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THE NORTH CAROLINA

Volume 10 Issue 1 / Winter 2014

quarterly news in north carolina family medicine

Dr. William Dennis Inaugurated as NCAFP President


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2013-2014 NCAFP Board of Directors Executive Officers President William A. Dennis, MD President-Elect Thomas R. White, MD Vice President Rhett L. Brown, MD Secretary/Treasurer Charles W. Rhodes, MD Board Chair Shannon B. Dowler, MD Past President (w/voting privileges) Brian R. Forrest, MD Executive Vice President Gregory K. Griggs, MPA, CAE

AAFP PRESCRIBED

CREDITS

District Directors District 1 - Jessica Triche, MD District 2 - Matthew M. Williams, MD District 3 - Eugenie M. Komives, MD District 4 - Tamieka Howell, MD District 5 - Janice E. Huff, MD District 6 - Alisa C. Nance, MD District 7 - David A. Rinehart, MD At-Large Holly Biola, MD At-Large Jennifer L. Mullendore, MD IMG Physicians Joseph P. Pye, MD Minority Physicians Benjamin F. Simmons, MD New Physicians Matthew G. Kanaan, DO

2014 NCAFP

NC Family Medicine Departments Brian A. Kessler, DO (Campbell) Family Medicine Residency Directors Geoffrey Jones, MD (MAHEC-Hendersonville) Resident Director Aaron George, DO (Duke) Resident Director-Elect Deanna M. Didiano, DO (Cabarrus) Student Director Julie Barrett (ECU) Student Director-Elect Christian A. Jasper, MPH (WFU)

Sports Medicine Symposium & Mid-Summer Family Medicine Digest

June 29 - July 4, 2014 Myrtle Beach, SC See Page 16 for details

Medical School Representatives & Alternates Chair (Campbell) Alternate (Duke) Alternate (ECU) Alternate (UNC) Alternate (Wake)

Brian A. Kessler, DO J. Lloyd Michener, MD Kenneth K. Steinweg, MD Warren P. Newton, MD, MPH Richard Lord, Jr., MD

AAFP Delegates & Alternates AAFP Delegate AAFP Delegate AAFP Alternate AAFP Alternate

Mott P. Blair, IV, MD Karen L. Smith, MD, FAAFP Michelle F. Jones, MD Robert L. ‘Chuck’ Rich, Jr., MD

The NCAFP Family Medicine Councils Advocacy Council

Robert L. Rich, Jr., MD, Chair

CME Council

Thomas R. White, MD, Chair

Health of the Public Council Practice Enhancement Council

Charles W. Rhodes, MD, Chair Rhett L. Brown, MD, Chair


The NCAFP Strategic Plan Mission Statement: To advance the specialty of Family Medicine in order to improve the health of patients, families, and communities in North Carolina. Vision Statement: Family physicians will be universally valued for their role in providing high quality care to the people of North Carolina. Core Beliefs:

Hertford’s Dr. Robert Lane Named 2013 NC Family Physician of the Year

We believe that Family Medicine is essential to the well-being of the health of North Carolina, and that Family Medicine is well-suited to improve the health of the residents of our state.

We believe in a healthcare system that is primary care-driven. We believe there is an inherent value in a primary care medical home - providing quality, access and affordability.

We believe in a healthcare system that is fair, equitable, and accessible.

We believe in the elimination of health disparities and barriers to access to healthcare for North Carolina.

We believe in a comprehensive approach to patient care and value the health and well-being of patients, families, and communities.

We value collaborative communication with all parties concerned with healthcare delivery, and advocate for a positive practice environment to nourish the specialty of Family Medicine.

We value the professional and personal well-being of our members.

Core Values: • • • • •

See page 6

Quality, evidence-based, timely education. Professional excellence and integrity. Fiscal responsibility, organizational integrity and viability. Creativity and flexibility. Member-driven involvement in leadership and decision making.

Additional details on the NCAFP strategic plan are located at www.ncafp.com/academy/mission

Inside

THE NORTH CAROLINA

..,

William Dennis Inaugurated as 2013-2014 NCAFP President......................................... 4

PUBLISHED BY THE NORTH CAROLINA ACADEMY OF FAMILY PHYSICIANS, INC. R a le igh, Nor th Ca r olina 27605 919.833.2110 • fa x 919.833.1801 http://www.nc a fp.c om M ANAGING EDITOR & PRODUCTION Peter T. Gr a be r, Dir e c tor of Communic a tions

President’s Message............................................... 4 Chapter Affairs........................................................... 6

Value-Based Care: Preparing for The Future.................................................................. 6 The Fountainhead......................................................................................................... 8 NCAFP Stresses Need for Accurate Diagnosis for Successful Medicaid Reform.......... 10 A Day in the Life: Envisioning the Future of Family Medicine...................................... 12

Student Interest...................................................................... 8 Policy & Advocacy................................................................ 10 Residents & New FPs............................................................ 12.

Practice Management............................................................ 14 Meetings & Eduation............................................................ 16.


President’s Message Dr. William A. Dennis 2013-2014 NCAFP President

Dr. william dennis of henderson was installed as the 65th President of the NCAFP on December 7th, 2013. Below are the remarks he shared with members during his inaugural address.

I’ve been around for a while, obviously, and I’ve spoken in front of crowds from time to time. But this is the biggest group I’ve ever addressed without a body laid out in front of me. In fact, at one of the eulogies I gave, a guy fell out in one of the front pews just a few seconds after I started to speak. In medical terms that would be a DFOAC - “done fell out at church.” Thankfully he was OK, and I made it to the end of my talk. But I would appreciate it if all of you at least pretended to stay conscious until I get through here today. I have to say, it’s every bit as scary being up here as I imagined it would be, but don’t let Dr. White hear me say that. I do want to help Greg Griggs realize his worst nightmare - it’s a presidential tradition - by starting with a somewhat off-color story, which is absolutely true. I was lucky enough to attend the East Carolina University School of Medicine, and I loved it. I was not in that distinguished group known as “Jim Jones’ boys,” since he had moved on by the time I got there, but I proudly count myself as one of Jim Jones’ gray-headed step-children. As you know, the first two years of traditional medical school are spent mostly in the classroom. Then your third year starts right after you catch your breath from Step 1 of the boards, and this is when they start throwing you out into the “real world” of medicine with rotations through the main medical specialties. My first rotation was surgery, and I don’t mind saying, I was absolutely clueless. I was assigned to the GI service, under a droll old surgeon who didn’t talk or smile a great deal, and I could never figure out whether he liked me or not. Perhaps one clue was that when

he handed out study topics for our student team to present during rounds, he gave me one on “anal fistulas.” I wasn’t sure whether this was because he didn’t like me, or because he DID like me and “anal fistulas” was his favorite topic. Either way I figured I was in trouble. The first surgical case I went in on was a lady who I think had either colon cancer, or a lower intestinal bleed, or possibly alien tapeworms - I wasn’t too concerned about the diagnosis, I was just excited to actually get to see the insides of a living person. It was a huge thrill to get to stand at the side of the operating table, the big stage, a front row seat to the mysteries of the medical universe. For a few minutes, anyway. About the time they got the abdominal cavity opened and I got a quick glimpse of the omentum, feeling cozy and invisible in my role as “anonymous med student,” I heard the surgeon call my name. “Dennis!” He always called me “Dennis.” “Holy sh--, I mean, yes sir?” “We need you to get down there.” “Down where?” “Down there, under the table.” “Under the table, sir?” “That’s right, we’ll tell you what to do.” “Yes sir.” So I stepped down from my front-row seat and actually got under the operating drapes

and table, centered myself between this poor lady’s legs, and listened for my instructions. Which were, for me to take my right hand that I had just spent 20-minutes scrubbing and gloving and stick it basically where the sun didn’t shine. That’s right - in what we students of advanced human anatomy call the Greater Wazoo. To this day, I don’t know what it was exactly they were doing topside, but they made it clear my job was to apply as much pressure as possible to the wazoo, apparently so they could have better access to the rectum for reconnecting her intestines after cutting out the bad parts. All I heard from them about every five minutes was, “Harder, Dennis. Push harder.” Now, you can train for marathons, swimming the Florida Straits, triathlons, Iron Man competitions, you name it, but there is no training regimen rigorous enough to prepare you for 60-minutes of kneeling underneath a surgical table with your arm up in the air, pressing as hard as you can on some 300-pound woman’s most southerly regions. Right before I thought my arm was either

Dr. Dennis graduated from medical school at East Carolina University/Brody School of Medicine in 1999 and completed his residency in 2002 at Anderson Area M Journalism, and spent 20 years as an editor, reporter, and columnist at the Henderson Daily Dispatch newspaper in Henderson, NC. During medical school, Dr. D Clinical Pathologists’ Award for Academic Excellence and Achievement in 1999. He was also a member of Alpha Omega Alpha, an academic honors society for m

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THE NORTH CAROLINA FAMILY PHYSICIAN • Winter 2014


Dr. William Dennis speaks to Academy members during his inaugural address last December.

going to drop off, or worse, break on through to the other side and be sewn in to the cecum, I heard the surgeon say, “How you doing down there, Dennis?” I paused for a moment and replied quietly, “My Momma would be so proud of me right now!” Thus began my journey toward family medicine. Well, I was lucky to have my Momma around then, and am still lucky to have her here with me today, along with the rest of my family. Now, seriously, I am very very proud, and very very humbled to stand here in front of you today. The view is much better up here than it was under that table. But neither position is something I ever aspired to, or campaigned for, or felt capable of. I was asked to get involved in this organization almost ten years ago, I think mainly because they needed some help with their newsletter. And 5,000 board meeting hours later, here I stand. During that time, I have had the joy of working with some of the smartest, most

creative, most energetic, most inspirational people I’ve ever been around, and I count some of you among my very best friends. I am not worthy of representing you, but I promise I will do my absolute best to get the job done. To keep my fist pressed as firmly as I can on the wazoo of progress, so to speak. (Mott, if you run for office again, feel free to borrow that as your campaign slogan.) As many of you know, medicine is my second career. The reason this board thought I could help with the newsletter ten years ago is that I spent the first 20-years of my working life as a newspaper man. I graduated from UNCChapel Hill in 1975 with a degree in journalism and went to work for my grandfather at the family newspaper in Henderson, pulling down a princely $135 a week. I started in sports and gradually worked through every job in the newsroom, eventually taking over as editor in the last couple of years. When I first started there, the newspaper was a deafening din of noise, with typewriters, linotypes, the AP teletype, metal plates, ringing phones - all endured through a thick cloud of cigarette smoke.

You would type your story, edit it with colored pencil, send it to the linotypist, who would cast your words in reverse out of molten lead - zipping along at about 5 lines a minute. This product would be inked over, and rolled with newsprint to get a readable copy, which would come back to the proof readers for corrections, which then in turn would have to be typed in by the linotypist, who pulled out the bad lines and inserted the corrections. This corrected type would then go to the page form, where the actual page would be assembled on a table top with various blocks of type, headlines, ads, pictures - all in reverse. Then a cardboard-like mat would be rolled over the page form and pick up the full image of the page. This in turn would be used to pour a full copy out of molten lead, which would be cooled and curved into the heavy plate that would actually fit on the press. Now to get a photograph in the paper, you had to put something called “film” in a camera, take the picture, bring the camera back to the office, then in complete darkness unload the film and spool it onto these clumsy little metal reels -- I firmly believe this process is where many of our cuss words originated, especially the multi-syllable ones. The little reels were placed in canisters into which a series of developing and fixing chemicals were poured for specific amounts of time each. If you did it all right and didn’t kink the film while spooling in the dark, it gave you something called a “negative,” which then had to be hung up to dry. You then scanned the negatives for the best shots, and - working in dim, red light - you used a focused white light to expose photographic paper for just the right length of time, and ran this through another set of developing and fixing chemicals, plus washing and drying. Then the chosen print had to be placed on an etching machine that would make plates that fit on the page forms I mentioned earlier. If you could get a picture from camera to the press in less than 2 hours, you were doing pretty well. All in black and white. We won’t even talk about color pictures - you’re talking weeks. Today, things have changed. Now you can get a picture from the scene of the event to printing-press in about three clicks of a mouse. In full, living color. Half a world away if necessary. Now the whole printing process is practically screen to press. The newspaper where I used to work is still written in Henderson, but the pages are laid See ‘Inaugural’ on p. 18

derson Area Medical Center in Anderson, SC. Prior to his medical career, he graduated from the University of North Carolina in Chapel Hill with a B.A. in school, Dr. Dennis was a 1996 Rural Health Scholar, received the Merck Award for Academic Excellence in 1998, and was awarded the American Society of society for medical students. Dr. Dennis currently practices at Duke Primary Care in Henderson.

Winter 2014 • THE NORTH CAROLINA FAMILY PHYSICIAN

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Chapter News & Affairs ncafp.com/academy

Executive’s Desk

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

Value-Based Healthcare:

Preparing for the Future It’s probably not the first time you’ve heard about Value-Based healthcare. In fact, it’s not the first time I’ve mentioned it or written about it in one of NCAFP’s publications. But now more than ever, I ask you to pay attention to what’s being said about this key concept. In all likelihood, valuebased healthcare will drastically impact how you practice medicine in the next few years. Let’s just examine a few of the things that are going on in our state and around the country. First, in the next few months, it is a reasonable bet that Congress will repeal the Sustainable Growth Rate (SGR) formula for Medicare. This is the formula that has tried to cap what the federal government can spend on Medicare. Time and time again, Congress has had to take action to avoid significant cuts in Medicare payment, cuts of up to 25 to 30 percent. Legislation now being considered by Congress would practically eliminate future payment increases under the fee-for-service model of healthcare. In three years, there would be no more updates to fee-for-service. Only physicians participating in alternative care delivery models would receive any payment increase. These alternative models include the Patient-Centered Medical Home or an Accountable Care Organization. Both of these models have been shown to improve quality and lower overall healthcare costs. In other words, if you want to see any future increase in your Medicare payment, you better become recognized as a Patient-Centered Medical Home and/ or become involved in an Accountable Care Organization -- and you better do it soon. Second, no matter what happens with our state’s Medicaid Reform efforts -- and we hope and truly believe that at this point, that won’t be managed care -- how Medicaid is paid and managed is going to change. The most likely model will be around Accountable Care Organizations.

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If you haven’t read our publication on “What Every Family Physician Needs to Know about ACOs,” you should. They are coming -- one way or the other. The concept of an ACO is really taking a Medical Home and moving it into a Medical Neighborhood. All providers -- working together to improve care and lower costs -- can share in any savings that are ultimately achieved for taking care of a population of patients. But there also can be risk. Third, private payers are moving toward alternative payment models as well. BCBSNC is rewarding movement toward the PCMH model. They are also becoming involved in ACOs and have some bundled payment initiatives underway. Fourth, the CMS Center for Innovation has now said that they will NOT provide any innovation funds for states who do not have a plan to manage “population health” by the year 2017. The bottom line -- a move toward value-based payment is coming! Family physicians are uniquely positioned to help drive the discussion, better manage care and ultimately lead these efforts. But you simply can’t sit still and do things just like they’ve always been done. I guarantee you that not a family physician in our state cares for patients clinically like they did the first day out of medical school. Evidencebased medicine has changed how you make clinical decisions. And now how you operate and manage your practice and your patient population must also change. It’s not easy. Some people have described making this change while still operating under fee-for-service as changing clothes while riding a bicycle. And they are probably right. But if we don’t -- as a profession -move toward different practice design models -- we’ll soon find we’re riding a bicycle that is obsolete with clothing from a different century. The Academy -- at both the state and

THE NORTH CAROLINA FAMILY PHYSICIAN • Winter 2014

See ‘Value-Based Care’ on Back Cover

Dr. Robert Earl Lane of Hertford, with his wife Chris. Dr. Lane’s life work and service to p the 2013 NC Family Physician of the Year Award.

Academy Names 38th Family Phys

Robert Earl Lane, MD, fro Named 2013 NC Family Phy Inspired at a young age by his own family doctor to pursue a career in medicine, family physician Dr. Robert E. Lane of Hertford, NC, always wanted to ‘do-it-all’ for his patients and families. For over 40-years he’s succeeded, delivering full-scope family medicine that has touched the lives of thousands. In recognition of his remarkable medical career and lifelong commitment to patients and families, Dr. Lane was named North Carolina’s 2013 Family Physician of the Year. Lane is the 38th family physician to receive the award. In his own words, Dr. Lane was inspired to become a family physician while a teenager. His own family doctor had such a strong influence on him that by the time he was a senior in high school, all Lane could think about was practicing medicine himself. This vision drove Lane to obtain his undergraduate degree from Mississippi State University, finish medical school at Tulane Medical School, and complete his residency training in 1972 in General Practice. After medical school and residency training, Lane completed two years of service with the United States Navy as a Submarine Medical Officer. In 1973, he relocated to North Carolina and began practice in Edenton. Lane would eventually establish Coastal Carolina Family Practice in Hertford in 1987, growing the practice into the largest family medicine group in that region. Today, one can find Dr. Lane continuing to serve patients like he always has, with no immediate plans on retiring. He will turn 72 at the end of February. “During my forty-plus years in practice, I have been fortunate to do something I truly love. All these years of caring for families and taking care of our community have made my life and my practice of medicine complete,” expressed Dr. Lane in receiving the award.


NCAFP HIGHLIGHTS NC Spin Filmed at NCAFP’s Winter Meeting Can Be Viewed on YouTubeNC Spin, the popular public policy program hosted by Raleigh’s Tom Campbell, broadcast a special edition of its program in late January that was filmed during the Academy’s Winter meeting in Asheville last December. Panelists included NCAFP Past President Dr. Conrad Flick (2004); State House Appropriations Chair, Representative Nelson Dollar; BCBSNC Chief Medical Officer and family physician Dr. Don Bradley; John Hood of the John Locke Foundation; Peg O’Connell; and host Tom Campbell. The main topic of the segment is healthcare, including Medicaid Expansion and Reform, Healthcare Cost and Transparency and Personal Accountability. To view the 26-minute segment, visit: http://www.youtube.com/user/NCSPINtube .

and service to patients in and around Perquimans County was honored with

Family Physician of The Year

MD, from Hertford, N.C. ly Physician of the Year Dr. Lane’s commitment as a physician, mentor and community leader are well-known.  His medical staff, patients and community colleagues from around Perquimans County described his commitment in numerous letters of support. Dr. Lane’s success in providing care has helped grow Coastal Carolina Family Practice into one of the largest family practice groups in the Perquimans area. The practice consists of Dr. Lane, Dr. Matthew Woleslagle, and three physician assistants. A full medical support staff and facility enable them to deliver comprehensive family medicine. His office has active medical charts for approximately 30,000 patients. In addition to his medical practice, Dr. Lane has served his local community and the greater medical profession throughout his long career. For example, he has held numerous volunteer leadership roles at Vidant Chowan Hospital, most recently serving as its Chief of Staff. He has also been active with the Perquimans’ County Medical Society, the Brian Center Nursing Facility, the Emergency Medical Services for Perquimans’ County, the Perquimans County Schools, as well as the Brody School of Medicine at East Carolina University as an Assistant Clinical Professor. Lane’s work in the community was honored recently by the Town of Hertford in a Resolution of Appreciation in mid-January. In addition to his medical pursuits, Lane has also been long-active with the Holy Trinity Episcopal Church in Hertford. Dr. Lane resides in Windfall, NC, with his wife of 30-years, Chris. They are the proud parents of five children and grandparents to nine.

Three NCAFP Leaders Appointed to National AAFP CommissionsThe AAFP announced the physician and Chapter staff appointments to its seven commissions. Each AAFP commission deliberates issues within their scope of work, including new strategic ideas and considers and debates referrals from several entities within the AAFP. Three NCAFP leaders were selected, including NCAFP Past Presidents Dr. Karen Smith, FAAFP (2005) to the Commission on Governmental Advocacy, and Dr. Brian Forrest (2012) to the Commission on Quality and Practice; as well as NCAFP Executive Vice President Greg Griggs, MPA, CAE, to the Commission on Membership and Member Services. Two additional NCAFP leaders continue to serve on other AAFP commissions, including Past Presidents Dr. Richard Lord (2011) on the Commission on Continuing Professional Development; and Dr. Robert L. (Chuck) Rich, Jr., on the Commission on Health of the Public and Science.

NCAFP’s Dr. Devdutta Sangvai is 160th NC Medical Society PresidentDevdutta G. Sangvai, MD, MBA, FAAFP, an NCAFP member and the Associate Chief Medical Officer for Duke University Health System, and the Medical Director for DukeWELL, was inaugurated in late October as the 160th President of the North Carolina Medical Society (NCMS). Dr. Sangvai is a graduate of Medical College of Ohio at the University of Toledo and completed his residency training in family medicine at the Medical College of Ohio Hospital in 2001. He subsequently earned his MBA from Duke’s Fuqua School of Business in 2003. Dr. Sangvai is the first alumnus of the Medical Society Foundation’s Leadership College to serves as NCMS president.

Blair Campaign for AAFP Board of Directors will Ramp Up NCAFP Past President Mott P. Blair, IV, MD (2003) of Wallace, NC, announced his candidacy for AAFP Board of Directors last September. Over the next few months, the campaign will be gearing-up and working to spread Dr. Blair’s vision for helping to move the specialty forward in a changing environment. NCAFP members should be on the lookout for announcements on how to get involved. If you would like to make a small contribution to Dr. Blair’s campaign, simply visit http://www.ncafp.com/blair-for-board

Chapter Needs Assessment Gift Card Winners Announced- Ten NCAFP members who participated in the Academy’s 2013 Member Needs Assessment have been randomly chosen to receive $50.00 gift cards. The ten NCAFP members selected include Drs. Surah Grumet; Janice Huff; Miranda Turner; Ananda Vieages; Ward Patrick; Elizabeth Vandergriff; Larry Hollar; Viviana Martinez-Bianchi; Sara Beyer; and Jason Foltz. The Academy wishes to thank all members who participated in our comprehensive needs assessment survey. Feedback and results that were generated will be used in the Academy’s strategic planning process that began last December and will culminate this spring.

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Scott Gremillion is currently a 3rd year medical student at the Brody School of Medicine. He has been recognized as a Brody Scholar and an NCAFP Family Medicine Scholar. He received his BA in International Studies from the UNC-Chapel Hill and previously served on active duty as an officer in the U.S. Air Force.

Student Interest & Initiatives ncafp.com/students

The Fountainhead By Scott Gremillion

During the fall of my 2nd year of medical school, I received a text saying, “Scott, swing by. There’s a gentleman here with a cool heart murmur.” The message was from Dr. Maureen Murphy, my mentor in the NC Family Medicine Scholars Program. As luck would have it, we had been studying heart pathology and murmurs in school plus I just happened to be driving on I-85 at the time, fairly close to her office. So, I took a quick detour. In my jeans and t-shirt, I walked into the Cabarrus Family Medicine office. The office staff, remembering me from my month long internship the previous summer, greeted me with warm smiles and let me into the back. I walked to Dr. Murphy’s office, hugged her, and then we went to go see her patient. In that moment I got to hear a murmur for the first time and I actually knew what it was and what it meant. It was awesome! It was also one of my fondest memories of medical school. Without the support of and opportunities provided by Dr. Murphy, Tracie Hazelett, and the NCAFP Family Medicine Scholars Program I may not have had the strength and foresight to stay in medical school and remain clear in my devotion to becoming a family physician. A quick search of medical journals shows what is probably intuitive to anyone who goes through medical education: medical school is difficult and draining. In fact, moderate to severe depression amongst medical students is more prevalent relative to society1 and empathy plummets during our four years of education2. Medical students are in desperate need of support, strength, empathy, and vision, especially from physician mentors. Family physicians, I believe, are best equipped to give this type of mentorship. Medicine is changing and I believe the future of medicine will be more about healing than it has ever been in modern medicine. To heal literally means, “to make whole.” This healing is intrinsic to family medicine, the one specialty that does a little bit of everything and overtly

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THE NORTH CAROLINA FAMILY PHYSICIAN • Winter 2014

places importance on the whole person, including physical, mental, emotional, cultural, social, and spiritual spheres. For those who are inclined, family medicine mentors, like you, can play a vital role in healing our future healers and helping them see beyond the stress and possible depression and trauma of medical training. Just like our patients, we all, including students, yearn to have someone else invest in us, especially someone we admire. Our educational system trains us extensively in evidence based, logical, algorithmic medicine, which is wonderful and absolutely necessary. However, it is not sufficient in the realm of education, which literally means, “to bring up or out.” Education requires personal investment in its students. Rumi, the Sufi poet, summarizes these dual pursuits of education and intelligence. There are two kinds of intelligence: One acquired, as a child in school memorizes facts and concepts from books and from what the teacher says,collecting information from the traditional sciences as well as from the new sciences. With such intelligence you rise in the world. you get ranked ahead or behind others in regard to your competence in retaining information. You stroll with this intelligence in and out of fields of knowledge, getting always more marks on your preserving tablets.

that I was so fortunate to be a part of is changing this year. Moving forward, as Dr. Murphy reminded us at the recent NCAFP Winter Meeting, the existence of this program and all student support relies on each of you family physicians

“ Without the support of and opportunities provided by Dr. Murphy, Tracie Hazelett, and the NCAFP Family Medicine Scholars Program I may not have had the strength and foresight to stay in medical school and remain clear in my devotion to

becoming a family physician. — Scott Gremillion

reading this article. Please donate your time, money, or empathy to a medical student, because all medical students can benefit from the healing, holistic perspective of a family physician mentor. In fact, it is only that type of personal investment that allows a students’ “fountainhead” to erupt from within.

There is another kind of tablet, one already completed and preserved inside you. A spring overflowing its springbox. A freshness in the center of the chest. This other intelligence does not turn yellow or stagnate. It’s fluid, and it doesn’t move from outside to inside through the conduits of plumbing-learning.

1.

TL

Schwenk,

“Depression, medical

stigma,

students.”

The Family Medicine Scholars Program

L,

and

suicidal

JAMA.

Wimsatt ideation

LA. in

2010;304:1181-1190

2. DC Chen, Kirshenbaum DS et al. “Characterizing changes in student empathy throughout medical school.” Medical

This second knowing is a fountainhead from within you, moving out. 3

Davis

Teacher.

2012;34(4):305-11

3. Rumi, Jelaluddin. “Two Kinds of Intelligence.” The Essential Rumi. Trans. Coleman Barks. New York, NY. Castle Books, 1997. Print. p. 178


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Health Policy & Advocacy ncafp.com/advocacy

By: Joanna Spruill, JD NCAFP Director of Government Affairs & General Counsel

NCAFP Stresses Need of Accurate Diagnosis for Successful Medicaid Reform In January, the North Carolina Academy of Family Physicians and other members of the medical community, including the North Carolina Medical Society, Community Care of North Carolina, and the North Carolina Pediatric Society, testified in front of the state’s Medicaid Reform Advisory Group sharing their thoughts on Medicaid reform. The medical community’s comments as a whole strongly opposed managed care. Medicaid Reform Advisory Group Established When lawmakers passed the state budget in July of 2013, it included a provision establishing a five-person advisory panel that was charged with recommending a reform plan for Medicaid to the General Assembly by no later than March 17, 2014. The Medicaid Reform Advisory Group consists of three members who were appointed by Governor Pat McCrory, a member of the House of Representatives, and a member of the Senate. The members include Dennis Barry, CEO emeritus of Cone Health, Peggy Terhune, executive director/CEO of Monarch, Richard Gilbert, an anesthesiologist who serves as the chief of staff for Carolinas Medical Center, Representative Nelson Dollar (R-Wake County) and Senator Louis Pate (R-Lenoir, Pitt, and Wayne counties). Last year, the Academy lobbied for a family physician to serve on the Advisory Group to no avail. However, the physician on the committee, Dr. Gilbert, has reached out to the Academy for our comments. As part of their charge to develop a reform plan, the General Assembly required the Advisory Group to accomplish three priorities: create a predictable and sustainable Medicaid program, increase administrative ease and efficiency for providers, and provide care for the whole person by “uniting”

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physical and behavioral healthcare. So far, the Advisory Group has met twice, in December and in January, and plans to meet again before their March deadline. The Academy Presents to the Advisory Group At the Advisory Group’s first meeting in December, staff from the Department of Health and Human Services provided an overview of possible reform plans based on structures in other states, including Florida, Maryland, and Virginia. At its second meeting on January 15, 2014, the Advisory Group invited stakeholders to share their thoughts on reform. The Academy was one of over forty presenters who testified in front of the Advisory Group. Among the speakers was a group of medical students who presented a letter signed

by over 300 North Carolina medical students. The letter championed CCNC and cautioned that the elimination of support for CCNC would hurt North Carolina’s reputation as a center for healthcare innovation and lessen its appeal to new medical graduates. Dr. William Dennis, President of NCAFP, spoke on behalf of the Academy, specifically urging the Advisory Group to develop an accurate diagnosis of the problems within Medicaid before prescribing a course of treatment. Dr. Dennis stressed the effectiveness of care delivery in North Carolina, praised the efforts of CCNC and the patient-centered medical home, and noted that any reform must build upon the investments already made in North Carolina. “We believe the issues with Medicaid that need to be addressed have more to do with inaccurate budget forecasting than actual care delivery. Per recipient claims spending in North Carolina is actually decreasing and overall Medicaid claims spending is growing at a rate lower than

NCAFP Guiding Principles of Medicaid R

The Academy’s Guiding Principles of Medicaid Reform are based on the fo 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) 14) 15)

Have any problems with Medicaid been accurately diagnosed and does the plan truly address each pr what needs to be changed about Medicaid in North Carolina? Does the plan build on what is currently working in North Carolina? Is the plan patient-centered and built on a Patient-Centered Medical Home model? Does the plan reduce administrative complexity? Does the plan encourage multiple practice environments including independent practice? Does the plan propose to effectively integrate physical and mental healthcare? Is the plan based on the collection, accessibility, and usability of accurate data utilizing appropriate Does the plan propose innovation in alternative reimbursement models and appropriately adjust f Does the plan increase access to high quality healthcare based upon principles of evidence-based Does the plan appropriately focus on the long-term healthcare needs of the state, including long-te scarce healthcare dollars in our state? Does the plan address the need for better forecasting and budgeting? Does the plan create effective healthcare markets? Does the plan consider social determinants of health? Does the plan encourage personal responsibility? Does the plan encourage physician involvement in reform, including ongoing evaluation?


the growth in number of recipients,” Dr. Dennis noted. The Academy also distributed the NCAFP Guiding Principles of Medicaid Reform, a 15-point framework designed to evaluate any proposed Medicaid Reform plan. Grassroots Still Important The Advisory Group is scheduled to meet again in February before their March deadline. Any decision to move forward with reform will ultimately be that of the General Assembly. Reaching out to legislators to share our fifteen fundamental principles and our perspective on reform will be critical during the next few months. Our state’s lawmakers must realize family physicians stand ready and willing to work with them to design and implement a plan that leverages the investments we’ve already made in North Carolina and emphasizes care for our patients.

icaid Reform on the following fifteen questions:

dress each problem by first and foremost determining

NORTH CAROLINA

FAMPAC

Empowering Family Medicine in North Carolina

ce?

appropriate technology? tely adjust for patient risk? ence-based medicine? uding long-term budget predictability? Does it keep

n?

Family Medicine FAMPAC Forerunners Continues to Grow Register Today to Help Raise Family Medicine’s Voice Thank you to our Family Medicine Forerunners and to all those who made FAMPAC contributions last year! We added more contributors to our Forerunners club during the Annual Meeting and now have a total of 22. Interested in becoming a Family Medicine Forerunner? Forerunners agree to make $100 quarterly contributions to FAMPAC; the NCAFP conveniently charges your credit card each quarter. To register, signup online today at https://www.ncafp.com/advocacy/fampac/contribute. Contributing to FAMPAC offers an easy and low-risk way for you to be part of the political process. With Medicaid Reform on the table this year, we need more than ever to have a strong voice so we can stress the importance of physician-driven, patient-centered primary care and build on what’s already working in North Carolina.


Residents & Chapter Affairs New Physicians

By Dr. Aaron George, Resident Director & Dr. Farhad Modarai, Foundation Trustee

ncafp.com/residents-newfps

A Day in the Life.....Envisioning the Future of Family Medicine As the voices of the future of family medicine, we often reflect upon how our training is preparing us to be outstanding clinicians today, as well as leaders of clinical care tomorrow. The face of primary care is changing, both from a structural and process delivery standpoint. While the face-to-face fifteen-minute office visit will always be a foundation of our practice, we need to look toward innovative ways to increase continuity and decrease costs. With rising patient needs for chronic disease management as well as a flood of newly eligible insurees under the Affordable Care Act, we simply cannot expect to continue with primary care business as usual. We offer the following perspective on our vision of what a day in the life of a family doctor will look like in 2030:

7:30 am: Driving on the way to the office in my automated car, I pull up a daily report of my highest risk patients. This report is based-off of predictive analytic algorithms, which incorporate both clinical data and various metrics of social determinants of health. I make a quick call to my high risk case manager, and we put together a game plan for this group. 8:00-11:30 am: Traditional face-to-face care with my continuity patients. However, these office visits are designed via a smart, data-driven scheduling system. Walk-ins and acute visits are managed during this time as well. 11:30-1:00 pm: The middle of my day includes an hour and a half block of time for patient care outside of the clinic – but I never need to leave the comfort of my office chair. Throughout the morning, our clinic data analyst has been analyzing live stream data from my

12 THE NORTH CAROLINA FAMILY PHYSICIAN • Winter 2014

patient panel, with particular emphasis on my most challenging chronic disease sufferers. This is the data that my patients effortlessly collect via their mobile health devices, and it automatically is integrated into the electronic medical record. After a quick thirty minute meeting with my team, I spend the next hour proactively conducting acute care visits with my highest risk patients via telemedicine. If a home visit is warranted, I will send one of my on-call team members along with the patient's case manager out before the end of the day. If I need to see the patient in clinic the next day or two, we make sure we book the appointment. 1:30 pm: My afternoon clinic is dedicated to clinical time via group visit models. I have four rooms arranged, each with eight patients that are collectively aligned with similar conditions. One room includes some of my hypertensive patients, a second with diabetics, and a third composed of prenatal mothers. A specialized facilitator works in each of these rooms throughout the entire twohour block. Meanwhile, I stop in for thirty minutes to each of these rooms for quick evaluations and discussions. In this way, I am able to take five office staff and provide sixty-four hours of physician supervised care for thirty-two patients in a two-hour block. 4:00 pm: At the end of the office day, I have an hour set aside for a team meeting with my medical assistants, nurses, advanced practitioners, social workers, case managers, community health workers, and data analysis to discuss any concerns of the day or issues with particular patients. This is our Patient Centered Medical Home time. Along with this time, we will often film brief videos or audio files to forward to targeted sub-populations of our patient panel. A key difference between the clinical of-

fice day of the future, and that of the environment we practice in today, will be in the amount of time spent in one-onone patient care. Leveraging digital technology for population management will allow the future family physician to connect with dozens or hundreds of patients at one time. There will always be an implicit need for direct and individualized care. However, the primary care delivery system of the future will value approximately half as much daily time for physicians to spend in these activities. Continuity of care will always be fundamental to family medicine. However, the three-month standard chronic disease follow up visit will be obsolete when we can collect real time clinical measurements and proactively reach out to those in need for acute care visits, and, equally important, reward and reinforce good behavior. In essence, patients will be scheduled visits dynamically based upon therapeutic response rather than temporal convenience. In concert with this, increased integration of group visit models and online platforms will allow a stronger community and facilitate continuity with the health system. Of course, none of this will be possible without the backbone of the Patient Centered Medical Home. The PCMH model is successful because of the community base it builds as a foundation for care. Patients feel genuine ownership as part of the medical home and this feeling will only be strengthened with the integration of the group models of care and technology we have addressed here. 5:00 pm: After wrapping up the team meeting with some positive affirmations and team building exercises, I am back in my automated car for the drive home in which I review my clinic patients that will be arriving for the coming day. I arrive home just in time to eat dinner with my family and catch my son's championship basketball game.


Our Residencies: New Hanover Regional Medical Center Family Medicine Residency Program

The New Hanover Regional Medical Center Family Medicine Residency-

North Carolina’s Coastal Training Hotspot

PROGRAM AT A GLANCE

Ask a medical student knee-deep in residency interviewing about the impact location has on their rank list, and they’ll tell you it plays a significant role. After four years of grueling academics and demanding rotations, for a lot of students the ‘where’ is just as important as the curriculum, program facilities and faculty. At North Carolina’s only coastal-based family medicine residency program -- the New Hanover Regional Medical Center Family Medicine Residency -- promoting the lifestyle advantages of training near the beach certainly gets the attention of students. But the true strength of the program and what’s led it to have such strong recruiting over the last decade is its well-rounded training experience that builds on its dual-accreditation, its faculty diversity and thorough training. Founded in 1997 and now operating as a dually accredited AOA/ACGME communitybased program, New Hanover residents and faculty hail from all over the United States. Over 50% of the program’s graduates stay in the immediate Wilmington region after graduating, with as much as 70% residing in state. That’s a strong testament to both the program and gives support to the saying that, ‘once you get to New Hanover, it’s hard to leave.’ Coastal Family Medicine Training at its Best Dr. Janalynn Beste, Residency Program Director is excited for the future.

New Hanover currently trains six physicians each year, with classes equally split between osteopathic and allopathic physicians. In 2006, the program became North Carolina’s first duallyaccredited family medicine residency program, and later, in 2010, was able to expand the number of training slots it offered through the Affordable Care Act’s Primary Care Residency Expansion Program (PCRE). The combination of MD and DO education has allowed the program to develop a unique training experience. “Our combination of allopathic and osteopathic training has allowed our physicians in both disciplines to learn from each other. Our osteopathic physicians show their

The New Hanover Family Medicine Residency Program Location:

Wilmington, NC

Accreditation: ACGME & AOA Approach: Community-based, dually-accredited program. Positions:

(6) Annually

New Hanover Regional Inpatient: Medical Center, Wilmington Residency Clinic Outpatient: Web: http://www.coastalfmresidency.com

allopathic colleagues techniques we might not be able to learn otherwise, and vice versa. Plus, it’s opened up some services to patients we couldn’t have provided before, ‘ explained Dr. Janalynn Beste, New Hanover’s residency program director. Dr. Beste came to New Hanover in 2007 from East Carolina University where she had previously served on the See ‘New Hanover’ on back cover

Winter 2014 • THE NORTH CAROLINA FAMILY PHYSICIAN

13


Practice Management ncafp.com/practice-mgt www.ncafp.com/resources/practicemgt

Practice Briefs Round-Up Six New Accountable Care Organizations Approved in North Carolina by CMS - More evidence that accountable care is gaining momentum. The Centers for Medicare and Medicaid Services (CMS) announced in late December the approval of 123 new Accountable Care Organizations nationally, six of which that are either based in North Carolina or serving NC patients. These six new ACOs bring North Carolina’s total number of Medicare ACOs to 14. AAFP Offers Clinical and Coding Resources on ACA’s Preventive Services As part of the Patient Protection and Affordable Care Act (ACA), an increasing number of insurance plans now cover preventive services without any cost-sharing measures, such as co-pays or coinsurance. For instance, all ACA Marketplace insurance plans and a growing number of other health insurance plans now cover USPSTF A & B Preventive Services, and all immunizations as recommended by the CDC’s Advisory Committee on Immunization Practices. To help providers and practices take full advantage of these, the AAFP has published a new series of resources designed to educate you on what services patients can now access and how to code and get paid for them. For a complete summary to these new preventive services including a listing of all covered services and coding resources, visit http://www.aafp.org/advocacy/act/aca.html . CMS’s New “Two-Midnight” Provision Could Impact FPs with Admitting PrivilegesFamily physicians with hospital admitting privileges are likely already aware of CMS’ new benchmark for inpatient hospital admissions that went into effect on Oct. 1. If not, you will be hearing about it soon from the hospitals you admit patients to! Dubbed the “two-midnight provision,” the rule instructs physicians on when an inpatient hospital admission should be ordered and clarifies when such admissions qualify for Medicare Part A payment. Although the rule won’t directly affect physicians’ payment, it does affect how hospitals get paid by Medicare. The AAFP has published a review of the key provisions of the rule at http://www.aafp.org/news-now/practice-professionalissues/20131120twomidnight.html NCTracks Launches Notification System for Incorrect Billing AddressesNCTracks launched new functionality in late January aimed at helping providers fix pended claims flagged for ‘Incorrect Billing Address’. Corrections may now be made from within the Provider Portal while logged-in. Since the launch of NCTracks last July, when a claim was received with an incorrect Billing Provider Location, the claim was listed as pended in NCTracks. This occurred when the billing provider location submitted on the claim did not match the location(s) in the provider record. When an error like this occurs now, a secure message is sent to the provider’s Inbox in the provider portal, with a link to a screen that will enable them to select the correct Billing Provider Location from a drop down list. The claim will then released to continue processing. This approach should allow providers to correct claims themselves, rather than having it deny for incorrect Billing Provider Location. Providers should have received communications from NCTracks that will include a link to instructions on how to complete the process.

THE FAMILY PHYSICIAN RESIDENT’S GUIDE TO HOSPITAL EMPLOYMENT

THE FAMILY PHYSICIAN RESIDENT’S TO HOSPITAL EMPLOYMENT

Guide

page 1

©2013 Smith, Anderson, Blount, Dorsett, Mitchell & Jernigan, L.L.P.

Academy Releases New Guide on Hospital Employment Aimed at Resident Physicians The NCAFP released a new 22-page general guide on the basics of hospital employment. The guide is aimed at educating resident physicians on the key terms of any proposed employment contract they’ll consider as an employee of a hospital or health system. To assist residents in making well-informed decisions, the guide presents an overview of employment options available to new graduates; the potential advantages and disadvantages of employment with a hospital or health system; and offers general guidance on negotiating the terms of employment with these types of employers. The NCAFP partnered with Raleigh’s Smith Anderson law firm to develop the guide. The guide can be downloaded at the NCAFP website at http:// www.ncafp.com/resident_employ_guide.pdf .

NC Medicaid Releases New Guide to EHR Program Attestations The NC Medicaid EHR Incentive Program has created a Quick Reference Guide for NC Medicaid EHR Incentive Program Attestations to identify solutions to the most common attestation errors. The reference guide also provides initial troubleshooting suggestions for those providers who are experiencing difficulty logging on to NC-MIPS. See the one-page guide here http://www.ncafp.com/files/EHRAttestationsGuide.pdf

14

THE NORTH CAROLINA FAMILY PHYSICIAN • Winter 2014

C


MEMBERSHIP NEWS & BRIEFS Wilmington Business Journal Honors Dr. Jim Jones- Past AAFP and NCAFP President Dr. James G. Jones of Hampstead, NC, was awarded the Greater Wilmington Business Journal’s highest healthcare honor: The Lifetime Achievement Award. Dr. Jones was lauded for his five-decades of contributions to healthcare delivery throughout North Carolina and specifically his efforts to the Wilmington area. To read the highlight published by the Journal, see http://www.wilmingtonbiz.com/industry_news_details. php?id=6018 . Pictures from the recognition event are available at http://www.flickr.com/photos/102059499@N03/

MAHEC Asheville Residency Director’s Research is Turned Into Workforce One-Pager by AAFP’s Graham Center The United States could significantly reduce the mal-distribution of physicians by changing the dissemination of graduate medical education funding, according to research in the Nov. 15 issue of American Family Physician. Dr. Blake Fagan, Program Director at the MAHEC Asheville family medicine residency program, and his colleagues, reviewed data from the American Medical Association Physician Masterfile to determine where newly minted physicians practiced after completing residency training. The one-pager was published in the Nov. 15th edition of the American Family Physician.

DUES NEWS YOU CAN USE 2014 AAFP Membership Dues - If you haven't yet paid your 2014 AAFP/ NCAFP membership dues, there's still time! Invoices were mailed in October to primary addresses with a due date of 1/1/14. Please pay your balance prior to May 1st, which is the drop date for dues non-payment.Need another invoice or want to check your balance? Please call AAFP at 1-800-274-2237 or go online to www.aafp.org/checkmydues . Your username/login is your AAFP ID# and you will need to change your password for security reasons if you haven't already done so. How to pay: By phone at 1-800-274-2237; by mail to address on invoice--AAFP, P.O. Box 419662, Kansas City, MO 64141; or online at www. aafp.org/checkmydues . Please note that if you are unable to pay the entire balance, an installment plan is available. To sign up, please call AAFP at 1-800274-2237 or go online to www.aafp.org/checkmydues . Installments will be taken out through August 2014. If you have/will move or retire, please contact AAFP so the appropriate changes may be made to your status. Retirees may be eligible for Life membership and those moving out of NC will need to relocate their state chapter membership and pay appropriate state chapter dues in order to maintain AAFP membership. Remember that since membership is unified, both AAFP and state chapter dues must be paid to maintain AAFP membership according to AAFP bylaws. All dues or web login questions may be directed to AAFP at 1-800-274-2237 between the hours of 8:00 a.m. - 5:30 p.m. CST. USAFP Members/NCAFP Affiliate Membership Military personnel living in NC, who are also members of the USAFP, should have received a mailed application to become an affiliate member of the NCAFP. Current affiliate members should have received an annual renewal application. We would love to keep you informed of our meetings and news pertinent to you. For more information, please contact Tara Hinkle, NCAFP Membership Coordinator, via email at thinkle@ncafp.com or by phone: (919) 833-2110 or NC toll free (800) 872-9482.

Family Medicine Charlotte Metro Area

CAROMONT HELSTH CaroMont Health

Outstanding outpatient family medicine opportunities available in communities located minutes from Charlotte, one of the fastest growing cities in the country. These are employed opportunities and will offer competitive compensation packages including two year salary guarantee, productivity bonus potential, generous benefits and relocation expenses. CaroMont Medical Group operates under the guidance of a physician-led Governance Committee allowing for an active partnership with the Medical Staff. Over 300 active medical staff representing all major medical specialties at Gaston Memorial Hospital, a modern and progressive 435-bed hospital which provides comprehensive care to patient base of over 300,000. These lovely communities have easy access to the beautiful North Carolina Mountains and some of the most popular beaches on the East coast. Just minutes from an international airport and two large lakes, communities offer unlimited cultural and recreational amenities. A superb quality of life exists here with many charming neighborhoods and stellar public and private schools. If interested in being considered for this opportunity, please send CV to: Celia G. Billings Manager, Physician Recruitment CaroMont Health 2240 Remount Road Gastonia, NC, 28054 T: 704-834-2153 | F: 704-834-4615 Email: billingc@caromonthealth.org


Looking for Additional CME Opportunities? Access the NCAFP’s website for several online

CME Meetings & Education

CME courses at www.ncafp.com/cme

ncafp.com/education

Academy Providing Education on New DOT Medical Examiner Certification

Save The Date

DOT

New Requirements Go Into Effect This May Effective May 21, 2014, all health care professionals who perform physical examinations and issue medical certificates for interstate commercial motor vehicle (CMV) drivers will be required to complete an accredited certification training course and pass an examination. Medical examiners who complete the training and successfully pass the test are included in an online directory on the National Registry website.

Mark your calendars now and make plans to participate in the NCAFP’s DOT training course that will be held on March 22, 2014. The training will last from 8:00 am to 3:00 pm and will provide 6-hours of instruction. The seminar is taking place at the Crowne Plaza Hickory (1385 Lenoir-Rhyne Boulevard, Hickory, NC 28602). Online registration is currently available for the event by visiting http://www.ncafp.com/dot

Medical Examiner

Training

Sat., March 22, 2014 Crowne Plaza Hickory Hickory, NC www.ncafp.com/dot-training

+ 0 3

2014 NCAFP

AAFP PRESCRIBED

CREDITS

www.ncafp.com/msfmd

Sports Medicine Symposium & Mid-Summer Family Medicine Digest

June 29 - July 4, 2014

HOTEL RESERVATIONS For Hotel Reservations, please call the Kingston Plantation at 800-876-0010. Be sure to mention the NCAFP in order to receive the discounted room rate. Rooms fill up quickly! Note all conference educational programs will be held in the Embassy Suites Hotel at Kingston Plantation. For more information about these programs, please fax this side of the card to the NCAFP Meetings Department at 919-833-1801 or call the NCAFP at 919-833-2110 or 800-872-9482 (NC Only) or visit us www.ncafp.com/msfmd.

Myrtle Beach, SC 2014 Sports Medicine Symposium: Sunday, June 29th (1pm to 9pm) M idsummer Family Medicine Digest Sessions: Monday, June 30th - Thursday, July 3rd (7:30 am to 1:15 pm) Optional Workshops and Seminars: Valuable Hands on Procedures - Tuesday, July 1st (2pm to 5pm)

Practice Management - Friday, July 4th (7:30 am to 1:00 pm)

Optional SAMS Study Working Group: Friday, July 4th (7:30 am to 2:30 pm)

Sports Medicine Symposium Lecture Topics: The Aging Athlete, Hand Problems in Athletes, Atrial Fibrillation, Frozen Shoulder, Concussions, Fitness and Longevity and more. The Sports Medicine Symposium will also include hands-on workshops on the evaluation of upper and lower extremities. Midsummer Family Medicine Digest Lecture Topics: ER/LA Opioid REMS: Achieving Safe Use While Improving Patient Care,  Type II Diabetes, Immunizations Update, Hepatitis C, Lipid Update, Mental Health, Smoking Cessation and much more!

16 THE NORTH CAROLINA FAMILY PHYSICIAN • Winter 2014


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out at headquarters in Kentucky, and those are zipped to the printing plant in Durham, where the paper is actually printed and then hauled by truck back to Henderson, 40 miles away. Of course, if you subscribe electronically, you can view the whole thing on line even before it’s printed. Pretty amazing, right? Of course it is. Except that now, with all these

etc etc etc. Newspapers have the finest of technology, amazing advances, time saving devices, money saving ideas - the very best of electronic record-keeping so to speak .... but it hasn’t been enough. And nobody is really sure what the answer is. They’re up against too many more powerful forces. There is at least one bright area for newspapers, though - many of the small papers, the ones that print just local news, the things readers can’t get

miraculous improvements, ours and almost every other newspaper in the country has a paid circulation and daily page count less than two-thirds of what we had in the “bad old low tech days.” The newsroom is half the size or less. There IS no composing room, and they’re trying to sell the old press for scrap. It’s sad to ride by the place, though the product remains pretty decent. Nationwide, the story for newspapers is similar, actually much worse in some areas. Some papers, major ones, have gone out of business. Many more are on the ropes. I would ask at this point for a show of hands: how many of you are under 40 years old (be honest). ... a fair number. Now, how many of you who just raised your hands still read a real daily newspaper, the kind that comes to your doorstep and you can pick it up and hold it in your hands? (hardly any) That’s what I thought. The reasons for all this are complicated - but I guess best are summed up by the phrase, Time Marches On. And it has marched on faster than newspapers have been able to keep pace with. There is competition from TV, radio, internet, Hulu, Netflix, Google, Facebook, Twitter,

anywhere else - the news about births, deaths, high school sports, the hot sauce festival ... the papers who know their people “intimately” so to speak, the papers that are “there” for their readers ... these newspapers are doing relatively well, and are expected to continue to do so. Warren Buffett is BUYING some of them. Now, before many more of you start to think I’ve prepared a speech for the wrong group, let me change gears just a little. Last year after I became “presidentelect” of this group, our local paper wanted to do a story on me. I tried to get them to wait till this year, but they insisted. So they sent a nice, intelligent, 23-year-old reporter over to talk to me, and she asked me why I changed careers from newspapering to medicine. First, I said, I wanted better hours... which I got. And second, I had a family to feed, clothe and educate, which would be dicey on a newspaper salary. Lifestyle wasn’t the biggest reason though. The real reason is, probably like some of you out there, since high school I had wanted to be like Marcus Welby. Actually my own hybrid of Marcus Welby and Patch Adams, but that gets

Inaugural Address: from p.5

complicated. So I told this nice young reporter, “I wanted to be another Marcus Welby.” I waited for a logical followup question, but after an uncomfortable pause I looked up at her face. It was blank. “You have no idea who Marcus Welby is, do you?” I said. She didn’t. I started to throw her out of the office at that point, just on age principles alone, but it began to hit me that Marcus Welby is G-O-N-E. He is a dinosaur. The world’s greatest family doctor ever is graveyarddead. And in today’s corporate medicine environment, if you try to add some levity like Patch Adams, they’ll send a whole team of compliance officers to beat you with the employee manual till you conform to company rule. Now I know some of you do come very close to being like Marcus Welby, and you guys are my heroes. But it ain’t easy. Today’s medical environment doesn’t favor the conditions that allow a Marcus Welby to thrive. There just isn’t enough time, not enough oxygen, not enough sunlight. Today, if you let somebody pay you with a dozen eggs and a couple of collards, the law says you have to let EVERYBODY pay with a dozen eggs and a couple of collards. Which starts to smell after a while. I know it’s idealistic, but I just think that’s a shame. Today we know a lot more than good ol’ Dr. Welby did. Many of his television patients who kicked the bucket back then would be alive and well if they’d gotten those same illnesses today. We’ve come a long way in a short time. We have CAT scans, MRIs, chemotherapy, radiation, lasers, positrons, cardiolite, and telemedicine. We have the Patient Centered Medical Home. We have electronic medical records. Computers have replaced our crappy handwriting and taken the prescription pads out of our pockets. We have ethics now - if we DO write a prescription, by gosh it won’t be with a Lipitor pen given to us by an evil drug rep. We have meaningful use, an Affordable Care Act, open access, CCNC, prior authorizations, voice recognition. The RUC, CMS, HIPAA, RVUs, EMTALA, ICD10 … please don’t make me continue. We don’t have to stuff our doctor coats with 40 pounds of handbooks, drug manuals and Sanford Guides - we have access to the entire library of medicine, all current and up to date, within our 6-ounce iPhones. This is wonderful stuff, amazing stuff, awe-inspiring stuff - both for doctors and our patients - and most of it has happened in the 11½ years since


I completed my residency. I can’t even imagine how incredible it will be when you current students and residents get a few years down the road. But let us not get too confident that technology is going to make family medicine well. We should all embrace this technology, get familiar with it, learn to love it - but as family physicians we must not forget ol’ Marcus Welby. THIS is what makes us different and, I think, BETTER than most other specialties. For example, and I exaggerate only a little, our office now has one of the most advanced EMR systems in the history of big-time medicine. It can do just about anything short of performing surgery and publishing a newspaper. It can produce a beautiful templated progress note that goes on for 6 pages about a mere runny nose … but doesn’t communicate a doggone thing. And this is how our visits too often go: Good morning, Ms. Johnson, what brings you in today? (She’s sitting behind you on the table while you’re facing the computer and typing). I’ve been having chest pressure when I go up the steps at home. Oh, really, tell me more. Well, I also get kind of sweaty and feel a tightness in my neck and left arm. Uh, huh, well, OK -- WHOA, the computer says you haven’t had your shingles shot. Or your mammogram either. Let me call the nurse .. ... now, what were you saying? Well, by the time I’m at the top of the stairs, I’m really short of br...... Hold on a minute, let me click this box that says I reviewed your medicine list and your social history. Now, where were we?

I was telling you that I am getting symptoms of a heart attack when I go upstairs. Yes, that’s right. Now, let me click here where it says problem list reviewed and put in a couple of test orders. You were saying ... I’m very worried about my heart .... I understand, but let me make sure my orders are associated with a diagnosis that Medicare will pay for. OK, go ahead. As you know, both my parents died of heart One minute now, let me click on these little bubbles that show I talked with you about falls and advanced directives. But doctor .. Hold on a sec ... click, click, click. Doctor.!!!’ Ms. Johnson would you please shut up!! I’ve got to get all these boxes clicked or we won’t get “meaningful use.” OK, OK, I exaggerate. A little. But you see where I’m going. Yes, we have a lot of things going in our favor. Insurance companies and the government have at least started to realize family physicians’ value to the system, and the fact we above others have the key to “bending the cost curve,” as they say. We have the Patient Centered Medical Home. We have (and would like to keep, hint, hint) CCNC. But we need to make sure we’re using these things in the right way, which, at least in our PCMH, we’re not always able to do, though we’re working on it. We need to take that laser-like focus we were using a few years ago, and put it directly on our patients, listening to them, and hearing them, one by one, appointment by appointment, hour by hour, day by day. We have to be there for them, when they need us, and where they need us. Nobody can do the job of a family physician the way a family physician can do it. If we do it right, I think we’ll always be where we want to be. And we’ll be able to attract more medical students into family medicine.

If we don’t, well, I’m afraid we could wind up like the big newspapers -- all “tech’d up” with no place to go. So HOW do we do it right? It’s not going to be easy. There are a lot of obstacles in our path, despite all that’s going well for us. When I was at the newspaper, I wrote a weekly column that seemed pretty popular. At least to me it did. Usually I tried to make it funny, though sometimes it was serious. Sometimes it was some of both. But it ran every week, if for no other reason because I controlled what went in the paper, therefore nobody could cancel me. Anyway, an older lady came up to me one night at a party, grabbed my arm, pulled me aside, and started to compliment one of my columns. I could tell she had been, shall we say, “partying well.” “You know, Bill,” she said, “just to look at you, a person would never know you were so clever.” …. pause I looked back at her face, and could tell she was serious. I wasn’t quite sure what to say, so I just replied, “Well, uh, Ms. Doe, uh, thank you. Thank you very much. I think.” So my charge to us here today is, well, just to look out there at a lot of these faces, one might not think we were all that clever. The ones of us in that category know who we are, so I don’t need to point fingers. We don’t generally drive the fancy cars, vacation on the Riviera, winter at Palm Beach, or wear $1,500 suits. We just aren’t, on average, a flashy bunch (except for Dr. White). But we ARE a CLEVER bunch. We ARE clever enough to master the challenges coming our way - financial, political, and philosophical. We ARE clever enough to adopt the cold technology of Dr. House, yet keep the warm touch of Dr. Welby. We can continue to do, and learn to do even better, the great things we are doing for our patients. As for myself, personally, I’m afraid I’m not even as HALF as clever as I look. But I am honored, awed, and humbled, to be in this position. In this coming year, I pledge to you that I will say what I need to say, do what I need to do, and go where I need to go - even if it’s crawling under a surgical table - to represent all of you and this wonderful organization. Thank you all so much!


Value-Based Care: from p.6 national level -- is here to help. But we can’t do it all. We need you to take the opportunity to learn about value-based payment models. We need you to be a leader in your practice, in your community and

NEW HANOVER: from p.13 school’s family medicine faculty, including being its residency program director. According to Dr. Beste, New Hanover’s participation in the PCRE has been extremely beneficial. One critical advantage has been a shift in how the program is perceived in terms of its relative size among recruits. “I think for a lot of our prospective trainees, our current size is just right now, not too big or small,” she explained. “Our residents feel they have an ample number of colleagues to learn from, but don’t feel lost.” Beste pointed out that the expansion has also helped the program’s clinical operations, including its inpatient and outpatient services, and has introduced more diversity into its training experiences. The program will graduate its first sixperson class later this year. Right-Sized & Diversified Physician Training New Hanover’s attractive coastal location draws student interest, but its overall training program is really what holds it. The program stands out by providing a diverse training program that’s delivered through a dedicated, well-rounded, and experienced faculty, in facilities that are large but enable a small close knit experience. The program’s in-patient training center is New Hanover Regional Medical Center (NHRMC), an 855-bed teaching and referral hospital that serves patients from up and down the NC coast. NHRMC is everything you would expect in a key regional referral hospital. The hospital provides an exhaustive

in your health system. We cannot afford for family physicians not to be at the table. We’ve already seen some systems speak about moving to value-based care but still pay their primary care physicians based on volume. They’ve not given the primary

care practice the resources needed to truly manage their patient populations. We’ve got to demand better, but we need your help. I believe the future of healthcare is built on a foundation of family physicians. But we simply can’t afford to sit back and

let change happen to us. That foundation will only be strong if family physicians are helping drive the change. So today, I’m urging you. Get educated. Get involved. And demand better. Only you can help drive the positive change.

range of ambulatory, surgical, and clinical services, and acts as an important hub for Wilmington’s medical community. But for a larger hospital like NHRMC, it only houses a total of four residency programs. This affords New Hanover residents with the in-patient training experience of a large hospital, but reinforces a close-knit, collaborative feel with the local provider community. One key area where this becomes an advantage is in pediatric and hospitalized children’s health training. NHRMC does not house a pediatrics residency, so New Hanover residents receive a unique experience. New Hanover residents work side-by-side with Southeastern AHEC pediatric faculty in the hospital’s newborn nursery, its general pediatrics unit, as well as its pediatric ICU. “I think our residents get some of the best pediatric training experiences I’ve ever seen in a residency program,” Beste noted. She stated that all pediatric attendings treat New Hanover residents as their own and as a result, program residents serve an inordinately large number of pediatric patients. Additional experiences in adolescent care are available through Wilmington Health Access for Teens, where a faculty member is medical director, which helps draw New Hanover residents into the local community by conducting sports physicals and other related services. New Hanover faculty and residents operate their own family medicine in-service at NHRMC serving its clinic patients, the unassigned, and a frequent number of patients admitted by community physicians. Beste notes that many of these

admitting physicians are graduates of New Hanover themselves, which helps to build relationships faster and improve communication. Another advantage of having a growing pool of program graduates in the area, according to Dr. Beste, is the flexibility it offers relative to developing unique training experiences. She described one rotation led by a former graduate that enables New Hanover residents to experience a much more rural setting, including working in a small practice and a small critical access hospital in Pender County. “Our residents enjoy experiencing a very different practice and hospital in their rotations in Pender County. At 25 acute beds and with limited resources when compared to New Hanover Regional, our residents enjoy the challenges,” noted Beste. For its outpatient training, New Hanover residents staff an NCQA-recognized PatientCentered Medical Home that features a full stable of clinical, diagnostic and integrative services. The clinic serves a diverse patient population that reflects its coastal roots, but also its geographic proximity to several military installations. The clinic’s patient population includes a large Medicaid base, with significant numbers of retired Medicare beneficiaries, and a growing military population.

program is working to identify ways to improve the physician training experience while recognizing the changes taking place in family medicine and overall healthcare delivery. One approach under investigation is expanding the program’s collaborations with its local medical community. Dr. Beste noted that while the potential of these are promising, solving the sustainability puzzle continues to be a challenge. “Trying to figure out creative ways to pay for and reward collaborations with our medical community is our greatest challenge,” she explained. The program is also working to leverage the practice management training its residents receive to help drive quality and cost improvements throughout the local medical community. Because New Hanover graduates enter practice as highly-skilled with health information technology like EHRs and are knowledgeable with approaches like disease registries, population management, value-based payment and accountable care, New Hanover alumni have already begun to help drive change in their practices, both locally and across the state. In the Wilmington region, this is helping local primary care practices transform. “Our residents receive a fantastic education, are clinically wellprepared, possess great practice management knowledge, and are comfortable with the changes taking place in care delivery. These are exciting times for our graduates and the program.”      

Looking to the Future New Hanover’s first residents graduated in 2000. Since then, the program has graduated a total of 58 family physicians. With an eye towards the future, the

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