COVID-19 RIPPLES THROUGH ALL ASPECTS OF PERSONAL, PROFESSIONAL LIFE BY PAFP PRESIDENT TRACEY CONTI, MD
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PRESIDENT'S MESSAGE BY TRACEY CONTI, MD
COVID-19 ripples through all aspects of personal, professional life
Family medicine remains strong in the midst of COVID-19 PAFP COVID-19 advocacy timeline The PAFP Family Medicine Recovery Plan 2020-21 FY State Budget Update
14 15 16 17
COVER STORY The COVID-19 pandemic has affected all aspects of family medicine, from work life to home life and everything in between. In her inaugural Keystone Physician column, PAFP President Tracey Conti talks about the unique pressures she has faced practicing in the midst of this global outbreak.
Congrats to PAFP members in 'Top Physicians Under 40' PAFP member in AAFP News: Implementing telemedicine on the fly PAFP wins AAFP membership award New CME webcasts now available
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PRESIDENT'S MESSAGE TRACEY CONTI, MD, President email@example.com
COVID-19 ripples through all aspects of personal, professional life OVID-19 has impacted us all in a variety
in the context of a wave that data suggest has
of ways, from changing the scope of our
still not yet crested. Now there are nearly 1.5
clinical practice to modifying how we live our
million infected and more than 80,000 deaths.
day-to-day lives. As physicians, we all have per-
Our testing and contact-tracing apparatus is
sonal stories that affirm just how quickly cir-
overwhelmed, understaffed, and sub-optimally
cumstances can change, and perhaps for me,
equipped. We are learning more about this virus
nowhere is this more evident than in the first
every day, which makes the scientist in me awe-
few months of my PAFP presidency.
struck and the wife, mom, sister, and daughter in me extremely worried.
On March 6, when I was installed, the current COVID-19 tsunami wave was just a small ripple.
As I contemplated what I wanted to say and
On that day, there were only 319 cases nation-
how best to use my voice in this season of my
wide and 15 reported deaths. And while we all
life and career, I was fueled by the sense of
enjoyed fellowship and perhaps the most awe-
community and family that these last 12 weeks
some make-your-own candy bar event ever, we
have ignited in me. Not that I didn’t value family,
had no idea of the storm that was coming, nor
friends, colleagues, patients, or career before
did I have any idea just how significantly the
the virus, but as is the case for many of us, life-
coronavirus was going to imprint and shape my
altering moments and seasons have a way of
tenure as your president.
shifting our focus and our priorities. My hope is that my story in some way might connect with
Fast-forward a few months and we face relaxed
some aspect of your “now” so that you might
restrictions and multi-colored re-opening charts
be inspired and empowered to know that you
COVID-19 CORONAVIRUS UPDATE
are not alone and that there are hundreds, if
social distancing edicts, I have come to realize
not thousands, of your colleagues who share
many things. Distance-parenting for the better
your fears, fatigue, and focus. Know that you
part of most weekdays, in the midst of a global
are riding this rollercoaster of changing clinical
pandemic no less, has affirmed in me the power
practice, heightened emotions, and managing
of faith and family. This season has also affirmed
your tenuous work-life balance in the company
the significance of the grace, strength, and
of others who understand and can absolutely
presence of my mother in the lives of our chil-
dren. What resonates most is the fact that each of our children is processing this pandemic dif-
ferently and that the foundations that were laid in their younger years are now clearly evident.
Many of you know that I am the mother of seven
Perhaps nothing hit home more profoundly
children, five of whom are currently home: one
than when my daughter (11) was writing out the
in elementary school,
chores for herself and
one in middle school,
her brothers on a dry
two in high school,
erase board, and her
and one home from
only “chore” for my
college. The closure
husband and me was
of school both here
“don’t bring corona
and for my college-
age son has taken a lot of adjustments. It is a daily juggling act on multiple levels. With
Working from home PAFP President Tracey Conti, MD has been recording regular video updates regarding the COVID-19 crisis. Watch www.pafp.com for future messages.
at the helm and a lack of access to our go-to
affectionately known as “Jones Care”) due to shelter-in-place and
has become a more familiar part of my routine, but with the addition of teacher, cyber-
Distance-parenting for the better part of most weekdays, in the midst of a global pandemic no less, has affirmed in me the power of faith and family
expert and IT helpdesk professional all added to my list of mom-job qualifications. This has meant creative solutions
“homeschooling” my children.
between the school day, the workday and worklife balance in general became blurred, but as a family we have adjusted. This new environment of working from home some of the time has been challenging, but it has also provided some respite: though I was working through interruptions, “kid drama” Xbox emergencies and snack-catastrophes, I was home. Now, I find myself navigating a “new normal,” and although being a dance-mom and a soccer-mom produced schedule craziness
In hindsight, it amazes me just how powerful denial can be – knowing the statistics, it never crossed my mind that I could have been one of the 20-30% whose test might have been a false negative.
and end-of-the-day fatigue, COVID-19 seems to have had no problem filling up any voids. I have learned to stress less and to roll with stuff, knowing that because the traditional schedule
first-hand how complex the public health and
no longer exists, the work will get done.
hospital infrastructures are. From the moment that I became alarmed, I began to follow all
AND THEN THIS HAPPENED
the shelter-in-place guidelines. Being a physician that works in both inpatient and outpatient
As we were all becoming used to social distanc-
settings, serving a high-risk population with a
ing, new routines, cyber-socializing, and trying
highly contagious pathogen, my concern for
to strike the right balance between acquiring
my family was immense. And while I waited,
evidence-based clinical data and avoiding infor-
wondered, and worried, sequestered at home
mation and emotional overload, the cough that
in my quarantine-space, my husband and my
I had since January caused me to take notice. I
children would visit me while standing outside
was OK with a nagging cough, but when I devel-
the door of my bedroom. Our testing velocity in
oped a fever – everything changed. That’s right:
the United States, at the time, was likely being
I got sick. While working on the front lines, and
measured in the hundreds – thousands, at best
while living in a house with seven people (one
– however, I was able to get tested within days
of whom is an emergency physician), I got sick.
and received my results relatively quickly.
I quickly realized just how “real” life during a
My testing experience was straight out of a sci-
pandemic can be. Moreover, I experienced
fi movie. The testing site I was assigned to go
COVID-19 CORONAVIRUS UPDATE
to was a now-closed hospital. The emergency
My relief, however, was short-lived. Just days
department was outfitted as a testing site.
later, my father got sick and his results were far
There was a security guard outside in an N95
mask to direct people-flow and to ensure only authorized entry. I remember there were lots
The call was on a Wednesday that he was febrile,
of checkpoints and doors throughout the pro-
“very tired,” with a headache and dyspnea. I
cess, and my identity was checked and verified
later learned that he had been sick for nearly a
at least three times.
week and had been trying to contact his PCP to arrange for COVID testing. Does anyone else
Once through the first door, there were instruc-
have that same story of having family members
tions to sanitize my hands and then to put on
get sick while the physician always seems to be
a mask. More doors. Now people in full pow-
the last to find out? Though I was able to speak
ered air-purifying respirator (PAPR) gear. Con-
to him on the phone, this was several weeks
trolled access-door, identification check-point
prior to my parent’s Zoom/FaceTime in-service
– all of this before the actual check-in and test-
training, so I did not have the luxury of video
ing. The testing rooms were old-school-style
emergency department exam rooms. No open spaces, only closed doors – cold and isolat-
My father finally and reluctantly presented to
ing. One final identification check, and finally
an urgent care center where he was promptly
testing followed by a final set of exit doors and
triaged and found to be febrile, hypoxic, with
other security officers wearing PPE.
radiographic evidence of pneumonia and rapid atrial fibrillation. He was directed to the local
The entire experience was quick, organized,
emergency department but refused to go by
efficient and surreal. As an administrator and
ambulance – which I only found out as he called
clinical leader, I appreciated the efficiency of
me during his drive there.
the workflow; as a patient, I was emotionally overwhelmed by how isolated one can feel
Upon arrival to the hospital, another COVID
even when surrounded by people. I was so
test was performed to ensure timely results. His
relieved when my test came back negative.
hospital course was uneventful, except for the
In hindsight, it amazes me just how powerful
fact that we could not visit him. As he sat in his
denial can be – knowing the statistics, it never
room, dyspneic and on a Cardizem drip, he was
crossed my mind that I could have been one
isolated from us and we from him, only to con-
of the 20-30% whose test might have been a
nect by phone. His hospital-based COVID test
was negative; however, on the day of discharge, WWW.PAFP.COM
he was notified of a positive test result from the
information and adding new clinical skillsets,
urgent care center. Though I am grateful to all
while attempting to remember certain skills last
who played a role in his recovery, my father’s
used decades earlier in medical school, was a
ordeal confirmed for me the seriousness of
case study in highly organized chaos.
this virus – particularly among at-risk individuals – and how desperately we need consistently
Working with our team and seeing the collabora-
accurate, accessible, and more widespread
tive effort to ensure that our office was optimally
safe for everyone and best able to accommodate our patients was, in a word, extraordinary.
Managing clinical and inpatient schedules as well as home and nursing home visits, with the
Many of you can similarly attest that, even pre-
addition of technology-based telemedicine
COVID, the work-life balance of a physician can
coverage, all while ensuring that our residents
be tough. Often, wearing multiple “work hats”
were continuing to progress through their core
is just as much a necessity as it is a conscious
curriculum, was an amazing display of team-
decision. Many of you know I serve as the Vice
work. And all of this, as I am sure many of you
Chair for the Family Medicine at the University
can likewise attest, was done “on the fly.” There
of Pittsburgh as well as the Program Director for
were no global pandemic protocols; there was
UPMC McKeesport Family Medicine Residency.
no playbook at all.
As the COVID crisis ramped up and as our health system began to prepare, life at work got
A series of events in planning for coverage for
instantly busier and more complex. Aside from
our hospital also ushered in one of the most
the often “maternalistic” and multi-layered rela-
challenging, yet rewarding, experiences of my
tionship that evolves between program direc-
life. I was one of the physicians that volunteered
tors and their residents, every aspect of work
to work in our COVID unit, where staff were in
from patient care to planning now became
a negative-pressure space and wearing PPE for
their entire time on the unit. All our confirmed COVID patients were dispositioned to this
From adjusting schedules to accommodate and
space, from the moderately sick to the critically
prepare for mandated periods of self-isolation
and quarantine to modified process, workflow, and protocols, working in concert with others to
Many of the aspects of being on this unit trans-
transition in response to COVID-19 was daunt-
ported me back to medical student and resi-
ing. The combination of learning new clinical
dency rotations; I had to relearn the language
COVID-19 CORONAVIRUS UPDATE
of critical care from which I had been so far removed for a long time. Other aspects, like displaying empathy to loved ones unable to see their families and having end-of-life care discussions, were practices in my current wheelhouse. This was my reminder and affirmation of just how pliable our specialty is, and how the broad breadth of our training positions family physicians for times like these. While COVID can be an extremely devastating disease, it did give me the opportunity to reflect on how grateful
Available on PAFP.com
I am as a family doc to have a broad spectrum of skills that allowed me to be an integral piece to this work while
The PAFP has collected information and
remaining connected to the tenets
resource for family physicians to combat
of our craft as compassionate, multidimensional clinicians. Additionally, as more data about this fascinating and elusive disease pours in, I now find myself colliding with my passion for advocacy, equity, and justice as it relates to health disparities. As the dust begins to settle and as we shift from a “crisis phase” response
the COVID-19 pandemic on its website. The COVID-19 Resource Center includes vital updates from organizations like the Centers for Disease Control and Prevention (CDC) and the Pennsylvania Department of Health (DOH), as well as health alert networks (HANs) from federal, state, and local agencies, tools to connect with other physicians, and much more.
to long-term patient management and population health strategies, I anticipate working on this “front line” with just as much focus and commit-
ment. I have no doubt that the disparate dynamics of COVID-19 impacting WWW.PAFP.COM
at-risk individuals and families will linger long after the global trackers of COVID-19 have been taken offline. PAFP LIFE I have to say that I imagined this year going differently. After all, there was a PAFP strategic agenda before I arrived, and I was confident going in that the programmatic agenda was doable and would demonstrate admirable stewardship over the office. But no one factors a pandemic into their personal or professional life.
Working together, we can model the highest standards of clinical excellence, academicmedical expertise, and administrative leadership. We can engage, inform, and empower our patients and their families to live optimally healthy lives.
Additionally, when something of this magnitude is inserted into an organization with so many
and highlight our worth as a specialty to our
moving parts, you come to realize just how
legislators. We have been able to amplify your
much work goes on behind the scenes on all of
voice on behalf of our patients and encourage
our behalves. Your PAFP staff is incredible and
our Commonwealth leaders to act.
tireless in their work to represent our interests while micromanaging the smallest day-to-day
In the midst of the COVID-19 chaos, with staff
details and simultaneously attending to their own personal and family needs. It has been an
assistance and your support, we drafted an open letter to Gov. Tom Wolf to consider a
honor working with staff on how best to meet
Health in All Policies (HiAP) strategy. This cor-
the needs of our members and how to advo-
respondence encapsulates a key element of my
cate for those needs to the highest levels of our
presidential year and echoes my response to a
Commonwealthâ€™s government. Their support
PAFP Board of Directors member who inquired
and counsel have been invaluable, allowing for
about what my focus for the year would be.
a seamless transition of leadership in the face of
This HiAP communication epitomizes a focused
determination to advocate for codifying and planning at the highest levels of our Common-
The combined efforts of your PAFP leadership
wealthâ€™s government to commit to improving
and staff have helped galvanize our message
the health care of all Pennsylvanians.
COVID-19 CORONAVIRUS UPDATE
I am equally passionate about being a cham-
medical expertise, and administrative leader-
pion for health equity, diversity and justice;
ship. We can engage, inform, and empower
even during a global pandemic, I remain tire-
our patients and their families to live optimally
less in my resolve to work to be a change-agent
healthy lives. We can build bridges rather than
in the lives of our patients. Family medicine is
barriers to care access and delivery. Working
indelibly woven into the fabric of our commu-
together, we will leave no doubt in the hearts
nities. Of all of the lessons that I have learned
and minds of all who are listening and paying
in and through these last 12 weeks, the glaring
attention that the care we provide matters, the
presence and significance of health disparities
patients we serve matter, and the impact that
is perhaps the most profound.
the physician-patient partnership can have on our communities matters.
Working with staff and other leaders, we have embarked on a plan to establish the PAFP as
I am truly humbled and grateful to serve as
the leader in health promotion and disease
your PAFP president. I am honored that you
prevention efforts for all Pennsylvanians. We
have shown your trust in my capacity to serve
have embarked on a mission that positions the
the PAFP, its mission, goals, and communi-
PAFP to be a catalyst for community health
ties, through your support and involvement. I
advocacy at the local, regional and state levels,
commit to continue working tirelessly on your
ensuring that all Commonwealth citizens have
behalf in order to create an atmosphere con-
a voice with respect to their health care needs.
ducive to innovation, clinical excellence, aca-
As I mentioned in my installation speech, the
demic success, and professional development.
agenda is ambitious and the goals are lofty, but
I look forward to working with you, confident
if COVID-19 has shown us nothing else, it has
that together we can leverage our value as cli-
confirmed that we are strong, capable, flex-
nicians, hospital and health system leaders,
ible and resilient. Working together, no goal is
community and public advocates, scholars,
beyond our reach. Through collaboration and
academicians, and scientists so that our prac-
creativity, we can share the workload and lift
tices and our patients may reap the benefits of
each other up as we work together to leave
our Commonwealth better from a health and wellness standpoint than it was when COVID
Your work has been recognized. Your impact
has left a footprint. Your commitment is appreciated, and your voice has resonated. Thank
Working together, we can model the highest
you for all that you do. Now let us press onward,
standards of clinical excellence, academic-
for there is still much work to be done! WWW.PAFP.COM
GOVERNMENT AFFAIRS JENNIFER REIS, Chief Government Affairs Officer firstname.lastname@example.org
FAMILY MEDICINE ADVOCACY REMAINS STRONG IN THE MIDST OF COVID-19 he PAFP understands that family physicians are on the front lines of this growing public health emergency, and we couldn’t be prouder of our members’ hard work and dedication to their patients during this challenging time. In addition to our 2019-20 State Legislative Agenda items, the PAFP is closely monitoring state policy being enacted in response to COVID-19 and will continue to advocate for policies that are in the best interest of our members and their patients. Over the past few months, the PAFP has been in regular communication with Gov. Tom Wolf and members of the Pennsylvania General Assembly to ensure that our family physician members are included in the state’s efforts to support the health care community. PAFP President Tracey Conti, MD, along with our primary care physician counterparts, sent a letter calling on the governor and cabinet 14
officials to mandate reimbursement for telehealth services by commercial insurers, following suit with updates adopted by the state Medicaid managed care and federal Medicare programs. Additionally, the PAFP has advocated for the allocation of life-saving PPE supplies to family medicine physicians to guarantee that our members can continue treating their patients safely and effectively.
COVID-19 CORONAVIRUS UPDATE
PAFP COVID-19 ADVOCACY TIMELINE
PAFP urges Wolf administration to adopt "Health in All Policies" strategy [ READ MORE ]
PAFP requests telehealth payment parity [ READ MORE ]
PAFP joins other Pennsylvania providers urging Gov. Wolf to grant medical liability immunity [ READ MORE ]
PAFP launches Speak Out campaign calling on legislators to enact immunity protections for providers [ READ MORE ]
PAFP urges Gov. Wolf to sign executive order for physician immunity [ READ MORE ]
PAFP releases the Family Medicine Recovery Plan [ READ MORE ]
PAFP urges action to mandate waivers for prior authorizations on generic drugs and COVID-related testing and treatment from commercial insurers [ READ MORE ]
March 26 PAFP urges Gov. Wolf to implement a statewide stay-at-home order [ READ MORE ] March 26 PAFP joins PA Provider Coalition calling on lawmakers to create state Healthcare Coronavirus Emergency Response Fund for frontline providers [ READ MORE ] March 23 PAFP calls on Gov. Wolf, DOH, and PEMA to consider family physicians when allocating PPE [ READ MORE ] March 20 PAFP and Primary Care Coalition urge Gov. Wolf to mandate telehealth reimbursement, parity from commercial insurers [ READ MORE ] March 18 PAFP calls for expanded telehealth options from commercial insurers
[ READ MORE ]
UPDATED AS OF MAY 1, 2020
In April, the PAFP joined a large coalition of health care organizations calling on Gov. Tom Wolf to sign an executive order granting immunity from medical liability to health care providers during the COVID-19 emergency. Many states – including New York, New Jersey, Connecticut, Rhode Island, Massachusetts and Illinois – have enacted similar protections for providers on the front lines of the pandemic. Pennsylvania’s providers are coping with the fear of civil and criminal liability as they work to administer life-saving care. They deserve these protections so they can fully focus on treating their patients and taking care of themselves and their families.
billion in support to help maintain an adequate health care workforce, access essential supplies, enhance infrastructure, and keep providers’ doors open for patient care. The PAFP will provide more information on this legislation once it is introduced.
The PAFP, as part of the Pennsylvania Provider Coalition, called on lawmakers back in March to establish a state Healthcare Coronavirus Emergency Response Fund for frontline providers – including physicians and other health care professionals, hospitals, health systems, and community health and homecare organizations. The coalition has since worked to draft legislative language that seeks to allocate $1.2
We will continue to work diligently to secure the support our members’ needs and ensure that family physicians across the Commonwealth continue to thrive. As Pennsylvania’s health care landscape continues to evolve through this crisis, the PAFP will remain engaged in state legislative and executive policies that help advance the practice of family medicine and patient health.
The PAFP has also engaged in other advocacy efforts that have included urging the governor to mandate suspension of prior authorizations for generic drugs and COVID-related testing and treatment by private health insurers and requesting that hospitals and health systems accept orders for COVID testing from independent and direct primary care physicians.
THE PAFP FAMILY MEDICINE RECOVERY PLAN In order to address some of the difficulties that have arisen from the COVID-19 crisis, and those that have been impacting family physicians for years, the Pennsylvania Academy of Family Physicians (PAFP) has developed a recovery plan for family medicine. Our plan focuses on immediate and long-term actions that can and should be taken to ensure the sustainability of the practice of family medicine as well as the health care of all Pennsylvanians. 16
COVID-19 CORONAVIRUS UPDATE
2020-21 FY STATE BUDGET UPDATE In May, the Pennsylvania General Assembly passed, and Gov. Tom Wolf signed, a partial budget for the 2020-21 fiscal year that will levelfund most state operations and line items for five months beginning July 1 through Nov. 30; education funding will receive a full 12-month appropriation based on the current fiscal year. Despite taking a backseat to COVID-related legislation, legislators and Gov. Tom Wolf worked together to enact the stopgap budget before the June 30 constitutional deadline. The legislature is expected to return to Harrisburg
in the fall – once there is a better understanding of the financial fallout from the coronavirus – to approve a spending plan for the final seven months of the fiscal year. Although the full impact of the pandemic on the state’s finances is still unknown, recent projections are putting the state’s budget deficit at around $5 billion over the next several cycles. As of now, the PAFP’s Residency Expansion Program, which is funded through the Primary Health Care Practitioner line item within the Dept. of Health, will remain flat-funded for at least five months.
THE PENNSYLVANIA ACADEMY OF FAMILY PHYSICIANS
Together we can do more.
PAFP-PAC is the official political action committee of Family Medicine in Pennsylvania. Through individual contributions, PAFP-PAC supports candidates for the state legislature who demonstrate an interest in issues impacting family physicians. By contributing to PAFP-PAC, you join your colleagues in creating a stronger voice for Family Physicians in Harrisburg. In today’s environment, PACs are an important part of the political process and a necessary advocacy tool.
Make your contribution today. WWW.PAFP.COM
MEMBER NEWS THE LATEST NEWS AND INFORMATION FOR PAFP MEMBERS For more, visit: www.pafp.com
PAFP on twitter
Congrats to PAFP members in 'Top Physicians Under 40' The PAFP congratulates several of its members for their inclusion on the Pennsylvania Medical Society's (PAMED) 2020 Top Physicians Under 40 list: Joshua D. Czerwinski, DO; Eldra Daniels, MD, MPH; Elizabeth A. Mohan, MD; Julie L. Orlosky, DO; and Christian D. Shuman, MD. This year’s recipients were nominated by colleagues and selected by a committee of PAMED member physicians. Way to go!
Eldra Daniels, MD, MPH
Elizabeth A. Mohan, MD
Julie L. Orlosky, DO
Christian D. Shuman, MD
PAFP member in AAFP News: Implementing telemedicine on the fly The American Academy of Family Physicians’ AAFP News featured PAFP member Russell Miller, MD on April 21 discussing transitioning patient visits to telemedicine. Miller, an independent family physician in rural Cambria County, kept a journal as he quickly adapted his practice to a telemedicine model to keep his patients and staff safe in the midst of COVID-19. Click here to read the full column.
Russell Miller, MD
PAFP wins AAFP membership award
New CME webcasts now available
The American Academy of Family Physicians
If you need CME credit, thereâ€™s no need to wait
(AAFP) has awarded the PAFP the 2019 AAFP
until lockdown is lifted â€“ just visit www.pafp.
Student Membership Award: Highest Percent
com to meet your educational needs, abso-
Increase in Student Members, second place
lutely free. The PAFP has just published 13 new
among extra-large chapters. We share this rec-
high-quality, clinically relevant CME webcasts
ognition with all of our student Family Medicine
covering topics including opioid prescribing,
Interest Group (FMIG) leaders at Pennsylvania
critical thinking, pain management, patient
medical schools for their hard work recruiting
engagement, and much more. Each webcast
student members through their on-campus
meets the mandated patient safety require-
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Strategies for Physicians in Uncertain Times hank you for the work you’re doing. We’ve heard stories from primary care physicians about how much harder it’s become to deliver care, with patients afraid to come into the office, proper examinations difficult, telehealth compensated but phone calls often unpaid, and all of this compounded by doctors’ worries about their own health and that of their loved ones. Thank you. Today, physicians are at ground zero of the most volatile intersection of medicine and finances ever seen in human history. You may well be facing the worst combination of job stress, personal health concerns, and financial uncertainty of your life. As someone who’s been providing financial advice since 1978, let me offer what perspective I can on this unprecedented crisis. First and always, recognize your most valuable asset, and protect it. That is the lifetime value of your medical education, training, and licensure. For a young doctor couple, that value can easily
be in excess of $10 million. Even if your practice or hospital fails, our nation faces a growing shortage of doctors, and compensation must follow that reality. You are necessary, and you will be able to earn a good living in the future. For all physicians: Interest rates are near all-time lows. Consider refinancing mortgages or other loans. (Student loans are a special, more complex case.) Your health may be at risk. Don’t miss life or disability insurance payments. This might be a good time to review your beneficiary designations. Make sure you have a will, advance directive, and health-care power-of-attorney. Early-career physicians: Rare good news on student loans: your public sector loan payments will be paused, but will still count toward Public Service Loan Forgiveness (PSLF) and other programs. Take maximum advantage of pretax savings plans through your employer or your practice. As a saver, you are a buyer of financial assets, and buyers always ben-
First and always, recognize your most valuable asset, and protect it. That is the lifetime value of your medical education, training, and licensure. 20
efit from lower prices. A bear market advantages you, the more severe the better. Invest at least 60% of your retirement savings in diversified stock funds. Mortgage rates are historically low, but real estate markets are unsettled. A buying opportunity for residential real estate may emerge, but it's not here yet. As always, don’t buy too much house. Mid-career physicians: You’ll still be a net buyer of financial assets between now and retirement. Be sure to maximize your pretax savings. Most of your holdings should be in diversified stock vehicles. We’re all experiencing involuntary spending restraint on travel, meals and entertainment. This may free up new savings or debt paydown opportunities. Once past the crisis, you’ll have an opportunity to assess which experiences you most missed, and which you can easily do without. You may find you like cooking at home (fewer costly dinners out), but desperately miss walking on the beach (vacations at the Jersey Shore instead of in a big city). Or vice versa.
qualified financial advisor may help you move forward with greater clarity and confidence.
Physicians near retirement: Experiencing a bear market in stocks near your retirement date can be an economic challenge. Be open to revising your financial plan. Avoid panic. Remember your economic time horizon. It’s not between now and your retirement date, it’s between now and your actuarial mortality date. Don’t sell out of equities. You’ll probably get the timing wrong, and returns on bonds and cash will likely be low. If you can put your retirement decision on hold until after the combined health and financial crises, and keep working and earning a paycheck, that may be wise. A best-practice retirement cash flow plan should be robust and resilient enough to withstand unanticipated financial events. This is an area where working with a
TriageMD by TGS Financial Advisors offers programs designed to improve the financial trajectories of physicians and their families. To learn more, click here.
We work with doctors at all stages of their medical careers. We recognize that these are times of unique stress and great financial uncertainty. If you’re a member of the PAFP, and have questions about finances, we’re happy to try to answer them as a special courtesy during this uncertain time, without payment or any expectation of a future business relationship. Simply direct your question(s) to email@example.com and we’ll answer them in the order we receive them. By James S. Hemphill, CFP®, CIMA®, CPWA® Jim presents financial workshops for physicians and speaks at physician conferences. He is the co-author of two books: Pay Yourself First: A Financial Guide for Doctors Entering Practice and Changing Outcomes: A Financial Recovery Strategy for Peak-Career Physicians.
FEATURE IN-DEPTH COVERAGE ON TOPICS THAT MATTER MOST TO YOU Join the discussion on this topic and others at PAFP Connect
PAFP learns, celebrates at Sweetest Place on Earth he first weekend of March brought together nearly 300 PAFP members and guests to celebrate and enjoy the PAFP’s CME conference, Annual Business Meeting, and Research Day at The Hotel Hershey. The weekend kicked off with a rundown of the PAFP’s wellness opportunities happening over the weekend and how to make the most of movement breaks that teach attendees purposeful movements to improve their health and wellbeing as well as their patients’ health. Featured speakers of the PAFP’s wellness track included Doug Lentz, MS, CSCS, Director of Fitness and Wellness for Summit Health; Liz Mueller, PT and certified Qi Gong teacher; and Mike Hayduk, certified yoga instructor. The PAFP’s Annual Business Meeting included the induction of 10 new fellows of the American Academy of Family Physicians. The annual event also included the installation of newly 22
elected officers and directors, and of course, the PAFP’s new president, Dr. Tracey Conti of UPMC McKeesport. Congratulations to the PAFP’s annual award recipients: Dr. Jeffrey Martin of Penn Medicine Lancaster General Health earned the Public Health Award; Dr. Abdul Waheed of Wellspan Good Samaritan in Lebanon earned the Exemplary Teacher of the Year award; and the honor of Family Physician of the Year was awarded to both Dr. Delana Wardlaw of Nicetown and to Dr. Ed Zurad of Tunkhannock. The board review focus for this program was endocrinology. The track included sessions on various aspects of endocrinology both common and uncommon in family medicine and concluded with a moderated Q-&-A segment of expert faculty. The PAFP continued its offerings of state-mandated CME including Act 31
child abuse recognition and reporting and opioid education.
dents, and faculty presented nearly 50 topquality oral and poster presentations.
Adding to the full slate for the weekend, awardwinning photographer, Dr. T. Toe Thane of Chambersburg graciously offered three interactive and informative sessions for guests to learn how to take the best quality photos using just a cell phone. Dr. Thane’s course finished with a trip to Hershey Gardens’ butterfly house to put newfound skills into action.
This year’s research topics covered the breadth of family medicine in several categories: quality improvement, research design, case presentation, and public health. You can view all of the submitted abstracts and download the Research Day compendium on the PAFP website.
The future of family medicine is thriving, evidenced during the weekend in Hershey at the PAFP’s annual Research Day. Residents, stu-
Research Day winners for best oral presentation and a $300 award were Raina Jain (Dartmouth) for best medical student presentation; Lionel Varela, MD (Geisinger Lewistown),
Resident and student leaders came out in full force for the Hershey CME Conference.
PAFP immediate Past President Mary Stock Keister, MD (left) congratulates new PAFP President Tracey Conti, MD.
The PAFP’s Career Development Track addressed critical topics including educational debt management, financial literacy, and advocacy.
best resident presentation; and the faculty team of Courtney Humphrey, MD and Renata Carniero, PhD, LMFT (St. Lukeâ€™s) for best faculty presentation. The student presentation by Raina Jain was selected for the Mark A. Connelly, MD, Best Overall Presentation and an additional $300 award. View the oral presentation abstracts here. Poster winners, selected in each category, include: for best case presentation, Ryan Stolakis, MD (resident, York); for best quality improvement project, Don Davis, MD, Farah Vayani, MD, Rajan Joshi, MD, Mandeep Singh, MD, Rajbir Grewal, MD (faculty, Wright Center); and for best research design project, Stephanie Miller, MD and Samuel Sawyer, DO (residents, Forbes). These winning projects are included in the website abstracts directory.
PAFP Past President and AAFP Board Director Dennis Gingrich, MD swears in new PAFP President Tracey Conti, MD.
A featured program developed just for residents and students, the PAFPâ€™s Career Development Track, addressed critical topics including educational debt management, financial literacy, advocacy, and wrapped up with an evening networking reception with PAFP leaders and physician recruiter exhibitors. New this year was a young physician panel which shared personal insights and lessons learned during the transition from residency to practice. Special thanks to the PAFP-member physician volunteers who made the panel discussion possible: Thiri Bickel, MD (Etters); Tiffany Leonard, MD (Willow Grove); Jason Woloski, MD (Wilkes Barre); Andrew Lutzkanin, MD (Hershey); and Jason Assalita, DO (Cornwall), and thanks also to the PAFP resident and student leaders who inspired the topic. 24
Exhibitors were on hand with great information as well as fun giveaways and prizes for attendees.
PAFP Exemplary Teacher of the Year Abdul Waheed, MD (left) poses for a shot with members of his program.
PAFP President-elect Tiffany Leonard, MD smiles alongside PAFP Past President Russel Breish, MD.
Amy Crawford-Faucher, MD presented this yearâ€™s Lila Stein Kroser, MD Memorial Lecture.
The PAFP proudly presents its 2020 class of American Academy of Family Physicians (AAFP) fellows.
PAFP Board Directors Susan Fidler, MD and Jason Woloski, MD break for refreshments.
Perhaps the youngest attendee of the Hershey CME Conference sneaks in a quick power nap.
Abdul Waheed, MD, the PAFP’s 2020 Exemplary Teacher of the Year, accepts his award.
PAFP Past President David O’Gurek, MD presents PAFP 2020 Co-Family Physician of the Year, Edward Zurad, MD, his award.
PAFP events are family affairs, especially in the Sweetest Place on Earth!
Congratulations to the PAFP’s 2020 Research Day award winners!
The PAFP’s community outreach program, Susquehanna Service Dogs, brought some four-legged friends with them.
You can’t visit Hershey’s Chocolate World without enjoying a milkshake! (L-R) PAFP Board Directors David O’Gurek, MD; Thiri Bickel, MD; and Tiffany Leonard, MD.
The PAFP’s Resident and Student Affairs Committee is making sure the family medicine pipeline is alive and well in the Keystone State!
Celebrating women in family medicine: Tiffany Leonard, MD Welcome to a new Keystone Physician feature where we celebrate the women who make the Pennsylvania Academy of Family Physicians. In this issue, we feature PAFP President-elect Tiffany Leonard, MD to discuss her family medicine story.
1. What are the unique challenges women in medicine face?
2. Who is a role model or mentor that you look up to as a woman in medicine?
While I cannot speak for everyone, I have encountered a fair amount of sexism throughout my path into medicine from the undergraduate adviser who tried to convince me that women should be nurses and not doctors, to the employer asking my male colleague (who was three seats away) whether I would be willing to work one specific weekend, to the huge pay disparity between me and some of my male colleagues (which only came to light when I saw some paperwork I was not supposed to see). It is not always obvious (and often not visible to those outside the situation) but it is frequently present in some form. The inequality has improved greatly just since I graduated college in 2004, but we still have a long way to go.
This is a tough question because I've never really been a "role model" or "mentor" kind of person (I find it to be too stagnant and I'm not looking to mirror my life or expectations after anyone else's). The few people I would consider role models growing up were never in medicine and did more to teach me to be independent and to be an individual rather than showing me a path in medicine specifically. That being said, the range of women physicians who I would currently consider "role modelesque" would include my friends and colleagues Drs. Christine Degnon, Kissi Blackwell, Julie Gunther, Staci Benson and Pam Wible, among others. All of these amazing women have stepped outside of the "norm" in their own way to make their
CELEBRATING WOMEN IN FAMILY MEDICINE
career and lives what they want, and have donated countless hours and worked tirelessly to help others do the same (not encouraging others to follow in their footsteps, per se, but helping them find their own paths to success and career happiness). 3. What advice would you give to young women who want to pursue a career in family medicine? The amazing thing about family medicine is how versatile it is. In family medicine you never have to settle for "good enough" - there is always another option or a different path you can take. All it takes is the courage to do so. The job you take fresh out of residency does not have to be the job you have when you retire. They don't even have to be similar in any way. For instance, fresh out of residency, I worked as a nocturnalist for a local hospital system. I was then employed in academic medicine through a residency program for a few years. Now I own a direct primary care (DPC) practice. And while I love DPC and love my practice, there is nothing that says "this is the end of your line" - if my circumstances change, it is entirely possible for my career to change again as well.
The amazing thing about family medicine is how versatile it is. In family medicine you never have to settle for "good enough" - there is always another option or a different path you can take. - Tiffany Leonard, MD If you or someone you know would like to be featured in a future 'Celebrating Women in Family Medicine,' email Bryan Peach at firstname.lastname@example.org
FOUNDATION PRESIDENT'S MESSAGE JASON R. WOLOSKI, MD, Foundation President email@example.com
PAFP Foundation continues to promote, foster family medicine pipeline A letter from PAFP Foundation President Jason Woloski, MD Dear PAFP members, I am honored to be serving as your PAFP Foundation President. For those who may be unfamiliar with the PAFP Foundation, the Foundation is the nonprofit 501(c)(3) wing of the Academy, dedicated to fostering educational programs, research, and philanthropic endeavors, while working to secure a talented and sustainable family medicine workforce and pipeline. As a residency program faculty member, one of my favorite times of the year is reading family medicine residency applications and interviewing prospective residents. Applicants openly and energetically relay their passion for the field of family medicine and dream of their future practice. Personally, as an educator, father, and a physician still practicing both inpatient and outpatient medicine, my goal is to continue to nurture this excitement in our future pipeline physicians, while reinvigorating those already in practice. 30
The Foundation remains proud of its ability to promote the field of family medicine to students and residents in many ways, including: Supporting a full-time Director for Resident and Student Initiatives Scholarship support for Pennsylvania students and residents to attend the AAFP National Conference Discounted CME and conference pricing for students and residents Resident and student representatives on all PAFP Committees, including the Board of Directors and an exclusive Resident and Student Affairs Committee A yearly PAFP Research Day, fostering the development of research and presentation skills, including a career development series The Foundation supports all PAFP members through administration of CME programs to
PAFP FOUNDATION Your donation builds a home for future docs
“ Having been a benefactor of the PAFP in so many ways, my service is a unique opportunity to continue to give back.” David O’Gurek, MD Assistant Professor, Family and Community Medicine Temple University
“ For continued growth of the PAFP Foundation and to help the organization support its members through advocacy and education it needs ongoing support for all its members so that we as family physicians continue to provide the best health care in our communities.” Munima Nasir, MD
“ As a person transitioning to PA for residency, my opportunities to be involved in the PAFP allowed me to develop meaningful and lasting connections with mentors and colleagues, making my decision to stay in PA to practice a no brainer.” Debra Bell, MD COE Medical Director/Hanover Site Lead Physician Family First Health - York, PA
“ I am so grateful for the foundation’s support when I was a medical student and resident, which allowed me to grow as a leader and advocate for family medicine.” Jason Woloski, MD Geisinger Wyoming Valley Wilkes-Barre, PA
Penn State Hershey Medical Group Middletown, PA
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Thank you for your support! FM InSpIRe (Family Medicine INfluencing SPecialty Interest REvolution) is a PAFP initiative to create awareness WWW.PAFP.COM | 31 of the PAFP Foundation and raise funds that directly support residents and students.
FOUNDATION PRESIDENT'S MESSAGE
increase the knowledge and skills of family physicians and meet state-mandated requirements on opioids and child maltreatment. At each live CME event, youâ€™ll acquire enough patient safety credit to satisfy the state mandate for the licensure period! The Foundation also works in collaboration with both state and community organizations on a wide variety of public health initiatives, including physician burnout and wellness. There is no doubt close collaboration between members and our learners in Pennsylvaniaâ€™s medical schools and residency programs will continue to drive excitement for our field. The PAFP Foundation believes by recruiting, educating, and retaining family physicians of today, we will improve access to cost-effective, quality health care here in Pennsylvania. Every year, approximately 250 family medicine residents finish their residency training in Pennsylvania. I want each of them to continue
their practice within the great state of Pennsylvania! I would urge you to consider a donation to the Foundation to advance our efforts, and I extend my gratitude to those who have already contributed. We will keep you informed of our progress, either in our digital publication, Keystone Physician, or by direct letters and annual reports. Thank you again for the care you provide daily to the residents of Pennsylvania, especially during these challenging times. We are blessed to have such a talented and generous family medicine cohort. Join me in building and securing a strong and gifted pipeline! Warmest regards, Jason R. Woloski, MD President, The PAFP Foundation
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2020 PAFP AWARD WINNERS CELEBRATING EXCELLENCE IN FAMILY MEDICINE For more, visit: www.pafp.com
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Co-Family Physician of the Year
DELANA WARDLAW, MD Interview
PAFP 2020 Co-Family Physician of the Year Delana Wardlaw, MD discusses her career in family medicine, equal access to care, and why representation matters. Letâ€™s go all the way back to the beginning: when did you realize you wanted to be a doctor?
Why did you decide to pursue the specialty of family medicine as a career?
Initially I thought I wanted to be an elementary school teacher. However, as I journeyed through school, I realized math and science were my strengths and teaching wasn't quite for me.
I wanted a specialty that allows me to have a direct impact on my patients and my community. There are many health disparities that exist in medicine and my goal is to decrease such. My grandmother died of breast cancer, a disease that if diagnosed at an early stage, she would have had a higher chance of survival.
When I was 8 years old, my maternal grandmother died at the age of 53 from breast cancer. That is a mere eight years older than I am today. I did not learn of the exact cause of her death until I was in high school. It was at that time I became interested in pursuing a career in medicine. 34
Equal access to quality health care allows patients who face social and economic challenges to have better detection and survival rates. As a family physician, I have the unique opportunity to bridge the gaps in health care by
2020 PAFP AWARD WINNERS
directly educating my patients about disease processes, treatment plans, and emphasize preventive medicine as well. By allowing my patients to have an integral part in their health matters, compliance improves greatly. Patients appreciate when their voices are heard. What is your favorite part of practicing family medicine? Treating multiple generations of several families and the variety of medical conditions I am able to diagnose and treat on a regular basis. Also being a part of community events and educating patients outside of the office.
I am grateful for all those who submitted a nomination on my behalf. I am a proud family medicine physician and honored to take care of my patients. It is an amazing feeling to know that others recognize all the hard work and dedication.
Do you have any role models that have impacted the way you practice medicine? I have a few. My mother and paternal grandmother were the first to introduce me to the medical field. My mother worked as a phlebotomist at Kensington hospital and she always treated the patients with kindness and respect. She had a calming effect that allowed them to relax and she could draw the blood with ease. It seemed as if she never missed. As a physician, if you allow the patient to feel comfortable and relax, it allows for a more productive encounter. My grandmother worked as nurse on the labor and delivery unit at Pennsylvania hospital. She worked the overnight shift and sometimes we 36
would stay up late to drop her off. The mere exposure to such a career at a young age allowed me to realize anything was attainable. My residency director, the late Dr. William H. Rodgers, III was the epitome of a family physician. He trained the residents to not only treat medical problems, but to also address social situations. He taught us to put the pen down (this was before electronic medical records) and listen to the patient. Advocating for the patient and proper documentation are also skills he shared that I still rely upon today. Another role model is Dr. Wilfreta Baugh. As a student rotating through her outpatient medi-
cal office, she provided me with tools to navigate the male dominated medical field. What advice would you give to aspiring family physicians? Excel in your course work, particularly math and science, volunteer at a local hospital or long-term care facility, identify a mentor that will help you navigate the various educational and medical school processes. Shadow a family physician in the office or hospital. Identify educational opportunities that will increase your exposure to medicine. As a junior at Temple University, I participated in an internship through the Medical Society of Eastern Pennsylvania. I was exposed to a different medical specialty every week for two months. The experience confirmed my interest in medicine and it allowed me to connect with mentors. Once you are in medical school, be sure to find a good study partner. My twin sister, Dr. Elana McDonald, is a pediatrician, and we did all of our schooling together. Thus, I was fortunate to always have a reliable study partner. We still bounce clinical scenarios off each other today. What does representing the PAFP as the family physician of the year mean to you? For me, representation is important. As an African American female, only 2% of the physicians in this country look like me. There are still several times when I am not recognized as
the physician in a clinical setting because itâ€™s not common to see African American female physicians. As a recipient of this award, it will encourage aspiring physicians to pursue their dream. Seeing is believing which leads to achieving. I am grateful for all those who submitted a nomination on my behalf. I am a proud family medicine physician and honored to take care of my patients. It is an amazing feeling to know that others recognize all the hard work and dedication. I am also highly appreciative of the tremendous support system I have including my husband, Khalif, who has been unwavering in his support of all my dreams and my wonderful children who never complain when Mommy has to work late. My parents, for whom I am forever grateful for instilling in me the value of a good education and for making tremendous sacrifices for me and my three siblings. Thank you all for helping me be the best I can be.
2021 AWARDS NOMINATIONS Watch www.pafp.com for information about about next year's PAFP awards contest. Nominations for 2021 award winners will open later this year.
2020 PAFP AWARD WINNERS CELEBRATING EXCELLENCE IN FAMILY MEDICINE For more, visit: www.pafp.com
PAFP on twitter
Co-Family Physician of the Year
ED ZURAD, MD Profile
PAFP 2020 Co-Family Physician of the Year Ed Zurad, MD discusses the difficulties and joys of practicing family medicine and why there’s “nothing like it.” On deciding to be a doctor: For me, it was kind of late, because I was actually in my second year of college. I went to school to be a teacher. I went to West Chester State to be an English teacher, got involved in lots of activities, I was on the newspaper, the radio, and the community service corps. I realized when I got involved with the local community service corps, which was affiliated with a lot of health care situations, I really enjoyed that aspect of health and human services. So that’s when I decided to refocus my efforts and start signing up for science courses. I got the chance to go to Jefferson right out of college, and life was good! On pursuing family medicine: Once I decided that I wanted to be a physician, I really liked diversity in terms of the types of patients that one was seeing. And when I got to 38
medical school, it reinforced that. I also knew that the diversity was something that I would be able to maintain at a rural practice. When I was at Jefferson, I was able to do some rural rotations, which reinforced that. I had done rural rotations in Latrobe, Pennsylvania, as well as New Hampshire, and that just really sealed it for me. I was able to then go to Lancaster General, which had a nice rural focus, and a Quarryville practice, and I did a rural health program in rural North Carolina for two years for the (U.S.) Public Health Service. On the best part of family medicine: At this point, because I’ve been doing it for so long, it’s the fact that I’ve been in the same position for 33 years. So it is absolutely gratifying to treat four and five generations of the same family and watch them and their children and
their children’s children grow and develop and become successful. There’s really nothing like it that I can think of in my life that has that same satisfaction other than raising your own kids.
ago – and they were able to really assess their patients just because of their long-term knowledge of them very quickly in their office environments.
On role models:
On advice to aspiring family physicians:
Some of the original members of the PAFP that I can think back to when I was a resident were really role models for me. I’m thinking of some of the folks – Jan Pendle was involved with the Lancaster General program, Dr. William Weaver.
I think the best advice that I would give would be remain open to every clinical option you have. Try to remain as wide scale in your scope of practice as you can. Because you never know what you’re going to truly find yourself being directed to in family practice. I’ll take it back a little bit further: it’s such a diverse specialty. There are so many arenas that one could take a fork in the road in in family medicine, during the training years, to try to get that good, full bird’s eye view of every possible option in family practice. By doing that, you can keep yourself
Most of these guys were rural solo family doctors who kind of did everything, and they had such a great grasp and a wide view, that, to me, they were clinical gods. They could diagnose anything with very limited diagnostic testing available to them back then – almost 50 years
2020 PAFP AWARD WINNERS
stimulated through your career as you change directions both clinically and in terms of your possible interests and focus as you grow as a clinician. I think that’s the best advice I can give.
banks. I think the difficulty now for family physicians is trying to apply that in the context of practice when I think there are so many forces that prevent doctors from practicing freely.
On the difficulties of practice:
On young PAFP members:
I think it’s probably more difficult to go into family practice today than it’s ever been. We have such a huge amount of knowledge and the breadth of practice is so deep today. I think it’s harder to be a young family physician than ever. And having said that, the young family physicians that I see coming through have amazing training and unbelievable basic knowledge
I would salute our young family physicians in the sense that the ones that I’ve met are driven, they’re well-trained, they’re knowledgeable, and they’re excited about family practice. I would say just continue to maintain that excitement so that you can deal with some of the obstacles that unfortunately are a reality in practice.
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2020 PAFP AWARD WINNERS CELEBRATING EXCELLENCE IN FAMILY MEDICINE For more, visit: www.pafp.com
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Public Health Award Winner
JEFFREY MARTIN, MD Profile
PAFP 2020 Public Health Award winner Jeffrey Martin, MD discusses his career, the variety in family medicine, and why all family physicians are public health providers. On deciding to be a doctor: I think I was one of those who realized pretty early on that that’s what I wanted to do. Probably, I would say, in elementary school. My mom was a nurse, our family had no other physicians, and for some reason I latched onto it pretty early. I think I was certainly taken by the way my family doctor cared for me – that he made me feel comfortable. Of course, he made me feel better. But he also seemed to respect me even though I was just a young kid, and I think that impressed me. On family medicine: I was pretty much set on family medicine even before going into medical school. Just because by nature, I’m more of a generalist. I enjoyed many facets of medicine, but also, I enjoyed dif42
ferent cultures and humanities and the kind of totality of human experience. So to me, it was just something that seemed like a natural fit. On the best part of practicing: For me, it’s the variety – you never know, even if you have a chief complaint listed on the paper of the next patient you’re going to see, you don’t know if that’s actually the concern or the complaint. Having the variety like that every day is very stimulating. On teaching: Teaching is something that I really enjoy. In part, it’s because I learned so much from our learners. I feel like I’m pushed each day to try to be better, and I’m challenged, and I understand it well. Or our learners will call me out on that. At Lancaster General, we’re just blessed with having, almost every year it seems like, a great group of resi-
Jeffrey Martin, MD (left) was presented with the 2020 Public Health Award by PAFP Past President David O'Gurek, MD (right)
2020 PAFP AWARD WINNERS
dents. It’s one aspect of my professional life that I don’t think I’ll ever give up. On role models: Since I graduated from this program, some of the other faculty of this program, like Dr. Zervanos, Dr. Olin, Dr. Peterson, have certainly been amazing role models. But I would say even in college, the physician I saw in college was a role model. I feel like I continue to have role models today. You have to have somebody that you can look to, to ask questions to, to bounce issue off of in order to be an effective physician. On public health: I would say that all family doctors are public health providers. On a daily basis we “sample” what is going on in the populations we serve. We often are attuned to issues that are flaring up even before the public health infrastructure is aware. We are also well positioned to find solutions to public health issues since we see the community and what is going on in the community as a natural extension of caring for individual patients. We are holistic and comprehensive and often have a broader view of health systems than other specialists. Finally, family doctors know how to form relationships, establish rapport and explain things to the public in a way that non-medical folks can understand. I think for these reasons, we are profoundly capable and willing to be public health change agents in our communities. 44
On the state of family medicine: I think it’s even more of an exciting time to go into family medicine. The problems that we face are generally problems that cross sectors, meaning they’re not just medical issues, they’re socioeconomic issues as well, and I think family medicine is really primed to be able to step into that space of dealing with these broad population health questions. In general, I think family docs are well-positioned to work in all aspects of a health care system. The administrative [aspect] – you can do that, because you spend a lot of time on the different services, both inpatient and outpatient, you have a line of sight of much of what goes on in a health care system. So the opportunities for both population health and also non-traditional family medicine, like going into administration, are endless. On effecting change: I still think that we can be powerful change agents and advocates for issues that we discover every day in our offices. I know that sometimes it’s difficult with having to complete charts and fill the directives of the electronic medical record. But I still think at the heart of family medicine, we’re well positioned to help not only significant change to better our community, but also to advocate on behalf of the patients we see on a regular basis. That’s not an old fogey idea!
A message to the Class of 2020 from the Pennsylvania Academy of Family Physicians
Congratulations and best wishes to the medical school and residency graduates of the Class of 2020! Please know that as you engage in virtual commencement ceremonies, socially distant and virtual celebrations of your achievements, we are cheering for you. This unprecedented health crisis has proven that family physicians are needed more now than ever, and your leadership, adaptability, clinical acumen and passion to advocate for your patients and community will help lead us out of this pandemic and into a brighter and healthier future for all Pennsylvanians and across the U.S. Your friends at the PAFP are here for you and join that fight beside you. CHEERS TO YOU, THE CLASS OF 2020! WWW.PAFP.COM
LEGAL AND COMPLIANCE UPDATE CHARLES I. ARTZ, Esq., General Counsel firstname.lastname@example.org
Medical necessity fraud: Objective falsehood requirement rejected new U.S. Court of Appeals decision adopting an anti-physician medical necessity fraud position is important to consider for internal audit, documentation and compliance purposes.
The Third Circuit U.S. Court of Appeals rejected the objective falsehood requirement for FCA falsity, reversed the dismissal, and remanded the case for trial. The U.S. Court of Appeals’ important legal holdings include the following:
In U.S. ex rel. Druding v. Care Alternatives, ___ F.3d ___ (3rd Cir. 2020) (2020 WL 1038083), a whistleblower filed a False Claims Act (FCA) case against a health care provider for allegedly billing for medically unnecessary services. At the federal trial court, both parties introduced expert reports. The provider’s expert testified that a reasonable physician would have found all of the patients’ services were properly documented and medically necessary. The federal trial court (properly) held that a mere difference of opinion between experts regarding the accuracy of a patient’s medical prognosis and documentation was insufficient to create a case that could go to trial; and required the government and whistleblowers to provide evidence that an objective falsehood existed. The federal trial court dismissed the case on summary judgment in favor of the provider.
1. Although making a medical prognosis is not an exact science, physicians are required to make certain that the physician’s clinical judgment can be supported by clinical information and other documentation that provides the basis for any treatment certification and recommendations (hospice care, in this case).
2. The premise of the District Court’s holding – that a “mere difference of opinion” is insufficient to show the False Claims Act falsity – is at odds with the meaning of “false” under the FCA. Objective falsity improperly conflates the elements of falsity and intent. 3. The FCA “intent” requirement helps to limit the possibility that providers would be exposed to liability under the FCA anytime
the government can find an expert who disagreed with the certifying physician’s medical prognosis/opinion. 4. Under the “legal falsity” FCA theory, physicians can be liable for medical necessity fraud if the clinical information and other documentation do not support the medical prognosis or opinion. FCA liability is not premised on factual falsity alone, but a certification is false simply if the service or procedure was not reasonable and necessary under the government’s definition of that phrase. 5. The bright-line rule that a physician’s clinical judgment cannot be false was rejected. 6. Medical opinions are not insulated from fraud scrutiny. Medical opinions may trigger liability for fraud when they are not honestly held by their maker. 7. A good faith medical opinion is not punishable under the FCA, but a bright-line rule that medical opinions can never be false fails to hold accountable a physician who saw one thing on a test and consciously wrote down another, and then used that misinformation to perform and bill unnecessary services and procedures.
A new U.S. Court of Appeals decision adopting an antiphysician medical necessity fraud position is important to consider for internal audit, documentation and compliance purposes.
8. Whether a physician was acting in good faith or committing fraud is a question for the jury. Pre-trial judgment through a motion to dismiss or summary judgment is not available. Medical opinions may be “false” and an expert’s testimony challenging a physician’s medical opinion can be appropriate evidence for the jury to consider on the question of falsity. 9. In adopting and applying the “objective falsity” standard, the district court relied on U.S. v. AseraCare, 938 F.3d 1278 (11th Cir. 2019). That case involved dueling expert opinions from two different physicians on both sides of the case whether, based on their own clinical judgment, the medical WWW.PAFP.COM
LEGAL AND COMPLIANCE UPDATE records supported the medical necessity
reversed on that issue. The physicians can
certifications. That decision found that the
defend the case on lack of intent or reck-
relevant inquiry was whether the govern-
less disregard of the medical necessity
ment had sufficient evidence against the
regulatory and documentation standards.
accuracy of the physician’s clinical judgment.
The compliance implications of this extremely unfavorable ruling include the following:
10. In rejecting the AseraCare approach, the court held that, under the legal falsity the-
1. Every challenge by a whistleblower or the
ory, a medical opinion that differs from the
government alleging medical necessity
certifying physician’s opinion is relevant
fraud due to failure to create documenta-
evidence of the regulatory documenta-
tion consistent with regulatory standards
tion requirements, i.e. whether there was
can now be subjected to False Claims Act
documentation accompanying the certifi-
liability, with litigation all the way through
cation that supported the medical prog-
nosis and medical opinion. 2. All Medicare Contractor medical necessity 11. The Court of Appeals in this case disagreed
policies and documentation requirements,
with the AseraCare analysis holding that
including Medicare Manual provisions,
clinical judgments cannot be untrue.
should be studied carefully and explained to physicians that sufficient documenta-
12. The common law definition of fraud permits a finding that subjective opinions
tion must exist in the medical record to avoid this type of disastrous result.
may be considered false and that medical opinions can be false and are not shielded
3. Good faith medical opinions should be
from FCA scrutiny. The court stated: “We
well documented and consistent with all
therefore find a difference of medical
applicable federal program regulations,
opinion is enough evidence to create a
Manual provisions and interpretive guide-
triable dispute of fact regarding FCA fal-
lines – just to be safe – even though the
current Department of Justice and several other federal courts have held that Manual
13. The whistleblower’s expert report chal-
provisions are not the law.
lenging the physician’s medical necessity
certification creates a triable issue of fact
4. Medical necessity reviews should be an
for the jury regarding falsity. Dismissal
inherent component of periodic internal
of the case on summary judgment was
Pennsylvania Academy of Family Physicians Foundation
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