Texas Family Physician, Summer 2016 by Texas Academy of Family Physicians

TEXAS FAMILY PHYSICIAN VOL. 67 NO. 3 2016

APP STORM Leverage New Tech To Improve Health And Engage Patients

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TEXAS FAMILY PHYSICIAN VOL. 67 NO. 3 2016

There’s an app for that

Sometimes change is good and sometimes, technology is indeed the answer. You can leverage emerging tech to improve care and increase patient engagement. By Jeffrey M. Bullard, MD

Physician compensation under the microscope

The OIG is stepping up investigations of health care providers and family physicians should be concerned. By Corinne Smith

HPV: A Texas-sized problem

Texas has among the highest rate of hepatitis C and the lowest HPV vaccination numbers in the country.

By Carolyn Aldigé and Erich M. Sturgis, MD, MPH

The effect of the amino acid L-theanine on alertness and vigilance

By David W. Bauer, MD, PhD

6 FROM YOUR PRESIDENT Managing change and how your Academy is helping 8 NEWS BRIEF MACRA: New options allow you to pick your pace 10 MEMBER NEWS Dallas residency program wins AAFP grant | TMA re-elects Athens FP to board of trustees | Castroville FP selected for AAFP position | Remembering two longtime leaders 13 ANNUAL SESSION & PRIMARY CARE SUMMIT PREVIEW Everything you need to know to have a great meeting in Dallas this November 26 FOUNDATION FOCUS TAFP Foundation awards first Henry J. Boehm, Jr., MD, Scholarship 30 TAFP PERSPECTIVE Med students, spend some time with a family doc

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PRESIDENT’S COLUMN

TEXAS FAMILY PHYSICIAN VOL. 67 NO. 3 2016 The Texas Academy of Family Physicians is the premier membership organization dedicated to uniting the family doctors of Texas through advocacy, education, and member services, and empowering them to provide a medical home for patients of all ages. TEXAS FAMILY PHYSICIAN is published quarterly by TAFP at 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Contact TFP at (512) 329-8666 or jnelson@tafp.org.

OFFICERS president

Ajay Gupta, MD

president-elect vice president

Tricia Elliott, MD

Javier “Jake” Margo, MD

treasurer

Janet Hurley, MD

parliamentarian

Rebecca Hart, MD

immediate past president

Dale Ragle, MD

EDITORIAL STAFF managing editor

Jonathan L. Nelson

associate editors

Perdita Henry and J.D. Harris chief executive officer and executive vice president

Tom Banning chief operating officer

Kathy McCarthy, CAE

advertising sales associate

Michael Conwell CONTRIBUTING EDITORS Carolyn Aldigé David W. Bauer, MD, PhD Herbert Rosenbaum Corinne Smith Erich M. Sturgis, MD, MPH The Texas Diabetes Council

SUBSCRIPTIONS To subscribe to TEXAS FAMILY PHYSICIAN, write to TAFP Department of Communications, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Subscriptions are $20 per year. Articles published in TEXAS FAMILY PHYSICIAN represent the opinions of the authors and do not necessarily reflect the policy or views of the Texas Academy of Family Physicians. The editors reserve the right to review and to accept or reject commentary and advertising deemed inappropriate. Publication of an advertisement is not to be considered an endorsement by the Texas Academy of Family Physicians of the product or service involved. TEXAS FAMILY PHYSICIAN is printed by AIM Printing and Marketing, Austin, Texas. LEGISLATIVE ADVERTISING Articles in TEXAS FAMILY PHYSICIAN that mention TAFP’s position on state legislation are defined as “legislative advertising,” according to Texas Govt. Code Ann. §305.027. The person who contracts with the printer to publish the legislative advertising is Tom Banning, CEO, TAFP, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. © 2016 Texas Academy of Family Physicians POSTMASTER Send address changes to TEXAS FAMILY PHYSICIAN, 12012 Technology Blvd., Ste. 200, Austin, TX 78727. 6

TEXAS FAMILY PHYSICIAN [No. 3] 2016

MACRA and managing change By Ajay Gupta, MD TAFP President family medicine at the national level. Valueas many of you are acutely aware, our health based health care is here and no matter who care delivery system is undergoing dratakes over the White House, it’s here to stay. matic changes. For those of you who have There has been a lot written about the been around as long as I have, this has been a payment reforms stemming from the Medisimilar theme for several years. One common care Access CHIP Reauthorization Act of phrase I have heard over the years is the idea 2015 — MACRA — and the effect it will have of “change.” Many of us have been frustrated on us. While I see several issues with it, I by the changes in the past. These changes do feel it provides a framework for placing have been unfavorable for family media true value on the praccine. One thing is clear: the tice of family medicine. current system is broken The trouble, of course, is and unsustainable. MACRA is in the details. The new Every day patients actually rewarding system will require a higher ask my opinion on these level of data reporting. On changes. Will it help family practices that do a positive note, the data medicine? Will private quality reporting recorded is more specific and practice survive? What’s with higher the process is more streamgoing to happen to you and lined. CMS has committed your colleagues? I respond payments. This to helping smaller practices by telling them I feel our is an increase get the support they will current system is indeed from the current need and has recognized the broken. need to commit resources to The gap between us and system in which practices decide what our specialty colleagues has these rewards will help payment system to choose. only increased. Personally, soon be phased MACRA is actually I have no issues with sperewarding practices that do cialists or others who hold out. Furthermore, quality reporting with higher a job making what they the penalties for payments. This is an increase make. While I do feel it’s lower quality from the current system in unfair to a degree, I do which these rewards will not fault my colleagues. I reporting will be soon be phased out. Furdo not fault entertainers less than those thermore, the penalties for and athletes for the same that exist now. lower quality reporting will reasons. Most of us do not be less than those that exist turn down money when now. For those of you who it’s offered to us based on have already achieved medical home status, what is perceived as our value. I do feel the the work you have done will be recognized pot of money going into health care has in the new MACRA system and can be used gone up rapidly and is unsustainable. I am, for data reporting. This is not the case in the however, more optimistic than before that existing system. the distribution gaps will narrow. Hopefully The most important thing that MACRA this translates into family medicine getaccomplished was to replace the annual SGR ting a higher percentage of the distribution threat that would lower Medicare physithan before. If we don’t shift to the right of cian payments. This issue caused significant the distribution curve, I fear more doctors angst and utilized resources for all of us. It will choose other specialties. This would will be up to all of us to make sure that CMS be a horrible turn for our country and for follows through with its proposals and conour health care system. I feel there is more tinues to value family medicine. There are awareness of this potential exodus from

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still areas of MACRA that need improvement, but I am glad we finally have something that recognizes the value we bring to the system. For the first time in years, I am cautiously optimistic. AAFP has created MACRA Ready, a resource to help make MACRA more understandable for everyone. Found on the AAFP site, MACRA Ready has videos and frequently asked questions ready to give an introduction to the changes coming with MACRA in 2019, as well as news and more in-depth breakdowns of policy changes. There are tools to break down the plentiful acronyms found throughout MACRA documentation, important procedural dates to look out for, and more. Sign up for AAFP’s email updates so you can be aware of any changes as soon as they take place. www. aafp.org/practice-management/payment/ macraready.html At TAFP, educating our members about MACRA and helping you find the tools and resources you need to succeed in this new payment paradigm is the top priority of our communications department. Articles in Texas Family Physician, on TAFP. org, and in TAFP News Now have and will continue to explore the transition to valuebased payment and how the new payment and reporting requirements for Medicare can be met. We have partnered with TMF Health Quality Institute to bring you the most up-to-date regulatory information from CMS and to introduce you to the many resources the organization offers free of charge. You can explore TAFP’s practice transformation resources at www.tafp. org/practice-resources/change, including our video collection, “Family Physicians Embracing Change,” in which TAFP members describe their practices in alternate payment models. We are also presenting MACRA education at our Annual Session and Primary Care Summit, November 4-6 in Dallas, so plan to join us. With these resources, you can feel confident in tackling MACRA alongside your Academy.

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NEWS BRIEF

COMING SOON ON TAFP’S

CME SCHEDULE Annual Session & Primary Care Summit Nov. 4-6, 2016 Nov. 2-3: Business meetings and preconference workshops

The Westin Galleria Dallas, Texas C. Frank Webber Lectureship & Interim Session April 7-8, 2017 Renaissance Austin Hotel Austin, Texas Texas Family Medicine Symposium June 2-4, 2017 La Cantera Hill Country Resort San Antonio, Texas

2017 and MACRA are on the way, but now you can pick your pace By Perdita Henry the march from volume-to-value by way of the Medicare Access and CHIP Reauthorization Act of 2015 has been steady, and as we prepare to meet 2017, anxiety about the new Quality Payment Program has left many wondering what hurdles they will have to face. CMS recently announced the Pick Your Pace Program, specifically designed to assist medical providers at different readiness levels as they prepare for MACRA. The announcement was a welcomed development by AAFP Board Chair Robert Wergin, MD, who took it as a sign that CMS not only took into account AAFP’s comment letter in reference to MACRA but also realized physician success in implementing the new payment program benefits everyone in the health care community. “Family physicians welcome the news that CMS will allow physicians to choose the pace at which they will move toward fully participating in the MACRA Quality Payment Program,” Wergin said in a September 9 press release. “In our response to the proposed rules to implement MACRA, the American Academy of Family Physicians outlined a series of steps — including delay or flexibility in launching the performance year — that CMS could take to ensure the success of the payment reforms.” Physicians will have the opportunity to choose four paths to participate in the Quality Payment Program. 1. Test the Quality Payment Program Ensure your system is working and prepare for broader participation in 2018 and 2019.

2. Participate for part of the calendar year. Submit data performance for a shorter period of time during 2017 — your choice of what part of the year — and still have time to explore and learn about meaningful use in the Quality Payment Program before diving in fully. 3. Participate for the full calendar year. Ready to conquer the MACRA Quality Payment Program on January 1? Go for it. 4. Participate in an Advanced Alternative Payment Model in 2017. If you’re already in an ACO participating in Tracks 2 or 3 of the Medicare Shared Savings Program, or you practice in another CMS-identified Alternative Payment Model, then this pathway is for you. Andy Slavitt, acting administrator of CMS, commented on the recent change in a September 8 blog post on CMS.gov. “However you choose to participate in 2017, we will have resources available to assist you and walk you through what needs to be done. ... Your feedback will be invaluable to building this program for the long term to achieve outcomes that matter to your patients.” This new pick-your-pace approach is a direct result of AAFP and numerous other organizations working hard to make sure the implementation of MACRA’s Quality Payment Program does not leave physicians with a learning curve so large it impedes upon the reason MACRA was developed in the first place: improving the value of patient care.

Are you MACRA ready? Check out these AAFP resources: www.aafp.org/practice-management/payment/macraready.html

TEXAS FAMILY PHYSICIAN [No. 3] 2016

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MEMBER NEWS

Dallas residency program wins AAFP vaccine grant The Methodist Family Medicine Residency Program of Dallas was awarded one of seven 2016 Senior Immunization Grants from AAFP. Rajasree Nair, MD, and her team focused their project on improving vaccination rates for family medicine patients 65 and older. “We are planning to conduct an immunization drive in the community and the majority of the cost will be the cost of the vaccines themselves, along with staff time for the administration of the vaccine,” Nair says. “Receiving such an award to further our work provides us not only with the resources to improve the immunization rate but also provides a sense of accomplishment for the work done by the entire team. In addition to transforming our practice and improving the immunization rate we hope to train the resident physicians on basic principles of population health, working in teams, effective communication with patients and staff, assessing the health literacy of patients, and developing standardized protocols for improving immunization rates.” The award includes a majority share for funding of the project, along with a smaller portion to cover one resident’s fees when the team sends a member to present their findings at the 2017 National Conference of Family Medicine Residents and Medical Students. 18 applications were submitted for the grant which included a detailed proposal and a preliminary budget, with Nair’s team making it through to become one of the final selections. “We would like to sincerely thank AAFP foundation for giving us this opportunity and our clinical team who is very committed to the care of our patients,” Nair says. “We would also like to thank the Methodist Health System Foundation who will be assisting us the with grant process. Participation in such projects enhances the residents’ understanding of health care, of the communities they serve, and ways in which they can be active participants and leaders for improving the health of local population.” 10

TEXAS FAMILY PHYSICIAN [No. 3] 2016

TMA re-elects seasoned advocate to its board of trustees tafp congratulates Douglas W. Curran, MD, who was recently re-elected to the Texas Medical Association’s Board of Trustees. Curran practices family medicine in Athens, Texas, and over his 36 years as a family doctor, he has become a recognized advocate for the patients and physicians of the state. He played a leading role in the passage of Texas’ groundbreaking medical liability reforms, Douglas Curran, MD fought for sweeping patients’ rights reforms including holding managed care companies accountable for their actions, championed legislation to improve the Children’s Health Insurance Program and Medicaid, and fought attempts by non-physician practitioners to expand their scope of practice. He will serve his second three-year term on the board. Communication between physicians of different specialties is important in improving the health care system and TAFP members holding leadership positions in TMA and other professional physician organizations facilitate just that. “When doctors from all specialties are communicating, we find out we have much in common and our goals are consistently oriented toward improving patient care and the overall health of all Texans,” Curran says. Curran is determined to improve access to care for all Texans — especially the working poor — and to decrease payment hassles for physicians. His position on the board allows him to advocate on behalf of both parties. He says bringing the hardships patients face to the forefront of the conversation is one of the pillars of facilitating change within the health care system. “We must tell our stories of patient care and the needs of our patients with character, integrity, and persistence.” Curran has been a leader in TMA, TAFP, and AAFP, serving on numerous committees and in various officer roles. At TMA, he has served on the Council on Legislation

and the Select Committee on Medicaid, CHIP, and the Uninsured; he chaired the Select Committee on National Health System Reform and is a member of TEXPAC. As a past president of TAFP, Curran has held every office of the organization. He has also chaired the Commission on Membership and Member Services, and the Commission on Legislative and Public Affairs, and is an active member of TAFPPAC. In 2000, Curran was named Texas Family Physician of the Year. He also served on the AAFP Commission for Governmental Advocacy and is currently the TAFP Alternate Delegate to the AAFP Congress of Delegates. His dedication to his patients and his passion for advocacy make a difference in Texas. By telling the stories of his patients and shining a light on hurdles facing physicians, he continues to help unify the voice of organized medicine.

Castroville FP selected for AAFP position at this year’s aafp National Conference of Constituency Leaders, Mary Nguyen, MD, was elected to be the minority co-convener for NCCL 2017 and a member constituency alternate delegate for the AAFP Congress of Delegates. NCCL will be held in Kansas City, Missouri from April 2729, 2017, while the Congress of Delegates met in Orlando, Florida from September 1921, 2016. Nguyen practices at the Medina Valley Mary Nguyen, MD Family Practice in Castroville, Texas, has been a member of both TAFP and AAFP since 1992, and adds her new titles to a lengthy list of leadership positions. She received her bachelor’s degree in English and biology from St. Mary’s University and her medical degree from the University of Texas Health Science Center at Houston. After graduation, Nguyen completed her residency at the CHRISTUS Santa Rosa

“I very much enjoy being active in the Academy and appreciate the fact that the AAFP gives all members an opportunity to be heard as well as an opportunity to serve as a leader.” — Mary Nguyen, MD

Family Medicine Residency Program in San Antonio. “I very much enjoy being active in the Academy and appreciate the fact that the AAFP gives all members an opportunity to be heard as well as an opportunity to serve as a leader,” Nguyen says. “I hope to increase membership involvement in the special constituencies. I very much enjoy advocating for my patients.” Serving as the minority co-convener, Nguyen will assist the NCCL convener, Dr. Ravi Grivois-Shah of Tucson, Arizona, in running their meeting at the conference and will run the minority caucuses with another co-convener, Dr. Eleanor LavadieGomez of Iowa City, Iowa. Nguyen has been elected to four NCCL delegate positions in the past and said she feels comfortable with the duties and responsibilities the title brings with it. She hopes to become more active in her state chapter and possibly become a state officer in the future. She has graciously accepted these positions but also wants to acknowledge her support system. “I am married to a family physician who is a past AAFP board member, Lloyd Van Winkle, MD. He is extremely supportive of my decisions and interests in leadership at all levels,” Nguyen says. “He is my business partner as well as my life partner and I am very grateful for his love and support. I would not be able to do what I do without it.”

In memoriam Robert Echols, MD TAFP life member Robert Echols, MD, passed away at the age of 94 on August 25, 2016, in Rockwell, Texas. Echols was born June 23, 1922 in Little Rock, Arkansas and grew up in St. Louis, Missouri. He graduated from the University of Missouri, Columbia and went on to attend medical school at Washington University School of Medicine. In 1952, Echols, his business partner, Dr. Henry Crawley, and their families relocated to Kilgore, Texas and established the Kilgore Medical Clinic. For 43 years he practiced an array of family medicine duties ranging from obstetrics to emergency room care; to house calls and mission trips abroad in Mexico and Belize. His interest in cardiology led him

to become one of the first CPR instructors in the state and to help establish one of the first cardiac rehabilitation centers in East Texas. Echols a founding members of AAFP, was named Fellow in 1972 by the organization, and was recognized by TAFP as the 2008 Physician Emeritus. Along with these distinct honors, he also served as Chief of Staff at Laird Memorial Hospital and as a board member to Memorial Hospital, East Texas Treatment Center, and the Hospital Foundation. He is survived by his wife of 65 years, Billie Anne Echols, their three children, including TAFP member Dr. Bruce Echols, five grandchildren, six greatgrandchildren, and a nephew.

Edwin Lee Mueller, MD TAFP Life Member Edwin Lee Mueller, MD, passed away on August 3, 2016 at the age of 89. Mueller was born September 12, 1926 in San Antonio Texas, and graduated from Central Catholic High School. After a stint in the U.S. Navy during WWII as a Signalman, Muller resumed his education and received his medical degree from St. Louis University Medical School in 1951. He practiced medicine for 40 years in his hometown, often caring for multiple generations of the same families, until his retirement in 1994 to spend more time with his family. Son of first-generation TAFP member, Dr. Edwin Mueller, Sr., he became a second-generation member in 1948.

During his career he served as President of the Medical Staff of Santa Rosa Northwest Hospital and was an active member of several professional organizations. In 1997 the TAFP Alamo Chapter partnered with the TAFP Foundation to establish the Edwin L. Mueller, MD, Scholarship to benefit medical students at UTHSC San Antonio. He is survived by his wife of 66 years, Mary Helen, their 8 children, including TAFP members Dr. Francis Mueller of San Antonio and Dr. Thomas E. Mueller of Columbus who is a past TAFP President and Physician of the Year, 23 grandchildren, 12 great-grandchildren, and five siblings.

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TEXAS FAMILY PHYSICIAN [No. 3] 2016

6/12/11 7:18:42 PM

TAFP’S 2016 ANNUAL SESSION & PRIMARY CARE SUMMIT November 4-6, 2016

Celebrate the specialty of family medicine at TAFP’s 2016 Annual Session and Primary Care Summit this November. Join your colleagues from across Texas to learn, network, and explore the latest in techniques, products, and services. Here’s a quick look at what’s in store for this year’s conference. 3 must-see CME topics at ASPCS, according to Jessica Miley, TAFP’s CME expert • Physician Leadership in a Time of Change Christopher Crow, MD, MBA • Brainstorm: Migraine Treatment and Management and Treatment Overview of Type 2 Diabetes Jeff Unger, MD

Annual Session business: Nov. 2-5 Preconference workshops: Nov. 2-3

• Tamra K. Deuser, MD, Lecture: Ethics – Palliative Care in Primary Care Clare Hawkins, MD, MSc

THE WESTIN GALLERIA HOTEL DALLAS, TEXAS

TAFP mobile app We have so many great events planned, you need something to keep track of it all. Check out the ASPCS mobile app. Not only can you build your own schedule, but you can track your CME, access exclusive content, download meeting materials, and more. What’s better than access in the palm of your hand? Download it now by searching “TAFP” in your app store.

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MEMBER NEWS

Where? The Westin Galleria Dallas 13340 Dallas Pkwy | Dallas, Texas 75240 Features: in-room spa service, fitness center, and The Second Floor by Scott Gottlich.

Things to do near the hotel: It doesn’t have to be all work and no play. Keep it close to home and dine at one of the superb restaurants located in the hotel. Maybe take an adventure with the kids at the Perot Museum of Nature and Science. And don’t forget that a little retail therapy goes a long way at the Galleria Dallas. Galleria Dallas: Adjacent to the hotel is one of North Dallas’ biggest attractions, including stores like Nordstrom, American Girl, Coach, Pottery Barn, Tiffany & Co., and restaurants like Grill on the Alley, The Second Floor by Scott Gottlich, Oceanaire, Mi Cocina, and more. Ice Skating at the Galleria: That’s right. Lace up your skates and practice your Triple Lutz. The rink at the heart of the Galleria should be open during the conference.

Go to www.tafp.org for more information and to register.

KSA Group Study Workshops Health Behavior Wednesday, Nov. 2, 1 – 5 p.m. Moderated by Clare Hawkins, MD, MSc Hypertension Friday, Nov. 4, 1:15 – 5:15 p.m. Moderated by Dale Moquist, MD Diabetes Friday, Nov. 4, 1:15 – 5:15 p.m. Moderated by Karen V. Smith, MD Well Child Care Sunday, Nov. 6, 8 a.m. – 12 p.m. Moderated by Rebecca Hart, MD

At the Member Assembly on Friday, Nov. 4 during this year’s TAFP Annual Session and Primary Care Summit, members will elect two of their colleagues to the TAFP Board of Directors. Three members are running for one available at-large position and two members are running to hold the new physician position. According to the TAFP Bylaws, a slate of candidates are proposed by the Nominating Committee. Candidates may also be nominated by local chapters provided the nominations are made at least 90 days prior to the election, and candidates may be nominated from the floor at the Member Assembly. If you have any questions about the nomination or election process, please contact Kathy McCarthy at kmccarthy@tafp.org.

AT-LARGE DIRECTOR A graduate of both the University of Texas at Houston Health Science Center and School of Public Health, Emily Briggs, MD, MPH, completed her residency with the CHRISTUS Santa Rosa Family Medicine Residency Program. Briggs is currently the medical direcEmily Briggs, MD tor for the Comal and New Braunfels Independent School Districts and the founder of the Briggs Family Medicine private practice clinic. She has served as president, president-elect, vice-president, and secretary of the TAFP Alamo Chapter, and served three years as new physician director on the TAFP board and

TEXAS FAMILY PHYSICIAN [No. 3] 2016

one year as new physician director on the AAFP board. After graduating from the University of Texas at Houston Medical School, Grant Fowler, MD, stayed on to complete his residency training at Memorial Family Residency Program. Fowler is currently a professor and vice chair of the Department of Family and Community Medicine at the McGovern Medical School. Grant Fowler, MD He is a member of the National Procedures Institute advisory committee and the TAFP Commission on Continuing Professional Development. He is also the co-editor of “Pfenninger and Fowler’s Procedures for Primary Care.”

Oscar Garza, MD, served in the United States Navy, in active duty from 19741979 and as a reservist from 1979-1984, before being awarded his medical degree from the Medical College of Wisconsin in 1985. Garza went on to complete his Oscar Garza, MD residency at the Texas Tech University Health Center in 1988. He now lives in Pearsall, where he is the medical director for the Family Medicine Clinic and Pearsall Nursing and Rehab, as well as the chief of staff for the Frio Regional Hospital. Garza has served on the TAFP Commission on Professional Development, the Finance Committee, and the Leadership Development Committee.

TAFP member events TAFP business meetings will take place Wednesday – Saturday, Nov. 2 – 5. Other TAFP member events include: FRIDAY, NOVEMBER 4 Research Poster Competition | 8 a.m. – 5 p.m. Member Assembly Luncheon 11:45 a.m. – 1 p.m. Reception in the Exhibit Hall | 5 – 6 p.m. TAFP Foundation Gourmet Dinner | 6:30 p.m. (Tickets are $150 each; proceeds benefit the TAFP Foundation) SATURDAY, NOVEMBER 5 Business and Awards Luncheon | 12 – 2 p.m. Members’ Reception | 5:30 – 6:45 p.m. President’s Party | 7 – 10 p.m.

NEW PHYSICIAN DIRECTOR An alumnus of the University of Texas at Houston Medical School, Angela Cade, MD, completed her residency at UT Health Northeast Family Residency Program in Tyler, where she is now an assistant professor of medicine. She has held two professor positions and worked for Good Shepherd Medical Associates of Longview. Cade is a Angela Cade, MD member of the TAFP Commission of Academic Affairs and has volunteered free-to-low-cost medical care in multiple East Texas cities. Upon graduating from the University of Benin Medical School in Benin City, Edo State, Nigeria, Ikemefuna “Ike” Okwuwa, MD, completed his residency at Texas Tech University Health Sciences Center of the Permian Basin, where he is now on staff. He was elected to be a representative from the National Conference of Constituency Leaders to the ConIke Okwuwa, MD gress of Delegates in 2015, served as alternate delegate that year and as a member constituency delegate in 2016, and was elected to the rules committee for this year’s congress.

PROPOSED AMENDMENTS TO TAFP BYLAWS The proposed amendments to the TAFP Bylaws are in accordance with the TAFP Bylaws, Chapter XVII, Amendment of Bylaws. An affirmative vote of at least two-thirds of the members present and voting at the annual business meeting shall constitute adoption. If you would like a complete copy of the TAFP Bylaws, contact Kathy McCarthy at (512) 3298666, ext. 114. The Bylaws Committee and the Board of Directors recommend adoption of these amendments. Chapter VI. Classes of Membership and Election SECTION 7. A student member may not shall not vote nor hold office in the Academy, but shall have the privilege of addressing the membership and serving on committees and commissions. However, one student may be elected to the Board of Directors. Chapter X. Annual Business Meeting SECTION 3. Any member of the Academy in good standing may submit a resolution to the Board of Directors for consideration at the annual business meeting and to be published in the official journal on the Academy website prior to the annual meeting, provided: (1) the resolution is signed by five other members in good standing, and; (2) it is sent by registered mail to Academy headquarters at least 60 days prior to the annual business meeting. Chapter XI. Member Assembly SECTION 1. A Member Assembly shall convene at least annually to review policy and direction implemented by the Board of Directors, Executive Committee, and committees of the Board. The Assembly, composed of delegates from TAFP local chapters, shall elect officers, Delegates to the AAFP, and the TAFP Board of Directors, and act on business specifically referred by the Board of Directors. In addition, the delegates to the Assembly may, by majority vote, approve referenda for submission to the members of TAFP on questions affecting the policy or recommendations of the Academy. Any member in good standing may attend the Member Assembly. Voting shall be limited to the members specified in Section 2. Chapter XII. Board of Directors Sub-chapter 1. Policy and Procedure

special constituency membership of the Academy, respectively. The Section on Medical Students, Section on Resident Physicians, and Section on Special Constituencies shall select members in good standing at their Interim Session meeting to recommend for those director positions. They shall be elected by the annual Member Assembly and begin serving at the conclusion of the Annual Session. The term of office shall be one year and they may succeed themselves. There shall be a limit of three consecutive terms for the special constituency position on the TAFP Board of Directors. Members would be allowed to serve on the Board in another capacity. Members would be eligible to serve as special constituency director after a minimum of a one-year hiatus. Members having completed three consecutive one-year terms as the special constituencies director would be allowed to serve on the Board in another capacity. Such members would also be eligible to serve as special constituencies director again after a minimum of a one-year hiatus. Chapter XII. Board of Directors Sub-chapter 1. Policy and Procedure SECTION 10. At the Interim Session meeting of the Board of Directors, the Nominating Committee shall present prepare nominations for officers, directors, and Delegate and Alternate Delegate to the AAFP Congress of Delegates. Nominations may be made from the floor at the Annual Session Member Assembly. A Delegate or Alternate to the Congress of Delegates of the AAFP may hold another elected or appointed office; and provide further that any additional Delegates from the Texas Chapter to the AAFP may be elected at the Annual Session Board of Directors meeting without further amendment of the Bylaws. Chapter XII. Board of Directors Sub-chapter 3. Elected Positions SECTION 7. AAFP Delegates The term of office of a Delegate to AAFP shall not exceed three consecutive two-year terms. The term of the office of Alternate Delegate to AAFP shall not exceed three consecutive two-year terms. The terms of the TAFP Delegates and Alternate Delegates to the AAFP will begin and end at the end of the AAFP Congress of Delegates conclusion of the TAFP Annual Session.

SECTION 2. The student, resident, and special constituency directors shall be nominated from among the student, resident, and

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cover story

Leverage technology to improve patient health and engagement

There are apps for that By Jeffrey M. Bullard, MD

hile most would agree that resistance to change is normal, there seems to be a consensus that when it comes to the state of health care in America, change is necessary and inevitable. In response to the high cost of care, there has been an unrelenting shift in the design of care delivered in the United States. Most notably, thereâ&#x20AC;&#x2122;s a shift to value-based care with the recognized need to create care teams, address the needs of the whole patient, increase communication with patients, and focus more on health than illness. In other words, we need to keep patients healthy instead of spending our time and money trying to reverse ill health. Some doctors are fully on board with this. They are aware of the necessity to adapt. Many are turning over the business reins so they can focus all their energy on care coordination. Others are joining forces and taking a more active role in the business. They are forming accountable care organizations and clinically integrated networks representing large groups of physicians whose purpose is to provide better quality care at lower costs. These physicians look at the pressures from the market as a potential opportunity for improvement, not as a devastatingly negative situation. Their hope is that by increasing physician engagement in the rapidly evolving business of medicine, there will be opportunities for significant improvements in care delivery, population wellness, and the cost of care. As a member of the board of governors for a clinically integrated network, Catalyst Health Network, which represents 300 primary care providers and over 150,000 patients in the Dallas-Fort Worth area, I have had an opportunity to experience this process firsthand. By banding together, we now have an opportunity to capitalize on each physicianâ&#x20AC;&#x2122;s unique understanding of the requirements of care delivery and use that information to drive business decisions and shape the way care is delivered.

TEXAS FAMILY PHYSICIAN [No. 3] 2016

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OVER THE LAST 25 YEARS WE HAVE SEEN: • The addition of a myriad of new imaging technologies, lab tests, and medications; • The explosion of the Internet with an abundance of readily available medical information once held only by those in medical fields; • A change in the patient’s expectations of the doctor-patient relationship from a paternalistic to an interactive cooperative one; • A rapidly growing interest in alternative medicine and an onslaught of products and programs to support that interest; • A transition to employer-led health insurance decisions; • Several failed attempts at ‘managed care’ delivery as well as other health care delivery overhauls; • A transition from fee-for-service to a rapid increase in value-based reimbursement; • The introduction of Obamacare, its increased administrative intricacies, and now a transition to MACRA; • Growing doctor frustration and burnout; • Patients looking for alternatives to traditional care; • Doctors exiting the field of patient care to escape the chaos; and • The awareness that despite claims that the United States has the best health care in the world, our system is broken and not delivering the value or outcomes it should or could. 18

TEXAS FAMILY PHYSICIAN [No. 3] 2016

THE TECH UNDERCURRENT In the midst of the chaotic and rapidly changing world of the business of health care, something else has been silently brewing. Application designers and technology vendors have been cranking out a plethora of health-related apps that are designed to improve patient health. These apps do everything from track blood pressure to differentiate depression from anxiety. Micro-technology is being designed that can be inserted into the circulatory system and provide constant feedback about a diabetic’s blood sugar or the presence of cancer cells. Amazing, right? But there are some obstacles to adoption of these devices. I have had the opportunity to be involved in the creation of two health-related apps. As a result of this work, I have spent a great deal of time talking with providers across the country and gained a greater understanding of challenges providers face when dealing with these technologies. Most of these apps are stand alone, single-purpose applications that the majority of health care providers view as just another source of information they have to somehow fit in and manage. It may be cool but … it produces DATA! Now, we providers have more data to deal with. These technologies generate questions like what to do with the data now that it’s available, where to store the data, how to talk to patients about the data generated, and how to incorporate the data collection into the current office workflow. A real downside is that most insurance companies don’t have a mechanism for paying for the use or interpretation of the data that many of these apps and devices produce. At the end of the day, we do what we are paid to do. If we examine this a bit more, we see other obstacles in addition to the data. As doctors, we have been trained to treat the patient in front of us. As a result of the changing world of health care, we are experiencing change overload. We must dedicate time to interpret and address the external knowledge patients bring to consultations about their care and learn new, complicated technologies required to meet government regulations. We must control the cost of care, comply with reporting requirements, and deal with payer pressure to change the way we deliver and document care or we will face decreased reimbursements. When asked to consider using new apps that can improve patient health or improve patient engagement in wellness efforts but not get paid for it, many of us simply do not have the head space or motivation to tackle one more thing.

CLINICAL DECISION SUPPORT My second app, Vault, was designed to tackle some of the challenges providers face in the complicated world of value-based reimbursement. What doctors desperately need are tools that allow them to leverage the onslaught of data, not just provide them with more. At heart, health care providers all want the same thing: to be effective in helping their patients get healthy. They need tools that assist them, speed their workflow, and leverage the data collected to positively impact patient care, not ones that just flood them with more information. We refer to these tools as “clinical decision support tools,” and they basically take data and intelligently assimilate it in a way that doctors can use it quickly and easily to steer treatments successfully. In other words, the doctors don’t just get raw data, they get data that already has a set of treatment rules applied to it. The results can then be used to make treatment decisions. Now increased data becomes a meaningful win for both patient and provider. See the difference?

At heart, health care providers all want the same thing: to be effective in helping their patients get healthy. They need tools that assist them, speed their workflow, and leverage the data collected to positively impact patient care, not ones that just flood them with more information. Let’s use Vault as an example. Vault assesses patients for mental health issues. In addition, it collects data from patients about issues like obesity, hormone imbalances, allergies, cancer risk, and pain that all affect overall wellness. Once that data is collected, a rules engine sorts through the data and looks for opportunities to move the patient towards wellness or to address obstacles that might be preventing this move. The data is processed intelligently and the results are presented to the doctor — not just the basic raw results. Vault also allows doctors to push the testing to the patient’s smartphone, computer, or tablet so they can complete tests anywhere and at any time. With these types of clinical decision support apps that engage the patient, doctors can follow patients between appointments, monitor treatment progress, track symptoms, and affect patient behaviors all from the same data. Like some of the newer tools, Vault can interact with other clinical decision support tools, sharing data, and supporting care delivery. That’s a powerful use of data. That’s the kind of support providers need if they are to squeeze value out of the data in which they are drowning. Unlike many other apps, the testing and interpreting of the data from Vault is reimbursed by most insurance payers, including Medicare. That’s a big plus for doctors as they try to pay for the ever increasing overhead costs associated with the transition to value-based reimbursement.

TECHNOLOGY WIN Change is uncomfortable and energy consuming, but it is inevitable and necessary in health care today, driven by obvious needs and potential benefits. We all need to be looking at what will result in the best outcomes, one where we have happier, healthier patients and providers, and significantly improved results from the care provided. In many cases, the answer is technology. I’m not talking about more tests, more drugs, and more intricate surgery, although they can also play a part. I am talking about using the technology we already have and are creating to transform the face of medicine into the caring, personalized, interactive, outcomes-driven model we are striving for it to be. That future involves using your smart phone, tablet, or laptop to connect With patients. There are countless opportunities to impact the quality, accessibility, and cost of care but we have to embrace the options available. We have the tools at our disposal to marry ancient wisdom and traditional medicine with cutting-edge science to create a whole new medical paradigm — good medicine that takes the best of both worlds. The future is here.

Jeffrey M. Bullard, MD, is CEO for the behavioral health assessment and tracking tool, Vault, and is a member of the board of governors for Catalyst Health Network, a Dallas-Fort Worth based clinically integrated network. Bullard is the founder and serves as CMO of MaxHealth Medical Associates, a community-based primary care center and is founder and medical director of Acuity Brain Center and MaxFitness Peak Performance and Personal Training. He is the current president of the Academy of Allergy and Asthma in Primary Care and serves as a medical advisory board member for multiple health care entities. For more on Vault, visit www.vaultintohealth.com.

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TEXAS FAMILY PHYSICIAN [No. 3] 2016

12/21/09 2:52:24 PM

OIG steps up investigations of health care providers: Physician compensation under the microscope By Corinne Smith, Strasburger and Price

eadlines like this should make you feel very uncomfortable. If it weren’t already hard enough to follow Medicare billing rules, the government’s scrutiny of physicians and compensation arrangements with health care entities adds an extra layer of complexity (and anxiety). In June the Dallas-based office of the Department of Justice Office of Inspector General boasted that they had issued 61 arrest warrants for the largest criminal health care fraud takedown in the history of the Department of Justice. The focus of this sweep highlighted arrangements between physicians, home health agencies and nursing homes. In addition to the arrest warrants issued, the OIG has identified an additional 255 health care agencies in Texas for further investigation. In the Dallas area, the report identified 52 agencies and 174 physicians that filed claims showing a lack of documentation, upcoding and a high percentage of care episodes despite the lack of face-to-face meetings between the physician and patient. Home health visits for diabetes and hypertension are particularly suspect, as are multiple home health admissions for the same patient. One report found that a single physician referred the same patient for admission to 10 different home health agencies in one year. In a particularly egregious Texas

case, a physician billed claims for services rendered to nursing home residents on dates Where he did not actually render services. In some instances, the claim was submitted for a date after the patient died or was discharged. After investigation, the physician was ordered to pay a fine of $100,000 and sentenced to 71 months in prison. The new focus on investigations of physicians and physician practices is noteworthy because historically the OIG’s scrutiny has focused on hospitals and large health care providers. Until this past year, physicians have rarely been implicated in these type of investigations — let alone been sentenced to prison for Medicare fraud. Last year, the OIG entered into settlements with 12 Texas physicians who had “questionable” or “sham” medical directorship and office staff arrangements. In each of these cases, the OIG determined the medical director arrangements were not for legitimate purposes but just served as extra compensation to the physician to solicit continued referrals of Medicare or Medicaid patients. The medical directors did not receive prison sentences but were all excluded from participation in federal health care programs for several years. Their settlements with the government ranged from $5,000 to $250,000. Many physicians have medical director agreements with hospitals or other health care providers to develop new programs, provide program www.tafp.org

TOP TEN SIGNS THAT YOU MAY BE THE TARGET OF A CRIMINAL INVESTIGATION 10. You receive notice from a patient that the patient was contacted by an investigator. 9. The OIG, the U.S. Attorney, or the State Attorney General serves you with a subpoena for records. 8. You are approached and questioned by a government agent. 7. You get a demand letter in a Medicare False Claims Act case. 6. Other professionals with whom you do business are arrested. 5. You receive a telephone call from a government agent or local law enforcement. 4. The government executes a search warrant for your records. 3. A government agency seizes your bank accounts. 2. You receive notice from an employee or former employee that he/she was contacted by an investigator.

1. And the number one sign that you may be the target of a criminal investigation …

You receive a target letter from the U.S. Attorney’s Office notifying you that you are a possible target in a criminal investigation.

TEXAS FAMILY PHYSICIAN [No. 3] 2016

oversight or fill administrative positions. You will want to review any compensation agreements you have with hospitals for medical director positions to ensure that they would withstand OIG scrutiny. While many of these reported cases involved physicians who were “bad actors,” you could still be found to have violated the law if you enter into improper financial relationships even without ill intent. Stark law is not an intent-based statute. This means that any breach of the law is a per-se violation and ignorance is not a defense. Here’s how you can enter into arrangements with hospitals, home health providers, and other health care entities and comply with the OIG’s directives. As HHS-OIG’s fraud alert discusses, to ensure that an arrangement fully complies with applicable laws and regulations, it is essential that you have an executed written compensation arrangement detailing the services to be provided. To avoid any antikickback violations, physician compensation must be at a fair market value for services provided. Absent extenuating circumstances, $150 per hour is considered a ball-park number for reasonable compensation for medical director services. Fair market value is a concept largely determined by industry salary surveys and leaves little room for negotiating compensation rates. The medical director must maintain written documentation of services provided and should submit a detailed timesheet showing time worked and duties performed. You should be very suspicious of unusual arrangements proposed by home health, hospital, durable medical equipment companies, hospitals, and any other health care providers. Never enter into any arrangement without a written agreement that sets the fee in advance. Payment can never be tied to the value or volume of referrals. Make sure your payments tie back to an invoice and that the invoice matches the terms of the agreement. Do not EVER allow anyone to bill Medicare or Medicaid using your billing number unless you have control over the billing entity or have an indemnification agreement. Be cautious about supervising mid-level practitioners if they are not your employees or working for you as independent contractors. And while this may seem obvious, never accept cash payments from anyone! These recent criminal take-downs, coupled with recent CMS Fraud Alerts, clearly signal that the OIG now intends to look more closely at physicians. Hospitals may be one of the few groups that think the focus on physicians is good news, as they have struggled for years to get physicians to recognize the importance of compliance with anti-kickback and Stark requirements. However, these laws limit the ability of physicians and hospitals to partner on new programs and innovative care solutions that are the focus of Medicare’s future payment methodologies. Many practices are heavily dependent on Medicare and Medicaid patients and cannot risk exclusion from the federal programs. In addition, exclusion from Medicare and Medicaid will result in exclusion from managed Medicare, managed Medicaid and potentially commercial plans as well. Being excluded from Medicare and Medicaid has been called the “economic death penalty” for a physician practice.

Corinne Smith, partner in Strasburger & Price LLP’s Austin office, advises health care providers about complex health care transactions, regulatory matters, and reimbursement. Prior to joining Strasburger she served as inhouse counsel for Seton Health care Family and UT Medicine San Antonio/ UT Health Science Center San Antonio. She is also a former health care administrator and Fellow in the American College of Healthcare Executives.

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PUBLIC HEALTH

A Texas-sized problem Texas has among highest rate of hepatitis C, lowest HPV vaccination numbers in the U.S. By Carolyn AldigĂŠ and Erich M. Sturgis, MD, MPH

s a family physician, your patients rely on you â&#x20AC;&#x201D; not just for annual check-ups, diagnoses, prescriptions, and treatments, but also to inform them of what they need to know to enjoy long, healthy lives. But a growing number of patients say they are not getting much-needed guidance from their primary care physicians on a major public health problem: certain viruses that can lead to cancer. This is why the Prevent Cancer Foundation launched Think About the Link, an education campaign to increase awareness of the connection between these viruses and cancer. The campaign targets three viruses: human papillomavirus, hepatitis B, and hepatitis C, and urges health care providers to talk to their patients in an effort to increase screenings, vaccinations, and treatments for these viruses. Texas especially needs greater awareness; the state has the fifth lowest three-dose HPV vaccination rate for girls and tenth lowest three-dose HPV vaccination rate for boys in the country. San Antonio is an unfortunate case-in-point: though the Centers for Disease Control and Prevention recommend that all girls and boys get the HPV vaccine at age 11 or 12, currently only about 15 percent of boys and 31 percent of girls in San Antonio received all three doses. While reported rates of acute hepatitis B in Texas decreased by 71 percent between 2009 and 2013, the National Viral Hepatitis Roundtable reports that Texas has the second highest hepatitis C rate in the United States, with an estimated 300,000 Texans currently infected with the virus. These rates put many Texans at risk for cancers caused by these viruses. As a family physician, you likely know that HPV is responsible for more than 90 percent of all cervical cancers and a majority of five other types of cancer, including vulvar, vaginal, penile, anal, and oropharyngeal, can be attributed to HPV. You also know that most liver cancers are caused by the hepatitis B or hepatitis C virus. However, most patients do not know either of these facts. The Prevent Cancer Foundation conducted a survey of more than 650 health care professionals and 1,000 adults across the 24

TEXAS FAMILY PHYSICIAN [No. 3] 2016

U.S. to understand the familiarity, perceptions and behavior as they relate to the three viruses, including vaccinations and treatments. The survey found that 53 percent of adults are unaware HPV can lead to cancer if left untreated and 67 percent of adults are unaware hepatitis B increases the risk of liver cancer. Just as alarming, 57 percent are unaware the HPV vaccine can significantly reduce the risk of certain types of cancer, 76 percent of adults are unaware the hepatitis B vaccine can lower the risk of liver cancer, and 73 percent are unaware treatment for hepatitis C can cure the virus infection and prevent subsequent liver cancers. While science has proven the HPV and hepatitis B vaccines aid in cancer prevention, 93 percent of adults say their physicians have not recommended one or more vaccines specifically to reduce their cancer risk. However, increased physician communication could potentially increase compliance. More than 92 percent of adults believe more education about the dangers of HPV is needed. In addition, 81 percent of adults would more seriously consider vaccinations they have never received if their physician discussed the benefits and 78 percent would be more likely to get vaccinations if their physician provided more detailed information. This survey sends an important message: Patients want to hear from their family physicians. Do not assume that a patient is uninterested in the HPV and/or hepatitis B vaccines â&#x20AC;&#x201D; research debunks this myth. Family physicians have a critical role in helping to educate patients, and cancer prevention is a key message to use in recommending vaccinations. Talk to parents and other adults about the cancer prevention benefits of screenings, vaccinations, and/or treatments. We can stop cancer before it starts and save more lives when the link between these viruses and cancer is elevated in Texas and the rest of the country. To learn more about Think About the Link and the link between certain viruses and cancer visit: http://www.preventcancer.org/Think-About-The-Link.

Carolyn R. (“Bo”) Aldigé is founder and president of the Prevent Cancer Foundation. Ms. Aldigé is a member of the board of the National Coalition for Cancer Research, having served for eight years as its president. Erich M. Sturgis, MD, MPH, is a professor in the Department of Head and Neck Surgery, Division of Surgery at The University of Texas MD Anderson Cancer Center. He leads a major research effort in molecular epidemiology of head and neck malignancies.

Empower your patients with diabetes selfmanagement education By the Texas Diabetes Council

iabetes education works. But less than 60 percent of people with diabetes have had formal diabetes education. Physicians can increase that number by referring their patients with diabetes to diabetes self-management education. Research shows that people who have received diabetes education are more likely to:

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• Use primary care and preventive services, • Take medications as prescribed, • Control their blood glucose, blood pressure, and cholesterol levels, and

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• Have lower health costs. The Texas Diabetes Council and the Texas Department of State Health Services have created new materials for providers to empower their patients with diabetes through DSME. The message to patients is, “Do you have diabetes? Help yourself to better health.” Physicians and health care providers can access the updated Texas Diabetes Council toolkit, download or order free educational materials, and locate local DSME programs at www.tdctoolkit.org. Materials include: • A poster for display in physician offices, • An informational card and fact sheet for distribution to patients, and • A patient referral form in tear-off pads for physicians to refer patients to a DSME program. The form also features an algorithm that defines four critical times to assess, provide, and adjust DSME Diabetes self-management education is a benefit covered by Medicare and most health plans when provided by a diabetes educator within an accredited/recognized program.

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FOUNDATION FOCUS

Working to build the Foundation of family medicine in Texas By Kathy McCarthy for decades the tafp foundation has focused on three strategic objectives: encouraging medical student interest in family medicine, assisting family medicine residents as they become the leaders of tomorrow, and funding practice-based primary care research. The Foundation has continued and expanded on efforts in all of these areas this year. The Foundation provides funding for medical students to attend AAFP’s National Conference in Kansas City each summer, and this year we are proud to report that a whopping 32 students received travel funds. Another program of the Foundation is to support Family Medi-

cine Interest Groups to allow them to plan meetings on campus and encourage student interest. With new campuses and medical schools opening around the state, the TAFP Foundation is ready to support FMIGs wherever there are medical students. At the end of 2015, the Foundation Board of Trustees voted to expand our research funding for the first time in over two decades by increasing the maximum amount that can be awarded, which resulted in more interesting research proposals for the Research Grants Committee to review. Projects funded in 2016 will examine physician burnout, behavioral therapy for obesity management in primary care, and screening and referral for abuse in emergency care settings. In addition to these three objectives, the board added a fourth area of focus this year to improve the health of Texans. Dr. Tamra Deuser, a longtime TAFP leader, passed away in 2015 after a battle with metastatic breast cancer. She shared her experience as a patient at the 2015 C. Frank Webber Lectureship in an effort to help her colleagues provide better end-of-life care to their patients. To honor her and continue this important work, the TAFP Foundation started an endowment to support an annual Tamra K. Deuser Memorial Lecture on end-of-life care. The first lecture will be given at TAFP’s Annual Session and Primary Care Summit in Dallas by her friend, colleague, and former residency director, Dr. Clare Hawkins. We hope to finish funding the endowment at the upcoming meeting in Dallas with a special Foundation Gourmet Dinner fundraiser.

TAFP Foundation awards first Henry J. Boehm Jr., MD, Scholarship By J.D. Harris Aaron Reinke, MD, is the first recipient of the Henry J. Boehm, Jr., MD, Scholarship. The scholarship was created to honor the career of Boehm, who has practiced family medicine for more than 50 years. “I’m am certainly humbled and very gracious for the award,” Reinke says. “I extend my sincere thank you for the Boehm family’s generous gift. Indeed, I have heard nothing but incredible things about Dr. Boehm.” The scholarship was created to benefit residents at the Texas A&M HSC Family Medicine Residency Program in the community Boehm served throughout his career. The funds have been designated to help cover attendance costs for an AAFP continuing medical education conference. “I was originally working on a project for improving our transitions-of-care for our hospitalized patients,” Reinke says. “Handoffs are an issue with any medical practice of multiple providers and I found it to be a particular interest after seeing the process in place at our residency. After working on the issue for several months, our program director, Dr. [Kory] Gill emailed us about the Boehm scholarship and was looking for

TEXAS FAMILY PHYSICIAN [No. 3] 2016

individuals who had proposals of projects for the residency.” Boehm graduated from the University of Texas Medical Branch at Galveston in 1962. He spent 34 years at the Brenham Clinic, then at his own office. He served as president of the Washington–Burleson County Medical Society, as well as chief of staff of Bohne, St. Jude’s, and Trinity hospitals. Boehm was also a member of the faculty of the Texas A&M medical school, and was the medical director of the Washington County EMS and of AMA Home Care and Gazebo Terrace Nursing Home. Reinke received his medical degree from the Dartmouth Medical School in 2014. He is currently in his third year at the Texas A&M Family Medicine Residency Program. Reinke plans to pursue rural full-spectrum family medicine somewhere in the mountains, as well as international mission work in the future. “I want to thank Dr. Kory Gill, Dr. Ana Lichorad, Courtney Dodge, and Robin Fuller for all the time and effort they put forth to advocate for the changes we made and are still making to improving patient safety and delivery of better care through our project,” Reinke says.

RESEARCH

Support for this project included a grant from the Texas Academy of Family Physicians Foundation.

Support for TAFP Foundation Research is made possible by the Family Medicine Research Champions.

GOLD LEVEL

The effect of the amino acid L-theanine on alertness and vigilance

Richard Garrison, MD David A. Katerndahl, MD Jim and Karen White SILVER LEVEL Carol and Dale Moquist, MD TAFP Red River Chapter

David W. Bauer, MD, PhD Program Director, Memorial Family Medicine Residency Program

BRONZE LEVEL Joane Baumer, MD Gary Mennie, MD Linda Siy, MD Lloyd Van Winkle, MD George Zenner, MD

Thank you to all who have donated to an endowment.

For information on donating or creating a new endowment or applying for research grants, contact Kathy McCarthy at kmccarthy@tafp.org.

Introduction Both caffeine and theanine have been associated with physiological and behavioral effects. Four studies have investigated the effects of theanine on cortical activity through electroencephalography (EEG) at rest and during task performance. Theanine is associated with an increase in alpha-brain wave activity compared to placebo, indicating a higher level of relaxation with theanine. (Bryan 2008) Effects on mood, anxiety, and behavior have shown mixed results. Rogers et al. concluded that theanine antagonized the effect of caffeine on blood pressure but did not significantly impact jitteriness, alertness, or other aspects of mood. In contrast, Haskell et al. found that 250 mg of theanine improved choice reaction time and reaction times on two memory tasks. These results also suggested that beverages containing theanine and caffeine have a different pharmacological profile than those containing only caffeine. A study using caffeine and theanine in combination, but not in isolation, showed significant improvements in attention on a switch task, but subjective alertness and intersensory attention were not improved. (Einother 2010) Similarly, Giesbrecht et al. found the combination of 97 mg theanine and caffeine significantly improved accuracy of a switch-task and self-reported alertness and tiredness. There were no significant effects on other cognitive tasks. A further study by Owen et al. compared caffeine with and without 100 mg theanine on cognition and mood. Caffeine improved subjective alertness

and accuracy on the attention switching task while the combination improved both speed and accuracy and reduced susceptibility to distracting information in the memory task. (Owen 2008) Regarding anxiety and psychological stress, Lu et al. evaluated the effects of 200 mg theanine compared to alprazolam on self-reported measures of anxiety. Results showed that neither theanine nor alprazolam reduced anticipatory anxiety. Kimura et al. demonstrated that 200 mg theanine reduced heart rate and salivary immunoglobin A, markers of psychological stress, during a stressful arithmetic task. To date, no studies have looked at the effects of theanine alone (without caffeine) on subjective levels of arousal, vigilance, and salivary cortisol levels. Salivary cortisone level correlates strongly with subjectively perceived stress level and serum cortisol level at a time 30-60 minutes prior to the sample collection (Bassett JR et al., 1987). Drinking tea has traditionally been associated with stress relief. However, caffeine has been shown to increase cortisol levels in response to stress. (Lovallo 2006). In a study comparing the effects of chronic tea administration on acute stress responses, cortisol levels were reduced and greater subjective relaxation was reported in the tea group compared to placebo. (Steptoe 2007) Although caffeine is rarely consumed in isolation, less is known about other dietary components in caffeinated beverages. Theanine is a possible candidate in contributing to these effects. www.tafp.org

Alertness rating

Pleasantness rating 7.8

5.0 4.9

7.6 4.8 7.4

4.7 4.6

7.2

4.5 7.0 4.4 4.3

Active

Pre-ingestion

Placebo

Subjects: 25 subjects 18 years of age or greater participated. Subjects were screened for psychotropic medication use (anxiolytic, antidepressant, stimulant), anxiety disorder, depression, or sleep disorder. Study design: This was a prospective, randomized, placebo-controlled, double-blind, within- subjects repeated-measure study. Each subject participated in one session in which he or she received a placebo, and in a separate session received 200 mg of L-theanine. At the beginning of the first session for each subject, he or she completed a short form collecting demographic information (age, sex, ethnicity, amount of caffeine ingested in the last 12 hours, amount of tea and caffeine ingested in the last 12 hours, and number of hours of sleep the night before). Next, a baseline blood pressure and heart rate were recorded by the researcher. Each subject then completed the alertness/ vigilance test described below, followed by completion of an “Affect Grid,” also described below. Upon completion of these tasks, each subject was given a capsule to swallow. Subjects randomized to the placebo condition took a placebo capsule and those randomized to the experimental condition took a capsule containing 200 mg of L-theanine. Each subject waited 40 minutes — the time needed for orally ingested theanine to reach peak serum concentrations. He or she then underwent repeat blood pressure and heart rate readings, and completion of the vigilance/ alertness test and the Affect Grid. A salivary sample of cortisol was then obtained by swabbing the inside of each subject’s cheek with a cotton swab and sent to a reference laboratory. He or she returned within the next five days for a second session in which he or she repeated all steps of the study received the other capsule — the placebo if having taken the active placebo during the first sesTEXAS FAMILY PHYSICIAN [No. 3] 2016

Active

Placebo

Post-ingestion

Experimental design and methods

6.8

sion, and the active capsule if having taken the placebo during the first session. Vigilance testing: The test used to measure vigilance involved the subject watching a computer screen on which at random intervals a small square appeared. The subject was to press any key on the keyboard as soon as he or she detected it. A mean response time and standard deviation were calculated for each subject. Alertness Level Testing: We used the Affect Grid (Russell, Weiss, and Mendelsohn, 1989) to measure levels of pleasant/unpleasant feeling and alertness/sleepiness simultaneously. This instrument has been well validated and is simple and non-intrusive to administer. Because vigilance and cortisol levels follow a circadian rhythm, both visits for each subject were done between late morning and late afternoon, within one hour of the same time of day. Analyses: The main independent variable is L-theanine/ placebo ingestion. Covariate independent variables include age, sex, amount of caffeine ingested in the previous 12 hours, and number of hours of sleep reported for the night before each visit. Dependent measures were cortisol level, vigilance score, and affect score.

Results We found no significant effect of L-theanine on blood pressure, vigilance score, or alertness rating. There did appear to be a significant placebo effect as noted in the graph above, where alertness and pleasantness were subjectively increased after taking a pill, regardless of whether it was the active or placebo capsule.

Conclusions Although powered to detect a medium effect, we were not able to demonstrate that L-theanine affects either alertness or subjective “pleasantness” in this study.

References Owen GN, Parnell H, De Bruin EA, Rycroft JA. The combined effects of L-theanine and caffeine on cognitive performance and mood. Nutr Neurosci 2008; 11: 193-198. Yokogoshi H, Kobayashi M, Mochizuki J, Terashima T. Effect of theanine, r- glutamyethylamide on brain monoamines and striatal dopamine release in conscious rats. Neurochemistry Research 1998; 23: 667-673. Ito K, Nagato Y, Aoi N, et al. 1998;72: 153-157. Effects of L-theanine on the release of alpha brain waves in human volunteers. Nogeikagaku Kaishi; 1998; 72: 153-57. Bryan J. Psychological effects of dietary components of tea: caffeine and L-theanine. Nutr Rev 2008; 66: 82-90. Rogers PJ, Smith JE, Heatherly SV, Pleydell-Pearce CW. Time for tea: mood, blood pressure and cognitive performance effects of caffeine and theanine administered alone and together. Psychopharmacology 2008 ; 195: 569-577. Haskell CF, Kennedy DO, Milne AL, Wesnes KA, et al. The effects of L-theanine, caffeine and their combination on cognition and mood. Biolol Psychol 2008; 77: 113- 122. Einother SJL, Martens VEG, Rycroft JA, De Bruin EA. L-theanine and caffeine improve task switching but not intersensory attention or subjective alertness. Appetite 2010; 54: 406-409. Giesbrecht T, Rycroft JA, Rowson MJ, De Bruin EA. The combination of L-theanine and caffeine improves cognitive performance and increases subjective alertness. Nutr Neurosci 2010; 13: 283-290. Lu K, Gray MA, Oliver C, et al. The acute effects of L-theanine in comparison with alprazolam on anticipatory anxiety in humans. Hum Psychopharmacol Clin Exp 2004; 19:457-465. Kimura K, Makoto O, Juneja LR, Ohira H. L-theanine reduces psychological and physiological stress responses. Biolol Psychol 2007; 74:39-45. Russell JA, Weiss A, Mendelsohn GA. Affect grid: a single-item scale of pleasure and arousal. Journal of Personality and Social Psychology 1989; 57 (3), 493-402. Lovallo WR, Farag NH, Vincent AS, et al. Cortisol responses to mental stress, exercise and meals following caffeine intake in men and women. Pharmacol Biochem and Behavior 2006;83:441-447. Steptoe A, Gibson EL, Vounonvirta R, et al. The effects of tea on phychophysiological stress responsivity and post-stress recovery: a randomized doubleblind trial. Psychopharmacology 2007;190:81-89. 12. Bassett JR, Marshall PM, Spillane R. The physiological measurement of acute stress (public speaking) in bank employees. Int J Psychophysiol. 1987 Dec;5(4):265-73.

Interested in participating in practice-based research? www.tafp.org/practice-resources/research TAFPâ&#x20AC;&#x2122;s Section on Research wants you to know that Texas is home to lots of practice-based primary care research opportunities. Check out our new research page at tafp.org to learn more and to contact like-minded colleagues and find a project to dive into.

FAMILY MEDICINE PRACTICE-BASED RESEARCH RESOURCES AHRQ PBRN website: pbrn.ahrq.gov The Agency for Healthcare Research and Quality supports practice-based research networks, or PBRNs, all over the country. AAFP NRN: www.aafp.org/patient-care/nrn/nrn The AAFP National Research Network is affiliated with regional practice-based research networks throughout the country. RRNeT: familymed.uthscsa.edu/rrnet The Residency Research Network of Texas is a collaboration of family medicine residency programs dedicated to improving family physiciansâ&#x20AC;&#x2122; interest and skills in research and to find answers to clinical questions relevant to family medicine patient populations. SPUR Net: www.prime-net-consortium.org/spur-net.html The Southern Primary Care Urban Research Network is organized by the Family Medicine Department at Baylor College of Medicine in Houston and is a member of the Primary Care Multi Ethnic Network. STARNet: http://familymed.uthscsa.edu/starnet08/index.asp The South Texas Ambulatory Research Network is a learning community of primary care clinicians, staff, and patients in clinics across South Texas. CenTexNet http://researchers.sw.org/dorfam/informationabout-centexnet The Central Texas Primary Care Research Network is based in Temple, Texas, in the Department of Family and Community Medicine at Scott & White Memorial Hospital and the College of Medicine, Texas A&M Health Science Center.

www.tafp.org

PERSPECTIVE

Med students: Want to step out of the classroom and into the exam room? By Herbert Rosenbaum by the end of my first year of medical school and destined for my “last summer ever,” I left my rigorous preclinical curriculum with an unsettling combination of exhaustion and frustration. I came to medical school to help the sick, not sit in some stuffy lecture hall, spend innumerable hours meticulously studying complicated biomolecular pathways, or learn about the zebras among zebra diagnoses. Despite my excitement at the beginning of medical school, the sobering realization of the academic and impersonal nature of preclinical years disturbed me immensely. I felt my zeal slowly seeping away. And, despite the strong push for students to pursue research activities during that precious summer, I knew neither pipetting for hours nor endless analysis of chart-reviewed data could ever recharge me. In short, I needed a doctor — a mentor who could help me reinvigorate my passion for medicine. A Google search later, I found the Texas Family Medicine Preceptorship Program, funded by the state in an effort to increase the number of primary care physicians throughout Texas. Physicians seek eager medical students to spend 2-4 weeks in their clinics, each one with a personalized description and listed specialized interests (women’s health, sports medicine, et cetera). In contrast to shadowing, as preceptees, students work alongside physicians as members of the clinic, taking histories, doing physical examinations, and learning the foundations of medical assessment and planning. (And the stipend certainly did not hurt!) I remember thinking to myself, “I don’t know if I am interested in family medicine. Sure, my passions rest in geriatrics and primary care, but I don’t know if I should apply if I am not committed to family medicine. Maybe I should just do research like everyone else.” That night, I filled out the application. I refused to again entertain the thought of doing research. A few weeks later, I matched with San Antonio-based physician Dr. Sara Apsley-Ambriz. Immediately Dr. Apsley-Ambriz expected me to practice my history-taking and physical examination skills and present to her with diagnoses and a plan, just like third- and

fourth-year medical students. But if you think I only saw ear and urinary tract infections all month, think again. A highlight of my month was diagnosing what was later confirmed to be a cerebellar tumor uncommonly seen in adults—as a preclinical medical student in a family medicine clinic! Therein rests the beauty of family medicine: anything can enter your door. Family physicians serve on the front lines to detect and prevent virtually every disease, and specialists rely on the findings and clinical judgement of family physicians to first catch potential diagnoses. In my patient’s case, my observations allowed diagnosis of cancer in its earliest stage and thus provided her with the best possible prognosis. My four weeks provided so many educational opportunities, including seeing the therapeutic benefits of osteopathic manipulation, performing well-child examinations, learning breast examinations, speculum exams, and Pap smears in an amazing introduction to women’s health. The most impactful element of my experience was gaining a better understanding of medicine’s socioeconomic barriers including access issues, prior authorization paperwork for adequate coverage of appropriate therapies, and language barriers. I left my month with a strong and informed desire to serve as a health care advocate, a promise to perfect my Spanish to help reach more patients, and a clear vision of the central role of the family physician in the greater context of American medicine. Two years later and in the midst of residency applications, I realize this program is perhaps the very reason I am now proudly pursing family medicine. So if you’re a preclinical medical student and you find my experience intriguing, check out the Texas Family Medicine Preceptorship Program at www.tafp.org/preceptorship. And if you’re a family doctor who wants to help shape the future of family medicine in Texas, consider signing up to be a preceptor. Your influence could be helping patients across the state for years and years to come.

I left my month with a strong and informed desire to serve as a health care advocate, a promise to perfect my Spanish to help reach more patients, and a clear vision of the central role of the family physician in the greater context of American medicine.

TEXAS FAMILY PHYSICIAN [No. 3] 2016

Herbert Rosenbaum is a fourth-year medical student at UT Southwestern Medical Center. Reach him @hbrosenbaum.

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