond: If I don’t, then nobody will. When I saw this program, I knew that this way I could learn to rock the boat but the right way – the more effective way. And, as a bonus, I got to use data and spreadsheets (those that know me understand my excitement). I still wanted to be a “real doctor,” and they had this cool program – the Paul Ambrose Fellowship – where you could combine it with your fourthyear medical school curriculum if you did Family Medicine. So, I thought, why not?! Fast forward a year, and I’m having a romantic Valentine’s dinner in a snowstorm with my future program director and his wife – because they wanted me to feel welcome the night before my interview. And I did. It was still kind of awkward though.

Obviously, I have come a long way from mediocre acceptance to a full-on passion for Family Medicine. When people ask what kind of doctor I am, I proudly tell them I am a family physician. And when they say, “Is that like, some kind of generalist?”, I tell them that we have specialized training to take care of the whole person, the whole family, and the whole community – cradle to grave. What they don’t stick around to hear about is one thing I love about Family Medicine - that our scope can change with the seasons of our lives. I started in a private practice, working harder than I ever have doing outpatient, inpatient and obstetrics at two hospitals, and nursing home (with one day a week doing quality improvement before it was cool). When I got the opportunity to move to public health about 20 years sooner than I planned and start a new primary care practice there, I went with it because I was ready for a change and growing tired of the lack of continuity and fast pace in my current location. I wanted to spend time with patients. I wanted to have more meaningful interactions. And I loved the opportunity to have a greater community focus. I still sprinkled in some side-gigs with the hospital, hospice, and a local detention center because I love variety and wanted to keep up all my skills. Except delivering babies. I stopped in 2018 and I don’t have any interest in delivering any more babies. Ever. Those of you that do, thank you! Around that same time I realized that to make any difference in our very significant local opioid epidemic, I needed to start providing treatment for people with opioid use disorder. With the support of my health department colleagues, we started the first office-based opioid treatment program in a health department

in NC. This started a journey that I say changes the shape of my brain and stretched all of our public health/harm reduction hearts, and it has been immensely rewarding. I had no idea at the time that this would lead to a renewed passion in my professional and personal life.

And now – with our primary care program at the health department reaching maturity - I’m not leaving, but I am stepping back and I have opened Sunflower Direct Primary Care (a nod to my Kansas roots) – where I can really practice the way I have always wanted to…while also serving part-time as the CMO at our local hospital. I just really love being a family physician, and there are so many roles we can play, scopes we can practice, and places we can go (literally and figuratively). Family Medicine is not at all what I envisioned when I went to medical school, and yet, I’m exactly where I’m supposed to be. If you aren’t happy where you are, you can make a change! Ask Talia Aaron or Tom White or many others in this room who have drastically changed directions in their careers. Think big! Define your passion! You are infinitely employable and deserve to be happy. Your patients deserve a doctor who is happy.

We are family physicians. We are smart enough to manage complicated patients (but can still explain concepts in a way non-doctors can understand), we look at the whole picture, and we’re nimble enough to change entire workflows when global pandemics happen so that we can still care for our patients. We are unique unicorns that actually exist and we get to do the coolest stuff! And for the medical students here worried about paying off their loans, YOU WILL -- all physicians are paid well and if family medicine feels right for you, why not pay them off doing something you love?

In my role as President of the NCAFP, and with their support, I will do everything in my power to protect and support our ability to practice freely, up to our scope, with as few administrative burdens as possible so we can do what we’re good at – not just TREATING our patients – but CARING for them, generations of their families, and our community. Because, in the wise words of the great Dr. Maureen Murphy, (a fellow Jayhawk):

“We are Family Physicians, because freakin’ awesome is not a job title.”

Dr. Guthrie with her Grandmother, Diana Guthrie.

CHAPTER AFFAIRS

By Gregory K. Griggs, MPA, CAE NCAFP Executive Vice President

April 9, 1948

The Birthdate of the North Carolina Academy of Family Physicians

It may have been an innocuous date in 1948 for most individuals: April 9. But it wasn’t in the life of Family Medicine in North Carolina. That was the date that the NC Chapter of the American Academy of General Practice was officially chartered, and some 75 years later the NCAFP is still going strong.

As we begin to celebrate the 75th Anniversary of our Chapter, we have been poring over some of our archives. Included in those archives is our official charter, which was verified

by five of the original members of our chapter: Drs. John R. Bender, Roscoe D. McMillan, G. Grady Dixon, Vernon W. Taylor, and W.E. Selby.

Just as a refresher on the formation of what was then the AAGP and now the AAFP: In June of 1947, a group of generalists gathered at the AMA Meeting to organize the American Academy of General Practice. After World War II, specialization was becoming more of a norm in medicine, and generalist physicians wanted to make sure their voices remained strong, which led to the formation of the AAGP.

On Feb. 21, 1948, Missouri became the first state to constitute a chapter, followed by 32 other states that same year, including North Carolina. In March of 1948, AAGP established its headquarters in Kansas City. Later that summer, on June 21, the AAGP held the first meeting of the Congress of Delegates just prior to the Annual Meeting of the AMA at the Sheraton Hotel in Chicago. Delegates from 26 chapters attended.

It didn’t take long for CME to become a mainstay of the AAGP, holding the first Scientific Assembly in Cincinnati in early March of 1948 with 3,500 family physicians in attendance. Thus, many of the tenets of the specialty were established very early in the

75

YEAR ANNIVERSARY OF THE NORTH 75

Feb. 22, 1948: Organizational meeting held in Greensboro with 48 individuals present.

April 25, 1948: Charter granted for the 21st chapter for North Carolina. Dr. John R. Bender was the first President.

1950-51: State headquarters established in Winston-Salem in the offices of Dr. Bender.

1959-60: NC Academy employed its first executive secretary, Jack Knowles.

1960-61: Headquarters moved to Raleigh.

1964: Dr. Amos Johnson serves as President of the AAGP, the first President from North Carolina.

1969-70: Name changed to NC Academy of Family Physicians.

1974-75: Ms. Liz Cook became the first medical student member of the NCAFP Board.

1975-76: East Carolina Family Practice Residency Program approved.

1976-77: Dr. Thomas Creek named first NC Family Physician of the Year.

1982-83: The first computer was approved for the headquarters building.

1984: NC Family Physician of the Year, Dr. Jane Carswell, becomes the first female recipient of the National Family Physician of the Year Award.

1986-87: NCAFP budget reaches almost $400,000.

1987: Dr. James G. Jones serves as President of the AAFP.

1988: Dr. J. Seaborn Blair, Jr., named AAFP Family Physician of the Year.

1993-94: Dr. Sharon S. Sweede serves as the first female president of our Chapter.

history of the organization – from emphasizing continuing education to our form of policy development.

In 1969, Family Medicine was officially recognized as a specialty in a stronger response to the increasing specialization of US medicine with patients being segregated by age, systems, or disease. In his seminal talk in 1979 and a subsequent article, G, Gayle Stephens, MD, highlighted the social-reform ethos and countercultural nature of the specialty of Family Medicine. His article stated:

“It is my conviction that, on balance, the family practice movement has more in common with this counterculture than it does with the dominant scientific medical establishment. Maybe we never intended that it should be this way, and I doubt that many of us have an image of ourselves as revolutionaries. Most of us deal, on a day-to-day basis, with a much smaller quantum of reality; and, in truth, are much more motivated by purely personal goals than the heady stuff of national purpose. I suspect that this is the way all revolutions look from the inside.”

Today the Family Medicine Revolution remains in full force, and the North Carolina Chapter has long played an important role in that national revolution.

For example, our Chapter has had four presidents of the

AAGP/AAFP, including: Dr. Amos Johnson (1964), Dr. James G. Jones (1987), Dr. Douglas E. Henley (1995), and Dr. Lori Heim (2009). And of course, Dr. Henley went on to serve as the Executive Vice President and CEO of the AAFP for many years. In addition, North Carolina has had five national Family Physicians of the Year, including the first female Family Physician of the Year, Dr. Jane Carswell (1984). Other national winners from North Carolina include Dr. J. Seaborn Blair, Jr. (1988), Dr. Melvin Pinn (1998), Dr. Maureen Murphy (2016), and Dr. Karen Smith (2017).

Throughout this year, we will be highlighting the history of family medicine, the history of our Chapter, and the impact that your specialty has on our state and nation. Our CME, our magazine, and our e-newsletter will all emphasize the history of your organization. We hope you will join us as we examine the last 75 years and at the same time prepare for the future. While some of the problems that led to the formation of the AAGP still exist today, I truly believe we are on the cusp of a true Family Medicine Revolution, where every patient deserves — and has — a consistent and meaningful relationship with a family physician.

Please join us on this journey of celebration for 75 years as we prepare for an eventful and successful future for Family Medicine.

NORTH CAROLINA ACADEMY OF FAMILY PHYSICIANS

1995: Dr. Douglas E. Henley serves as president of the AAFP.

1996-97: NCAFP’s first website goes online.

1998: Dr. Melvin Pinn named AAFP Family Physician of the Year.

2000-01: Annual Meeting attendance reaches an all-time high of 463 participants.

2008-09: NCAFP achieves 100% resident membership for fifth consecutive year.

2009: Dr. Lori Heim serves as President of the AAFP.

2009-10: NCAFP implements Family Medicine Interest and Scholars Program to increase student interest in Family Medicine.

2011: Annual Meeting attendance tops 750 participants. Overall membership grows to just under 3,200.

2013-14: Multiple members testify before Medicaid Reform advisory Group.

2014-15: NC hosts Health is Primary City Tour in Raleigh.

2016: Dr. Maureen Murphy named AAFP Family Physician of the Year.

2017: Dr. Karen Smith named AAFP Family Physician of the Year, giving North Carolina back-to-back winners.

2020: NCAFP Meetings, including our Annual Meeting, went virtual due to COVID-19.

Learn even more about our history on our 75th Anniversary Timeline at www.ncafp.com.

KEY DATES IN THE HISTORY OF THE AAFP

June 1947: American Academy of General Practice organized during AMA Meeting.

March 1948: First AAGP Scientific Assembly.

Feb. 21, 1950: First State Officers Conference – now the Annual Chapter Leadership Forum.

April 1950: First issue of GP, the forerunner of the American Family Physician, is published.

March 1956: Then Vice President Richard M. Nixon makes a surprise visit at the Eighth Annual Scientific Assembly in Washington.

March 1957: Mary E. Johnston of Virginia elected first women on the AAGP Board of Directors.

Nov. 18, 1958: AAGP Foundation chartered.

April 1965: AAGP Congress of Delegates passed Resolution No. 11 “To Extend Equal Rights for AAGP Membership” stating that the Academy was “unalterably opposed to the denial of membership in county and state chapters to any duly licensed physician in the family practice of medicine because of race, color, religion, ethnic affiliation, or national origin.”

Feb. 8, 1969: Family practice approved as American medicine’s 20th specialty. The first certifying exam was held Feb. 28 - March 1, 1970.

Oct. 3, 1971: AAGP officially changed name to the American Academy of Family Physicians and approved a “Fellow” membership clarification.

Oct. 4, 1971: Actor Robert Young (who portrayed Marcus Welby, MD, on ABC) was keynote speaker at the Academy’s Scientific Assembly. He also appeared in 1974 and 1984.

Sept. 26, 1972: First fellowship convocation in New York City with 10,000 attendees and 4,000 degrees conferred.

July 6, 1977: First Family Doctor of the Year Award given to Robert Boyer, MD, of Kansas.

2019 AAFP Calendar

Dec. 31, 1980: AAFP membership topped 50,000.

Oct. 9, 1985: Resident observer to the AAFP Board given full voting privileges.

June 9, 1986: In Bowen, Secretary of Health and Human Services, et al. v. Michigan Academy of Family Physicians, the U.S. Supreme Court overturned Medicare’s dual fee system that paid family physicians less than other specialists for conducting the same procedures. The AAFP provided a great majority of the funding for the Michigan Academy as it pursued this case through the court system.

June 9, 1988: First meeting of the Subcommittee on Student Interest. Later that year, medical student membership in the AAFP reached 9,666.

Jan. 1, 1989: Began requiring residency completion as a condition for active membership.

Aug. 24-26, 1990: First National Conference of Women, Minority, and New Physicians held (now the National Conference of Constituency Leaders).

Aug. 15, 1992: Guam Chapter chartered, bringing the total number of constituent chapters to 55.

1993: Academy endorses Tar Wars.

Jan. 1, 1993: AAFP acquired the Advanced Life Support in Obstetrics Program from the University of Wisconsin Department of Family Medicine and Practice.

Oct. 1993: First issue of Family Practice Management published.

Oct. 6, 1993: Slotted seats approved for women, minority, and new physician constituencies and delegates seated.

Jan. 1, 1995: AAFP joined forces with American Academy of Pediatrics and the Advisory Committee on Immunization Practice to develop a new schedule for childhood immunizations, replacing three separate schedules previously recommended by the organizations.

Jan. 1996: Family Medicine becomes the first specialty in America with residency programs in all 50 states.

June 1998: Academy member Nancy Dickey, MD, elected the first female AMA President.

Aug. 1, 2000: Douglas E. Henley, MD, of Fayetteville, NC, became new AAFP Executive Vice President, the first practicing family physician to fill that role.

Oct. 2001: Warren Jones, MD, of Maryland, a captain in the Navy, was installed as the first African American President of the AAFP.

Oct. 2002: Cynthia Romero, MD, approved as the first member of the AAFP to represent new physicians.

Oct. 2004: Mary Frank, MD, of California became the first female president of the AAFP.

June 2005: FamMedPAC, a federal political action committee, launched.

Sept. 27, 2006: Family medicine leaders and practicing physicians converged on Capitol Hill for a rally called Vote for America’s Health.

March 31, 2017: Academy announces formation of the Center for Diversity and Health Equity to address the social determinants of health.

Oct. 13-17, 2020: Academy hosted FMX/Scientific Assembly virtually for the first time due to COVID-19 pandemic.

SOURCE: The Center for the History of Family Medicine

@HEADQUARTERS

Academy Adds Communications and Membership Manager to Staff

The NCAFP is excited to announce the addition of Kevin LaTorre to its headquarters team as the new Manager of Communications and Membership. Kevin joined the staff on Jan. 4, 2023, and oversees the communications messaging and membership support which help the NCAFP improve Family Medicine for every physician and patient in North Carolina. His experience in public relations and healthcare journalism equipped him to begin the role, but he looks forward to perfecting his work with input from his fellow staff, the 75-year

Dr. Andrea DeSantis appointed to AAFP Commission on Federal and State Policy

Andrea DeSantis, DO, a family physician from Charlotte, has been appointed to the AAFP Commission on Federal and State Policy for a two-year term. The Commission on Federal and State Policy informs and guides the Academy’s federal advocacy program and the AAFP’s support for constituent chapters in their advocacy efforts before state governments. Commission members participate in two meetings each year (one in person and one virtual) and ongoing work electronically between meetings. Dr. DeSantis practices at Atrium Health NorthPark Family Medicine in Charlotte. Congratulations to Dr. DeSantis.

Dr. Kevin E. Burroughs Appointed to NC Brain Injury Advisory Council

Recently, Dr. Kevin E. Burroughs, a family physician in Concord, was appointed to the NC Brain Injury Advisory Council by Governor Roy Cooper.

example of the NCAFP, and all the association’s members.

Kevin graduated from the University of North Carolina with a Master’s in Strategic Communications. He and his wife will welcome their first son this upcoming summer and soon become very, very familiar with family medicine as patients. In his free time, Kevin enjoys reading, hiking, and listening to music no younger than 40 years old.

If you missed our 2022 NCAFP Annual Meeting, then you must listen to this podcast. And even if you attended, it’s worth a listen again as outgoing President Dr. Dimitrios (Takie) Hondros provides the 2022 State of the Academy Address during our Annual Awards Luncheon. Dr. Hondros outlines the many accomplishments of the NCAFP throughout the last year.

You can listen to the podcast by clicking here, going to the NCAFP website at www.ncafp.com or by subscribing to NCFM Today on Spotify, on the Google Store, on the Apple Store, or wherever you listen to podcasts.

Family Medicine Community Podcast

Physician Advocacy Is a Team Sport

By: Jason Newton, General Counsel, Curi

Many times, advocacy efforts within the medical malpractice sphere can feel like an uphill battle.

The reality is that plaintiffs’ attorneys are arguably better networked, more motivated, and more successful at seeking change and maintaining a landscape favorable to them than the more fragmented “defense” industry. Simply put, plaintiffs’ lawyers don’t sleep on advocating for their own economic interests.

It never fails to seem as though any improvement that appears to favor physicians, keep insurance costs down, or keep evidence in cases “fair,” is subject to being struck down by a trial judge or appellate court if given the chance. Examples of the issues involved include protections around peer review, prohibitions on “phantom” damages (damages that permit plaintiffs to recover the amount “billed,” rather than “paid”), permitting evidence of known risks of procedures and complication rates (even if informed consent is not at issue in the underlying case), or keeping third-party litigation financing in the shadows.

Advocacy for physicians must be a team sport, and oftentimes, getting involved can be a simple task. Advocacy for an individual physician usually includes being a member of the state’s medical society and seeking ways to get informed and involved both for physicians and their office staff. Voting regularly in state and federal elections, particularly in lesser-known judicial elections, is also extremely important for advocacy efforts. Physicians also need to participate in grassroots advocacy when called upon. In a dream state, more doctors would run for office, and more defense lawyers would have an interest in becoming judges.

For Curi, and for myself, advocacy efforts go hand-in-hand with holistically serving doctors in medicine, business, and life as our mission statement promises.

Throughout my daily life, I’m often reminded of what it means to be a strong partner to the community we serve. There’s a convenience store around the corner from me in Raleigh, where Curi is headquartered, that’s been around for decades. Its slogan, permanently emblazoned on its sign, is “Big enough to serve you, small enough to know you.” I often think about that as analogous to Curi’s role in physician advocacy.

In the core states in which Curi operates, we engage with our sweat and equity in advocacy where we can. We aim to provide education to members about elections, we have memberships in state-specific organizations that focus on litigation reform, we lend support to “friend of the court” briefs on issues that impact physicians (even when our own insureds are not involved in the underlying case), and we administer grassroots advocacy tools to our physician owners when circumstances demand it.

It’s a privilege to work for a company that altruistically devotes resources and time to identifying legislative and judicial issues that are important to our members on a regular basis. When we engage in advocacy, it’s not to gain a competitive edge in the market it’s because we view it as table stakes given our company’s mission.

Sometimes it’s a struggle to find partners who share the same outlook. If you are one of our members, please take time to read advocacy information we share with you, and act upon it when you’re so inclined. If you are not currently a Curi member but want to get involved in advocacy efforts, feel free to reach out to me at jason.newton@curi.com. To truly generate change, we need you on to be on the field with us, fighting alongside us on our advocacy team as we work together to protect the medical community.

For more information about Curi or to read more of Curi’s blog content, visit curi.com and blog.curi.com, respectively.

Sights & Scenes from Chapter Events

By Peter Graber NCAFP Communications

MEMBER AWARDS

How can one family physician rise through the ranks at NC Medicaid, diligently treat STIs through volunteer practice in Buncombe County, earn statewide recognition, and write her first book? Dr. Shannon Dowler just chose to serve anyone and everyone to the best of her abilities. The fruits of her service and career came in pursuit of that first goal.

During the 2022 Winter Family Physicians Weekend, NCAPF Outgoing President Dr. Dimitrios Hondros named Dr. Dowler the 2022 Distinguished Family Physician of the Year. This annual award recognizes a family physician whose career demonstrates an unwavering commitment to their patients, the improved quality of life in their community, and the bedrock ideals of Family Medicine. As the Chief Medical Officer (CMO) at NC Medicaid and Deputy CMO at Health Access in the NC Dept. of Health and Human Services, Dr. Dowler has more than met those standards in serving the state’s patients and physicians during both routine practice and emergency pandemic response – she has far exceeded them.

We had the chance to ask Dr. Dowler about her initial start in Family Medicine, her formative experiences and mentors, and what she’d recommend to anyone just beginning Family Medicine.

NCAFP: What first inspired you to become a family physician?

Dr. Dowler: When I was a premed student, I was torn

“The Choose Your Own Adventure Path”: Wisdom from the 2022 NCAFP Distinguished Physician of the Year, Dr. Shannon Dowler

between vet school and med school and decided to do an internship at the local hospital. In my time in the ER, I was shocked and alarmed by all the people who sought care without health insurance, and by how advanced their conditions were because of their lack of access to care. That experience was transformative and set my desire to become a family doctor with a goal of treating all-comers, regardless of their ability to pay.

NCAFP: Were there any physicians who impacted you and your own practice of medicine?

Dr. Dowler: Maureen Murphy was perhaps my first and most influential family physician mentor. I was still in medical school when I met Maureen, and she took me under her wing. Her openness, complete willingness to be herself, and her passion for Family Medicine were contagious and confirmed that my instincts for Family Medicine had put me on the right track.

NCAFP: Do you have any tips for a medical student or young physician just beginning Family Medicine?

Dr. Dowler: I like to say Family Medicine is the “Choose Your Own Adventure” path in medicine. The beauty of it is in the many pathways you can take – some parallel and some intersecting – and how you can course-correct as life throws things at you. If you are a student who loves all fields of medicine and are agonizing over the “right” choice, then Family Medicine allows you to build, grow, and adapt continuously.

Part 2 of our conversation with Dr. Dowler will appear in the summer issue of The North Carolina Family Physician, where she’ll reflect on her leadership as a physician executive and her role as a public servant.

And remember that book we mentioned? Dr. Dowler’s first book, “Never Too Late: Your Guide to Safer Sex After 60,” will appear (quite naturally) on Valentine’s Day!

Dr. Dowler with her husband Jared Dowler and her mother.

PROFESSIONAL DEVELOPMENT

By: Kathryn Atkinson, CMP Director of CME & Events

Accolades, Awards, and Achievements

The 2022 Winter Weekend Celebrated Champions of Family Medicine All Weekend Long

Thank you to everyone who joined us for the NCAFP’s 2022 Winter Family Physicians Weekend! After enjoying over 745 attendees, more than 70 vendors and sponsors, 30 mainstage lectures, nine optional workshops and seminars, and countless opportunities for networking and fun, we all agree that our favorite annual weekend in the Blue Ridge Mountains was a resounding success. While important clinical updates and unique learning opportunities are the capstones of the annual four-day conference, several of your colleagues and peers were also celebrated for their accolades, achievements, and dedication to the specialty of Family Medicine over the long weekend.

Saturday evening’s Presidential Gala, complete with guests in sparkling gowns, a gourmet meal, and live music, featured the swearing-in of Dr. Shauna Guthrie as the 2023 NCAFP President. Sworn in by Dr. Sterling Ransone, Board Chair of the AAFP, the night was made extra special when Dr. Guthrie’s grandmother, Ms. Diana Guthrie, joined her on the stage to take the Presidential Oath. During her poignant acceptance speech, Dr. Guthrie underscored the versatility of family physicians, emphasized the importance of asking

for help when you need it, described her love for the scope of Family Medicine, and shared the rewarding journey that led her to where she is today. You can read Dr. Guthrie’s full inaugural address right here in this issue, or you can listen to it on our podcast by subscribing to NCFM Today on Spotify, in the Google Store or the Apple Store, or wherever you listen to podcasts. You can also listen via our website at www. ncafp.com/podcasts.

Speaking of inspirational leaders and podcasts: you can also listen via NCFM Today to Outgoing President Dr. Dimitrios (Takie) Hondros’s 2022 State of the Academy Address. His thoughtful speech highlighted much of the dedicated work and accomplishments of the NCAFP’s leaders, volunteers, and staff. This summary of their tireless efforts, along with Dr. Hondros’s personal experiences as chapter president, characterizes

the strength and importance of the Academy and its members. I encourage you to tune in (or perhaps listen again!) to both heartwarming speeches during your next run, commute, or quiet time. You will certainly feel inspired, motivated, challenged, and, most of all, appreciated.

The 2022 Distinguished Family Physician Award, the NCAFP’s highest honor, was presented to Dr. Shannon Dowler, Chief Medical Officer (CMO) for NC Medicaid and Deputy CMO for Health Access within the NC Department of Health and Human Services. The NCAFP, along with family members and a few close friends of Dr. Dowler, managed to surprise her with an award presentation that highlighted her ongoing efforts to combat sexually transmitted infections and, more recently, her work at Medicaid to swiftly change many policies, including telehealth policies, during the pandemic. The presentation also highlighted Dr. Dowler’s work to minimize patient disruptions and administrative burden for primary care during the Department’s transition to Medicaid Managed Care. Congratulations, Dr. Dowler! We are so proud of you and the excellent work that you do!

medical education and research. AAFP Fellows help make Family Medicine the premiere specialty through their service to their community and profession, and we were delighted to honor 12 members during this year’s convocation ceremony. Please join us in congratulating these recent Degree of Fellow awardees:

Scott Baker, MD, FAAFP

Amir Homayoun Barzin, DO, FAAFP

Rebecca S. Bassett, MD, FAAFP

Nichole Lynette Johnson, MD, FAAFP

Keli Beck Jones, MD, FAAFP

Richard H. Jones, MD, FAAFP

Michelle K. Keatin, DO, MEd, FAAFP

S. Mark McNeill, MD, FAAFP

Bradley Propst, MD, FAAFP

Neil Sparks, DO, MS, CAQSM. FAAFP

Adam C. Wenzlik, MD, FAAFP

Audy Whitman, MD, FAAFP

The NCAFP is extremely proud of the 645+ members who already carry the AAFP’s distinction of Degree of Fellow. AAFP Fellows are members who have distinguished themselves among their colleagues, as well as in their communities, by their service to Family Medicine, their advancement of healthcare to the American people, and their professional development through

We also celebrated five outstanding family physicians who generously share their time to advance the principles and ideals of Family Medicine by teaching and mentoring the next generation of family physicians. The 2022 Outstanding Community Teaching Award Winners are:

John Bernot, MD

Wake Forest University School of Medicine

Drs. Vickie Fowler, Steven Manning, and Nathan Sison, 2022 Community Teaching Award honorees.

Vickie Fowler, MD University of North Carolina School of Medicine

James Lester, DO Campbell University School of Osteopathic Medicine

Steven Manning, MD Brody School of Medicine at East Carolina University

Nathan Sison, MD Duke University School of Medicine

Congratulations to these outstanding community teaching winners, and thank you to the many preceptors and mentors who continue to nurture a strong, diverse, and much-needed Family Medicine workforce. We appreciate you!

Quite possibly the NCAFP Foundation’s largest poster contest to date, the 2022 Research Poster Contest featured entries from over 35 residents and medical students. In the Resident Category, Dr. Connor Brunson of the MAHEC Boone

Family Medicine

Residency Program won for the poster “One in 36 Million: An Exceptional Case of Lyme Carditis.” Dr. Toria Knox, also of the MAHEC Boone Program, finished as first runner-up for the poster “Cutaneous Metastasis of Stage IV Lobular Breast Cancer.” For medical students, Grant O’Brien of the Brody School of Medicine at East Carolina University won for the poster “Improving HPV Vaccine Initiation in 9-10 Year Old Patients in a Residency-Based Pediatrics Clinic.” XiXi Yi, a Campbell University School of Osteopathic Medicine student,

The NCAFP would like to thank the recent 2022 Winter Family

This highly-anticipated annual possible without the support and their dedication to Family

Dr. Connor Brunson

Grant O'Brien

thank the many terrific sponsors of Family Physicians Weekend.

annual event would not have been support of these fantastic sponsors Family Medicine. Thank You!

was first runner-up for “Potential Cancer Screening Biomarker – Anti-tNASP Antibodies Exploration in Prostate, Pancreatic and Ovarian Cancers.” Please join us in congratulating the winners and thanking everyone who participated by submitting quality and relative family medicine research.

On behalf of the entire NCAFP Team, congratulations again to all 2022 award winners and family medicine champions. It is a privilege each year to host this wonderful weekend filled with CME, camaraderie, and celebrations. We remain incredibly grateful for your continued support and participation year after year. Consider joining us again this year at the Omni Grove Park Inn, Nov. 30 – Dec. 3, 2023, when we commemorate the NCAFP’s 75th Anniversary. We can’t wait to celebrate this milestone anniversary and the many awards and achievements this year will bring to so many of you!

If you missed the Winter Weekend’s fun and celebrations, or if you were there and want to relive the excitement, be sure to check out the many fantastic moments and memories captured by our photographers at www. ncafp.com/wfpwgallery. You can also catch a fun “2022 NCAFP Year in Review” video shared during the conference at www.ncafp.com/yearinreview.

For more information about the NCAFP’s upcoming CME opportunities, visit us at www.ncafp.com/cme or contact me at Katkinson@ncafp.com. Best wishes for a wonderful and happy 2023, and we look forward to seeing you at an NCAFP event soon!

FAMILY MEDICINE ON CAMPUS

Spotlight on the 2022 Foundation Scholarship Winners

The NCAFP Foundation would like to congratulate the following four medical students who won 2022 NCAFP Foundation scholarships:

Mereze Visage – Campbell University School of Osteopathic Medicine (CUSOM)

Mereze is Vice President and Geriatric Chair of CUSOM’s FMIG, Research Chair of CUSOM’s Student Government, an AAFP Family Medicine Leads

Scholarship winner, an ACOFP National Emerging Osteopathic Leader Award winner, Student Representative on the Executive Board, a William Morris Department of Osteopathic Medicine Award winner for Top Osteopathic Student at Campbell, and a member of Sigma Sigma Phi, the National Osteopathic Medicine Fraternity. Mereze encountered Family Medicine while working at CUSOM’s Mobile Clinic, saying, “I feel especially connected to this vulnerable patient population, as I remember what it was like when I was unable to speak English. Working at the clinic confirmed my passion for Family Medicine, as it allowed me to meet patients where they are at and form long-term relationships.”

Brinda Sarathy – UNC School of Medicine (UNCSOM)

Brinda is President of Medical Students for Choice at UNC, Service Chair of the American Medical Women’s Association, and a member of UNCSOM’s

FMIG. She was also a Paul A. Godley Art of Medicine Fellow. She says, “Family Medicine is the perfect specialty fit for me because it affords me the privilege of patient stories and continuing pursuits I am passionate about. I feel confident that Family Medicine will allow me to be an equitable primary care physician and carry on playing a role in patient stories.”

Sierra Fowler – Campbell University School of Osteopathic Medicine (CUSOM)

Sierra served as Site Representative at CUSOM’s Johnston Regional Site, Treasurer of CUSOM’s Student Alumni Association, Member in the Peer Navigator Program, and is a student member of STFM and CUSOM’s FMIG. Sierra says, “I found my passion in working in underserved healthcare. I learned that preventive care was key, healthcare was not simply prescribing medications, and the best healthcare came from an understanding of the patient population.” Her goal going forward is to perfect “serving underserved populations of North Carolina as a primary care physician.”

David Faircloth – Campbell University School of Osteopathic Medicine (CUSOM)

David is a member of Sigma Sigma Phi National Osteopathic Medicine Fraternity, a volunteer with the CUSOM Community Care Clinic, a volunteer with the CUSOM Mobile Clinic, and a member of CUSOM’s FMIG. David finds that Family Medicine allows him to fulfill his desire to know his patients holistically and finds “joy in being able to converse with patients through all their illness, how they connect and work through problems together.” He wants to serve a rural community like the one where he grew up and both advocate for and educate his patients.

Learn | Connect | Engage | Celebrate

2023 Family Medicine Academic Summit

Friday, Feb. 17 – Saturday, Feb. 18, 2023

Sheraton Imperial Hotel

Raleigh, Durham

Approximately 5 credits

Networking Dinner with 30-Minute

Hot Topic Exchanges

Charlotte

Thursday, March 30, 2023

Atrium Health Carolinas Medical Center

Family Medicine Residency

Approximately 1.5 credits

2023 Virtual Complex Pain Project

Two Opportunities!

Tuesday, May 2, 2023 (6 p.m. – 8 p.m.) or Saturday, May 6, 2023 (9 a.m. – 11 a.m.)

Approximately 2 credits

2023 Virtual Summer Symposium

Saturday, June 24, 2023

From your favorite location!

Approximately 6 credits

*Pre-Conference KSA on Friday, June 23, 2023

Networking Dinner with 30-Minute

Hot Topic Exchanges

Chapel Hill

Tuesday, Sept. 19, 2023

UNC Family Medicine Center

Approximately 1.5 credits

2023 Winter Family Physicians Weekend

Thursday, Nov. 30 – Sunday, Dec. 3, 2023

Omni Grove Park Inn | Asheville, NC

Approximately 30 credits

*Pre-Conference KSA on Wednesday, Nov. 29, 2023

Celebrate your commitment to providing the best possible care to your patients with these fantastic learning opportunities in 2023!

This article follows Part 1 of our Moms in Family Medicine series from the November 2022 issue. The first part explored some of the challenges that our member sources faced, while this part includes their advice for navigating those challenges, whom they look to for guidance, and how being a mom has shaped them into the successful family physicians they are today!

MOMS in Family Medicine

Navigating a Fulfilling Career and Family: Part II

By: Perry Price Manager of Workforce Initiatives

colleagues, and mentors. I recall during a particularly challenging time with my teenage daughter that Dr. Sue Slatkoff gave me guidance and support to feel empowered to ask for time to be present for my teenage daughter, just as I had needed to feel empowered to be home with my younger children.

Who did you look to for advice and guidance when navigating the stages of motherhood in medicine? Whom do you look to today?

Jessica Triche, MD: My residency classmates. Four of us had kids. We leaned on each other.  My youngest had neonatal jaundice. My classmate helped me not panic (it was during Christmas holiday and the clinic was closed) and even came over to reassure me. Later, as my kids aged and I became involved in leadership, I talked to Shannon Dowler. She had two boys as well, and her kids are amazing. She told me I could be a great mom and a great leader.

Vickie Fowler, MD: I looked to my female friends,

Kelley Lawrence, MD: Good question. I don’t think there was one person, so I will name a few that were impactful for each of my pregnancies — some female and having traveled the same physiologic paths before me, some male and having an understanding and empathy that was profound:  my mom (Jean Vance, who was a full-time teacher and mother), Dr. Teresa Terezis, Dr. Amy Weil, Dr. Charlie Baker, Amelia Henning, CNM, Dr. Wendy Barr, Dr. Kay Nordling, Dr. Mark Higdon, Dr. Jennifer Higdon, Dr. Heather Doty, and Lauren Penwell-Waines, PhD.

Jackée Clement, MD: I was fortunate to have a faculty team leader and mentor in Dr. Kelley Lawrence. She was such an advocate for me to do what was best for my family while maintaining a career in family medicine. I appreciated hearing her stories of having children in residency. In addition, she is a lactation specialist. I definitely used my phone-a-friend privileges often in that department.

Liz Baltaro, MD: I absorbed narratives from physician

moms long before I was a mom myself — from the very start of medical school. I had so many sources of inspiration — my parents, my residency program director and advisors, colleagues, faith-based community, our local Moms of Multiples chapter, and non-medical family and friends. More recently, I have enjoyed listening to “Dr. Mama Podcast” created by a family physician, Dr. Alice Kaufman, and found inspiration in JAMA’s “A Piece of My Mind” column, and the novel “We Are All Perfectly Fine” by a Canadian Internist Dr. Jillian Horton.

What advice do you have for young parents balancing their careers and family?

JT: Use available resources!  If you don’t have family close by, work out things with your kids’ friends’ parents. Shared rides, alternating practice attendance, etc. Family should come first but, as you will learn, you are pulled in the other direction. At times, you may need to take a step back and really focus on family. It’s ok to miss work for your family. You don’t want regrets. When interviewing, see if you can gauge how family friendly the practice or organization is.

VF: It is important to reset your expectations of yourself, such as what you can accomplish or perhaps should aim to accomplish. The early years are magical and go by very quickly.

KL: My career has had stops and starts that many of my colleagues — who were not physically growing children inside (and outside) of their bodies — did not have. I worried a lot about what that different path would mean for me as a physician; I worried too much.  My career has brought me much joy and fulfillment, and my family has even more so.  I’m very grateful to have spent the time I did nourishing my children — and I still try to keep that in mind, because my children only have one mom, but others can fill in as docs to my patients or teachers to my medical learners if or when needed.

JC: My advice for young parents who are trying to balance their careers with increasing their family size is that you definitely need to have a plan for what is going to take priority in your life and for how long. When I was taking care of my newborn baby, that was my focus. And I was fortunate enough to not have work interfere with that time. Make sure you know your job’s policy regarding maternity leave. Will you need to go on disability? Will the leave be paid or unpaid? If you are a medical student reading this, please be courageous and ask about these policies. Only in this way will other programs realize that they need to take a second look at their policies if they want to remain competitive.

LB: Medicine in general still feels set up like most doctors have a stay-at-home partner and no caregiving or reproductive needs themselves. Women and mothers who are working in a system like this are bound to face many challenges — these are systemic problems, not personal failings. I still remember a sign on the office of an attending physician mother during my third-year clerkship which said, “You can have it all. You can’t have it all at once.” Now I deeply understand the hardship of combining a caregiving profession with the demands of motherhood. I acknowledge that both medicine and parenting are individualized experiences — unpredictable, uncontrollable with many transitions that require reprioritizing, tough decisions, and sacrifices.

How has being a mother impacted your service as a physician?

JT: It has helped me care for my pediatric population! Easier to reassure parents about “normal” development, or let a mom know that an adolescent attitude is normal! I think having kids keeps me grounded. I put artwork and schoolwork up in my exam rooms, and my patients always ask about my kids. I think this makes me more relatable. I then tell the kids about the compliments, and they like that. Sometimes patients will see us in public and tell them how great their artwork is. They love it!

VF: As with all skills, firsthand experience is the best instructor! As a family physician who cared for obstetrical and pediatric patients during much of my career, I became a much more knowledgeable and empathetic physician due to my own experiences. I can relate much better to my patients who are parents as to their joys and their concerns. Also motherhood gives my life so much more meaning and ensures that I do not lose myself in my work.

KL: Being a mother has given me a visceral understanding of the vulnerability and fear that accompanies any pregnancy problem, any childhood sniffle or cough.  It has helped me better communicate with all that in mind with parents and their children of all ages. It has also fulfilled a deep desire to nurture and love that I didn’t even realize I had prior to being a mother.

JC: Overall, being a mother has had a positive impact on my role as a physician, because I am able to provide not only medical knowledge but also first-hand experience with my patients and their families. There are certain things about parenting and caring for another person that you just do not learn from a textbook. And at the very least, getting to see it on a day-to-day basis just helps reinforce what continues on back cover

By Robert W. Shaw and John W. Gibson, Attorneys at Smith, Anderson, Blount, Dorsett, Mitchell & Jernigan, LLP

Key Regulatory Considerations for Direct Pay and Concierge Models in Family Medicine

As the health care industry continues to evolve at a rapid pace, many family physicians are exploring innovative practice models, including concierge and direct pay care. These models have gained traction in primary care in recent years because they can streamline the administrative burden of maintaining a practice and stabilize revenue, enabling physicians to provide more personalized and convenient care to their patients. Patients in turn benefit from greater accessibility to their doctor and can avoid some insurance hurdles as well.

While both models are alternatives to traditional fee-forservice practice, there can be important differences. The direct pay structure allows providers to bypass billing payors, instead charging patients directly, typically on a membership fee basis that covers all services in the practice. This approach enables providers to decrease overhead and provide a predictable scope of services for their patients.

Concierge practices also charge a membership fee, but many continue to bill insurance as well. These providers must ensure that the services offered under the membership fee are not the same as services reimbursed by payors, as Medicare rules prohibit physicians from charging patients extra for services covered by Medicare, and some commercial payor contracts may also have limitations that impact services that physicians can provide outside of covered services in the contract. While these stipulations add a layer of complexity, concierge providers often provide a greater range of services than their direct pay counterparts, which can simplify the treatment process for patients that might otherwise have to seek care outside of the practice.

While direct pay and concierge medicine can be attractive options, family physicians should be aware of their surrounding legal framework for compliance before making the transition to either.

DOES HIPAA APPLY TO THESE MODELS?

It’s a common assumption that all health care providers are subject to HIPAA. However, HIPAA rules only apply to providers that are covered entities, which are providers that transmit health information in electronic form in connection with what DHHS terms “standard transactions.” Many of these standard transactions involve the exchange of health care data to insurers, including, but not limited to, data transmitted in connection with payment and remittance advice, obtaining claims status, enrollment and disenrollment in a health plan, coordinating benefits, determining eligibility for a health plan, and obtaining referrals or authorizations.

Providers that do not transmit any health information electronically to a third-party payor in connection with a standard transaction are generally not considered covered entities and thus are not subject to HIPAA rules. However, this does not apply to providers that offer a membership fee for services outside of insurance coverage but also continue to bill payors, a group which can include concierge providers as well as direct pay strategies in which some of the practice’s patients are direct pay while other patients are covered by third-party payers. Moreover, considering the frequency of data exchange in the health care industry and corresponding security threats, even providers that do not submit claims to payors are generally best served by complying with HIPAA regulations to effectively protect the

privacy and security of patient data and ease the burden of compliance in the event of future transfers of data that do fall under HIPAA. Additionally, providers that are not covered entities may still be subject to HIPAA if they provide services to covered entities as a business associate. Finally, other data security and privacy laws may still apply, even if HIPAA rules do not. A careful understanding of these rules as they apply to the practice’s particular circumstances is an important part of setting up a compliant practice using these alternative compensation models.

THE ROLE OF TELEMEDICINE IN DIRECT PAY AND CONCIERGE CARE

Telemedicine is an essential service to many family medicine providers operating under direct pay or concierge models. Accelerated by the COVID-19 pandemic when remote care took on a new level of importance, telemedicine is at the forefront of many modern care delivery models. Virtual services can enhance the convenience of direct pay and concierge membership for patients and can be particularly valuable to family physicians who provide for patients with chronic conditions, allowing them to close gaps in care and ultimately improve the overall health of patients.

CYBERSECURITY CONSIDERATIONS

While telemedicine can be an important service offered under these models, it also presents cybersecurity challenges to providers. Threats to the privacy and security of patient data are nothing new in health care, but the emergence of telemedicine adds a layer of complexity due to the lack of unified security framework across multiple networks and devices.1 Providers can guard against security risks by complying with safeguards under the HIPAA Privacy and Security Rules and engaging cybersecurity and legal professionals to establish a security strategy prior to providing virtual care. DHHS also stresses the importance of providers ensuring their insurance covers telemedicine, including coverage in multiple states if applicable.

MEDICAL BOARD COMPLIANCE

In addition to considerations related to patient health information, family physicians interested in providing virtual care as a service in their direct pay or concierge practices must comply with the North Carolina Medical Board (NCMB) guidance governing the practice of telemedicine.2

The NCMB holds licensees practicing telemedicine to the same standard of care as those practicing in-person care, in-

cluding reliance on appropriate evaluations prior to diagnosing and/or treating a patient. Evaluations can be made through virtual technology if such technology allows providers to accurately diagnose and treat a patient in conformity with the applicable standard of care, necessitating case-by-case consideration by physicians prior to each evaluation.

Physicians must also take steps to appropriately establish a patient relationship prior to providing telemedicine services, including verifying the patient’s identity and location, making the provider’s information available, and ensuring the availability of appropriate follow-up care as applicable. Physicians must be licensed in North Carolina to provide telemedicine services to patients in the state.

LEGAL AND ETHICAL OBLIGATIONS FOR MEDICAL RECORDS

In most circumstances, direct pay and concierge providers own the medical records of their patients and must comply with the same rules as providers operating under traditional models. Even if these providers are not subject to HIPAA requirements related to patient right of access, the NCMB states that licensees have a legal and ethical obligation to maintain records, provide patients with access, protect confidentiality of records, and facilitate transfer of patient information to other providers in a safe manner.

SUMMED UP: DIRECT PAY AND CONCIERGE AS POTENTIAL CARE MODELS

As potential models for family medicine, both direct pay and concierge pose opportunities to decrease overhead and simplify pay systems. However, family physicians considering either model should carefully consider their unique compliance challenges in HIPAA concerns of electrical information and coverage payments, telemedicine usage within strategic cybersecurity and NCMB requirements, and medical record-keeping which maintains the expected legal and ethical obligations to serve patients with their records.

For any interest in adopting either care model, make sure to always involve legal counsel for a specified understanding of case-by-case compliance needs.

1. Healthcare and Public Health Sector – Critical Infrastructure Security and Resilience Partnership. (2021). Health Industry Cybersecurity – Securing Telehealth and Telemedicine. Health Industry Cybersecurity – Securing Telehealth and Telemedicine (HIC-STAT) - Health Sector Council.

2. North Carolina Medical Board – Position Statement 5.1.4 “Telemedicine”.

By Thomas J. Zuber, M.D., M.P.H., M.B.A.

The Afghan Refugee Projects

I have just returned to North Carolina after 13 months, having participated in what was described by some as the largest humanitarian effort ever undertaken by the United States. I had the privilege of serving as Chief Medical Officer (CMO) for Operation Allies Welcome (OAW) Projects 1 and 2. These historic projects represented some of the most rewarding activities in my 40-year medical career.

When Kabul, Afghanistan, fell to the Taliban in Aug. 2021, the U.S. Government assisted with Afghan refugee evacuation and relocation. In OAW 1, eight U.S. military bases provided food, housing, clothing, and medical assistance while the refugees were resettled. This was a well-coordinated effort between the U.S. Department of Homeland Security, U.S. State Department, U.S. Department of Defense, and a host of other U.S. government and non-governmental agencies.

Individuals that escaped the initial horror at Kabul Airport were the first to arrive in this country in August 2021. Many had been beaten, shot, and traumatized. Many of the initial refugees escaped with nothing more than the clothes on their backs. Often bewildered in a new country with new customs, the Afghan families needed our medical care and support to transition to their new lives.

At our site, we rapidly erected Alaska tents that would serve as our medical facility for the next six months. We assembled a medical team of 500 outstanding medical personnel. Our clinicians included physicians in Family Medicine, pediatrics, Internal Medicine, obstetrics, Emergency Medicine, public health, and other subspecialties. Our nursing, midwife, medical technician, behavioral health, EMT, pharmacy, and linguist interpreter colleagues provided excellent support for the operations.

Our OAW 1 site provided over 40,000 medical visits over the initial months. The medical tents provided 24-hour well care, urgent care, and emergency services. We cared for over 300 pregnant women, and coordinated nearly 200 deliveries with local hospitals. Each day would provide new challenges, especially during the COVID outbreak. We needed to be able to identify possible infections less-commonly seen in the U.S., including malaria, active tuberculosis, leishmaniosis, measles, and polio. Pediatric congenital issues that we encountered included cardiac anomalies, orthopedic anomalies, and metabolic disorders.

I had the privilege of escorting a governor, U.S. senator, congressional members involved with the armed services, military generals and admirals, and many other governmental and military leaders through our medical tents. One of the visiting brigadier generaIs was a former Family Medicine residency director, allowing us to discuss our similar pasts.

Some of our staff were former or active military staff, and many had served in Afghanistan. For those who had lost their own blood or watched the loss of loved ones in Afghanistan, this project took on great emotional meaning. Their dedication to the projects was an extension of their

overseas mission. I have deep gratitude for the military members and leadership whom I was able to work with on a daily basis.

The Afghan children were the ones who stole my heart. Afghan families are large, averaging about eight members per family (and they travel to the clinic as a group). The children wanted to play, smile, and make friends.

My medical office was a Conex (metal container) that was located steps away from our negative airflow isolation tents. While our public health team performed daily visits to the isolation families, I would gown and mask to visit the families in isolation whenever possible. Every evening when our medical work slowed, children would gather to kick a soccer ball or bump a volleyball with me. While many could speak no English, and I was slow to learn Dari and Pashto, we still communicated with our shared joy and play.

I was asked to return as CMO for the second project. OAW2 was a smaller project housed in a conference center. OAW2 was in a more controlled physical environment, but I missed the shared camaraderie with the clinicians and Afghan “guests”

(as we referred to them) of the tents!

In OAW2, we coordinated with the State Department to bring in individuals with more complex medical problems. We performed over 6,000 patient visits in the clinic. Resettlement of individuals with complex medical issues was often a complicated process. Coordination was required with outside specialists and hospitals, and for future medical care in the communities to which they resettled.

I was honored to work alongside a number of family physician leaders in military and public health leadership positions. Having previously worked in private practice and university settings, I was surprised at the number of family physicians supporting U.S. military and U.S. public health service operations. These colleagues may have less visibility in our specialty, but their dedication and work earned my respect.

As I reflect back on my long medical career, I believe that my varied family practice experiences prepared me for the OAW projects. My time working at a tuberculosis and Hansen’s Disease hospital in India helped with possible infectious disease identification. My years in private practice, sports medicine, procedural medicine, dermatology, and in emergency medicine helped in the coordination of 400500 patient visits a day in OAW1. My exposure to other specialties serving as residency director and teaching at the universities, and my prior leadership experience as a medical director helped with supervision of the many specialties.

As I come to the twilight of my medical career, I can look back on the progress of our specialty. I believe that the breadth of Family Medicine represents its strength, flexibility, and future. I salute the many family physicians in the government, military, and public health sectors. During the OAW projects, I saw family physicians directing various medical specialties in the unified care of needy human beings. I was honored to participate in such a historic medical mission.

I believe the specialty of Family Medicine will continue to train clinicians and leaders that well serve our specialty and all of medicine. The future shines bright for our specialty. Thank you for supporting me over the years, and for permitting me to share this story with our members.

'Moms in Medicine,' continued from pg. 27

I’ve already learned. There are some negatives to becoming a parent as a resident. Obviously, I was not able to see as many patients as my colleagues while I was on leave. I am still working to catch up on my patient count. I do feel I was not able to study anything else during my months away, and I did have to use an elective while I was raising my child. Lastly, becoming a mother during training really forced me to narrow down my interests and say no to extraneous projects that would not help me meet my goals as a mother and physician.

LB: I am a more compassionate and better leader — willing to let go of expectations and agendas, embrace imperfections, and understand others. I feel less in a rush to get through my “doctor checklist” and more interested in listening and shared decision-making. And I am much more in tune with the social challenges to women’s health, especially Black women’s health.

What is an important thing you can do to succeed as a parent and physician?

JT: Make time for your family. Bring your kids to events such as conferences. Let your patients know about your family. When you are overwhelmed, call your colleague friends. I have Tamieka, Shannon, and Talia — they all helped me!

VF: What is an important thing you can do to succeed as a parent and physician? Set boundaries!!!! Family time is sacred. Protect it.

KL: Take time off with your kids when they have school breaks — do things with them, and try to consciously put the Mom before the MD.

JC: I think it’s important to realize that trying to be the perfect parent or physician is a recipe for disaster. There are too many unknown variables that can upend whatever plan you had for that day, so it’s best to remain flexible.

LB: Outsource. hire, and accept help. Let colleagues cover your inbox and patients. Use your paid time off. Challenge the status quo that doctors don’t take sick or personal time. You can set a positive example for others that way. Plan time for self-care, especially restorative creative experiences. Get a therapist. Do all this without guilt.

Why is Family Medicine a good specialty for those who wish to have a family?

JT: The specialty practices what we do as moms. We care for our kids from newborns through their lives.  Illnesses, development, mental health issues, sports, and more.  Your experience as a physician will help you as a mom, and your experience as a mom will help you practice family medicine.

VF: Family Medicine is an amazing specialty in that it allows a physician to change practice scope during the various stages of their careers and lives. You are also more likely than many other specialties to find yourself surrounded by empathetic and compassionate individuals who understand the importance of family.

KL: Because for the most part, we get it. We understand growing families from pregnancies through old age. Family docs can be some of the most supportive colleagues to have on your side! Also, we can go through different seasons as family docs — part-time, full-time, broadscope, limited-scope as needed for our families to function well.

JC: Family Medicine is a good specialty for those who wish to have a family, because we are at the forefront of trying to change medical education and make it more family friendly. Of course, there’s the added benefit that you will learn not only about pediatrics, but also obstetrics. Essentially, you will be as prepared as you can be to become a parent if you choose Family Medicine as your specialty. And then you will be able to take those skills that you’ve acquired from your training and personal experience in service of your patients of all ages.

LB: There is joy in being professionally grounded in a discipline that promotes family. A career in Family Medicine has more freedom than most jobs — it allows pivots to complement phases of life and motherhood, including geographic pivots, new focus areas, teaching, leadership, research all practice types, and either full- or part-time.

Our sincere gratitude to Jessica Triche, MD, Vickie Fowler, MD, Kelley Lawrence, MD, Jackée Clement, MD, and Liz Baltaro, MD, for sharing their stories, challenges, advice, and wisdom with us and with all of you!