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The

Bulletin Saginaw County Medical Society

November 2021 | Volume 79 | No 8

SAVE THE DATE! January Membership Meeting

“Management of Sleep-Related Disorders from a Medical and Dental Perspective”

SCMS Calendar of Meetings for 2022 p. 5

The Current Standard of Care of COVID-19 Treatment, and the Confusion of Booster Doses p. 12 Snakes and Ladders of Medical Publishing p. 20

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contents

The

Bulletin Saginaw County Medical Society

2021-2022 OFFICERS AND DIRECTORS President Anthony M. Zacharek MD President-Elect Tiffany K. Kim MD Past President Mildred J. Willy MD Secretary Caroline G.M. Scott MD Treasurer Miriam T. Schteingart MD Board of Directors Mark G. Greenwell MD Christopher J. Allen MD Furhut R. Janssen DO Harvey K. Yee MD Mary J. McKuen MD Kai Anderson MD Bulletin Editor Louis L. Constan MD Resident Representatives Jessica H. Faris MD Lydia T. Mansour DO Mohammed A. Saiyed MD Retiree Representative Caroline G.M. Scott MD Medical Student Representatives Ann Sobell, MD Candidate, Class of 2023 Mary Galuska, MA, MD Candidate, Class of 2024 MSMS Delegates Elvira M. Dawis MD Julia M. Walter MD Anthony M. Zacharek MD Christopher J. Allen MD Miriam T. Schteingart MD Kala K. Ramasamy MD Jennifer M. Romeu MD MSMS Alternate Delegates Caroline G.M. Scott MD Waheed Akbar MD Mohammad Yahya Khan MD Steven J. Vance MD Karensa L. Franklin MD Judy V. Blebea MD Elizabeth M. Marshall MD Nicholas E. Haddad MD Peer Review Ethics Committee Waheed Akbar MD, Chair Caroline G.M. Scott MD James R. Hines MD MSMS Region 7 Representative Mildred J. Willy MD MSMS President-Elect Thomas J. Veverka MD Executive Director Joan M. Cramer Administrative Assistant Keri Benkert

5, 32

SAVE THE DATE! January Membership Meeting “Management of Sleep-Related Disorders From a Medical and Dental Perspective”

8

What Helps, What Hurts Surviving a Death to Suicide

12

The Current Standard of Care of COVID-19 Treatment, and the Confusion of the Booster Doses

5, 32

SCMS Calendar of Meetings and Events for 2022

7

Renew Your SCMS/MSMS Membership for 2022 *LAST CHANCE! Free CME credit if renewed by 11/30/21

4

22

President’s Letter

5

Guest Writers Welcome!

5

Caduceus Meeting for Recovering Health Care Professionals

6

From the Editor

18

Member News

18

Retirees Meet for Lunch

19

Applications for Membership

19

New Members

21

FREE Confidential Counseling For Frontline Healthcare Workers

16-17 20

October Membership Meeting Snakes and Ladders of Medical Publishing

AMA – 2022 Medicare Physician Fee Schedule Final Rule and more

22

Birthdays – December

24

MSMS – Legislative Update Please Contact Your Lawmakers!

26

Covenant HealthCare

27

In Memory – Dr. Don Tuckey

28

Ascension St. Mary’s

30

Advertiser Index

31

SafeHavenTM Confidential Support

The Bulletin can be viewed online at www.SaginawCountyMS.com under the Bulletin tab.

COVER PHOTO: COURTESY OF BROOKE KOWALSKI EDITOR Louis L. Constan, MD EXECUTIVE DIRECTOR Joan M. Cramer DESIGNER Lori Krygier

PUBLISHER Saginaw County Medical Society 350 St. Andrews Rd., Ste. 242, Saginaw, MI 48638-5988 Telephone (989) 790-3590 | Fax (989) 790-3640 Cell (989) 284-8884 | jmcramer@sbcglobal.net Hours By Appointment | SaginawCountyMS.com

All statements or comments in the Bulletin are those of the writers, and not necessarily the opinion of the Saginaw County Medical Society. Contributions are welcome. We publish committee reports, letters to the editor, Alliance reports, public health activities of the members, and some personal items (birthdays, weddings, graduations and like events). The Editor determines which are accepted. Advertisements are accepted as space is available at our going rates. Members may advertise office information, professional services, skills, and procedures, also at our going rates. We do not accept advertisements from nonmembers, or non-Saginaw hospitals. The Bulletin is mailed free of charge to SCMS members as part of their membership. Complimentary copies are sent to various other parties. Others may subscribe at the rate of $50 per year.

The Bulletin | November 2021 3


PRESIDENT'S LETTER

The Value Equation in Health Care Anthony M. Zacharek, MD MHA

W

e all want better health care for ourselves and our families. The question then becomes, what defines better health care? You can hopefully remember an example of when you received good health care, but was that because you liked your doctor or because you had a good result, or was it because of both reasons? The value equation in health care represents one way to look at the quality of health care. The value equation can be stated as follows - the quality of care (made up of outcomes, safety and service), divided by the total cost of patient care over time (Smith, T. What is Value-Based Care? AMA Association. org, 2020). Another way to state the value equation in health care is value = quality/cost. According to the value equation, the value of the care you receive will increase as quality increases and as cost decreases.

With insurance companies pushing more for value-based care from its providers, it would do us good as a Medical Society to try to understand what value-based care means. Value-based care has already begun to affect the reimbursement that providers are receiving, through such organizations as accountable care organizations (ACOs), which reward providers for better outcomes at lower cost. The health care value equation helps an organization understand how well it is doing, and incorporates the ideas of STEEEP and the Triple Aim. “The National Academy of Medicine has developed a widely accepted approach that describes high-value health care as: Safe, timely, effective, efficient, equitable and patient-centered—STEEEP for short. The Institute for Healthcare Improvement later translated this into a framework for action, the Triple Aim, which is made up of better patient outcomes, improved

patient satisfaction and lower costs. The Triple Aim has since been expanded to the Quadruple Aim, which includes physician and health care professional well-being” (Smith, T. What is Value-Based Care? AMA Association.org, 2020). Our County Medical Society can better serve our community by focusing on the ideas contained in the value equation in health care. By considering not only the quality of the care that you provide, but also the cost of that care, value to the patient and our community will increase. The United States spends more on health care than any other country in the world, and the value equation would suggest that overall value therefore is lower than it could be. Health care is a complex issue, but by talking about ways to improve care, so that it is more safe, timely, effective, efficient, equitable, and patient-centered, we all can benefit.

Value-based care has already begun to affect the reimbursement that providers are receiving, through such organizations as accountable care organizations (ACOs), which reward providers for better outcomes at lower cost.

Read previous issues of The Bulletin at www.SaginawCountyMS.com. The SCMS paused printing hard copies of The Bulletin during the COVID pandemic due to economic struggles. All issues were distributed electronically. To view the current and prior issues, visit www.SaginawCountyMS.com and click on the Bulletin tab. If you would like to receive hard copies of The Bulletin, please email jmcramer@sbcglobal.net. 4

The Bulletin | November 2021


CALENDAR OF MEETINGS AND EVENTS FOR 2022* Tuesday, January 18, 2022 Horizons Conference Center, 6200 State Street, Saginaw Board Meeting – 5:30 p.m. Membership Meeting Joint with the Saginaw County Dental Society – Social (cash bar) at 6:30 p.m., followed by dinner, meeting and program at 7 p.m. Program: “Management of Sleep-Related Breathing Disorders from a Medical and Dental Perspective” Speakers: Christopher J. Allen, MD and Michael Thomas, DDS Email meeting notices will be sent in early January. Online reservations are required. Tuesday, February 15, 2022 CMU College of Medicine, 1632 Stone Street, Saginaw Board Meeting – 5:30 p.m. There is no Membership Meeting in February. Tuesday, March 15, 2022 CMU College of Medicine, 1632 Stone Street, Saginaw Board Meeting – 5:30 p.m. There is no Membership Meeting in March. *subject to change

Tuesday, April 19, 2022 Horizons Conference Center, 6200 State Street, Saginaw Board Meeting – 5:30 p.m. Membership Meeting – Social (cash bar) at 6:30 p.m., followed by dinner, meeting and program at 7 p.m. Program and Speakers TBA Email meeting notices will be sent in early April. Online reservations are required. Saturday-Sunday, April 30-May 1, 2022 MSMS House of Delegates (location TBA) Tuesday, May 17, 2022 Horizons Conference Center, 6200 State Street, Saginaw Board Meeting – 5:30 p.m. ANNUAL MEMBERSHIP MEETING and ANNUAL SCMS FOUNDATION MEMBERSHIP MEETING – Social (cash bar) at 6:30 p.m., followed by dinner and meetings at 7 p.m. Email meeting notices will be sent in early May. Online reservations are required. Saturday, June 4, 2022 SCMS Foundation Golf Outing – Saginaw Country Club Tuesday, June 14, 2022 (second Tuesday) CMU College of Medicine, 1632 Stone Street, Saginaw Board Meeting – 5:30 p.m. There is no Membership Meeting in June.

GUEST WRITERS WELCOME! If you would like to write an article of interest to your colleagues for publication in a future issue of The Bulletin, please contact Joan Cramer at jmcramer@sbcglobal.net for further information. Articles are not designed for self-promotion, but rather as information for members.

Caduceus Meeting for Recovering Health Care Professionals Third Thursday of each month at 7 p.m. Zion Lutheran Church 454 7th Street, Freeland, Michigan (Behind Pat’s Grocery Store on Midland Road in Freeland)

Caduceus meetings are available to health care industry professionals, and have adopted many of the principles of 12-Step programs. Caduceus meetings are “closed” meetings for recovering health care professionals including, but not limited to, nurses, doctors, dentists and pharmacists. We engage in group discussions where members may want to speak up, ask questions or share thoughts with fellow members.

Focusing our practice on the needs of our community, we provide the following services for both individuals and businesses: n Monthly Accounting n Tax Planning n Financial and Business Consulting Service n Payroll Service n Tax Preparation Service n Retirement Planning Contact us for a complimentary visit at 989-791-1040. Three convenient locations to serve you in: Saginaw | Vassar | Frankenmuth

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The Bulletin | November 2021 5


FROM THE EDITOR

Imagine That! By Louis L. Constan, MD

M

uch as we love our profession; much as we love the interaction with patients, the intellectual challenges, the prestige… we must admit that sometimes we can find it tedious. I’m talking about dealing with all the rules - from the government, the insurance companies, the hospitals. All those forms. All that (endless) charting. There are just so, so many hoops to jump through and it is just so, so intellectually and emotionally draining. The irony of medical practice at the beginning of the 21st Century is that we have this explosion of knowledge of how the human body works and how to heal that body when it doesn’t work as it should, but we in our society seem stuck by forces; societal, political, governmental, even psychological…that prevent us from using that knowledge to it’s fullest extent. That’s a major frustration. It seems to me that something has to change. Something has to give. But what? Now bear with me as I turn for inspiration, not to another physician, but to a physicist, Albert Einstein. He gave us the Theory of Relativity, of course; but consequently for us he also gave us everything related to nuclear biology which includes isotope scans, MRI scans, probably the whole fields of genetic

engineering and biotechnology. We owe this man a lot. He has some advice for those of us who are facing a dilemma and are uncertain as to how to proceed: Imagination is more important than knowledge. For knowledge is limited to what we know and understand, while imagination embraces the entire world, and all that there ever will be to know and understand. I think Albert would say to us, or to anyone who finds themselves stuck, “don’t keep doing what you’re doing, don’t do another double-blind study, but think outside-the-box, use your imagination to think of something new like I did - and see what happens.” The highly imaginative (and let’s face it, way out there) thing that Professor Einstein did was to imagine himself riding on a beam of light…and from that he deduced that the speed of light was constant, but time and space were relative. And because of that one imaginative act, our world changed completely. Could we imagine a different practice model for ourselves, for our colleagues, for our community? Mr. Einstein would say that the first step to meaningful change is to engage the imagination. Examples, and this is just me, but I throw these ideas out partly because of my

perspective these days as mostly being a patient and seeing medical care from that perspective. Right now I personally imagine a future healthcare system in which hospitals and doctors are not incentivized to do marginally useful medical procedures because they are lucrative for the bottom line. I imagine a future in which insurance companies (and the government) do not have a strangle-hold on how doctors and hospitals practice medicine. I imagine a future in which the first question a doctor should always ask is “what is right for this patient?,” never what my employer or someone else says is right for this patient. I do not know how this would work. I am not an advocate of Medicare-for-all, but it seems that there needs to be some way to re-direct power away from big insurance companies and give it back to doctors and patients. I know that there are plenty of doctors out there using their imaginations in constructive ways. We tend to think about those in national and state positions of power, like politicians, writers, entertainers. But we should not forget everyone who works for our Society, from our President on down; those listed in the opening pages of this publication. They are all imagining something better for us and working to achieve that. continued on page 7

I imagine a future in which the first question a doctor should always ask is “what is right for this patient?,” never what my employer or someone else says is right for this patient. 6

The Bulletin | November 2021


continued from page 6

My thought here is that everyone, every single member of our great Society can do what Albert Einstein urges us to do, in some way, small or big. Change our personal medical practice, with the way we interact with patients, with our employer, with our colleagues, with our community, with our state, with our nation. Your choice. Make Albert proud…and many others! If you find it difficult to communicate with your doctor; if you find it hard to get personal attention from an 'impersonal healthcare industry'; if you don't understand all those insurance-company rules; if you don't know how to change your bad health habits; if you think you may be on unnecessary medications; if you are perplexed by those annoying healthproduct advertisements; and if you'd like to know which are your greatest health risks - you'll appreciate this Family Doctor's advice, gleaned from 44 years of practice. Each chapter is illustrated with reallife examples from his and other doctors' practices. Each chapter ends with 'bonus' essays written by the author and published in newspapers and magazines giving the doctor's viewpoint. This will give you a unique perspective and allow you to 'get into the mind' of a doctor. Sweet! Available on Kindle (different cover but same book) and paperback. Available on Amazon by clicking HERE

All statements or comments in The Bulletin are those of the writer, and not necessarily the opinion of the Saginaw County Medical Society (SCMS). The Bulletin is made available electronically for members as an informational service. Reliance on any such information is at the user's own judgment. The SCMS, its officers and employees, cannot guarantee the accuracy, reliability, completeness or timeliness of any information, and may not be held liable for any individual’s reliance on our web or print publications. For questions or the latest information, please contact Joan Cramer of the SCMS at (989) 284-8884 or jmcramer@sbcglobal.net.

1

PLEASE PAY YOUR 2022 MEMBERSHIP DUES Free CME for Your SCMS/MSMS Membership Renewal by November 30 As a thank you for your loyalty as a member of the SCMS/ MSMS and for paying early all physicians who pay their 2022 dues in full by November 30 will receive a $100 coupon towards a CME course at an MSMS educational session. Installment payments available. HOW TO PAY • Online CLICK HERE • Fax to (517) 481-3976 • Mail to: MSMS Membership Department PO Box 950 | East Lansing, MI 48823 Tax Information SCMS/MSMS dues are not deductible as a charitable contribution but may be deductible as an ordinary and necessary business expense (check with your tax specialist). SCMS dues are 100 percent deductible as an ordinary business expense, and 87.4 percent of MSMS dues are deductible because a portion of dues is attributable to lobbying activities. The SCMS and MSMS are non-profit organizations focused on improving the lives of physicians so they may best care for the people they serve. Click HERE for Benefits of SCMS Membership. The strength and effectiveness of SCMS/MSMS as your professional association is predicated on strong membership. The free CME course is just a small token of appreciation for your continued support of organized medicine. For questions about membership or if you have not yet received your 2022 dues invoice, please contact Joan Cramer, SCMS Executive Director at jmcramer@sbcglobal.net. WHY PAY DUES? • Because all physicians need to “fund their voice.” • National polls show physicians as one of the most respected professions. Sadly, they don’t use their clout often enough to preserve their profession and protect their patients. • There is strength in numbers. Together we are stronger.

The Bulletin | November 2021 7


What Helps, What Hurts | Surviving a Death to Suicide Highlights from Barb Smith’s Interview with Julie Hart (September 2021) Julie’s 20-year-old nephew died by suicide in October of 2020. In response to her nephew’s death, Julie has become an advocate for suicide awareness and prevention, and has joined the Board of Directors of the Barb Smith Suicide Resource & Response Network. Julie shares her story with Barb. Following are excerpts from the interview which can be viewed in its entirety by clicking HERE. Barb Smith: According to a study, there's an estimated 135 people who are impacted by one death to suicide here in the United States. With approximately 1,457 suicides in Michigan in 2019, that’s over 191,000 people who have been impacted by or experienced a loss to suicide right here in Michigan. Our message today is that if you've been impacted or you know of someone who has, that you're not alone and it's okay to talk about. Our idea is to destigmatize and open this up for conversation. Suicide grief is complex - there's no two that are alike. Today we are going to talk about how someone might survive a loss to suicide. Julie Hart: My nephew, Ben, who was 20-years-old at the time, died on October 6, 2020. I was so proud to be Ben’s aunt, and I still am. He had a big character, he was a big goofy, joking young man. He had a lot of composure when he was under stress. He was a hockey goalie and we know how composed they need to be. Ben had one of the strongest work ethics of anyone I know. He was an extremely intelligent young man graduated with high honors from high school and was in the process of getting his degree in mechanical engineering at Michigan Tech University. Barb: After someone dies by suicide, sometimes we start to learn more about who they were and the side of them that we didn't know when families or friends get together and they start to talk about the last few weeks or days. What are some things you learned after his death? Julie: I would have never known based on the interactions I had with Ben that he was struggling in any way. He was excited to go back to school. After talking, we realized he did open up to some of his friends about his struggles with different situations in his life, some family dynamics that were at play, that we didn't realize he was struggling with because in our eyes he was a very successful young man. One thing I've learned since is that I would have wanted him to share he was struggling with us because we would have been there for him in a minute.

Barb: I think it's hard sometimes when I bring people back to that moment when we say we knocked on the door or you found out about your loved one's death. The reason I ask this question is not about dramatizing it but to really help the audience understand the devastation that families go through after a death to suicide and how complex it can be. Can you explain a little bit about those first responses because you talked about Ben, you had no idea he was struggling, so it was just really you going about your day and then all of a sudden you get this news? Can you help maybe understand what families might go through and really normalize for someone who's had that experience what it might be like? Julie: It's very hard to put it into words but I would say it feels like you're in the middle of a cyclone. You have all of these thoughts and feelings that are rushing in and competing with each other and you're trying to make sense of it. One of the things I was reminded of by someone who was standing in that room when I found out the news was just to take a breath. You've heard about other people experiencing a tragedy like this and you have empathy for them and you think I never want to be there and then you're there, all of a sudden you’re there. It's like you're having an out-of-body experience - you're going through the motions of life, you realize that the world is going on around you, but you can't quite grasp hold of any meaning and at that time you feel hopeless. Barb: What helped you get through those first days or weeks as a family? What are some things that you did as a family or someone else did to help you? Julie: So as you know, you were there from the first minute of our family finding out this information. I keep trying to figure out how we would have navigated the really early steps that we needed to take without some guidance in that regard. And what I mean by that is working with the police and law enforcement up in the U.P. and the medical examiner and those types of things. But then over and above that just the explanations about the fact that what we were feeling was a normal way to respond to something that's indescribable. Barb: So it helped to have someone there even at the onset because I think sometimes people and friends feel like ‘I don't want to go there, this is family private time,’ but was it helpful to have your family and friends show up immediately after? I don’t mean a hundred people, but what did some people do that was helpful? continued on page 9

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The Bulletin | November 2021


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Julie: I really think it's just being there and not trying to rush in and not trying to say, ‘oh how could this have happened,’ ‘whose fault is this,’ ‘what event, what single event must have triggered this.’ I have a favorite saying that I refer to is we always look for that single thing. I've learned since that it's not a single event or interaction that causes someone to take their own life. I compare it to saying which cheeseburger caused the heart attack. It's an accumulation of a lot of things – genetics, brain chemistry and your life experiences.

someone that had good intentions but what came out of their mouth was very hurtful. Have you experienced that? Julie: I think the thing that hit me the hardest was when someone suggested to me that it was a very conscious choice on my nephew's part and in that somehow it was a kind of a flaw. That person didn't say that exactly, but that's how at the time I perceived it. Barb: That could be really hurtful because we try and teach people that suicide isn't really a choice, it's a response, and I don't think anyone would choose to hurt those people left behind. I don’t believe that’s the intention, and I feel like when we think about it as a response it takes away that space of them doing it to intentionally hurt anyone. When we think about good intentions of people saying ‘wow you're so strong,’ ‘wow you're handling all this and the mom's doing so great,’ when in reality you're just numb you're going through the motions. I think we need to respect where

Barb: I think when families and friends come together sometimes they're trying to figure out as much as you are. I use the analogy that it's like this thousand piece puzzle and when someone delivers this news or you experience it, it's like we start to put those pieces together and we want it to make sense. It can come across as accusing for families - like you're trying to blame this last thing or the last thing I said or the last thing that was done, and so from the get-go. Sometimes in the Survivors of Suicide Support Group, they'll talk about

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The Bulletin | November 2021 9


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people are at because nobody can prepare you for this and intellectually we know it's grief. We can name it but you can't really express what it feels like and there is no normal reaction. Some people can't stop crying, some people can't cry - that numbness is so surreal, some people can't get out of bed and some people just sleep 24/7. I think we have to respect that grief is grief, and it's individual just like that suicide itself. I heard Dr. Anderson from Good Morning America speak, and she said something beautiful. She said you just have to feel to heal. You can't go around it, we can't avoid it, but those feelings are so painful that sometimes we just want to skip over it and it's just a journey. What was your most intense or most uncomfortable emotion after Ben died by suicide, and what did you do with that? Julie: I would say that immediately and most intensely it was hopelessness. It was hard to see a path forward. We all, of course, had incredible sadness and a lot of disbelief, but the hopelessness - I really didn't see a way out of that initially. Barb: That to me is somebody just standing in front of you and saying ‘this is very painful and it's the hardest thing in your life, but together we can survive it. What is the one thing you wish you knew before Ben died that you know now? Julie: That it is truly not a choice, it is a reaction to the pain, the emotional pain that exists in someone who is able to really

override their own neurological system in order to end their own life. Barb: It just doesn't discriminate does it? Julie: No, it's the mom’s, it's the dads, it's the nieces and nephews who are doing so well. It’s your sisters and brothers, it's professional people with high levels of education, and it's people who you know work in an everyday type of job. There is no discrimination. Barb: That's really the reason we need to talk about it because if we don't talk about suicide prevention or aftercare, people suffer in silence and when we open it up for discussion, we're very almost surprised of how many people are willing to talk about it. Do you have a message that you really want to share with a survivor who might be new in their grief, that might be new in this journey whether you wish you heard it yourself or you just want them to know as a new survivor of suicide? Julie: I think the number one thing is that there is hope even though it feels like there is not. A couple of other thoughts I have is to find the help that is helpful to you. Don't let others prescribe what your help is going to look like. My sister and I found a lot of help through the Survivors of Suicide Support group. continued on page 11

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Barb: So in that support group it really gave you permission - it helped you understand. I think that it's important and I really appreciate when you said it's got to be right for you. Support group's are not right for everyone. Individual counseling isn't right for everyone. Someone's faith might be helpful, it might be hurtful. Julie: Sometimes you're just sitting alongside someone and you just feel their presence and their love without them having to say any perfect words because there aren't any perfect words. Barb: What has your family done to find purpose for your pain, to honor Ben and who he was in life?

to tough it out and get over it,’ and it's usually coming from somebody that doesn't understand the extent of the pain, so it's not an attention seeking behavior to ask for help. Barb Smith Suicide Resource & Response Network Ben’s Blue Stars Watch the entire episode at https://www.youtube.com/ watch?v=w8Tne8TXe0U Are you in crisis? Call 1-800-273-TALK (8255) or text TALK to 741741. 24/7 support. MCTV Network - Midland Michigan's Community Voice This episode of What Helps, What Hurts - Surviving a Death to Suicide, is produced by Joan Timmer 9/18/21

Julie: As you know, I have joined the Board of Directors for the Barb Smith Suicide Resource & Response Network. One of the other things I did when we were preparing for the Walk for Hope, was start a Facebook page called Ben’s Blue Stars. What started as a page about coordinating our team turned into a place where I could share information that I found helpful about suicide, grief, surviving the journey of grief, destigmatizing mental health and asking for help when you need it and recognizing your emotions and being able to name what they are in order to be able to do something to address them if something needs to be addressed. Barb: How many people do you have that post, and are you making it a comfortable space and are people willing to talk about it? Julie: People are willing to talk about it. I’ve had people who say they look at it, they read it and it means a lot to them. They may not comment or share, but it’s been meaningful to them. I feel like I have Ben's spirit behind me when I'm working on that. Barb: What would you say to a listener who's maybe having suicidal thoughts right now? Julie: I would say don't feel guilty about having those thoughts – they come from a variety of sources as we've just talked about and it's not a flaw in who you are as a person. There are so many people out there that love and care for you and want you to stay. Reach out to one of them and if one of them doesn't give you the response you need, reach out to someone else. Barb: You told me before about how many people came together for Ben at the funeral, and if he only could have seen those people or he could have made one of those calls… Julie: If love could have saved him, he would have lived forever. I would like to add one more thing that I would say to someone who has those thoughts - please don't feel like by reaching out your begging for attention in some way. I’ve read some things and heard comments shared in the support group about things that aren't helpful. If someone is struggling, there are many people that will say ‘oh gee, you're just going to have

Creating a

safety network for our

community Our goal is to save lives through prevention, intervention, and aftercare.

Our Network trains individuals in evidence-based suicide prevention with the hope of destigmatizing suicide, increasing help-seeking behaviors, and caring for those impacted by suicide. To request trainings or resources, contact info@srrn.net I www.srrn.net I 989.781.5260 The Bulletin | November 2021 11


The Current Standard of Care of COVID-19 Treatment, and the Confusion of Booster Doses Nicholas Haddad, MD, FACP, FIDSA Internal Medicine Residency Program Director Associate Professor of Infectious Diseases CMU College of Medicine

The management of COVID-19 has evolved over the course of this pandemic. Starting out initially with concerns about the use of steroids, currently, the mainstay of therapy for patients who require supplemental oxygenation is dexamethasone. This was confirmed in the RECOVERY trial in the NEJM on July 17, 2020, and has subsequently been updated a few times. The trial showed a reduction in 28-day mortality among patients treated with dexamethasone who required invasive mechanical ventilation (IMV) or supplemental oxygen but not in those requiring no respiratory support. Subsequently, several trials fine-tuned therapy for COVID-19, especially studied in hospitalized patients who require some form of respiratory support, such that the current standard of care is governed by frequently-updated NIH guidelines, as summarized below. Corticosteroids Currently, the NIH guidelines recommend dexamethasone for hospitalized patients requiring oxygen therapy (level of evidence BI) or invasive respiratory support (ventilation or ECMO, level of evidence AI). The mechanism of action is thought to be related to the anti-inflammatory effect of corticosteroids which diminish lung injury and multiorgan dysfunction from SARS-CoV2-induced systemic inflammation. The dose of dexamethasone is 6 mg IV or PO once per day for up to 10 days. Of note is that equivalent doses of corticosteroids may be administered if dexamethasone is not available, and these are prednisone (40 mg), methylprednisolone (32 mg) or hydrocortisone (160 mg) (BIII for all). Although inhaled corticosteroids have been shown to impair SARS-CoV2 replication, there is currently no firm evidence to support its use in the treatment of COVID-19. Of note is that currently, there is no evidence supporting the use of corticosteroids in patients who do not require supplement oxygen. Corticosteroids may be utilized in IV or oral formulation, as clinically appropriate for the particular patient. Remdesivir (Veklury) Remdesivir (exists in IV formulation only) is recommended for use with or without dexamethasone in hospitalized patients who require either minimal or high-flow supplemental oxygenation or noninvasive ventilation (NIV) (BII a to BIII), but not in patients requiring IMV or ECMO. Remdesivir is an adenosine nucleotide prodrug that inhibits the SARS12 The Bulletin | November 2021

CoV2 RNA-dependent RNA polymerase (RdRp), an enzyme essential for viral replication. The ACTT-1 trial, a RCT in 1,062 patients hospitalized with COVID-19 and evidence of lower respiratory tract infection showed that remdesivir shortened the time to recovery from 15 days to 10 days in the placebo vs. treatment arms, which was additionally associated with clinical improvement of symptoms. The current utilization of remdesivir is without corticosteroids in patients who require minimal supplement oxygen who are thought to have an inflammatory response not intense enough to indicate corticosteroids. Its combination with corticosteroids is recommended when there are increasing O2 requirements, although this scenario has not been conclusively evaluated in clinical trials and hence stands at BIII as a level of evidence. The dose is 200 mg IV once daily for 4 to 10 days, and it is not recommended if the eGFR is <30 mg/min. Baricitinib (Olumiant) Baricitinib (exists in oral formulation only) is recommended for hospitalized patients who require supplemental oxygenation via high flow devices or NIV. In this subgroup of patients, it is utilized in addition to either dexamethasone monotherapy or combination therapy of dexamethasone plus remdesivir. It has no documented role in patients who require IMV or ECMO. Baricitinib is a Janus kinase (JAK) inhibitor that reduces the phosphorylation and activation of signal transducers and activator of transcription responsible for cytokine and growth factors involvement in hematopoiesis, inflammation and immune function. Its dose is eGFRdependent, starting at 4 mg/day for normal kidney function, and used daily for up to 14 days. It is not recommended if the eGFR is below 15 ml/min. Barcitinib use was supported by the international randomized controlled COV-BARRIER trial in 1,525 hospitalized COVID-19 patients with pneumonia and elevated inflammatory markers. In the intervention arm, barcitinib was added to standard of care (dexamethasone ± remdesivir). Although the trial demonstrated no difference in frequency of disease progression in the intervention arm, it was associated with reduced 60-day all-cause mortality (10% for baricitinib + SOC vs. 15% for SOC alone), with a similar serious adverse events profile in both arms. Tofacitinib (Xeljanz) Tofacitinib (oral formulation only), also a JAK inhibitor, is utilized as alternative to baricitinib when this is not available or precluded due to a GFR <15, as Tofacinib may be utilized in CKD patients whose eGFR is <60 mL/min (with renal adjustment to 5 mg PO twice daily from 10 mg twice daily). Duration of use is similar, up to 14 days. continued on page 13


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Tocilizumab (Actemra) Tocilizumab (IV formulation only) has a role in combination therapy with standard of care for hospitalized patients who require supplemental O2 via high flow, noninvasive ventilation, IMV or ECMO. In the latter two subgroups of hospitalized patients, it is added to dexamethasone therapy alone (where remdesivir is not indicated). Hence, its use is substitutive of Baricitinib in the subgroup of hospitalized patients requiring high flow O2 or NIV, whereas in the IMV/ECMO requiring patients, it is utilized in conjunction with dexamethasone (Barcitinib not being indicated in this subgroup). It is an interleukin-6 (IL-6) inhibitor that binds specifically to both the soluble and membrane-bound IL-6 receptors and has been shown to inhibit IL-6 mediated signaling via these receptors. It is administered as a single IV dose of 8 mg/kg, and a second dose at least 8 hours later may be considered if clinical signs or symptoms worsen or do not improve. Data on outcomes in patients who received one vs. two doses are not available (REMAP-CAP). The RECOVERY trial showed mortality benefit but did not delineate a particular subgroup of hospitalized patients to benefit most from it, hence there are no clear recommendations on its preferential use over baricitinib, and hence its utilization should be based on local factors such as local guidelines, availability and other patient related factors. Of note is that baricitinib and tocilizumab are utilized in combination with corticosteroid therapy and so far have not documented role as monotherapies, with no preference of one over the other as there are no studies that directly compare one to the other. Additionally, there are no studies to support the combination of those two agents together, as they are both potent immune suppressants and consequently may have deleterious consequences when combined. Sarilumab (Kevzara) Sarilumab (subcutaneous formulation only) is utilized as alternative to tocilizumab when this latter is not available. It is similarly an IL-6 inhibitor. The dose is 400 mg once. Its indication was supported by the REMAP-CAP trial in the treatment of hospitalized patients with COVID-19, in combination with dexamethasone alone or combination dexamethasone/remdesivir in patients requiring high flow O2 or NIV, or in combination with dexamethasone alone in patients who require IMV or ECMO. The bottom line in management of severe COVID-19 is dexamethasone, in combination with remdesivir when supplemental O2 is required. Addition of baricitinib OR tocilizumab to dexamethasone is indicated when there is a need for high flow or NIV. For hospitalized patients requiring IMV or ECMO, the current standard of care is dexamethasone plus tocilizumab. Alternatives to barcitinib is tofacinib, and

for tocilizumab is sarilumab, with less data to support use of alternatives at this time. Antibody based therapies (Anti-SARS-CoV-2 monoclonal antibodies) In patients who do not require hospitalization or supplemental O2, with mild to moderate COVID-19 at high risk of progression to severe disease, there are three monoclonal antibody (mAbs) regimens currently recommended based on local circulation of variants, availability and local guidelines: • Bamlanivimab plus etesevimab; or • Casirivimab plus imdevimab; or • Sotrovimab Delta (B.1.617.2) is the predominant circulating variant in the U.S. and is susceptible to the above three mAbs. Treatment should be started soon after a positive test, within 10 days of symptom onset, to those who are at highest risk (immune suppression, age >50, malignancy, cardiovascular disease, diabetes, chronic lung disease, obesity BMI >30, pregnancy and sickle cell disease). CDC recommends deferring COVID-19 vaccination for at least 90 days in those who have received anti-SARS-CoV-2 mAbs. This approach is more of a precautionary measure since the prior receipt of mAbs treatment may interfere with vaccine-induced immune responses. Notably, individuals who develop breakthrough COVID-19 infection (i.e. who are fully vaccinated and get COVID-19) would be eligible for treatment with mAbs using the same standard of eligibility for unvaccinated individuals. The mechanism of action of mAbs is binding to one more epitopes in the spike protein. Recently, the FDA has expanded the EUA for bamlanivimab plus etesevimab and casirivimab plus imdevimab as postexposure prophylaxis for exposed individuals who are at high risk for progressing to serious illness. So far, although studied in hospitalized patients with severe COVID-19, mAbs have not demonstrated benefit neither in reduction of disease severity nor in mortality, and hence their use in this setting should occur in the context of a clinical trial. COVID-19 Vaccine Third Doses and ‘Boosters’ A COVID-19 vaccine booster is recommended for certain individuals. These are persons 65 years of age and older, those 18 and older who live in long-term care, have underlying medical conditions or work or live in high-risk settings. For those who received the single-shot Johnson & Johnson (J&J) vaccine, individuals 18 and older who were vaccinated at least two months previously are eligible. The nuance between the nomenclatures of a booster versus a third dose is related to continued on page 14

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the indication. A third dose is indicated in individuals who do not achieve an adequate response after the first series primarily due to immune suppression, whereas a booster is indicated for other individuals without immune suppression. Emergent data suggest that immunity from SARS-CoV-2 vaccination may wane over time, and that vaccines may be less effective at protecting vaccinees against the Delta variant. A recent NEJM study showed that six months after completion of the Pfizer COVID-19 vaccine series, the level of neutralizing antibodies decreased across all recipient subpopulations, particularly men, individuals older than 65, and immune suppressed individuals. Additionally, the Israeli ministry of health has observed the waning immunity in their population and the effectiveness of an additional booster dose. Recently, the FDA has granted additional booster recommendations for the three existing vaccines. FDA decisions were based on several types of data for each of the three licensed vaccines. The first set of data are from the manufacturers, which ranged in number of participants. Antibody responses were measured after the additional doses and compared with those after the initial series. We do not know at this stage of the pandemic and from studies to date, the absolute antibody level that would correlate with an adequate level of protection. However, higher neutralizing antibody levels do appear to impart better immunity. Importantly, no additional safety concerns were

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noted after a third dose, except for additional cases of myocarditis. However, for meaningful interpretation of immunologic observations, we need to see them pegged to clinical outcomes. And the reason for this observation is that immunity is not solely a function of neutralizing antibody levels, and innate T-cell responses do play a role in the immunologic parameters. We do know antibodies work, but we also know they are not the only immune parameter preventing disease. This leads us to believe that a booster dose will likely boost the cellular immune response as it does the humoral one (antibody levels). In a study by the largest Israeli PHO (Calit) during a time when all disease was caused by the Delta variant, protection was shown to dramatically increase after the second dose. This is one of the first studies that was relied upon to recommend a booster dose. Regarding J&J, the company demonstrated data on boosting. A single dose has shown protection, which in most published studies was not as robust as that from two doses of mRNA vaccines. Hence, a second dose may likely provide more protection. One difference with that J&J vaccine as compared to mRNA vaccines is that the antibody levels decline less over time, (data not published nor peer reviewed yet). One concern with the J&J vaccine remains, and some trial of boosting were paused after reports of Thrombosis with Thrombocytopenia (TTS).

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It is still rather early to have clear recommendations regarding the absolute indication of boosters, as well as, regarding mixing of vaccine. The safest approach is now to get the ‘booster’ in persons in whom it is indicated. Yet, recently, the CDC gave a green light to the ‘mix-and-match’ strategy, so individuals who are eligible for boosters can decide to get a dose of a different brand than the one they first received. How would one decide on such a strategy? Let me help with this. Early results of the “Mix and Match” study looked at receipt of a different booster than the primary vaccines received. There were nine small groups since the permutation of three different vaccines would result in nine possible combinations. Several immunologic outcomes were measured, mostly antibody levels. In all those trials, an additional dose of any vaccine increased antibody levels. The additional mRNA vaccines, however, increased levels more robustly than did the J&J vaccine, and all combinations appeared to be safe. It is likely that individuals who initially received the J&J vaccine will be recommended to receive a mRNA vaccine booster. Hence, the current approach to ‘mixing and matching’ is based on encouraging safety and immunogenicity data that support boosting and possibly using a different vaccine, particularly in J&J followed by mRNA vaccines. There remain multitudes of challenges - especially when we factor in the broader options of vaccines utilized globally, the time interval between vaccines, vaccine doses, and other

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factors, all of which are parameters that need to be analyzed. What is next? Children between 5 and 11 years old are up next on the FDA’s regulators’ list to approve for vaccination. Early data from Pfizer have highlighted the benefits for this subgroup of the population, with essentially no added risk, and hence Emergency authorization could come very soon. Moderna’s data are being finalized now and will follow suit. The big question remains: Will there be another wave? The U.S. has already had four waves of COVID-19 surges, and a fifth major one could be speculated. Although we certainly hope it won’t be as severe if it occurs, and most importantly we do know based on robust information that it will be so in vaccinated individuals. As for those who are not vaccinated, it is prime time they do. The data demonstrate robust protective effects and a very high safety profile. Hence, we hereby send a sincere plea to them to reconsider their decision, if not for society at large, for themselves and their families.

SARS-CoV2 Transmission Transmission of the SARS-CoV2 virus is primarily via the respiratory route. Both droplet and airborne transmissions have been well documented, and account for the vast majority of infections. This is why infections occur more commonly in indoor settings, when individuals are unmasked and susceptible to it (e.g. due to lack of vaccine-induced immunity or those continued on page 18

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SCMS Membership Meeting Minutes

T

he Saginaw County Medical Society Membership Meeting was held on Tuesday, October 19, 2021, at Horizons Conference Center. Anthony M. Zacharek MD, President, called the meeting to order at 7:05 p.m. Dr. Zacharek welcomed Marilyn Skrocki, the evening’s speaker, and Dr. Marcia Ditmyer, the new Dean of the SVSU College of Health & Human Services. Dr. Zacharek thanked the following Key Provider in attendance for their ongoing support of SCMS programs: • Ascension St. Mary’s o Eric Maher from Neuro/Stroke; o Nicole Stewart and Kathi Smith-Nowlin from Seton Cancer Institute; and o Quintisha Walker MD and Joginger Singh MD, new primary care providers. Dr. Zacharek then conducted the following business of the SCMS: • The Minutes of the September 21, 2021, Membership Meeting were attached to the Agenda and published in The Bulletin. MOTION: Accept the September 21, 2021, Meeting Minutes as printed. MOTION APPROVED. • Announced new members approved at tonight’s Board Meeting: o Taylor Gaudard MD - CMU Health, Family Medicine o Alan I. Rebenstock MD - Advanced Diagnostic Imaging, Diagnostic and Pediatric Radiology

• •

o Lodewijk J. vanHolsbeeck MD - Advanced Diagnostic Imaging, Diagnostic and Pediatric Radiology. Introduced new members attending their first meeting: o Resident Representatives to the SCMS Board: • Jessica H. Faris MD - CMU PGY-3 Ob/Gyn • Lydia T. Mansour DO – CMU PGY-3 Emergency Medicine o Medical Student Representatives to the SCMS Board: • Mary Galuska, MA, MD Candidate, Class of 2024 • F. Ann Sobell, MD Candidate, Class of 2023 Referred members to the Calendar of Events for 2022, and asked them to mark their calendars for future meetings. Advised members that current and past issues of The Bulletin are available on our website www. SaginawCountyMS.com under the Bulletin tab. The October issue of The Bulletin contained information on the following: o Summary of the Interim Final Rule on the No Surprises Act issued by the Biden Administration on September 30. The Rule takes effect on January 1, 2022. Noted current legislation and asked those attending to contact their representatives through the SCMS at www.SaginawCountyMS.com under the Advocacy tab, or MSMS at www.MSMS.org under the Advocacy tab: continued on page 17

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o Senate Bill 247 – Prior Authorization (Health Can’t Wait) o House Bill 4486 and Senate Bill 314 – Auto accident victims’ right to recover o House Bill 4355 – Maintain quality of care and protect Michigan patients o Senate Bill 191 – Protect patients – mental health o Senate Bills 184 and 185 – Ensure safe drinking water in Michigan schools TONIGHT’S PROGRAM Marilyn Skrocki presented a program on “Future of Physician Leadership: Regionally and Nationally.” The program was accredited for 1.5 AMA PRA Category 1 CreditsTM. Dr. Zacharek thanked Marilyn for her presentation, and reminded members to sign in at the registration table and complete the online survey within 30 days to receive CME credit for the program. The next Membership Meeting will be held on Tuesday, January 18, 2022, at Horizons. There being no further business, the meeting was adjourned at 8:12 p.m. Respectfully submitted, Joan M. Cramer Executive Director

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The Bulletin | November 2021 17


MEMBER NEWS

Dr. Kai Anderson, Co-Founder of Coalition to Advance Antiracism in Medicine (CAAM) Kai Anderson, MD, Assistant Director, Psychiatry Residency Training Program and Assistant Professor/Director of Psychotherapy Training at CMU College of Medicine, is co-founder of the Coalition to Advance Antiracism in Medicine (CAAM). Dr. Anderson serves as Executive Director of Strategic Partnerships with CAAM. Due to healthcare disparities highlighted by the confluence of the COVID-19 pandemic, racial violence and police brutality against black and brown people, Dr. Anderson joined Dr. Omolara Uwemedimo in May of 2020 to form a workgroup to combat racism in medical education and residency training programs. Following the tragic death of Dr. Susan Moore, a black physician, whose white coat did not protect her from blatant racism, the need to join forces to combat racism in all aspects of healthcare delivery and medical education was evident. These forces have led Dr. Anderson to work with the Coalition to Advance Antiracism in Medicine to create a just and equitable healthcare system where all lives are valued. CAAM’s mission is to create an inclusive, equitable and just healthcare system; to eliminate structural racism in systems of education, practice, research of medicine through the execution of policies, procedures and protections grounded in antiracism; and to reinforce with systems and structures of accountability.

RETIREES MEET FOR LUNCH! Retired physicians meet for lunch every Wednesday at 12 noon at IHOP, 2255 Tittabawassee Road in Saginaw. Those attending are responsible for their own lunch, and the informal gathering lasts about an hour. Join your retired colleagues whenever you like! If you have questions, please contact Joan Cramer at (989) 284-8884 or Dr. Caroline Scott at (989) 295-2721.

Look who you missed on Wednesday, Nov. 10! (l-r) Drs. Caroline Scott, Larry Kelly, George Gugino, Ron Jenson, Les Webb and Dennis Boysen

18

The Bulletin | November 2021

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with a weakened immune system). The difference between ‘droplet’ and ‘airborne’ transmission is a function of the size of the respiratory droplets. Droplet transmission of SARS-CoV2 on droplets that are 5 to 10 micrometers in diameter is the most common route for infecting contacts from an index case. Droplets are formed when one sneezes, coughs, talks or sings. These droplets can stay suspended in the air for a short period of time (<15 minutes), and rarely are they expelled beyond one meter (three feet) from the source patient. This is behind the criteria defining exposure that has been the standard since the onset of this pandemic (within three feet and more than 15 minutes define exposure to an infected individual). Microscopic droplets on the other hand (<5 micrometers) are amenable to evaporation and hence stay in the air for longer periods of time than 15 minutes (exact time depends on several factors) hence the term ‘airborne.’ For comparison, other airborne infections that use those microscopic droplets include tuberculosis, varicella (Chickenpox) and measles. Hence, those are three highly infectious microorganisms and require a ‘negative pressure’ room in the hospital. This room removes air from the patient room to outside the hospital building, hence preventing the spread of those evaporationladen organisms to other patients in the hospital. Given the occurrence of aerosol generating procedures in the hospital, airborne transmission of COVID-19 does occur in healthcare settings, and hence healthcare workers are more vulnerable to exposure, which had in fact materialized and documented early on in this pandemic. Of course, many confounders come to play here, most important of which is presence of a high number of infected individuals in the hospital, so dissecting the role of pure airborne transmission vs. other modes of transmission from an index case is nebulous, although few published reports describe transmission from one area of the hospital to another, incriminating a significant role of airborne transmission in healthcare settings. The least ‘efficient’ way of infecting other individuals is via contact, such as from surfaces or objects (called fomites) which are ‘contaminated’ by SARS-CoV2 when, for example, expelled respiratory secretions land on them. This is the least efficient mode of transmission, and the one with most variables. For example, viability of the virus depends on the viral load in the contaminated secretions, the type of surface (porous vs. non-porous), humidity of the environment, timing since contamination until contact with another individual, and importantly, the need for those secretions to be picked up by a vulnerable individual (e.g. on their hand, stethoscope, other vehicles) and inoculated into the eyes, nose or mouth. When considering real-world transmission scenarios and the surface survival information, the risk of fomites contaminated by continued on page 19


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infected respiratory secretions in turn leading to an infection is negligible after three days, regardless of when the surface was last cleaned. Very few published cases linked infections to fomites, and experimental modelling estimates this risk to be in the order of 1 in 10,000. This means that each contact with a surface contaminated with the coronavirus has less than 1 in 10,000 chance of transmitting the infection. This risk is likely to be even lower on outdoor surfaces as harsher conditions there (sunlight, dilution by air) would shorten viability of the virus and cut the chain of transmission. Based on this discussion, there are two important corollaries to be deduced. The first would support the need for hand hygiene as a barrier to fomite transmission and has been associated with lower risks of infection. The second would be recent voices within the ID community and beyond questioning the role for gowns in cutting the cycle of transmission in healthcare. However, to date, gowns are recommended by the CDC when caring for patients with COVID-19. Of note is that other body fluids, such as blood, plasma, urine and feces, although sometimes reported to be positive by PCR testing in infected individuals, have not been shown to transmit SARS-CoV2 to other individuals. It is theorized that non-viable viral fragments ‘seep’ into the blood sometimes, and from there to other body fluids, and these are detected by PCR but do not pose a risk of infection of the SARS-CoV2 virus to other individuals. An issue worth tackling within the clinical context of transmission is that associated with non-respiratory COVID-19 symptoms. As already known and documented, respiratory symptoms are the primary route of transmitting the virus from an infected individual to a susceptible one. However, what is the risk of transmission when COVID-19 primarily manifests as non-respiratory symptoms, such as gastrointestinal, or ageusia/dysgeusia, anosmia/dysosmia or vascular thrombosis? It is important to remember that those may be the initial manifestations of COVID-19, followed later by respiratory symptoms. In a study by Lin et al, gastrointestinal samples (endoscopic samples, stools) in patients with COVID-19 and predominantly GI symptoms were screened for the virus, and found to be positive in 70% of the samples (also found in samples from patients without GI symptoms). Although a potential liaison has been theorized, no cases of transmission by GI secretions have been documented. Additionally, there is no evidence that SARS-CoV2 can be transmitted via food or water, or via recreational activities such as swimming in natural bodies of water or swimming pools. References available upon request.

APPLICATIONS FOR MEMBERSHIP

Readings for Tuesday, November 16, 2021

FIRST READING:

Applications for membership for first reading at the November 16, 2021, Board Meeting: Michael J. Mishkin, DO (Ascension St. Mary’s Riverfront Cardiology/MCVI) Specialty: Cardiovascular Disease - Board Certified 2015 Medical School: Nova Southeastern University College of Osteopathic Medicine, Fort Lauderdale, FL, 2008 Internship: Largo Medical Center, Largo, FL, Traditional, 6/08-6/09 Residency: University of South Florida, Tampa, FL, Internal Medicine, 7/09-6/12 Fellowship: University of South Florida, Cardiovascular Medicine, 7/12-7/15 Sponsors: Doctors Sarosh Anwar and Vipin Khetarpal Anirudh V. Penumetcha, DO (Ascension St. Mary’s Riverfront Cardiology/MCVI) Specialty: Non-Invasive Cardiology - Board Certified 2021 Medical School: Michigan State University College of Osteopathic Medicine, 2015 Internship/Residency: Wayne State University, Detroit Medical Center, Internal Medicine 7/15-6/18 Fellowship: Wayne State University, Cardiovascular Disease, 7/18-6/21 Sponsors: Doctors Sarosh Anwar and Vipin Khetarpal

NEW MEMBERS Taylor S. Gaudard MD CMU Health - Family Medicine 1575 Concentric Blvd., Ste. 1 Saginaw, MI 48604-9494 Office (989)-746-7500 (989)-746-7766 Fax (989)-746-7923 www.cmich.edu/colleges/cmed/ Family Medicine Alan I. Rebenstock MD Advanced Diagnostic Imaging, PC 3400 N. Center, Suite 400 Saginaw, MI 48603-7920 Office (989)-799-5600 Fax (989)-799-7430 www.adirads.com Radiology - Diagnostic and Pediatric Lodewijk J. vanHolsbeeck MD Advanced Diagnostic Imaging, PC 3400 N. Center, Suite 400 Saginaw, MI 48603-7920 Office (989)-799-5600 Fax (989)-799-7430 www.adirads.com Radiology - Diagnostic and Pediatric The Bulletin | November 2021 19


Snakes and Ladders of Medical Publishing: Use Metrics to Assess Quality of Journals and Distinguish Predatory Journals Neli Ragina, PhD Associate Professor of Genetics and Director Students and Residents Clinical Research, CMU College of Medicine, Mt. Pleasant, MI

David Weindorf, PhD Professor and Vice President for Research and Innovation, CMU, Mt. Pleasant, MI

Professional writing in every discipline is different. It is influenced by readership, techniques used, professional terms, specialty, discipline, etc. For example, clinicians readily use acronyms like CRP (C-reactive protein) or US (Ultrasound), but to those writing in mathematics, such terms would be elusive. Thus, it is important to know who your audience will be as you develop your manuscript. Other important points when preparing to write your manuscript are to perform an in-depth literature review and be aware of how much data you have. If you have a lot of data addressing multiple outcomes, then think about the possibility of splitting your data into two or even three manuscripts to keep the foci succinct. In general, being too broad or far reaching in a single manuscript can be troublesome. To avoid that, make sure you know the scope of your project, as well as, your audience. A. Finding a journal appropriate to your study There is often a dilemma in finding a journal to publish your findings. The journals’ scope could be local, regional, national or international. Local and regional journals are best suited for publishing applied research, demonstrations of established approaches or studies that are unique to small areas. The peer review process is generally less rigorous. Contrariwise, national, and international journals are best suited for large scale studies, new and/or innovative approaches or studies with broad applicability. Such journals have a strong peer review process. Regardless of the type and scope of your research, a well written manuscript can and should still be published! All you need is to find the appropriate journal. Below is a link to a commonly used journal finder from Elsevier publishing group that helps identify the most suitable journal for your study that this specific publisher prints, as well as, provides information on the impact factor, review speed and acceptance rate of the recommended journals: https:// journalfinder.elsevier.com/ 20 The Bulletin | November 2021

B. Metrics used to assess journal quality Not all research journals are equal in each field of study. There are metrics used to assess the quality of journals and provide some idea of how broadly it is read. The most common ones are the Impact Factor (a.k.a. Impact Index/Citation Index) and journal Quartile (Q1-Q4). 1) The Impact Factor (IF) is based upon the total number of citations a journal received in the previous two or three years divided by the total number of articles published in the previous two years in a given journal. A higher IF generally indicates that the journal is highly cited and more impactful. The IF is calculated using the following two approaches: a) The Journal Citation Reports (JCR). This is a paid-for tool which is accessed via the Web of Science platform. The database of citations on which it is supported, the Web of Science Core Collection, is a paid-for service platform. The citation period covers two years, and every citation has the same weighting and the same value regardless of which journal a particular article is cited by. b) SCIMAGO Journal and Country Rank (SJR) is another platform used to calculate IF. SJR is a free platform, however, the database of citations on which it is supported, Scopus, is a paid-for service platform. The SJR citation period covers three years, and the citations are all weighted, meaning that the value of the citation depends on the position occupied by the journal in which the citations are made. Generally, publishing in journals with higher IF is desirable. Below is a link to the Scimago Journal & Country Rank portal (SJR) (https://www.scimagojr.com/) 2) Quartiles (Q1 – Q4). In addition to the IF, rankings of journals in each subject category are divided into quartiles by both JCR and SJR. JCR and SJR rank the journals from highest to lowest based on their IF. There are four quartiles: Q1, Q2, Q3 and Q4. Q1 is occupied by the top 25% of journals in the list, Q2 is occupied by journals in the 25-50% group, Q3 is occupied by journals in the 50-75% group and Q4 is occupied by journals in the 75-100% group. The most prestigious journals within a subject area are those occupying the first quartile, Q1. The importance of the other journals declines moving down through the quartiles. C. Identifying predatory journals When one looks for journals to publish their findings, they continued on page 21


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must make sure that the journal of choice is NOT a predatory journal. Predatory journals and publishers are entities that prioritize self-interest at the expense of scholarship and are characterized by false or misleading information, deviation from best editorial and publication practices, a lack of transparency, and/or the use of aggressive and indiscriminate solicitation practices. (Grudniewicz et al. (2019) https://www. nature.com/articles/d41586-019-03759-y). Often such journals send unsolicited e-mails inclusive of: 1) overly flattering language 2) mention of your previous publications which have no relation to their journal 3) awkward language 4) the promise of rapid review, doi assignment, indexing in “off brand” databases 5) feature bizarre, dated websites with minimal information. Figure 1 below shows an example of a predatory journal pitch.

In summary, one must avoid predatory journals at all costs. Such papers will not be counted as scholarly activity at Central Michigan University and other academic institutions (e.g., cannot be used to count for Promotion and Tenure (P&T) productivity, etc.). Papers in predatory journals are not counted in metrics which help academia advance in national rankings. In short, these “journals” are not recognized by the academic community and will waste your time, energy and money. To check if a journal is a predatory vs. legitimate and indexed in the MEDLINE database, follow the links below: • For the general website: https://www.nlm.nih govarchive/20130415/tsd/serials/lji.html 1 • All journals: https://www.ncbinlmnihgovnlmcatalog?ter m=currentlyindexed%5BAll%5D • For a list provided by NLM which is updated quarterly follow the link below: http://www.nlm.nih.gov/bsd/lstrc/ newtitles.html D. Plagiarism detection software (iThenticate) Many journals nowadays use plagiarism detection software to scan all incoming articles. One of the most commonly used plagiarism detection software programs is called iThenticate. The iThenticate score should reveal a similarity index of <15%. No instance of plagiarized work is acceptable. Some similarity

revealed in the similarity index score often comes from Materials and Methods section of the manuscript that are common amongst many publications and authors. If you do not have iThenticate, try simply using Google to search a phrase that appears suspicious. When plagiarism exists, often the language quality is dramatically different than the surrounding text. If you are a CMU faculty, please contact Amy Courter at court1al@cmich.edu for access to the software. E. Open access journals According to the Springer Publishing group, “Open Access (OA) is when publications are freely available online to all at no cost and with limited restrictions with regards reuse. The unrestricted distribution of research is especially important for authors (as their work gets seen by more people), readers (as they can access and build on the most recent work in the field) and funders (as the work they fund has broader impact by being able to reach a wider audience).” Most of the journals would charge the reader a fee to access your publication. However, OA journals provide content for free on the web and charge researchers to publish their findings. To see if a journal is either open-access or supports open access, look underneath the journal's title. For journals that support open access, ScienceDirect users can click on the openaccess article link on the left-hand sidebar to navigate to the open access articles published in the journal. Follow the link below (https://www.elsevier.com/connect/6-ways-to-findelseviers-open-access-content).

A new service to support and assist frontline healthcare workers with behavioral health services is now available from the Saginaw County Community Mental Health Authority.

Free Confidential Counseling for Frontline Healthcare Workers Free, confidential counseling services are available for healthcare professionals and their immediate family to provide help coping with the stress and anxiety due to the COVID-19 pandemic. Professional counselors provide primary care screening, assessment and monitoring of key health indicators. These services are available to those that need extra help coping during this extremely stressful time. There is no shame in talking, in person or virtually, with someone.

Call the Saginaw Community Care HUB at

989.498.2266

for an immediate appointment

The Bulletin | November 2021

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2022 Medicare Physician Fee Schedule Final Rule On November 2, 2021, the Centers for Medicare & Medicaid Services (CMS) released the final rule for the CY 2022 Medicare physician fee schedule. AMA staff are thoroughly analyzing the 2,400+ page rule and will provide a comprehensive summary in the near future. Notably, the 2022 Medicare conversion factor will be reduced by approximately 3.85% from 34.8931 (2021) to 33.5983. This is largely a result of the expiration of a 3.75% increase to the conversion factor at the end of calendar year 2021, as averted in 2021 by Congressional action. The AMA continues to strongly advocate for Congress to avert this significant cut and extend the 3.75% increase for 2022, as it further compounds the growing financial instability of physician practices due to the severe reduction in revenue caused by the continued COVID-19 PHE. Additionally, CMS finalized provisions that extend coverage of services that were added to the Medicare telehealth list on an interim basis in response to the COVID-19 PHE until the end of 2023 and eliminated geographic barriers, allowing patients in their homes to access telehealth services for diagnosis, evaluation and treatment of mental health disorders. In addition, CMS announced plans to permanently increase payment for immunization administration, beyond COVID vaccines, and relied on information from the AMA and the RUC in developing the improved payment rates. CMS is also moving forward with the first round of seven MIPS Value Pathways (MVPs) that will be available, beginning with the 2023 performance year. Click HERE to read the CMS Press Release Click HERE to view the Physician Fee Schedule Fact Sheet

AMA Releases Four New Behavioral Health Integration (BHI) How-to Guides The AMA has released four new practice guides that equip physician practices and health systems with practical strategies for overcoming obstacles to accessible and equitable treatment for patients’ behavioral, mental and physical health needs. These guides focus on four key

areas of effective integrated care: Practice workflow design, pharmacological treatment, substance use disorder and suicide prevention. Additionally, the BHI Compendium, which serves as a tool to help provide a proven pathway for delivering integrated behavioral care, has also been enhanced with additional resources and practice case studies ensuring physician practices and health systems have the most recent, actionable information at their disposal. Click HERE to view the guides.

AMA Telehealth Use Survey The AMA is conducting a survey to assess the current landscape and use of telehealth among physicians and other health care practitioners. The goal is to learn more about physicians’ experience with telehealth, including ongoing challenges, benefits, and opportunities. Survey results will help inform future telehealth research and advocacy, resource development, and continued support for physicians, practices and health systems. The survey will close on December 31, 2021, at 11:59 p.m. ET. Click HERE to take the Survey.

AMA to Host Mini-Boot Camp Focused on Highlights from the 2021 Telehealth Immersion Program The AMA will host a Telehealth Immersion Program miniboot camp from 5-7 p.m. ET on Tuesday, December 7 that will provide participants with a recap of the 2021 Telehealth Immersion Program, highlight physician and practice wins, and provide an overview of the telehealth landscape for the future, including key policy changes for 2022. Click HERE to register.

Scope of Practice Physician Authors Explore What Rise of NPs, PAs Means for Patients As Alexus Ochoa-Dockins, a 19-year-old college athlete, was being rushed to the hospital, the responding paramedic contacted the emergency department to alert them that a patient with a suspected pulmonary embolism would be arriving shortly. The family nurse practitioner (NP) who would see Alexus in the ED ordered an array of tests, including a chest CT scan continued on page 23

BIRTHDAYS December

Syed S. Akhtar MD Ahmad Alsughayer MD Anisah Al-Qadi Student Arshad Aqil MD Catherine M. Baase MD Nathanial Bartosek Student Kayla Bennett Student J.G. Marc Bertrand MD Wendy S. Biggs MD Marshall A. Brown MD Sarah Bunker Student Thomas M. Burkey MD

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John F. Cherry MD Sanjay Das Student Virginia R. Dedicatoria MD Libing K. Dong Student Rosalinda A. Elazegui MD Frederick W. Foltz MD Jack E. Goodwin MD Halimah Hamidu-Egiebor Student Duane B. Heilbronn, Jr. MD Jennifer A. Henrich MD Steven L. Jensen MD Dalia Khader Student

The Bulletin | November 2021

Sambasiva R. Kottamasu MD Yanyu Long MD Emmanuel Luciano Lorenzo MD Carlotta M. Maresca MD Joanne E. Mathew MD Andrew C. Ostosh MD B. Babu Paidipaty MD Che Song Park MD Sundarachalam Pindicura MD Manasvi Pinnamaneni Student Nivin A. Qudeimat MD Nathan M. Razbannia MD

Lekha K. Richardson MD Brian M. Shear Student James F. Shetlar MD Farhad K. Shokoohi MD Shipra Singh MD Logan A. Steffke Student Gregory P. Sutton MD Tarek A. Taha MD Cindy Tantilert Student Andrew S. Wagner MD Julia M. Walter MD Liaqat Zaman MD


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that would have confirmed the paramedic’s suspicions. But the scan was postponed after Alexus fainted and a urinalysis showed “presumptive positive detection” for methamphetamine even though the test was negative for amphetamine. Ten hours later, the CT scan was performed and was misread by the NP as a crushed sternum. While the diagnosis was wrong, it led to Alexus being transferred to a larger hospital where a physician correctly diagnosed her pulmonary embolism and began treatment. But it was too late, and she died two hours later. Rebekah Bernard, MD, uses Ochoa-Dockins’ story as a thread that ties together the issues she reports on in Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare, the book she co-wrote with Niran Al-Agba, MD, a pediatrician in Silverdale, Washington. Their book details how care from nonphysicians is dangerously being promoted as “just as good” as that provided by doctors - despite the huge differences in education and training requirements. “The more we dug through the case, the more we realized that everything that we were talking about of concern, seemed to happen in her case - just so many perfect examples of just so many things going wrong,” Dr. Bernard said in an interview with the AMA. “The sad thing is that this is not an isolated incident, it's just an incident in which everything kind of came together to create this horrific outcome,” she added. The book delves into how many patients don’t know that - despite their white coat - the person in the exam room with them is not a physician. “Unfortunately, most Americans have remained dangerously unaware of this revolution in health care,” the book says. And, “if patients do wonder about being treated by a non-physician, they are reassured that their nurse practitioner or physician assistant is ‘just as good’ as a doctor, an idea reinforced by multimillion-dollar direct-to-patient advertising campaigns.” An Oklahoma jury awarded Alexus’ estate $6.19 million, and their attorney said that there was hope that the verdict would lead to changes to ensure that “appropriately qualified medical providers” were on hand at all the state’s hospitals. It’s about protecting patients Dr. Bernard says her passion for the scope-of-practice issue is “about making sure that patients have the right quality of care and making sure that we're going to have the care for ourselves because, ultimately, we're all going to be patients someday.” Dr. Bernard is a member of the Florida Medical Association and the AMA, and research from the AMA is cited throughout her book. She also cites a 2019 study “Potential Crisis in Nurse Practitioner Preparation in the United States,” published in the

peer-reviewed journal Policy, Politics & Nursing Practice. That study analyzes the American Association of Colleges of Nursing’s list of accredited doctorate of nursing practice (DNP) programs. Of the 533 DNP programs established between 2005 and 2018, researchers found, only 15 percent were clinical in nature while the others focused on leadership and administration topics. “That means 85 percent don't give them any additional clinical training, yet now they have doctor in front of their name,” Dr. Bernard said. “Patients don't know that it's almost more like an academic type of a doctorate than a clinical doctorate.” Lesson to be learned Dr. Bernard said the political wins NPs and physician assistants have garnered on some scope-of-practice fronts have come from a laser-like focus on gaining independent practice and direct payment for their services. “They got all this done because they worked together,” she said. “If physicians worked together to the same extent, you can just imagine what we would accomplish.” For more than 30 years, the AMA’s state and federal advocacy efforts have safeguarded the practice of medicine by opposing NP and other nonphysician professional attempts to inappropriately expand their scope of practice. That includes more than 75 scope-of-practice victories in 2019 and 2020. The AMA Truth in Advertising Campaign is designed to ensure health care providers clearly and honestly state their level of training, education and licensing. Patients deserve to have this information when in face-to-face encounters, as well as, when they read health care providers’ advertising, marketing and other communications materials. Patients are confused about the qualifications of different health care professionals. Many non-physicians earn advanced degrees, and many of those degree programs now confer the title “doctor.” As a result, patients often mistakenly believe they are meeting with physicians (medical doctors or doctors of osteopathic medicine) when they are not. To ensure patients know which “doctor” is providing their care, truth in advertising legislation: • Requires all health care professionals to clearly and accurately identify themselves in all writings, advertisements and other communications. • Requires all health care professionals to wear, during patient encounters, a name tag that clearly identifies the type of license they hold. • Prohibits advertisements or websites advertising health care services from including deceptive or misleading information. Andis Robeznieks, Senior News Writer

MEMBER APPRECIATION! Enter to win a $50 Amazon Gift Card as a thank you for reading The Bulletin! To enter, send an email to Joan Cramer at jmcramer@sbcglobal.net with “I WANT TO WIN - NOVEMBER 2021” in the subject line. The winner will be randomly drawn on December 1.

The Bulletin | November 2021 23


Current Legislative Projects – Part 2

for mandated CME hours at 150 hours per three-year cycle, a contributing factor to physician burnout. New Issues and continued from October 2021 Bulletin House Bill 5414 currently resides in the House Health Policy • NEW! Nurse Practitioner Scope of Practice – Senate Bill 680 Committee and a hearing is expected in early December. On October 6, 2021, dangerous legislation was introduced MSMS will be meeting with members of the committee over in the Senate that would allow nurse practitioners to practice the coming weeks to discuss solutions that will better serve independently. Senate Bill 680, sponsored by Senator Rick Michigan’s children. Click HERE to contact your Outman, would allow nurse practitioners to provide direct lawmakers now! care without physician involvement or collaboration, and they • MSMS and the SCMS Join New Coalition would also be allowed to prescribe opioids and other Trained experts. Compassionate caregivers. A true team controlled substances. Senate Bill 680 was referred to the Senate Health Policy and Human Services Committee. A hearing of individuals, each playing an essential role and doing their part - with the patient at the center of it all. It’s on the bill has not been scheduled at this time. MSMS and the Michigan for Advancing Collaborative Care Teams (MiACCT) the kind of care Michigan patients expect for coalition will be working to educate House and Senate members themselves and their loved ones. And frankly, we believe it’s the kind of care they all deserve. about the dangers of this legislation and the importance of physician-led care. Please contact your elected officials about With that in mind, we’re excited to announce we’ve joined a new coalition - Michigan for Advancing Collaborative Senate Bill 680 by clicking HERE. See also MiACCT below. Care Teams (MiACCT) that solely focuses on preserving and • NEW! Lead Poisoning Identification and Treatment as a strengthening the health care teams we all rely on for our care. Condition of License Renewal – House Bill 5414 And we believe it’s a coalition that couldn’t have come at a On October 19, 2021, legislation was introduced in the better time. Michigan House that would mandate all licensed medical Every day, across the country, powerful special interest professionals to take Continuing Medical Education (CME) groups work to undermine the team-based approach to courses on lead poisoning identification and treatment health care all in the interest of making a buck. The policies as a condition of license renewal. Specifically, House Bill they promote take physicians away from their patients and 5414 would require CME courses to include content regarding jeopardize the patient care and safety in the process. the screening of children who are six years of age or less for Thankfully, MiACCT is here to fight back. Made up of a lead poisoning, the physiological and behavioral signs of lead growing number of health care providers and patient advocacy poisoning, the treatment needs of children with elevated organizations united and committed in the belief that the timeblood lead levels, and the referral of children with elevated tested, physician-led, patient-centered model of care is the very blood lead levels to appropriate state agencies. MSMS policy best way to increase health care access without compromising supports Early and Periodic Screening, Diagnosis and patient safety or quality of care, MiACCT exists to fight for Treatment Programs (EPSDT) to reach as many eligible what’s best for Michigan’s patients. That’s what they need. children as possible, and urges all its members to screen That’s what they deserve. And we’re happy to be a part of it. children for their risk on contact with lead hazards and Senate Bill 680 was recently introduced in the Michigan subsequent lead poisoning, and to complete a capillary or Senate that will allow for full independent practice for nurse venous blood test for any child deemed to be at high risk practitioners (NPs). Under the bill, not only would NPs be for this serious health problem. However, MSMS policy allowed to provide direct care without physician supervision opposes any attempt to introduce compulsory content of or collaboration, but they would also be allowed to prescribe mandated CME in the state of Michigan and opposes House opioids and other controlled substances. Further, the bill Bill 5414 for the following reasons: wouldn’t even require additional training or education for NPs. • House Bill 5414 takes a one-size fits all approach that does We know this isn’t what’s best for patients. They want and not consider different specialties which may never need deserve a robust care team that collaborates for their best to use the knowledge provided. interest. The way to do that is NOT creating silos of care. It’s • Many specialists will never need to perform lead NOT putting those with less training and experience in charge screening; however, this bill would require all physicians of their care. Let your Senator know this isn’t the right plan to take CME for it. for Michigan’s patients. Make sure your Senator knows • There are already sufficient guidelines and quality Nurse Practitioners should be part of the care team, not measures related to lead screening (NCQUA-HEDIS independent from it! Measure, Bright Futures, and CHIP programs). Clinicians • Behavioral Health Integration (HBs 4925-4929/SBs 597 seeing these patients are already performing screenings. and 598) • Michigan already ranks amongst the highest in the nation 24

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Both the House and Senate recently introduced proposals that would overhaul Michigan’s mental health system. While both proposals essentially eliminate pre-paid inpatient health plans (PIHPs), the Senate plan relies more on shifting that layer of managed care to private insurers, while the House plan is more so a “fee-for-service” model that attempts to allow individuals to choose the care they want with the state more directly picking up the cost. Summary of HBs 4925-4929 Establishes “administrative services organization (ASO)” that is contracted by DHHS to provide certain specified administrative services necessary to manage the public behavioral health system on the state’s behalf. ASO must be organized as a nonprofit, public, or quasi-public entity and cannot be a community mental health services program. Contract must require the ASO to perform all of the following: • Eligibility verification • Utilization management • Intensive care management • Quality management • Coordination of medical and behavioral health services • Provider network development and management • Recipient rights and provider services and reporting • Customer service • Corporate compliance • Clinical management services not retained by the department Within one year of the effective date, DHHS shall utilize a self-insured financing and delivery system structure to provide or arrange for the delivery and integration of specialty services and support for eligible Medicaid beneficiaries with a mental illness, emotional disturbance, intellectual or developmental disability, or substance use disorder. The department specialty services and supports shall be carved out from the basic Medicaid health care benefits package. Medicaid beneficiaries currently receiving limited behavioral health services through the basic Medicaid health care benefits package may continue to do so or choose to receive behavioral health services through the self-insured financing and delivery system. Summary of SB 597 and 598 Establishes “specialty integrated plans (SIPs)” that would operate as community mental health services programs. By June 1, 2022, MDHHS is required to develop and begin implementation of a plan to fully integrate the administration of physical health care services and behavioral health specialty services and supports for eligible Medicaid beneficiaries with a serious mental illness, developmental disability, serious emotional disturbance, or substance use disorder and eligible Medicaid beneficiaries who are children in foster care. The plan must provide for full integration and administration of physical health care services and behavioral health specialty services and supports through SIPs by 2026.

MSMS Input MSMS policy supports strategies to improve access to mental health services in Michigan that ensure each person can receive the patient-centered care he or she needs when and where it is needed. Such access requires a seamless, integrated system responsive to the needs of patients across the entire spectrum of symptom severity. While the bills are only starting points, MSMS has concerns and will be working with the sponsors and other stakeholders over the coming months. At the request of Senate Majority Leader Mike Shirkey, MSMS has also provided the following recommendations to Senate Bill 597 and 598: • Add the Michigan State Medical Society (MSMS) to the “interested parties” whose input is to be considered. • Include language solidifying a clinical model that recognizes the important role of primary care and patient centered medical homes in coordinating health services for beneficiaries whose conditions are often fluid across the continuum from mild/moderate to severe. • Add language that supports provision of a collaborative care model. • Require SIPs, PIHPs, and community mental health (CMH) agencies to communicate and collaborate with primary care providers/patients’ medical homes including, but not limited to: o Enabling the PCP/medical home to be central in the referral process for subspecialty mental health care through CMH. o Providing the PIHP/medical home standing to appeal adverse determinations by the CMH. • Consider aligning the metrics, standards and payment methodology with those required of Certified Community Behavioral Health Clinics (CCBHCs) that meet required federal criteria. CCBHCs are designed to: o Provide integrated, evidence-based, trauma-informed, recovery-oriented and person-and-family-centered care. o Offer the full array of CCBHC-required mental health, substance use disorder (SUD) and primary care screening services. o Have established collaborative relationships with other providers and health care systems to ensure coordination of care. • Include language to reflect the need for screening to ensure early intervention and onset of comprehensive and appropriate treatment. • Include language that requires SIPs, PIHPs, and CMHs to utilize health information technology that supports the sharing of information with all care providers and meets federal certification requirements. Talking Points • The majority of persons with a mental health condition are served in a primary care setting. Regarding patients continued on page 30

The Bulletin | November 2021 25


Covenant Sleep Center Celebrates 15 Years of Accreditation - American Academy of Sleep Medicine

Miss out on the 2021 event? Watch CovenantKidsMI.com for details around the 2022 event.

We are proud to announce that the Covenant HealthCare Sleep Center recently achieved reaccreditation from the American Academy of Sleep Medicine (AASM). The Sleep Center was first accredited by AASM in 2011, and the reaccreditation process takes place every five years. To maintain accreditation, a sleep center must meet or exceed all standards for professional health care as designated by the AASM. These standards address core areas such as personnel, facility and equipment, policies and procedures, data acquisition, patient care and quality assurance. Additionally, the sleep center’s goals must be clearly stated and include plans for positively affecting the quality of medical care in the community it serves. “Our team at the Covenant Sleep Center is thrilled to have achieved reaccreditation,” says Dianne Gray-Fiting, Sleep Center Coordinator. “This designation is a testament to our team’s devotion to providing the best care possible for patients suffering from sleep disorders - and to be able to provide this resource locally is a blessing.” Christopher J. Allen, MD serves as Medical Director for the Covenant Sleep Center. We are proud of the team’s dedication to making advancements in the field and providing extraordinary care for patients in the region.

Covenant Medical Group Welcomes New Providers

Covenant Kids Gala Purchases Lifesaving Transportation For more than 40 years, families in the Great Lakes Bay Region and beyond have relied on Covenant HealthCare to provide the highest level of newborn care. In October, the firstever Chrysalis: A Gala for Covenant Kids supported the purchase of three state-of-the art infant isolette transport units for the LifeNet Helicopter and MMR ambulances. This equipment will now provide the safest method for bringing premature babies and sick infants to Covenant from regional hospitals who rely on the specialized equipment and advanced training Covenant offers. The Covenant Kids Gala was originally scheduled to take place in April of 2020. At the time, the goal was to raise money to purchase equipment to help transport newborns via air or ground to Covenant when needed. Eighteen months after the original event was scheduled, the equipment has not only been purchased, it is also in use. Thanks to the sponsors and attendees for taking part in the purchase of lifesaving equipment for our region’s tiniest patients. 26

The Bulletin | November 2021

Hospital Medicine Dr. Nancy Joy and Dr. Jonathan Schwartz Join Covenant Hospital Medicine Covenant HealthCare welcomes Nancy E. Joy, MD, and Jonathan M. Schwartz, MD, as members of the Covenant Medical Group as part of the Covenant Hospitalist Nancy E. Joy, MD Jonathan M. Schwartz, MD team. Their office is located at 1447 North Harrison, Saginaw, MI 48602 and the team can be reached at 989.583.4220. Primary Care Dr. Randall Nall Joins Covenant Medical Group Family Medicine Covenant HealthCare welcomes Randall L. Nall, MD, as a member of the Covenant Medical Group. Dr. Nall joins the Covenant Primary Care team. The office is located at 2429 Trautner Drive, Saginaw, MI 48604 and can be reached at Randall L. Nall, MD 989.583.5514. Specialty Care Dr. Ronald Barry Joins Covenant Plastic Surgery Covenant HealthCare welcomes Ronald C. Barry, MD, as a member of the Covenant Medical Group. Dr. Barry has been board certified by the American Board of Plastic Surgery for more than 25 years. He brings a wide variety of experience, Ronald C. Barry, MD local service and expertise to the Covenant Plastic Surgery team. His office is located at 4677 Towne Center, Suite 105, Saginaw, MI 48604 and the plastic surgery team can be reached at 989.583.5675. Dr. Angala Borders-Robinson Joins Covenant Neurology Covenant HealthCare welcomes Angala Borders-Robinson, DO, as a member of the Covenant Medical Group. Dr. Borders-Robinson joins the Covenant Neurology team. She is a graduate of Michigan State University College Angala BordersRobinson, DO of Osteopathic Medicine, and completed her residency at St. John Oakland Hospital, Madison Heights. She completed her fellowship at St. John Oakland Hospital, Madison Heights, in neuromuscular disease. She is board certified by the American Osteopathic Board of Neurology and Psychiatry, and has a focus on Multiple Sclerosis and general neurology. Her office is located at 3400 N. Center Road, Saginaw, MI 48603 and the neurology team can be reached at 989.583.3150.


IN MEMORY Donald Luke Tuckey, MD left this world peacefully after a lifetime of accomplishments and achievements. He died on Saturday, October 23, 2021, at the age of 86 at Covenant Healthcare. Don was born the fifth child of Luke and Evelyn Tuckey on February 1, 1935, in Cass City, Michigan. After graduating from Cass City High School in 1953, he attended Central Michigan University where he played football on Central's 1957 championship team. Following graduation, he married his college sweetheart, Kathlyn, in Capac, Michigan on February 8, 1958. He then entered Naval Officers' Candidate School in Newport, Rhode Island. After accepting his commission, he spent three years assigned to the staff of the Commanderin-Chief Atlantic in Norfolk, Virginia. In 1961, Don entered medical school at the University of Virginia. In 1965, he began his internship at Saginaw General Hospital and completed his residency in 1969 with a specialty in Obstetrics and Gynecology. He entered practice with Women's OB-GYN and throughout his career, delivered over 5,000 babies. He served as chief of the OB-GYN Department and served two years as Chief of Staff at Saginaw General Hospital. An avid outdoorsman, Don loved hunting and fishing

diabetes SELF MANAGEMENT PROGRAM

and went on many grand adventures. He was exceptionally well-read and never without a book at his side. He traveled extensively and was always up for a game of golf or playing cards with his buddies. He was a member of St. Lorenz Lutheran Church, as well as, the Frankenmuth Lion's Club and Frankenmuth Conservation Club. Don is survived by his wife, Kathlyn, children, grandchildren and great grandchildren: Patrick and Katie Tuckey, Georgia and Wyatt, Waxahachie, Texas; Elizabeth and Robert Stearns, Jacob, Annie and John; and Nances and Jerome Sheppard, Caleb, Bailey, Luke, Ashton, Grace and Olivia, all of Frankenmuth. Also surviving are siblings Charles and Iris Tuckey, Eunice Kaufmann, Roy and Kathy Tuckey, Delores Tuckey, Sylvia Tuckey and Barbara Tuckey; as well as, many nieces and nephews. He was predeceased in death by his brothers and sister: Dorothy Mantey, J.D. Tuckey, William Tuckey, and Robert Tuckey; and brothers -in-law; Carl Mantey and Donald Kaufmann. Funeral services took place on Wednesday, October 27, 2021. Those planning an expression of sympathy may wish to consider memorials to St. Lorenz Media Ministry or Covenant NICU. Please sign our guest book or share an online condolence with the family at www.cederbergfh.com.

In the United States, 30.3 MILLION people are living with diabetes – 84 million are living with prediabetes. Covenant HealthCare is the region’s most experienced diabetes management team. Our program is certified by the Association of Diabetes Care & Education Specialists (ADCES) through the Michigan Department Health and Human Service (MDHHS). We are certified to provide education for patients of all ages and diabetes diagnoses, including pregnant women. Put your trust in the region’s most experienced diabetes management team – your Patient-Centered Medical Home partner. We also have a Diabetes Prevention Program to help prevent or delay Type 2 diabetes.

To refer a patient or for more information call:

989.583.5193.

©2020 Covenant HealthCare. All rights reserved. PK 2/20 13001

The Bulletin | November 2021 27


Ascension St. Mary’s Hospital Receives Top Honors for Quality Stroke Care Ascension St. Mary’s has received the American Heart Association’s top honor for stroke care Get With The Guidelines® Stroke Quality Achievement Award Gold Plus with Honor Roll Elite, Advanced Therapy and Target: Type 2 Diabetes Honor Roll recognition. The award acknowledges the hospital’s commitment to ensuring stroke patients receive the most appropriate treatment according to nationally recognized, research-based guidelines centered on the latest scientific evidence. Ascension St. Mary’s Hospital is also the only Comprehensive Stroke Center (CSC) north of Flint, a higher designation than primary stroke center as recognized by The Joint Commission. As a CSC, Ascension St. Mary’s Hospital has the specific resources, staff and training to receive and treat the most complex stroke cases, leading to better outcomes. They achieved this certification status as a result of interdisciplinary program enhancements, including: • The ability to treat both ischemic and hemorrhagic strokes, including brain aneurysms • Offering the most complex neurosurgical procedures, including intra-arterial stroke treatment procedures, such as thrombectomies to remove blood clots • Establishing dedicated patient care units that provide specialized post-stroke care Ascension St. Mary’s physicians, nurses and clinicians are ready and able 24/7 to provide patients with the best possible stroke care for the most complicated and serious strokes when seconds count. Ascension St. Mary’s is the first hospital north of Flint, and only the 11th hospital in Michigan, to earn this designation. There are currently fewer than 200 hospitals in the United States that have achieved CSC certification. Expanded Emergency Care Center at Ascension St. Mary’s Hospital Nears Completion Groundbreaking for an expanded Emergency Care Center occurred in October 2019 and now, two years later, the expansion and renovation project is nearing completion. A blessing and dedication is planned for Tuesday, November 30. The $17.6 million expansion which included a 12,600-square foot addition, renovation of existing space and improved access for ambulances and the public, will be complete by the end of November. The investment transformed the facility into a modern-day emergency and Level II trauma care center 28

The Bulletin | November 2021

with 26 exam/treatment rooms and two state-of-the-art trauma rooms. Ascension St. Mary’s has been a designated Level II trauma center since 2008. The new design of the expanded Emergency Care Center also improves both ambulance and public access. An airport style drop-off/pick up and continuous drop-off canopy for inclement weather are welcomed enhancements for both ambulances and the public. “We are extremely excited that this new, leading-edge Emergency Care Center is almost complete,” said Stephanie J. Duggan, MD, Regional President, Ascension St. Mary’s. “The investment into an expanded care facility allows for an increase in capacity, support improvements in the flow of patient care and efficiency, as well as, easier access for ambulances, patients and families. We look forward to continuing to provide high quality, compassionate, personcentered emergency care to all people we serve across the region.” Breast Cancer Fund Benefits From the 14th Annual Pink Out Hockey Game Ascension St. Mary’s and the Saginaw Spirit honored 60 breast cancer survivors at the Pink Out hockey game on Sunday, October 17. It was the 14th annual partnership between the organizations to spread awareness about breast cancer and the importance of early detection and treatment, as well as, give hope to those battling the disease. Individuals were recognized by name in a pre-game ceremony. Physician, Lisa M. WintonLi, MD, surgical breast surgeon and medical director of oncology services at Ascension St. Mary’s, and Amy Slough, breast oncology nurse navigator, participated in the ceremonial puck drop with the team captains. Jennifer Jarvis, pharmacist at Ascension St. Mary’s Hospital, also sang the Canadian and American national anthems. Thanks to the volunteers who sold raffle tickets, t-shirts and pink beads, as well as, a live post-game auction of the commemorative Pink Out hockey jerseys, it’s estimated that over $8,000 will be donated to the Ascension St. Mary’s Foundation Breast Care Fund. Nearly $68,000 has been directed to the fund since 2006. Check out the WNEM TV 5 news clip. Ascension St. Mary’s Hospital Announces Medical Director of Quality Hassan Beiz, MD, has accepted the role of Medical Director of Quality at Ascension St. Mary’s Hospital. Dr. Beiz is a practicing board certified internal medicine physician with an emphasis on hospital medicine and a passion for quality, patient safety and satisfaction. Prior to coming to CMU and Ascension St. Mary’s Hospital, he practiced in Marshall, Michigan where he served as the physician lead for quality and safety. During his tenure, the continued on page 30


Welcome New Providers Ascension Medical Group is pleased to welcome the following new providers to our employed medical staff.

Selina Akbar, MD

Toby Blosser, AT

Internal Medicine AMG Primary Care Towne Centre

Athletic Trainer AMG Orthopedics & Sports Medicine

Carlyn Hinish, DPM

Jasleen Kaur, MD

Podiatry AMG Orthopedics & Sports Medicine

Rheumatology AMG Rheumatology

Anirudh Penumetcha, DO Amanda Petzold, PA Cardiology AMG Riverfront Cardiology

Electrophysiology AMG Riverfront Cardiology

Angela Ritter, PA

Joginder Singh, MD

Neurosurgery AMG Neurosurgery

Jessica Ruff, PA

Family Medicine AMG Family Physicians - Gratiot

Pragna Dholakia, NP Cardiology AMG Riverfront Cardiology

Leigh Gilpin, DO Urology Placed with TriCity Urology

Lisa Guyot, MD

Neurosurgery AMG Neurosurgery Genesys

Melissa Kildow, NP

Christopher Kukla, PA

Alexey Levashkevich, MD

Sefako Phala, MD

Patchawan 'PorPor' Phunwutikorn, PsyD

Nathan Quaderer, DO

Neurosurgery AMG Neurosurgery Genesys

Family Medicine AMG Bay City Family Physicians

Jason Streff, DO

Family Medicine Placed with Fenton Family Physicians

Sports Medicine AMG Orthopedic & Sports Medicine

Psychology AMG Bariatrics

UroGynegology AMG Obstetrics & Gynecology - Genesys

Family Medicine Placed with Fenton Family Physicians

Tiffany Wirtz, NP Orthopedics AMG Orthopedics

October 2021


Ascension continued from page 28

hospital achieved a five-star CMS rating, Leapfrog group A rating and was named Consumer Reports’ Safest Hospital in the Country. Compelled to teach, Dr. Beiz became part of the CMU residency program in 2017. Since his arrival, he has been a key advocate for quality. In 2018, he was identified as a leader in our community and became the chair of the Ascension Michigan Hospitalist Clinical Care Transformation Team, which aims to

improve quality and safety outcomes for hospitalized patients. Additionally, he led the transition to the CMU hospitalist group, and has been a critical member of our physician COVID-19 response. Dr. Beiz is an academic faculty member with CMU College of Medicine and a site director of the internal medicine residency program. Dr. Beiz can be reached via Perfect Serve or by email at beiz1hh@cmich.edu.

MSMS continued from page 25

with clinical depression, 42 percent are first diagnosed by a primary care physician. • Patients don’t “stay” within a particular symptom severity, and this is particularly true when appropriate treatment is not available. A system grounded in collaborative care and evidence-based approaches provides the expertise necessary to treat patients who are experiencing mild to moderate symptoms where they are most likely to seek care combined with the ability to rapidly access subspecialty care to effectively intervene when symptoms become more severe and returning care oversight back to the patient’s medical home when symptoms have stabilized. • The collaborative care model is an evidenced-based model that has shown superior efficacy to treatment as usual in over 80 randomized trials. o It is based on systematic screening, treatment to target concepts and uses a team approach with the primary care physician overseeing care, including treatment for medical conditions and prescribing medications, the behavioral health care manager/specialist providing care management and short-term interventions, and the psychiatrist acting as a consultant, reviewing diagnoses and medication regiments. o Michigan Medicaid recently began paying for these codes. • For care to be truly integrated, information must be timely available at point of care to all clinicians involved as part of the patient’s care team. Current Status Hearings on Senate Bill 597-598 have continued throughout the month of September in the Senate Government Operations Committee. Jayne Courts, MD, FACP provided testimony on behalf of MSMS on Tuesday, September 21,

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2021, in which she discussed the recommendations outlined above (see under ‘MSMS Input’). A hearing has not been scheduled at this time for House Bills 4925-4929. Contact your lawmakers now by clicking HERE. • Filter First – Senate Bills 184 and 185 Testing drinking water sources in schools is slow and costly. Students are more effectively protected by proactively installing filtered drinking water stations that reduce lead and other impurities. Senate Bills 184 and 185 provide for clean drinking water in schools and child care centers and create requirements for installations of filtration systems. A proposed supplemental budget allocation of $55 million would provide for the installation of filtered drinking water stations in all Michigan public schools. Current Status The bi-partisan bill package has been referred to the Senate Environmental Quality Committee and is currently awaiting a hearing. MSMS supports this legislation. Contact your lawmakers now by clicking HERE. CONTACT YOUR ELECTED OFFICIALS TODAY! Click on the following topics and access a prewritten, editable letter to send to your lawmakers in under a minute each! • Health Can’t Wait, SB247, writing to the House of Representatives in support • Auto No-Fault, asking lawmakers to support HB 4486 and SB 314 • Opposition to HB 4355 which allows out-of-state physicians to treat patients without a Michigan license via telemedicine • Expanding the mental health professional definition to include physician assistants, certified nurse practitioners and clinical nurses - oppose SB 191 • Ensure Safe Drinking Water in Michigan Schools - support SBs 184-185 • Support Behavioral Health Integration by adding language to SBs 597-598 which would ensure the utilization of the team-based collaborative care model • Oppose SB 680 which expands scope of practice for nurse practitioners

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The Bulletin | November 2021


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The Bulletin | November 2021 31


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CALENDAR OF MEETINGS AND EVENTS FOR 2022* Tuesday, January 18, 2022 Horizons Conference Center, 6200 State Street, Saginaw Board Meeting – 5:30 p.m. Membership Meeting Joint with the Saginaw County Dental Society – Social (cash bar) at 6:30 p.m., followed by dinner, meeting and program at 7 p.m. Program: “Management of Sleep-Related Breathing Disorders from a Medical and Dental Perspective” Speakers: Christopher J. Allen, MD and Michael Thomas, DDS Email meeting notices will be sent in early January. Online reservations are required. Tuesday, February 15, 2022 CMU College of Medicine, 1632 Stone Street, Saginaw Board Meeting – 5:30 p.m. There is no Membership Meeting in February. Tuesday, March 15, 2022 CMU College of Medicine, 1632 Stone Street, Saginaw Board Meeting – 5:30 p.m. There is no Membership Meeting in March.

All statements or comments in The Bulletin are those of the writer, and not necessarily the opinion of the Saginaw County Medical Society.

Tuesday, April 19, 2022 Horizons Conference Center, 6200 State Street, Saginaw Board Meeting – 5:30 p.m. Membership Meeting – Social (cash bar) at 6:30 p.m., followed by dinner, meeting and program at 7 p.m. Program and Speakers TBA Email meeting notices will be sent in early April. Online reservations are required. Saturday-Sunday, April 30-May 1, 2022 MSMS House of Delegates (location TBA) Tuesday, May 17, 2022 Horizons Conference Center, 6200 State Street, Saginaw Board Meeting – 5:30 p.m. ANNUAL MEMBERSHIP MEETING and ANNUAL SCMS FOUNDATION MEMBERSHIP MEETING – Social (cash bar) at 6:30 p.m., followed by dinner and meetings at 7 p.m. Email meeting notices will be sent in early May. Online reservations are required. Saturday, June 4, 2022 SCMS Foundation Golf Outing – Saginaw Country Club Tuesday, June 14, 2022 (second Tuesday) CMU College of Medicine, 1632 Stone Street, Saginaw Board Meeting – 5:30 p.m. There is no Membership Meeting in June. *subject to change

Joan Cramer/SCMS | Office 790-3590 | Fax 790-3640 | Cell 284-8884 | jmcramer@sbcglobal net | www.SaginawCountyMS.com