TEXAS FAMILY PHYSICIAN VOL. 68 NO. 3 2017
CAPITOL REPORT
Family Medicine Stood Strong In The 85th Texas Legislature
PLUS: Artificial Intelligence On The Horizon Beach Bound: TAFP Heads To Galveston For ASPCS 2017 Understanding ADHD In Kids
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INSIDE
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TEXAS FAMILY PHYSICIAN VOL. 68 NO. 3 2017
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Family medicine in the 85th Texas Legislature
In a contentious regular session and a heated special session, TAFP fought to help Texans stay healthy and to improve the practice environment for family doctors.
6 FROM YOUR PRESIDENT Health care: Right or privilege? 8 MEMBER NEWS Two FPs named Health Heroes | Schneider heads UTSW FM department | Seto wins AAFP GME award | Luna joins TMB | Humanitarian award goes to Sheets
By Jonathan Nelson and Perdita Henry
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Member profile: Doug Curran, MD
Meet a recent Member of the Month, the new president-elect of the Texas Medical Association, Douglas Curran, MD, of Athens. By Perdita Henry
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Beach bound
Family physicians from across the state will head to Galveston as TAFP hosts the 2017 Annual Session and Primary Care Summit.
By Perdita Henry
31
Research: Changes in risk for type 2 diabetes among Mexican-American children
By Kimberly Fulda, DrPH; Susan Franks, PhD; Shane Fernando, PhD; Anna Espinoza, MD; and Didi Ebert, DO
14 CANDIDATE PROFILES Meet the candidates running for two positions on the TAFP Board of Directors and for the office of TAFP Parliamentarian. 16 YOUR ACADEMY TAFP governance profile: Section on Maternity Care and Rural Physicians 19 TECHNOLOGY An expert’s take on AI in medicine 26 PUBLIC HEALTH Understanding kids with ADHD 36 TAFP PERSPECTIVE The 24-hour primary care clinic
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PRESIDENT’S COLUMN
TEXAS FAMILY PHYSICIAN VOL. 68 NO. 3 2017 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 Tricia Elliott, MD
president
president-elect vice president
Janet Hurley, MD
Javier “Jake” Margo, Jr., MD
treasurer
Rebecca Hart, MD
parliamentarian
Amer Shakil, MD, MBA
immediate past president
Ajay Gupta, MD
EDITORIAL STAFF managing editor
Jonathan L. Nelson
associate editors
Perdita Henry and Jean Klewitz chief executive officer and executive vice president
Tom Banning chief operating officer
Kathy McCarthy, CAE
advertising sales associate
Michael Conwell CONTRIBUTING EDITORS Didi Ebert, DO Anna Espinoza, MD Shane Fernando, PhD Anise Flowers, PhD Susan Franks, PhD Kimberly Fulda, DrPH Maggie Kjer, PhD Jon Pearce J. Stefan Walker, MD
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. © 2017 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] 2017
What kind of system do we want? By Tricia Elliott, MD TAFP President Medicare or Medicaid, and aren’t fortunate in his seminal book “The Signal and the enough to have access to affordable health Noise,” renowned statistician, Nate Silver, insurance through your employer, or are examines the world of prediction, investigatsimply priced out of the individual market, ing how we can distinguish the truth — the then health care is a privilege based on one’s signal — from the noise, which he describes ability to pay. as a universe of ever-increasing information, Health care reform doesn’t have to be relatively little of which is useful. an either/or, binary choice. Both universal Any candid observer of the now nearly coverage and the private market have their decade-long effort to reform our health care pros and cons and both require trade-offs. system will readily admit that the health If health care is a right, then how do we care debate we’ve been engaged in has genfinance it? What services, treatments and erated a lot of noise and useless information medicines are covered? Do we regulate the for political gain. Our elected leaders, on prices physicians, hosboth sides of the aisle, pitals, drug makers, and have been busy creating others can charge? Who this noise and are now If health care is a makes these decisions? trapped in a political vise privilege, are we If health care is a of their own making. privilege, are we willing They’ve sadly left the willing to allow to allow people to suffer public with a binary people to suffer or or die from a disease or choice of whose health die from a disease medical problem because care solution is better, of an inability to pay? that of the Republicans or medical problem Are we willing to allow or the Democrats. because of an families to go bankrupt This politically inability to pay? to pay for health care? simplistic way of trying How we design and to fix our health care Are we willing to finance our health care system — your way, my allow families to go system doesn’t have to be way, or no way — has bankrupt to pay for an all-or-nothing, onelargely avoided engaging size-fits-all approach. In the public to answer the health care? many countries, a universingle most fundamental sal public program works question that must be in conjunction with the private market. addressed before any long-term solution This is a question that has vexed the can be designed: is health care a right or a American public for over a century and we privilege? still don’t seem ready, willing, or able to Right now the answer is that health care tackle it. Our elected leaders can continue is both a right and a privilege, which has attacking symptoms of our dysfunctional created a system that is completely inefhealth care system and calling it health care ficient and really expensive. reform, but until we answer the fundamenHealth care is a right — an entitletal question of whether health care is a right ment — if you are 65 or older. It’s called or a privilege and have an honest debate Medicare. If you are poor or disabled, it is a about the trade-offs, we’ll be stuck with a right. It’s called Medicaid. Combined, these costly, inefficient system that serves no one two programs cover more than 112 million particularly well. Americans. Health insurance is an employAs W. Edwards Deming, the celebrated ment benefit that covers another 156 milmanagement consultant once said, “Every lion Americans, though their employer may system is perfectly designed to get the choose what benefits to provide and how results it gets.” We can design a much better much employees should have to pitch in. health care system once we can agree on But if you are one of the unlucky 22 what kind of system we want. million Americans who don’t qualify for
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MEMBER NEWS
COMING SOON ON TAFP’S
CME SCHEDULE Annual Session & Primary Care Summit Nov. 10-12, 2017 Nov. 8-9: Business meetings and preconference workshops
Galveston Island Convention Center, The San Luis Resort, and Hilton Galveston Island C. Frank Webber Lectureship & Interim Session April 13-14, 2018 Renaissance Austin Hotel Austin, Texas Texas Family Medicine Symposium June 8-10, 2018 La Cantera Hill Country Resort & Spa San Antonio, Texas 8
TEXAS FAMILY PHYSICIAN [No. 3] 2017
Two FPs named Health Heroes TAFP members Michael McLeod, MD, and past Physician of the Year, Jasmine Sulaiman, MD, were both honored by the Texas Medical Association Foundation during their annual meeting, TexMed. Both physicians led and participated in all three of TMA’s
TAFP past president tapped to head family medicine department at UTSW F. David Schneider, MD, was selected Chairman of the Department of Family and Community Medicine at UT Southwestern Medical Center. Schneider is a past president of the Academy and is looking “to strengthen the presence of family medicine at UT Southwestern,” he told Center Times. “I want to expand our clinical footprint, train the best doctors, and establish a research infrastructure that advances primary care. Being at an academic medical center provides us the ability to do research — to understand what works, what doesn’t work, and how to best help our patients — and to provide cost-effective, high-quality care.”
Livingston FP joins TMB The Texas Medical Board welcomed six new members at its meeting last month. Among those appointed was TAFP’s very own Jeffrey Luna, MD, who will serve as a board member until April 13, 2021. Luna is a physician in private practice. He has been practicing for more than seven years in Livingston, Texas.
outreach programs: Be Wise — Immunize, Hard Hats for Little Heads, and Walk With a Doc Texas. Sulaiman and McLeod were two of four physicians honored with a Health Heroes award for their dedication to improving their community’s health.
“I want to expand our clinical footprint, train the best doctors, and establish a research infrastructure that advances primary care. — F. David Schneider, MD
Seto selected for AAFP GME award Edward Seto, MD, was selected as one of AAFP’s 2017 Award for Excellence in Graduate Medical Education. Awarded to only 12 family medicine residents each year out of the 3,500 eligible for this honor, winners must exhibit outstanding leadership, exemplary patient care and interpersonal relationships, and civic involvement. Seto is in his third year of residency at Christus Santa Rosa and he will receive the award at AAFP’s Family Medicine Experience in San Antonio.
Sheets wins AAFP’s 2017 Humanitarian Award Kyle Sheets, MD, FAAFP, was selected to receive AAFP’s 2017 Humanitarian Award for his years of service and dedication to humanitarian efforts abroad. He is the founder of PAPA — Physicians Aiding Physicians Abroad —Missions an organization created with the original goal of providing training to physicians with no practical experience planning mission trips. Over the years the, organization’s focus transi-
tioned into sending supplies and volunteers to those in need. PAPA Missions has sent numerous volunteers to half a dozen countries, shipped millions of dollars’ worth of supplies to facilities in need around the globe, and is currently working with Docs for Hope to construct a full-service hospital in rural Guatemala. Sheet’s will receive the award at this years’ Family Medicine Experience in San Antonio.
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MEMBER NEWS
F
ormer TAFP President, Douglas Curran, MD, has been around awhile. He’s witnessed and participated in bringing about groundbreaking and essential health care legislation to ensure Texas looks after every Texan, regardless of their ability to pay or insurance status, and that physicians are fairly compensated for that care. As you may have heard, the fight to make sure Texas invests in the health of its citizens continues but Curran has once again taken on a new role — that of president-elect for the Texas Medical Association. He continues to stay in the fight on behalf of his colleagues and all of their patients. Typically, this is the part where I give you a few highlights of our conversation but as many of you already know, Dr. Curran is one of the most quotable people you’ll ever be fortunate enough to speak with. He has a happy and determined way about him that is ever apparent when he speaks about his life, his profession, and his calling. So rather than summing it up, I’ll just let him talk.
Athens FP wins race to become TMA president-elect June 2017 Member of the Month Doug Curran, MD By Perdita Henry 10
TEXAS FAMILY PHYSICIAN [No. 3] 2017
PH: Tell me a little about yourself and your career. DC: I’ve been around since Moby Dick was a minnow. I left John Peter Smith and then came to Athens, where I have been since 1979. I’ve practiced family medicine from cradle to grave for that entire time. I’m still doing obstetrics, including operative obstetrics, bread-and-butter surgery, taking calls, and taking care of patients in ICU as well as on the floor. I’ve had the privilege of being part of a wonderful community. I’ve got to love on them and they have got to love on me and that’s as good as it gets. I have always wanted to be a doc that was endeared to patients and enjoyed medicine. It’s a trite comment, but it’s absolutely accurate, I have gotten to live the dream. PH: What sent you down the road toward family medicine? DC: I grew up in a small community that had two brothers who practiced there. We became friends and they were the ones who encouraged and empowered me. I remember talking to Dr. Weaver about going to medical school. I told him I thought I might want to become a doctor and asked him to tell me about it. He said, “well you have to get through four years of college, four years of medical school, and three or four years of residency.” And I said, “Oh my goodness, I can’t do another 12 years.” He replied, “Oh, you don’t do another 12 years, you do one
day at a time.” I had no idea I’d be looking at this kind of career. I haven’t done years, I’ve done one day at a time, just like he said. PH: You have a unique perspective as a rural physician. What has practicing fullscope family medicine meant to you? DC: I can honestly say almost all my patients have become my friends. The hardest part about not doing this every day is I would miss seeing all my friends. They come in, we work together, and figure out how to best take care of them, and keep them doing the things they want to do. That’s the scariest part of slowing it down, missing those friendships and relationships. I think that’s one of the unique opportunities rural medicine offers you. PH: Advocacy has been a large part of your career. Where did that passion come from? DC: It started 20 years ago with testifying at the Capitol on issues I’m passionate about, Medicaid — taking care of everybody not just people who have insurance. Our group decided somebody needed to go tell the story of small-town family medicine, where we do everything and we take care of everybody whether they have money or not. We needed to be sure that part of the story was told. That’s how I began my experience in organized medicine. I’ve met some real encouragers along the way. One of them was Tom Banning. Tom and I visited many times and he said, “You know you’ve got to do this, we need you,” and that was all the encouragement I needed. I visited with Lou Goodman at the Texas Medical Association and he asked me some strategic questions, “How does your family feel about you being involved in this?” and “How does your group feel about covering for you when you’re asked to do extra things?” Those were important questions I needed to answer. My group said, “go get ‘em” and my wife said, “I’d rather you do this than run for political office.” So that’s how I went down that road. When Texas added about a million kids to CHIP, it was exciting because I had testified so many times. As it passed, they interviewed one of the conservative legislators who apparently stated that he wasn’t going to vote for it. When the reporter asked him why he decided to vote for expansion he told a story. He told one of the stories I’d told about one of my patients that needed care, but couldn’t get it because of their circumstance. He said, “We just need to fix that.” For me that was a real humbling
moment because maybe I helped a million kids get on CHIP. I won’t see a million kids in my career. I won’t see a million people, but if I helped a million kids get care, that’s huge and it’s such a good feeling.
tions when it comes to advocacy but still just as passionate about my responsibility to step up, to say the right thing, to do the right thing, and try to move things in the right direction.
PH: Do you believe family physicians recognize the importance of their voice as advocates? DC: Docs realize what they have to say is important, but they often feel like nobody listens. You can get really frustrated after a while when you think “no one is listening to me” and “I really can’t do what I want to do.” I think that’s the biggest reason docs are frustrated now and why we see increased burnout and all these other things going on. I think a lot of it also has to do with the constant threat of change and everything that keeps happening. We’re all in this state of flux, but there is great opportunity for us. Now more than ever we need to speak up as family doctors. Speaking for our patients in such a way so we can develop good policy. I think we will be listened to when we bring common solutions to the table. That’s what family docs do. We figure out how to take care of patients in a common-sense way. When we bring that to solving problems for insurance companies, Medicare, Medicaid, and all those other things, we can make an enormous difference if we can just be heard. We can’t get discouraged even though people may not listen or not pay attention, we just have to get up, dust ourselves off, and try to keep changing it. Don’t give up!
PH: You are a past TAFP President. What do you envision for your term as president of TMA? DC: As far as where I think TMA is headed, it’s in a direction to improve the quality of care patients get. Improve the access to care, for all patients. Right now, we have access issues for Medicaid patients and enormous access issues for the working poor. We must address those. I will work on the areas of how we get better access to health care for all Texans. I also want to work on better and fairer payment for all physicians. I think as alternate payment models come out, it’s going to give us an opportunity to change how we pay doctors. I’m looking forward to making all of that work. I think that’s where doctors are, they want to be paid fairly and properly. My time will be spent being sure patients get the best they can get, in terms of quality and having adequate access to care, and for physicians, I want less hassle and a more appropriate payment model.
PH: How has your outlook on advocacy shifted as your career progressed? DC: I’m a little more realistic. To quote a well-used phrase, “advocacy and change is the art of the possible.” You can do certain things in a certain environment and other things just aren’t possible. I think I’m more realistic about what I can get done and I try to look at things like, “okay, here’s an opportunity and I’ve got to take advantage of that now, but my opportunity may be different in two years depending on who is in the House or the Senate.” I’m not afraid to fail. I’m not afraid to step up and say, “Look, this is what you ought to do, whether you do it or not is your problem, but I have to tell you the truth.” I’ve been telling people they have an illness or disease for years and it’s not fun. If I have to tell my patients hard things, I can certainly tell a politician they ought to do the right thing. I’m realistic about my expecta-
PH: Why is it important for family medicine physicians to participate in advocacy? DC: It’s not just important, it’s essential. If you look at how physicians are paid in today’s world, probably half of our payment is in some way coming from entities influenced by the Legislature. Even insurance companies are influenced and regulated by the Legislature. If you’re not there defending your profession and advocating for your patients then we’re not going to get the things we need to take care of our people. You need to be in the game. If you’re not, you miss out on opportunities to improve the care of your patients.
TAFP’s Member of the Month web feature highlights Texas family physicians and their approach to family medicine. If you know a family physician colleague who you think should be featured as a Member of the Month or if you’d like to tell your own story, nominate yourself or your colleague by contacting TAFP by email at phenry@tafp.org or by phone at (512) 329-8666. View past Members of the Month at www.tafp.org/membership/spotlight. www.tafp.org
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Celebrate the specialty of family medicine at TAFP’s 2017 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 • When the Physician Becomes the Patient Kent Brantly, MD • Hepatitis A, B, and C Prevention and Treatment: Inexpensive Treatments Available Clare Hawkins, MD, MSc • Ethics – Interpersonal Violence: What We Need to Know Rita Schindeler-Trachta, DO
UTMB alumni reception and golf tournament Join your fellow classmates, faculty, and university administration at this year’s ASPCS. UTMB will host a scramble golf tournament and a “Welcome Home Alumni Reception” on Thursday, Nov. 9. Go to the ASPCS Special Events page at www.tafp.org to RSVP for each event.
TAFP mobile app Check out the ASPCS mobile app. Not only can you keep up with all the happenings of the weekend, you can track your CME, access exclusive content for those must-see presentations, download meeting materials, conference maps, and more. Download it now by searching “TAFP” in the Google Play or Apple app store.
www.tafp.org
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MEMBER NEWS
Where? Galveston Island Convention Center 5600 Seawall Blvd. | Galveston, Texas 77551 Conference hotels: The San Luis Resort and the Hilton Galveston Island Resort
Things to do near the conference: Recharge with a stroll along the beach, take the kids on a thrilling adventure at the Pleasure Pier, or practice your swing at the Moody Gardens Golf Course. Whatever your pleasure, there are numerous ways to unwind and find your joy in Galveston. Pleasure Pier: A one-stop shop for family fun. It features a roller coaster, a Ferris wheel, numerous other rides, carnival games, and souvenir shops. Moody Gardens: Stroll through the Aquarium Pyramid or Rainforest Pyramid, or take in a show at the MG 3D or 4D Special FX Theaters. No matter what you choose, you are sure to have a great time.
KSA Group Study Workshops Preventive Care Wednesday, Nov. 8 | 1 – 5 p.m. Moderated by Linda Siy, MD Coronary Artery Disease Friday, Nov. 10 | 1:15 – 5:15 p.m. Moderated by Dale Moquist, MD Maternity Care Sunday, Nov. 12 | 8 a.m. – 12 p.m. Moderated by Rebecca Hart, MD
Go to www.tafp.org for more information and to register. At the Member Assembly on Friday, Nov. 10, during this year’s ASPCS, members will elect two of their colleagues to the TAFP Board of Directors and one as the TAFP Parliamentarian. Two members are running for one available at-large position, three members are running to hold the new physician position, and two are running for the officer 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 Terrance Hines, MD, FAAFP, completed undergraduate and medical school at Texas A&M and residency at John Peter Smith Hospital in Fort Worth. He joined Baylor Scott & White in 2009 and is medical director for several clinics with emphasis on recruitment and development of Terrance Hines new physicians. He is also a clinical assistant professor at Texas A&M College of Medicine. He’s served on several TAFP commissions and committees, served as chair of Bylaws, the Section on Special Constituencies, and is a former member of the Board of Directors. Hines enjoys
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TEXAS FAMILY PHYSICIAN [No. 3] 2017
all aspects of primary care with a particular interest in LGBT health, including transgender hormone therapy and PrEP for HIV prevention. He believes family medicine must seize the opportunity to be a stabilizing force in the evolving health care market and that TAFP must strongly advocate for all patients and physicians. He is married, has two sons, and loves Aggie football. Loren S. Lasater, MD, FAAFP, is a native Texan hailing from Houston, who received his undergraduate degree from TCU and completed Loren S. Lasater medical school at UTMB. After completing a family medicine residency, he practiced in multiple settings includ-
ing private practice, single-specialty family practice, multispecialty practices, and academic medicine. He currently practices in Grapevine, Texas. Motivated by the September 11 terrorist attacks, he volunteered for the Army reserve and currently serves as a Colonel with 14 years of service. He has three active-duty mobilizations under his belt, two in the United States and one in Germany. He considers it a great privilege to serve our troops and their families. During his career in medicine, he says he has seen many changes, stresses, and challenges. His breadth of practice experiences within health care gives him a unique perspective to empathize and relate with his colleagues.
NEW PHYSICIAN DIRECTOR Lawrence M. Gibbs, MD, FAAFP, is an alumnus of the University of Pittsburgh Medical School. He completed his residency at St. Louis University’s Scott Air Force Base Family Medicine Residency program in Belleville, Illinois. After residency he remained on staff as faculty and Lawrence Gibbs element chief of the Belleville Family Medicine Clinic. After separating from the United States Air Force, he returned to his home state of Texas in 2016. He continues to serve as a reservist at Carswell Joint Reserve Base. He is a faculty physician at the Methodist-Charlton Family Medicine Residency Program in Dallas, and he serves as Director of Inpatient Medicine and Medical Student Clerkships. He has served as a member of the Uniformed Services Academy of Family Physicians Clinical Investigations and Education Committees and is a current member of TAFP’s Commission on Academic Affairs.
PARLIAMENTARIAN Adrian Billings, MD, PhD, FAAFP, received his medical education at Texas A&M, the University of Texas Medical Branch, and John Peter Smith Hospital. He was awarded a scholarship to medical school by the National Health Service Corps and went Adrian Billings on to complete his service obligation in Alpine, where he continues to practice. He’s served on the National Advisory Council to the National Health Service Corps, on TAFP’s Board of Directors, and as physician advisor for TMA’s Hard Hats for Little Heads program. Billings is an Associate Professor of Family and Community Medicine at Texas Tech University Health Sciences Center. Medical student and resident education continues to be central to his practice, and he has been recognized for his contributions to teaching, receiving several awards. He
Mary Anne Snyder, DO, received a Bachelor of Science in biology with a Spanish concentration at the University of Dallas. She received her Master of Arts in bioethics and Doctor of Osteopathic degrees from Kansas City University of Medicine and Biosciences. She completed residency at the University of Texas Health Science Center in San Mary Anne Snyder Antonio, where she was an administrative chief resident and was involved in many research and quality improvement projects. She enjoys volunteering her time at health fairs, women’s shelters, and refugee clinics. Snyder is currently practicing outpatient medicine at the Toyota Family Health Center in San Antonio. She enjoys staying active in TAFP and she recently attended the AAFP Advocacy Summit. She loves participating in international medical outreach and is excited to be a member of the founding faculty at the new Osteopathic School of Medicine at the University of Incarnate Word.
Irvin Sulapas, MD, FAAFP, is currently an assistant professor at Baylor College of Medicine. He is a Houston native who received his Bachelor of Science in biomedical engineering from the University of Texas at Austin and his medical degree from Ross University. Sulapas completed both his family medicine residency Irvin Sulapas and sports medicine fellowship at Texas Tech University Health Sciences Center at Lubbock. He is active in the Texas Medical Association, where he’s a current member on the Council of Medical Education. He is a current member of TAFP’s Commission on Academic Affairs and serves locally as one of the Harris County Medical Society delegates to TMA. Sulapas is a team physician for Texas Southern University and volunteers as a staff physician for the Houston Marathon. In his free time, enjoys exercising and advocating for healthy living to the general public.
serves as the director of the Texas Family Medicine Preceptorship Program. He is also the immediate past chief of staff of Big Bend Regional Medical Center and was recently elected to the Alpine Independent School District Board of Trustees.
Special Constituency member. She is the current Alamo Chapter Treasurer and was recently selected to serve on AAFP’s Reference Committee on Advocacy. She’s an avid supporter of the arts and she enjoys attending the symphony and theater with her husband and spending time with their 11-year-old son.
Mary Nguyen, MD, FAAFP, shares a family medicine practice with her husband in the rural town of Castroville and counts special needs advocacy as near and dear to her heart. She is currently a Member Constituency Delegate to the AAFP Congress of Delegates and Mary Nguyen previously held the position of Minority Co-convener for the 2017 National Conference of Constituency Leaders. Nguyen has served on several TAFP commissions and committees, including the Executive Committee and she currently serves on the TAFP Board of Directors as the
TAFP member events TAFP business meetings will take place Thursday, Nov. 9 – Saturday, Nov. 11 Other TAFP member events include: FRIDAY, NOVEMBER 10 • • • •
Research Poster Competition Member Assembly Lunch Resident POCUS Workshop TAFP Foundation Seafood Dinner (Tickets are $75 each; proceeds benefit TAFP Foundation)
SATURDAY, NOVEMBER 11 • Business and Awards Lunch • Members’ Reception • President’s Party
www.tafp.org
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YOUR ACADEMY
TAFP governance profile: Section on Maternity Care and Rural Physicians By Jean Klewitz do you have a specific interest in rural medicine? Want learn how to face challenges as a rural physician or a maternity care provider? This active section can help you work through those challenges. The integration of full-spectrum maternity care in rural family practices is their focus and they seek to create more opportunities for growth in these remote communities. The section also works with AAFP’s Rural Health Member Interest Group and AAFP’s Reproductive Health Care Member Interest Group to provide opportunities for rural medicine and maternity care education, training, support, interest, and involvement for physicians, students, and residents. While addressing topics inclusive to rural practice and maternity care, the section provides an outlet for communication, participa-
tion, recruitment, and retention of practicing family physicians. They share best practices in full-scope family medicine and strive to remove barriers that prevent physicians from providing maternity care in their practice. Working through challenges is an important goal for the Section on Maternity Care and Rural Physicians, says Emily Briggs, MD. “It’s helpful in creating a network with other people in a similar environment.” The group meets for one to two hours twice each year at TAFP’s Annual Session and Interim Session. Usually seven to 15 members attend, but only the chair and the vice chair are appointed members of the section. Anyone interested in these topics can attend and participate. As a section, they can send action items to the TAFP Board of Directors and refer items to other committees. “It’s a group of people with like-minds working through the same ups and downs,” Briggs says. “There are things that make your day and things that will destroy it. It is in those times that you can rely on those connections and ask their experiences.” Some topics of discussion the section has addressed lately are how to increase interest among residents and medical students in rural medicine by including more obstetrics in their curriculum and how to remove roadblocks that prevent family physicians from delivering babies. They’ve also discussed how to make practices more efficient, such as expanding access without over-extending, and approaching physicians and nurses who may be difficult to work with. For those who might be interested in joining, but are on the fence, Briggs says “you should have joined last year!” The next meeting of the Section on Maternity Care and Rural Physicians will be during Annual Session in Galveston, November 10, from 3:30 to 5:30 p.m.
TAFP committees, commissions, and sections TAFP is governed by a system of committees, commissions, sections, and task forces made up of TAFP members. These groups report to the Board of Directors who ultimately decide the direction of the Academy. These policy-making groups meet twice a year at Interim Session in the spring and Annual Session in November. TAFP is only as strong as its members. TAFP committee and commission members serve as the infrastructure of the Academy, developing policy and making the decisions that keep the organization at the forefront of the specialty. All TAFP members are welcome and encouraged to serve on committees, commissions, and sections.
Bylaws Committee Finance Committee Leadership Development Committee Nominating Committee Commission on Academic Affairs Commission on Continuing Professional Development Commission on Core Delegation Commission on Health Care Services and Managed Care Commission on Legislative and Public Affairs Commission on Membership and Member Services
Appointments to committees and commissions are made by the president-elect prior to Annual Session. Most active member appointments are for three-year terms and students and residents are one-year terms. Section meetings are open to any TAFP member to discuss interests or issues. Interested in serving on one of TAFP’s committees, commissions, sections, or on the Board of Directors? Fill out our involvement form online at tafp.org/membership/getinvolved/make-your-mark and indicate your interest. Questions? Contact Juleah Williams, TAFP’s Membership and Workforce Development Manager, at jwilliams@tafp.org or (512) 329-8666 ext. 135.
Commission on Public Health, Research, and Clinical Affairs Section on Maternity Care and Rural Physicians Section on Medical Students Section on Research Section on Resident Physicians Section on Rural Physicians Section on Special Constituencies TAFP Foundation Board of Trustees TAFP Political Action Committee Board of Trustees www.tafp.org/membership/get-involved/committees
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TEXAS FAMILY PHYSICIAN [No. 3] 2017
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TECHNOLOGY
How artificial intelligence is shaping health care delivery
Perhaps the most robust use of AI in health care is in the area of virtual care. Through increasingly complex algorithms and advances in machine learning, AI is providing more useful and less intrusive clinical decision support for physicians delivering care online. Ultimately, this is helping to ensure more accurate diagnosis and increasing guideline adherence for prescribing. Though online care is a newer care delivery channel, the support provided by AI algorithms is making it simple for physicians, and safe and effective for patients. And that’s just the beginning.
By Jon Pearce Zipnosis CEO and co-founder
The future of care delivery and the promise of AI
there is no shortage of articles — scholarly and magazine — around the ways that artificial intelligence (or, as it’s commonly known, AI) will change health care delivery. We are at the precipice of a digital and genomic explosion in health care that has the potential to out-pace even the smartest, most diligent physician’s ability to keep up. That said, AI is poised to help physicians effectively navigate this changing landscape and improve the care they can offer patients. Looking to the future is exciting and intriguing. It’s also speculative. AI is still very much in its infancy, which means that people can overestimate or underestimate its potential impact. I’m going to try not to do either, and instead present a clear picture of how AI is impacting care delivery today and the ways it will do so in the near-term.
What AI won’t do The list of changes AI is purported to bring about in health care is long and inevitably topped by eliminating the need for doctors. Frankly, I find this difficult to believe. While AI is certainly on the road to supplementing physicians, an outright replacement of all health care providers is something that will certainly not happen in my lifetime, and I’m guessing not over the next several generations’ lifetimes. A recent study in the Journal of the American Medical Association pitted physicians against online symptom checkers — the most basic type of AI available — and found that the physicians significantly out-performed symptom checkers, particularly for high-acuity conditions. The study’s authors went on to say that future studies should examine how algorithmic clinical protocols could augment physicians to improve diagnostic accuracy. Which brings me to…
AI in health care today I’ve already mentioned symptom checkers as the most basic form of AI in use, but this isn’t the only place AI appears in health care right now. For example, IBM’s muchtouted “Watson” is currently aggregating vast amounts of patient information to help oncologists create precise and personalized cancer treatments. AI is also helping providers detect abnormalities in X-rays and MRIs, supporting population health, and helping to streamline patient experience.
The current uses of AI provide a tantalizing glimpse into its potential for transforming health care. Going forward, I anticipate current AI technology will serve as a foundation for advances that will help relieve administrative burden from health systems and providers, and enable physicians to focus more on patient interactions and providing personal, high-touch care. As technology becomes increasingly sophisticated, AI will move from being an interesting addition to health systems’ technology landscape to becoming an integral part of care delivery by assisting physicians in areas like: • removing the documentation burdens placed on physicians by EMR systems and insurance companies; • filtering out noise in the data — whether from Dr. Google, claims, or publications, the information AI can present is personalized and contextualized for their panel; • reducing malpractice probabilities by helping physicians quickly assess the risk/reward of various treatment options for not just a cohort but a specific patient; and • helping patients access the right level of care at the right time, reducing physician burnout and unnecessary care. Initial forays into AI are already making an impact in some of these areas today. But we are just beginning to tap the potential it holds for improving care, simplifying workflows for physicians and health systems, and effectively supporting patient needs. The age of data is upon us, and the ability to aggregate and interpret a large volume of information is increasingly the key to providing care at both a population and personal level. AI is the tool that‘s emerging to help health systems and providers make effective use of this data. With AI as part of the growing digital health care toolkit, the future looks increasingly bright.
Jon Pearce is CEO and co-founder of Zipnosis, a Minnesotabased telemedicine company. Find him @ZipnosisJon.
www.tafp.org
19
FAMILY MEDICINE IN THE
85 TEXAS LEGISLATURE th
BY JONATHAN NELSON AND PERDITA HENRY
C
oming in to the 85th Texas Legislature, Gov. Greg Abbott, Lt. Gov. Dan Patrick, and Speaker Joe Straus laid out their policy priorities for the session. Among them were: sanctuary cities, the transgender bathroom bill, property tax cuts, school finance reform, school choice, shoring up the foster care and child protective services systems, ethics reforms, Gov. Abbott’s desire to call for a convention of states to amend the U.S. Constitution, and of course, passing a balanced budget. Nowhere in that list are any big-ticket health care items, and that’s no surprise. In the run-up to the session’s start in January 2017, everyone predicted the Affordable Care Act would be the unchallenged law of the land under President Hillary Clinton, fully funded and completely operational. Why consider options for Medicaid reform like block grants, work requirements, copays, and the like? Consequently, when lawmakers arrived in Austin shortly before President Donald Trump was sworn into office, no policy plans were prepared for what might be possible under Republican rule in both Washington, D.C., and the statehouse. So health care policy was low on the priority list this session. Even so, with more than 6,500 bills filed and fewer than 1,200 passed, the Lege took up a number of issues of interest to physicians and their patients.
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TEXAS FAMILY PHYSICIAN [No. 3] 2017
www.tafp.org
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“IF WE WANT TO IMPROVE ACCESS TO CARE IN RURAL AREAS, WE SHOULD STRENGTHEN OUR EFFORTS TO RECRUIT PHYSICIANS FROM RURAL COMMUNITIES TO MEDICINE. WE NEED TO CONTINUE TO PROVIDE LOAN REPAYMENT AS A RECRUITMENT STRATEGY AND WE NEED COMPETITIVE REIMBURSEMENT FOR OUR MEDICAID PATIENTS.” — EMILY BRIGGS, MD, MPH THE 2018-2019 BUDGET First on the docket as always was the state budget, and lawmakers knew coming in the fiscal forecast looked grim. Sagging oil prices and our growing population among other things meant the state faced a $6 billion shortfall. The House and Senate agreed on a budget for the 2018-2019 biennium totaling $216.8 billion in all funds, which included $106.8 billion in state general revenue. The remainder is federal money drawn down by state expenditures for programs like Medicaid and CHIP. Lawmakers also agreed to use $1 billion from the state rainy day fund. The Legislature funded Medicaid at $62.4 billion, $1.9 billion less than the current biennium, and they appropriated $79.45 billion to Health and Human Services, $1.83 billion less than 2016-2017. While many other programs related to public health languished this session, the state followed through on its commitment to increase funding for mental health. The budget spends $300 million for replacement or repair of state mental hospitals or other inpatient mental health facilities, and added $160 million for state hospital deferred maintenance. The Legislature also approved $67 million for community-based crisis service provisions, $30 million to reduce homelessness and recidivism, and $67.6 million to eliminate adult and child mental health waiting lists. 22
TEXAS FAMILY PHYSICIAN [No. 3] 2017
GRADUATE MEDICAL EDUCATION The Legislature continued its recent efforts to expand graduate medical education capacity, increasing GME expansion grants by $44 million and adding $4.3 million to GME formula funding. Throughout the session, lawmakers on committees of jurisdiction over GME made it clear they were concerned that Texas didn’t have enough during a time of medical school expansion. Senate Bill 1066 by Senator Schwertner requires new medical schools to offer new GME positions to keep pace with the number of medical graduates they produce. In the last weeks of the session, a program near and dear to family physicians suffered a significant blow. The Family Practice Residency Program is a budget strategy administered by the Texas Higher Education Coordinating Board that dedicates funding directly to the state’s family medicine residency training programs. The program had maintained its funding throughout the budget-writing process in both houses, but when budget conferees met to work out the differences in the two versions, they decided to slash the program by 40 percent, dropping its funding from $16.78 million to $10 million. TAFP will maintain close communication with the state’s residency programs, studying the effects of this funding cut and making those effects known to the Legislature.
FIRST, DO NO HARM Once again this session, organized medicine won important legislative battles by ensuring many bad bills didn’t become law. Sometimes the best defense is just a really good defense. Nurse practitioner organizations were back in force this session with a raft of bills designed to allow advanced practice registered nurses to practice medicine independently. None of those bills succeeded in either the House or the Senate. On April 25, TAFP member Emily Briggs, MD, MPH, of New Braunfels, testified before the House Committee on Public Health in opposition to House Bill 3395, which would have allowed advanced practice registered nurses to practice medicine independently in counties having no physicians. Briggs told the committee that she shared their goal to expand access to care in rural communities, granting nurses the authority to diagnose and prescribe is not the solution. She described the complexity and the variance of problems rural physicians treat on a daily basis. “Patients with chest pain, lacerations, burns, broken bones, or a woman in labor. … Even highly trained primary care physicians who may have done an extra year of training in rural practice many times do not feel prepared for rural practice. If we want to improve access to care in rural areas, we should strengthen our efforts to recruit physicians from rural communities to medicine. We need to continue to provide loan repayment as a recruitment strategy and we need competitive reimbursement for our Medicaid patients.” The bill didn’t make it out of the committee.
CLEARING THE WAY FOR TELEMEDICINE IN TEXAS After years of lawsuits and friction between large telemedicine providers and the Texas Medical Board, the advancement of telemedicine in the state had reached an impasse. National direct-toconsumer telemedicine firms wanted free rein to sell their services outside of the state’s regulatory oversight and without regard for patients’ existing relationships with their physicians. The medical
“It’s a wonderful thing to practice family medicine in the state of Texas, to have the opportunity to get to know our patients and their families and to take care of them. As members of the Texas Academy of Family Physicians, we don’t just care for our patients in the exam room. We take care of them at the State Capitol, too. “I’m a monthly donor for the TAFP Political Action Committee because if we want policies that are good for our patients and our practices, we have to elect politicians who understand our issues. Support TAFPPAC and make your voice heard.” Justin Bartos, MD 2016 TAFPPAC Award recipient
www.TAFPPAC.org
In a session without much focus on health care and no extra money to spend, public health initiatives gained little momentum, except in the case of a few important mental health issues like the $300 million investment in our state hospitals and other state-funded inpatient mental health facilities mentioned above. H.B. 2561 by Rep. Senfronia Thompson, D-Houston, seeks to address people’s misuse of, and addiction to, opioid pain medicines. It includes Physician Drug Monitoring Program initiatives to identify potentially harmful prescribing or dispensing patterns or practices that might suggest drug diversion or “doctor shopping.” The prescribing amendment calls for physicians and all other prescribers and dispensers to check the PDMP before prescribing any of the listed classes of medications after Sept. 1, 2019. To help alleviate Texas’ shortage of psychiatrists, S.B. 674 by Sen. Schwertner creates an expedited licensing process for psychiatrists who are licensed to practice medicine in another state and are board certified. H.B. 3576 by Rep. Bobby Guerra, D-McAllen, will improve the state’s testing and screening capabilities for infectious diseases, such as the Zika virus.
The issue of maternal mortality is a concern all over the country but Texas unfortunately has the distinction of being the worst. In fact, Janet Realini, MD, MPH, president of Healthy Futures of Texas and chair of Texas Women’s Healthcare Coalition, spoke about her concerns during her TAFP Member of the Month interview. “Texas women have the highest maternal mortality rate of any state — higher than many third-world countries,” she said. “Preventive care and contraception are incredibly important in addressing this issue in two ways: preventing unplanned pregnancies that can stress women with health issues and serving as an entry to health care for women with health risks.” Several representatives arrived at the Capitol with the intention of finding out why Texas women are dying at a higher rate, ensuring they have access to the care needed, and finding out why AfricanAmerican women — who give birth to 11 percent of babies born but account for almost 29 percent of all maternal deaths — die at higher rates than other women in the state. Two specific bills aimed to do just that were House Bill 2403 by Rep. Shawn Thierry, D-Houston, and Senate Bill 1929 by Sen. Lois Kolkhorst R-Brenham. H.B. 2403 would have required the Maternal Mortality and Morbidity Task Force to conduct a study of the causes of death in African-American women and S.B. 1929 would have extended the Maternal Mortality and Morbidity Task Force through 2023. Both bills were killed in what has become known as the Mother’s Day Massacre, when more than 100 bills were allowed to expire due to political push-back from the House Freedom Caucus. At the end of the regular legislative session, only two bills addressing maternal mortality passed. H.B. 1158 by Rep. Sarah Davis, R-West University Place, will make postpartum screenings available to women on Medicaid but will not offer treatment to those diagnosed. Senate Bill 1599 by Sen. Borris L. Miles, D-Houston, requires the Department of State Health Services to post protocol for pregnancyrelated death investigations and best practices for reporting those deaths to the medical examiner or justice of the peace of each county. When lawmakers returned to the Capitol for a 30-day special session, Rep. Kolkhorst filed S.B. 17 to extend the work of the Task Force on Maternal Mortality and Morbidity until 2023. The bill passed and the governor signed it into law. Funding for Healthy Texas Women and the Family Planning Program remained level for the next biennium, which is a major victory considering the cuts many public health programs sustained this time around. A rider in the budget directs HHSC to seek a Medicaid 1115 waiver to provide a 90/10 federal match for the Health Texas Women’s program. If the federal government approves the waiver, funding for the program would start in 2019, which could have a significant impact on the budget and structure for women’s health programs in the state.
WOMEN’S HEALTH
YOUR ACADEMY IN ACTION
In a 2016 study published in the journal Obstetrics & Gynecology, researchers found that from 2011 to 2015, 537 Texas women died while pregnant or within 42 days of delivery, compared to 296 from 2007 to 2010. This doubling of maternal deaths made Texas the most dangerous place to give birth in the developed world. Maternal mortality was on the agenda for the 85th Legislature but many of the bills that would help us understand and identify the dangers facing new and expectant mothers failed to pass.
Despite a tough political climate and a difficult budget process, strong physician leadership in TAFP and a well-respected advocacy team represented the specialty well this session, standing in support of family physicians and their patients. Great appreciation goes out to all those members who served as Physician of the Day during the regular session and the special session, and to those members who provided testimony, contacted their representatives and state officials, served as Key Contacts, and supported the Academy’s efforts.
board rules held that a physician couldn’t treat a patient via telemedicine unless the physician had established a relationship with the patient in a previous face-to-face visit, a stipulation companies like Dallas-based Teladoc found unworkable. In the months leading up to the start of the legislative session, TAFP, TMA, and the Texas e-Health Alliance drew together a diverse group of stakeholders and over the course of many meetings, brokered an improbable agreement in which all sides could claim victory. In the end, Gov. Abbott signed into law a measure passed unanimously by both the Senate and House that protects the standard of care for patients, defines the responsibilities physicians must maintain when providing telemedicine services, and allows for innovation and progress in the market. Senate Bill 1107 by Sen. Charles Schwertner, MD, R-Georgetown, establishes a statutory definition for telemedicine and clarifies that the standard of care for a traditional, in-person medical setting also applies to telemedicine services. In the House, Rep. Four Price added language making it clearer that telemedicine is not a distinct service but a tool physicians can use. The bill also prohibits health plans from excluding telemedicine from coverage just because the care isn’t provided in person. Under the new law, TAFP fully expects that family physicians in the state can offer telemedicine services to their patients in a safe and efficacious manner and that they will be able to compete with large companies like Teladoc and American Well.
PUBLIC HEALTH
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TEXAS FAMILY PHYSICIAN [No. 3] 2017
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PUBLIC HEALTH
Understanding children with ADHD in family practice By Anise Flowers, PhD and Maggie Kjer, PhD
REFERRING FOR AN ADHD EVALUATION Family physicians are often the family’s first point of contact when children are struggling in school and at home due to behavioral health issues, including Attention Deficit Hyperactivity Disorder. In some states, schools refer families to their physician for ADHD diagnosis consideration. This is a standard practice in Texas because ADHD is often diagnosed by the child’s family physician or pediatrician, with supporting evidence from the school and parents. According to the National Institutes of Health, approximately one in five children in the United States suffers from some form of mental illness, yet 80 percent of these children do not receive treatment. It is estimated that 75 percent of children and adolescents with psychiatric disorders are seen by their family physician. Furthermore, 7.5 percent of children and adolescents are prescribed a psychiatric medication, and 85 percent of psychopharmacologic prescribing is by pediatric providers. ADHD is one of the most common mental health diagnoses in children, affecting around 11 percent of children in the U.S. according to the CDC. The core symptoms of ADHD are inattention, impulsivity, and hyperactivity. Children with ADHD often have difficulty concentrating and are easily distractible, disorganized, impulsive, and hyperactive. The most common symptoms associated with poor school performance are inattention and impulsivity. Hyperactivity alone does not have a negative effect on academic performance. In fact, many high-performing students and graduate students are hyperactive. The inattention coupled with impulsivity has the most 26
TEXAS FAMILY PHYSICIAN [No. 3] 2017
devastating impact on academic performance and social skills in children with ADHD. An inattentive student isn’t likely to get straight As, but many hyperactive children who are not inattentive are top performers academically. There are three types of ADHD diagnoses: inattentive type, hyperactive-impulsive type, and combined type. The most common type is combined. Children with this type have symptoms of both inattentive and hyperactive-impulsive types. The diagnostic criteria for ADHD in DSM-5 includes 18 symptoms, which are divided into two symptom domains (inattention and hyperactivity/impulsivity), of which at least six symptoms in one domain are required for diagnosis. There is a cross-situational requirement that several symptoms must be present in more than one setting, and several inattentive or hyperactive-impulsive symptoms must have been present prior to age 12. The DSM-5 has placed ADHD in the neurodevelopmental disorders chapter to reflect recent research into brain development and current practices.
ASSESSMENT APPROACH When a child is referred for an ADHD evaluation, best practice suggests a multimethod multi-trait approach. First, multimethod means that more than one assessment practice will be used. An evaluation may include interviews, observations, rating scales, or direct assessment and should utilize multiple respondents. In 2011, the American Academy of Pediatrics released an updated report on practice guidelines for the diagnosis of ADHD recommending that information be
DSM-5 SYMPTOMS Inattention
Hyperactivity-Impulsivity
Not paying attention to detail, making careless mistakes
Fidgeting or squirming
Failing to sustain attention and keep on task
Often getting up when remaining seated is expected
Not listening
Running or climbing at inappropriate times
Being unable to follow instructions or complete schoolwork and chores
Having trouble playing quietly
Trouble organizing activities or materials Avoiding tasks that involve sustained effort Being easily distracted
Talking too much Interrupting or blurting out in conversation Difficulty taking turns Often “on the go” as if “driven by a motor”
Often forgetful Losing things that are needed to complete tasks
obtained from both home and school settings and evaluations cover multiple areas including symptom onset/duration and the degree of impairment on everyday functioning. Second, multi-trait means that the evaluation should include a broad-band measure that will assess multiple aspects of the child’s behaviors, emotions, or personality. Broad-band assessment is important for a couple of reasons. A narrowband measure, like an “ADHD Rating Scale,” will result in too many false positives. If you only test for one condition then you are likely to over identify that condition and miss alternative explanations for the behavior problems. For example, during an initial evaluation, a physician would usually run a comprehensive blood panel as opposed to testing for a single indicator. Also, for children who are diagnosed with ADHD, comorbidity with another disorder (depression, anxiety, conduct disorder, etc.) is more often the rule than the exception. Comorbidity is another reason that comprehensive measures are important, since as many as one-third of children diagnosed with ADHD also have a co-existing condition. According to the 2011 AAP Practice Guidelines, “In the evaluation of a child for ADHD, the primary care clinician should include assessments for other conditions that might coexist with ADHD, including emotional or behavioral (e.g., anxiety, depressive, oppositional defiant, and conduct disorders), developmental (e.g., learning and language disorders or other neurodevelopmental disorders), and physical (e.g., tics, sleep apnea) conditions.”
TYPES OF ASSESSMENT TOOLS In addition to interviews with the child, parents, or teachers, a psychologist will generally use multiple assessment approaches. Classroom observations are important for verifying the problematic behaviors in a naturalistic setting. Observations may be informal or data may be collected on specific behaviors in a structured manner such as with the BASC-3 Student Observation System. Comprehensive rating scales (BASC-3, Achenbach CBCL) for the child, parent, and teacher are an example of the broad-band measures mentioned
above. Rating scales yield norm-referenced scores which indicate how a child’s behavior compares to that of a nationally representative comparison group. In addition to diagnosis, behavior rating scales can be used as an objective way to measure medication efficacy. Using data versus the informal parental report is a more psychometrically sound method of establishing change in behavior. Sometimes monitoring may be conducted with a shorter questionnaire than the comprehensive measure that is used for an initial evaluation. For example, the BASC-3 Flex monitor allows clinicians to create a brief rating scale that will reliably measure target symptoms and graph change over time. Lastly, direct assessments are instruments that are administered directly to the child. If academic performance is a concern, this may include a test of achievement or cognitive ability. For ADHD evaluations, a continuous performance test such as Quotient or the Conners CPT will often be utilized. A continuous performance test measures different areas of attention such as sustained attention, inattentiveness, impulsivity, and vigilance to provide objective data regarding a child’s attentional challenges.
TREATMENT CONSIDERATIONS Behavioral health care provided by family physicians for children with ADHD may include psychological education for the family. Depending on the needs of the child, a treatment plan may also include neuropsychological testing to assess for learning and other comorbid disorders, determine targeted interventions, behavior plans, and psychotherapy. Behavior therapy is commonly used to treat symptoms of ADHD in children, particularly in preschool age children. For school age children, a combination of behavior therapy and medication is often the most effective approach. ADHD is very responsive to stimulant medications and as a result, ADHD diagnoses and the use of stimulant medication have steadily increased over time. The American Academy of Pediatrics and the American Academy of Child and Adolescent www.tafp.org
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ASSESSMENT MEASURE EXAMPLES Assessment
Publisher
BASC-3 (Rating Scales, Student Observation System, Flex Monitor)
Pearson Clinical Assessment
Achenbach CBCL
ASEBA
Quotient
Pearson Clinical Assessment
Conners CPT
MHS Assessments
Psychiatry practice guidelines endorse stimulant medications as first-line treatment. Recommendations for medicating ADHD children are robustly evidence based. Specifically, the multimodal treatment of ADHD trials showed improvement in inattention, hyperactivity, and impulsivity and reduction of general disruptive behavior and, to a lesser degree, improvements in academic achievement and appropriate social skills and peer relations. An ADHD diagnosis carries with it a high comorbidity rate (between 50 percent and 90 percent) with anxiety and depression. The use of selective serotonin re-uptake inhibitors is considered first-line treatment for depression and anxiety symptoms in children but physicians must be aware of drug interactions when prescribing with stimulant medication for their patients with ADHD. Physicians must also be aware of additional commonly occurring comorbid psychiatric disorders with ADHD, such as oppositional defiant disorder, conduct disorder, bipolar disorder, and substance abuse. These present a complex set of symptoms that may be best evaluated using an integrated mental healthcare model where the child’s family physician collaborates with a psychologist and/or psychiatrist to develop a treatment plan for these depressed or anxious ADHD children and adolescents. A child or adolescent with an ADHD diagnosis does not automatically receive special education services through the Individuals with Disabilities Education Act in school. There must be a documented academic and/or social skills deficit or emotional disorder that impacts academic performance and age appropriate peer relations. If, for example, a child is evaluated and their ability is highaverage but their performance in school is average or lowaverage due to ADHD type symptoms, they may not be provided special education services under IDEA. Unless the ADHD significantly impairs the child’s everyday functioning in school as reported by teachers, the student, and/or the parents, the child will not qualify for Special Education services. The school evaluation team may consider a medical diagnosis of ADHD during the evaluation process and determine the child may receive accommodations through Section 504 of the Americans with Disabilities Act instead of special education services. A best practice model for making sure a patient receives the appropriate level of support and services in school for ADHD is 28
TEXAS FAMILY PHYSICIAN [No. 3] 2017
to ensure clear communication between the family physician and the school, usually through the parent. However, there are a few recent school mental health framework models that build direct communication channels between all professionals working with the patient (physicians, psychologists, psychiatrists, teachers, school staff) and the parents. The onset and diagnosis of ADHD generally occurs in childhood. However, research shows that ADHD is a developmental disorder that often continues into adulthood. Sometimes, a parent has a child referred for an ADHD evaluation and then the parent realizes that they have had this undiagnosed condition as well. As children grow into adolescence and young adulthood, some of them have an improvement in symptoms and may no longer require medication. Other individuals — as many as 60 percent — will continue to need treatment for ADHD symptoms into adulthood.
SUMMARY Decades of research has established that ADHD is a neurodevelopmental problem which affects approximately 11 percent of children in the U.S. Family practice physicians are instrumental in the identification and treatment of these children. Key issues to remember include 1) the importance of a comprehensive assessment that encompasses comorbid disorders; 2) treatment may include both behavior management and medication; 3) medication titration is essential and rating scales can provide some objective data to assist with maximizing success while minimizing side effects; 4) collaboration and communication between physicians, parents, and school personnel is essential; and 5) ADHD symptoms will often continue into adulthood.
About the authors Dr. Anise Flowers is an Assessment Consultant for Pearson Clinical Assessment in South Texas and Arkansas. She has a PhD in Clinical Child Psychology and has experience working in Pediatric Psychology at several children’s hospitals. Dr. Maggie Kjer is an Assessment Consultant/Regional Manager for Pearson Clinical Assessment in the Southwest/Southeast region. Dr. Kjer is a former special education administrator and teacher. She has extensive experience working with ADHD children and their parents in school settings.
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Krentz HB, Auld MC, Gill MJ. The high cost of medical care for patients who present late (CD4 < 200 cells/μL) with HIV infection. HIV Medicine. 2004;5:93-8.
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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
Changes in risk for type 2 diabetes among Mexican-American children Kimberly Fulda, DrPH UNT Health Science Center
Anna Espinoza, MD UNT Health Science Center
Susan Franks, PhD UNT Health Science Center
Didi Ebert, DO UNT Health Science Center
Shane Fernando, PhD UNT Health Science Center
Richard Garrison, MD David A. Katerndahl, MD Jim and Karen White SILVER LEVEL Carol and Dale Moquist, MD TAFP Red River Chapter BRONZE LEVEL Joane Baumer, MD Gary Mennie, MD Linda Siy, MD Lloyd Van Winkle, MD George Zenner, MD
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For information on donating or creating a new endowment or applying for research grants, contact Kathy McCarthy at kmccarthy@tafp.org.
Introduction Diabetes is a chronic disease that can cause health complications and contribute to increased morbidity and mortality among youth. Nationally, the prevalence of both type 1 and type 2 diabetes in children increased significantly from 2001 to 2009.1 While the prevalence of type 1 diabetes increased by 30 percent in youth 0 – 19 years of age, the prevalence of type 2 diabetes, or T2DM, increased by 35 percent in youth 10 – 19 years of age. During this time period, significant increases in the prevalence of T2DM were observed for white, black, and Hispanic youth. Disparities by racial and ethnic group were also observed with rates per 1,000 population of T2DM at 0.17 for white, 0.79 for Hispanic, and 1.06 for black youth in 2009.1 Youth with T2DM may be asymptomatic or misdiagnosed as having type 1 diabetes. Therefore, the estimates of T2DM among youth are likely underestimated.2 Additionally, early onset and longer duration of T2DM are associated with an increased risk of complications. Essentially, youth with T2DM may be at a higher risk of developing diabetes related complications than youth with type 1 diabetes.2 The American Diabetes Association recommends testing children and adolescents for T2DM if the they have a BMI ≥ 85th percentile for age and gender and have two other risk factors including a family history of T2DM in a first or second degree relative; being of certain racial or ethnic groups; and signs of insulin resistance, such as presence of Acanthosis Nigricans, elevated glucose, hypertension, or dyslipidemia.3 The increase in incidence among youth along with the potential consequences associated with having T2DM point to both a need for proper diagnosis of T2DM and for improved prediction of children who are “at-risk” for T2DM. The purpose of this study was to examine how
risk for T2DM changed in Mexican-American children over two years.
Methods Participants from a research study titled “Factors Associated with Being at Risk for Type 2 Diabetes among Mexican-American and Mexican Children” were asked to return for a follow-up visit approximately two years after their initial participation. Child participants were classified as either low or high risk for T2DM. The study included 144 Mexican-American children aged 10 to 14 years with one parent or legal guardian recruited through family medicine clinics in the North Texas Primary Care Practice-Based Research Network and the North Texas community. The study was considered the baseline measurement for the current project. In both study visits, the child participants completed a survey assessment that included measurements of family, psychosocial, and environmental factors associated with being high risk for T2DM. Child subjects also had their height, weight, waist circumference, and percentage of body fat measured; had their blood pressure taken twice; and completed the Children’s Depression Inventory. The child’s blood glucose level was also measured. Adult subjects completed study related questionnaires about the child including the parent report form of the Children’s Depression Inventory. Furthermore, a quick inspection of the neck was performed on the child by a clinician to look for Acanthosis Nigricans. Lastly, a blood draw was performed by the on-site laboratory to obtain the child’s lipid profile — total cholesterol, HDL cholesterol, LDL cholesterol, and triglycerides measured in mg/dL. All study materials were available in English and Spanish, and bilingual coordinators were also available. www.tafp.org
31
Table 1: Changes in risk factors for type 2 diabetes in Mexican-American children Baseline Follow-up n (%) n (%) p value
Glucose 1.00 High risk
6 (12.0)
7 (14.0)
Low risk
44 (88.0)
43 (86.0)
Acanthosis Nigricans Positive
23 (46.0)
29 (58.0)
Negative
27 (54.0)
21 (42.0)
BMI ≥ 95th percentile Yes
24 (48.0)
25 (50.0)
No
26 (52.0)
25 (50.0)
0.21
1.00
Blood pressure ≥ 95th percentile Yes
0 (0.0)
0 (0.0)
No
50 (100.0)
50 (100.0)
Risk status for T2DM High
14 (28.0)
17 (34.0)
Low
36 (72.0)
33 (66.0)
0.01
Table 2: Changes in percent body fat and lipid profile in Mexican-American children
Baseline Follow-up mean (sd) mean (sd) p value
Percent body fat
28.6 (9.6)
30.0 (11.6)
0.11
158.4 (28.2)
154.6 (34.5)
0.39
HDL (md/dL)
48.9 (12.2)
45.2 (11.0)
0.01
LDL (mg/dL)
83.7 (23.4)
86.6 (24.5)
0.44
128.9 (73.2)
137.9 (89.2)
0.36
Total cholesterol (mg/dL)
Triglycerides (mg/dL)
A child subject was classified as high-risk if he or she had three or more of the following five risk factors. A child subject was classified as low-risk if he or she had two or fewer of the following five risk factors. • BMI percentile 95 or above • History of hypertension or average systolic or diastolic blood pressure readings at or above 95th percentile • Acanthosis Nigricans present • Family history of T2DM in a first or second degree relative 32
TEXAS FAMILY PHYSICIAN [No. 3] 2017
• A positive finger stick glucose test (random blood glucose 140 – 199 mg/dL or fasting blood glucose 100 – 125 mg/dL)
Data Analysis Descriptive analyses of baseline and follow-up variables included frequency counts, percentages, means, and standard deviations. McNemar Test for Related Samples was used to compare differences in baseline and follow-up for glucose risk (high/low), presence of Acanthosis Nigricans (positive/negative), BMI 95th percentile [cont. on 34]
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s
lood pr essure £ He art dise ase £ Fam ily hi of kidn story ey dise ase
[cont. from 32]
(yes/no), and risk status for T2DM (high/low). A pairedsamples t-test was used to compare differences in baseline and follow-up for percent body fat, total cholesterol, HDL cholesterol, LDL cholesterol, and triglycerides.
Results A total of 50 children from the 144 children in the study returned for a follow-up. Of these child participants, 30 (60.0 percent) were male and 20 (40.0 percent) were female. The average age was 11.9 (sd = 1.5) at baseline and 14.3 (sd = 1.6) at follow-up. The follow-up visit was conducted at approximately two years from their initial assessment with an average follow-up time of 27.7 months (sd = 4.5). Table 1 provides the number of participants with risk factors from baseline to follow-up. Baseline measurements showed that 14 (28.0 percent) were high risk for T2DM; however, upon reassessment, 17 (34.0 percent) were high risk for T2DM (p = 0.01). No significant differences were observed for changes in glucose risk, presence of Acanthosis Nigricans, and BMI percentile or blood pressure percentile. Table 2 shows changes in percent body fat, total cholesterol, HDL cholesterol, LDL cholesterol, and triglycerides between baseline and follow-up. Mean HDL significantly decreased from 48.2 (sd = 122) at baseline to 45.2 (sd = 11.0) at follow-up (p = 0.01). No other significant changes were observed.
Discussion This study assessed change in risk factors for T2DM among Mexican-American children living in North Texas. Due to the potential for severe complications associated with T2DM, it is critical to identify high risk children early and to introduce preventive measures.2 It is also critical to understand how risk for T2DM changes and what factors are associated with that change. Over approximately two years, there was an observed increase in being high risk for T2DM among our study participants. The single risk factor
that demonstrated the largest increase in prevalence between baseline and follow-up was the presence of Acanthosis Nigricans. This change was not significant; however, it is noteworthy. Kobaissi et al. found that while body adiposity is the primary risk factor for insulin sensitivity among overweight Hispanic children, presence of Acanthosis Nigricans also independently predicts insulin sensitivity.4 Our study also identified a significant decrease in HDL cholesterol. Dyslipidemia, including low HDL, is associated with having T2DM in children.5 Therefore, detecting changes in lipid markers early may serve as an indicator to increase prevention efforts. Not all children were fasting during the collection of blood samples. Glucose readings were analyzed as high or low based on whether the sample was fasting or random, but the lipid markers were not controlled for fasting or not. Future research should include looking at racial and ethnic differences in risk for T2DM and psychosocial factors associated with change in risk.
References 1. Dabelea D., Mayer-Davis EJ, Saydah S., et al. (2014). Prevalence of Type 1 and Type 2 Diabetes Among Children and Adolescents from 2001 to 2009. JAMA; 311(17): 1778-1786. 2. Reinehr, R. (2013). Type 2 Diabetes Mellitus in Children and Adolescents. World Journal of Diabetes; 4(6): 270-281. 3. American Diabetes Association. (2000). Type 2 Diabetes in Children and Adolescents. Diabetes Care; 23(3): 381-389. 4. Kobaissi HA, Weigensberg MJ, Ball GDC, et al. (2004). Relation Between Acanthosis Nigricans and Insulin Sensitivity in Overweight Hispanic Children at Risk for Type 2 Diabetes. Diabetes Care; 27: 1412-1416. 5. American Diabetes Association. (2003). Management of Dyslipidemia in Children and Adolescents with Diabetes. Diabetes Care; 26(7): 2194-2197.
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.
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TEXAS FAMILY PHYSICIAN [No. 3] 2017
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PERSPECTIVE
THE 24-HOUR PRIMARY CARE CLINIC: A MODEL WHOSE TIME HAS COME J. Stefan Walker, MD
36
TEXAS FAMILY PHYSICIAN [No. 3] 2017
luke fildes’ portrait “the doctor” epitomizes the primary care physician that our younger selves aspired to become. That kind of doctor-owned practice is now slipping away as quickly as the business model supporting it. Where $300,000 per year is the new benchmark for employed primary care positions, the prospect of starting or joining a private practice only to tread water in a sea of acronyms (MACRA, HIPAA, HMO, ACO, etc.) for margins that barely cover overhead no longer makes sense to most family physicians. No wonder that in 2016, for the first time, less than half of American doctors partly or fully own their practices. As the care of inpatients became a separate field, primary care was mostly sidelined into a 9 to 5 office job — in a role now shared with mid-level practitioners, retail clinics, and telemedicine services. Unlike many other specialists still seeing patients during nights and weekends, primary care is now conspicuously absent in that important space, further putting pressure on family physicians to justify the level of reimbursement that can support independent practices. Now a rarity, small primary care practices — even those now thriving — risk succumbing to this tide of obsolescence, not unlike local department stores and indoor shopping malls. But the most powerful innovations are borne of necessity. To survive impending demise, independent primary care must evolve to fulfill a market niche. As it turns out, doctors, patients, and payers alike agree on their most critical need. They call it the Triple Aim, a concept one might interpret as three core tenets: higher quality of care, reduced cost of care, and expanded access to care. Despite a decade of efforts, this common goal of U.S. health care remains mostly unrealized and care has never been more fragmented, patients more dissatisfied, nor physicians more demoralized than right now. Here, then, might be a golden opportunity for family physicians to address this elusive Triple Aim by embracing two key elements largely missing in today’s health care system: personal continuity of care, and authentic commitment between the physician and patient. To achieve this, we will need to fundamentally change our practice logistics to embrace patient care around the clock, as doctors have done for millennia — but now from the context of a 24-hour clinic.
Enter a practice arrangement in which seven to 15 doctors work in a physical clinic they themselves own and operate 24/7 and 365 days a year by rotating shifts. This clinic is always open, always staffed, and always ready to see established patients. Care is available anytime — even at, say, 3 a.m. — and includes routine, preventive, chronic, or urgent visits. This model normalizes the personal doctorpatient commitment, which is the only way patients maintain access to the practice and its services. Care is affordable — even for uninsured, cash-paying patients, and fits all three primary care payment models — insurance, direct primary care, and concierge — simultaneously, under one roof. No more having to miss school or work for doctor visits. No unfamiliar places and provider off hours. No segregation of patients within the same clinic, as all patients are ‘concierge class’ in this model. Payers save millions by eliminating unnecessary ER visits and hospitalizations, resulting in industry-leading feefor-service rates negotiated by the group practice. For the clinic’s doctors, the satisfaction of delivering true continuity care as a team is extraordinary, being able to address patient needs in real time with excellence, no longer bound by the 15-minute-per-visit treadmill nor by endless arbitrary paperwork. The 24-hour group’s partners enjoy the esteem of their outside colleagues, who witness them taking care of their patients quickly and responsibly, not merely pushed downstream to mid-levels, ERs, or urgent care clinics, unless the case at hand truly exceeds the physician or facility capabilities. Doctors in the group needing schedule flexibility for parental duties or other commitments can sign up to work more odd hours and weekend shifts in their clinic as opposed to having to moonlight, or being forced into working in part-time arrangements merely due to schedule constraints. Even when not covering the call shift on a given day for walk-ins, any of the doctors can work in their patients, off hours if desired or needed, since the facility is always staffed. The clinic also fully optimizes the office space, which would otherwise lie empty and unused on nights and weekends. In stark contrast with the tenuous and frustrating experience in many small practices today, the 24-hour primary care clinic offers a way for family physicians to achieve success on par with or exceeding other contemporary models of care, while simultaneously preserving the autonomy so important to the doctor-patient relationship. It appears that now might be the time to deploy this unique practice rubric to actualize better and more sustainable care — not only in our field, but for the greater health care ecosystem. J. Stefan Walker, MD is a board-certified family physician. He is one of five partners at Corpus Christi Medical Associates, PA, at an independent adult primary care clinic in south Texas. The practice, established in the early 1980s, is exploring a transition into the 24-hour model described above. Dr. Walker may be reached at jstefanwalker@yahoo.com.
www.tafp.org
37
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