Answering the Call
A Physicianâ€™s Guide to Disaster Medicine Simple Ideas to Maximize Profits Seeking Positive Change in Trenton New Rule Prohibits Collecting Rent from Labs
Editorial and Executive Staffs
Executive Editor Robert W. Bowen Managing Editor Bonnie Smolen
Contributors Laurie A. Clark Michael S. Lewis Deborah R. Mathis Executive Officers President President-elect Vice President Treasurer Secretary Immediate Past President NJAOPS Staff Executive Director Business Manager Director, Exhibit Services Director, Medical Education Director, Marketing & Communications Office Manager
Timothy L. Hoover Mark E. Manigan
Lee Ann Van Houten-Sauter, DO Antonios Tsompanidis, DO Karen Kowalenko, DO John LaRatta, DO Todd Schachter, DO Alan Carr, DO Robert W. Bowen Alice Alexander Kristen Bowen Lila Cleaver Bonnie Smolen Diana Lennon
The Journal is the official magazine of the New Jersey Association of Osteopathic Physicians and Surgeons (NJAOPS). NJAOPS is the sixth largest state affiliate of the American Osteopathic Association. NJAOPS represents the interests of more than 3,600 active osteopathic physicians, residents, interns and medical students. Founded in 1901, NJAOPS is one of the most active medical associations in New Jersey with 12 county societies. Opinions expressed in The Journal are those of authors or speakers and do not necessarily reflect viewpoints or official policy of NJAOPS or the institutions with which the authors are affiliated, unless expressly noted. NJAOPS/The Journal is not responsible for any statements made by any contributor. Although all advertising is expected to conform to ethical medical standards, acceptance does not imply endorsement by this publication. The appearance of advertising in The Journal is not an NJAOPS guarantee or endorsement of product or service, or the claims made for the product or service by the advertiser. When NJAOPS has endorsed a product or program it will be expressly noted. All advertising contracts, insertion orders, inquiries, correspondence, and editorial copy should be mailed to: The Journal (attention: Executive Editor), NJAOPS, One Distribution Way, Suite 201, Monmouth Junction, NJ 08852-3001. Telephone: 732-940-9000. The Journal editorial staff reserves the right to edit all articles and letters to the editor on the basis of content or length. The Journal (ISSN 0892-0249) is published quarterly (January, April, July, and October) from the executive and editorial offices at NJAOPS headquarters in Monmouth Junction, New Jersey. Periodical postage paid at Princeton, New Jersey, and additional mailing offices. POSTMASTER, please send address changes to The Journal of the New Jersey Association of Osteopathic Physicians and Surgeons, One Distribution Way, Suite 201, Monmouth Junction, NJ 08852-3001. Subscription to The Journal is included in NJAOPS membership dues. Non-member subscription is $25. Designed and printed in the USA by Mastergraphx, Monmouth Junction, New Jersey. The Journal is printed on environmentally friendly paper. By using products with the FSC label you are supporting the growth of responsible forest management worldwide.
THE JOURNAL | fall 2010
TABLE OF CONTENTS President’s Message. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 NJAOPS President Lee Ann Van Houten-Sauter, DO, encourages members to take advantage of the numerous opportunities for growth offered at county district society meetings.
From the Executive Director. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 NJAOPS Executive Director Robert Bowen recognizes NJAOPS members who give their time and knowledge outside the association at both the state and national levels.
Capital Views. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Government Affairs and Legislative Counsel Laurie Clark details the action taken in Trenton on several bills this quarter, including new PIP regulations and a CME bill vetoed by the governor.
Answering the Call. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 The best of intentions are not enough when it comes to providing aid in developing countries and during times of natural or manmade disasters. Travel medicine specialist Michael Barnish, DO, explains what physicians need to know before jumping on a plane to “answer the call.” Plus, vascular disease specialist Bruce Mintz, DO, recounts his experience in Haiti after the devastating earthquake in January left hundreds of thousands in need of medical assistance.
Managing Liability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 In the age if international travel, NJAOPS’ medical liability insurance expert Timothy Hoover explains the liability risks of a shrinking globe.
Legal Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Health law specialist Mark Manigan discusses the new regulation that puts strict limitations on clinical laboratories that operate collection stations inside practices.
The Professional Practice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Medical management experts Deborah R. Mathis, CPA, CHBC, and Michael S. Lewis, MBA, FACMPE, take a look at some new alternatives for generating practice revenue and reducing expenses to maintain – and even improve – your profitability.
Member News. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 NJAOPS recognizes the latest achievements of our members.
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April 6–9, 2011 • Bally’s Atlantic City AROC Information: 732-940-9000 AROC Registration Fax: 732-940-8899 Bally’s Group Reservations Desk: 800-345-7253 Monday–Friday, 9:00 a.m.–5:00 p.m. (Group Code “GBAR11”)
Convention Registration Online registration and hotel reservations are available at www.njosteo.com/aroc. Please print clearly if you complete and fax this form. AOA#:
Year of Graduation:
Office Information (Required for badge bar code)
Preferred Contact Information (If different from office)
Street Address: City, State, ZIP:
City, State, ZIP:
Office Web Site: Badges are required by registrants and accompanying guests (including children of any age) for exhibit hall entry. First and Last Names of Guests (i.e., spouse, children, etc. @ $35 each):
Registration Type (Check one)
Postmarked by January 31 March 21
Membership in state associations is verified prior to AROC.
DO or MD Active/Associate Member in respective state society (state: ) DO Retired Member DO Life Member APN Physician Assistant DO Intern Member* Resident Member* Student Member* (*Reception/gala not incl.) DO Applying for Active Membership in New Jersey Non-member DO or MD
After March 21 or Onsite
Note: NJAOPS dues must be paid by March 31, 2011.
Additional Function Tickets NJAOPS 110th Anniversary Reception & Gala (One reception/gala ticket is included in a full registration) Yes! I plan to attend the gala. No. I am unable to attend. Total number attending: Number of additional tickets:
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Cancellation Policy: Requests for cancellation refunds must be postmarked by March 2, 2011, otherwise an AROC 2012 credit will be issued. Mail or fax completed registration to: AROC • One Distribution Way • Suite 201 • Monmouth Junction, NJ 08852 • (FAX) 732-940-8899 9/2/10
Finding Knowledge, Friendship and a Voice Lee Ann Van Houten-Sauter, DO
ny association is only as strong its membership and NJAOPS is no different. The roots of the association start at the county level and extend to the headquarters where NJAOPS offers a variety of ways for you to stay knowledgeable about your chosen profession.
and keep informed about developing trends in the medical problems facing your community. There is a camaraderie one experiences when you become a regular attendee of these meetings that you just don’t experience elsewhere.
The Journal, for one, helps keep you up to date on various political and business hot topics. Then there’s the NJAOPS Update, which highlights current issues and upcoming events. There is also much to explore on our continually evolving Web site, including our physician resources page, information about member benefits and our new blogs, the New Physicians in Practice Forum and my own President’s Forum. Have you read my weekly blog yet? I want to hear from you so check it out!
Ten years ago, county meetings were attended by both primary care physicians and specialists. The meetings were a way for the specialist to put a face to the name of the referring family doctor and also for the family doctor to meet new specialists to whom they could send their patients. Today, very few specialists attend county meetings and this loss has been noticed by the primary care doctors. A resurgence in attendance would benefit specialists and primary care doctors alike. To help further this cause, we are now offering specialty credit at some of the CME dinners. Check your invitations and the Web site for information on which meetings offer specialty credit.
One of the places that I learn the most is at my county district society meeting. NJAOPS district societies were started more than 50 years ago to allow the small town doctors to have a voice at the state level. For 20 years, I have been involved with the Tri-County Association, comprising Salem, Cumberland and Gloucester counties. I attended as a student and always felt welcome to share my student experiences and listen to the “seasoned” doctors’ stories of “how we used to do it.” Each month our Director of Medical Education Lila Cleaver works tirelessly to find useful and medically relevant topics for the county meetings. These topics include information on the newest medications, the evaluation of the compromised driver, medical nutrition for the Alzheimer’s patient, radiology and its role in diagnosing coronary artery disease and much more. As you can see, the topics are fresh and new and not the same old thing. The county meetings also allow you to meet the physicians that are practicing in your region and make important business connections. Networking with your fellow physicians allows you to garner new ideas about the business aspects of your practice
Specialty Credits Now Offered
Another benefit of attending county meetings is learning about the association and our role in serving you. We discuss member benefits, such as purchasing power for vaccines or better rates on professional liability insurance through the Woodland Group. Did you know that through NJAOPS you could get better rates on your mortgage, homeowners or auto insurance? Visit www.njosteo.com under member benefits for a full listing of potential options. During our meetings, we discuss the current issues in Trenton being pursued by our political lobbyist Laurie Clark, who is fighting to maintain our current practice rights. NJAOPS stays in tune with all the issues and advocates for our physician practice abilities. We learn about Board of Medical Examiners news through Kathryn Lambert, DO, who updates us on issues such as the medical marijuana legalization or the prescribing of Schedule II medications. Our members are given updates on UMDNJ-SOM and the programs offered to both the community
and students at the Stratford campus under the leadership of Thomas Cavalieri, DO. NJAOPS supports UMDNJ-SOM and is working hard to get students, interns and residents involved at our county level. A fall multi-county event is planned to be held at SOM to allow students and local physicians to interact and join in an evening of education.
The Path to Leadership Finally, the county monthly meeting is where the association grows new leaders of the profession. If you are interested in beginning a path toward a leadership role in the association, the place to start is at the monthly county meeting. That’s where you can find out about serving your county as a representative to the House of Delegates. The House of Delegates is the voting body that creates policies and nominates and elects the NJAOPS Board of Directors. Delegates lend their individual voices to guide the association and bring issues from the different parts of the state to one table. We all recognize that involvement takes time and can sometimes seem to be a chore. So when does participation become less of a chore and more of a benefit? It’s when you care about the future of your career and your profession. It’s when you want to maintain the uniqueness of the profession for future osteopathic physicians. All these reasons and the reasons stated in this column show the benefits of attending county district educational meetings. Whether you are a student or physician practicing 50 years, a primary care doctor or a specialty physician, becoming involved at the county level will give you knowledge, friendship and a voice to be heard. Come to your district society meeting and participate. See our Web site calendar or NJAOPS Update for a meeting near you! ■ Lee Ann Van Houten-Sauter, DO, is 2010– 2011 president of NJAOPS. She is a family physician practicing in Williamstown.
THE JOURNAL | fall 2010
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FROM THE EXECUTIVE DIRECTOR
NJAOPS Recognizes Physician Leaders Robert W. Bowen
ou’re invited to join us for a full schedule of county dinners this fall as we kick off the 2010–2011 CME Dinner Series. With some 75 programs planned throughout the state, there will be a wide variety of topics, speakers, locations and dates to meet every schedule and interest. We’re also introducing weekend CME programs this year with a 10-hour cardiovascular conference for primary care physicians. The third in our “physicians and their families” initiative, the conference will be held at Great Wolf Lodge in the Poconos November 5–6 during the New Jersey teachers conference long weekend. Whether you’re a regular attendee or have never participated, every program is open to all our members and we hope you will attend at least one and hopefully more.
The complete events calendar is available online at www.njosteo.com/calendar. At the beginning of the year, I reported on attending the AOA Advocacy Summit with then President-Elect Lee Ann Van HoutenSauter, DO, and included one presenter’s attention getter: “If you’re not at the table, you’re probably on the menu.” That was a humorous but pointed way of highlighting the essential need of physicians to be engaged in setting health care policy on every level—practice, hospital, county, state, profession and federal. We often refer to the activities of the NJAOPS board or committees but don’t mention the numerous physicians who are serving in other capacities as often as they deserve to be mentioned. Even as we invite our members to expand their vision to consider accepting greater responsibilities, we’d like to
acknowledge those who are offering that leadership at all levels. We’ll be adding the names of those serving to our Web site and also listing additional opportunities to serve this fall. If we missed you, or if you have a specialty college appointment, please allow us to include you in the future by emailing your information to firstname.lastname@example.org.
State of New Jersey Department of Banking and Insurance ■■
Department of Children and Families ■■
Martin Finkel, DO, Task Force on Child Abuse and Neglect
Department of Health and Senior Services ■■ ■■
Specializing in Medical Malpractice Insurance
Albert Talone, DO, Medical Care Availability Task Force
Thomas Cavalieri, DO, New Jersey Commission on Aging William Felegi, DO, State Advisory Council for Basic and Intermediate Life Support Services Training Linda Jones–Hicks, DO, Director, Maternal, Child and Community Health Services Ronald Librizzi, DO, Mandated Health Benefits Advisory Commission Stephen Vetrano, DO, State Advisory Council for Basic and Intermediate Life Support Services Training
Department of Human Services ■■ ■■ ■■
David Condoluci, DO, Drug Utilization Review Board Calixto Garcia, DO, Advisory Council on Traumatic Brain Injury Howard Weinberg, DO, Catastrophic Illness in Children Relief Fund Commission
Department of Law and Public Safety ■■ ■■ ■■ ■■
Louis Conte, DO, Audiology and SpeechLanguage Pathology Advisory Committee Kathryn Lambert, DO, State Board of Medical Examiners Roger Rossi, DO, Acupuncture Examining Board George Scott, DO, State Board of Medical Examiners
NJ Commission on Higher Education The Commons at Brewster • 630 S. Brewster Road, Suite B3 • Vineland, NJ 08361 Toll Free: 866.304.9909 Phone: 856.692.7702 Fax: 856.691.0059 Email: info@PLIGofSJ.com www.PLIGofSJ.com Also providing Business Owners, Group Health and Workers Compensation coverages
Susan Volpicella-Levy, DO, Advisory Graduate Medical Education Council of New Jersey
continued on page 24
THE JOURNAL | fall 2010
Seeking Positive Change in Trenton Laurie A. Clark
n late June, Governor Christie’s first budget for the state fiscal year 2011 was passed by the Legislature and signed into law. In total, the final budget appropriated $29.4 billion in state funds. Massive cuts included in the budget reflect $848 million in reductions to senior citizen and disabled property tax rebates, $175 million in cuts to higher education including UMDNJ and GME funding as well as a $45 million cut in hospital charity care and a new $300,000 cap on the ambulatory surgery center tax. Soon after the dust settled on the budget, several regulatory adoptions were published despite a groundswell of physician opposition. We will continue to utilize all channels available to us to seek positive changes to these new regulations.
New PIP Regulation Adopted Despite our vociferous objections, a proposal submitted last year by the New Jersey Department of Banking and Insurance (DOBI) was recently adopted with an effective date of July 6, 2010. This regulation provides automobile insurers with the ability to waive PIP co-payments and deductibles when physicians in Organized Delivery Systems (ODS) under contract with the automobile insurer perform treatment. In addition, the regulation stipulates a 30% out-of-network copayment penalty for treatment provided by ambulatory surgery centers. Our organization was in the forefront of advocating in opposition to this regulation. We will now refocus our efforts on seeking potential legal and legislative remedies to correct this egregious situation. A meeting with DOBI officials will take place in the near future as well as meetings with key legislators. We will keep you updated. The new regulation has an expiration date of June 11, 2011 and members can view its full text at www.njosteo.com/journal.
DHSS Adopts New Lab Rules On July 19, the Department of Health and Senior Services published
notification of regulatory adoption prohibiting clinical laboratories from paying rent, sharing employees and providing other goods or services to physicians as an inducement to do business with the laboratory. (See Legal Perspectives on page 20 for full details of the new rule.) NJAOPS disagrees with the manner in which this proposal was adopted and gave testimony in strong opposition at a public hearing last year. We are exploring options to ameliorate these regulations. For reference, the new rule is NJAC 8:44-2.14 and has an expiration date of January 9, 2012.
CME Bill Vetoed Governor Christie conditionally vetoed a bill that would have allowed physicians to earn CME credit by volunteering medical services. The bill (S-515), which was sponsored by Sen. Loretta Weinberg (D- Bergen) and passed both houses in June, required the state Board of Medical Examiners to offset up to 10 CME credits biennially at a rate of half a credit for each hour of volunteer medical service rendered. The bill also applied to veterinarians who provide volunteer veterinary services. The governor’s recommendations in the conditional veto message gave the medical and veterinary licensing boards the discretion to determine an appropriate level of required continuing education and the authority to allow volunteer services to offset up to 10% of the continuing education requirement. The bill defines volunteer medical services as “medical care provided without charge to low-income patients for health care services for which the patient is not covered by any public or private third-party payer, in accordance with such standards, procedures, requirements and limitations as are established by the board.” The bill also requires the state boards of Medical Examiners and Veterinary
Medical Examiners to establish specific courses or topics that are to be required for continuing education and designate core requirements for continuing medical and veterinary education, including the number of required hours, subject matter and content of courses. The establishment of these requirements will be achieved through the regulatory process. The state Senate approved the governor’s recommendation on August 23. The bill now heads to the New Jersey General Assembly for concurrence with the governor’s recommendation.
Governor Signs Jaden’s Law Legislation sponsored by Sens. Loretta Weinberg (D-Bergen) and Teresa Ruiz (D-Essex) to promote bone marrow and blood stem cell donation awareness was also signed into law by Governor Christie. The law (PL 2010 Ch. 61) will require DHSS to create an online brochure about bone marrow and blood stem cell donations, based on information from the National Marrow Donor Program. Physicians are encouraged to give the brochure, which will be posted on the department Web site, to patients to provide information about becoming a donor and to answer common questions about marrow and stem cell donations. The legislation will also require the state health commissioner, within the limits of available resources, to promote awareness among physicians and the public about their option to become a bone marrow or peripheral blood stem cell donor. The law is named after Jaden Hilton, a 3-year-old Camden County boy who died of leukemia in 2007 after a suitable bone marrow match could not be located. It takes effect 90 days following enactment. ■ Laurie A. Clark is NJAOPS’ government affairs and legislative counsel. She is also president of LegisServe.
THE JOURNAL | fall 2010
Photo: iStockphoto/M&H Sheppard
Answering the Call
A Physician’s Guide to Disaster Medicine Michael A. Barnish, DO, FACOI
looding in Pakistan. Earthquake in Haiti. Tsunami in the Indian Ocean. Millions of people left in the most dire of circumstances. At any given time, somewhere in the world, someone is in need of aid after catastrophic natural disaster strikes. Physicians and other health care professionals have been answering the call to provide assistance and expertise to developing countries that have experienced natural disasters for a great many decades. The usually voluntary pro bono care provided by these health care professionals is indispensable to the beleaguered regions of the world that lack the infrastructure and resources to recover from tragedy. One of the more recent disasters — the January 12 earthquake in Haiti — is a clear example of an existing resource-poor country hit with a catastrophic event that left the region with no visible means of recovery without the assistance of foreign
THE JOURNAL | fall 2010
intervention. More than eight months after the event, the country still finds itself with little ability to secure the welfare of its citizens without outside help. Medical care providers have responded to this crisis and others in overwhelming numbers, but the question that must be asked is how much help have these workers actually provided with respect to short- and long-term impact, and are there circumstances in which they may have actually hindered relief efforts or, worse yet, put themselves at risk in an attempt to render care? Physicians and other health care professionals infrequently receive any formal training in the area of international disaster relief. While it is in our nature to want to provide expertise and compassion to those in need, we often find ourselves ill-prepared to take on such challenges.
In this article, I’ll address the issues surrounding providing overseas medical assistance following natural disasters, including the description of available formal programs that teach competent and professional emergency preparedness training, utilization of triaging skills, selfsufficiency and psychological safeguards. In this way, those of us who wish to answer this calling can do so in the most productive manner possible.
Understand the Lay of the Land
Many volunteers from the United States have limited comprehension of the varied and novel characteristics of a developing country that define its existence. This lack of insight can present a formidable barrier in our efforts to bring a developing region back to its feet in the midst of a calamity. Our experiences in foreign countries are often restricted to the secure confines of a resort area, far removed from the realities
of a local populace with unique cultural beliefs as well as limited creature comforts in their everyday life. These circumstances are usually far removed from our own societal experiences. It is essential that we recognize and respect the differences in our cultures. Even in times of despair following a natural disaster, we cannot lose sight of the pride and social mores practiced by a local community. We must remember to conduct ourselves as the guests we are, even as we take on the role of aid-provider. Many relief workers are astounded by what they encounter concerning the living conditions of people in resource-poor countries. Poverty often drives people to live in unsafe locales out of necessity or desperation. These areas can include geologically unstable hillsides, flash flood zones or low-lying tidal basins. The Natural Hazards Research Group noted that “the world’s population pressure and hunger for land are forcing more and more people to inhabit the earth’s hazardous zones.”1 Asia is most prone to disasters, averaging fifteen major disasters per year, followed by Latin America and Africa with ten each and Europe and Australia with one. Natural disasters include floods, cyclones and hurricanes, droughts and famine, earthquakes, tsunamis and volcano eruptions. The United States suffers tornadoes, hurricanes and wildfires, but these are not considered major disasters by virtue of the number of lives lost. The United States and
had 31 events involving 91,000 deaths, Nicaragua with 106,000 deaths following 17 events and Bangladesh with 63 events leading to 633,000 deaths.2 There is a general absence of safety regulations concerning building or zoning codes in developing countries, and what few may exist are subject to financial shortcomings, lack of enforcement measures or corruption. These conditions contribute to greater casualties from natural disasters. For instance, deforestation of vulnerable mountainsides can lead to mud slides or poorly constructed buildings can collapse in earthquakes and hurricanes.
The temptation to “practice” on third world patients or perform procedures above the capability level of a training physician is ethically problematic and has led to adverse public relations regarding American health care personnel
Do what you can do well and leave the rest to others— you cannot be all things to all people. Know Your Role
Unsafe conditions often persist well after the occurrence of a natural disaster. If we as medical responders do not recognize these dangerous conditions, we put ourselves at risk of injury and even death. This is certainly not what victimized locals need in addition to their own plight. Few of us are qualified to be first responders so we must leave the rescue and recovery efforts to others and devote our efforts to providing medical relief to survivors. Immediate problems confronting disaster victims, particularly following earthquakes, include crush injuries, wound infections and dehydration. These are medical conditions best addressed by emergency service personnel first responders. It is not until the recovery phase that infectious disease outbreaks, manifestations of unaddressed chronic diseases and malnutrition become active problems.
Volunteer relief can have profound benefits to the targeted population served. There are many wellD known examples M n, Ted Kuh urtesy of of this. Surgeons in Photo co s n o edicati m d who repair cleft n a re sic ca rovide ba palates or separate p to n o p lied u re n e conjoined twins ft o ers are sion work the world. is or optometrists performing the m l a ic d Me areas of r o simple act of providing eyeglasses to the o p e resourc visually impaired all bring much needed other resourcehelp to underserved populations. rich countries are able to prepare for natural disasters before they However, well-intentioned physicians or strike and respond accordingly post-disaster, surgeons need no formal qualifications, keeping the death toll comparatively low. board certification or CME requirement For example, over a recent 21-year period to hop on a plane, fly to a remote Japan suffered 43 events, which resulted in impoverished destination and volunteer 2,700 deaths. Compare these numbers with their services for the satisfaction of helping Peru, which over the same 21-year period
human kind. The number of physicians who do just that is troubling. In 2006, 27% of U.S. medical students participated in international health electives, but only 30% of them received any specific training beforehand.3 Perhaps of greater concern, 90% of surgical residents in one study were interested in working overseas in order to acquire new skills.4
volunteering in developing countries. The reality of this concern, however, is probably tempered by the fact that, in some instances, students and residents may be pressured into performing procedures and treatments by local community authorities, often with no supervision.3 Furthermore, coming into a situation with no game plan whatsoever can have a deleterious effect. In “Duffle Bag Medicine,” an opinion piece in the Journal of the American Medical Association, Maya Roberts illustrates the damaging impact well-intentioned intrusions can play on a resource-poor community. The article, among many observations, cites the potential for ignoring the knowledge or usurping the authority of local health care practitioners, creating constipation in children taking free vitamins as if they were candy and failing to provide long-term remedies to chronic medical conditions.5 Roberts recommends a number of points that can make volunteer work productive and rewarding. These include: ■■
the provision of long-term benefits in the form of health maintenance and preventive care through education — rather than short-term fixes with vitamins and blood pressure samples; working with local health care professionals to better understand how culturally sensitive interventions can lead to more effective care; and observing daily household activities to see how public health measures can be efficiently instituted.
Successful excursions are usually the ones involving established programs in regions and countries with long-term needs. These organizations will typically provide specific services to a targeted population, and are well-versed in the bureaucracies, entrenched obstacles and cultural idiosyncrasies encountered. These programs are typically run by church organizations, charities and academic institutions. (For a listing of aid agencies,
THE JOURNAL | fall 2010
visit the Practice Resources Page at www.njosteo.com/practice) But even among well-organized sponsors, unpredictability is a way of life in developing countries. Transportation breaks down, strikes and protests disrupt standard services and supply shortages are routine. Flexibility, resourcefulness and adaptation are essential qualities to effective aid programs. Medical mission workers need to know that their trip will be based less on what they want to do and more on what is needed to be done. That said, however, volunteers need to recognize that tasks should be within one’s scope of training or ability. Do what you can do well and leave the rest to others—you cannot be all things to all people.
Get Training Before You Go
Relief workers are a help to no one if they get ill or injured overseas and cannot take care of themselves. When going into a disaster zone, safety comes before rescue efforts. Special training beyond basic and advanced cardiac life support is available in select medical schools in the United States and abroad. One such program is found at the Office of Disaster Medicine in the Center of Operational Medicine, part of the Department of Emergency Medicine at the Medical College of Georgia in Augusta.6
The Office of Disaster Medicine oversees a Disaster Medical Assistance Team that trains medical personnel for disaster relief missions. (For other programs, see Disaster Medicine Programs on page 12.) Health care professionals in these types of programs get field training that is invaluable. They Training prog ra are taught to be aid mission. ms will help you prepare Here, a wom fo Photo courte aware of common an demonstra r the varied situations yo sy of Ted Ku hn, tes how to br u safety hazards ing supplies sa might encounter while on MD fe an ly across a body typically found in of water. disaster situations, such as electrocution risks in standing water, how to recognize Another good source a damaged structure, whether power lines of information is the journal Disaster are safe, how to handle animals, what to Medicine and Public Health Preparedness, be aware of among debris piles and what which is published by the American to do in case of fire. They acquire special Medical Association.7 training regarding common infectious diseases found in the recovery phase. Don’t Be a Liability Outdoor skills are taught as well, including When volunteering for such a mission, the safe use of water-crossing rope lines it is critical that you know beforehand to transport supplies in flash flood zones, where you are going, where you are mock clinic setup, the handling of material staying, who is picking you up and resources and crowd control. The safety of what you will be doing there. Contacts the team is high priority, and leaders are and means of communication at home highly experienced. and in the destination country must be
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completely established before departure, with contingency plans in place in case of emergencies. Built-in redundancies in planning should be standard operation. Resources are scarce following natural disasters in developing countries. As a result, medical relief personnel must be entirely self-sufficient and cannot be a burden on those who are being helped. Local resources are typically depleted or severely stretched, so aid workers must not depend on them.
s icine Program Disaster Med National Disaster Life
the In addition to four formal tion, there are da un e country Support Fo in llowships th fe e in ic ed m disaster n: ard certificatio that lead to bo de Island University/Rho ■■ Brown of Emergency t en tm ar Hospital, Dep s Gathering aster and Mas Medicine: Dis ip arch Fellowsh Medicine Rese ity, rs ve ni U n to Washing ■■ George ncy Medicine: ent of Emerge tm ar ep D ine Fellowship Disaster Medic ic Health and Center of Publ ■■ UCLA ic Health aster and Publ Disasters: Dis Fellowship uthwestern, ity of Texas So ■■ Univers Medicine: y nc erge Division of Em ine ergency Medic Government Em ) es (GEMSS Security Servic ice for links steo.com/pract Visit www.njo Disaster ms and other to these progra urces. Medicine reso In general, one should bring as a minimum a five-day supply of food, water and supplies for self-support. Personal effects to bring include: ■■ ■■ ■■ ■■ ■■ ■■ ■■
soap and water cleaner; insect repellent and bed net; loperamide and antibiotic; oral rehydration salts; extra eyeglasses and/or contact lenses; water purification measures; and an emergency contact list.
Vaccinations to get ahead of time include:
Refugee camps can be breeding grounds for infectious diseases because of overcrowding, poor sanitation, inadequate water supply and food shortages. Diarrheal illnesses are generally followed by respiratory illnesses and measles. Lack of clean water can lead to diseases such as salmonellosis, shigellosis, Hepatitis A, cryptosporidiosis and cholera. Outbreaks of malaria and dengue fever can occur as well. The Centers for Disease Control and Prevention Web page on guidance for relief workers and others traveling to Haiti for the earthquake response provides an excellent overview on what preparations should be made, and the site is updated frequently.8 Mental health issues comprise a significant though underemphasized problem in disaster zones. These issues can be broken down into three categories. The first involves underlying disorders among the local population, including schizophrenia, autism, mood and anxiety disorders. Very often these victims suffer loss of access to care, medications and caregivers. The second is the profound sadness and grief experienced by the general population at large. The third group involves first responders themselves. Recognition of vulnerability to the emotions of profound sadness, grief and anger in this group is critical in order to preserve the effective function of the relief worker organization. Not everyone can “tolerate” the stress of a major disaster and as a result, every member of a team must be looked after. Early counseling lessens the possibility of long-term psychiatric problems in the “rescuers.” There are many warning signs of a problematic psychological reaction to a disaster. A responder may insist on remaining at a rescue scene until the work is finished. One may try to override stress and fatigue with dedication and commitment and deny the need for rest and recovery time. Managing stress becomes vital to ensuring your psychological stability. Some suggestions include: ■■
■■ ■■ ■■ ■■ ■■ ■■ ■■
updated measles/mumps/rubella; diphtheria/tetanus; seasonal and H1N1 influenza; varicella; Hepatitis A and B; typhoid; and rabies (not always necessary, but a sound precautionary measure).
■■ ■■ ■■ ■■
What to Expect on the Ground
Large scale infectious disease epidemics are not a problem immediately following major disasters, but outbreaks usually occur in the recovery phase.
limiting on-duty work time to no more than 12 hours per day; rotating work assignments between high stress and lower stress functions; drinking plenty of water and eating healthy snacks and energy foods; taking frequent, brief breaks from the scene when one is able; keeping an object of comfort in one’s possession, such as a family photo, favorite music or religious material; staying in touch with family and friends; and pairing up with another responder so that you can monitor each other’s stress.
Make “Order” Out of Chaos
Medical relief workers will be unable to help anyone if chaos is not reined in. The most experienced in a group should be in charge of triaging. Setting up a perimeter medical camp in the proper fashion is critical for the efficient function of any relief effort. In addition to the physical layout, assignment of roles among the group and distribution of medicines and supplies are tantamount to a productive mission. In most disaster relief efforts, the amount of supplies is rarely the problem. The issue is in organization. Packages and medications frequently are poorly labeled or mislabeled, in multiple languages and placed in no particularly organized location. Perhaps more so than anything else, the ability to quickly organize the camp and its supplies for rapid and efficient use represents the most important component of a relief effort. And once again, expertise is required in this function. As long as there are natural disasters, human nature will allow for the desire to help the victims involved. As physicians, we will usually be at the front of the line to provide our assistance. Being prepared to help beyond our medical expertise alone is not only a rewarding experience, but can provide an invaluable service to those truly in need. ■ Author’s Note: I would like to acknowledge W. “Ted” Kuhn, MD, DTMTH, Professor of Emergency Medicine and Director of the International Medicine Program at the Medical College of Georgia, for his invaluable assistance in the preparation of this manuscript. An infectious disease specialist in private practice in Voorhees, NJ, Michael A. Barnish, DO, FACOI, holds a certificate of travel health through the International Society of Travel Medicine and has a certificate of knowledge sponsored by the American Society for Tropical Medicine and Hygiene. 1. Natural Hazards Research Group, University of Colorado, Boulder. 2. Guha-Sapir D, Hargitt D, Hoyois P, Thirty Years of Natural Disasters 1974 2003: The Numbers. Center for Research on the Epidemiology of Disasters. UCL Presses Universitaires de Louvain. World Health Organization. 2004. Louvain-la- Neuve, Belgium. 3. McCarthy A, International Travel to Give or Receive Health Care. 56th American Society of Tropical Medicine and Hygiene Conference. Nov 2007. Philadelphia, PA. 4. Powell AC, Mueller C, Kingham P, et al, International Experience, Electives, Volunteerism in Surgical Training: A Survey of Resident Interest. J Am Coll Surg 2007; 205:162-168. 5. Roberts M, Duffle Bag Medicine. JAMA 2006; 295:1491-1492. 6. Office of Disaster Medicine. http://www. mcg.edu/ems/COM/Disaster. 7. http://www.dmphp.org 8. http://www.cdc.gov/travel
THE JOURNAL | fall 2010
Putting Skin in the Game Bruce Mintz, DO
ews stories with headlines of human calamity cause us to refocus our priorities. I often hear people speak of giving back, and when I do, I’m offended on some level. To me, being a physician is a gift, and being allowed entry into the most intimate parts of others’ lives is a privilege with its own rewards. When a magnitude 7.0 earthquake struck southern Haiti on Tuesday, January 12, serving there was not a matter of giving back for me. In that moment I felt I belonged there. So that day when my students at Touro asked me what they could do to help, I cautioned them to be prudent and not to get on a plane and go to the center of the storm. I told them perhaps the hardest thing I had to say to any student of the healing arts. I implored them to focus on their skill; to hold onto the emotion and place it in a cherished savings account. After decades of work in developing countries, I had learned that wanting to do good is just not good enough.
My wife tempered the excitement with her concern. Unlike my children, she suffered no illusions, having experienced the wide range of judgment calls I’d made over the years. She was reserved but supportive and understood my need to go. The nightly newscasts were led by stories of aftershocks in Port-au-Prince, which made my reassurances to my parents less than convincing. But it was the continuing escalation of the circumstances in Haiti that made the trip all the more compelling. What I wanted most was to get there and begin. At 11 p.m. Friday, it was confirmed that my name was among the chosen. So many thoughts stirred in my mind. What struck me most was a memory of my physician father accompanying a child with a terminal illness back to Puerto Rico on a small plane to die in his native town. My pride in that deed fueled many sleepless nights during medical school and residency. Saturday morning my wife and daughter drove me to the airport. We were told to
I found myself wedged between rescue dogs and expatriate Haitian doctors and nurses. I, however, felt I needed to be in Haiti. By Thursday I received an email from the Association of Haitian Physicians Abroad, headquartered in Brooklyn. A review of my credentials had yielded a standby opportunity for a flight Saturday morning. They instructed me to bring enough food and water for a week and be at Kennedy Airport at 6 a.m. Saturday. My status would be confirmed by 9 o’clock Friday night. I’ve planned medical trips to emerging countries before, so I was skeptical at best about the short notice and minimal instructions, and my wife was less than enthusiastic. Thursday night ended with a flurry of calls and detailed lists of personal and medical needs for the trip. I called the administrator of another local hospital and was warmed by his immediate and generous commitment of supplies for wound care, my specialty. The next morning I brought four large suitcases to the hospital, which were soon packed full of wound supplies. My wife went to the store and purchased 150 protein bars, four jars of peanut butter and a mosquito net. Our daughter Emma went to Costco, and obtained two pallets of water. I began to feel the details falling into place. A father of five, I spoke to each of my children individually, and they were equally enthusiastic about my decision.
THE JOURNAL | fall 2010
find our flight facilitators, the men with the yellow jackets, for further instructions. As we made our way, we noticed the subscript on those jackets read “The Church of Scientology.” My wife looked at me with a mix of anxiety and disbelief, gave me a kiss and said, “See you in a week.” Along with our facilitators and a variety of medical professionals, our eclectic group included members of the Jersey City and Bedford Stuyvesant Fire and Rescue squads. I found myself wedged between rescue dogs and expatriate Haitian doctors and nurses. As we took our seats on the plane, the person next to me for the flight was a 280-pound young man with “BED-STUY” shaved into his hair. Across the aisle from him was his German shepherd, who, incidentally, got a whole row to himself. I was part of a surreal menagerie. I once read somewhere that the more bizarre the experience the better the story. This may be true, but that presupposes a good outcome, of which, at this point, I was unsure. Our flight was delayed, and our in-flight experience was punctuated by rumors and misinformation—something I’d become accustomed to over the next week. In the air, the pilot informed us there was a chance we would miss our “three-minute window” for landing. We had been granted
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special permission to land within a given timeframe since civilian flights weren’t officially operating at Port-au-Prince International Airport, which was under the control of the U.S. Air Force. Ultimately, we did make our window, although our landing was a rough one. As we bumped along the airstrip, Paul, my new 19-yearold search and rescue buddy, offered me a swab of Vicks Vapor rub for my nose. I accepted it with a puzzled look. “To hide the smell of the bodies,” he explained. All bravado was pierced, and the relief I felt from touching ground gave way to a fresh flood of apprehension. The scene outside the plane was akin to something from Apocalypse Now, with military aircraft and troops of every nationality buzzing around. As civilians, our transport options were limited but our facilitators had made advance arrangements. We loaded our supplies into the back of a large garbage truck and jumped on board. The walls of the truck blocked sight in and out of the vehicle, which seemed to be by design. The people of Haiti were the poorest in the hemisphere even before the nightmare began. Now, just a few days after the first shock, food and water were scarce. The streets were dark and void of police presence. Our facilitators were young but dedicated and seemed to understand the issues on the
ground. I began to view them with a whole new sense of respect. They clearly had skin in the game.
made it to the compound. Given the impact of my surroundings, it seemed irrelevant.
With the high walls of the truck, the ride to our compound was dark; no sights would be seen this night. The sounds around us were stifled by a loud engine and no muffler, while pungent smells burned in our nostrils. The scents were hard to identify, but one could imagine.
Though we were all tired, sleep was fitful at best. Sounds stabbed the air throughout the night. The ground trembled, and the sky was filled with the roar of cargo planes, and the dogs and roosters sang a continuous chorus, telegraphing one another’s positions.
After a few miles’ journey we arrived at the compound. It had been the home of a Scientologist who agreed to allow us to use the grounds as our base camp during the mission. I was relieved to find our group would be surrounded by a tall, secure wall topped with barbed wire. There was a place to shower and a bathroom, which made our accommodations The Ritz from my standpoint. As luck would have it, the weather was lovely and cell service was available. I called my wife to tell her how beautiful the night was. Her response gave me pause. She said it sounded similar to 9/11, where the beauty of the day was in such sharp contrast to the horror of the event.
Morning came, and we began organizing our supplies. We were pleased to find some industrious locals selling Haitian coffee. It was like rocket fuel, and I felt ready to move. A large bus pulled up next to the compound. We boarded and sandwiched our supplies and personal items between our bodies.
No buildings were safe for shelter, so we settled in for the night with our sleeping bags on a concrete slab, forming a human mosaic. My mosquito net had gotten lost with one of my bags, and my water never
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The bus rolled down the winding roads, and for the fist time daylight bore witness to the utter devastation. It was almost impossible to believe, but nothing was left unaffected. The streets were filled with the displaced, and rubble was everywhere. Live electrical wires were commonplace, as were people’s temper flares. The scene was staggering. Our journey to the makeshift hospital took us past the Presidential Palace. Previously, the palace embodied the most regal, even
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opulent, of this otherwise depleted island nation. The debris that remained of the great building epitomized the earthquake’s destruction; bearing witness that nothing had been spared. Though I have always respected their sacrifices, I have never highly regarded the military. I’ve found it hard to identify with their assignments in real-time and viewed their mission as contrary to my own. That changed as I saw the military in action on the ground. The mission of the United States military personnel in Haiti under presidential dominion astounded me from start to finish. Our troops combined extraordinary discipline and talent with youth and desire for good. No request was too large for them, and the security they provided was crucial to the work that would be done. We entered the gates of the hospital and unloaded our equipment. Within minutes, we were at our new posts. Because of my specialty in vascular medicine, I was assigned to a postoperative tent. In those first hours, we became oriented to the environment and imposed structure within chaos. Locating medications and analgesia for the never-ending wounds seemed an overwhelming task. But before long I began to realize something: Though the magnitude and extent of injuries were of
unprecedented proportions, so was the human response to it. As each hour passed, I interacted with more and more colleagues. I was stunned by not only the quantity but quality of the volunteers. There was a steady influx of teams from the United States and all over the world. Many faces I saw were friends from the medical community and others were familiar from national meetings. At one point, I saw a colleague from New Jersey, Jean Paul Bonnet, DO, an osteopathic family physician, walking through the courtyard with a stretcher. Later, a young military physician walked into our tent to assess our progress. In our brief exchange, I asked him where he was from and where he had trained. He laughed and said he was from Missouri but that his medical school would be “unfamiliar to me.” I told him from his description alone I was sure we had the same alma mater — Kirksville. These occurrences clearly corroborated my wife’s’ dictum that you’re “always one osteopath away from any other osteopath in the world.” As the week progressed, the work was constant, and we congregated as a team to develop strategies of care. There were so many injuries sustained by such a
wide cross section of patients. Early on it became clear that process was the key to best care. We worked like many arms of one body, but the needs seemed endless. I was initially put in charge of a postoperative tent of 50 patients, which grew from one tent to two by the end of the first day. Different from so many other experiences, there was no jockeying for position among the physicians or other medical staffers. Our group was led by Bob Norris, MD, the Chief of the Division of Emergency Medicine at Stanford University Medical Center. The rest of us, regardless of credentials, were worker bees. We instituted a practice of SOAP (Subjective, Objective, Assessment, Plan) notes on all of our patients, with each service putting its label on the patient’s chart. We worked with the nurses to begin a rigid process of patient assessment and documentation. For wound care, the times and dates of each debridement were placed on each dressing, and physician rounding mimicked the rounds of the nurse assessors who would precede us with intravenous analgesia. Our routine began to make sense. When a patient needed surgical intervention, we called on teams from Mt. Sinai, Dartmouth, Médecins du Monde (from France) or a host of others from across the United States
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and around the world. The response from each team was quick, and the quality of the intervention rivaled care anywhere. As the days progressed the problems changed. As anticipated, we marshaled the transition from acute trauma to guillotine amputations and more definitive levels of amputation. We began to develop an understanding of who among us had what equipment and what skills. Photos courtesy of Bruce Mintz, DO As the Finnish Red Cross had a skin anything I’d ever seen. unlike was d Dermatome, we found a fertile stream The destruction on the groun of solutions to degloving wounds, but with them, new problems. By the fourth day, we began to see more flies and the color of some of the wounds began to take on a green hue with a sweet smell. This was followed by other infections and maggots feeding on dead tissue. In preparation for the mission I had packed my old hand-held Doppler, which I hadn’t used for years. I was quite proud that not only did I have it, but I remembered how to use it. When word got around camp that I was a vascular specialist, I began receiving requests for requirements to rule out DVT. I pulled out my Doppler with great pride, showing it to the Stanford guys. They responded to my 30-year-old device by pulling out a brand new duplex ultrasound. “Would this be a bit better?” they asked. My ear-to-ear grin answered their question. They had the brand new portable Doppler that I had only recently evaluated at my hospital. So in between my care of patients in the post-op tent, I’d perform emergency venous ultrasounds. I couldn’t believe the level of care we were privileged to offer our patients. As the end of our trip approached, a new sense of anxiety came over me. There was no clear recipient of the baton. When we asked about our transition, we were told the embassy dictated we could leave when we were relieved. Ethically, we understood appropriate stand-ins were needed, but we had already
We left as unceremoniously as we arrived. We had no documentation of our visit. I had no stamp on my passport to mark those days in Port-au-Prince. To the world, I had not been there. I had not seen any of the island. The breadth of my experience was limited to an airport, a concrete slab and a tent city hospital. The stamp was in the tattoo of our time and in the faces of those who had permitted us into their lives to share in their tragedy.
Since childhood, I recall my mother prevailing on me to ask, “What do we take away from any experience? What Buildings were destroyed was learned upon leaving?” and the people built ma keshift tents for shelter There was no moral in Haiti. . Though massive, the tragedy was of no one’s doing. I found myself in uncharted waters. What was clear was this: There is no surrogate for skill and no substitute for action. To be a citizen of this world we must come to grips with the fact that we all have skin in the game. ■
I was relieved to find a group of dedicated people on the ground who devoted themselv es to helping the residents of Haiti. That’s me on the left with a group of other aid workers.
of a post-op I was put in charge , ine dic me lar scu ialty in va doubled. Because of my spec the end of the day that number By s. nt tie pa 50 tent of
strained the charity of our coverage at home. My wife was likely interviewing my replacement. But amid the anxiety, provision arrived in the form of 27 fresh physicians from Rush Presbyterian in Chicago, ready for action. Confident that our patients were secure in the arms of compassionate and competent physicians, we passed the baton.
Bruce Mintz, DO, is board certified in internal medicine and medical peripheral vascular diseases. He is the Medical Director of the School of Vascular Technology at the University of Medicine and Dentistry of New Jersey and is the Director of Anticoagulation Services for Atlantic Health Systems in Morristown, NJ.
We worked quickly to introdu ce process to wound care. The magnitude of the injuries was unprecedented but so was the human response.
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Foreign Medicine is Not Without Local Risk Timothy L. Hoover, CPCU
he shrinking globe is bringing worldwide risk to local medical practices. Whether it’s the practice of medicine outside the U.S., the medical assessment of foreign patients, or consulting with local patients on medicine abroad, physicians need to individually explore their protection for the financial risks that could arise. Depending on your type of practice, your malpractice insurance may cover anywhere from all to none of your legal and financial costs. That’s too wide a risk spread to leave unaddressed.
The Traveling Doctor Most physicians realize that when they travel outside the U.S. to practice, a whole new set of liability rules apply. The question to answer is, am I insured or not for this risk? As a precaution, a call to your insurance advisor should precede every foreign practice excursion. Find out if your malpractice policy covers all of your legal expenses, even those abroad. If you ever need to hire a foreign attorney, will you have to do it out of your own pocket? What about travel costs to address legal actions? I have personally received many calls from clients questioning whether their malpractice coverage applied for travel, accompanying student field trips, teaching conferences, medical research, educational internships, medical transport and providing aid after catastrophic disasters (both in the US and abroad) and providing care in developing countries. The risks are obvious. The legal standards, licensing requirements and judicial systems vary from country to country as well as on the high seas. One could easily breach local laws by falsely assuming that U.S. standards apply universally. They do not. For example, want to be a cruise doctor for a few months a year? Do you know what medical and pharmaceutical licenses apply? With patients potentially from around the world, what courts apply? Are these different on the high seas versus in port? Does your current professional
liability insurance apply, or do you need a special insurance policy? While disaster relief and third world care may not present as many liability problems, care provided in developed countries of the world could be an issue. Take the time to know if your license applies everywhere you practice, as most malpractice policies specifically exclude unlicensed care. No two malpractice policies are alike and variations occur in how each address foreign practice. Each policy will have a provision that defines the policy “territory.” Some are quite broad, applying anywhere in the world as long as the legal action is brought in the U.S. However, some other companies restrict their coverage territory to only one state. Know how your policy defines covered territory before you leave home. Many physicians incorrectly assume that every world citizen would welcome the chance to sue in U.S courts. But that’s not always the case in places like Canada, Europe and other nations with unique or liberal laws. So even when worldwide policy coverage does apply, there can still be a gap for uninsured costs when foreign legal actions are elected. Be sure to evaluate your specific risk to these personal expenses.
Before Your Patient Goes Abroad Risk also occurs for physicians whose practice includes assessing and immunizing patients who travel abroad (travel medicine). The leading causes of travel deaths include trauma and cardiovascular illness. If a patient visits your office for immunizations and you don’t also advise them about cardiovascular disease or their risk from trauma during vehicular accidents, swimming or criminal activity, are you at legal risk if they suffer injury abroad? Perhaps. There is a line of thought that provides that these diagnostic exposures exist as part of travel medicine. As such, the consequences of non-existent facilities, foreign medical malpractice or poor care rendered abroad can be predicted, and therefore liability could be imputed back to the consulting local
travel medicine physician who did not give their patient adequate warning of these increased medical risks. So matching an itinerary with a table of immunizations may not be enough. Be aware of the requirements of a complete travel assessment to avoid potential liability.
Medical Tourism An estimated six million Americans will travel abroad in 2010 for medical care, mostly cosmetic and dental. Patients with high deductible health plans also consider the cost benefits of medical tourism. Local physicians will inevitably find themselves drawn into consultations with these patients on their foreign medical care, thus assuming more of this foreign risk. If you have a patient you are treating for cardiovascular disease, diabetes or arthritis and that patient asks you about surgery abroad, what do you say? Are you prepared to give adequate medical advice? And what happens when that patient returns home to your ongoing care? You may end up inheriting the risks of treating complications that are not fully documented. How do you provide continuing care after a foreign procedure –even a successful one — when you can’t speak to the surgeon? And what advice do you give your patients with inadequate health benefits who choose to fill prescriptions using foreign medications? Don’t ignore these hazards. Failure to address these significant issues can result in malpractice claims. Fortunately most malpractice policies would defend and respond to suits against U.S. physicians arising from travel medicine as well as pre- and post-care related to medical tourism patients, especially those claims that manifest themselves here. But don’t leave it to chance. Any concerns should be discussed and addressed with your insurance company or advisor. ■ Timothy L. Hoover, CPCU, is the Healthcare Practice Leader with the Woodland Group. He can be contacted at tim_hoover@ woodlandgroup.com or 973-300-4216.
THE JOURNAL | fall 2010
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Endorsed by NJAOPS
Rule Prohibits Rent Collection from Labs Mark E. Manigan, Esq.
ew Jersey physicians are now prohibited from collecting rent from clinical laboratories that operate collection stations in the physicians’ offices under a new regulation adopted recently by the Department of Health and Senior Services. Many operators of clinical laboratories set up collection stations in physicians’ offices as a convenience for patients, who then can provide lab specimens without having to leave the doctor’s office. Laboratory specimens are collected at the collection station in the physician’s office and then sent to a central laboratory for analysis. Prior to the adoption of the new rule, the laboratory would pay the physician a rental fee in exchange for operating the collection station. This new rule ends rental payments and drastically alters the parameters by which labs can operate such a station. The rule, which went into effect on July 19, does not allow for grandfathering of existing arrangements between labs and physicians’ offices. Laboratories that entered into long-term leases in an attempt to circumvent the rule will have to stop paying rent and other remuneration or be subject to enforcement action. As a result, immediate compliance is required. According to the DHSS, the rule was in response to reports that collection station rental agreements between labs and physicians exceeded fair market value and influenced patients’ selection of laboratory services. In issuing the ruling, DHSS said that it has “no effective means of assuring that these rental agreements do not exceed fair market value.”1 DHSS said the new rule is intended to ensure that New Jersey’s licensed clinical laboratories operate under the same standards and practices to eliminate any perceived or actual conflict of interest or abuse. Further, DHSS said that the payment of rent or the offer of goods or services by laboratories has unduly influenced the selection of laboratories to operate collection stations in physician offices. The new rule places all laboratories on a level playing field with regard to prohibiting payments or other remuneration
to physicians, which should place the laboratories that provide superior service to patients and physicians at an advantage. In its Notice of Adoption, DHSS advised that the funds currently paid for rent and other goods or services should not be available to enhance customer service for patients.1 Under the new rule, a lab that operates a collection station in a physician’s office is now limited to collecting specimens only from patients of the physician’s office in which the collection station is located, and must comply with the following provisions:
the terms of the space arrangement and delineates the laboratory’s responsibilities for compliance with the proposed rule.”1 On the other hand, the new rule does not prohibit laboratories from operating a patient service center in a building owned by physicians provided that the patient service center is not located in a physician’s office. Also the patient service center must be: ■■
No reimbursement, fees, rent or any type of direct or indirect payment may be made to the physician by the clinical laboratory. Employees of the lab are not permitted to perform services for the physician that are normally the responsibility of the physician’s staff, such as taking patient vital signs or other nursing functions, drawing specimens or performing clerical services. The clinical laboratory and physician’s office may not share employees or independent contractors. Except as necessary for the reporting of test results, the lab may not provide supplies, waste disposal services, test kits for the physician’s use, electronic medical records systems or other goods or services to the physician. The collection station must be licensed by DHSS and the license must be prominently displayed in the collection station area. A copy of the signed lease or agreement between the physician and clinical laboratory for the operation of the collection station must be made available to DHSS upon request.
Although a lab may not pay rent to a physician for space for a collection station, the parties may still have a lease agreement in place and a copy of that agreement must be provided to DHSS upon request. While the rule does not require a written lease agreement, DHSS stated that it shall “encourage laboratories operating collection stations in physician offices to have a written agreement that outlines
Open to and serve the general public, and not restricted to serving one or more specific medical practices; Located in a freestanding building or occupy a space in a public access building; Accessed directly through an exterior building entrance or from a public access foyer or hallway that clearly identifies the name of the laboratory and the days and hours of operation; Not accessible through a physician’s office; Identified to the public by clearly visible signage on the exterior of the building and listed in the building on-site directory and advertisements of the laboratory must list the address and numbers of the patient service center; Self-contained with regard to all aspects of operations including the waiting room, reception area, phlebotomy rooms, restroom facilities and specimen and supply storage areas, except that the patient service center may share a common waiting area that is used by all tenants of a building, provided that two or more tenants renting separate office spaces are not referring physicians or health care providers; and A copy of the signed lease between the lab and physician’s office is made available to DHSS upon request. ■
Mark Manigan is a member of Brach Eichler LLC’s Health Law Practice Group. Brach Eichler LLC serves as NJAOPS’ general counsel. He was assisted in the writing of this article by Lauren Fuhrman, an associate of Brach Eichler LLC’s Health Law Practice Group. They can be reached at 972-228-5700. 1. 42 NJR 1530(a)
THE JOURNAL | fall 2010
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The Professional Practice
Maximize Profits with These Simple Ideas Deborah R. Mathis, CPA, CHBC Michael S. Lewis, MBA, FACMPE
f your practice is experiencing a decrease in revenue and patient volume, you’re not the only one. Physicians facing these challenges fall into two categories. There are those who believe that the odds are stacked against them and have accepted that their practices will be less profitable. Then, there are the physicians who have decided to be proactive and look at new alternatives for generating revenue and reducing expenses to maintain or even improve profitability.
providing echocardiograms or spirometry. Primary care physicians are also joining together to form hospitalist programs to retain revenue that may have been lost by outsourcing. They are offering new enticements to bring in patients, such as cosmetic procedures (including Botox and dermal fillers and laser hair removal); and products (including medicated creams and shampoo).
We are also seeing a rise in the popularity of the concierge or boutique practice. In this business model, physicians receive a Increasing Revenue flat yearly fee per patient and the patient Physicians are looking to expand their gets unlimited access to that doctor. The services as a way to increase revenue physicians who have chosen this route have and bring in additional patients. agreed to limit their panel sizes and in Many physicians provide services that some cases are able to have higher revenue traditionally they would have referred with of life. to a specialist, such as family doctor Our Team - NJAOPS ad:Layout 1 11/12/2009 5:44 PMbetter Pagequality 1
Smart businesspeople will also focus on ways to reduce practice expenses and work more efficiently thereby increasing profits. Some of the largest expenses for most practices are staffing and benefits, building and occupancy, and technology.
Staff costs most likely are the highest percentage cost of net medical revenue, second only to physician compensation. When looking at places to trim staff costs, many practices want to know how many staff members they should have in each job function and whether their salaries/ rates and benefits are competitive. To find these answers, you’ll need to do a staffing analysis. To get started, you need to: ■■
When it comes to the business of healthcare, what makes
Cowan, Gunteski & Co. stand out from the crowd?
Calculate number of full-time equivalent staff by job function (Number of hours divided by 2,080 hours per year) Calculate number of full-time equivalent staff physicians Divide number of employees by number of physicians
After you do your staffing analysis, you will want to look at the following indicators: ■■
The answer is simple:
O ur T eam .
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Salaries and benefits as a percentage of revenue Number of full-time equivalent staff Average total compensation per full time equivalent staff Average salary per full-time equivalent staff
The results of this analysis should be compared to benchmarks from the Medical Group Management Association or other survey publications to see how you compare to your peers. Practices are also being hit with significant increases in health insurance premiums. Consideration should be given to reducing the dollar amount that you pay for an employee’s health coverage. Many practices now only pay for a portion of single health coverage, with the employee paying for their share on a pre-tax basis.
Building and Occupancy
Healthcare Solutions, LLC
The cost of your office space includes more than only rent or mortgage expense. It also continued on page 24
THE JOURNAL | fall 2010
2009 Commissions Earned by Medical Malpractice Insurance Agents and Brokers in New Jersey. $12,419,551
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Ever wonder why your insurance agent hasn’t recommended us? Three reasons why you need to contact NJ PURE: 1. At NJ PURE, we haven’t had a rate increase in over 6 years. 2. NJ PURE is the only insurer in the past 6 years to return profit or pay dividends back to policyholders. 3. NJ PURE does not use agents and brokers. Which means none of your premium dollars are used to pay a middleman. For more information, call 1-877-2NJ-PURE or visit njpure.com. (And don’t expect your agent or broker to mention us anytime soon.) ©2010 New Jersey Physicians United Reciprocal Exchange
MEMBER NEWS Please join us in congratulating the following NJAOPS members on their well-deserved honors and achievements.
the meeting with the NJAOPS delegation including Past AOA President Floyd Krengel, DO, (left) and NJAOPS President Lee Ann Van Houten-Sauter, DO. Dr. Levine is a family physician with offices in Bayonne and Jersey City. Joseph N. Bottalico, DO, has joined the medical staff at Shore Memorial Hospital, Somers Point, with privileges in obstetrics and gynecology. He will practice with Pennsylvania Hospital Maternal-Fetal Medicine in Voorhees Township, Camden County.
NJAOPS Past President Martin S. Levine, DO, was named president-elect of the American Osteopathic Association during its annual business meeting in Chicago. Dr. Levine is pictured above being escorted into
The family practice of Ira P. Monka, DO, has been awarded Patient Centered Medical Home recognition by the NQCA’s Physician Recognition Program. The Patient Centered Medical Home is a model for care provided by physician practices that
seeks to strengthen the physician-patient relationship by replacing episodic care based on illnesses and patient complaints with coordinated care and a long-term healing relationship. Building on principles developed by primary care specialty societies, the program’s nine standards emphasize the use of systematic, patientcentered, coordinated care management processes. There are 10 elements physicians or practices must pass in order to win this recognition. Dr. Monka, a past president of NJAOPS, operates a family practice in Cedar Knolls, NJ. Send your professional achievements to The Journal so we can share them with your colleagues. Email a brief description to email@example.com for inclusion in the next issue.
FROM THE EXECUTIVE DIRECTOR continued from page 6
American Osteopathic Association ■■
Martin S. Levine, DO, President-Elect
Steven Scheinthal, DO, (Vice-Chair) Bureau of Osteopathic Specialists and Program and Trainee Review Committee
AOA Department of Educational Affairs
AOA Department of Business Affairs
Ronald Ayres, DO, (Chair) Bureau of Osteopathic Specialists Thomas Brandeisky, DO, Council on Osteopathic Postdoctoral Training Thomas Cavalieri, DO, Commission on Osteopathic College Accreditation Paul Krueger, DO, Commission on Osteopathic College Accreditation Carl Mogil, DO, Program and Trainee Review Committee
Ira Monka, DO, (2012 OMED Program Chair) Bureau of Conventions Ryan Smith, DO, Bureau of Healthcare Facilities Accreditation
AOA Department of Government Affairs ■■ ■■
Joseph Kuchinski, Jr., DO, Bureau on Federal Health Programs Ira Monka, DO, Bureau of State Government Affairs
William Ranieri, DO, Bureau on International Osteopathic Medical Education and Affairs
AOA Department of Affiliate Relations ■■ ■■
Alvin Dubin, DO, Bureau of Osteopathic Specialty Societies Robert Maurer, DO, Bureau of Osteopathic Specialty Societies
Everyone is challenged by time and other commitments, but these physicians have made serving a priority and we congratulate them and wish them success in their duties. ■ Robert W. Bowen is the executive director of NJAOPS.
The Professional Practice continued from page 22 includes utilities, maintenance and property and casualty insurance. Increases in utilities rates have resulted in increased costs without increased usage. Practices looking for ways to reduce utility consumption are using programmable thermostats to ensure that offices are not being heated or cooled when not in use. They are also making use of standby modes for computer systems. Preventive maintenance is being utilized with medical equipment and office equipment to avoid costly repair bills. Property and casualty insurance policies should be reviewed to ensure that appropriate coverage is in place without including coverage that is not needed. Since rent or mortgage is the major component in this category, physicians
are increasingly looking for ways to use their space more efficiently. Physicians have been reviewing patient flow and maximizing revenue producing space (exam rooms). They are looking for opportunities to sublease space in their offices to other physicians whose practices complement, not compete.
While adoption of EHR and e-prescribing is essential, the real challenge will be the adoption of this new technology while controlling costs. Physicians often complain that the cost of their EHR far exceeded what they expected. Physicians need to make sure that prospective vendors provide a comprehensive picture of costs for any system. Aside from the obvious costs of the software, hardware and licensing, often overlooked costs include staff time for training, file conversion,
interface with practice management systems or clinical equipment, cabling, furniture and more. Practices that understand the potential total costs for installing systems will be better able to budget and plan and find ways to finance their technology changes. Now more than ever physicians need to understand the economics of their practice and think outside the box for ways to increase revenue and maintain or reduce overhead expenses. Don’t let the recession tide pull you under. Navigate your way to a better tomorrow. ■ Deborah R. Mathis, CPA, CHBC, is Shareholder/Director, Healthcare Services Group for Cowan, Gunteski & Co, and Michael S. Lewis, MBA, FACMPE, is Director, Healthcare Services Group for Cowan, Gunteski & Co. They can be reached at (732) 349-6880.
THE JOURNAL | fall 2010
New Jersey Association of Osteopathic Physicians and Surgeons
2011 NJAOPS Awards Nominations The NJAOPS Awards Committee is requesting nominations for 2011 awards. All nominations should be submitted to the Executive Director by November 30, 2010, by fax to 732-940-8899 or online at njosteo.com (click About Us, then Awards). Please include your contact information should the committee need additional information. Physician of the Year
Active in promoting the public health of the community or state through participation in public health programs; Active in supporting high standards of osteopathic education; Active membership in AOA, NJAOPS and his/her county society for at least 10 years; Active in contributing to the advancement of the osteopathic profession in New Jersey; Active in supporting scientific research through the osteopathic profession.
Special Service Award
Recognition of specific outstanding service to the state, community, osteopathic profession or NJAOPS. Note: Honorary awards may be given to non-NJAOPS members.
Recognition of specific outstanding service to the state, community, osteopathic profession or NJAOPS, but not sufficient to require a Special Service Award. Note: Honorary awards may be given to non-NJAOPS members.
Recognition of an NJAOPS’ committee’s efforts above that normally expected.
Each nomination should include award, name and supporting comments or other documentation. Nomination(s)
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