Due to the statewide travel ban, all MMS activities at all Massachusetts Medical Society locations on Tuesday, Jan. 27, are cancelled.
What mattered most to Massachusetts physicians in 2014? The most heavily visited pages on the MMS website may offer some hints.
This list is not a complete traffic report; it covers only individual articles. It doesn’t include transaction pages, or the pages that list individual article pages.
The top 25 are listed here, ranked by the number of page views. Perhaps you will find it of some interest.
- Health Care Proxy Information and Forms
- Continuing Medical Education Requirements for Physician License Renewal in Massachusetts
- Choosing a Specialty
- Find a Physician
- MMS Careers
- End-of-Life Care Series (Online CME course)
- MMS Leadership
- Health Care Proxies and End of Life Care
- Opioid Prescribing Series (Online CME course)
- Physician Health Services
- Medical Marijuana
- Important Differences Between Health Care Proxies and Living Wills
- Managing Risk When Prescribing Narcotics Painkillers (Online CME course)
- House of Delegates
- Legal Advisor: Advance Directives (Online CME course)
- The Importance of Discussing End of Life Care (Online CME course)
- Medical Price Transparency Law Rolls Out: Physicians Must Help Patients Estimate Costs
- MMS Study Shows Patient Wait Times for Primary Care Still Long
- Proposed EHR/Meaningful Use Regulations
- Medical Marijuana CME (Online CME course)
- Physician Health Services: Success Story – An Amazing Journey to Sobriety
- Avoiding Failure-to-Diagnose Suits (Online CME course)
- Legal Advisor: Identifying Drug Dependence (Online CME course)
- Medical Mistakes: Learning to Steer Clear of the Common Ones (Online CME course)
- Massachusetts Medical Marijuana Law: Considerations for Physicians
The kidneys are vital organs in the human body, performing such critical functions as cleaning blood, removing waste, and controlling blood pressure. Yet more than 20 million Americans have chronic kidney disease, a serious condition that raises the risks of heart attack, stroke, and end-stage kidney disease.
To create awareness among patients about the condition, Physician Focus begins 2015 with a guest appearance by Martin Gelman, M.D., (photo, right) a board-certified internist and nephrologist who practices at Milford Regional Medical Center and St. Elizabeth’s Medical Center in Boston. He joins program host Bruce Karlin, M.D., (photo, left) a primary care physician in Worcester, in conversation about various aspects of the disease.
Among the topics discussed are the functions of the kidney in the human body, the major causes and effects of chronic kidney disease, who is most at risk for the condition, kidney dialysis and transplants, and a look at what the future might hold in renal replacement therapy with a bio-implantable artificial kidney that has just been approved for clinical trials.
Physician Focus, now in its 11th consecutive year of production, is available for viewing on public access television stations throughout Massachusetts. It is also available online at www.massmed.org/physicianfocus, www.physicianfocus.org, and on YouTube.
The letter cited every pharmacist’s corresponding responsibility, along with physicians, to ensure that every prescription for a controlled substance “must be issued for a legitimate medical purpose.”
The letter said Walgreen’s pharmacists would start taking additional steps when verifying certain prescriptions for controlled substances. MMS has heard from several physicians inquiring about this policy.
Walgreens’ policy states: “Our pharmacists are required to take additional steps when verifying certain prescriptions for controlled substances. This verification process may, at times, require the pharmacist to contact you … information requested may vary, potential questions could include information about the diagnosis, ICD-9 code, expected length of therapy and previous medications/therapies tried and failed.”
According to an FAQ provided to the New Hampshire State Medical Society, Walgreens has emphasized that this new policy should not mean calls to prescribers on every, or even most, prescriptions for controlled substances.
Why did this happen?
Over the past few years, the Drug Enforcement Agency (DEA) has increasingly been looking at the problem of narcotics abuse in this country. While the DEA has investigated and prosecuted individual prescribers of prescription narcotics and synthetic opiates, the DEA is also looking at the distributors and dispensers of these prescription drugs.
The DEA has also been visiting states nationwide and presenting an intense power point lecture to help train pharmacists and remind them of their corresponding duty under federal regulations to ensure that each prescription for a controlled substance is issued for a legitimate medical purpose by each individual prescriber.
In response, Walgreens revised its policy on good faith dispensing of controlled substances, using in part “red flags” as determined by the DEA. Walgreens wants its pharmacists to be comfortable when they fill a prescription for controlled substances and the policy lays out suggestions on how to assure that the prescription is legitimate.
Where do things stand?
MMS has worked closely with the AMA in sharing information and gaining a perspective of this problem on the national scale. The AMA, along with the national medical societies for family physicians, emergency physicians, anesthesiologists, and osteopathic physicians have been part of broad medicine-pharmacy meetings convened by the National Association of Boards of Pharmacy, with Walgreens, CVS, the National Association of Chain Drug Stores, National Community Pharmacy Association, PhRMA, DEA and other groups to identify “red flags” that stakeholders agree would warrant some sort of further review. It is anticipated that this set will be reviewed by the stakeholders in Spring 2015.
Red Flags of Illicit Use, Doctor Shopping, and Diversion of Controlled Substances
- Symptoms incompatible with reported injury
- History of problems with no medical records
- Patient reports being from out of town
- Multiple accidents
- Insistence on drug of choice
- Requests drugs by their street names, e.g. “blues” “Ms”
- Loss of prescription or medications
- Failure to provide or go for medical testing
- Taking more medicine than directed
- Requests medicine refills early
- Use medicines from multiple physicians or filled at multiple pharmacies (as seen on the Prescription Monitoring Program)
- Use of medicines prescribed for others
- Use medicines in combination with alcohol
- Paying in cash or sometimes uses insurance and other times cash
- Prescriptions for large quantities of a “cocktail” or “holy trinity” of opioids, benzodiazepines, and carisoprodol
- Diagnosis of lower lumbar pain. DEA testified that 90 percent of the pill mill doctors use lower lumbar pain as a diagnosis code
- Pattern prescribing. Prescriptions for the same drugs, the same quantities, coming in from the same doctor
- Shared addresses by customers presenting prescriptions on the same day
- Customers going to the pharmacy counter with dilated pupils and difficulty concentrating
- Unusual physical distance between the doctor, the patient, and the pharmacy
- Patients paying in cash or sometimes uses insurance and other times cash
- Prescriptions done in a “factory-like” manner – no reason to prescribe 15mg and 30 mg oxycodone because 30mg tablets are scored down the middle
- Use medicines from multiple physicians or filled at multiple pharmacies (as seen on the Prescription Monitoring Program)
- Inordinately large quantity of controlled substance prescribed
- Prescriptions refilled at inconsistent intervals based on quantity
- Use of street drug name by either the patient or the prescriber
- Suspicion of forged or altered prescription
- Suspicion of forged or altered identification or refusal to provide
What should you, the prescriber do?
If you or your patients have difficulties filling prescriptions for controlled substances at any pharmacy please contact the MMS Physician Practice Resource Center at (781)434-7702 or firstname.lastname@example.org.
Board of Registration in Medicine Gives Final Approval to EHR Proficiency Regulations; New Rules Effective Jan. 2Posted in Electronic health records, Electronic Medical Records, Uncategorized on December 17th, 2014 by Erica Noonan – 1 Comment
The Board of Registration in Medicine today gave its final approval to new regulations, strongly supported by the MMS, interpreting that law in a way that allows physicians many options in how they demonstrate proficiency in the use of electronic medical records.
The new regulations will go into effect January 2, 2015, but all physicians renewing their licenses before March 31, 2015 will receive a one-time waiver from the requirements.
In addition, physicians with renewal dates up to 60 days after March 31 could submit a renewal application prior to March 31, and be within the window for an automatic waiver.
The regulations establish multiple ways in which physicians would be in compliance with the requirement. There are also a broad set of exemptions for certain license categories, where electronic health record use is intrinsic or not relevant. Read full details of state’s new EHR proficiency requirement and exemptions here.
Today’s action successfully culminates a two-year effort to work with the Board to interpret the state legislature’s 2012 law connecting federal Meaningful Use and a Massachusetts medical license in a way that did not disenfranchise thousands of physicians.
“The Massachusetts Medical Society believes that electronic health records have enormous potential for patient care, and the Society’s extensive policy on EMRs declares support for them and a desire to work toward improving them,” said MMS President Richard Pieters, MD. We are grateful that the Board of Registration in Medicine has taken a reasonable approach on this issue, exhibiting utmost concerns for patient safety and access to care.”
Since its introduction some ten years ago, Pay-for-Performance (P4P) has been the object of much confusion, conversation and scrutiny in the medical industry.
Such programs have raised a host of practical questions: What criteria do you use to objectively judge performance? How do you develop incentives for accomplishment and penalties for falling short? What principles do you use to guide such programs?
Practical considerations aside, the payment system has also raised some important ethical questions, and those were the focus of the Ethics Forum at the 2014 MMS Interim Meeting on Friday, December 5 presented by the Committee on Ethics, Grievances and Professional Standards.
Offering their perspectives on the topic of Ethics of Pay for Performance were Alyna T. Chien, M.D., M.S., a pediatrician at Boston Children’s Hospital and the lead investigator in four different projects focusing on the effectiveness of payment and quality incentives, and Sachin H. Jain, M.D., M.B.A., Chief Medical Information and Innovation Officer at Merck and Lecturer in Health Care Policy at Harvard Medical School.
“We are in a revolution,” said Dr. Chien, “as the entire organization of medicine is changing, progressing to one of integrated health care.” She noted that most incentives move from the payer to the hospital or physician practice, and that most of the data regarding the impact of P4P programs exists at the organizational level. There’s little data on how it works at the individual physician level.
Dr. Chien believes these performance programs can have one of three effects in delivering care: a neutral effect, where the status quo is preserved; a narrowing of care, where more attention is paid to quality and more programs are tailored to patients; or a widening of care, where gaps will occur between rich and poor and physicians will selectively pick their patients.
Dr. Jain acknowledged that the public perception of the profession has changed and that physicians should be at “a point of soul searching and questioning where we are in society.” He offered a scenario of physicians as either “knights” (motivated by altruism and being the ultimate champion of the patient), “knaves” (driven by self-interest and financial gain), or “pawns” (pushed by rewards and penalties of the system in which they operate).”
While he pointed out that such a framework can also be applied to others (for example, patients, health plans, pharmaceutical companies, nurses, and hospital executives), Dr. Jain believes organized medicine has focused too much on reimbursement and that physicians are perceived not to be trusted to do what’s right unless there’s a carrot or stick approach.
“We are losing our more intrinsic value in favor of pay-for-performance,” Dr. Jain says, “and the intrinsic motivation of doing what’s right for the patient must be preserved. It is what differentiates us from other professions. It is what tells others that we will do the right thing whether we get paid or not.”
His prescription is direct: a proper system of reimbursement must offer a reasonable salary, reject incentive contracting, focus on clinically meaningful measures, make it easy for physicians to do the right thing for patients, and find ways to honor and reward the intrinsic motivation of what’s best for the patient that most physicians have.
Presentations at the Ethics Forum may be viewed here.
This year’s Annual Oration, Medical Education Across The Continuum: A Snapshot in Time, focused on changes in medical school curriculum have impacted residency training, how residency training influences change in practice, and how clinical practice now informs continuing medical education.
The speaker Michele P. Pugnaire, MD, professor of Family Medicine and Community Health and Senior Associate Dean for Educational Affairs at the University of Massachusetts Medical School, spoke of the changes in the medical education process over the past century. “We are what I am calling `forever learners’ because that is what is expected by the public, our patients and our students,” said Dr. Pugnaire.
There are four drivers in medical educational change: team-based learning, practice-based learning/simulations, outcome-based learning, and improvement based learning, said Dr. Pugnaire. Today’s medical schools are embracing all of them, and some programs are switching from timeline-based programs to more flexible curriculum that judges competency rather than time spent in a classroom, she said.
The future will inevitable cause the educational driving forces to converge on a shared goal for learning: patient safety and quality medical care, she said.
“We are training the next generation of future physicians – our replacements. They will be taking care of us and our families, so we had better do a very good job,” she said.
The MMS Annual Oration dates back to 1804 when Dr. Isaac Rand delivered his dissertation entitled, On Phthisis Pulmonalis, and the Use of the Warm Bath. For more than 200 years, MMS orators have addressed a wide spectrum of topics germane to the evolving practice of medicine.
To open the 2014 MMS Interim Meeting of the House of Delegates, President Richard Pieters, M.D, recounted the changes and challenges in health care in the second year of the Commonwealth’s health care cost control system.
The 2.3 percent rise in health care spending in the first year of the system — well below the state’s target of 3.6 percent — is “evidence that the entire health care community took the challenge of affordability very seriously,” said Dr. Pieters at the meeting’s opening session Friday morning.
Yet Dr. Pieters cautioned colleagues that the changes involve more than just cost control. “This new era of health care,” he said, “is transforming almost everything we do.”
He cited significant changes in the state’s health care system, such as the emergence of new payments models, with new technologies being developed to support them; the continued consolidation of hospitals and physician practices, including more physicians moving from independent practice to employed status; and changes in prescription drug use, as successful new medicines are coming under intense scrutiny because of soaring costs.
The Society’s activity has also changed, he said, as advocacy has shifted from legislative to regulatory efforts. He called attention to the Society’s successful efforts over two years to ensure that the state’s mandate on physician proficiency with electronic health records was implemented with care and without disruption to physician practices and patient care, and he cited efforts in working with health officials in enhancing the state’s Prescription Monitoring Program in the face of a rising drug epidemic and without creating barriers to care.
Dr. Pieters also spoke of the Society’s new strategic direction regarding the advent of team-based health care, noting the formation of a Task Force on Interprofessional Care, led by Past President Ronald W. Dunlap, M.D., that will include representatives from other professions on the team and the preparation of legislation to “ensure that physicians are in the leadership positions of these teams.
“Physicians have the broadest and deepest training of anyone on the team, and the buck stops with us,” said Dr. Pieters.
Finally, Dr. Pieters acknowledged the Society’s efforts in assisting physicians in practice management, continuing medical education, membership development, and a renewed effort to engage young physicians.
“We must prove our value to our colleagues and our external stakeholders each and every day,” Dr. Pieters said, “because that what they have to do in their world, too. It’s a challenging world, but the MMS is in the right place at the right time to make a difference. ”
In 1978, under the pseudonym Samuel Shem, psychiatrist Stephen Bergman published “The House of God,” an iconic novel drawn from his medical internship in Boston in the early 1970s. Earlier this year, Dr. Bergman spoke at the commencement of the New York University School of Medicine. With his permission, the following is adapted from those remarks.
By “Samuel Shem, MD”
I began writing The House of God as a catharsis, to make sense of what seemed like the worst year of my life.
These are times we all have each day, finding ourselves doing things—or not doing things we should have done—and we say to ourselves, “Hey wait a second, why did I just do that–or not?” There were so many of these, I started writing.
Looking back, what have I learned from The House of God?
My generation came of age in the ‘60s. We grew up with the idea that if we saw an injustice and took action together, we could change things: we helped put the civil rights laws on the books, and we stopped the Vietnam War.
In 1973 when we entered our internship, we were idealistic young doctors, wanting to learn, dedicated to treating our patients humanely. But soon we were asked to do things that we thought were inhumane.
We were caught in a profound conflict: between the received wisdom of the medical system, and the call of the human heart. And so, without thinking about it, we resisted. In fact, The House Of God can be read as a kind of medical manual of non-violent resistance.
I have four suggestions for how to stay human in medicine.
1: Stay Connected
Isolation is deadly; connection heals. And connection comes first. Think of a relationship you’re in: if you’re in a good connection, you can talk about anything; if you’re not, you can’t talk about anything!
The hospitals we entered were large medical hierarchies. In these “power-over” systems, we interns got isolated. Not only did we get isolated from each other and our friends and families, each of us got isolated from our authentic experience of the system itself. We started to think that we were crazy, for thinking it was crazy.
Isolation can mean death—as when Potts, one of the interns, commits suicide. In a power-over system, the only real threat to the dominant group—whether dominance is based on gender, race, ethnicity, class, religion, or sexual preference—is the quality of connection among the subordinate group. So in your training, please remember: Stick together. Connection comes first.
2: Speak Up
When we notice injustices and cruelties in the medical system—and believe me you will—speak up. Speaking up is necessary not only to call attention to the wrongs of the system, speaking up is essential for your survival as a human being.
If we see something and say nothing, it will gradually tear us apart. Because others before you have spoken up, your on-call hours are more humane. And believe me, that matters, a lot.
3: Learn Empathy
Once, when I mentioned this to second-year Harvard medical students, one raised his hand, “We learned empathy already.” What? “Yes, last year in interviewing. Empathy is when you repeat the last three words the patient says and nod your head.”
How do you learn empathy? By putting yourself in another person’s shoes, feelingly. By seeing, in that tiresome old lady, your mother, and in that cranky child, your son. By finding good teachers who live compassion—and following along behind, like a duckling a mother duck. Realize that any good connection is mutual; the other person is getting as much out of it as you are.
Warning: studies show that medical student empathy peaks at the end of year two—and goes downhill from there. It’s a real challenge, to stay empathic during the rigors of your residency.
4: Learn Your Trade, In the World
The patient is never only the patient—the patient is the spouse, the family, the friends, the community, the toxins, the crashing climate, where the water comes from and where the garbage goes. The patient is the world.
And here’s the good news: you graduates are totally awesome in one big way that my generation was not: you are citizens of the world. You have been everywhere, done everything. To you, foreigners are not foreign.
You are not isolated from, or suspicious of, different people and cultures, you are with them–even if only through your texts and twitters. You are the hope of the planet, and I—and your families and friends here today—are so proud of you it brings tears to our eyes!
So: Stay connected. Speak up. Learn empathy. Learn your trade, in the world.
Let me end with another moment from The House of God.
One of my patients was a middle-aged woman with metastatic breast cancer. The surgeons operated on her, found they could do nothing, and closed her up and sent her back to the ward.
After she woke up, a nurse came to me and said that no one had told her what the surgeons had found, and that I should. I couldn’t face it. I said that it was her private doctor’s job, not mine. I’m not sure who finally told her, but it wasn’t me. That was a “Hey wait a second” moment, an emblematic moment that I’ve never forgotten.
To this day, 40 years later, I’m still ashamed of my turning away, letting her down. And so in the novel I decided to write what I should have done. The Fat Man volunteers to take care of it:
“I watched the Fat Man [a character in House of God] enter her room and sit on the bed. The woman was forty. Thin and pale, she blended with the sheets. I pictured her spine x-rays, riddled with cancer, a honeycomb of bone. If she moved too suddenly, she might crack a vertebra, sever her spinal cord, paralyze herself. Her neck brace made her look more stoic than she was. In the midst of her face, her eyes seemed immense.
“From the corridor I watched her ask Fats her question, and then search him for his answer. When he spoke, her eyes pooled with tears. I saw the Fat Man’s hand reach out and, motherly, envelop hers. I couldn’t watch. Despairing, I went to bed. Later, after an admission, I looked into the room gain. Fats was still there, playing cards, chatting. As I passed, something surprising happened in the game, a shout bubbled up, and both the players burst out laughing.”
You never know when such a moment can happen, and change you as a person and a doctor—it’s still so fresh in my heart. You’re probably saying, “But who has the time to stay with her like that?”
True, and yet time’s a funny thing–it’s really not a matter of time: studies show that if a doctor’s intention is to listen deeply to a patient, it only takes about 18 seconds to have a moment experienced by the patient of “being with,” of good connection, of “feeling seen”—and then of being more open to revealing personal information.”
That present moment may be the most significant thing we do for someone who is suffering, that moment of mindfulness, what the Dalai Llama calls, “being a beautiful presence.” And hey—these are the moments we live for, yes? And you never know when they might suddenly appear! So be ready—as Hamlet put it, “the readiness is all!”
Or, as a patient of mine once said, “Doc, y’know, you never know, y’know.”
My new novel, The Spirit of the Place, is about primary care doctors in a small town—a young doctor joining his former mentor in practice. This was a dream of mine, to go back home to practice. It didn’t work out in life, so I did it in fiction.
At one point the young doctor is making a difficult personal decision, and hears the words: Don’t spread more suffering around. Whatever you do, don’t spread more suffering around.
This is the basic human story. We are all on the same journey. Every one of us will suffer–that’s the Buddha’s First Noble Truth. There’s no way around it. The crucial question is not suffering, it’s how we move through it.
If we isolate ourselves and try to gut it out, alone, “stand tall, draw a line in the sand”, we will suffer more, and spread more suffering around. But if we move through the crucible of suffering with others—with caring others, and that’s where we doctors come in, that’s our job!—we will not suffer as much, we will not spread more suffering around, and understanding will arise, and even kindness and awareness.
This is not a psychological healing, but a spiritual one—greater than your self. Each of you has been touched by it, the spirit, at least once, or you wouldn’t have made it here, now.
As a doctor, a writer, a husband, a father and a person, I believe in this power of good mutual connection to heal, I believe in this spirit, this redemption.
That’s the challenge, the thrill, the joy in The House of God: to become aware that the pain and suffering of others is the same as our own; to become aware that if we are ignorant of our neighbor’s sorrow, we bring sorrow to our own door; and with that awareness, to take anger and spin it to compassion; to give solace, to heal. For at our best, we don’t just doctor, we heal.
This article originally appeared on the blog What Works For Me.
By Richard Pieters, M.D., President, Massachusetts Medical Society
My President’s Message in the November issue of Vital Signs, our monthly publication for MMS members, cited encouraging findings from The Physicians Foundation 2014 survey. The survey, which received responses from more than 20,000 physicians across the U.S., found that 49 percent of us feel positive about the future of the medical profession. While that’s still below half, it’s a huge 26 percent increase from TPF’s 2012 survey.
Despite the trend, however, pessimism and negativity are growing, even from some colleagues within the profession. In an August 29 essay in The Wall Street Journal headlined Why Doctors Are Sick of their Profession, cardiologist Dr. Sandeep Jauhar writes:
“Today medicine is just another profession, and doctors have become like everybody else: insecure, discontented and anxious about the future …. The growing discontent has serious consequences for patients.”
Other physicians have expressed similar dissatisfaction with the profession, whether it stems from administrative overload, more legislative or regulatory requirements, or intrusion into the physician-patient relationship.
This kind of perspective is reaching patients. An essay entitled Doctors Tell All – and It’s Bad in the November edition of The Atlantic by Meghan O’Rourke – a self-described “patient and the daughter of a patient” – states:
“A recent crop of books offers a fascinating and disturbing ethnography of the opaque land of medicine, told by participant-observers wearing lab coats. What’s going on is more dysfunctional than I imagined in my worst moments…. Few of us have a clear idea of how truly disillusioned many doctors are with a system that has shifted profoundly over the past four decades.”
Medicine has indeed changed dramatically. But is our profession deteriorating as fast as some suggest? Are patients being negatively affected?
Many of us may bristle at the increasing administrative hassles, the interference in the physician-patient relationship, and the loss of independence.
I do not, however, believe medicine is “just another profession.” And I don’t think our patients do either.
Consider these assessments: a Gallup poll ranks doctors fourth among professions in honesty and ethics, and a Harris poll shows doctors to be regarded as the most prestigious occupation in America. The Harris poll also found that 91 percent of respondents would encourage a child to become a doctor.
Consider also an October 23 Perspective article in the New England Journal of Medicine, which seems to paint a different picture.
A review of polls on public trust in U.S. physicians and medical leaders from 1966 through 2014, as well as a survey of 29 countries, reveals that “public trust in the leaders of the U.S. medical profession has declined sharply over the past half century and that “the level of public trust in physicians as a group in the United States ranks near the bottom of trust levels in a survey of 29 industrialized countries.”
The authors of the article cite a Gallup poll of June 2014 indicating that only 23 percent of the public has confidence in the U.S. health care system. “We believe,” the authors write, “that the medical profession and its leaders are seen as a contributing factor.” Yet another Gallup poll released in November shows that 66 percent of Americans are satisfied with how the health care system works.
But here’s the key finding from the NEJM article: the decline in trust is not reflected in patient satisfaction with medical care. While the U.S. may rank near the bottom internationally in the public trust in physicians, it ranks near the top in patient satisfaction with medical treatment.
Our own public opinion poll of last year found a similar result. The overwhelming majority of Massachusetts residents (84 percent) remains as satisfied with the health care they receive as they were before reform began in 2006. The biggest reason: the “quality of care.” That reflects the work we’re doing as physicians.
So as the polls continue, and the pessimism persists, let’s take both in stride. Most of all, let’s listen, to our patients. They are, in the end, the best judges of our performance as physicians, and they’re telling us we’re doing well.
The President’s Podium appears periodically on the MMS Blog, offering Dr. Pieters’ commentary on a range of issues in health and medicine.