Fall 2019 – MONTANAAFP.ORG

In This Issue: LGBTQ Health and Why It Is Important for the Family Physician Facilitating Practice Transformation in Frontline Health Care FMRWM Recognized for Rural Graduate Numbers Work hard. Play hard.

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benefi s.org | Start your journey today: benefi srecruiting@benefi s.org CONTENTS EDITION 3

The Montana Family Physician is printed, addressed, and mailed to every family physician, resident, and medical student in Montana as well 4 MAFP President’s Welcome as all 50 other state chapters.

6 In Memoriam: Dennis Salisbury, MD, FAAFP 8

8 ParentingMontana.org a Source of Support for Montana Families

9 Montana WWAMI Update

10 UM Family Medicine Program Top Rural Doctor Producer in Nation 10 11 LGBTQ Health and Why It Is Important for the Montana Family Physician

14 Facilitating Practice Transformation in Frontline Health Care

18 Misconceptions in Addiction Medicine

pcipublishing.com 20 Stopping Burnout at the Source: 20 Created by Publishing Concepts, Inc. Delegating the Administrative Burden David Brown, President [email protected] For advertising info contact 22 Big Mountain Medical Conference Eva Bakalekos [email protected] 1-800-561-4686, ext. 115 Edition 3

Spring 2019 | Montana Family Physician • 3 MAFP President’s Welcome

Amy Matheny, MD, MPH, FAAFP Hello Montana family physicians, residents, and medical students!

reetings Fellow Montana Family the energy and advocacy that so defines this supplement was emailed to MAFP Physicians, this stage of training and discovery. members in September, and the link GAs the autumn season is upon From the efforts of the Montana to the supplement is reprinted in this us and the landscapes change, we WWAMI Family Medicine Interest edition. Also, a submission shared from are reminded of the transitions and Group in promoting our great specialty, the Ohio Academy of Family Physicians transformations that are part of the to the formative rotational experiences highlights one clinic’s experience with cycles of our lives. Some are exciting that shaped a PNWU student’s career a model of practice transformation with a sense of discovery and newness, path, our Montana medical students to limit administrative burden that while others force us into a new reality show the bright future of our workforce. subsequently reduced burnout. for which we were not ready. Thus Our resident board member from the are the seasons of our personal and Montana Family Medicine Residency Before you know it, the seasons will professional lives. I can’t help but think shares an update on LGBTQ health in change again. Of course, the winter this quarter’s magazine highlights such a Montana, while the Family Medicine season in Montana brings snow, which theme. Residency of Western Montana is will complement our 61st annual recognized nationally for its number Big Mountain Medical Conference I would be remiss to not first recognize of graduates practicing rurally. Both in Whitefish! This year’s conference a major jolt and change for us at the articles highlight the dedication of our promises to bring another excellent Montana Academy of Family Physicians state’s residency programs to caring and collection of CME offerings. In addition Board of Directors. In our inaugural advocating for our communities. to multiple clinical topics, the meeting summer edition, we introduced you all will also include optional programs on to Dr. Dennis Salisbury from Butte, Along a continued theme of Point of Care Ultrasound (POCUS) who was a long-time member of our transformation, a reprint from the and a 4-hour Medication-Assisted board, serving as a past president and August 2019 supplement of the Annals Treatment training that provides half national AAFP delegate, among other of Family Medicine highlights findings of the required hours to qualify for the national leadership roles. We were from a number of recent studies focused DEA waiver to prescribe buprenorphine. excited to announce his candidacy for on practice transformation. Access to Check out the meeting brochure at the the AAFP Board of Directors. end of this issue for more details. Unfortunately Dennis had an unexpected change in his health As Thanksgiving approaches, in the interim, and we lost a dear I want to express my sincere friend and colleague just a few gratitude for your membership weeks ago in early October. You in the Montana Academy of can learn more about Dennis Family Physicians. Regardless in the In Memoriam article that of the season of your career, follows. He has touched the lives from the Grand-doctors to the of patients in Butte for over 25 students experiencing Family years, as a “Grand-doctor” as he Medicine for the first time, you proudly called himself, as well create the fabric of one of the as Family Physician colleagues most incredible Family Medicine across the nation. His presence communities in the country. The will be deeply missed. The Montana delegation at the AAFP Congress of Delegates. From left to heart and soul of what Family right: Jeffrey Zavala, MD, Alternate Delegate, Billings; Heidi Duncan, MD, Medicine is all about is alive and A collection of articles and essays Delegate, Billings; Amy Matheny, MD, Alternate Delegate, Missoula; Janice well in Montana, and that is submitted from Montana medical Gomersall, MD, Delegate, Missoula; Michael Strekall, MD, Board Member, because of YOU. students and residents highlights Helena; Linda Edquest, MAFP Chapter Executive, Helena.

4 • Montanan Family Physician Have a career. Have a life.

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We are an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran Montanastatus. Family Physician • 5 In Memoriam

Dennis Salisbury, MD, FAAFP 1962-2019

he Montana Academy of Family Physicians celebrates the life of Dr. Dennis Salisbury, a former chapter president and long-time member of the board of directors. An To honor Dr. Salisbury’s Tincredible Family Physician leader and advocate, Dr. Salisbury passionately represented legacy, a memorial fund Montana family physicians and their patients from the local level to many leadership roles with the American Academy of Family Physicians. His leadership, friendship, sense of humor, has been established and kindness will be greatly missed. through the AAFP Dennis was born in 1962 in Walnut Creek, California. He moved with his family to Foundation. To make a in 1972 where he lived until graduation from high school in Coeur d’ Alene. He attended donation in his honor, the University of Idaho, Whitworth University, and the University of College of Medicine, where he met the love of his life Jessie. He completed residency at Phoenix Baptist please visit https://www. in 1993 and high-risk OB fellowship in Spokane, Washington in 1994. He moved to Butte, aafpfoundation.org/ Montana in 1994 and remained in practice there until the time of his death. Dennis was highly respected in the field of Family Medicine both locally and at the state level. He was foundation/get-involved/ a member of a group of physicians that is monikered “Grand-doctors:” this title means he give/donation-form.html served the citizens of Butte long enough to deliver babies to women that he had delivered. He and select the “Dennis was very dedicated to the care of patients. Nationally he worked tirelessly for patient advocacy through the AAFP and on Capitol Hill; his work impacted many individuals. Salisbury Fund” from the designation drop down Dennis had a great sense of humor and a positive attitude. He was known for his ability to build consensus with wit and thoughtful perspective. He was an active member of St. John’s menu. Thank you for Episcopal Church and then Christ Church Anglican. He was an avid percussionist for the considering this token Butte Symphony for many years. He enjoyed reading multiple books simultaneously, dabbling in coffee roasting and telling dad-jokes. He loved his family, traveling, skiing, camping, hiking of remembrance and in Montana, and collecting various watercraft. His wife and three children as well as his celebration of our dear extended family, coworkers and colleagues will ardently miss his loquaciousness, his genuine friend and colleague. love of the Lord and his intentionality.

6 • Montanan Family Physician Kalispell Regional Healthcare Opens First-of-it’s Kind Pediatric Facility in Montana Finding local, high-quality specialized medical care for a seriously or chronically ill child can be one of the most daunting challenges in an already gut-wrenching scenario. For many families in Montana, that used to mean traveling out of state, causing more stress and financial hardship in an already difficult situation. Not anymore. That’s because Kalispell Regional Healthcare, one of the largest and fastest-growing health systems in Western Montana, has announced the opening of Montana Children’s, the first children’s pediatric facility of its kind in the state. Montana Children’s began treating patients in its new $60-million, three-story, 190,000 square-foot facility on July 1, 2019.

Montana Children’s brings together all the high-level pediatric specialists, some not found anywhere else in the state, to serve patients in an advanced facility designed especially for children and their families. More than 100 pediatric/ family medicine primary care providers and more than 40 pediatric subspecialties, including cardiology, critical care, dentistry, endocrinology, gastroenterology, maternal-fetal medicine, neonatology, neurology,neurosurgery, oncology and hematology, psychiatry, radiology, sleep medicine, surgery, among others, are members of the pediatric medical staff. The new facility’s first floor opened on July 1 and the second and third floors will open in later phases in the coming years. The first phase includes a 12-bed pediatric unit, a 6-bed pediatric intensive care unit (PICU) and a 12-bed neonatal intensive care unit (NICU). All rooms are designed for maximum privacy with a home-like comfort and large enough to accommodate overnight family members who want to be with their children. The NICU has dedicated sleeping rooms for parents who want to be close to their babies but need rest away from the sounds of medical monitors. Both the PICU and NICU each have a dedicated family room equipped with a seating area, TV, full kitchen, washer, dryer and showers to provide families with the comforts of home.

Set on the campus of Kalispell Regional Medical Center in Kalispell, Montana, the new children’s facility will eventually house many pediatric physicians, including the largest team of pediatric subspecialists in the state of Montana. “Before the pediatric program started at KRH in 2015, thousands of children were forced to leave the state annually to seek pediatric specialty medical care,” says Federico G. Seifarth, MD, FAAP, FACS, pediatric surgeon and medical director of Montana Children’s. “Our new hospital will serve families across Montana. By providing care to patients close to home we aim to make children and families more comfortable and allow access to pediatric specialized care to everybody.”

For more information on Montana Children’s, please visit montanachildrens.org

Montana Family Physician • 7 Public Health Corner

ParentingMontana.org a Source of Support for Montana Families

ouldn’t it be great if kids raising children came with instructions? (such as WBeing a family doctor, grandparents) to you’re often asked about parenting, support a child’s how to handle certain behaviors, success from birth and available resources. The through the teen Department of Public Health and years. You’ll find Human Services collaborated with easy-to-use tools Montana State University to develop and practical ParentingMontana.org; a website guidance for issues focused on parenting. like establishing routines, getting ParentingMontana.org provides homework completed, growing to easily find guidance quickly. evidence-based tools for family doctors, confidence, handling bullying, and even “Our family medicine doctors receive parents, foster parents and other adults preventing the misuse of substances. training on developmental milestones The site is designed to work well on but not on how to solve the wide range desktop computers, mobile devices, and of behavior dilemmas parents bring to us tablets. You can search by age and issue regularly,” explained Nanette Lacuesta, MD, a family medicine residency program director. Family doctors often face a host of issues for which they TOOLS could use guidance. Family doctors have available through ParentingMontana.org media such FOR as posters and handouts that can be downloaded and printed to give to patients or provided in waiting rooms. YOUR The guidance can be viewed online or printed. Summary documents of the CHILD’S guidance can also be printed. Check out the website at www. ParentingMontana.org. As you use the SUCCESS website, if you have suggestions or questions contact ParentingMontana@ gmail.com; to connect with a Montana Prevention Specialist in your region see https://dphhs.mt.gov/Portals/85/ amdd/documents/SubstanceAbuse/ PSCountyRegionList.pdf.

Reference: Board on Children, Youth, and Families. (2019). Consensus Study Report, Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda, Washington DC: The National Academies of Sciences, Engineering,

This product was supported [in part] by CFDA 93.959 from the Substance Abuse and Mental Health Services Administration (SAMHSA). The content of and Medicine. Available online at: this publication does not necessarily refl ect the views or policies of SAMHSA or Health and Human Services. http://www.nas.edu/MEB-Health.

8 • Montanan Family Physician Montana WWAMI Update

Written by MaKenna Siebenaler, MS2 Outgoing Medical Student Representative to the MAFP Board of Directors

ontana WWAMI has recently welcomed the new E-2019 class Mhere in Bozeman. Although many of them do not know yet what they want to specialize in, they are all very excited about participating in Family Medicine Interest Group (FMIG) events! Morgan Julian and Kristen White, the current FMIG leaders, have exciting events planned this fall. These include a casting and splinting workshop and a delivery workshop. Both of these workshops have been very successful in the past and they hope to provide valuable skills to future students. “We are looking forward Morgan Julian and Kristen White, current Montana WWAMI Family Medicine Interest Group leaders, holding a to introducing the new incoming class to 2018/2019 American Academy of Family Physicians Program of Excellence Award recognizing the group’s strong the wide variety of opportunities work in promoting Family Medicine. that Family Medicine offers,” says Morgan. The Montana WWAMI FMIG was honored for their hard work in promoting Family Medicine with a 2018/2019 American Academy of Family Physicians Program of Excellence Award (see picture).

Other WWAMI developments include the creation of an inter- professional course dedicated to teaching students to work with other health professionals. The Health Equity course is at several medical schools throughout the Pacific Northwest, and we are excited that Bozeman is now participating. This is important training during the didactic curriculum, and current The University of Washington clerkship students comment on School of Medicine + the importance of these skills in Montana State University = clinic. WWAMI students have also been busy advocating, most notably Montana WWAMI for the continuation of graduate medical education funding. Several Educating the next generation of physicians for WWAMI students going into Family Montana since 1972. Medicine want the opportunity to train at teaching health centers in For more information about the UW School of Medicine WWAMI program: our state, and we have been vocal uwmedicine. org/school-of-medicine/md-program/wwami about preserving these valuable resources as learners and for patients.

Montana Family Physician • 9 UM Family Medicine Program Top Rural Doctor Producer in Nation

Reprinted from UM News Service

he University of areas, with 72% remaining Montana’s Family in the state in Montana TMedicine Residency communities, including of Western Montana Browning, Helena, recently was recognized for Lewistown, Libby, Polson, graduating more family Red Lodge, Ronan and physicians that go into Whitefish, as well as staying rural practice than any locally in Missoula and other program surveyed in The 2019 graduating residency class with FMRWM faculty and staff. The ’s Kalispell. the country. Family Medicine Residency of Western Montana recently was recognized for graduating more family physicians that go into rural practice than any other program surveyed in the country. “We developed a program The Rural Training Track with a robust curriculum Collaborative conducts where residents spend time an annual survey of residency programs The program accepts 10 new residents working in rural communities throughout to recognize those who consistently a year from about 800 medical student the state,” said Dr. Darin Bell, FMRWM produce high numbers of rural doctors applicants. The three-year training assistant director of rural education. “We on a three-year rolling average. The 2019 program prepares them to practice rural have a dedicated group of clinics and survey found that FMRWM produced an family medicine, with a goal of having hospitals in rural areas that are invested average of seven new rural doctors each them stay in Montana. Of FMRWM’s in helping our residents become the best year. four graduating classes, 77% have gone family doctors they can be. It’s fantastic on to practice in rural or underserved to see those efforts paying off, as our “We have made great efforts to build a graduates often get hired by the same training program with deep connections rural communities that help train them.” to rural Montana communities,” said Rob Stenger, the residency program “It is a privilege to The residency program is sponsored by director. “It is a privilege to recruit recruit and train the Missoula’s Providence St. Patrick Hospital and train the next generation of rural and Community Medical Center, as Montana family physicians, and next generation of well as Kalispell Regional Medical wonderful to be recognized nationally for rural Montana family Center. Resident and faculty physicians our efforts.” physicians, and have outpatient clinics at Partnership Health Center in Missoula and Flathead Montana suffers from a shortage of wonderful to be Community Health Center in Kalispell. primary care physicians, which is recognized nationally All residents spend a significant portion predicted to grow to almost 200 new of their time working and training at a doctors needed by 2030. Before the for our efforts.” network of 15 rural hospitals and clinics creation of FMRWM in 2013, Montana throughout western Montana. had the lowest number of postgraduate Rob Stenger, training positions for new doctors per Residency The newest class to join the program capita of any state in the nation. Program Director. started in July, and recruiting for the next class begins this month. FMRWM, which is a program of the UM College of Health Professions and RTTC is a network of medical schools Biomedical Sciences, was created with and primary care residencies across the a mission to develop family physicians dedicated to increasing the who are compassionate, clinically training and development of doctors who competent and motivated to serve practice primary care medicine in rural patients and communities in the rural areas. and underserved areas of Montana. This release is online at: http://bit.ly/2km0xAw

10 • Montanan Family Physician LGBTQ Health and Why It Is Important for the Montana Family Physician

Written by Brook Murphy, MD Montana Family Medicine Residency Resident Representative to the MAFP Board of Directors

The Realities of Homosexuality in Rural Areas I am very proud to say that I grew up in rural Montana and many of the values I hold near to my heart were modeled beautifully to me from a young age. I am humbled by how well my community took care of one another growing up. After the death of my grandfather, neighbors were eager to offer their condolences and support. They provided food for my family so we could focus on We can’t heal their trauma, but we can help heal their future. spending time with one another and honoring my grandfather’s life. SHODAIR CONNECT While in many ways rural towns understand this community living A FREE telephone consultation best, one particular group is often service funded through Shodair unable to participate, or becomes a Children’s Hospital now available to chameleon in order to participate. Montana’s primary care pediatric and Our need for belonging is important, and depression fills its void. This psychiatric providers that strengthens explains why many LGBTQ youth and supports the individuals who hide their identity until they graduate care for children and families who and leave our rural towns for a larger, experience mental health concerns. more inclusive community. This in turn fuels the notion in rural areas that homosexuality is a choice, as For more information on enrollment, it does not seem to exist where it is requirements, hours of operations, not welcomed. Unfortunately, the appointments, and information on damage done early on is often long- frequently asked questions, please visit: lasting, especially in those who were abandoned by family. Depression and suicide rates among LGBTQ, as shodair.org a result, are much higher than the Shodair Outpatient Services national average. As Montana family physicians, we are painfully aware 406-444-7521 that we lead the nation in suicide rates. The LGBTQ community is a group that needs our help and focus. To heal, help and inspire hope continued on page 12 >

Montana Family Physician • 11 continued from page11>

The Numbers to keep the peace, it is important to remember that likely no one avoids care for • Depression in LGBTQ is 9 times higher this change, but many avoid care because than the general public. we have not adapted. For the patient angry • LGB youth are 3x more likely to die by about the intake form, this can provide a suicide; Trans youth are 4x more likely to moment to inform them of the realities die by suicide. they may not know exist. • Montana ranks #1 in the country for the When recently asking a friend what state with the highest suicide rate. prevents his peers from seeking care, he • 59.5% of US LGBTQ youth felt said a large portion of judgement comes unsafe at school because of their sexual from the front desk, nursing, or MA who orientation. see them prior to our visit. While we often • 70.1% of US LGBTQ youth were get limited training on LGBTQ health, our verbally harassed at school due to their staff often receive none. Modeling this care orientation. to staff demonstrates that this community but more data needs to be collected. • 34% of LGBTQ youth stated they have deserves our respect. During your DVT risk factors can be reduced by using been bullied on school grounds, 10% interaction, allow yourself to apologize if transdermal estrogen as opposed to oral with a weapon. you addressed your patient inappropriately. estradiol. Counsel your patient of the • 5% of Americans are LGBTQ; what This tells your patient that you care potential risks. percentage of your patients are LGBTQ? about getting this right. Heterosexual and homosexual patients alike often lie about And lastly, prevent HPV and HIV. The What We Can Do their sexual health if they feel judged, and 9-valent HPV vaccine series covers the it is important to be able to take a detailed viruses affecting 90% of cervical and >90% Like other youth, we know that LGBTQ sexual history. For example, testing for of anal cancers. Lesbian women have a youth who grow up in a safe environment gonorrhea and chlamydia needs to be higher rate of HPV and cervical cancer, have better health outcomes. Look for tested at the site of intercourse (vagina, but receive fewer pap smears. The HPV other accepting individuals in your anus, and even throat). Anal pap smears vaccine is recommended up to age 26, community who can provide a safe should be done on gay men starting at age but older patients also benefit. All sexually environment. Most Episcopal churches 40, or at 25 if your patient is HIV positive. active individuals should be screened for are doing a great job at this. Many Pap smears with lesbian women should HIV. For those in a relationship with communities in SW Montana have PFLAG mirror that of straight women. someone with HIV, discuss PrEP, which chapters, and this can be easily expanded is up to 96% effective in preventing HIV to your community. For moments of Care for Transgender patients can be most transmission with consistent use. It is crisis, your patients should be aware of the daunting. One in two Trans patients say often provided at a discount from the drug Trevor Project Crisis Hotline which can be they had to teach basic Trans health to company if not covered by the patient’s reached at 1-886-488-7386. their provider. To make this simple, ask: insurance. If a patient had an encounter “Which organs does my patient have and with someone with HIV, PEP can be While we want to make an impact now are they on hormonal therapy?” Male to provided in the first 72 hours which can in our clinics, the challenge at this time is female patients should receive preventive prevent transmission. Finally, test for STDs getting LGBTQ patients into our clinic care as you would provide for a male yearly if your patient has a new partner. as they have not felt welcomed. Taking patient if they still have testicles and a Most infections are asymptomatic. a walk through your clinic through the prostate. Conversely, for female to male Remember that all those in your eyes from someone in this community patients, continue with pap smears and community deserve a safe place to live in can help see the barriers. Starting at the mammograms as you would for your and also deserve basic preventive care. Join front, does your clinic have a rainbow female patients as long as they still have a the movement in making this a patient’s flag, or “Everyone is Welcome” signage cervix and breast tissue. If they still have right! at the front? Signage can be obtained by a uterus, uterine abnormalities such as joining the PrideFoundation.org network. endometrial cancer should still be taken “LGBT Youth | Lesbian, Gay, Bisexual, and A contentious but important change is to into consideration for abnormal uterine Transgender Health | CDC.” Centers for edit intake forms to include options for bleeding. Disease Control and Prevention, Centers sexual orientation, pronouns, preferred for Disease Control and Prevention, name, sex at birth, gender identity and Hormonal therapy can increase https://www.cdc.gov/lgbthealth/youth.htm. relationship status. I was recently in one of triglycerides and blood pressure, but our rural, satellite clinics where a patient evidence for increased cardiovascular risk Wheeler CM, Skinner SR, Del Rosario- began our visit by showing his disgust of is mixed at this time. The greatest risk for Raymundo MR, et al. Efficacy, safety, our intake forms which had such language. cardiovascular disease appears to be among and immunogenicity of the human While it can be tempting to avoid change male to female patients receiving estrogen, papillomavirus 16/18 AS04-adjuvanted

12 • Montanan Family Physician YOU vaccine in women older than 25 years: 7-year follow-up of the phase 3, double- blind, randomised controlled VIVIANE study. Lancet Infect Dis 2016; 16:1154. D O N T

Elamin MB, Garcia MZ, Murad MH, et al. Effect of sex steroid use on cardiovascular risk in transsexual H AV E TO individuals: a systematic review and meta-analyses. Clin Endocrinol (Oxf) 2010; 72:1.

Asscheman H, Giltay EJ, Megens JA, B E S O et al. A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. Eur J Endocrinol 2011; 164:635. STRONG “PFLAG National Says, ‘Protect Our BUT IF I’M NOT, WHO WILL? Care!”.” PFLAG, 26 Sept. 2019, https:// pflag.org/. Being a caregiver takes a special kind of commitment. AARP.ORG/CAREGIVING We know your strength is super, but you’re still human. 1-877-333-5885 “Montana.” Pride Foundation, https:// FIND SUPPORT FOR YOUR STRENGTH . pridefoundation.org/region/montana/.

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Montana Family Physician • 13 Facilitating Practice Transformation in Frontline Health Care “Reprinted with permission from the Annals of Family Medicine”

Robert L. Phillips, Jr, MD, MSPH1 Ann Fam Med 2019;17:S2-S5. https://doi.org/10.1370/afm.2439. Deborah J. Cohen, PhD2 Arthur Kaufman, MD3 This supplement to the Annals of Family Medicine brings together early learning from multiple W. Perry Dickinson, MD4 examples of health extension and practice transformation support, with the goal of informing Samuel Cykert, MD5,6 future efforts to improve our health care system. As this supplement is published, 2 major 1Center for Professionalism federal investments testing health extension, a model of practice facilitation, to achieve & Value in Health Care, practice transformation will be ending. One is the $112 million, multiregion EvidenceNOW: Lexington, Kentucky Advancing Heart Health in Primary Care initiative of the Agency for Healthcare Research and 2Department of Family Medicine, Quality (AHRQ), a multistate research effort to test the health extension model.1,2 The other Health & Science is the nearly $700 million Transforming Clinical Practice Initiative (TCPI) of the Centers for University, Portland, Oregon & Services (CMS), a practice facilitation demonstration project touching 3Office for Community Health, all 50 states that aimed to support 140,000 clinicians.3 The response to the call for papers for University of New Mexico, this supplement garnered 50 submissions. Although we are not able to publish all of them, Albuquerque, New Mexico work not published here will also contribute to what has been learned from these large federal 4Department of Family Medicine, investments. University of Colorado School of Medicine, Aurora, Colorado The history of how we got to EvidenceNOW and TCPI is important, and the special report 5Division of General Medicine and by Kaufman et al4 in this supplement reminds us of the history behind Section 5405 of Clinical Epidemiology, School of the Patient Protection and Affordable Care Act (ACA) that authorized the Primary Care Medicine, University of North Extension Program.5 This program was modeled after the Cooperative Extension Program (US Carolina, Chapel Hill, North Department of Agriculture), which revolutionized farming in the United States over the last Carolina 100 years by testing and speeding dissemination of innovation. Its application to health care 6Cecil G. Sheps Center for Health was pilot-tested by the Regional Extension Centers under the Health Information Technology Services Research, University of for Economic and Clinical Health Act of 2009. The ACA authorized but did not fund the North Carolina, Chapel Hill, Primary Care Extension Program; however, AHRQ used this authorization to launch a pilot North Carolina project in 2011, Infrastructure for Maintaining Primary Care Transformation (IMPaCT), with 4 states, which Kaufman et al4 describe. The success of this pilot project led to EvidenceNOW Conflicts of interest: guest and further supported the decision by CMS to invest in the TCPI demonstration project. editors report none; Although authorization of the Primary Care Extension Program remains law, it is unclear how furthermore, guest editors were these important demonstration projects will translate into new programs that can continue not involved in the to speed development and dissemination of innovation in health care. Cooperative Extension peer review or acceptance has demonstrated considerable returns on investment, both in the United States and abroad.5 decisions about articles on Without sustained investment in a health care extension, however, it is difficult to achieve a which they are authors. similar return on investment.

CORRESPONDING AUTHOR Facilitation can sometime help practices figure out how to return Robert L. Phillips, Jr, MD, MSPH to their roots by focusing on core functions of primary care. Continuity is a basic, highvalue Center for Professionalism & function of primary care shown to be related to improved patient outcomes, reduced costs, and Value in Health Care greater satisfaction of both patients and clinicians. Yet, it is not routinely measured or supported 1648 McGrathiana Pkwy, Ste 550 in clinical practice. Gukasyan and Wong6 describe their development and implementation Lexington, KY 40511 of an empanelment toolkit in safetynet clinics that were part of the Los Angeles Practice [email protected] Transformation Network. The authors’ expressed goal was to support continuity, and the effort required considerable practice facilitation for implementation and routine use. Practice facilitation is necessary not only for the novel, but often for the fundamental functions.

Facilitation is sometimes necessary when introducing new tools that enable small practices to expand their capacities. Pariser and her team at the University of Toronto7 extended a

14 • Montanan Family Physician decadeold model of interdisciplinary care states, offering the practices various Primary Care Redesign teambased model into a virtual, telemedicine consultation types of implementation support plus tested by Smith and colleagues.12 This environment to support practices that facilitation. They found that large model increased the ratio of medical did not have interdisciplinary teams proportions of practices did not engage assistants to clinicians from about 1:2 to and were struggling to adequately care in shared learning opportunities or 2.5:1 while also expanding the role of for very complex patients. Hourlong educational outreach visits, both of medical assistants, and was facilitated by consultations produced a robust set of which provided practices the opportunity practice coaches. Clinician burnout was patient-informed recommendations for connecting with colleagues at other reduced by one-half with simultaneous that reflected the interplay between practices. This lack of engagement improvements in quality, patient access, polypharmacy, functional disability, social might be a sign of workload in busy and clinician panel size—all while determinants of health, and chronic practices. The study further found that maintaining staffing costs. Most practice physical and mental health conditions. all practices improved, regardless of transformation efforts do not increase These consultations reduced emergency the combination of implementation resources, and this study demonstrates department visits and hospitalizations, strategies offered. Their results suggest that doing so can improve all aspects and were generally agreeable to both that effective facilitation may need to of the quadruple aim,13 including at physicians and patients. Practices that work at relationship and engagement in least holding pervisit costs constant. cannot bring expanded patient services order to compete with existing practice Although clinician burnout was reduced into their offices need help when priorities and stressors. This is not to significantly, as in the study by Grumbach introducing virtual tools that produce the say that remote practice facilitation and colleagues,11 staff stress scores same functionalities, but that might be will not work at all or for at least some increased initially before returning to too complex otherwise. changes, however. Adler and his TCPI baseline. team10 developed remote practice Wagner and colleagues at the University coaching for nearly 3,000 optometrists Sometimes, practice facilitation seems of Alberta8 illuminate differences in in all 50 states to promote provision of straightforward as in the case of Guck primary care team mental models urgent eye care to reduce emergency and his colleagues,14 who describe a and implications for supporting department use. Practice facilitators (here single-practice innovation as an approach transformation in practices that are not called quality improvement advisors) to high-risk patients. They implemented early adopters. They found a range of remotely conducted practice assessments, an interprofessional collaborative practice practice models from “the doctor takes established goals with each practice, and (IPCP) model within an academic care of patients and hires some people assisted with implementing iterative plan- practice that included staff and clinician to help her/him” to “we take care of do-study-act cycles. Electronic reporting training, patient care preparation, and patients,” with varying levels of care demonstrated increases in urgent eye care care-planning conferences. Analysis of delegation in between. Early adopters visits with associated cost reductions of patient outcome data collected for a year tend to function in teambased models, more than $150 million over 13 months. before and a year after implementation spreading authority among team members of the IPCP model found meaningful to help in decision making, are more It is important to remember that practice improvements on multiple out-come willing (and likely) to experiment with transformation can induce stress, too, as measures. It is unlikely that this model innovations, and can hold big-picture Grumbach and his team11 found. Their would be easily spread without practice ideas about how innovations fit their study further showed that team members facilitation. practice vision. The authors suggest may not experience this stress in the same that moving beyond the early adopter direction. They assessed burnout among A qualitative study of small, independent phase will require even more coaching, clinicians and staff engaged in primary practices by Rogers et al15 is instructive skill building, and team development. care redesign over 7 years and found about the complexity of support offered Understanding these differences between variation in burnout, particularly that by practice facilitators. Specific sup- early adopters and other practices not staff may experience rising burnout when ports that were highlighted included only is critical for facilitators to support clinicians’ is in decline, and they surmise connecting practices to the external practice transformation, but also identifies that “primary care transformation requires health care environment, often through culture change as having a potentially continuing efforts to promote meaningful teaching and information sharing, important role. work and sustainable workloads among and providing electronic health record all members of the primary care team.” (EHR) and data expertise, commonly Understanding which practice facilitation This may be particularly true when by teaching functionality and providing modalities improve care remains an work is simply being shifted. If, instead, technical assistance. These small open question. Parchman and his team9 practices’ resources are increased while practices noted 3 key benefits of practice conducted a randomized controlled work is redistributed, all involved may trial in smaller practices across 3 benefit. This strategy was used in the continued on page 16>

Montana Family Physician • 15 continued from page 15>

facilitation: (1) creating awareness of quality gaps, (2) connecting practices to information, resources, and strategies, To read any of the articles referenced in this and (3) optimizing the EHR for quality improvement goals. Consistent with these piece, please visit findings, Khanna and colleagues in the Garden Practice Transformation Network16 http://www.annfammed.org/content/17/Suppl_1 focused on translating quality and cost data into a practice transforma-tion analytics dashboards for practices. Their study discrepancy. They conclude that “prac- fundamental transformation. These articles echoes both a qualitative study of family tices need tools to better understand the describe strategies for helping practices physicians participating in TCPI about communities they serve before they can use technology to strengthen relationships their reasons for doing so,17 and a study be expected to undertake population-level with patients and to offer complex patients by the EvidenceNOW evaluation team, interventions.” expanded services. They capture the ESCALATES.18 The dashboard became complexity and spectrum of practice culture a tool for practice facilitators to help What comes after EvidenceNOW and and the need to meet them where they practices develop quality improvement TCPI is an open question. How the are in order to help the difficult process plans and celebrate success, but fewer information learned will inform future of change. Most speak to the need for than one-half of practices still found the efforts to support practice transformation is, meaningful relationships and work, without information to be actionable. Khanna too. Letourneau et al22 outline a multistate which in-person support does not work, et al16 reiterate the lesson that “smaller effort by the Network for Regional Health and some show how remote support can practices are most likely to lack resources Improvement and its 30-member regional work when it is available. Two articles11,12 to review, interpret, and act on data.” health improvement collaboratives to increase remind us that the hard work of change can Gritzer and col-leagues in the Garden access to opioid use disorder treatment in produce stress and even burnout, sometimes Practice Transformation Network19 describe several states. They discuss a general approach differently across the team, but others an innovation that entailed facilitating to practice facilitation able to adapt to suggest that engaging the whole team can small practices’ use of patient portals that variation in state resources and policies, and enable meaningful improvements. Many are offers several exemplars of the study by in local relationships. The authors describe instructive bout the important functions of Rogers et al,15 namely, practice facilitator regional health improvement collaboratives practice facilitators and how these functions interventions with EHR vendors to enable as independent, nonprofit organizations may differ by practice type, offering guidance patient portal functionality, help practices composed of multiple stakeholders who on preparing this workforce. understand related return on investment, come together to improve health and health teach them to use portal functions, and care, and note that they must include health Most practices lack time, energy, and assist them in realizing the role of patients care professionals, payers (health plans), resources to make these changes on their in informing and improving quality. These health care purchasers (employers), and own, and most lack means of learning about studies are important for showing that consumers. Collectively, these collaboratives the policies pushing them to change or effective practice facilitation is not just cover 32 states and already serve as TCPI examples from which they can learn. Farming technical assistance, but rather may need entities, quality improvement organizations, was in a similar situation a century ago, to also include help with using quality data regional extension centers, and health prompting federal and state governments and building confidence and skills, sharing information exchanges. Opioid use disorder set up the Cooperative Extension system learning, and even conducting advocacy. is an important epidemic for which practice that is still facilitating and speeding facilitation could increase the rate of best- transformation of the process whereby that Addressing social determinants of health practice adoption, but its collaborative nation’s nutritional needs are met. It is one is increasingly discussed as a necessary management also presents an exemplar of the of our most emulated programs around function of outpatient care. Community- benefits of practice facilitation in addressing the world, and evidence of its investment oriented primary care is a well-tested and urgent health issues to come. returns make it one of the most supported systematic way for practices to define federal pro-grams. Practice facilitation, health practice community, then assess and address Several of the articles in this supplement are extension, and other forms of support for community needs, evaluate outcomes, and the early products of nearly $800 million practice transformation and community repeat.20 This approach has proven difficult invested by federal health agencies to test health improvement are important systems- to implement for several reasons, including transformation facilitation in thousands level interventions to improve health care problems with defining “community.” Rock of practices across the United States. and accomplish the quadruple aim.13 The and colleagues21 tested the relationship Collectively, they tell a story of practices benefits of such improvements generally between actual and clinician-predicted needing relationships and real support in accrue across multiple stakeholders, geographic service area and found vast achieving meaningful improvement, if not making funding of such “public good”

16 • Montanan Family Physician efforts a challenge. Further results from Practice Initiative Awards. https:// Doll J, Greene MA, DeFreece T. EvidenceNOW, TCPI, and other large-scale www.cms.gov/newsroom/fact-sheets/ Improved outcomes associated with practice and community health improvement transforming-clinical-practice-initiative- interprofessional collaborative practice. efforts will emerge over the next few years awards. Created Sep 29, 2015. Accessed Ann Fam Med. 2019; 17(Suppl 1): S82. and should inform whether and how Jul 28, 2019. 15. Rogers ES, Cuthel AM, Berry CA, the United States will support practice 4. Kaufman A, Dickinson WP, Fagnan LJ, Kaplan SA, Shelley DR. Clinician transformation facilitation and community Duffy FD, Parchman ML, Rhyne RL. perspectives on the benefits of practice health improvement efforts in the future. The role of health extension in practice facilitation for small pri-mary care transformation and community health practices. Ann Fam Med. 2019; To read or post commentaries in response improvement: lessons from 5 case studies. 17(Suppl 1): S17-S23. to this article, see it online at http://www. Ann Fam Med. 2019; 17(Suppl 1): S67- 16. Khanna N, Gritzer L, Klyushnenkova E, AnnFamMed.org/content/17/Suppl_1/S2. S72. et al. Practice transforma-tion analytics 5. Phillips RL Jr, Kaufman A, Mold JW, et dashboard for clinician engagement. Ann Key words: practice transformation; al. The Primary Care Exten-sion Program: Fam Med. 2019; 17(Suppl 1): S73-S76. organizational change; innovation; quality a catalyst for change. Ann Fam Med. 17. Hansen ER, Eden AR, Peterson LE, improvement; professional practice; health 2013; 11(2): 173-178. Bishop EM, Phillips RL Jr. Experi- extension; outreach; practice facilitation; 6. Gukasyan S, Wong M. An empanelment ence of family physicians in practice primary care; burnout; health information toolkit for the safety-net clinic setting. transformation networks. J Ambul Care technology; practice-based research Ann Fam Med. 2019; 17(Suppl 1): S84. Manage. 2019; 42(2): 92-104. Submitted June 13, 2019; submitted, revised, 7. Pariser P, Pham T-N(T), Brown JB, 18. Ono SS, Crabtree BF, Hemler JR, et al. June 18, 2019; accepted July 1, 2019. Stewart M, Charles J. Connecting people Taking innovation to scale in primary with multimorbidity to interprofessional care practices: the functions of health Funding support: This supplement was teams using tele-medicine. Ann Fam care extension. Health Aff (Millwood). supported by Funding Opportunity Number Med. 2019; 17(Suppl 1): S57-S62. 2018; 37(2): 222-230. CMS-1L1-15-002 from the U.S. Department 8. Wagner KK, Austin J, Toon L, Barber T, 19. Gritzer L, Davenport M, Dark M, of Health & Human Services (HHS), Centers Green LA. Differences in team mental Khanna N. Coaching small pri-mary for Medicare & Medicaid Services. models associated with medical home care practices to use patient portals. Ann transformation success. Ann Fam Med. Fam Med. 2019; 17(Suppl 1): S83. Disclaimer: The contents provided are solely 2019(Suppl 1); 17: S50-S56. 20. Institute of Medicine Division of Health the responsibility of the authors and do not 9. Parchman ML, Anderson ML, Dorr Care Services. In: Commu-nity Oriented necessarily represent the official views of HHS DA, et al. A randomized trial of external Primary Care: A Practical Assessment: or any of its agencies. practice support to improve cardiovascular Volume I: The Com-mittee Report. risk factors in primary care. Ann Fam Washington, DC: National Academies Acknowledgments: The authors wish to Med. 2019; 17(Suppl 1): S40-S49. Press; 1984. thank Dr Kevin Grumbach and Dr Jim 10. Adler RN, Ferguson WJ, Antar H, et 21. Rock RM, Liaw WR, Krist AH, et Mold who contributed greatly as part of the al. Transformation support provided al. Clinicians’ overestimation of their guest editorial team for this Annals of Family remotely to a national cohort of geographic service area. Ann Fam Med. Medicine supplement. optometry practices. Ann Fam Med. 2019; 17(Suppl 1): S63-S66. 2019; 17(Suppl 1): S33-S39. 22. Letourneau LM, Ritzo J, Shonk R, 11. Grumbach K, Knox M, Huang B, Eichler M, Sy S. Supporting physi- References Hammer H, Kivlahan C, Willard- cians and practice teams in efforts 1. Meyers D, Miller T, Genevro J, et al. Grace R. A longitudinal study of to address the opioid epidemic. Ann EvidenceNOW: Balancing primary care trends in burnout during primary care Fam Med. 2019; 17(Suppl 1): S77- implementation and implementation transformation. Ann Fam Med. 2019; S81. Wednesday, January 29, 2020 research. Ann Fam Med. 2018; 16(Suppl 17(Suppl 1): S9-S16. 1): S5-S11. 12. Smith PC, Lyon C, English AF, Conry The Lodge at Whitefish Lake 2. Cohen DJ, Balasubramanian BA, C. Practice transformation under the Afternoon Gordon L, et al. A national evalu-ation University of Colorado’s primary care 4:30 – 5:00 Registration of a dissemination and implementation redesign model. Ann Fam Med. 2019; 5:00 – 6:00 Evidence Update: 10 Recent initiative to enhance primary care practice 17(Suppl 1): S24-S32. Practice-Changing Papers For Family capacity and improve cardiovascular 13. Bodenheimer T, Sinsky C. From triple to Medicine—Timothy Caramore, M.D. disease care: the ESCALATES study quadruple aim: care of the patient requires 6:00 – 6:15 Break for Dinner (Buffet protocol. Implement Sci. 2016; 11(1): 86. care of the provider. Ann Fam Med. Provided) 3. Centers for Medicare & Medicaid 2014; 12(6): 573-576 6:15 – 9:15 Physician Health First — Services. Fact sheet: Transforming Clinical 14. Guck TP, Potthoff MR, Walters RW, Nicole Eull, PsyD

Montana Family Physician • 17 Misconceptions in Addiction Medicine

Essay written by Jessica Lancaster, OMS IV Pacific Northwest University College of Osteopathic Medicine

Hunched, with his hands on his knees, As I learned more about John, I was rubbing his sweaty hands together saddened to discover he was another anxiously, he sat staring at the ground. victim of medical negligence, suffering He was pleasant and answering my the consequences of the opioid crisis questions appropriately, but I knew that has plagued our society. Several something was off. Proceeding with years ago, John suffered a traumatic the conversation, I asked the typical amputation of the digits on his left questions of any MAT visit follow up: hand after a snow blowing accident. Are you using your medications as Partial re-attachment of the second prescribed? Is your current dosage still and third phalanges was successful, effective? How are your behavior health however he still suffered from terrible visits going? How, in general, are you phantom pain. After the surgery he was feeling? prescribed Oxycontin. As he came to the end of his prescription, he was left When I asked the last question, he high and dry; still suffering significant looked up, locked eyes with me, and pain but without a means of relief, replied, “I’ve been extremely anxious leaving him with no choice but to turn this week and haven’t been sleeping.” to the streets for pain management. After a brief pause, he continued, “I He self-medicated with mostly heroin made a phenomenal reference that I feel have been so stressed because at my which was the cheapest at the time. His is necessary to share. last MAT visit, I forgot to report that I addiction cost him his job, his wife, and started taking my gabapentin again and custody of his daughter. It is a tragic First of all, we have to understand what I know I’m supposed to report all the story of addiction, but John has grit. constitutes addiction. The American medications I am taking. I am so sorry, He knew he couldn’t fight the cravings Psychiatric Association describes please, please don’t kick me out of the he had, but something had to be done. addiction as “a complex condition, program. I have been so worried about That’s when he found the MAT clinic. a brain disease that is manifested by it this whole week!” compulsive substance use despite I’m embarrassed to admit, prior to harmful consequence”. The key here is John has been a patient of the this rotation I was biased. “Opioid “…brain disease”. Initial introduction community MAT (Medication-Assisted addiction...they know it’s wrong, it’s of an addictive substance and continued Treatment) program for almost two ruining their life, why can’t they stop? use cause changes in the brain’s years. This was my first visit with him Suboxone treatment – aren’t they just wiring leading to intense cravings and on my Family Medicine rotation and exchanging one addiction for another?” make it hard to stop despite negative during my encounter I was shocked at I was naïve. However, I think it’s safe consequences. Therefore, addiction is how distraught and fearful he was of to assume that many medical students a disease. That’s a hard, cold fact. Then losing access to his Suboxone treatment. and even physicians are naïve in their why is it so difficult for us to treat it To us, as providers, gabapentin is more knowledge surrounding this topic. It like one? or less a medication we would rather wasn’t discussed in my medical school see patients with chronic pain taking courses and if that’s true across the When attending this talk, the speaker than any of the alternative options. board, then this is a fault that should be compared Suboxone to albuterol - polar Furthermore, we would never scrutinize changed across the country. opposites you would think, but the a patient for taking this medication if further he broke down this comparison they believed it helped. However, John About a month ago, I attended a talk the clearer the world of addiction didn’t know this, he just saw his failure on addiction medicine, specifically treatment became. Here’s the scenario – to report as a potential catastrophe to Suboxone treatment. During this talk, you have two patients: one is a teenage his finally, normal life. I had a moment of enlightenment and female complaining of breathing also a feeling of sheer guilt. The speaker issues, and the other is a teenage

18 • Montanan Family Physician male complaining of heroin use. Your Suboxone is a combination medication occur. The second ingredient, naloxone, female patient reports, “Doctor, I have of buprenorphine and naloxone. is a full opioid antagonist, it binds difficulty breathing every time I try to Buprenorphine is a partial agonist to opioid receptors and blocks them run or exercise. I hate it. It’s keeping me at opioid receptors, which means it from being activated. It, however, is from being able to participate in sports causes lower activation as well as binds inactivated in the gut and instead is an with friends and I feel left out!” Easy – tighter and longer than true opioids added ingredient to keep users from you prescribe her an albuterol inhaler themselves. As the dose increases, its misusing Suboxone via snorting or and tell her to take a few puffs before analgesic effects reach a plateau and it injecting. For a provider to prescribe she exerts herself. Your male patient starts to act as an antagonist. Therefore, such medication, a Drug Addiction reports, “Doctor, I tried heroin several buprenorphine does not produce the Treatment Act (DATA) wavier is months ago with some friends. I know same high and it is much harder to required which is accomplished by I shouldn’t have done it and it was overdose on than your typical opioids. completing an eight-hour continuing supposed to be a one-time thing, but Additionally, due to its tight binding education class. Overall, this medication now I can’t stop using or thinking about affinity, if a user was to take another is a great option for long term treatment using. I’ve even started stealing money form of an opioid medication on top of opioid addiction. It provides minimal from my parents to buy more and the of their Suboxone dose, no high would abuse as well as overdose potential school is threatening to expel me!” Easy coupled with enough activating action – you prescribe Suboxone and instruct to prevent withdrawal and cravings. him to take his prescribed dose daily. Both patients return a month later. You “My views on addiction Back to John. Seeing the pleading in ask your female patient how she feels, his eyes when he begged me not to kick “I’m great Doctor, I take a couple puffs and chronic Suboxone him out of the MAT clinic solidified before I exercise, and I feel normal.” treatment have been for me the true impact this medication You ask your male patient how he feels, can have on a patient’s life. In fact, “I’m great Doctor, I haven’t used in a forever changed and I, John was now head mechanic at the month, yet I feel normal.” without a doubt, plan to local auto shop and had full custody attain my DATA waiver to of his thriving, five-year-old daughter. You succeeded as a physician, you A simple guy with a medical disease, helped both of the patients with their help patients like John.” taking a daily treatment, that makes disease. But here’s the mind-boggler, him function like his normal self is a would you ever make your asthmatic medical success, wouldn’t you say? patient stop taking their albuterol? Are they suddenly just going to cure My views on addiction and chronic themselves one day? Probably not. Suboxone treatment have been forever Then why is there implicit bias present changed and I, without a doubt, plan to when a patient is on chronic Suboxone attain my DATA waiver to help patients therapy? Why is the culture to wean like John. As family physicians, we are them off a substance, for a chronic first line in this ongoing war against disease, that makes them feel normal? opioid abuse. We have an opportunity Did they too just cure themselves to make a tremendous difference in overnight? You wouldn’t take albuterol many lives; I urge everyone to put away from an asthmatic so why take aside any bias they might have, educate Suboxone away from an addict? Seems themselves, and take time to obtain a simple when you spell it out this way, prescribing waiver. Together, let’s spread but like I said before, I wrongly thought more normalcy. Suboxone was indeed just exchanging one addiction for another.

Montana Family Physician • 19 Stopping Burnout at the Source: Delegating the Administrative Burden

By: Peter Anderson, MD with James Anderson, MD. Reprinted with permission from the Ohio Academy of Family Physicians

was drowning in a sea of it was the last straw—I knew I needed have delegated years earlier, it also allowed administrative requirements. With the to figure out a better way of practicing me to improve care and increase patient I advent of the electronic health record medicine. access. I was enjoying medicine again and (EHR) at my health system, I moved was going home at night with my charts much more slowly through patient visits What I wanted was an experience more 100% current. My patients were delighted and spent much of my time staring at the like a surgeon, who walks into the to find that they could now make same- screen rather than making eye contact operating room with the patient prepared, day appointments for acute conditions with my patients. I poured more and the equipment ready, and the nurses rather than seeing a stranger at an urgent more of my days (and my evenings) into available. That vision inspired me to care center. System leadership at Riverside tasks that did not require years of medical tinker, experiment, and innovate to create Health System in Newport News, VA, was school and residency training. Like all a comprehensive primary care workflow delighted to see my financial profile flip too many other family physicians, I was that would allow me to focus just on the from losing six figures per year to the most burning out. tasks that required my MD designation. productive practice in the network. Equipping, empowering, and expanding My long-time nurse felt similarly worn out my clinical support staff not only freed me In the ensuing years, the Team Care and when she turned in her resignation, up from administrative tasks that I should Medicine (TCM) Model has been

20 • Montanan Family Physician endorsed by the American Medical In the TCM Model, the clinical staff time, while an individual physician never Association, the American Board of (registered nurses, medical assistants, needs more than one scribe. A simple Internal Medicine, the American Academy etc.) take on a role called the Team Care workflow with two TCAs is illustrated of Family Physicians, and other healthcare AssistantTM (TCA). They execute six below. leaders across the United States. The TCM discrete steps in the patient visit. Crucially, Model reflects a handful of basic insights the physician is only present for two of In recent years, the Team Care Medicine but, like individual steps in a dance, them. Much of the administrative work Model has been adopted by a range of putting them all together in a cohesive, is performed at the beginning and the practices from coast to coast, including organic sequence takes good coaching and end of the visit, and is performed by the small federally qualified health centers intentional practice. To be clear, it is not a TCA rather than the physician. When the and large integrated delivery networks. set of tips and techniques to be selected a physician is present, the TCA summarizes Physicians have learned to coach, to la carte based on personal preference. the preliminary medical information lead, and to delegate in the exam room. that has already been collected, in much They’re reporting restored joy in medicine The transformation starts with a major of the same way that a medical student as they engage the patient rather than shift in mentality for the physician. presents the patient’s case to the attending the computer and go home on time with Though medical schools rarely include physician. Then the TCA scribes the very all their charts current. With improved the management training coursework concise examination by the physician, clinic access, patients are delighted to get included in an MBA program, providers freeing up the physician to hone in on the same day acute appointments with their must embrace the reality that they manage diagnosis and prescription without even own physician rather than an urgent care a team. Their role can and should be less touching the keyboard. center. Executives are pleased by a strong like the star player that needs the ball in ROI as the increase in visit volumes their hands all the time and more like the Because they operate extensively without easily covers the conversion costs, not team captain that raises the performance the physician in the room, each TCA to mention the improved morale and of the entire team through coaching and offers dramatically more leverage to the retention of the physicians. This is just leadership on and off the court. physician’s time than a scribe. Indeed, a the beginning and I’m delighted that relief high functioning TCM physician can be from administrative burden is beginning supported by up to four TCAs at the same to restore primary care nationwide.

Montana Family Physician • 21 Presents The 61st Annual Big Mountain Medical Conference January 29 – 31, 2020

The Lodge at Whitefish Lake Whitefish, Montana Register on line at:http://www.montanaafp.org

Application for CME credit has been filed with the AAFP. Determination of credit is pending

Afternoon Wednesday, January 29, 2020 1:45 – 4:15 Wednesday,Point of Care JanuaryUltrasound. 29, A Hands 2020 on Approach to Understanding The Lodge at Whitefish Lake The theLodge Applicability at Whitefish ofLake Bed-side Ultrasound — Elizabeth Paddock, M.D. REGISTRATION FORM Afternoon Afternoon ($100 additional registration fee required and space is limited) Please send this form to: 4:30 – 5:00 Registration 4:30 – 5:00 Registration Montana Academy of Family Physicians 4:30—5:30 5:00Hair – 6:00 & Scalp Evidence Disorders Update: 10—Amanda Recent Practice-Changing Hartman, M.D. Papers For Linda Edquest 5:00 – 6:00 Evidence Update: 10 Recent Practice-Changing Papers For Family 8 Cloverview Drive Family Medicine —Timothy Caramore, M.D. Helena, MT 59601 Medicine—Timothy Caramore, M.D. 5:30—6:30 Osteoarthritis: Before & After Joint Replacement Surgery— [email protected] 6:00 – 6:15 Break for Dinner (Buffet Provided) Timothy Joyce, M.D. 6:15 – 9:15 Physician Health First —Nicole Eull, PsyD 6:00 – 6:15 Break for Dinner (Buffet Provided) The Lodge at Whitefish. Lake Whitefish, Montana Online registration Available at: http:// www.montanaafp.org FACULTY Amanda Hartman, M.D. Please note MAFP is able to accept 6:15 – 9:15 Physician Health First — Nicole Eull, PsyD Fam. Med. Residency of Western MT credit cards for registration.

TimothyThursday, Caramore, M.D. January 30, 2020Missoula, MT Name ______Fam. Med.The Residency Lodge at ofWhitefish Western MTLake Thursday, January 30, 2020 Missoula, MT Amy Matheny, M.D. Title ______

The Lodge at Whitefish Lake Morning Fam. Med. Residency of Western MT Address ______

Morning Nicole Eull,7:00 PsyD – 9:00 Finding Truth in the Failed TheoriesMissoula, of MT Heart Disease— City ______Director of WellbeingJames for Academic Painter, Ph.D., R.D. 7:00 – 9:00 Finding Truth in the Failed Theories of Heart State ______Zip ______Affairs, Aurora Health Care Sophia Newcomer, PhD, MPH Disease —James Painter, Ph.D., R.D. What’s Your Carbohydrate & Fasting IQ? The Science Behind Both— Phone ______Milwaukee, WI Assistant Professor of What’s Your Carbohydrate & Fasting IQ? The Science Behind James Painter Ph.D., R.D. Epidemiology, U of M Email ______Both—James Painter Ph.D., R.D. 11:00 Ski Races James Galvin, M.D., MPH Missoula, MT

ProfessorAfternoon of Neurology REGISTRATION FEE: 11:00 Ski Races Florida Atlantic4:30 – 5:30 University Vaccine Safety in the U.S.—SophiaJames Painter, Newcomer, PhD, Ph.D., R.D. MPH *Before Jan. 1, 2020: After Jan. 1, 2020: Boca Raton, FL Nutrition Consultant 5:30 – 6:30 Hepatitis C—Management in Primary Care—Amy Matheny, M.D. Montana AFP Members $385 $410 Eastern Illinois University Afternoon Non-Members $435 $460 Timothy6:30 Joyce, M.D. Reception with food and drinksCharleston, IL 4:30 – 5:30 Vaccine Safety in the U.S. NP/PA $385 $410 Orthopedic Surgery Trophy Presentations for Ski/Snowboard Races —Sophia Newcomer, Ph.D., MPH Northwest Orthopedic & Sports Med Elizabeth Paddock, M.D. Residents $200 $200 Students $0 $0 Kalispell, MT Fam. Med. Residency of POCUS Workshop $100 5:30 – 6:30 Hepatitis C—Management in Primary Care Western MT Friday, January 31, 2020 —Amy Matheny, M.D. Missoula, MT Total ______The Lodge at Whitefish Lake 6:30 Reception with food and drinks Morning John B. Miller, M.D., Number of racers attending:______Winter Meeting Trophy Presentations for Ski/Snowboard Races 7:00 – 8:00 Update in Alzheimer’s Disease: Solutions For Early Identification & Program Chair, Missoula, MT Management—James Galvin, M.D., MPH Registration includes Wednesday night din- 8:00— 9:00 Cases in Diabetes Management: Incorporating The New Evidence— Friday, January 31, 2020 ner for registrants and Thursday night re- Elizabeth Paddock, MD The Lodge at Whitefish Lake ception for registrants and families 9:15—1:30 Optional Buprenorphine Course for Office Based Treatment of Opioid

Use Disorder—This treatment meets American Society of Addiction Morning Faculty Disclosure Medicine requirements for applying for DEA Waiver _____I would like to attend the 7:00 – 8:00 Update in Alzheimer’s Disease: Solutions MAFP must ensure balance, independence, objectivity and scientific rigor in its educational activities. Course For Early Identification & Management— Afternoon Buprenorphine Course director(s), planning committee, faculty, and all others James Galvin, M.D., MPH 1:45 – 4:15 Point ofwho Care are Ultrasound. in a position A Hands to conton Approachrol the content to Understanding of this edu- the Applicability of Bed-side Ultrasound — Elizabeth Paddock, M.D. cational activity are required to disclose all relevant Telephone 406-431-9384 8:00— 9:00 Cases in Diabetes Management: Incorporating ($100 additionalfinancial registration relationships fee required with anyand space commercial is limited) interest

The New Evidence—Elizabeth Paddock, MD 4:30—5:30 Hair & relatedScalp Disorders—Amanda to the subject matter Hartman, of the M.D. educational activity. "The AAFP invites comments on any activity that 5:30—6:30 Osteoarthritis:Safeguards Before against & After commercia Joint Replacementl bias haveSurgery— been put in has been approved for AAFP CME credit. Please for- place. Faculty also will disclose any off-label and/or ward your comments on the quality of this activity to 9:15—1:30 Optional Buprenorphine Course for Office Timothyinvestigational Joyce, M.D. use of pharmaceuticals or instruments [email protected]." Based Treatment of Opioid Use Disorder— discussed in their presentation. Disclosure of this in- This treatment meets American Society of 22 • Montanan Family Physicianformation will be published in course materials so Addiction Medicine requirements for applying those participants in the activity may formulate their for DEA Waiver The Lodge at Whitefish Lake own judgments regarding the presentation.

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Montana Family Physician • 23 Presorted Standard U.S. Postage Paid Little Rock, AR 8 Cloverview Drive, Permit No. 2437 Helena, Montana 59601 Medical Doctor Program

A loan tailored for you, from the credit union built for you Montana Health Federal Credit Union was established over 50 years ago to serve healthcare professionals.PRODUCT HIGHLIGHTS We recognize the AND unique ELIGIBILITY needs our REQUIREMENTSmembers have and provide financial products tailored for our members. 1 Unit Primary Residence, Single- Family Residence, Condo and PUD. Purchase and no cash outMedical refinance. Doctor Program Highlights • MaximumMaximum LTV LTV of of 95%. 95%. • At least one borrower on loan must have Maximum loan amount follows conforming loan limits. • Deferred student loan payments of one of the following designations: Medical Deferred student loan payments of borrower (medical) may be excluded borrower (medical) may be excluded from Resident, MD, DDS, DMD, OD , DPM, DO. from the calculation of a borrower’s monthly debt-to-income ratio. theAt leastcalculation one borrower of a borrower’s on loan must monthly have one •of theFuture following income designations: can be used if effective debt-to-incomeMedical Resident, ratio. MD, DDS, DMD, OD , DPM, DO.within 60 days of closing. Agency limits accepted. Future income can be used if effective within 60 days of closing. Contract mustContact be Jackienon-contingent Helman - 3 months reserve PITI. No verbal VOE for future income. to get started on your custom loan today. 406.259.2000

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