AMA Wire® Wed, 26 Oct 2016 16:09:00 GMT Physicians key to cutting stigma of opioid addiction Wed, 26 Oct 2016 16:09:00 GMT <p> Patients who struggle with a substance use disorder deserve stigma-free access to care similar to that available for other patients with chronic disease. This was the message conveyed by Patrice A. Harris, MD, chair of the AMA Board of Trustees, last week at an interdisciplinary symposium on opioids at Northwestern University’s Pritzker School of Law. Though physician efforts have begun to change the landscape of the opioid epidemic, vigilance is still required to ensure patients with chronic pain maintain access to treatment they need.</p> <p> Between 2013 and 2015, the number of  prescriptions dispensed nationwide for opioid medications fell by over 20 million, Dr. Harris said. In Illinois, prescriptions dropped 10 percent over the same time period—and this occurred without a legislative or regulatory mandate.</p> <p> Dr. Harris, who also chairs the AMA <a href="">Task Force to Reduce Opioid Abuse</a>, said the pattern, in part, likely reflects a more careful review of prescribing practices by physicians who recognize the potential for opioid-related harm and are doing what they can to ensure their patients’ safety. But physicians also need to make sure patients with chronic pain are receiving the care that addresses their specific needs, she added.</p> <p> The drop in opioid prescribing  has helped reduce the supply of prescription opioids  available for diversion. However, Dr. Harris said, it is important “that we continue to support comprehensive pain care and that we don’t increase the stigma associated with patients with real pain.”</p> <p> Dr. Harris recently spoke to a woman with chronic pain who said she felt like an outlaw the last time she visited her pharmacy. “We don’t want patients who are suffering from chronic pain to feel like criminals,” Dr. Harris said. “We want to make sure that we do not reduce the access to care for these patients.”</p> <p> <strong>80% of patients lack timely access to addiction treatment</strong></p> <p> Problems persist for individuals who develop an opioid use disorder and become addicted. “Unfortunately, we still have a lot of people who think that people who have substance use disorders have character flaws, or that having an addiction is a moral failing. It is not,” Dr. Harris said. “It is a brain disorder resulting in  a chronic medical condition analogous to other chronic diseases  like type 2 diabetes and high blood pressure. We have to do whatever we can to reduce the stigma.”</p> <p> Sadly, just two in 10 people who seek substance use disorder treatment have access at the time that they want it, Dr. Harris said.</p> <p> When patients who need treatment can’t access care, we are doing them, and our community, a major disservice. We strongly support more physicians to take the training necessary to treat patients with substance use disorders, and we strongly urge payers to make sure that affordable access to care exists without burdensome administrative hurdles,” she added.</p> <p> <strong>PDMPs help, but need improvement</strong></p> <p> Increasing prescription drug monitoring program (PDMP) registration and physician use is part of the solution, Dr. Harris said. Between 2014 and 2015, PDMP registration among prescribers rose by almost 150,000  and PDMP queries jumped by nearly 20 million.</p> <p> Last fall, the AMA surveyed 2,130 active physicians to learn more about their needs and practices as they relate to the opioid epidemic. The results showed that physicians credit PDMPs with helping them understand a patient’s prescribing history and identify those at risk for substance misuse.</p> <p> Effective PDMPs allow physicians to view a patient’s prescription history for opioids and other controlled substances, or allow a member of the physician’s staff to access it prior to an appointment. When connected with other states, a PDMP can inform a physician whether a patient has received opioids or any other controlled substances in or out of state. If the PDMP is updated when a controlled substance is dispensed, it can help identify when a patient may need special counsel, a change in the treatment plan, or is in need of treatment for substance use disorder. Not many PDMPs, however, have this level of functionality or technological capability.</p> <p> Despite the flaws, said Dr. Harris, physicians are using the tools more than ever and taking steps to reduce the stigma that surrounds substance use disorder through a <a href="">different approach to the patient-physician interaction</a> that includes a forthright approach, the use of medication-assisted treatment and treating substance use disorder as a disease.</p> <p> “Prescription opioid abuse touches every corner of society,” Dr. Harris said. “Millions of Americans now suffer from dependency and addiction, contributing to thousands of preventable deaths each year. We must turn the tide in this opioid epidemic for people currently suffering and for all those at risk in the future. We will not be successful in this effort without a focused plan of attack that produces meaningful change in our practices and in our communities. This is our calling as physicians.”</p> <p> <strong>More on physician efforts to reduce prescription opioid abuse and treat chronic pain:</strong></p> <ul> <li>          <a href="">Physician efforts to reverse opioid epidemic quantified</a></li> <li>          <a href="">Treating substance use disorder as a family physician</a></li> <li>          <a href="">Neurosurgery makes pain management curricular breakthroughs</a></li> <li>          <a href="">Three things every physician should do when treating pain</a></li> <li>          <a href="">Physicians team up to treat addiction in rural areas</a></li> <li>          <a href="">The antidote: Three things to consider when co-prescribing naloxone</a></li> <li>          <a href="">How residents in one state gained access to their PDMP</a></li> </ul> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:c9b2af86-973e-4091-892c-9789c4d78217 Nuanced approach needed to assure senior physician competency Tue, 25 Oct 2016 23:00:00 GMT <p> The growing number of seniors in the physician workforce and increasing expectations for physician accountability are bringing attention to the question of whether age-based competency screening may be necessary to assure safe and effective practice. A recent article in the <em>Journal of Continuing Education in the Health Professions</em> (<em>JCEHP</em>) notes several challenges to establishing a national screening standard. These include designing an evidence-based screening process, determining the appropriate body to administer the screening and striking the right balance between patient protection and fairness to senior physicians.</p> <p> The article, “<a href="" rel="nofollow" target="_blank">Ensuring Competent Care by Senior Physicians</a>,” notes that the number of U.S. physicians 65 and older more than quadrupled between 1975 and 2013. Seniors now make up almost one-quarter of the physician workforce nationwide, and nearly 40 percent are actively engaged in patient care.</p> <p> <strong>Effects of age on competency<a href="" target="_blank"><img src="" style="margin:15px;float:right;width:460px;height:256px;" /></a></strong></p> <p> Research suggests there is an increased risk for competence and practice-performance decline with increasing years in practice, but the effect of age on individual physicians’ competency is highly variable. Other factors, such as one’s practice environment, can also affect a physician’s clinical performance.</p> <p> Moreover, the article notes, aging itself does not cause cognitive impairment. In addition, “some attributes needed to deliver quality health care—such as wisdom, resilience, compassion and tolerance of stress—may increase with aging.” Older physicians, the authors add, have a valuable place in clinical environments and arbitrary retirement or unnecessary restrictions could have a negative impact on patients’ access to care.</p> <p> Still, in the aggregate, increases in age and time since graduation do predict poorer performance, and the decline is not limited to cognitive function. Manual dexterity and visuospatial ability also drop with age. Taken together, this all suggests steps should be considered to protect patients, support delivery of high-quality care throughout doctors’ careers and maintain the physician workforce, says the <em>JCEHP</em> article. The article, published over the summer, was co-written by AMA Medical Education Outcomes Vice President Richard E. Hawkins, MD, and colleagues at the AMA, the University of Massachusetts Medical School, Worcester, Duke University School of Medicine and University of Texas Health Northeast.</p> <p> <strong>Some physicians already screened by age</strong></p> <p> The article’s authors say competency screening of some form should be considered, but many challenges arise in the effort to fairly implement such screening. For example, the question of who should oversee senior physicians’ competency is a troublesome one for licensing authorities, certifying bodies, hospitals, clinical directors and even insurers.</p> <p> Some hospitals and health systems already require physicians to undergo physical and cognitive exams once they reach a certain age as a condition of privilege renewal. Many other health care organizations oppose such a policy, ostensibly because evidence does not support a specific age threshold. A growing number have policies requiring age-triggered assessments of practice patterns and abilities to practice safely, but the screening ages and intervals of testing are variable.</p> <p> Another unsettled question is which screening tools are most effective. Peer reporting, while generally viewed as a key mechanism for identifying physicians with compromised competence, is “not reliable,” the article says. A <a href="" rel="nofollow" target="_blank">national survey</a> found nearly half of practicing physicians with direct knowledge of a colleague who was impaired or incompetent failed to report that physician.</p> <p> Peer review, on the other hand, is a more formal quality oversight process, but significant variability exists across institutions in their mechanisms, methods, criteria and perceptions of quality.</p> <p> Maintenance of Certification (MOC) programs might seem to be the logical way to assess competency, but these too have limited applicability. Many senior physicians are exempt from MOC requirements because of “grandfather” rules. In addition, MOC does not apply to physicians who are not board certified.</p> <p> <strong>Potential outcomes of screening</strong></p> <p> Not to be lost in the discussion are the effects—both positive and negative—that screening can have on senior physicians affected by cognitive decline.</p> <p> “When competency to practice safely is in question, the strategy to address it must be individualized,” the article’s authors write, noting that in some situations state medical boards may intervene and revoke a physician’s license. “If the condition is potentially reversible, or the deficit potentially remediable, state medical boards and hospitals may refer physicians to specialized programs for competency and practice assessments and remediation.”</p> <p> Some affected physicians may delay retirement by altering their practice environment or by engaging in tailored continuing professional development activities to help mitigate the effects of age-associated cognitive changes.</p> <p> “Shifting away from procedural work, allocating more time per individual patient, using memory aids, and seeking input from professional colleagues may help physicians successfully adjust to the cognitive changes that accompany aging,” the authors say.</p> <p> <strong>First steps to national standard</strong></p> <p> In light of the challenges of using cognitive assessments to predict quality of care by senior physicians and the highly individualized nature of effectively addressing cognitive decline, the authors recommend that regulators and policy makers consider:</p> <ul> <li> Developing an evidence-based screening process that addresses the influence of patient and practice variables</li> <li> Eschewing policies that mandate age-specific retirement</li> <li> Establishing consistent quality standards that are applied equitably to all physicians throughout their practice careers</li> </ul> <p> In the absence of such standards, the authors write, “physician organizations should consider whether guidelines for monitoring and assessing the competence and performance of senior physicians fulfills our professional obligation to our patients and what additional evidence is necessary to inform such guidelines.”</p> <p> <strong>Join the discussion</strong></p> <p> A recent <em>AMA Journal of Ethics</em> poll asked website visitors and Twitter followers:</p> <p> <em>An elderly and esteemed surgeon needs assistance to safely complete his or her cases. How should his or her colleagues respond?</em></p> <ul> <li> 5 percent of respondents said they should report the surgeon to the licensure board</li> <li> 48 percent said they should bring the issue to the attention of the department chair</li> <li> 38 percent said they should confront the surgeon directly and privately</li> <li> 9 percent said they should place a call to the organization’s patient safety hotline</li> </ul> <p> <a href="" target="_self">Share your answer</a> on the <em>AMA Journal of Ethics</em> website, and <a href="" target="_self">explore a case</a> posing more of the critical ethical and clinical questions surrounding aging physicians with diminished capacities in the October issue of the <em>AMA Journal of Ethics.</em></p> <p> <strong>Read more about senior physicians and ethics:</strong></p> <ul> <li> <a href="" target="_self">Senior physicians recognized for caring for the underserved</a></li> <li> <a href="" target="_self">Senior physician activities at the AMA Interim Meeting, Nov. 12 in Orlando</a></li> <li> <a href="" target="_self">New tool identifies short-term volunteer and paid opportunities</a></li> <li> <a href="" target="_self">Code of Medical Ethics modernized for first time in 50 years</a></li> <li> <a href="" target="_self">Get the revised Code of Medical Ethics</a></li> </ul> <p align="right"> <em>By AMA staff writer Tim Smith</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:592cc3b0-0972-4caa-9571-e34e3be619fe Rising teen obesity rate sparks push for healthier schools Tue, 25 Oct 2016 21:00:00 GMT <p> The overall childhood obesity rate has been stable over the past decade, but obesity among the nation’s teens is still on the rise. A recent report calls for early-childhood and school-based policies and programs to accelerate the progress in helping kids achieve and maintain healthy weights.</p> <p> About 17 percent of the nation’s children are obese, a rate that has held steady the past 10 years, according to “<a href="" target="_blank" rel="nofollow">The State of Obesity: Better Policies for a Healthier America</a>,” a 143-page report issued by the nonprofit Trust for America’s Health. When data is broken down by age groups, each group is seeing a little something different.</p> <p> The nation’s youngest children—ages 2 to 5—have seen obesity rates fall over the past decade, the report showed. Meanwhile, the rates among the oldest children, between 12 and 19 years old, have risen during that time. Kids in the middle—ages 6 to 11—have seen rates stabilize.<a href="" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> While it is encouraging that some childhood obesity rates are falling or stabilizing, obesity among children of all ages is much more prevalent today than when the baby boomers were having children. Since 1980, the obesity rate for children between 2 and 19 years old has tripled. When broken down by age:</p> <ul> <li> Kids between 6 and 11 years old have seen their obesity rates jump to 17.5 percent in 2014, more than doubling the 7 percent rate in 1980.</li> <li> Children between 12 and 19 years old have seen their obesity rates quadruple, with 20.5 percent of these children being obese in 2014, compared with 5 percent in 1980.</li> </ul> <p> In addition to differences among age groups, there also are “significant” racial and ethnic inequalities, the report noted. For example, almost 22 percent of Latino children and nearly 20 percent of black children are obese; nearly 15 percent of white children are obese and almost 9 percent of Asian children are obese.</p> <p> “Obesity remains one of the biggest threats to the health of our children and our country, putting millions of Americans at increased risk for a range of chronic diseases and contributing to more than $147 billion to $210 billion dollars in preventable health care spending,” the report said.</p> <p> <strong>Gaming, food deserts make matters worse</strong></p> <p> The report also found that there is room to improve lifestyle and other factors that contribute to unhealthy weights. Among the findings:</p> <ul> <li> Nearly 42 percent of high school students report playing video or computer games three or more hours a day, up from 22 percent in 2003.</li> <li> More than 29 million children live in “food deserts” and more than 15 million children live in “food insecure” households with not enough to eat and limited access to healthy food.</li> <li> Farm-to-school programs now serve more than 42 percent of schools and 23.6 million children.</li> <li> Eighteen states and Washington, D.C., require a minimum amount of time that elementary students must participate in physical education; 14 states and Washington, D.C., require a minimum amount for middle schoolers and six states require a minimum amount for high schoolers.</li> </ul> <p> <strong>Limit access to screens, junk food</strong></p> <p> Among the report’s recommendations to speed up progress in addressing obesity, there are a number of suggestions on how to help children.</p> <p> The report’s authors outlined ways to target early childhood policies and programs, such as supporting better childhood health through healthier meals, more physical activity, limited screen time and connecting families to community services through Head Start. They also called for prioritizing early-childhood education opportunities under the <a href="" target="_blank" rel="nofollow">Every Student Succeeds Act</a> (ESSA) and implementing the updated nutrition standards covering the <a href="" target="_blank" rel="nofollow">Child and Adult Care Food Program</a>.</p> <p> Schools can make a difference, by continuing the implementation of the U.S. Department of Agriculture’s so-called <a href="" target="_blank" rel="nofollow">"smart snacks"</a> rule to improve the nutritional value of snacks and beverages sold in schools. Schools also should eliminate in-school marketing of unhealthy foods and take opportunities to support health, physical education and activity under ESSA, the report said.</p> <p> <strong>Physician resources</strong></p> <p> The American Academy of Pediatrics provides information and resources on fighting childhood obesity through its <a href="" target="_blank" rel="nofollow">Institute for Healthy Childhood Weight</a>.</p> <p> The AMA’s online resource, <a href="" target="_self">Prevent Diabetes STAT</a>, provides information that can help physicians and their care teams partner with patients to prevent or delay type 2 diabetes.</p> <p> <strong>Read more about how doctors are helping patients prevent diabetes and fight obesity:</strong></p> <ul> <li> <a href="" target="_self">Physicians, patients take active approach to diabetes fight online</a></li> <li> <a href="" target="_self">5 Nutrition Facts misconceptions that sabotage patient health</a></li> <li> <a href="" target="_self">Inside look: A physician's success story as a prediabetic patient</a></li> <li> <a href="" target="_self">What's it like to be in obesity medicine: Shadowing Dr. Lazarus</a></li> </ul> <p align="right"> <em>By contributing writer Tanya Albert Henry</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:a294b7fd-78c6-44ac-9e92-ae8b81567597 Identifying superbugs: HHS offers $20 million for faster tests Mon, 24 Oct 2016 22:00:00 GMT <p> Antibiotic resistance is reaching dangerously high levels in all parts of the world, making infections such as pneumonia, tuberculosis and blood poisoning more difficult—and sometimes impossible—to treat. To combat this global epidemic and help health care teams more quickly diagnose patients with infections, two agencies of the U.S. Department of Health and Human Services (HHS) recently announced a prize competition for new rapid, point-of-care laboratory diagnostic tests for drug-resistant bacteria.</p> <p> The <a href="" target="_blank" rel="nofollow">Antimicrobial Resistance Diagnostic Challenge </a>will award $20 million in prizes from the National Institutes of Health (NIH) and the Office of the Assistant Secretary for Preparedness and Response (ASPR) over the next four years in support of the goals outlined in the White House’s <a href="" target="_blank" rel="nofollow">National Action Plan for Combating Antibiotic Resistant Bacteria</a>.</p> <p> The structure of the awards is a deliberate departure for the agencies.<a href="" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> “This is a different way of funding research,” NIH Director Francis Collins, MD, PhD, said <a href="" target="_blank" rel="nofollow">in a video</a> on the research agency’s website. “Traditionally, NIH waits for grant applications or we send out a note saying we’re interested in research in a particular field, but this is more like a prize—a big prize. And we hope that the size of that award will attract attention from people who might have worked on something else and now will work on this.”</p> <p> Two key clinical challenges informed the decision to create the competition.</p> <p> One is simply the need for clinicians to distinguish between viral and bacterial infections to reduce unnecessary use of antibiotics. Antibiotic-resistant bacteria cause at least 2 million infections and 23,000 deaths each year in the U.S., according to the Centers for Disease Control and Prevention (CDC).</p> <p> The other major challenge “is to find out when somebody has a bacterial infection that is going to be resistant to existing antibiotics and therefore needs to be treated in a special way,” Dr. Collins said. “Today, if somebody has pneumonia, for instance, or a urinary tract infection, the way in which we find out whether that particular infection is highly resistant takes about 72 hours.</p> <p> “By that time, the person may be very sick … [and] the resistant organism may have been passed to other people because you didn’t know to put this person in isolation. So the other challenge is come up with a test where, in three or four hours, you can say, ‘This person has a highly resistant organism. Let’s bring a wholly different approach to taking care of them.’”</p> <p> The competition will play out over these three phases:</p> <ul> <li> Concepts must be submitted by Jan. 9 for the first phase of the competition. As many as 20 semifinalists will be selected from the applicant pool, each receiving up to $50,000.</li> </ul> <ul> <li> In the second phase of the competition, on Dec. 3, 2018, up to 10 finalists will be selected to each receive up to $100,000. These funds can be used to develop prototypes for evaluation by two CLIA-certified independent laboratories, which will be considered when final winners are selected.</li> </ul> <ul> <li> In the final phase, winners are expected to be announced on July 31, 2020. The competition specifies that up to three winners can be selected, and winners will share an amount equal to or greater than $18 million.</li> </ul> <p> The NIH’s National Institute of Allergy and Infectious Diseases and ASPR’s Biomedical Advanced Research and Development Authority each contributed $10 million to the competition. The CDC and the Food and Drug Administration provided technical and regulatory expertise to its design.</p> <p> For more information about the challenge or how to apply, <a href="" target="_blank" rel="nofollow">visit the HHS website</a>.</p> <p> “My hope is that this competition will spur exceptional innovators to rise to the challenge and deliver effective tools,” Dr. Collins said. “This is a huge public health problem. We need all hands on deck.”</p> <p> <strong>Learn more about health care technology innovation:</strong></p> <ul> <li> <a href="" target="_self">Online DPP tackles challenges of location and participation</a></li> <li> <a href="" target="_self">Three teams tapped to create a healthier nation</a></li> <li> <a href="" target="_self">From idea to practice solution: Becoming a physician entrepreneur</a></li> </ul> <p align="right"> <em>By AMA staff writer Tim Smith</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:10ef6eca-2a46-4392-9557-c2bcc15ccae9 Med school lends an ear to those at risk of suicide Sat, 22 Oct 2016 00:00:00 GMT <p> Educating patients, identifying those at high risk for disease and taking preventive action are key parts of physician practice. Those methods also are proving essential to one medical school’s efforts to spot depression and thwart suicide. The University of California San Diego (UCSD) School of Medicine’s <a href="" target="_blank" rel="nofollow">Healer Education Assessment and Referral</a> (HEAR) program helps spot people at risk of suicide and depression through self-assessment and offers access to counseling for UCSD medical students, residents, fellows and faculty.</p> <p> Sobering statistics tell the tale of why such an effort is needed, as the <a href="" target="_self">suicide rate among physicians</a> greatly exceeds that of the general public. Yet worries about stigma and career impact discourage use of essential mental health services among physicians and doctors in training.</p> <p> UCSD’s HEAR program combines a variety of approaches aimed at lowering the risk of suicide among faculty, residents, fellows and medical students.</p> <p> <strong>Listening for signs of depression, risk of suicide</strong></p> <p> A key component of the program is a web-based screening tool, developed by the American Foundation for Suicide Prevention (AFSP). UCSD medical students, residents, fellows and faculty members are encouraged to complete a brief—and completely confidential—online questionnaire to determine whether stress and depression is affecting them in their personal and professional lives.</p> <p> The screening tool includes the nine-item Patient Health Questionnaire scale, which assesses depression and gathers information about prior suicide attempts, suicidal thoughts and behaviors, alcohol and drug use, distressing emotional states, eating behaviors, and current mental health treatment.</p> <p> Though the questionnaire is completely anonymous, participants may include an email address so that a counselor can provide an interpretation of the assessment, recommendations for further evaluation and referrals to local resources when needed.</p> <p> The questionnaire is not a crisis intervention tool. Rather, it is designed to provide people with rapid feedback about their current mental health status and, if needed, encourage them to seek further evaluation and access external support.</p> <p> The educational component of the HEAR program incorporates a multidisciplinary committee consisting of school faculty, program counselors and medical students who deliver one-hour, live presentations about physician suicide.</p> <p> Presentations include an informational lecture, screening a 15-minute portion of an AFSP film about physician suicide called “<a href="" rel="nofollow">Struggling in Silence</a>,” and a question-and-answer session.</p> <p> Lectures review the scope of the problem and discuss the relationships among burnout, depression and suicide, and highlight factors that affect physicians’ care-seeking behavior. Each presentation is modified for different settings, such as professional workshops, brief meetings and departmental grand rounds. This kind of flexibility allows the HEAR program to garner interest from a variety of physician and student audiences.</p> <p> <strong>The results so far</strong></p> <p> As of 2014, <a href="" target="_blank" rel="nofollow">the HEAR program had been delivered to 1,008 medical students</a>, 34 percent of whom completed the questionnaire. Almost eight percent of those who responded met the criteria for high or significant suicide risk. Less than a quarter of the at-risk students were already receiving mental health treatment, showing how the program could help close the gap in access to potentially life-saving care.</p> <p> In the seven years since the inception of the HEAR program, the UCSD staff has delivered almost 120 presentations. More than 2,600 medical students, residents, fellows and faculty have completed the anonymous online questionnaire.</p> <p> A new module from the AMA’s <a href="" target="_blank" rel="nofollow">STEPS Forward™</a> collection of practice improvement strategies focuses on the unique vulnerability and treatment needs of physicians. The module, “<a href="" target="_blank" rel="nofollow">Preventing Physician Distress and Suicide</a>,” includes four steps for identifying at-risk physicians and referring them to appropriate care, provides answers to common questions about physician distress and suicidal behavior, and offers downloadable tools to help you and your organization.</p> <p> There are seven new modules available from the AMA’s STEPS Forward collection, bringing the total number of practice improvement strategies to 42. Several of the modules were developed thanks to a grant from and collaboration with the <a href="" target="_blank" rel="nofollow">Transforming Clinical Practices Initiative</a>.</p> <p> <strong>For more on physician, resident and medical student wellness and burnout:</strong></p> <ul> <li> <a href="" target="_self">How physician burnout compares to general working population</a></li> <li> <a href="" target="_self">Specialties with the highest burnout rates</a></li> <li> <a href="" target="_self">How the Mayo Clinic is battling burnout</a></li> <li> <a href="" target="_self">A double-edged sword: What makes doctors great also drives burnout</a></li> <li> <a href="" target="_self">Accreditor lays out plan for resident well-being</a></li> <li> <a href="" target="_self">Out of tragedy comes a new focus on resident health</a></li> <li> <a href="" target="_self">The physician’s essential art of balancing emotion and logic</a></li> <li> <a href="" target="_self">Student wellness: Blueprints for the curriculum of the future</a></li> <li> <a href="" target="_self">Medical school burnout: How to take care of yourself</a></li> </ul> <p align="right"> <em>By AMA staff writer</em> <a href="" target="_blank" rel="nofollow">Troy Parks</a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:eaf42897-2d3c-4aae-9e50-f97573a748f8 Podcast series explores new Medicare quality program, pay models Fri, 21 Oct 2016 23:00:00 GMT <p> The Quality Payment Program (QPP) starts in January, so physicians still have time to educate themselves and prepare for its implementation. A podcast series produced by ReachMD in collaboration with the AMA features interviews with industry experts and physician leaders who take doctors “<a href="" target="_blank" rel="nofollow">Inside Medicare’s New Payment System</a>.” The series delves into key aspects of the program and provides tips on what physicians can do now to get ready.</p> <p> Several podcasts will be added as the experts learn more about the Centers for Medicare and Medicaid Services’ (CMS) <a href="" target="_self">final rule on the Medicare Access and CHIP Reauthorization Act</a> (MACRA), the legislation that repealed the flawed Sustainable Growth Rate (SGR) formula and created the QPP. Eight podcasts are now available and can be streamed on the ReachMD website or downloaded for later listening.</p> <ul> <li> <a href="" target="_blank" rel="nofollow">Why Participating in Clinical Practice Improvement Activities (CPIA) Matters</a><br /> The Merit-based Incentive Payment System (MIPS) is the value-based payment program that will replace the Physician Quality Reporting System (PQRS), the value-based modifier and Meaningful Use. The MIPS will also incorporate a new reporting category for CPIAs. This podcast offers an overview of the CPIA category, how to report these activities and how CMS will factor them into overall MIPS scores. (5:29)</li> </ul> <ul> <li> <a href="" target="_blank" rel="nofollow">How an EHR Can Help You Participate in MACRA</a><br /> Although electronic health records (EHR) are still in need of improvements in usability, flexibility and interoperability, EHRs have already changed the practice of medicine. This podcast explains the importance of EHRs to participation in the QPP. (6:30)</li> </ul> <ul> <li> <a href="" target="_blank" rel="nofollow">Preparing for Quality Reporting: Keys to Keeping Your Practice on Track</a><br /> Under the QPP, physicians can report as an individual or as a group practice. This podcast digs into the reporting options under MIPS, with an extra focus on the quality performance category. (6:00)</li> </ul> <ul> <li> <a href="" target="_blank" rel="nofollow">Implementing MACRA: The AMA’s Keys to Advancing Opportunities, Avoiding Pitfalls</a><br /> With the recent release of CMS’ MACRA final rule, it is evident that physician recommendations were heard during the comment period and included. In this podcast, learn about the AMA’s efforts to work with CMS to maximize the legislation’s opportunities while avoiding potential pitfalls. (16:00)</li> </ul> <ul> <li> <a href="" target="_blank" rel="nofollow">APMs in Cancer Care: The Patient-Centered Oncology Payment Model</a><br /> An Advanced Alternative Payment Model (APM) is one of two options for participation in the QPP. In this podcast, Robin Zon, MD, an oncologist and chair-elect of the American Society of Clinical Oncology (ASCO), explains the phases of ASCO’s Patient-Centered Oncology Payment model and how it can function as an Advanced APM under the QPP. (21:59; transcript available)</li> </ul> <ul> <li> <a href="" target="_blank" rel="nofollow">The Rise of Specialist-Driven Alternative Payment Models in American Medicine</a><br /> Some physicians across the country have taken it upon themselves to design APMs that work within their specialties. In this podcast, Lawrence Kosinski, MD, a gastroenterologist in Illinois, describes SonarMD, a web-based platform that pings patients to keep track of their symptoms outside the office visit to get ahead of issues before they become emergencies. (27:00; transcript available)</li> </ul> <ul> <li> <a href="" target="_blank" rel="nofollow">Thoughts on Physician Advocacy and Payment Reform with AMA President Andrew Gurman, MD</a><br /> At the 2016 AMA Annual Meeting, AMA President Andrew W. Gurman, MD, sat down with ReachMD’s Matt Birnholz, MD, to talk about current and future AMA initiatives as well as physician payment reform under MACRA and the new Medicare payment system. (14:29; transcript available)</li> </ul> <ul> <li> <a href="" target="_blank" rel="nofollow">The Future of Medicare Payment Reform: Perspectives on MACRA with CMS’s Andy Slavitt</a><br /> While CMS Acting Administrator Andy Slavitt was in attendance at the 2016 AMA Annual Meeting, he took the time to discuss his leadership role at CMS and the next steps for implementing the new Medicare payment system. (13:29; transcript available)</li> </ul> <p> Several other resources and educational materials also are available on the AMA’s <a href="" target="_self">Understanding Medicare Reform</a> webpage, which will be continually updated to reflect what is in the rule.</p> <p> Modules in the AMA’s <a href="" target="_blank" rel="nofollow">STEPS Forward™</a> collection of practice improvement strategies can help you <a href="" target="_blank" rel="nofollow">maximize your preparedness for quality reporting</a>, <a href="" target="_blank" rel="nofollow">prepare for value-based care</a>, <a href="" target="_blank" rel="nofollow">choose the best electronic health record (EHR) for your practice</a> and <a href="" target="_blank" rel="nofollow">implement an EHR system</a>.</p> <p> The AMA will be hosting two webinars on the QPP: <a href="" target="_blank" rel="nofollow">Nov. 21, 7 p.m. EDT</a>, and <a href="" rel="nofollow">Dec. 6, 8 p.m. EDT</a>. Registration for both webinars is open. Regional meetings will be held Dec. 1 in Atlanta and Dec. 10 in San Francisco. The regional meetings can be attended in person or online. Details and registration will be available soon.  </p> <p> Watch <a href="" target="_self"><em>AMA Wire®</em></a> in the coming weeks for a more detailed look at what CMS included or changed in the final rule as experts decipher its impact on practices that serve patients under Medicare.</p> <p align="right"> <em>By AMA staff writer</em> <a href="" target="_blank" rel="nofollow"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:0806d060-b34d-4408-91e8-fa11221b9141 Physician voice shapes Medicare pay reform final rule Thu, 20 Oct 2016 20:35:00 GMT <p> <em>An AMA Viewpoints post by AMA President Andrew W. Gurman, MD</em></p> <p> <a href="" target="_blank"><img src="" style="height:150px;width:100px;float:left;margin:15px;" /></a></p> <p> With the issuance of its final rule on the Medicare Access and CHIP Reauthorization Act (MACRA), the Centers for Medicare and Medicaid Services has created a new Medicare payment system called the Quality Payment Program (QPP).</p> <p> CMS issued its <a href="" rel="nofollow" target="_blank">final rule</a> last week and our initial review shows Acting Administrator Andy Slavitt was true to his comments, first made in January, that <a href="" target="_self">CMS would be listening to physicians</a> as development progressed. I would like to thank him for being a sincere partner during the process.</p> <p> Through <a href="" target="_self">comment letters and conversations</a> with CMS, the AMA recommended many changes that would create a more flexible transition to the updated Medicare program, and CMS has adopted a majority of those recommendations in its final rule.</p> <p> There is still work to be done to improve the QPP, but it appears that we are off to a strong start. CMS’ revisions will allow for a reasonably paced progression into the program so that physician practices can learn and adjust over time.</p> <p> The key elements of the proposed rule that CMS changed based on our recommendations are:</p> <ul> <li> <strong>A transition period and avoiding the QPP penalty.</strong> The proposed rule stated that physicians would have to successfully report in all four Merit-based Incentive Payment System (MIPS) categories to avoid a negative payment adjustment. The AMA advocated for a transition year with lower reporting burdens. In the final rule, the only physicians who will experience a negative 4 percent penalty in 2019, the first year of the program, are those who choose to report no data.<br /> <br /> Participating in one of four options under “<a href="" target="_self">Pick Your Pace</a>” will help you avoid penalties. At the very least, if you choose to report for only one patient on just one quality measure, one improvement activity, or the four required Advancing Care Information (ACI) measures you will avoid a negative payment adjustment.<br /> <br /> We recommended that CMS create a transition period to allow enough time for physicians to prepare for the QPP. The final rule establishes a 90-day reporting period, a significant change over the proposed rule’s full calendar-year requirement for most reporting. If you report for at least 90 continuous days in 2017, you will be eligible for a positive payment adjustment. This revision allows you to start later so that you will have more time to prepare your practice.</li> </ul> <ul> <li> <strong>An increase in the low-volume threshold.</strong> Initially, the proposed rule set the threshold for exemption for QPP participation for physicians with less than $10,000 in Medicare payments and fewer than 100 Medicare patients per year.<br /> <br /> The AMA recommended increasing the threshold to $30,000 or fewer than 100 Medicare patients and CMS opted for that baseline in the final rule, estimating the provision will exempt 32.5 percent of eligible clinicians from MIPS reporting.</li> </ul> <ul> <li> <strong>A reduction in the programwide reporting burden.</strong> One of the leading causes of our frustration as physicians is Medicare’s overwhelming reporting burden.<br /> <br /> For example, under the ACI category that replaces the electronic health record (EHR) Meaningful Use program, the number of required reporting measures was cut from 11 in the proposed rule to four in 2017 and five thereafter.</li> </ul> <ul> <li> <strong>Further flexibility for small, rural, health professional shortage area (HPSA) and non-patient facing physicians.</strong> In the proposed rule, physicians who do not have bedside interactions with patients and doctors practicing in small, rural and HPSA settings were required to report two activities under the Clinical Practice Improvement Activities (CPIA) category. We called on CMS to create flexibility for these practice types—and CMS listened.<br /> <br /> The final rule allows these physicians to report on just two medium-weighted or one high-weighted activity to achieve full credit in the CPIA category.</li> </ul> <ul> <li> <strong>A zero percent weight for resource use. </strong>One of the four categories of the MIPS is resource use. The final rule sets resource use at a zero percent weight toward your score in the first year. However, CMS will provide feedback on how you performed on those measures.</li> </ul> <ul> <li> <strong>A reduction in reporting thresholds.</strong> In the first year of the program, 2017, you will only have to report successfully on a measure on 50 percent of patients, and 60 percent of patients in 2018. This threshold was set in the proposed rule at 90 percent for those who report electronically and 80 percent for those who report via claims.</li> </ul> <p> These are only a few of the changes that CMS made in the final rule based on our recommendations. As a physician who will be undergoing this transition at the same time as you, I want to do whatever I can to make sure we are all prepared, educated and set up to succeed under this new program.</p> <p> There will be further developments as other provisions of MACRA are implemented and we will continue to work with CMS to make sure the QPP is positioned to work for all physicians.</p> <p> <strong>We need to educate ourselves and prepare now</strong></p> <p> Over the next few months, it is critical that all of us educate ourselves and prepare our practices for the first year of the program in 2017. The AMA’s <a href="" target="_self">Understanding Medicare Reform</a> collection of educational materials, resources and tools will be continually updated as we learn more.</p> <p> The AMA will be hosting two webinars on the QPP: Nov. 21, 7 p.m. Eastern Time and Dec. 6, 8 p.m. Eastern Time. We will also hold regional meetings Dec. 1 in Atlanta and Dec. 10 in San Francisco. The regional meetings can be attended in person or online. More details on how you can register will be available soon.</p> <p> This is a monumental change to the practice of medicine. The repeal of the flawed Sustainable Growth Rate (SGR) was the first step. Based on the changes we have seen in the final rule, we know that CMS is listening to physicians. The AMA is in a unique position to make recommendations and will continue to do so. If you have not joined us already, now is the time to get off the sidelines and help us make sure this historic Medicare payment transformation sets us all up to provide the high-quality care we know our patients deserve and that we know we can give them. </p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:97173566-fec5-4098-a47c-deaa3df3c4ea PDMP access among residency-related proposals at 2016 Interim Meeting Wed, 19 Oct 2016 23:00:00 GMT <p> The upcoming AMA 2016 Interim Meeting will see several resolutions up for consideration that could affect graduate medical education (GME) training programs. Learn about three of these GME-related proposals and how you can get involved in shaping them ahead of the meeting.</p> <p> At the <a href="" target="_self">2016 AMA Interim Meeting</a> which runs Nov. 12-15 in Orlando, Fla., the AMA House of Delegates will consider proposals that address key issues encompassing the breadth of U.S. medicine.</p> <p> Here are three resolutions that could affect residency:</p> <ul> <li> <strong>Universal prescriber access to prescription drug monitoring programs (PDMP). </strong>Resident and fellow physicians made up almost <a href="" rel="nofollow" target="_blank">11 percent of the physician workforce</a> in 2014 and can write prescriptions for controlled substances in most states, yet they do not all have access to the state PDMPs that can help them safely order these medications. Residents in Massachusetts <a href="" target="_self">recently advocated for, and received, PDMP access</a>, but the Bay State appears to be an exception to the rule.<br /> <br /> Many of the 49 state laws responsible for the creation of PDMPs do not explicitly grant resident access. This resolution calls for the AMA to support legislation and regulatory action that would authorize all prescribers of controlled substances, including residents, to access their state PDMP.</li> </ul> <ul> <li> <strong>Primary care and mental health training in residency. </strong>A 2012 study found that primary care physicians often feel unprepared to <a href="" rel="nofollow" target="_blank">manage patients with complex psychiatric comorbidities</a>, while other research has found that <a href="" rel="nofollow" target="_blank">half of primary care visits involve concerns about behavioral health comorbidities</a> and 60 percent of mental illness is treated by primary care doctors.<br /> <br /> This resolution calls on the AMA to advocate for the incorporation of integrated mental health and primary care services into existing psychiatry and primary care training programs. The proposal also asks the Association to encourage primary care and psychiatry residency programs to create and expand opportunities for residents to get clinical experience working in an integrated mental health and primary care model.</li> </ul> <ul> <li> <strong>Protecting the rights of breastfeeding residents and fellows. </strong>About 40 percent of physician trainees <a href="" target="_self">plan to have a child during their GME training</a>, a recent study from <em>Academic Medicine</em> shows. AMA policy recognizes that breastfeeding is the optimal form of nutrition for most infants and “encourages all medical schools and GME programs to support residents, medical students and faculty who provide breast milk for their infants, including appropriate time and facilities to express and store breast milk during the working day.”<br /> <br /> This resolution calls for the AMA to work with the appropriate bodies to mandate language in training program policy on the protected time and locations for expression and storage of breast milk, and include language related to the learning and work environments for breastfeeding mothers in regular program reviews.</li> </ul> <p> Share your thoughts on these important residency topics and shape AMA policy via the <a href="" target="_self">AMA Online Member Forums</a>. Any AMA member can comment on any item of business. Though the forums will be open until the start of the meeting, comments posted after Nov. 7 may not be captured in the comment summaries that will be shared with reference committee members and posted on the <a href="" target="_self">2016 AMA Interim Meeting website</a>.</p> <p> Another opportunity to get involved in shaping policy is the AMA <a href="">Resident and Fellow Section (RFS) Virtual Reference Committee</a>. Resident members can submit online commentary to reports and resolutions that will be presented at the AMA-RFS Interim Meeting. The Virtual Reference Committee closes this Sunday, Oct. 23, at midnight Eastern Time. </p> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:aecb7759-1147-45f6-9be7-823e39247db8 Hotspotting: 10 steps to help patients hospitalized most Wed, 19 Oct 2016 20:00:00 GMT <p> As a rule, health care systems are designed to work for the typical patient. Yet it’s well known that a small proportion of patients with complex, hard-to-manage needs and chronic conditions drives much of the cost in U.S. health care. So what’s being done to change this at the community level? One technique identifies these outliers individually, maps the constellation of problems they encounter, organizes resources around their needs and designs interventions to improve their care.</p> <p> The approach, dubbed hotspotting, aims to fashion a system of multidisciplinary, coordinated care that in large part seeks to meet patient needs by addressing nonmedical issues that affect health. These include housing, mental health, substance abuse and emotional support. <a href="" rel="nofollow" target="_blank">It isn’t a new concept</a>, but it is being applied in new ways.</p> <p> <strong>Now part of medical school curricula<a href="" target="_blank"><img src="" style="margin:15px;float:right;" /></a></strong></p> <p> Beginning in 2014, the Association of American Medical Colleges (AAMC) joined with the Camden Coalition of Healthcare Providers and Primary Care Progress to launch the <a href="" rel="nofollow" target="_self">Interprofessional Student Hotspotting Learning Collaborative</a>, in which participants learn from hotspotting pioneers how to identify and help patients who have multiple complex health conditions and use care frequently.</p> <p> The 2016-2017 cohort features 31 teams of students at 27 schools across the country, including several member schools in the AMA’s <a href="" target="_self">Accelerating Change in Medical Education Consortium</a>. The program also ims to broaden students’ understanding of their understanding of colleagues across professions. </p> <p> Teams are comprised of students in medicine, nursing, pharmacy, dentistry, social work, public health, psychology, physician assistant, epidemiology, biomedical science, occupational therapy, health administration, medical dietetics, community health and business.</p> <p> <strong>A hotspotter’s guide to accelerating change</strong></p> <p> Each student’s work begins with identifying one patient who has been cared for in the inpatient setting three or more times in the previous six to nine months. Over the course of six months, the student follows 10 steps to gain insight into why the patient might be sick in the first place, determine why his or her condition hasn’t improved and then share these findings with health care system decision makers. As a student hotspotter, your tasks are to:</p> <p style="margin-left:.5in;"> <strong>Step 1:</strong> <strong>Prepare a media and medical record release form.</strong> This will allow you to interview the patient and review their billing and medical records.</p> <p style="margin-left:.5in;"> <strong>Step 2:</strong> <strong>Approach a care team member</strong> and ask that team member to contact you when someone who has been hospitalized three or more times over the last six to nine months is admitted again.</p> <p style="margin-left:.5in;"> <strong>Step 3:</strong> <strong>Meet the patient and learn their story.</strong> Explain that you are trying to learn more about the challenges the patient faces in getting health care and that you would like to continue to meet after the patient is discharged. Ask them to sign the release form.</p> <p style="margin-left:.5in;"> <strong>Step 4:</strong> <strong>Find out when the patient will be discharged</strong> as well as when any primary care or specialty care appointments are scheduled. Ask the patient for permission to meet him or her at those appointments.</p> <p style="margin-left:.5in;"> <strong>Step 5:</strong> <strong>If the patient agrees, go to their home or shelter</strong> on the day they are released. Bring a fellow hotspotter with you. Get to know the patient’s personal history, interests and recent experiences seeking health care. The goal is to better understand the patient’s personal circumstances, which will then provide insights into their struggles with accessing needed care.</p> <p style="margin-left:.5in;"> <strong>Step 6:</strong> <strong>Attend the patient’s follow-up medical appointments</strong> as an observer and find out what care looks like from their perspective. If the patient is eligible for any social services, accompany them in the application process so you can see firsthand what it’s like.</p> <p style="margin-left:.5in;"> <strong>Step 7:</strong> <strong>Obtain a copy of the patient’s billing record</strong> and put together a summary showing how many times the patient has been admitted to the hospital in the past year and total the charges. Find someone in the billing office who can help you understand and graph the data.</p> <p style="margin-left:.5in;"> <strong>Step 8:</strong> <strong>Prepare a case report of the interview and the patient’s medical history</strong> to shed light on why the patient has had to be hospitalized so many times. Share it with your colleagues and identify interventions that could improve the patient’s ability to access care outside of the hospital or emergency room.</p> <p style="margin-left:.5in;"> <strong>Step 9:</strong> <strong>Put together a multidisciplinary team for a case conference.</strong> Determine how representative this patient is of patients with similar needs. Discuss what they have in common, where the health system fails them and what costs are incurred from their preventable care.</p> <p style="margin-left:.5in;"> <strong>Step 10:</strong> <strong>Meet with the hospital CEO, the medical school dean and/or a faculty member.</strong> If the patient is willing to attend, bring them with you. Discuss the various implications of the patient’s experience, conclusions that can be drawn from their case and recommendations for improvements.</p> <p> AAMC provides numerous <a href="" rel="nofollow" target="_blank">hotspotting resources</a> for students and faculty, including patient interview questions, sample medical record and media release forms, notes from the original cohort and more detailed descriptions of the 10 steps.</p> <p> <strong>Read more about changes in medical education:</strong></p> <ul> <li> <a href="" target="_self">The “structure” of the medical school of the future</a></li> <li> <a href="" target="_self">Health care and population health: A team sport</a></li> <li> <a href="" target="_self">Rethinking how race contributes to a patient’s health</a></li> <li> <a href="" target="_self">Treating the community as your patient</a></li> <li> <a href="" target="_self">Students deliver care in homes, communities</a></li> </ul> <p align="right"> <em>By AMA staff writer Tim Smith</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:5aeec8eb-ea08-4ab3-9283-69220f92409a How three boards are changing MOC Part III Tue, 18 Oct 2016 23:00:00 GMT <p> The Maintenance of Certification (MOC) Part III examination process is experiencing changes within the American Board of Medical Specialties (ABMS) specialty boards. Though some board-certified physicians are satisfied with their current MOC process, several boards have responded to physician concerns by making meaningful changes to learning and assessment that are transforming the way physicians stay up on the constantly evolving medical landscape.</p> <p> The American Board of Anesthesiology has recently initiated a <a href="" target="_self">pilot—the MOCA Minute™ program—that could ultimately change their MOC examination process</a>. The pilot enables physicians to take the exam over a longer period, one question at a time. Here are three other boards that are also changing that process to best fit their specialists’ needs.</p> <p> <strong>ABD exam prep and format gets a reboot</strong></p> <p> In an effort to emphasize the learning experience, the American Board of Dermatology (ABD) selected a comprehensive item pool representing the expected breadth of knowledge of practicing dermatologists that is delivered as modules.</p> <p> All examinees take the general dermatology module, which consists of 100 clinical images designed primarily to assess diagnostic skills. Then, each examinee chooses from 50-item subspecialty modules in medical dermatology, dermatopathology, pediatric dermatology or dermatologic surgery.</p> <p> Six months before the exam, the ABD publishes a list of diagnoses that the general dermatology clinical images will be drawn from, along with a list of questions that are used to generate subspecialty modules.</p> <p> The ABD’s approach encourages dermatologists to study this material in groups or at dermatologic society meetings. Passing scores are still required for both the general and subspecialty modules—but pass rates generally exceed 90 percent. The ABD has expressed that proof of mastery of this material helps identify dermatologists who are maintaining their competence.</p> <p> Not only does the ABD offer subspecialty exam modules, they have also conducted trials employing remote proctoring to monitor exam administration in physicians’ homes or offices. The ABD was able to both ensure the identity of the test taker and monitor the progress of the exam, which allowed test administrators to identify any irregular behavior.</p> <p> Feedback has shown that dermatologists were pleased to be able to take the exam in a comfortable, familiar environment and not have to travel to a testing center, which can place a financial burden on physicians participating in maintenance of certification. The ultimate goal of the ABD is to launch an open-resource exam that allows access to texts, journals and the Internet, more closely mimicking how dermatologists apply knowledge in practice.</p> <p> <strong>ABPS changes how plastic surgeons prep for exams</strong></p> <p> The American Board of Plastic Surgery (ABPS) believes that assessment drives learning through learners’ preparation for and post-assessment review of the exam.</p> <p> To prepare for the ABPS MOC Part III exam, which is a secure, modular, computer-based test that physicians take once per 10-year cycle, plastic surgeons may use an ABPS produced MOC study guide. The study guide includes more than 2,300 multiple choice questions compiled from the same sources used for the MOC exam and is distributed by ABPS.</p> <p> Physicians can study the guide in its totality or focus on four specialty-specific practice content areas—reconstructive, cosmetic, hand or craniomaxillofacial surgery. The study guide includes rationales for each question that identify the key learning principles. For each 200-item MOC exam, 25 percent of the items address core principles while 75 percent are sub-specialty-based. So far, the overall pass rate has averaged around 95 percent.</p> <p> The examinees also receive their performance results to help them focus their future learning on the areas where the exam revealed knowledge gaps. The plastic surgeons have provided positive feedback so far on the exam’s dual emphasis on learning and assessment of knowledge.</p> <p> <strong>ABP to make Part III examination more convenient</strong></p> <p> The American Board of Pediatrics (ABP) is introducing a new method for its MOC examination Part III that will launch as a pilot in 2017. The new approach would entail shorter and more frequent assessments of physician knowledge.</p> <p> The Maintenance of Certification Assessment for Pediatrics (MOCA-Peds) is a new testing platform designed as an alternative to the current MOC Part III examination. What is different about MOCA-Peds is that it will provide immediate feedback and references to foster enhanced learning for pediatricians.</p> <p> The ABP will release a series of questions through mobile devices or a web browser at regular intervals. Twenty multiple-choice questions will be available every three months and may be answered anytime during the quarter, making the examination more convenient for busy pediatricians.</p> <p> The pilot model will allow for questions to be tailored in regards to the practice profile of the pediatrician and each participant in the pilot will be able to give ABP feedback on individual questions so that the exam can be continuously improved.</p> <p> <strong>Physician groups are calling for a change</strong></p> <p> The AMA Council on Medical Education continues to work on behalf of physicians to bring the physician voice to the American Board of Medical Specialties (ABMS) member boards to transition MOC toward a more relevant framework of high-quality assessment and learning activities.</p> <p> A <a href="" target="_self">resolution to retire the MOC Part III secure, high-stakes recertifying examination</a> was passed by the AMA House of Delegates at the 2016 AMA Annual Meeting. Additional adopted policy calls for the AMA to work with the ABMS to encourage the development by and the sharing between medical specialty boards of alternative ways to assess medical knowledge other than by a high-stakes examination.</p> <p> Although some physicians have expressed concern about the value and cost of MOC participation, groups such as the American Academy of Family Physicians (AAFP) Congress of Delegates recently did not approve a resolution aimed at eliminating the MOC Part III “high stakes” examination. In a Medscape article last month, the AAFP argued that the Part III examination is a way to distinguish its members from nurse practitioners and other nonphysician clinicians.</p> <p> Stay tuned to <em>AMA Wire</em>® to learn more about the ABMS Portfolio Program which offers MOC credit for quality improvement activities.</p> <p align="right"> <em>By AMA staff writer </em><a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:b7f3c427-ec67-4a72-bd31-575efa177f78 Weigh in on pressing health care issues by November 7 Mon, 17 Oct 2016 21:16:00 GMT <p> How do you think the practice of medicine should be improved in the United States? Share your thoughts on important health care topics—and have a chance to shape AMA policy—via the <a href="" target="_self">AMA Online Member Forums</a>. They’re open in advance of the <a href="" target="_self">2016 AMA Interim Meeting</a>, taking place Nov. 12-15 in Orlando.</p> <p> The forums will be open until the start of the meeting, but comments posted after Nov. 7 may not be captured in the summaries shared with reference committee members.</p> <p> Online forums allow AMA members to weigh in on <a href="" target="_self">key policy issues facing medicine</a> at the convenience of their own schedules. By participating in the forums, you can add your voice to the AMA policy discussion from your home, at your office or on the go.</p> <p> Resolutions and reports up for discussion at the 2016 AMA Interim Meeting address such topics as:</p> <ul> <li style="margin-left:33pt;"> Reducing gun violence</li> <li style="margin-left:33pt;"> Primary care and mental health training in residency</li> <li style="margin-left:33pt;"> Integrating mobile health applications and devices into practice</li> <li style="margin-left:33pt;"> Improving mental health at colleges and universities for undergraduates</li> <li style="margin-left:33pt;"> Removing restrictions on federal public health crisis research</li> <li style="margin-left:33pt;"> Protecting the right of breastfeeding residents and fellows</li> </ul> <p> All items of business from initial reports and resolutions for this policymaking meeting are posted in the forums, which are sorted by reference committee. Any AMA member can comment on any item of business. The comment summaries will be shared with reference committee members and posted on the <a href="" target="_self">2016 AMA Interim Meeting website</a>.</p> <p align="right"> <em>By AMA staff writer</em> <a href="" target="_blank" rel="nofollow"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:c40ec3dd-89d0-4406-bda6-d781ad4e4a13 5 things to know about HIPAA and cloud computing Mon, 17 Oct 2016 21:00:00 GMT <p> Protecting patients’ health information is critical to the future of data collection that informs population health. But how can physicians make sure they are in compliance with Health Insurance Portability and Accountability Act (HIPAA) regulations when using cloud computing?</p> <p> The Department of Health and Human Services Office of Civil Rights (OCR) recently issued <a href="" rel="nofollow" target="_blank">guidance on HIPAA and cloud computing</a> that confirms cloud services providers (CSP) are business associates under HIPAA.<a href="" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> If you are currently using a CSP or are planning to soon, the guidance offers detailed direction on the nature of cloud computing, business associate agreements (BAA) and how it all relates to HIPAA, including:</p> <ul> <li> <strong>Physicians and health care professionals can use mobile devices to access ePHI in a cloud.</strong> Accessing information in a cloud is appropriate as long as physical, administrative and technical safeguards are in place to protect the confidentiality, integrity and availability of the ePHI on the device and the cloud.<br /> <br /> Read the OCR and Office of the National Coordinator for Health IT <a href="" rel="nofollow" target="_blank">guidance on the use of mobile devices and tips</a> for securing ePHI on those devices.</li> </ul> <ul> <li> <strong>A HIPAA-covered entity or business associate can use a cloud service to store or process ePHI.</strong> The covered entity or business associate must first enter into a HIPAA-compliant BAA with the CSP that will be creating, receiving, maintaining or transmitting ePHI on its behalf.<br /> <br /> The BAA establishes how ePHI can be disclosed and used. OCR offers <a href="" rel="nofollow" target="_blank">guidance on the elements of BAAs</a>. To address more specific business expectations with your CSP, you can enter into a Service Level Agreement (SLA). SLAs can include provisions that address HIPAA concerns such as system availability and reliability, back-up and data recovery, <a href="" rel="nofollow" target="_blank">how data will be returned to the customer after service use termination</a>, security responsibility and use, retention and disclosure limitations.<br /> <br /> The AMA offers <a href="" target="_blank">a sample BAA for your reference</a>.</li> </ul> <ul> <li> <strong>Using a CSP to maintain ePHI without a BAA is a violation of HIPAA rules.</strong> Entering into a BAA with your CSP is the key first step. However, if a CSP meets the definition of a business associate—in other words, the CSP creates, receives, maintains or transmits ePHI on behalf of a covered entity or another business associate—remember that it is a business associate and must comply with all applicable HIPAA rules, regardless of whether it has executed a BAA.<br /> <br /> The key takeaway is that if you use or are thinking of using a CSP to create, receive, maintain or transmit ePHI on your behalf, you must have a BAA with the CSP or both you and the CSP will be in violation of HIPAA.    </li> </ul> <ul> <li> <strong>A CSP that stores encrypted ePHI and does not have a decryption key is still considered a HIPAA business associate.</strong> Because the CSP receives and maintains ePHI for a covered entity or other business associate, lacking an decryption key for the data does not exempt a CSP from business associate status.</li> </ul> <ul> <li> <strong>If a CSP experiences a security incident it must report the incident to the covered entity or business associate.</strong> HIPAA requires business associates to identify and respond to suspected or known security incidents, mitigate harmful effects that are known and document security incidents and their outcomes.<br /> <br /> The <a href="" rel="nofollow" target="_blank">Breach Notification Rule</a> specifies the content, timing and other requirements to report for incidents that rise to the level of a breach of unsecured patient information. For more on security incidents, see the <a href="" rel="nofollow" target="_blank">FAQ about reporting security incidents</a>.</li> </ul> <p> <strong>For more on cloud use and health IT:</strong></p> <ul> <li> <a href="" target="_self">Why medicine needs a cloud</a></li> <li> <a href="" target="_self">Finding tech passion in an unlikely place</a></li> <li> <a href="" target="_self">Patient-first technology: Improving care for the chronically ill</a></li> <li> <a href="" target="_self">4 ways HHS hopes to simplify and support patient care</a></li> <li> <a href="" target="_self">3 barriers keeping data from improving health outcomes</a></li> </ul> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:2e4f0f1b-2732-465c-a20d-8fd7235aa138 CMS finalizes historic Medicare reform law Fri, 14 Oct 2016 16:00:00 GMT <p> A <a href="" rel="nofollow" target="_blank">final rule</a> released today by the Centers for Medicare and Medicaid Services (CMS) details the final regulations for implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), the historic Medicare reform law that repealed the Sustainable Growth Rate (SGR) formula last year.</p> <p> The AMA will now pore over and dissect the final regulations in the coming days to make sure you know exactly what the rule contains and how it will impact your practice.</p> <p> <strong>What we know already</strong></p> <p> CMS made some significant changes in the proposed rule issued last spring, demonstrating that they took physician input into consideration, announcing changes that will help physicians make the transition, including:</p> <ul> <li> <strong>Pick your pace:</strong> CMS announced in September that <a href="" target="_self">the final regulation will exempt physicians from any risk of penalties</a> if they choose one of four participation options in 2017. The takeaway—even minimal performance reporting will exempt you from any penalties, and opportunities for a shorter, 90-day reporting period will make you eligible for positive payment adjustments.</li> </ul> <ul> <li> <strong>Low-volume threshold exemption:</strong> Practices with less than $30,000 in Medicare payments or fewer than 100 Medicare patients will be exempted from performance reporting entirely.</li> </ul> <ul> <li> <strong>Resource use holds 0 percent weight in year one:</strong> The Merit-based Incentive Payment System (MIPS) has four components, one of which is resource use. In the first year of implementation, this category will hold 0 percent weight toward your MIPS score.</li> </ul> <p> <strong>What to do right now</strong></p> <p> Take advantage of the resources and educational materials on the AMA’s <a href="" target="_self">Understanding Medicare Reform</a> Web page.</p> <ul> <li> The AMA <a href="" target="_self">Payment Model Evaluator</a> can help you determine the impact the final regulations will have on your practice and will be updated continually to reflect what is in the rule.</li> </ul> <p> Several modules are available from the AMA’s <a href="" rel="nofollow" target="_blank">STEPS Forward™</a> collection of practice improvement strategies that can help your practice:</p> <ul> <li> <a href="" rel="nofollow" target="_blank">Maximize your preparedness for quality reporting</a></li> <li> <a href="" rel="nofollow" target="_blank">Prepare for value-based care</a></li> <li> <a href="" rel="nofollow" target="_blank">Choose the best electronic health record (EHR) for your practice</a></li> <li> <a href="" rel="nofollow" target="_blank">Implement an EHR system</a></li> </ul> <p> The AMA will host educational events in the next few months to help physicians understand what the regulations mean for the future of their practice, which will be accessible both in-person and online. Details and registration will be available soon.</p> <p> Watch <a href="" target="_self"><em>AMA Wire®</em></a> in the coming weeks for a more detailed look at what CMS included or changed in the final regulations as experts decipher their impact on practices that serve patients under Medicare. </p> <p style="text-align:right;"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:be0d62c7-d06f-4f2f-8b99-89113f053428 3 ways to get ahead financially even if you're not an expert Thu, 13 Oct 2016 21:00:00 GMT <p> Younger physicians can struggle to adequately prioritize saving for retirement, as starting a family and servicing student loans may seem more urgent. But simple strategies like “paying” one’s retirement first can provide budgeting clarity and reduce much of the stress of juggling life goals. A new report notes the complex financial needs of physicians and provides concrete advice to help you get ahead of schedule in preparing for life after practice.</p> <p> It’s well known that physicians have unique personal finance needs. They start their careers eight to 10 years later than many other professionals, carry $150,000 – 200,000 more in student loan debt and often have little time to dedicate to financial planning.</p> <p> Still, there are many physicians who feel they are on track or even ahead of schedule when it comes to saving for retirement.</p> <p> <strong>Attitude and behavior determine success</strong></p> <p> A new study by AMA Insurance, <a href="" target="_self" rel="nofollow"><em>2016 Report on U.S. Physicians’ Financial Preparedness®</em></a><em>,</em> looked at practicing physicians who are ahead of schedule and contrasted their responses with those of physicians who say they are behind in retirement planning to demonstrate that the major differences are not demographic but rather attitudinal and behavioral in nature.</p> <p> The most dramatic difference is that physicians who are ahead in saving for retirement are eight times more likely to say they are very knowledgeable about personal finance. But what if you don’t know much about retirement planning, investing and insurance? What can you do anyway—and immediately—to put yourself in position to have enough money for a comfortable retirement?</p> <p> <strong>Here’s where to start</strong></p> <p> According to the report, which includes responses from more than 2,300 practicing physicians, you should:</p> <ol> <li> <strong>Get a professional financial advisor.</strong> Two-thirds of physicians who are ahead use one. Those who are behind and don’t use an advisor say it is because they lack time and haven’t found anyone they can trust.<br /> <br /> “When selecting an advisor, look for competency, but also someone you can communicate with. Trust is won or lost through communication,” said Bill Zelenik, CEO of Millennium Brokerage Group. “You may not pick the right one the first time, or the second time for that matter. Make sure they have technology—for busy physicians, technology is essential to facilitate communication. Ideally, you should be able see your balance sheet on your phone.”</li> </ol> <ol> <li value="2"> <strong>Max out your 401k/403b contribution annually.</strong> Physicians who are ahead are nearly twice as likely to contribute the maximum to their qualified plan. In addition, less than half of physicians who are behind max theirs out.<br /> <br /> “Don’t underestimate the power of maxing out your qualified plan contribution,” Zelenik said. “It’s tax-favored, un-attachable by creditors, and if you’re getting an employer match, it’s getting another 50% on your money. It should be the first retirement vehicle that gets funded, and if your portfolio is built efficiently, it should be the last money you take out in retirement.”</li> </ol> <ol> <li value="3"> <strong>Carry less debt.</strong> In addition to carrying business or practice debt, physicians who are behind also carry considerable amounts of consumer debt, including credit card balances, mortgages, car loans and home equity loans. Again, paying your retirement first every month will help clarify how much debt is affordable.<br /> <br /> “Strive to enter retirement debt-free,” Zelenik explained. “No mortgage, no car loan. To plan for this, you need to be cognizant of your debt and expenses. I’ve known physicians who can tell me their monthly income without hesitation but don’t know how much their monthly ‘nut’ is. It’s important to track what’s going out.”</li> </ol> <p> <strong>Get started on step 1 right now</strong></p> <p> Financial independence is a lifetime job, the report notes, so today’s the day to get started, no matter your age. The Physicians Financial Partners program provides access to a nationwide network of independent, local and experienced financial professionals who have undergone a comprehensive due-diligence process by AMA Insurance. To speak with an approved Physicians Financial Partner, call 1-855-210-4015.</p> <p> <strong>Read more about financial planning for younger physicians:</strong></p> <ul> <li> <a href="" target="_self">What you need to do now to secure a firm financial future</a></li> <li> <a href="" target="_self">5 financial planning tips every young physician should know</a></li> <li> <a href="" target="_self">How to partner with a physician-friendly financial adviser</a></li> <li> <a href="" target="_self">How to kick your financial plan into high gear</a></li> <li> <a href="" target="_self">Top personal finance tips from experienced physicians</a></li> </ul> <p align="right"> <em>By AMA staff writer Tim Smith</em></p> <p> About Bill Zelenik: Bill Zelenik is CEO of Millennium Brokerage Group, a strategic marketing partner of AMA Insurance in its Physicians Financial Partners program. Millennium has operations with offices nationwide delivering advanced underwriting and planning services through advisors, banks, broker dealers, financial professionals and family offices.</p> <p> Securities offered through The Leaders Group, Inc., member FINRA/SIPC.</p> <p>  </p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:45304dcd-2ee1-45e3-9702-69911e3f1f06 Recognize the positive when changing your practice Wed, 12 Oct 2016 23:00:00 GMT <p> When undertaking organizational change, focusing only on what is wrong in your practice can create a negative atmosphere. But taking the time to recognize what is positive in your practice can help your care team see more clearly what gives life, vitality and joy to their daily work—and make sure those aspects remain.</p> <p> “Appreciative inquiry”—developed at Case Western University in the 1980s—is an approach to change that identifies and builds on what is already working well in an organization to move a practice toward positive change. It uses unconditional positive questions to identify what is best in an organization, such as:</p> <ul> <li> “Think of a recent successful team project. What made the team so successful?”</li> <li> “Have you noticed a colleague go beyond the call of duty recently? What happened?”</li> <li> “What is something that went well for you today?”</li> <li> “What is a recent positive experience in your work or personal life?”</li> </ul> <p> While you’re making changes around what is not working well, these types of questions can help your team stay focused on what they are already doing well as those changes are put into place.<a href="" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> A new module from the AMA’s <a href="" rel="nofollow" target="_self">STEPS Forward™</a> collection of practice improvement strategies shows you how to <a href="" rel="nofollow" target="_self">change your organizational culture using appreciative inquiry</a>. The module can help your practice use this technique in daily huddles, staff meetings, leadership meetings, performance evaluations and interactions with patients and family members.</p> <p> <strong>How it’s working in Indy</strong></p> <p> At Rockville Plaza Family Practice in Indianapolis, appreciative inquiry became a significant part of their transition to becoming a patient-centered medical home.</p> <p> “The stress and turmoil of this change could have had a negative effect on morale and communication,” said Jason Everman, DO, a family physician at Rockville Plaza Family Practice. “In my role as a physician leader, I’ve seen just the opposite.”</p> <p> “Because we used appreciative inquiry as we pursued this strategic improvement aim, the atmosphere in our practice has actually become more positive,” he said.</p> <p> Dr. Everman’s practice uses appreciative check-ins when they begin staff meetings, appreciative debriefs when those meetings conclude and appreciative interviewing as they conduct their strategic planning for the year.</p> <p> “The changes in the practice have been noticeable,” Dr. Everman said. “I’ve seen more human touches in our clinic over the last few months than previously,” including:</p> <ul> <li> Real laughter among patients and staff while handling disease and life changes</li> <li> Smiles and kindness even during the most tense moments of the day</li> <li> Side conversations focused on raising the bar for the approach to patient care</li> <li> Questions of why the practice functions in certain ways and if it can be improved</li> <li> Innovation in clinic-patient communication to raise satisfaction for patients</li> </ul> <p> During one of the practice’s appreciative inquiry exercises, Dr. Everman said it became apparent that some of the staff already had an internal drive for improvement, and that can often be more powerful than external incentives.</p> <p> “Staff members displayed a readiness to put the patient first,” he said. “Since that exercise, I have come to really appreciate the power of humanism to change the culture of a health care organization—and to help us effectively implement improvement projects … It helped us grow together and provide even better care to our patients.”</p> <p> There are seven new modules now available from the AMA’s STEPS Forward collection, bringing the total number of practice improvement strategies to 42; several thanks to a grant from and collaboration with the <a href="" rel="nofollow">Transforming Clinical Practices Initiative</a>.</p> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:96939223-cd4d-46e0-a3a4-f64414bf729f Error-reporting confidentiality threatened in court Wed, 12 Oct 2016 21:00:00 GMT <p> A case before the Supreme Court of Iowa holds the confidentiality of peer-review materials in the balance. Will the court uphold an Iowa statute meant to maintain confidentiality of such documents in order to reduce error leading to morbidity and mortality and improve public health?</p> <p> <strong>What happened in Iowa</strong></p> <p> At stake in <em>Willard v. State of Iowa</em> is whether the Iowa Morbidity and Mortality Study Law (MMSL), a type of peer-review statute meant to keep peer-review information and materials confidential, created a privilege against legal discovery of a hospital’s patient safety network incident report (PSN) and related documents.</p> <p> Dennis Willard was injured in a motorcycle accident and taken to a hospital in Davenport, Iowa, for treatment. Because of the seriousness of his injuries, Willard was transferred to the University of Iowa Hospital—an agency of the State of Iowa. Willard was under heavy sedation at the time of the transfer and sued the State of Iowa alleging he was handled negligently during the transfer process and suffered further injuries as a result.</p> <p> During discovery, Willard sought production of various documents pertaining to his care, including the hospital’s incident report. The hospital objected to the discovery, claiming the requested documents were privileged under MMSL.</p> <p> After hearing testimony from the hospital regarding the nature of the contested documents and ordering an <em>in camera</em> review— review of the hospital’s documents by the judge without their disclosure to Mr. Willard’s attorneys in order to determine the validity of the hospital’s privilege claim—the trial court ordered the production of the PSN report. The hospital filed an Interlocutory Appeal.</p> <p> <strong>Peer-review confidentiality makes a safer health care system</strong></p> <p> In a report, “<a href="" target="_blank" rel="nofollow">To Err is Human: Building a Safer Health System</a>,” the National Academies of Sciences, Engineering and Medicine (formerly the Institute of Medicine) determined that at least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of preventable medical errors.</p> <p> The report states that the majority of errors do not result from individual recklessness or the actions of a particular group. This is not a “bad apple” problem; more commonly, errors are caused by faulty systems, processes and conditions that lead to mistakes or failed prevention. The report said that mistakes are best prevented by designing the health system at all levels to make it safer. A key first step to a safer health system is identifying error so that it can be studied.</p> <p> Iowa’s MMSL advances vital public health and patient safety interests in dynamic, robust review and analysis of how medicine can do better in treating and curing disease and preventing death.</p> <p> “In order to be able to identify error, everyone—physicians, nurses, hospital staff, etc.—must be willing to report the error,” the <a href="" target="_self">Litigation Center of the AMA</a> and the Iowa Medical Society (IMS) said in an amicus brief supporting the hospital’s objection. “The only way people will be willing to do so is if there is a system of protection in place for such reporting.”</p> <p> Effective surveillance through data gathering, incident reporting and identification of policies, procedures and other circumstances is essential to assessing medical errors and making the proper changes for prevention of future errors—the MMSL is Iowa’s means of accomplishing this.</p> <p> This data and information must be protected by confidentiality. The <a href="" target="_self">newly updated AMA Code of Medical Ethics</a> recognizes the unique position physicians have to impact quality medical care and patient safety and advises physicians to “play a central role in identifying, reducing and preventing medical errors.”</p> <p> Both as individuals and collectively as a profession, physicians should study circumstances underpinning medical errors. The Code explains that a legally protected review process is essential for reducing health case errors and preventing patient harm and that physicians should establish and participate fully “in effective, confidential, protected mechanisms for reporting medical errors.”</p> <p> Iowa’s MMSL is such a mechanism and “the liability protections afforded are in keeping with medical ethics and advance patient and public interest in ongoing, information-based studies of outcomes, procedures, policies and protocol affecting morbidity and mortality,” the AMA and IMS said.</p> <p> “Since the inception of the [MMSL], Iowa physicians and medical staff have operated under the belief and practice that information submitted under the statute would be fully protected,” the AMA and IMS said. “The District Court’s decision compelling disclosure of the PSN documents … defies the purpose, policy and express language of the Iowa [MMSL] and if upheld, will act to chill the reporting of information under the statute, therefor harming public health care.”</p> <p> <strong>Other cases in which the Litigation Center is involved:</strong></p> <ul> <li> Investigate how <a href="" target="_self">peer-review confidentiality is under threat in Pennsylvania</a></li> <li> Find out how a <a href="" target="_self">challenge to medical liability law could complicate pre-suit process</a></li> <li> Learn how a case <a href="" target="_self">could lead to unlimited awards of punitive damages</a></li> <li> Get the details on a <a href="" target="_self">case that could extend medical liability</a></li> </ul> <p align="right"> <em>By AMA staff writer </em><a href="" target="_blank" rel="nofollow"><em>Troy Parks</em></a></p> <p>  </p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:75138a0c-94ad-4c36-90f2-90fb020bfb22 Payment model proposal process for MACRA begins Tue, 11 Oct 2016 23:00:00 GMT <p> The Medicare Access and CHIP Reauthorization Act (MACRA) established the Physician-Focused Payment Model Technical Advisory Committee (PTAC) to make recommendations to the Secretary of the Department of Health and Human Services (HHS) on physician-focused payment models (PFPM)—and the PTAC is now preparing to accept proposal submissions.</p> <p> HHS is required by MACRA to establish criteria for PFPMs and to respond to the recommendations of the PTAC. Individual physicians and stakeholder entities can now profess intent to submit their proposed models to the PTAC for consideration. The PTAC will evaluate whether or not each proposal meets HHS’ criteria and make recommendations for refinement, further study, testing and implementation of the proposed PFPMs.</p> <p> <strong>Submitting your proposal</strong></p> <p> There are two steps to submitting a proposed PFPM. The first step is to submit a non-binding letter of intent at least 30 days in advance of your full payment model proposal submission—this began Oct. 1.</p> <p> The second step will be to submit a full proposal for consideration, and the PTAC will begin accepting full proposals on Dec. 1.</p> <p> The <a href="" rel="nofollow" target="_blank">letter of intent template</a> will guide you to make sure the PTAC has all of the information it needs ahead of your proposal submission. A letter of intent should be two pages or less, single spaced, and include:</p> <ul> <li> Expected participants</li> <li> Goals of the payment model</li> <li> A model overview</li> <li> Implementation strategy</li> <li> Timeline</li> </ul> <p> For more detailed information on each of these points, check out the <a href="" rel="nofollow" target="_blank">instructions for letter of intent submissions</a>.</p> <p> All letters of intent must be sent as an attachment to <a href="" rel="nofollow"></a> as either a PDF or Word document with 12-point Times New Roman font. The email subject line should include LOI (letter of intent) followed by the organization name and a key word or phrase describing the model.</p> <p> Read more about the <a href="" rel="nofollow" target="_blank">PTAC, letters of intent, proposal requirements</a> and the characteristics of payment models likely to be recommended by the PTAC.</p> <p> To learn more about alternative payment models (APM) and their place in the new Medicare payment system, visit the AMA's <a href="">Medicare payment reform Web page</a>.</p> <p> For more on physician efforts to develop and implement APMs:</p> <ul> <li> <a href="" target="_self">Payment models that can help you better address patients’ needs</a></li> <li> <a href="" target="_self">Specialty development key to new payment models’ success</a></li> <li> <a href="" target="_self">Payment model design needs to be physician-led: New report</a></li> <li> <a href="" target="_self">How doctors are developing new payment models for their specialties</a></li> <li> <a href="" target="_self">Testing new payment models: One pilot program’s success</a></li> <li> <a href="" target="_self">New model makes patient care more than face-to-face visits</a></li> </ul> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:17fd7fdb-6fc9-4f57-9460-b8f9f1dafeba Court case tests New York City sodium warnings rule Tue, 11 Oct 2016 22:00:00 GMT <p> The New York City Department of Health and Mental Hygiene (NYC DOHMH) recently adopted a rule requiring larger restaurant chains to post icons on their menus warning patrons of dishes that contain more than the US government’s daily limit for sodium. The National Restaurant Association (NRA) sued to block the rule and lost, but it now seeks to reverse the state supreme court’s decision. Besides the millions of vulnerable New Yorkers who are in need of the warnings, the case has implications for medical and public health organizations nationwide.</p> <p> <strong>What happened in New York</strong></p> <p> The NYC DOHMH adopted the rule in response to a crisis of hypertension in the city. More than one in four adults in New York City has been told by a health professional that he or she has hypertension, meaning there are almost two million New Yorkers for whom a reduction in sodium consumption is crucial for improved health and a longer life.</p> <p> Warnings about sodium consumption are also critical for the city’s residents who are at high risk, including African-Americans, people age 51 and older and those with high blood pressure, diabetes or kidney disease, who together make up more than half of the city’s population.<strong><a href="" target="_blank"><img src="" style="margin:15px;float:right;" /></a></strong></p> <p> At stake in <em>National Restaurant Association v. New York City Department of Health and Mental Health, </em>currently before the New York Supreme Court’s Appellate Division, is whether the rule is an appropriate response to a public health problem, how the First Amendment applies to required science-based warnings, what constitutes arbitrary and capricious actions by health agencies and when local law may be preempted by the federal Nutrition Education and Labeling Act.</p> <p> The NRA lost initially in the trial court and again in seeking a preliminary injunction pending appeal.</p> <p> <strong>Local and national importance</strong></p> <p> In the past several months, the U.S. Department of Agriculture (USDA) and the U.S. Department of Health & Human Services have released the final Dietary Guidelines for Americans for 2015–2020, which recommend that adults consume less than 2,300 milligrams (mg) of sodium per day. Research from the USDA indicates that mean daily sodium consumption for adults is nearly 3,600 mg.</p> <p> “Notwithstanding the NRA’s attempt to sow doubt and uncertainty about the contribution of sodium consumption to hypertension, there is clear scientific consensus regarding the link,” said the <a href="" target="_self">Litigation Center of the AMA and State Medical Societies</a> in an amicus brief defending the rule. “The requirement that chain restaurants post a warning statement and a symbol indicating that a single menu item exceeds the recommended total daily sodium limit is a moderate and reasonable response to a severe public health threat.”</p> <p> The brief also refuted three NRA claims that have national importance.</p> <p> “First, the rule comports with the First Amendment, which favors factual disclosures in the commercial context,” the brief said. “Second, far from being arbitrary or capricious, the Rule’s lines are in fact drawn with a keen understanding of the boundaries of the [Department’s] authority. Third, the Rule is not preempted by federal law; savings clauses in the Nutritional Labeling and Education Act explicitly preserve ‘warnings’ of this type.</p> <p> “The [Department of Health] has taken a modest but vital step to provide information to consumers that may help to save their lives.”</p> <p> In addition to its work in the courts, the AMA is providing physicians and care teams with strategies and resources to help control high blood pressure and ultimately prevent heart disease. <a href="" target="_self">M.A.P</a>.—Measure accurately, Act rapidly and Partner with patients, families and communities—developed in partnership with Johns Hopkins Medicine, features tools for practices and health systems to address hypertension control rates, develop new teamwork and communication strategies and improve workflow processes.</p> <p> <strong>Read more on the AMA’s work to prevent heart disease:</strong></p> <ul> <li> <a href="" target="_self">The one graphic you need for accurate blood pressure reading</a></li> <li> <a href="" target="_self">3 questions to ask patients when measuring blood pressure</a></li> <li> <a href="" target="_self">Rethinking how physicians learn to prevent, manage chronic disease</a></li> <li> <a href="" target="_self">Why you should use self-measured blood pressure monitoring</a></li> <li> <a href="" target="_self">What successful self-measured BP looks like in practice</a></li> </ul> <p align="right"> <em>By AMA staff writer Tim Smith</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:86c1653e-1b44-4c9c-b548-b497cb62dc94 In recognition of Angus McBryde, MD Tue, 11 Oct 2016 06:00:00 GMT <p> Angus McBryde, Jr., MD, of Columbia, S.C., chair-elect of the Senior Physicians Section, passed away unexpectedly on Oct. 4. Dr. McBryde attended Duke Medical School and served as Vice President of the AMA’s Medical Student Section. After medical school, Dr. McBryde conducted his internship and residency in general surgery at the Hospital of the University of Pennsylvania. He spent the following two years in the U.S. Navy as a medical officer on the U.S.S. St. Paul and at Balboa Naval Hospital during the Vietnam War.</p> <p> Dr. McBryde went on to complete his orthopaedic residency at Duke in the ensuing years and in 1971 was appointed Clinical Assistance Professor of Orthopaedics. Dr. McBryde chaired the Departments of Orthopaedic Surgery for the University of South Alabama at Mobile and the University of South Carolina in Charleston. He also co-founded and was president of the Southern Orthopaedic Association and the Southern Medical Association. He enjoyed serving in leadership positions in his specialty field, serving on 11 editorial boards and publishing more than 70 scholarly publications including two books. A noted academician and skilled surgeon with nationally-recognized expertise in sports medicine, Dr. McBryde took the adage, “Time waits for no man,” to heart, living each day of his life quite literally to its fullest.</p> <p> A memorial service to celebrate Dr. McBryde's life was held in Charlotte, N.C., on Oct.11. Dr. Barbara Schneidman SPS Chair noted, “The Governing Council of the Senior Physicians Section had so much respect and admiration for Angus that we had elected him unanimously as chair-elect at our last meeting. We will miss his presence immensely.”  </p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:0e5bca6c-627d-468e-82d1-415c6d509959 From Zika to gun violence, CME sessions at 2016 Interim Meeting Tue, 11 Oct 2016 01:00:00 GMT <p> Numerous continuing medical education (CME) courses will be available for credit at the 2016 AMA Interim Meeting in Orlando this November. Among the hot topics: gun violence, the Zika virus and physician burnout.</p> <p> This year’s meeting features expert speakers from public health organizations, physician practices and government agencies. Education sessions and forums sponsored by AMA sections and special groups are open to all members and many offer CME credit, including:</p> <ul> <li> <strong>Emerging issues in medical staff affairs:</strong> 8-9 a.m., Friday, Nov. 11<br /> This session will provide an overview of trends and tips on how medical staffs can address issues such as criminal background checks and drug testing for medical staff members, revised requirements for reporting adverse medical staff actions, assessment of senior physician competency and problems arising among medical staff composed of both hospital-employed and independent members.</li> </ul> <ul> <li> <strong>Gun violence: What do we know? What can physicians do?:</strong> 9-10:15 a.m., Saturday, Nov. 12<br /> Nationally recognized speaker Camara Jones, MD, PhD, MPH, president of the American Public Health Association, will discuss what a comprehensive public health response to gun violence might look like and the components of a balanced situation and what physicians can do to be part of the solution.<br /> <br /> Also speaking with participants will be Rex Archer, MD, MPH, director of health at the Kansas City, Mo., Public Health Department.</li> </ul> <ul> <li> <strong>Engaging independent and employed physicians:</strong> 10:30-11:30 a.m., Saturday, Nov. 12<br /> Examining the importance of physician engagement and using real-world examples and case scenarios, this program will offer guidance on how medical staff organizations can engage and align both employed and independent physicians to improve patient care.</li> </ul> <ul> <li> <strong>Stay young, stay fit, avoid burnout:</strong> Noon-1:30 p.m., Saturday, Nov. 12<br /> This session will look at what it takes to create a more positive, strength-based approach for empowering physicians to take charge of their own health and find sources of support before burnout occurs.<br /> <br /> Speakers include Robert L. Hatch, MD, professor and director of medical education at the University of Florida Medical School, Robert M. Wah, MD, former AMA president and faculty at the Walter Reed National Military Medical Center, and Barbara S. Schneidman, MD, MPH, chair of the AMA Senior Physicians Section Governing Council.</li> </ul> <ul> <li> <strong>Zika virus: What physicians need to know:</strong> 3-4 p.m., Sunday, Nov. 13<br /> Public health officials from the state and federal levels will provide the latest updates  the Zika virus. This session will include an update on the epidemiological aspects of the current outbreak, describe efforts by public health agencies to prevent transmission and explain the latest guidance for physicians and their patients.</li> </ul> <p> Remember to bring your AMA username and password to the meeting so you can complete the CME activity evaluation forms and save your certificates on the AMA Online Learning Center for credit.</p> <p> Take a closer look at the schedule and details by reading the "<a href="" target="_self">Speakers' Letter</a> (log in),” from AMA House of Delegates Speaker Susan R. Baily, MD, and Vice Speaker Bruce A. Scott, MD; or read more about and register for the 2016 AMA Interim Meeting to take place Nov. 12-15 in Orlando.</p> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> <p>  </p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:ab661d33-12aa-4efe-8bb9-90803c47d938 Health professionals with disabilities: Ethics and progress Fri, 07 Oct 2016 21:27:00 GMT <p> Though nearly 20 percent of the U.S. population has a disability, health professionals and medical students with disabilities still encounter roadblocks throughout training and their careers. What are the ethical considerations that could initiate progress for health professionals and medical students with disabilities?</p> <p> Take a moment and consider this situation: An elderly and esteemed surgeon needs assistance to safely complete his or her cases. How should his or her colleagues respond?</p> <p style="margin-left:40px;"> A.    Report the surgeon to the licensure board</p> <p style="margin-left:40px;"> B.    Bring the issue to the attention of the department chair</p> <p style="margin-left:40px;"> C.    Confront the surgeon directly and privately</p> <p style="margin-left:40px;"> D.    Place a call to the organization’s patient safety hotline</p> <p> This is a challenging situation for any professional. <a href="" target="_blank">Give your answer</a> to this poll in the October issue of the <em>AMA Journal of Ethics®.</em> <a href="" target="_blank">The October issue</a> explores what “disability” means, how we can learn from physicians with disabilities and what medical schools can do to accommodate medical students with disabilities.</p> <p> Articles featured in this issue include:</p> <ul> <li> “<a href="" target="_blank">Perspectives on the Meaning of ‘Disability</a>.’” Public policy changes have shifted the meaning of “disability” over time, protecting people with disabilities under civil rights law. The criteria for judging people to be disabled likewise fluctuate across social and cultural contexts. Investigate whether and when policy-level interventions and reasonable accommodations create equal opportunity.</li> </ul> <ul> <li> “<a href="" target="_blank">Learning from Physicians with Disabilities and Their Patients</a>.” How can medical schools revise institutional policies to increase the matriculation and graduation rates of medical students with disabilities? Find out how systematically gathering information on the needs and experiences of four distinct groups of individuals with disabilities could provide data leading to change.</li> </ul> <ul> <li> “<a href="" target="_blank">Medical Schools’ Willingness to Accommodate Medical Students with Sensory and Physical Disabilities: Ethical Foundations of a Functional Challenge to ‘Organic’ Technical Standards</a>.” Students with sensory and physical disabilities are underrepresented in medical schools despite the availability of assistive technologies and accommodations. Learn how considering the ethics of justice and beneficence could prompt change in this area.</li> </ul> <p> In the journal’s <a href="" target="_blank">October podcast</a>, Louise Andrew, MD, JD, a fifth-generation physician attorney, discusses mental health challenges for physicians and medical students and recommends strategies for colleagues to intervene and assist.</p> <p> <strong>Submit an article</strong></p> <p> The journal’s editorial focus is on commentaries and articles that offer practical advice and insights for medical students and physicians. <a href="" target="_blank" rel="nofollow">Submit your work</a> for publication.</p> <p align="right"> <em>By AMA staff writer</em> <a href="" target="_blank" rel="nofollow"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:5eb33cb8-d9f7-43d3-a172-92456e497f08 Med students plunge into ACOs, patient-centered medical homes Fri, 07 Oct 2016 15:50:00 GMT <p> Medical schools are enhancing students’ experiences by embedding them into patient-centered medical homes and accountable care organizations (ACO)—two care models changing health care delivery. Explore the work some schools are doing with the AMA’s Accelerating Change in Medical Education Consortium.</p> <p> Immersing students in these care models is part of the schools’ work with the AMA’s <a href="" target="_self">Accelerating Change in Medical Education Consortium</a>. The consortium, working to modernize and reshape the way physicians are trained, brings leaders form schools together to share ideas and experiences with innovative programs designed to improve competency, leadership and patient care.</p> <p> <strong>Navigating the system in Cleveland</strong></p> <p> First year students at Case Western Reserve University School of Medicine (CWRU) in Cleveland this year will have the chance to work directly with veterans and refugees, helping these patients navigate the health care system and assisting them in reestablishing themselves in society.</p> <p> On a volunteer basis, medical students can go into patient-centered medical home practices through the VA Centers of Excellence in Primary Education. They can also go into the Neighborhood Family Practice, a group of community health centers in Cleveland that are seeing refugee families.</p> <p> Students will guide refugees who are new to the U.S. in filling out forms and will educate the patients on the workings of the U.S. health system such as when it is best to use the emergency department. They will help veterans returning from deployments readjust to life in the U.S. and help them learn how to navigate the VA system.</p> <p> “The idea is to get students to understand the system and to understand the patient’s perspective,” said Mamta “Mimi” Singh, MD, MS, assistant dean of health systems science at CWRU. “The best way is to have the students navigate the system themselves.”</p> <p> The goal during the pilot phase of this program is for the medical students to work in teams of four, with about 20 students heading into the VA system and another 20 students working with refugees through Neighborhood Family Practice.</p> <p> The medical school has a long history of embedding students in the community, including a student-run free clinic where second, third and fourth year students work with a nurse and a preceptor.</p> <p> This new program “is a way to highlight the third pillar of medical education, health systems science,” Dr. Singh said. “It is important to give students the experience to navigate the system.”</p> <p> <strong>Creating a six-year program in Cleveland</strong></p> <p> Ohio University Heritage College of Osteopathic Medicine in Cleveland, in affiliation with the Cleveland Clinic, is preparing a curriculum that will embed students longitudinally in patient-centered medical homes with strong ties to community services.</p> <p> The program, scheduled to begin in two years, will be linked to a three-year DO program and a three-year family medicine residency program. The embed will begin the first week of medical school and continue through the last day of residency.</p> <p> “The exciting part of our project is that the curriculum, the care model, and the community integration components are being developed together to ensure each component can inform the other two,” said Isaac J. Kirstein, DO, dean of Ohio University Heritage College of Osteopathic Medicine’s Cleveland campus. “Embedding students for more of their learning will create new ways to reinforce clinical education, while providing new opportunities to experientially learn the complexities of health care delivery.”</p> <p> The medical school has a 40-year history of embedding students in the community which reinforces the basic sciences and clinical sciences traditionally taught in lectures and labs.</p> <p> “The AMA consortium schools share the Heritage College’s belief that physician leaders must excel in a new third science--health systems science,” Dr. Kirstein said. “We are designing our program with the assumption that this new science requires embedded learning as a priority.”</p> <p> Dr. Kirstein noted that embedding students allows their education to transform as the health care system changes.</p> <p> “Students will be part of the evolution and not just reacting to it,” he said.</p> <p> <strong>Helping patients manage disease at home in New Jersey</strong></p> <p> At Rutgers Robert Wood Johnson Medical School (RWJMS), medical students are teaming up with students from other disciplines to help care for patients with multiple chronic conditions in their homes.</p> <p> As part of their curriculum, medical students--along with an interprofessional team of pharmacy, social work, nursing and physician assistant students–are embedded within teams led by nurse care coordinators. Medical students make visits to patients’ homes to help patients learn to better manage their diseases outside of office visits; help improve patients’ safety and preventive health at home; and track, assess and strategize on improving quality and cost.</p> <p> “The experience of going into a patient’s home is eye opening,” said Carol A. Terregino, MD, senior associate dean for education at RWJMS and the associate dean of admissions. “They are learning about health systems sciences <em>in vivo</em>.”</p> <p> The medical school and hospital have a partnership called Robert Wood Johnson Partners, an integrated care system where a nurse care coordinator manages patients in the system. The students join the nurse for a first visit to a patient’s home and after that, the student team members continue to make visits to the same home.</p> <p> A pilot program was conducted in the spring and students identified safety issues and medication errors, including a loose rug that was a tripping hazard to the patient and a problem with the patient’s medicine that prompted calls to the nurse care coordinator and treating physician.</p> <p> “A preliminary survey on the experience indicates that the students identify that there is much room for personal growth with regard to confidence in caring for patients with multiple chronic conditions and for working on interprofessional teams,” Dr. Terregino said.</p> <p> This fall the entire second-year medical school class will be embedded in the real world ACO to learn about the Triple Aim of Care: better patient experience, higher quality of care and lower health care costs. Dr. Terregino said the goal is for the students to augment the care that patients receive and to improve the health of the population.</p> <p> “What we are hoping is that patients look forward to the visits and that these experiences will be value-added for the patient and the care coordinators, as well as the students,” she said.</p> <p> <strong>Learn more about the consortium schools:</strong></p> <ul> <li> See what’s new in how <a href="" target="_self">medical schools focus on quality improvement and patient safet</a>y</li> <li> Review <a href="" target="_self">9 med ed challenges</a> educators and consortium members want to solve now</li> <li> Learn <a href="" target="_self">how educators are creating the impossible</a> for future physician training</li> <li> Discover the <a href="" target="_self">current projects</a> these 11 founding members have underway</li> </ul> <p align="right"> <em>By contributing writer Tanya Albert Henry</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:e34f80b8-6fa6-4946-9c06-7a0ff3b73691 The “structure” of the medical school of the future Thu, 06 Oct 2016 21:00:00 GMT <p> With the advent of dramatic changes in how medicine is taught—from active learning to interprofessional education—medical schools are now rethinking the design of their buildings and classrooms as well. Learn how the University of North Dakota (UND) approached building the medical school of the future for its new School of Medicine & Health Sciences (SMHS), completed this summer.</p> <p> UND SMHS started its patient-centered learning curriculum nearly 20 years ago. The school has had a required course in interprofessional education (IPE) since 2006, and in 2012 it added team-based learning to the curriculum.</p> <p> “As a school of health sciences, we have nine programs, and we are by our nature interprofessional,” said Gwen Halaas, MD, MBA, senior associate dean for education at UND SMHS, at a recent meeting of the AMA’s <a href="" target="_self">Accelerating Change in Medical Education Consortium</a> in Chicago. “We believe that is the way to address some of the efficiency and quality issues in health care.”</p> <p> <a href="" target="_blank"><img src="" style="float:right;margin:15px;height:243px;width:365px;" /></a>So faculty and administrators at UND SMHS have been working to create more interprofessional learning experiences.</p> <p> “Medical schools have had learning communities for a long time, but our interprofessional learning communities are designed to change the culture to support IPE and collaboration,” Halaas said. “And I think by having students learn and socialize together throughout their entire programs, they will be much more apt to … collaborate with and respect each other and communicate easily.”</p> <p> <strong>It had to be healthy</strong></p> <p> The decision to build the new SMHS came out of a partnership with the state legislature. In conversations about class sizes, it became clear that UND wouldn’t be able to accommodate the desired increase, so the state did a one-year study with the architects and came up with options ranging from renovation of the existing hospital to constructing an all-new building.</p> <p> “They recognized that investing a lot of money in a 60-year hospital wouldn’t return the investment as well as building a brand-new building good for another hundred years,” Halaas said.</p> <p> But this would be the first time the school would have all of its students in one building. About 1,200 students are enrolled in SMHS—300 of those are medical students—and around 800 of them are on campus at any one time. These numbers necessitated having shared spaces instead of owned ones.</p> <p> “In terms of the design of the building, we had a lot of stakeholders involved in it,” Halaas said. “We talked about what was important: It had to be healthy. It had to have daylight. It had to have a walking path. It had to be able to serve healthy food.”</p> <p> Administrators of the school actively engaged about 200 people on a regular basis in the design process and surveyed around 850 stakeholders, including alumni. They engaged architects with experience in medical education and made visits to other new medical and health sciences schools. They even piloted the furniture that was selected.</p> <p> “We wanted everything to be visible to the public and to all of us,” Halaas said.</p> <p> <strong>Look inside</strong></p> <p> That transparency is now evident in every corner of the building. Its glass exterior walls allow plenty of daylight into the building—not a small consideration in North Dakota—and many of its classrooms feature floor-to-ceiling glass walls.</p> <p> “You can see everything we do,” Halaas said. “You can see [into] the learning communities and conference rooms all up and down four stories.”<strong><strong><a href="" target="_blank"><img src="" style="margin:15px;float:left;" /></a></strong></strong></p> <p> But even more than visibility, the new school emphasizes collaboration and enhanced technology.</p> <p> There are eight learning communities, and all students are assigned randomly into these communities for the length of their programs. The building features 12 discussion-focused classrooms, each with white-board capability, as well as six scale-up team-based classrooms, which feature small-group tables with stowable monitors. There are also larger “medium–tech” rooms.</p> <p> And it has only one lecture hall, called the Learning Hall. But even here students can engage in enhanced small-group learning. The Learning Hall seats 200 and features two tables on each of three tiers, along with mobile chairs, so students in the front of each tier can have active conversations with people behind them.</p> <p> There are small group study spaces and quiet study spaces, along with a shared recreational eating space.</p> <p> The new SMHS also features a virtual hospital and clinic.</p> <p> “We’ve had technology vendors and mannequin vendors in and they have all asked, ‘Can we showcase your space?’ because while it’s not the largest, it is the most sophisticated and the most useful,” Halaas said. “It has a full operating room with a full operating lighting system, six hospital rooms, one task training room, fourteen exam rooms. It really looks like a clinic and a hospital.”</p> <p> <a href="" target="_blank"><img src="" style="margin:15px;float:right;" /></a>Research too is interdisciplinary—all of the school’s labs are now open labs. And even the librarians are embedded.</p> <p> Medical students were the first at UND SMHS to move into the four-story, 325,000-square-foot, $124-million building in Grand Forks, on August 1.</p> <p> <strong>Piloting the medical technology of the future</strong></p> <p> UND SMHS is one of 32 member medical schools in the AMA’s Accelerating Change in Medical Education Consortium. As part of its grant, the school is piloting using robots to teach medical students telemedicine skills.</p> <p> “We’re a rural community, and we want to encourage more telemedicine,” Halaas said. “We use it in our simulation center when we’re training students in certain scenarios to be able to call upon the robot as the consulting cardiologist, or if it’s a patient in the home or an institutional setting, to connect with their family physician on the other end.”</p> <p> It too is taking collaboration and technology enhanced learning to new levels.</p> <p> “The students have to learn to work with the robot as a member of the team,” Halaas said, “but also to be on the other side of the robot in terms of communicating at a distance with the patient or family or team.”</p> <p> <strong>Read more about changes in medical education:</strong></p> <ul> <li> <a href="" target="_self">The physician of the future: More like da Vinci</a></li> <li> <a href="" target="_self">Health care and population health: A team sport</a></li> <li> <a href="" target="_self">Michigan students launch peer-reviewed medical journal</a></li> <li> <a href="" target="_self">Treating the community as your patient</a></li> <li> <a href="" target="_self">Students deliver care in homes, communities</a></li> </ul> <p align="right"> <em>By AMA staff writer Tim Smith</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:8f47df00-0ab7-4400-a1a6-7be48f3e3f90 The physician of the future: More like da Vinci Wed, 05 Oct 2016 21:00:00 GMT <p> Which skills and qualities should typify the physician of the future? Answering this question is crucial for medical schools, especially given the many forces acting on medical education, including health care funding, the impact of technology and evolving patient users. According to one expert, the answer is clear but also complex: The physician of the future will need to be a little bit of everything.</p> <p> Meg Gaines, JD, LLM, is a distinguished clinical professor of law at the University of Wisconsin–Madison. She is also a co-founder of <a href="" rel="nofollow" target="_blank">The Center for Patient Partnerships</a>, which trains students from the schools of Law, Medicine, Nursing, Pharmacy and Social Work to provide advocacy to cancer patients and conducts research on issues relevant to patient care and health care delivery from the patient perspective.<a href="" target="_blank"><img src="" style="float:right;margin:15px;" /></a></p> <p> At a recent meeting of the AMA’s <a href="" target="_self">Accelerating Change in Medical Education</a> Consortium in Chicago, she described the physician of the future from her perspective as an interprofessional team member.</p> <p> “Patients will need their doctors to be advocates,” Gaines said.</p> <p> And partnering, she explained, will be the key to fulfilling that role.</p> <p> “[It’s] the vital 21<sup>st</sup> century skill,” she said. “For practicing professionals, I think we need to be even more Leonardo da Vinci than we have been before, crossing the professional boundaries, being a little bit lawyers, a little bit doctors, a little bit nurses, a little bit social workers.”</p> <p> Collaboration is already required at all levels, she noted, foremost with patients, but it will gain its fullest expression out in the community in the pursuit of the social determinants of health. It is the mechanism that will enable physicians to go upstream of not only many patients’ health problems but also some of physicians’ own health problems, such as burnout.</p> <p> <strong>Overcoming barriers to change</strong></p> <p> Getting there, Gaines thinks, will require change not just in medical education but also in what physicians consider their scope of work.</p> <p> “[One] of the barriers is the guild mentality in all professions, including medicine,” she said. We have ego stuff—it’s true in law too. We own some things, and we don’t like it when the Internet allows you to [do them] without us. So we really do have to be ready to let go of some things.”</p> <p> One of the things Gaines says physicians will have to let go of is what she calls “the rescue fantasy.”</p> <p> “[It’s] this notion that we’re putting all this time and energy into this gestalt that’s about saving people’s lives, when really we do relatively little of that—maybe if we’re trauma surgeons [we do] more of it—but mostly what we do is empower people to save their own lives. And that’s what we have to teach.”</p> <p> That means building curricula for how to build capacity in others, she explained.</p> <p> “Do the math,” she said. “There aren’t ever going to be enough of you to take care of all of us. So you have to have us taking care of ourselves. I want every primary care doctor to have a sign up in their office that says, ‘You are your own primary care provider 99.9 percent of the time. How can I help you?’”</p> <p> Gaines noted her own involvement as a primary investigator for <a href="" rel="nofollow" target="_blank"></a>, the US arm of the University of Oxford’s <a href="" rel="nofollow" target="_blank"></a>, which recently published its first module, on <a href="" rel="nofollow" target="_blank">young adults’ experiences with depression</a>. The module is not a collection of anecdotes; it is a qualitatively and quantitatively researched sampling of experiences that people from across the US have had. It’s an example, Gaines noted, of using technology to teach and not having to have people in the room with a patient.</p> <p> <strong>On the edge of a new education frontier</strong></p> <p> Another core element of a new curriculum, Gaines said, will be self-care and well-being, and this will require medical schools to embrace human fallibility.</p> <p> “[Professional curricula is] big on teaching striving for excellence and [not] on teaching what happens when you say, ‘Uh oh, wish I’d done that differently.’” Gaines said. “I think it comes from being afraid that if we let down our façade of striving for excellence, [our students] will be ordinary, and we just have to let go of that. We need to help them figure out what happens at the ‘Uh oh’ moment and how they can stay alive and even well and get past it and help each other.”</p> <p> Gaines thinks such a shift will have some discomforting implications for medical schools, but the discomfort will be temporary because physicians embrace change.</p> <p> “[Students] do what they see us do, not what we tell them,” she said. “So we need to co-create curriculum with patients, families and communities. We have to walk our talk. There’s no way around it. And our first reaction—trust me, I have it—is, ‘Yikes! How do we do that?!’ This is a new frontier.”</p> <p> <strong>Read more about changes in medical education:</strong></p> <ul> <li> <a href="" target="_self">Health care and population health: A team sport</a></li> <li> <a href="" target="_self">Rethinking how race contributes to a patient’s health</a></li> <li> <a href="" target="_self">Michigan students launch peer-reviewed medical journal</a></li> <li> <a href="" target="_self">Treating the community as your patient</a></li> <li> <a href="" target="_self">Students deliver care in homes, communities</a></li> </ul> <p align="right"> <em>By AMA staff writer Tim Smith</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:eeeab696-8fb2-45e9-9ae7-53eca4aa24b3 Preparing for upcoming Medicare changes? Tools to help your practice Wed, 05 Oct 2016 14:54:00 GMT <p> The Centers for Medicare and Medicaid Services (CMS) is slated to release its Medicare Access and CHIP Reauthorization Act (MACRA) final rule by Nov. 1. While the program does not affect Medicare payments until 2019, physicians need to prepare for the changes now. To help your practice prepare for this historic change, the AMA has been developing a collection of valuable online tools and resources.</p> <p> The new <a href="" rel="nofollow" target="_blank">AMA Payment Model Evaluator</a> helps you determine how MACRA will impact your practice. After answering questions and following the steps—which should take ten minutes or less—you’ll receive a brief assessment as well as relevant educational and actionable resources to help you navigate the new regulations.</p> <p> Once you’ve filled out the online assessment in the Payment Model Evaluator, you will receive guidance as to which payment model might best fit your practice under proposed rules, so that you can begin to assess the impact.</p> <p> The aim of the new tool is to ease the transition to MACRA. You’ve heard all about the Merit-Based Incentive Payment System (MIPS) and alternative payment models (APM), but now is the time to see how they may fit the characteristics of your own practice. </p> <p> The tool holds MACRA education resources including:</p> <ul> <li> MACRA 101: The Basics</li> <li> Introduction to Value-Based Care</li> <li> Information on the MIPS and APMs</li> <li> Implementation & Next Steps</li> <li> MACRA Timeline</li> </ul> <p> An important aspect of the Payment Model Evaluator is that it will be updated to reflect future regulatory changes.</p> <p> Also, the tool is free to both physicians and practice administrators. To create a personalized assessment, all you need is an AMA account to sign in and you can access the tool and other available <a href="" target="_self">educational resources on Medicare payment reform</a>. </p> <p> <strong>Other tools and resources to prep for Medicare changes</strong></p> <p> The <a href="" rel="nofollow" target="_blank">AMA STEPS Forward™</a> collection of practice improvement strategies has grown to 42 modules including a variety of educational modules to help your practice implement <a href="" rel="nofollow" target="_blank">team-based care</a>, <a href="" rel="nofollow" target="_blank">electronic health records</a>, <a href="" rel="nofollow" target="_blank">value-based care</a>, <a href="" rel="nofollow" target="_blank">team documentation</a>, and many others in collaboration with the <a href="" rel="nofollow" target="_blank">Transforming Clinical Practices Initiative</a>.</p> <p> Accurate reporting on quality metrics will be critical under the new Medicare payment system, and new resources in the STEPS Forward collection provide a high-level understanding of the quality programs and show you ways to <a href="" rel="nofollow" target="_blank">maximize your preparedness for quality reporting</a>.</p> <p> Several podcasts are available now online that all have to do with the coming changes to the Medicare payment system. An AMA sponsored series on ReachMD, “<a href="" rel="nofollow" target="_blank">Inside Medicare’s New Payment System</a>,” offers many audio resources to help you learn about the coming changes, including:</p> <ul> <li> <a href="" rel="nofollow" target="_blank">Implementing MACRA: The AMA’s Keys to Advancing Opportunities, Avoiding Pitfalls</a></li> <li> <a href="" rel="nofollow" target="_blank">APMs in Cancer Care: The Patient-Centered Oncology Payment Model</a></li> <li> <a href="" rel="nofollow" target="_blank">The Future of Medicare Payment Reform: Perspectives on MACRA with CMS's Andy Slavitt</a></li> <li> <a href="" rel="nofollow" target="_blank">The Rise of Specialist-Driven Alternative Payment Models in American Medicine</a></li> <li> <a href="" rel="nofollow" target="_blank">Thoughts on Physician Advocacy and Payment Reform with AMA President Andrew W. Gurman, MD</a></li> </ul> <p> <strong>More on the new Medicare payment system:</strong></p> <ul> <li> <a href="" target="_self">MACRA penalties can now be avoided, CMS says</a></li> <li> <a href="" target="_self">A primary care model for the new Medicare payment system</a></li> <li> <a href="" target="_self">Changes to shore up small practices under MACRA</a></li> <li> <a href="" target="_self">How Medicare regulatory penalties will change</a></li> <li> <a href="" target="_self">3 useful changes to Meaningful Use</a></li> <li> <a href="" target="_self">Physicians are guiding the new payment system, CMS chief says</a></li> </ul> <p> The AMA is also planning two educational sessions, available both in-person and online, to help physicians prepare for MACRA implementation. The first will be held Thursday, Dec. 1 in Atlanta, and the second will be held Saturday, Dec. 10 in San Francisco. More information will soon be available.  </p> <p> Watch <em>AMA Wire®</em> for more on what’s happening around the MACRA final rule and other resources that can help you navigate the new Medicare payment system.</p> <p align="right"> <em>By AMA staff writer <a href="" rel="nofollow" target="_blank">Troy Parks</a></em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:676b2260-dd6b-4298-ade3-a69f6bc0e7f2 Finding tech passion in an unlikely place Tue, 04 Oct 2016 23:00:00 GMT <p> With many gains in health information technology over the past decade, newly appointed National Coordinator for Health IT Vindell Washington, MD, took time at Health 2.0 last week to describe his first experience with health technology, what it means for the health care community and new tools for physicians and entrepreneurs.</p> <p> Dr. Washington found his passion for health care technology as a captain in the U.S. Army. He was stationed in Haiti leading the emergency department in the 28<sup>th</sup> combat support hospital when a patient presented with “a fever, a rash, a really unusual constellation of symptoms,” he said.<a href="" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> Unable to diagnose the patient, Dr. Washington and his colleagues took the advice of a Colonel who suggested using the new equipment that may be helpful.</p> <p> “We literally drove the Humvee to the side of the emergency department and set up our first satellite telemedicine hookup,” Dr. Washington said. “In about 20 minutes we had consult from the Walter Reed Army Medical Center helping us with the case … a dermatologist and an infectious disease doctor [helped us] make our first diagnosis of porphyria [a rare skin or nervous system disorder].”</p> <p> “We were able to help that soldier and get him evacuated out of theater,” he said. “At the time I thought to myself, the way I practice medicine moving forward won’t ever be the same. Once you have had access to technology that allows you to significantly improve patient outcomes … you never want to go back. And why should you?”</p> <p> Many physicians and health systems are developing innovative ways to bring telemedicine into practice. For example, the University of Virginia (UVA) Health System’s research efforts <a href="" target="_self">brought telemedicine to their ambulances </a>to improve care for patients who are experiencing a stroke through its telestroke model. </p> <p> UVA services a large, rural area, which means more time is needed to get patients to the hospital. During a stroke, every minute matters and their telestroke model is shortening that critical period of time.</p> <p> Physicians who treat patients via telemedicine in multiple states, must have a medical license from each state. That process will be easier now that the Interstate Medical Licensure Compact is in effect. The compact will facilitate a speedier process with fewer administrative burdens for physicians seeking licensure in multiple states. </p> <p> One health insurer earlier this year explained <a href="" target="_self">why it is embracing telemedicine</a>, but only on one condition—that it provides value in practice for physicians.</p> <p> Delegates at the AMA Annual Meeting in June <a href="" target="_self">adopted new policy</a> that outlines ethical ground rules for physicians using these technologies to treat patients. The AMA in 2014 released model state legislation (log in) that provides guidance on licensure, payment and practice issues, and states are using this model to move telemedicine forward.</p> <p> <strong>Physicians taking interoperability into their own hands</strong></p> <p> “Over the past decade, we made historic gains when it comes to the adoption and use of electronic health records (EHR),” Dr. Washington said. “It’s not just hospitals and doctors who are benefitting from this progress, it’s individuals and communities all across America.”</p> <p> The vision that was established years ago for health care was a paperless, interoperable system in which physicians could share information to improve patient care. But physicians are working toward that so far unfulfilled promise of interoperability. In Kansas, the state medical society and KaMMCO Health Solutions realized that physicians were not involved in the development of the solutions being offered and created their own system that now <a href="" target="_self">connects 94 hospitals across the state</a>.</p> <p> And at Vanderbilt University, one team of physicians has figured out <a href="" target="_self">several innovative ways to use EHR data in practice at the point of care</a>.</p> <p> <strong>But challenges remain </strong></p> <p> “We saw survey data released by the team here at Health 2.0 suggesting that it can be difficult particularly for small tech innovators to access health data from some of the larger EHR vendors,” Dr. Washington said.</p> <p> Data from a recent AMA <a href="" target="_self">digital health survey</a> corroborates these concerns from the physician side.  While physicians overwhelmingly see potential for digital health to favorably impact patient care—85 percent of those surveyed said that digital health solutions are advantageous—data privacy and workflow integration with EHR systems is still a major concern.</p> <p> “That’s why we’ve <a href="" target="_self">launched challenges and funding announcements</a> intended to unlock electronic data for innovators … so that [patients] can aggregate their data in one place, so that physicians will have a more user-friendly experience, and so that new products and standards can improve the flow of information for care teams.”</p> <p> Dr. Washington discussed two additional tools developed by the ONC to help physicians maximize their EHRs:</p> <ul> <li> The new EHR contract guide, “<a href="" rel="nofollow" target="_blank">EHR Contracts Untangled: Selecting Wisely, Negotiating Terms, and Understanding the Fine Print</a>,” explains important concepts in EHR contracts and includes example contract language to help physicians and health administrators in planning to acquire an EHR system and negotiating contract terms with vendors.</li> </ul> <ul> <li> The <a href="" rel="nofollow" target="_blank">Health IT Playbook </a>is a web-based tool intended to make it easy for physicians and their practice administrators to find practical information and guidance on specific topics as they research, buy, use or switch EHRs. The Playbook features a collection of specific tools, resources and guides that can help physicians implement and use health information technology that best serves their practices—including supporting transitions toward alternative payment models.</li> </ul> <p> <strong>For more on the future of health IT:</strong></p> <ul> <li> <a href="" target="_self">Patient-first technology: Improving care for the chronically ill</a></li> <li> <a href="" target="_self">New survey shows physician optimism and requirements for digital health</a></li> <li> <a href="" target="_self">AMA CEO James L. Madara, MD, talks with Health 2.0 about digital tools</a></li> <li> <a href="" target="_self">Court case examines telemedicine safety regulations</a></li> </ul> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:2069c80e-c471-4b11-8aab-25a64a9ec16f Accreditor lays out plan for resident well-being Tue, 04 Oct 2016 23:00:00 GMT <p> Dr. Brigham started with Lewin’s equation: <em>B</em> = <em>f</em>(<em>P</em>, <em>E</em>). It states that behavior is a function of a person and his or her environment. He then pointed to its implications for physicians and physician well-being. “Think about what we expose our residents to: death and dying, other people’s secrets, other people’s sickness, depression and anxiety. But it’s not all depressing.”</p> <p> Timothy Brigham, MDiv, PhD, chief of staff and senior vice president in the Department of Education at the Accreditation Council for Graduate Medical Education (ACGME), was speaking to representatives from the 32 member schools of the AMA’s <a href="" target="_self">Accelerating Change in Medical Education</a> Consortium at the 2016 consortium meeting in Chicago. His keynote, which focused on physician well-being, referenced what many know but are reluctant to mention.</p> <p> <strong>What separates physicians<a href="" target="_blank"><img src="" style="float:right;margin:15px;" /></a></strong></p> <p> “There’s a set of personality characteristics that differentiate physicians, residents and medical students,” Dr. Brigham said. “One is, in a non-psychiatric way, you tend to be more obsessive-compulsive. It’s about order, control and focus, which helps most people get through those first two years. If you don’t have those qualities, you develop those qualities.”</p> <p> More to the point, physicians tend to get things done where other people give up, he explained.</p> <p> “One of the major problems with us in terms of duty hours is not program directors’ saying, ‘You have to work more hours,’” he said. “It’s young training physicians who desperately want to take care of that patient, who desperately want to learn a little bit more, and they say, ‘I’m going to stay longer to do that.’”</p> <p> Another personality trait of physicians, he said, is pleasure deferment.</p> <p> “You like ice cream and don’t like broccoli? You eat the broccoli before the ice cream,” Dr. Brigham said. “What physicians have tended to do is take that to a pathological degree. You’re always deferring pleasure.”</p> <p> Still, many physicians and physicians-in-training, he continued, are reluctant to give themselves credit for their abilities and accolades.</p> <p> “In this room is representative of the top two percent of people in terms of accomplishment, intelligence and talents,” he said. “But the level of self-doubt that permeates any physician gathering exceeds that of most other people. In other words, there’s a good deal of people who are sitting in this room today who are just waiting to be discovered to be the fraud that they think they are.”</p> <p> <strong>Accepting responsibility for environmental effects</strong></p> <p> The point of Dr. Brigham’s prelude was to demonstrate that the personality traits that make physicians and residents effective also make them particularly vulnerable to the often overly demanding environment of medical training and practice.</p> <p> “Those environmental characteristics and personality characteristics can result in what Gary Small in 1981 described as the house officer stress syndrome,” he said,” which includes episodic cognitive impairment, [such as] not knowing how you got home, or being in the middle of a conversation and hearing, ‘Blah blah blah blah blah,’ even though a few seconds before you were interested.”</p> <p> It can also involve chronic anger, cynicism and family discord. Those severely affected by it may also suffer from major depression, suicidal ideation and substance abuse.</p> <p> “You can see this is not a new problem. This was described in 1981. So why are we focusing on this now?” he asked.</p> <p> There’s a deepening awareness of what’s happening, Dr. Brigham explained. Citing research, he noted that medical students as a group are psychologically healthier at orientation than their peer comparison group.</p> <p> “And then what happens? Depression goes up. Burnout goes up. Stress goes up. Empathy goes down. Compassion goes down,” he said. “We get them, and then we do something bad to them. The emphasis should be on what we’re doing.”</p> <p> Along with that deepening awareness, however, the problem has become more acute.</p> <p> “Fifty-four percent of practicing physicians evidence symptoms of burnout,” Dr. Brigham said. “If fifty-four percent of physicians were getting something like cardiovascular disease because of being physicians, we’d be on that like lint on a blue suit.”</p> <p> Part of the challenge, he explained, is that interest in the issue of physician well-being has always been cyclical.</p> <p> “What we’re committed to is to not have that happen again,” he said.</p> <p> <strong>A new plan for promoting well-being</strong></p> <p> The ACGME last year convened a symposium to address issues related to physician well-being, including building resilience, fostering and nurturing well-being, recognition and intervention, reducing stigma and helping grieving communities heal.</p> <p> The overall purpose of the symposium, Dr. Brigham explained, was to advise the ACGME Board of Directors on how it could effect change to improve well-being for residents, faculty and practicing physicians. Out of it grew an <a href="" rel="nofollow" target="_blank">action plan and recommendations</a> for six areas of impact on which the ACGME needs to focus:</p> <ul> <li> Building awareness among physicians, scholars and the press</li> <li> Working to maximize levers for change, including the Clinical Learning Environment Review and Common Program Requirements</li> <li> Ongoing dissemination to support awareness building</li> <li> Continuum collaboration involving the Coalition for Physician Accountability, the National Academy of Medicine and annual symposia</li> <li> Research from continuing ACGME’s own research to stimulating research within the field</li> <li> Large-scale culture change that includes CEOs and payers</li> </ul> <p> As part of its <a href="" rel="nofollow" target="_blank">physician well-being initiative</a>, the ACGME will be convening a follow-up symposium this fall.</p> <p> “There’s a story in the Talmud,” Dr. Brigham said in conclusion, “where in the temple they had a series of courtyards, and as you got closer to the center, it got more sacred. In the very center of the temple was the house of God. And nobody was allowed in there, except once a year. The high priest at Yom Kippur went in with one task: He had to say the name of God.</p> <p> “Nobody knows what he said, and they surmised that either he just breathed or he wept. But they wondered what would happen if something happened to the high priest in the center of the temple. Nobody could go in and get him. So they tied a rope onto his ankle so if something happened, they could pull him out.</p> <p> “We put our physicians into temples of awe, where people are either taking their first breath or taking their last breath. What we need to indicate is that we’re connected to them in ways that say, ‘We’re there for you, and if something happens, we’ll pull you out. We’ll be with you. We’ll nurture you. We won’t leave you on your own.’”</p> <p> <strong>Learn more about physician wellness:</strong></p> <ul> <li> <a href="" target="_self">New tool for recognizing physician distress, preventing suicide</a></li> <li> <a href="" target="_self">Physicians and veterinarians join forces for wellness</a></li> <li> <a href="" target="_self">Physician wellness: A global collaboration</a></li> <li> <a href="" target="_self">Physicians take to “reset room” to battle burnout</a></li> </ul> <p align="right"> <em>By AMA staff writer Tim Smith</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:054fb410-f4b9-481e-b748-1cace8140523 Reports show 2017 Medicare payment adjustments Mon, 03 Oct 2016 21:35:00 GMT <p> Two new reports are now available with information on 2015 cost and quality data that indicate which physicians or practices will see related Medicare payment adjustments in 2017.</p> <p> The 2015 Physician Quality Reporting System (PQRS) Feedback Reports and 2015 Annual Quality and Resource Use Reports (QRUR) were released on Sept. 26. The Centers for Medicare & Medicaid Services (CMS) began mailing 2015 PQRS penalty letters to physicians on that date as well.</p> <p> <strong>What’s in the reports</strong></p> <p> A penalty letter is your notification that you are scheduled to receive a two percent penalty in 2017 based on 2015 PQRS reporting. Letters are only issued to those who will receive negative payment adjustments, but if you do not receive a letter it is still a good idea to check your reports for any discrepancies. The PQRS feedback report allows you to look up whether you will receive a two percent 2017 PQRS penalty, and also contains detailed information on program year 2015 PQRS reporting results</p> <p> The 2015 Annual QRURs provide information on your practice performed on quality and cost measures used in the Value Modifier (VM) and whether your VM payment adjustment will be positive, negative or neutral and also details the specific amount.</p> <p> VM penalties can range from -1 to -4 depending on practice size and performance. Bonus payments depend on how much money is collected from penalties and to date the 2017 bonus size has not been publically announced. Drill-down tables in the reports contain detailed information on care delivered to individual patients by other providers as well as the physicians in the practice.</p> <p> The payment adjustments detailed in these reports are associated with current performance-based Medicare payment incentives that will be replaced in 2019 with a new system created under the Medicare Access and CHIP Reauthorization Act (MACRA). If you believe there are errors in the report or calculation of the payment adjustment, you should file for an informal review prior to midnight Eastern Time on Nov. 30.</p> <p> <strong>Accessing the reports</strong></p> <p> An Enterprise Identity Management (EIDM) account with the appropriate role is required to obtain 2015 PQRS feedback reports and 2015 Annual QRURs.</p> <p> If you already have an EIDM account, <a href="" rel="nofollow" target="_blank">visit the CMS website</a> to sign up for the appropriate EIDM role or contact QualityNet Help Desk to determine if someone in your practice already has that role. To sign up for an EIDM account, visit the <a href="" rel="nofollow" target="_blank">CMS Enterprise Portal</a> and click “New User Registration” under “Login to CMS Secure Portal.” You can access both reports on the portal using the same EIDM account.</p> <p> For more information on viewing the reports, view the <a href="" rel="nofollow" target="_blank">PQRS Analysis and Payment Web page</a> and <a href="" rel="nofollow" target="_blank">How to Obtain a QRUR Web page</a> .</p> <p> <strong>Here is how you can request an informal review:</strong></p> <ul> <li> For 2017 PQRS negative payment adjustment informal review, view the “2015 Physician Quality Reporting System (PQRS): 2017 Negative Payment Adjustment - Informal Review Made Simple” guide on the <a href="" rel="nofollow" target="_blank">PQRS Analysis and Payment Web page</a>.</li> </ul> <ul> <li> For informal review on 2015 QRURs or the 2017 Value Modifier calculation, see the <a href="" rel="nofollow" target="_blank">2015 QRUR and 2017 Value Modifier Web page</a>.</li> </ul> <p> The CMS Helpdesk is available to help you through these processes. For assistance regarding EIDM or the content or data contained in your PQRS Feedback Reports, contact the QualityNet Help Desk at (866) 288-8912 [TTY (877) 715- 6222)] from 7 a.m. to 7 p.m. Central Time, Monday through Friday, or via <a href="" rel="nofollow">email</a>.</p> <p> For additional assistance regarding the QRUR or the Value Modifier, or if you are having trouble accessing the PQRS Feedback Reports, <a href="" rel="nofollow">email</a> the Physician Value Help Desk or call (888) 734-6433 (select option 3).</p> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:a1ec0df8-597e-456b-9ee5-753467904f29 Health care and population health: A team sport Sun, 02 Oct 2016 23:00:00 GMT <p> The faculty at Dell Medical School at the University of Texas at Austin are enjoying a unique opportunity. Dell is the first new medical school at a tier-one university in the U.S. in 60 years, having welcomed its inaugural class in 2016. Its instructors don’t just have the chance to build a new medical school. They can build a medical school of the future.</p> <p> “As you might guess, population health is right at the center of all of that,” said William Tierney, MD, professor and chair of Dell’s Department of Population Health, during a panel presentation focused on curricular innovations at the recent <a href="" target="_self">International Conference on Physician Health™</a> in Boston, moderated by Richard Hawkins, MD, AMA vice president of medical education outcomes. “There really aren’t a lot of models. There are only eight other departments of population health at academic medical centers in this country.”</p> <p> But there are even more important reasons to come up with a new model.</p> <p> “It has really broken my heart to see the joy leeching out of medicine,” Dr. Tierney said. “There are financial pressures, clinical pressures, information pressures, technology pressures and growing demographic pressures as my generation gets older and we have increased health inequities.</p> <p> “The focus isn’t on health care. We focus on illness care. When you think about what we do day to day, we focus on diagnosing and treating chronic diseases. There’s some risk-factor reduction … but the focus is on clinical medicine. And what’s wrong with that?”</p> <p> Citing a study from the University of Wisconsin, Dr. Tierney noted that, in the U.S., health care delivery only affects about 20 percent of life expectancy and quality of life. Social and economic factors—including education, employment, income, family, social support, community and safety—affect 40 percent. And behaviors—such as smoking, diet, exercise, alcohol and sexual activity—affect another 30 percent.</p> <p> “Yet where has all our money gone?” he asked.</p> <p> <strong>The curriculum: Different from day one</strong></p> <p> Dell is one of 32 member schools in the AMA’s <a href="" target="_blank">Accelerating Change in Medical Education Consortium</a>. Its vision is to incorporate value-based care, team-based care and interprofessional education into the curriculum, and to focus on the triple aim, physician leadership, community engagement and social and behavioral determinants of health, from day one.</p> <p> “We’re trying to get upstream from the things we see every day in our practices, focusing on health promotion and disease prevention,” Dr. Tierney said. “I want us to see a new patient presenting with type 2 diabetes mellitus as an abject failure. Because it’s a preventable disease.”</p> <ul> <li> <strong>Year 1: Essentials.</strong> The curriculum focuses on integrating scientific principles into clinical presentations and health system contexts. It holds that team-oriented care delivery is the future of health care. Students learn in small-group, team-based environments. Large-group learning is interactive and pushes students to apply knowledge in new frameworks. Courses include Interprofessional Education and Leadership.<br /> <br /> It limits structured classroom time to less than  10 hours a week and routine feedback helps students gauge their depth of understanding of the scientific content. A pass/fail grading system encourages collaboration and learning together in the integrated curriculum.</li> </ul> <ul> <li> <strong>Year 2: Delivery.</strong> Clerkships permit students to apply the scientific principles learned during Year 1 to daily care delivery activities in the clinical setting. Students are expected to consider the scientific underpinning of clinical decision-making during the clinical activity of the clerkships, reinforcing the integration of basic science and clinical medicine begun in Year 1. Courses include Primary Care, Family and Community Medicine, Developing Outstanding Clinical Skills, Interprofessional Education and Leadership.<br /> <br /> It is composed of five block clerkships and a Primary Care, Family and Community Medicine Longitudinal clerkship, where students will have the opportunity to experience long-term relationships with a group of patients. Students see how the health care team can help a patient maintain health and manage chronic and acute disease in outpatient primary care settings.</li> </ul> <ul> <li> <strong>Year 3: Growth.</strong> A nine-month Innovation, Leadership and Discovery block gives students the opportunity to individualize experiences toward long-term goals. Students can choose to undertake an independent discovery project in one of three areas of distinction—Healthcare Innovation and Design, Population Health or Clinical/Translational Research—or to pursue one of several dual-degree programs. Students’ work contributes to the school’s pursuit of making Austin a model healthy city. Courses include Innovation, Leadership and Discovery, Primary Care, Family and Community Medicine, Developing Outstanding Clinical Skills, Interprofessional Education and Leadership.</li> </ul> <ul> <li> <strong>Year 4: Exploration.</strong> Students have the opportunity to explore personal career interests and select electives to further examine residency disciplines and pursue higher-level clinical rotations such as critical care, emergency medicine and an acting internship. Substantial time is set aside for residency interviews. A capstone experience takes place in the spring to facilitate the transition between medical school and internship. Courses include Developing Outstanding Clinical Skills, Interprofessional Education and Leadership.</li> </ul> <p> Dr. Tierney noted that one of the themes of the curriculum is how population health impacts patients and communities over time.</p> <p> “We should care about the upstream things that affect our patients,” he said. “We should care about the people who aren’t our patients and hopefully prevent them from becoming our patients.</p> <p> “In conclusion, the past is prologue. We can do better. We can put joy back in medicine. Our first class of medical students, they’re the most excited people. They’re not burned out. So let’s not burn them out.”</p> <p align="right"> <em>By AMA staff writer Tim Smith</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:56eac0a1-2ac8-42c2-9b41-18a3ad34e847 Patient-first technology: Improving care for the chronically ill Sun, 02 Oct 2016 20:33:00 GMT <p> Prevention is one of the most important aspects of health care, but what about those patients who already have serious chronic illnesses that do not have a cure? Harvey Fineberg, MD, president of the <a href="" rel="nofollow">Gordon and Betty Moore Foundation</a>, spoke last week at Health 2.0 in Silicon Valley reminding entrepreneurs that we need to develop solutions for patients with chronic illnesses to live happier, more comfortable lives.  </p> <p> Since his time as President of the Institute of Medicine from 2002 to 2014, Dr. Fineberg said he’s been working toward understanding where and how a patient-centered health system is possible and where the current system is falling short.</p> <p> “Our objective is to improve the experience and outcomes of patient care,” Dr. Fineberg said. His work is centered around a group of patients that often is too diffusely scattered, patients who don’t fall into a single disease category and are not “well caught in our health care system.”<a href="" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> “This is a group of patients who have serious illness,” he said. “[They] have one or more long-lasting conditions that is not curable and that changes in an important way your function and your ability to live your life the way you would like.”</p> <p> Though the importance of technology is obvious, Dr. Fineberg said, there is one fundamental driver that is so basic it is often overlooked—demographic and epidemiologic trends.</p> <p> “Two thirds of those today who are age 65 or older have two or more chronic diagnoses, that doesn’t mean they’re all seriously ill, but they are in jeopardy of becoming seriously ill,” Dr. Fineberg said. “In fact, serious illness by this definition can affect anyone at any age, but it is especially problematic and especially a challenge for those as we get older. </p> <p> <strong>The care that you want vs. the care that you get</strong></p> <p> When patients have a serious illness there is often a major difference between the care that they want and the care that they get, Dr. Fineberg said. “In fact, what most people want is a better quality of life.”</p> <p> “71 percent say [quality of life] is more important to them than the chance of improvement through interventions,” he said. “Only 30 percent of care that people actually receive aligns with their actual preferences.”</p> <p> Most people, when they have chronic late-stage illness, especially approaching their death, want to be at home, he said. “They want to be surrounded by loved ones. I certainly would. I don’t want to be isolated with a bunch of tubes sticking out of every orifice. I don’t want to be separated from the people who mean my life to me; I want to experience their love and their comfort up until the end. Well, only one-third of deaths occur at home.”</p> <p> “We can do better,” he said. “What will it take? Well, it will take a lot. We are trying to approach that from the vantage point of a foundation by taking a system’s approach.”</p> <p> Dr. Fineberg said we need to look at the problem with five key components:</p> <ul> <li> “<strong>Educating the public</strong> so that every individual knows what their entitlement is for the control of their own care and their own life destiny.</li> </ul> <ul> <li> “<strong>Looking at the payment system</strong>, because if the payment system is going to pay up to, let’s say, $100,000 for a pill you need to extend your life … but will not pay for hot meals delivered to your home, we have a problem.</li> </ul> <ul> <li> “<strong>Better development of the workforce</strong>; we need clinicians, doctors, and nurses who understand that the goals of the patient are what we begin and end with. We need to be able to prepare those at home and family members who are caring for those who are seriously ill. We have to design the kinds of teams and support structures that will enable them to work effectively and meet their loved one’s needs to make their serious illness less burdensome and make their final days more sympathetic.</li> </ul> <ul> <li> “<strong>Design model programs in communities</strong>, because institution-based systems will not solve this problem. We need to have community-based care systems that will organize to meet the needs of the seriously ill. In fact, there are many models in development. In our preliminary survey, we found more than six dozen well-designed community-based models on which we can bet.</li> </ul> <ul> <li> “<strong>A monitoring system</strong> to track the workforce and make sure the public is fully educated and prepared to do their part as well.”</li> </ul> <p> Dr. Fineberg told the technology community exactly what they can do to improve care for this vulnerable population.</p> <p> First, develop platforms specifically for seniors with unmet needs—platforms that accommodate the range of those needs, regardless of a patient’s illness, health status and living situation.</p> <p> Second, design systems that adapt as patient needs progress and that connect clinicians with patients and their families.</p> <p> Third, acknowledge that a population of seriously ill patients cannot be served by applications that are only about staying well. Help them connect seamlessly to their caregivers through remote and other technologies.</p> <p> “I believe that if we focus on the patient and focus on putting more life into years as well as more years into lives, we can meet the needs of these millions of patients,” Dr. Fineberg said, “and we can do it in a way that is less costly … and we can do it in a way that demonstrates the power of technology with systems design to solve people’s problems.”</p> <p align="right"> <em>By AMA staff writer <a href="" rel="nofollow">Troy Parks</a></em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:8f831089-5140-418f-8b26-6841554c97f4 Get the new Code of Medical Ethics commemorative edition Fri, 30 Sep 2016 20:00:00 GMT <p> The AMA’s <em>Code of Medical Ethics</em> is regularly cited as the medical profession's authoritative voice in legal opinions and in scholarly journals. The updated <em>Code </em>is the culmination of an eight-year project to modernize ethical guidance for relevance, clarity and consistency, and it represents the first comprehensive review of the <em>Code</em> in more than half a century. To mark this important chapter in the history of the <em>Code,</em> the AMA is offering a special commemorative edition.</p> <p> This collectible features:</p> <ul> <li> A black, bonded leather cover with silver embossing</li> <li> Full-color end sheets</li> <li> Decorative black-and-white headband</li> <li> Archival, acid-free paper</li> </ul> <p> The revised <em>Code</em> is simpler to navigate and related opinions are easier to find so physicians can more readily apply it to their daily practice. It also features a new preface designed to clarify the different levels of ethical obligation in the various ethical opinions.</p> <p> The <em>Code </em>was adopted at the first AMA meeting in 1847. Much in medicine has changed since then, but this founding document—the first uniform code of ethics of its kind—is still the basis of an explicit social contract between physicians and their patients. It has a place in every medical library and practice office, and the commemorative edition makes a fitting gift for a graduating medical student.</p> <p> Visit the <a href="" target="_self">AMA Store</a> for more information or to order online. AMA members receive a 20 percent discount on this product and others from the AMA Store. If you’re not a member, <a href="" target="_self">join today</a>.</p> <p>  </p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:746fabd2-6395-4c86-a807-e2c659035d28 Get the new ICD-10 chronic disease coding cards Fri, 30 Sep 2016 14:00:00 GMT <p> The ICD-10 code set update for 2017 is now in effect and five new chronic disease coding cards from the AMA Store can help your practice navigate the changes.</p> <p> Created for the 2017 edition of the ICD-10 code set, the new <a href="" target="_blank">ICD-10-CM 2017 Chronic Disease Coding Cards: Multiple Specialties</a> provide a unique methodology for selecting the correct diagnosis code for commonly reported chronic diseases. They are available for a number of conditions, including diabetes, hypertension, asthma, arthritis, dysrhythmia, substance abuse and more.</p> <p> With these new coding cards, you can build a code in a compliant and efficient manner by navigating through a series of color-coded choices. Once you arrive at a green box, your code is complete.</p> <p> Some of the key features of the chronic disease coding cards include:</p> <ul> <li> Methodology that ensures specificity and helps avoid incomplete codes and rejected claims</li> <li> Common risk-adjusted diagnoses, which includes codes commonly used incorrectly</li> <li> Unique visual design that clarifies the documentation requirements for coding specific diagnoses</li> </ul> <p> Visit the <a href="" target="_blank">AMA Store</a> to select the correct version for your coding purposes. AMA members receive a 20 percent discount on this product and others from the AMA Store. If you’re not a member, <a href="" target="_blank">join today</a>.</p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:db07e475-c729-4256-81cf-3fed8f16bbeb Test your USMLE Step 2 readiness with this most-missed question Thu, 29 Sep 2016 20:00:00 GMT <p> The United States Medical Licensing Examination® (USMLE®) Step 2 is a major measure of any medical student’s clinical knowledge, so <em>AMA Wire</em>® is providing frequent expert insights to help you prepare for it. Take a few minutes here to work through another of the most-missed USMLE Step 2 test prep questions and view an expert video explanation of the answer from Kaplan Medical.</p> <p> Once you’ve got this question under your belt, be sure to test your knowledge with <a href="" target="_self">other posts in this series</a>.</p> <p> Ready. Set. Go.</p> <p> <strong>This month’s question that stumped most students:</strong></p> <p> A 54-year-old woman comes to the physician for a routine health maintenance examination. She has had no weight loss, fever, cough, decreased appetite, chest pain, lower extremity swelling or blood in the stool or urine. She has a history of osteoarthritis in her right knee treated with ibuprofen. Her temperature is 36.5º C (97.7º F), blood pressure is 128/72 mm Hg and pulse is 75/min. Neck examination shows a solitary nodule in the thyroid gland that is readily palpable. The remainder of the examination shows no abnormalities. Laboratory studies show TSH 0.4 µU/mL and free thyroxine (FT<sub>4</sub>) 10 ng/L. Ultrasound of the thyroid shows a 1.5-cm hyperechoic nodule in the right lower lobe.</p> <p> Which of the following is the most appropriate next step in management?</p> <p style="margin-left:.5in;"> A. Fine-needle aspiration (FNA)</p> <p style="margin-left:.5in;"> B. No further management is necessary</p> <p style="margin-left:.5in;"> C. Radioactive iodine uptake (RAIU)</p> <p style="margin-left:.5in;"> D. Surgical resection</p> <p style="margin-left:.5in;"> E. Thyroid replacement therapy</p> <p style="margin-left:.5in;"> F. Treatment of subclinical hyperthyroidism</p> <p>  </p> <p> <object data="" height="350" id="ltVideoYouTube" src="" type="application/x-shockwave-flash" width="450"><param name="movie" value="" /><param name="quality" value="best" /><param name="bgcolor" value="#ffffff" /><param name="wmode" value="transparent" /><param name="allowFullScreen" value="true" /><param name="allowScriptAccess" value="always" /><param name="flashvars" value="playerMode=embedded" /></object></p> <p>  </p> <p> <strong>The correct answer is C.</strong></p> <p> <strong>Kaplan says, here’s why:</strong></p> <p> The patient has a solitary thyroid nodule. Measuring TSH level is the next step in management. If serum TSH concentration is low, indicating hyperthyroidism, the nodule is most likely hot, and thyroid scintigraphy (RAIU scan) is the next step in diagnosis. Scintigraphy determines whether the nodule is "hot" or "cold" (i.e., whether it takes up iodine or not, respectively). A hot nodule is unlikely to be malignant, and if it is not causing hyperthyroidism it can be left alone. A cold nodule is more concerning for malignancy and surgical resection is recommended. It is important to note, however, that most cold nodules are benign. If serum TSH concentration is high or normal, there is a four- to six-percent possibility that the nodule is neoplastic, and then FNA is the next step. FNA results guide further management.</p> <p> <strong>Why you shouldn’t choose the other answers:</strong><br /> <em>Read these explanations to understand the important rationale for each answer.</em></p> <p> <strong>Choice A:</strong> FNA is indicated in patients with ultrasound findings that suggest malignancy, such as hypoechoic nodules or RAIU scan which shows nonfunctioning or indeterminate nodules.</p> <p> <strong>Choice D:</strong> Surgical resection is premature without assessing the functionality or pathology of the nodule. Surgery is indicated for nodules that have features of malignancy or are malignant.</p> <p> <strong>Choice E:</strong> Thyroid replacement therapy is appropriate with hypothyroidism.</p> <p> <strong>Choice F:</strong> A subclinical hyperthyroidism diagnosis is based on the combination of low serum TSH (<0.5 µU/mL) and normal serum T<sub>4</sub> and T<sub>3</sub> in an asymptomatic patient. Replacement therapy is not indicated in these cases.</p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:ae5f72b7-551d-416b-8a6f-82a951f9a8ff New tool for recognizing physician distress, preventing suicide Thu, 29 Sep 2016 03:00:00 GMT <p>  </p> <p> Physicians die by their own hands at much higher rates than do members of the general public—40 percent higher in males and 130 percent higher in females—so recognizing and responding to physician distress is crucial. Physicians themselves are uniquely positioned to do this for their colleagues, but many are uncomfortable intervening and unsure what steps to take if they do get involved. A new resource offers guidance in successfully identifying distressed colleagues and helping them get the care they need.</p> <p> Risk factors for physicians may be similar to those for the general public, but many physicians feel their identities are closely tied to their professional images, and this makes them more vulnerable to distress when problems arise at work.</p> <p> Almost every state in the nation has a physician health program (PHP), and the <a href="" rel="nofollow" target="_blank">Federation of State Physician Health Programs maintains a listing</a> of state PHPs with a description of the services provided by each. State PHPs may even be able to assist physicians in identifying others with experience and expertise in treating distressed physicians.</p> <p> Still, physicians are often reluctant to access care.</p> <p> <a href="" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> <strong>Care for your colleagues, care for yourself</strong></p> <p> If you believe a physician colleague is displaying signs of distress, how should you approach her or him? How can you teach your care team to recognize physicians in distress or at risk for suicide? What actions can you take to support them?</p> <p> <a href="" rel="nofollow" target="_self">Preventing Physician Distress and Suicide</a>, a new module from the AMA’s STEPS Forward™ collection of practice improvement strategies, focuses on the unique vulnerability and treatment needs of physicians.</p> <p> It includes four steps to identifying at-risk physicians and referring them to appropriate care:</p> <p> <strong>1. </strong><strong>Talk about the risk factors and warning signs for suicide.</strong> Risk factors can range from relationship problems to being named a defendant in a lawsuit. Warning signs can be as obvious as mood changes and increased alcohol use.</p> <p> <strong>2. </strong><strong>Take steps to standardize care-seeking in your organization.</strong> One easy step is encouraging colleagues to take time off for vacation and sick leave.</p> <p> <strong>3. </strong><strong>Make it easy to find help.</strong> For starters, be sure to post referral lists for resources inside and outside your organization in a highly visible location that does not require a password, and assure users that there is no tracing of page visits or downloads.</p> <p> <strong>4. </strong><strong>Consider creating a support system for physicians in your organization. </strong>This can include simply reducing a physician's patient caseload and offering regular screenings for depression.</p> <p> The <a href="" rel="nofollow" target="_self">module</a> also features sample scenarios, scripting for approaching distressed physicians, a self-assessment for medical malpractice stress syndrome, a list of suicide prevention resources and other downloadable tools.</p> <p> And don’t forget: Self-care is one of the most visible ways to standardize care-seeking in your practice. Allow yourself time to recharge, talk about your own stress, say “no” when you need to and learn to recognize the signs of distress in yourself.</p> <p> There are seven new modules now available from the AMA’s STEPS Forward collection, bringing the total number of practice improvement strategies to 42, thanks to a grant from and collaboration with the Transforming Clinical Practices Initiative.</p> <p align="right"> <em>By AMA staff writer Tim Smith</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:ae6fd23c-d1fd-4a8e-9f94-dbbe5c8cf1d5 5 tips to start and grow a happy family during residency Thu, 29 Sep 2016 02:00:00 GMT <p> Residency often coincides with the time when many young physicians would like to start families, but undertaking these two life events simultaneously can be daunting. A third-year family medicine resident with three young children recently shared her tips for making it work with minimal stress.</p> <p> When Chelsea Slade, MD, and her husband began talking about having kids, she was in medical school and he was in law school, and they decided it would be best to hold off on starting a family until after her residency. But as his third year of law school progressed with no job offer, their plans shifted. He agreed to stay home so they could start a family right away.</p> <p> “We got pregnant and then a couple weeks later, he got a job offer,” Dr. Slade said. “But we were then able to work things out with my parents, so for about nine months we lived with them. They helped take care of the baby when I went back to school, and it all went really well.”<a href="" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> And when Dr. Slade started her residency, at McKay-Dee Family Medicine Residency at Intermountain Healthcare, in Ogden, Utah, her husband was able to work from home, so they decided to have another child, who was delivered at the end of Dr. Slade’s intern year. That too went well, and they soon decided to have their third, who arrived eight weeks ago, at the start of Dr. Slade’s third year of residency.</p> <p> “Each time, we thought it would work out if we had a kid sometime in the next 18 months, and then we got pregnant right away,” Dr. Slade said, “which was great, but at the same time it was kind of surprising.”</p> <p> Despite the surprises, they were able to continue building their family and their careers because they had considered what it would take from the start. Dr. Slade shared their game plan, as well as advice for taking the stress and guesswork out of starting a family and maintaining a happy marriage during residency:</p> <p> <strong>1. </strong><strong>Plan well. </strong>This includes communicating your plans.</p> <p> “We made sure we were using good contraception until we were ready to have a kid,” Dr. Slade said. “And we also planned how we would work it out logistically—really being conscious of when we were ready to start our family. That said, a lot of pregnancies don’t come when they are wanted, or take unexpected turns, so we were ready to be flexible too.<br /> <br /> “We communicated our wishes to my medical school advisors and, later, to my residency coordinator—keeping them updated when I did become pregnant or if there were other developments—just so we could work the logistics out as easily as possible.”</p> <p> <strong>2. </strong><strong>Make sure the important things are taken care of ahead of time.</strong> It will provide immediate peace of mind.</p> <p> “We made sure our health insurance, our finances, our rainy-day fund, my short-term disability and my FMLA paperwork were all in order,” she said. “So if we ran into a major complication in a pregnancy or otherwise, we wouldn’t be stressed about the financial side of things.”</p> <p> <strong>3. </strong><strong>Go on dates regularly.</strong> Couples need to make and keep time to themselves.</p> <p> “We still go out on real dates where we’re by ourselves several times a month,” she said. “That’s been really important, because it’s easy to fall into the rut of just child care and work and not really nurturing your own marriage.”</p> <p> <strong>4. </strong><strong>Take the initiative.</strong> Don’t worry about whose turn it is.</p> <p> “At home, it’s easy to pretend I don’t smell a poopy diaper and just wait for my husband to notice it and take care of it, but that leads to resentment towards one another and tensions,” Dr. Slade said. “So it’s better, when you notice something needs be done, to just do it. It leads to a happier home and a happier marriage.”</p> <p> <strong>5. </strong><strong>Keep things light and in perspective.</strong> You don’t need extra stress.</p> <p> “Sometimes one of our parents will come stay with us, and our parenting philosophies don’t always totally mesh,” she said. “So I have to step back and think, ‘Okay, if someone gives my daughter a couple extra cookies after dinner, is that going to affect her negatively ten years from now? No, probably not. That’s fine. I can let it go.’”</p> <p> Dr. Slade’s family’s plans extend well beyond her residency too.</p> <p> “I’m planning on taking a position as a hospitalist, which is a little unconventional for family medicine, and working part time,” Dr. Slade said. “My husband is going to expand his legal practice and work part time to full time. We’d like to have more kids. And we’d like to move up somewhere we can have a little more land and start a family farm. We really like it here.”</p> <p> <strong>Additional insights for physician families:</strong></p> <ul> <li> <a href="" target="_self">6 tips to nurture your family during training</a></li> <li> <a href="" target="_self"><u>4 building blocks for a successful medical marriage</u></a></li> <li> <a href="" target="_self"><u>How to balance a two-physician family</u></a></li> <li> <a href="" target="_self"><u>Physician-recommended steps to work- and home-life balance</u></a></li> <li> <a href="" target="_self"><u>5 financial planning tips every young physician should know</u></a></li> </ul> <p align="right"> <em>By AMA staff writer Tim Smith</em></p> <p>  </p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:b8ac2f31-7b90-4588-b627-ee3c380f79e9 Self-regulation key to the future of health care tech Tue, 27 Sep 2016 21:00:00 GMT <p> There are tools that work and there are tools that do not, but it’s important for the health care industry to decide what is required of these technologies for the future. And that means patients, physicians and developers working together. AMA Chief Executive Officer James L. Madara, MD, sat down with Matthew Holt of Health 2.0 at the annual conference yesterday to discuss the future of health care technology.</p> <p> On center-stage during the first day of the Health 2.0 conference in Santa Clara, Calif., Matthew Holt, co-chairman of Health 2.0, asked Dr. Madara about his past comments on digital health tools and what needs to be done so that they work in clinical practice to enhance patient care.</p> <p> <strong>Holt: </strong>The first thing that you said was that we have a bunch of remarkable tools already, which doctors are using … often there is at least dispute about the clinical efficacy of some of those tools.</p> <p> Is it fair to say that you’re saying that stuff is all well and good or do you have any doubts, issues or problems with those?<a href="" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> <strong>Dr. Madara:</strong> There are issues with all of these things, Matthew. The issue that I was trying to raise, by the way thank you for noticing, [is] that in the ‘do you love us, do you hate us’ … there is love in it. Let me give you an example of love and an example of hate. The love is that <a href="" target="_self">physicians want to engage digital health</a>, [our survey demonstrates that]. And the reason they want to engage digital health is for better outcomes for patients and better work flows. We have developed digital solutions—<a href="" rel="nofollow" target="_blank">STEPS Forward™</a> for physicians’ offices to engage patients, helping physicians plan so that when the patient comes in it will be a collaboration.</p> <p> We’re working with [Omada Health and Intermountain Health to fight prediabetes]. So we’re engaging digital broadly and we love that. What we love about it, take Omada as an example, there are many others, [Omada is] evidence-based, validated, it is actionable, it improves patient care, there are outcomes measures. Having said that let me tell you what we don’t like.</p> <p> Digital health is rapidly emerging. This conference is wonderful because it stretches the thinking as conferences should, but it also has a little sense of woebegone, everyone is above normal, there are no problems, but there are a few problems and I’d like to name some of them.</p> <p> Instant blood pressure … was one of the best-selling, highest downloaded apps from the app store in 2014-2015. In the digital health literature, your magazines, it was criticized as not being accurate. JAMA did a scientific study … that showed that if you took everyone with hypertension and you did readings with this app, 80 percent of the hypertensives would be called normotensive. Hypertension is the number one killer in the United States.</p> <p> What one has to recognize is that health care is not a normal market. You put a leaky faucet out there, the market is efficient, people stop buying it, no harm no foul except for a minor investment. In health care it’s different. If something doesn’t work there is potential patient harm.</p> <p> <strong>Holt: </strong>The usability of the average EMR tends to be that pretty much all the clients say they want to go back to the 1990s. When you say digital health … do you regard it as all the same?</p> <p> <strong>Dr. Madara:</strong> No one wants to go back to paper. In the late 80s when I was a faculty member at Harvard we were always thinking about this solution and it would be wonderful when x-rays wouldn’t be in someone’s trunk, you could read each other’s notes, it could all be organized with the push of a button.</p> <p> A recent [time-motion] study that we did with Dartmouth … showed that <a href="" target="_self">50 percent of a physician’s time now during the day is spent on data entry</a> and only a third on interacting with patients. And patients feel that, and also complain about that.</p> <p> That 50 percent, it does not give the meaning to the career that the other 30 percent does and it leads to burnout.</p> <p> <strong>Holt: </strong>I agree. No one’s debating that. The patient community sites … the patient self-education sites, a lot of things, which let’s be fair, back in the olden days the AMA was saying don’t trust the website, trust your doctor, but I have one issue or frustration with that. Most of those were founded because somebody had a problem, sought a technological solution, because the health care system and solutions weren’t giving them what they need.</p> <p> A lot of this patient-activated and consumer health movement, a lot of it’s a scam, you’ve got the guys selling digital snake oil, that’s still around, we’re not rid of that completely, but nonetheless you’ve got to realize there’s a real pain there and that a solution is needed.</p> <p> <strong>Dr. Madara:</strong> There are two points I’d like to make around that, Matthew. The first is you’re absolutely right, and not only patients but physicians haven’t been involved as deeply as they should be in solutions. I think if the patient community and the physician community would have been more involved in EHR rollout, we would have a different product.</p> <p> And that’s why we have <a href="" rel="nofollow" target="_blank">Health2047</a>, our work with <a href="" rel="nofollow" target="_blank">MATTER</a> and these kinds of things. I think perhaps the more important point of the entire conversation is why raise a siren now with this intentionally used term—snake oil? And the reason is that I think we’re in a period of criticality for [digital health]. And the criticality is that there’s no regulatory framework.</p> <p> Does anyone think that you’ll get to the future that was outlined here … without regulation? So you have two choices: You can self-regulate or let the government do it.</p> <p> We work really well with government regulatory agencies. These are friends of ours, but let me tell you, they tend to be heavy-handed, they overreach, they’re not nuanced, and it’s one-size-fits-all.</p> <p> If a community shows a responsibility to self-regulate, you can have a different story. We’ve done that in many areas [including the joint commission for hospital accreditation and a liaison committee for medical school certification, among many others].</p> <p> We convened some stakeholders around this topic [and developed principles which we would have liked to announce at this meeting] but it’s not quite developed yet. The initial idea would be to establish some principles that the field … and then move that forward step by step to get to some self-regulating body that an agency under Health and Human Services (HHS) will say, yes, I will deem that authority.</p> <p> Because what we have now, from the FDA point of view, are pretty loose criteria. An example of that is if you have a [digital health tool] and it’s to treat obesity, it probably goes to the FDA because it’s treating a disease. If you have a [tool] that’s for weight-loss, you’re home free.</p> <p> So I think the most important thing is how you move through this period of criticality to get a self-regulatory framework that feels good to the industry and allows it to flourish and not have the noise and lost opportunities.</p> <p> <strong>Holt: </strong>I think we all agree that that’s true; we need to figure out how to get to that place. We also have to work together… How are we going to get this done?</p> <p> <strong>Dr. Madara:</strong> Our preliminary group … included physicians, patient-oriented domains, everything.… Now we’re getting another broader group that will have to get together … to establish principles that will or will not be accepted by the community and agreed upon and then keep working that. Because ultimately, I’ve got to tell you, if these things are as important to health transformation as we think that they are, there is not only going to be regulation but there will be a certification of some kind. That can be nuanced, flexible, it can be adaptive to the industry or it can be central-federal that usually doesn’t have the characteristics that I’ve just described.</p> <p> <strong>Holt: </strong>How do we all get involved in that process?</p> <p> <strong>Dr. Madara:</strong> Let us roll this out. There will be companies that are represented here I’m sure, as well as large companies that are stakeholders in this ecosystem, and patients … I mean this is really all about the patients.</p> <p style="text-align:right;"> <em style="text-align:right;">By AMA staff writer </em><a href="" rel="nofollow" style="text-align:right;" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:211a6485-903f-49ad-93d0-af4435064479 Overcoming gender obstacles in medicine Tue, 27 Sep 2016 19:40:00 GMT <p> A lack of women in leadership positions, a gender pay gap, stereotypes and self-confidence all play a role in gender inequality in medicine. At the inaugural Women in Medicine Symposium, Vineet Arora, MD, detailed these issues and discussed how women could be more empowered in the medical field.</p> <p> Dr. Arora has spent most of her career in academic medicine and is currently assistant dean for Scholarship and Discovery at the University of Chicago. Because there is good data, she said, academic medicine is a great lens to track women in medicine. The data and results of many studies prove there are specific obstacles that women face, and now the focus needs to be on finding the solutions.</p> <p> <strong>The gender gap</strong></p> <p> A study from 2016 looked at data through the Freedom of Information Act from state institutions controlling for factors like age, years of experience, specialty, scientific authorship, number of Medicare patients and more. The absolute difference between salaries of men and women was $50,000, and after the controls were taken into account it was still $18,000.<a href="" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> “When I went to medical school in 1998, at Washington University in St. Louis, I was part of a medical class that for the first time had more women than men,” Dr. Arora said. The number of women entering medical school is increasing.</p> <p> Looking at data from the Association of American Medical Colleges, 46 percent of applicants to medical school and 47 percent of matriculates are women, one in five full professors are women and only 16 percent are deans.</p> <p> “I don’t think we can say we just have poor representation because there are fewer women,” she said. “38 percent of faculty in academic health centers are now women, but only 13 percent of those women are full professors,” but as they move on in their careers, there is a clear separation in leadership roles.</p> <p> Assistant dean, she said, is usually a job in medical education. Citing a stereotype, Dr. Arora said, “When you think about teachers you think teachers are women … but the path to become a department chair or division chief is usually through research and it’s usually through clinical leadership …”</p> <p> When you look at the data even closer, she said, “you’ll see there are some nuances there. We’re making some gains in some areas, but it may be because those areas are associated with gender stereotypes for teaching, and not making gains in other areas.”</p> <p> <strong>Stereotype threats</strong></p> <p> “I remember being a resident … and Janet Bickle, who is a well-known luminary in the field, a PhD scientist who studies women in medicine, had come to give grand rounds at the University of Chicago,” Dr. Arora said. “She presented a lot of the same data … and somebody raised their hand in the back and said maybe women don’t want to lead.”</p> <p> “You may have heard this too in your career at some point and maybe not about you,” she said. “Maybe you were in a meeting and you were debating the merit of somebody else and then someone else says ‘Oh they have small kids at home, they probably don’t want this position,’ and you just looked them over.”</p> <p> It might be that you even think that about yourself, Dr. Arora said. “At some point in your career, maybe you thought, ‘I’m probably not the right fit for this job because it’s kind of a man’s job.’”</p> <p> “That’s what we call stereotype threat,” she said. Stereotype threat is when you start believing the stereotype that women cannot do everything a men can do.</p> <p> Dr. Arora talked about one study where women and men were asked to take a math test under two conditions. In one condition, the participants were told it was a high stakes exam, and both genders did well. But in the stereotype threat condition, the participants were told they were about to take a test that exposes gender differences in math. Under that condition, women’s performance dropped and men’s performance rose.</p> <p> <strong>Impostor syndrome</strong></p> <p> Many women do become leaders, but they often face what is called “impostor syndrome,” Dr. Arora said. “Impostor syndrome is experiencing feelings of inadequacy because you do not feel skilled to do your job. This is known to affect women way more than it affects men.”</p> <p> For example, “I go to grand rounds every Tuesday at noon to hear the latest speaker and I often look to see who asks questions at the end,” she said. “Occasionally I have a question. But I have to formulate it in my head and think did the speaker actually address that already? Because I don’t want to ask a question and they say it was on slide three, but by that time somebody has already raised their hand and asks the same question that I was thinking.”</p> <p> “So what was I thinking?” she asked. “I had impostor syndrome. I was thinking that what I know is a microcosm of what everyone else knows, but really it’s that there may be people who know more than me in one field but I know quite a lot about my field …  and a way to overcome this is that we just accept this.”</p> <p> “How do you get rid of stereotype threat and impostor syndrome?” she asked. “A lot of it is about empowering women at early stages in their career and telling them that they can do it … but who is going to do that mid-career?”</p> <p> And that’s where we need to empower each other, Dr. Arora said. “We need to stop thinking that we live in a man’s world. Because in the frame of you can do everything a man can do, the reference group is the man."</p> <p> “The first person that must believe you can do it is yourself,” she said. “And you must believe you can do it and not view being a woman as a hindrance. If we frame context that being a woman is a hindrance, we’re never going to get anywhere.”</p> <p> To learn more about solutions to gender inequality in medicine, read Dr. Arora’s article, “<a href="" rel="nofollow" target="_blank">It’s time for equal pay for equal work for physicians—paging Dr. Ledbetter</a>,” published in JAMA Internal Medicine earlier this month.</p> <p style="text-align:right;"> <em>By AMA staff writer </em><a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:02dfb4b5-1ac4-4617-82ff-41168eb3bbc3 Obesity rates fall in 4 states, but overall rates remain high Tue, 27 Sep 2016 00:00:00 GMT <p> Adult obesity rates decreased in four states, according to a new annual study. But with obesity beginning to slow nationwide, there’s still a lot of work to be done so that millions of Americans aren’t at an increased risk of diabetes and heart disease.</p> <p> <strong>A few signs of change<strong><strong><a href="" target="_blank"><img src="" style="margin:15px;float:right;height:1324px;width:200px;" /></a></strong></strong></strong></p> <p> There’s a glimmer of good news on the adult obesity front this year: Minnesota, Montana, New York and Ohio saw rates decline between 2014 and 2015, according to the newly released study, <a href="" rel="nofollow" target="_blank"><em>The State of Obesity: Better Policies for a Healthier America</em></a>.</p> <p> With the exception of a decline in Washington, D.C., in 2010, this is the first time in the past decade that any state has seen a decrease in its adult obesity numbers, according to the report by the Trust for America’s Health and the Robert Wood Johnson Foundation.</p> <p> But the report says work to lower obesity rates is far from over, and notes that its findings are “an urgent call to action.”</p> <p> <strong>Obesity rates still high</strong></p> <p> Adults in Kentucky and Kansas saw obesity rates rise between 2014 and 2015, the study showed. And, although other states saw rates remain stable, adult obesity rates remain above 30 percent in half the nation’s states.</p> <p> In 2015, Louisiana had the highest adult obesity rate, at 36.2 percent; Colorado ranked the lowest with a 20.2 percent obesity rate, authors found.</p> <p> Keep in mind, though, that in 1991 every state’s obesity rate was below 20 percent.</p> <p> “These new data suggest that we are making some progress, but there’s more yet to do,” said Richard Hamburg, interim president and CEO of Trust for America’s Health. “Across the country, we need to fully adopt the high-impact strategies recommended by numerous experts. Improving nutrition and increasing activity in early childhood, making health choices easier in people’s daily lives and targeting the startling inequities are all key approaches we need to ramp up.”</p> <p> More detailed policy recommendations are outlined in <a href="" rel="nofollow" target="_blank"><em>The State of Obesity</em> </a>report.</p> <p> <strong>Location, heritage and education matter</strong></p> <p> Minorities, those who live in the South, those with lower incomes and those who did not graduate high school are more likely to be obese, according to the report.</p> <p> Among the study’s findings on where people live:</p> <ul> <li> Nine of the 11 states with the highest obesity rates are in the South</li> <li> 22 of the 25 states with the highest obesity rates are in the South and Midwest</li> <li> 10 of the 12 states with the highest rates of diabetes are in the South</li> </ul> <p> When broken down by ethnicity, the study found obesity rates are:</p> <ul> <li> 48.4 percent among blacks</li> <li> 42.6 percent among Latinos</li> <li> 36.4 percent among whites</li> <li> 12.6 percent among Asian-Americans</li> </ul> <p> And here is how education and income impacts rates:</p> <ul> <li> Nearly 33 percent of adults who did not graduate high school were obese compared with 21.5 percent of college or technical college graduates</li> <li> More than 33 percent of adults who earn less than $15,000 annually are obese; 24.6 percent who earned at least $50,000 annually were obese</li> </ul> <p> For more interactive graphs, charts and obesity rates visit <a href="" rel="nofollow" target="_blank"></a></p> <p> <strong>Physician resources to combat diabetes, obesity</strong></p> <p> The AMA’s online resource <a href="" target="_self">Prevent Diabetes STAT</a> provides physicians with information and tools to help patients prevent diabetes.</p> <p> And for more information on how physicians are helping patients prevent diabetes and fight obesity:</p> <ul> <li> <a href="" target="_self">Physicians, patients take active approach to diabetes fight online</a></li> <li> <a href="" target="_self">Five Nutrition Facts misconceptions that sabotage patient health</a></li> <li> <a href="" target="_self">Inside look: A physician's success story as a prediabetic patient</a></li> <li> <a href="" target="_self">What's it like to be in obesity medicine: Shadowing Dr. Lazarus</a></li> </ul> <p align="right"> <em>By contributing writer Tanya Albert Henry</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:3b9cf26d-084d-48df-a7cb-212a145d2beb Test your readiness with this month’s USMLE Step 1 stumper Mon, 26 Sep 2016 23:00:00 GMT <p> The United States Medical Licensing Examination® (USMLE®) Step 1 exam is often the first major test of a medical student’s knowledge, and some of its questions are missed by all but a select few highly prepared test takers. Check out this month’s question that Kaplan Medical says stumps most students, and view an expert video explanation of the answer.</p> <p> Welcome to this month’s installment of the <em>AMA Wire</em>® series, Tutor talk: Tips from Kaplan Medical on the most missed USMLE test prep questions from Kaplan’s Qbank: Step 1. Each month, <em>AMA Wire® </em>reveals questions many physicians-in-training miss on the USMLE and provides helpful analysis of correct answers, along with videos featuring tips on how to advance test-taking strategies. See <a href="" target="_self">all posts in this series</a>.</p> <p> Think you have what it takes to rise above your peers? Test your USMLE knowledge below.</p> <p> Ready. Set. Go.</p> <p> <strong>This month’s question that stumped most students:</strong></p> <p> Gastrin, acetylcholine and histamine all regulate gastric acid secretion from parietal cells under normal conditions. Administration of atropine will most likely cause which of the following changes in the ability of gastrin, acetylcholine and histamine to stimulate acid secretion?</p> <p> <a href="" target="_blank"><img src="" style="margin:15px;float:left;" /></a></p> <p>  </p> <p>  </p> <p>  </p> <p>  </p> <p>  </p> <p>  </p> <p>  </p> <p>  </p> <p>  </p> <p> <object data="" height="350" id="ltVideoYouTube" src="" type="application/x-shockwave-flash" width="450"><param name="movie" value="" /><param name="quality" value="best" /><param name="bgcolor" value="#ffffff" /><param name="wmode" value="transparent" /><param name="allowFullScreen" value="true" /><param name="allowScriptAccess" value="always" /><param name="flashvars" value="playerMode=embedded" /></object></p> <p>  </p> <p> <strong>The correct answer is C.</strong></p> <p> <strong>Kaplan says, here’s why: </strong></p> <p> Parietal cells express at least five different receptors types that control acid secretion—three excitatory, two inhibitory. All five receptors signal their occupancy via G-proteins. The three excitatory receptors bind acetylcholine (ACh), gastrin and histamine.</p> <ul> <li> The ACh receptor is an M<sub>3</sub> AChR that activates in response to ACh released from vagal nerve endings. It couples intracellularly via G<sub>q</sub> to the IP<sub>3</sub> signaling pathway. The AChR facilitates reflex acid secretion in response to the sight and smell of food (a vagovagal reflex).</li> <li> Gastrin binds to a cholecystokinin B (CCK<sub>B</sub>) receptor that also couples intracellularly via G<sub>q</sub> to the IP<sub>3</sub> signaling pathway. Gastrin is released from G cells located in the gastric mucosa. They release gastrin in response to luminal peptides and amino acids whose appearance indicates that a meal has begun. G-cells are also regulated by the vagus nerve, but the nerve terminals signal via a peptide neurotransmitter (gastrin releasing peptide; GRP) rather than the usual ACh.</li> <li> Histamine binds to an H<sub>2</sub> receptor that couples via G<sub>s</sub> to the cAMP intracellular signaling pathway. Histamine originates from enterochromaffin-like (ECL) cells, which are neuroendocrine cells located in the gastric mucosa. ECL cells secrete histamine when stimulated either by the autonomic nervous system or by gastrin. <ul style="list-style-type:circle;"> <li> ECL cells are innervated by the vagus nerve. They are activated via ACh release and an M<sub>3</sub> AChR.</li> <li> ECL cells also express CCK<sub>B</sub> receptors, which allows them to respond to gastrin when G cells are activate.</li> </ul> </li> </ul> <p> Histamine is the primary stimulus for gastric acid secretion. Even though ACh and gastrin are secretagogues also, their effects are entirely secondary to histamine. Thus, mice models lacking H<sub>2</sub> receptors are unable to secrete acid, even when the vagus nerve and G-cells are active and releasing ACh and gastrin, respectively. The importance of the histamine pathway is also reflected in the efficacy of H<sub>2</sub> blockers (e.g. cimetidine, ranitidine) in controlling acid secretion in patients with peptic ulcers and gastroesophageal reflux disease. Note that H<sub>2</sub> blockers, unlike knock-out studies, cannot inhibit the histamine pathway by 100%. Any residual H<sub>2</sub> receptor signaling is subsequently potentiated by the ACh and gastrin pathways, which is why proton pump inhibitors (e.g. omeprazole) have replaced H<sub>2</sub> blockers as the drugs of choice in controlling gastric acid production.</p> <p> Under normal circumstances, all three secretagogues are released during a meal and all three receptor types are active and their effects on acid secretion are multiplicative; their combined actions are greater than might be expected from the sum of their individual actions. This phenomenon is known as “potentiation”, and reflects the power of G-protein signaling pathways to interact with and amplify sensory signals.</p> <p> <a href="" target="_blank"><img src="" style="margin:15px;float:left;" /></a></p> <p>  </p> <p>  </p> <p>  </p> <p>  </p> <p>  </p> <p>  </p> <p>  </p> <p>  </p> <p> Atropine is an M-type AChR (mAChR) antagonist. Referring to the pathways above, it would be expected to block the parietal cell mAChR and the mAChR on ECL cells. The ability of ACh to stimulate acid secretion is, thus, clearly reduced.</p> <p> Because gastrin and histamine act through different receptor types that are not blocked by atropine, their ability to stimulate acid secretion might be expected to be resistant to mAChR blockade. In practice, however, the phenomenon of potentiation means that the loss of the ACh-mediated signal decreases the potency of both gastrin and histamine, so all three secretagogues have decreased efficacy when atropine is applied (choice C).</p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:21fe8f3d-0ad8-4046-b33b-d7d288035875 Physicians demand more of digital tools, yet remain optimistic Mon, 26 Sep 2016 10:00:00 GMT <p> Physician enthusiasm about digital health innovation requires a few “must haves” to turn that enthusiasm into adoption of digital tools in clinical practice. A new AMA survey shows that physician optimism toward digital health products is present across all ages, but the tools must be beneficial to clinical practice and not a burden. One way to make sure the tools are effective in practice is to get physicians involved in their development.</p> <p> The AMA <a href="" target="_self">digital health survey</a> asked 1,300 physicians about their motivations and requirements for integrating digital health tools in their practices. Conducted by Kantar TNS, one of the world’s largest research agencies, the survey asked physicians to answer questions regarding telemedicine and telehealth, mobile health, wearable, remote monitoring, mobile applications and many others.</p> <p> <strong>Patient care among top concerns</strong></p> <p> The top three characteristics that attract physicians to digital health tools are that they improve work efficiency, increase patient safety and improve diagnostic ability. All three relate directly to patient care. If a tool does not make the work day run more efficiently, that affects patient care—and physicians strive every day to make sure their processes and tools work for patients above all else.</p> <p> With 85 percent of physicians surveyed saying that digital health solutions are advantageous to patient care, it is clear that the medical community sees the potential of these tools.</p> <p> But physicians need tools that fit within current systems and look to technology experts to meet those needs—tools that don’t <a href="" target="_self">take away time spent face-to-face with patients</a>. When asked what requirements must be met by digital health tools of the future, three themes emerged:</p> <ul> <li> Tools should be easy to use and as effective as current methods of patient care—if not more effective</li> <li> Liability coverage, data privacy and work flow integration are essential</li> <li> Physicians should be paid for time spent using the tools</li> </ul> <p> If tools meet the requirements physicians have set forth, physicians anticipate rapid adoption and minimal disruption to their practice, the survey found. Nearly half of all physicians surveyed, regardless of age, stated high enthusiasm for new digital solutions.</p> <p> When asked how much of an advantage digital health solutions provide to a physician’s ability to care for patients, 87 percent of primary care physicians said there was definite or some advantage and 83 percent of specialists agreed.</p> <p> A prime example of a tool that has the potential to transform clinical practice is the electronic health record (EHR). Physicians have adopted EHR technologies at a rapid rate and recognize the promise of EHRs, but that promise has not been met. A <a href="" rel="nofollow" target="_self">study</a> by the AMA and the RAND Corporation found that <a href="" target="_self">EHRs are one of the top sources of physician dissatisfaction</a>. Yet, it also found that among the 30 participating practices, 28 were using an EHR at the time of the study.</p> <p> <strong>Getting physicians involved in development</strong></p> <p> Developers agree that physician involvement is critical to making sure digital health tools enhance care and have the longevity to improve patient health outcomes. Several recent AMA efforts focus on helping physicians take on a greater role in leading changes that will move technological innovations forward.</p> <p> Physicians are willing to move health care technology into the future and are getting more involved each day. If you want to get involved, sign up for an invitation to the AMA Physician Innovation Network, which connects entrepreneurs to practicing physicians to consult on new ideas and technologies. The AMA offered a sneak peek of the Physician Innovation Network at Health 2.0 2016 and it will be live in October. The future of health IT is one that involves collaboration between developers and physicians and both sides have shown they are more than willing to work together to improve patient health and care delivery.</p> <p> Some physicians are taking matters into their own hands. Frank Opelka, MD, a physician in Louisiana, is leading a statewide effort to <a href="" target="_self">create a larger cloud architecture where EHRs are the access point</a> to using data for quality improvement and clinical support. Lawrence Kosinski, a gastroenterologist in Illinois, founded SonarMD, which he uses to <a href="" target="_self">track patients between visits</a>.</p> <p> At <a href="" target="_self">Health2047</a>, a San Francisco-based health care innovation company, strategy, design and venture opportunities are developed in partnership with physicians, leading companies and entrepreneurs.</p> <p> In an expanded partnership with <a href="" target="_self">MATTER</a>, Chicago’s health care technology incubator, physicians and entrepreneurs collaborate on the development of new technologies, services and products in a simulated health care environment. This enables them to make sure that the number-one requirement of physicians—that the technologies work in practice—is met.</p> <p> Though Health2047 and MATTER bring practicing physicians and entrepreneurs together, medical students also are tackling clinical problems by developing technological solutions at <a href="" rel="nofollow" target="_self">IDEA Labs</a>, a student-run biotechnology incubator that helps the next generation of physicians and young entrepreneurs address unmet needs in health care delivery.</p> <p> Physicians also play a key advisory role in the <a href="" target="_self">SMART project</a>, created to ensure EHR systems work better for physicians and patients through the development of a flexible information infrastructure that allows for free, open-development of “plug and play” apps to increase interoperability. AMA Board Member Jesse Ehrenfeld, MD, sits on the advisory board for the SMART project.</p> <p> Dr. Ehrenfeld has also taken the initiative at Vanderbilt University by creating a team focused on better use of technology that was already at physicians’ fingertips. Their solutions bring <a href="" target="_self">actionable information from the EHR to clinical faculty</a> to help them better track patients’ progress and prepare for the next day’s patients.   </p> <p align="right"> <em>By AMA staff writer </em><a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:eeab9434-c5c2-47ef-9fa7-dca0272b72ee Rethinking how race contributes to a patient’s health Mon, 26 Sep 2016 04:30:00 GMT <p> Physicians have been trained to think about race as a demographic factor that may influence a patient’s health, but understanding how race influences health is evolving. One medical school is attempting to expand the way future physicians think about race in the exam room.</p> <p> Jennifer Tsai and Bryan Leyva, medical students at Warren Alpert Medical School of Brown University, shared how students at their school succeeded in changing how race is addressed in their curriculum in a presentation titled, “Moving past diversity toward decolonization: Bringing critical race theory to the Warren Alpert Medical School of Brown University.”</p> <p> The talk was held during the AMA’s <a href="" target="_self">Accelerating Change in Medical Education</a> Consortium student-led meeting on health equity and community-based learning at the University of California, Davis, School of Medicine in early August. The Warren Alpert Medical School of Brown University is a member of the consortium, but this work on race theory is not a part of their consortium project.</p> <p> <strong>What is race?</strong></p> <p> Race is socially and politically constructed, Tsai told those gathered at the meeting. Racial categories on the U.S. Census have changed every decade since 1790, showing just how vulnerable they are to the current political climate, she said.</p> <p> “Race becomes a poor surrogate for family history,” she said. For example, a physician could say, “‘You’re from Africa, so you have a higher rate of this disease.’ …. But Africa is a whole continent.”</p> <p> With that in mind, Brown medical students went through lecture slides at their medical school to find examples of how race is used as a biological factor. They found that of the 102 slides that mentioned race, 96 percent of them suggested a biological risk. Just 4 percent of the slides acknowledged social determinants of disease disparities among people of different races.</p> <p> Tsai said the results were “surprising.” The students’ findings were published in <a href="" target="_blank" rel="nofollow"><em>Academic Medicine</em></a>.</p> <p> In addition, she said, “A school-wide survey of 180 students showed 90 percent of students supported curriculum reform on race and when it came to race and about 80 percent felt inadequately prepared to use and talk about race in the clinic.”</p> <p> <strong>What did Brown do with the findings?</strong></p> <p> Medical students in December 2014 sent a letter detailing their concerns on teaching race as biology. From there, a task force of students and administrators worked to implement changes.</p> <p> For example, the medical school designated an elective for first year medical students. The 10-session class includes lectures, discussions and case studies. Students address topics such as the health of minorities, race and segregation, Leyva said.</p> <p> The program encourages developing a healthy skepticism of research. For example, students looked at a study that found there was no genetic difference among racial groups, yet the study’s abstract said there were differences.</p> <p> Students in the class also address how racism is prevalent in structures in society. They talk about the historical structural and political forces that created problems and then propose solutions, Leyva said.</p> <p> The students talk about restrictive covenants that prohibited African-Americans and other racial and ethnic minorities from buying homes in certain neighborhoods—and redlining—where insurance companies and banks decided which communities would receive money for insurance and loans and which would not.</p> <p> “Segregation… did not happen on its own,” Leyva said. “It is intentional, driven at the local, state and federal level, and it has an impact on people’s lives today.”</p> <p> Tsai said students also discuss the idea of medical authority and how it has been used through history when discussing race and health.</p> <p> <strong>How the discussions are making a difference</strong></p> <p> Leyva said surveys and focus groups have shown that students appreciate the discussions and new ways of thinking. Students also said they have a better understanding of bias and institutional racism, as well as have the skills to talk about race and racism in clinical and non-clinical contexts.</p> <p> Tsai asked those gathered how medical school leaders can hold themselves accountable, noting that they need to think about things such as admissions, research dollars and community interaction “so we can be committed to and practice equity in ways that critical race theory works.”</p> <p> Other topics discussed at the recent Accelerating Change in Medical Education consortium meeting included:</p> <ul> <li> How <a href="" target="_self">zip code impacts patients' health</a> more than genetics</li> <li> Learning to<a href="" target="_self"> treat the community as your patient</a></li> <li> What it means to <a href="" target="_self">work upstream to achieve the quadruple aim</a></li> </ul> <p align="right"> <em>By contributing writer Tanya Albert Henry</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:276e61ae-093a-4cb1-b813-c97cb6d33e20 How physician input is changing MOC Fri, 23 Sep 2016 01:00:00 GMT <p> With Maintenance of Certification (MOC) in its second decade, many changes are underway. Through conversations between physicians and the American Board of Medical Specialties (ABMS), these changes are intended to make the MOC process, including the Part III examination, more relevant to clinical practice and less burdensome. </p> <p> In recent years, the AMA’s Council on Medical Education (Council) has developed a constructive working relationship with the ABMS on these issues. Council work has been effective in contributing to moving the Boards to consider alternatives to high-stakes testing and other changes in MOC to make it more relevant for physicians.</p> <p> An <a href=",.98450.aspx" target="_blank" rel="nofollow">article</a> that describes a conference discussion between the Council and ABMS details the changes that are currently underway and what could be coming in the future through conversations between the two organizations.</p> <p> “The AMA has been very helpful in bringing the voice of the physicians to the Boards Community,” said Mira Irons, MD, senior vice president for academic affairs at the ABMS, “and to help us understand the greatest concerns that physicians have regarding MOC.”</p> <p> “The Council has created an opportunity for the Boards Community to maintain a dialogue with relevant groups of the AMA.” Dr. Irons said. “This is a way to learn about what each organization is doing and, more importantly, the context in which these innovations are being created.”</p> <p> <strong>Physicians detail issues with current MOC approach</strong></p> <p> One challenge to the current approach to MOC examinations is that practice patterns evolve over the years. Examination measurement standards require a thorough and explicit definition of the content of the domain, yet physicians have expressed concern that the material included on the exam is broader than what typically presents in most physician practices.</p> <p> AMA members have raised a number of important issues about the exam; for example, that it needs to be more personalized to practice and it needs to be more about clinical judgment and patient management skill. And the experience needs to be more convenient and easier to integrate into their busy practices.</p> <p> As a result, the Boards are piloting a number of changes specifically to address these issues:</p> <ul> <li> <strong>Modularizing the exam</strong> to make it more relevant</li> <li> <strong>Incorporating audio and video</strong> to simulate real-life decision-making</li> <li> <strong>Redesigning questions</strong> to move from recall to clinical judgment and decision making</li> <li> <strong>Incorporating remote proctoring</strong> that moves the experience from testing centers to the home or office environment</li> <li> <strong>Moving to more frequent, low-stakes testing</strong> in place of the single high-stakes exam</li> <li> <strong>Providing more feedback</strong> to make the experience more formative and helpful to continuing professional development</li> </ul> <p> <strong>Alternatives to the current MOC Part III examination</strong></p> <p> In response to both physician input and emerging views on how to increase the relevance and benefit of the Part III exam, several ABMS member boards are piloting alternative formats consistent with the Standards for the ABMS Program for MOC. The Standards offer flexibility to individual boards for implementation, and some of the boards have been taking advantage of that flexibility with major innovations in content and delivery.</p> <p> <strong>The ABA’s MOCA Minute</strong><sup>®</sup></p> <p> After analyzing feedback from board-certified anesthesiologists and the availability of information technology, the American Board of Anesthesiology (ABA) explored ways to enhance the Maintenance of Certification Anesthesiology Program<sup>®</sup> (MOCA<sup>®</sup>) through a program redesign called <a href="" target="_blank" rel="nofollow">MOCA 2.0<sup>®</sup>.</a> MOCA 2.0 is intended to promote continuous lifelong learning, increase the relevance of MOCA to practices, integrate Parts II, III and IV of MOC and include continuous longitudinal (low-stakes) assessment.</p> <p> The result of the ABA’s exploration and discussions is the implementation of <a href="" target="_blank" rel="nofollow">MOCA Minute<sup>®</sup></a>, an online longitudinal assessment tool. Introduced as an expanded pilot in January to replace the cognitive high-stakes exam taken every 10 years, physicians who are enrolled in MOCA 2.0 answer 120 MOCA Minute questions annually.</p> <p> The questions include core information essential for anesthesiologists as well as topics that are reflective of an anesthesiologist’s areas of subspecialization. Once a physician accesses a question, she or he has one minute to answer. As soon as the question is answered, the physician is shown a feedback page that includes the correct answer, a critique explaining the answer with references and a one-sentence summary of the material. The critiques from previous questions are available at any time to reinforce learning.</p> <p> Initial analysis of the pilot showed that participation was associated with positive diplomate feedback and improved performance on the MOCA examination. Additional analyses are underway.</p> <p> Watch <em>AMA Wire®</em> for more examples of how medical boards are changing the MOC process.</p> <p align="right"> <em>By AMA staff writer </em><a href="" target="_blank" rel="nofollow"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:f39ca154-a348-47a8-a76e-bf0a0364b9dc Redesigning the Gas Lounge: How residents changed their space Thu, 22 Sep 2016 01:00:00 GMT <p> Anesthesiology residents at Stanford used to spend their few precious moments of relaxation in a lounge that looked like a dirty apartment. With a low-budget, resident-led plan, they found the funds and redesigned the anesthesiology lounge—known as the “Gas Lounge”—into a space that is clean, calm and where they would actually want to eat and sleep.</p> <table align="right" border="0" cellpadding="1" cellspacing="15" style="width:365px;"> <tbody> <tr> <td>  </td> <td> <a href="" target="_blank"><img src="" /></a></td> </tr> <tr> <td>  </td> <td> <em><span style="font-size:10px;">The Gas Lounge "before"</span></em></td> </tr> </tbody> </table> <p> Physicians spend a large portion of their lives at work and most of the time they get to actually relax is in the on-call room. Adam Was, MD, a fifth-year resident in the combined pediatrics and anesthesia program at Stanford, spoke this week to physicians at the <a href="" target="_self">International Conference on Physician Health™</a> in Boston about how he and his fellow residents redesigned their own on-call room.</p> <p> The changes to the Gas Lounge came about through the <a href="" rel="nofollow" target="_blank">Peer Support and Resiliency in Medicine Program</a> (PRIME) at Stanford, which was built in 2010 around Jon Kabat-Zinn’s <a href="" target="_self">mindfulness-based stress reduction work</a> and is intended to create a new culture that fosters interdependence, concern for others, self-care and emotional literacy. The program holds resident wellness retreats, regular wellness sessions led by faculty and wellness education sessions.</p> <p> Then, in 2014, the addition of a scholarship for resident-driven wellness initiatives opened the door for residents in the program to make meaningful changes that affect their daily lives.</p> <p> “It was really wonderful because they had these funds and made them available and invited residents to put together whatever ideas they could come up with that they thought might help resident wellness,” Dr. Was said. And the residents lead the programs.</p> <p> <strong>Residents decide what goes into their home away from home</strong></p> <table align="right" border="0" cellpadding="1" cellspacing="15" style="width:365px;"> <tbody> <tr> <td>  </td> <td> <a href="" target="_blank"><img src="" /></a></td> </tr> <tr> <td>  </td> <td> <em><span style="font-size:10px;">The Gas Lounge "after"</span></em></td> </tr> </tbody> </table> <p> Dr. Was initiated a project to improve the Gas Lounge. It was feasible, could easily be implemented and was cost-effective. “We really wanted to empower the beneficiaries of the scholarship,” he said, “let the residents choose what they wanted, lead the selection of that and be a guide and a means to an end for them.”</p> <p> The group surveyed the 79 anesthesia residents regarding their current use and satisfaction with the lounge. They asked for ideas for improvements as well as their permission to make those improvements “to make sure that they were on board and didn’t feel like we were changing the existing structure … and that we weren’t forcing any changes on people,” Dr. Was said.</p> <p> In the initial survey, the residents suggested a total of 33 potential improvements ranging from couches, coffee tables and lighting to hot tubs and massage therapists—the latter of which were not quite feasible.</p> <p> “We asked what kept them from using it more often,” Dr. Was said. “People said they use it pretty frequently … but in terms of limitations a good portion of people said it’s just too small, or it’s dirty, or they often forget their key.”</p> <p> They also asked residents if they would use the lounge more often if these improvements were made and whether they felt these interventions would improve their well-being. Fifty-nine percent said it would improve their well-being—and so the group budgeted and began purchasing items and redesigning the Gas Lounge.</p> <p> <strong>Revealing the Gas Lounge makeover</strong></p> <p> The selected improvements included a new couch, monthly cleaning, badge-entry rather than key-entry, snacks, phone chargers, new lighting and pillows and blankets among several others. Once the room was completely cleaned from top to bottom, they placed all of the new items in the room.</p> <table align="left" border="0" cellpadding="1" cellspacing="15" style="width:365px;"> <tbody> <tr> <td> <a href="" target="_blank"><img src="" /></a></td> <td>   </td> </tr> <tr> <td> <span style="font-size:10px;"><em>Anesthesiology residents in the Gas Lounge</em></span></td> <td>   </td> </tr> </tbody> </table> <p> Dr. Was said that some of the things they found under the old couch were not for repeating to an audience. “Suffice to say, I didn’t know that oranges could turn black,” he said. “And I don’t know how long that takes.”</p> <p> In a post-intervention survey, residents were asked how often they used the Gas Lounge. Before the interventions, only about 20 percent of residents said they used it daily. After the interventions, almost 70 percent of residents said they used it daily.</p> <p> One resident wrote in the survey, “I go to the Gas Lounge nearly every day for lunch because I know I can sit down with the people I love (my co-residents) and get a half hour of socializing and humor. It is also my home-base for those long call evenings, and essential for naps while on cardiac call.”</p> <p> Another resident said, “The Gas Lounge is my home. If we didn’t have it I’d be an orphaned child … I love the new changes.”</p> <p>  </p> <p align="right"> <em>By AMA staff writer </em><a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:fc8a48c6-cf39-46f3-bb7a-09383b881013 New tool identifies short-term volunteer and paid opportunities Thu, 22 Sep 2016 01:00:00 GMT <p> A new interactive tool provides physicians interested in volunteering or working outside of their normal practice settings with short-term opportunities in the field of medicine. The <a href="" target="_self">Physician Opportunities Portal</a>, launched today by the AMA, enables physicians to quickly and easily identify opportunities to add stability and longevity to their careers and increase joy in practice by giving back.</p> <p> The Portal features many opportunities, including:</p> <ul> <li> Consulting</li> <li> Legal expert</li> <li> Locum tenens</li> <li> Emergency and safety</li> <li> Health and wellness</li> <li> AMA opportunities</li> </ul> <p> Users may search by location, start date and even time of day. The Portal also features opportunities in areas that are not health care focused, such as advocacy, education and recreation.</p> <p> <strong>Created from physician feedback</strong></p> <p> The Physician Opportunities Portal grew out of an initiative in which the AMA reached out to physicians across the country to start a dialogue about the realities of practicing medicine in today’s world and how the AMA can better serve them. Feedback indicated physicians in small practices are highly stressed by administrative burdens and government regulations. Many have very little time and multiple pressing priorities, so they are seeking quick, short-term opportunities to create additional revenue streams to help stabilize their practices.</p> <p> The AMA also received feedback from retired physicians indicating they are interested in staying connected to medicine and may continue to work in the field of medicine.</p> <p> <strong>Additional tools supporting physicians</strong></p> <p> The Portal is the latest product developed by the AMA to help physicians plan their careers and manage their finances.</p> <p> The AMA also recently launched the <a href="" target="_self">Health Workforce Mapper</a> to help practices identify high-priority areas for workforce expansion. It illustrates the geographic distribution of the health care workforce and enables users to filter physician and non-physician health care professionals by specialty and employment setting at the state, county and metropolitan levels.</p> <p> The latest version of the mapper incorporates every specialty and subspecialty in the <a href="" target="_self">AMA Physician Masterfile</a> and the <a href="" rel="nofollow" target="_blank">CMS National Provider Identifier database</a>, including non-physician specialties. It also includes resident physicians.</p> <p> Meanwhile, the <a href="" rel="nofollow" target="_self"><em>JAMA</em> Career Center</a> aggregates career opportunities, news and information relevant to the full spectrum of medical practice. Job postings are available from nearly every specialty, practice setting and region in the United States. Opportunities can range from remote rural and underserved urban areas to thriving neighborhoods in towns and major metropolitan centers.</p> <p> The <em>JAMA </em>Career Center also presents select international physician employment and volunteer opportunities and offers a <a href="" rel="nofollow" target="_self">list of organizations looking for volunteers</a>, which includes the areas each organization serves and the specialties needed.</p> <p> <strong>Physician feedback an important factor</strong></p> <p> The Physician Opportunities Portal is a free tool, and all users may view available volunteer opportunities. With a free online AMA account, users can also save searches and receive timely alerts. AMA members may save searches, receive alerts and access paid opportunities.</p> <p> Your feedback can help ensure the tool is providing the resources you need. If you have opinions of the Physician Opportunities Portal, the AMA would like to <a href="" rel="nofollow">hear from you</a>.</p> <p align="right"> <em>By AMA staff writer Tim Smith</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:1c27ca10-686a-40b9-97e7-42b8d7caa2ba New analyses support blocking pending insurance mergers Wed, 21 Sep 2016 10:00:00 GMT <p> Two analyses released today demonstrate further that the proposed Anthem-Cigna and Aetna-Humana health insurance mergers would exceed federal antitrust guidelines designed to preserve competition and jeopardize patient access to affordable coverage and care.</p> <p> The analyses are based on data from the 15<sup>th</sup> edition of <em>Competition in Insurance: A Comprehensive Study of U.S. Markets,</em> published today by the AMA, which continues to find the majority of commercial health insurance markets in the United States are highly concentrated.</p> <p> High market concentration can lead to enhanced market power by health insurers on physicians and patients, wherein payments to physicians are lower than those resulting in a competitive market and premiums charged to patients are higher with no added benefits.</p> <p> <strong>The most complete picture of competition in health insurance<strong><strong><a href="" target="_blank"><img src="" style="float:right;margin:15px;width:300px;height:627px;" /></a></strong></strong></strong></p> <p> Using 2014 data from captured from commercial enrollment in fully and self-insured plans, <em>Competition in Insurance</em> presents the two largest insurers’ commercial market shares and the market concentrations for 388 metropolitan statistical areas (MSAs), the 50 states and the District of Columbia.</p> <p> “This is the most complete picture available of competition in health insurance markets,” the report said.</p> <p> In terms of market concentration, it shows:</p> <ul> <li> <strong>Seventy-one percent</strong> of the combined health maintenance organization (HMO), preferred provider organization (PPO), point-of-service (POS) and health exchange (EXCH) markets are highly concentrated.</li> <li> <strong>Ninety-three percent</strong> of HMO markets are highly concentrated.</li> <li> <strong>Eighty-seven percent</strong> of PPO markets are highly concentrated.</li> <li> <strong>One hundred percent</strong> of POS markets are highly concentrated.</li> <li> <strong>Ninety-five percent</strong> of exchanges are highly concentrated.</li> </ul> <p> In terms of market shares, it found:</p> <ul> <li> <strong>In 40 percent of the MSAs,</strong> one insurer had a combined HMO+PPO+POS+EXCH market share of 50 percent or greater.</li> <li> <strong>In 64 percent of the MSAs,</strong> one insurer had an HMO market share of 50 percent or greater.</li> <li> <strong>In 59 percent of the MSAs,</strong> one insurer had a PPO market share of 50 percent or greater.</li> <li> <strong>In 86 percent of the MSAs,</strong> one insurer had a POS market share of 50 percent or greater.</li> <li> <strong>In 75 percent of the MSAs,</strong> one insurer had an exchange market share of 50 percent or greater.</li> </ul> <p> <strong>Pending mergers would cause harm across numerous markets</strong></p> <p> In 2015, Anthem announced its intent to acquire Cigna, and Aetna announced plans to acquire Humana. All are among the five largest commercial health insurers in the country.</p> <p> The motivation for <em>Competition in Insurance</em> has been to help identify markets where mergers would cause competitive harm. The analyses of those mergers using data from this year’s report calculated the changes in market concentration that would result from the mergers and then classified markets based on how anticompetitive the mergers would be.</p> <p> They found:</p> <ul> <li> <strong>The <a href="" target="_self">Anthem-Cigna merger</a> would diminish competition in 121 metropolitan areas located in all of the 14 states where Anthem is licensed to provide commercial coverage,</strong> including California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, New York, Ohio, Virginia and Wisconsin.</li> <li> <strong>The <a href="" target="_self">Aetna-Humana merger</a> would diminish competition in 57 metropolitan areas in 15 states,</strong> including Arizona, Florida, Georgia, Illinois, Indiana, Kansas, Kentucky, Louisiana, Mississippi, Ohio, Tennessee, Texas, Utah, West Virginia and Wisconsin.</li> </ul> <p> “The AMA analyses show that the Anthem-Cigna and Aetna-Humana mergers would significantly compromise market competition in the health insurance industry and threaten health care access, quality and affordability,” said AMA President Andrew W. Gurman, M.D. “With existing competition in health insurance markets already at alarmingly low levels, federal and state antitrust officials have powerful reasons to block harmful mergers and foster a more competitive marketplace that will operate in patients' best interests."</p> <p> The AMA and state medical societies have worked behind the scenes in opposition to the two mergers.  The AMA has encouraged the Department of Justice (DOJ) and a number of state attorneys general to oppose both on antitrust grounds.</p> <p> The AMA believes more can be done in states where state regulators have not yet taken a strong stance against the mergers, and it will work to expand the bi-partisan group of state attorneys general that has already joined the DOJ to block the massive deals.</p> <p> <em>Competition in Insurance: A Comprehensive Study of U.S. Markets</em> is free to AMA members. It is also available to non-members. To order a copy, visit the <a href="" target="_self">AMA store</a> or call (800) 621-8335 and mention OP number 427116.</p> <p align="right"> <em>By AMA staff writer Tim Smith</em></p> <p>  </p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:7be28f9c-afa9-4116-b88d-a4eb9971f60b When good work is acknowledged, we aspire to work harder Tue, 20 Sep 2016 18:30:00 GMT <p> <em>An AMA Viewpoints post by AMA President Andrew W. Gurman, MD</em></p> <p> <a href="" target="_blank"><img src="" style="width:100px;height:150px;margin:15px;float:left;" /></a></p> <p> In a time of unprecedented change in medicine, the AMA has evolved to become a more nimble, responsive and forward-thinking organization that better prepares physicians for the unique challenges of a rapidly evolving health care system, according to an independent study being released this week. Such change is seldom quick or easy, and far too often we fail to pause and reflect on just how far this organization has come.</p> <p> The international public affairs and communications firm, APCO Worldwide, this week ranked the AMA first in its annual <a href="" rel="nofollow" target="_blank">TradeMarks survey</a> of the 50 most effective professional and trade organizations in the U.S., not just in the health care sector but across all industries. In fact, the AMA finished first or second overall in 14 of the 15 leadership characteristics identified by APCO, including advocacy work in Washington D.C., coalition building and partnerships, local impact and effective communications with members, stakeholders and the media.</p> <p> This is a remarkable achievement that is a credit to the vision established by the AMA’s Board of Trustees, its senior management, the AMA employees that advance that vision, but also the tens of thousands of physicians across the country who support the AMA and champion the causes that move our profession forward.</p> <p> As president of the AMA, I am proud of my colleagues and their tireless work to advance our strategic initiatives to improve health outcomes for patients, professional satisfaction for physicians and create the medical schools of the future.  </p> <p> <strong>No one on the sidelines</strong></p> <p> At my inauguration in June, I spoke about the power in advocating for our profession and leaving a legacy in medicine that we all could be proud of. And I asked my fellow physicians to get off the sidelines and get involved in these efforts, either through the AMA or their state and specialty societies. Take a stand on the issues that are important to you, your practice and your patients.</p> <p> Our message is simple: Your opinion matters. Your involvement matters. </p> <p> Anyone who practices medicine today understands the frustrations that are, unfortunately, driving too many of our most experienced and accomplished colleagues from the profession. We’re frustrated by the pace of our jobs, by unnecessary regulations that steal time from our patients, and by <a href="">EHRs that are inefficient</a>, difficult to use and don’t advance the quality of care we are trying to provide. We’re frustrated when we feel unsupported by administrators, and by complicated new payment models that seem to have no connection to the real-world demands of our jobs.</p> <p> The APCO survey is important because it independently validates the efforts of the AMA and physicians like you who lend your time and your voice to make a difference for all of us who practice medicine. You have done so by speaking out against the fatally-flawed Medicare Sustainable Growth Rate and we achieved repeal last year. You’ve also done so by participating in our <a href="" rel="nofollow">Break the Red Tape</a> campaign to fight back against burdensome regulations.</p> <p> Another fight that physicians have taken on is to help our patients gain access to treatment for substance use disorders and lifesaving medications that prevent overdose. The opioid epidemic is affecting communities across the country no matter their size or location. Our <a href="">task force</a> has worked tirelessly to ensure access to naloxone, improve prescription drug monitoring programs and increase their use; and have continued to emphasize that substance use disorder is a brain disease, not a moral failing.</p> <p> Other physicians have lent their expertise to tech innovators as they design and develop the tools that will one day transform health care, or helped our nation’s efforts to reduce chronic disease and opioid abuse and addiction. Some have simply chosen to become members.</p> <p> For all of you who are already participating in these efforts, I thank you. For those who have not yet joined our ranks, I hope the APCO survey will cause you to look anew at our efforts, and to consider adding your voice to ours.</p> <p> Let’s use the power of our collective voice to create a health care system that works for patients and physicians by removing the obstacles that contribute to so much dissatisfaction and dysfunction. Help us spread the word. Help us bring more of our colleagues to the table.</p> <p> Never forget that we physicians are the custodians of a marvelous profession and a noble tradition of healing and ethics. Health care as we know it will not survive unless physicians make professional advocacy a part of our commitment to the profession; a part of our mission.</p> <p> Let this be the year we capitalize on this momentum by working collaboratively to create a future that supports thriving physicians, expands quality care and strengthens the health of our nation for our patients.</p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:9458c746-a439-4ce2-8dbf-504beaeaeb02 Building emotional intelligence in medical trainees Mon, 19 Sep 2016 23:00:00 GMT <p> Medical schools around the world are working to help students develop resilience to not only make them better physicians but also healthier individuals. At Cardiff University in the United Kingdom, they are accomplishing this with a new program that focuses on building emotional intelligence.</p> <p> At the <a href="" target="_self">International Conference on Physician Health™</a> in Boston, Debbie Cohen, MD, OBE, an occupation health physician and director of student support at the Centre for Psychosocial and Disability Research at Cardiff University in the United Kingdom, explained the theory behind Cardiff’s emotional intelligence development program and how it works.</p> <p> “We have to provide structures to both manage and support our learners,” Dr. Cohen said. “That is becoming a priority. And within that … we have to have both systems to provide the health and well-being for our learners.”</p> <p> “What an opportunity to think about how we might change those structures,” she said. “It’s a challenge, because what we’re talking about is changing behavior.”</p> <p> Dr. Cohen outlines two ways of thinking:</p> <p> You can either teach people by telling them what to do and give them interventions like put your personal things aside, get enough sleep and make sure you get enough exercise, she said. “Or, you can try and bring about change, and that’s about guiding them…. Guide them to understand more about their emotions to enable better use of their own inherent skills and learn when and how to use skills and strategies to support well-being.”</p> <p> Making valuable change takes time, importance and practice, Dr. Cohen said. “It’s what you do every day and how you do it.”</p> <p> <strong>How does resilience fit into the equation?</strong></p> <p> “Emotional intelligence is about how you perceive your emotions,” she said. “It’s how you integrate them into what’s going on and how you manage it. What are the impacts?”</p> <p> In order to accomplish emotional intelligence four things need to happen, Dr. Cohen said. You need to accurately perceive emotions, integrate them with cognition, understand the emotional causes and consequences and manage those emotions for personal adjustment.</p> <p> “We have to be careful about this,” she said. “Because if you want to build emotional intelligence you have to talk about cognitive empathy, and that’s different than sympathy.”</p> <p> Cognitive empathy, she said, is about understanding your patient’s experiences while keeping a certain affective distance. While sympathy involves sharing in the patient’s suffering.</p> <p> “The problem that we see is if you have too much sympathy maybe that’s when we wind up in emotional exhaustion,” she said. “We shift the way we’re functioning from empathy to sympathy and that’s what drains us.”</p> <p> At Cardiff, Dr. Cohen and her colleagues are implementing a new method of training future physicians where they guide them to understand both their personal values and their professional values. The problem, she said, is when those personal values conflict with those professional values.</p> <p> <strong>What they’re doing at Cardiff</strong></p> <p> To build emotional intelligence and help trainees develop strategies, they use a series of guided observation and reflection tasks over a period of time. Tasks that ask students and doctors to spend five minutes every day completing a task that trains them to become aware of how they communicate and what the effect of their communication is on the other person, while they are actually communicating.</p> <p> Then they are asked to write a reflective piece on their experiences and share it online.</p> <p> Third-year medical students have a 10 week block of self-observation and reflection where they complete workshops and observation tasks. The first workshop teaches them how to do self-observations, communicate well and to understand their personal values while listening and communicating will colleagues and patients. The tasks include:</p> <ul> <li> <strong>Listening to others.</strong> In this task students are asked to reflect on their own pattern of listening and then answer the question, how do your personal and professional values influence your actions?</li> <li> <strong>Discussing and asking questions.</strong> Students are asked to investigate, do you try to really listen to find out what their ideas are or are you more concerned about getting the other person to listen to your opinions and ideas? Or do you do a bit of both depending on the situation?</li> <li> <strong>Understanding and managing emotions.</strong> Students are asked to discover what irritates, frustrates or annoys them and when those emotions occur. They are also asked what happens to the other person and your communication when you are experiencing those emotions?</li> </ul> <p> In the second workshop, the students investigate what they have found out about themselves and their emotions while listening and communicating with their colleagues and patients in the first workshop, including what comes next. Three major themes emerged from their qualitative responses:</p> <ul> <li> Recognizing negativity and its destructive influence on work morale and taking steps to turn it around to the positive.</li> <li> Recognizing insecurity, tiredness and vulnerability and acknowledging it rather than ignoring and fearing it as they had before, and taking steps to take care of themselves.</li> <li> Getting perspective on what goes on around them—not reacting automatically, but rather taking a step back and acting from awareness.</li> </ul> <p> Dr. Cohen shared one student’s response: “I have noticed over the last few weeks that my feelings of anger and irritation have greatly reduced … I find that I have a lot more patience for both patients and colleagues. I feel I am more empathetic to others [and] I try to see it from their perspective before evoking a reaction. … If I am in a situation which has evoked these emotions [anger and irritation] the way I handle them and deal with them has also changed for the better.”</p> <p> This program has been in the pilot phase for three months and Cardiff is rolling it out on a larger scale this week.</p> <p align="right"> By AMA staff writer <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:0d4ee8c5-7f6f-4924-a25b-7a7ea5c8ea88 Michigan students launch peer-reviewed medical journal Mon, 19 Sep 2016 23:00:00 GMT <p> A University of Michigan Medical School student, Sagar Deshpande, noticed a trend emerging in the student experience. He heard colleagues repeatedly voicing frustration at having spent time on methodologically sound research without getting their work published because their results were not what principal investigators had expected. So he had an idea: Why not start a medical journal run by students, for students’ own research?</p> <p> Deshpande shared the idea with a fellow student, Spencer Lewis, and in 2014 the two approached a faculty member, Mike Englesbe, MD, in the Department of Surgery.</p> <p> “I immediately appreciated how well it fit into a lot of the broader goals we’re trying to achieve with our new medical school curriculum, including fostering leadership and autonomy in students,” Dr. Englesbe said. University of Michigan is one of 32 member schools in the AMA’s <a href="" target="_self">Accelerating Change in Medical Education Consortium</a>. “One of the keys was that early on we got aggressive buy-in from higher-level folks in the institution, especially my boss, who said, ‘Whatever it costs, we can cover it.’”</p> <p> <strong>Making better scientists<strong><a href="" target="_blank"><img src="" style="float:right;margin:15px;" /></a></strong></strong></p> <p> Dr. Englesbe realized the journal could also provide opportunities for students to learn how to write, edit and talk like scientists. Previously, there were few specific opportunities for this kind of learning in medical school. Most of it came later, on the job, with no formal structure.</p> <p> He contacted a colleague in the medical school, Jasna Markovac, PhD, who had years of experience in journal publishing and runs the Learning Design and Publishing group within Health Information Technology and Services. Together, Drs. Engelsbe and Markovac created a new course for fourth-year medical students, Medical Editing and Writing, which included significant hands-on journal work.</p> <p> “The journal in some ways would be the ‘lab’ part of the course,” Dr. Markovac said. “It’s all about how to express yourself, what makes a good paper, how to do peer review, the whole end-to-end workflow.”</p> <p> They needed a publisher too, so Dr. Markovac looked across campus to Michigan Publishing Services, a unit of the University library, which had published various journals on behalf of learned societies but hadn’t done much journal publishing with the medical school.</p> <p> Meanwhile, Dr. Englesbe recruited a fourth-year medical student, Shannon Cramm, to serve as the journal’s first editor-in-chief.  She then assembled a team of about 30 student editors and reviewers.</p> <p> “Having been on the research side but never on the publication side, the logistics of how one actually publishes a journal were very unfamiliar to me and to the rest of our editorial staff,” Cramm said. “So establishing that relationship [with Dr. Markovac and the library] was essential to our success.”</p> <p> <strong>Putting it all together</strong></p> <p> Students were empowered to run every aspect of the journal and make all decisions.</p> <p> “The most important thing in a new idea like this is to keep your ear to the ground,” Cramm said. “Over the course of the year, we found shifts in what was needed. Eventually, we learned that some students wanted to be able to publish their parts of larger projects as the first author, to get experience writing manuscripts and working with reviewers and review teams.”</p> <p> Dr. Markovac’s staff and the publishing services staff from the library provided guidance and kept students from being tripped up by things they wouldn’t necessarily know.</p> <p> For example, in reviewing a draft layout of the first issue of the journal, Dr. Markovac noticed that the attribution of authors in the table of contents was irregular, not something she had ever seen.</p> <p> “I was thinking, ‘Hmm, now this is a teachable moment,’” she said. “‘Let’s teach them exactly how papers are called out in tables of contents and what the differences are between medical and nonmedical journals.’ For example, readers expect medical journals will be eight-and-a-half by 11 inches when formatted and printed, whereas humanities journals can be much smaller. Students don’t empirically know that, but if they’re going to run a journal, they need to know all of those things.”</p> <p> <strong>Delivering more than a publication</strong></p> <p> The first issue of the <em><a href="" rel="nofollow" target="_blank">Michigan Journal of Medicine</a></em> (<em>MJM</em>) was published in May. It was the culmination of a full school year’s work and was the editorial team’s final product.</p> <p> “I heard over and over from student reviewers and editors what a unique experience this was,” Cramm said. “It has definitely made me a better scientist, better at critically analyzing literature and a better scientific writer. It has only furthered my passion for academics and for research.</p> <p> “Working with a journal as a medical student isn’t just for people who are interested in academics. There’s a lot of benefit to honing your critical analysis skills, to honing your writing skills, to honing your [reading] skills, no matter which practice setting you choose.”</p> <p> Drs. Engelsbe and Markovac’s hope is that this curriculum will become a full four-year experience. Part of their charge is to transform students—to empower them to think beyond taking care of one patient at a time. For some students, medical writing and editing would be a significant focus in their careers, but for most it would be a small but important part of what they do as they learn how to be successful, impactful physicians.</p> <p> As they look to the journal’s second year, Drs. Engelsbe and Markovac are encouraging the new editorial team to try to publish two issues. The new editorial team and the infrastructure are in place—the submission system and production workflow are set up through the library, and there is institutional memory—so whether they will depends simply on how many manuscripts they can get.</p> <p> “The danger in starting student journals in general is that when the students graduate, the journal ceases to exist because there’s no one to take it over who has the same enthusiasm,” Dr. Markovac said. “The advantage of this is that it is now part of the curriculum, and we have other people in addition to the students who are involved who are very dedicated. So we’re seeing a long shelf life here.”</p> <p> The experience has also been helpful to the library’s publishing services staff who weren’t previously very familiar with medical publishing, and it has furthered one of the university’s priority initiatives: cross-campus collaboration.</p> <p> “The nice thing about the <em>MJM</em> story is that people who are not intimately involved with journal publishing or the curriculum can actually understand what we are doing and can appreciate it,” Dr. Markovac says. “That’s been the attraction across campus. It’s a good story that’s easy to tell.”</p> <p> <strong>For more on the Accelerating Change in Medical Education Consortium: </strong></p> <ul> <li> <a href="" target="_self">Treating the community as your patient</a></li> <li> <a href="" target="_self">Working upstream to achieve the quadruple aim</a></li> <li> <a href="">Physician wellness: A global collaboration</a></li> </ul> <p align="right"> <em>By AMA staff writer Tim Smith</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:f262a263-9795-458c-b663-5da2bc0ede0d Get the CPT® 2017 Standard edition Mon, 19 Sep 2016 20:00:00 GMT <p> The <em>CPT® 2017 Standard </em>codebook helps professionals remain compliant with annual Current Procedural Terminology code set changes. This is the AMA's official coding resource for procedural coding, rules and guidelines, which can help readers perform accurate claims submissions.</p> <p> It is designed to help improve CPT® code competency and assist professionals in complying with current CPT® code changes, enabling them to submit accurate procedural claims.</p> <p> The CPT® Standard codebook covers hundreds of code, guideline and text changes and features the following enhancements:</p> <ul> <li> <strong>A comprehensive and updated index</strong> helps you in locating codes related to a specific procedure, service, anatomic site, condition, synonym, eponym or abbreviation</li> <li> <strong>Anatomical illustrations</strong> aid coders in understanding the anatomy mentioned with the codes</li> <li> <strong>Alphabetical tabular listing of most analytes in the Pathology and Laboratory section</strong> eases your code search by directing you to applicable molecular pathology codes based on a specific analyte</li> <li> <strong>Increased granularity in Molecular Pathology</strong> improves your ability to assign the proper code for a laboratory procedure</li> </ul> <p> Other features include a summary of additions, deletions and revisions to previous editions, as well as multiple appendixes offering quick reference to resources covering such topics as modifiers, clinical examples, add-on codes and vascular families.</p> <p> AMA members receive a $27 discount on their order. Not an AMA member? <a href="" target="_self">Join today</a>.</p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:10aaee6d-4d88-4999-b355-cb06ec0c9963 Five ways to recognize patient cues, understand needs Mon, 19 Sep 2016 04:00:00 GMT <p> When physicians show true empathy while listening to their patients in the exam room, patients and their families are often more satisfied and more open to adopting their advice—and it builds a much stronger patient-physician relationship. Though it seems simple, empathetic listening requires understanding how to recognize the cues that patients offer.</p> <p> Practicing empathy can save time and help physicians navigate difficult situations that arise in practice. It can also forge deeper connections with patients that lead to greater professional satisfaction and joy in work for physicians.</p> <p> <strong>Listening with empathy, recognizing cues</strong></p> <p> Highly charged situations may arise in practice and those are the ideal times to use empathetic listening. A new <a href="" rel="nofollow">module</a> from the AMA’s <a href="" rel="nofollow">STEPS Forward™</a> collection of practice improvement strategies can help you become a better listener and get to the heart of your patients’ needs.</p> <p> Once you have decided that connecting with empathy is the best way to approach the patient, follow these steps to improve that skill:</p> <ul> <li> <strong>Honor the first “golden moments.”</strong> The first few minutes of a clinical encounter are precious. There are many tasks that need to be completed during the visit—questions to ask, problems to analyze and solve—and you may feel pressured to dive right in. But if you leap into these tasks without listening first, you may miss key information. Set aside charts, computers, phones, alarms and pagers that may be distractions so that you can give your full attention to the patient and find the golden moments that reveal the patients true concerns or symptoms. Use subtle body language cues to convey that you are listening intently. You can start by sitting so that you are near to and facing the patient. Lean toward them and make eye contact. It is important to make sure that your arms are not crossed—this can signal to the patient that you are closed off and not really listening.</li> </ul> <ul> <li> <strong>Listen for underlying feelings.</strong> Sometimes a patient’s feelings are on the surface, but other times they are hidden. A patient may bring up an emotional situation briefly and wait for the physician’s cue that it is okay to continue. Watch for feelings hidden in body language, facial expressions or other non-verbal cues and allow the patient to elaborate.</li> </ul> <ul> <li> <strong>Listen for underlying needs or values.</strong> Deep empathetic listening means being attuned to the underlying value or need that the emotion the patient is expressing is pointing to—for example, safety or security, honesty or integrity, autonomy or control, meaning or purpose, among many others.</li> </ul> <ul> <li> <strong>Remain present.</strong> Become comfortable with silence. Non-verbal body language such as an open and comfortable stance, eye contact, nodding your head or murmuring simple responses like “uh huh” or “oh” can show that you are listening without interjecting. Give the patient an opportunity to express feelings to completion. Their feelings and values will surface if they are given ample time to express themselves in a welcoming environment. Focus on the moments when the patient seems to display the most energy: more rapid speech, a change in facial expressions or more pronounced gestures. These signs can provide the clues to what the patient values most.</li> </ul> <ul> <li> <strong>Look for cues that the patient has finished.</strong> These cues might be a decrease in emotional intensity, a deep sigh or a shift in the focus of the conversation. At this point, it is natural to move to another stage of the communication process—either expressing yourself, attempting to solve a problem together or attending to the needed medical care needed.</li> </ul> <p> No one expects that you listen in this manner to all of your patients or coworkers all of the time. If you are new to empathetic listening, make it a goal to apply it with one person a day to learn how the process works best for you.</p> <p> Increasing administrative responsibilities due to regulatory pressures and evolving payment and care delivery models reduce the amount of time physicians spend delivering direct patient care. Training yourself to recognize emotional and body-language cues can help you defuse situations where a patient is dissatisfied or struggling to express themselves in a clear way.</p> <p> Check out the <a href="" rel="nofollow">module</a> for a more in-depth look at how the process of empathetic listening can improve your relationships with patients.</p> <p> There are seven new modules now available from the AMA’s STEPS Forward collection, bringing the total number of practice improvement strategies to 42, thanks to a grant from and collaboration with the Transforming Clinical Practices Initiative.</p> <p align="right"> <em>By AMA staff writer</em> <em><u>Troy Parks</u></em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:6dc90ace-b9ae-4d14-bf2e-01fcc75341c5 Being in attendance: Where medicine and meditation merge Mon, 19 Sep 2016 03:00:00 GMT <p> In a hospital setting, physicians are often called “attendings.” One expert in the merging of meditation and medicine recently spoke to physicians about the importance of making that word matter by being in attendance at each moment of the day to heal and maintain your own well-being so that you can be a better healer for your patients.</p> <p> At the start of a session at the International Conference on Physician Health in Boston, Jon Kabat-Zinn, PhD, professor of medicine emeritus and creator of the Mindfulness-Based Stress Reduction Clinic and the Center for Mindfulness in Medicine, Health Care, and Society at the University of Massachusetts Medical School, led attendees in a mindfulness activity from the first moment to “drop in on your own presence in your mind.”</p> <p> “Befriend the present moment, by befriending the feeling and the sensations of the breath moving in and out of your body, because it’s always here,” he said. “Without any contrivance, you’re not forcing anything to happen, you’re simply tuning in to what’s already happening.”</p> <p> “You’re not trying to achieve any special feeling,” he said, “you’re simply attending … the present moment is really the only moment we are ever inhabiting.”</p> <p> Focusing on joy in practice, the conference brought together the best minds around the globe with attendees and presenters from the United Kingdom, Norway, New Zealand, Canada and the U.S., just to name a few.</p> <p> “It’s not merely work-life balance, which some people have the idea that there’s some magical work-life balance and if I only get that formula then it will all fall together for me,” Dr. Kabat-Zinn said. “There’s only life. And so if you don’t bring your life to work, there’s no life in work; and when you get home you have no energy for life either so we’re talking about one seamless whole.”</p> <p> “What is healing? My working definition of healing is coming to terms with things as they are,” he said. “It’s a process. You can, sooner or later, come to terms with the actuality of things … as they are, not as I want them to be, not as if we could magically fix them, but now.”</p> <p> “And it turns out that when you do this you recruit a seemingly infinite array of interior capacities and capabilities and intelligences that very often we have no idea that our mind thinks.”</p> <p> <strong>The most important muscle to exercise</strong></p> <p> Everyone needs to exercise and physicians offer that advice to their patients all the time. But the most important muscle to exercise is the muscle of your own presence of mind, Dr. Kabat-Zinn said. “ It’s the muscle of living the life that’s yours to live and living it in a way that’s ethical, that is generous and that is clear.”</p> <p> Burning yourself out by helping everybody else and ignoring where the source is coming from is not the way to wellness, he said. “Medicine and meditation—if you notice they kind of sound a little alike,” he said. “We now know about the plasticity of not just the brain but of the entire organism … medicine and meditation are linked at the etymological core. Meditation can actually transform your brain.”</p> <p> Dr. Kabat-Zinn started practicing meditation when he was a student at the Massachusetts Institute of Technology (MIT). “I had to, to survive MIT,” he told the audience. “It wasn’t optional. It was either protect my own mind or it would be consumed by the stuff going on.”</p> <p> Then he brought out his meditation cushion and sat comfortably on a table top on the stage.</p> <p> <strong>Just remove the arrow</strong></p> <p> “I want you to know that this is a behavior change,” he said. “You have to be willing to carve out 45 minutes a day, at least, 6 days a week. Who’s got time for that? The important thing is that the quality of our doing and the quality of joy that we can experience isn’t some kind of magical pot of gold at the end of some rainbow. It’s completely integrated into every aspect of life unfolding.”</p> <p> Thinking too much about where you’re going, where you’ve been, what could happen and what you want to happen can block your ability to be present—to be in attendance, he said. “Most of what we tell ourselves is not true and it seriously compounds the suffering.”</p> <p> “The Buddha actually recognized that … let’s say you get shot by an arrow,” he said. “Instead of taking out the arrow or addressing the how to do that, you actually want to know who shot it and why, where it came from, what the kind of wood it was, what the kind of feathers are—but wait a minute, now you’re shooting yourself with another arrow.”</p> <p> “Let’s say there’s an earthquake or a death in the family—that happens,” he said, “it’s part of life. How are we to deal with it? Well, if you shoot yourself with the other arrow of ‘you’re to blame for this yourself, nobody’s any good, I’m not any good’—do you hear that narrative? That’s what’s going on in the mind over time and it’s toxic.”</p> <p> <strong>How to get started</strong></p> <p> Practicing meditation has nothing to do with your posture, Dr. Kabat-Zinn said. You can do it lying down, sitting, standing, walking, running, chopping vegetables, in a chair, on the floor—as long as you’re being mindful and present in the moment it will be effective. There is no time when you are awake in which it is wrong to be present: to be fully awake.</p> <p> Often your mind seems to be “not getting with the program” right off the bat, he said. But each thought and emotion that comes is valid and must be recognized and allowed to pass.</p> <p> How do you overcome the overwhelming amount of thoughts that occupy your mind? “One way is to exercise the muscle, and that means practice,” Dr. Kabat-Zinn said. “You make time. I do it early in the morning before the day starts. You can even do it in bed, there’s no excuse.”</p> <p> Even if you’re anxious, being aware of your anxiety is in itself being present. Investigate that awareness. Do it for five minutes, ten minutes or an hour.</p> <p> “Play, not work, but play at the joy of being who you already are,” he said. “From the point of view of joy … it’s here already if we can only get out of our own ways.”</p> <p align="right"> <em>By AMA staff writer </em><a href="" rel="nofollow"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:3a0842a0-d598-4b81-aef6-3b2e9f6de126 Court overturns physical therapy decision Fri, 16 Sep 2016 03:00:00 GMT <p> A positive decision for patients Thursday was made in the South Carolina Supreme Court to allow physician practices to employ physical therapists, ending a longstanding disagreement regarding how the practice of physical therapy should be regulated in the state.</p> <p> At stake in <em>Joseph v. South Carolina Department of Labor</em>, was whether physical therapists in South Carolina can provide treatment as direct employees of physicians to make that service more easily available for patients. The ruling: Physicians in South Carolina can now employ physical therapists in their practice.</p> <p> “This patient-centered decision from the Court supports our contention that integrated physical therapy services can be in the best interest of patients when handled ethically and in compliance with existing self-referral restrictions,” the South Carolina Orthopaedic Association said in a <a href="" target="_blank" rel="nofollow">statement</a>.</p> <p> <strong>What led to the overturn</strong></p> <p> The South Carolina Board of Physical Therapy has long sought to require physical therapists to provide their services directly to patients or through a practice group of physical therapists. However, other licensed health care professionals such as occupational therapists, speech pathologists and nurse practitioners may be employed by physicians in the state.</p> <p> In 2006, the South Carolina Supreme Court ruled in <em>Sloan v. South Carolina Board of Physical Therapy</em> that the state’s Physical Therapy Practice Act prohibited physical therapists from working in a physician’s office and providing physical therapy to the physician’s patients through what are referred to as “in-practice referrals.”</p> <p> The decision caused many problems for patients, physicians and physical therapists, changing the way physical therapy was practiced in South Carolina and making it more difficult for patients to access physical therapy services. That decision was overruled Thursday, allowing physical therapists to work directly with physicians to provide their services to patients.</p> <p> “In Sloan, this Court interpreted … the South Carolina Code as prohibiting a physical therapist from being employed by a physician when the physician refers patients to the physical therapist for services,” the Court said in the decision. “Contrary to that decision, we now find that the classification, which distinguishes physical therapists from other licensed health care professionals, has no rational relationship to the legislative purpose of the statute.”</p> <p> The <a href="" target="_self">Litigation Center of the AMA and State Medical Societies</a> and the South Carolina Medical Association jointly supported the plaintiffs, who were a physical therapist and two orthopedic surgeons. The now overruled <em>Sloan </em>decision had unnecessarily burdened patients’ access to health care services—an obstruction which the Litigation Center has worked hard to overcome.</p> <p align="right"> <em>By AMA staff writer</em> <a href="" target="_blank" rel="nofollow"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:a209e2df-8748-4836-9fd3-a3217bf3a9e1 Salary comparison reminds residents: Plan now Wed, 14 Sep 2016 21:00:00 GMT <p> An infographic comparing the incomes of physicians and teachers underscores the need for comprehensive financial planning early in physicians’ careers. <a href="" rel="nofollow" target="_blank">“The Deceptive Salary of Doctors,”</a> published by, pulls data from the Association of American Medical Colleges, the Bureau of Labor Statistics and numerous other sources to demonstrate the huge costs of becoming a physician and maintaining a practice.</p> <p> It draws a stark conclusion: Over a lifetime, physicians make less per hour than teachers do. After loan debt, physicians can expect to make a little more than $4.7 million in their careers; teachers, a little less than $2.4 million. But physicians will work almost twice as many hours.</p> <p> The real value of the graphic, however, lies not as much in comparing the two professions as in providing a reminder that, with physicians’ working so many hours, they can easily overlook adequate financial planning that can make life easier later in their careers.</p> <p> Residents in particular need to prioritize financial preparedness. Although many enjoy a huge jump in income from their student years, a 2015 study by AMA Insurance found that 71 percent of young physicians feel somewhat or not very knowledgeable about financial planning.</p> <p> <em>AMA Wire®</em> regularly features financial planning advice for young physicians. Several resources can help you get ahead on financial planning for the future:</p> <ul> <li> <a href="" target="_self">What you need to do now to secure a firm financial future</a></li> <li> <a href="" target="_self">5 financial planning tips every young physician should know</a></li> <li> <a href="" target="_self">What you need to know to negotiate your first employment contract</a></li> <li> <a href="" target="_self">6 tips for living on a budget during training</a></li> </ul> <p> Check back soon for takeaways from the <a href="" rel="nofollow" target="_self">2016 Report on U.S. Physicians’ Financial Preparedness</a> from AMA Insurance.</p> <p align="right"> <em>By AMA staff writer Tim Smith</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:c47fceed-480c-4eea-8256-4da072ce7f1b Parental leave in GME: Two physicians recognized for research Wed, 14 Sep 2016 15:00:00 GMT <p> Two physicians will conduct one of the first studies in more than 20 years on present-day parental leave across medical specialties in graduate medical education (GME). They were awarded the Joan F. Giambalvo Fund for the Advancement of Women grant for their work, announced Wednesday in conjunction with Women in Medicine Month.</p> <p> The AMA <a href="" target="_self">Women Physicians Section</a> (WPS) hosts <a href="" target="_self">Women in Medicine Month</a> each September to acknowledge pioneering women, celebrate their accomplishments and help cultivate future women physicians. The <a href="" target="_self">Joan F. Giambalvo Fund for the Advancement of Women</a> was established by the AMA-WPS and the <a href="" target="_self">AMA Foundation</a> to offer funding specifically for health care researchers to identify and address the issues that affect women physicians and medical students.</p> <table align="right" border="0" cellpadding="1" cellspacing="15" style="width:365px;"> <tbody> <tr> <td> <a href="" target="_blank"><img src="" style="width:200px;height:300px;" /></a></td> <td> <a href="" target="_blank"><img src="" style="width:200px;height:300px;" /></a></td> </tr> <tr> <td> <em><span style="font-size:10px;">Shobha W. Stack, MD, PhD</span></em></td> <td> <em><span style="font-size:10px;">Jennifer Best, MD</span></em></td> </tr> </tbody> </table> <p> The winners of this year’s award are Shobha W. Stack, MD, PhD, and Jennifer Best, MD, acting instructor and associate professor, respectively, in the Department of Medicine at the University of Washington. They are the principal investigators for the research project, “Childbearing among physicians in training: A cross-sectional survey of trends and factors.”</p> <p> <strong>Investigating the factors that influence parental leave</strong></p> <p> About 40 percent of physician trainees <a href="" target="_self">plan to have a child during their GME training</a>, a study in the July issue of Academic Medicine found. Drs. Stack and Best have dug into a more focused aspect of family building in their research.</p> <p> Leading up to their study, Drs. Stack and Best found that, in 1983, 50 percent of children born to women physicians were born during residency training. A 1993 survey showed that the average trainee maternity leave was less than eight weeks. Yet, there was no concurrent assessment of the consequences of leave to the residents or the training programs.</p> <p> “The primary aims of our study are to characterize parental leave practices across specialties, determine the factors that influence its length and assess the effect of parental leave on trainee well-being and the training environment,” Dr. Stack said.</p> <p> “I have been deeply interested in the issues that women face in medical training since undergoing my own postgraduate years as a new mother,” Dr. Stack said. “With the help of the Giambalvo research grant, we will conduct the first study in more than 20 years specifically addressing present-day parental leave across medical specialties in graduate medical education.”</p> <p> “We are very grateful to the AMA’s Women Physicians Section for granting us the joint Giambalvo award, but more importantly for prioritizing this research that we hope will create a more sustainable environment for women in medicine,” Dr. Best said.</p> <p> The state of women in medicine is changing. In 2010, women accounted for more than half of the population—meaning female patients are the majority–yet women are still underrepresented in medicine, making up one-third of the physician workforce. But now almost one-half of students and residents are women.Learn more about how the AMA aims to increase the number and influence of women physicians in leadership roles through the AMA <a href="" target="_self">Women Physicians Section</a>.</p> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:ec09df34-b0a4-458a-8935-5a9e2d4720ed Physician efforts to reverse opioid epidemic quantified Wed, 14 Sep 2016 03:00:00 GMT <p> When patients present with issues, physicians look to the most effective tools for treatment. The same is true in addressing an epidemic. While much more work remains to reverse the nation’s opioid epidemic, using tools such as prescription drug monitoring programs (PDMP), medication-assisted treatment and naloxone, physicians are making progress. A new fact sheet provides some evidence of that progress on a number of fronts.<a href="" target="_blank"><img src="" style="height:1500px;margin:15px;float:right;width:318px;" /></a></p> <p> <strong>Focused prescribing practices</strong></p> <p> In a fact sheet released by the AMA, <a href="" target="_blank">physicians’ progress to reverse the nation’s opioid epidemic</a> was quantified showing new trends in the use of available tools. The data was collected from AMA surveys, IMS Health, the Drug Enforcement Administration Office of Diversion Control (DEA), the Substance Abuse and Mental Health Services Association (SAMHSA), the Centers for Disease Control and Prevention (CDC), and the American Journal of Public Health.</p> <p> In October 2015, the AMA and many medical and other health care organizations <a href="" rel="nofollow" target="_blank">joined</a> the President in Charleston, W.Va., to commit to clear metrics to reduce the nation’s opioid epidemic. Though there is still more to be done, the numbers show some progress.</p> <p> Every state in the nation saw a reduction in opioid prescribing in 2015, which amounted to a 10.6 percent decrease nationally, IMS Health reported. Though these decreases are important, physicians need to ensure that patients with pain receive comprehensive—and compassionate—treatment. While the nation’s opioid supply will almost certainly continue to decrease, providing patients with a full range of evidence-based, non-opioid and non-pharmacologic treatments becomes crucial.</p> <p> PDMP use can play a significant role in combating the epidemic. These tools contain information on whether a patient is receiving multiple prescriptions from multiple pharmacies and can be helpful in clinical decision-making. State-based PDMPs were checked nearly 85 million times in 2015, a 40 percent increase over 2014, an AMA survey found.</p> <p> Several states recently implemented PDMPs, including Pennsylvania in August. Registering for these tools is critical to reversing the opioid epidemic and has been a recommendation of the AMA’s <a href="" target="_self">Task Force to Reduce Prescription Opioid Abuse</a> since its conception in 2014.</p> <p> Registration for PDMPs increased by over 150,000 physicians and other health care professionals nationally from 2014 to 2015 and these increases were seen in states with and without mandated PDMP use. </p> <p> “Physicians and other health care professionals have increased their <a href="" target="_self">use of the state’s [PDMP] every year</a>,” said Patrice A. Harris, MD, chair of the AMA Board of Trustees and the AMA Task Force to Reduce Prescription Opioid Abuse in <a href="" rel="nofollow" target="_blank">The Olympian</a>. “We need to address opioid addiction and overdose across the entire spectrum, from prevention to treatment.</p> <p> <strong>Education and medication assisted treatment increases</strong></p> <p> Between 2012 and 2016, the nation saw an 81 percent increase in physicians certified to treat substance use disorders, data from the Substance Abuse and Mental Health Services Association (SAMHSA) showed. That’s more than 33,000 physicians across all 50 states.</p> <p> Medication-assisted treatment, such as buprenorphine, can help patients with opioid use disorders recover safely and stick to their recovery plans. Prescriptions to help treat opioid use disorder increased by 11 percent from 2014 to 2015. These medications are becoming more common as substance use disorders are recognized as a chronic disease and not a moral failing.</p> <p> The AMA survey also showed that nearly 50,000 physicians had participated in educational activities related to opioid prescribing, pain management or other related areas since October 2015. The AMA will soon release continuing medical education tools including a primer on the opioid epidemic and two state-specific physician toolkits in Rhode Island and Alabama in cooperation with the state medical associations and governors’ offices. The toolkits will highlight key resources to help reduce opioid-related harm, provide guidance on prescribing practices and direct patients to additional resources in these states.</p> <p> <strong>Naloxone helps reduce overdose</strong></p> <p> Fifteen states saw reductions in the number of overdose deaths in 2014 compared to 2013. These reductions occurred in the midst of increased co-prescribing of naloxone, <a href="" target="_self">the life-saving opioid overdose reversal antidote</a>. The second quarter of 2015 saw a massive 1,170 percent increase in naloxone prescriptions over the fourth quarter of 2013.</p> <p> “Naloxone can and will save lives, and while co-prescribing the drug is important, it’s simply not enough,” Dr. Harris said in an <a href="" rel="nofollow" target="_blank">op-ed for TribTalk</a>. “Naloxone must be accessible and affordable. For this to happen, insurers must cover the medication and offer it to individuals at a reasonable price.”</p> <p> The physician role in the epidemic is an important one—and the physicians of the nation are recognizing that role and taking it on with vigor, as the numbers show. There is still much to be done, but the effort and motivation is there.</p> <p> The AMA and other organizations have long been pressing for state legislation to increase access to naloxone and, as of today, more than 45 states have naloxone access laws.</p> <p> <strong>For more on physician efforts to reverse the opioid overdose epidemic:</strong></p> <ul> <li> <a href="" target="_self">How to talk about substance use disorders with your patients</a></li> <li> <a href="" target="_self">Physicians team up to treat addiction in rural areas</a></li> <li> <a href="" target="_self">Entire state gets one naloxone prescription</a></li> <li> <a href="" target="_self">How naloxone can be a way to start the broader conversation about risk</a></li> </ul> <p align="right">  </p> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:2b4e1ff5-c457-4c86-ad2a-58d22c8d7f7e Meaningful Use gets a meaningful change: 90-day reporting Tue, 13 Sep 2016 04:00:00 GMT <p> The Centers for Medicare and Medicaid Services (CMS) have issued a proposed change that would make Meaningful Use more flexible for physicians by allowing them to report only for a 90-day period in 2016. Also included in the change is a hardship exemption for first time Meaningful Use participants to report once in 2017 to satisfy both Meaningful Use and the Advanced Care Information (ACI) performance category in the upcoming Merit-based Incentive Payment System (MIPS).</p> <p> Physicians have long called for the Meaningful Use program to be more flexible. In its <a href="" rel="nofollow" target="_blank">Outpatient Prospective Payment System proposed rule</a>, CMS announced it may grant a 90-day reporting period for Meaningful Use for 2016, rather than maintaining the current full-year reporting period, which will make it less difficult for physicians who are currently experiencing a number of other practice changes, including:</p> <ul> <li> Making the required system changes to certified electronic health record technology</li> <li> Implementing a new application programming interface to comply with Stage 3</li> <li> Preparing for a transition to the MIPS program in 2017 under the Medicare Access and CHIP Reauthorization Act (MACRA)</li> </ul> <p> Yet, there is still one major concern. The proposed change to the reporting period may not be finalized until November, which would leave physicians with less than 90-days left in the year to report on—which is exactly what happened last year when the policy was not finalized until after the start of the final reporting period so many physicians were not able to take advantage of the additional flexibilities.</p> <p> In a <a href="" target="_self">comment letter to CMS</a>, the AMA recommended that CMS issue guidance notifying physicians of the 90-day reporting period and begin educating physicians about the change as quickly as possible so they will still have enough time.</p> <p> The lack of alignment between Meaningful Use and the Physician Quality Reporting System (PQRS) in 2016 is also cause for concern. “If a physician would like his or her Meaningful Use electronic clinical quality measure requirement to count towards PQRS,” the AMA said in the comments, “the physician must report for a full 2016 calendar year, as opposed to taking advantage of the flexible 90-day reporting period.”</p> <p> To address this concern, CMS should allow the Meaningful Use 90-day reporting period to count toward successfully reporting quality for both PQRS and the Meaningful Use in 2016.</p> <p> CMS has made several other changes in the past two weeks. One gives physicians <a href="" target="_self">more flexibility and allows for an easier transition to MACRA in its initial year</a>. The other—changes to the Medicare Physician Fee Schedule—holds <a href="" target="_self">several positive changes but still needs some work</a>.</p> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:9830da24-c6e4-412b-8527-e44a4fdc3d65 Ethics and interprofessionalism in medical education Mon, 12 Sep 2016 21:00:00 GMT <p> According to a 2015 Institute of Medicine report, interprofessional education (IPE) happens when health professions trainees learn, “with, from, and about each other to improve collaboration and the delivery of care.” Examine how IPE is benefiting physicians, students and patients and informing the ethics of collaboration for enhanced educational opportunities.</p> <p> The <a href="" target="_self">September issue</a> of the <em>AMA Journal of Ethics®</em> considers the roles of medicine in motivating the clinical and ethical benefits of interprofessionalism for physicians, other health professionals and patients. Articles featured in this issue include:</p> <ul> <li> “<a href="" target="_self">Teamwork in Health Care: Maximizing Collective Intelligence via Inclusive Collaboration and Open Communication.</a>” Teams are smartest when everyone feels free to speak up, and they function best when leadership is inclusive and patient-focused. Review research from the field of organizational behavior that sheds light on what makes for a collectively intelligent team.</li> </ul> <ul> <li> “<a href="" target="_self">Interprofessional Training: Not Optional in Good Medical Education.</a>” Interprofessional collaboration is a vital part of medical education, and teamwork will only become more important as physician shortages continue and medical care becomes more complex. When a medical student resists learning from a nurse-midwife on a rotation, how should a faculty member respond?</li> </ul> <ul> <li> “<a href="" target="_self">Decentering the Doctor: The Critical Value of a Patient Care Collective.</a>” Rehabilitation environments are cross-disciplinary, enabling patients to show rather than tell physicians what they can do, which helps remove barriers to rehabilitation. Find out what one physician learned in a hospital playroom about rehabilitation, interprofessional collaboration and patient-centered service delivery.</li> </ul> <ul> <li> “<a href="" target="_self">Overcoming Historical Separation Between Oral and General Health Care: Interprofessional Collaboration for Promoting Health Equity.</a>” Health equity can benefit from physician-dentist collaboration. Check out next steps for integrating oral and general health care.</li> </ul> <p> In the journal’s <a href="" target="_self">September podcast</a>, Lachlan Forrow, MD, associate professor of medicine at Harvard Medical School, discusses the benefits of interprofessional collaboration and the importance of biopsychosocial approaches to patient care.</p> <p> <strong>Take the ethics poll</strong></p> <p> <a href="" target="_self">Give your answer</a> to this month’s poll: True or false? Medical students being taught only by physicians is an indicator of the highest quality medical education.</p> <p> <strong>Submit an article</strong></p> <p> The journal’s editorial focus is on commentaries and articles that offer practical advice and insights for medical students and physicians. <a href="" rel="nofollow" target="_self">Submit your work</a> for publication.</p> <p align="right"> <em>By AMA staff writer Tim Smith</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:1d92dad9-ccf3-4cfc-8365-5d5035e011b1 Medicare fee schedule proposed rule needs work Fri, 09 Sep 2016 21:39:00 GMT <p> Physicians last week submitted comments to the Centers for Medicare and Medicaid Services (CMS) on its proposed rule to revise the Medicare Physician Fee Schedule and Part B. Some of the provisions align with physicians’ previous recommendations while others will require some changes, especially those that mean more costs for patients and undercut the Medicare Access and CHIP Reauthorization Act (MACRA).</p> <p> The AMA last week <a href="" target="_self">submitted a letter to CMS</a> urging changes throughout the proposed rule while also citing areas of agreement that should be finalized.</p> <p> Three of the proposed policies that physicians recommended changes to include:</p> <ul> <li> <strong>Collecting data on every 10-minute increment of patient care activities before and after each surgery or procedure.</strong> CMS proposed a new series of eight G-codes intended to collect data on the pre- and post-operative activities in 10- and 90-day global services.  The G-codes are based on place of service, complexity of patient, and completion time. Asking physicians and their staff to use 10-minute increments to document all their non-operating room patient care activities is by itself an incredible burden, and especially so during MACRA implementation—the most significant payment system change in 25 years.<br /> <br /> A significant weakness with these G-codes is the inability to match them with the E/M services assumed to be bundled in the current global surgical package.<br /> <br /> “Layering on a new regulation that requires reports based on 10-minute increments of service would <a href="" target="_self">burden physicians already attempting to comply with existing regulations</a> that require them to spend too much time with record keeping and too little with patients,” said AMA President Andrew W. Gurman, MD.<br /> <br /> The AMA and the RUC recommended that the data collection process should not include all services, as many surgical global codes are low volume which would make it difficult to find a meaningful sample, and urged CMS to adopt a data collection method that is limited in scope and uses a representative sample to better understand the necessary post-operative visits.</li> </ul> <ul> <li> <strong>Creating an add-on payment for services provided to patients with mobility-related disabilities.</strong> CMS proposed a new add-on code that would add a $44 fee for services rendered to patients with mobility-related disabilities. This proposal raises program integrity questions, creates unequal coverage for care of disable patients, and increases out of pocket costs for patients with disabilities. Based on the $44 add-on payment for physicians, patients with mobility-related disabilities would have an additional $9 copayment each time special equipment is required during a visit.<br /> <br /> CMS intends to fund the new add-on payment by eliminating the physician payment increase that Congress provided for 2017 in the MACRA legislation.<br /> <br /> The AMA and the Specialty Society RVS Update Committee (RUC) have offered to work with CMS to develop a more appropriate solution.</li> </ul> <ul> <li> <strong>Changing quality measures used to assess Accountable Care Organization (ACO) performance.</strong><span style="font-size:12px;"> </span>There are significant issues with CMS’ proposals to change the ACO quality measures and the risk adjustment model used by CMS for some of these measures.<br /> <br /> Physicians also urged CMS to avoid overly prescriptive regulations for ACOs’ use of health information technology and, instead, to recognize that ACOs are best equipped to improve the health of their patients when they are able to utilize health information technology in ways that best and most effectively meet the needs of those patients.</li> </ul> <p> The letter submitted to CMS also detailed several areas where physicians were in agreement with the proposal, including:</p> <ul> <li> <strong>Improved payment accuracy for primary care, care management, and patient-centered services</strong>. Specifically, the letter supported a separate payment for non-face-to-face prolonged Evaluation and Management services, separate payments for services furnished using the Psychiatric Collaborative Care Model, the implementation of other codes in the CPT family of Chronic Care Management services, and a separate payment to recognize the work of a physician in assessing and creating a care plan for beneficiaries with cognitive impairment. </li> </ul> <ul> <li> <strong>Expansion of the Diabetes Prevention Program. </strong>The letter commended CMS’ proposal to expand coverage of the Medicare Diabetes Prevention Program (DPP) model to Medicare patients at risk of developing type 2 diabetes. This expansion will help at risk seniors and people with disabilities lower their risk factors and prevent their condition from advancing.<br /> <br /> "CMS has offered a comprehensive approach in the new proposal—and some of it hits and some of it misses,” Dr. Gurman said. “The programmatic changes for prediabetes are exactly right."</li> </ul> <ul> <li> <strong>Addition of new telehealth codes. </strong>Physicians expressed their support for the new codes and asked CMS to develop a far more expansive set of strategic proposals that are cohesive and forward-looking in order to expand coverage and access to telehealth services for Medicare beneficiaries.</li> </ul> <p> The comment period for the proposed rule closed on Sept. 6. The AMA and RUC will continue working with CMS to make sure that these recommendations are finalized in a way that is beneficial for both physicians and their patients without adding unnecessary burdens and regulations to patient care processes.</p> <p> CMS has published a <a href="" rel="nofollow" target="_blank">fact sheet</a> that summarizes the proposed rule.</p> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:cc755e8a-13e9-44c7-9bc9-4464725ec44a Treating the community as your patient Fri, 09 Sep 2016 21:00:00 GMT <p> Community health intervention can be a highlight of medical school for many students. But what differentiates successful programs from unsuccessful ones? Students with experience in both recently shared their thoughts, with advice distilled down to a simple concept: Listen to your community as you would an individual patient.</p> <p> The students were from Morehouse School of Medicine, in Atlanta, which offers a first-year Community Health course. They were speaking to medical and health professions students at the student-led Health Equity and Community-based Learning meeting, hosted by the University of California, Davis, School of Medicine, which is part of the AMA’s <a href="" rel="nofollow" target="_self">Accelerating Change in Medical Education Consortium</a>.<a href="" style="font-size:12px;" target="_blank"><img src="" style="float:right;margin:15px;" /></a></p> <p> One of the presenters, Stephany Rush, began by underscoring the need for the course—that good intentions alone won’t produce successful interventions.</p> <p> Rush had previously taken part in a private community service project that involved building community gardens in Atlanta. She and others on the project thought gardens were an obvious answer to some of the community’s most visible problems—poor diet and lack of access to healthy foods.</p> <p> “At the end of it, one lady, she came up to me and [asked], ‘What is this?’” Rush recalled.</p> <p> “This is a zucchini,” she replied.</p> <p> “I’ve never eaten this before,” the woman said. “I don’t even know how to cook this. What do I do with this?”</p> <p> Rush and her partners on the project realized then that they hadn’t truly listened to the community during their assessment and that the gardens were, in fact, not the right intervention.</p> <p> <strong>Identifying the community’s chief complaint</strong></p> <p> So what, then, typifies the right intervention? The other presenter, Collin Shumate, explained that students have to resist the urge to decide paternalistically what a community should want.</p> <p> “You’re treating the whole community as your patient,” he said. “So if you do a history and physical exam on a real person, you take stock of what ails them. In the same way, we’re looking for strengths and weaknesses of the community and what they need. What’s their chief complaint?”</p> <p> The Community Health course is taught by many of the same experts who teach in Morehouse’s Master’s in Public Health program. While medical students spend a year partnered with communities, their professors partner with sites, which are often day-care centers, homeless shelters and senior-living facilities, over several years to ensure continuity and facilitate longer-term interventions.</p> <p> Each intervention starts with a “windshield survey.” This is a walk or drive around the community to note a variety of social, environmental and economic factors, including ease of access to public transportation and the retail mix—whether there are more liquor stores than healthy grocery stores, for example—the state of housing, sidewalks and roads and the types of people one sees on the street, including children and the elderly.</p> <p> The survey helps drive interviews with key community members, people who grew up in the area or have lived in it for many years. If the community site is an elementary school, for example, students will interview not just teachers and principals but also parents, janitors and anybody who spends significant time there. The goal is to reveal what’s going on in the community beneath the surface and what its residents feel are their greatest needs.</p> <p> The results of the interviews are then taken to focus groups, where students have their findings evaluated and either confirmed or denied by members of the community.</p> <p> “At the end of these assessments, we have a composite of what the community has told us are the needs,” Rush said. “It’s interesting because, from the windshield surveys, we kind of have an idea of what we think, and it’s always totally different by the time we finish the focus groups what the communities tell us that they need.”</p> <p> <strong>When the intervention meets the community’s needs</strong></p> <p> To illustrate this point, Rush and Shumate broke the students into groups to discuss three case studies of community sites drawn from the Morehouse course: an early learning center, a senior living center and a homeless shelter.</p> <p> The groups worked through the various stages of needs assessments and were able to see, in each case, how different a community’s needs might appear from the perspectives of the windshield survey, the key interviews and the focus groups.</p> <p> Shumate noted, for example, that he initially saw his community as a food desert, but community members didn’t report that as their chief complaint. They were more concerned with mental health issues and the availability of helpful resources and social support.</p> <p> So instead of implementing an intervention consisting of community gardens or healthy food trucks, the community instead opted for a combination of parent social activities, a community resource guide with family, financial and health resources, stress management modalities and frequent blood pressure checks.</p> <p> The goal of all the interventions was two-fold—to improve health outcomes in the community and to concretize for students some of the concepts at the heart of the movement to change how medicine is taught and practiced in America.</p> <p> “Some people focus on the word disparities,” Shumate said, paraphrasing one of his professors. “But we want to focus on equity.”</p> <p> <strong>For more on the student-led meeting: </strong></p> <ul> <li> <a href="" target="_self">Working upstream to achieve the quadruple aim</a></li> <li> <a href="" target="_self">Death by ZIP code: When address matters more than genetics</a></li> <li> <a href="" target="_self">Students deliver care in homes, communities</a></li> </ul> <p align="right"> <em>By AMA staff writer Tim Smith</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:eeeb6b6e-e123-4f81-a535-46a2572cd1b8 MACRA penalties can now be avoided, CMS says Fri, 09 Sep 2016 01:00:00 GMT <p> Avoiding penalties under the Medicare Access and CHIP Reauthorization Act (MACRA) just got easier. The Centers for Medicare and Medicaid Services (CMS) Acting Administrator Andy Slavitt Thursday announced that the final MACRA regulation will exempt physicians from any risk of penalties if they choose one of three distinct reporting options in 2017.</p> <p> In a <a href="" rel="nofollow" target="_blank">blog post</a>, Slavitt announced that CMS heard physicians’ concerns about the proposed start date for performance reporting under the new Medicare payment system and that the agency will offer three reporting options for the Merit-based Incentive Performance System (MIPS)—and if you choose one for 2017, you will not receive a negative payment adjustment in 2019.</p> <p> The options will be described fully in the final rule, but here are the basics:</p> <ul> <li> <strong>Option one: Test the program</strong><br /> As long as you submit some data to the Quality Payment Program, including data from after Jan. 1, you will avoid a negative payment adjustment, Slavitt said. This option is intended to ensure that the system is working and that physicians are prepared for broader participation in the coming years as they learn more.</li> </ul> <ul> <li> <strong>Option two: Partial-year reporting</strong><br /> Physicians can choose to report Quality Payment Program information for a reduced number of days. Your first performance period could begin well after Jan. 1 and your practice could still qualify for an incentive payment.<br /> <br /> Slavitt offered an example. “If you submit information for part of the calendar year for quality measures, how your practice uses technology and what improvement activities your practice is undertaking,” he said, “you could qualify for a small positive payment adjustment.”</li> </ul> <ul> <li> <strong>Option three: Full-year reporting</strong><br /> If your practice is ready to get started on Jan. 1, you can choose to report Quality Payment Program information for the full calendar year. Your first performance period would begin on Jan. 1, and if you submit information for the entire year your practice could qualify for a modest positive payment.</li> </ul> <ul> <li> <strong>Advanced Alternative Payment Model (APM) option. </strong><br /> This option is still available and qualified participants in advanced APMs will be eligible for five percent incentive payments in 2019.</li> </ul> <p> Choosing any of these options guarantees that you will not receive a negative payment adjustment.</p> <p> The announcement confirms that physician input is playing a critical role in the development of the final MACRA rule. Slavitt stated his appreciation for the constructive participation of physicians in the feedback process and added that CMS looks forward to further engagement with physicians to make sure the new Medicare payment system works for everyone, including patients.</p> <p> "By adopting this thoughtful and flexible approach, the Administration is encouraging a successful transition to the new law by offering physicians options for participating in MACRA,” said AMA President Andrew W. Gurman, MD, in a <a href="" target="_self">statement commending Slavitt and Department of Health and Human Services Secretary Sylvia Mathews Burwell</a>.</p> <p> “This approach better reflects the diversity of medical practices throughout the country,” he said. "The AMA believes the actions that the Administration announced today will help give physicians a fair shot in the first year of MACRA implementation.”</p> <p> This kind of flexibility is what physicians were seeking throughout the draft rule comment period—and now it is a reality. The only way to receive a negative payment adjustment now is by not participating at all.<br /> <br /> More resources and tools are provided by the AMA are available to <a href="">help your practice navigate Medicare payment reform.</a></p> <p align="right"> <em>By AMA staff writer <a href="" rel="nofollow" target="_blank">Troy Parks</a></em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:e129fc02-02aa-4e02-ad5c-5ab5cfeb627f Report reveals complexities of GME reform Wed, 07 Sep 2016 22:41:00 GMT <p> Graduate Medical Education (GME) is in need of changes that address the rapidly changing health care system and to better prepare physicians-in-training for the future. A new report asked physicians, residents and other stakeholders from around the nation to identify GME-related issues or concerns.</p> <p> A recent <a href="" rel="nofollow" target="_blank">report</a> from the Association of Academic Health Centers brings together the input of physicians and residents, several medical societies, accreditation bodies, regional experts and other organizations with GME interests to discuss the current state of GME and what changes could be made to meet future health care needs.</p> <p> <strong>What needs to change about GME</strong></p> <p> The roundtable discussions had similar themes across the board and pointed out the specific areas where changes to the structure and strategy of GME could lead to enhanced residency programs and better prepared physicians.</p> <p> Here are six of the themes that appeared in the discussions:</p> <ul> <li> <strong>Organizational conflict between teaching hospitals and medical schools.</strong> Because teaching hospitals are the recipients of most Medicare GME funding, conflict between those hospitals and the medical schools responsible for the teaching and accreditation of the programs was a key factor throughout the roundtables.<br /> <br /> Participants identified a clear lack of alignment in organizational missions, a lack of transparency in approaches and disparate yet overlapping areas of responsibility.<br /> <br /> “The overall funding of GME may need to be changed in order to adequately address the organizational conflict,” the report said.</li> </ul> <ul> <li> <strong>Private sector influence on the health care system.</strong> Roundtable participants said that market forces are driving a lot of the changes in the health care system, yet they also stated they feel unfamiliar or disconnected with entrepreneurial activity being done that will impact GME training programs.<br /> <br /> There was also recognition that entrepreneurs in the private sector could be very helpful in filling some of the training gaps where current programs do not have appropriate expertise or time to provide additional training. Learning from the private sector could enhance GME programs.</li> </ul> <ul> <li> <strong>Mental health and well-being of residents.</strong> Issues of mental health and wellness were identified in all discussions and residents were recognized as having an increased desire for confidential and easily accessed mental health resources in recent years. Factors contributing to this problem were also identified and include limited time off, increased responsibilities with fewer resources, threatened job satisfaction and more stress.<br /> <br /> <a href="">Wellness programs</a> were recognized as a critical and currently lacking component of GME programs for both faculty and residents.</li> </ul> <ul> <li> <strong>Revisions to program and accreditation structure.</strong> In every session, participants discussed the need for revisions to the structure of GME programs and the accreditation entities that incentivize and drive that structure.<br /> <br /> “The overwhelming consensus view was that medical schools need much more flexibility to properly train physicians of the future,” the report said. “If academic health centers were able to tailor programs to both medical students’ and residents’ areas of interest, the length of time of medical education, as well as the cost, might be significantly reduced.”</li> </ul> <ul> <li> <strong>Addressing difficulties providing health care to rural and underserved areas.</strong> Roundtable participants identified a need for training in environments in which future physicians will practice, rather than a one-size-fits-all approach in the clinical/hospital environment.<br /> <br /> It was also recognized that there is an overall shortage of physicians, residents and teaching faculty in rural and underserved areas due to lower salaries, which increases the challenges in repaying tuition debt, as well as a lack of opportunities for families.<br /> <br /> Technology, including telemedicine, was seen as a possible solution in this area, the report said. “However, it was emphasized that the current funding, reimbursement and regulatory schemes do not currently support the use of technology in many instances.”<br /> <br /> Greater inclusion of interprofessional partnerships and training were pointed to as critical for addressing limitations in current programs.</li> </ul> <ul> <li> <strong>More health care workforce planning is needed.</strong> Comprehensive and accurate workforce analyses were felt to be essential for a successful GME strategy. Workforce planning must be sufficient and focus on all health care providers, not just physicians.<br /> <br /> “Accreditation programs could be fashioned in such a way as to promote and support workforce needs in line with a comprehensive strategy,” the report said.</li> </ul> <p> <strong>On the matter of GME funding and further reform</strong></p> <p> Though the current structure of <a href="" target="_self">GME funding</a> was intentionally left out of the discussions, it was clear to researchers that all participants believed that it is essentially broken. “There was a strong consensus that reworking the funding mechanism for GME could ameliorate a number of the issues raised,” the report said. “If designed properly, [a new funding structure] could facilitate GME programs that better fit today’s health care marketplace, enhance the roles of academic health centers … in residency programs, and support the changing health care delivery systems to support patient needs.”</p> <p> The roundtables were conceived in response to a 2014 National Academies of Sciences, Engineering and Medicine (formerly the Institute of Medicine) <a href="" target="_self">report that called for transitioning the current GME system</a> to a transparent, performance-based system.</p> <p> The AMA has long advocated for and adopted numerous <a href="" target="_self">policies and reports that support the modernization of GME</a>, including a report on the physician workforce shortage and approaches to GME financing (log in). At this year’s AMA Annual Meeting, delegates adopted policy to advocate for the appropriation of Congressional funding in support of the National Healthcare Workforce Commission, established under the Affordable Care Act, to provide data and healthcare workforce policy and advice to the nation and provide data that support the value of GME.</p> <p> Recently, the AMA supported the Creating Access to Residency Education Act (CARE) to expand funding for GME and improve access to health care for patients in underserved areas. The organization also supports the Resident Physician Shortage Reduction Act of 2015, to help increase the number of residency slots and address physician shortages.  </p> <p> The Accreditation Council for Graduate Medical Education (ACGME) recently launched the <a href="" rel="nofollow" target="_blank">Physician Well-Being initiative</a>, intended to create a learning environment that recognizes physician well-being as critical to their ability to deliver the safest, best possible care to patients. Also, the ACGME earlier this year announced its <a href="" rel="nofollow" target="_blank">Pursuing Excellence in Clinical Learning Environments initiative</a>.</p> <p> Through its <a href="" rel="nofollow" target="_blank">SaveGME</a> campaign, the AMA continues to strongly urge Congress to protect federal funding. The campaign website offers many resources and ways to take action to improve GME.</p> <p> The AMA’s <a href="" target="_self">Accelerating Change in Medical Education</a> initiative is also addressing some of these issues by supporting medical school projects that accelerate student progress, allowing them to enter residency sooner and contribute more rapidly to expanding the physician workforce. Learn <a href="" target="_self">how medical schools are embedding students</a> in real world environments to enhance the learning process.</p> <p align="right"> <em>By AMA staff writer <a href="" rel="nofollow" target="_blank">Troy Parks</a></em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:f6fb90f1-6155-41be-a32d-0173853c3e4d New model of care offers MACRA advantage Wed, 07 Sep 2016 22:00:00 GMT <p> Applications are due on Sept. 15 for the Centers for Medicare and Medicaid Services (CMS) five-year primary care medical home model, Comprehensive Primary Care Plus (CPC+). This model builds on experience with an ongoing five-year pilot model by making significant improvements that could help participating physician practices succeed—and it could also help your practice during the upcoming Medicare Access and CHIP Reauthorization Act (MACRA) transition.</p> <p> Under MACRA, physicians can either participate in the new Merit-based Incentive Payment System (MIPS) or an Advanced Alternative Payment Model (APM). Qualifying APM participants are exempt from MIPS and earn five percent bonus payments each year, on top of the additional funding they can receive from the APM itself. One way to qualify for the Advanced APM track is to apply for CPC+.</p> <p> CPC+ is a five-year primary care medical home model that aims to provide more flexibility and support than is typically available in fee-for-service, especially for non face-to-face services such as proactive patient outreach, care coordination and development of treatment plans. Up to 5,000 practices will be selected to participate.</p> <p> The AMA is strongly encouraging interested practices to submit applications during the short application period which closes on Thursday, Sept. 15, giving physicians just six weeks to apply. Submit a CPC+ application via the <a href="" rel="nofollow" target="_blank">online portal</a> by 11:59 p.m. Eastern time that day. CMS has no plans to allow new applicants later in the five-year period.</p> <p> <strong>The advantages of new models of care</strong></p> <p> “Physicians like the upfront prospective payment as well as the potential for shared savings bonuses,” said William Golden, MD, medical director of Arkansas Medicaid, who played an essential role in the original pilot as well as the development of a statewide medical home in Arkansas. “It is a highly attractive model that is resulting in greater team-based care and, in many practices, better morale for the doctors, nurses and staff.”</p> <p> One of the major differences between the pilot and CPC+ is that shared savings under the pilot were regional, Dr. Golden said. “There were seven regions that got CPC, and all the docs in that region had to reach shared savings to get bonuses. It was very hard for a region to qualify.”</p> <p> In CPC+, the pool approach is out, the bonuses are paid up-front, and performance will be driven at the practice level, he said. “The opportunity for high-performing practices to earn bonuses is much greater.”</p> <p> “CPC+ lets physicians focus more on chronic disease management and prevention,” Dr. Golden said. “This new model incentivizes you to spend more time with the chronically ill and lets you manage you population in a much more efficient way without necessarily having them come into the office.”</p> <p> “It encourages phone management, televideo and alternative care,” he said. “It also encourages trying to avoid use of the emergency department … you’re really responsible for the outcomes of your panel.”</p> <p> “I think the patients have enjoyed it,” he said. “It takes away a lot of the overhead pressures in a busy primary care practice and it encourages alternative visit approaches and, frankly a lot of docs are saying, ‘This allows me to practice medicine in the way I wanted to and the previous reimbursement model didn’t let me.’”</p> <p> “Many of the practices have welcomed this change in orientation, they really like this way of doing business,” Dr. Golden said. “It means less burnout because it is a more targeted use of their time.”</p> <p> CPC+ is a multi-payer model, so other payers will join Medicare in making monthly care management and performance-based payments to participating physician practices. <a href="" rel="nofollow" target="_blank">Learn more</a> about the 14 CPC+ regions and provisionally selected payers.</p> <p> CMS has offered several resources for practices that choose to apply. Get your questions answered in the <a href="" rel="nofollow" target="_blank">Practice FAQs</a>. Register for one of the 20 upcoming <a href="" rel="nofollow" target="_blank">CPC+ Practice Open Door Forums</a> in August and September. Watch the <a href="" rel="nofollow" target="_blank">CPC+ Video Series</a> to get an overview of CPC+ payment innovations and care delivery transformation. Download the CPC+ toolkit: <a href="" rel="nofollow" target="_blank">CPC+ In Brief</a>, <a href="" rel="nofollow" target="_blank">CPC+ Care Delivery Transformation Brief</a>, and <a href="" rel="nofollow" target="_blank">CPC+ Payment Innovations Brief and Case Studies</a></p> <p> <strong>Learn more about APMs:</strong></p> <ul> <li> <a href="" target="_self">Tracking patients between visits: A new care model</a></li> <li> <a href="" target="_self">New model makes patient care more than face-to-face visits</a></li> <li> <a href="" target="_self">Payment model design needs to be physician-led: New report</a></li> <li> <a href="" target="_self">How doctors are developing new payment models for their specialties</a></li> <li> <a href="" target="_self">Who’s using new delivery and payment models?</a></li> <li> <a href="" target="_self">Payment models that can help you better address patients’ needs</a></li> <li> <a href="" target="_self">Specialty development key to new payment models’ success</a></li> </ul> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:e9c59fcb-3b73-41bd-9f9a-1d3cb8c9b1e8 Clicks and keyboards stealing face time with patients Tue, 06 Sep 2016 22:00:00 GMT <p> Almost one-half of the physician workday is now spent on electronic health record (EHR) data entry and other administrative desk work while only 27 percent is spent on direct clinical face time with patients, a time-motion study published Monday in the <em>Annals of Internal Medicine</em> found. This finding is further proof that administrative burdens are directly affecting the patient-physician relationship. Though efforts are underway to make EHRs more practical for clinical use, there are ways to relieve this burden through team-based care.</p> <p> The <a href="" rel="nofollow" target="_blank">time-motion study</a>, conducted by experts at the AMA and Dartmouth-Hitchcock Health Care System, also found that for every hour of face-to-face time with patients, physicians spend nearly two additional hours on their EHR and other clerical desk work throughout the day.<a href="" style="font-size:12px;" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> Physicians do not feel these are the tasks that should be taking up a majority of their work day—they undercut the patient-physician relationship.</p> <p> “I am not surprised to hear these results, and I can tell you no one who practices medicine today would be surprised by them,” said AMA Immediate-Past President Steven J. Stack, MD, to entrepreneurs at MATTER, Chicago’s health care technology incubator. “But they highlight exactly why new technologies that can bring greater efficiencies to medicine are so important.”</p> <p> The time-motion study correlates with a <a href="" rel="nofollow" target="_blank">study</a> published recently in the <em>Journal of Graduate Medical Education</em> that tracked the average <a href="" target="_self">“mouse miles”—or active time—residents spent using EHRs</a>. The study found that first-year residents spent an average of five hours per day on the EHR caring for a maximum of 10 patients.</p> <p> <strong>Taking back time for patients</strong></p> <p> The importance of the <a href="" target="_self">patient-physician</a> relationship is why some physicians are looking at ways to take back that stolen time. Kevin Hopkins, MD, a family physician at the Cleveland Clinic in Strongsville, Ohio, saw this happening in his practice and implemented a new team care model. “I was staring at the computer screen rather than looking at the patient,” he said. “This is one of the biggest complaints we get from patients.”</p> <p> “One day I realized that if I didn’t have to do this documentation I would really like my work,” Dr. Hopkins said. So he and his team developed templates specific to their practice and patients. He taught his staff how to use health maintenance reminders in their EHR to place orders for mammography screening, labs and immunizations. They also made workplace modifications such as installing curtains to offer privacy to patients while the medical assistant remains in the exam room to document, and a computer workstation in the hallway to allow Dr. Hopkins to make minor note edits between patients.</p> <p> “We have worked with the MAs to develop their multi-tasking skills,” he said. “They need to be typing, listening to me and watching what parts of the exam I am doing all at the same time. We trained them with shadowing and repetition.”</p> <p> “The MAs are more fully engaged in patient care than they have ever been and they enjoy their work,” he said. “They have increased knowledge about medical care in general and about their individual patients.”</p> <p> A module from the AMA’s <a href="" rel="nofollow" target="_self">STEPS Forward™</a> collection of practice improvement strategies can show you how to bring <a href="" rel="nofollow" target="_self">team documentation to your practice</a>. The collection offers several modules to help physicians relieve the burden of current EHR inefficiency, including <a href="" rel="nofollow" target="_self">EHR software selection and purchase</a> and <a href="" rel="nofollow" target="_self">EHR implementation</a>.</p> <p> Other ways to alleviate administrative burdens included in the collection are modules on how to <a href="" rel="nofollow" target="_self">adopt a patient pre-registration process</a>, implement <a href="" rel="nofollow" target="_self">synchronized prescription renewal</a> and <a href="" rel="nofollow" target="_self">expanded rooming and discharge protocols</a>.</p> <p> <strong>Findings ways to do less homework</strong></p> <p> The time-motion study also found that outside office hours, physicians spend another one to two hours of personal time each night doing clerical work—mostly related to EHRs. The findings suggest that documentation support with either dictation or documentation assistance services may increase direct clinical face time with patients.</p> <p> Jim Ingram, MD, a family physician in Auburn, Ind., saw some of the same issues that Dr. Hopkins saw at the Cleveland Clinic and took action as well. He now works with two certified medical assistants (CMA). One CMA rooms the patient, then updates the problem list, the medication list, and allergies and uses EHR templates to get as much history as possible.</p> <p> The CMA then leaves the room to huddle with Dr. Ingram and they review all of the information before performing the exam. This frees Dr. Ingram up to build the valuable trust that is needed for an effective patient-physician relationship. He is not staring at the computer in the exam room—he is looking at the patient.</p> <p> After the exam, Dr. Ingram and the CMA step outside of the exam room and review everything that was discussed and the treatment plan. He then joins the second CMA and repeats the process with the next patient.</p> <p> “I never come in on my day off or work in the evenings on notes like I used to,” he said. “I am much more relaxed during the visits and I am more thorough with my patients. I no longer have to flip through the chart looking for things or look away from the patient.”</p> <p> “The biggest return on investment was achieving a real sense of teamwork, increased joy in practice and getting rid of extra work at nights,” Dr. Ingram said. “Patients are better served by me and the CMAs, and patient satisfaction has increased.”</p> <p> <strong>Making EHRs interoperable, less burdensome for physicians</strong></p> <p> The time-motion study quantifies the results of an AMA study with the RAND Corporation that confirmed poorly designed EHRs and other administrative tasks have become obstacles to providing high-quality care to patients and are leading contributors to physician burnout.</p> <p> Late last year, the AMA and MedStar developed a new framework to evaluate the top EHR products, said Michael L. Hodgkins, MD, AMA vice president and chief medical information officer. “And only three vendors got perfect scores.”</p> <p> The <a href="" target="_self">EHR User-Centered Design Evaluation Framework</a> employs a 15-point scale intended to evaluate EHR vendors’ compliance with best practices for a user-centered design process to encourage the Office of the National Coordinator for Health Information Technology to raise the bar on federal usability certification.</p> <p> Also, the AMA’s grassroots campaign <a href="" rel="nofollow" target="_blank"></a> in January held a town hall, in which physicians came together to offer solutions to <a href="" target="_self">what EHRs need</a> and how they could work better for physicians and their patients.</p> <p> In 2014, a panel of experts led by AMA President Steven J. Stack, MD, developed and published <a href="" target="_self">eight top challenges and solutions</a> for improving EHR usability for physicians and their patients. These principles focus on leveraging the potential of EHRs to enhance patient care, improve productivity and reduce administrative costs</p> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:fe426cf1-1f53-492b-b047-c2bab735c7e5 LGBT residents provide insights to match applicants Tue, 06 Sep 2016 21:00:00 GMT <p> Matching for residency programs can be stressful for LGBT applicants. Is it okay to be out? How much should I reveal about my LGBT advocacy work? What should I do if an interviewer tries to determine my sexual orientation indirectly? Five LGBT residents, including one couple, recently took part in a webinar to share their experiences and answer these and other questions LGBT students commonly have before and during the match.</p> <p> The webinar, <a href="" rel="nofollow" target="_self">Navigating the Residency Match as an LGBT Applicant</a>, co-hosted by the AMA and the Association of American Medical Colleges in August, addressed the rules governing questions that can be asked of program applicants and the concerns related to openly sharing one's identity during the interview process.</p> <p> It begins with what many applicants might not be aware of in detail. The National Residency Matching Program (NRMP) has established a <a href="" rel="nofollow" target="_blank">Match Communication Code of Conduct</a> for all program directors and other interviewers. In summary, it specifies that they must commit to:</p> <ul> <li> <strong>Respecting an applicant’s right to privacy and confidentiality. </strong>Program directors and other interviewers are not allowed to ask identifying information about other programs you’ve applied to.<br />  </li> <li> <strong>Accepting responsibility for the actions of recruitment team members.</strong> Program directors assume responsibility for the actions of the entire interview team. Anyone who is a part of the interview selection process is representing the entire program, and responsibility goes all the way up to the program director.<br />  </li> <li> <strong>Refraining from asking illegal, coercive and non-job-related questions.</strong> Interviewers can’t ask questions about age, gender, religion, sexual orientation or family status, and they have to ensure that communication with applicants remains focused on whether the applicant fits within their program.<br />  </li> <li> <strong>Declining to require second visits or visiting rotations.</strong> Program directors can’t require visiting rotations—second visits—or imply that second visits are used in determining applicant placement on a rank order list. <br />  </li> <li> <strong>Discouraging unnecessary post-interview communication.</strong> Interviewers aren’t allowed to solicit or require post-interview communication from applicants or engage in post-interview communication that is disingenuous for the purpose of influencing applicants’ ranking preferences.</li> </ul> <p> So while some questions are off limits, sensitive subjects still come up. Many LGBT applicants look to the advice and anecdotes of other members of the LGBT community who have experienced the match.</p> <p> <strong>It starts on your application</strong></p> <p> Kaitlyn McCune, MD, an obstetrics and gynecology resident at Wake Forest Baptist Medical Center in North Carolina, recently applied for a military residency through the Air Force. She decided to be out from the start, and she took three main lessons away from the experience.</p> <p> “My first lesson is not to be afraid to be yourself,” Dr. McCune said. “I put the activities on my resume and was told by family members that I was waving my pride flag in people’s faces, and that I shouldn’t put my advocacy work that I had worked so hard on in medical school on my application.”</p> <p> But she decided to use it as a probe.</p> <p> “I sort of said, ‘Forget that,’” she said. “Because the Defense of Marriage Act and Don’t Ask Don’t Tell had been overturned, I took the stance that legally no one could touch me. They couldn’t discriminate against me. In reality, when I think back now, I realize that could have been a very bad move. It could have been very naïve, because these program directors in your interviews really carry a lot of weight in the military, so they could have rated me really poorly.”</p> <p> Dr. McCune took that approach in her civilian applications as well. She was proud of what she had done in advocacy and felt she shouldn’t have to omit it.</p> <p> “I was asked quite often about it,” she remembers. “One person…asked me, ‘What is your specific interest in LGBTQ health advocacy?’ And while he didn’t specifically ask me if I was gay, he sort of asked me the question that forced me to come out, and I did and it was fine. So I encourage you to take that risk if you’re comfortable with it.”</p> <p> <strong>Don’t shy away from questions of fit</strong></p> <p> Dr. McCune’s second lesson: Scope out the residents.</p> <p> “Those dinners beforehand are so incredibly important,” she said. “They’re your time to ask all the questions that you may be afraid to ask in an interview or wouldn’t be appropriate to ask in an interview. I always used that as my best resource for the feel of the program. I would drop my significant other status into casual conversation or ask residents about their significant others so that I could bring up my own.”</p> <p> The third lesson: Be honest and realistic about where you want to end up.</p> <p> “The military is a little bit different [from civilian programs], in that all the program directors get together,” she said. “So unlike civilian residency, you can’t tell every single one of them that that’s where you want to end up. If you were to [do that], when they all got together and talked about you, there would be a discrepancy.</p> <p> “They really encourage you in the military to be honest about whether you want a military residency, which [one] you want, and if you want a civilian residency, to ask for it. And that’s what I did. Civilian residency made the most sense for my life and my situation, and I asked for it and was logical and reasonable about my reasons for wanting it and was awarded it in the end.”</p> <p> Among the many other points Dr. McCune made, she noted that just two weeks after she matched at Wake Forest, North Carolina’s House Bill 2, the so-called “bathroom law,” passed.</p> <p> “I remember emailing my fantastic program director and program coordinator … just very upset, wondering how this was going to affect the program and how this was going to affect my situation,” she said. “They were wonderful and said, ‘This is not going to affect [you]. The university has come out and said they that do not support this and they support diversity and inclusion.’</p> <p> “So don’t be afraid to ask about those things. If you have concerns and the interview has gone well … and you see these concerning things either in hospital policy or in state laws, don’t be afraid to ask, ‘Hey how does this law affect this institution? Does it affect it at all?’”</p> <p> <strong>90 minutes of examples and advice</strong></p> <p> The webinar also features presentations by:</p> <ul> <li> <strong>Dre Irizarry, MD,</strong> surgery resident at Beth Israel Deaconess Medical Center. At the time of interviews, Dr. Irizarry had begun transitioning and was continuing to present as a female with a female partner.<br />  </li> <li> <strong>Chelsea Dawn Unruh, MD,</strong> chief family medicine resident at Providence St. Peter Family Medicine. Dr. Unruh was an IMG who had studied in Poland and wasn’t out during match.<br />  </li> <li> <strong>Jeffrey Eugene, MD, </strong>pediatrics resident at University of Pittsburgh Medical Center, and <strong>Joseph Langham, MD, </strong>pediatrics resident at University of Pittsburgh Medical Center. Drs. Eugene and Langham met during medical school. They would be the first same-sex couple from their school to go through match.</li> </ul> <p> It also includes a robust question-and-answer session. Among the many topics explored: What happens if things go wrong?</p> <p> <strong>Learn more about conducting a successful residency search:</strong></p> <ul> <li> Review the student’s <a href="" target="_self">fourth-year essential checklist</a>.</li> <li> See <a href="" target="_self">4 tricks to a successful residency program search</a>.</li> <li> <a href="" target="_self">How many residency programs</a> do students really apply for?</li> <li> Read about the <a href="" target="_self">record Match rate</a> for 2016.</li> </ul> <p>  </p> <p align="right"> <em>By AMA staff writer Tim Smith</em></p> <p>  </p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:37ffb5a5-a40d-4068-82fa-7b96fc1d5c20 How to respond to bad online reviews Sat, 03 Sep 2016 02:00:00 GMT <p> In the age of online reviews, medical professionals have been accused of violating the Health Insurance Portability and Accountability Act (HIPAA) for how they responded to negative online reviews from patients. To avoid that pitfall and other missteps, here are some do's and don’ts for responding to online critics.<a href="" style="font-size:12px;" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> <strong>The pitfalls</strong></p> <p> A <a href="" rel="nofollow" target="_blank"><em>ProPublica</em></a> investigation earlier this year, co-published with the <a href="" rel="nofollow" target="_blank"><em>The Washington Post</em></a><em>, </em>combed through more than 1.7 million patient Yelp public reviews and found dozens of instances where medical professionals’ responses to complaints led to disputes over patient privacy.</p> <p> In one case, a patient filed a complaint with the Office for Civil Rights within the U.S. Dept. of Health and Human Services, the office that enforces HIPAA. The patient claimed the dentist posted her personal information in response to a Yelp review, according to the investigation.</p> <p> In a 2013 California case, a hospital was fined $275,000 for disclosing patient information to the media without permission, “allegedly in retaliation for the patient complaining to the media about the hospital,” the article noted.</p> <p> These online reviews are going to happen because that is the nature of the internet’s presence in the modern medical landscape. So how do you handle them?</p> <p> <strong>The do's and don’ts of responding</strong></p> <p> With these pitfalls in mind, here are some dos and don’ts for physicians to consider when a patient posts a negative review.</p> <p> What to do:</p> <ul> <li style="margin-left:0.25in;"> <strong>Consider taking the response offline.</strong> Phone the patient or invite him or her into your office to sit down and talk about their concerns. Sometimes, the personal contact results in the patient taking down the negative review, or results in the patient adding an online review that lets other patients know your office is listening. <br />  </li> <li style="margin-left:0.25in;"> <strong>Speak about general policies and standard protocols if you chose to respond online. </strong>For example, if a patient is upset he did not receive an antibiotic, a physician could respond, not by mentioning anything about the specific patient, but instead by saying that office policy and standard medical practice is to determine if a patient has a viral or bacterial infection and to only prescribe antibiotics when there a bacterial infection is present.<br />  </li> <li style="margin-left:0.25in;"> <strong>Remember, one bad review will not destroy your online reputation.</strong> Patients look at a physician’s overall rating and when there are many good reviews, a few bad ones will not stand out as the norm.<br />  </li> <li style="margin-left:0.25in;"> <strong>Establish your own online profile.</strong> Get a professional headshot; make sure your information is up-to-date on your practice website, health rating websites such as Healthgrades and RateMDs, and other online sources.</li> </ul> <p> What not to do:</p> <ul> <li style="margin-left:0.25in;"> <strong>Don’t respond immediately. </strong>Take a deep breath and walk away. If you respond immediately, you may come across as angry. That won’t lead to anything productive.<br />  </li> <li style="margin-left:0.25in;"> <strong>Don’t disclose any information about the patient—don’t even acknowledge the person is a patient in your office.</strong> HIPAA still applies. Even if a patient has disclosed his or her information in an online review, remember that HIPAA prevents a physician from disclosing any information about a patient without the patient’s permission. A patient’s own disclosure is not permission for the doctor to disclose anything.</li> </ul> <ul> <li style="margin-left:0.25in;"> <strong>Don’t ignore criticism.</strong> Instead, objectively look at the criticism from the patient’s point of view and determine whether there is something you or your office can do differently.<br />  </li> <li style="margin-left:0.25in;"> <strong>Don’t shy away from online reviews. </strong>Ask your patients to rate and review you online. In most cases, reviews are positive. And remember that many positive reviews dilute many negative reviews.</li> </ul> <p> For more reading on how to manage an online presence:</p> <ul> <li> <a href="" target="_self">Social media: How to reap the benefits while avoiding the hazards</a></li> <li> <a href="" target="_self">Physician behind KevinMD reveals how to leverage social media</a></li> <li> <a href="" target="_self">KevinMD answers doctors’ top social media questions</a></li> <li> <a href="" target="_self">Will social medial impact your residency, fellowship application?</a></li> <li> <a href="" style="font-size:12px;" target="_self">How to manage your online reputation: Top 4 tips</a></li> </ul> <p align="right"> <em>By contributing writer Tanya Albert Henry</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:646d8ee9-b775-45eb-b89f-2a982f123fa7 Online DPP tackles challenges of location and participation Fri, 02 Sep 2016 21:00:00 GMT <p> The Centers for Disease Control and Prevention’s (CDC) National Diabetes Prevention Program (National DPP) has been proven effective at helping participants make substantial and sustainable lifestyle changes. But up until now, adoption of the program has been greatly limited by challenges in enrolling patients into local programs and scaling the program beyond its brick-and-mortar settings. A new approach—providing the program digitally and remotely—is tackling both simultaneously.</p> <p> “Any kind of a health care professional telling someone, ’Look, you’ve got prediabetes, you need to make some lifestyle changes,’ just hopes and prays that the patient goes out and does it,” said Sean Duffy, co-founder and CEO of <a href="" rel="nofollow" target="_blank">Omada Health</a>, a San Francisco-based digital health startup. “But deep down they know that without the right support, there’s not likely going to be success.”</p> <p> So Omada has <a href="">partnered</a> with the AMA and <a href="" rel="nofollow" target="_blank">Intermountain Healthcare</a>, a Salt Lake City-based health system, to integrate Omada’s Program —one that goes online to overcome challenges of geography but that features a social experience similar to what a patient experiences in an in-person program—into the health system setting at Intermountain.</p> <p> <strong>Diabetes prevention must-haves: Simplicity and support</strong></p> <p> From a user-experience standpoint, the goal of the program is to include all of the instruments patients need to take action, as well as to remove any barriers to their use of the tools and support.</p> <p> When they begin the Omada program, each patient receives a welcome package that includes a wireless scale with an embedded cellular chip linked to the patient’s profile. The scale requires no setup beyond inserting the included batteries. Then, patients just step on the scale, and it instantly transmits their data, providing a baseline weight and a benchmark for progress in the program.</p> <p> <a href="" style="font-size:12px;" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> But even the smartest, simplest technology wouldn’t be enough on its own. What makes Omada different from many other online DPPs is its human touch.</p> <p> “A lot of what’s needed for these intense programs used to only be available in person,” Duffy said. “That includes peer support, camaraderie, feeling like you’re not alone—a lot of the emotional dynamics that are involved in making lifestyle change successful and sustainable.”</p> <p> On the first day of the new-group kickoff, patients log in to the website and meet their personal health coach via live streaming or a recorded video. The coach’s job is to monitor their progress and give feedback in real time. Patients can then reach the coach at any time by private messaging, a group discussion board, text message, phone or video chat.</p> <p> The program features a food and activity tracker, where participants enter what they are eating, drinking and doing each day. Graphics indicate each person’s progress toward their five-to-seven percent weight-loss goal. The site also features “healthy competition” to help motivate patients and make them feel accountable to the group. As participants move along in the curriculum, they receive additional tools, such as a digital pedometer, to keep them motivated and aid their progress.</p> <p> <strong>Two phases meet patients’ changing needs</strong></p> <p> “We think of our program a lot like a symphony, where all these programs need to feel emotionally moving in the same way that Beethoven’s Fifth feels emotionally moving,” Duffy said. “You wouldn’t be able to create that feeling with just a bassoonist–you need all the instruments. Those are the scale, the coach, the group, the curriculum, the timeline, the goal setting, the food and activity tracking. And you can’t just have all the instruments play at once. You need them to play on a timeline—and you need someone conducting the symphony.”</p> <p> The proprietary curriculum, which was approved by the CDC’s Diabetes Prevention Recognition Program, is broken into two phases: Foundations and Focus. During Foundations, which lasts 16 weeks, patients are asked to complete one interactive health lesson each week. These tackle the physiological, social and psychological factors that may contribute to prediabetes. Key concepts are then reinforced through interactive games that give participants opportunities to apply what they are learning in real-life scenarios.</p> <p> Each participant and his or her coach have access to a private progress page, and each time the participant steps on the scale, a new data point is automatically added to their profile. Eighty percent of people who start the Foundations program successfully complete it, and a third lose more than seven percent body weight. Average weight loss after six months in the program is right around five percent.</p> <p> Once participants complete Foundations, they graduate into the Focus phase, designed to help them maintain their new habits over time. Each patient continues to get individual attention from a health coach, but they also join a broader peer support group and an expanded curriculum that focuses on overcoming real-life obstacles to staying healthy long term.</p> <p> <a href="" style="font-size:12px;" target="_blank"><img src="" style="margin:15px;float:left;" /></a><strong>The right partners and the right patients</strong></p> <p> The partnership with Omada and Intermountain expands on the <a href="">AMA’s efforts to prevent type 2 diabetes</a> by giving physicians new tools and resources to better manage at-risk patients. It will create a roadmap for health care organizations across the country to integrate proven online prevention programs into physician referrals and clinical workflows.</p> <p> Before working with the AMA and Intermountain, Omada partnered primarily with health plans and employers, because those organizations hold the most financial risk when it comes to health care. In taking the next step and rolling out the program to health systems and partnering with an established group like the AMA, Omada sought to better integrate the program into the clinical workflows of hospitals, doctors and care teams. Intermountain fit the profile for a few reasons.</p> <p> For starters, Duffy noted, it’s a very forward-leaning company in the areas of prevention-oriented and value-based care, having recognized, as the <a href="" rel="nofollow" target="_blank"><em>New York Times</em></a> noted, that costs can be brought down by providing more care at the right times.</p> <p> But Intermountain was also an attractive partner because it has a largely rural patient population, which by its very nature is difficult to reach with in-person DPPs, and one in which prediabetes is prevalent. It’s estimated that more than 114,000 people in Intermountain’s service area have the condition.</p> <p> “For a big health system like Intermountain, that’s a clinical epidemic,” Duffy said. “At the same time, it’s an economic imperative, because they know as soon as someone who does not have diabetes proceeds to type 2, they’re going to cost their health care payer on average $8,000 to $10,000 more every year to treat.”</p> <p> <strong>Making referrals “one-clickable”</strong></p> <p> The goal is to initially enroll 250 patients in the program, which will have three phases. The first, which is now complete, involved determining which patients were eligible.</p> <p> The second and current phase is the referral piece, which involves determining which outreach approaches could be used to get patients into the program.</p> <p> The third phase will involve designing those outreach approaches, setting them up in physicians’ offices and then making sure Omada is delivering actionable information back to those care teams to create personalized patient plans.</p> <p> “What is the better version of the classic pamphlet that someone could leave with to learn more about the program?” Duffy asked, “… and how do we help doctors to communicate the key elements of the program in the way that is most likely to get the person to take action?”</p> <p> Omada and Intermountain will also exploit conventional channels like phone and fax to enable physicians’ offices to refer patients into the program directly. Plus they will explore EHR trigger referrals, so providers could set up Omada as an outpatient referral in the same way that they would order a visit with a specialist or send a patient to a lab for bloodwork.</p> <p> “We want to make this one-clickable,” Duffy said. “We want to get to the point where, when a provider is seeing a patient that is the right clinical fit for these programs, they can instantaneously refer.”</p> <p> <strong>Writing a best-practices playbook</strong></p> <p> Once they start enrolling patients, Duffy notes, it will be imperative to start getting data back to learn what kind of information—and what level of detail—best enables providers to take additional action.</p> <p> “That’s what the partnership is all about,” said Duffy, “finding ways that we can effectively create a referral system into a DPP and, at the same time, create a feedback loop where physicians get information as their patients go through the program that can impact the whole care plan.”</p> <p> “And that’s why we’re so excited about AMA’s participation, to come away with a best-practices playbook for how you can integrate a digital health solution into a clinical workflow. The implications of that are really widespread and exciting.”</p> <p> <strong>Learn more about the AMA’s work on diabetes prevention:</strong></p> <ul> <li> <a href="" target="_self">“Groundbreaking effort” to prevent diabetes announced</a></li> <li> <a href="" target="_self">Awareness of risk status key to prevention of diabetes</a></li> <li> <a href="" target="_self">Physician-tested tools can improve patients’ health</a></li> <li> <a href="" target="_self">Prevent Diabetes STAT: Screen, Test, Act – Today™</a></li> <li> <a href="" rel="nofollow" target="_self">Do I have prediabetes?</a></li> </ul> <p>  </p> <p align="right"> <em>By AMA staff writer Tim Smith</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:4dfdf38d-6607-4809-8250-141e56e257bb Working upstream to achieve the quadruple aim Fri, 02 Sep 2016 21:00:00 GMT <p> “None of us went into this work to achieve mediocrity, to achieve a sub-standard level of care,” said Rishi Manchanda, MD. “We’re in it for excellence. For professional satisfaction. For joy at work. For impact.” Although Dr. Manchanda was speaking to medical and health professions students at a recent AMA <a href="" rel="nofollow" target="_blank">Accelerating Change in Medical Education Consortium</a> meeting, his talk held lessons for physicians at every stage of their careers.</p> <p> In fact, he said, the key to achieving satisfaction is achieving a higher standard of care. And he had advice for how to do that.</p> <p> “The better stream of care we can achieve has to involve understanding upstream issues,” he said. Upstream issues are the general socio-economic, cultural and environmental conditions—including living and working conditions, social and community networks and individual lifestyle factors—that lead to health problems and health care utilization downstream.<a href="" style="font-size:12px;" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> Dr. Manchanda, an internist and pediatrician and the president of <a href="" rel="nofollow" target="_blank">HealthBegins</a>, a provider of upstream tools and resources, was speaking at the student-led Health Equity and Community-based Learning meeting hosted by the University of California, Davis, School of Medicine. His presentation, “Upstreamist Doctors,” focused on achieving the quadruple aim: better care, lower total medical costs, more satisfied patients and more satisfied physicians.</p> <p> The key, he said, is the integration of social determinants in health care.</p> <p> <strong>Social determinants do affect public health</strong></p> <p> “Health care providers in the U.S. right now have no choice but to understand upstream issues better because there hasn’t been adequate investment in other social services,” Dr. Manchanda said. “Unlike all of our peer nations, we have more spending on health care than social services. That actually creates a scenario where you have a doctor talking about moving upstream.”</p> <p> To illustrate his point, he cited a pilot medical-legal partnership he initiated while serving as lead physician for homeless primary care at the VA West Los Angeles Medical Center.</p> <p> The challenge was how to provide better access to care and improve outcomes for high-utilizer homeless veterans. Instead of looking to add health care professionals to his staff, he brought in a public interest lawyer once a week to work with patients to identify unmet legal needs that were the drivers of their poor outcomes.</p> <p> “[For example], if you have a jaywalking ticket and that ticket goes unpaid, it becomes a misdemeanor,” he said. “That record now prevents you from getting housing.”</p> <p> The pilot cost the VA $525 per homeless veteran, but it had a return of more than six to one in disability and other cash benefits paid to patients. One hundred thirty-nine veterans participated in the program.</p> <p> “That’s over half a million dollars in benefits. If you’re a guy who can’t afford an apartment, consider what $3,600 does for you in terms of creating economic opportunity,” Dr. Manchanda said, adding that, over the 11-month span of the pilot, health care utilization decreased by 24 percent.</p> <p> “Is this better care? Is this a glimpse into the quadruple aim?” he asked the students. “Yes, when you see the quadruple aim in front of you, you have to name it. If you don’t name it, you forget it. If you forget it, you can’t replicate it.”</p> <p> Without integrating social determinants, he added, physicians are working with one hand behind their backs, and the quadruple aim cannot be achieved. But he’s confident many providers and policy makers are coming around to this idea.</p> <p> “Even though I’m a primary-care-trained provider, I’m not a specialist or a comprehensivist. I view myself as an upstreamist,” he said. “If we don’t name what we are as upstreamists, it’s hard for us to learn best practices, share them and actually amplify our impact.”</p> <p> <strong>For more on addressing social determinants in practice:</strong></p> <ul> <li> <a href="" target="_self">Death by ZIP code: When address matters more than genetics</a></li> <li> <a href="" target="_self">Students deliver care in homes, communities</a></li> <li> <a href="" target="_self">From volume to value: How one health system is making the change</a></li> <li> <a href="" target="_self">Ways a Chicago health network is improving community health</a></li> </ul> <p align="right"> <em>By AMA staff writer Tim Smith</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:fc09e724-7d0c-454b-874f-ff8ba096baf1 A simple tool to ensure treatment plan effectiveness Thu, 01 Sep 2016 21:15:00 GMT <p> The patient-physician relationship is a partnership that requires a two-sided dialogue in order to decide on the most effective treatment options. The Choosing Wisely® campaign from the American Board of Internal Medicine (ABIM) aims to promote conversations between patients and physicians to choose evidence-supported, low-risk, necessary care that is not duplicative of other tests or procedures already completed.</p> <p> Physicians want their patients to be well informed because it only makes their partnership in shared decision-making stronger. The goal of Choosing Wisely is not only to foster a conversation between physician and patient that helps them discuss when a test or procedure might not provide benefit to a particular patient but also to give patients the courage to question why a test or procedure is being done and what might be the potential benefits or harm.</p> <p> The campaign gathered more than 70 professional societies to create lists of “<a href="" rel="nofollow" target="_blank">Things Providers and Patients Should Question</a>.” The recommendations cover tests, treatments and procedures commonly encountered in a variety of specialties, including:</p> <ul> <li> The American Society for Metabolic and Bariatric Surgery suggests avoiding routine postoperative antibiotics because extending the duration of prophylactic antibiotics may increase the risk of superinfection with Clostridium difficile and the development of antimicrobial resistance.</li> <li> The American Urogynecologic Society suggests avoiding the removal of ovaries at hysterectomy in pre-menopausal women with normal cancer risk because there is evidence from observational studies that surgical menopause may negatively impact cardiovascular health and all-cause mortality.</li> <li> The American Medical Society for Sports Medicine suggests that physicians avoid recommending knee arthroscopy as initial/management for patients with degenerative meniscal tears and no mechanical symptoms because degenerative meniscal tears may respond to non-operative treatments.</li> </ul> <p> The examples in the lists offer comprehensive guidance that can help physicians avoid procedures and tests that may not be necessary, and each bit of advice is supported by evidence detailed in the lists.</p> <p> <strong>How to use Choosing Wisely in practice</strong></p> <p> Though the lists are thorough and hold valuable, physician-authored recommendations, actively using them in practice means a slight change in culture and procedure.</p> <p> A new <a href="" rel="nofollow" target="_self">module</a> from the AMA’s <a href="" rel="nofollow" target="_self">STEPS Forward™</a> collection of practice improvement strategies offers steps that can help you implement Choosing Wisely into your practice:</p> <p style="margin-left:40px;"> <strong>1.   </strong><strong>Engage your physicians and medical staff</strong><br /> Centering the conversation around patient benefits will resonate more than discussions of waste and cost reduction. Pilot Choosing Wisely in one disease area or with one diagnosis first and see how it works before expanding.<br /> <br /> The recommendations are conversation starters, not mandates. As always, medical decision-making is based on the patient’s best interest. Remember, unique circumstances for individual patients may mean deviating from the recommendations.</p> <p style="margin-left:40px;"> <strong>2.   </strong><strong>Engage your patients</strong><br /> The success of these materials depends on your ability to involve patients in a dialogue about the purpose of tests, treatments and procedures so they have a clear understanding of what’s necessary, that’s not and what could cause them harm.<br /> <br /> Initiate the dialogue by demonstrating empathy for your patient’s desires, needs and concerns—their cues will tell you when they are ready for you to introduce decision aids or patient education, which can be found in the module.</p> <p style="margin-left:40px;"> <strong>3.   </strong><strong>Establish an implementation plan</strong><br /> Implementation could take the form of a formal educational program, as well as checklists and protocols to help standardize the new processes. You may even choose to work with your IT department to embed Choosing Wisely recommendations into clinical decision support tools within the electronic health record (EHR).<br /> <br /> However, remember that the recommendations are intended to be starting points for conversation, not rigidly imposed guidelines and they should be treated as such if embedded in the EHR.<br /> <br /> To educate your practice, consider using the physician communication modules from Choosing Wisely. Physicians and medical staff can watch the videos and work through the modules during a scheduled team meeting.</p> <p style="margin-left:40px;"> <strong>4.   </strong><strong>Use data to understand and improve performance</strong><br /> Tracking and reporting will help determine the effectiveness Choosing Wisely is having on your practice. Sharing peer comparison data over time is one of the strongest interventions available for change, and should be part of any strategy.<br /> <br /> Ideas for improvement could come from reviewing data in your EHR, pre-printed order sheets, standing orders or ideas from your team members. Target the tests you suspect may be overused, inconsistently used or harmful to patients.<br /> <br /> Consider starting with clinical areas where the frequency of overuse is highest, such as lab testing or imaging. Another target area is any area where large amounts of variation exist. Review common tests and treatments by physician, establish a baseline and then compare and contrast to identify variability.</p> <p> There are seven new modules now available from the AMA’s STEPS Forward™ collection, bringing the total number of practice improvement strategies to 42, thanks to a grant from and collaboration with the <a href="" rel="nofollow" target="_blank">Transforming Clinical Practices Initiative</a>.</p> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:aaff4dc5-6d9c-4c0f-a6d3-56626ac369ac Don’t miss the CPT® and RBRVS 2017 Annual Symposium Thu, 01 Sep 2016 21:00:00 GMT <p> 2017 brings changes to the CPT® code set and Medicare’s Resource-Based Relative Value Scale (RBRVS). Face these changes head on by attending the CPT® and RBRVS 2017 Annual Symposium, Nov. 16-18 in Chicago.</p> <p> The <a href="" target="_blank">2017 CPT® and RBRVS Annual Symposium</a> will feature discussions of the many significant changes to CPT® 2017 codes and descriptors, as well as payment policy and RBRVS changes to the Medicare physician fee schedule.</p> <p> Experts on CPT®, RBRVS and Medicare payment policy will present. They include representatives from:</p> <ul> <li> CPT® Advisory Committee</li> <li> CPT® Editorial Panel</li> <li> AMA/Specialty Society Relative Value Scale Update Committee (RUC)</li> <li> Centers for Medicare & Medicaid Services (CMS)</li> <li> Contractor medical directors (CMD)</li> </ul> <p> <a href="" target="_blank">View and download</a> the tentative Sympsium schedule.</p> <p> <a href="" rel="nofollow" target="_blank">Register now</a> to attend. A special $150 discount is available until November 1 for AMA members, CPT® and RUC advisers or staff, past AMA symposia attendees, CPT® licensees, and AAPC, AHIMA and PAHCOM members.</p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:e7984932-f897-4aff-892b-8f188eb76b7b Doctors who serve: Becoming a Navy flight surgeon Thu, 01 Sep 2016 02:19:00 GMT <p class="p1"> Physicians have a long history in the military from treating disease in the Civil War to treating battle wounds in field hospitals in Afghanistan. One emergency medicine resident is training now to become a Naval flight surgeon, and when he completes training, he will attach to a jet and helicopter squadron and deploy with those soldiers as their front line physician. Wherever they go, he will go—and then he will return to residency training.</p> <p class="p1"> After doing a one-month rotation in flight surgery last year with the Navy where he spent time on an aircraft carrier and steered a helicopter over the water, Josh Lesko, MD, a former emergency medicine intern in the Navy, decided it was right up his alley and headed to Pensacola, Fla., to continue his training. </p> <p class="p1"> “There are a couple of things that have a reputation—one is called 'the dunker,' which is where you are strapped into a helicopter simulator and it’s allowed to sink,” Dr. Lesko said. “When helicopters sink, they turn upside down. So we are about ten feet underwater strapped into the helicopter and have to learn how to get out with full gear on, with black out goggles so we can’t see … to simulate all the different ways we might be in a helicopter when it goes down.”</p> <p> <a href="" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p class="p1"> <b>Training to serve those who serve</b></p> <p class="p1"> There are three tracks for resident physicians in the Navy who decide to complete an operational tour before finishing training. The first, <a href="" rel="nofollow" target="_blank"><span class="s1">General Medical Officer</span></a>, is a physician on a ship or in a clinic. The second, <a href="" rel="nofollow" target="_blank"><span class="s1">Undersea Medical Officer</span></a>, is a physician attached to a dive unit. And the third, <a href="" rel="nofollow" target="_blank"><span class="s1">Flight Surgeon</span></a>, is a physician attached to a flight squadron—which is what Dr. Lesko is training to be. </p> <p class="p1"> Several options exist for a flight surgeon, he said. There’s the opportunity to go with the Marines in one of their squadrons as well as isolated helicopter and jet squadrons, which usually have a couple hundred people in the unit. </p> <p class="p1"> “Then there are the Carrier Air Groups, which is what I want to be attached to,” he said. “In that case, you are one of two flight surgeons for six or seven different squadrons that comprise both of jets and helo[copters]. So you are on an aircraft carrier when you deploy.”</p> <p class="p1"> For flight surgery training, which is treated as a break from residency, Navymen go through three stages. The first phase is the same training that pilots and flight officers go through, which is five weeks of academic work on aerodynamics, weather, navigation, engines, flight rules and regulations.</p> <p class="p1"> In the second phase, called primary, they learn how to fly a plane and a helicopter. In the third phase, they spend six weeks learning physiology in abnormal conditions—or aerospace medicine—which teaches the medical trainees how to be better physicians specifically for this unique subset of pilot patients that they will be treating. </p> <p class="p1"> “It’s more than just classes,” Dr. Lesko said. “There’s a water survival component where we have to learn how to evacuate from a theoretical sinking ship … emergency egress from a helicopter that’s submerged, and more specific aeronautical tactics.”</p> <p class="p1"> “In the Air Force and the Army they don’t do the flight component,” Dr. Lesko said. “But the Navy’s belief is that to really understand what the pilots are going through and be part of the community we have to go through the same training as they do.”</p> <p class="p1"> For the majority of flight surgery residents there is a program called the Health Profession and Scholarship Program (HPSP). Residents apply to HPSP simultaneously with medical school, but residents also choose a military branch. If selected for HPSP, tuition and required costs are covered. In return, the resident owes “a year for a year” of service to that military branch. Residents in civilian programs often apply after or during residency. .</p> <p class="p1"> “We are really the first line for our squadron,” Dr. Lesko said. “We are their doctor; wherever they go, we go. Any incidents that happen on a plane or on a ship we have to handle. So we’re their clinic doc, but we’re also the safety officer and are part of any investigation into a crash to see if there was a human component that was at fault.”</p> <p class="p1"> <b>Physicians who deploy around the world</b></p> <p class="p1"> Any military aircraft that flies will have a flight surgeon attached to it. Marine One, the President’s helicopter, has a flight surgeon dedicated to it. There are international billets in Japan, Italy, Spain, Bermuda, the United Kingdom, and all over the United States. </p> <p class="p1"> “You’re going to be in a cool place and doing something fantastic,” Dr. Lesko said. “It’s an honor to be able to treat and serve those who serve and really be there for them and be a part of the mission of the Navy as a global force for good.” </p> <p class="p1"> “That’s part of the appeal,” he said. “One of my attendings put it best: What separates us from civilian doctors? Are we just doctors who wear uniforms or are we doctors who are out there training with them and deploying when they deploy? That’s what helped me make up my mind about flight surgery.”</p> <p class="p3" style="text-align:right;"> <i>By AMA staff writer</i> <a href="" rel="nofollow"><span class="s2"><i>Troy Parks</i></span></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:f15a93fe-610a-4845-abc6-a39e22bbf0de Precision medicine: What to know about cell-free DNA screening Wed, 31 Aug 2016 08:00:00 GMT <p> With more women seeking tests for common chromosome conditions in pregnancy, many are now opting for newly developed non-invasive cell-free DNA (cfDNA) screening. But like all screening tests, it has limitations and isn’t appropriate for all patients. Find out how cfDNA works and which of your patients may benefit from the screening.</p> <p> A <a href="" target="_blank">new continuing medical education (CME) module,</a> developed by AMA in partnership with Scripps Translational Science Institute and The Jackson Laboratory, is helping physicians understand what the test detects, which patients benefit most from it, what to consider when ordering the test and a lot more.<a href="" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> <strong>First, how cfDNA screening works</strong></p> <p> Prenatal cfDNA screening detects small fragments of fetal DNA released by placental cells into the mother’s blood stream. cfDNA screening looks for a relative increase or decrease in specific regions of the fetal DNA that would suggest the presence of a chromosome condition.</p> <p> The screening is now being offered for trisomies 21, 18 and 13. Some tests also include sex chromosome conditions and a few conditions caused by chromosomal micro-deletions or micro-duplications, but research is still underway to verify their clinical validity. Unlike other maternal serum screening tests, cfDNA cannot detect structural birth defects, so additional testing may be necessary.</p> <p> Screening for cfDNA is not a diagnostic test, but rather a screening test. Results can only determine if a woman is at increased or decreased risk for chromosome conditions. If the results suggest an increased risk, more extensive diagnostic testing is needed.</p> <p> <strong>Who benefits most from it?</strong></p> <p> While originally offered only to women at high risk for chromosome conditions, many professional societies now support offering cfDNA screening to women in the general obstetric population. Women at high risk for chromosome conditions include those of advanced maternal age and women with a positive screening test or who have a previous child with a chromosome condition.</p> <p> The <a href="" target="_blank">CME module</a> covers numerous topics to help physicians determine if prenatal cfDNA screening is right for a patient, including:</p> <ul> <li> Benefits and limitations of the test</li> <li> Interpreting results</li> <li> Considerations when ordering the test</li> <li> Indications and contraindications</li> <li> Counseling women who are considering the test</li> </ul> <p> The module also features point-of-care guidance about prenatal cfDNA screening, access to a predictive value calculator, comparisons of cfDNA screening to other prenatal screening and testing options and other tools for physicians, including resources physicians can share with patients.</p> <p> <strong>Test your knowledge: A case study</strong></p> <p> Megan is 30 years old and at 12 weeks gestation in her first pregnancy. She is worried about invasive testing but still wants to learn as much as possible about pregnancy risks. She read online about cfDNA screening and is interested in cfDNA as an alternative for chorionic villus sampling (CVS) or amniocentesis. What would you tell Megan about whether cfDNA screening is appropriate for her? Can cfDNA screening take the place of CVS or amniocentesis?</p> <p> Case studies like these are included in the module and enable you to test your knowledge of cfDNA and practice applying it to patient scenarios. </p> <p> You can also dig deeper into the benefits and limitations of cfDNA screening, find answers to logistical issues—like how to work with genetics experts and how to find labs that offer the test—and easily compare cfDNA screening to other prenatal testing options.</p> <p> The prenatal cfDNA screening module is the second in the Precision Medicine for Your Practice education series. Genetic testing is a key element of precision medicine, a tailored approach to health care that accounts for the individual variability in the genes, environment and lifestyle of each person.</p> <p> <a href="">The first module</a>, covering expanded carrier screening, was released in July. Future topics will include precision medicine and its applications in oncology, neurology and cardiology.</p> <p> <strong>Find out more about precision medicine:</strong></p> <ul> <li> <a href="" target="_blank">Precision Medicine For Your Practice: Expanded Carrier Screening module</a></li> <li> <a href="" target="_self">The Precision Medicine Initiative: Report of the AMA Council on Science and Public Health</a></li> <li> <a href="" target="_self">What is precision medicine?</a></li> <li> <a href="" target="_self">Personalized medicine resources for physicians</a></li> </ul> <p align="right"> <em>By AMA staff writer Tim Smith</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:c27e6123-b02f-4fe4-82be-bdd832fb31d5 Get the revised Code of Medical Ethics Tue, 30 Aug 2016 21:00:00 GMT <p> The AMA’s <em>Code of Medical Ethics</em> is regularly cited as the medical profession's authoritative voice in legal opinions and in scholarly journals. It was adopted at the first AMA meeting in 1847, and while much has changed in medicine since, this founding document—the first uniform code of ethics of its kind—is still the basis of an explicit social contract between physicians and their patients. At the AMA Annual Meeting this year, delegates voted to update the AMA <em>Code.</em></p> <p> The revised edition is the culmination of an eight-year project to modernize the AMA <em>Code's</em> ethical guidance for relevance, clarity and consistency. It represents the first comprehensive review of the AMA <em>Code</em> in more than half a century.</p> <p> One of the goals of the modernization was to make the AMA <em>Code</em> simpler to navigate and related opinions easier to find so that physicians could more readily apply it to their daily practice of medicine. Changes include:</p> <ul> <li> A more intuitive chapter structure so that guidance is easy to find</li> <li> A uniform format for opinions so that guidance is easy to read and apply</li> <li> A single, comprehensive statement on each topic</li> <li> Harmonized guidance on related issues</li> </ul> <p> The updated AMA <em>Code</em> also features a new preface to clarify the different levels of ethical obligation in the various ethical opinions.</p> <p> It is available in three formats: e-book, hard cover and commemorative. Visit the <a href="" target="_blank">AMA Store</a> for more information or to order online. AMA members receive a 20 percent discount on this product and others from the AMA Store. If you’re not a member, <a href="" target="_blank">join today</a>.</p> <p>  </p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:53adb49a-a643-4c70-b539-add09a0e124c Peer-review confidentiality critical, but under threat Tue, 30 Aug 2016 20:48:00 GMT <p> Without confidentiality, the peer-review process cannot be an effective tool for improving quality of care. A case before the Supreme Court of Pennsylvania could establish rules that narrow the scope of peer-review protected materials, harming the process.</p> <p> At stake in <em>Reginelli v. Boggs</em>, is whether the Pennsylvania Peer Review Protection Act (PRPA) privilege against legal discovery should apply when an independent contractor of a hospital reviewed the performance of a physician on the hospital’s medical staff.</p> <p> <strong>How the situation unfolded</strong></p> <p> Eleanor Reginelli presented to the emergency department at Monongahela Valley Hospital (MVH) with chest and back pains. Marcellus Boggs, MD, an emergency medicine physician at MVH, ordered and interpreted the results of an electrocardiogram and blood work. He diagnosed Mrs. Reginelli with gastro-esophageal reflux disease and discharged her that day.</p> <p> Five days later, Mrs. Reginelli experienced the same symptoms. An ambulance transported her to the emergency department of a different hospital where she was told she was experiencing a heart attack. She subsequently suffered permanent heart damage.</p> <p> Dr. Boggs was an employee of Emergency Resource Management, Inc. (ERMI), which had been hired as an independent contractor to staff MVH’s emergency department. Mrs. Reginelli and her husband sued Dr. Boggs, MVH and ERMI for medical liability.</p> <p> As part of discovery in the case, the plaintiffs deposed Brenda Walther, MD, the medical director of the MVH emergency department and an ERMI employee. Dr. Walther disclosed that she maintained a performance file on Dr. Boggs, which included peer-review evaluation required by ERMI.</p> <p> The plaintiffs called on MVH to produce the evaluation file, but MVH objected based on a claim of peer-review privilege in the PRPA. The trial court ordered production of the file, finding that MVH could not claim privilege for a document it had neither generated nor maintained. On appeal, the Pennsylvania Superior Court affirmed and the case is now on appeal before the Pennsylvania Supreme Court.</p> <p> <strong>An agreement for unity in providing quality care</strong></p> <p> A 2010 “Emergency Department Services Agreement” outlined the relationship and respective duties between MVH and ERMI, noting that the hospital wished to have ERMI provide certain services to facilitate the operation of the emergency department, including the provision of qualified emergency medicine physicians.</p> <p> The agreement also included materials on quality improvement and peer-review. ERMI was to conduct clinical reviews and provide regular reports to the hospital for its peer-review process. Hospitals commonly use independent contractors to fulfill staffing needs, and those employees then become members of the hospital staff as well as the contractor.</p> <p> ERMI is a medical practice in the specialty of emergency medicine. During the contract’s term, it was the sole provider of emergency service to MVH. Dr. Walther, the ERMI employee who served as the emergency department’s medical director, was effectively the department chairman for MVH as well.</p> <p> Monitoring physician performance and sharing the results was an integral part of measuring compliance with and achieving the quality of care goals. ERMI did not make decisions independently of MVH, and MVH could unilaterally choose not to re-credential a physician when it thought that action was warranted.</p> <p> <strong>Medical organizations take a stand</strong></p> <p> “Peer review is an important tool in improving the quality of health care,” said the <a href="" target="_self">Litigation Center of the AMA and State Medical Societies</a> in an amicus brief defending the PRPA. “The willingness to criticize peers that an effective review process requires cannot occur without ironclad confidentiality.”</p> <p> “Here, the medical director of a hospital emergency department reviewed treatment records of a department physician,” the brief said. “That is the paradigm for protected activity under the Peer Review Protection Act.”</p> <p> The Superior Court erred in concluding that ERMI had destroyed any privilege that may have existed by sharing Dr. Boggs’ performance file with MVH, the brief said. This fails to recognize the cooperative nature of the MVH-ERMI agreement. MVH chose to have the person best suited to evaluate the competency of the emergency department physicians, the department’s medical director, perform the reviews.</p> <p> Both Dr. Walther and Dr. Boggs worked for a third party with whom the hospital had contracted to run and staff the emergency department. “Superior Court incorrectly thought that the entity’s status as an independent contractor deprived its work product of protection,” the brief said. “Nothing in the [PRPA] imposes that rule.”</p> <p> “The performance review of a hospital emergency department physician by its medical director is a peer review-protected activity,” the brief said. “It is irrelevant that the hospital had contracted with a third party to staff and run the emergency department.”</p> <p> <strong>Current medical liability cases in which the Litigation Center is involved:</strong></p> <ul> <li> Find out how a <a href="" target="_self">challenge to medical liability law could complicate pre-suit process</a>.</li> <li> Learn how a case <a href="" target="_self">could lead to unlimited awards of punitive damages</a>.</li> <li> Get the details on a <a href="" target="_self">case that could extend medical liability</a>.</li> <li> Find out how one case could <a href="" target="_self">increase liability exposure and redefine injury</a>.</li> <li> Learn what one case <a href="" target="_self">intends to change about informed consent</a></li> </ul> <p align="right"> <em>By AMA staff writer </em><em><a href="" target="_blank" rel="nofollow">Troy Parks</a></em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:d5b2f266-97f1-49da-8693-d10556e4ef5d 7 takeaways from ethics of image-sharing pathology tweet chat Mon, 29 Aug 2016 22:00:00 GMT <p> As pathologists embrace image-sharing on social media for educational and informational purposes, patient privacy can be a concern. How can pathologists navigate the tumultuous waters of the digital world while still reaping the benefits? A recent tweet chat gathered the answers and resources.</p> <p> The <a href="" target="_blank"><em>AMA Journal of Ethics</em></a> (@<em>JournalofEthics</em>) joined the AMA (@AmerMedicalAssn) to co-host a tweet chat with two expert pathologists.</p> <p> Genevieve (Eve) Crane, MD, (@EveMarieCrane) is a research/clinical fellow in the Dept. of Pathology and the Children's Research Institute at UT Southwestern Medical Center in Dallas pursuing stem cell research and serves as a section editor for social media at the <em>Archives of Pathology & Laboratory Medicine</em> and as an ambassador for the United States and Canadian Academy of Pathology.</p> <p> Jerad M. Gardner, MD, (@JMGardnerMD) is an assistant professor at the University of Arkansas for Medical Sciences (UAMS), where he practices dermatopathology and sarcoma pathology. He is chair of social media for the United States and Canadian Academy of Pathology (USCAP) and the American Society of Dermatopathology (ASDP). He is deputy editor-in-chief at <em>Archives of Pathology & Laboratory Medicine </em>and manages social media for the journal. </p> <p> Here are the top seven questions from the tweet chat, along with resources that can help you in your practice:</p> <p> <strong>1. Why is image-sharing useful for pathologists on social media, and what are some potential ethical pitfalls?</strong></p> <p> Takeaway: It can enable free, global teaching of pathology and facilitate recognition of the rarest conditions, but patient-identifying details must never be posted. Consult <a href="" target="_blank" rel="nofollow">the list of 18 HIPAA identifiers</a>.</p> <p> <a href="" target="_blank"><img src="" /></a></p> <p> <strong>2. What inspired you to write the article? Are there problematic situations you wanted to respond to?</strong></p> <p> Takeaway: Those who make institutionalrules are often neither doctors nor Twitter-savvy. In addition, there is a lot of apprehension around sharing images, and even some legal departments are not sure what is legal or ethical.</p> <p> “I wanted to have published literature to use when others claim #SoMe not good for #MedEd,” Dr. Gardner tweeted.</p> <p> “I also feared lack of guidelines and good info would result in unnecessary restrictions,” Dr. Crane tweeted.</p> <p> <strong>3. You wrote the following in your recent article. How does that play out, especially on social media? </strong></p> <p> <a href="" target="_blank"><img src="" /></a></p> <p> Takeaway: Pathologists see the mechanisms underlying most diseases social media might bring out the teacher in all of us, but the format is particularly powerful for pathology.</p> <p> “We see mechanism underlying most diseases,” Dr. Gardner tweeted. “All docs want to know WHY. We can show/explain why.”</p> <p> <a href="" target="_blank"><img src="" /></a></p> <p> <strong>4. Are there situations where a pathology image shouldn’t be shared on social media? Give an example?</strong></p> <p> Takeaway: The image should not be shared any time the pathology is linked to a high-profile event, such as a widely reported crime or the death of a celebrity.</p> <p> The <em>AMA Journal of Ethics®</em> offered an article from the August 2016 issue, “<a href="" target="_blank">Public Figures, Professional Ethics, and the Media,”</a> which discusses the death of superstar musician Prince and how the media’s coverage led to the release of his medical records. </p> <p> <a href="" target="_blank"><img src="" /></a></p> <p> <strong>5. What are some of the merits/drawbacks of social media vs. print-based journal case reporting?</strong></p> <p> Takeaway: Among the merits: It has faster publication, reaches a broader audience and provides ongoing discussion. One of its drawbacks is that it is not peer-reviewed.</p> <p> <a href="" target="_blank"><img src="" /></a></p> <p> <a href="" target="_blank"><img src="" /></a></p> <p> <strong>6. What are some takeaways for how other clinicians should use social media?</strong></p> <p> Takeaway: Social media is a powerful way to interact with other physicians and the public, plus it can play a crucial role in patient-centered research and engaging patients.</p> <p> <a href="" target="_blank"><img src="" /></a></p> <p> <a href="" target="_blank"><img src="" /></a></p> <p> <strong>7. Do the challenges of online sharing via social media differ across platforms (i.e. Facebook, Twitter, Figure1)?</strong></p> <p> Takeaway: The privacy concerns are the same across platforms, but it is important to know each platform’s audience and tailor your approach accordingly.</p> <p> <a href="" target="_blank"><img src="" /></a></p> <p> If you missed the tweet chat, visit <a href="" target="_blank" rel="nofollow">the Storify for this #AHealthierNation chat</a> to see all of Dr. Crane’s and Dr. Gardner’s answers and tweets from participants in a chronological recap of the event.</p> <p> You can also check out Drs. Crane and Gardner's recent article published in <em>AMA Journal of Ethics</em>, <a href="" target="_blank">"Pathology Image-Sharing on Social Media: Recommendations for Protecting Privacy While Motivating Education."</a></p> <p align="right"> <em>By AMA staff writer Tim Smith</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:9ed0874c-3568-4754-899e-8ef9e0555b3e Interactive tool reveals where physicians are needed Mon, 29 Aug 2016 20:00:00 GMT <p> The distribution of the health care workforce has major implications for residents, physicians, advocates, policymakers and, of course, patients. An updated mapping tool can help you better grasp that distribution and how it relates to population health and professional opportunities.</p> <p> The AMA <a href="" target="_self">Health Workforce Mapper Version 2.0</a> is a customizable, interactive tool that illustrates the geographic distribution of the health care workforce. Users can filter physician and non-physician health care professionals by specialty and employment setting at the state, county and metropolitan levels.<a href="" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> The mapper also features geographic and policy data relevant to the health care workforce, including health professional shortage areas, hospital locations and population indicators. This data can be used to:</p> <ul> <li> Help residents determine which regions are most in need of physicians in their given specialty</li> <li> Help practices distinguish possible areas of both deficiency and overlap and identify high-priority areas for workforce expansion</li> <li> Help advocates demonstrate to policymakers the geographic distribution of the health care workforce to assist them in making appropriate, evidence-based decisions</li> </ul> <p> For example, with just three clicks, a user could determine that 49 of Ohio’s 88 counties lack a single geriatrician; that 18% of Belmont County’s 70,000 residents are over the age of 65; and that Delaware County’s population increased more than 58% from 2000 to 2010.</p> <p> Basemaps provide further detail in the form of geographic features, highways, health care facilities and health policy areas, including primary care health provider shortage areas and medically underserved areas and populations.</p> <p> <strong>Includes all specialties, plus population health data</strong></p> <p> The new version of the mapper incorporates every specialty and subspecialty in the <a href="" target="_self">AMA Physician Masterfile</a> and the <a href="" rel="nofollow" target="_blank">CMS National Provider Identifier database</a>, including non-physician specialties. It also includes resident physicians.</p> <p> The tool’s new Population Health Explorer displays a variety of population health factors, including:</p> <ul> <li> Morbidity and mortality rates per health indicator</li> <li> Health care access and quality, from percent uninsured to hospital readmission rate</li> <li> Health behaviors, such as smoking and alcohol use</li> <li> Demographics, including age and race</li> <li> More than a dozen social environment factors</li> </ul> <p> For example, a user can quickly determine that Douglas County has the highest rate of uninsured people under 19 years of age in Illinois.</p> <p> <a href="" target="_self">Access</a> to the mapper is free and open to the public. AMA members may export customizable Excel files ranking health workforce and demographic data by county.</p> <p> The AMA Health Workforce Mapper was developed in collaboration with the American Academy of Family Physicians (AAFP) Robert Graham Center and HealthLandscape, and it was funded by the AMA Scope of Practice Partnership. For more information about the mapper, contact the <a href="" rel="nofollow">AMA Advocacy Resource Center</a>.</p> <p align="right"> <em>By AMA staff writer Tim Smith</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:168f1628-f435-4485-a58b-39570d454801 Restoring joy in practice through team-based care Mon, 29 Aug 2016 01:00:00 GMT <p> While health systems across the country are implementing team-based care, few are doing it in exactly the same way. But many are doing it for the same reasons.</p> <p> “There’s never any straightforward or easy patient anymore,” said James Jerzak, MD, of Bellin Health, in Green Bay, Wisc. “In Wisconsin, the copays and the deductibles are huge. So every office visit is jammed with a lot of questions, and it can be really overwhelming to the individual clinician.”</p> <p> <a href="" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> Dr. Jerzak, a family medicine physician, made his remarks in a recent presentation, “Restoring Joy in Practice through Team-Based Care,” at the University of Illinois at Chicago (UIC). UIC is a part of the <a href="" rel="nofollow" target="_blank">Great Lakes Practice Transformation Network</a>, a regional group that encompasses Illinois, Indiana and Michigan. Practice transformation networks are peer-based learning networks designed to coach, mentor and assist physician practices and health care systems.</p> <p> Team-based care, he explained, is a means to an end: effective population health management. But it can deliver another, equally positive effect.</p> <p> “This is what solves the burnout problem in this country,” he said. “It’s not some of these other things that put band-aids on it. You have to take away the causes of burnout—the EHR demands and the demands of the complicated visits.”</p> <p> Bellin Health is a relatively small health system, with 35 clinics, one hospital and about 150 physicians and other health care professionals. It is primarily fee-for-service, and its leadership knows the impending shift to value-based payment will require changes in how care is delivered.</p> <p> <strong>Expanding some roles, narrowing others</strong></p> <p> The best way to improve quality measures, Dr. Jerzak has found, is to get the physician out of the picture and let the team handle a lot of tasks.</p> <p> To do this, Bellin Health is implementing a team-based care model that, for starters, greatly expands the roles of medical assistants and licensed practical nurses to serve as care team coordinators (CTCs). Following standard rooming procedures, the CTC:</p> <ul> <li> Populates visit diagnoses from problem list</li> <li> Sets up one-year refills</li> <li> Identifies the visit agenda</li> <li> Identifies and addresses care gaps</li> <li> Pulls up appropriate template</li> <li> Starts documentation</li> </ul> <p> Here’s how it works.</p> <p> The physician enters the room without a computer and, after a warm handoff, addresses the patient. The CTC remains in the room, continuing documentation in the background so the physician can focus on the patient and MD-level work.</p> <p> The CTC then reviews tests, provides some health coaching and motivation to the patient and makes sure the patient understands the care plan. The CTC also enters orders for consults, new medications and tests and acts as patient advocate.</p> <p> Meanwhile, the physician returns to a computer station in a colocation space to edit documentation and review and sign off on orders. The patient’s chart is usually closed before the physician goes on to the next exam room.</p> <p> <strong>Why team-based care works to restore joy in practice</strong></p> <p> “The thing I find most satisfying in this is empowering the staff,” Dr. Jerzak said. “I love it when I’m in the room and I’ll say to the care team coordinator, ‘Let’s have case management involved,’ and they look at me and say, ‘I already ordered it.’ We don’t need the clinician to be approving everything when it’s obvious it has to be done.”</p> <p> Other lessons Dr. Jerzak said Bellin Health learned from adoption of team-based care:</p> <ul> <li> Colocation is critical and can be done without any extra staff</li> <li> Electronic messaging is very inefficient and should be avoided</li> <li> The number one thing in team-based care is personality—being able to work with the people around you</li> </ul> <p> Dr. Jerzak noted that burnout is not limited to physicians—in fact, it affects all health care professionals—and he thinks team-based care has the potential to restore joy not just to physicians but to everyone involved.</p> <p> “When we’re in our pod and people are working, I often times stop and think that it’s just fun to do this again,” he said. “I think patients really pick up on that too.”</p> <p> <strong>Learn more about team-based care and physician health</strong></p> <p> The AMA offers a free <a href="" rel="nofollow" target="_self">team-based care training module</a> in its STEPS Forward™ collection of practice improvement strategies to help physicians make transformative changes to their practices. Other modules include <a href="" target="_self">starting Lean health care</a>, <a href="" target="_self">implementing daily huddles</a> and <a href="" target="_self">addressing EHR woes with team documentation</a>.</p> <p> Thirty-five modules are available, and several more will be added later this year, thanks to a grant from and collaboration with the <a href="" rel="nofollow" target="_blank">Transforming Clinical Practices Initiative</a>.</p> <p> Bellin Health will be hosting a team-based care <a href="" rel="nofollow" target="_blank">Training Camp</a> Nov. 1-3 at Lambeau Field, in Green Bay, and the <a href="" rel="nofollow" target="_self">International Conference on Physician Health</a>, a collaboration of the AMA, the Canadian Medical Association and the British Medical Association, will showcase research and perspectives about Increasing Joy in Medicine for physicians Sept. 18-20 in Boston.</p> <p align="right"> <em>By AMA staff writer Tim Smith</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:daacdc3d-9949-4f31-937d-ba5324236795 Med student meets metaphor: Comics in med school Sun, 28 Aug 2016 22:00:00 GMT <p> In medical school, there are few opportunities for students to stop, pause and reflect on where they’ve been, who they’ve become and where they are going. At Penn State College of Medicine, one physician professor is using comics to teach medical students how to creatively reflect on their experiences as they form their professional and personal identity.</p> <p> For seven years, Michael Green, MD, an internist and bioethicist at Penn State where he is vice chair of the department of humanities and director of the program in bioethics, has taught a class called “Comics in Medicine.”<a href="" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> “The purpose of art is washing the dust of daily life off our souls,” Pablo Picasso said. And that’s what the “Comics in Medicine” course is all about, according to Dr. Green. When it comes to understanding an important experience, talking about it is good, writing about it may be better, but finding a creative way to express feelings visually can help the artist—or student—better grasp what the experience was all about.</p> <p> “Medical school is an intense experience,” Dr. Green said. “It’s like running a marathon at sprint speed—you never slow down. During this course, [medical students] get to slow down, pause and try to make sense of who they are right now.” And, the juxtaposition of words and images in the comic format provides an effective medium for students to reflect on the formative experiences of medical school.</p> <p> In an <a href="" target="_blank" rel="nofollow">article</a> published in <em>Academic Medicine</em>, Dr. Green describes five distinct themes that appear in students work: How I found my niche, the medical student as patient, reflections on a transformative experience, connecting with a patient and the triumphs and challenges of becoming a doctor.</p> <p> “The medium of comics frees students up to express themselves metaphorically in ways they might not be inclined to do otherwise,” he said. “One troubling theme that comes up again and again is how students feel powerless and mistreated. And so they depict people who are supposed to be their role models and mentors in less than flattering ways.”</p> <p> “There’s always a grain of truth in dark humor,” he said. “A lot of times students depict their attending physicians and mentors as monsters, using imagery from horror fiction and film. Though it’s over the top and exaggerated, the images nevertheless reveal how students perceive their place in the medical hierarchy.”</p> <p> <strong>Are we in Gotham or med school?</strong></p> <p> Penn State College of Medicine is home to the first department of humanities at a U.S. medical school and has pioneered many innovative techniques for teaching humanities in the medical school setting.</p> <p> “The humanities department plays a very prominent role in the curriculum at Penn State,” Dr. Green said, “and the comics course is but one example of innovations that are taking place throughout the curriculum.”</p> <p> Comics in Medicine is a month-long course where students meet twice a week for two and a half hours. In a hybrid seminar-workshop style, students experience three types of activities:</p> <p style="margin-left:40px;"> <strong>1.   </strong><strong>Reading comics and graphic narratives about medical themes.</strong> “There are many book-length graphic narratives that have been published over the past decade that address medical themes such as experiences with illness, dealing with cancer and stories about the medical system,” Dr. Green said.</p> <p style="margin-left:40px;"> <strong>2.   </strong><strong>Drawing and brainstorming.</strong> Another aspect of the course is “engaging in creative activities where we practice drawing, creative writing or brainstorming ideas,” Dr. Green said.</p> <p style="margin-left:40px;"> <strong>3.   </strong><strong>Completing a comic narrative.</strong> “From the first day of class students are working on a final project, which is to tell their own story about a formative experience they’ve had during medical school in the format of a comic. This is a very labor intensive, time-consuming and challenging activity,” he said.<br /> <br /> “We spend a lot of time workshopping, where they start out with the idea then write a draft and make sketches,” Dr. Green said. “They eventually turn it into a comic that we publish in booklets and post online.”</p> <p> <strong>Med students and the adventures of clinical training</strong></p> <p> Often, the student who walks into the course is different from the student who walks out the door at the end, Dr. Green said. And every time he teaches the course, Dr. Green asks the students what they expect out of it.</p> <p> “Initially, my expectation was that I’d get a lot of students who’d say they were lifelong fans of comics and love to draw,” he said. “But most students say they don’t read graphic novels and they can’t draw.”</p> <p> “But they’re interested,” he said. “They say it sounds fun or they want to do something different and new. I ask them how relevant they think comics are to their medical education; and by  the end of the class the numbers go up dramatically.”</p> <p> “One of the reasons I teach using comics is that I think the process of carefully reading and creating comics involves skills that are relevant to being a doctor,” Dr. Green said.</p> <p> “I’ve had students say, for example, after reading a graphic novel where there are images of how doctors are portrayed, they’ve never noticed how it makes somebody feel if you’re talking to them and your back is turned toward the computer,” he said. In one of the course materials, “the doctor is giving bad news about cancer and has a huge smile on her face and the family can’t understand why she’s smiling. The students say, ‘Wow, I do that, I smile when I get nervous and never knew that was so offensive.’”</p> <p> Students practice the skill of paying close attention to detail by drawing their own comics. “You have to really concentrate and be an observer of the world around you if you want to accurately depict a scene where a doctor is interacting with a patient,” he said. “You have to think about their body position, the expression on their face and where the patient is situated in relation to the doctor.” And how students make these choices in their own work reveals a great deal about how they see themselves within the medical culture.</p> <p> More and more, the humanities are part of the medical school curriculum. Another example  art is medical school is Mark Stephens, MD, a family physician and professor at the Uniformed Services University in Maryland, who is using art to give students time for self-exploration. Through the <a href="" target="_self">making of masks</a>, students explore the ultimate question: Who am I?</p> <p align="right"> <em>By AMA staff writer </em><a href="" target="_blank" rel="nofollow"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:bb228699-a5e4-47d7-967f-0b331e23ae02 Donate to the AMA Foundation: International Medical Graduates Honor Fund Fri, 26 Aug 2016 13:00:00 GMT <p> The AMA Foundation supports the efforts of physicians and other volunteers working at free clinics to provide quality, affordable health care. The program awards $10,000 grants to physician-led free clinics. To date, over $1.6 million has been awarded to 81 free clinics across the country.</p> <p> IMG physicians – members are invited to support the physician-led free clinics in the United States through the AMA Foundation's <a href="" target="_blank"><em>Healthy Communities/Healthy America</em></a><a href=""> program</a>. Many IMG physicians have donated to kick-off this funding initiative. The IMG Section goal is to raise $250,000, at which point investment income from this endowment fund can be awarded to physician-led free clinics.</p> <p> Consider donating and support this great funding initiative. <a href="" target="_self">Donate or learn more</a>.</p> <p>  </p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:b8b161d7-ae4b-4997-8b44-6875934f602e Death by ZIP code: When address matters more than genetics Thu, 25 Aug 2016 21:00:00 GMT <p> Health inequity has left many communities around the nation with health disparities that are out of their control. Understanding the concept of how socioeconomic and environmental factors play a major role in population health is the most effective way to reshape our traditional health narrative.</p> <p> Anthony Iton, MD, senior vice president of healthy communities at the California Endowment, recently spoke to medical students at the University of California, Davis, School of Medicine during the AMA’s <a href="">Accelerating Change in Medical Education</a>  consortium meeting on health equity and community-based learning.</p> <p> When Dr. Iton left Montreal years ago for medical school at Johns Hopkins in Baltimore, he was given a tour of the city by an upperclassman. As they drove through East Baltimore he was shocked.<a href="" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> “East Baltimore looked to me like Beirut,” he said, “with bombed out buildings and cars up on their axels and little mangy dogs running around and babies playing in and amongst all of this and I thought, how is this possible?”</p> <p> “I had never seen anything like this in my life,” he said. “[The upperclassman] saw my mouth agape, and he said, ‘What’s wrong with you?’ And I said, ‘When was there a war here?’”</p> <p> “We conveniently overlook the fact that there has been a narrative in this country,” Dr. Iton said, “and this narrative shapes policy, and that policy creates conditions.”</p> <p> “We of course know what’s happened in Baltimore more recently,” he said. “For those of us who have spent time in Baltimore, this has been happening for forty years. Baltimore has been a roiling insurrection for literally half a century because of these conditions. And yet we act surprised when we see it erupt all of a sudden.”</p> <p> Scott County Indiana has had an outbreak of HIV which puts their incidence rate higher than sub-Saharan Africa, Dr. Iton said. “Scott County Indiana is 98.5% white. Yet it has the very same socioeconomic situations as East Baltimore.”</p> <p> “We end up seeing devastating disease in clinics because of the social policies that leave people essentially bereft of the resources that they need to be able to manage and navigate a healthy life,” he said. “What is the social contract in East Baltimore? What is the social contract in Scott County?”</p> <p> Dr. Iton thought hard about all of this inequality as he went through medical school and one question arose in his mind: Does your ZIP code matter more than your genetic code when it comes to your health?</p> <p> <strong>Investigating the root causes of health inequity</strong></p> <p> When he became the health director for Alameda County, California, Dr. Iton had access to the database of death certificates which details how someone died, their age, race or ethnicity and where they lived. And those four pieces of data can reveal a lot about patterns of death in a community over time.</p> <p> What they found after looking back several years was that “there are places where you pay a price in loss of life because of your address,” he said. They expanded their research to many other cities and “everywhere we looked we found life-expectancy differences in the same city on the order of 15-20years.”</p> <p> “In an ideal world … where you live shouldn’t predict how long you live,” he said, “but we do not live in an ideal world. What drives health is beyond just health behaviors and access to the doctor…. There’s a whole host of environmental and social determinants that are actually much more influential on our health trajectories, and we have no organized practice for dealing with them.”</p> <p> “We know that much of what affects our health happens outside the doctor’s office,” he said. “We know increasingly more about stress [and] various different policy-mediated factors that shape how our bodies respond. The things that we make difficult for people in life—getting health insurance, getting access to primary care—these are stressors that are unnecessary that actually change our physiology.”</p> <p> Stress, or the release of cortisol, can have major implications for health, Dr. Iton said. “When you walk into a low income community, cortisol levels are high. People are constantly being threatened. Most of these threats are policy-mediated threats. They’re not somebody with a gun or a hammer, although that happens. It’s often the inability to meet your basic needs with the resources you have at your disposal.”</p> <p> “So you’re constantly bathed in cortisol and when that happens that stimulates hypertension, cardiovascular disease, glucose intolerances, insulin resistance, inflammation, decreases your immune responses and causes atrophy and cell death in critical parts of our brains,” he said. “Low income people and wealthy people in this country are physiologically different,” Dr. Iton said. “Not because they were born that way, but because we made them that way through policy.”</p> <p> “When you’re seeing health disparities, you’re only seeing the tip of the iceberg,” he said. “You’re not seeing all the underlying, structural inequities that produce those disparities. And then we try to treat those disparities with pills and brochures.”</p> <p> <strong>A framework for change</strong></p> <p> “When I was in medical school, I knew something was happening, I just didn’t have words for it,” Dr. Iton said. “I would see patients that seemed so frazzled and stressed and sick, and the frame that I was taught is that I have to teach this person how to live in 15 minutes.”</p> <p> The Bay Area Regional Health Inequities Initiative developed a framework “which tries to understand how we design strategies to intervene in what we’re seeing,” Dr. Iton said. “It came together out of frustration with the medical model, [which] really didn’t provide the tools for intervening in the broader forces that were creating inequity in our society.”</p> <p> “It starts with this notion that when you see premature death, whether it be infant mortality or shortened life expectancy, you think about diseases and injury and the burden of those things,” he said. “We spend a lot of time trying to change people’s behaviors with health education … and then we try to get them access to health care and intervene in the downstream cascade…. You have to think about what are the factors upstream that are working at the societal level.”</p> <p> “We know if you don’t have access to healthy food it’s much less likely that you’re going to eat healthy food,” he said. “We know that if you don’t have access to parks and recreation it’s much less likely that you’re going to exercise and do the things that we tell people to do all the time.”</p> <p> These consequences are systemic. It causes not just health consequences but also disparities in education and employment opportunities. “The solutions are about enlisting the very people who are experiencing those inequities, building their social, political and economic power, so that they can participate in reshaping these policies,”</p> <p> Check out “<a href="" rel="nofollow" target="_blank">A Tale of Two ZIP Codes</a>,” a video from Health Happens Here that gives a practical example of how where you live can affect your health.</p> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:79977e27-ec8c-48e8-85c9-90e693ef7395 Register for 19th Interim Meeting of AMA-IMG Section Thu, 25 Aug 2016 14:00:00 GMT <p> The AMA Interim Meeting will take place Nov. 11-14 in Orlando. The AMA International Medical Graduates section will host several events for its members.</p> <p> <strong>Planned events include:</strong></p> <ul> <li> <strong>AMA 13th Research Symposium and Reception: 1– 7:30 p.m. on Friday, Nov. 11</strong><br /> Come to hear educational sessions, oral research presentations and view abstracts by our IMG ECFMG-certified candidates who are waiting residency.  The medical students and residents are also a part of this AMA Research Symposium.</li> </ul> <ul> <li> <strong>AMA-IMG Section reception and Congress: 5:30–7:30 p.m. on Saturday, Nov. 12</strong><br /> Come network with colleagues, participate in a meditation exercise and discuss policy items for the IMG Section and House of Delegates reports/resolutions of interest.<br /> <br /> Featured speaker: Humayun Chaudhry, DO, MS, MACP, CEO/President, Federation of State Medical Boards.</li> </ul> <ul> <li> <strong>Busharat Ahmad, MD, Leadership Development Program: 2-3 p.m. on Sunday, Nov. 13</strong><br /> Come and learn about how to be an effective physician leader and follower. Featured speaker: Nestor Ramirez-Lopez, MD, “Followership, The Other Face of Leadership.”</li> </ul> <ul> <li> <strong>AMA-IMGS & Minority Affairs Delegates Caucus: 8:30-9:30 a.m. on Monday, Nov. 14</strong><br /> Review reference committee reports and discuss strategies for supporting IMG Section and House of Delegates policy items.</li> </ul> <p> Bring a colleague or a friend and take advantage of these events.  To register, visit the <a href="" target="_self">AMA-IMG webpage</a>, <a href="" rel="nofollow">email</a> the AMA-IMG section or call (312) 464-5397 for more information. </p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:e7b38a77-6fcb-4adb-8e18-63918d20f517 Surgeon General mails letters to America’s physicians Thu, 25 Aug 2016 03:00:00 GMT <p> Check your mailbox over the next two weeks—there should be a letter from U.S. Surgeon General Vivek H. Murthy, MD, calling on all physicians throughout the nation to raise awareness and further efforts to end the opioid overdose epidemic.</p> <p> Physicians are in a unique position of leadership when it comes to this epidemic—they are on the front lines witnessing the impact every day from emergency department overdoses to substance use disorder treatment. The letter asks directly for physicians’ help to solve and bring an end to the opioid overdose epidemic.</p> <p> “We will educate ourselves to treat pain safely and effectively,” Dr. Murthy said in the <a href="" rel="nofollow" target="_blank">letter</a>, suggesting physicians examine the <a href="" rel="nofollow" target="_blank">many resources</a> from the Centers for Disease Control and Prevention, the Substance Abuse and Mental Health Services Administration and the National Institute on Drug Abuse.</p> <p> “We will screen our patients for opioid use disorder and provide or connect them with evidence based treatment,” he said. “We can shape how the rest of the country sees addiction by talking about and treating it as a chronic illness, not a moral failing.”</p> <p> <strong>Awareness can make a difference</strong></p> <p> This style of raising awareness has worked before. In 1988, U.S. Surgeon General C. Everett Koop, MD, sent a seven-page brochure, “Understanding AIDS,” to all 107 million households in the country. The mailing raised awareness that the AIDS epidemic affected every one and not just a small group of Americans. The opioid epidemic the country now faces similarly affects those of all ages, races and economic status.</p> <p> Dr. Murthy earlier this month launched <a href="" rel="nofollow" target="_blank"></a>, where physicians can take a pledge and make a commitment to end the opioid crisis.</p> <p> “Years from now, I want us to look back and know that, in the face of a crisis that threatened our nation, it was our profession that stepped up and led the way,” he said in the letter.</p> <p> <strong>Physician efforts already underway</strong></p> <p> Steven J. Stack, MD, AMA immediate-past president, in May issued an <a href="" rel="nofollow" target="_blank">open letter to America’s physicians</a> calling on them to re-examine prescribing practices and help reverse the epidemic. “We must accept and embrace our professional responsibility to treat our patients’ pain without worsening the current crisis,” he said.</p> <p> The AMA <a href="" target="_self">Task Force to Reduce Prescription Opioid Abuse</a> has been working to raise awareness of the crisis for almost two years. The task force put forth <a href="" target="_self">recommendations for physicians</a> to register for and use state prescription drug monitoring programs, educate themselves on pain management and safe prescribing, support increased access to naloxone, reduce the stigma of substance use disorder and enhance access to comprehensive treatment.</p> <p> <strong>For more on what physicians can do:</strong></p> <ul> <li> <a href="" target="_self">Treating substance use disorder as a family physician</a></li> <li> <a href="" target="_self">How one physician uses his PDMP to help patients</a></li> <li> <a href="" target="_self">The antidote: 3 things to consider when co-prescribing naloxone</a></li> <li> <a href="" target="_self">Pain expert: Judge the opioid treatment, not the patient</a></li> <li> <a href="" target="_self">3 steps for talking with patients about substance use disorder</a></li> </ul> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:030a28c9-30c4-43d6-a54d-43b7a96b42e6 This year’s most influential people in health care Wed, 24 Aug 2016 21:39:00 GMT <p> Among the attorneys general, administrators, justices, senators and representatives, many physicians made <em>Modern Healthcare’s</em> annual list of the 100 Most Influential People in Healthcare. This year, 17 AMA members were honored.</p> <p> AMA President Andrew W. Gurman, MD, made the list at No. 27 just two months after his <a href="">inauguration</a>. Dr. Gurman recently spoke out against the <a href="">mergers of four major health insurers</a> and will lead AMA efforts as the Medicare Access and CHIP Reauthorization Act begins next year.</p> <p> Robert Wachter, MD, made the list at No. 58. Dr. Wachter is an associate chairman of the department of medicine at the University of California—San Francisco, which is a founding member of the AMA’s Accelerating Change in Medical Education Consortium.</p> <p> These physicians and AMA members joined such notables as President Barack Obama at the No. 1 spot, Centers for Medicare and Medicaid Services Acting Administrator Andy Slavitt came in at No. 10, and Secretary of the U.S. Department of Health and Human Services Sylvia Mathews Burwell at No. 5. The honorees were nominated by their peers and voted on by both readers and senior editors of <em>Modern Healthcare</em>.</p> <p> Other AMA members include:</p> <ul> <li> No. 29: Delos “Toby” Cosgrove, MD, president and CEO of the Cleveland Clinic</li> <li> No. 30: John Noseworthy, MD, president and CEO of the Mayo Clinic in Rochester, Minn.</li> <li> No. 41: Atul Gawande, surgeon, professor, writer and researcher at Harvard Medical School and Harvard School of Public Health in Boston</li> <li> No. 44: Gary Kaplan, MD, chair and CEO of the Virginia Mason Health System in Seattle</li> <li> No. 47: Georges Benjamin, MD, executive director of the American Public Health Association</li> <li> No. 51: Halee Fischer-Wright, MD, president and CEO of the Medical Group Management Association</li> <li> No. 53: Francis Collins, MD, PhD, director of the National Institutes of Health in Bethesda, Md.</li> <li> No. 62: J. Mario Molina, MD, president and CEO of Molina Healthcare Inc</li> <li> No. 65: Mark Chassin, MD, president and CEO of the Joint Commission in Oakbrook Terrace, Ill.</li> <li> No. 77: Tejal Gandhi, MD, president and CEO of the National Patient Safety Foundation in Boston</li> <li> No. 78: Jonathan Perlin, MD, PhD, president of clinical services and chief medical officer of HCA in Nashville and chair of the American Hospital Association</li> <li> No. 88: Eugene Washington, MD, president and CEO of Duke University Health System</li> <li> No. 96: Patrick Soon-Shiong, MD, chairman and CEO of NantHealth</li> <li> No. 97: Victor Dzau, MD, president of the National Academy of Medicine</li> <li> No. 98: Troyen Brennen, MD, executive vice president and chief medical officer of CVS Health</li> </ul> <p> <a href="" target="_blank" rel="nofollow">Read about</a> this year’s top physician leaders and <a href="" target="_blank" rel="nofollow">see the full list</a> at <em>Modern Healthcare.</em></p> <p align="right"> <em>By AMA staff writer</em> <a href="" target="_blank" rel="nofollow"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:34dd52c9-ff27-4296-a30a-9edf56f1289e Using neurosurgical solutions to manage chronic pain Tue, 23 Aug 2016 21:16:00 GMT <p> Back pain is one of the most common ailments chronic pain patients face. For some, a neurosurgical approach can offer much relief and may be an alternative to long-term opioid therapy. Here’s what one neurosurgeon and member of the AMA Task Force to Reduce Prescription Opioid Abuse had to say about treating patients with chronic pain and the Task Force’s efforts to end the opioid overdose epidemic.</p> <p> <strong>Treating chronic back pain in neurosurgery</strong></p> <p> Jennifer Sweet, MD, is a neurosurgeon at University Hospitals Case Medical Center in Cleveland and the physician representative for the American Association of Neurological Surgeons on the AMA <a href="" target="_self">Task Force to Reduce Prescription Opioid Abuse</a>. Dr. Sweet sees patients with chronic pain who have what is called failed back surgery syndrome.</p> <p> “When patients are referred to me they’ve had big spine fusions and they’re still not getting better,” she said. “If patients don’t tolerate systemic opioids, or if high-dose opioids still don’t manage their pain, then I can offer another option. Interventions such as intrathecal pain pumps can provide the pain relief patients need, without all the side effects of systemic opioids.</p> <p> “While this has traditionally been reserved for patients with cancer pain,” she said, “we are now realizing the potential benefit for chronic pain patients without terminal disease.”</p> <p> The intrathecal pain pump delivers opioids locally to the area where the patient is experience pain through the spinal fluid. “It helps them get off the systemic opioids so they have less chance for addiction and less of the side effects,” Dr. Sweet said. “Over the last five years, it has become increasingly common to utilize these therapies for patients with isolated back pain from Failed Back Surgery Syndrome and even for neuropathic pain.”</p> <p> “I don’t think it’s going to solve the major opioid epidemic,” she said, “but it may help treat patients who are truly debilitated by their pain, who have few alternative options.”</p> <p> “I also see a big opportunity to really re-introduce into our pain management treatment algorithm other non-opioid medications, such as anti-inflammatory agents, antidepressants and anti-epileptics," Dr. Sweet said. "There are many more drugs available than just opioids, and a multimodal approach may represent another key strategy.”</p> <p> Most of the patients Dr. Sweet sees want to get off of their pain medications. “They’re scared that they can’t get the pain medications easily, it’s becoming more and more difficult,” she said. “Their quality of life is not enjoyable and they don’t like the side effects.”</p> <p> “If we determine the intrathecal pain pump is the best option, we do a trial and if they benefit from the trial we’ll implant the intrathecal pump in a small outpatient procedure,” she said. “All patients also must see a pain psychologist, and we will often refer patients to an addiction specialist when necessary to manage any physical or psychological opioid dependency or other co-occurring issue.”</p> <p> “For the right patient, neuromodulatory approaches such as intrathecal pain pumps can be life-changing,” Dr. Sweet said.</p> <p> <strong>Dr. Sweet talks Task Force, prevention and education </strong></p> <p> Nationwide there are many efforts underway to combat the opioid epidemic from all angles. The AMA Task Force to Reduce Prescription Opioid Abuse has been in this fight for several years, enlisting the help of physician members who are working to end the epidemic through several goals.</p> <p> “The task force has been addressing a lot of important things,” she said. “First of all, getting physicians to register with their prescription drug monitoring programs (PDMP) so that we can look up patients, and every time we prescribe opioids we are documenting that so that other physicians can see who’s prescribing, how much and when.”</p> <p> “We’re also trying to sort out the difference between a chronic type of pain, like the back pain patients that I see, versus an acute pain which would be when we prescribe opioids postoperatively,” she said. “Are there other types of medications that can be administered or other treatment options? So education is a tremendous focus of the task force.”</p> <p> Another important effort the task force has made is “getting the message out there that legislation needs to change to increase naloxone availability,” Dr. Sweet said. “Also, it’s important to have greater access to addiction specialists in the community ready to treat these patients.”</p> <p> “One of the areas where I think the biggest changes need to occur is in physician education,” she said. “And one of the ways we can do this is by <a href="" target="_self">teaching young physicians</a> who are in their residencies that there are other options besides just opioids, although opioids do have their place in reducing pain, that there are other medications and that can help in prevention.”</p> <p> ”We have a lot of work to do,” she said, “and neurosurgeons are very glad to help the task force’s efforts efforts in prevention, education and advocating for patients.”</p> <p> <strong>For more on the opioid epidemic and how physicians can help:</strong></p> <ul> <li> <a href="" target="_self">Treating substance use disorder as a family physician</a></li> <li> <a href="" target="_self">How one physician uses his PDMP to help patients</a></li> <li> <a href="" target="_self">The antidote: 3 things to consider when co-prescribing naloxone</a></li> <li> <a href="" target="_self">Pain expert: Judge the opioid treatment, not the patient</a></li> <li> <a href="" target="_self">3 steps for talking with patients about substance use disorder</a></li> </ul> <p style="text-align:right;"> <em>By AMA staff writer</em> <a href="" target="_blank" rel="nofollow"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:c9eeedca-3355-4d69-80ab-0d9e35161902 What it’s like to be in sleep medicine: Shadowing Dr. Chervin Tue, 23 Aug 2016 20:29:00 GMT <p> As a medical student, do you ever wonder what it’s like to be a sleep specialist? Here’s your chance to find out.</p> <p> Meet Ron Chervin, MD, a sleep specialist and featured physician in <em>AMA Wire’s</em>® <a href="" target="_self">“Shadow Me” Specialty Series</a>, which offers advice directly from physicians about life in their specialties.</p> <p> Read his insights to help determine whether a career in sleep medicine might be a good fit for you.<a href="" style="font-size:12px;" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> <strong>“Shadowing” Dr. Chervin</strong></p> <p> <strong>Specialty:</strong> Sleep medicine</p> <p> <strong>Practice setting:</strong> Academic medical center</p> <p> <strong>Years in practice:</strong> 22</p> <p> <strong>A typical day in my practice:</strong></p> <p> I usually arrive at my office by about 8:20 a.m., after I drop my kids off at school, and I typically leave my office between 6:00 and 8:00 p.m. Sometimes there is then an hour or two of email to catch up on from home in the evening.</p> <p> On weekends, I often work one additional short day, for about six hours. During my time at work, I have a varied portfolio that includes seeing my own patients with sleep disorders, assisting sleep medicine fellows in seeing their patients and reviewing sleep studies with fellows to teach them how to interpret the data and provide optimal patient care.</p> <p> I spend a substantial portion of my time—typically one-third or more of my work hours over the past two decades—on clinical sleep research, which means managing teams of staff members and collaborators, as well as analyzing and reporting data or writing new grant applications. I also spend many hours on administrative issues for a large academic sleep center, on mentorship of junior faculty and fellows and on national service, primarily through the American Academy of Sleep Medicine (AASM). This academic year, I am serving as President for the AASM.</p> <p> <strong>The most challenging and rewarding aspects of caring for patients in sleep medicine:</strong></p> <p> Sleep-wake disorders often have a serious, pervasive impact on health, productivity, quality of life and enjoyment of waking hours. When we are not able to figure out a diagnosis, or provide effective treatment, we can face desperate patients and family members, not to mention frustrated physicians.</p> <p> On the other hand, the most rewarding aspect of sleep medicine is that for the vast majority of patients, we do arrive at a logical diagnosis and, more importantly, highly effective treatment. For the patient, this can be life-changing. When this is my patient, I have the pleasure and satisfaction of knowing I’ve contributed something with enormous benefit.</p> <p> <strong>Three adjectives to describe the typical physician in sleep medicine:</strong></p> <p> Creative. Happy. Passionate.</p> <p> <strong>How my lifestyle matches or differs from what I envisioned in med school:</strong></p> <p> My lifestyle involves more hours at work than I would have predicted in medical school. However, I believe this is a consequence of my choice to pursue an academic career with a traditional tripartite focus—patient care, research and education—rather than an embedded feature of sleep medicine.</p> <p> Many clinicians in sleep medicine do manage to create an excellent work-life balance and juggle sleep medicine with raising a family. Physicians who are on call in this field can receive questions from a sleep laboratory at times but almost never have to leave home because of night call. Patients wait to discuss their sleep problems during daytime office hours, and there are only very rare medical emergencies in sleep medicine.</p> <p> Despite ongoing changes in types of studies for sleep disorders and in insurance coverage, sleep medicine continues to offer reasonable payment, a highly rewarding multidisciplinary practice and bright promise for the future. This is because:</p> <ul> <li> Healthy sleep is increasingly seen as vital to almost every other aspect of good health</li> <li> Sleep medicine still has far too few physician specialists to address sleep disorders that are highly prevalent</li> <li> The essential contributions that sleep physicians make to health systems will be highly valued as medicine increasingly adopts alternative care organization (ACO) models for health care</li> </ul> <p> <strong>The main skills every physician in training should have for sleep medicine but won’t be tested for on the board exam:</strong></p> <ul> <li> The wisdom to value a good medical history and put testing results into perspective</li> <li> The patience to dissect the complicated health and psychological backgrounds that present together for many people with insomnia</li> <li> The ability to communicate and teach well, even in non-academic settings, as every sleep physician is involved with education of colleagues as well as patients about sleep disorders and their impact</li> </ul> <p> <strong>One question every physician in training should ask themselves before pursuing sleep medicine: </strong></p> <p> Do you find obstructive sleep apnea fascinating? Although dozens of sleep disorders exist, this one condition is to sleep medicine as diabetes is to endocrinology. Sleep apnea affects a wide range of other health conditions, and as a neurologist I have been fascinated for many years by profound effects of sleep apnea on neurologic conditions, the brain, cognition and behavior, especially in children. Others can be fascinated by its intimate relationships with pulmonary disease, metabolism, endocrine function or immune function. However, it may be hard to be a sleep physician if you find obstructive sleep apnea boring.</p> <p> <strong>Three books every medical student in sleep medicine should be reading:</strong></p> <p> American Academy of Sleep Medicine. <em>International classification of sleep disorders, 3rd ed</em>. Darien, IL: American Academy of Sleep Medicine, 2014.</p> <p> Olson EJ, Winkelman JW, editors; for the American Academy of Sleep Medicine. <em>Case book of sleep medicine, 2nd ed</em>. Darien, IL: American Academy of Sleep Medicine, 2015.</p> <p> Dement WC, Vaughan C. <em>The promise of sleep</em>. New York: Delacorte Press, 1999.</p> <p> <strong>One online resource they should follow: </strong></p> <p> <a href="" target="_blank" rel="nofollow"></a></p> <p> <strong>A quick insight I’d give students who are considering sleep medicine:</strong></p> <p> Sleep medicine is a field defined by fellowship rather than residency training. You can enter sleep medicine from a background in internal medicine, pulmonary medicine, family medicine, neurology, psychiatry, pediatrics, otolaryngology or anesthesiology. Choose a pathway that you find most fascinating and most rewarding.</p> <p> However, keep in mind that a sleep medicine fellowship after training in one of the eligible traditional fields can lead to a highly rewarding full-time or part-time focus on helping people with the one-third of their lives spent asleep, and the other two-thirds that depend heavily on healthy function during that one-third.</p> <p> <strong>If I had a mantra or song to describe my life in this specialty, it’d be:</strong></p> <p> Achieving optimal health through better sleep (the vision of the American Academy of Sleep Medicine)</p> <p> <strong>Want to learn more about your specialty options?</strong></p> <ul> <li> Read more profiles in <em>AMA Wire’s</em> <a href="" target="_self">Shadow Me Specialty Series</a> to learn additional insights from physicians in such specialties as <a href="" target="_self">endocrine surgery</a>, <a href="" target="_self">obesity medicine</a>, <a href="">neurology</a>, <a href="">nephrology</a>, <a href="">otolaryngology</a>, <a href="">vascular surgery</a> and <a href="" target="_blank">infectious disease</a>, among others.</li> <li> Check out the AMA’s <em>Choosing a Medical Specialty</em> <a href="" target="_blank">resource guide</a> (member log in required).</li> <li> Be sure to avoid these <a href="" target="_blank">5 common mistakes students make</a> when choosing a specialty.</li> </ul> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:99d0a2fb-09a9-46b5-9547-47ce05571583 Lean strategies help a Boston practice improve patient care Tue, 23 Aug 2016 04:00:00 GMT <p> A clinician’s highest priority is caring for patients, not running an office. But what if inefficiencies in a practice’s operations get in the way of patient care? For Harvard Vanguard Medical Associates, the solution was Lean health care.</p> <p> At Harvard Vanguard’s Boston office, the room where the weekly clinical operations meeting is held is aptly named Mission Control. It serves as the hub of Harvard Vanguard’s implementation of Lean health care, which was developed to improve efficiency and give physicians more time with patients.<a href="" style="font-size:12px;" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> This is where improvement specialists, physicians and nurses together tackle their list of open improvement issues, by identifying barriers, assigning responsibilities and establishing due dates. They also review the status of recent “Rapid Improvement Events”—one‑ and two‑week intensive Lean activities—as well as longer‑term projects.</p> <p> <strong>Press 1 for improvement</strong></p> <p> One recent Rapid Improvement Event involved optimizing the automated phone triage system. Formerly, the only option callers received was, “Press 1 for medical advice.” But when the team reviewed call data, they quickly learned that most calls were for refills, followed by appointments and then medical advice.</p> <p> So they reordered the automated options accordingly. Now option 1 connects patients to someone who can assist with refills; option 2 is for appointments and so on.</p> <p> It was a simple change that has enabled Harvard Vanguard to more quickly get calls to the right people to meet patients' needs.</p> <p> <strong>Standardizing helps; following up helps more</strong></p> <p> Obviously, not all of the practice’s operations are automated, so standardizing work is the cornerstone of Harvard Vanguard's Lean philosophy. For every work process, there is a clearly defined series of steps for those who do that work, and each task has been mapped for how it feeds into larger processes.</p> <p> To help all staff members standardize their processes, team members periodically observe each other in informal peer‑to‑peer audits. If a worker completes a process correctly, the auditor shows a green card. If the work is done incorrectly, the auditor shows an orange card.</p> <p> The purpose of the audit is not to embarrass workers who make mistakes but to determine how consistently a process actually occurs and whether a member of the team needs assistance or additional training.</p> <p> <strong>Implementing Lean: A lot of the work has already been done for you</strong></p> <p> Lean is more than a method—it’s also a mindset. Lean thinking leads to cultural change, where all team members are empowered to identify sources of inefficiency and create innovative solutions to address problems.</p> <p> An <a href="" rel="nofollow" target="_self">online module</a> in the AMA’s STEPS Forward™ collection of practice improvement strategies explains how to implement Lean into your practice and includes:</p> <ol> <li> Descriptions of common Lean methods to help physicians select the right ones for their practices</li> <li> Six steps to help implement Lean improvements</li> <li> Answers to common questions and concerns about Lean thinking and methods</li> <li> Vignettes, like this one about Harvard Vanguard, describing how practices are successfully using Lean techniques to organize workflows and provide better patient care</li> </ol> <p> It also includes a process map toolkit to help practices visually map their process flows like Harvard Vanguard did. Process maps help identify what's working, what’s not and where more subtle opportunities for improvement may exist.</p> <p> Indeed, Harvard Vanguard remains committed to Lean only because its process improvement team has seen it work outside of Mission Control—by eliminating time-eating practices in the workday and freeing up clinicians to spend that time with their patients.</p> <p> Some practices, however, find it daunting to implement practice transformation without outside support, so the module also has a customizable search feature to help physicians find local consultants who are skilled in practice transformation and have expertise in specialized functional areas.</p> <p> Thirty-five STEPS Forward modules are now available, and several more will be added later this year, thanks to a grant from and collaboration with the <a href="" rel="nofollow" target="_blank">Transforming Clinical Practices Initiative</a>.</p> <p align="right"> <em>By AMA staff writer Tim Smith</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:be4bc02d-e4ec-40b6-97b4-10e096951162 Liability suit seeks change to informed consent Sat, 20 Aug 2016 00:00:00 GMT <p> A case before the Supreme Court of Pennsylvania could have major implications on how physicians obtain informed consent prior to a surgery.</p> <p> At stake in <em>Shinal v. Toms</em>, is whether a patient’s informed consent to surgery can be predicated on information provided in part by a physician’s assistant, as opposed to just the physician. Both the Medical Care Availability and Reduction of Error Act (MCARE) and common law have made it the physician’s duty to see that the proper information is conveyed, but the question is whether delegating tasks to qualified professionals is also within the bounds of the law and common medical practice.</p> <p> <strong>How the case unfolded</strong></p> <p> In 2004, Megan Shinal underwent surgery to remove a tumor, but it regrew and by 2008 she was experiencing severe headaches and was referred to Steven A. Toms, MD, for a second surgery.</p> <p> This type of surgery—the removal of a craniopharyngioma, a very serious and recurrent rumor located deep in the base of the brain—is one of the most complex surgeries in all of neurosurgery. For this reason, there were numerous important surgical decisions to be made, some by the surgeon and some collaboratively with the patient.</p> <p> The major decisions were which of two surgical approaches to take—through the nose and the sphenoid bone, or through the skull—and whether to remove the entire tumor or leave a portion of the tumor in place. Removing the entire tumor usually produces a better long-term outcome, but involves more surgical risk. One of those risks is a potential rupture of the carotid artery, which can cause serious injuries. Yet, the alternative to surgery would be to accept disability and then death as near inevitable outcomes.</p> <p> Dr. Toms testified that he and Ms. Shinal discussed this issue at length and that she had agreed that he would determine during the surgery whether he should remove the entire tumor.</p> <p> The complaint filed by Ms. Shinal and her husband at first included a detailed negligence claim, but this theory was abandoned before trial. Instead, the plaintiffs asserted that Dr. Toms had not advised of the risk of damage nor adequately explained the risks and complications associated with the surgical approach, particularly the risks and benefits of a total vs. partial tumor removal.</p> <p> They asserted that, because Dr. Toms’ physician assistant had provided the information to inform the consent, and not Dr. Toms himself, Mrs. Shinal had not been adequately informed and did not provide consent.</p> <p> <strong>What has been provided, not who provided it</strong></p> <p> Informed consent doctrine has focused on providing the patient with appropriate information to make a knowledgeable decision to proceed or to forgo surgery. Neither common law nor statute has prescribed who must provide the information.</p> <p> The record reflected that Dr. Toms’ staff had provided certain information to Ms. Shinal and the trial court properly instructed the jury to consider the testimony.</p> <p> “Imposition of a duty is quite different from mandating that the physician provide all of the information,” the Litigation Center of the AMA and State Medical Societies said in an amicus brief. “Physicians’ delegation of some of their duties to other health care professionals while maintaining liability if those delegated services are not properly performed is commonplace.”</p> <p> “Surgeons may be the ‘captain of the ship,’ and liable for a crew member’s errors, but they do not work alone and need not personally perform every task,” the brief said. “The trend of delegating will only be more common in the future as medical care seeks greater efficiencies.”</p> <p> The brief asked the Court to affirm the decision that information relative to obtaining a patient’s informed consent could be provided by qualified staff on behalf of the surgeon.</p> <p> <strong>Current medical liability cases in which the Litigation Center is involved:</strong></p> <ul> <li> Find out how a <a href="" target="_self">challenge to medical liability law could complicate pre-suit process</a>.</li> <li> Learn how a case <a href="" target="_self">could lead to unlimited awards of punitive damages</a>.</li> <li> Get the details on a <a href="" target="_self">case that could extend medical liability</a>.</li> <li> Find out how one <a href="" target="_self">case could increase liability exposure and redefine injury</a>.</li> </ul> <p align="right"> <em>By AMA staff writer </em><a href="" target="_blank" rel="nofollow"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:0c0cd52b-e8f6-465a-899b-a5f1cb989538 Prepping for USMLE Step 2? Here’s a commonly missed question Sat, 20 Aug 2016 00:00:00 GMT <p> The United States Medical Licensing Examination® (USMLE®) Step 2 is a formidable test, so <em>AMA Wire</em>® is providing frequent expert insights to help you prepare for it. Take a few minutes here to work through another of the most-missed USMLE Step 2 test prep questions and view an expert video explanation of the answer from Kaplan Medical.</p> <p> Once you’ve got this question under your belt, be sure to test your knowledge with <a href="" target="_self">other posts in this series</a>.</p> <p> Ready. Set. Go.</p> <p> <strong>This month’s question that stumped most students:</strong></p> <p> A 27-year-old immigrant from El Salvador has a 14 x 12 x 9-cm mass in her left breast. It has been present for seven years and has slowly grown to its present size. Her grandmother has breast cancer and her father has prostate cancer. Physical examination shows that the mass is firm, nontender, rubbery and completely movable, and it is not attached to the overlying skin or the chest wall. There are no palpable axillary nodes or skin ulceration.</p> <p> Which of the following is the most likely diagnosis?</p> <p style="margin-left:40px;"> A. Chronic cystic mastitis</p> <p style="margin-left:40px;"> B. Cystosarcoma phyllodes</p> <p style="margin-left:40px;"> C. Inflammatory breast cancer</p> <p style="margin-left:40px;"> D. Intraductal papilloma</p> <p style="margin-left:40px;"> E. Mammary duct ectasia</p> <p>  </p> <p> <object data="" height="350" id="ltVideoYouTube" src="" type="application/x-shockwave-flash" width="450"><param name="movie" value="" /><param name="quality" value="best" /><param name="bgcolor" value="#ffffff" /><param name="wmode" value="transparent" /><param name="allowFullScreen" value="true" /><param name="allowScriptAccess" value="always" /><param name="flashvars" value="playerMode=embedded" /></object></p> <p>  </p> <p>  </p> <p> <strong>The correct answer is B. </strong></p> <p> <strong>Kaplan says, here’s why: </strong><br /> Cystosarcoma phyllodes occurs in young women and grows to a huge size over many years, and yet spares the skin, the nodes and the underlying chest wall. There is no particular connection with Central America, but often these tumors are seen in immigrants of limited financial circumstances who have had no access to medical care in their own countries.</p> <p> <strong>Why you shouldn’t choose the other answers:</strong><br /> <em>Read these explanations to understand the important rationale for each answer.</em></p> <p> <strong>Choice A:</strong> Chronic cystic mastitis also known as fibrocystic changes of the breast, is seen in women of reproductive age who complain of tender and lumpy breasts preceding the menstrual cycle. Large cysts can develop in this disease, but not to the huge size described in the vignette.</p> <p> <strong>Choice C:</strong> Inflammatory breast cancer presents most often in older women complaining of swollen, edematous, erythematous breast with or without ulceration. Obstruction of lymphatic vessels accounts for the edematous appearance of the breast.</p> <p> <strong>Choice D:</strong> Intraductal papilloma is the most common cause of bloody nipple discharge. These tumors are tiny, just a few millimeters in diameter, and are located in the ductal lumen.</p> <p> <strong>Choice E:</strong> Mammary duct ectasia is a benign process due to subacute inflammation of the ductal system. Patients present with nipple discharge (sticky and of various colors), noncyclic breast pain, nipple retraction, and/or subareolar mass.</p> <p> <strong>One tip to remember:</strong></p> <p> Cystosarcoma phyllodes is a slow-growing and usually benign (90%) tumor that may reach very large and impressive sizes in premenopausal patients. The tumor is freely mobile, usually 4-5 cm, smooth, and well-circumscribed. All tumors should be resected after diagnosis has been established.</p> <p>  </p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:a755d501-3efb-45b6-a605-4eabfebc8052 Students deliver care in homes, communities Thu, 18 Aug 2016 22:06:00 GMT <p> Serving patients with unmet health needs is taking on a new meaning for medical students as they provide care for urban and rural patients both in patients’ homes and in their communities. The experiences also are providing clarity about the social determinants of health and the importance of continuity of care as students become more attuned to their patients’ needs.</p> <p> The immersions into the clinics and greater community are part of the schools’ work with the AMA’s <a href="" target="_self">Accelerating Change in Medical Education Consortium</a>. The consortium, working to modernize and reshape the way physicians are trained, brings leaders from schools together to share ideas and experiences with new programs that are designed to improve competency, leadership and patient care through innovations that bridge the curriculum gap between medical school and practice.</p> <p> Students from the consortium schools recently came together at University of California, Davis, School of Medicine to share their experiences and gain insights from experts that they can put into practice throughout their careers.</p> <p> <strong>Taking health care to patients’ homes in Florida</strong></p> <p> Students at Florida International University Herbert Wertheim College of Medicine are embedded directly into underserved households in Miami-Dade County.</p> <p> Students very early on see first-hand the challenges that some patients face in taking care of their health, and they gain skills to help the whole patient, said Onelia Lage, MD, FIU HWCOM’s chief of education and faculty development in the Department of Humanities Health and Society.</p> <p> “They learn to address the social determinants of health for households, participate in health education, provide clinical monitoring of blood pressure, medication reconciliation, vital signs … and address social, behavioral, educational and legal needs,” she said.</p> <p> The Green Family Foundation Neighborhood Health Education Learning Program (NeighborhoodHELP™) introduces first-year medical students during the NHELP orientation and the community practicum to the school’s community outreach team, which has relationships with more than 160 community partners. During their second, third and fourth years, students are part of an interprofessional team that includes at least one of the following: nursing, social work and physician assistant students. They go into households together to take care of individual families.</p> <p> “Working with an interprofessional group in their preclinical years aims to prepare students to more effectively work with interprofessional teams later on,” Dr. Lage said.</p> <p> The program has been teaching students this way for a decade.</p> <p> Students say that they have become more knowledgeable about cultural differences, more comfortable working with interprofessional students, and more empathetic and sensitive to households’ needs, Dr. Lage said.</p> <p> <strong>Bringing basic science to life in Washington </strong></p> <p> During the first week of medical school, students across University of Washington School of Medicine’s six regional campuses in five states embed themselves in a primary care setting. More than 250 preceptors in areas such as family medicine, internal medicine and pediatrics are helping the students with the hands-on learning. The change in the medical school curriculum took place in the fall of 2015.</p> <p> “From the students’ perspective, it is probably their favorite part of the new curriculum,” said Michael J. Ryan, MD, the medical school’s associate dean for curriculum. “It makes the basic science they are learning stick much better because they are seeing how the science works [with real patients].”</p> <p> It also reminds people why they went to medical school. “As they get burnt out on basic science, students can say ‘Yes. This is why I am in medical school,’ ” Dr. Ryan said.</p> <p> For many students, working in a primary care setting reinforces the reasons they usually say they chose to go to medical school in the first place. The foundational science course can be challenging; seeing patients throughout the foundations phase makes the students say, “’Yes, this is why I am in medical school,’” he said.</p> <p> The embedding is often in primary care offices in smaller rural communities, and students are there long enough to gain an appreciation for the continuity of care. For example, medical students are able to see a patient throughout the various stages of a pregnancy or an illness. And the students don’t just shadow a physician. They are expected to take patient histories and explore what brought the patient into the office.</p> <p> “We are hearing that in their first year, some students have more confidence in talking to and assessing patients than previous students had,” Dr. Ryan said.</p> <p> Going forward, students also will get hands-on experiences to learn about the health system, health systems science, and patient safety and quality initiatives.</p> <p> <strong>Interested in more med ed innovations?</strong></p> <p> These schools aren’t the only ones with innovative programs that embed medical students into patient care in their communities. <a href="">Read more</a> about how three other schools in the consortium are giving students this hands-on experience.</p> <p> Additionally, <a href="" target="_blank">Consortium</a> founding members <a href="" target="_blank" rel="nofollow">University of California, Davis, School of Medicine</a>; <a href="" target="_blank" rel="nofollow">Penn State College of Medicine</a>; and <a href="" target="_blank" rel="nofollow">Vanderbilt University School of Medicine</a>, along with <a href="" target="_blank" rel="nofollow">Morehouse School of Medicine</a>, which joined the consortium in January, also have programs aimed at placing students in underserved communities so they can help patients and gain experience in the community.</p> <p> You also can read more about consortium work in these articles:</p> <ul> <li> Review <a href="" target="_self">9 med ed challenges</a> educators and consortium members want to solve right now.</li> <li> Learn <a href="" target="_self">how educators are creating the impossible</a> for future physician training.</li> <li> Discover the <a href="" target="_self">current projects</a> the consortium’s 11 founding members have underway.</li> </ul> <p align="right"> <em style="font-size:12px;">By contributing writer Tanya Albert Henry</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:8a85c342-c186-4d8b-a2de-a7b023b4cba6 Treating substance use disorder as a family physician Thu, 18 Aug 2016 03:00:00 GMT <p> Patients with substance use disorders may experience stigma that can interfere with treatment options. But when substance use disorders are recognized and treated as a chronic disease, that stigma can be reduced. </p> <p> Treating patients with substance use disorders in a family medicine setting can be a unique situation because physicians are often treating other members of the patient’s family as well. At first, patients may be reluctant to discuss substance use but once the condition is out in the open, having the family involved can be beneficial.</p> <p> “I really think it’s an advantage,” said Sarah Fessler, MD, a family physician and president-elect of the Rhode Island Medical Society. “I care for the whole family and it always becomes a family effort to help someone and keep them in sobriety. People definitely have a much better chance of succeeding if they have that family support,” she said.</p> <p> <strong>Working with patients who feel like family </strong></p> <p> Primary care physicians, especially those in family medicine, know many of their patients very well and have established a long-term relationship. That can be advantageous when a patient begins to show signs of a substance use disorder.</p> <p> “It’s interesting and tricky,” Dr. Fessler said, “but that’s where it’s helpful to know the person and have a relationship so there’s a certain amount of trust already there. Usually, you get a sense that there’s something else going on when an interaction doesn’t go the way you expect it to in the office.”</p> <p> “Sometimes I realize that someone has an alcohol problem, for instance, when they end up in the emergency room for an alcohol-induced injury or an overdose,” she said. “In those cases it’s pretty easy to bring it up with the patient.”</p> <p> “It’s not always that straight forward,” she said. “Sometimes you have to read between the lines a little bit. You know the patient well enough, just like if they were a close family member, you wonder … and by knowing someone in a longitudinal way it’s easier to see that something is going on.”</p> <p> Acknowledging that the patient’s demeanor has changed by asking, “You don’t seem like yourself today, is something going on?” is a way to begin the conversation, Dr. Fessler said. “You open the door to them, let them know they can ask you for help, and identify yourself as a resource.”</p> <p> “It becomes a much easier conversation once substance abuse is out in the open,” she said. “And there’s nothing that cements a relationship like reaching out to the patient and offering them help.”</p> <p> <strong>Reducing stigma in the primary care setting</strong></p> <p> Once the physician and patient have had a conversation about substance use and have determined that it would be best to seek treatment, the primary care setting can be a great place for that treatment to occur. Some patients feel more comfortable when their substance use disorder is treated in the same way as any other medical condition, which can also reduce the stigma.</p> <p> Dr. Fessler uses medication-assisted treatment (MAT) in her practice and is a waivered buprenorphine prescriber. She has been practicing family medicine in a community health center for 22 years.</p> <p> “I remember hearing a fellow health center director talk about [MAT] in a very positive way,” she said. “I also remember thinking, ‘I don’t know, it seems like there’re so many barriers to making this work in our office.’”</p> <p> “But over time, with the opioids crisis, people were moving to even more dangerous forms of opioids,” she said. “I’d seen people overdose and realized that a lot of my existing patients had problems they needed some help with and I decided I should take another look.”</p> <p> So Dr. Fessler took the training to become a waivered buprenorphine prescriber, and now her practice treats opioid use disorders in house. Her practice is hoping to expand the program to all the primary care physicians in the office because of the positive impact of MAT.</p> <p> “We are intending to have this as part of our primary care practice,” she said, “taking care of patients’ other needs as well as their substance abuse problems.”</p> <p> Dr. Fessler and her primary care colleagues are treating many patients with substance use disorders as well. “I view it as another chronic medical problem like high blood pressure and diabetes,” she said. “It’s something we can help them with and I’ve seen some really positive results—people whose lives were spinning out of control really get things under control, get back to work and repair their relationships.”</p> <p> “It’s not easy for everyone and a lot of people have trouble getting on buprenorphine, staying on it and using it correctly, and they’ll relapse,” Dr. Fessler said. “I took another step back and I thought, well my diabetic patients don’t always stay on their meds either and come to the office and their sugars are really high. But we talk about what worked and what didn’t work, and it seems that that’s human nature. You can keep trying different angles with each patient and eventually it might stick.”</p> <p> A barrier that has arisen is that some patients don’t show up for the induction of buprenorphine treatment. “Staff is all geared up to help somebody with their induction and they don’t show up, because that’s the nature of substance abuse,” she said. “Sometimes, when it comes down to the wire they aren’t ready.”</p> <p> “You just keep trying,” Dr. Fessler said. “I leave the door open.”</p> <p> “If somebody doesn’t show we’ll do a follow-up phone call and I’ll often do that myself,” she said. “They often don’t pick up because they know it’s our office calling, but I’ll leave a message and I’ll say, ‘Sorry we didn’t’ see you, I know this is a hard thing to start, sometimes people just aren’t ready, but if you want to try again the door is always open; or if you’d like to talk about a different kind of treatment I’d be glad to do that too.”</p> <p> “[Patients] really appreciate being able to come to a primary care provider and not to a substance abuse treatment office,” Dr. Fessler said. “At a primary care provider where they already feel connected and they’re just another patient in the waiting room sitting beside other people who don’t have that same problem, they’re able to shake some of the stigma off. And I think that helps them too.”</p> <p> “The goal is to normalize it,” she said. “[Substance abuse disorder] is just something that happens, it’s another chronic medical problem and should be treated that way.”</p> <p> <strong>A collaboration to provide more resources</strong></p> <p> The AMA, RIMS and officials from the Rhode Island Department of Health and the Rhode Island Department of Behavioral Healthcare, Developmental Disabilities and Hospitals recently announced a partnership to develop and distribute a statewide educational toolbox for healthcare providers to help reverse the state's opioid epidemic. Rhode Island and Alabama are the two states participating in this pilot program with the AMA.</p> <p> The pilot program will build a toolbox—available online and in print—that incorporates the best information from the AMA, the state medical societies and state health officials. Physicians and other health care professionals will have access to key data, valuable resources and practice specific recommendations they need to enhance their decision-making when caring for patients suffering from chronic or acute pain and opioid use disorders, as well as for patients needing overdose prevention education.</p> <p> The toolbox will be released in September, and the AMA, the state medical societies and state officials will work together to distribute it throughout Rhode Island. “I hope it makes all this much easier and demystifies a lot of it for physicians who are considering being substance abuse treatment providers,” Dr. Fessler said.</p> <p> “It’s going to be really helpful to expand our treatment in Rhode Island by just having that support for docs who are on the fence, or are not sure,” she said. “But there’s a long way to go and there’s still way too many overdoses and misconceptions on appropriate treatment of pain. I hope it’s a model for other states.”</p> <p> Reducing the stigma of substance use disorders and enhancing access to treatment for those who have a disorder is one of the <a href="" target="_self">five things physicians can do to prevent opioid abuse</a>, recommended by the <a href="" target="_self">AMA Task Force to Reduce Opioid Abuse</a>, which physicians convened to help the nation move closer to the goal of ending the opioid epidemic.</p> <p> <strong>For more on treating substance use disorders:</strong></p> <ul> <li> <a href="" target="_self">How one physician uses his PDMP to help patients</a></li> <li> <a href="" target="_self">The antidote: 3 things to consider when co-prescribing naloxone</a></li> <li> <a href="" target="_self">Pain expert: Judge the opioid treatment, not the patient</a></li> <li> <a href="" target="_self">3 steps for talking with patients about substance use disorder</a></li> </ul> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:9174e58a-d50c-49d8-ab29-447355d4104a USMLE Step 1 stumper: Can you answer it correctly? Thu, 18 Aug 2016 03:00:00 GMT <p> The United States Medical Licensing Examination® (USMLE®) Step 1 exam is notorious for pushing the limits of medical students’ knowledge, so you might like to know which test prep questions are commonly missed. Check out this month’s question that Kaplan Medical says stumps most students, and view an expert video explanation of the answer.</p> <p> Welcome to this month’s installment of the <em>AMA Wire</em>® series, Tutor talk: Tips from Kaplan Medical on the most missed USMLE test prep questions from Kaplan’s Qbank: Step 1. Each month, we’re revealing the top questions physicians in training miss on the USMLE, a helpful analysis of answers and videos featuring tips on how to advance your test-taking strategies. See <a href="" target="_self">all posts in this series</a>.</p> <p> Think you have what it takes to rise above your peers? Test your USMLE knowledge below.</p> <p> Ready. Set. Go.</p> <p> <strong>This month’s question that stumped most students:</strong></p> <p>  </p> <p> <a href="" target="_blank"><img src="" /></a></p> <p>  </p> <p> The diagram shows changes in blood pressure and heart rate in an animal with intact reflexes in response to drug X (agonist) and drug Y (antagonist). Assume that the antagonist's effects will last for the duration of the experiment and that the agonist's effects are transient. Drug X and drug Y are most likely to be which of the following?</p> <p style="margin-left:40px;"> A.  X=Isoproterenol/Y=Atropine</p> <p style="margin-left:40px;"> B.  X=Isoproterenol/Y=Phentolamine</p> <p style="margin-left:40px;"> C.  X=Isoproterenol/Y=Propranolol</p> <p style="margin-left:40px;"> D.  X=Norepinephrine/Y=Atropine</p> <p style="margin-left:40px;"> E.  X=Norepinephrine/Y=Phentolamine</p> <p style="margin-left:40px;"> F.  X=Norepinephrine/Y=Propranolol</p> <p>  </p> <p> <object data="" height="350" id="ltVideoYouTube" src="" type="application/x-shockwave-flash" width="450"><param name="movie" value="" /><param name="quality" value="best" /><param name="bgcolor" value="#ffffff" /><param name="wmode" value="transparent" /><param name="allowFullScreen" value="true" /><param name="allowScriptAccess" value="always" /><param name="flashvars" value="playerMode=embedded" /></object></p> <p>  </p> <p>  </p> <p> <strong>The correct answer is D. </strong>A good approach for such questions is the process of elimination.</p> <p> <strong>Kaplan says, here’s why:</strong></p> <p> Because the agonist raises arterial blood pressure, it must be a pressor, such as norepinephrine (NE). Isoproterenol, a beta agonist, would cause a decrease in blood pressure by vasodilation; therefore, choices A, B, and C can be immediately eliminated. The decrease in heart rate is due to a baroreceptor reflex. The increased blood pressure leads to increased parasympathetic and decreased sympathetic tone to the heart.</p> <p> The next step is to see if any antagonists can be eliminated. Drug Y alone causes no change in blood pressure but an increase in heart rate. Phentolamine (choice E), an alpha antagonist, can be eliminated because this should decrease blood pressure by blocking sympathetic tone to arterioles. Propranolol (choice F), a beta antagonist, would be expected to cause a small decrease in blood pressure and a decrease in heart rate. So choices E and F can be eliminated.</p> <p> Every option except choice D has been eliminated, but working through choice D would still be a good idea. Atropine blocks muscarinic receptors, but has virtually no effect on blood pressure because the muscarinic receptors in the vasculature (M3 receptors) are not innervated and therefore have no tone. However, blocking M2 receptors on the SA node results in an increase in heart rate due to the removal of the dominant parasympathetic tone that normally slows the heart.</p> <p> Administration of NE after atropine would still lead to the alpha-1 receptor-mediated vasoconstriction, thus increasing blood pressure. However, because atropine is still blocking muscarinic receptors in the SA node when NE is administered the second time, there is no slowing of the heart rate because it was primarily mediated by increased parasympathetic activity. Therefore the direct beta-1 adrenergic effects of NE on the SA are unopposed and the heart rate increases. This is consistent with the drug trace in the question.</p> <p> <strong>One key tip to remember:</strong></p> <p> When looking at drug traces, always think about blood pressure first and then heart rate second. Changes in blood pressure will be due to a direct effect on blood vessels and changes in heart rate may be due to either a baroreceptor effect or a direct effect on the heart.</p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:575e078c-51d1-4eee-9263-d6f2c8fe518b Masks, comics and the art of med school: Part one Wed, 17 Aug 2016 04:15:00 GMT <p> At a military medical school in Maryland, one physician professor is using art to give students time for self-exploration. Through the making of masks, students explore the ultimate question: Who am I?</p> <p> Medicine is both science and art. And for three years now at the Uniformed Services University of the Health Sciences (USU), medical students, at a particular phase in the curriculum when they are at high risk for burnout, have taken part in a collaborative mask-making exercise to promote self-exploration and personal identity formation.<a href="" style="font-size:12px;" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> The university’s curriculum is a bit different than that of other medical schools. After 18 months of preclerkship, 12 months of clerkship, and a two-month study block for Step 1, students begin the mask-making exercise.</p> <p> Students are given blank masks and little direction other than examples of previous USU students and military service members who have gone through the art therapy program at the <a href="" rel="nofollow" target="_blank">National Intrepid Center of Excellence </a>(NICoE). “We don’t want to tell them what should go on their masks,” said Mark Stephens, MD, a family physician and professor of family medicine at USU in Bethesda, Md. “That’s not our place, that is theirs…. As we frame the activity, we are very nonspecific in terms of giving them ample personal creative space.”</p> <p> “Most students choose to put something on the outside [of the mask], and most of the time it’s an explorative narrative of the mask that they present to the world,” he said. But some students draw and paint on the inside of the masks as well.</p> <p> “There are two canvases there for students to create a mask,” he said. “What do we present to the outside world? That’s what a lot of people say is the outer part of the mask. For the students who have chosen to draw on the inside, the theme that I see the most is insecurity.”</p> <p> At the time of the activity, “we have our own internal burnout data suggesting that a fair amount of them are emotionally exhausted, have a fair amount of depersonalization and a relatively low sense of personal accomplishment—the three domains of burnout,” Dr. Stephens said.</p> <p> “Just like you need to know the narrative of the patient to take optimal care of them, you need to know the narrative of self-identity to be true to self in the context of patient care,” he said. “If you bury your true sense of self long enough, there’s some real danger for both the individual and the patient.”</p> <p> “I see the mask making as very complementary in what I would call a self-narrative,” Dr. Stephens said. “I’m a big believer in the central importance of professional identity formation on the journey of becoming a physician.”</p> <p> “The mask making, for me, has been a wonderful journey of self-exploration and identity formation for our students,” he said. “I feel like, in many ways, medical education sets up situations where people are forced to put elements of themselvesto the side or ignore them—whether that’s an ethical conflict or feeling your way through failure.”</p> <p> <strong>How the mask-making exercise began</strong></p> <p> Art therapy at NICoE on the Walter Reed National Military Medical Center campus in Bethesda is part of a comprehensive and integrative treatment <a href="" rel="nofollow">program for active duty service members</a> with traumatic brain injury and underlying psychological health conditions.</p> <p> One day, Dr. Stephens was visiting NICoE’s art therapy studio when he met Melissa Walker, an art therapist who has worked with over one thousand active duty service members to create masks that are “magnificent works of art,” Dr. Stephens said.</p> <p> “There was a real connection,” he said, “in terms of the role of mask making in identity and self-exploration for our medical students.”</p> <p> Dr. Stephens and Ms. Walker collaborated to develop the mask-making exercise for USU medical students. From that partnership was born an activity that is now spreading to several other institutions in the context of self-exploration and professional identity formation.</p> <p> Working with collaborators such as Karlen Bader, in the department of family medicine, Lara Varpio, MD, in the department of internal medicine, and recently graduated senior medical students Sara Wilson, MD, and Kimera Joseph, MD, the team performed an extensive qualitative analysis on a subset of the student masks. </p> <p> Some of the themes identified are disturbing or haunting. They often depict a sense of identity conflict, numbness, emptiness or hollowness. It is important to recognize and externalize those feelings in order to deal with or overcome them, Dr. Stephens said. Students tend to bury or ignore those feelings. </p> <p> "In this context, the broader the space between true and projected self, the more identity dissonance or role confusion there is going to be," Dr. Stephens said. "I see that as having real implications for patient care." </p> <p> Medical students at a school like USU have to play multiple roles. They are not only medical students, they are also military officers. “The question is,” he said, “are the students of the uniformed services the same as other medical students?”</p> <p> Through a partnership with Penn State University and the University of California, Irvine, Dr. Stephens hopes to find an answer. “We’re going to look at a series of students over time,” he said, “because what we think is students who enter the door are different than students heading out for their first clinical clerkship who are different than students who are ready to graduate…. Phases of identity formation on the professional continuum are iterative.”</p> <p> Watch <em>AMA Wire®</em> in the coming weeks for the second part of a series on the arts and humanities in medical school, featuring Michael Green, MD, of Penn State University, who has developed the course, “Comics in Medicine.” In the course, fourth year medical students examine their clinical experiences through long-form graphic narratives. </p> <p> <strong>For more on student burnout:</strong></p> <ul> <li> <a href="" target="_self">Medical school burnout: Taking care of yourself</a></li> <li> <a href="">Student wellness: Blueprints for the curriculum of the future</a></li> <li> <a href="">Ward off burnout: Your peer network may impact more than you think</a></li> </ul> <p align="right"> <em>By AMA staff writer <a href="" rel="nofollow">Troy Parks</a></em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:7457729e-ecad-4ebe-89c3-fc1cdba92724 CDC discusses updated guidelines in Zika virus webinar Mon, 15 Aug 2016 21:00:00 GMT <p> The AMA and the Centers for Disease Control and Prevention (CDC) recently held a webinar to provide an update for physicians and other clinicians on the status of the Zika virus outbreak and the latest clinical guidance to help them diagnose and manage patients and prevent further transmission.</p> <p> “As the Zika virus outbreak continues to evolve and more Americans become impacted by the virus,” said AMA President <a href="" target="_self">Andrew W. Gurman, MD</a>,” we must ensure that our nation’s physicians, and all clinicians, are prepared to handle possible cases of the virus and are equipped with the most up-to-date information to answer patients’ questions.”</p> <p> The webinar, “Preparing for Zika transmission in the United States,” is available online at the AMA’s <a href="" target="_self">Zika Virus Resource Center</a>. Experts provided details of the latest epidemiological and clinical aspects of the current Zika outbreak, implications for pregnant women and the CDC’s most up-to-date clinical guidance to support health care professionals in combatting and preventing complications.<a href="" target="_blank"><img src="" style="float:right;margin:15px;" /></a></p> <p> <strong>Updated pregnancy guidelines</strong></p> <p> There is emerging data indicating Zika virus RNA can be detected for prolonged periods of time in some pregnant women. The CDC hopes to increase the proportion of pregnant women with Zika virus infection who receive a definitive diagnosis by expanding real-time reverse transcription polymerase chain reaction (rRT-PCR) testing.</p> <p> Testing recommendations vary according to the type and timing of possible exposure. “Possible exposure” is defined as travel to or living in an <a href="" rel="nofollow" target="_blank">area with Zika virus</a>, or sex without barrier protection, such as a condom, with a partner who has traveled to or lives in these areas. The CDC stressed that all pregnant women should be asked at each prenatal visit if they have had one of these exposures.</p> <p> For symptomatic pregnant women, the CDC recommends:</p> <ul> <li> Those evaluated less than two weeks after symptom onset should receive Zika virus rRT-PCR testing of both serum and urine</li> </ul> <ul> <li> Those evaluated two to 12 weeks after symptom onset should first have a Zika virus immunoglobulin (IgM) test; if this result is positive or equivocal, serum and urine rRT-PCR should be performed</li> </ul> <p> The CDC also delivered recommendations for testing of asymptomatic pregnant women. A flowchart detailing testing and recommendations is available on the <a href="" rel="nofollow" target="_blank">CDC's website</a>.</p> <p> <strong>Preventing sexual transmission</strong></p> <p> Because the Zika virus can be sexually transmitted, the CDC offered new guidance for couples at risk, including:</p> <p> Couples in which a woman is pregnant:</p> <ul> <li> Pregnant women with sex partners who live in or have traveled to an area with active Zika virus transmission should consistently and correctly use barriers against infection during sex or abstain from sex for the duration of the pregnancy</li> </ul> <p> Couples who are not pregnant and are not planning to become pregnant:</p> <ul> <li> Couples in which a partner had confirmed Zika virus infection or clinical illness consistent with Zika virus disease should consider using barrier methods against infection consistently and correctly or abstain from sex as follows:</li> <li style="margin-left:40px;"> Men with Zika virus infection for at least 6 months after onset of illness</li> <li style="margin-left:40px;"> Women with Zika virus infection for at least 8 weeks after onset of illness</li> <li> Couples in an area without active Zika transmission in which one partner traveled to or resides in an area with active Zika virus transmission but did not develop symptoms of Zika virus disease should consider using barrier methods against infection or abstaining from sex for at least 8 weeks after that partner departed the Zika-affected area</li> <li> <p> Couples who reside in an area with active Zika virus transmission might consider using barrier methods against infection or abstaining from sex while active transmission persists.</p> </li> </ul> <p> The <a href="" target="_self">webinar</a> also includes up-to-date statistics on the spread of Zika in the U.S., recommendations for counseling women and men living in areas with ongoing spread of Zika virus who are interested in conceiving, and the use of standard precautions to prevent the spread of Zika in the health care setting.</p> <p> <strong>Congress must provide more resources</strong></p> <p> With an increasing number of Zika cases confirmed in the U.S., including this week’s news of the death of a newborn baby with Zika-linked microcephaly, the AMA continues to call on policymakers on Capitol Hill to immediately make the necessary resources available to combat the growing threat of the virus and protect public health. Congress failed to pass legislation to deploy a robust public health response to the Zika virus before it adjourned for summer recess.</p> <p> The AMA will also continue to update its online <a href="" target="_self">Zika Virus Resource Center</a> with the latest Zika-related information from CDC and other trusted organizations to support health care professionals’ efforts to prevent and combat complications from the virus.</p> <p style="text-align:right;"> <em>By AMA staff writer Tim Smith</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:802601e7-9c22-45d1-ae1e-d3cb8b4f5e1f Out of tragedy comes a new focus on resident health Mon, 15 Aug 2016 20:56:00 GMT <p> After news that a star surgical resident, who had recently left Stanford to pursue a fellowship, had committed suicide, the residency program leadership decided to create a new structure that addresses the underlying issues affecting resident health and promotes a healthier work-life balance.</p> <p> <strong>Shifting toward work-life balance in residency</strong></p> <p> When Greg Feldman, MD, a general surgery resident from Stanford University, took his own life during his fellowship in Chicago, the general surgery department was shocked at the news. He had been one of the most accomplished resident physicians the program had ever seen. He was warm and outgoing and seemed happy.</p> <p> One fellow trainee described him as “extremely good at balancing his work and non-work life and cared about getting other residents to have fun both at work and outside the hospital.”</p> <p> During the healing process, the program leadership decided to take action to get to the heart of what affects resident health and began to develop a wellness program for residents.</p> <p> <a href="" target="_blank" rel="nofollow">Balance in Life</a> is a holistic, multifaceted program with the primary mission to support and promote the physical, psychological, social and professional well-being of general surgery residents and to provide them with the tools they will need to successfully navigate life as a surgeon.</p> <p> <strong>The four parts of a healthy medical life</strong></p> <p> Residents are trained in everything they need to know in the clinical setting so that they can be the most effective physicians possible, but why can’t residents also receive training in maintaining work-life balance?</p> <p> The Balance in Life program focuses on four aspects of a healthy professional and personal lifestyle:</p> <ul> <li> <strong>Physical.</strong> Residents have 24-hour access to the Goodman Surgical Education Center which holds a residents-only refrigerator stocked with healthy food and drinks. Also available for residents is an “After Hours” guide that provides all the names of local primary care physicians, OB-GYNs and dentists recommended by colleagues. It also includes a list of gyms, fitness centers, grocery stores, movie theaters, restaurants and places for hiking and biking in the area.<br /> <br /> Residents are encouraged—and expected—to schedule regular dental and primary care appointments. Even if they can’t find an appointment time outside clinical duty hours, program faculty will make the time available if necessary. At the program director bi-annual meetings, residents are asked if they have seen their primary care physician and dentist.</li> </ul> <ul> <li> <strong>Psychological.</strong> Every Tuesday morning residents meet on a rotating schedule with Lisa Post, PhD, a clinical psychologist at Stanford with expertise in coaching high-performance teams. The meetings are mandatory and strictly confidential.<br /> <br /> The goal of the meetings is to facilitate difficult conversations about challenges residents face in both their personal and professional lives.</li> </ul> <ul> <li> <strong>Professional.</strong> Each September, first and second year general surgery residents are paired with fourth—and fifth-year residents to act as mentors throughout the year. The pairs are expected to meet at least three times per year and the program provides gift cards to coffee houses and other places for the meetings.<br /> <br /> Each class also elects a representative to the program directors to create an avenue for residents to discuss issues that arise and cultivate solutions constructively.</li> </ul> <ul> <li> <strong>Social.</strong> The social chair is responsible for organizing events that promote socializing among residents and to continue their extracurricular interests, which have included dinners, sporting events, happy hours, wine tastings and hiking.<br /> <br /> Team-building, camaraderie and communication among residents is also important to Balance in Life. So each year a full-day offsite retreat is provided for residents, which has included team sailing in the San Francisco Bay and a high-ropes course in the Santa Cruz Mountains.</li> </ul> <p> Balance in Life has created a strong sense of community among residents and remains deeply embedded in the ethos of the training program. Residents feel they are part of an environment where asking for help is welcomed, encouraged and supported.</p> <p> An <a href="" target="_self" rel="nofollow"><u>online module</u></a> in the AMA’s STEPS Forward™ collection of practice improvement strategies explains what is needed to prevent burnout among physician trainees, based on lessons learned by successful residency wellness programs. </p> <p> Thirty-five modules now are available, and several more will be added later this year, thanks to a grant from and collaboration with the <a href="" target="_blank" rel="nofollow">Transforming Clinical Practices Initiative</a>.</p> <p> <strong>Explore other wellness solutions for residents and fellows:</strong></p> <ul> <li style="margin-left:18.75pt;"> <a href="" target="_self">The physician’s essential art of balancing emotion and logic</a></li> <li style="margin-left:18.75pt;"> <a href="" target="_self"><u>Residents are beating burnout with help from the theatre</u></a></li> <li style="margin-left:18.75pt;"> <a href=""><u>How one program achieved resident wellness, work-life balance</u></a></li> <li style="margin-left:18.75pt;"> <u><a href="" target="_self">Ways residents have found to conquer burnout</a></u></li> <li style="margin-left:18.75pt;"> <a href="" target="_self"><u>Ward off burnout: Your peer network may impact more than you think</u></a></li> </ul> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow"><em><u>Troy Parks</u></em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:a6451460-56bf-4444-b715-8bc992a29e5c Physicians and veterinarians join forces for wellness Sun, 14 Aug 2016 16:36:00 GMT <p> <em>An AMA Viewpoints post by AMA Immediate-Past President Steven J. Stack, MD, and American Veterinary Medical Association President Joe Kinnarney, DVM</em></p> <p> It’s been said that one person can’t change the world. Still, one person can make a difference.</p> <p> Each of us, physicians and veterinarians alike, needs to be that one person when it comes to wellness. Many of our colleagues are struggling with wellness issues and they need our help. We need to be compassionate listeners, not judgmental or cynical or proud. We need to help lift the stigma too often associated with wellness struggles, and we need to be there for our colleagues when they face those struggles. It starts with us—and it starts now.</p> <p> Compassion fatigue, burnout, depression and anxiety: These words have become all too common in the vocabulary of physicians and veterinarians alike. Our doctors are at risk, and we can no longer look the other way. For the first time, the leadership of the AMA and the American Veterinary Medical Association (AVMA) are working together to bring more awareness to the important issue of wellness among health care professionals.</p> <p> This joint column is a reflection of our early efforts. Both organizations have devoted time, energy and resources to addressing the mental health crisis in our respective professions. But, we must all begin to work more closely together—to share resources, passion and commitment—to break down the stigma and lead our colleagues on a brighter path to well-being. We can save lives.</p> <p> <strong>Efforts to take action, build resources</strong></p> <p> The AMA has made physicians’ wellness and ability to thrive a top priority. In fact, one of our three strategic focus areas is Professional Satisfaction and Practice Sustainability. As part of this initiative, we have created our <a href="" rel="nofollow" target="_self">STEPS Forward</a>™ collection of practice improvement strategies. These are online modules, which offer proven solutions by physicians for physicians.</p> <p> Three modules are specifically focused on physician wellness: One gives steps for <a href="" target="_self">preventing burnout</a>, another outlines solutions for enhancing joy in practice and mitigating stress, and a third focuses on ways to promote the well-being of physicians in training.</p> <p> Other modules provide ways to improve elements of the practice environment that can be risk factors for burnout, such as improving work flow through<a href="" target="_self"> team documentation</a>, expanded rooming and discharge protocols, <a href="" target="_self">pre-visit planning</a> and synchronized prescription renewal.</p> <p> We’re also hosting the International Conference on Physician Health, September 18–20 in Boston. This collaborative conference of the AMA, the Canadian Medical Association, and the British Medical Association will explore the theme “Increasing Joy in Medicine.” The conference showcases research and perspectives into physicians’ health and offers practical, evidence-based skills and strategies to promote a healthier medical culture for physicians.</p> <p> And we’re also working to prepare the next generation of physicians to be more fully equipped to thrive in the evolving health care landscape and to fully embrace a lifelong commitment to wellness—both for them and their colleagues.</p> <p> Wellness among physicians in training is an increasing focus for medical schools that are members of the AMA’s <a href="" target="_self">Accelerating Change in Medical Education Consortium</a>. In fact, the medical community is coming together to address this issue from every part of the professional continuum, from training through retirement.</p> <p> You can learn more about the work underway at specific medical schools, residency programs, health systems, and medical organizations at <a href="" target="_self"><em>AMA Wire®</em></a>.</p> <p> As an association, the AVMA has recommitted itself to addressing issues related to wellness. Our Future Leaders program, which provides an opportunity for AVMA members who have been out of veterinary school for 15 years or less to take the next step in leadership and service to our profession, has focused on wellness for three years running.</p> <p> Program participants have helped develop continuing education programming at our annual convention and have developed a more-comprehensive <a href="" rel="nofollow" target="_blank">wellness webpage</a> for veterinarians that now adds a validated self-assessment tool to our already extensive array of resources. This year’s class has developed a wellness plan for veterinary practices.</p> <p> In 2016, the AVMA hosted a Veterinary Wellness Roundtable that brought together representatives from across the profession to discuss the mental health crisis and what we can all do to address it. At the AVMA Convention in August, Dr. Dan Siegel spoke to thousands of attendees about the human mind and how we can use it to create strategies for increasing mental health.</p> <p> It is our hope the AVMA can serve as a trusted convener of the many groups that have an interest in veterinarians’ wellness and can help ensure the development and success of programs that will help all those we call colleagues and friends. We invite you to join us by bringing your perspective and helping build strength and momentum toward addressing these issues.</p> <p> <strong>What’s needed now</strong></p> <p> From our students to our seasoned professionals, we need to create, strengthen and enhance programs and resources that lift the veil of silence and stigma so that we can begin attending to our own well-being as healthcare professionals.</p> <p> We need to contribute energy and resolve to help our colleagues, both through the actions of our associations and as individuals. This problem has existed for many, many years, and the conversation has only recently heated up. We will not let this go like others have in the past. We want to turn the heat up even more. The conversation around this issue has started and we will keep it going.</p> <p> We encourage you to help start the change in your profession. Have open conversations about mental health, and work to break down the stigma. Although our respective professions have slightly different risk factors for mental health issues and wellness problems, we can work together because these are ultimately human problems, and are not specific to what type of medicine we practice or what species we treat.</p> <p> We challenge you to support each other. We are all in this together; no one should feel as though he or she is alone or deserves to be stigmatized, labeled, or rejected. Change can indeed start with one person, and that person resides in each of us.</p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:44dd020b-285f-489a-a006-06b7f19c63ec How Medicare regulatory penalties will change Fri, 12 Aug 2016 22:00:00 GMT <p> Regulatory penalties under the current Medicare payment system have been rising, overwhelming physicians with reporting burdens just to avoid payment cuts. But how will financial penalties and bonuses change in the new system? Under the Medicare Access and CHIP Reauthorization Act (MACRA), regulatory penalties starting in 2019 will be much less severe, and physicians will have greater opportunity for bonuses.</p> <p> <strong>How MIPS will be different</strong></p> <p> The current pay-for-performance programs—the Physician Quality Reporting System (PQRS), the value-based payment modifier (VBM) and the Meaningful Use electronic health record program—each judge physicians separately on various metrics.</p> <p> Under MACRA, physicians who remain in Medicare’s fee-for-service program will participate in the Merit-based Incentive Payment System (MIPS). Though improvements to the proposed regulatory framework are needed for implementing MIPS, there is no question that the system offers improvements over current Medicare law.</p> <p> MIPS consolidates and better aligns the separate quality and performance measurement programs that currently affect physicians’ payments. It adds one new component—clinical practice improvement activities—with a menu of more than 90 activities through which physicians can demonstrate high-value services and receive credit.</p> <p> The current system includes quality measures that overlap and sometimes conflict. For instance, a physician who did not successfully report under PQRS automatically received a second negative payment adjustment under the VBM. With MIPS, that will no longer be the case. In addition, CMS is proposing to reduce the number of quality measures that physicians must report, as well as allowing greater flexibility in their choice measures.</p> <p> Also in the current system, the Meaningful Use and PQRS programs were scored on a pass/fail approach, which required physicians to be 100 percent successful on all reporting requirements to avoid penalties.</p> <p> Under the MIPS, physicians will receive partial credit for elements they are able to report on successfully, have the chance to earn bonuses if they score above average performance thresholds and avoid penalties if they meet those thresholds.</p> <p> <a href="" target="_blank"><img src="" /></a></p> <p> As the table illustrates, financial risk regarding penalties will be significantly less under MIPS than it was under the previous system. The future severity of VBM penalties and bonuses under prior law is unknown because CMS ceased proposing them after MACRA passed; prior to MACRA’s passage, the penalties and potential bonuses increased each year.</p> <p> MIPS is characterized by not only a change in penalties but also a new bonus structure that increases as the program moves forward each year. Learn more about MACRA in the AMA’s <a href="file:///C:/Users/trparks/Downloads/16-0384-advocacy-macra-action-kit%20(1).pdf" target="_self" rel="nofollow">MACRA Action Kit</a>.</p> <p> <strong>Learn more about MACRA and Medicare quality reporting:</strong></p> <ul> <li> <a href="" target="_self">Changes needed to help small practices succeed under MACRA</a></li> <li> <a href="" target="_self">Later start date could ease transition to new Medicare payment system</a></li> <li> <a href="" target="_self">Key changes the new Medicare payment system needs</a></li> <li> <a href="" target="_self">Three useful changes to Meaningful Use</a></li> </ul> <p>  </p> <p align="right"> <em>By AMA staff writer</em> <a href="" target="_blank" rel="nofollow"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:3fbab577-aef1-4e3f-89b2-d278f5d17ffc Get the new Principles of ICD-10-CM Coding Fri, 12 Aug 2016 21:00:00 GMT <p> The fourth edition of <em>Principles of</em> <em>ICD-10-CM Coding</em> provides the tools needed for physicians and payers to accurately and effectively use the ICD-10-CM code set. It clarifies the new diagnosis codes in detail to assist in making correct coding choices.</p> <p> Updated to include the 2017 code set, it helps health care professionals learn how to make correct decisions when selecting diagnosis codes from the ICD-10-CM code set. It is written for all skill levels and is appropriate for both self-learners and the classroom. It will help you:</p> <ul> <li> Understand the purpose of ICD-10-CM and its relationship to the reimbursement process</li> <li> Understand and apply coding conventions when assigning codes</li> <li> Interpret basic coding guidelines for outpatient care</li> <li> Assign ICD-10-CM codes to the highest level of specificity</li> <li> Properly sequence ICD-10-CM codes</li> </ul> <p> Some key features of the fourth edition include:</p> <ul> <li> Conventions and terminology used in the ICD-10-CM coding system</li> <li> Real-life chart notes</li> <li> ICD-10-CM guidelines for coding</li> <li> Chapter checkpoint exercises</li> </ul> <p> Visit the <a href="" target="_self">AMA Store</a> for more information or to order online. AMA members receive a 20 percent discount on this product and others from the AMA Store. If you’re not a member, <a href="" target="_self">join today</a>.</p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:96e50a6c-b5a6-42b0-b43e-2adff672949f Register for the Interim Meeting by November 5 Fri, 12 Aug 2016 15:00:00 GMT <p> Register for the American Medical Association Young Physicians Section (YPS) Interim Meeting, which will take place on Nov. 11 at the Walt Disney World Swan and Dolphin Resort, Orlando, Florida.</p> <p> The AMA-YPS Interim Assembly Meeting is the ideal venue for young physicians to take a stand and become a force for change for the future of medicine. This year’s meeting offers a variety of events, including leadership training, policy discussion and education sessions.</p> <p> The deadline to submit <a href="" rel="nofollow">resolutions</a> for consideration at the Interim Business Meeting of the AMA YPS is Sept. 30.</p> <p> <a href="">Register</a> for the meeting by 3 a.m. Eastern Time Nov. 5.</p> <p> <strong>Send your accomplishments for the AMA-YPS Activities Report</strong></p> <p> Have you been elected President of your medical society? Did you receive an appointment to serve on a special committee? Are you the recipient of a distinguished honor? Share your recent achievement in organized medicine with the AMA-YPS.  Please forward your accomplishments to <a href="" rel="nofollow"></a> by September 16, 2016.</p> <p> <strong>YPS Involvement Opportunities</strong></p> <p> Please see below for various opportunities to participate in YPS committees and leadership positions.  To sign up or get more information, email the <a href="" rel="nofollow">AMA-YPS</a>.</p> <ul> <li> YPS Convention Committees (sign up by September 30). <span style="font-size:12px;">Please consider volunteering for the section’s reference, handbook review or credentials committee. </span></li> </ul> <ul> <li> AMA-YPS Leadership Position:  Alternate Delegate (nomination forms due October 14). <span style="font-size:12px;">If you would like to get more involved in organized medicine, consider running for an open seat on the AMA-YPS Governing Council. </span><a href="" style="font-size:12px;">Nomination forms</a><span style="font-size:12px;"> for alternate delegate will be accepted until Friday, October 14 in order to be posted on the AMA-YPS website.  Please note that nomination forms will be accepted until Friday, November 11 during the 2016 AMA-YPS Interim Assembly meeting.</span></li> </ul> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:91f14b8f-4d04-4d25-b48f-ea5e96a6e134 Medical students get first-hand experience serving the underserved Thu, 11 Aug 2016 22:00:00 GMT <p> Medical schools are finding effective ways to embed students into their communities to care for underserved patients and gain hands-on experience that could change both how and where they ultimately practice medicine. See how some students and schools are making a difference.</p> <p> The immersions into the clinics and greater community are part of the schools’ work with the AMA’s <a href="" target="_self">Accelerating Change in Medical Education Consortium</a>. The consortium, working to modernize and reshape the way physicians are trained, brings leaders form schools together to share ideas and experiences with new programs that are designed to improve competency, leadership and patient care through innovations that bridge the curriculum gap between medical school and practice.</p> <p> Students and faculty from the consortium schools are coming together today and tomorrow at University of California, Davis, School of Medicine for a meeting on Health Equity and Community-based Learning to share their experiences and gain insights from experts that they can put into practice throughout their careers.</p> <p> <strong>Working with medically underserved in Texas</strong></p> <p> University of Texas Rio Grande Valley School of Medicine opened its doors to its first students this summer, and they soon will deploy into communities throughout the medically underserved Lower Rio Grande Valley.</p> <p> The students started the year studying biochemistry and clinical skills. In about six weeks, they will select or be assigned to a family medicine clinic in the <em>colonias</em>. These impoverished rural settlements are in unincorporated areas along the U.S.-Mexico border, where most residents were born in the U.S. and are under 18. The population is indigenous to the valley and typical of other underserved patient groups in the area.</p> <p> Students will conduct exams and practice their clinical skills as they assume the care of a family with their preceptor. In addition, they will work with a team that provides integrated care to connect patients with behavior health and other resources.</p> <p> “They are not just starting early; they are starting in a unique environment,” said Francisco Fernandez, MD, founding dead of the Rio Grande Valley School of Medicine. “It will help students better understand the needs of their patients in their environments.”</p> <p> And the hope is that the students who come into medical school with high altruistic values and a desire to advocate for patients will keep those feelings going forward, Dr. Fernandez said. Often those two things decline by the time medical students are in their third year, he said.</p> <p> “The students are where they can do the most good. They are able to look and see the impact they are having on patients,” he said. “I think that will stay with them.”</p> <p> <strong>Embedding in urban and rural community health centers  </strong></p> <p> A.T. Still University School of Osteopathic Medicine in Arizona opened in 2007. Working in partnership with the National Association of Community Health Centers, it pioneered a total immersion training model, in which students are embedded in 12 urban and rural community health centers during their second, third and fourth years of medical school.</p> <p> “It is combining pubic health and primary care,” said Joy H. Lewis, DO, PhD, chair of ATSU SOMA’s Department of Public Health and director of public health and practice-based research. “Students have the benefit of living in the community and working with providers dedicated to serving underserved patients and whole communities.”</p> <p> Dr. Lewis said students gain confidence early on in interviewing patients. In the community setting, students then become adept at exploring people’s stories a little deeper, and they learn to evaluate and address the social determinants of health. For example, students learn to ask patients questions, such as who helps them look after their children or why they are not taking their medication as directed.</p> <p> “In community health centers, students can work with patients to find the resources they need, such as connecting them with a free exercise program at the community recreation center or a farmers market,” Dr. Lewis said.</p> <p> Students also have a chance to develop and complete a community-oriented primary care project. By being embedded in the community, students figure out what the needs are, evaluate those needs and develop a strategy to implement change. The teams compete for the privilege of presenting their community project results at a national conference of community health centers.</p> <p> And when students graduate, Dr. Lewis said, they express interest in primary care, community service, community health and continuing to work in underserved areas.</p> <p> <strong>Hands-on experience in New York FQHCs</strong></p> <p> Students at Sophie Davis Program in Biomedical Education/CUNY School of Medicine enter a seven-year BS/MD program that prepares students to become primary care physicians in medically underserved areas. The school has partnered with numerous federally qualified health centers (FQHC) in New York City, and students are embedded in the health centers for three years, beginning in the third year of the seven-year program.</p> <p> During the third year, students shadow their physician preceptors and develop their clinical history-taking skills. They also learn about team-based care in an FQHC and rotate with nurses, dieticians and social workers to learn about how each professional contributes to patient care. The medical students are trained as health coaches, and they begin to meet with patients in that role, helping them identify health-related behavioral changes, such as exercise and diet changes. They follow up with those patients longitudinally.</p> <p> Students return to the same FQHC during the next two years of their longitudinal clinical experience and assist with value-added tasks, such as medication reconciliation and developing and disseminating patient education tools.</p> <p> “We hope that the biggest benefit for students in this experience will be the opportunity to understand deeply how FQHCs currently address the health needs of communities, to recognize the value of team-based care and other innovations in primary care delivery, and to be inspired to choose careers in primary care in underserved areas,” said Rosa Lee, MD, assistant dean for clinical science curriculum and associate medical professor in the Department of Medical Education.</p> <p> Third-year students last year were the first to take part in the new curriculum. Preliminary feedback is that they enjoyed the experience and appreciated the introduction to team-based care in an FQHC.</p> <p> “The students … are looking forward to returning to the clinical sites, especially as they gain more knowledge and skills to participate more fully in clinical activities at these health centers,” Dr. Lee said.</p> <p> <strong>Interested in more med ed innovations?</strong></p> <p> These schools aren’t the only ones with innovative programs that embed medical students into patient care in their communities.</p> <p> <a href="" target="_self">Consortium</a> founding members <a href="" rel="nofollow" target="_blank">University of California, Davis, School of Medicine</a>; <a href="" rel="nofollow" target="_blank">Penn State College of Medicine</a>; and <a href="" rel="nofollow" target="_blank">Vanderbilt University School of Medicine</a>, along with <a href="" rel="nofollow" target="_blank">Morehouse School of Medicine</a>, which joined the consortium in January, also have programs aimed at placing students in underserved communities so they can help patients and gain experience in the community.</p> <p> You can read more about consortium work in these articles:</p> <ul> <li> Review <a href="" target="_self">9 med ed challenges</a> educators and consortium members want to solve right now.</li> <li> Learn <a href="" target="_self">how educators are creating the impossible</a> for future physician training.</li> <li> Discover the <a href="" target="_self">current projects</a> the consortium’s 11 founding members have underway.</li> </ul> <p align="right"> <em style="font-size:12px;">By contributing writer Tanya Albert Henry</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:689a822f-3a28-427c-80b9-ab8c9b5c4c4a How a new transitions model helped one patient Wed, 10 Aug 2016 21:49:00 GMT <p> After discharge it has often been up to the patient to adhere to medication regimens and alert their physician to any complications or confusion, but patients don’t always have the tools or circumstances to make this an easy task. Learn how a new transitions model helped one patient take charge of his health and better understand and adhere to his care plan.</p> <p> The <a href="" target="_self">SafeMed model</a> was developed at the University of Tennessee in partnership with Methodist Le Bonheur Healthcare in Memphis. It was designed with the strengths of primary care in mind and relies on a collaborative team effort from physicians, pharmacists, nurses and community health workers to form a support network for high-risk and high-needs patients as they transition from the hospital to the outpatient setting.</p> <p> <strong>Helping one patient take charge of his health</strong></p> <p> Mr. S had multiple chronic conditions—coronary artery disease, congestive heart failure, chronic kidney disease, hypertension, and a history of depression and cocaine use.</p> <p> He was initially admitted to the hospital because his automatic implantable cardioverter-defibrillator kept firing, causing severe emotional and physical discomfort.</p> <p> Social risk factor screening indicated that he had low to moderate social support at home. Mr. S was on Medicaid and received government disability assistance. His complex medical history and lack of social support made Mr. S an obvious candidate for the intensive care transitions services provided by the SafeMed program and he was enrolled.</p> <p> Over the next three days of his hospitalization, the SafeMed team—which included a nurse practitioner, a pharmacist, a pharmacy technician and a licensed practical nurse community health worker—worked to develop rapport with Mr. S and assess his unique needs.</p> <p> Because of his limited income, cost was a major barrier for Mr. S’ medication adherence, the pharmacist learned. So the pharmacist and the pharmacy technician helped Mr. S simplify his medication regimen, made sure he was paying the lowest possible cost for his medications and reviewed his plan following discharge.</p> <p> When he left the hospital, they gave him a patient-friendly medication list describing each of his medications.</p> <p> The team learned that, because Mr. S had many negative health care experiences in the past, he didn’t feel comfortable describing why it was difficult for him to follow medical advice and felt judged when he talked to medical professionals.</p> <p> The nurse practitioner and the community health worker counseled him on how to share his concerns with his physicians and worked closely with him to prioritize, schedule and arrange transportation for his outpatient visits following discharge.</p> <p> They also gave him educational materials, including a congestive heart failure symptom tracker to help him know when he needs to contact the physician.  At discharge, the nurse practitioner worked with the pharmacist to complete a brief SafeMed continuity of care document to send to his primary care physician and cardiologist before his follow up appointments.</p> <p> <strong>Staying involved through the continuum of care</strong></p> <p> The community health worker visited Mr. S in his home and reviewed his patient-friendly medication list and congestive heart failure symptom tracker. She learned that Mr. S did not have full comprehension of the self-management care guidelines he had been given in the hospital.</p> <p> They discussed his care plan in greater detail along with his health goals, which included outpatient medical follow-up as a priority and diet and exercise as secondary goals.</p> <p> In a bi-weekly case review meeting to discuss Mr. S’ needs and care plan, the community health worker met with the entire SafeMed team to refine the approach to Mr. S’ care. The team decided that the community health worker should attend his outpatient cardiology follow-up visit to assist him in communicating his concerns to the physician.</p> <p> This support made Mr. S more comfortable discussing issues regarding the circumstances that led to his defibrillator’s repeated firing and he revealed to the cardiologist that it always occurred during sexual activity.</p> <p> The cardiologist was able to fine-tune the device in response to Mr. S’ activity level to help him avoid future unnecessary shocks.</p> <p> Because the SafeMed team facilitated communication between Mr. S and his Medicaid case manager, he was able to get the assistance he needed with medications and home services. With the help of counseling, ongoing education and a supportive care team, Mr. S is meeting his health goals, attending his follow-ups, walking in his neighborhood and exercising daily for cardiac rehabilitation.</p> <p> The SafeMed team helped him speak up for himself and get the care he needed most, Mr. S said. He looks back positively on the experience.</p> <p> Mr. S was not receptive initially, according to the SafeMed team. But, once he understood that the SafeMed team members were there to help him, he was able to take the actions he needed to gain control of his health and avoid further hospitalization.</p> <p> <strong>Learn how to implement the SafeMed model in your practice</strong></p> <p> A new module on <a href="" target="_self" rel="nofollow">using the SafeMed model for transitions of care approach </a>is one of eight new modules recently added to the AMA’s <a href="" target="_self" rel="nofollow">STEPS Forward™ </a>collection of practice improvement strategies to help physicians make transformative changes to their practices.</p> <p> The University of Tennessee Health Sciences Center contributed this STEPS Forward module after <a href="" target="_self">winning</a> the AMA-MGMA Practice Innovation Challenge. The module can help practice teams implement the SafeMed model, which enables them to work closely with patients to build strong relationships that make it easier to coordinate and manage their care.</p> <p> Thirty-five modules now are available, and several more will be added later this year, thanks to a grant from and collaboration with the <a href="" target="_blank" rel="nofollow">Transforming Clinical Practices Initiative</a>.</p> <p> <em>AMA Wire®</em> explores many of the other <a href="" target="_self">modules</a>, including why your practice needs a health coach and four questions to ask to find out if your patients have unmet needs.</p> <p align="right"> <em>By AMA staff writer </em><a href="" target="_blank" rel="nofollow"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:dd015988-74be-43a1-8372-d3e0cda58bb5 More residents building families during training Wed, 10 Aug 2016 21:47:00 GMT <p> Having children isn’t easy, but intense medical training, limited parental leave and a shrinking workforce make building a family even more difficult. With more residents working to build their families during training, a new study looks at the trends and calls on graduate medical education (GME) to improve policies to increase work-life balance for residents.</p> <p> <strong>Who is having children and when</strong></p> <p> According to a 1983 survey, about 13 percent of female residents became pregnant during residency. More recently, that number has increased significantly, demonstrating that residents are spending their GME years building families.</p> <p> About 40 percent of physician trainees plan to have a child during their graduate medical education training, according to a <a href="" target="_blank" rel="nofollow">study</a> in the July issue of <em>Academic Medicine</em>.</p> <p> Researchers gathered information about pregnancy, institutional policies and parental leave from nearly 650 male and female trainees at Mayo School of Graduate Medical Education sites in Minnesota, Florida and Arizona. Among the physicians in training, 41 percent had children and 7 percent were currently pregnant themselves or had a partner who was pregnant.</p> <p> Among the 41 percent who had children, researchers learned:</p> <ul> <li style="margin-left:9pt;"> <strong>Most pregnancies occur during the GME years.</strong> Among the 398 pregnancies researchers had details on, about three quarters of pregnancies occurred during GME.</li> </ul> <ul> <li style="margin-left:9pt;"> <strong>More men report having children than women</strong>. About 35 percent of female residents reported having children compared to 47 percent of male residents.</li> </ul> <ul> <li style="margin-left:9pt;"> <strong>Both women and men plan to have more children during training.</strong> About one third of women and 35 percent of men said they planned to have their next child during their current training program. While another 18 percent of women and 17 percent of men planned to have their next child during their next training program.</li> </ul> <p> Some residents and fellows were waiting to become parents until after GME training. A majority of women said that having a child would extend training, interfere with fellowship plans and they were also concerned about potential pregnancy complications. However, the study found that the number one concern about having children for men was financial hardship.</p> <p> <strong>A call for parental leave, other policy changes</strong></p> <p> The research revealed that mothers took a median five to eight weeks for maternal leave, while fathers took less than one week of parental leave. Among women who took leave, researchers discovered that 40 percent still participated in career-related activities during that time, often for research. Women also wrote papers, studied for exams or pursued advanced degrees or other training.</p> <p> Most institutions, including the Mayo Clinic, have formalized parental leave policies. While leave policies that include part-time options, flexible scheduling and specific policies for pregnancy improve the situation for trainees returning to work after childbirth, the authors of the study said those policies alone may be insufficient in addressing the burden trainees perceive when colleagues take parental leave—a reduced workforce within the programs.</p> <p> The majority of trainees surveyed—59 percent—did not have a child. Two-thirds of those residents and fellows said they planned to have a child at some point in the future.</p> <p> Approximately one-half of both male and female trainees who were childless, but planned to have children at the time of the study, told researchers they hoped to do so during their current or next training program.</p> <p> “Program directors must address the challenges related to pregnancy and parental leave for this growing group of both male and female trainees,” study authors said.</p> <p> The growth of training programs and flexible—nonteaching—attending staff physician services may alleviate workforce issues, researchers said. “But such options might not be available on demand and thus will require planning and resources to implement.”</p> <p> Study authors said institutions should “pursue policies and practices to minimize the effects of parental leave on the workforce as trainees build their families.”</p> <p> <strong>Read more about residency and parenthood:</strong></p> <ul> <li> <a href="" target="_self">Making residency more family friendly</a></li> <li> <a href="" target="_self">The impact of parenthood on residency</a></li> </ul> <p align="right"> <em>By contributing writer Tanya Albert Henry</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:2d5540d5-11ed-433b-b038-b592b06645b1 AMA members recently appointed to med ed leadership roles Wed, 10 Aug 2016 20:00:00 GMT <p> Several AMA members were recently appointed by medical education organizations to leadership positions. These individuals were nominated by the AMA to the respective organizations, each of which made the final appointment decision from among the candidates it received.</p> <ul> <li> <strong>Sepideh Amin-Hanjani, MD, </strong>Chicago, Ill., has been appointed to the Accreditation Council for Graduate Medical Education<strong>, </strong>ACGME, Review Committee for Neurological Surgery, effective July 2017. Dr. Amin-Hanjani has been an AMA member for 15 years.</li> </ul> <ul> <li> <strong>Dusica Babovic-Vuksanovic, MD, </strong>Rochester, Minn., has been appointed to the ACGME Review Committee for Medical Genetics and Genomics, effective July 2017. Dr. Babovic-Vuksanovic has been an AMA member for 17 years.</li> </ul> <ul> <li> <strong>Leah Backhus, MD, </strong>Stanford, Calif., has been appointed to the ACGME Review Committee for Thoracic Surgery, effective July 2016. Dr. Backhus has been an AMA member for four years.</li> </ul> <ul> <li> <strong>Jonathan M. Chen, MD, </strong>Seattle, Wash., has been appointed to the ACGME Review Committee for Thoracic Surgery, effective July 2017. Dr. Chen has been an AMA member for one year.</li> </ul> <ul> <li> <strong>Robert M. Cromer, MD, </strong>Biloxi, Miss., has been appointed to the ACGME Review Committee for Surgery, effective July 2017. Dr. Cromer has been an AMA member for four years.</li> </ul> <ul> <li> <strong>Paul J. Dowling, MD, </strong>Kansas City, Mo., has been appointed to the ACGME Review Committee for Allergy and Immunology, effective July 2017. Dr. Dowling has been an AMA member for 10 years.</li> </ul> <ul> <li> <strong>John T. Gorczyca, MD, </strong>Rochester, N.Y., has been appointed to the ACGME Review Committee for Orthopaedic Surgery, effective July 2017. Dr. Gorczyca has been an AMA member for six years.</li> </ul> <ul> <li> <strong>Gabriella G. Gosman, MD, </strong>Pittsburgh, Pa., has been appointed to the ACGME Review Committee for Obstetrics and Gynecology, effective July 2017. Dr. Gosman has been an AMA member for four years.</li> </ul> <ul> <li> <strong>Kymberly A. Gyure, MD, </strong>Morgantown, W.Va., has been appointed to the ACGME Review Committee for Pathology, effective July 2016. Dr. Gyure has been an AMA member for 14 years.</li> </ul> <ul> <li> <strong>Misop Han, MD, </strong>Baltimore, Md., has been appointed to the ACGME Review Committee for Urology, effective July 2017. Dr. Han has been an AMA member for six years.</li> </ul> <ul> <li> <strong>Robert E. Harbaugh, MD, </strong>Hershey, Pa., has been appointed to the ACGME Review Committee for Neurological Surgery, effective July 2017. Dr. Harbaugh has been an AMA member for 11 years.</li> </ul> <ul> <li> <strong>Jeffrey R. Kirsch, MD, </strong>Portland, Ore., has been appointed to the ACGME Board of Directors, effective October 2016. Dr. Kirsch has been an AMA member for 18 years.</li> </ul> <ul> <li> <strong>Catherine M. Kuhn, MD, </strong>Chapel Hill, N.C., has been appointed to the ACGME CLER Evaluation Committee, effective July 2016. Dr. Kuhn has been an AMA member for 25 years.</li> </ul> <ul> <li> <strong>Edward H. Livingston, MD, </strong>Chicago, Ill., has been appointed to the ACCME Accreditation Review Committee, effective January 2017. Dr. Livingston has been an AMA member for seven years.</li> </ul> <ul> <li> <strong>Robert S. Mayer, MD, </strong>Baltimore, Md., has been appointed to the ACGME Review Committee for Physical Medicine and Rehabilitation, effective July 2017. Dr. Mayer has been an AMA member for 12 years.</li> </ul> <ul> <li> <strong>Eli Mizrahi, MD, </strong>Houston, Texas, has been appointed to the ACGME Review Committee for Neurology, effective July 2017. Dr. Mizrahi has been an AMA member for 19 years.</li> </ul> <ul> <li> <strong>Linda Regan, MD, </strong>Timonium, Md., has been appointed to the ACGME Review Committee for Emergency Medicine, effective July 2017. Dr. Regan has been an AMA member for nine years.</li> </ul> <ul> <li> <strong>Sheri Slezak, MD, </strong>Baltimore, Md., has been appointed to the ACGME Review Committee for Plastic Surgery, effective July 2017. Dr. Slezak has been an AMA member for one year.</li> </ul> <ul> <li> <strong>Mark Stafford-Smith, MD, </strong>Chapel Hill, N.C., has been appointed to the ACGME Review Committee for Anesthesiology, effective July 2017. Dr. Stafford-Smith has been an AMA member for one year.</li> </ul> <ul> <li> <strong>Lakshmana Swamy, MD, </strong>Brookline, Mass., has been appointed to the ACGME CLER Evaluation Committee, effective July 2016. Dr. Swamy has been an AMA member for nine years.</li> </ul> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:8b30a03f-c9f7-4739-93e3-e88e5ea0a508 Physician wellness: A global collaboration Tue, 09 Aug 2016 21:00:00 GMT <p> Researchers and physicians around the world are facing the same issue—keeping physicians healthy in a rapidly changing health care environment. Learn what one physician researcher from Mayo Medical School had to say about the need for a global collaboration to share approaches to physician, resident and medical student health and well-being.</p> <p> “Meeting with researchers from around the globe helps us get outside of our little box and think more broadly, get new ideas and approaches that we wouldn’t have thought about otherwise,” said Lotte Dyrbye, MD, professor of medicine at Mayo Medical School, who will participate in a panel on medical education at the International Conference on Physician Health™. This year, the conference will be held in Boston, Sept. 18-20.</p> <p> <strong>How changing med ed relates to physician well-being</strong></p> <p> Mayo Medical School is a member of the first cohort of the AMA’s <a href="" target="_self">Accelerating Change in Medical Education</a> (ACE) consortium which awarded $11 million in grants to 11 leading medical schools for major medical education innovations in 2013. This year a second cohort of 21 additional medical schools joined the consortium.</p> <p> There is a definite link between medical education and physician well-being, Dr. Dyrbye said. She has studied burnout in medical education since 2004.</p> <p> “Either you can be totally unprepared and go into this new health care delivery field and feel unempowered to make a difference,” she said, “and you can end up feeling demoralized, burnt out and unhappy … or you can take another approach.”</p> <p> “You can equip yourself with the other skills that you need to really thrive in the evolving health care system by understanding quality improvement,” she said. For example, “by having a good concept of how you can improve your diabetes metrics.”</p> <p> “If you have the skill set and you feel empowered, not only can you reach the new goals and expectations,” Dr. Dyrbye said, “but you’re also likely able to be more of a change agent to shape health care delivery in a way that will benefit patients.”</p> <p> The response Mayo has taken with their grant is to better <a href="" target="_self">equip the next generation of physicians</a> to practice within the new and evolving systems for two reasons, Dr. Dyrbye said:</p> <ul> <li> So they don’t feel as overwhelmed and are better able to manage personally and also meet new goals of care.</li> </ul> <ul> <li> So that they have the skills they need to shape and influence what health care delivery looks like in the future—to be willing to step up and be an advocate for change.</li> </ul> <p> <strong>Physicians gathering in Boston</strong></p> <p> The <a href="" rel="nofollow" target="_blank">International Conference on Physician Health</a> is an opportunity to learn how researchers and physicians from around the world are working to improve physician health and well-being. Although the conference is a collaboration of the AMA, the Canadian Medical Association and the British Medical Association, researchers from around the world will be in attendance.</p> <p> Other speakers include:</p> <ul> <li> Jon Kabat-Zinn, PhD, professor emeritus at the University of Massachusetts Medical School and founder of the Center for Mindfulness in Medicine, Health Care and Society and its Mindfulness-based Stress Reduction Clinic.</li> </ul> <ul> <li> Christine Sinsky, MD, vice president of the AMA’s professional satisfaction and practice sustainability initiative and author of “From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider.”</li> </ul> <ul> <li> Suzie Brown, MD, a congestive heart failure/cardiac transplant specialist at Vanderbilt University Medical Center and singer-songwriter who writes songs to process her life and medical career.</li> </ul> <p> <strong>For more on physician, resident and medical student wellness:</strong></p> <ul> <li> Learn Dr. Dyrbye’s <a href="" target="_self">six ways to avoid “distress” in medical school</a></li> <li> Find out <a href="" target="_self">how deliberate mentorship can help med students</a></li> <li> Examine the <a href="" target="_self">double-edged sword—what makes doctors great also drives burnout</a></li> <li> Learn <a href="" target="_self">how a “reset room” is helping medical professionals in Minnesota</a></li> </ul> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:27833f97-7bd7-4265-b24b-9268599c2fd4 A primary care model for the new Medicare payment system Mon, 08 Aug 2016 22:46:00 GMT <p> <span style="font-size:12px;">The Centers for Medicare and Medicaid Services (CMS) recently announced the open application period for physician practices to participate in a new, nationwide primary care payment model. Comprehensive Primary Care Plus (CPC+) is a primary care medical home that could qualify physicians for the incentive payment for Advanced </span><a href="" style="font-size:12px;" target="_self">Alternative Payment Model</a><span style="font-size:12px;"> (APM) participants under the new Medicare Access and CHIP Reauthorization Act (MACRA) starting in 2019.</span></p> <p> In designing CPC+, CMS tried to build on physicians’ experience with its predecessor medical home model and give participating practices better opportunities for success. Physicians want to be able to deliver comprehensive, high-quality care for each patient in the most effective way and without a rigid payment system that doesn’t provide the resources they need. Several APMs that are <a href="" target="_self">already in use</a> as pilots have proven that APMs can be effective for this purpose.</p> <p> CPC+ is a five-year primary care medical home model that aims to provide more flexibility and support than is typically available in fee-for-service, especially for non face-to-face services such as proactive patient outreach, care coordination and development of treatment plans. Up to 5,000 practices will be selected to participate.</p> <p> The AMA has strongly encouraged interested practices to submit applications during the short application period which closes on Thursday, Sept. 15, giving physicians just six weeks to apply. Submit a CPC+ application via the <a href="" target="_blank" rel="nofollow">online portal</a> by 11:59 p.m. Eastern time that day. CMS has no plans to allow new applicants later in the five-year period.</p> <p> CPC+ is a multi-payer model, so other payers will join Medicare in making monthly care management and performance-based payments to participating physician practices. CMS has provisionally selected 57 payer partners, including commercial insurers, state Medicaid agencies, Medicaid managed care organizations and Medicare Advantage plans in 14 regions across the nation. <a href="" target="_blank" rel="nofollow">Learn more</a> about the 14 CPC+ regions and provisionally selected payers.</p> <p> <strong>Two tracks for success in CPC+</strong></p> <p> Practices that are selected for participation will have the option to choose one of two CPC+ tracks for different types of payments. Both tracks promote high quality and high value care and practices will receive prospective performance-based incentive payments.</p> <ul> <li> <strong>Track one:</strong> Includes a monthly fee in addition to regular Medicare fee-for-service payments.</li> </ul> <ul> <li> <strong>Track two:</strong> Practices will receive a monthly fee, but also a hybrid of reduced Medicare fee-for-service payments and up-front comprehensive primary care payments to grant greater flexibility in how they deliver care.<br /> <br /> <span style="font-size:12px;">In this track, practices can deliver more comprehensive services for patients with complex medical and behavioral health needs.</span></li> </ul> <p> CMS has offered several resources for practices that choose to apply. Get your questions answered in the <a href="" target="_blank" rel="nofollow">Practice FAQs</a>. Register for one of the 20 upcoming <a href="" target="_blank" rel="nofollow">CPC+ Practice Open Door Forums</a> in August and September. Watch the <a href="" target="_blank" rel="nofollow">CPC+ Video Series</a> to get an overview of CPC+ payment innovations and care delivery transformation. Download the CPC+ toolkit: <a href="" target="_blank" rel="nofollow">CPC+ In Brief</a>, <a href="" target="_blank" rel="nofollow">CPC+ Care Delivery Transformation Brief</a>, and <a href="" target="_blank" rel="nofollow">CPC+ Payment Innovations Brief and Case Studies</a></p> <p> <strong>Learn more about APMs:</strong></p> <ul> <li> <a href="" target="_self">Tracking patients between visits: A new care model</a></li> <li> <a href="" target="_self">New model makes patient care more than face-to-face visits</a></li> <li> <a href="" target="_self">Payment model design needs to be physician-led: New report</a></li> <li> <a href="" target="_self">How doctors are developing new payment models for their specialties</a></li> <li> <a href="" target="_self">Who’s using new delivery and payment models?</a></li> <li> <a href="" target="_self">Payment models that can help you better address patients’ needs</a></li> <li> <a href="" target="_self">Specialty development key to new payment models’ success</a></li> </ul> <p align="right"> <em>By AMA staff writer</em> <a href="" target="_blank" rel="nofollow"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:3b23c00d-4ccb-45d3-8d1a-3f32e8ffca7f Medical school burnout: How to take care of yourself Mon, 08 Aug 2016 22:43:00 GMT <p> The pressures of medical school can have a major impact on students’ mental health and wellness. A group of medical students recently gathered to discuss these pressures and maintaining mental health during medical school. Learn what an expert had to say about taking care of yourself during medical school and how students are taking their own steps toward improving their own mental health and wellness.</p> <p> “Doctors actually live pretty healthy lives,” Joshua Nathan, MD, said to medical students at the 2016 AMA Annual Meeting. “If you look at the mortality rates, we tend to live at least as long if not longer than other people.”</p> <p> Dr. Nathan is an assistant professor of clinical psychiatry and director of the mood and anxiety disorders program at the University of Illinois, Chicago (UIC).</p> <p> “Where we suffer the most is mental health,” he said. “Depression and anxiety can certainly interfere with being empathetic. We have to talk about mental health and wellness in students without stigmatizing it.”</p> <p> <strong>Barriers to mental health: From the student perspective</strong></p> <p> “What are the barriers that you guys face?” Dr. Nathan asked, opening the session to conversation. “What are the challenges to your mental health?”</p> <p> “Part of it is stigma,” one student said. “The other part is time. One of my roommates was struggling with mental health issues and she was seeing someone, but when she got to third year she didn’t really have time to continue seeing this person and so she relapsed because she didn’t have time to take care of herself.”</p> <p> “We could probably do a lot better taking care of ourselves,” another student replied, “but also to take care of each other. We are in a unique position to understand and relate to one another. It’s getting a little better, but we’re still bred to be competitive and to not put ourselves out there if we are having a bad day.”</p> <p> “We’re often scared to seek treatment for depression,” a third student said. “We’re afraid of how it might affect our career.”</p> <p> “I think for first and second year students especially, people don’t know the difference in whether this is a normal amount of stress or is this diagnostic anxiety or depression,” another student offered. “A lot of people think, ‘this is med school, I’m stressed out all the time, this is just normal.’ Opening that discussion up and telling students, ‘no you can actually get through this and we can help you out’ would help.”</p> <p> <strong>Anticipating the causes of stress and burnout</strong></p> <p> “When we talk about physical health we do a great job,” Dr. Nathan said. “But how do you prevent mental illness? How do you prevent burnout?”</p> <p> According to Dr. Nathan, the best thing to do is identify the things we can anticipate. “We know there might be a heavy workload,” he said. “Some things about the work that we do in medicine we can change, but some things we can’t. But we can anticipate both of those things. The things that we can change maybe we can do something about that.”</p> <p> “There is quite literally more to know now than there was 50 years ago [when it comes to medical education],” he said. “Genetics wasn’t a big part of medicine then, but it is now. And the stuff that was part of medicine 50 years ago is still part of medicine. There’s just more information to know.”</p> <p> “There are also some things we can’t change,” he said. “In part of the work I’m doing with empathy, believe it or not, we all get less empathic as we get through medical school. We start out idealistic, ‘this is awesome we’re going to help people’—and then we actually meet patients.”</p> <p> Dr. Nathan developed the Clinicians Acting to Reinforce Empathic Skill (C.A.R.E.S) course at UIC, which includes an empathy development workshop and mental health and wellness training for medical students.</p> <p> “With patients, things aren’t quite as we envision them to be,” he said. “We actually distance ourselves emotionally from what’s happening. We can anticipate this because we know that it happens.”</p> <p> “That’s when you start to talk about tools,” he said. “What can we do when things start to get hard? Because we know they’re going to.”</p> <p> “No matter how much pressure we take off before that, at some point you realize people are dying—and sometimes we can’t help them,” Dr. Nathan said. “Death is a part of life and we can start to accept that but it’s tougher than we expected it to be.”</p> <p>  “How many people are going to med school in the same city as their parents? How many of you are more than a five hour drive from your parents?” he asked.</p> <p> “You get removed from your friends, you get removed from your family, you’re thrown into a heavy workload, your supports are far away, the things you’re used to are far away,” he said. “That’s a real challenge to trying to figure out how to take care of yourself in a brand new place and connect to your supports.”</p> <p> <strong>How three students overcome barriers</strong></p> <p> “So what do we do when it does start to get hard?” Dr. Nathan asked. “When we start to feel sad, when we start to feel stressed by the burden of having to take care of somebody?”</p> <p> Three students offered ways they have found to deal with the pressures of medical school and continue to grow both emotionally and clinically as a medical student:</p> <ul> <li> <strong>Peer support:</strong> “I live with four other people in my year and one of the things that works for us is coming together at the end of the day to cook dinner. We talk to each other so we have a really good support system. Five of us live there together. When you see a death, which definitely happens and that’s something hard, it’s really nice to have people to talk to about that.”</li> </ul> <ul> <li> <strong>Carving out time for exercise: </strong>“First year was really tough, there were a lot of exams and I was extremely busy. I realized I had changed my routine. I didn’t take care of myself as much and I wondered, ‘Why do I feel like cr@p all the time?’ And so now, in anticipation of third year, I brought exercise back into my life. I stopped exercising in first year because I didn’t feel like I had enough time. I would eat all day [while] studying and I gained weight and I felt so unhealthy. I realized that running again would make me feel good and I needed to be more mindful of that. Carving out [time for exercise] no matter how busy I was or how stressed out school made me changed things.”</li> </ul> <ul> <li> <strong>Journaling:</strong> “I’m a rising MS4 and I’m part of a bioethics program where we were tasked to, for every single clinical rotation we’d taken, write three journal entries. I have found that there’s something about a blank piece of paper and being required to write about my experiences that is very cathartic. It has helped me understand the harsh feelings I’ve had about surgery or really happy feelings I’ve had about psych or pediatrics. It’s sort of an all-encompassing thing that it’s okay to feel this huge range of emotions and that’s allowing me to grow and deal with the good and the bad and the feelings in the middle.”</li> </ul> <p> <strong>Learn more about physician burnout and solutions:</strong></p> <ul> <li> <a href="" style="font-size:12px;" target="_self">Student wellness: Blueprints for the curriculum of the future</a></li> <li> <a href="" style="font-size:12px;" target="_self">Ward off burnout: Your peer network may impact more than you think</a></li> <li> <a href="" style="font-size:12px;" target="_self">Stopping burnout a top priority for physicians in training</a></li> <li> <a href="" style="font-size:12px;" target="_self">How physician burnout compares to general working population</a></li> </ul> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank">Troy Parks</a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:e7403765-8693-4359-a316-47f51f536c40 Changes to shore up small practices under new Medicare payment system Fri, 05 Aug 2016 19:56:00 GMT <p> <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:14px;">The final rule for the new Medicare payment system is expected by November, yet the draft rule issued in April has many physicians in small or rural practices concerned that proper considerations have not been taken to set them up for success.</span></span></p> <p> <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:14px;">When Congress enacted the Medicare Access and CHIP Reauthorization Act (MACRA), it recognized the unique challenges of small and rural practices and required that special consideration be given to these practice types. But, the <a href="" rel="nofollow" target="_blank">proposed rule</a> provides only limited flexibility for small and rural physicians, which may jeopardize their ability to successfully participate.</span></span></p> <p> <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:14px;"><strong>The infamous “table”</strong></span></span></p> <p> <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:14px;">If you are in a small or rural practice, or a health professional shortage area, by now you’ve heard about the regulatory impact analysis table the Centers for Medicare and Medicaid Services (CMS) included in the MACRA proposed rule. Although many observers claimed that this table showed that the <a href="" target="_self">Merit-based Incentive Payment System</a> (MIPS) would negatively impact most physicians in solo and small practices.</span></span></p> <p> <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:14px;">But, the table doesn’t actually present a clear picture of the likely impact under MIPS for five reasons:</span></span></p> <p style="margin-left:40px;"> <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:14px;">1.   It doesn’t reflect the accommodations in the proposed rule that are intended to provide flexibility to small practices</span></span></p> <p style="margin-left:40px;"> <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:14px;">2.   It only looks at 2014 quality and resource use data and omits performance in the Advancing Care Information and Clinical Practice Improvement Activities categories</span></span></p> <p style="margin-left:40px;"> <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:14px;">3.   It includes many non-physician health professionals such as dentists and chiropractors, who were previously not eligible to participate in Medicare’s quality and resource use programs</span></span></p> <p style="margin-left:40px;"> <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:14px;">4.   It includes specialties and practices that may be exempt from certain MIPS measures or categories</span></span></p> <p style="margin-left:40px;"> <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:14px;">5.   It is based on 2014 data when physicians and other clinicians in many solo and small practices did not report their performance</span></span></p> <p> <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:14px;">Unfortunately, it is not possible to develop an accurate estimate of MIPS impacts, but it is clear that there are several changes CMS could make in the proposed MIPS policies that would improve the likelihood of success for physicians in solo, small, rural and health professional shortage area practices.<a href="" style="font-size:12px;" target="_blank"><img src="" style="margin:15px;float:right;" /></a></span></span></p> <p> <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:14px;"><strong>What needs to change before November</strong></span></span></p> <p> <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:14px;">In a <a href="" target="_self">comment letter</a> to CMS, the AMA outlined a number of recommendations to help these physicians succeed under MACRA:</span></span></p> <ul> <li> <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:14px;"><strong>Increase the low volume threshold to exempt more physicians.</strong> The proposed rule would exempt from MIPS physicians and groups with less than $10,000 in Medicare allowed charges and fewer than 100 unique Medicare patients per year. It its comments, the AMA recommended that physicians with less than $30,000 in Medicare allowed charges per year or fewer than 100 unique Medicare patients.<br /> <br /> The key word above—other than the $20,000 increase to the threshold—is the word “or.” That provides two possibilities that create a safety net for physicians in solo and small practices.</span></span></li> </ul> <ul> <li> <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:14px;"><strong>Compare practices to their peers rather than larger or more advanced entities.</strong> If peers are compared to peers, group size or specialty is no longer the determining factor to a practice’s success.<br /> <br /> The scoring methodology should not provide distinct advantages for practices simply because they are large or part of a hospital system, and should not penalize others for their size or unique patient population.<br /> <br /> Also, CMS should revise the rule using a consistent definition of small practices across performance categories so that physicians don’t qualify for one accommodation but not others.</span></span></li> </ul> <ul> <li> <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:14px;"><strong>Lower reporting burdens for small, rural and similarly situated practices.</strong> CMS should include explicit exemptions and lower thresholds throughout the proposed rule for physicians in these practice types.<br /> <br /> Incorporating specific accommodations into each of the four MIPS categories as well as approving alternative payment models specifically designed for small and mid-sized practices will provide the flexibility these practices need for success.</span></span></li> </ul> <ul> <li> <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:14px;"><strong>Provide education, training and technical assistance to small practices. </strong>Physicians in small or rural practices will need assistance to help them onboard the new programs—and this assistance should start as soon as possible.<br /> <br /> Help desks and staff ready to assist physicians when they have questions about the program should be provided by CMS as well as other educational information.<br /> <br /> The AMA is developing several resources that will soon be available. Check out the AMA’s <a href="" style="font-size:12px;" target="_self">MACRA resources</a> for more information on the new Medicare payment system.</span></span></li> </ul> <ul> <li> <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:14px;"><strong>Allow participation in virtual groups as soon as possible.</strong> The MACRA statute included the concept of virtual groups to help assist small practices. However, CMS proposes not to implement the groups until the 2018 performance period. CMS needs to form these groups as soon as possible.<br /> <br /> Smaller practices will need more time to learn about virtual groups to make them effective. CMS should provide a timeline for this implementation and offer significant flexibility in forming these groups including no initial, annual or other limits placed on the maximum number of groups approved each year—or required geographic proximity or specialty composition of the groups.</span></span></li> </ul> <p> <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:14px;">The MACRA rules are still in the draft phase. The AMA continues to work with CMS to make sure that all practice types and sizes are provided the flexibility to be successful in the new program.</span></span></p> <p> <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:14px;">For more information on how to prepare for the new Medicare payment systems, review the AMA’s <a href="" target="_self">MACRA checklist</a>, or check out the AMA’s <a href="" rel="nofollow" target="_self">STEPS Forward™</a> collection of practice improvement strategies that can help your practice <a href="" rel="nofollow" target="_self">prepare for value-based care</a>.</span></span></p> <p> <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:14px;"><strong>Learn more about the new Medicare payment system:</strong></span></span></p> <ul> <li> <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:14px;"><a href="" target="_self">Later start date could ease transition to new Medicare payment system</a></span></span></li> <li> <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:14px;"><a href="" target="_self">Key changes the new Medicare payment system needs</a></span></span></li> <li> <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:14px;"><a href="" target="_self">4 steps to prepare for Medicare’s new payment system</a></span></span></li> <li> <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:14px;"><a href="" target="_self">3 principles driving the new Medicare payment system</a></span></span></li> </ul> <p align="right"> <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:14px;"><em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></span></span></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:9d705a23-c89c-4509-a789-7519b6aa60d5 AMA-SPS at the 2016 Interim Meeting Fri, 05 Aug 2016 14:00:00 GMT <p> Join members of the Senior Physicians Section (AMA-SPS) at the 2016 Interim Meeting in Orlando from Nov. 12 to 15. The section is hosting a number of meetings for its members.</p> <p> <strong>Assembly Meeting</strong>: Saturday, Nov.12, from 11 a.m. to noon in Americas Seminar (Dolphin). Those present may introduce new items of business related to the section's mission and review items in the House of Delegates Handbook related to senior physician issues. A luncheon will be served at 11:30 am on a first-come, first-served basis. We hope you can join us and enjoy the fellowship of your senior physician colleagues. If you have questions about the meeting or <a href="">registering</a>, please contact Alice Reed via <a href="" rel="nofollow">e-mail</a> or call (312) 464-5523.</p> <p> <strong>SPS Educational Program: </strong>Saturday, Nov. 12, from noon to 1:30 p.m. in Americas Seminar (Dolphin). “Stay Young, Stay Fit, Avoid Burnout,” will look at creating a more positive, strength-based approach for empowering physicians to take charge of their own health and find sources of support before burnout occurs.</p> <p> The featured speakers are Robert L. Hatch, MD, professor, director of medical education, Department of Community Health and Family Medicine, University of Florida Medical School and Robert M. Wah, MD, faculty, reproductive endocrinology and obstetrics/gynecology at the Walter Reed National Military Medical Center and the National Institutes of Health, and former president of the AMA (2014–2015).  The moderator is Barbara S. Schneidman, MD, MPH, Chair, AMA-SPS Governing Council.  </p> <p> To recognize and support physician health at each stage of professional development, Dr. Hatch will speak on how to ensure that physician wellness is not forgotten—either in academic medicine, with its focus on physicians in-training, or for physicians approaching semi-retirement and retirement. Separately, Dr. Wah’s presentation will address the AMA’s recent policy on physician health that was established by the World Medical Association and developed during his year as president of the AMA.</p> <p> A luncheon will be served at 11:30 am on a first-come, first-served basis during the SPS Assembly Meeting.  We hope you can join us and enjoy the fellowship of your senior physician colleagues.  Advanced registration is appreciated.  If you have questions about the meeting or <a href="">registering</a>, please contact Alice Reed via <a href="" rel="nofollow">e-mail</a> or call (312) 464-5523.</p> <p> <em>The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.  The American Medical Association designates this live activity for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:f66286c3-b386-4214-8b4a-bb06b883ea91 Med schools focus on quality improvement, patient safety Thu, 04 Aug 2016 15:25:00 GMT <p> Improving quality and safety has been a focal point in medical education for more than a decade, but improvements have not been dramatic. Here’s a look at how some medical schools are changing their curriculum—and cultures—to make greater strides through their work with the AMA’s <a href="" target="_self">Accelerating Change in Medical Education Consortium</a>.</p> <p> <strong>Thinking about safety improvement and taking action in Georgia</strong></p> <p> Emory University School of Medicine in Atlanta this fall continues its project to create a standardized education in quality improvement and patient safety among its medical students, residents, fellows, faculty, affiliated physicians and interprofessional colleagues spread among four different health systems.</p> <p> Students that entered last fall were part of the first class that will experience all of the quality improvement and patient safety activities being added into each year of the school’s undergraduate curriculum.</p> <p> “Hopefully, going forward, students will have a more robust toolset and if something happens they will get involved and make a change,” said Nathan O. Spell, MD, chief quality officer at Emory University Hospital and an associate professor of medicine at Emory.</p> <p> New this fall, third year medical students will be excused from clinical rotation so they can come back to the classroom and talk about their first-person experiences with patient safety and quality improvement.</p> <p> “When they come back, we can ask, ‘What did you see? How did you analyze the situation? How did you react? Did someone report what happened?’” Dr. Spell said. “We want to try to get people to think critically about what happened, analyze it, think about how it can be changed and make [that] change.”</p> <p> Faculty members are being taught to think this way as well. Emory this fall will continue to educate them about patient safety and quality improvement through a development course. Faculty members will come to the class with a project in mind and be placed on a team with a physician trainee and an interprofessional colleague throughout the course.</p> <p> “We want the faculty to be talking about patient safety and quality improvements with the same vocabulary that trainees are using,” Dr. Spell said, noting that most faculty members did not go through medical training that focused on the subjects in the way Emory is now.</p> <p> There also will be a set time for the teams to present an oral report on their projects. Last year, they presented posters with no oral portion, Dr. Spell said.</p> <p> <strong>Expanding patient safety initiatives in Michigan</strong></p> <p> Based on feedback from faculty and students in a pilot program, Michigan State University College of Osteopathic Medicine is getting ready to roll out its curriculum for all students entering clerkship in September.</p> <p> The tweaked initiative incorporates quality improvement elements and an expanded patient safety component.</p> <p> “The feedback indicated there was more time available within the didactic timeframes to allow for it,” said Saroj Misra, DO, director of clinical clerkship curriculum and associate professor of family and community medicine at MSU College of Osteopathic Medicine.</p> <p> The changes create a more comprehensive approach to patient safety, including developing new initiatives based on quality improvement, she said, noting that “the added benefit is that students will be able to achieve a Basic Certificate from the Institute for Healthcare Improvement in patient safety and quality improvement, which may be valuable as they apply for residency programs.”</p> <p> The faculty in the pilot program said they found the curriculum easy to implement and students found the curriculum valuable. Students were surprised by what they “didn’t know that they didn’t know” when it came to patient safety, Dr. Misra said.</p> <p> MSU also is updating the curriculum for GME programs across Michigan to use as part of a statewide initiative for residency training in patient safety.</p> <p> “We have been pleased to see the support of our students, faculty and partner institutions in this initiative,” Dr. Misra said. “Having a unified system of education has proved to be valuable to our partners in healthcare.”</p> <p> <strong>More hands-on experiences in North Carolina</strong></p> <p> Students entering their first year of medical school at Brody School of Medicine at East Carolina University this fall will find a new immersion course that focuses on health systems and provides hands-on experience through simulations, patient navigation and interprofessional shadowing.</p> <p> The new approach is part of Brody’s ongoing longitudinal health systems science curriculum that includes components that begin the first week of medical school, continue through foundational science courses and clinical rotations and culminate with a transition to residency capstone course during a student’s final year of medical school.</p> <p> Brody also recently welcomed its second cohort of Leaders in Innovative Care (LINC) Scholars, a program that accepts up to 10 students per year. The students will graduate with enhanced training and applied experience in health systems science, including patient safety, quality improvement, populations health and team-based care.</p> <p> Over the summer, the scholars gained patient navigation experience and presented their suggestions for improvement to health systems leaders, participated in an interprofessional panel to understand the importance of an interprofessional team, attended a North Carolina legislative session and met with representatives, and interviewed with health systems leaders, said Luan Lawson, MD, MAEd, an assistant professor at Brody and the assistant dean of curriculum, assessment and clinical academic affairs.</p> <p> The school also launching a new group of faculty in the Teachers of Quality Academy (TQA) 2.0, which will provide faculty development in patient safety and quality improvement so they are prepared to lead frontline clinical transformation while teaching and modeling these concepts for the next generation of learners.</p> <p> Curriculum changes are having a real world impact, Dr. Lawson said. TQA faculty members have an extensive list of completed and ongoing clinical quality improvement projects, she said.</p> <p> “One faculty member commented that the [TQA] had changed the way he approaches his practice in that he now views the world through a quality improvement lens,” Dr. Lawson said. “This same physician created an enhanced recovery after surgery program that lowered costs and improved quality for patients undergoing complex abdominal procedures. He attributes being able to do this to what he learned through the TQA.”</p> <p> <strong>Read more about consortium schools</strong></p> <p> In addition to changing what medical students are learning about patient safety and quality improvement, consortium schools are taking new approaches to how they <a href="" target="_self">prepare physician leaders.</a> They also are <a href="" target="_self">paving new paths to residency</a>, <a href="" target="_self">relaying student competency to residency programs</a> and <a href="" target="_self">training students for rural medicine</a>. </p> <p align="right"> <em>By contributing writer Tanya Albert Henry</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:faad1b3a-3dd6-4aa1-bd17-52d922fdeb51 A healthy environment makes healthier patients Wed, 03 Aug 2016 21:32:00 GMT <p> Public health has always been a major concern for physicians, but continued pollution and energy overconsumption have caused many health and safety issues. As part of a green initiative based in Florida—and now used in 24 states and 14 countries—some physician practices are taking action to reduce their energy consumption to save money and promote a healthier environment for their patients—the public.<a href="" style="font-size:12px;" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> My Green Doctor, developed through the collaboration of the World Medical Association, the Florida Medical Association and the Florida Academy of Family Physicians, is a free comprehensive environmental sustainability program designed to help medical practices save energy and promote healthier practices among their patients.</p> <p> “It’s really up to individuals,” said Todd Sack, MD a gastroenterologist in Florida and editor of <a href="" rel="nofollow" target="_blank"></a>. “Physicians, as role models of our communities, if we’re thinking about environmental health and how important it is for our patients and our community, then it’s easier for our patients also to adopt these environmental practices.”</p> <p> <strong>How it works</strong></p> <p> The program—developed by physicians—was set up to give physicians tools with two important goals, he said, to create a healthier office environment and to save the physicians money on their utility bills and supplies.</p> <p> “A test group out of Escambia County, Florida … implemented what we recommended,” Dr. Sack said, “and they’re saving their office about $2,000 per doctor per year.”</p> <p> “[An important] component of My Green Doctor is teaching these concepts to our patients,” he said, “whether it’s in the exam room or the waiting room. We want to give doctors tools … to teach better environmental health practices.”</p> <p> My Green Doctor offers seven free workbooks on topics ranging from solid waste and recycling to drug disposal and chemicals. The first workbook, energy efficiency, offers dozens of energy efficient action and education choices for an office to consider, including:</p> <ul> <li> Adopt a thermostat policy for your office—74 degrees in the summer and 68 degrees in the winter.</li> <li> Change all incandescent light bulbs to compact fluorescent bulbs.</li> <li> Turn off your hot water. Most offices can safely turn off hot water heaters with no adverse health consequences.</li> </ul> <p> <strong>How it’s working in Escambia County</strong></p> <p> “Doctors are everywhere, they can have a great influence in their community,” said John Lanza, MD, director of the Florida Department of Health in Escambia County, one of the first locations to implement the My Green Doctor program.</p> <p> “[Physicians] have the ability to pick and choose to a great extent the type of paper that they use in their offices, and various other things to control energy usage in their offices … but they also have the ability to pass this information on to their patients.”</p> <p> In Escambia County’s offices, they reduced the amount of hot water being used, shut off over half of the fluorescent lights and installed sensor faucets in all of the restrooms and hand washing stations. The implementation of an electronic health record also greatly reduced the amount of paper they used.</p> <p> “We saved about 108,000 pounds of carbon dioxide generated. Because of the fact that we have our lights turned off and we’re not burning gas,” Dr. Lanza said. In the first year of participation, 2011, “we saved about $20,000 on utility costs.”</p> <p> Getting involved is easy and free for all practices. Visit <a href="" rel="nofollow" target="_blank"></a> to <a href="" rel="nofollow" target="_blank">register</a> and get started in your practice.</p> <p align="right"> <em>By AMA staff writer </em><a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:4fc389d3-c373-4ce8-ab95-716442a41399 Measuring residents’ moral courage Wed, 03 Aug 2016 21:29:00 GMT <p> At the heart of being a physician is caring for those who can’t care for themselves, so a healthy sense of moral courage is an important quality to nurture among physicians in training. New research has found a promising way to measure moral courage and pointed to differences based on gender, length in residency and religiousness.</p> <p> Interns and residents from two Northeastern academic medical centers were tested in 2013, when researchers employed a pioneering test that called on trainees to anonymously complete a survey about moral courage, empathy and speaking up about patient safety.</p> <p> For the purposes of this experiment, moral courage is defined as the willingness to stand up for and act on one’s ethical beliefs despite barriers, such as medical hierarchy and concerns about evaluations and career opportunities.</p> <p> “Such courage is critical to physicians’ commitment to act in the best interest of patients,” said the researchers in a <a href="" target="_blank" rel="nofollow">report published in <em>Academic Medicine</em></a>. Their study is the first known attempt, they said, to measure moral courage in physicians, and their survey model could help educators measure the effectiveness of medical school education in ethics.</p> <p> In its first run, the survey tool revealed some provocative results:</p> <ul> <li> <strong>Women are less likely than men to act on their moral beliefs.</strong> “These findings are consistent with prior research demonstrating gender-based differences of empowerment and confidence for physicians in training,” the report said. “More research to confirm and better understand these differences is needed.”</li> </ul> <ul> <li> <strong>Residents were more likely to show moral courage than interns.</strong> Researchers said interns’ reluctance to act could be linked to their “greater susceptibility to the conforming pressures in the clinical environment that may conflict with their own moral values.”</li> </ul> <ul> <li> <strong>Survey results showed religious trainees were no more likely than nonreligious trainees to act on their values.</strong> “In the context of the doctor-patient relationship, other motivators, such as a sense of fiduciary duty to patients, may motivate morally courageous behavior regardless of the religiousness of the physician,” the authors said.</li> </ul> <p> In the survey, 352 subjects in internal medicine and surgical specialties reacted to statements intended to gauge moral goals, moral agency and endurance of threats. Statements included:</p> <ul> <li> I do what is right for my patients, even if it puts me at risk (e.g., legal risk or risk to reputation).</li> <li> My patients and colleagues can rely on me to exemplify moral behavior.</li> <li> I use a guiding set of principles from my profession to help determine the right thing to do for my patients.</li> </ul> <p> The researchers concluded that their tool advances the scrutiny of moral courage at a time when medical schools are investing more resources in the study of ethics, “and may help researchers and educators identify deficits, track progress on a set of desired behaviors in response to curricular interventions, and better understand the foundations of physician behavior.”</p> <p> By its very use, their measurement model could underline the importance of moral courage as an educational and institutional priority, the authors said.</p> <p> They said future research should examine the relationship between scores on their model and measurements of burnout and other factors that affect physicians.</p> <p> <strong>For more on ethics and related topics, consult other AMA resources:</strong></p> <ul> <li> <a href="" target="_self">AMA <em>Code of Medical Ethics</em> modernized for first time in 50 years</a></li> <li> <a href="" target="_self">The physician’s ethical role in mental illness</a></li> <li> <a href="" target="_self">Focus on training: Treating patients with intellectual disabilities</a></li> <li> <a href="" target="_self">Ethical questions concerning medicine and the law</a></li> <li> <a href="" target="_self">Ethics committees: Exploring the past, present and future</a></li> <li> <a href="" target="_self">New era of high-value care meets medical ethics</a></li> </ul> <p align="right"> <em>By contributing writer Michael Winters</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:a39f5820-c38d-46de-a15b-ac40354b284a Learn about Strategies for financial wellness: The basics Wed, 03 Aug 2016 16:00:00 GMT <p> Join us for dinner, drinks and an exclusive opportunity to learn about strategies that will help promote your financial wellness. The dinner will take place Friday Sept. 30 from 6 to 9 p.m. at Hotel Sorrento in Seattle, Wash.</p> <p> The evening kick off this meeting with three short presentations covering:</p> <ul> <li> Navigating the employment contract process</li> <li> Preparing for your financial future</li> <li> Getting your financial questions answered</li> </ul> <p> Following the presentations, we will break into small groups to take a deeper dive into these topics. Get your questions answered by experienced financial professionals, attorneys and physicians who have real-world experience.</p> <p> The event is free for AMA members. <a href="">Register and learn more</a>.</p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:3c50cf45-63ae-4569-a616-ae631f40bd6c Register to attend the AMA-IMG Section Interim Meeting Wed, 03 Aug 2016 15:00:00 GMT <p> Register today for the American Medical Association International Medical Graduates (IMG) Section Interim Meeting to be held Nov. 10-12 at Walt Disney World Swan and Dolphin Resort in Orlando. Invite a colleague or friend to become involved in the AMA’s policymaking meeting, participate in Section events and hone your leadership skills.</p> <p> All IMG Section meetings will be held at the Dolphin, including:</p> <ul> <li style="margin-left:0.25in;"> <strong>The 14th annual AMA Research Symposium and reception: Friday Nov. 11, 1–7:30 p.m.</strong><br /> Hear educational sessions, oral research presentations and view abstracts by AMA-IMG Section ECFMG-certified candidates who are waiting residency. Featuring the work of AMA members from the medical student and resident sections as well, the symposium typical showcases the research of more than 600 participants.</li> </ul> <ul> <li style="margin-left:0.25in;"> <strong>AMA-IMG Section reception and congress: Saturday Nov. 12, 5:30–7:30 p.m.</strong><br /> Network with colleagues and discuss policy items for the AMA-IMG Section as well as AMA House of Delegates reports and resolutions of interest.<br /> <br /> Invited guest speakers: Humayun Chadhury, DO, CEO and president of the Federation of State Medical Boards; Thakor Patel, MD, adjunct associate professor of medicine at the Uniformed Services of the Health Sciences, Bethesda, Maryland.<br />  </li> <li style="margin-left:0.25in;"> <strong>Busharat Ahmad, MD, Leadership Development Program: Sunday Nov. 13, 2–3 p.m.</strong><br /> Learn what it takes to be an effective physician leader through followership. Featured speaker: Nestor Ramirez-Lopez, MD, “Followership, the Other Face of Leadership”<br />  </li> <li style="margin-left:0.25in;"> <strong>AMA-IMG Section and AMA Minority Affairs Section delegates caucus: Monday Nov. 14, 8:30–9:30 a.m.</strong><br /> Review reference committee reports and discuss strategies for supporting both the AMA-IMG Section and relevant AMA House of Delegates policy items.</li> </ul> <p> <a href="">Registration</a> will close on November 5. <a href="" rel="nofollow">Book your hotel reservations</a> now. For more information, email <a href="" rel="nofollow"></a> or call the AMA-IMG Section at (312) 464-5397.</p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:0c53ff7e-23c1-4565-8f9e-bde9b01d6282 Participate in IMG Section Online Member Forum Wed, 03 Aug 2016 14:00:00 GMT <p> The International Medical Graduates Section (IMGS) Online Member Forum will provide comments and testimony for resolutions being considered for the November Interim Meeting Aug. 31 – Sept. 7. Engage with the AMA-IMG Section by providing your comments for the resolutions.</p> <p> You can review the resolutions by visiting <a href="" rel="nofollow">SurveyMonkey</a>. After your review, select your choice of support or non-support for each resolution. Your comments are also welcome.</p> <p> Please note you will also be requested to approve the resolutions presented during the ratification period Sept. 12 –16. </p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:fca8f695-f2d6-48bf-a26c-fb04d2fbc97e Neurosurgery makes pain management curricular breakthroughs Tue, 02 Aug 2016 21:37:00 GMT <p> Leaders in neurosurgery have taken a hands-on approach to training residents with an eye toward filling knowledge and skill gaps—one such gap is pain management. Learn how they’re making strides in preparing residents for the board exam and more effective patient care.</p> <p> Neurosurgery “boot camps” were created in 2009 to help fill in some of the knowledge gaps in resident training. Neurosurgeons in training attend one boot camp at the start of internship and another before becoming a junior resident.</p> <p> “The boot camps … use extensive simulation labs with ICU crises where you have a mannequin on a table with an ICU monitor,” said Christopher Winfree, MD, an assistant professor of neurological surgery at the Columbia University College of Physicians and Surgeons in New York City. “They go through all kinds of scenarios. The important thing is to have the residents trained across all of the topics they need to know.”</p> <p> The Neurological Surgery Milestone Project, developed in 2013, was created to further formalize the content of residency training. The content addresses areas such as procedural skills, professionalism and interpersonal relations with colleagues and patients. The Milestones also facilitate resident assessment to make sure residents are making appropriate progress as they go through their training.</p> <p> <strong>Training neurosurgical residents in pain management</strong></p> <p> Six years ago, Dr. Winfree became president of the pain section of the two major neurosurgery groups, the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. The executive committees asked him to make pain management in neurosurgery more prominent.</p> <p> Dr. Winfree developed a module for the resident boot camp that includes everything residents need to know about pain management in neurosurgery. Topics covered include different types of pain, neuropathic pain medications, how opioids work, treatment ladders, chronic and acute pain management, caring for patients with opioid dependence or substance use disorder, and buprenorphine treatment.</p> <p> “I thought that would be an excellent opportunity to teach pain management at a boot camp level so the interns and junior residents are not only getting comprehensive neurosurgical training but also a focus—at least in one module—on pain,” he said.</p> <p> <strong>Making sure the knowledge sticks</strong></p> <p> “Everybody likes to think that when you institute a new curriculum, it’s going to be great,” Dr. Winfree said. “But we had no data to prove that. Further, we had neurosurgery residents and attendings not doing so well in the pain sections on their board exams.”</p> <p> “People weren’t really getting it and weren’t really learning what they needed to learn,” he said. “We tried to address that with the boot camp [and] the milestones, and that was a good start, but we were still making little progress on board exam performance.”</p> <p> As a member of the editorial board of the Self-Assessment Neurological Surgery (SANS), which writes the board exam questions, Dr. Winfree wrote 150-200 questions, vetted by the Board, for a rotating practice exam, which includes a different set of 100 questions each year. Using the results from these tests, they can now see how the residents are doing on the sections regarding pain.</p> <p> Some of these pain questions are used at the boot camp sessions. The residents study the material and take a test before they arrive and then are tested again at the end of the course.</p> <p> In Dr. Winfree’s pain lecture, he talks about pain management for neurosurgery, including craniotomy, spine surgery, post-operative pain management, use of non-opioid medications, the treatment ladder, management of specific chronic pain conditions and much more.</p> <p> “We’re trying to get away from passive learning, because how many times have we all sat in lectures and retained probably 10 percent,” he said. “When you have somebody study ahead of time and test them on it ahead of time, then show it to them in person, where they can sit one-on-one with faculty members in these sessions, and then you test them on it again, they have this stuff for life.”</p> <p> “This isn’t just stuff that the residents blow off,” he said. “They study [it]. They’re professionals, and we treat them like professionals. But we test them also. We make sure that they know the material.”</p> <p> “Every question has an explanation at the end,” he said. “It’s self-assessment, but it’s not just yes, no, you got it right or wrong. The residents get an explanation as to <em>why</em> the answer is right or wrong.”</p> <p> <strong>Changing the curriculum at Columbia</strong></p> <p> Dr. Winfree is also changing how he teaches neurosurgical residents at Columbia University Medical Center. “I would give talks on the material,” he said, “and randomly call the residents after and quiz them about the lecture—and the results were terrible. It was almost like the residents did not attend the lecture.”</p> <p> “The whole passive, didactic learning thing is 20th century,” he said. “What we’ve been actively trying to do is get things to the 21st century. Now, instead of just giving a random talk on neuro for pain, I designed a curriculum that directly follows the milestones.”</p> <p> Every week, residents training with Dr. Winfree present a case, and the group addresses the topic. Instead of a long lecture, the residents’ case study lasts 15 minutes, with Dr. Winfree moderating. “Studies have shown that an educated person’s attention span for a talk is 18 minutes,” he said. “That’s why TED Talks are 18 minutes and contain stories, because a story represents a cognitive hook that allows a person to pay attention more.”</p> <p> “It’s not a lot of PowerPoint and bullet presentations,” he said. “It’s images that reinforce the stories that are being told … so it captivates the residents’ attention. It’s active learning, not passive learning.”</p> <p> So how have the residents responded? They like it, a lot.</p> <p> “Nobody wants to sit through an hour lecture,” Dr. Winfree said. “We’ve been doing these boot camp courses every year now, and every time we do it, we survey the residents. Every resident says, ‘Get rid of the didactic lectures, we’re falling asleep, [and] we’re not learning anything.’”</p> <p> “What does work is a shorter, case-based set of scenarios,” he said, commenting on survey results and exam performance data. “We’re not having hour-long lectures, we’re doing 15 minute small group sessions to go over all of those things, and the residents are responding.”</p> <p style="text-align:right;"> <em>By AMA staff writer</em> <a href="" target="_blank" rel="nofollow"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:222f35ed-ecac-4ef0-9c96-ae548ca038c9 Challenge to medical liability law could complicate pre-suit process Tue, 02 Aug 2016 21:34:00 GMT <p> A medical liability case, even if successful, can cause financial, emotional and reputational harm to a physician—and also to the patient who brings the suit. A 2013 amendment to the Florida Medical Liability Act, which requires the plaintiff to release relevant health information to determine whether a claim for medical liability is meritorious, is under threat in the Florida Supreme Court.</p> <p> At stake in <em>Weaver v. Myers</em> is whether the Florida Medical Malpractice Act, which requires the plaintiff to authorize the release of otherwise confidential health information as a condition of bringing a lawsuit for medical liability, is valid. Both a trial court and the Florida First District Court of Appeals confirmed the amendment’s validity.</p> <p> Florida’s pre-suit investigation process was intended to allow both claimants and potential defendants the opportunity to determine whether a medical liability claim has merit and to encourage early resolution of claims between the parties. This process can avoid costly and time-consuming proceedings through a less complicated pre-suit process that allows both parties to examine the evidence.</p> <p> <strong>What happened</strong></p> <p> Emma Weaver, widow and representative of Thomas C. Weaver, sued her late husband’s physician, Stephen C. Myers, MD, for medical liability. However, she did not want to allow Dr. Myers’ attorneys to interview the other physicians who had treated her deceased husband. She asserted that the Florida constitution and a regulation promulgated under the Health Insurance Portability and Accountability Act (HIPAA) to protect patient privacy invalidated the Florida Medical Malpractice Act.</p> <p> When a case goes into suit, the Rules of Civil Procedure allow parties to have a fair chance to fully explore their opponents’ medical condition when that condition has been placed at issue. For example, a defendant may even require the plaintiff to sit for a compulsory medical examination by another physician of their choosing.</p> <p> The Florida Medical Malpractice Act was passed in response to a common complaint from advocates and clients on both sides: Medical liability lawsuits take too long to be brought to resolution. The intent of the act was to reduce the cumbersome and expensive process of discovery. A formal deposition can disrupt the physician practice and displace patients in that physician’s schedule.</p> <p> “The time, expense and potential asymmetry of information can be cured by allowing the current law to stand,” said the Litigation Center of the AMA and State Medical Societies in an amicus brief. “A phone call between defense counsel and the treating physician can serve to facilitate the same information that would be revealed during a formal deposition.”</p> <p> Allowing the claimant to withhold key information unfairly prejudices potential defendants and circumvents the goals of the pre-suit investigation process.</p> <p> “If the right to this informal discovery is removed,” the brief said, “the result will be to return to an uneven playing field and the inability to avoid cumbersome and costly formal discovery.”</p> <p> <strong>Current medical liability cases in which the Litigation Center is involved:</strong></p> <ul> <li> Learn how a case <a href="" target="_self">could lead to unlimited awards of punitive damages</a>.</li> <li> Get the details on a <a href="" target="_self">case that could extend medical liability</a>.</li> <li> Find out how one <a href="" target="_self">case could increase liability exposure and redefine injury</a>.</li> </ul> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:4447326b-bc52-4cdd-b68f-77fbe9b887ce Ethics in pathology: Images, the media and diagnosis Mon, 01 Aug 2016 21:40:00 GMT <p> When Prince died in April, details of his death and autopsy slowly trickled into the public sphere, but isn’t patient health information private? Examine this and other complex ethical questions that pathologists face in practice and how media and publicity can complicate these matters even more.</p> <p> The <a href="" target="_blank">August issue</a> of the <em>AMA Journal of Ethics®</em> considers neglected ethical issues in pathology practice, including shifts in social and cultural attitudes toward autopsy, cautions about the use of social media for sharing images, how to communicate about errors or pathology results and what the death of Prince tells us about the public and professional obligations of physicians who interact with the media. Articles featured in this issue include:</p> <ul> <li> “<a href="" target="_blank">Pathology image-sharing on social media: Recommendations for protecting privacy while motivating education.</a>” With a rising interest in social media use by pathologists, use of pathology images on these channels is being debated. Particularly photographs of dermatologic conditions and from gross examination or autopsy suggest a need for professionals to adopt practical social media guidelines that can help mitigate breach of privacy risk to patients.</li> </ul> <ul> <li> “<a href="" target="_blank">Public figures, professional ethics, and the media.</a>” If health information is private, why does the public know so much about Prince’s death? Death certificates and autopsy reports contain personal information protected under the Health Insurance Portability and Accountability Act (HIPAA). Examine the critical ethical questions that have not yet been settled about whether and when this information should be made public.</li> </ul> <ul> <li> “<a href="" target="_blank">I might have some bad news: Disclosing preliminary pathology results.</a>” When, if ever, is it appropriate for cytopathologists to share preliminary diagnostic impressions with patients at the bedside? Investigate communication strategies for navigating uncertainty that apply not only to pathologists but to all clinicians.</li> </ul> <ul> <li> “<a href="" target="_blank">The use of visual arts as a window to diagnosing medical pathologies.</a>” In medical school, the art of observation and learning to look can be taught using the humanities—especially visual arts such as paintings and film. Learn how the curriculum at Australia’s Bond University uses art to build students’ diagnostic skills.</li> </ul> <p> In the journal’s <a href="file:///I:/Communications%20Documents/Morning%20Rounds%20Daily/Week%20of%2008_01_2016/Final/" target="_blank" rel="nofollow">August podcast</a>, Theonia Boyd, MD, associate professor of pathology at Harvard Medical School, discusses ethical issues pathologists face when conducting autopsies and obtaining specimens.</p> <p> <strong>Take the ethics poll</strong></p> <p> <a href="" target="_blank">Give your answer</a> to this month’s poll: When communicating about errors—whether to clinicians or patients—what should pathologists say to help conversations about errors go smoothly?</p> <p> <strong>Submit an article</strong></p> <p> The journal’s editorial focus is on commentaries and articles that offer practical advice and insights for medical students and physicians. <a href="" target="_blank" rel="nofollow">Submit your work</a> for publication.</p> <p align="right"> <em>By AMA staff writer </em><a href="" target="_blank" rel="nofollow"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:1d49ed44-aa6d-4e53-a1d0-a1a0c7c03df6 Making the pitch: How to take your innovations to market Mon, 01 Aug 2016 21:37:00 GMT <p> Students and physicians often find they have a tech idea that could improve care, but how to ignite interest among financial backers is another thing altogether. Find out what venture capitalists and other funders have to say about making a pitch that will get your idea to market.</p> <p> <strong>Giving wings to your dreams</strong></p> <p> Many innovations in medical technology, devices and software never take flight because their creators don’t know how to present them, financiers said. They offered the dos and don’ts of making a pitch during a session at the <a href="" target="_self">2016 AMA Annual Meeting</a> in Chicago.</p> <p> Omar Maniya, a Harvard Business School graduate, medical student in his final year at Georgetown University School of Medicine and medical student member of the AMA Board of Trustees, summed up the anatomy of a pitch with a favorite acronym, BALZAC:</p> <ul> <li> <strong>Brevity.</strong> “That is the absolute No. 1 thing,” Maniya said.</li> <li> <strong>Audience.</strong> Know the inside story on every person who will be hearing your pitch.</li> <li> <strong>Language.</strong> Take care with medical jargon, and gear your terminology to your audience.</li> <li> <strong>Zoom level.</strong> Know when to drill down into the details of a topic and when to keep it light.</li> <li> <strong>Analogies.</strong> Link your ideas to things your audience can relate to; illustrating your pitch with stories from the outside world.</li> <li> <strong>Confidence.</strong> Be the master of your project. “If you are not the most knowledgeable person in that room about your idea, you should not be in that room,” Maniya said.</li> </ul> <p> Washington venture capitalist Arnab Sarker said the successful pitcher knows his or her product and its industry, can explain the problem the product will solve, fields a quality team (including members with clinical experience) and has a sound business plan. The last aspect is a feature that many medical students fail to include, he said.</p> <p> <strong>Watch for stumbling blocks</strong></p> <p> Sarker named common weaknesses that can sour a pitch:</p> <ul> <li> A lack of understanding about how venture capitalists make their money</li> <li> More than two people presenting the pitch</li> <li> Slides with too many words</li> <li> Forgetting to consider regulatory issues</li> <li> Using language that is wrong for the setting</li> </ul> <p> <strong>Fueling the world of innovation</strong></p> <p> Students and physicians can find other resources to help make their ideas a reality. One resource is <a href="" target="_blank" rel="nofollow">IDEA Labs</a>, a student-run biomedical entrepreneurship incubator based at Washington University in St. Louis. In partnership with the AMA, IDEA Labs has expanded to the University of Minnesota, the University of Pennsylvania and Harvard/MIT. Chapters are being started at the University of Michigan and Tulane/Louisiana State University.</p> <p> IDEA Labs enables students from medical, engineering and business backgrounds to collaborate in identifying the needs of clinicians and meeting them with marketable products.</p> <p> The AMA’s collaboration with IDEA Labs underscores the association’s expanding role in supporting health care innovation. The AMA is deeply involved in driving transformative health care innovation as the organization ramps up efforts to bridge the gap between creative idea development and the realities of patient care.</p> <p> In addition to the collaboration with IDEA Labs, the AMA’s innovation ecosystem includes:</p> <ul> <li> An expanded partnership with <a href="" target="_blank" rel="nofollow">MATTER</a>, Chicago’s health care technology incubator, to allow entrepreneurs and physicians to collaborate on the development of new technologies, services and products in a simulated health care setting.</li> <li> An investment as founding partner in <a href="" target="_blank" rel="nofollow">Health2047</a>, a San Francisco-based health care innovation company that combines strategy, design and venture disciplines, working with companies, physicians and entrepreneurs to improve health care.</li> <li> A total of $50,000 in prizes to the three winners of the <a href="" target="_blank" rel="nofollow">AMA Healthier Nation Innovation Challenge</a>, which recently invited medical students, residents and physicians from across the country to submit their ideas.</li> </ul> <p align="right"> <em>By contributing writer Michael Winters</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:c4b49145-7dfc-4b61-be09-343ee923d987 Register for 14th Annual Research Symposium Mon, 01 Aug 2016 15:00:00 GMT <p> Don’t miss the opportunity to register for the AMA 14<sup>th</sup> Annual Research Symposium. Medical students, residents and ECFMG-certified candidates awaiting residency are invited to showcase their research.  The deadline to submit your abstracts is Wednesday, August 17<sup>th</sup>.</p> <p> Participants may submit abstracts in the following categories:</p> <ul> <li> Clinical Vignette</li> <li> Clinical Medicine</li> <li> Improving Health Outcomes (cardiovascular disease, diabetes)</li> </ul> <p> Register, submit your abstracts or obtain more information on the <a href="">Research Symposium web page</a>.</p> <p> Judges are also needed to help mentor tomorrow’s physicians.  <a href="">Register</a> or email <a href="" rel="nofollow"></a> if you are interested in becoming a judge for this exciting event. Judges will be accepted through Nov. 1. </p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:d261c8d3-10e1-4f71-bc06-01e0e0755330 AMA-WPS Women in Medicine Symposium Mon, 01 Aug 2016 14:00:00 GMT <p> <u><a href="" target="_self"><u>Register</u></a></u> by September 19 to attend the first-ever American Medical Association Women Physicians Section (WPS) Women in Medicine Symposium. Held in conjunction with the AMA’s Women in Medicine Month, this symposium will help attendees tackle priority issues that women physicians face in medicine today.</p> <p> This event features a tour of the AMA headquarters, dynamic presentations, panel discussions and breakout sessions covering:</p> <ul> <li> Physician resiliency and burnout</li> <li> Women of impact: overcoming obstacles in daily practice</li> <li> Personal wellness break</li> <li> Participate in the AMA’s national listening tour</li> </ul> <p> This event will take place on Thursday, Sept. 22, from 12:30 to 5 p.m. in Chicago at AMA Plaza, 330 N. Wabash Ave. The registration fee is $25 for AMA physician members, $10 for student and resident members, and $95 for nonmembers. If you invite a colleague during registration and they sign up, you will receive a 50% discount off your registration fee to be refunded at a later time.</p> <p> Please contact the <a href="" rel="nofollow">AMA-WPS</a> with any questions.</p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:eb1f2379-d31a-4761-8d64-965bb0f11b35 Strategies for financial wellness: The basics Mon, 01 Aug 2016 14:00:00 GMT <p> Join us for dinner, drinks and an exclusive opportunity to learn about strategies that will help promote your financial wellness on Friday, Sept. 30 from 6-9 p.m. at the Hotel Sorrento in Seattle.</p> <p> We will kick off the evening with three short presentations covering:</p> <ul> <li> Navigating the employment contract process</li> <li> Preparing for your financial future</li> <li> Getting your financial questions answered</li> </ul> <p> Following the presentations, we will break into small groups to take a deeper dive into these topics. Get your questions answered by experienced financial professionals, attorneys and physicians who have real-world experience.</p> <p> The event is free for AMA members. The fee for nonmembers is $99 and for guests $49. <a href="">Learn more and register</a>.</p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:2091a540-fdab-4f45-8b81-c43c46955a48 Speak up about gaps in residency training Mon, 01 Aug 2016 12:00:00 GMT <h3> <span style="font-size:9pt;font-family:Arial, sans-serif;font-weight:normal;">A new project, led by the AMA, will conduct informal meetings in-person and by phone with selected residents and fellows to understand their needs, challenges, training gaps and aspirations. The goal of the project is to develop or enhance resources and services to help during training.</span></h3> <h3> <span style="font-size:9pt;font-family:Arial, sans-serif;font-weight:normal;">The discussion will take approximately 30 minutes. If you are interested, please <a href="" rel="nofollow">email the Residents and Fellows Section</a> with the day and time most convenient for you. </span></h3> <p>  </p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:7dac099e-8197-4ce5-8579-96a46ae7d04e How deliberate mentorship can help med students Sun, 31 Jul 2016 22:00:00 GMT <p> Mentorship can help medical students hone their clinical skills and improve their patient interactions, but mentors can also guide students through tough times both in school and their personal lives. Stanford has implemented a medical school mentorship program that builds a community atmosphere to support their students.</p> <p> Stanford University Medical Center in 2010 launched the Stanford Committee for Professional Satisfaction and Support to help physicians balance the increasing demands of practice environments. The guiding principle of the committee is that the professional fulfillment of clinicians is inextricably linked to quality, safety and patient-centeredness.</p> <p> The medical school also recognized that it wasn’t just physicians in practice who needed support, but the medical students needed support thorughout their rigorous training as well. That’s why they implemented the <a href="" rel="nofollow" target="_blank">Educators-4-Care program</a>, which pairs five to six medical students with a faculty member who serves as teacher, mentor and colleague for the duration of their time at the school of medicine.</p> <p> <strong>Supporting students throughout med school</strong></p> <p> “It gives students a person to go to when they’re in stress because we really get to know the students well,” said Lars Osterberg, MD, associate professor of medicine at Stanford School of Medicine and director of the Educators-4-Care (E4C) program.</p> <p> “It’s a deliberate mentoring … which gives them a more personalized and dedicated mentorship,” he said. “Unlike the old paradigm of med school where the students had to find a mentor on their own … because some students don’t always find the right person and don’t always have someone to reach out to.”</p> <p> Stanford is part of the <a href="" rel="nofollow" target="_blank">Learning Communities Institute</a>, a nonprofit organization that works to improve health care education across the continuum of learning. The organization fosters scholarship, professional development and the centrality of relationships among learners and teachers as a way to promote compassionate, patient-centered care, physician well-being and lifelong learning.</p> <p> Mentors guide students in clinical skills training and patient interactions, but they also check in with the students regularly to make sure they’re doing well personally, Dr. Osterberg said. “We have definitely noticed a change in the culture, our students are much stronger clinically … and they’ve dramatically improved since the inception of the E4C program.”</p> <p> “We had a lot of students who ended up coming to us in the beginning of our program that we didn’t anticipate,” he said, “who had life events that occurred during medical school, that we think could have avoided some really bad things, like even possible suicide…. With the pressures of med school there is often depression, and the first person they’d go to is often the E4C faculty.”</p> <p> Stanford measures aspects of their students’ wellness and empathy. “Students usually decline in their empathy skills during their clinical years,” he said. “[But] our students haven’t declined as they did in the past. We feel like the learning communities model really does fulfill that supportive role and is reflected in the students’ well-being.”</p> <p> <strong>How the program has affected faculty</strong></p> <p> The program surveyed the faculty who are involved as mentors and the response was that being a mentor is very rewarding. “The faculty have commented that being involved as a mentor in the learning community motivated them to stay in academia and [continue to be] a mentor,” he said. “They love seeing their students grow and seeing that they are making a difference in students’ lives.”</p> <p> “It also creates a community of other faculty of like-minded people that are trying to make a difference in medical education,” Dr. Osterberg said. “Part of every mentor’s conversation [with students] is just checking in to see how they are doing emotionally, mentally and physically.”</p> <p> The Educators-4-Care program was highlighted in a module on <a href="" rel="nofollow" target="_self">preventing physician burnout</a> from the AMA’s <a href="" rel="nofollow" target="_self">STEPS Forward™</a> collection of practice improvements initiatives. Other available modules on burnout cover preventing resident and fellow burnout and improving physician resiliency.</p> <p> Thirty-five modules now are available in the STEPS Forward collection, and several more will be added later this year, thanks to a grant from and collaboration with the <a href="" rel="nofollow" target="_blank"><u>Transforming Clinical Practices Initiative</u></a>.</p> <p> Physicians and experts from around the world will gather Sept. 18-20 in Boston for the <a href=""><u>International Conference on Physician Health™</u></a>. This collaborative conference of the AMA, the Canadian Medical Association and the British Medical Association will showcase research and perspectives into physicians’ health and offer practical, evidence-based skills and strategies to promote a healthier medical culture for physicians.</p> <p> The conference also will include a panel highlighting innovative changes in American, British and Canadian medical school curricula and their potential to positively impact physician health in the future. Liselotte Dyrbye, MD, and William Tierney, MD, both representatives of the AMA’s <a href="" target="_self">Accelerating Change in Medical Education Consortium</a>, will be panelists. Richard E. Hawkins, MD, vice president of medical education programs at the AMA, will moderate. <a href="" target="_blank"><u>Learn more and register</u></a>.</p> <p> <strong>For more on how practices and organizations are preventing physician burnout:</strong></p> <ul> <li> <a href="" target="_self">Physicians take to “reset room” to prevent burnout</a></li> <li> <a href="" target="_self"><u>How the Mayo Clinic is battling burnout</u></a></li> <li> <a href="" target="_self"><u>4 physician-recommended steps to work- and home-life balance</u></a></li> </ul> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow">Troy Parks</a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:d986e710-aefd-4516-9e97-15295b8f9eb1 New model makes patient care more than face-to-face visits Fri, 29 Jul 2016 18:21:00 GMT <p> Two things that physicians want for their patients are more stability and fewer visits to the emergency department. But often the services that are needed to do so are unbillable, and the resources are hard to find otherwise. A new care model for oncologists intends to solve this problem by providing the resources needed to closely manage patients’ care in-between their face-to-face treatments to reduce complications.</p> <p> The American Society of Clinical Oncology (ASCO) developed the patient-centered oncology payment model, an alternative payment model (APM) that focuses on two things: making sure the patient is taken care of in a way that prevents complications, which helps them progress toward improved overall health, and ensuring physicians have the necessary resources to provide that quality care.</p> <p> “The current system is flawed in many ways because it doesn’t pay for the services and the support that patients need and want,” said Robin Zon, MD, an oncologist and member of the ASCO’s Oncology Payment Reform and Implementation Workgroups. “But physicians are paying for it in a number of other ways in order to be able to deliver those services to the patient.”</p> <p> “What’s happened over time,” she said, “is that practices aren’t able to accommodate those expenses to be able to optimally care of the patient. There are services that the patient is receiving and needs, but they’re non-reimbursable services.”</p> <p> <strong>How the model works</strong></p> <p> “We developed a system that does three major things,” Dr. Zon said. The model shifts the focus away from typical fee-for-service, holds physicians accountable for high-quality care and makes physicians accountable for only those services they are able to control.</p> <p> So how does the payment model work, and what kind of difference will it make? Dr. Zon gave an example of a patient we will call John:</p> <ul> <li> <strong>Before the new model</strong><br /> Three years ago, before the patient-centered oncology payment model, John would go into a small practice for his chemotherapy. Then he would head home afterwards with instructions to call the office with any concerns or questions. The next day he didn’t feel very good. But he didn’t want to bother the doctor, thinking it was a normal reaction to the chemotherapy or the underlying cancer, so he didn’t call the office. Since this is a small office, there is no extra staff to conduct outbound triage to check on John. Two days later he had severe diarrhea and nausea and ended up so dehydrated that he had to go to the emergency department.</li> </ul> <ul> <li> <strong>After the new model</strong><br /> Now, John goes into a practice that has implemented the patient-centered oncology model. The next day, an outbound triage nurse calls him at home and asks how he is doing. John says he’s not feeling too great. The nurse says, “Let me talk to the doctor and get back to you.” The nurse calls John again with recommendations from the doctor based on how he is feeling and reeducates him on how to use his supportive care medications.<br /> <br /> The nurse calls again the next day to see if John is feeling any better. John says he’s feeling a little better but not perfect. The nurse responds, “Let me talk to the doctor again.” The next phone call to John includes some adjustments in hydration and diet, as well as recommendations on how to use the supportive medications. In the end, they’re able to help John get through those initial three days, and he never ends up at the hospital.</li> </ul> <p> “The exciting thing about this model is that the focus really is on the patient, which is why I like the name of the model so much,” she said. “It’s patient-centered, meaning the [payment] supports the resources needed to provide the care the patient needs and wants. This is opposed to the current system of [paying] only for face-to-face visits, which does not care for the patient between these encounters.”</p> <p> <strong>Three payment options in the model</strong></p> <p> “Our philosophy, from the ASCO perspective,” she said, “is that really what we should be designing is a [payment] system that supports the services that patients need and deserve and want,” not just those that are provided when the patient comes into the practice for a visit or chemotherapy.</p> <p> ASCO designed a system that has three payment options for oncologists:</p> <p style="margin-left:40px;"> <strong>1.   </strong><strong>Care management payments.</strong> This approach takes the existing E/M codes and adds care management codes during an episode of care. An episode of care is defined as a period of time that a patient receives chemotherapy, approximately six months.<br /> <br /> Calculating the total cost for time and resources was the next step. Currently, when physicians see a new patient they are paid X by an E/M code. The amount of time and resources spent in the new patient evaluation and treatment planning is really X plus Y, which is the care management component. But physicians are only paid for X.<br /> <br /> The care management payment would also persist during active treatment and would “help pay for things like outbound triage nurses that check on patients,” Dr. Zon said. “After the active payment period, there would be a short period of continued care management because there is management of the after effects of treatment that do require resources from the office, and [they don’t] require a face to face visit.”<br /> <br /> “Right now, we only get paid for face to face encounters,” she said, “but we do so much more for patients that is beyond face to face and not billable.”</p> <p style="margin-left:40px;"> <strong>2.   </strong><strong>Monthly payments.</strong> In this option, there are monthly fees for treatment design and then for active treatment and follow up. The intention is to better support the array of services that are needed when a patient is first diagnosed with cancer and to allow more flexibility in how care is delivered to the patient. The monthly fee would replace the E/M codes with monthly payment codes.<br /> <br /> This option would significantly reduce the number of codes required for billing. The doctor is then responsible for allocating the resources in a manner that supports the services required for the patient’s care.</p> <p style="margin-left:40px;"> <strong>3.   </strong><strong>Bundled payment.</strong> A bundled payment is paid to the physician. It includes not only the oncology practice costs but also other costs such as tests, hospitalizations and possibly drugs.<br /> <br /> It is yet to be decided if the bundled payment will be paid ahead of time or after delivery of services.</p> <p> “It’s important to stress in all three of the options there is a transitioning away from fee-for-service to what we are calling value-based patient-centered care which includes accountability,” Dr. Zon said. “In fact, the model includes providers being measured with regards to delivery of quality care, but only for the services that oncologists can control.”</p> <p> The big difference between this APM and the Center for Medicare and Medicaid Innovation’s Oncology Care Model is that physicians are only held accountable for the areas they can control, she said. For example, “if the patient has a cardiac event under our APM … that would not be included in our requirements to attest to delivering quality care because we can’t control what the cardiologist thinks is necessary for that patient.”</p> <p> “Other demonstration projects have actually have shown … that just by providing the money for care management as well as non-face-to-face, non-reimbursable services,” she said, “that you’re able to reduce … some of the biggest cost [drivers] in health care, which is acute hospitalizations.”</p> <p> ASCO is currently testing the model in several pilot programs and plans to present this model to the Physician-Focused Payment Model Technical Advisory Committee (PTAC)—a committee of experts who will advise CMS on APMs for the new Medicare payment system.</p> <p> Watch for a podcast interview from <a href="" rel="nofollow" target="_blank"><u>ReachMD</u></a> in the coming weeks with Dr. Zon.</p> <p> Listen to a <a href="" rel="nofollow">podcast interview</a> with Lawrence Kosinski, MD, who discusses his APM, SonarMD. Also, learn about <a href="" target="_self">Dr. Kosinski’s APM</a> at <em>AMA Wire®.</em></p> <p> <strong>Learn more about APMs:</strong></p> <ul> <li> <a href="" target="_self"><u>How doctors are developing new payment models for their specialties</u></a></li> <li> <a href="" target="_self"><u>Better health, costs: One practice’s value-based care outcomes</u></a></li> <li> <a href="" target="_self"><u>Testing new payment models: One pilot program’s success</u></a></li> <li> <a href="" target="_self"><u>From volume to value: How one health system is making the change</u></a></li> <li> <a href="" target="_self"><u>Payment model design needs to be physician-led, new report</u></a></li> </ul> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow"><em><u>Troy Parks</u></em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:2888b9b6-a34c-4e42-92f2-5ba57db1318c Join a CDC, AMA webinar on Zika virus Thu, 28 Jul 2016 21:22:00 GMT <p> The Centers for Disease Control and Prevention (CDC) and the AMA will host a webinar to update clinicians on the current state of the Zika virus outbreak and the latest clinical guidance.</p> <p> The webinar will feature two experts from the CDC who will offer valuable information to help health care professionals <a href="" rel="nofollow">diagnose and manage</a> patients with possible Zika virus infection and explain the latest <a href="" rel="nofollow" target="_blank">clinical guidance</a> on preventing transmission:</p> <ul> <li> Susan Hills, MBBS, CDC medical epidemiologist, will present an update on the epidemiological and clinical aspects of the current outbreak.</li> <li> Kiran Perkins, MD, CDC medical officer, will discuss the implications for pregnant women, including the CDC’s updated interim clinical guidance.</li> </ul> <p> The presentations will be followed by a question and answer session with webinar participants.</p> <p> The webinar will take place during the Department of Health and Human Services’ health provider “Week of Action” on Zika virus. <a href="" rel="nofollow" target="_blank">Register</a> to participate in the webinar on Wednesday, Aug. 10, from 7 to 8 p.m. Eastern time.</p> <p> The AMA continues to update its <a href="" target="_self">Zika Resource Center</a> to provide the latest on the outbreak to the public, physicians and other health care professionals.</p> <p> <strong>Learn more about Zika virus and what you can do:</strong></p> <ul> <li> <a href="" target="_self">AMA delegates call on lawmakers to act immediately on Zika funding</a></li> </ul> <ul> <li> <a href="" target="_self">What you can do now to help address a U.S. Zika outbreak</a></li> </ul> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:c1654b0b-478e-40a0-b329-0f706f08afcc Rethinking how physicians learn to prevent, manage chronic disease Wed, 27 Jul 2016 20:55:00 GMT <p> As the number of patients with chronic conditions continues to climb, so do the rates of burnout among physicians. Fundamental changes to how physicians approach chronic care are taking shape in medical schools across the country—and these changes may improve the health and well-being of both patients and physicians.</p> <p> <strong>The growing burden of chronic disease</strong><a href="" style="font-size:12px;" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> Physician educators from nearly two dozen medical schools recently came together for an AMA <a href="" target="_self">Accelerating Change in Medical Education Consortium</a> meeting to hear from population health experts and learn about each other’s efforts to enhance chronic disease curricula so students are equipped to thrive in their profession and help their patients lead healthier lives.</p> <p> “Almost half of all Americans have at least one chronic disease, and 13 percent have more than three,” said Omar Hasan, MD, vice president of <a href="" target="_self">Improving Health Outcomes</a> at the AMA.</p> <p> Dr. Hasan pointed to data showing that the number of people between 25 and 44 years of age who had more than one chronic condition more than doubled between 1996 and 2005. Those numbers are only expected to further increase, with 157 million Americans predicted to have more than one chronic disease by 2020.</p> <p> The most common chronic conditions are diabetes, mental and behavioral disorders, heart disease and cancer. Many of the risk factors for developing these conditions reflect the modern lifestyle—dietary risks, smoking, high body mass index, physical inactivity, alcohol use, high blood pressure and high fasting plasma glucose.</p> <p> Whether patients already have a chronic condition or are at risk of developing one, patient care today should look vastly different from several decades ago when most care was focused on acute medical needs. But most physicians still go through training under a model concentrated on the care of acute conditions.</p> <p> Having a chronic disease—especially if a patient has more than one condition—also “adds considerable complexity to the office experience,” Dr. Hasan said. “The more medications patients come in with, the more time it takes to reconcile …. That adds a lot of complexity to health care delivery.”</p> <p> And that complexity is only compounded by operating in a care delivery model or office space that is based on providing care for acute conditions.</p> <p> <strong>Preparing medical trainees for the new paradigm</strong></p> <p> “What are the skills our folks would need in the real world?” said Pamela Allweiss, MD, medical officer for the Division of Diabetes Translation at the Centers for Disease Control and Prevention. “We have to interact with patients in a different way.”</p> <p> Dr. Allweiss spoke about her experience working with academic medical centers to make hands-on clinical changes in the resident curriculum around diabetes care management. The care took on a form different from traditional residency training, putting an emphasis on team-based care, incorporating group visits into care plans and building patients’ involvement in their own care.</p> <p> The results showed that patients with diabetes received more care to keep them healthy, leading to better health outcomes. For instance, the program led to a 300 percent increase in the number of patients who received two Hemoglobin A1c tests each year. Residents, meanwhile, mastered important competencies, such as interacting with patients in a more engaging way and collaborating with an interprofessional care team that can provide more comprehensive care without overly burdening the physician.</p> <p> Trainees also need to get first-hand experience with the realities of outpatient care for patients with chronic diseases. Whereas traditional training often instills a sense of professional accomplishment in seeing a patient through an acute episode of care, day-to-day care for patients with chronic diseases means ongoing management of conditions from which patients may never recover and overlapping issues that could land a patient in the hospital.</p> <p> Christine Sinsky, MD, AMA vice president of <a href="" target="_self">professional satisfaction</a>, noted that there are five main challenges for chronic care:</p> <ul> <li> Chaotic office visits with overfull agendas</li> <li> Inadequate support for patient care</li> <li> Poorly functioning health care teams</li> <li> Vast amounts of time spent on documentation and administrative requirements, which leaves many physicians feeling as though they spend more time on these activities than delivering patient care</li> <li> Electronic health record work that often has become the physician’s responsibility when it previously could have been handled by other members of the health care team</li> </ul> <p> “Care of the patient requires care of the providers,” Dr. Sinsky said. “The only way we can get to the Triple Aim … is to consider the fourth aim of professional well-being.”</p> <p> And that depends on operational efficiencies designed around today’s health care needs, she said. For physicians in ambulatory care, that means customizing the care delivery model with chronic care in mind—from the configuration of the team to set-up of the office space.</p> <p> Dr. Sinsky said it’s also important to train students and residents in these sorts of environments. “How can medical schools expose medical students to the most functional forms of practice? Right now, we expose our students to some of the least functional modes of care delivery. And then we wonder why they aren’t choosing the specialties we need.”</p> <p> Marshall H. Chin, MD, the Richard Parrillo Family Professor of Healthcare Ethics, who specializes in health disparities at the University of Chicago Pritzker School of Medicine, said it’s important for students to really understand the problems in patient care if they are to thrive in the new health care paradigm.</p> <p> “For most of us in medical school,” Dr. Chin said, “we teach students very little of how often we fall short of the mark.” He also noted the danger of students feeling disempowered, which is why the University of Chicago also embeds “an advocacy component into addressing chronic disease and health disparities.”</p> <p> Exposing medical trainees to the shortcomings of the current system and activities that can help improve how care is delivered can cultivate an openness to change that can better serve both patients and physicians.</p> <p align="right"> <em>By AMA Wire editor</em> <a href="" target="_blank" rel="nofollow"><em>Amy Farouk</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:ca4bd416-fbfb-4516-8cc6-dd210b5008bc Supercharge career skills at the AMA Research Symposium Wed, 27 Jul 2016 20:50:00 GMT <p> Each fall physicians in training have a chance to spotlight their research projects before leaders of the medical community. Find out how the AMA Research Symposium can boost your visibility, build your CV and expand your network. Last year’s symposium winners also offer tips for competitors.</p> <p> Symposium participants compete for cash prizes and benefit from the chance to present their findings before experts in their fields. The symposium takes place Nov. 11-12 during the 2016 AMA Interim Meeting at Walt Disney World Swan and Dolphin Resort in Orlando.</p> <p> <strong>Build credibility, polish your CV</strong></p> <p> Discussing your research before a reputable panel of judges can set you on the fast track to credibility and advance your career. Michael Lause won the student biochemistry category last year with a presentation on esophageal carcinoma.</p> <p> “Participating in the AMA Research Symposium was definitely a boost to my CV,” said Lause, now a third-year student at the Ohio State University School of Medicine. “It provided me an opportunity to put an exclamation point on a successful summer research project. I put this award on my resume, and I do feel it will serve as a positive factor in any job or endeavor in the future.”</p> <p> <strong>Build your professional skills</strong></p> <p> “The feedback and questions I received at the AMA Research Symposium helped me shape my presentations,” Tanya Khasnavis said. “I also refined some of my research graphs to be more easily presentable.”</p> <p> Khasnavis, a third-year student at the Medical College of Georgia and last year’s winner in the neurobiology category for work on Lesch-Nyhan disease, said she has published two papers based on her research topic.</p> <p> Simply applying and being accepted to the symposium provided a learning experience, Lause said.</p> <p> “More than this, though, are the intangible skills,” he said, “like designing an efficient yet aesthetically appealing poster and captivating an audience through compelling public speaking. All of this shines through on a CV when you have presented at a national research conference.”</p> <p> Eric Melancon, MD, winner in the improving health outcomes category in the residents division for his research on COPD test results, said the symposium even improved his clinical care skills.</p> <p> “I took my information and data to how I approach patient care, and improved on overall quality of care,” said Dr. Melancon, who recently completed his training at the University of Alabama at Birmingham family medicine program.</p> <p> <strong>Invaluable networking</strong></p> <p> Last year, nearly 400 of the country’s brightest medical students, residents, fellows and international medical graduates (IMG) presented and discussed their research among hundreds of AMA Interim Meeting attendees. Presenters also met symposium judges from medical schools, residency programs and hospitals.</p> <p> “The symposium was a wonderful way to meet my peers and share our research experiences,” Khasnavis said. “It has served as an invaluable element of my medical school experience.”</p> <p> For Lause, the symposium allowed him to drill deeper into the workings of the medical world: “It exposed me to the mission and mechanics of the AMA, and now I am an alternate delegate for my region. It got me involved in the politics of medicine, and that is a major benefit from the symposium.”</p> <p> <strong>Hints and tips for competitors</strong></p> <p> Last year’s winners offered advice for their peers considering the 2016 symposium. Abhishek Maiti, MD, the resident group’s overall podium winner for research on renal cell carcinoma, underlined the value of a presentation that is concise and at the same time engaging.</p> <p> “I think a good presentation needs to convey the complex nature of your research but be simple enough for the audience to quickly understand,” he said.</p> <p> Lause said confidence can play a major role in any project: “The best advice I can give is to present your research as the most important thing in the world of science,” he said. “Your energy and passion will be contagious, and your presentation elevated. The award winners are often the people who convince the judges that their results are going to drastically change the landscape within that field of medicine.”</p> <p> Other winners echoed the idea that projects should offer new insights into the practical realities of clinical care.</p> <p> “I would suggest any new presenters choose a subject that every physician can relate to, and one that will not only enhance your medical knowledge but improve patient care,” Dr. Melancon said. “In the end, that is why we are here.” </p> <p> Students, residents and IMGs all report a symposium experience that not only builds skills, networks and careers, but ignites a new kind of excitement about their profession.</p> <p> “I absolutely loved it and would encourage all medical students and residents to participate,” Dr. Maiti said. “Thanks to the AMA for creating such an opportunity.”</p> <p> <strong>Submit your research for the symposium</strong></p> <p> Members of the AMA are eligible to take part in the symposium. Research submissions this year are being accepted in these groups:</p> <ul> <li> <strong>For students: </strong>Submit your abstract for one of eight categories—biochemistry/cell biology, cardiovascular disease/diabetes, clinical outcomes and health care improvement, immunology/infectious disease/inflammation, neurobiology/neuroscience, public health and epidemiology, radiology/imaging, or surgery/biomedical engineering.<br />  </li> <li> <strong>For residents and fellows: </strong>Submit your abstract for one of three categories—clinical vignette, clinical medicine (this includes quality improvement, health policy, clinical research and medical education) or improving health outcomes (cardiovascular disease and diabetes).<br />  </li> <li> <strong>For IMGs: </strong>If you are certified by the Educational Commission for Foreign Medical Graduates and awaiting residency, you can submit your abstract for one of three categories—clinical medicine, clinical vignette or improving health outcomes (cardiovascular disease and diabetes).</li> </ul> <p> Each eligible participant may submit only one abstract and must submit his or her research using the symposium’s online submission form.</p> <p> Abstracts are due Aug. 17. See the <a href="" target="_self">symposium web page</a> for key registration details, submission guidelines and more. The annual AMA Research Symposium is organized by the AMA <a href="" target="_self">Medical Student Section</a>, the AMA <a href="" target="_self">Resident and Fellow Section</a> and the <a href="" target="_self">AMA-IMG Section</a>.</p> <p> <strong>Planning to present or publish your own research? Don’t miss these must-have resources:</strong></p> <ul> <li> Learn how to publish your research like a pro with <a href="" target="_self">these five strategies</a>.</li> <li> Bookmark <a href="" target="_self">this list</a> of the top journals that accept research from physicians in training.</li> <li> Read <a href="" target="_self">how to get your research published</a>.</li> <li> Follow <a href="" target="_self">these 9 expert tips</a> for getting published in a medical journal.</li> <li> Remember that publishing (like research) is a learning process, so if your paper gets rejected—don’t worry. Here’s <a href="" target="_self">how to handle it.</a></li> </ul> <p align="right"> <em>By contributing writer Michael Winters</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:ca0d9bd3-b01e-4ada-b43e-a1354f7dc30b Network with academic colleagues Nov. 11 in Seattle Wed, 27 Jul 2016 14:00:00 GMT <p> Academic physicians can <a href="" target="_self">register now </a>to attend the 2016 AMA Academic Physicians Section (APS) Interim Meeting, Nov. 11 at the Grand Hyatt in Seattle. This event will be held prior to the annual meeting of the Association of American Medical Colleges, taking place Nov. 11-15.</p> <p> The meeting begins at 1 p.m. (with an optional new member orientation/update at 10 a.m.). Meeting registration is free of charge.</p> <p> Plan to attend this important event so that you can:</p> <ul> <li> Hear an update on the progress of the AMA's <a href="" target="_self">Accelerating Change in Medical Education</a> Consortium</li> <li> Play a role in developing AMA medical education policy by reviewing, debating and voting on reports and resolutions to go before the AMA House of Delegates</li> <li> Participate in an education session on health systems science, the third pillar of medical education that has emerged from the work of the AMA’s Accelerating Change in Medical Education Consortium.</li> <li> Enjoy a networking reception with your academic physician colleagues nationwide, along with representatives of the 32 member medical schools of the AMA’s Accelerating Change in Medical Education Consortium</li> <li> Hear an update on the <a href="" target="_self">Academic Leadership Program</a>, which offers 20 percent or higher discounts on AMA dues for medical school deans and faculty</li> </ul> <p> More details to come soon. Be sure to check the <a href="" target="_self">AMA-APS web page </a>to stay apprised of updates. Also, read a <a href="" target="_self">summary</a> of the June 2016 AMA-APS meeting.</p> <p> The AMA welcomes your feedback: Please <a href="" rel="nofollow" target="_self">email the section</a> or call (312) 464-4635.</p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:3f660db6-a92c-4b5d-95e7-77f181b144d8 From hospital to home: A model for safer transitions Tue, 26 Jul 2016 21:00:00 GMT <p> Patients with multiple chronic conditions, polypharmacy and unmet social needs are often at risk for serious drug therapy problems during the transition from hospital to home. A new model has made these transitions safer and decreased hospital admissions and emergency department visits for patients.</p> <p> Developed by the University of Tennessee in partnership with Methodist Le Bonheur Healthcare in Memphis, the SafeMed model uses a primary care-based team, which includes physicians, pharmacists, nurses and community health workers, to form a support network for high-risk and high-needs patients as they transition from the hospital to the outpatient setting.</p> <p> A new <a href="" target="_self" rel="nofollow">module</a> from the AMA’s STEPS Forward™ collection of practice improvement initiatives can help practice teams implement the SafeMed model, which enables them to work closely with patients to build strong relationships that make it easier to coordinate and manage their care.</p> <p> <strong>How they did it in Memphis</strong></p> <p> The University of Tennessee Health Sciences Center, which contributed this STEPS Forward module after <a href="" target="_self">winning</a> the AMA-MGMA Practice Innovation Challenge, saw 30 percent fewer hospitalizations, 44 percent fewer 30-day readmissions and 52 percent fewer ED visits for patients with multiple chronic conditions and frequent ED visits in just six months.</p> <p> The SafeMed program starts with a report every morning that tells the clinic which of its assigned patients have been hospitalized in the last 24-72 hours. The nurse leader uses the report to determine which patients might benefit from SafeMed care transitions support so that home visits by a community health worker can be scheduled.</p> <p> Community health workers meet with the SafeMed team physician, pharmacist and nurse leader to address specific medication problems or care management issues identified during home visits. They also meet with the SafeMed team leaders on a weekly or monthly basis to conduct case reviews and refine care plans.</p> <p> Participating patients are invited to regular clinic-based SafeMed peer group support and education sessions, where they suggest topics for discussion and ask questions to help them better navigate the health system. Each patient is asked to remain in the program for at least three months to receive the full benefit of the approach.</p> <p> <strong>Getting started in your practice</strong></p> <p> The SafeMed approach used in Memphis can be adapted by individual practices to reduce drug therapy problems, patient morbidity and mortality resulting from preventable drug therapy problems, and avoidable hospital readmissions. It can also lower costs and improve medication adherence, disease management and overall patient health.</p> <p> The Health Sciences Center followed four steps to implement the SafeMed program:</p> <p style="margin-left:40px;"> <strong>1.   </strong><strong>Develop a care transitions plan.</strong> Regular team meetings are important in the planning process. Think about how to scale the model to fit your practice’s needs and take care of patients.</p> <p style="margin-left:40px;"> <strong>2.   </strong><strong>Identify complex patients who are good candidates for the program.</strong> Pinpoint the most vulnerable patient populations that will receive the greatest benefit from intervention by the SafeMed team.</p> <p style="margin-left:40px;"> <strong>3.   </strong><strong>Assemble and train the SafeMed team.</strong> First, select a leader to designate team leads and hire any additional staff you need to make the plan work. A typical team consists of three team leaders—a physician, a nurse, a pharmacist. The full team may include two community health workers, one pharmacy technician and one licensed practical nurse, medical assistant or health coach.<br /> <br /> Team members should be knowledgeable about practice work flows and chronic disease symptoms, signs, medications and treatment. All team members should receive training in motivational interviewing, patient advocacy, transitions of care and mental health issues.</p> <p style="margin-left:40px;"> <strong>4.   </strong><strong>Start the transition process and refine the plan over time.</strong> Use your electronic health record (EHR) to identify patients who meet your practice’s criteria so they can be flagged for the transitions team immediately in the event of an ED visit or hospital admission. The daily report will help you identify eligible patients. Track performance to better understand the impact and make improvements to the process.</p> <p> <strong>More practice resources</strong></p> <p> The module on <a href="" rel="nofollow">using the SafeMed model for transitions of care approach </a>is one of eight new modules recently added to the AMA’s <a href="" target="_self" rel="nofollow">STEPS Forward</a> collection of practice improvement strategies to help physicians make transformative changes to their practices. Thirty-five modules now are available, and several more will be added later this year, thanks to a grant from and collaboration with the <a href="" target="_blank" rel="nofollow">Transforming Clinical Practices Initiative</a>.</p> <p> <em>AMA Wire</em> explores many of the other <a href="" target="_self">modules</a>, including why your practice needs a health coach and four questions to ask to find out if your patients have unmet needs.</p> <p align="right"> <em>By AMA staff writer</em> <a href="" target="_blank" rel="nofollow"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:9dcda6bc-d5d0-436c-85e1-b19303d86796 Physicians, patients take active approach to diabetes fight-online Tue, 26 Jul 2016 14:45:00 GMT <p> A new project underway is creating a roadmap for large health care organizations to partner with their patients to fight off type 2 diabetes when they are most at risk of developing the disease. The program spurs patients to make the necessary behavioral changes and gives care teams the data they need to keep their patients healthy.</p> <p> The project is a collaboration of the AMA, <a href="" rel="nofollow" target="_blank">Omada Health</a>, a digital behavioral medicine company, and <a href="" rel="nofollow" target="_blank">Intermountain Healthcare</a> in Utah, an industry leader in the adoption of innovative prevention care strategies to reduce costs while providing high-quality care.</p> <p> The group Tuesday announced a new effort aimed at reducing the alarming number of adults who develop type 2 diabetes. The project will allow Intermountain physicians and care teams to track their patients’ progress through an evidence-based online diabetes prevention program offered by Omada.</p> <p> “This collaboration expands upon the <a href="" rel="nofollow" target="_blank">AMA’s robust efforts</a> to prevent type 2 diabetes in this country through the scalable adoption of proven innovative tools and resources that can help physicians better manage patients with chronic conditions,” said AMA President Andrew W. Gurman, MD, in a press release. “Together we hope to showcase a continuum of care model that bridges technology and clinical care in a way that hasn’t been done before.”</p> <p> <strong>Improving patient care</strong></p> <p> Access to real-time actionable data from Omada allows care teams to create specific, proactive touch points with patients to support their completion of the program.</p> <p> Participating in evidence-based diabetes prevention programs can reduce the risk of developing type 2 diabetes by nearly 60 percent, research has shown. Up to 90 percent of people with prediabetes are unaware that they have the condition. It’s estimated that one in 20 adults—more than 114,000 people—are living with prediabetes within Intermountain’s service area.</p> <p> “Intermountain’s integration of the Omada program, and [the] AMA’s focus on ensuring digital tools work to empower providers will give patients with prediabetes another proven option to meet their care needs,” said Omada Health CEO Sean Duffy. “It will also give physicians and their care teams additional treatment options and actionable data to better understand how to deliver lasting lifestyle change for those in need of it.”</p> <p> Last year, Omada became the first digital health company to publish <a href="" rel="nofollow" target="_blank">peer-reviewed results demonstrating</a> that program participants maintained reductions in body weight and average blood sugar levels—critical indicators of diabetes progression—two years after beginning the program.</p> <p> <strong>Learn more about preventing type 2 diabetes:</strong></p> <ul> <li> Take an inside look at <a href="" target="_self">one physician’s success story as a prediabetic patient</a></li> <li> Learn <a href="" target="_self">how to diagnose prediabetes</a></li> <li> Find out <a href="" target="_self">how a practice in Minnesota is preventing diabetes</a></li> <li> Learn <a href="" target="_self">three steps you can take to address prediabetes in your practice</a></li> <li> Check out the AMA-CDC initiative <a href="" target="_self">Prevent Diabetes STAT: Screen, Test, Act—Today™</a></li> </ul> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:bf349e9e-5f1a-4168-a165-1598bf4756dd 3 ways to battle the “July effect” in teaching hospitals Mon, 25 Jul 2016 21:24:00 GMT <p> Each summer new residents and faculty figure out the layout of large facilities and meet a host of new teammates and patients. They also struggle with efficiency, quality and patient safety during the dawn of the academic year.<a href="" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> But there are ways to combat the legendary “July effect” that involve a more collaborative mindset among internal medicine trainees, attending physicians and faculty. A new report calls for novel strategies, some borrowed from aviation and other industries with a keen concern for safety, and all designed to boost teamwork, communications and effectiveness among the key players in the clinical setting.</p> <p> <strong>Promise and problems</strong></p> <p> “While teaching hospitals have long relied on the triad of attending physician, senior resident and intern to provide team-based care, new teams providing care in July are paradoxically part of the problem,” said the authors of a <a href="" rel="nofollow" target="_blank">commentary published in <em>Academic Medicine</em></a>.</p> <p> The authors said that studies show costs, hospital stays and patient mortality peak in July. They outlined three policies to roll back the July effect:</p> <p style="margin-left:40px;"> <strong>1.   </strong><strong>Improving leadership</strong>. A select group of “July-able” attendings, known for their dynamic style, teaching prowess and ability to foster camaraderie, take the lead in teaching trainees. They encourage autonomous decision making, with early and direct feedback as a tool for improvement. Teaching hospitals identify and develop these master educators and put them in place well before July.</p> <p style="margin-left:40px;"> <strong>2.   </strong><strong>Pairing good leaders with good followers</strong>. Senior residents are groomed and selected on the basis of their ability to mentor new interns. Grooming includes interdisciplinary rounds, which cultivate resident education and improve relationships with nurses. “Taking full advantage of nurses’ experience is of paramount importance,” the authors said.</p> <p style="margin-left:40px;"> <strong>3.   </strong><strong>Cultivating bidirectional communication</strong>. A free-flowing, bidirectional communications system is nurtured, encouraging a willingness to report unexpected events to attendings. Health care institutions can borrow from other “institutions that seek to avoid catastrophe,” such as aviation, nuclear power and firefighting. Airlines, with their interdisciplinary conferences, checklists for daily activities, directed feedback and debriefing methods that focus on actionable improvement ideas, are worth studying as a model.</p> <p> <strong>Don’t miss the fireworks</strong></p> <p> The authors called for further study of the July effect, especially determining whether reproducible and transferable practices are already in use and worth adopting in more hospitals.</p> <p> The authors said the reforms they propose could transform the troubled academic year transition into a positive mentoring and growth experience for interns, faculty and senior residents.</p> <p> “Most important, such reforms will allow teaching hospitals to provide consistent care to our patients 365 days per year,” the authors concluded. “As we do so, getting sick in July may become problematic for one reason only—missing the fireworks.”</p> <p> <strong>Additional information to help in the transition to residency:</strong></p> <ul> <li> <a href="" target="_self">10 concepts that will help you thrive as an intern</a></li> <li> <a href="" target="_self">7 things you need to know to succeed as a medical intern</a></li> <li> <a href="" target="_self"></a></li> <li> <a href="" target="_self">The physician’s essential art of balancing emotion and logic</a></li> <li> <a href="" target="_self">Resident burnout: Unearthing the bigger picture</a></li> <li> <a href="" target="_self">Making residency more family friendly</a></li> </ul> <p align="right"> <em>By contributing writer Michael Winters</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:8fe47abd-6510-43a0-8ba7-d811a91d2286 USMLE Step 2: This month’s question to beat Mon, 25 Jul 2016 20:13:00 GMT <p> Getting ready for the United States Medical Licensing Examination® (USMLE®) Step 2 is no easy feat, but we’re sharing expert insights to help give you a leg up. Take a look at the exclusive scoop on this month’s most-missed USMLE Step 2 test prep question. Think you have what it takes to rise above your peers? Test your USMLE knowledge, and view an expert video explanation of the answer from Kaplan Medical.</p> <p> Once you’ve got this question under your belt, be sure to test your knowledge with <a href="" target="_self">other posts in this series</a>.</p> <p> Ready. Set. Go.</p> <p> <strong>This month’s question that stumped most students:</strong></p> <p> A 14-year-old girl comes to the physician because of heavy menstrual bleeding that began with menarche two years ago. Her menstrual periods last eight to 10 days and occur approximately every 28 days. Her last menstrual period ended three days ago. Vital signs are temperature 37.0ºC (98.6ºF), blood pressure 110/70 mm Hg, pulse 90/min and respirations 18/min. Physical examination shows a slender, calm girl who is in no distress but appears pale. The remainder of the examination is unremarkable. Laboratory studies show:</p> <ul> <li> WBC:  7,000/mm<sup>3</sup></li> <li> Hb:  9 g/dL</li> <li> Hct:  27%</li> <li> Plt:  250,000/mm<sup>3</sup></li> </ul> <p> Which of the following is the most appropriate next step in management?</p> <p style="margin-left:40px;"> A. Begin a transfusion of packed red blood cells</p> <p style="margin-left:40px;"> B. Order a pelvic ultrasound to rule out polycystic ovaries</p> <p style="margin-left:40px;"> C. Order coagulation profile</p> <p style="margin-left:40px;"> D. Reassure that heavy bleeding is caused by anovulatory cycles</p> <p style="margin-left:40px;"> E. Start oral contraceptive therapy</p> <p>  </p> <p> <object data="" height="350" id="ltVideoYouTube" src="" type="application/x-shockwave-flash" width="450"><param name="movie" value="" /><param name="quality" value="best" /><param name="bgcolor" value="#ffffff" /><param name="wmode" value="transparent" /><param name="allowFullScreen" value="true" /><param name="allowScriptAccess" value="always" /><param name="flashvars" value="playerMode=embedded" /></object></p> <p>  </p> <p>  </p> <p>  </p> <p> <strong>The correct answer is C.</strong></p> <p> <strong>Kaplan says, here’s why: </strong><br /> Dysfunctional uterine bleeding (in this case, menorrhagia, or prolonged menstrual bleeding that occurs at regular intervals and lasts more than seven days) is often the presenting symptom of a blood dyscrasia. The most common inherited disorder of bleeding, von Willebrand disease, is generally transmitted as an autosomal-dominant trait and is more commonly diagnosed in women, because it might present with heavy bleeding at menarche as in the vignette.</p> <p> Lab findings associated with von Willebrand disease are normal PT and either normal or slightly prolonged aPTT. Platelet count is normal. Bleeding time is increased, however, because vWF is required for normal binding of platelets to blood vessels. Factor VIII and vWF are usually decreased. Ristocetin activity (vWF activity) is always abnormal. von Willebrand disease is often not diagnosed until severe bleeding after surgery or when noted on menarche. Patients who have von Willebrand disease often have family histories of abnormal bleeding.</p> <p> <strong>Why you shouldn’t choose the other answers:</strong><br /> <em>Read these explanations to understand the important rationale for each answer.</em></p> <p> <strong>Choice A:</strong> Transfusion of packed red blood cells is incorrect. The patient in the question is not unstable (mild tachycardia, stable blood pressure), and because she is not currently bleeding, she can be managed as an outpatient without the need of a transfusion.</p> <p> <strong>Choice B:</strong> Pelvic ultrasound to rule out polycystic ovaries is incorrect. Although polycystic ovary syndrome is a common cause of dysfunctional uterine bleeding, it is marked by irregular cycles and heavy bleeding (menometrorrhagia). The patient here is not typical of polycystic ovary syndrome in that she is not overweight.</p> <p> <strong>Choice D:</strong> Reassurance that heavy menstrual bleeding is likely secondary to anovulatory cycles is incorrect. Although dysfunctional uterine bleeding is often secondary to anovulatory cycles in the first few years after menarche, what distinguishes this patient’s bleeding is that she began with heavy, prolonged periods at menarche. The patient’s anemia also demands that further diagnostic studies be done.</p> <p> <strong>Choice E:</strong> Oral contraceptive therapy is incorrect. Once von Willebrand disease is diagnosed, the treatment of oral combined contraceptives and oral iron therapy can be started, but it would be incorrect to begin treatment without performing further diagnostic studies first.</p> <p> <strong>One tip to remember:</strong></p> <p> Von Willebrand disease is the most common inherited bleeding disorder and should be thought of when a young girl presents with heavy bleeding since the onset of menses. von Willebrand factor (vWF) is instrumental in linking platelets to endothelial cells and acts as a carrier for clotting factor VIII, which is found at low levels and has a short half-life if vWF is absent. Laboratory testing for vWF antigen, vWF activity and factor VIII activity is usually enough to make the diagnosis.</p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:d8e258ff-1eca-4124-8895-547ecdd92953 Banning expert testimony from liability cases: Court decides Fri, 22 Jul 2016 19:57:00 GMT <p> Can trial courts block physicians’ expert witnesses from testifying in medical liability cases? One Wisconsin court recently did, leaving it to the court of appeals to decide whether a physician defendant has the right to present expert testimony that differs from that of the plaintiffs.  </p> <p> At stake in <em>Bayer v. Dobbins</em> was whether trial court had properly excluded expert testimony regarding injuries to a newborn that had resulted in complications in the birthing process.<a href="" style="font-size:12px;" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> <strong>What happened in Wisconsin </strong></p> <p> Leah Bayer was delivering her child under the care of Brian D. Dobbins, MD, when the progress of the delivery slowed and she began to show signs of exhaustion. Dr. Dobbins made the decision to use a vacuum to advance the child down the birth canal.</p> <p> The child’s shoulder became stuck inside the canal, causing shoulder dystocia, a condition in which the fetal shoulder becomes lodged on the maternal pelvis. A shoulder dystocia is considered an emergency because it can lead to compression of the umbilical cord, which can compromise blood flow and oxygen supply to the child.</p> <p> After using two “traction” maneuvers, Dr. Dobbins was able to successfully deliver the child. But the child had reduced movement of her right arm and was ultimately diagnosed with a permanent right brachial plexus injury—which severely limited her ability to use her right arm and hand.</p> <p> The Bayers sued Dr. Dobbins, claiming that he had used excessive traction during the delivery. Dr. Dobbins contended that he had appropriately used only gentle downward traction to deliver the child and that the injury was caused by maternal forces of labor, including the forces associated with contractions and pushing.</p> <p> In support of Dr. Dobbins’ medical care, the defense tendered as expert witnesses four well-known medical scientists whose testimony was supported by dozens of peer-reviewed medical studies. Many of the studies had been published by or were connected with the American College of Obstetricians and Gynecologists (ACOG). One of the studies Dr. Dobbins proffered as evidence concluded that the condition “has been shown to occur entirely unrelated to traction ….” The study was published by ACOG in 2014.</p> <p> Before the trial began, the Bayers filed a motion asking the circuit court to exclude all expert testimony relating to Dobbins’ theory that maternal forces of labor caused the injury, arguing that the experts’ opinions were unreliable because the Bayers’ biochemical engineering expert had disproved the maternal forces theory in 2007 using a simulator.</p> <p> The trial court ultimately ruled in favor of the Bayers and excluded the defendant’s expert witnesses. It also determined that the medical literature was “inappropriate” because it did not adequately differentiate between permanent and temporary brachial plexus injuries.</p> <p> <strong>On appeal, court reverses decision</strong></p> <p> A Wisconsin Court of Appeals granted Dr. Dobbins’ appeal of the order that prevented his expert witnesses from testifying.</p> <p> Citing the ACOG study, the <a href="" target="_self">Litigation Center of the AMA and State Medical Societies</a> and the Wisconsin Medical Society said in an amicus brief, “This resource, which Dr. Dobbins’ experts used to support their opinions, is an example of a systematic review of observational studies. … publications like this represent some of the best evidence available to physicians in medical decision making.”</p> <p> “This court has the opportunity with this case to provide significant guidance to Wisconsin’s trial courts,” the brief said. “The society can envision no more logical source of determining the reliability of such evidence than medicine’s own standards of reliability.”</p> <p> Last week, the Wisconsin Court of Appeals ruled that, because competing scientific theories were presented, it was for the jury to decide which of the theories best fit the facts of the case.</p> <p> “If experts are in disagreement,” the court said in the decision, “it is not for the court to decide ‘which of the several competing scientific theories has the best provenance.’”</p> <p> As a result of the decision, Dr. Dobbins’ expert witnesses and the medical literature supporting their testimony will be allowed in the case.</p> <p> <strong>Current medical liability cases in which the Litigation Center is involved:</strong></p> <ul> <li> Learn how a case <a href="" target="_self">could lead to unlimited awards of punitive damages</a>.</li> <li> Get the details on a <a href="" target="_self">case that could extend medical liability</a>.</li> <li> Find out how one <a href="" target="_self">case could increase liability exposure and redefine injury</a>.<br />  </li> </ul> <p style="text-align:right;"> <em style="font-size:12px;">By AMA staff writer</em><span style="font-size:12px;"> </span><a href="" rel="nofollow" style="font-size:12px;" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:13759ca5-7e56-41a1-8d97-070ca9d53216 Don’t be stumped: This month’s USMLE Step 1 question Fri, 22 Jul 2016 19:55:00 GMT <p> When it comes to taking exams, not all questions are created equal. If you’re preparing for the United States Medical Licensing Examination® (USMLE®) Step 1 exam, you need this exclusive scoop on one of the most commonly missed USMLE test prep questions. Find out what this month’s challenging question is, and view an expert video explanation of the answer from Kaplan Medical.</p> <p> Welcome to this month’s installment of the <em>AMA Wire</em>® series, Tutor talk: Tips from Kaplan Medical on the most missed USMLE test prep questions from Kaplan’s Qbank: Step 1. Each month, we’re revealing the top questions physicians in training miss on the USMLE, a helpful analysis of answers and videos featuring tips on how to advance your test-taking strategies. See <a href="" target="_self">all posts in this series</a>.</p> <p> Think you have what it takes to rise above your peers? Test your USMLE knowledge below.</p> <p> Ready. Set. Go.</p> <p> <strong>This month’s question that stumped most students:</strong></p> <p> A 39-year-old African-American man comes to the physician because of anorexia, malaise, dark urine and upper abdominal discomfort. His temperature is 37.9ºC (100.2ºF). Physical examination shows scleral icterus and moderate right upper quadrant tenderness. The liver is palpable below the right costal margin. Laboratory studies show:</p> <ul> <li> HBsAg:  positive</li> <li> HBsAb:  negative</li> <li> Anti-HBc IgM:  positive</li> <li> HBeAg:  positive</li> </ul> <p> Which of the following will most likely change in his serologic findings when this patient enters the window period?</p> <p style="margin-left:40px;"> <strong>A.</strong> He will become HBcAg-positive</p> <p style="margin-left:40px;"> <strong>B. </strong>He will become HBc IgG-positive</p> <p style="margin-left:40px;"> <strong>C.</strong> He will become HBeAg-negative</p> <p style="margin-left:40px;"> <strong>D.</strong> He will become HBsAb-positive</p> <p style="margin-left:40px;"> <strong>E.</strong> He will become HBsAg-negative</p> <p>  </p> <p> <object data="" height="350" id="ltVideoYouTube" src="" type="application/x-shockwave-flash" width="450"><param name="movie" value="" /><param name="quality" value="best" /><param name="bgcolor" value="#ffffff" /><param name="wmode" value="transparent" /><param name="allowFullScreen" value="true" /><param name="allowScriptAccess" value="always" /><param name="flashvars" value="playerMode=embedded" /></object></p> <p>  </p> <p>  </p> <p> <strong>The correct answer is E.</strong></p> <p> <strong>Kaplan says, here’s why: </strong><br /> This patient has acute hepatitis B. The “window period” refers to that period in infection when neither hepatitis B surface antigen (HBsAg) nor its antibody (HBsAb) can be detected in the serum of the patient. It is an immunologically mediated phenomenon caused by the precipitation of antigen-antibody complexes in their zone of equivalent concentrations and, thereby, their removal from the circulation.</p> <p> Because of this, the first thing that will happen in the window period is that the serum will become negative for the surface antigen (HBsAg) as that antigen is precipitated out of the serum by developing levels of its specific antibody (HBsAb). Serologic tests conducted during the window period will be positive for HBcAb and HBeAb.</p> <p> <a href="" target="_blank"><img src="" style="margin:15px;" /></a></p> <p> <strong>Why you shouldn’t choose the other answers:</strong><br /> <em>Read these explanations to understand the important rationale for each answer.</em></p> <p> <strong>Choice A:</strong> HBcAg is not typically measured in the serum during the symptomatic phases of hepatitis B infection. It would be found before the patient develops symptoms and would likely remain present as long as the patient has an active HBV infection, regardless of whether the patient is in the window period or not.</p> <p> <strong>Choices B and C:</strong> Levels of anti-HBc IgG and HBeAg do not have a relationship to the window period. The antibody against the main core of the virus (HBcAb) is used to diagnose history or presence of an infection since it is the first antibody made by the patient, and it will remain in the body well after resolution of a HBV infection or in patients with chronic HBV infections. The HBeAg (a second core antigen) is found in the blood when virions are also present in the bloodstream. It is therefore used as a measure of how infectious the patient would be.</p> <p> <strong>Choice D:</strong> Levels of HBsAb will not be detectable until there is antibody excess and the patient is leaving the window period.</p> <p> <strong>Key tips to remember:</strong></p> <ul> <li> During the “window period” of hepatitis B infection, neither hepatitis B surface antigen (HBsAg) nor its antibody (HBsAb) can be detected in the serum of the patient.</li> <li> This is due to precipitation of antigen-antibody complexes in their zones of equivalence and, thereby, their removal from the circulation.</li> <li> Serologic tests conducted during the window period will be positive for HBcAb and HBeAb.</li> </ul> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:cd2dfb49-bf6a-4ca4-b415-f063fc3a69f6 Submit your recent achievements to the AMA-YPS Fri, 22 Jul 2016 14:00:00 GMT <p> In preparation for the 2016 AMA Young Physicians Section (YPS) Activities Report, the section is requesting information on your recent achievements in organized medicine. </p> <p> <a href="" rel="nofollow">Email your accomplishments</a> to the section by Sept. 15. </p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:9fe7b8b6-7f28-4a07-b402-3c0dd80a43b6 DOJ, states side with patients and physicians-file to block insurance mergers Thu, 21 Jul 2016 22:23:00 GMT <p> <a href="" style="font-size:12px;" target="_blank"><img src="" style="margin:15px;height:150px;width:100px;float:left;" /></a><em>An AMA Viewpoints post by AMA President Andrew W. Gurman, MD</em></p> <p> Prospects for major health insurance consolidation took a major hit when the U.S. Department of Justice (DOJ) and a number of states filed antitrust lawsuits Thursday to block both the Aetna, Inc.-Humana, Inc. and Anthem, Inc.-Cigna Corp. mergers. The DOJ asserted that the mergers would substantially lessen competition.</p> <p> When something comes up that could negatively affect our patients and the quality and affordability of the care they receive, physicians take the lead and engage policymakers. With the same drive that put us through late nights in med school, carried us through the intensity of our residencies and continues to push us every day to go the extra mile for our patients and their families, we took these mergers on—and our voices were heard.</p> <p> Creating even larger goliaths would be unacceptable—and I said so in a public <a href="" target="_self">statement</a> today. Federal and state officials have a strong obligation to enforce antitrust laws to protect patients by ensuring a competitive marketplace that operates in patients’ best interests.</p> <p> The DOJ’s action is a significant step toward the kind of marketplace that doesn’t put the insurers first but rather puts patients first. And that’s what we as physicians care about most.</p> <p> <strong>Physicians fight to protect patients </strong></p> <p> Both mergers were announced in July of last year. My colleague, Immediate-past President Steven J. Stack, MD, responded swiftly with a statement detailing how the mergers would increase health insurance market concentration and reduce competition in both the market for the sale of health insurance and in the market in which health insurers purchase physician services, ultimately resulting in further patient injury due to a decrease in the quality and quantity of available physician services. Neither development is something we as physicians can allow.</p> <p> At the outset of the DOJ and state investigation of these mergers, the AMA was armed by our annual market studies on competition in health insurance and by an AMA study published in a leading academic journal establishing that a previous merger—United Health Group Inc.’s 2008 merger with Sierra health services—resulted in higher premiums.</p> <p> Over the course of the next year, we physicians took it upon ourselves to <a href="" target="_self">stand up against the mergers</a> of these powerful insurers by submitting testimony in congressional and state proceedings and preparing memoranda to state and federal officials investigating the mergers. In this effort, the AMA joined with state medical societies and gained the assistance of influential lawyers and economists to gather the evidence and present the arguments against the mergers to the DOJ, state attorneys general and state insurance departments.</p> <p> I <a href="" rel="nofollow" target="_blank">testified</a> at a congressional hearing examining the proposed mergers and the impact they would have on competition in September, urging them to closely scrutinize the mergers and utilize enforcement tools at their disposal to protect patients and preserve competition.</p> <p> Two weeks before, my colleague, Barbara L. McAneny, MD, who is a member of the AMA board of trustees, <a href="" rel="nofollow" target="_blank">testified before Congress</a> with a similar message. Together, we carried that message into the 2015 AMA Interim Meeting, where the AMA House of Delegates passed <a href="" target="_self">new policy</a> that emphasized the need for active opposition to consolidation in the health insurance industry that could result in anticompetitive markets.</p> <p> In December, the AMA identified the “big 17”—states where the mergers would have the greatest impact—and formed a coalition to block the mergers. A survey was developed relating to the monopsony issues raised by the proposed mergers and sent out to physicians in those states. Physician feedback was included as the big 17 coalition drafted letters sent to the DOJ.</p> <p> What’s important is that the medical community came together under this coalition, not with the intention of fighting the goliath companies that would be formed by the mergers, but rather to prevent them from happening. The physician voice is stronger when we can all come together under the same leadership.</p> <p> As the letters were drafted and sent, we continued to lay on the pressure and the argument of the coalition became stronger and harder to refute.</p> <p> Last month, the California Department of Insurance issued a letter urging the DOJ to <a href="" target="_self">block the Anthem-Cigna merger</a>. The insurance commissioner based this conclusion on a March 29 <a href="" target="_self">public hearing</a> that included testimony and written comments from the public, patient advocates, experts on health insurance mergers, and both the AMA and the California Medical Association (CMA).</p> <p> Jointly with the CMA, we filed a comprehensive, evidence-based <a href="" target="_self">analysis</a> (log in) explaining why the merger should be blocked. At the hearing, our top antitrust attorney testified that the consequences of the proposed merger would have long-term consequences for health care access, quality and affordability.</p> <p> Similarly, Missouri, with our input, took a hard stand against Aetna’s acquisition of Humana in May when the Missouri Department of Insurance issued a cease-and-desist <a href="" rel="nofollow" target="_blank">order</a> preventing the companies from doing any post-merger business in Missouri’s Medicare Advantage markets and some commercial insurance markets.</p> <p> All of these efforts raised awareness and ultimately led to this moment today—on the cusp of a win for our patients.</p> <p> Today’s news is especially gratifying. The DOJ /state suit against Anthem-CIGNA incorporates the AMA’s concerns that the merger would result in a health insurer buyer “monopsony” power over the physician marketplace. The suit against Aetna adopts the AMA’s long-held and strenuously argued view that Medicare Advantage is a separate market that would suffer antitrust injury by the proposed Aetna-Humana merger. Finally, the AMA is thankful the state Attorneys General, like Florida, who listened to the physicians’ concerns and joined the lawsuits.</p> <p> <strong>The fight isn’t over yet</strong></p> <p> A merger of this magnitude would compromise physicians’ ability to advocate for their patients—something we consider an integral part of our place in society. In practice, market power allows insurers to exert control over clinical decisions, which undermines our relationships with patients and eliminates crucial safeguards of patient care.</p> <p> On the other hand, competition can lower health insurance premiums, enrich customer service and spur inventive ways to improve quality and lower costs. Patients benefit when they can choose from many different insurers that are competing for their business by offering coverage that patients want and at competitive prices.</p> <p> The suit filed by the DOJ is not the end—yet. Both companies have stated that they plan to fight the battle in court and challenge the DOJ lawsuit. The AMA will remain engaged in this process and relentless in our quest to preserve competition in the health insurance marketplace. </p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:64a8593e-052c-446f-8bc6-ef1aad5d22bc 3 useful changes to Meaningful Use Wed, 20 Jul 2016 20:40:00 GMT <p> The Centers for Medicare & Medicaid Services (CMS) has proposed changes to the Meaningful Use program that are intended to relieve physician reporting burdens. Those changes include reducing the 2016 reporting period to 90 days.</p> <p> Based on feedback from the health care community, the proposed changes “better support physicians in providing beneficiaries with the right care at the right time,” CMS Acting Administrator Andy Slavitt said in a <a href="" target="_blank" rel="nofollow">press release</a>. These changes were detailed in the 2017 Hospital Outpatient Prospective Payment System (OPPS) proposed rule released last week.</p> <p> <strong>What changed?</strong></p> <p> The AMA continues to drive home the message that the current problems of the Meaningful Use program must not be carried forward—and the changes recently proposed in the OPPS to Meaningful Use are a good start.</p> <p> Physicians around the country are expecting similar thoughtfulness from CMS about reducing burdens under Medicare’s Merit-based Incentive Payment System (MIPS) when the Medicare Access and CHIP Reauthorization Act (MACRA) final rule is released in the fall.</p> <p> Here are three key changes to Meaningful Use in the proposed rule:</p> <ul> <li style="margin-left:0.25in;"> <strong>90-day reporting period in 2016.</strong> The OPPS proposed rule would allow physicians, hospitals and critical access hospitals (CAH) to use any 90-day, continuous reporting period between Jan. 1 and Dec. 31, 2016, rather than the full calendar year reporting period currently required under Meaningful Use.<br /> <br /> CMS has also proposed a 90-day electronic health record (EHR) reporting period for clinical quality measures. However, the rule does not make any changes to the Physician Quality Reporting System (PQRS) reporting period, so if you are using clinical quality measures to satisfy PQRS reporting, you will still need to report clinical quality measures for a full calendar year in 2017.</li> </ul> <ul> <li style="margin-left:0.25in;"> <strong>Hardship exception for new participants.</strong> CMS proposed 2017 as the first performance period for MACRA. But 2017 is also the last year first-time Meaningful Use participants may attest to avoid penalties in 2018. The result is that a first-time participant would be required to report for both Meaningful Use and the Advancing Care Information (ACI) category under MIPS to avoid a payment adjustment 2018.<br /> <br /> In the OPPS proposed rule, however, CMS stated its intent to provide first-time participating physicians the opportunity to apply for a significant hardship exception from the 2018 payment adjustment.<br /> <br /> Physicians wishing to apply for the hardship exception will need to submit an application by Oct. 1, 2017, to demonstrate their eligibility. While the application has not yet been released, CMS indicates that it will require an explanation of why, based on the physician’s particular circumstances, meeting requirements of the Meaningful Use program for the first time in 2017 while also reporting on measures for the ACI performance category of MIPS would result in significant hardship.<br /> <br /> The AMA pressed CMS for the hardship exception for 2017 and will continue to work toward making this process simple for physicians.</li> </ul> <ul> <li style="margin-left:0.25in;"> <strong>Changes to measures and threshold reductions.</strong> CMS is also proposing to eliminate or reduce objectives and measures for eligible hospitals and CAHs attesting under the Meaningful Use program for calendar year 2017 and subsequent years.<br /> <br /> Some of these changes are intended to help align the hospital Meaningful Use program with MIPS when it is implemented beginning next year.<br /> <br /> For example, CMS proposed to eliminate the clinical decision support and computerized physician order entry objectives and measures for eligible hospitals and CAHs. Additionally, the threshold for the health information exchange measure requiring physicians to create a summary of care will be reduced from more than 50 percent to more than 10 percent.<br /> <br /> The secure messaging threshold for eligible hospitals and CAHs will be reduced from more than 25 percent to more than 5 percent in Stage 3 because patients who are in the hospital for an isolated incident may not have a reason to follow up with the hospital via secure messaging.</li> </ul> <p> For more information on these proposed changes, take a look at the OPPS proposed rule <a href="" target="_blank" rel="nofollow">fact sheet</a> from CMS.</p> <p align="right"> <em>By AMA staff writer</em> <a href="" target="_blank" rel="nofollow"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:403c1e49-7d53-4554-b38e-1eb29d9dd095 Tracking patients between visits: A new care model Tue, 19 Jul 2016 22:24:00 GMT <p> As the health care system transitions to value-based care, new models of care will be a critical part of the new Medicare payment system. Learn how one physician is using a new model of care to track patients in between face-to-face visits in his practice.</p> <p> <strong>What patients and submarines have in common</strong></p> <p> <a href="" target="_blank"><img src="" style="margin:15px;float:right;" /></a>Imagine your patients, as you probably do every day, out in the world living their lives. You may wonder if their treatment is working, their medication is causing any side effects, their blood pressure is rising or any number of possibilities that could be percolating unknown—but you can’t find out until they come in for their next visit or call your practice or head to the hospital with an emergency.</p> <p> “Patients are like submarines … out there submerged,” said Lawrence Kosinski, MD, a gastroenterologist and founder and chief medical officer of <a href="" rel="nofollow" target="_blank">SonarMD</a>. “We can’t see them; we don’t know how they are [because] they only come in when they’re in trouble. Which means that, number one, they have to recognize that they’re in trouble and, number two, realize that they can’t fix it themselves …. So we need a sonar system to ping them.”</p> <p> Two years ago, Dr. Kosinski created SonarMD, a web-based platform that pings patients once a month with a set of validated questions, which allows his practice to get out ahead of any complications or progressing medical issues before an emergency occurs. And his practice has been using it since June of last year.</p> <p> <strong>How it works</strong></p> <p> Dr. Kosinski led the development of an initiative known as Project Sonar, which is an intensive medical home for the management of Crohn’s disease created in partnership with Blue Cross Blue Shield of Illinois. SonarMD is the platform that coordinates with their electronic health record (EHR) system to help identify emerging health issues before they result in hospitalization.</p> <p> “What we’ve created is a sonar system that pings patients in between their face-to-face visits,” Dr. Kosinski said. “One of the main issues that results in high complication rates in the patient population is that they don’t recognize they’re deteriorating when they’re deteriorating. They don’t call the physician; they don’t reach out for help, and bad things can happen to patients in the long-run.”</p> <p> “If we ping them in between visits with a structured set of questions,” he said, “we get to intervene before anybody realizes things are getting bad.”</p> <p> Working with Blue Cross Blue Shield of Illinois, Dr. Kosinski’s practice enrolls all of their inflammatory bowel disease (IBD) patients in SonarMD. “[The insurer] pays us a monthly management fee for these patients, and part of that payment goes to the medical practice, and part of the payment goes to SonarMD to manage the platform [and] the data,” he said.</p> <p> The patient has an initial enrollment visit, and a nurse care manager works with the patient to set up an action plan for the goals they want to accomplish. “We assess barriers to attaining those goals,” Dr. Kosinski said. “It creates a team-based approach of physicians and nurse care managers interacting with patients.”</p> <p> The pings go out automatically on the first Monday of every month with a set of questions to identify and track symptoms and developing conditions. It takes patients about one minute to answer all of the questions, and SonarMD calculates a “Sonar Score.” If the score is rising, that means something may be wrong, and the nurse care manager coordinates with the physician to contact the patient or bring the patient in for a visit.</p> <p> Since they began using the SonarMD platform, Dr. Kosinki’s patients have responded at a rate of approximately 80 percent. </p> <p> “We built parameters into an algorithm so that the scores change colors at certain levels,” he said. If the physician needs to be brought in, the nurse care manager goes into the EHR and sends a message to alert the physician that a patient’s score is rising. The nurse care managers monitor about 100 patients each.</p> <p> “We’ve demonstrated a 10 percent decrease in cost of care in these patients over a year,” he said, “driven largely by a 50 percent decline in inpatient costs. So we’re keeping them out of the hospital, we’re keeping them healthy, we’re keeping the costs down, and the patients are happy.”</p> <p> SonarMD started with IBD patients, but Dr. Kosinski and his colleagues have expanded it to irritable bowel syndrome and are now working on expanding it to End Stage Liver disease and Gastroesophogeal Reflux disease. “Our goal is to be able to handle over 50 percent of the encounters for a gastroenterologist so we can actually function as an alternative payment model (APM),” he said.</p> <p> Making sure that SonarMD fits into the new payment system as a qualified APM is a challenge, he said.</p> <p> “We’re trying very hard to do everything we have to stay in the game,” Dr. Kosinski said, speaking as a member of the governing board of the American Gastroenterological Association. “It’s very important that we are part of the solution to the problem.”</p> <p> Listen to a <a href="" rel="nofollow">podcast interview </a>with Dr. Kosinski, and watch in the coming weeks for an interview with Robin Zon, MD, who will discuss her oncology APM and MACRA.</p> <p> <strong>Learn more about APMs:</strong></p> <ul> <li> <a href="" target="_self">How doctors are developing new payment models for their specialties</a></li> <li> <a href="" target="_self">Better health, costs: One practice’s value-based care outcomes</a></li> <li> <a href="" target="_self">Testing new payment models: One pilot program’s success</a></li> <li> <a href="" target="_self">From volume to value: How one health system is making the change</a></li> <li> <a href="" target="_self">Payment model design needs to be physician-led, new report</a></li> </ul> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:c9983801-83fe-45c7-b3cc-85a631b36d51 What’s keeping PrEP under wraps Tue, 19 Jul 2016 20:49:00 GMT <p> PrEP, or pre-exposure prophylaxis, is a safe and effective medication that can prevent at-risk patients from contracting HIV, yet the treatment is not widely known by physicians or the patient base that could benefit most from it. Learn what HIV experts say about the treatment and the obstacles to integrating it into primary care practice.</p> <p> <strong>Getting the word out</strong></p> <p> PrEP reaches a small proportion of the Americans who could benefit from it, experts said at an education session by the AMA LGBT Advisory Committee during the <a href="" target="_self">2016 AMA Annual Meeting</a>.</p> <p> “What’s really interesting about it is a lot of people haven’t heard about it,” said Magda Houlberg, MD, chief clinical officer of the Howard Brown Health Center in Chicago. “You’d think people would want to shout it from the mountains.”</p> <p> PrEP consists of tenofovir/emtricitabine, a once-a-day prevention option for HIV-negative men and women that reduces the risk of HIV. While the U.S. Food and Drug Administration approved PrEP in July 2012, a <a href="" target="_blank" rel="nofollow">2015 survey by the Centers for Disease Control and Prevention</a> (CDC) found that 34 percent of primary care physicians and nurses had never heard of it. The CDC offers more information on PrEP at its <a href="" target="_blank" rel="nofollow">website on HIV/AIDS</a>.</p> <p> <strong>What gets in the way of adoption</strong></p> <p> Obstacles to use remain, said panelist Noël Gordon, Jr., HIV specialist with the Human Rights Campaign. While 1.2 million Americans could benefit from the treatment, about 4 percent of them have used it, he said.</p> <p> He named several factors that have slowed adoption of PrEP:</p> <ul> <li> <strong>Unawareness.</strong> Just 25 percent of gay and bisexual men have heard of PrEP, Gordon said.</li> <li> <strong>Low self-perception of risk.</strong> “I once talked to a friend and asked him what he thought his risk was, and he said low,” Gordon said. “Then I asked him if he used condoms on a regular basis, and he said no. I just can’t reconcile those two things in my mind.”</li> <li> <strong>Stigma and expense.</strong> The stigma around HIV risk is still alive despite gains, Gordon said. And while insurance coverage is widespread, many patients associate PrEP with high cost.</li> </ul> <p> Dr. Houlberg has introduced about 2,000 patients to PrEP at her Chicago clinic. Howard Brown Health Center initiated 1,137 PrEP treatments in 2015, about 5 percent of the national total, according to official clinic numbers. <a href="" target="_blank" rel="nofollow">NAM</a>, a UK-based charity that tracks HIV/AIDS issues<em>,</em> reports that more than 49,000 patients in the U.S. have so far filled prescriptions for PrEP.</p> <p> Panelists named groups they believed were most at risk of HIV and could benefit most from PrEP:</p> <ul> <li> Men who have sex with men</li> <li> Transgender women</li> <li> Intravenous drug users and their partners.</li> <li> Heterosexuals who have many sex partners</li> </ul> <p> Gordon said those four populations remain largely unaware of HIV risks, despite efforts to educate them.</p> <p> <strong>Moving it into primary care</strong></p> <p> Dr. Houlberg said that in many cases PrEP treatment has served a wider purpose by providing patients with a door into the world of medical care.</p> <p> “A lot of it is more like health counseling,” she said. “We’ve gotten a lot of people into preventive care overall. We see them and we can say, ‘Wow, you have high blood pressure.’ We never would have gotten that opportunity otherwise.”</p> <p> Dr. Houlberg said primary care physicians often remain reluctant to adopt PrEP treatment, perhaps leery of treating a disease that has not appeared or fearful that treating PrEP patients would open the floodgates to endless monitoring, follow-ups and tests.</p> <p> But she said PrEP treatment is far more trouble-free than many physicians believe, and she would like to see primary care embrace it.</p> <p> “I want people to be able to access care with someone they trust, someone they’re familiar with,” she said.</p> <p> Consult the Centers for Disease Control and Prevention’s <a href="" target="_blank" rel="nofollow">guidelines for using PReP</a> to learn more.</p> <p align="right"> <em>By contributing writer Michael Winters</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:ad458c7a-6728-4cb1-86e8-6dbbd81a3239 Later start date could ease transition to new Medicare system Mon, 18 Jul 2016 20:26:00 GMT <p> Testifying before the U.S. Committee on Finance, Centers for Medicare & Medicaid Services (CMS) Acting Administrator Andy Slavitt made known concerns about physician readiness for implementation of the new Medicare payment system. Physicians already know the answer to that problem—a later start date and transition period.</p> <p> “We need to launch this program so that it begins on the right foot, and that means that every physician in the country needs to feel like they’re set up for success,” Slavitt said. “We remain open to multiple approaches. Some of the things … that we’re considering include alternative start dates, looking at whether shorter periods could be used and finding other ways for physicians to get experience with the program before the impact of it really hits them.”</p> <p> CMS issued the Medicare Access and CHIP Reauthorization Act (MACRA) <a href="" target="_self">proposed rule</a> earlier this year. The current start date for the new program is Jan. 1, 2017. In <a href="" target="_self">comments</a> sent to CMS on the MACRA proposed rule, the AMA recommended starting the program on July 1, 2017, to provide additional time between the issuance of the MACRA final rule and the start of the reporting period.</p> <p> The final rule is due in November, leaving physicians with just two months to prepare for and implement the most significant change to the Medicare payment system in more than two decades if the current implementation date stays in place. That’s clearly an inadequate amount of time for such major changes.</p> <p> <strong>Why a later date and transition period would help</strong></p> <p> The proposed start date is too early and will create significant problems for the launch of the MACRA programs, the AMA said in its comments on the draft rule. CMS needs to recognize the fundamental changes enacted as part of MACRA and treat the first year as a transitional period that allows physicians to move away from the existing Medicare reporting requirements, learn about MIPS and alternative payment models (APM) and implement work flow and system changes to become successful MACRA participants.</p> <p> The comments cite several reasons that physicians require a later start date and transitional period, including:</p> <ul> <li> <strong>Time to prepare the tools.</strong> Setting the performance year too soon will compromise the ability for vendors, registries, electronic health record vendors (EHR) and others to update their systems to meet program requirements.<br /> <br /> The MIPS program asks that these entities incorporate a significant number of new measures, and physicians have serious concerns that there will be inadequate time to not only include new measures but also to test and ensure the data submitted is accurate and reliable.<br /> <br /> Starting too soon could worsen usability and add to the existing problems with technology.</li> </ul> <ul> <li> <strong>Readying APMs.</strong> Physicians are also concerned that an early start date will limit the number of available APMs. A July 1 start date would provide time to modify CMS’ existing APMs so they can qualify under the MIPS or as Advanced APMs.<br /> <br /> The Physician-Focused Payment Model Technical Advisory Committee (PTAC) is still in the process of developing the framework for reviewing APMs and has not had sufficient time to review or even recommend new models. A later start date gives the PTAC more time to conduct its work identifying physician-focused payment models.</li> </ul> <ul> <li> <strong>More time to address physician concerns.</strong> Starting implementation at a later date would also provide more time for CMS to address several issues that were not in the proposed rule.<br /> <br /> These unaddressed issues include the development of virtual groups, improved risk-adjustment and attribution methods, further refinement of episode-based resource measures and measurement tools, and more actionable feedback reports.</li> </ul> <ul> <li> <strong>Physicians can’t report without the correct information.</strong> MACRA requires CMS to give timely feedback—such as quarterly reports—to physicians. By selecting Jan. 1 as the first performance period, physicians will not have received their first feedback reports. This would leave physicians without the information needed to successfully start the MIPS program, leaving them in the dark for over half of the first performance period.<br /> <br /> MACRA also requires a quality development plan with annual progress reports, and the first report progress is supposed to be issued by May 1. By starting the program on Jan. 1, before the quality progress reports are finalized, CMS is skipping ahead and not finalizing key program requirements before it begins MIPS.</li> </ul> <p> <strong>Learn more about the new Medicare payment system:</strong></p> <ul> <li> At the 2016 AMA Annual Meeting, Slavitt discussed <a href="" target="_self">how physicians are guiding the new payment system</a></li> <li> Learn about <a href="" target="_self">key changes the new Medicare payment system needs</a></li> <li> Find out <a href="" target="_self">how the new Medicare payment system intends to help small practices</a></li> <li> Take a walk through the <a href="" target="_self">4 steps to prepare for MACRA implementation</a></li> <li> Learn the <a href="" target="_self">three principles driving the new Medicare payment system</a></li> </ul> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:e2c91e17-af82-4060-bf21-56fd68d00b85 Social media: How to reap the benefits while avoiding the hazards Mon, 18 Jul 2016 19:00:00 GMT <p> A tweet said the small-town hospital was deluged with suicidal patients that day, and the person who posted it appeared to show frustration with the endless hassle. The post could be seen as whiny, disrespectful and invasive of patient privacy—or supportive and compassionate, depending on how it was read.</p> <p> <strong>Thinking ahead</strong></p> <p> This tweet illustrates the two edges of the social media sword—an opportunity to promote health care and a minefield that can scar a physician for years to come. How to navigate Facebook, Instagram, Twitter and other social media to help your patients and foster your online image as a positive one was the subject of a student education session at the <a href="" target="_self">2016 AMA Annual Meeting</a> in Chicago.</p> <p> “Avoid saying anything you would not say out loud at work to your boss,” said Tyeese Gaines, DO, Medical Director at Landmark Medical Center in Woonsocket, RI, and media strategist for Doctor Ty Media, LLC. At stake, she told trainees, is patient privacy, their reputation and their job—current and future.</p> <p> “There are a lot of things you can’t take back, so think about these things early,” Dr. Gaines said. “Are these the things you want potential employers and colleagues to see?”</p> <p> <strong>Posts live forever</strong></p> <p> Insider commentary, criticism and rants have led to reprimands and dismissal, said Dr. Gaines, who spent 15 years in journalism and today advises physicians on media relations. She listed some pitfalls to avoid:</p> <ul> <li> Post no information that would cause an individual patient to be recognized—especially in small communities.</li> <li> Avoid unflattering opinions and photos.</li> <li> Don’t assume a forum is private.</li> <li> Remember that online posts live forever, and potential employers will search them.</li> </ul> <p> All the more reason to limit posts, keep them professional, avoid friending co-workers and classmates, and clean up past posts that could be taken out of context, Dr. Gaines said.</p> <p> <strong>Context is everything</strong></p> <p> “This is your profession, this is what you chose, and you can’t just post anything anymore,” she told students. They seemed to take her counsel to heart.</p> <p> “A good rule to live by is, if there’s any doubt in your mind that it could be misconstrued, just don’t post it,” said Nicole Paprocki, a rising second-year student at Midwestern University College of Osteopathic Medicine.</p> <p> The session inspired some students to look for more information and guidance.</p> <p> “Our training should be a lot more reflective about things like this,” said Nousha Hefzi, a rising second-year student at Wayne State University School of Medicine. “It’s mostly about how to protect your password, things like that.”</p> <p> That training could benefit both students and seasoned physicians who did not grow up with social media, she said.</p> <p> At its very best, social media offers a chance to advocate for patients and provide better care, Hefzi said: “Any sort of media can be turned into an educational message, depending on how you use it.”</p> <p> <strong>Read more about making social media work for you and your patients:</strong></p> <ul> <li> Learn <a href="" target="_self">KevinMD founder’s guidance</a> for making a difference with social media and protecting your reputation.</li> <li> See expert <a href="" target="_self">answers to physicians’ top social media questions</a>.</li> <li> Learn how social media can <a href="" target="_self">impact your residency or fellowship applications</a>.</li> </ul> <p align="right"> <em>By contributing writer Michael Winters</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:647c14f7-2a68-45f7-8119-806fe8141351 5 Nutrition Facts misconceptions that sabotage patient health Fri, 15 Jul 2016 20:27:00 GMT <p> The fight against diabetes and heart disease also means fighting nutritional misunderstandings and offering sound advice to patients. A new video helps dispel common misconceptions about the Nutrition Facts label found on food packages and offers physicians guidance on how to educate their patients.<a href="" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> Designed to help patients better understand what they are consuming and make more informed decisions about their daily diet, the Nutrition Facts label can be a powerful tool when used correctly.</p> <p> A <a href="" target="_blank" rel="nofollow">new video</a> from the AMA and the U.S. Food and Drug Administration (FDA) offers tips to get started using the label and describes some of the most common misunderstandings:  </p> <p style="margin-left:49.5pt;"> <strong>1.   </strong><strong>The % Daily Values do not add up vertically to 100 percent</strong>. Many patients are confused by the % Daily Value on the Nutrition Facts label. The video illustrates how physicians can discuss with patients the % Daily Value and clarify that it indicates how much of the daily recommended amount of a nutrient is found in one serving of that food.</p> <p style="margin-left:49.5pt;"> <strong>2.   </strong><strong> A 2,000 calorie daily diet should be used for general nutrition advice</strong>. Patients often overlook the fact that some of the daily values on the Nutrition Facts label are based on a 2,000 calorie daily diet, which is not necessarily how many calories each person should consume on a daily basis. Patients need to understand that the Daily Values may be higher or lower, depending on their calorie needs, which vary according to age, gender, height, weight and physical activity level.</p> <p style="margin-left:49.5pt;"> <strong>3.   </strong><strong>Small packaged foods aren’t necessarily a single serving</strong>. Many patients assume that small packages of foods—such as chips or bottled beverages—are a single serving. However, all of the nutrition information listed on the Nutrition Facts label is based on one serving of the food, even if a package contains more than one serving. Patients should always check the serving size and servings per container on the Nutrition Facts label to determine how many calories and nutrients they are consuming if they eat the entire package.</p> <p style="margin-left:49.5pt;"> <strong>4.   </strong><strong>All calories count.</strong> As a general rule, 400 calories per serving is high and 100 calories is moderate. Patients need to understand that “fat-free” doesn’t mean “calorie-free.” Some lower fat foods may have as many calories as the full-fat versions.</p> <p style="margin-left:49.5pt;"> <strong>5.   </strong><strong>Most dietary sodium doesn’t come from table salt.</strong> More than 75 percent of dietary sodium comes from packaged and restaurant foods, and many patients unwittingly eat far more than the recommended daily amount. Much of this comes from 10 common types of foods, including bread, cheese, deli foods, pizza, soup, savory snacks, and mixed pasta and meat dishes.<br /> <br /> In addition to sodium chloride (salt), sodium can come from ingredients such as saline, sodium benzoate, sodium bicarbonate (baking soda), sodium nitrite and monosodium glutamate (MSG). Physicians can illustrate for patients that the daily recommended amount for sodium amounts to less than a teaspoon of salt.<br />  </p> <p> <strong>New resources</strong></p> <p> The video is 30 minutes long and offers continuing medical education credit through the <a href="" target="_self">AMA Education Center</a>. It shows how physicians can turn office visits into teachable moments—helping patients track individual nutrients, compare foods and make choices armed with a stronger understanding of the Nutrition Facts label.</p> <p> “One of the simplest ways patients can make healthier food choices is referencing the Nutrition Facts label,” AMA President Andrew W. Gurman, MD, said in a <a href="" target="_self">news release</a>. “This new video showcases different strategies that physicians can easily incorporate into their work flow to help guide patients on making better food choices that will have a lasting, positive impact on their health outcomes.”</p> <p> In addition to the video, the AMA and FDA teamed up to offer <a href="" target="_blank" rel="nofollow">patient handouts</a> on understanding the Nutrition Facts label and key nutrients for health.</p> <p> The AMA has made the fight against chronic disease a priority through its <a href="" target="_self">Improving Health Outcomes</a> initiative, which seeks to prevent heart disease and type 2 diabetes. These two diseases affect millions of Americans and cost the economy hundreds of billions of dollars. The AMA works with allied organizations to reduce risk factors and improve treatment. The new Nutrition Facts label is one element of the campaign to reduce risk factors by improving patients’ diets.</p> <p> <strong>Continuing a collaboration</strong></p> <p> The <a href="" target="_blank" rel="nofollow">new version of the Nutrition Facts label</a>, announced in May, will reflect the latest scientific research to help consumers maintain healthy diets. The AMA and the FDA will continue working together to provide education for physicians on all aspects of the Nutrition Facts label, emphasizing the changes and improvements that will come in the years ahead.</p> <p> <strong>Learn more about how you can prevent type 2 diabetes and heart disease:</strong></p> <ul> <li> <a href="" target="_self">“Groundbreaking effort” to prevent diabetes announced</a></li> <li> <a href="" target="_self">How to diagnose prediabetes</a></li> <li> <a href="" target="_self">Why you should use self-measured blood pressure monitoring</a></li> <li> <a href="" target="_self">What successful self-measured BP looks like in practice</a></li> </ul> <p align="right"> <em>By contributing writer Michael Winters</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:e7e2b668-8127-4067-a499-7c773a4bc5e5 Easing the burden: An end-of-life decision tool to help patients Fri, 15 Jul 2016 20:22:00 GMT <p> Talking about and planning for end-of-life care can be difficult for patients and their families. Often these conversations occur too late or even not at all. Recently, Stanford University Department of Medicine developed a project that empowers patients to take the initiative to talk to their physician about what matters most to them at the end of their lives.<a href="" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> Without end-of life decisions on file, a patient’s care decisions may be made by family members and the care team and not reflect what the patient actually wants. A new <a href="" target="_self" rel="nofollow">module</a> from the AMA’s STEPS Forward™ collection of practice improvement initiatives can help physicians facilitate a conversation with a patient about end-of-life decisions before an emergency situation arises and those desires are left unknown.</p> <p> Stanford, which contributed this STEPS Forward module after <a href="" target="_self">winning</a> the AMA-MGMA Practice Innovation Challenge, conducted research and enlisted the help of multi-ethnic, multi-lingual patients and their families to create a letter template that guides patients through the process of making important advanced planning decisions they might otherwise have put off.</p> <p> <strong>The Letter Project</strong></p> <p> The template, called “the Letter Project,” allows patients to talk about what matters to them most on a personal level unrelated to medical care. Patients also use the template to document how they like to handle bad news, describe their medical decision preferences, give input on the treatment interventions they want and don’t want at the end of life, and document their preference for palliative sedation.</p> <p> The letter format is personalized and accessible, written in straightforward language that is easily understood and free of medical and legal jargon that can be confusing to patients.</p> <p> After successful testing with hundreds of patients and families from various ethnic and racial backgrounds and in many languages, Stanford began spreading the Letter Project to different venues. Participants have included high school students who made their preferences known to their families, older adults who filled out the letter at local community centers and patients at Stanford. And so far, the response has been very positive, Stanford reports.</p> <p> Many of the participants said they appreciated the opportunity to discuss their decisions and that they and their families developed a greater understanding of what end-of-life care entails. They also said the process resulted in deeper connections with each other as they talked through the decisions.</p> <p> Physicians also gained much from the process, learning that when patients are given the opportunity to talk about what is important and share information in a letter format, they feel more confident that their care team will adhere to the decisions that they made.</p> <p> Now, at Stanford, a large multi-disciplinary committee is working to implement the letter both in the in-patient and out-patient settings. The letter template is now available in all hospital units at Stanford and through the STEPS Forward module. Each printed letter has a unique barcode that can be scanned into the electronic health record (EHR).</p> <p> There is a free <a href="" target="_blank" rel="nofollow">Letter Project app</a> available and Stanford hopes to create a secure, HIPAA-compliant repository of 100,000 letters that can serve as examples for patients interested in writing their own.</p> <p> <strong>More practice resources</strong></p> <p> The module on <a href="" target="_self" rel="nofollow">planning for end-of-life decisions with your patients</a> is one of eight new modules recently added to the AMA’s <a href="" target="_self" rel="nofollow">STEPS Forward</a> collection of practice improvement strategies to help physicians make transformative changes to their practices. Thirty-five modules now are available, and several more will be added later this year, thanks to a grant from and collaboration with the <a href="" target="_blank" rel="nofollow">Transforming Clinical Practices Initiative</a>.</p> <p> <em>AMA Wire</em> explores many of the other <a href="" target="_self">modules</a>, including why your practice needs a health coach and four questions to ask to find out if your patients have unmet needs.</p> <p align="right"> <em>By AMA staff writer</em> <a href="" target="_blank" rel="nofollow"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:a1f9ecc4-42a1-4bf0-b4b4-e9aca31f32bb Keys to cultivating empathy in residency Thu, 14 Jul 2016 20:27:00 GMT <p> With burnout on the rise and so many competing demands, cultivating a healthy sense of empathy can be a struggle. Dhruv Khullar, MD, a resident physician at Massachusetts General Hospital in Boston and contributor to the <em>New York Times Well</em> blog, shared insights following a special <a href="" target="_blank" rel="nofollow">AMA tweet chat</a>.</p> <p> <strong><em>AMA Wire</em></strong><strong>: How can a resident work to maintain pragmatic empathy over the long term?</strong></p> <p> <strong>Dr. Khullar:</strong> We go into medicine to help others, and empathy is at the core of what we do as doctors. But as enriching and inspiring as medical training can be, it can also be demanding and overwhelming. Maintaining our empathy and compassion throughout it all can sometimes be challenging.</p> <p> Recent studies show that <a href="" target="_self">one-third of residents experience depressive symptoms and burnout</a>. This can make it hard to care for patients in a way that’s good for them and good for us. When we’re not at our best, patient care isn’t at its best.</p> <p> There are tangible steps that trainees can take to maintain their sense of purpose during residency. The first is to recognize you’re never alone. If you’re struggling, if you’re feeling down, it’s likely that others are too. Opening up to colleagues, family members and significant others is critical. I’ve found that when one person discusses what they’re going through, others inevitably do as well. This creates a supportive environment for everyone.</p> <p> Another important step is to carve out time to reflect. This can be done alone, with friends or through facilitated discussions within training programs.</p> <p> It’s important that medical schools and residencies have appropriate support systems in place to help trainees transition from one step to the next. We should invest in wellness programs like mindful medication, narrative medicine and facilitated group discussions. Research shows that these programs work—they can improve well-being, job satisfaction and professionalism, while reducing burnout and exhaustion.</p> <p> <strong><em>AMA Wire</em></strong><strong>: How can value be put into quality, when so much effort has gone into reducing and managing quantity for residents?</strong></p> <p> <strong>Dr. Khullar:</strong> So far in residency reform, the focus has been on reducing the number of hours worked, rather than improving the quality of hours worked. There’s a perception that resident and student wellness depends on separating work and life—that well-being will grow out of limiting duty hours. This may be partially true, but there’s much that needs to be done to improve the quality of time trainees spend in the hospital.</p> <p> We should reduce the time residents spend on administrative tasks and non-clinical activities to allow them to focus on direct patient care and education. First-year residents spend just eight minutes with each patient per day—about a quarter as long as they do <a href="" target="_self">behind a computer screen</a>. That’s unacceptable. We need to find ways to ensure residents spend more time with patients and families and less time with phones and computers.</p> <p> Some initial steps include improving the ease of communication with nurses and consulting medical services; enlisting medical scribes to assist with documentation; and employing administrative assistants on medical wards to help with paperwork, obtaining medical records, and coordinating discharge appointments. Small changes would go a long way. Most importantly, I think better supported residents will lead to better cared for patients.</p> <p> <strong><em>AMA Wire</em>: What should spouses, family and friends expect as new residents adjust to the emotional strain and requirements of work?</strong></p> <p> <strong>Dr. Khullar:</strong> We all adjust to new situations differently, so there’s a lot of variability in how residency training affects relationships with friends and family. Some people compartmentalize their home and work life; for others, it’s helpful to talk about work at home. Ideally, over time, there’s a synergistic relationship between the two—so that one makes you better at the other.</p> <p> But everyone approaches these things differently. Loved ones should recognize that residency can be a uniquely stressful experience, even if it’s an extremely rewarding one. It’s important to be understanding and supportive in ways and at times you may not have anticipated.</p> <p> <strong><em>AMA Wire</em></strong><strong>: How does a more analytical person learn to practice compassion—and how does a more empathetic person curb their emotional side as needed?</strong></p> <p> <strong>Dr. Khullar:</strong> We all exist on a continuum of rationality and emotionality at various times. The most important thing is being aware of where you are—and where you need to be. Just monitoring and understanding what’s going on inside you can help you more effectively manage and express it. These skills are honed over time, but not naturally or effortlessly. They require dedicated practice and constant evaluation. </p> <p> <strong>Explore the concepts of personal and professional wellness during residency:</strong></p> <ul> <li> <a href="" target="_self">Residency training environments primed for transformation</a></li> <li> <a href="" target="_self">Preventing resident burnout: Mayo Clinic takes unique approach</a></li> <li> <a href="" target="_self">Ward off burnout: Your peer network may impact more than you think</a></li> <li> <a href="" target="_self">6 key aspects residents need for well-being</a></li> </ul> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:158a1a17-be7c-40fb-9b00-cd8c5e8380de HHS begins second phase of HIPAA audits Wed, 13 Jul 2016 21:16:00 GMT <p> The second phase of audits for compliance with the Health Insurance Portability and Accountability Act (HIPAA) regulations is underway. These audits provide an opportunity to get out ahead of problems that may exist before they result in breaches. Learn what you need to know about the process and the specific HIPAA provisions being reviewed.</p> <p> The 2016 phase 2 HIPAA audit program, conducted by the Department of Health and Human Services Office for Civil Rights (OCR), is a key part of OCR’s health information privacy, security and breach notification compliance activities. The audit program allows OCR to assess covered entity compliance with the HIPAA regulations.</p> <p> The AMA recently met with OCR about the audits to inform the agency of their concerns, noting that physicians are already attempting to successfully comply with the new Medicare payment system, the most significant change to that system in the last 25 years.</p> <p> OCR underscored that the audit results are a tool to identify best practices and discover risks and vulnerabilities that OCR may not be aware of through their normal enforcement mechanisms and will be used for educational purposes, not enforcement.</p> <p> The agency noted that if it uncovers a serious compliance issue through the audit process, it may initiate a compliance review to further investigate. The ultimate goal of the audits, however, is to help OCR provide better guidance to the health care community.</p> <p> <strong>What to watch for and how to prepare</strong></p> <p> Earlier this year, OCR asked for contact information from a number of entities, though not all physicians contacted were selected to be audited. OCR selected a total of 167 health plans, health care providers and health care clearinghouses to be audited. Selected physician practices would have received an email from OCR on July 11. The email may be incorrectly classified as spam, so check your spam and junk folders to make sure you didn't miss it.</p> <p> To determine auditees, OCR looked at a broad group of candidates to assess HIPAA compliance across the industry by factoring in size, affiliation with other health care organizations, the type of entity and its relationship to individuals.</p> <p> If your practice is selected for an audit, you will need to submit the requested documentation and any written comments demonstrating your compliance with the following HIPAA requirements to OCR by July 22:</p> <ul> <li> <strong>Privacy rule: </strong>Notice of Privacy Practices and Content Requirements, Privacy—Specific Requirements for Electronic Notice and Privacy—Right to Access.</li> <li> <strong>Breach notification rule: </strong>Breach Notification—Timeliness and Breach Notification—Content.</li> <li> <strong>Security rule: </strong>Security Risk Analysis and Security Risk Management.</li> </ul> <p> Physicians can look up the specific information OCR will look for within the documentation for each of the above standards by searching for the standard on OCR’s <a href="" target="_blank" rel="nofollow">audit protocol website</a>.  Note that OCR is <strong>not</strong> collecting information on all of the provisions in the audit protocol; rather, it is only collecting documentation on the above provisions. </p> <p> OCR also told the AMA that it plans to offer a webinar to auditees with specific expectations about timeliness including instructions on how to upload the documents to its web portal.</p> <p> The final audit report will be completed within 30 days of your response and OCR will share a copy of the final report with you.</p> <p> The AMA has a number of resources available on its <a href="" target="_self">website</a> to assist physicians with HIPAA compliance, including a sample Notice of Privacy Practices, privacy and security toolkit, and a podcast on security risk assessments.</p> <p> For more information on phase 2 of the OCR’s HIPAA compliance audit program, check out the <a href="" target="_blank" rel="nofollow">audit phase 2 program objectives and frequently asked questions</a>. </p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:df31c3ab-5011-427a-831a-b22e5dbad6c2 Online database simplifies residency, fellowship search Wed, 13 Jul 2016 18:00:00 GMT <p> The go-to online resource for finding residencies and fellowships is turning 20. Learn what users have to say about <a href="" target="_self">FREIDA Online</a>®, the AMA Residency & Fellowship Database™, and how students can use it to make informed decisions about the next big step in their careers.</p> <p> <strong>Customizing the search</strong></p> <p> <a href="" target="_blank"><img src="" style="margin:15px;float:right;" /></a>FREIDA—Fellowship and Residency Electronic Interactive Database Access—provides custom searches of more than 10,000 residency and fellowship programs to help students and residents find a match. Users can search by geographic areas, specialties and keywords. They can review basic program data and training statistics, find maps and websites, and determine key application deadlines.</p> <p> Since its launch, FREIDA has become indispensable.</p> <p> “I think it’s an essential tool for any medical student,” said Jerry Abraham, MD, “but especially for third- and fourth-year students as they conduct their residency search and determine which programs to apply to and interview with.”</p> <p> Dr. Abraham, chief resident physician in family and community medicine at the University of Southern California Keck School of Medicine, interviewed with 30 programs and made ample use of FREIDA. It helped him compare programs and keep the information in one place.</p> <p> At the University of Cincinnati College of Medicine, Director of Career Development Alice Mills, MD, specializes in helping students apply for residencies.</p> <p> “We introduce FREIDA to our rising fourth-year medical students at a class meeting, then regularly recommend it during their individual advising appointments,” Dr. Mills said. “Students have found FREIDA useful as they start exploring programs in their specialty. Students like being able to search for residency programs by state and by keywords.”</p> <p> <strong>The need for more information</strong></p> <p> FREIDA began to take shape in the late 1980s. The AMA House of Delegates endorsed the creation of a one-of-a-kind computerized reference tool at the urging of the AMA Resident and Fellows Section, after reports from residents that they lacked enough information to make sound choices on programs when they had conducted their residency searches.</p> <p> FREIDA was launched in 1991 as an electronic diskette format for medical schools and libraries, and the service went fully online five years later. Since then, the AMA has introduced a number of innovations and upgrades:</p> <ul> <li> Optimization for tablets and phones</li> <li> Maps that display program and training institutions</li> <li> Comparison tables to organize and save searches</li> <li> Sophisticated keyword searches that go beyond the basics to help students identify programs that include a hospitalist track, require a USMLE or COMLEX score for interview consideration, provide child care, offer free parking, and meet a range of other needs</li> </ul> <p> <strong>Organizing the options</strong></p> <p> Poornima Oruganti is in the midst of her residency application process. The rising fourth-year medical student at Northeast Ohio Medical University credited FREIDA with reducing stress and helping organize all her program options.</p> <p> “I have used it throughout medical school, starting my first year,” said Oruganti, an at-large officer with the AMA Medical Student Section. “I find it extremely useful to organize programs and get a sense of what residencies I’m interested in. It also allows me to create a list and compare programs.”</p> <p> <strong>Spreading the word</strong></p> <p> Christopher Libby, a rising fourth-year student at the University of Massachusetts Medical School, has encouraged other students to use FREIDA and to join the AMA to take advantage of premium FREIDA features.</p> <p> “I used it several times a week when developing a list of away rotations to apply to,” said Libby, the chair of the governing council for the AMA Medical Student Section. “I like being able to search by specialty and geographic area.”</p> <p> All the residency and fellowship programs listed on FREIDA are accredited by the Accreditation Council for Graduate Medical Education, or are board-approved combined programs. Information for the listings comes from the National GME Census conducted by the AMA and the Association of American Medical Colleges. Hospital data come from Health Forum, part of the American Hospital Association.</p> <p> New information is uploaded each August, October and February.</p> <p> <strong>Premium features</strong></p> <p> Anyone can access FREIDA’s basic functions. With an AMA account, students can perform searches and save them to a comparison table. AMA members enjoy even more features, including the ability to save program searches into the comparison table across sessions. Members can rate, notate and sort programs into a custom dashboard, then return to searches with one easy click.</p> <p> If you’re not an <a href="" target="_self">AMA member</a>, <a href="" target="_self">join today</a> for access to these features and other resources. For more information, complete the <a href="" target="_self">free registration</a> for FREIDA Online and <a href="" target="_self">review the database’s FAQs</a>.</p> <p> <strong>Learn more about conducting a successful residency search:</strong></p> <ul> <li> Review the student’s <a href="" target="_self">fourth-year essential checklist</a>.</li> <li> See <a href="" target="_self">4 tricks to a successful residency program search</a>.</li> <li> <a href="" target="_self">How many residency programs</a> do students really apply for?</li> <li> Read about the <a href="" target="_self">record Match rate</a> for 2016.</li> </ul> <p align="right"> <em>By contributing writer Michael Winters</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:4bced26c-4f1f-4670-a092-cc06fc95cfc3 How faculty, students can improve care while saving money Tue, 12 Jul 2016 22:05:00 GMT <p> Medical school faculty could do more to cultivate a new generation of physicians focused on containing health care costs, a new research report finds. It outlines the opportunities and obstacles on the road to greater cost consciousness.</p> <p> <strong>The ethical imperative</strong></p> <p> Nine out of 10 students agree that physicians have a role in containing costs as well as limiting unnecessary tests and treatments for the sake of patients and society, according to <a href="" target="_blank" rel="nofollow">a report in <em>Academic Medicine</em></a>. But it found that faculty and physicians must lead the way, modeling cost-conscious behavior and making clear it has a place in clinical practice.</p> <p> “[Students] recognize that excess testing and unnecessary procedures threaten patient safety and that spending more money on health care does not necessarily lead to better health outcomes,” the report’s authors said.</p> <p> The findings are based on a survey of 3,395 students at 10 medical schools, all of them members of the <a href="" target="_self">AMA Accelerating Change in Medical Education Consortium</a>.</p> <p> The authors outlined the severity of the cost-control challenge. Up to 30 percent of health care spending is wasted, largely because of unnecessary services, they said. Wasted care exposes patients to added risk, burdens them with more out-of-pocket costs and displaces the care they actually need. Medical education must enlist faculty and future physicians in the campaign to control costs, the authors found.</p> <p> <strong>The need to role model cost consciousness</strong></p> <p> However, most students reported seeing role models that displayed “wasteful” behaviors, such as ordering numerous tests all at once rather than waiting for the results of initial tests or repeating tests rather than trying to get the results of recently performed tests.</p> <p> Students who took the survey identified other barriers to cost consciousness:</p> <ul> <li> More than one-half of students thought ordering fewer tests would raise the risk of medical liability litigation.</li> <li> One-half of students said that ordering a test is easier than explaining to a patient why it is unnecessary.</li> <li> Only 11 percent of students said it is easy to determine how much tests and procedures cost.</li> <li> Many students said the organizational culture makes it hard to address the cost of care.</li> </ul> <p> The authors suggested students training in institutions that provide few cost-conscious role models could be “imprinted” with a culture of higher spending. To prevent that they said educators must both teach and model cost consciousness. They called on medical schools to:</p> <ul> <li> Encourage faculty to understand that any action observed by learners is role modeling.</li> <li> Strategically expose students to physicians who are known to model high-value, cost-conscious care.</li> <li> Pursue cost savings in ways that are visible to students, praise them for proposing cost-effective plans of care and encourage them to include value in their case presentations.</li> <li> Encourage cost-conscious role modeling in high-spending environments.</li> <li> Introduce concepts of stewardship and systems thinking early, equip student with strategies to overcome barriers to cost-conscious care, and encourage discussion about whether the overall learning environment reinforces what is taught in the formal curricula.</li> </ul> <p> The campaign for cost-conscious care could well pay off in the long run for patients, medical systems and society, the report’s authors concluded: “Efforts to enhance physician role modeling in undergraduate medical education may play an important role in preparing the next generation of physicians to address health care costs.”</p> <p> <strong>Learn more about changes underway in medical education:</strong></p> <ul> <li> <a href="" target="_self">Teaching students how to be part of a system should enhance care</a></li> <li> <a href="" target="_self">New science prepares students for care delivery beyond exam room</a></li> <li> <a href="" target="_self">4 ways schools are paving a new path to residency</a></li> <li> <a href="" target="_self">Students at the forefront of changing medical education</a></li> </ul> <p align="right"> <em>By contributing writer Michael Winters</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:5ad73e4f-27e0-4b9a-983b-dc9b6f1f3c34 Court case examines telemedicine safety regulations Tue, 12 Jul 2016 22:00:00 GMT <p> A case before a United States Court of Appeals could restrict a state medical board from protecting patient safety through the regulation of telemedicine in that state.</p> <p> At stake in <em>Teladoc, Inc. v. Texas Medical Board</em> is whether the Texas Medical Board has demonstrated immunity from federal antitrust laws. <a href="" target="_blank"><img src="" style="margin:15px;float:right;" /></a></p> <p> The Court of Appeals is being asked to determine whether the Board may be held liable under the antitrust laws for its rule requiring a “defined physician-patient relationship to exist before a physician may prescribe dangerous or addictive medications. The necessary relationship is defined as established through either an in-person examination or an examination by electronic means with a health care professional present with the patient.</p> <p> Teladoc, which uses telecommunications to connect patients and physicians, provides services in a way that would allow physicians to prescribe medications without the establishment of the required patient-physician relationship. Teladoc alleges that if the Board’s rule is valid, Teladoc would be limited in the way it could carry on business in Texas. It contends that this rule is anticompetitive and seeks to hold the Board liable under federal antitrust laws.</p> <p> Telemedicine is advancing rapidly as a tool to improve access to care and reduce the growth in health care spending. Last month the AMA House of Delegates <a href="" target="_self">adopted new ethical ground rules</a> for telemedicine. But the telemedicine standards of care and practice guidelines are constantly evolving and vary based on specialty and the services provided. It is important that state medical boards remain free to regulate the practice of medicine to ensure patient safety and appropriate prescribing.</p> <p> “Telemedicine offers significant potential benefits to patients, including expanded access to medical care,” the <a href="" target="_self">Litigation Center of the AMA and State Medical Societies</a> said in an amicus brief. “At the same time, telemedicine is inappropriate for certain medical conditions, and it carries risks. Because a physician treating a patient remotely may be called upon to act with limited information, the quality of care may suffer, and a potential exists for fraud and abuse.”</p> <p> “Given the complex and evolving state of telemedicine,” the brief said, “Texas’ balance of reliance on the expert board to act in the first instance, with state supervision as needed, is entirely appropriate—and should not be subject to second-guessing under the federal antitrust laws.”</p> <p> <strong>Why telemedicine regulation matters</strong></p> <p> Patient safety is the guiding force behind the Texas Board’s rule. With telephonic consultations, there may be no observation or physical examination of the patient, and there may be no laboratory or other diagnostic work that the physician can use to determine a diagnosis and course of treatment.</p> <p> One patient case detailed in the brief offers an example of how telephonic consultation, without an in-person examination to establish a patient-physician relationship, led to treatment errors.</p> <p> “There can be real, material risk of harm from treatment without any physical examination,” the brief said. “That risk is amplified where, as in this complaint, treatment is provided to a patient who cannot even communicate his or her own condition but must rely solely on characterizations by a layperson.”</p> <p> <strong>More court cases in which the Litigation Center is involved:</strong></p> <ul> <li> <a href="" target="_self">Confidential patient safety information threatened in Florida</a></li> <li> <a href="" target="_self">Court decides on medical liability protections under MICRA in California</a></li> <li> <a href="" target="_self">Federal court to hear case on freedom of patient-physician conversation</a></li> <li> <a href="" target="_self">Supreme Court case could limit the authority of the EPA to restrict carbon emissions</a></li> </ul> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:eb3c3946-4a3b-4913-84b7-db8ec0ed856b The physician’s essential art of balancing emotion and logic Tue, 12 Jul 2016 19:45:00 GMT <p> From patient to patient and from hospital to home, physicians have to toggle back and forth between the emotional and rational parts of their minds to be effective in both establishing a therapeutic relationship and logically determining the best course of treatment. But how do you find the appropriate balance?</p> <p> In a piece for the <em>New York Times Well</em> blog titled, “<a href="" rel="nofollow" target="_blank">Death and sandwiches</a>,” Dhruv Khullar, MD, a resident physician at Massachusetts General Hospital in Boston, investigated a skill that physicians develop over the course of their training—toggling between the rational and emotional sides of their minds.</p> <p> This dichotomy allows physicians to be empathic and compassionate with a patient, which helps them understand their concerns and condition, and at the same time gives them the ability to switch to a more rational, logical side to determine the best course of treatment to help that patient. <em>AMA Wire</em>® spoke to Dr. Khullar about the essence of this tension and the need to perfect the art of balance.<a href="" target="_blank"><img src="" style="margin:15px;float:right;height:365px;width:243px;" /></a></p> <p> <strong>What it means to “toggle”</strong></p> <p> “I think it’s hard, and it’s something that you hone over time,” he said. “The first few times you see someone or something, you approach it in a very emotional way because many of these situations are difficult and trying. Patients are really going through a lot, so it really strikes you.”</p> <p> “Over time you learn to toggle back and forth a little better or start to blunt this emotional response, and so the visceral feelings that you have become less at the forefront and the more rational side takes over,” he said, “which I think has both its pros and cons.”</p> <p> “Now, after two or three years of being in residency, I’m starting to evolve to that side of things,” Dr. Khullar said. “The tension now is to try to bring a perfect balance and come back to the middle, where you’re able to explore both sides of yourself when you’re meeting a new patient and you’re in difficult situations.”</p> <p> “The danger sometimes becomes that we shut one part of ourselves down,” Dr. Khullar said. “Usually that’s the empathic part, the emotional part, because it is less visible.” Part of the therapeutic relationship is trying to understand how an illness is affecting a patient’s life and what they’re missing out on because they’re sick, he said. Yet, it’s important to focus on the rational as well in order to help the patient.</p> <p> For example, “after the first few codes you’ve been to, you know the drill and automatically flip into this rational, algorithm kind of person,” he said. “It’s not until afterward that you realize this has been a really traumatic experience for yourself, your colleagues and the patient.”</p> <p> “It’s something that most doctors have to contend with, and there are innumerable ups and downs,” he said. “There are some really trying situations that you’re witnessing with patients and their families and what they’re going through. … At the same time, you have to think, and you have to apply, and you have to operate, and you have to learn to distance yourself emotionally in order to be an effective clinician.”</p> <p> “There’s this pretty profound tension that occurs in the hospital, ED or the clinic between getting wrapped up in the emotions and the trauma of your patients’ lives and at the same time trying to create enough distance to think clearly about what the most effective next diagnostic step would be,” he said.</p> <p> “We often hear that we need to merge the art and science of medicine,” he said, “that we need to bring both of these rational and empathic aspects to bear when we’re caring for patients.”</p> <p> <strong>Training the physician brain</strong></p> <p> One <a href="" rel="nofollow" target="_blank">study</a> that looked closely at physicians’ brains while they watched someone experience pain shows “that it’s very difficult—if not impossible—to merge those things in the same moment,” Dr. Khullar said. “When you’re thinking in a very rational way, you’re probably not feeling as much, and when you’re feeling and you’re expressing that part of yourself, you’re not thinking as well.”</p> <p> That skill over time becomes “recognizing, being self-aware of which mode of thinking you’re employing right now and is that the appropriate one?” he said. “It’s a pretty personal process, and at the end of the day, it’s a balance, a spectrum that we exist on from rationality to emotionality … and most people find themselves closer to one end of the spectrum.”</p> <p> Dr. Khullar offered three tips that have helped him understand the importance of toggling back and forth between emotion and logic:</p> <ul> <li> <strong>Find the balance</strong>. Many people start out naturally on one side or the other—emotional or rational, Dr. Khullar said. “The work that people have to do is try to come back to the center, or try to know when to employ one aspect or the other aspect.”<br /> <br /> “People have natural tendencies toward one,” he said, “but everyone needs to work on exploring that other realm as well.”</li> </ul> <ul> <li> <strong>Reflect on what you experience.</strong> For Dr. Khullar, writing has been an outlet to reflect and express the emotions of the day. “I write … to understand what’s going on not only around me but also what’s going on inside of me,” he said.<br /> <br /> “It doesn’t necessarily have to be something like writing or another creative outlet,” he said. “During medical school I wasn’t writing as much, but every Sunday we’d have a group of four guys who would sit around for one hour, put our smartphones away and … we’d talk about what went well that week, what didn’t go well, difficult patient experiences, good patient experiences and that hour, to me, was tremendously enriching.<br /> <br /> “It’s important for everyone to know they’re not alone,” he said. “When you start opening up to your colleagues, other residents, other medical students, you’ll find that most people are going through similar feelings and sensations to a lesser or greater extent.”</li> </ul> <ul> <li> <strong>It’s OK to take time for yourself.</strong> The issue of balance exists not only within the hospital between the emotional and rational modes of thinking but also between personal and professional life.<br /> <br /> “You’re pronouncing someone dead in the afternoon, and then you’re leaving and going to have dinner with your friends in the evening,” he said. “It’s very strange.”<br /> <br /> “Having the space and creating the time and having people with whom you can discuss what’s really a strange experience for everyone is important,” he said. “Only by engaging that dialogue by journaling or writing, having small groups, or talking to your family about it—only then can you observe these small changes that are occurring in ourselves every day, every month of training.”<br /> <br /> At the end of the day, taking this time to cultivate your own well-being makes you a better physician and caregiver, he said. If you take the time for yourself, when you go back into the hospital the next time your patients will be better off because of it.</li> </ul> <p> As part of the AMA’s annual <a href="" rel="nofollow" target="_blank">residents and fellows Facebook</a> “Welcome to residency” campaign, Dr. Khullar participated Tuesday in a <a href="" target="_blank" rel="nofollow">tweet chat</a>, where he discussed with participants how residency changes you as caregiver and a person. </p> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:8817ed06-e76f-4477-9c21-dbb023c4d2d8 How much do you know about carrier screening? Mon, 11 Jul 2016 23:10:00 GMT <p> As prenatal genetic screening options expand, physicians face questions about which screening is best for individual patients. Test your knowledge about new expanded carrier screening and what role it can play in clinical practice.</p> <p> <strong>Casting a wider net</strong></p> <p> Genomics is part of precision medicine, the science of crafting treatments to fit a patient’s particular genes, environment and lifestyle. Unlike traditional one-size-fits-all treatments, precision medicine tools enable clinicians to better understand a patient’s health and conditions, and better determine what treatments will be most effective for that particular person.</p> <p> Carrier screening provides information about reproductive risks by identifying genetic variations in parents that usually do not affect their own health but could result in diseases in their children. Results allow patients to consider their reproductive options.</p> <p> Traditional prenatal screening detects about a dozen conditions that are more prevalent in certain ethnicities. In contrast, new expanded carrier screening can test for more than 100 genetic conditions and isn’t limited to only certain ethnicities.</p> <p> As screening becomes available to more patients, physicians should consider additional factors and discuss them with patients before and after screening. For example, testing for more diseases, especially those that are less common, can lead to uncertainty about residual risks and clinical outcomes when data on those diseases is limited.</p> <p> <strong>Learn more about carrier screening </strong></p> <p> Extensive information on working with expanded screening can be found in a <a href="" target="_self">new continuing medical education (CME) module</a>. It is the first of 12 modules the AMA is creating in partnership with Scripps Translational Science Institute and The Jackson Laboratory on the benefits and limitations of genetic testing and how and when it is appropriate to incorporate it into patient care.</p> <p> In this first module, clinicians learn more about how to determine who is a good candidate for expanded carrier screening. The module includes patient scenarios illustrating issues that clinicians face as they weigh the merits of expanded carrier screening.</p> <p> <strong>Test your knowledge</strong></p> <p> Test your understanding of expanded carrier screening issues in clinical practice by considering three patient scenarios:</p> <p> <strong>Scenario 1: </strong>Sasha and Eli are planning to start a family soon and have been advised by their rabbi to consider preconception screening for “Jewish diseases.” They want to rule out as many serious disorders as possible before pregnancy.</p> <p> <strong>Scenario 2: </strong>Shonda is in her first pregnancy. She doesn’t know her family medical history or ethnicity but wants to know if her baby might have a treatable condition.</p> <p> <strong>Scenario 3: </strong>Martha is of Southeast Asian descent and is 16 weeks pregnant. The father of the baby is not involved. She is highly anxious about her ability to raise a child with special needs as a single mother.</p> <p> How would you answer questions for each of the three scenarios? They include:</p> <ul> <li> Is the patient more suited to expanded carrier screening or ethnicity-based screening?</li> <li> What is the impact if just one parent is a genetic carrier?</li> <li> What steps should be taken if screening reveals that one or both prospective parents are carriers or have disease risk themselves?</li> <li> What information is important to discuss with the patient before carrier screening?</li> <li> What is the best option if the father of the pregnancy is not available for testing?</li> </ul> <p> The <a href="" target="_self">CME module</a> offers answers to these questions and more. The module breaks down into three parts: A video overview of the topic, an opportunity to practice applying key points to real-world patient cases and referral to additional information for those who want to dig deeper into expanded carrier screening.</p> <p> Additional CME genomics modules will follow. Module 2, expected to launch later this summer, addresses prenatal cell-free DNA screening, sometimes referred to as non-invasive prenatal screening. Other topics will include precision medicine and its applications in oncology, neurology and cardiology.</p> <p> Find out more about precision medicine:</p> <ul> <li> <a href="" target="_self">The Precision Medicine Initiative: Report of the AMA Council on Science and Public Health</a></li> <li> <a href="" target="_self">What is precision medicine?</a></li> <li> <a href="" target="_self">Personalized medicine resources for physicians</a></li> </ul> <p align="right"> <em>By contributing writer Michael Winters</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:7a658f97-b9fe-40c3-b9d1-53f6fa349355 Inside peek: Test-driving clinical skills before rotations Mon, 11 Jul 2016 23:08:00 GMT <p> The rising third-year student, tongue between his teeth, slowly drove his needle into a silicone pad meant to mimic human skin, then pulled his thread tight and started in again.</p> <table align="right" border="0" cellpadding="0" cellspacing="15" style="width:365px;"> <tbody> <tr> <td>  </td> <td> <a href="" target="_blank"><img src="" /></a></td> </tr> <tr> <td>  </td> <td> <p> <em><span style="font-size:10px;">Steady hands and keen focus meant clean stitches at the suturing table, one of seven skills stations at the clinical skills workshop.</span></em></p> </td> </tr> </tbody> </table> <p> Theodore Zaki sealed up the gash with a classic horizontal mattress suture, not unlike the stitches in a baseball, then straightened up and took a satisfied breath.</p> <p> “You want to do anything you can to avoid looking like an idiot on the first day,” said Zaki, a medical student at Yale School of Medicine, who is just two days from the start of his surgical rotation. “When the doctor hands me a needle and asks me to suture something up, I’ll definitely be prepared.”</p> <p> <strong>Learning from mistakes and successes</strong></p> <p> It was that motivation to get ready that brought hundreds of students to a workshop on clinical skills during the <a href="" target="_self">2016 AMA Annual Meeting</a>. There they found a safe setting to make their mistakes and learn what they will need to know when they first treat patients. With guidance from experienced specialists, they tried their hands at not only suturing but airway management, radiology, hematology, orthopedics, prediabetes screening and blood pressure care.</p> <p> Clinicians urged students to dive in with and sample every specialty they could. The workshops mean more comfort and confidence for students in their transition to caring for patients, Paul Glat, MD, said. He walked students through the finer points of suturing while others waited for their chance.</p> <p> “Most have never held an instrument before,” said the plastic surgeon and professor of surgery at Drexel University College of Medicine in Philadelphia. “Surgery is a tough specialty—it’s sort of militaristic in a way. This is all about how not to stick themselves or another member of the team. It’s sort of self-preservation.”</p> <p> <strong>Carrots and splints</strong></p> <p> Bales of carrots surrounded Jessica Brozek, MD, an orthopedic resident at the University of Kansas School of Medicine. But she wasn’t offering nutritional tips.</p> <p> “I can’t really break your arm to show you, but we can break some carrots,” Dr. Brozek told a student. “Carrots break in the same way as arm bones.”</p> <p> Fascinated students bunched around the carrots, then picked one. Some inflicted a transverse break, others a spiral or oblique. Then, with Dr. Brozek’s tutoring, they began mending.</p> <table align="right" border="0" cellpadding="0" cellspacing="15" style="width:365px;"> <tbody> <tr> <td>  </td> <td> <a href="" target="_blank"><img src="" /></a></td> </tr> <tr> <td>  </td> <td> <p> <em><span style="font-size:10px;">Jessica Brozek, MD, right, an orthopedic resident at the University of Kansas School of Medicine, uses carrots to show a student the fundamentals of mending a broken bone. Orthopedics was one of seven skills stations at the AMA Medical Specialty Showcase and Clinical Skills Workshop.</span></em></p> </td> </tr> </tbody> </table> <p> Collin Shumate, who just finished his first year at Morehouse School of Medicine, rolled his fiberglass wrap too tightly at first. With a second effort and some coaching, he crafted a workable cast.</p> <p> “You get to do something hands on and learn how to use the tools in the real world,” Shumate said.</p> <p> Nearby, students did their best to intubate a mannequin and build airway management skills. Stephanie Winslow felt a particular motivation to “save” the mannequin known as Bob. A University of Florida College of Medicine student, Winslow will help conduct research during the summer before her second year on post-intubation morbidity and mortality. Her earlier work in an emergency room helped spark her passion for emergency medicine.</p> <p> “I found myself in an ER as a scribe, and I fell in love with it,” she said. “I’ve always wanted to come back for more.”</p> <p> <strong>Getting acquainted with specialties</strong></p> <p> Between hands-on workshops, students at the event also had the chance to pore over information on nearly 50 medical specialties and talk with physicians and residents in the field. Steven Hao, MD, helped acquaint students with cardiology.</p> <p> “I remember vividly as a student, you had wide-open eyes, looking for opportunities, very idealistic,” said Dr. Hao. “These sessions are an opportunity to work with someone out in the real world and get an idea where your passions will take you.”</p> <p> Student Gina Jamal took her turn with radiology, finding how tough it can be to route a catheter through a model torso. She started in a femoral artery and worked the tiny tube toward the neck and head. Turning and pulling, she found a sharp angle too hard to navigate.</p> <p> “When I thought I had it, I didn’t,” said the rising second-year student at the University of Texas School of Medicine in San Antonio. “Honestly I think it was the user.”</p> <p> Nevertheless, Jamal was among the countless students who cherished the chance to step out of the classroom and test-drive a variety of skills in something close to a real-care setting.</p> <p> “I’m trying to get exposure to all I can,” she said. “This is the most fun event—all these specialties all in one place.”</p> <p> The next AMA Clinical Skills Workshop will be offered Nov. 12 in Orlando as part of the 2016 AMA Interim Meeting.</p> <p> <strong>Explore more practical tips for students:</strong></p> <ul> <li> Learn <a href="" target="_self">7 clinical rotation tips</a> from experienced physicians.</li> <li> Consult <a href="" target="_self">this must-have checklist</a> of tasks to prioritize during your first and second years of training. This will help you begin preparing a strong application for residency.</li> <li> Review a second checklist <a href="" target="_self">for success during your third year</a> of med school.</li> <li> Prepare for entering your fourth year with this <a href="" target="_self">roadmap to graduation and residency</a>.</li> <li> Master these <a href="" target="_self">4 tricks to a successful residency program search</a>.</li> <li> Find out <a href="" target="_self">how many residency programs students really apply to</a> each year.</li> </ul> <p align="right"> <em>By contributing writer Michael Winters</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:68d14558-38eb-4d1c-ae81-b1cd1d2cd29a How one physician uses his PDMP to help patients Sun, 10 Jul 2016 22:00:00 GMT <p> Prescription drug monitoring programs (PDMP) can be an effective clinical tool to assist physicians in making prescribing decisions. Effective PDMPs can help identify red flags in prescription use, and provide information when assessing and making treatment decisions. Learn how one physician in New York uses his PDMP to inform treatment options and discuss safety issues with patients.</p> <p> <strong>What a PDMP can do for patients and physicians</strong></p> <p> “The bottom line is that New York’s PDMP is a good tool to use to get some information for your assessment and discussion with your patient,” said Frank Dowling, MD, clinical associate professor of psychiatry at SUNY at Stony Brook and medical director at Long Island Behavioral Medicine. “It’s like blood sugar or hemoglobin A1c [data]. They give you certain information about your diabetic patient—how they’re doing over time and what’s going on and the PDMP can be used similarly regarding controlled medications.”</p> <p> The New York PDMP is fully funded, can be integrated into practice work flow and contains the relevant and timely information that physicians need. It is a tool to see exactly what prescriptions for controlled substances are being filled for individual patients, Dr. Dowling said. “So many patients in pain management are afraid to tell me as their psychiatrist that they’re taking [opioid analgesics]. And then if I’m giving an anxiety drug, for example, they’re afraid to tell the pain specialist that they’re on a tranquilizer because … they know there’s a stigma, and they feel kind of like they’re stuck between a rock and a hard place.”</p> <p> When a patient is being treated with controlled medications, it’s important to be careful about quantity and interactions with other medications, he said. Medications aside, the medical conditions themselves may increasse risk for smoe patients, so the information from the PDMP can be useful during the discussion with a patient.</p> <p> “I actually print up the PDMP report,” Dr. Dowling said. “We could just pull it up on the screen and eyeball it, but we print it up. And if there’s no major discussion, I write a line in the chart, and we shred it. But if there’s a [need for] discussion, I show the patient.”</p> <p> When the PDMP report shows, for example, that the patient has been prescribed controlled medications from two different physicians, it provides an opportunity for physicians to have a conversation about how to better coordinate that patient’s care.</p> <p> In New York, the PDMP report identifies all prescribers, prescriptions and amounts that were dispensed. It also shows which pharmacy the patient used and how the prescription was paid for. “[Payment information] comes up either public, private, self-pay or cash because those are additional red flags that can help you to intentify a possible problem,” Dr. Dowling said.</p> <p> “It’s a conversation and further assessment,” Dr. Dowling said. “I love to show them what the PDMP shows. Just like if I do a toxicology screen, and it shows something aberrant or something different than what I expect or hope to see.”</p> <p> “I try to be open and come across as nonjudgmental as I can,” he said. “If it’s high doses of a few different [drugs], I have to say I’m a little worried. Sometimes this is appropriate, but sometimes it could be a risky situation, and we need to talk and work it out together. It’s still about the patient and about the situation that’s unsafe, not that the patient did a bad thing—this is for their own safety.”</p> <p> In Dr. Dowling’s practice, every patient’s PDMP report is examined, whether or not he is prescribing a medication because it’s useful information for assessment and decision-making, he said.</p> <p> “When we first started using the PDMP, we looked up about 400 people over the first few months,” Dr. Dowling said. “It stirred up about 40 or 50 conversations,” some of which were about how a pain medication could interact with a psychiatric medication and required his practice to follow more closely, “due to the risk of sedation and accidental overdose,” he said.</p> <p> “Sometimes they’re just people who get in over their head with pain medications, and they’re just looking for some help,” he said. “And you can talk with them. You can give them a pathway … prescribe buprenorphine … connect them to therapy and meetings, detox or rehab if needed.”</p> <p> Speaking on a panel at the 2016 AMA Annual Meeting last month, Dr. Dowling offered one of <a href="" target="_self">three things every physician should do when treating pain</a>, including information on how to use a PDMP.</p> <p> <strong>Focusing on the individual patient</strong></p> <p> Dr. Dowling detailed one case in which the PDMP helped him identify a patient who was in need of help. The PDMP report showed that the patient was receiving multiple prescriptions from multiple physicians, and he was using different pharmacies as well.</p> <p> The patient was prescribed buprenorphine for opioid use disorder. “He’d had a problem with heroin in his teens,” Dr. Dowling said. But the patient had been off of opioids for several decades and was a high-level executive. But then he experienced a physical injury to his shoulder, for which an opioid medication was prescribed.</p> <p> There were 23 scripts in a short period of time, and the patient was taking about 12 tablets a day when three or four is usually the daily maximum, Dr. Dowling said.</p> <p> “I was very worried about him, and I called him,” Dr. Dowling said. “I started to talk with him on the phone, and I said, ‘Is there anyone in your family with the same name?’”</p> <p> The patient sounded nervous but relieved, Dr. Dowling said. The patient then said, “Why do you ask?”</p> <p> Dr. Dowling told him that the PDMP report showed that he was receiving more than one medication from more than one prescriber and that he was worried. The patient replied that he was glad that Dr. Dowling called because he had gotten himself in troubleand he didn't know how to deal with it.</p> <p> “He told me everything,” Dr. Dowling said. “He said, ‘I’m seeing these two other docs, and I got myself in over my head. I’m terrified that none of you will work with me, and I don’t know what to do.’”</p> <p> Dr. Dowling then told him, “That’s why I’m calling, so come on in.”</p> <p> “I set up a visit the next day, and we talked and cleared the air,” Dr. Dowling said. “I told him that what’s important here is you have an addiction problem and we’ve got to get a handle on it. [You need] one prescriber, and you should let me talk to the other docs. If you’re comfortable with one of the other docs, that’s fine, and we’ll do a smooth handoff. If you’re comfortable with me, that’s fine too; you can let them know, and we’ll consolidate with me.”</p> <p> “He decided to stick with me,” Dr. Dowling said. “This particular patient, to his credit, is active in 12-step meetings, and he said, ‘You know, doc, I owe these other two doctors an amends. Can you give me a couple of days to call them so they hear it from me first?’”</p> <p> “That was great—that’s the perfect, ideal thing,” Dr. Dowling said. “We tapered him down by one dose every two days in the outpatient setting without a problem. And since then there’s been no aberration with the PDMP or toxicology screens.”  The patient only takes buprenorphine as prescribed and has been functioning well for several years.</p> <p> One of the recommendations of the AMA <a href="" target="_self">Task Force to Reduce Prescription Opioid Abuse</a> is to register for and use your state PDMP to check prescription history. Check out all <a href="" target="_self">five recommendations</a> for physicians to take action and prevent opioid abuse.</p> <p> <strong>For more on physician efforts to end the opioid overdose epidemic:</strong></p> <ul> <li> <a href="" target="_self">How to talk about substance use disorders with your patients</a></li> <li> <a href="" target="_self">Physicians team up to treat addiction in rural areas</a></li> <li> <a href="" target="_self">3 steps for talking with patients about substance use disorder</a></li> <li> <a href="" target="_self">Entire state gets one naloxone prescription</a></li> <li> <a href="" target="_self">How naloxone can be a way to start the broader conversation about risk</a></li> </ul> <p align="right"> <em>By AMA staff writer</em> <a href="" rel="nofollow" target="_blank"><em>Troy Parks</em></a></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:020a0649-b3c9-4316-9ff1-cefd234eb7c7 Senior physicians recognized for caring for the underserved Fri, 08 Jul 2016 21:36:00 GMT <p> Four physicians are being recognized by the AMA Foundation for showing an extraordinary commitment to leadership, community service and care for those in need—each with decades of service that run the gamut from Ebola research to primary care. Find out who has been awarded this year’s honors.</p> <p> <strong>Serving underserved international populations</strong></p> <p> The AMA Foundation presented this year’s <a href="" target="_self">Excellence in Medicine Awards</a> to  physicians June 10 at the 2016 AMA Annual Meeting in Chicago.</p> <p> <strong>Jennifer A. Downs, MD, PhD,</strong> assistant professor of medicine and assistant professor of microbiology and immunology at the Center for Global Health at Weill Cornell Medical College, is equally comfortable in Ithaca as in her small concrete home in Tanzania.</p> <p> When she went to that country years ago as a rotating resident, she didn’t suspect she would develop a heartfelt commitment to caring for its people.</p> <p> “But now I love this country,” said Dr. Downs, “and it is difficult to imagine not working here.”</p> <p> She is the recipient of this year’s Dr. Debasish Mridha Spirit of Medicine Award, which recognizes a U.S. physician who has demonstrated altruism, compassion, integrity, leadership and personal sacrifice while providing care to marginalized populations.</p> <p> Dr. Downs’ first days working with the underserved population of Africa led to an epiphany: “I took care of women younger than I was who were dying of AIDS,” she recalled. “It was haunting. And I knew then that I wanted to come back and work to address the problem.”</p> <p> Dr. Downs, who has learned the local language and become enmeshed in the culture of Tanzania, teaches, mentors and carries out clinical care. She makes the care and education of women a priority.. A $2,500 grant will be given to the Center for Global Health in her name.</p> <p> <strong>Adam Levine, MD</strong>, an associate professor of emergency medicine at the Warren Alpert Medical School of Brown University, is the recipient of the Dr. Nathan Davis International Award in Medicine. It comes with a grant of $2,500 to the International Medical Corps.</p> <p> The award recognizes Dr. Levine for outstanding international service. He has responded to humanitarian emergencies in Haiti, Libya, South Sudan and Liberia, and has led research and training initiatives in Zambia, Bangladesh, Rwanda, Liberia and Sierra Leone.</p> <p> He currently serves as the emergency medicine coordinator for the USAID-funded Human Resources for Health Program, helping to develop the first emergency medicine training program in Rwanda. He serves as the primary investigator for the Ebola research team of the International Medical Corps, a disaster and humanitarian relief organization, and as director for the Humanitarian Innovation Initiative at Brown University.</p> <p> Dr. Levine also is editor-in-chief of Academic Emergency Medicine's annual Global Emergency Medicine Literature Review. His research focuses on improving the delivery of emergency care in resource-limited settings and during humanitarian emergencies.</p> <p> <strong>Providing care for U.S. patients without access</strong></p> <p> This year the AMA Foundation recognizes two recipients of the Jack B. McConnell, MD, Award for Excellence in Volunteerism, honoring senior physicians who provide treatment to U.S. patients who lack access to health care.</p> <p> <strong>Charles Clements, MD</strong>, a family medicine specialist in Huntington, W.V., helped found the Marshall Medical Outreach, a medical screening and treatment program for the local homeless community. The program provides an average of 35 patients a day with family medicine, internal medicine, ophthalmology and dermatology treatment. Many patients are referred to Recovery Point, an addiction treatment facility.</p> <p> Dr. Clements plans to spend his summer with a group of medical students on his seventh trip to treat underserved villages in Honduras. He and his students will examine and treat more than 1,500 people, providing perhaps the only medical attention they receive this year.</p> <p> His award comes with a grant of $2,500 to Marshall Medical Outreach.</p> <p> The second McConnell recipient, <strong>Rafael A. Zaragoza, MD</strong>, is a urologist who lives in Delaware. His award comes with a $2,500 grant to the Delaware Prostate Cancer Coalition.</p> <p> Dr. Zaragoza formed the Volunteer Ambulatory Surgical Access Program to provide free low-risk outpatient surgery to the uninsured in Kent County, Del., who cannot afford private pay and are not eligible for Medicaid.</p> <p> Participating surgeons and nurses volunteer their time, and use of operating rooms is free to patients. He also launched the Hope Clinic, which provides non-emergency medical care to the uninsured.</p> <p align="right"> <em>By contributing writer Michael Winters</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:7c6f4ebc-ac74-43f2-a0ab-5baeeafe9db5 How med schools are training tomorrow’s physician leaders Thu, 07 Jul 2016 20:55:00 GMT <p> Medical school faculty members recognize that, as the health care delivery system changes, curricula must incorporate new classes and hands-on experiences to create future leaders in medicine. Find out what several schools are doing to better prepare the next generation of physician leaders.</p> <p> These leadership curriculum changes are part of the schools’ work with the AMA’s <a href="" target="_self">Accelerating Change in Medical Education Consortium</a>. The consortium is working to modernize and reshape the way physicians are trained. It brings schools together to share ideas and experiences with new programs designed to improve competency, leadership and patient care.</p> <p> <strong>Building leaders in Chicago</strong></p> <p> The University of Chicago Pritzker School of Medicine will teach students about the value of care, improvement science, safety of patients and team training (a program they abbreviate as “VISTA”) to help shape physician leaders. It also is implementing a four-step strategy to create a learning environment that transforms medical students into frontline advocates for a better health care system, including creating a sense of urgency and building a guiding coalition.</p> <p> VISTA students will be able to actively participate and lead patient safety and quality activities rather than just observe them, said Vineet Arora, MD, assistant dean for Scholarship and Discovery at Pritzker School of Medicine. Also, she said “we need to have graduating students who are equipped to not only provide the best care but also the highest value care. This is a critical skill we hope VISTA students will carry with them to residency.”</p> <p> Jeanne Farnan, MD, assistant dean for Curricular Development and Evaluation at Pritzker, said it also will be critical for physician leaders to function as part of a team because health care delivery is now more than ever a “team sport.”</p> <p> “VISTA prepares students for that through earlier immersive exposure to health care team members in the health care delivery system as well as through a greater emphasis on team communication and function and vulnerable points in a patient’s passage through the health care system, such as care transitions,” Dr. Farnan said.</p> <p> <strong>Individual leadership paths in Texas</strong></p> <p> At Dell Medical School at the University of Texas at Austin, all students will go through a core leadership curriculum but will have the opportunity to pursue an individual leadership path that allows them to explore areas that they are interested in during medical school.</p> <p> “The competencies needed now for physicians are different than when we went to medical school. It is more about leading a team and working on a team, advocacy and person-centered care,” said Susan “Sue” Cox, MD, executive vice dean for Academics and chair of Medical Education for Dell Medical School.</p> <p> In their third year, students will be able to pursue distinctions in health care redesign, population health and basic science/translational research and dual degrees with a focus on leading change in an area in which they are interested. For example, a student or team of students can carry out a population health study on diabetes in a particular zip code or help improve health care in a clinic setting.</p> <p> “Physicians will not just be leaders in coordinating health care in the clinical setting, but they will be leaders in the community in general,” said executive coach and leadership expert Eddie Erlandson, MD, leadership advisor for Dell Medical School. </p> <p> <strong>Community leaders in Atlanta</strong></p> <p> Morehouse School of Medicine in Atlanta is increasing its ongoing efforts to recruit medical students from underserved urban and rural populations and will provide those students with learning communities that begin on the first day of medical school. Students will take an interactive, learner-centered approach to engage in building teamwork, communication and professionalism skills.</p> <p> For the past 20 years, Morehouse medical students have been part of a yearlong service learning course in which they work with a community site to assess needs and develop, implement and evaluate an intervention. Morehouse in its application to the consortium said the school is expanding this effort and creating a program that keeps students “longitudinally linked to their communities for ongoing collaboration in addressing the health and well-being of these communities.”</p> <p> “The goals of our revised curriculum support our mission of helping lessen the physician shortage that exists, especially in the area of primary care, and to help train physicians, especially physicians of color, who will choose to serve in medically underserved urban and rural communities,” said associate professor of clinical obstetrics and gynecology Ngozi F. Anachebe, Pharm.D, MD, Morehouse’s associate dean of undergraduate medical education and associate dean of admissions and student affairs.</p> <p> A major focus of the revised curriculum is enhanced self-directed learning, Dr. Anachebe said. The goal is for students to take ownership of their learning with academic portfolios and personal development planning.</p> <p> “Our hope is for students to continue regular self-assessment and to continually seek out resources for this continuous self-improvement and learning,” she said. “The doctors of tomorrow must take advantage of the information explosion that is occurring to stay in the forefront of medicine.”</p> <p> <strong>Patient safety leaders in Michigan</strong></p> <p> The goal of curriculum changes at Michigan State University College of Osteopathic Medicine is to give medical students the skills they need to become leaders in patient safety by being able to identify safety concerns and find solutions to make the situation better.</p> <p> Students need a specific curriculum that gives them the opportunity to practice the skills associated with patient safety in clinical settings where they learn, said Saroj Misra, DO, associate professor of family and community medicine at Michigan State University College of Osteopathic Medicine.</p> <p> “It is our belief that our approach to this curriculum will create a student who is better versed in the basic tenets of patient safety so that they can make meaningful contributions to the systems they learn in and feel confident that they are giving back to those systems that train them,” Dr. Misra said.</p> <p> Consortium schools are also changing other ways medical school students learn, including <a href="" target="_self">paving new paths to residency</a>, <a href="" target="_self">relaying student competency to residency programs</a> and <a href="" target="_self">training students for rural medicine</a>. You also can read about what <a href="" target="_self">students at the forefront of transforming med ed</a> have to say about their experiences.</p> <p align="right"> <em>By contributing writer Tanya Albert Henry</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:6bee62a9-5592-4a19-9cbb-0e5b6ff92a23 Resident burnout: Unearthing the bigger picture Wed, 06 Jul 2016 21:40:00 GMT <p> To fortify our understanding of burnout among residents, we have to widen the list of themes we consider, a leading scholar told a gathering of physicians from across the medical continuum. Learn what guidance he had to offer.</p> <p> <strong>A broader conversation</strong></p> <p> The conventional focus on the work and learning environments, though important, is not enough to address burnout in residents, said DeWitt Baldwin, MD, senior scholar in residence at the Accreditation Council for Graduate Medical Education (ACGME).</p> <p> In his remarks to the council’s first <a href="" rel="nofollow" target="_blank">Symposium on Physician Well-being</a>—part of the ACGME’s larger effort to <a href="" target="_self">transform residency to foster wellness</a>—Dr. Baldwin encouraged consideration of the socio-economic setting in which residents work, the moral-ethical environment and the personal characteristics that individuals bring to the job.</p> <p> Standing in the way of the search for solutions is a culture that holds onto the stigma that surrounds mental and emotional health issues, he said.</p> <p> “The culture of medicine still entertains the view that persons who cannot cope or err or fail or are weak have violated the traditional norms of the physician as a strong, independent, self-sufficient perfectionist who does not and should not need help,” he said.</p> <p> “Absurdly, seeking therapy or even help from a wellness program may be seen [as] a weakness or failure,” he said, and it is sometimes looked on as something that could interfere with licensure and employment opportunities.</p> <p> <strong>Casting the net</strong></p> <p> While the profession works to shed outdated attitudes, Dr. Baldwin said, it must cast a wider net to weigh more facets of resident well-being, including:</p> <ul> <li> <strong>Moral-ethical factors:</strong> Toxic and unprofessional learning environments prevent engagement and quash the youthful idealism and enthusiasm that students often bring to the table.</li> </ul> <ul> <li> <strong>Individual</strong> <strong>factors:</strong> Examination of burnout must take into account the motivations, temperament, capability, education and health of individual trainees. This can include considering childhood maltreatment trainees may have suffered, and how it can give rise to such conditions as depression and post-traumatic stress disorder.</li> </ul> <ul> <li> <strong>Social-economic setting:</strong> Residents work in conditions that differ widely in terms of the medical needs of the community and patient safety, factors that can influence burnout.</li> </ul> <p> <strong>Changing the fundamentals </strong></p> <p> The call to renew and refocus efforts to prevent burnout is loud and strong. Thomas Nasca, MD, CEO of the ACGME, opened the symposium with some sobering statistics. Close to 400 physicians take their own lives each year, he said, while other suicides most likely go unreported.</p> <p> “The pain that this scourge is heaping on our profession … is unbearable at times,” he said, and suicide only represents “the tip of the iceberg,” with other forms of distress below the surface. Dr. Nasca called on physicians as a whole to reimagine the campaign against burnout.</p> <p> “We can’t just stand by and wring our hands and then walk out the door and go back to doing what we usually do,” he said.</p> <p> As urgent as the call for action may be, Dr. Baldwin said, there are miles to go in the fight to overturn fundamental factors in medical education that stand in the way. One obstacle is the low priority burnout sometimes holds.</p> <p> “Wellness and well-being just don’t pay,” he said. “It takes too long. It’s neither glamorous nor dramatic, and there’s little sense of slaying the dragon.”</p> <p> Change means confronting what he called an antiquated, assembly-line education model that dehumanizes trainees and undercuts their well-being.</p> <p> “We need to take from them the task of having to gain their well-being,” Dr. Baldwin said. “We should be providing it for them.”</p> <p> <strong>Continuing the conversation</strong></p> <p> The ACGME will host a webinar, “Combating burnout, promoting physician well-being: Building blocks for a healthy learning environment in GME,” with speakers Lyuba Konopasel, MD, and Carol Bernstein, MD, from 2 to 3 p.m. Eastern time July 13. <a href="" rel="nofollow" target="_blank">Register to participate</a>.</p> <p> The ACGME also will be holding its next Symposium on Physician Well-Being this fall. Learn more: Access <a href="" rel="nofollow" target="_blank">resources and videos</a> from the 2015 symposium.</p> <p> <strong>Learn how physician groups are addressing burnout:</strong></p> <ul> <li> <a href="" target="_self">Student wellness: Blueprints for the curriculum of the future</a></li> <li> <a href="" target="_self">How Stanford achieved resident wellness, work-life balance</a></li> <li> <a href="" target="_self">Mayo Clinic takes unique approach to battling resident burnout</a></li> <li> <a href="" target="_self">A double-edged sword: What makes doctors great also drives burnout</a></li> <li> The <a href="" target="_self">International Conference on Physician Health</a>™ will take place Sept. 18-20 in Boston</li> </ul> <p align="right"> <em>By contributing writer Michael Winters</em></p> Blog:e38cf47a-fc5f-473b-9234-c9e714c1c8f0Post:3d6d4ca9-6cb6-4b2c-8225-ff5132222e3b Inside look: A physician’s success story as a prediabetic patient Wed, 06 Jul 2016 21:37:00 GMT <p> As a patient enrollee in her local diabetes prevention program, Nancy Nielsen, MD, PhD, didn’t want anyone to know she was a physician. But now she’s sharing her experience far and wide because it quite possibly changed her life.</p> <p> <strong>Altering her family history</strong></p> <p> “My father had his first heart attack when I was in ninth grade, and he died at 62—a diabetic,” Dr. Nielsen, an internal medicine physician, told physicians last month. “So were both his parents and seven of his eight siblings. And so I knew: With a sedentary lifestyle, I was a prime candidate.”</p> <p> Dr. Nielsen last month spoke to two groups of physician leaders at the <a href="" target="_self">2016 AMA Annual Meeting</a> and a special meeting of the AMA <a href="" target="_self">Accelerating Change in Medical Education Consortium</a> and <a href="" target="_self">Improving Health Outcomes</a> initiative, which focused on preparing students how to best care for patients with chronic diseases. Dr. Nielsen is a past president of the AMA and senior associate dean for health policy at the Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, The State University of New York.</p> <p> “It was at an AMA meeting that I got my hemoglobin A1c,” Dr. Nielsen said. “It was creeping up. Isn’t denial so interesting in all of us? I thought I was eating healthy, but I never had time to measure or count or really worry about all this stuff. I really thought I was eating healthy.”</p> <p> That’s when Dr. Nielsen got a referral from her primary care physician to participate in the YMCA’s Diabetes Prevention Program, which had become available for the first time at her neighborhood Y.</p> <p> Dr. Nielsen isn’t in an uncommon situation when it comes to type 2 diabetes risk. In fact, 86 million U.S. adults—one in three—have prediabetes, according to estimates by the Centers for Disease Control and Prevention (CDC). What is far less common is that Dr. Nielsen knows her risk and is taking action to reduce it. The CDC estimates that only 90 percent of adults with prediabetes are even aware they have it.</p> <p> <strong>Why the prevention program works</strong></p> <p> The YMCA’s Diabetes Prevention Program is based on the <a href="" target="_blank" rel="nofollow">National Diabetes Prevention Program</a>, which is offered by a variety of community organizations and even is available from some providers online. It’s an evidence-based program that helps patients with elevated blood sugar levels make the necessary lifestyle changes to prevent the onset of type 2 diabetes, one of the most disabling and expensive chronic diseases.</p> <p> In the YMCA’s yearlong program, participants meet once a week for 16 weeks and then once a month for the remainder of the year. Participants meet as a group with an experienced life coach and learn the knowledge and skills to adopt healthy behaviors that lower their risk of developing type 2 diabetes. Two of the primary goals for participants are 5-7 percent weight loss during the course of the year and 150 minutes of weekly exercise, changes that can cut a patient’s diabetes risk by more than half.</p> <p> “If you looked at the curriculum, you as physicians would be bored,” Dr. Nielsen said. “It’s very simple.”</p> <p> “[But] that is not the power,” she said. “The power is being together, having a life coach. The dynamics of changing human behavior are not just knowledge.”</p> <p> Dr. Nielsen admitted that she isn’t one who enjoys working on her individual goals as part of a group, but being part of a group and working together toward common goals was very motivating.</p> <p> “One night just for fun, [our group’s life coach] brought in a bunch of foods and put them on the table, and we had to guess” how many calories and grams of fat were in them, Dr. Nielsen said. “And, boy, were we off. And I wasn’t better than anyone else.”</p> <p> Dr. Nielsen explained that the program included such practical activities as counting fat grams and recording everything they ate. There were weekly weigh-ins, and the Y provided access to its facilities and a session with a fitness trainer.</p> <p> Out of the 35 people in her group, every single one of them met their 7 percent weight loss goal.</p> <p> <strong>What physicians can do</strong></p> <p> Dr. Nielsen encourages all physicians to refer their patients with prediabetes to a diabetes prevention program.</p> <p> “In our curriculum, how do we teach nutrition?” Dr. Nielsen said. “When I took it, it was biochemistry … [and offered] very little practical advice. As a busy internist, I didn’t have time to sit and talk about nutrition with people. And frankly from a practical standpoint, I wouldn’t have known what to tell people.”</p> <p> Referring patients to a diabetes prevention program gives patients access to the information and support that they need to make important lifestyle changes without placing the resource burden entirely on busy physician practices.</p> <p> In partnership with the CDC, the AMA offers the <a href="" target="_self">Prevent Diabetes STAT: Screen, Test, Act–Today™</a> toolkit, which makes it simple for physicians and their care teams to screen, test and refer patients to diabetes prevention programs.</p> <p> Participation in the programs is covered by some insurers, which soon will <a href="