THE OFFICIAL PUBLICATION OF THE PALM BEACH COUNTY MEDICAL SOCIETY
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WHAT WILL OUR LEGACY BE? As I sat on a plane a couple weeks ago, I began to think about my legacy. I was returning to Florida from California following the celebration of life for my Mother, Vivien Duncan, who passed away 2 days after her 90th birthday. In giving her eulogy, I’d prepared remarks about her life and all that she had accomplished. Her life was so impactful and purposeful, and she conquered so many causes as an educator, civil rights activist, world traveler and philanthropist. It left me wondering if I was doing all that I could to “lift as I climbed,” help others and create a positive and meaningful legacy. We’ve all spent many years training, have personally sacrificed and experienced delayed gratification to become physicians. It is true that everyday we make a difference in the lives of our patients and community. But, what do you want your legacy to be? I think that should be a broader question for us all. Each of us should develop clarity on our own personal mission statement. I became involved with the Palm Beach County Medical Society because I wanted to defend and protect the practice of medicine for all doctors in Palm Beach County and to champion fair and equitable healthcare for all. The Palm Beach County Medical Society was formed in 1919 by a group of local physicians who understood that their collective efforts would make the practice of medicine for physicians more sustainable, and provide a higher quality of care to the community. It was formed during the throws of the Spanish Flu, where thousands died state-wide. Now, some 100 years later, we are still together, and just as relevant to the COVID-19 pandemic with over 600,000 US citizens and four million deceased world-wide. Our legacy has to be to continue what our founders started and to collectively defend the honorable field of medicine and advocate for patient care. Organized medicine is very important to our continued survival as physicians. Gone are the days when one went to medical school, achieved their degree and
By Roger Duncan, MD 2021 PBCMS President
enjoyed the fruits of their labor. Our practice is under constant attack by outside groups who are lobbying state legislatures and successfully degrading the doctorpatient care relationship and intruding on the practice of medicine. I hope to be remembered for my efforts to get my colleagues to donate their resources, but more importantly their time, to redirect things in Tallahassee and Washington D.C. I hope to be remembered for my fights to protect proper reimbursement for my colleagues and advocacy for medical student loan indebtedness reform. We do indeed have to be at the table in deciding our future and direction or, we will, become the main course. I hope to be remembered for investing in our youth and helping to create a pipeline of healthcare providers. Following in the footsteps of my parents, I have spent the last 30 years giving back to the community. I have organized back to school health fairs for the underserved community, designed an annual year-long internship program for 8th graders at Good Samaritan Medical Center and designed and produced an annual Healthcare and Science Career Symposium, typically attended by some 1000 area-wide students and, at one such event, featured Dr. David Satcher, the former US Surgeon General, as the keynote speaker. My message to the students is that with, or without a stethoscope, you can make a difference in healthcare and science. I want to be remembered for taking the lead, even when it’s controversial. From advocating for early masks utilization and social distancing, to physicians being on the forefront of vaccine policy and distribution, as well as, guidelines for the appropriate use and distribution of medical marijuana. We have to lead on these issues in order to make Palm Beach County and South Florida, a healthier place for us and future generations. President’s Message continued on page 5 2021.Q3
TABLE of CONTENTS DEPARTMENTS
BOARD OF DIRECTORS
President’s Report Welcome New Members
FEATURES Chief Executive Officer of Palm Beach County Medical Society
By Kelly Skidmore, CEO PBCMS
What You Didn’t Learn in Medical School PLA Teaches Physicians Critical Leadership Skills By Karen Harwood, Director of Community Programs
BOARD OF TRUSTEES
Future of Medicine Maintaining Excellence in Times of Crisis
Reducing Physician Burnout: The Role of HealthCare Systems
By Stefan A. Pasternack, M.D. DLFAPA
How did COVID-19 affect your teaching/education? By Stuart J. Bagatell, MD FACP
Alternative Treatments and Teamwork to Improve Recovery Rates By Paul Pellinger, CAC, Lizabeth Olszewski, Erin Dorval
Seven Tips for Telehealth Clinical Documentation By Sue Boisvert, BSN, MHSA, Patient Safety Risk Manager II, The Doctors Company
Women in Medicine Celebration Dinner
Upcoming Events Save the Date
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 2019 Palm Beach County Medical Society, Inc. OnCall Journal is designed and edited by Mad 4 Marketing. Visit us on the web at mad4marketing.com 954.485.5448
Roger Duncan, MD – President Claudia Mason, MD – President-Elect Dawn Davanzo, MD – First Vice-President Martha Rodriguez, MD – Secretary Andrew Berkman, MD –Treasurer Larry Bush, MD – Immediate Past President Ayesha Abid James Heron, MD Rena Amro, MD Marc Hirsh, MD Jose Arrascue, MD Krishna Kishor, MD Stephen Babic, MD Ekaterina Kostioukhina, MD Shawn B. Baca, MD Catherine Lowe, MD Colette Brown-Graham, MD Harish Madhav, MD Ramon L. Cuevas-Trisan, MD Alan B. Pillersdorf, MD Kleper de Almeida, MD David Shulan, MD Michael Dennis, MD Ali Syed, MD James Goldenberg, MD Charles Szuchan Gregg Goldin, MD Justin Williams, DO Faustino Gonzalez, MD Jack Zeltzer, MD Henry M. Haire, MD Brandon Luskin, MD Marc J. Hirsh, MD Larry Bush, MD Alan Pillersdorf, MD Mark Rubenstein, MD Jack Zeltzer, MD Jose F. Arrascue, MD Chair Roger Duncan, MD Claudia Mason, MD Dawn Davanzo, MD Martha Rodriguez, MD
BOARD OF DIRECTORS Ivy Faske, MD – President Matt Gracey – Vice President Stuart Miro, MD – Secretary Paul Wieseneck – Treasurer Michael Dennis, MD – President Emeritus Jean Acevedo Elaine Alvarez Jose F. Arrascue, MD Brenda Atkins Don Chester Madelyn Christopher Ljubica “Jibby” Ciric John Dalton Gregg Goldin, MD James Heron, MD
Barbara James Andrew Larson, MD Roshan Massoumi Alan B. Pillersdorf, MD Brent M. Schillinger, MD Mollie Shulan, MD Ben Starling III Maureen Whelihan, MD Jack Zeltzer, MD
Kelly Skidmore – CEO Deanna Lessard - Director of Member Services and Physician Wellness Karen Harwood – Director of Community Programs Mindi Tingler – Director of Communications Katherine Zuber - Director of Membership Development & Events John James - Director of Public Health & Disaster Services
PALM BEACH COUNTY MEDICAL SOCIETY WELCOME NEW MEMBERS Rian Pillitteri MD Emergency Medicine
Scott Gasiorek, MD Radiation Oncology
JoEllen Brown, MD (Semi Retired-Part Time) Emergency Medicine
Vincent P. Miraglia, MD Urology
Yefim Cavalier, DO (Retired)
Christopher Gregory Rao, MD Family Medicine
Mary Chryssiadis, MD (Retired)
Harvey B. Uano, MD (Retired)
FINANCIAL Tiffany Protection Amanda Weakley, MD Luanne Codella, MD Internal Medicine Investment PLANNING FOR Internal Medicine Wealth Creation TODAY'S Retirement For membership information HOSPITALIST contact Deanna Lessard at firstname.lastname@example.org or 561-433-3940 x105.
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Continued from page 2 President’s Message by Roger Duncan, MD
I hope to be remembered for being a truth bearer and vocal against misinformation and dis-information on the internet or social media regarding COVID-19 and vaccinations. We are still facing a public health emergency amongst the unvaccinated community as reflected by the fact that 97% of all recent COVID-19 deaths are in unvaccinated individuals. The highest incidence of new cases lies with the “Invincibles,” the folks in the 20-40 age range, who have low vaccination rates and low compliance with public health measures such as masking and social distancing. Especially with the Delta and Lambda COVID-19 variants, we have to be the ones who speak with authority and knowledge to curb the spread and this behavior. Last, but certainly not least, I want to be remembered for bringing continued awareness to true cultural sensitivity and appreciation in the practice of medicine. Study after study has shown that greater cultural sensitivity and understanding leads to greater patient compliance and better healthcare outcomes which lowers healthcare costs for all. All of us can, and should, have our own individualized vision of what our legacy should be. Over the years, I have
been heartened by the long history of leadership and service of some of my colleagues like, Services Board members, Drs. Michael Dennis and Jose Arrascue and Board of Trustees member, Dr. Alan Pillersdorf. Dr. Michael Dennis has been instrumental in the creation and direction of the FAU Schmidt College of Medicine and has even paid the membership dues for all of the students to become members of the Palm Beach County Medical Society. He has also created the Physician Assistant program at Stanford University and has traveled the world, conducting for free, thousands of operations to repair cleft palates and other deformities. Dr. Jose Arrascue has championed the Triple AIM Initiative which has increased the level of healthcare for all in the community. Dr. Alan Pillersdorf’s tireless leadership and involvement on legislative matters in Tallahassee, Washington D.C. and with the various medical societies (at all levels) has provided us with a voice and influence on outcomes. Each has pursued a different path in creating a meaningful legacy. As I salute both my Mother and Father, I strive daily to make a lasting and meaningful legacy! One patient at a time, one child at a time! I challenge you to establish your legacy. We are all here to make Palm Beach County and South Florida, a healthier place.
STETHOSCOPE DONATIONS THANK YOU The Palm Beach County Medical Society is supporting the Florida Atlantic University Charles E. Schmidt College of Medicine incoming class of medical students with the presentation of a new stethoscope at their “white coat” ceremony. Thank you to the following who have so graciously donated money to support our incoming FAU medical students. Patricia Anastasio, MD Jose Arrascue, MD Stephen Babic, MD Jeffrey Mark Berman, MD Larry Bush, MD Anthony Campo, MD Yefim Cavalier, DO David Dershewitz, MD Howard Doyle, MD Roger L. Duncan, MD Judith Dunn Ivy Faske, MD Allison Ferris, MD Joseph P. Goldberg, MD Howard Goldman, MD Mark A. Goldstein, MD Faustino Gonzalez, MD
Kwamena Goodin James Heron, MD Marc Hirsh, MD Reuben M. Hoch, MD Gordon L. Johnson, MD Stuart Katz, MD Kitonga Kiminyo, MD Joseph Z. Krause, MD, PA Ricardo A. Leano MD, MBA Claudia Mason, MD Casandra Mateo, MD Medical Specialists of the Palm Beaches Tom Murphy Vicki D. Norton, MD Stefan A. Pasternack, MD Alan Pillersdorf, MD
Scott Raffa, MD Phillip Scott Rice, MD PhD Martha Rodriguez, MD PA Mark Rubenstein, MD Zbigniew Scheller, MD Brent M. Schillinger, MD Debra A. Schwinn MD David Shulan, MD Mollie Shulan, MD Kelly Skidmore Joshua Solano, MD Ben Starling III Mark Stein, MD Rowena G. Uy, MD Maureen Whelihan, MD Dr. Michael & Mrs. Denise Zeide Jack Zeltzer, MD
CHIEF EXECUTIVE OFFICER OF
PALM BEACH COUNTY MEDICAL SOCIETY By Kelly Skidmore CEO PBCMS
As one of five siblings, I recall with clarity just how excited my parents were for the start of the school year when I was a child. Summers in South Florida were filled with long, languid beach days, fun-filled pool days, multi-night sleep overs on docked boats with friends, and memorable road trips in the family station wagon. In retrospect, keeping us busy, entertained, safe, and on track with the summer reading list must have been exhausting work for them. In equal measure, my siblings and I often lamented the end of summer and worried about the upcoming academic year, yet anticipated a welcome return to the routine, seeing our friends, attending football games, decorating floats for the homecoming parade, and preparing for prom, (depending on our grade level), while my wearied parents longed for a modicum of peace and quiet at home. I imagine today’s families are experiencing the postpandemic juxtaposition of a completely new level of appreciation and consternation for in-person classes and reuniting with friends while congregating in classrooms, hallways, cafeterias, and bleachers. Having spent 2020 and parts of the 2021 school year at home and in virtual classrooms online, many students and faculty will be adjusting to being in close proximity to each other, some with masks and some without, some with vaccinations and some without, based on personal beliefs as well as age eligibility. There is also something known as the COVIDslide, which is similar to the Summer-slide, where some students regress when outside of the classroom setting where there is more oversight and accountability, putting into question whether students will return to school on grade level. Throw in the more highly contagious delta variant, plus others as they may appear, and anxiety increases exponentially. Guidance is available! The first day of school is no time for a Manic Monday. As always, planning and preparing in advance reduces stress on the whole family. For example, parents can begin by first discussing and then implementing
new schedules that ease their kids into earlier bedtimes and wake times, which add up to a good night’s sleep. Timely shopping for necessities eliminates the hectic hustle-bustle of searching for required supplies and coveted trends, and stocking up on easy, nutritious breakfast items reduces the burden of leaving the house on time to catch the bus. These standard suggestions are meant to decrease the normal pressures and tensions of back-to-school so that the additional concerns surrounding COVID-19 safety and hygiene become more manageable. The American Federation of Teachers understands inschool learning is a priority and creating a welcoming and safe environment that is grounded in common sense and science is paramount. The Centers for Disease Control agrees and advises that unvaccinated students, whether under age 12 or by choice, wear a mask in the classroom to reduce the risk of transmission. Not without its controversy, this policy varies across the country and within school districts but is perceived as a critical part of the multi-layer approach needed to keep students healthy. Additionally, the CDC recommends students maintain a three-foot physical distance whenever possible. Hand washing, cleaning, disinfection, enhanced ventilation, as well as testing and tracing are important layers of prevention to keep schools safe. Finally, students, teachers, and staff should stay home when they show signs of any infectious illness and should see a doctor for care. In addition to the traditional excitement and expected trepidation of going back to school, the 2021-22 school year does present some new challenges, concerns, and risks to families. With careful planning, open lines of communication between parents, children, and educators, and with strict adherence to prevention, however, students have every chance of enjoying a healthy, happy, and successful academic year. For more information, contact Kelly Skidmore at kellyspbcms.org or call 561-433-2940. 2021.Q3
What You Didn’t Learn in Medical School
PLA TEACHES PHYSICIANS CRITICAL LEADERSHIP SKILLS Vania Fernandez, MD was a member of the inaugural class of the Physician Leadership Academy (PLA) five years ago. Her experience was so life-changing that she chose to remain involved and is today the co-chair of the sevensession leadership development program offered through a collaboration with the Palm Beach County Medical Society Services (PBCMS) and the Broward County (BCMA) and Dade County Medical Associations (DCMA). Funded through a grant from The Physicians Foundation and endorsed by the Florida Medical Association, PLA is designed to support physicians who want to hone their leadership skills. Currently serving as president-elect of BCMA, Dr. Fernandez is a board-certified anesthesiologist and board certified, fellowship-trained interventional pain specialist with Hollywood-based Broward Spine Institute and Comprehensive Pain Management Center. “I was so excited to be part of the inaugural class and am now honored to be serving as co-chair of the program,” she said. “The program helped me to gain tools to better advocate for myself, my colleagues and our patients. Plus, it provides an opportunity to meet and network with other physicians who are interested in promoting and supporting our profession in the ever-changing healthcare arena.”
that opened his eyes to ways to be a more effective communicator. “It was very enlightening and useful,” he recalled. “We learned about how to speak in specifics and headlines and how to conduct more effective Zoom meetings. I had never thought about these areas before.” Dr. Fernandez agreed that physicians sometimes communicate in a scientific manner that is not easily understood by others outside the medical community. “We tend to stick to the facts on PowerPoint slides, and that can be difficult to follow and not very engaging when communicating ideas to others,” she said.
A member of the current class, Carmel Barrau, MD, is vice president of the DCMA and agrees that the program offers invaluable leadership skills development. “The program allowed me to polish and revamp my existing skills and learn new ones,” he said. “As doctors, we are accustomed to gathering a lot of scientific information but aren’t always good at serving it up in an easy-to-digest way.”
She also pointed to the presentation training as invaluable. “This topic isn’t taught in medical school, yet it is critical for being able to effectively get our message across to anyone, whether it be an administrator, a government official or a patient. If we want to make a difference, we need to embrace courses like these in order to enhance our ability to effect change,” she added.
Dr. Barrau, who is board certified in internal medicine and has practiced in Miami for more than three decades, pointed to sessions on media and presentation training
Having been a physician for more than 13 years and board certified in preventive medicine, Solaide Akintade, MD, a physician with Concentra in West Palm Beach, is
grateful to have this opportunity to learn about herself and leadership. She applied as soon as she heard about the program while completing her residency program in 2018 and is grateful to be a part of this cohort. “The program has allowed me to identify strengths within myself and appreciate them, and know how to work with others,” she said. “Topics like how to handle conflict resolution and resiliency were among the most valuable leadership areas for me. Especially during the pandemic, not everyone on the staff felt safe. Knowing how to encourage resiliency, help them stay the course and feel more appreciated went a long way in our office.” Dr. Akintade also pointed to the value of the session on culture. “It was very helpful to learn how to be more sensitive to how others think, to be more agile and try walking in the shoes of others so we can try to meet in the middle,” she explained. “That session allowed me to think differently and learn better ways to respond to others.” Dr. Barrau, who has extensive leadership experience with numerous volunteer roles, also pointed to the cultural session as one of his favorites. He is a co-founder of the Herbert Wertheim College of Medicine at Florida International University (FIU) and started a scholarship for minority students. He is also involved with the FIU Foundation and was appointed by the Governor to the state Board of Medicine, “A true leader must be well aware of his or her surroundings and be culturally competent,” he said. “You simply have to understand all of the various cultures to better communicate and support patients.”
In addition to the seven sessions, all PLA participants completed group projects. Dr. Akintade described her project as one of the highlights of the programs. Her group created a public awareness campaign, based on surveys, to help counter COVID-19 vaccine hesitancy. She hopes the campaign will be launched this summer and said, “We worked closely with the Department of Health in Palm Beach County to identify those groups that have concerns or lack of access so that they can make better informed decisions. This is an on-going need.” Since PLA began, 85 physicians have completed the academy, learning such topics as: understanding leadership styles and relationship building, advocacy and physician engagement, presentation skills, crisis management, cultural agility, innovative models of care and ethical leadership. Applications for class six will be available during the summer with sessions beginning in October. For more information, contact Karen Harwood, director of Community Programs at karenh@ pbcms.org or 561-433-3940, ext. 119.
THE 1919 SOCIETY Founding members of The 1919 Society Jose Arrascue, MD Clarence L. Brumback, MD* Michael Dennis, MD
Howard Green, MD Alan B. Pillersdorf, MD Brent Schillinger, MD Ida Sebastian, MD
J. John Goodman, MD & Judy B. Goodman, ESQ
The 1919 Society members listed below are present members of The 1919 Society Jose F. Arrascue, MD Henry Haire, MD Shawn Baca, MD Marc Hirsh, MD Jeffrey Berman, MD Alan Barth Pillersdorf, MD Larry Bush, MD & Maria Brent M. Schillinger, MD Vazques-Pertejo, MD Ida Sebastian, MD Michael Dennis, MD William Slomka, MD Malcom Dorman, MD Robert Tome, MD James Goldenberg, MD Maureen Whelihan, MD Ronald Zelnick, MD J. John Goodman, MD & Judy B. Goodman, Esq. Jack Zeltzer, MD Howard Allen Green, MD *Deceased
S AV E T H E DAT E 9 Q3.2021
MAINTAINING E CELLENCE in times of crisis
Thursday, October 7th • 6:00-7:00 PM
Friday, October 8th • 8:00 AM-12:00 PM
Members: $50 • Non-Members: $75 • Medical Students & Residents FREE Become a member of the Palm Beach County Medical Society before October 1st and receive a complimentary ticket to the event. QUESTIONS KATHERINE ZUBER KatherineZ@pbcms.org 561.433.3940 ext. 106 PBCMS.ORG
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Reducing Physician Burnout:
THE ROLE OF HEALTHCARE SYSTEMS By Stefan A. Pasternack, MD DLFAPA
Until recently the burden for dealing with and reducing burnout fell mainly on the shoulders of individual physicians. Burnout research was initially focused on the specific signs and symptoms of burnout and on rating scales which physicians could employ to assess their burnout level such as the Maslach Scale and the Oldenburg Inventory. These have helped physicians identify their stress levels and then take remedial actions. More recently clinical studies have emphasized specific measures physicians could employ to overcome burnout and foster resilience against recurrence. Physicians, especially those in private practices have benefited from a flood of information about stress in practice and burnout and how to cope optimally with the bureaucratic burdens imposed by insurance companies, government regulations, the Electronic Health Record, prior authorizations, pharmacy restrictions, clinical guidelines and the resulting progressive impingement on private practice. In spite of the ever-increasing stresses, physicians in private practice still were the “captain of the ship” with primary responsibility for patient care and treatment planning. Private practice physicians retain control over their office work sites, hours, any productivity issues, salary, benefits and staffing. They therefore have greater autonomy and can control practice patterns. Recently research has shown that the loss of autonomy is a major risk factor for burnout. Since “cognitive load” is a universal risk factor, reducing the task load even slightly- i.e., fewer patients, fewer hours more time off, a vacation when you want one, - the risk of burnout drops substantially. Just knowing you have the freedom to adjust your schedule if you choose to do so is empowering and lowers burnout risk. Being your own boss has some advantages. Now many private practice physicians have merged their private practices into healthcare organizations and more of the younger physicians who are just entering the work
force have taken positions in various hospital chains and health care systems. This now amounts to more than 50% of physicians. Increasingly physicians have less control over their working conditions. As the team approach to health care has progressed clinicians are no longer “the captain of the ship,” instead the leadership roles are filled by administrators and/or health care executives. Until recently many healthcare systems and organizations did not pay adequate attention to the problems of burnout. Recent studies have discovered many potentially damaging policies and procedures in healthcare systems that can foster burnout. We now must focus on the important role of healthcare organizations in finding and eliminating organizational risk factors for burnout. Since burnout is due to many factors beyond the physician’s control, more must be done at the organizational level. To help identify and ameliorate toxic work site factors that lead to burnout, the AMA has recently rolled out The Joy In Medicine Health System Recognition Program. This program is designed to encourage healthcare systems and organizations to invest in organizational practices and policies that foster physician wellness and to mitigate organizational and work site factors that lead to burnout. The Joy in Medicine Program establishes levels of award/recognition (Bronze, Silver, Gold) by the AMA for all healthcare systems that participate. Healthcare programs that participate will benefit from information and some assistance from the AMA in reducing burnout and in protecting both physician and patient well-being. All PBCMS members should be aware of these new programs. You should ask the hospitals, clinics and all health care organizations or physician employers with which you are affiliated to take part. You can learn more about the program on the AMA website.
THE SPECIFIC OBJECTIVES OF THE NEW AMA PROGRAM ARE TO: 1. Provide a road map for health system leaders to implement policies to support physician well -being 2. Unite the healthcare community in building a culture committed to increasing joy in medicine for the profession nationwide 3. Build awareness of solutions that promote joy in medicine and spur investment within health systems to reduce physician burnout It has been shown that a major stress factor leading to burnout is the loss of individual autonomy. While they still have the major responsibility for patient care, many employed physicians feel they lack authority and control over their caseload. Many feel they have not only lost control over their work environment, productivity and work schedules, but also over treatment decisions. The excessive focus on “evidence-based guidelines” often overlooks the importance of a physician’s judgement regarding treatment decisions as well as what type of treatment a patient prefers. Furthermore, managed care companies and pharmacy benefit companies often limit the types of medication a physician can prescribe or hassle physicians with seemingly endless demands for prior authorizations or onerous documentation. As a result, physicians experience a distressing loss of clinical autonomy. Similarly, since requests for MRI’s and CT scans and other specialized tests or treatments may be denied when insurance companies or HMO’s administrators second guess the physician, many physicians are caught in the double bind – if they do what they believe is best they may be penalized for not conforming to corporate guidelines and/or corporate policy. If they conform to guidelines against their own judgement, they lose personal integrity, feel devalued and their sense of well-being is compromised. This is a risk factor for burnout. Similarly, excessive productivity quotas and time limits per session undermine the physicians’ high ideals. Productivity quotas often interfere with medical professionalism and the Hippocratic tradition. The expansion of the business model as Wall Street “industrializes” medicine and as venture capital groups buy up specialty practices, further erodes professionalism and forces physicians to submit
to the medical “business model.” Time with patients is often limited so that both doctor and patient are frustrated because they cannot really develop a trusting relationship with which they can pursue health. To the extent that any healthcare system even appears to prioritize profits over quality care physicians in that system suffer a profound loss of professional identity and pride. As part of the new AMA Joy in Medicine program, the Collaborative for Health and Renewal In Medicine (CHARM) offers a Charter to strengthen health care systems and patient care by supporting physicians. The program is intended for health systems with 100 or more physicians but groups with less than 100 may engage in the AMA Steps Forward webinar series. Health care systems sign up with the AMA and submit information to be evaluated by the AMA according to the following criteria.
1. Commitment - organizational investment in establishing a wellness committee and/or well-being office
2. Assessment of physician well-being- via use of such assessment inventories as the Maslach Scale, Oldenburg Scale and May Clinic Well-Being Index/
3. Efficiency of the practice environmentwith organizational commitment to measuring the time physicians spend on the EHR after hours- a warning sign of organizational demand and provision of information technology training
4. Leadership with commitment to providing physician leadership development
5. Teamwork- establishment of teamwork metrics
6. Support demonstrated by establishment of peer support programs
Healthcare organizations must show that they care about the people involved in patient care. When physician’s burnout, their demoralization has an adverse effect on staff morale and patient care. Fortunately, more healthcare organizations are getting the message and taking steps to help reduce burnout.
Consider the example of the Southern California Permanente Medical Group (SCPMG)which took part in the new AMA Joy In Medicine program. SCPMG established a Wellness Officer, who reported that “taking part in the AMA program reinforces the importance of weaving the clinician experience throughout the organizational DNA and reiterates the fact that every part of our organization is responsible not only for patientcare but physician wellness.” Southern California PMG has been assessing physician well-being every three years, to carefully help physicians monitor themselves. SCPMG studies efficiency of practice to ensure that they are efficient enough during the day to go home and spend time with family, rejuvenate and preserve well-being. They have physicians who lead training to optimize other physician’s skills, thereby using the EHR to save hours each week instead of wasting time. Physicians spend up to 28 hours per month working on the EHR on nights and weekends. SCPMG also offers a variety of different support systems, including individual and group counseling and peer support to help people process feelings about their work and avoid burnout. Both the Massachusetts Medical Society and the Mass Health and Hospital Association have also focused on physician burnout. Dr. Steven Defossez from the Mass Health and Hospital Assn. emphasized that it is “important for people in the trenches to know that their leaders hear them, acknowledge burnout is a crisis and commit to improving it.” The Mayo Clinic is pioneering a new model designed to raise camaraderie and increase collaboration to reduce burnout among its physicians. The Mayo Clinic treated its physicians as the “architects in practice” designing new approaches rather than treat them as “construction workers” who were just following someone else’s plans. The Mayo Clinic involved its physicians in key leadership and decision-making roles. The first part of the Mayo program was establishing a formal listening forum to hear from physicians about the problems they encountered and helping physicians have some control of their daily and weekly schedules. The Mayo clinic allowed work flexibility and physicians felt their input was valued. The Mayo Clinic also did randomized, controlled studies with doctors regarding relationships with co-workers. Their studies showed that when physicians were provided opportunity to get together for a social activity and/or a dinner they felt closer to others and their burnout rates went down. The Mayo Clinic even paid for monthly evening dinner meetings to foster social connections among its physicians.
Health care systems and physicians can get further clarifications about these categories if they email Practice.Transformation@ama-assn.org for assistance. Medical societies and specialty associations are also in a unique position to address burnout. They can establish their own wellness programs to provide confidential individual or group counseling such as the Physician Wellness program at PBCMS. Medical Societies can also offer social activities and continuing education programs which foster a spirit of belonging to offset professional isolation. The PBCMS also maintains a “wellness library” of articles regarding burnout. It is available to all members. It is also time for physician groups and professional societies to develop measures by which to evaluate the performance of healthcare systems and the quality of the work environment they provide. For example, it would be helpful to a young physician who was seeking a job to know just how doctors who worked there rated the system’s policies about work hours, productivity quotas, vacations, sick or family leave time, salaries, the type of EHR used, support staff, supervisory experiences, adherence to terms of written contract, and opportunities for advancement and opportunities for continuing education. Since Medicare (CMS) already evaluates and publishes records of hospital performance to assist patients in selecting a system or medical center for their treatment, medical associations, professional societies or a professional group should do the same to help young physicians choose the best work site in which to practice. Physicians have a right to know what they are signing up for but often do not have access to relevant information. Unless healthcare organizations address problems of physician burnout, we may face a greater than expected shortage of physicians and/or the threat of physicians forming unions for assistance in dealing with large organizations.
References: Listed on the AMA Website: 1. Joy in Medicine Health System Recognition Program 2. AMA Steps Forward Webinar series on burnout Other sources: 3.Proceedings of the Mayo Clinic April 2020 4.” Physician Burnout – Contributors, consequences and solutions,” Shanafelt et al, J. Int. Medicine 2018.
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7/1/21 12:41 PM
HOW DID COVID-19 AFFECT
YOUR TEACHING/ EDUCATION?
PBCMS asked local medical educators, med students, and residents, “How did COVID-19 affect your teaching/education?”
“We have learned that we can use video conferencing platforms to interact with patients to teach standardized history-taking, communication skills, and components of the physical exam.” Gauri Agarwal, MD, F.A.C.P. Associate Professor Associate Dean for Curriculum University of Miami Miller School of Medicine
“I spent way more time at my computer than expected, and a state of flux became the new normal. But, I found fulfillment whenever possible.”
Sirpi Nackeeran Third Year Medical Student University of Miami Miller School of Medicine
“Every experience was drastically different from my expectations, but at the end of the year I feel competent in my skills moving into my next year.”
Allison Draper University of Miami Miller School of Medicine
“This pandemic has challenged the healthcare system more than ever before. Despite this, it brought hospital staff together in our efforts to combat this virus.”
Justin Williams Chief Resident Wellington Regional Medical Center, 2021-2022
“COVID meant isolation and loss. The new norm was breaking bad news to family members who had not seen their loved ones for months.”
Winta Assefaw Chief Resident Wellington Regional Medical Center, 2021-2022
“The hardest part of COVID was watching family’s say goodbye to their loved ones over the phone. It has made me more empathetic.”
Evan Stutchin Chief Resident Wellington Regional Medical Center, 2020-2021
“We transitioned to virtual lectures and exams, but we were still allowed in hospitals for the most part and saw a lot of patients.”
Charles Szuchan MD Candidate | Class of 2022 FAU Charles E. Schmidt College of Medicine
“COVID 19 forced us to reconsider why we all went into the practice of medicine in the first place. Concerns about personal safety and preserving personal protective equipment were sometimes in conflict with learning how to care for patients with a novel disease and sharing the workload with other physicians who did not have the luxury of limiting the number of COVID patients under their care.”
Stuart J. Bagatell, MD FACP Program Director University of Miami/JFK Medical Center Palm Beach Regional GME Consortium Affiliated Assistant Professor Department of Medicine, University of Miami Miller School of Medicine Dr. Bagatell, Dr. Dziadkowiec and Dr. Shaw
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Alternative Treatments and
TEAMWORK TO IMPROVE RECOVERY RATES Part IV of 2021 Opioid Educational Series for Physicians & Healthcare Providers Featured Insights on the Role of Pharmacists, Music-based Addiction Care and Equine Therapy in Supporting Patients with Substance Abuse Disorder
A patient at Recovery Unplugged (recoveryunplugged. com), a Fort Lauderdale drug and alcohol addiction treatment center, used lies to cover up his addiction and deal with most challenges in his life. Through a unique treatment approach using music, he listened to Billy Joel’s “Honesty” as a “recovery trigger” to remind him to make more positive choices. Paul Pellinger, CAC, the founder of this center as well as the Face the Music Foundation, shared this real-life story during Part IV of the 2021 Opioid Educational Series. He was one of three panelists who shared the value of unique treatment options, clear communications between Paul Pellinger, CAC providers and a closer team approach to helping patients through recovery. A person in recovery himself, Pellinger is an expert on music-based addiction care. A bestselling author, a veteran of the addiction treatment industry and a genuine music lover, he was inspired to take this unique approach after getting tired of the terrible outcomes of traditional treatment programs. “I watched 80% of addicts relapse and decided that instead of placing blame, I could make a difference using music,” he explained. “I’ve been doing this since 2013 and have seen a four-fold improvement in outcomes. Music is a catalyst. It is a medicine for mental health, as it gets patients to open up, improves moods and creates positive triggers. Music communicates to the soul.” Pellinger emphasized that his method is NOT music therapy, but instead is a behavior health technique that
when used as part of an overall treatment program can help build rapport with patients, improve compliance, even help with anxiety. “We know that using scare tactics won’t work, as addicts make bad choices despite being fully aware of the consequences,” he said. “Music helps with staying clean, which is the hardest part of recovery. I believe in this approach so much that I started a foundation to help cover the costs for those who can’t afford the program.” He added that including behavior health as part of a treatment program and working closer with doctors to help them better understand addiction can go a long way in reversing our nation’s addiction epidemic. In another unique approach to addiction treatment, Lizabeth Olszewski provided insight into Horses Healing Hearts (hhhusa.org) a program in Delray Beach she started 11 years ago to support people affected by substance abuse. The organization has helped more than 5,000 individuals to date.
“Because horses are prey animals, they can judge what’s going on inside a person,” she explained. “They instinctively know, for example, whether or not a cougar is faking sleep or really asleep. Likewise, with people, horses provide feedback without judgement.” She described the program as a way to authentically create connections. A typical therapy session includes no riding, only clients interacting with horses in an arena.
“In order to have connections with others, you have to connect with yourself,” she said. “The opposite of addiction is connection, not recovery. We see unique revelations play out in the arena, which allows the whole clinical team to gain more insight and better support each person.” Olszewski added that close dialog between the mental health therapists on her team and physicians is critical to the positive outcomes the participants experience. She reported high success rates with such symptoms as depression, anxiety, even PTSD. Success in ending the cycle of addiction also involves close involvementaofapharmacists, according to panelist ErinaDorval, PharmD, who teachesaover-the-counter medications, self-care, disease prevention and compounding, is an advisor of the student chapter for the American Pharmacists Association and a preceptor in an independent community pharmacy, Atlantis Pharmacy. Her current research interests include expanding community pharmacy practice through enhanced services, opioid use disorder screening and pain management. A strong proponent of the evidence-based, early intervention model, SBIRT, Dr. Dorval believes that pharmacists can be used more to help in the recovery process and to initiate earlier intervention. Erin Dorval
“Pharmacists and doctors should breakdown silos and talk to each other more,” she stressed. Despite frequent push back from some physicians, she works hard to provide patient feedback, especially when she sees that someone is taking more doses than prescribed and is requesting frequent early refills. “We see patients from a different lens and sometimes have more time with them and see them more often,” she said, recalling one incident where she alerted a pain doctor that his patient came in early for a refill because he thought it was ok to take more than prescribed, yet he was too afraid to discuss his pain with his doctor.
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“I want to work with doctors to help make the optimal decisions for patients,” she said. “We must work together on a plan to help patients. There is much work to be done.” 2021.Q3
SEVEN TIPS FOR
TELEHEALTH CLINICAL DOCUMENTATION
Sue Boisvert, BSN, MHSA, Patient Safety Risk Manager II, The Doctors Company
The standards of care for telehealth are identical to those for onsite medical care: Medical and dental professionals must practice with the same level of skill and expertise as qualified practitioners in the same specialty under the same circumstances. State regulations and associated rules define what constitutes telehealth, third-party payer contracts outline medical necessity expectations and the services that qualify for reimbursement, your organization’s policies and procedures define practice expectations, and case law clarifies the interpretation of all these standards. Clinical documentation plays a significant role in demonstrating regulatory compliance, establishing medical necessity for billing, and supporting your defense in the event of a professional board complaint or medical professional liability claim.
THE FOLLOWING SEVEN TIPS OUTLINE UNIQUE CONSIDERATIONS FOR DOCUMENTING TELEHEALTH CARE: 1. Modality. Specify clearly in the medical record what modality of telehealth is being used. Examples include “secure interactive audio-video session using Skype,” “medication management visit conducted by telephone,” or “asynchronous diagnostic test follow-up by portal/ text/email.” 2. Geography. Note the patient’s physical location and geography. For example, including “at her home in Tennessee” is important for billing purposes and for determining venue in the event of a regulatory or professional liability action. Also include the provider’s location (“clinic name and city” or “home office and city”) in the documentation. 3. Informed consent. Advise patients before asking them to consent to treatment by telehealth—about the
unique risks of a telehealth visit, including the potential for technical difficulties, information security concerns, and the potential for converting the visit to an in-office visit based on the patient’s needs. In the progress note, include a summary of the discussion and the patient’s decision, as well as a copy of the signed form if used. Find our sample Telehealth Informed Consent form on our Informed Consent Sample Forms page. 4. Identity. Confirm the identity of new patients by asking them to hold a photo ID close to the camera. Document confirmation of patient identity. Patients also have the right to ask for provider identification. 5. Appropriateness. Determine quickly if the patient and environmental conditions are appropriate for a telehealth visit. Some patients may not be appropriate based on their cognitive status. If the patient is unable to answer questions or provide an accurate history and no support person is available, the visit may need to be rescheduled. Documentation in this situation might include “the visit was rescheduled at the patient’s request because her husband could not be available.” Evaluate and address distractions in the environment. Carefully document the patient assessment and environmental conditions as well as any actions taken and recommendations made. For more information on addressing patient distractions, see our article “Telehealth’s Newest Safety Risk: Distracted Patients.” 6. Others present. Document the record with the name and relationship of everyone who is present on the patient’s side of the interaction and the names and roles of everyone present on the provider’s side. The patient’s family members may be present, or the patient may be a minor. For example, document “visit conducted with child sitting on mother’s lap.” Clinical assistants, students, or a scribe may be present on the provider’s side. An interpreter may assist from a third location by video or telephone. Include documentation of all participants.
7. Assisted assessment. Plan in advance and provide instructions for patient assistance, such as for patients who will obtain and report their own vital signs (including weight, blood pressure, pulse, and temperature). Document the information in the medical record as “patient provided.” If patients also assist in various aspects of physical examination, document the details as “patient assisted.” For more information on patientassisted assessment, see our article “Strategies for Effective Patient-Assisted Telehealth Assessments.”
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Following these seven tips can help you ensure that your telehealth documentation is patient centered, comprehensive, and effective. You can also benefit from familiarizing yourself with the regulatory and payer requirements specific to your practice location(s).
FINANCING NEEDS Convenient access to credit
THE PRACTICE’S INVESTMENTS Flexibility in balancing your risks and returns
SOLUTIONS • • • • • • •
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• • • • •
Commercial Real Estate Loans Lines of Credit Equipment Finance & Leasing Business Visa® Credit Cards Practice Buy-Ins
Money Market Savings Accounts Business Investment Sweep Accounts*
About The Doctors Company: Learn more about The Doctors Company at www.thedoctors.com. Contact our Department of Patient Safety and Risk Management at email@example.com or (800) 421-2368. Sweep accounts are not insured by the FDIC or any other federal government agency; may lose value; are not a deposit or other obligation of, or guaranteed by, any bank or bank affiliate; and are subject to investment risks, including possible loss of the principal amount invested.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.
Account openings and credit are subject to Bank approval. Member FDIC. Equal Housing Lender
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Women in Medicine CELEBRATION
THURSDAY $25 SEPTEMBER 23 6:00-8:00 PM BENVENUTO’S
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PBCMS Female Physicians, Medical Students & Physician Assistant Members Non-Member Female Physicians, Medical Students and Physician Assistants
WIM EVENT SPONSORS: Please email names to email@example.com
DEADLINE TO REGISTER: WEDNESDAY, SEPTEMBER 15TH AT 5:00 PM QUESTIONS — Please call Deanna Lessard (561) 433-3940 or email firstname.lastname@example.org
PBCMS IS REQUIRING ALL GUESTS TO BE FULLY VACCINATED
2021 HOST COMMITTEE CO-CHAIRS: Claudia Mason, MD & Martha Rodriguez, MD
Collette Brown-Graham, MD • Catherine Lowe, MD Maureen Whelihan, MD Mollie Shulan, MD • Ekaterina Kostioukhina, MD
THANK YOU TO OUR SPONSORS
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PA LM B E AC H Celebrating a Century of Medical Excellence
COUNT Y MEDICAL SOCIE T Y
S A V E T H E D AT E
DEADLINE REGISTER TO
SEPT 15TH - 5PM
Women in Medicine CELEBRATION
THURSDAY SEPTEMBER 23 6:00-8:00 PM
PBCMS Female Physicians, Medical Students & Physician Assistant Members
Non-Member Female Physicians, Medical Students and Physician Assistants
Benvenutorestaurant.com • (561) 364-0600 Complimentary Valet Parking
1730 N. Federal Highway, Boynton Beach, FL 33435
DEADLINE TO REGISTER: WEDNESDAY, SEPTEMBER 15TH AT 5:00 PM QUESTIONS — Please call Deanna Lessard (561) 433-3940 or email email@example.com
2021 HOST COMMITTEE CO-CHAIRS: Claudia Mason, MD & Martha Rodriguez, MD Collette Brown-Graham, MD • Catherine Lowe, MD Maureen Whelihan, MD • Mollie Shulan, MD
in times of crisis
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MAINTAINING E CELLENCE
1730 N. Federal Highway, Boynton Beach, FL 33435
OCTOBER VIRTUAL EVENT
THANK YOU TO OUR SPONSORS
6PM - 7PM
8PM - 12PM
Cleveland Clinic Thursday, October 7th • 6:00-7:00 PM Claudia Mason, MD
Professor Israel Reyes & Ekaterina Kostioukhina, MD
Friday, October 8th • 8:00 AM-12:00 PM
Bill Slomka, MD Ear, Nose and Throat
Members: $50 • Non-Members: $75 Medical Students & Residents FREE
PBCMS INSTALLATION GALA Become a member of the Palm Beach County Medical Society before October 1st and receive a complimentary ticket to the event.
QUESTIONS KATHERINE ZUBER KatherineZ@pbcms.org 561.433.3940 ext. 106
DECEMBER KRAVIS CENTER,
701 Okeechobee Blvd, West Palm Beach, FL 33401
FOR MORE INFORMATION VISIT WWW.PBCMS.ORG PBCMS.ORG