NC Family Physician: Winter 2020

Volume 16 Issue 1 • Winter 2020

The North Carolina

Family Physician Quarterly News in North Carolina Family Medicine

The 2019-2020 Inaugural Address

Embracing the Many “Cs”of Family Medicine

Join us in 2020 for top-quality CME

Choose from multiple events, including Saturday and after office hours options, that address a wide variety of topics.

2020 NCAFP Spring Symposium A Saturday CME Event Program Chair: Dimitrios “Takie” P. Hondros, MD

SATURDAY, APRIL 4, 2020 7:30 am to 4:45 pm Charlotte Marriott SouthPark Hotel Charlotte, NC Estimated 8.0 AAFP Prescribed Credits

You will always find enjoyable, out-of-the-box learning opportunities at NCAFP CME events.

Regional Dinner & CME Opportunity An After Office Hours Opportunity TUESDAY, JUNE 2, 2020 6:00 pm to 8:30 pm UNC Family Medicine Center Chapel Hill, NC Estimated 1.5 AAFP Prescribed Credits

Presenting 40+ AAFP Prescribed Credits in 2020 CME | Camaraderie | Networking | Fun

½ Day Saturday Sports Medicine Seminar SATURDAY, AUGUST 8, 2020 7:30 am to 12:00 pm Marriott Greensboro High Point Airport Greensboro, NC Estimated 4.0 AAFP Prescribed Credits

Case-Based Studies & Panel Discussions

Regional Dinner & CME Opportunity An After Office Hours Opportunity

Innovative Product Theaters

TUESDAY, SEPTEMBER 29, 2020 6:00 pm to 8:30 pm

Interactive & Hands-On Learning

Automatic Credit Reporting for AAFP Members

ECU Family Medicine Center Greenville, NC

After Office Hours Opportunities

Live Audience Polling

Estimated 1.5 AAFP Prescribed Credits

Convenient Mobile Conference App

Great Social & Networking Events

First-Rate Faculty Regional Locations Timely Requested Topics

2020 Winter Family Physicians Weekend THURSDAY, DECEMBER 3 – SUNDAY, DECEMBER 6, 2020 Program Chair: Victoria Kaprielian, MD

Have questions? Please contact Kathryn Atkinson, CMP, Manager of NCAFP Meetings & Events, at 919.214.9058 or at katkinson@ncafp.com.

All medical education topics offered by the NCAFP are reviewed by a family physician, and when possible and appropriate, are presented by a family physician. While the NCAFP may receive pharmaceutical funding to help provide education at our events, they are NOT allowed to influence the content presented. The integrity of the information provided is always the NCAFP’s primary concern.

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The Omni Grove Park Inn Asheville, NC Estimated 25+ AAFP Prescribed Credits

www.ncafp.com The North Carolina Family Physician

Inside Winter 2020

2019 NC FAMILY PHYSICIAN OF THE YEAR

Beating the Odds p16

PRESIDENT’S MESSAGE

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Embracing the Many “Cs” of Family Medicine

HEALTH POLICY & ADVOCACY

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National Academy of Medicine Summit Focuses on Value-Based Care

CHAPTER AFFAIRS

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PROFESSIONAL DEVELOPMENT

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The When and the Where of Top Quality Carolina CME in 2020

RESIDENTS & NEW PHYSICIANS

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A PERMA-nent Commitment to Family Medicine

MEDICAL STUDENT PROGRAMS

Keep Moving Toward Value Even with a Pause in N.C. Medicaid Transformation

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NCAFP’s Student Programs Helped Cement My Interest in Family Medicine

PUBLISHED BY

DEPARTMENTS

t 919.833.2110 •

President’s Message 4 Health Policy & Advocacy 10 Chapter Affairs 12 Membership 15 Professional Development 20

fax

919.833.1801 • ncafp.com

Managing Editor, Design & Production Peter T. Graber, NCAFP Communications

NCAFP Foundation 22 Residents & New Physicians 24 Medical Student Programs 28 Practice Management 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 pgraber@ncafp.com.

PRESIDENT’S MESSAGE to Members

By Dr. David Rinehart 2019–2020 NCAFP President

~ THE 2019 INAUGURAL ADDRESS ~

Embracing the Many “Cs” of Family Medicine On Saturday, December 7, 2019, Dr. David Rinehart of Belmont, North Carolina, was installed as President of the North Carolina Academy of Family Physicians.

His inaugural remarks to members appear below.

Thank you so much for welcoming me as your new President of the North Carolina Academy of Family Physicians. It is truly a great honor and privilege to be elected to this position. I have been involved in the leadership of this Academy for eight years and I will tell you that this has been a wonderful experience, meeting and getting to know so many highly skilled and committed family physicians over this time and working with a top notch Academy staff. We are a specialty that cares deeply about what happens in health care, about disparities that exist in health care, about access and quality and affordability of care.

1969, 50 Years Ago Fifty years ago, our country experienced many seminal events.

We saw the liberation of a generation in the experience of Woodstock. We marked the turning point in the gay rights movement at Stonewall. The country had a feel-good moment of technological breakthrough putting a man on the moon. And, as many of you know, in response to our forebear’s vision, and the recognition of the need for comprehensive, patient and family-centered, high Continues on next page 4

The North Carolina Family Physician

2019-2020

NCAFP Board of Directors

Executive Officers President

David R. Rinehart, MD

President-Elect

Jessica Triche, MD

Secretary/Treasurer

Dimitrios “Takie” P. Hondros, MD

Immediate Past President Executive Vice President

Alisa C. Nance, MD, RPh Gregory K. Griggs, MPA, CAE

At-Large Directors Talia M. Aron, MD Elizabeth B. Baltaro, MD Jewell P. Carr, MD Garett R. Franklin, MD Shauna L. Guthrie, MD, MPH Brian McCollough, MD Mark McNeill, MD Ying Vang, MD

Academic Position Mark L. Higdon, DO (Novant FMR)

Resident Director Elizabeth Ferruzzi, MD (Novant)

Resident Director-Elect Clayton Cooper, MD, MBA (Duke)

Student Director Katelyn Turlington (WFSOM)

Student Director-Elect Hannah Smith (ECU)

AAFP Delegates & Alternates AAFP Delegate

Michelle F. Jones, MD

AAFP Delegate

Karen L. Smith, MD

AAFP Alternate

Richard W. Lord, Jr., MD, MA

AAFP Alternate

Robert L. Rich, Jr., MD

2501 Blue Ridge Road, Suite 120, Raleigh, North Carolina 27607

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www.ncafp.com

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who became very interested in biology, physiology, diseases, and medical care. That was me.

I had the good sense to be born into a wonderfully supportive family that valued education as well as emphasized the importance of family relationships. I decided I wanted to be a doctor.

I found myself at the University of Virginia (UVA) for college, then four more years as a Cavalier for medical school. At UVA, I was greatly influenced by Dr. Lewis Barnett who was a wonderful advocate and thought leader and pioneer for Family Medicine in those years. Probably like many of you, I was fascinated by all the different specialties in medical school, and I decided I wanted to specialize in Family Medicine.

quality primary medical care -- and importantly for us here today -- was the creation of the new medical specialty of Family Medicine.

A little about me...

Also, about 50 years ago, there was this 14-year-old boy

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I came to North Carolina now more than 37 years ago, to Carolinas Medical Center for Family Medicine residency, drawn by another great intellect and visionary, Dr David Citron. I developed many wonderful friendships in Charlotte, and I had an excellent residency experience there, and I have not left.

When I precept medical students, I have always encouraged them to take away the best ideas and characteristics of each of the physicians that they encounter along their professional path. I have tried to do that with each of my physician mentors, and others, who have contributed to my professional path, and I am thankful for each of them.

From my Charlotte Family Medicine residency, I moved about 10 miles west to Belmont, to a small community, where I joined two other family physicians who had graduated from my residency a few years earlier, and we have

The North Carolina Family Physician

been South Point Family Practice ever since, now 34 years for me there. We grew quickly and practiced independently as a single specialty family practice group for more than 20 years, including a very busy hospital practice, then changed to outpatient Family Medicine and ownership by our local hospital system. I have been practicing most of the breadth of Family Medicine (except obstetrics) throughout my career.

patients get proper care, good preventive care.

But these are narrowly focused measures, mostly disease specific, and I think most of us would agree that they do not really tell the story about the breadth and essence of what we do in Family Medicine. They just don’t seem to me to be at the core of what we do, at the center of our founding principles. Sometimes we get caught up with the box-clicking that we might miss our core.

It has been a great ride for me and my colleagues, with so many wonderful patient relationships developed over the decades of time. I treat several generations of patients now and I’ve seen so many grow up as successful adults and parents and built so many caring relationships over the years.

I recently came across an article published earlier this year in the Annals of Family Medicine by RS Etz, et al*, that I think is very well done. The article tried to answer the question, “what really matters when we talk about quality in Family Medicine?” I know we struggle with these metrics and numbers every day, but at the core, what really matters? What is real quality? Is it any different than it was 50 years ago?

I met my wife, Lucille, as an undergraduate student at UVA. We have been married for more than 40 years now and have three wonderful children who are here tonight, and two grandchildren.

That is a little bit of history about my journey over the past 50 years.

Our founding 50 years ago So now I want to spend a few minutes reflecting on the founding ideals and precepts of Family Medicine and think about how those ideals, those principles, live on with us today. How have those founding ideas held up over time?

Let’s go back 50 years; what were the attributes of quality Family Medicine 50 years ago?

I reviewed some of the original documents from our founding and found discussion about the need for primary care physicians with the qualities we now might call “the many Cs of Family Medicine:” Contact (first contact), Caring, Comprehensiveness, Continuity, Community-oriented, Competent, Coordination, Cost Effective. Here, then, lie our roots, our core, our wonderful heritage. These “Cs” defined the quality of Family Medicine 50 years ago, and I believe also define quality Family Medicine today.

Our current “quality metrics” I want to spend a few minutes talking about today’s ideas of quality measures.

We are all used to grappling with our EMRs and quality metrics every day. The fall risk assessment, the PHQ 2s and 9s, the A1Cs, and colonoscopy, all of that necessary stuff that we need to keep track of in order to be sure our Winter 2020

Let us look at some other patient-centered practice quality metrics mentioned in this paper that I think we should be asking. Questions that we could ask of our patients to see if we are really following the principles set out for our specialty 50 years ago.

There are many different practice types represented in our specialty: traditional office practice, hospitalists, skilled nursing facility physicians, academic physicians, urgent care, direct primary care; all sorts. But whatever your practice type, see if you agree that these are useful measures for your practices today.

My practice makes it easy for me to get care CONTACT (FIRST CONTACT)

We must be available to our patients. This may involve ease of appointments in the traditional office, or access through patient portals, telemedicine, or after-hours care. Patient access is our priority.

My practice is able to provide most of my care COMPREHENSIVENESS

We know that physicians who practice the full spectrum of Family Medicine tend to be happier and their patients tend to be happier as well. They feel more fulfilled in their work and their patients are not running all over the place Continues on next page

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to multiple subspecialty offices which are often not needed.

Academy is trying to help with this.

In caring for me, my doctor considers all of the factors that affect my health

The care I get takes into account knowledge of my family

COMPREHENSIVENESS

We know that only a small part of a person’s health is affected by what we can provide in a medical office setting.

We have long understood that health involves more than the absence of disease and that there are numerous social determinants of health and we take them into consideration in our treatment plans.

My practice coordinates the care I get from multiple places.

COORDINATION

I have a patient who regularly sees 11 different subspecialists.

Do we keep careful track of our subspecialty consultants, do we have the analytics to understand where our patients are getting their care outside of our offices, particularly when they have multiple chronic conditions that require careful coordination?

COMPREHENSIVENESS

How many times has a child’s stomachache reflected a family’s discord, or the cause of a person’s fatigue be understood when we know the challenges they face as the sole caregiver of a demented family member?

The care I get in this practice is informed by the knowledge of my community COMMUNITY ORIENTED

Do we keep track of the resources available in our communities, the mental health resources, the food banks and

My doctor or practice knows me as a person CARING

I have an elderly man who used to tell me a different golf joke at each visit for many years, until he eventually became too demented and started telling me the same golf joke every time. Still funny. I have a 97-year-old man who writes a daily blog that I read. We get to know our patients.

My doctor and I have been through a lot together CONTINUITY

We have the rare opportunity and privilege to have patients share with us some of the most difficult times of their lives, the deep feelings of grief and depression and life-threatening illness, as well as the sharing their joys of health and comfort and healing.

My doctor or practice stands up for me COORDINATION

Do we power through those prior authorizations, those endless forms and questions and qualifications necessary for our patients to get the care they need, and do we keep trying to make the system work better for our patients? Your

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The North Carolina Family Physician

social services organizations and cost-effective medical services available to our patients?

Over time, my practice helps me stay healthy COMPETENT, COMPREHENSIVENESS, CONTINUITY, CARING

A large body of research proves that establishing an ongoing relationship with a primary care physician is one of the most reliable determinants of better health outcomes.

Over time, this practice helps me to meet my goals CONTINUITY AND COMPREHENSIVENESS

These are patient-centered goals. Our patients often have goals very different from the boxes in our EMRs. They may want to be able to have their arthritis controlled enough to dance at their daughter’s wedding or be healthy enough to attend the grandson’s graduation.

Patient-centered quality metrics for 50 years of Family Medicine You will not find these metrics in a check box in your EMR, but you will find them in the minds and in the hearts of family physicians throughout North Carolina and indeed the world. Our core mission, our core quality as reflected in these metrics, has endured over the last 50 years.

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We have a great tradition of patient-centered care that I believe will carry us forward for another 50 years.

Thank you. *Etz RS et al. New Comprehensive Measure of High-Value Aspects of Primary Care. Annals of Family Medicine, May/June 2019

Winter 2020

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Contact Peter Graber with the NCAFP at pgraber@ncafp.com 9

POLICY & ADVOCACY

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

National Academy of Medicine Summit in RTP Focuses on Value-Based Healthcare Importance of Primary Care/Family Medicine Emphasized

The National Academy of Medicine (NAM), under the direction of Dr. Victor Dzau, the former Chancellor of Health Affairs at Duke University, brought their Vital Directions for Health and Health Care Symposium to North Carolina last November, highlighting the innovative work going on in our state.

The NAM, formerly the Institute of Medicine, is Congressionally-chartered to serve as the advisor to the nation on health and healthcare. The Academy launched the Vital Directions Initiative in 2016 to create “a comprehensive assessment of the issues that matter most to improving health” and present a framework for achieving better health and well-being, high-value healthcare and strong science and technology for the nation. The symposium served as the first in a series of state-based extensions of the national initiative to bring stakeholders together to better understand actions that are being taken at the state-level to improve health.

Family Medicine played a central role in the two-day summit at the NC Biotechnology Center on November 21-22, 2019.

One of the keynote speakers, Karen DeSalvo, MD, MPH, MSc, called out the importance of Family Medicine and general Internal Medicine, noting that they 10

are two of the most underpaid and underappreciated specialties. DeSalvo was a Professor in the Department of Medicine and Population Health at the University of Texas at Austin Dell Medical School and previously served in the Obama Administration as Assistant Secretary for Health and National Coordinator for Health Information Technology. Last December, she joined Google as their Chief Health Officer.

“Technology and data analytics are tools that should give us more time and space and emotional energy to think and treat people as human beings,” DeSalvo said during her comments, emphasizing the personal touch of primary care. “Technology should help us understand context and trajectory to meet people where they are, but today we are too busy dealing with the cognitive burden. We need to get back to what is fundamental to all of this.”

DeSalvo called on a national dashboard for health, saying the United States is constantly looking in the rearview mirror. “We can’t forecast or even now-cast,” she said. In comparison, DeSalvo noted that the minister of health in Cuba finds out every morning what happened the day before and looks to see how to address key health issues daily.

In addition to keynote addresses by DeSalvo, North Carolina Governor Roy Cooper and NC Department of Health and Human Services Secretary Dr. Mandy Cohen, the event included a series of panels, including a perspective from Family Medicine in almost every panel.

Past NCAFP President Dr. Karen L. Smith (2005), served on the first panel charged with outlining health care priorities and challenges in North Carolina, along with Steve Neorr, Senior Vice President of Population Health for Cone Health, and Dr. John Lumpkin, President of the BlueCross BlueShield of North Carolina Foundation. Smith called on healthcare providers to be miracle makers for North Carolina healthcare transformation and make the ordinary, extraordinary.

Neorr noted that being responsible for an ACO makes him have a different reaction to a high census at the

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hospital than most hospital presidents have. And Lumpkin noted that Wake County is the healthiest county in the nation, but a distance of five miles still reflects an 11-year difference in life expectancy.

Family Physician Alisahah Cole, MD, Chief Community Impact Officer for Atrium Health, served on a panel discussing investments being made into whole person health by integrating physical, behavioral and social health.

Two family physicians also served on an additional panel discussing moving toward seamless information flow and data sharing, including Annette DuBard, MD, MPH, VP of Clinical Strategy for Aledade, and Eugenie Komives, MD, Chief Medical Officer for WellCare of North Carolina and Secretary-Treasurer of the NCAFP Foundation.

DuBard noted that primary care practices are ready to be valued differently and provide care the way it is meant to be provided. However, many primary care practices are just trying to keep their business alive and practice in an information vacuum. But there is hope.

Komives stated that primary care practices are pure and can make changes quicker than large systems. The key is managing limited resources. Komives said that care management is a limited resource, but data can help determine how to manage this scarce resource.

The discussion then moved to a 21st Century Health Workforce, with Erin Fraher, PhD, MPP, an Associate Professor in the Department of Family Medicine at UNC and Director of the Carolina Health Workforce Research Center, participating in the panel. Some of Fraher’s comments focused on the need to decentralize training away from tertiary care centers.

In another panel on paying for value, Rahul Rajkumar, MD, JD, FACP, Senior Vice President and Chief

Winter 2020

Medical Officer for BlueCross & BlueShield of North Carolina, highlighted the three ways his company is attacking rising healthcare costs: asking the largest healthcare systems in the state to share risk; ensuring there is a lane for independent primary care by providing right-sided risk powered with an arsenal of tools; and working with Advanced Primary Care practices such as Iora Health, CareMore and CityBlock. Those practices have reduced panel sizes but are also responsible for “incredible amounts of risk.”

Rajkumar noted that BlueCross NC wants to be in deep partnership with providers.

“Being a good partner means being in a long-term contract, committing to sharing data, and developing rational and simple approaches to quality measurement,” Rajukumar said. As part of his company’s commitment, they plan on investing at least 10% of every premium dollar into primary care. “Our risk model treats the primary care physicians as the quarterback, and you’ve’ got to provide resources to that quarterback.”

Finally, family physician Don Bradley, MD, MHSCL, a consulting professor in the Department of Community and Family Medicine at Duke, moderated a wrap-up panel on Vital Directions for health and health care.

To begin the conference, Governor Cooper called healthcare a moral imperative, noting that someone should not have to file bankruptcy because of an unexpected medical bill. Cooper called on a system-based on value, but value in a way that healthcare provides care for all North Carolinians, including the lowest wealth individual. Secretary Cohen echoed the Governor’s comments, noting that we need a commitment to a clear vision of health, alignment of incentives and initiatives that lead to action and alignment of cross-sector infrastructure investments.

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CHAPTER AFFAIRS

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

~ ACADEMY IN ACTION ~

Keep Moving Toward Value, Even with a Pause in N.C. Medicaid Transformation

Carolina are working to use physician-led, team-based care along with technology to provide care closer to where patients live and in a more integrated manner.

The bottom line: many people are embracing the promise and value of Family Medicine, but we cannot rest on our laurels.

So how do we all continue to work together to capitalize on this potential promise. First and foremost, we don’t stop preparing – for value-based care or Medicaid managed care. Here are just a few steps you can consider taking over the next few months: • Work to bring care management closer to your patients.

While the move to Medicaid managed care in North Carolina has temporarily hit the pause button, the march to value in our state and country continues.

And this is a march that can benefit Family Medicine greatly, if we are prepared and harness the opportunity.

Today, more than ever, employers, payers and individual patients are all realizing the value that Family Medicine brings to the healthcare system.

Blue Cross and Blue Shield of NC is increasing payment to high quality independent primary care practices, holding health systems more accountable for the total cost of care, and partnering with other companies to assist primary care practices in meeting the quadruple aim.

• Embrace technology to provide better care and shift administrative burden from physicians to other team members.

• Work to align any value-based incentives you may receive from any of your payers, whether it’s commercial insurance, Medicare Advantage plans or ultimately Medicaid managed care plans.

• If you work within a system, advocate for a better environment for Family Medicine. We have one-pagers and other information that can help you show your own system the value of primary care. (See sidebar) • Continue to choose partners that can help enhance the care you deliver.

Medicare, despite the bureaucratic nature of CMS, continues to experiment with ways to put primary care at the center of healthcare, including the Primary Care First Initiative which will be offered in parts of 26 states, even though it won’t yet be available in North Carolina.

• Examine your own referral patterns to see if you are utilizing high-value, low cost specialists when referring most of your patients.

Small and large employers alike are direct contracting with Direct Primary Care practices to provide much needed healthcare to their employers.

•And finally, let the Academy know how we can help advocate for you no matter your practice situation.

Today, we have better contacts with payers and health care systems than we have ever had before.

Primary care practice groups right here in North

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• Look for ways to identify care gaps and fill them in an efficient and effective manner.

The North Carolina Family Physician

Advocacy One-Pagers for Family Medicine Download at www.ncafp.com/one-pagers The Value of Family Medicine Critical For North Carolina to Improve Quality and Lower Costs

The Value of Family Medicine In simple, straightforward terms, describes FM’s value to patients, families and communities.

Family physicians: Your trusted healthcare advisor, for life.

❏ Increased access to primary care leads to better health outcomes for patients. Where access to primary care is higher, death rates from cancer, heart disease, and strokes are lower.1,2 ❏ On average, adults who have a primary care physician have 33% lower health care costs.3 ❏ Increased primary care access reduces emergency room visits, hospitalizations, and surgeries.4 ❏ Increasing the number of primary care physicians in a state by 1 per 10,000 population, while holding constant the total number of physicians, is associated with a rise in the state’s quality rank of more than 10 places, as well as a reduction in overall Medicare spending of $684 per beneficiary..5 ❏ For each one percent increase in primary care physicians, average-sized metropolitan areas experienced a decrease of 503 hospital admissions, 2,968 emergency room visits and 512 surgeries.6 ❏ Increasing the percent of the healthcare dollar spent on primary care reduces overall healthcare costs and improves quality. For example, from 2008-2011, total primary care spend for commercial health insurance members in Rhode Island increased by 23 percent, resulting in a reduction of 18 percent for total medical spending.7 ❏ Both increasing the level of physician-patient continuity (i.e., the same primary care physician seeing the patient regularly over time) and increasing the comprehensiveness of care provided by a family physician (i.e., a broader spectrum of services) lead to lower healthcare costs and fewer hospitalizations.8,9 The Ask:  Invest more in family medicine in your healthcare systems. As we move to value, that action will increase quality and lower overall cost of care.  Provide the needed resources to your primary care clinics as they continue to live in the two worlds of RVU compensation and value-based quality metrics. This could include the use of scribes, additional medical assistants, imbedded behavioral health services, etc.

Footnotes: 1 The Commonwealth Fund, “Health Reform & You – Primary Care: Our First Line of Defense.” 12 June 2013.

Macinko, J, B Starfield and L. Shi. “Quantifying the Health benefits of Primary Care Physician Supply in the United States.” International Journal of Health Services Research. 2007. Vol. 37, NO. 1:111-126).

3 Franks, P. and K. Fiscella. 1998. “Primary Care Physicians and Specialists as Personal Physicians. Health Care Expenditures and Mortality Experience.”

Journal of Family Practice 47:105-9.

4 Rosenthal, T. “The Medical Home: The Growing Evidence to Support a New Approach to Primary Care.” Journal of the American Board of Family Medicine. September-October 2008. Vol 21. No. 5.

5 Baicker, Katherine and Chandra, Amitabh. “Medicare Spending, the Physician Workforce and Beneficiaries’ Quality of Care.” Health Affairs Web exclusive w4.184 (7 April 2004: 184-197).

6 Kravet, Steven J., et al. “Health Care Utilization and the Proportion of Primary Care Physicians.” Amer J Med 121.2 (2008): 142-148.

7 ”Primary Care Spending in Rhode Island.” Office of the Health Insurance Commissioner. September 2012.

8 A Bazemore et al. “Higher Primary Care Physician Continuity is Associated with Lower Costs and Hospitalizations.” Annals of Family Medicine. Vol. 16, No. 6, November/December 2018.

9 A Bazemore et. al. “More Comprehensive Care Among Family Physicians is Associated with Lower Costs and Fewer Hospitalizations.” Annals of Family Medicine. Vol. 13, No. 3. May/June 2015.

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The Scope of Family Medicine Describes the breadth of training that FPs complete, as well as their typical scope of patient care.

provide a robust statewide resource directory to help address many of the social needs of your patient, including food insecurity, housing, transportation, and interpersonal violence. The program allows practices to electronically connect with community resources and close the feedback loop when someone in your office may need to refer a patient to social support services in your community.

The Scope of Family Medicine

Family physicians: Your trusted healthcare advisor, for life.

Family medicine’s cornerstone is an ongoing, personal patient-physician relationship focusing on integrated care. In the increasingly fragmented world of healthcare, one thing remains constant: a continuous and comprehensive relationship between a patient and their family physician. ❏ Family physicians provide the majority of care for America’s underserved populations and are distributed more proportionally than any other specialty.1 ❏ As part of their three-years of residency, family physicians participate in integrated inpatient and outpatient learning in six major medical areas: pediatrics, obstetrics and gynecology, internal medicine, psychiatry and neurology, surgery and community medicine.1,2 ❏ Family physicians also receive instruction in many other areas during residency, including geriatrics, emergency medicine, ophthalmology, radiology, orthopedics, otolaryngology, and urology.1,2 ❏ Family physicians deliver a range of acute, chronic and preventive medical services while providing patients with a patient-centered medical home.1 ❏ Delivery-related outcomes between family physicians and obstetricians/gynecologists have been studied for four decades and have shown little or no difference in the outcomes of family physicians practicing obstetrics compared to Ob/Gyns in low risk pregnancies. 3 ❏ A recent study went further comparing delivery-related complications without any risk adjustments and concluded that family physicians practicing obstetrics have comparable delivery related complications as Ob/Gyns when looking at 19 common delivery complications. 3 ❏ Without the Family Physician workforce, the loss of access to maternity services in economically disadvantaged communities will likely widen the health disparities in the United States.4 ❏ In a 2017 survey of North Carolina family medicine residents, 73 percent of the respondents said they would either leave or at least strongly consider leaving the state if they could not find a position with their desired scope of practice.

The managed care plans will be covering an array of services that Medicaid does not cover today. For example, some plans are providing cash incentives for baby products, gift card rewards for wellness visits, membership in youth or fitness clubs, assistance with life skills training or even a voucher to help someone receive their GED. Others are providing additional services such as hearing aids, acupuncture or even free meal delivery after a hospital stay. These are all items that are not available to your patients under traditional Medicaid.

The Ask  Consider how to provide your family physicians a broader scope of practice, including OB, if desired.

Footnotes: 1 A Description of the Specialty of Family Medicine, American Academy of Family Physicians, www.aafp.org.

2 Accreditation Council for Graduate Medical Education Program Requirements for Graduate Medical Education in Family Medicine.

3 Avery, DM; Waits, Shelley, Parton, JM. “Comparison of Delivery-Related Complications Among Obstetrician-Gynecologists and Family Physicians Practicing Obstetrics.” American Journal of Clinical Medicine, Winter, 2014.

4 Taylor, JT; Hartman, SG; Meunier, MR; Panchal, B; Pecci, CC; Zink, NM & Shields, SG. “Supporting Family Physician Maternity Care Providers.”

Family Medicine. Vol. 50, No. 9, 662, October 2018

North Carolina’s Family Medicine Workforce Pipeline As the state’s largest specialty, ensuring a robust pipeline of future family physicians is a key goal.

The Family Medicine Workforce Pipeline

Family physicians: Your trusted healthcare advisor, for life. ❏ Family medicine is by far the largest specialty in the state. Twenty-seven North Carolina counties do not have an Ob/Gyn, and 17 counties do not have a pediatrician. Only four counties lack a family physician.1 ❏ Family medicine is on the rise in our state. In 2018, over 15 percent of graduating medical students (92 of 597) in North Carolina chose family medicine as their specialty, compared to a national average of 9.4%.2 ❏ Early medical school exposure to primary care works. Over 57% of the participants in the NCAFP Family Medicine Scholars Program entered family medicine residencies, with 63% staying in state for residency.

Nearly a third of medical students who participated in other NCAFP summer clinical experiences entered family medicine residencies between 2013 and 2017, with 65% staying in state for training. Bn comparison, during that same period only 10.7% of allopathic medical students in NC entered family medicine, and only 48% stayed in state.3

The Ask  Provide dedicated time and/or compensation for community-based primary care physicians who precept/teach health professions students during their clinical day. High-quality, engaged and satisfied role models make a difference in student choice of specialty.  Invest in family medicine workforce and leadership development initiatives both in your system and externally.

Footnotes: 1 North Carolina Health Professions Data System, the Cecil G. Sheps Center for Health Services Research, University of North Carolina.

2018 Family Medicine Residency Match Results and Data from NC Medical Schools.

Results of the Family Medicine Scholars Initiative, A Joint Project of the NC Academy of Family Physicians Foundation and the Blue Cross and Blue Shield of NC Foundation.

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Now, back to NC Medicaid Managed Care for just a few minutes. As you know, the NCAFP fought hard against bringing managed care to our state. And once the legislature moved this direction, we fought hard to keep the process as simple for practices as possible.

And while we know things will not be perfect, there are some areas of Medicaid managed care that you may want to choose to embrace. For example: The waiver to allow managed care in North Carolina is providing an opportunity for a renewed focus on social determinants of health. As a result, the state has developed the NCCare360 platform, which will ultimately

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The new system will provide for “whole person care” without carve outs for behavioral health that have long caused confusion and administrative burden for both physicians and Medicaid recipients.

The new program design contains key policy and contract provisions that will require managed care companies to incentivize and reward primary care physicians for providing comprehensive, high quality care for their patients.

Yes, once Medicaid managed care begins to be implemented, there will be stumbling blocks, administrative issues and some problems. When there is a such a significant change for nearly 2 million patients in North Carolina, you can’t expect otherwise. But there are also some opportunities that can be seized as part of this transformation.

We don’t know when Medicaid managed care will be implemented, but it’s not a matter of if, it is a matter of when. So now is the time to prepare. Many of the things you do to prepare for Medicaid managed care now will help you with other value-based contracts as we move into the future.

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NCAFP

Sights & Scenes

MEMBERSHIP

By Peter Graber NCAFP Communications

NCAFP Members Receive Degree of Fellow Eight NCAFP members were formally recognized with the AAFP Degree of Fellow during this year’s Annual Meeting. They include: Elizabeth Baltaro, MD, FAAFP; Jewell P. Carr, MD, FAAFP; Christina M. Garcia, MD, FAAFP; Shivajirao P. Patil, MD, FAAFP; David E. Peltzer, MD, FAAFP; Anita M. Pisharody, MD, FAAFP; Robert E. Scott, MD, FAAFP; and Erika Steinbacher, MD, FAAFP. 2019 Community Teaching Award Honorees Several NCAFP members were recognized in December as Outstanding Community Teachers for their efforts to teach medical students in their practices. The honorees were: Benjamin S. Dieter, MD (The Brody School of Medicine at East Carolina University), Vance Family Medicine, Henderson; Andrea M. DeSantis, DO (University of North Carolina School of Medicine), North Park Clinic, Charlotte; Edward J. Bujold, MD (Wake Forest School of Medicine), Granite Falls Family Medical Care Center, Granite Falls; Ronnie J. Barrier, MD (Campbell University Jerry M. Wallace School of Osteopathic Medicine), Rowan Family Physicians, Salisbury; and Yvonne E. Berstler, MD (Duke University School of Medicine), Duke Primary Care, Butner-Creedmoor.

Dr. Tamieka Howell Appointed to AAFP Membership Commission Congratulations to NCAFP Past President Tamieka Howell, MD, (’18) on her recent appointment to the AAFP Commission on Membership and Member Services! The Commission is charged to manage the working tasks related to the memContinues on page 19

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Beating the Odds Gaston Physician Named 2019 North Carolina Family Physician of the Year

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The North Carolina Family Physician

AWARDS & RECOGNITIONS

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ourage to face and conquer extreme personal challenges is the hallmark of North Carolina’s 2019 Family Physician of the Year – Dr. Aregai Girmay of Gaston Family Health Services. Dr. Girmay was recognized with the award last December during the NCAFP’s Winter Family Physicians Weekend in Asheville.

Along his journey to Family Medicine, Dr. Girmay overcame tremendous personal obstacles. At the age of 19, Girmay fled his home country of Ethiopia, walking alone on foot for several days into neighboring Sudan. He would spend roughly the next three years as a refugee there waiting to be adopted by an American relief agency.

But in the course of this struggle, Dr. Girmay had experiences that would change the course of his life.

While a refugee, Girmay worked as a translator to a pediatrician and what he witnessed had a profound impact.

“I was able to witness the miracle of healing. I was inspired by his ability to take children from the brink of life and intervene in a way that immediately changed the course of their life,” Dr. Girmay noted.

When Girmay was finally rescued at the age of 22, he eventually landed in St. Louis with no money, no possessions and little to no knowledge of the English language. Undeterred, he went on to enroll at St. Louis University, graduating in just three short years with a chemistry degree. After graduation, he worked as a chemist, but the pull of serving others and the miracles of healing he had experienced as a younger man drew him elsewhere. He enrolled in medical school, attending the University of Illinois College of

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Medicine. Primary care was always on his mind.

“Overall, I was interested in primary care and thought that translated well to OB/GYN,” Girmay recalled.

After graduation, he entered an obstetrics/gynecology residency. “But after a few years, I decided to pursue Family Medicine so that I could provide a wider scope of care to a breadth of patients.”

When he entered Family Medicine at St. Joseph Medical Center in Yonkers, New York, he immediately was struck by its culture.

“Throughout my Family Medicine residency, I was impressed with the pleasant personalities of many of the family physicians that I encountered, which left a lasting impression on me,” he recalled. “Medicine tends to attract very driven and focused individuals, and I was drawn to the field where the physicians seemed very laid back and personable.”

After completing residency, a combination of fate and luck brought him to North Carolina. Hooking up with the North Carolina Office of Rural Health and its loan repayment program, Dr. Girmay was placed at Gaston Family Health Services, a Federally qualified health center headquartered in Gastonia in 1997.

He continues in practice there today, serving all patients with his unique combination of OB training and Family Medicine. In serving many indigent patients, Dr. Girmay has been able to recognize and help tackle some significant issues surrounding care access.

“I have realized that there is a gap that exists for many women who either do not have insurance or their insurance does not cover private OB/GYN visits,” described Girmay. “I took it upon myself to treat women who do not have access to proper pre-cancer treatment that is often provided by private OB/GYNs.” While Girmay’s focus remains on providing broadscope primary care to those in need, he has continually pursued his passion for women’s health, especially related to cervical cancer prevention. He oversees a Continues on next page 17

The Girmays (L to R) - Adina Girmay, Delina Girmay, Dr. Aregai Girmay, Zewdie Girmay, and Zachy Girmay. Not pictured, Ginet Girmay.

dysplasia clinic, as well as a colposcopy clinic, that provides vital clinical services to both insured and indigent populations of Gaston, Lincoln, Iredell, Catawba and Alexander counties. His work has helped move the needle and has saved lives.

“The scope of patients that we serve at federally qualified health centers offers a wider diversity of care.

Community health centers also pose an immense opportunity in solving the access problem that this country faces.”

Girmay also earned an HIV specialist certification as another component of his integrated care approach.

He serves patients with HIV and sexually transmitted diseases, and he has had particular success with Hepatitis C. His efforts have been key in helping cure over 180 uninsured patients through Hepatitis C treatment in just the last 3 years. He delivers addiction services and has also obtained his DATA waiver to provide Medication Assisted Treatment to patients diagnosed with opioid-use disorder.

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Outside of practice, Dr. Girmay is an active member of several initiatives working to advance his local community. He has served as a member of the Highland Community Resource Center Board that provides several social services supports to residents of the Highland community in Gaston County, such as GED training, community advocacy, and more. Girmay is also active with the Physician Advisory Panel of Health Net Gaston and has participated in the treatment linkage committee of the Gaston Controlled Substances Coalition.

In his daily personal life, Dr. Girmay embraces healthy lifestyles in nearly everything. He believes personal responsibility is a driving factor.

“Personal responsibility is a major aspect of a person’s overall health because it allows for them to have a role in determining the outcome of their health,” described Girmay. “By choosing healthy options, such as a balanced diet, daily exercise, and self-compassion, people have the ability to alter the trajectory of their life.”

The North Carolina Family Physician

For Girmay, Family Medicine occupies a special place in helping patients in this journey, but leading by example is also critical. “Family physicians are one of the most continuous faces a patient sees, so by mirroring healthy choices themselves, they are setting an example of not only being able to advise patients, but also doing the work themselves.”

With that in mind, Dr. Girmay adheres to a rigorous fitness and exercise regimen in his daily life.

Running occupies a central place.

“Personally, I found that daily exercise was a huge motivator for myself, my patients, and even my family. I find the time to run throughout the week as well as the weekends, serving as an example for my community and other professionals that these small choices make a big difference,” Girmay explained. Dr. Girmay has completed almost 70 marathons, including those in New York City and Boston.

Dr. Girmay’s career in Family Medicine and primary care has been blessed. Much of it, the result of his passion for caring and service.

“My biggest advice to family physicians and medical students would be to find fulfillment in your work because if they are excited about their work, their patients can only benefit.”

And Dr. Girmay believes the community health center is an excellent option.

“These health centers are closing the gap that exists and by incorporating upcoming physicians, we can increase the amount of safety net programs across the country and hopefully move closer to closing the gap altogether.”

Dr. Girmay and his wife Zewdie have been married 30 years, and are the proud parents of 4 children: Zachy (UNC), 27, is a healthcare data analyst for GFHS; Genet, (UNC) 24, works in San Francisco’s tech industry; and Adina (UNC) and Delina (UNCW), 22, who both recently graduated this past year.

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bership and member constituencies. This includes working to further AAFP goals in membership recruitment, retention and services. Dr. Howell will be serving a four-year term.

Foundation Trustee Dr. Amy Marietta Highlighted in NC Medicaid Annual Report North Carolina’s Medicaid and NC Health Choice programs released their 2018-2019 SFY annual report in late December. The report highlights the major accomplishments of the sprawling program and provides a series of snapshots on its impacts. NCAFP Foundation board member Dr. Amy Marietta, a family physician with Blue Ridge Community Health in Polk County, is highlighted for her work in providing full-spectrum care to Medicaid beneficiaries, especially related to prenatal care. Read the entire report at https:// files.nc.gov/ncdma/SFY2019-MedicaidAnnualReport-FINAL-20191220.pdf.

UNC’s Dr. Katrina Donahue Appointed to the U.S. Preventive Services Task Force University of North Carolina at Chapel Hill Department of Family Medicine professor and vice chair of research, Katrina Donahue MD, MPH, has been appointed to the U.S. Preventive Services Task Force (Task Force) as one of its newest members. The Task Force is an independent, volunteer panel of national experts in prevention and evidence-based medicine. Members come from primary care and prevention-related fields, including Internal Medicine, Family Medicine, Pediatrics, behavioral health, Obstetrics/ Gynecology, and nursing. Members are appointed to serve a 4-year term.

Dr. Donahue is a professor and vice chair of research at the University of North Carolina at Chapel Hill department of family medicine. She is a family physician and senior research fellow at the Cecil G. Sheps Center for Health Services Research. She is also the co-director of the North Carolina Network Consortium, a meta-network of six practice-based research networks and four academic institutions in North Carolina. Dr. Donahue’s research areas of interest include practice redesign of health care delivery, chronic disease care and prevention, health behavior change, and collaborations among public health and primary care.

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PROFESSIONAL DEVELOPMENT

By Kathryn Atkinson, CMP NCAFP Meetings & Events Manager

The When and the Where for Top Quality Carolina CME in 2020 The NCAFP’s 2020 CME events are locked-in! With over 40+ credits on the horizon, this year’s Carolina CME stops include Charlotte, Greensboro, Chapel Hill, Greenville, and Asheville. As always, these noteworthy learning opportunities are designed to provide you with top-quality CME that supports your commitment to providing the best possible care to your patients. Whether you prefer a full-day or a halfday Saturday conference, or a casual mid-week after office hours dinner program, we’ve got you covered.

See below for a quick rundown of this year’s CME meeting dates and locations.

Spring Symposium - Charlotte Join us on Saturday, April 4, 2020, from 7:30 am to 4:45 pm, for this year’s annual Spring Symposium at the Charlotte Marriott SouthPark Hotel. This popular one day Saturday CME opportunity, with program chair Takie Hondros, MD, is a fantastic chance to pick up approximately eight CME credits while in the company of colleagues and friends. Slated topics include updates on insomnia, diabetes, status-neutral HIV prevention, osteoporosis, vaping and tobacco use, cardiovascular risk reduction, hyperkalemia, migraines, health equity, and more. Those interested may also participate in a pre-conference ABFM Pilot Practice Improvement workshop on Friday, April 3rd, from 1:30 pm to 5:30 pm. Mark your calendars now and visit the conference website at

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www.ncafp.com/symposium for complete guest speaker details, schedule information, and online registration.

After Office Hours CME In 2019, we piloted two after-office hours dinner programs. Each of these unique educational opportunities included a fantastic dinner, 1.5 CME credits, intriguing lecture topics, and tremendous networking possibilities. Comments and feedback such as, “I look forward to more of these. I loved this style of CME.” “This was wonderful! The speakers, the topics, the food, and the venue. Wow! Thank you!” and “Great meeting! Do more!” have inspired similar 2020 CME dinner meetings in Chapel Hill and Greenville. For now, mark your calendars for Tuesday, June 2, 2020, from 6 pm to 8:30 pm at the UNC Family Medicine Center, and Tuesday, September 29, 2020, from 6 pm to 8:30 pm at the ECU Family Medicine Center. Registration fees are $25 per person and include a light reception, a casual dinner, and an estimated 1.5 CME credits.

Watch your emails for additional information and online registration coming soon for these notable learning and networking opportunities.

Half-Day Saturday CME Based on your requests for updates on clinical topics that you see most often, we are very excited to offer a sports medicine themed seminar in August. This new half-day Saturday program, led by program chair Karl “Bert” Fields, MD, is designed to tackle the most prevalent needs of your avid runners, weekend warriors, and pediatric athletes. Make plans now to join us at the Greensboro High Point Marriott Airport Hotel on Saturday, August 8, 2020, from 7:00 am to 12:00 pm. Registration fees are $100 per person and include a continental breakfast, light refreshments, and an estimated 4.00 CME credits. Watch your emails for additional information and online registration coming soon.

Annual Winter Meeting Last, but by no means least, the Winter Family Physicians Weekend (also known as the nation’s largest state specialty meeting of its kind!) is scheduled for Thursday,

The North Carolina Family Physician

Top-Quality CME: Join us and see for yourself 2020 Spring Symposium A Saturday CME Event Program Chair: Dimitrios “Takie” P. Hondros, MD

MARK YOUR CALENDARS One-day format & no lost office time Interactive Q&A opportunities Convenient regional location Timely, requested topics First-rate faculty

EARN AN ESTIMATED 8.0 AAFP PRESCRIBED CREDITS

Planned topics include: Insomnia, Diabetes, Hyperkalemia, Status-Neutral HIV Prevention, Vaping & Tobacco Use, Migraines, Osteoporosis, Cardiovascular Risk Reduction, Health Equity, and more.

SATURDAY, APRIL 4, 2020 • 7:30 AM TO 4:45 PM Charlotte Marriott SouthPark Hotel, Charlotte, NC

www.ncafp.com/symposium

All medical education topics offered by the NCAFP are reviewed by a family physician, and when possible and appropriate, are presented by a family physician. While the NCAFP may receive pharmaceutical funding to help provide education at our events, they are NOT allowed to influence the content presented.

The integrity of the information provided is always the NCAFP’s primary concern.

ning for this year’s conference is already underway. With program chair Victoria Kaprielian, MD spearheading the bustling weekend, this very popular gathering of colleagues and friends will again include an estimated 25+ CME credits, topnotch general session topics, unique CME workshops and seminars, and plenty of downtime for you to share with family and friends. Save the dates now and watch your emails for additional information regarding hotel reservations and online registration coming soon.

The NCAFP Meetings Department looks forward to supporting you with standout CME programs again this year. Complete with convenient regional locations, interactive learning sessions, first-rate faculty, and timely topics, we think our schedule-friendly 2020 CME calendar will be beneficial and rewarding for everyone. On behalf of the NCAFP, thank you for what you do every day within your communities, and we hope to see you at an NCAFP CME event this year!

Please contact Kathryn Atkinson, CMP, Manager of NCAFP Meetings & Events, via Katkinson@ncafp.com or 919-214-9058 with any questions about this year’s programs.

December 3 – Sunday, December 6, 2020, at The Omni Grove Park Inn in Asheville, NC. An annual favorite for over 800 attendees, planWinter 2020

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FOUNDATION UPDATES

By Tracie Hazelett NCAFP Foundation Liaison

NCAFP Foundation Raffle Raises Over $22K to Support Student Interest Initiatives The NCAFP Foundation’s efforts to support student interest initiatives in 2019 included a raffle that culminated during the Academy’s Annual WFPW. This year’s raffle sales, the substantial support from Curi and with generously donated items from Dr. Allen Dobson and the Omni Grove Park Inn for a live auction, over $22,000.00 was raised. The raffle winner was drawn during the Presidential Gala the evening of Saturday, December 7th.

DEADLINES Upcoming AAFP Application Deadlines for Residents and Medical Students March 1st - Emerging Leaders Institute This year-long leadership development program focuses on creating future Family Medicine leaders. Medical students and residents are eligible to apply. The leadership institute kicks off at National Conference in Kansas City in July 2020.

Formal leadership training or experience is not necessary, but a motivation to gain leadership skills and experience is.

Complete details can be found on the AAFP Foundation’s website at: www.aafpfoundation.org. If you would like to be connected to a student or resident who has been involved in this program, please contact Tracie Hazelett at thazelett@ ncafp.com.

Although the winner did not need to be present, Dr. J. Carson Rounds of Charlotte, NC, was on hand to see his name randomly pulled from the hundreds of entries. Dr. Rounds will have the pleasure of choosing from five experiences. Trip locations include: Sonoma County, CA, Chicago, Nashville, New York City, and San Diego.

And although the raffle has passed, the time is always right to support the important work of the NCAFP Foundation. You may contribute any amount, any time, to the Foundation or the Medical Student Endowment to support North Carolina’s future workforce at www.ncafp.com/contribute.

Congratulations Dr. Rounds, and enjoy your adventure!

If you have questions about the Foundation please contact Tracie Hazelett at thazelett@ncafp.com.

PICKING THE WINNER: Dr. Lisa Cassidy-Vu choosing the raffle winner.

March 15th - Family Medicine Cares Resident Service Award The $16,500 Family Medicine Cares Resident Service Award creates an opportunity for first-year and second-year FM residents to fulfill a desire to address health disparities by tackling the health needs of the underserved in their local communities. For complete details, requirements and the application on this 12-month service project, please visit the AAFP Foundation’s website: www.aafpfoundation.org.

April 1st - 2020 National Conference Poster Competition The AAFP invites residents and students to share innovative and effective educational programs and showcase unique community projects. Categories, submission requirements and full details can be found at the conference website at www.aafp.org/nc/posters.

May 1st - Family Medicine Leads (FML) Scholarships to attend the 2020 National Conference in Kansas City, MO. There are multiple FML scholarship categories, for eligibility requirements, submission deadlines and writing tips please visit: www.aafp.org/nc/scholarships. This conference has something for all stages of training -- MS1 to PGY3s -- offering interesting educational workshops, informative and inspiring leadership forums, and the opportunity to meet and network with students, residents and residency programs from North Carolina and across the country.

2019 ANNUAL MEETING RECAP

Big Resident and Student Presence at Annual Meeting Plus, Annual Research Poster Presentation Draws Record Entries Last December, 115 North Carolina medical students and 93 Family Medicine residents joined the NCAFP at its annual Winter Family Physicians Weekend in Asheville. Students and residents participated in educational sessions, business meetings, the research poster contest and took advantage of several social and networking opportunities.

During the State of the Academy & Awards luncheon, the 2019 Research Poster Contest winners were announced. This year’s event experienced a record number of entries, with 13 resident poster participants and 27 medical student participants.

In the resident category, Katy Key, DO (Cabarrus, PGY-3), claimed the top prize for her entry, ‘Quality Cervices: Improving Pap Smear Rates in a Rural Clinic’; and as the lead presenter for the submission, ‘One Night Strain: Improving Human Papilloma Virus Vaccination’, Olivia Tu, DO (PGY-3, Cabarrus), claimed the runner-up prize. Samuel Robinson, DO, was a co-author with Dr. Tu on this project.

In the medical student category, Ms. Ankita Mishra (Campbell, MS1) claimed the top prize for her submission, ‘Electronic Cigarette (E-Cig) Awareness, Use, Perception and the Effects of a School Based Intervention in Urban North Carolina.’ Co-authors on this submission included Whitney Green, MA; Radhika Kothadia, BS; Anan Islam; Samantha Elaine Poppenfuse; Janet Benjamin, MD; Lauren Bethune Scroggs, MS, NCC; and Vivek Anand, MD. Ms. Chelsea Viscardi (Brody SOM, MS3) claimed the runner-up prize for her entry, ‘Implementation of Sexual Health and Relationship Education for High Risk Adolescent Females.’ Co-authors included Gabrielle Kattan, BS; Kaitlyn Brobst, BS; and Tana Hall, MD.

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2019-2020 RESIDENT & STUDENT LEADERS During their respective resident and student section meetings, attendees were made aware of the many scholarship and programmatic opportunities available from the NCAFP and the AAFP. The recently appointed 2019-2020 resident and student leaders were also introduced.

For the Academy Board of Directors: Resident Director, Elizabeth Ferruzzi, MD (Novant Health); and Student Director, Katelyn Turlington (Wake Forest); and Resident Director-Elect, Clayton Cooper, MD, MBA (Duke); and Student Director-Elect, Hannah Smith (Brody).

For the Foundation Board of Trustees: Bryan Grove, MD (Atrium-CMC); Ryan Paulus, DO (UNC); Morgan Carnes (Wake Forest); and Caitlin Porter (Campbell).

Resident and Student Committee Representatives: Workforce Pipeline: Taylor Sandberg, MD (Atrium-Cabarrus) and Niki Winters (Brody); Payer & Systems Advocacy: Christine Wu, MD (Novant Health) and Lauren Waskowicz (UNC); Member Satisfaction & Practice Environment: Katherine Haga, DO (Novant Health) and Adam Glenn (UNC).

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RESIDENTS & NEW PHYSICIANS

By Elizabeth Ferruzzi, MD Novant Health Family Medicine Residency

A PERMA-nent Commitment to Family Medicine It was around this time last year I felt it as an intern- the growing sense of burnout.

We have all felt it at some point, whether in training or practice. What leads us there? A series of continuous inpatient rotations without break, winter’s chill, and minimal daylight hours, among other things. Even at a program that puts a priority on wellness, I felt a loss of energy, a loss of enthusiasm, and a loss of confidence.

However, with support from my classmates, my spouse, and my program, I made it through intern year and entered second year with joy, not only surviving but also learning how to thrive.

Recently in my cohort’s wellness group, our director of behavioral science introduced us to a model that brings life experiences into perspective in the demands of this profession. Moving past a one-size-fits-all approach to wellness, another lecture on the elusive “work-life balance,” or a one-time yoga workshop, our program encourages us to use the PERMA model (designed by Professor Martin Seligman, leading researcher for positive psychology and human flourishing).

It allows residents to tailor lifestyle adjustments to enhance their well-being based on what is important to them, their strengths, and their personal preferences. It stands for Positive emotion, Engagement, Relationships, Meaning, and Accomplishment. As I reflect on residency through the lens of PERMA, and compare my well-being to this time last year, I have truly come to believe

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that our wellness as residents can be embraced - and there is a better way.

Positive emotion: “the right balance of heartfelt positivity to boost our resilience.”

On my birthday last year as an intern, I discovered we had missed a brain mass on a patient with a headache because we did not initially get a head CT. Immediately, I felt a sense of personal failure and began to question, “What if?” and “Why did I not think about that?”

Tearing up while trying to explain to my attending, she took me aside and gently told me the most powerful words I had heard all year: “We are perfectionists in a field that is imperfect, so give yourself grace.” As residents and physicians, we will make mistakes, but it is about learning from them and moving forward. We have compassion for our patients, and cases such as these offer a unique opportunity to learn, and be better for the next patient. We can be optimistic and grateful, seeing the opportunities to learn from our mistakes. Heartfelt positivity, gratitude, and giving ourselves grace helps build Dr. Ferruzzi is a PGY-2 at continued resilience. the Novant Health Family Medicine Residency Program in Cornelius, NC, and is currently serving as the Resident Director on the Academy Board of Directors.

She hails from Lenoir, North Carolina, and completed her undergraduate degree in Marine Biology at NC State University, where she was Valedictorian and a University Scholar, and went on to graduate from the Brody School of Medicine at East Carolina University in 2018. As a medical student, Ferruzzi participated in the NCAFP’s Eastern Rural Health Immersion Program, served as a Trustee on the NCAFP Foundation Board of Trustees, and was a Leaders in Innovative Care (LINC) Scholar during her time at Brody. When she has a moment to spare, her hobbies include dancing, swimming, racquetball, rock climbing, running and reading.

Engagement: “the regular development of our strengths – those things we are good at and enjoy doing.”

I enjoy building relationships with others.

Talking with people, getting to know them, and representing them is energizing to me. A highlight of my intern year that has continued into this year has been my involvement with the NCAFP. With fellow residents, I’ve had the privilege to meet, greet, and represent Family Medicine residents, physicians, and potential future residents in various venues both within North Carolina and nationally. The mentors and colleagues I have gotten to know through this involvement have encouraged my growth in so many areas of my professional life. My hope is to continue to encourage other residents to be able to find their opportunities for engagement to share their gifts in the specialty of Family Medicine.

The North Carolina Family Physician

Relationships: “the creation of authentic, energizing connections.”

Meaning: “a sense of connection to something bigger than ourselves.”

Residency may be busy, but the relationships that grow within a class give us the foundation to support each other and persevere during difficult times. A favorite memory I have from this year began with defying the odds of our busy schedules. Every single second year resident and their people (spouses, significant others, children) met at an apple orchard this fall for a Saturday outing. It was beautiful - a chance to catch up with everyone without the pressures of clinic or didactics; we even got a family photo to document the day. Delicious apple cider and donuts, a hayride, and authentic, energizing conversations were true highlights of the season. It did take some scheduling and effort, but in prioritizing our relationships with one another, we were able to walk away with renewed appreciation for our relationships.

During the past 8 months, I had seen my patient and her family almost weekly. She had newly diagnosed end-stage liver cirrhosis and each week she needed fluid drained from her abdomen. One day in December, she was admitted to the ICU. I was in clinic, but something inside told me to go visit her. During lunch, I surprised her and was able to sit with her and her family. She was sitting in the armchair and truly looking better. Upon leaving, I told her I would stop in to check on her Monday. She looked at me and said she would surely be out by Sunday, so I replied that I would gladly see her in clinic the following week. Later that night, I found out that she had gone into cardiac arrest, and she never woke up. The next week, amidst all they had been through, her family came by my clinic to give me flowers and to thank me. Their appreciation and selflessness

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a goal, achieve it together, and enjoy the running and the fun company.

in their own time of loss and sorrow had me speechless. I will never forget my patient, their kindness, or what my time with their family meant to me and to them. In moments like that, I am reminded of why I chose Family Medicine for the relationships and for reaching beyond myself to share what I’ve learned and truly care for and connect with others.

Accomplishment: “the belief and ability to do things that matter most to us.”

We signed up for the 5k on a whim, and the date snuck up on me. However, my fellow resident and I showed up that morning and gave it our all. We pushed ourselves to run faster than we thought, but had some fun along the way by singing as we ran and dumping the tiny water cups over our heads pretending to be marathon runners. We finished breathless but with the goofiest grins on our faces.

We even got medals and sunglasses for running! We did not need to be perfect, or the fastest. We just needed to go out and have fun doing a race, because it mattered for us to set

Leadership Opportunities with the NCAFP and the AAFP May 31st, 2020 Application Deadline

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Looking back on intern year, it was challenging, but beautiful.

Having started second year of residency training with the intentional goal of finding wellness and being able to frame life through the PERMA lens, I have noticed a significant difference. It is the middle of winter and I just finished a night shift rotation, yet I can see the beauty of the winter around me. I feel the support of those who are helping me to learn and shaping me to grow in resiliency and joy. It is not easy, and never perfect, but our wellness and resilience is worth choosing to prioritize and maintain. Taking well-being into our own hands, we can choose a sustainable, and joy-inspiring path; our commitment to our patients and the field of family medicine can be PERMA-nent.

Seligman M. Flourish: A visionary new understanding of happiness and well-being. New York: Atria; 2011.

STATE LEVEL WITH THE NCAFP: Students and Residents interested in serving in a leadership role at the state level, can visit their student or resident page on the NCAFP website for more information, or contact Tracie Hazelett at the Academy’s office to inquire. Deadline to apply for all board and committee appointments for the 2020-2021 term is May 31st, 2020. For available positions and to meet the current student or resident leadership team, please visit www.ncafp.com.

NATIONAL LEVEL WITH THE AAFP: Although the AAFP deadlines are not until July, many national leadership options require support from the NCAFP; May 31st is the Chapter’s deadline for students and residents to submit their application for review by the NCAFP Nominating Committee for all elected positions and some appointed positions. Involvement at the Chapter level (this can be a former state if you are resident that attended medical school elsewhere) is required to be considered for a national position. Please note: there are a few appointed positions with a deadline of Aug. 5th.

Please refer to the NCAFP policy on AAFP Nominations at www.ncafp.com and the AAFP site for a complete list of available leadership positions: www.aafp.org/nc.

Please contact Tracie Hazelett at thazelett@ncafp.com for more information or if you have The North Carolina Family Physician questions on any of these opportunities.

jobs.ncafp.com The NCAFP CME & Meetings Department continues to explore new ways of bringing you the best possible educational and networking opportunities. With our promise of always providing top-notch CME on timely requested topics presented by first-rate speakers, to an advanced yet user-friendly mobile app and time-saving registration kiosks; we pride ourselves on providing members with a fantastic and rewarding experience at every event.

Discovery and feedback gathered in the 2018 Membership Survey inspired NCAFP leadership and staff to do a little brainstorming on ways to further enhance 2019 CME events. Armed with a fresh perspective of what members need and want, we began refocusing energy and resources towards providing elevated education and networking experiences to

Employers:

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MEDICAL STUDENT PROGRAMS

By Cameron Smith (MS4) Campbell University School of Osteopathic Medicine

NCAFP Student Programs Help Cement My Interest in Family Medicine I was thrilled when asked to write an article for this magazine and I decided to use the opportunity to show my gratitude for what this association of family physicians has done for me during my medical school career.

June in eastern NC. During the first week of this experience, we networked with current Family Medicine residents, practiced procedures, and attended didactics and workshops in Greenville, NC. The week culminated in a kayaking trip along the Pamlico River.

During my second week, I was fortunate to stay at the home of Dr. Aaron Lambert, meet his welcoming family, and shadow him and other physicians in a rural Mt. Pleasant practice. I consider this experience one of the key factors in my journey to Family Medicine because it was my first exposure to the scope, breadth, and possibilities available to family physicians.

I came into medical school interested in Family Medicine, among other fields. Since then, Family Medicine has become cemented in my mind as not only the best specialty overall, but the best specialty for me. All along the way, the NCAFP has been there to encourage, guide, and provide invaluable opportunities.

My first meeting with Chapter staff was at the annual Family Medicine Day held in Durham. This meeting is jam-packed with a motivational keynote address, hands-on workshops, and opportunities to engage with dynamic training programs all interspersed with the occasional joke from Dr. Higdon, the current Academic Representative on the NCAFP board. NCAFP staff were as energetic as ever, welcoming and excited to meet budding physicians struggling to find the right path. Like most NC medical students, Tracie Hazelett was my first point of contact with the Academy and the robust community of family physicians throughout the state.

Her continual support has taken me much farther than I could have gone on my own.

I was encouraged to apply for the summer rural internship experience, in which I was privileged to participate during two weeks in

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Mr. Smith is a 4th year medical student at Campbell University School of Osteopathic Medicine (CUSOM). He received his Bachelor of Science degree in Neuroscience from Brigham Young University in Provo, UT, prior to moving to NC. Once in medical school, he quickly became involved in the NCAFP through the Eastern Rural Health Program. After that experience, he sought other ways to get involved, which led to serving for two years on the Academy Board of Directors. In December 2019, he completed his term as the Student Director. During his first two years of medical school, Cameron served as President of the CUSOM Family Medicine Club and volunteered with Campbell’s Community Care Clinic. Cameron has completed his third and fourth-year clinical rotations in Fayetteville, NC.

My first trip to Asheville for the Winter Family Physicians Weekend was also a career highlight for me. I was impressed with the sheer number of people in attendance, so many of whom shared the same values and goals for the future of health care. The quality of the lectures was remarkable and the networking I was able to do with other students, residents, and practicing family physicians during the conference continued to impact me throughout my remaining time in medical school. During this event, I also had the honor of meeting other physician leaders and Academy staff, including the NCAFP’s EVP, Greg Griggs.

Each time I have the pleasure of interacting with him and the entire Academy team, I am blown away. From the facilitation of high-level board meetings, explanation of intimate legislative policies, and later rallying the crowd (mostly you, the Academy’s membership) to donate thousands of dollars for student programming, their commitment is unmatched.

Those generous donations have helped me and countless other students enjoy the benefits of conferences, clinical experiences, lectures, workshops, and net-

The North Carolina Family Physician

Family Medicine Day Saturday, March 7th, 2020 working. All these experiences made me want to do more, so I pursued a position on the NCAFP board of directors, which I had the privilege to serve on for two years.

I learned at the feet of great leaders such as Dr. Charlie Rhodes, Dr. Tamieka Howell, and Dr. Alisa Nance. Other board, committee, and Academy members -- too many to name -- have also been instrumental in encouraging and guiding me towards my bright future, and I cannot thank them enough.

To current medical students, I encourage you to investigate and apply for everything the NCAFP has to offer. The experiences are truly one of a kind and will leave you excited for Family Medicine.

To current physicians, on behalf of all students, I thank you for your generous gifts of time, money, encouragement, and mentoring along the way. Students are always looking for strong role models. If you feel able, consider becoming a community preceptor and take students in your clinic. We need more of you!

To the NCAFP physician leaders and staff: thank you, thank you, and thank you! I attribute all of my success thus far in my Family Medicine journey to you, and I will be forever grateful.

The future of Family Medicine is bright!

Winter 2020

Registration Now Open!

The NCAFP and the North Carolina Area Health Education Centers (AHEC) program are excited to present North Carolina’s 13th Annual Family Medicine Day. This fantastic one-day event is North Carolina’s premier family medicine residency recruitment conference. The day will begin with lunch with keynote speaker, Dr. Shannon Dowler, Chief Medical Officer for North Carolina Medicaid at NCDHHS, followed by 5-hours of clinical skills workshops led by North Carolina Family Medicine residency programs. Students will enhance clinical skills while getting to know the residents and faculty of the very diverse residency programs available in North Carolina.

During the evening residency recruitment fair, you will learn even more about North Carolina and other regional Family Medicine residency programs.

Don’t miss this incredibly fun, educational and hands-on day! Registration is currently open for exhibitors and medical students.

For complete information and online registration, visit www.ncafp.com/students/fmd.

Attention North Carolina Residency Programs: Thanks to the generosity of the North Carolina AHEC, we are pleased to offer you complimentary registration for this great event this year!

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PRACTICE MANAGEMENT

Lessons Learned from a Year-Long Journey as the CDC Foundation Clinical Consultant for the Opioid Crisis

By Blake Fagan, MD Mountain Area Health Education Centers Program I was fortunate to be selected to be the CDC Foundation North Carolina Clinical Consultant for the Opioid Crisis for 2019. I have a passion for this work as I have had patients die of opioid overdose. First, I want to acknowledge that for several years many people and organizations have been working diligently on prevention, treatment and recovery of persons with opioid use disorder (the new term for opioid addiction). And, they will be working on this problem for years to come. They are the true heroes in this struggle. Thus, pardon my naïveté as some of the following lessons that I learned are most likely, “of course, we have known that for years” moments for the folks working in the addiction space.

1) We need to prescribe opioids appropriately … which means a lot less or maybe none at all. For acute pain we need to follow the NC STOP Act, which states: if we are going to prescribe opioids for acute pain, prescribe 5 days or less and after surgery 7 days or less. North Carolina physicians are doing a great job at prescribing more appropriately. But we could do better. For example, the patient with a kidney stone. For years, I would prescribe oxycodone/acetaminophen until the patient could see the urologist. Substituting ibuprofen and acetaminophen given at the same time instead of an opioid, provides equivalent or better pain control without the risk of addiction.

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2) Children should not get opioids unless absolutely necessary. I believe this is true for all types of pain, but the only randomized controlled trial in adolescents is with third molar extraction. A study of 15-16 year olds who had their wisdom teeth out and were given oxycodone/acetaminophen show 6% entered into an opioid use disorder within the year. If instead they were given ibuprofen and acetaminophen (which the dental literature says is superior pain control after tooth extraction) then only 0.4% entered into an opioid use disorder within the year. You cannot tell which kids will fall within that 6%.

3) We should not start opioids for patients with chronic pain unless all other modalities have been exhausted.

The 2018 SPACE trial states, “Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee OA pain.” A 2007 Annals of Internal Medicine meta-analysis concluded that if a patient has chronic back pain and is on chronic opioid therapy, their lifetime risk of having a substance use disorder is 36 to 56%.

4) Encourage everyone to get unused opioids out of their homes. There are millions of unused opioids in unlocked

cabinets in people’s homes. This is one of the ways that kids, grandkids, friends and other relatives start misusing opioids.

5) Bottom line: Opioids can cause brain changes… not in everyone, but in some people. We do not know how an individual will react to opioids.

75% of daily heroin users started with opioid pills. Approximately 40% started with a legitimate prescription from their provider.

6) Access a. Expanding Medicaid would instantly allow about 400,000 North Carolinians to access medical care through insurance. Many patients with Opioid Use Disorder could get their chronic disease treated if they had health insurance. b. We need more providers waiver trained to prescribe buprenorphine.

Only 11% of people in North Carolina who had an opioid use disorder and tried to find treatment in 2016 were able to find a prescriber of medication assisted treatment like buprenorphine. The great thing about family physicians is that we can take care of their primary care needs as well!

7) Stigma kills people Patients, patients’ families, providers, law enforcement, and citizens in general continue to think of people with opioid use disorder (OUD) as having failed morally. However, OUD is a chronic relapsing disease just like asthma, diabetes, hypertension, or COPD. The stigma is a huge barrier to starting the medications like buprenorphine; and frankly, is a reason that patients stop taking their medications too early, often times inciting a return to use.

The North Carolina Family Physician

HEALTH PROMOTION

Academy Partners with NC Dental Society and NC Pediatric Society to Promote Children’s Dental Health Month in February MEMBERS: State Dental Varnish Project is an Excellent Way to Improve Care Five times more common than asthma, 36 percent of all North Carolina children have had tooth decay by the time they enter kindergarten…15 percent of it, untreated. Poor dental health affects overall health, and if left untreated, tooth decay can lead to tooth loss, infection and even death.

The NCAFP has partnered with the NC Dental Society and the NC Pediatric Society to promote the importance of dental health in young children and to raise awareness of North Carolina’s highly successful dental fluoride varnish program, Into the Mouths of Babes, that helps prevent tooth decay in young children. The NCAFP and Family Medicine was instrumental in launching this program in 2001.

Get Trained Online to Provide Dental Varnish

Varnish Program (IMB) is a successful medical model of providing oral health services for very young children. The IMB program has teamed with WAKE AHEC to offer a convenient online training option to physicians and other providers interested in offering the service. The training features an interactive e-learning course that teaches physicians and providers all the basics, including how to conduct an oral evaluation and risk assessment for children ages infant to 3 ½ years; how to refer young children to a dental home using risk-based guidelines; how to apply fluoride varnish to the teeth of young children; and file a Medicaid claim for the oral evaluation, counseling, and fluoride varnish procedure. Training is now available online!

The e-learning course is available to physicians and providers statewide at www.ncafp.com/imb-training.

North Carolina’s Into the Mouths of Babes Fluoride

Get to Know Value-Based Care with Videos Interested in learning more about value-based care and how it might be changing the way you get paid? The NCAFP partnered with Humana to produce an educational video providing an overview on this evolving topic. To watch the two-minute trailer, which was introduced at the recent NCAFP Winter Meeting, visit www.ncafp.com/vbc2020.

To view the entire video, simply visit www.ncafp.com/ value-based-care. Please remember to complete the very brief survey about the video, which helps us determine the value of these educational opportunities.

Winter 2020

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