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OnCall

QUARTER 4 2018

THE OFFICIAL PUBLICATION OF THE PALM BEACH COUNTY MEDICAL SOCIETY

Understanding ACES — Adverse Childhood Experiences

Page 10

Preventing Burnout

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There are many ways you could be wasting money on your malpractice insurance Did you know that most doctors unknowingly waste money on malpractice insurance, which is one of the largest expenses in a medical practice each year? Some of the most common ways doctors continually spend too much include:

#6. Not working with the right agent or broker Find an independent agent specializing in malpractice insurance placement for your type of practice setting (solo, group, hospital, surgical center, etc.) and one who has an educational approach versus a sales orientation. Your agent should be strong enough within the malpractice insurance marketplace to fully and competently negotiate the best rates for you with the top insurers in your state. With such a large expense and such costly mistakes possible, you deserve the best available assistance.

Isn’t it time you called Matt Gracey, the med mal insurance expert? Delray Beach • Jacksonville • Miami • Orlando • Panama City • Pensacola Matt@dannagracey.com • 800.966.2120 • www.dannagracey.com

;OL7)*4:>VYRLYZ»*VTW0UZ\YHUJL 7YVNYHT/HZH5L^5HTLHUKHU,UOHUJLK+P]PKLUK All current and new Palm Beach County Medical Society members are eligible for an enhanced dividend of \W[V . 7)*4:TLTILYZOH]LYLJLP]LKV]LY TPSSPVUHUKJV\U[PUN :PUJL[OLYH[LZMVY^VYRLYZ»JVTWLUZH[PVUPUZ\YHUJLHYLZL[I`[OLZ[H[LWYPJLZHYL[OLZHTLUVTH[[LY^OLYL`V\ ZLJ\YLJV]LYHNL)\[UV^`V\HYLLSPNPISLMVY[OPZLUOHUJLK KP]PKLUK^OPJOLMMLJ[P]LS`YLK\JLZ[OL[Y\LJVZ[ VMJV]LYHNL6[OLYWYVNYHTZTH`VMMLYZPTPSHYKP]PKLUKZVUHUPUKP]PK\HSIHZPZI\[V\YWYVNYHTPZIHZLKVU[OLNYV\W»Z L_WLYPLUJLHUKUV[[OLPUKP]PK\HS»ZL_WLYPLUJL;OPZWYV]PKLZHIL[[LYJOHUJL[VUV[VUS`YLJLP]L[OLKP]PKLUKI\[[V YLJLP]LHOPNOLYKP]PKLUK (T;Y\Z[5VY[O(TLYPJHMVYTLYS`*VTW6W[PVUZOHZILLUH[Y\LWHY[ULY[V[OL7HST)LHJO*V\U[`4LKPJHS:VJPL[`MVYTHU` `LHYZHUKUV^^P[O[OLYLZV\YJLZVM(T;Y\Z[YH[LK¸(¹,_JLSSLU[I`(4)LZ[^LHYLHISL[VWYV]PKL[OPZL_JS\ZP]L LUOHUJLKKP]PKLUKWYVNYHT[OH[PZSPRLUVV[OLYMVY-SVYPKHWO`ZPJPHUZHUKTLKPJHSWYHJ[PJLZ;VKH[L[OLZLWYVNYHTZOH]L YL[\YULKHKP]PKLUKMVYZ[YHPNO[`LHYZ^P[OV]LY TPSSPVUV]LY[OLWHZ[Ä]L`LHYZ[V-SVYPKHTLKPJHSHZZVJPH[PVUZ»TLTILYZ! TPSSPVUVM[OH[^LU[[V7)*4:TLTILYZ -VYTVYLKL[HPSZHUK[VLUYVSSPU[OPZILULÄJPHSWYVNYHTWSLHZL JVU[HJ[;VT4\YWO`VM+HUUH.YHJL`H[ VY [VT'KHUUHNYHJL`JVT


President’s Report

Brandon Luskin, MD

President Palm Beach County Medical Society

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Together We Are Empowered

s I approach the last quarter of 2018 and my last few months as President of the Palm Beach County Medical Society (PBCMS), I reflect on what we have accomplished so far this year. We now have more than 1,500 members ranging from medical students and residents to retired physicians, as well as physicians working in our communities. So many of our members are becoming more active in PBCMS, in its committees, events, mixers and programs. Our successful Heroes in Medicine event this year had well over 500 attendees. We hosted David O. Barbe, MD, MHA, the President of the American Medical Association, as our featured speaker for our State of Medicine Dinner. Through him we learned first-hand what the largest organization of physicians in the United States is doing about the issues we physicians face. In addition, I had the opportunity to appear before the Florida State House and Senate Subcommittees on Health. I testified about physician concerns regarding the pending-at-the-time Opioid Bill, which became law July 1, 2018.

Important Lessons

I have learned some important lessons when speaking candidly to my colleagues while in my area hospitals. I have discovered attitudes among the

physicians that range from complete engagement with many of the issues our profession faces to complete ambivalence. I am often told that our medical society’s advocacy actions to promote a better profession of medicine, while well intended, are futile. I find this position the most difficult to comprehend. The majority of these physicians tend to feel beaten down. Ironically, these are the ones who have little understanding of what we do as a medical society. And many of them appear to me to be dealing with burnout. These are the folks who have given up before even trying!

Stand Together

As I have written about previously, physician burnout is not an infrequent problem. It is probably becoming more the rule than the exception. All of us feel it to some extent, some just more than others. It is easy to see why so many would feel this way. But, there is some light at the end of the tunnel when we band together and face the growing problems of trying to squeeze out a career in medicine, despite the problems of dealing with an ever-changing health care system and its complex bureaucracy. Remember, we are Doctors of Medicine, not doctors of the health care system! By standing and banding together we are heard better than if we speak in isola-

tion, or don’t speak at all. This empowerment is a significant tool against the growing problem of burnout. Moreover, PBCMS has developed a very successful Physician Wellness Program that helps physicians discreetly deal with many issues that contribute to burnout. Furthermore, when we provide our community with meaningful programs such as My Health Access or Project Access, etc., we are perceived as more credible when we do speak, and not just as “out for ourselves” as some other constituency groups are viewed. We are speaking from a platform of righteousness rather than selfishness. Although we cannot expect to receive all of what we ask for, we are far more likely to receive more than if we did not speak at all. Lastly, as we approach the holiday season, join me in being thankful for what we do have. Although we face a growing set of problems, we are blessed to be in a position that is still vital and significant in the health care system. We still derive joy from caring for others, and although we sometimes feel shortchanged, our basket is more likely half full from our hard work and efforts. I wish everyone a happy and healthy holiday season filled with good family, good friends, and a sense of a serenity from our personal accomplishments. OnCall • Q4 2018 

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Contents

BOARD OF DIRECTORS Brandon Luskin, MD

Robert Tome, MD

Marc Hirsh, MD

Roger Duncan, MD

Larry Bush, MD

Shawn Baca, MD

Stephen Babic, MD Andrew Berkman, MD Berna Buyukozturk, Medical Student Dawn Davanzo, MD Kleper de Almeida, MD Michael Dennis, MD James Goldenberg, MD Henry Haire, MD James Heron, MD Hitesh Kapupara, MD

Milad Khoury, MD Krishna Kishor, MD Ekaterina Kostioukhina, MD Claudia Mason, MD Stefan Pasternack, MD Leslie Perla, MD Alan Pillersdorf, MD Ronald Zelnick, MD Jack Zeltzer, MD

President

Secretary

President-Elect

Treasurer

First Vice President

Past President

D E PA R T M E N TS

3 President's Report 6 Med Memo 6 Welcome New Members

BOARD OF TRUSTEES Jose Arrascue, MD Stephen Babic, MD Shawn Baca, MD Larry Bush, MD

James Goldenberg, MD Maureen Whelihan, MD Marc Hirsh, MD Ronald Zelnick, MD Brandon Luskin, MD Jack Zeltzer, MD Alan Pillersdorf, MD

BOARD OF DIRECTORS Michael Dennis, MD Don Chester President

Treasurer

Ivy Faske, MD

Matt Gracey

Vice President

Jean Acevedo William Adkins, MD Elaine Alvarez Jose F. Arrascue, MD Brenda Atkins Steven Borzak, MD Tish Carlo Ljubica “Jibby” Ciric

Secretary

Patti Corbett Mollie Shulan, MD Bobbi Horwich Kelly Skidmore Andrew Larson, MD Patricia Thomas Gary Lesser Maureen Whelihan, MD Roshan Massoumi Paul Wieseneck Stuart Miro, MD Jack Zeltzer, MD Alan B. Pillersdorf, MD Tenna Wiles, CEO Brent M. Schillinger, MD

PBCMS STAFF DIRECTORY Tenna Wiles Mindi Tingler

CEO

Lauren Stoops

Operations Director

Project Access Director

Deanna Lessard

Karen Harwood

Member Services & Physician Wellness Director

Katherine Zuber

Membership Development & Events Director

Care Coordination Services Director

John James

Public Health & Disaster Services Director

Subscriptions to OnCall are available for an annual rate of $50. For more information contact PBCMS at (561) 433-3940. The opinions expressed in OnCall are those of the individual authors and do not necessarily reflect official policies of Palm Beach County Medical Society or its committees. OnCall is owned and published four (4) times per year by Palm Beach County Medical Society, Inc., 3540 Forest Hill Blvd., #101, West Palm Beach, FL 33406. (561) 433-3940. ©Copyright 2018 Palm Beach County Medical Society, Inc. OnCall Magazine is designed by MillerDesignPros, email us at m.miller@millerdesignpros.com or visit us on the web at www.millerdesignpros.com

FE AT U R E S Spotlight on Children’s Services Council

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ACEs 10 Understanding — Adverse Childhood Experiences

Skills Help 16 Resiliency Prevent Burnout

18 

Review Your Life Insurance Policy

Page 10 ACEs awareness and education helps kids today towards better health outcomes.

19 Online Physician Reviews Are Often Misleading 20 The Case Against Cloning Medical Records 22 Virtual Reality — An Alternative to Opioids O N T H E CO V E R Understanding ACEs — Our cover story on page 10 in this issue addresses ACEs, the

adverse childhood experiences that have impacts on health issues later in life. The good news is that there is research, collaboration and work being implemented to overcome the harm caused by ACEs. OnCall • Q4 2018 

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Med Memo

Health Care Connection

Mark Your Calendar November 14, 2018

Health Care Connection “Where’s the Money?” Atlantis Country Club

December 1, 2018

PBCMS/HERC Opioid CME Educational Program for Physicians at Gregory School of Pharmacy Palm Beach Atlantic University December 12, 2018

Health Care Connection “Don’t Hire Your Next Lawsuit”

Presenters Christopher Acevedo, COO of Acevedo Consulting, Inc. and Meredith Hirsh, Executive Director of the Hirsh Center.

More than 45 health care professionals attended the Medical Societies’ first Health Care Connection (HCC) luncheon of the 2018-2019 season on October 10th at the West Palm Beach Marriott. Meredith Hirsh and Christopher Acevedo offered an excellent presentation on “Utilizing Non-Physician Providers in your Practice.” Meredith shared her “real world” experiences while Chris provided key information on the regulatory guidelines. Visit www.pbcms.org for the HCC series lineup, which runs October 2018-June 2019.

Attention Residents & Medical Students

PBCMS is seeking representatives (1 medical student and 1 resident) for the 2019 PBCMS Board of Directors. Visit www.pbcms.org to apply. Contact Deanna Lessard at 561-433-3940, ext. 105, for more information.

New PBCMS Members

West Palm Beach Marriott

Luis Castillo, MD

December 13, 2018

Retired Physician Luncheon Carlisle Palm Beach

Heroes in Medicine Set for May 17, 2019

February 7–8, 2019

The Future of Medicine Summit XII

Kimmerle Cohen, MD Arif I. Dalvi, MD David Dershewitz MD Joann Drowos, DO

Kravis Center

Pamela Ermine, DO Gregg Harrison Goldin, MD

Happy 99th Birthday PBCMS

Anil K. Goyal, MD

The first meeting of the Palm Beach County Medical Society was held on September 20, 1919, in the office of Dr. L.A. Peek. Their first order of business was electing officers, appointing a committee to prepare a constitution and bylaws and setting a fee schedule for county physicians. For example, the fee schedule for medical services nearly 100 years ago was $2 for West Palm Beach calls, $3 for out-of-town calls, $4 for night calls from 11 p.m. to 6 a.m. In addition, obstetrical calls were $30 and anesthesia calls ranged from $5 to $25.

William Gustave, MD Sonny Bert Litwin, MD John Dalton, CEO and President of OptimumRTS, the chair of Heroes in Medicine,(right) is assisted by co-chairs Judith Dunn, Manager of Healthcare Partnerships at CareerSource Palm Beach County (not in photo) and Gregory Cotes, MHA, Administrative Director, Support Services, St. Mary’s Medical Center. Many sponsor opportunities are available for the luncheon. Watch pbcms.org for the call for nominations. For information, contact Katherine Zuber at 561-433-3940 or email Heroes@PBCMS.org.

Jacob L. Lochner, DO Bertha L. Marcellino, MD Jenifer McCarthy, MD Ali S. Pakravan, MD Lynn C. Palmeri, MD Claudia Porrata, MD, MPH Alan M. Saitowitz, MD Marty Salas, MD Jordan Schwartzberg, MD Frederick Stuart Sherman, MD

2019 PBCMS Executive Committee 6 

Q4 2018 •  OnCall

President.................................................Marc Hirsh, MD President-Elect...................................... Larry Bush, MD First Vice-President.......................Roger Duncan, MD Secretary..........................................Claudia Mason, MD Treasurer......................................... Dawn Davanzo, MD Member at Large................... Martha Rodriguez, MD Immediate Past President....... Brandon Luskin, MD

Carmen Torres, MD Sarah Wood, MD Residents Yash B. Jobanputra, MD Sandy M. Lawrence, MD Carmen Marrero, DO Adam Eric Shestack, MD


Marc Hirsh, MD Installed as President at Starfish Gala PBCMS President Brandon Luskin, MD was enthusiastically saluted as he ceremonially turned over the gavel to the next PBCMS president Marc Hirsh, MD at the Starfish Gala held November 17 at the Kravis Center, Cohen Pavilion. Dr. Hirsh will begin his presidency in January 2019 and will deliver his State of Medicine at the Future of Medicine Summit in February 2019. As a nationally recognized musculoskeletal ultrasound instructor, Marc Hirsh, M.D., FACP, of The Hirsh Center in Delray Beach, Florida, is a leader in the field of rheumatology. Born and raised in Miami, Dr. Hirsh graduated Phi Beta Kappa with his Bachelor of Science degree and his medical degree from the University of Florida in Gainesville. After an internship at Northwestern University in Chicago, he completed his residency in internal medicine at Jackson Memorial Hospital, University of Miami.

Dr. Hirsh is a board-certified rheumatologist and a fellow of both the American College of Physicians and American College of Rheumatology. Brandon J. Luskin, MD (see his President’s Report on page 3 of this issue) is an orthopedic hand surgeon. He graduated Magna Cum Laude from SUNY University at Buffalo where he remained to do research with two-time Nobel Prize nominee Robert Guthrie, MD. He attended State University of New York Health Science Center at Syracuse for medical school, and went on to complete his orthopedic surgery training at the Long Island Jewish Medical Center, in New York City. Dr. Luskin has been practicing with Orthopaedic Surgery Associates Inc. since 1997. He is board certified in orthopedic surgery and hand surgery. He is a member of the American Society for Surgery of the Hand, the FMA and PBCMS.

Thursday, February 7, 2019 State of Medicine-Centennial Celebration: Celebrating our Past… Creating our Future Poster Symposium with the Medical Residents Marc Hirsh, MD, PBCMS President, Delivers The State of Medicine Harris

Patrice A. Harris, M.D., a psychiatrist from Atlanta, Ga., the president-elect of the American Medical Association (AMA), has been invited to speak. Dr. Corey Howard, President of the Florida Medical Association (FMA) speaks. The PBCMS 100-Year Centennial Celebration Launches

Friday, February 8, 2019 Topic 1: Panel — Innovation & Advancement in Medicine Topic 2: Panel — New Reality of Healthcare Delivery Howard

Luskin

Hirsh

Future of Medicine Summit XII

Celebrating our Past… Creating our Future

The acclaimed Future of Medicine Summit XII is set for February 7-8, 2019 at the Kravis Center. The expected schedule of events is shown in box at left.

Topic 3: Keynote Speaker — Social Responsibilities in Healthcare by Pedro Greer, MD, assistant dean of Academic Affairs and Chair of the Department of Humanities, Health and Society at the Florida International University Herbert Wertheim College of Medicine. Topic 4: Panel — Our Community, Our Responsibility Topic 5: Keynote Speaker — Finding the Joy in Medicine

Greer

Topic 6: Panel — Building Innovation: Training Physicians of Tomorrow

OnCall • Q4 2018 

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PBCMS Fall Photo Album Welcome Reception for Residents, Students and Faculty

PBCMS recently hosted a welcome reception for Palm Beach County Medical Society residents, medical students and faculty at the Meat Market restaurant.

Attendees included Natalie Gaughan, Hanna Slutsky, Briana Pallewonsky and Brandon Luskin, MD, president of PBCMS.

Mathew Romanelli, DO & Gregory Mandile, DO also attended the reception.

Women in Medicine Celebration

In honor of Women in Medicine Month, more than 65 women physicians and PBCMS supporters attended the Women in Medicine Celebration Dinner on September 26 at Benvenuto’s in Boynton Beach. Keynote speaker Barbara Schmidt of Peaceful Mind, Peaceful Life inspired guests with many “mindfulness” techniques and life skills. Sarah Wood, MD and Maureen Whelihan, MD were both honored as our Female Physicians of the Year. The next Women’s Physician Section event will be held January 17, 2019 at the office of Martha Rodriquez, MD.

Phillip Boiselle, Michelle LizotteWaniewski Ph.D., Barb Schmidt & Sarah Wood, MD

Circle of Friends Appreciation Luncheon

FMA Board Members

PBCMS physicians who also serve on the Florida Medical Association Board of Directors include (l to r) Alan Pillersdorf, MD; Mark Rubenstein, MD; and James Goldenberg, MD.

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Q4 2018 •  OnCall

PBCMS President Brandon Luskin, MD, (center, first row) joined nearly 20 Circle of Friends at an appreciation luncheon sponsored by the Palm Beach County Medical Society at Atlantis Country Club in October for an afternoon of sharing and networking.


Spotlight

Children’s Services Council of Palm Beach County

Evidence-Based Programs and Services Making a Difference

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By Lisa Williams-Taylor, Ph.D.

or more than 30 years, Children’s Services Council of Palm Beach County (CSC) has dedicated funding to help our children and their families have every opportunity to succeed. We do this by working with our community to identify needs as well as solutions. One key to making a difference comes by way of evidence-based programs and services. The concept of evidence-based originated in the medical field and did not start to filter into the health and human services arena until the 1990s. It was only a couple years later that CSC funded our first evidence-based program. Why has CSC chosen to fund in this way? Because despite decades of research on the causes and treatments of various Some examples of theses successful programs include social problems, most approach- the following. es aimed at helping families have • CenteringPregnancy. This program provides prenatal shown only modest effect. Too care to women in a group setting, incorporating the often, programs continue to three elements of prenatal care: assessment, educaoperate without ever showing tion, and support. that what they do works for the • Healthy Steps. Specialists work in pediatricians’ offices children and families they serve. to monitor child health and development, promote good A program may appear on the health practices and respond to parents’ concerns about surface to work, and logically their developing infants and toddlers. should work; but when formally • Nurse-Family Partnership. This program is a volevaluated, it may show no results untary, evidence-based nurse home-visiting program or may, in fact, be harmful to the that improves the health and well-being of low-income, Lisa Williams-Taylor population served. Don’t we owe first-time parents and their children. it to our children and families to do better? Absolutely. As • Mental Health Counseling Programs. These stewards of taxpayer dollars, we believe it is imperative that evidence-based mental health models are delivered we invest in programs demonstrating success. to pregnant moms and their children, ages 0-5, and in While there continues to be debate about the use of school-based settings. evidence-based programs in social services and ensuring • Teen Triple P (Positive Parenting Program). This is a community needs are met, we at CSC do not believe it’s an family intervention program for parents of adolescents either or decision. Currently we fund 57 programs, of which 11 ages 11-18 who have or are at risk of developing behavare evidence-based, and we are working to create evidence for ioral or emotional problems. many others. More important, we have data and evidence to These are only a few examples demonstrating our comsupport that the programs we have brought to our community mitment to every child in Palm Beach County growing up are making a substantial difference in terms of child and family healthy, safe and strong. outcomes. In fact, in various studies, independent researchers have found that CSC-funded national programs actually have Contact: Children’s Services Council CEO Lisa Williams-Taylor, Ph.D., lisa. had better outcomes than what previously had been found. williams-taylor@cscpbc.org, 2300 High Ridge Road, Boynton Beach OnCall • Q4 2018 

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Cover Story Understanding ACEs — Adverse Childhood Experiences

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By Ely Niroomand and Elaine Alvarez dverse childhood experiences (ACEs) are traumatic or stressful events that occur early in life and have impacts on physiological and psychological health issues later in life. In a groundbreaking study in the early 1990s, Vincent Felitti, MD, of Kaiser Permanente partnered with Robert Anda, MD, at the CDC to look at how traumatic childhood experiences impacted health outcomes. They surveyed more than 17,000 adult members of Kaiser Permanente in San Diego and asked about their exposure to ACEs, including physical, emotional, and sexual abuse; physical and emotional neglect; and growing up in a home with divorced

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parents, domestic violence, substance abuse, or mentally ill or incarcerated household members (See No. 3–What’s My ACE Score Questionnaire and No. 4 Resilience Questionnaire). They then tracked several important health indicators and found a strong graded relationship between an individual’s ACE score, the number of ACEs they experienced, and their odds of having negative health outcomes

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(See No.1–The Truth About ACEs Diagram). Individuals with ACE scores of four or more were two-to-four times more likely to have COPD, liver disease, and ischemic heart disease later in life, and four-to-12 times more likely to have alcoholism, drug abuse issues, and suicide attempts. People with an ACE score of six have a shorter lifespan — by 20 years. Further research

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Adverse Childhood Experience (ACE) Questionnaire Finding your ACE Score ra hbr 10 24 06

While you were growing up, during your first 18 years of life: 1. Did a parent or other adult in the household often … Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt? Yes No If yes enter 1

________

2. Did a parent or other adult in the household often … Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured? Yes No

If yes enter 1

________

3. Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way? or Try to or actually have oral, anal, or vaginal sex with you? Yes No If yes enter 1

________

4. Did you often feel that … No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other? Yes No If yes enter 1 ________ 5. Did you often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? Yes No If yes enter 1 ________ 6. Were your parents ever separated or divorced? Yes No

If yes enter 1

________

7. Was your mother or stepmother: Often pushed, grabbed, slapped, or had something thrown at her? or Sometimes or often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife? Yes No If yes enter 1 ________ 8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs? Yes No If yes enter 1 ________ 9. Was a household member depressed or mentally ill or did a household member attempt suicide? Yes No If yes enter 1 ________ 10. Did a household member go to prison? Yes No

If yes enter 1

________

Now add up your “Yes” answers: _______ This is your ACE Score

OnCall • Q4 2018 11


The Impressive Backstory of Ely Niroomand’s ACES Capstone Project

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By Elaine Alvarez

Continued from page 11

has since validated their findings, established other associations between early traumatic events and negative health outcomes, and provided biological plausibility in regards to these associations (See No. 5–Adverse Outcomes in People Who Experience 4 or More ACEs on next page).

Toxic Stress Is the Culprit

ACEs research shows the correlation between early adversity and poor outcomes later in life. Toxic stress explains how adverse childhood experiences “get under the skin” and trigger biological reactions that lead to those outcomes. In the early 2000s, the National Scientific Council on the Developing Child coined the term “toxic stress” to describe extensive, scientific knowledge about the effects of excessive activation of stress response systems on a child’s developing brain, as well as the immune system, metabolic regulatory systems, and cardiovascular system. Experiencing ACEs triggers all of these interacting stress response systems. When a child experiences multiple ACEs over time — especially without supportive relationships with adults to provide buffering protection — the experiences will trigger an excessive and long-lasting stress response, which can have a wear-and-tear effect on the body, like revving a car engine for days or weeks at a time (See No. 2–What Are ACEs? And How Do They Relate to Toxic Stress?).

This summer, Elaheh (Ely) Niroomand, University of Miami Miller School of Medicine (UMMSM) candidate for both the Doctorate of Medicine and the Master of Public Health (MD, MPH) degrees, Class of 2019, and a Palm Beach County Medical Society and Services (PBCMS&S) Hero in Medicine Medical Student 2018, delivered her Capstone Project lecture — A Medical Curriculum on Adverse Childhood Experiences and Trauma Informed Care in Medical Practice ­— to the Board of Directors of the PBCMS&S at the headquarters of Palm Beach County Children’s Services Council. The lecture was preceded by a presentation by Lisa Williams-Taylor, Ph.D., CEO of the Children’s Services Council, on their evidence-based work. Note: See page 9 in this issue for a Spotlight feature on the Children’s Services Council. The UMMSM innovative, highly selective and interdisciplinary program of 50 students (out of more than 8,000 who applied) integrates significant components of the MPH coursework into the MD curriculum and allows students to obtain both their medical and public health degrees in four years. During this time students complete a community-based Capstone project (which requires at least 1,000 hours over one full year of work) and spend part of their clinical years at the regional campus in Palm Beach County working with public health physicians and preventative medicine residents in clinical and public health activities. ACES Play Huge Role in Prevention We were delighted when Ely chose ACES – Adverse Childhood Experiences and Trauma Informed Care in Medical Care for her Capstone. This topic was suggested by several members of the PBCMS&S Board, because ACEs in childhood Continued on page 14

trauma informed lens, especially for the youngest and most vulnerable children, can help change the trajectory of that child and families’ lives. Now that we have incorporated the ACEs into the equation, that trauma-informed lens is further sharpened; how having a parent in prison, witnessing domestic violence; The Good News having an alcoholic or drug addicted parent; having been physHowever, the news is not all bleak. People who have experi- ically, sexually, or even emotionally abused; having been the enced significant adversity (or many ACEs) are not irreparably product of a divorce no matter how young, can create mental damaged. There is a spectrum of potential responses to ACEs and physical problems down the road and profoundly affect and their possible chain of developmental harm that can help brain development. But the good news, if we, in the judiciary, in a person recover from trauma caused by toxic stress. collaboration with our community partners, can recognize these Locally in Florida and nationally there is an enormous factors early on, we can break generational cycles and heal the amount of research, collaboration and work being implement- child and the family. That is what is so exciting about initiatives ed to overcome the harm caused by ACEs. such as early childhood court, which seeks to do exactly that.” Florida Supreme Court Justice Barbara Pariente, a staunch advocate for ACEs training within Florida courts, stated, “Our Quantum Foundation Has Leading Role judges see the effects of trauma on individuals every day, most In Palm Beach County, the Quantum Foundation has taken a importantly in cases involving children and families, from de- strong leading role in collaboration with the county, Children’s pendency to delinquency to dissolution of marriage to domestic Services Council (CSC), the school district, the Sheriff, other violence. Our ability to view the children and families with a Continued on page 14

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Continued from page 12

foundations, government and non-profit agencies to address ACEs in Palm Beach County. Quantum Vice President Randy Scheid explains Quantum’s intense focus, “There is a strong correlation between ACEs, poor health outcomes, and an increased risk for disease. Individuals with a high number of ACEs are also more likely to engage in negative health behaviors. These are very

Elaheh (Ely) Niroomand University of Miami Miller School of Medicine (UMMSM) candidate for the Doctorate of Medicine and the Master of Public Health (MD, MPH) degrees, Class of 2019, and a PBCMSS 2018 Hero in Medicine Medical Student.

Continued from page 12 and infancy play a huge and unrecognized role in adult disease and morbidity. ACEs represent “the most important opportunity for the prevention of health and social problems and disease and disability that has ever been seen,” according to Vincent J. Felitti, MD, internist and former Director of Preventive Medicine for Kaiser Permanente. Niroomand added critical topics of ACES and Opioids, Self-Care for physicians and health care workers, and Resilience to her curriculum. Niroomand received her BA degree in Public Health from the

costly conditions. In order to mitigate the impact of ACEs on individuals and the health system, we are promoting the development of education and awareness of ACEs, their impact, along with the development of opportunities to mitigate the impact of ACEs on the health of individuals. For additional resources and several more important charts and graphics, please go to https://www.pbcms.org/aces-adverse-childhood-experiences.

Elaine Alvarez Board Member, Palm Beach County Medical Society Services; Chair, ACEs Task Force. Founding Board Member and a Founding Chair, Children’s Services Council of Palm Beach County. Board Member, Florida Children’s Services Council. Founding member of the original state association for all children’s independent districts in Florida.

University of California, Berkeley, with honors. While at Berkeley, she interned in the Clinical Transformation Team at Cedars-Sinai Medical Delivery Network in Beverly Hills, CA. There she worked with the VP of Clinical Transformation and project managers to design and launch two Telehealth pilots, collaborated in creating workflows, evaluation plans and staff training materials. Exceptional Volunteer Experience As an MD/MPH student at UMMSM she has gained field Continued on page 15


Continued from page 14 and global health education and experience working with Child Family Health International in Cordoba, Argentina. She is one of five students who ran San Juan Bosco Clinic in Miami, a student-run health clinic that provides specialty care to uninsured patients. As the Professional Liaison she recruited more than 25 new physicians from different specialties to volunteer in the clinic, served as a Spanish medical interpreter and patient advocate. She was a founder and officer of Healthy Hospitals for You, a student organization committed to creating a Health District environment that promotes nutrition and wellness as preventive medicine. She designed a phone health application called UM EATS, which includes nutritionistapproved, healthful and affordable food options, locations, hours, menus for patients, their families, staff, and students at the Jackson/ UM Medical campus. While at UMMSM, Niroomand has been recognized for membership in several honor societies including Alpha Omega Alpha National Honor Society and also earned membership in the Gold Humanism Honor Society. The PBCMS&S Connection Niroomand’s Capstone Project Site was the Palm Beach County Medical Society and Services. I was honored to serve as her community partner, and her local review team included Brent Schillinger, MD; Ivy Faske, MD; and Gaetana Ebbole, retired CEO of Children’s Services Council of Palm Beach County.

Cost-Saving Benefit for PBCMS Members Group Health Insurance Offers a Range of Benefit Levels

Palm Beach County Medical Society offers the BCBS INSURANCE TRUST FUND, an exclusive, association-type health insurance opportunity to physician practices in Palm Beach County. The plans provide affordable health insurance to member employer-physicians, their full-time employees, and their families. It offers comprehensive plans and a range of benefit levels. The Trust Plans have both traditional plans and High Deductible Health Plans (HDHP) that utilize Health Savings Accounts (HSA). All plans are BCBS Blue Options Network plans (Their all-encompassing National/International network). There are no “gatekeeper” or “managed care” plans. The Trust Plans are a Co-Op/Association-type plan, where the members merge assets together to create a larger group, thereby reducing expense renewal costs and securing coverage for catastrophic claims to create a safety net to curb future increases. Other similar plans for physician offices have established reserves for future rate increases, and have dispersed cash refunds to physicians, and capitalized on the Federal MLR rebates mandated since 2011. The pricing structure alters the traditional age-based pricing for small groups (under 10 employees), thus giving younger, healthier employees an incentive to enroll and remain in the plan. If you are interested in receiving a proposal for your group, please reach out to Barry Levi or Jeremy Cohen of Levi & Assoc. Insurance at 561-353-1234.


Wellness

Preventing Burnout

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How Resiliency Skills Help Physicians By Sarah Steele

whopping 78 percent of physicians have experienced feelings of burnout, according to the 2018 Physicians Foundation survey. The AMA Steps Forward module “Preventing Physician Burnout” defines burnout as “a long-term stress reaction characterized by depersonalization, including cynical or negative attitudes towards patients, emotional exhaustion, a feeling of decreased personal achievement and a lack of empathy for patients.” Yikes. That doesn’t sound like a doctor any of us want to treat our loved ones. Physicians are viewed as role models, whether they intend it or not. If they aren’t addressing their own health,they’re not being good role models for their patients, colleagues or family.

The Good News

The good news is that despite 90 percent of physicians feeling they have no impact on the health care system, research shows that developing personal resiliency skills has a positive impact on burnout — and that’s completely within a physician’s control. The AMA notes that physicians who practice resiliency are better equipped to handle their many challenges and are less likely to experience burnout. It describes resiliency as “The capacity to recover from difficulties, the ability to spring back into shape or the ability to withstand stress and catastrophe. We can also deliberately enhance our resiliency by learning self-management skills and connecting with the meaning and purpose in our lives.”

The Nine Elements of Resiliency

In their research, TRACOM Group® identified nine elements of resiliency. Here’s a quick look at each. 1. Personal Responsibility is the belief that you control your own destiny with successes or failures determined by your own talents and motivations, rather than luck or fate. 2. Realistic Optimism is expecting the future to be good while realizing that challenges will arise. This crucial aspect of resiliency instills motivation while allowing one to anticipate and plan for challenges. 3. Personal Beliefs is the sense that life has meaning and purpose. This may take the form of religion, spirituality, or a sense of connection to causes you believe in. Bennet Omalu, MD, MBA, MPH, a forensic pathologist who discovered chronic traumatic encephalopathy (CTE), says,

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“Don’t let your job as a physician consume you and define who you are. You are who you are with or without medicine, and come what may, you are you. You must learn to be yourself and be happy being yourself.” Compare where you are spending your time and money to your core values and beliefs. Is there a mismatch? What is the legacy you want to leave behind? 4. Self-Assurance is a belief in yourself (without slipping into arrogance). You have confidence in your ability to handle challenges.

“Feeling like you made a difference in someone’s life is the best antidote to burnout.” Barbara McAneny,MD, AMA President

5. Self-Composure is the ability to manage stress and remain calm, dealing with challenges rationally without allowing emotions to rule. Ronald Vender, MD, professor of medicine and chief medical officer at Yale Medicine, cautions, “Burnout typically results from unrelenting stress, so I encourage my colleagues to regularly self-evaluate their stress levels and their sense of work-life harmony. If you are finding yourself experiencing more stress, you need to intervene before burnout develops. If burnout has developed, you need to recognize it and begin the process of dealing with it. Spend more time with your loved ones. Make sure you are exercising, and spend some time in nature at least once a week.” 6. Problem Solving is the ability resolve problems effectively by gathering information and planning carefully, using reason, logic, and creativity. Barbara McAneny, MD, a board-certified medical oncologist/hematologist and president of the AMA, credits the success of solving problems for the last 20 years of being managing partner and seeing patients has helped her avoid burnout. “Feeling like you made a difference in someone’s life is the best antidote to burnout,” she confirms.


7. Goal Orientation is setting appropriate professional/per“Each small step toward sonal goals, monitoring progress and adjusting behavior accordingly. Fatima Cody Stanford, MD, MBA, MPH, an improving resiliency obesity medicine physician scientist at Massachusetts will help reduce the risk General Hospital and Harvard Medical School, makes a commitment to make it to her gym class despite her of burnout, benefiting 80-plus-hour workweek. She said, “While I am certain I physicians, their families still have some burnout, this has helped to mitigate much of the burnout that I inevitably experience in a very rigorand their patients.” ous environment. I do realize that we are conditioned to Sarah Steele MBA, Chief Energy Officer put everyone before ourselves. I have been guilty of this, and I continue to strive to create work-life balance in the when you know and like the people you work with and, midst of what often seems to be work-work balance.” in parallel, outside the hospital having family to re-center 8. Courageous Communication is the tendency to comme — or friends to decompress — served as my medicine municate in a candid, respectful and courageous way. You to stay healthy,” said Tina R. Shah, MD, MPH, a pulmonary freely and effectively share ideas, ask difficult questions, and critical care physician, and the AMA’s 2018 Dedication and address problems directly. This may include the need to the Profession Award Winner. “It’s OK that you are feelto ask for or offer help. Robert Wachter, MD, chair of the ing burned out. Chances are, most of your colleagues are Department of Medicine at San Francisco School of Medtoo. The first step is to acknowledge it. Seek community Medicine solution.” icine, says, “This is a hard job and people will generally and support because it’s not a one-size-fits-all FINANCIAL be understanding and will pitch in to get you through Physicians also can seek professional help and connect Protection it. Wachter says when he was going through a difficult with local resources such as the PBCMS Physician WellInvestment PLANNING time, a wise friend gave him the best advice ever.“ ‘There ness Program thatFOR offers confidential counseling. Wealth is nothing in your life that is so bad that you can’t make Each small step toward improving resiliency willCreation help reduce TODAY'S Retirement it better.’ That may not be true in the very short term, but the risk of burnout, benefiting physicians, their families and physicians have lots of options, including taking time off.” their patients. HOSPITALIST 9. Social Support is feeling part of a supportive network and having close confidants you can turn to during diffi- Sarah Steele, MBA, Chief Energy Officer, Coach, Keynote, Change Agent. cult times. “Long hours in the hospital are more enjoyable Contact: sarah@sarahsteele.com, www.sarahsteele.com. Call 561-703-6809.


Financial

It’s Time to Review Your Life Insurance Policy

Think of an Annual Analysis Like Your Yearly Physical

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By Howard Wolkowitz

o you get a physical once a year? Do you bring your car in for service once a year? Do you have your life insurance independently reviewed once a year? A life insurance policy is a legal agreement between the insurance company and the owner of the policy. Very often it has provisions and options that must be managed. If not, the owner of the policy can lose valuable rights given to them. Often, after the policy is purchased it goes into a draw. For example, many term policies have very specific dates to

increased or your need for a particular type or amount of coverage may have changed. Since there are so many life insurance companies offering their own contractual obligations, it is very important to independently review your contract. You go to the dentist because you can’t see under your gums, you go to your doctor because you can’t see inside your body, and you have your life insurance policy reviewed because you can’t see the internal costs of your policy. Contact Howard Wolkowitz at HWolkowitz@mycoastalwealth.com or 954-558-3673.

“Since there are so many life insurance companies offering their own contractual obligations, it is very important to independently review your contract.” Howard Wolkowitz, mycoastalwealth.com

convert to a permanent policy without evidence of insurability. Many policy owners miss this window due to a lack of paying attention to important dates. All life insurance policies are based on assumptions outlined in a multiple-page illustration. Sometimes these illustrations exceed 30 pages. Do you think this is because they want to protect you or themselves? The answer is both. The assumptions are current or projected earning rates, mortality and expense costs, payment amounts and timing of payments and medical underwriting ratings.

Things Change From Year to Year

Since you purchased your policy, your health may have improved. For example, you may have stopped smoking, the earning projections may have decreased, you may have under-funded the contract, the internal expenses may have

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Opinion

Online Physician Reviews Are Often Misleading Add Positive Reviews for Balance

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By Steven E. Reznick, MD, FACP

colleague of mine asked me to write an article about physician reviews and care provided by doctors. I first became aware of social media and physician reviews when a marketing executive I work with asked me to establish a Facebook page and become a member of an online social media advertising group that you must pay an annual membership fee to access. So we joined this famous list and waited to see what happened. The first review was written a few weeks later. It was from an individual living out of our service area who complained about not being able to get an appointment to see me. The patient’s name and local city were listed on the review so, not recognizing the name, I looked her up in my electronic health system.

OnCall

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It turns out she could not get an appointment because she was not my patient. My office supervisor called her and asked her why she wrote a negative review about a practice she was not a member of and about a doctor she had never seen? We called the website she was using and explained the situation. They said she cannot retract the article nor can they pull it. Thus, the negative review remains online. My marketing guru said, “We need some positive reviews to balance this.” He asked for the names of satisfied patients, and after I contacted them for permission, he contacted them. They wrote testimonials based on their experiences. I suspect this is what happens with most online physician reviews. Dissatisfied and misinformed individuals are more likely to take the time to write a review. The satisfied patients have no need to and rarely write one until asked. If you wish to find a doctor, I suggest you ask a friend who they use and if they would recommend them and why. Next call the medical staff office of the hospitals where the physician has privileges. Ask them to verify the doctor’s active staff status and credentials. Call the county medical society and do the same. If you have the need to go online, access the National Practitioner Data Bank, which lists medical malpractice suits settled for $10,000 or more. You also can check with the state medical board and inquire about any disciplinary actions against the doctor. I suggest you call the physician’s office and see how the phone is answered. Ask to speak to the office manager and inquire whether the doctor ever meets perspective patients in advance for a meet-and-greet visit. I would ask if the doctor sees and cares for their patients when they are hospitalized. Many doctors today only see patients in the office. I would ask about who covers for the doctor if the doctor is away or ill. I might ask if the doctor will see you in the rehabilitation facility if you are recovering from an illness. These suggestions are far superior to reading the online reviews. Online reviews can be very misleading and, in some instances, completely inaccurate. Board Certified in internal medicine, with added qualifications in geriatrics, Dr. Reznick has practiced in Boca Raton since 1979. For information about his

For more information, Call Susan Fell, Wyckoff Fell Associates, 561-602-4595 or email swfell129@gmail.com

concierge medicine practice or to schedule a complimentary meeting with Dr. Reznick, call561-368-0191or visit www.BocaConciergeDoc.com.

OnCall • Q4 2018 19


Legal Issues

The Case Against Cloning Medical Records

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Copying and Pasting Patient Notes Can Be Disastrous By Jacqueline A. Bain, Esq.

he transition from paper medical records to electron- ministrative Contractor in the State of Florida, has stated that ic medical records has brought with it many conve- cloning “will lead to denial of services for lack of medical niences and some unintended consequences. One necessity and recoupment of all overpayments made.” example of an unintended consequence is cloning in Imagine if you are working for an insurance company and the medical record. Cloning is copying and pasting previously repeatedly see multiple lengthy visits with the same record recorded information from a prior patient note attached, or maybe one or two extra sentences into a new patient note. at the end. Wouldn’t you question whether the Providing quality medical care is only one part physician had a meaningful encounter with the of the job. Appropriately documenting that care patient? Would you be able to tell the substance of in order to be paid for your efforts is another. the physician’s interaction with the patient from And while medical professionals are trained at the cloned note? length to provide care, hardly any are aware of Even Federal courts have taken aim at cloning the potential pitfalls associated with improper in medical records. Last year, the 11th Circuit documentation. Court of Appeals (which has jurisdiction over In late 2015, CMS advised that cloning “is a the State of Florida) affirmed a conviction for problem in health care institutions that is not health care fraud, noting that “therapy notes were broadly addressed.” CMS specified that cloning copied and pasted from one session to another records may indicate fraud, waste and abuse in inso that patients’ files contained multiple versions Jacqueline A. Bain, Esq. quiries and audits and that each part of a “medical of the same notes.” The court inferred that the record must contain documentation showing the differences duplicate notes were created in an effort to cover for services and the needs of the patient for each visit or encounter.” not actually rendered. So, what’s the problem? Copying and pasting prior information does not indicate why a patient has presented for a sub- Cloning Can Result in Dire Consequences sequent follow up. A cloned record doesn’t indicate whether Failing to take the time (between patients, at the end of the the doctor had a meaningful interaction with a patient, and day, after business hours) to accurately document each patient it doesn’t reflect the often in-depth discussions that a medical encounter can lead to potentially devastating consequences. professional has with his/her patient which would lead to a From not getting paid for services rendered, to being required diagnosis and treatment. to pay money back even after it is paid, to an implication that Moreover, cloning calls into question the legitimacy of the your services were rendered in a fraudulent fashion, please record itself. “Medicare contractors have noted an increased come away from this article knowing that cloning is not a good frequency of medical records with identical documentation idea. Make an effort to ensure that your records document across services.” How can a physician substantiate the time each unique patient encounter in order to avoid this scrutiny. spent with a patient if each note is identical to the last? MACs have started to deny payments on the grounds that cloning Jacqueline A. Bain, Esq. is part of a highly select group of Florida licensed is a “misrepresentation of the medical necessity required for attorneys with both deep healthcare industry experience and a certification in services rendered.” First Coast, which is the Medicare Ad- healthcare compliance by the Health Care Compliance Association.

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Education

An Alternative to Opioids Virtual Reality for Pain Management By Miranda Felde, MHA, CPHRM

I

n 2016, the opioid epidemic’s toll hit $95 billion, with Mitigating VR Patient Safety Risks health care costs concentrated in emergency room visits, While therapeutic VR for pain management shows promise, hospital admissions, ambulance use, and Naloxone use. there are patient safety risks. They include: The personal costs to those who have lost loved ones • Falls. Patients wearing a full-surround headset cannot are uncountable. The epidemic’s impact is far-reaching and see their real-world environment and may walk into or has emotional, physical, and financial implications for our trip over objects. entire society. • Motion sickness. Many people experience some combiMany physicians are exploring VR technologies as an alnation of eye strain, headaches, and/or nausea. Patients ternative to prescriptions. The Gate Control Theory of pain, who are ordinarily prone to any of these symptoms may proposed by Melzack and Wall, suggests that a person may not be good VR candidates. interpret pain stimuli differently depending upon mental/ • Psychological effects. The brain can store VR experiences emotional factors such as attention paid to the pain, emoas memories in almost the same way it stores physical tions associated with the pain, and past experience of the pain. experiences. Young children, especially, may confuse VR VR addresses both attention paid to pain and the patient’s experiences with real experiences, especially when reemotional state. membering them later. • The unknown. VR technology is still in its infancy, and Getting Started With VR therefore, little is known about the long-term conseTo explore VR as an alternative therapy, first consider the quences of VR use. distinctions between two key terms. • Virtual Reality (VR). Provides an immersive experience The Future of VR for Pain Management via a computer-generated 3D environment for the user to To reap the potential benefits of VR while mitigating its explore. The user may be able to move objects or other- risks, clinicians could start with a two-part approach: idenwise change the environment. tifying patients with specific clinical indications that would • Augmented Reality (AR). Adds sounds, videos, and/or benefit from the use of VR and assessing patients for potential graphics to an existing environment, such as an outdoor risk factors. Successful implementation of VR for pain manplanetarium where AR viewing glasses show constella- agement depends on wisely deciding which patients are VR tions highlighted in the sky. candidates — and which are not. Then, evaluate VR interfaces that are relevant for patients managing pain, such as: Miranda Felde, MHA, CPHRM, • Head-mounted display (HMD). Like a heavy-duty pair Vice President, Patient Safety of goggles plus headphones. Completely surrounds the and Risk Management user’s visual field for an immersive experience. The Doctors Company • Treadmills and haptic gloves. Allow the user to physically www.thedoctors.com/patientsafety move around in the virtual environment and to physically move objects within that environment. Article contributed by The Doctors Company. And weigh the value of interfaces that are more relevant for The guidelines suggested here are not rules, do physician use, such as: not constitute legal advice, and do not ensure • Smart glasses. May look more like regular eyeglasses a successful outcome. The ultimate decision or more like safety glasses. May display information or regarding the appropriateness of any treatment help the physician capture information for the electronic must be made by each healthcare provider in light health record (EHR). of all circumstances prevailing in the individual • Desktop VR or Window on a World (WOW). Uses a situation and in accordance with the laws of the desktop or laptop computer to run simulation programs. jurisdiction in which the care is rendered.

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Q4 2018 • OnCall


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