fma magazine fall, 2008

Profiles: Women in medicine

making the grade

state of emergency

kamel elzaWahry, md, a gifted Physician

PrescriPtion Pain killer abuse the Quiet ePidemic

Fall 2008 Volume 2008, Number 4

Helping Physic ians Pract ice Medic ine FLO

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You know how to prevent colon cancer. Make sure your patients do too.

Colorectal cancer screening may not be the easiest topic to discusswith patients, but the fact that colorectal cancer can be preventedis something that they really need to hear. Unless you start theconversation, chances are, they won’t bring it up. For some helpfulresources, call 1-800-ACS-2345 or visit www.cancer.org/colonmd.

H o p e . P r o g r e s s . A n s w e r s . ® 1 . 8 0 0 . A C S . 2 3 4 5 w w w . c a n c e r . o r g

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www.fmaonline.org Florida Medical Magazine Fall 2008 1

c o N t e N t s

fall 2008

the Quiet ePidemic (cover story) every day, seven people in Florida die from abusing prescription narcotics. across the United States, the number of these abuse cases is growing more rapidly than those of heroin and cocaine combined. Find out what law enforcement officials and Florida’s physicians are doing to solve this quiet epidemic.

state of emergency emergency rooms throughout Florida are facing hard times. The precarious nature of er care is scaring off specialists, often leaving emergency physicians with nowhere to turn. Though many hospitals have made er on-call coverage mandatory, it has done little to solve the problem. Take a closer look at Florida’s state of emergency.

making the grade For several years, managed care organizations have been grading physicians on their quality of care and cost-effectiveness. However, many physicians question the fairness and accuracy of these “physician designation programs.”

Women in medicine These physicians are at the forefront of medical politics, academics and business. coming from a variety of backgrounds, their contributions to Florida’s medical community are as diverse as they are exciting. We invite you to meet these women in medicine, and learn more about how they’re making a mark on medicine in Florida.

kamel elzaWahry, md, a gifted Physician Few physicians have accomplished more, or touched more lives than Kamel elzawahry, Md. His ongoing contributions to Florida’s physicians leave a lasting impression on his friends, his family, his community and his colleagues. learn more about this true champion of medicine.

getting to knoW dean cannon among the many friends of medicine in Florida’s State legislature, one state representative is creating quite a stir. learn more about the future Speaker of the Florida House, representative dean cannon, and why physicians are calling him a “rock star.”

President’s letter

executive vice President’s letter

editor’s letter

sPecial Practice management suPPlement starts on back cover

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Florida Medical Magazine Fall 2008 www.fmaonline.org

Steven r. West, M.d.President

James B. dolan, M.d.President-elect

Madelyn e. Butler, M.d. Vice President

Vincent a. degennaro, M.d.Secretary

W. alan Harmon, M.d.Treasurer

alan B. Pillersdorf, M.d. Speaker

david J. Becker, M.d.Vice Speaker

Karl M. altenburger, M.d.immediate Past President

John n. Katopodis, M.d.district a

eli n. lerner, M.d.district B david M. McKalip, M.d.district c

Harold l. greenberg, M.d.district d

ralph J. nobo, Jr., M.d.district e

nabil a. el Sanadi, M.d.district F

Stephan Baker, M.d.district g

Silvio a. garcia, M.d.at large

neal P. dunn, M.d.at large

lisa a. cosgrove, M.d.Primary care Specialties

linda S. cox, M.d.Medical Specialties

alan S. routman, M.d.Surgical Specialties

Miguel a. Machado, M.d.council on legislation

e. coy irvin, M.d.aMa delegation

James H. rubenstein, M.d.FMa Pac

M. Kamel H. elzawahry, M.d.Specialty Society Section

ashley e. Booth, M.d. Young Physician Section

Joel r. Judah, M.d.resident and Fellow Section

Jeremy l. TharpMedical Student Section

diane r. andrews, Ph.d., r.n.FMa alliance

donald F. Foy, Sr.Public Member

Karen Wendland, M.S.council of Medical Society execs

ana Viamonte ros, M.d., M.P.H.State Surgeon general

robert e. cline, M.d.State Board of Medicine

Fall 2008 (VolUMe 2008, nUMBer 4)

Florida Medical Magazine is published four times a year (February, May, august and november) by the Florida Medical association, inc., located at 123 South adams Street, Tallahassee, Fl, 32301-7719.

copyright 2008 by Florida Medical association, inc. all rights reserved. Views expressed in this issue represent those of the individual authors and may not represent the views of the Florida Medical association, inc. The Florida Medical association, inc., does not represent the accuracy or reliability of any of the advertisers displayed in this publication and does not necessarily endorse any of the advertisers in this publication.

application to Mail at Periodicals Postage Prices is Pending at Tallahassee, Fl. PoSTMaSTer: Send changes to:Florida Medical Magazine123 South adams Street Tallahassee, Fl 32301-7719

rubenstein, M.

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alan B. Pillersdorf, M.Speaker

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Stephan Baker, M.d.istrict g

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Vincent ennaro, M.d.Secretary

W. alan Harmon, M.d

Harold l. greenberg, M.district d

ralph J. nobo, Jr., M.district e

nabil a. el Sanadi, M.district F

Stephan Baker, M.district

Steven President

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James B. President-

Madelyn . Butler, M.Vice President

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fall’08meDIcal

magazINe

FlorIDa

2008-2009 board of governors

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Editor-in- ChiEfMarc J. Yacht, Md, MPH

AssoCiAtE EditorsKarl M. altenburger, MdThomas l. Hicks, Md

MAnAging Editorlynne Takacs

PubliCAtion dEsignMichael [email protected]

stAff WritErJohn Tyler

AdvErtising Shawn Winship

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in florida Medical Magazine,

contact shawn Winship

at [email protected],

1-800-762-0233, or visit

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www.fmaonline.org Florida Medical Magazine Fall 2008

American College of Physician Executives:The training you need… in your own backyard.

Attend the ACPE’s Winter Institute January 24–29 at the Hyatt Grand Cypress in Orlando.

Get the education, training and networking necessary to advance your career. For more than 30 years, the American College of Physician Executives has been the AMA-designated specialty society committed to offering leadership training to physicians, health care administrators and nurse managers. From courses in health law and leadership skills to career counseling, there’s something at ACPE’s Winter Institute to benefit all medical professionals. And you don’t even have to leave the state.

For more information and to register, visit www.ACPE.org/winter

fall’08

3

Florida Medical Magazine Fall 2008 www.fmaonline.org4

This year we have several priority issues, including bringing Medicaid reimbursements for physician services up to at least Medicare levels. This is good public policy for three reasons. First, access to necessary medical care will improve for Medicaid patients and take some of the pressure off of our emergency rooms. Second, the state will save money because care will be provided earlier in the illness and in a low cost setting of physicians’ offices instead of the high cost environment of the emergency room or hospital. Third, increasing Medicaid rates will provide a booster shot for Florida’s weakened economy. For every dollar Florida spends on Medicaid, the federal government provides a match of almost one-to-one. although economic times are tough, the legislature has a projected budget of $66 billion.

Yes, there is plenty of money to adequately fund Medicaid. right now, the only thing lacking is political will. The FMa will help physicians practice medicine by providing the legislature with the political will to increase Medicaid reimbursements.

The FMa also will be working with the Florida Society of interventional Pain Physicians (FSiPP) to pass prescription drug monitoring legislation. This legislation will decrease drug diversion and abuse, saving countless lives. currently, more than 30 states have this type of drug monitoring system. in these states, the monitoring systems have a proven record of decreasing the easy availability of prescription controlled substances on the streets, in schools, and elsewhere.

by Steven R. West, MD, FMA President

With the 2009 legislative session quickly

approaching, your fma leadership and

staff are working hard in preparation. this session will prove

challenging, as the legislature wrestles with an economy in

decline and a projected budget deficit of $1.47 billion. however,

this budget shortfall will not dampen our resolve as we seek to

help make florida a friendlier place for physicians.

the Fma will help physicians practice medicine

by providing the legislature with the political

will to increase medicaid reimbursements.

legIslatIoNwIth You IN mIND


The development of the drug database will help physicians practice medicine by allowing physicians to be confident that prescriptions written to help patients relieve pain and suffering are used strictly for that purpose.

Finally, for some time now, insurance companies have been profiling physicians. Physicians are provided a grade regarding the quality and cost-effectiveness of care. The programs and processes used by the insurance companies to rank physicians do so unfairly and inaccurately.

in a column titled “curbing Physician Profiling,” published in the AMA e-Voice on July 24, 2008, aMa President nancy H. nielsen, Md, Phd, wrote, “While the aMa neither supports nor opposes physician profiling per se, we believe that when it is done, patients and physicians have a right to understand how the profiles are developed, as well as an expectation that the results accurately reflect the realities of the physician practice. Some health insurers have unfairly evaluated physicians’ individual work using an insufficient number of patient cases, questionable quality cost measures and poor adjustments for risk and case mix. others have even produced ratings that are solely or primarily based on physicians’ cost of care, with little or no attention paid to the quality of care provided.” She goes on to point out that, “not only can incorrect and misleading information tarnish a physician’s reputation . . . [erroneous] information can erode a patient’s confidence and trust in physicians, and disrupt long standing relationships with doctors who have known them and cared for them for years.”

You can learn more about this issue, and what the FMa is planning to do about it in next year’s legislative session, in this edition of Florida Medical Magazine. We have a lot of work to do for next year and beyond, and despite the challenges we’re sure to face, i’m confident and eager to see what we can all accomplish for the physicians and patients of Florida.

thE fMA Will Work to inCludE thE folloWing in lEgislAtion MAndAting

A drug Monitoring systEM:

- 1 -PatIeNt PrIVacY ProtectIoN

- 2 -secure, eNcrYPteD, PassworD-ProtecteD

websIte access For:

• Information on all Schedule II, III, IV medications dispensed within two years

• Mandatory data from all dispensing entities of scheduled drugs

• Fully licensed prescribers with DEA licensure for scheduled medicines

- 3 -the secure Database

• Does not require patient permission for data entry or retrieval

• Allows review by physicians and pharmacists for ac-tual patients or those requesting to become patients

• Should eventually integrate with similar databases nationwide

- 4 -secoNDarY use oF the Database Is restrIcteD to:

• The Department of Health with active investigation of fraud or medical standard of care

• Law enforcement with active investigation by subpoena

- 5 -the DePartmeNt oF health shoulD be

the leaD ageNcY that:

• Begins consultations for design, funding, and contracting for program implementation

• Oversees any contracted vendor(s)

• Investigates complaints of abuse or misuse of the website and/or refers to criminal justice or profes-sional responsibility board(s).


it is an honor and a privilege to become the eighth executive Vice President (eVP) of the Florida

Medical association (FMa). For the last 11 years, i’ve had the pleasure of working with Florida’s most talented and dedicated physicians. during this time, i have enjoyed working together with you to make sure physicians’ voices are heard and your interests are represented both in the halls of the capitol and in your community. The reason for this is simple – making Florida a better place for physicians to practice medicine is our priority. i am both proud and encouraged by the progress that has been made over the past decade and excited to see what we will continue to accomplish together.

We’ve seen remarkable success in the halls of the capitol. last year, the FMa successfully passed model managed care legislation, which significantly leveled the field between insurance companies and physicians. You can read more about this important legislation on our website at fmaonline.org. This year, we will continue to work on issues that will help physicians practice medicine. You can learn more about some of these issues in this edition of Florida Medical Magazine. Fighting on behalf of physicians has been a passion of mine for many years. it has always been exciting to see what is possible when physicians come together in pursuit of common goals. i have had the opportunity to experience this firsthand as both executive director of the Florida Medical association Political action committee (FMa Pac) and as Vice President of Public affairs for the FMa. Prior to joining the FMa in 1997, i began working in organized medicine, first with the Medical Society of the State of new York and later with the american Medical association. already we are off to a great start. i’m thrilled to announce that membership within our organization is reaching new heights. right now, more than 18,000 Florida physicians have joined the FMa, and that number is climbing. as we approach another legislative session, i’m confident that our collective voice will be heard, to the benefit of Florida’s physicians and their patients. Working together, i believe we can accomplish great things and make Florida a better place for you to practice medicine.

i look forward to serving you,

Timothy J. Stapleton

executIVe VIce PresIDeNt’s letter

making Florida a better place for physicians to practice medicine is our priority.

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Timothy J. Stapleton

Join the Florida Medical Association. Call 850.224.6496, or visit www.fmaonline.org.

The illness hasn’t been given a name, but it’s as ubiquitous as

the common cold — and almost as untreatable. Almost.

Ask just about any doctor and they’ll agree that the health care

industry is sick. Why is it that day in and day out you’re forced

to perform more like a CFO and less like an MD? Managing the

books isn’t the reason you spent your young adult life with your

head buried in medical textbooks. You became a doctor to care

for people, not to continue

caring for your bottom line.

Moreover:

Malpractice premiums

are much too high, forcing

many good physicians to

leave Florida or curtail their

practice altogether. Med-

icaid and Medicare haven’t

increased their payments in

years — not even to support

cost-of-living increases. And

truth be told, there will

never be a paperweight

big enough to hold down

your reams upon reams of

critical documentation.

Of course, these are only a few of the many ills Florida’s physi-

cians face every day. We not only want to see things change. We

want to see things truly get better.

The Florida Medical Association isn’t in possession of a magic

pill, but we are constantly working to protect physicians, and im-

prove the practice of medicine in Florida.

The FMA offers many services to help ease the burden of run-

ning your practice. As a member, you’ll be able to take advantage

of benefits like payment advocacy, continuing medical education,

practice management assistance and even expert help to ensure

proper coding so that payments for treatment are much less likely

to be denied.

Our Governmental Affairs Division represents you and your

patients before the Florida Legislature. We develop pro-medicine

legislation geared toward creating a more friendly climate for

doctors. We track hundreds

of bills concerning important

matters like scope of practice

and regulatory issues. We

strive to lessen the bureau-

cracy of medicine so doctors

can spend more time with

their patients. Quite simply,

if it concerns your practice,

it concerns us. As a matter

of fact, just this past year,

the FMA helped push the

very bill responsible for

reducing the look back

period from 30 months

to 12 — a victory that

incited an audible sigh of

relief from physicians statewide.

Although the state of medicine isn’t in the most perfect of

places right now, we’re working for you and our more than 18,000

physician members

to get it back on its

feet. Join us. Soon,

we’ll all be feeling

much better.

H o w d o y o u t r e a t a n i l l n e s s w H e n

y o u r p a t i e n t i s t H e m e d i c a l i n d u s t r y ?

head buried in medical textbooks. You became a doctor to care legislation geared toward creating a more friendly climate for

doctors. We track hundreds

of bills concerning important

matters like scope of practice

and regulatory issues. We

strive to lessen the bureau

cracy of medicine so doctors

can spend more time with

their patients. Quite simply,

Knowledge is vital. It is important that physicians understand they

have the power to shape the future of medicine in Florida.

James Howard Rubenstein, M.D. Radiation Oncologist, Ft. Myers

FMACampaign.indd 1 11/4/08 5:05:01 PM


When i look back at what our counties accomplished last year, i am in awe. Here are some of the highlights. alachua fulfilled a wish list from their elementary schools. They provided everything requested, from paper cups to a wheelchair. Broward met multiple community needs, engaging their members in numerous projects. They raised thousands of dollars for scholarships, participated in a variety of health projects, and were very involved in legislative efforts.

capital Medical Society was busy recruiting new members and raising funds for scholarships. They especially were proud of the funds they raised to support their health project, Faux Paw, which provides children with internet safety education. duval focused on the medical family, working to support physicians’ families and promoting

the image of physicians in the community. Hillsborough’s list of accomplishments is lengthy. They built membership, raised funds for every conceivable project, and were active in legislation. a high point of their efforts last year was on behalf of Screen out!, a national effort to bring attention to the gratuitous use of tobacco products in movies directed toward children and teens.

Membership, health projects, and fundraising for scholarships dominated lee county’s accomplishments. They focused on building relationships for the medical family through their welcome brunch, annual potluck, holiday party, and installation of officers. Sarasota worked hard to rebuild membership and encourage

members to be active. They supported a number of health projects and raised funds for their foundation at their annual “Fall Fling.”

Seminole county’s efforts focused on domestic violence. They participated in an anti-bullying campaign and supported Safehouse of Seminole through a variety of activities. last, but hardly least, is St. Johns. Small but mighty, they worked hard to raise funds for aMa Foundation Scholarships and Prn and to support a broad variety of health projects.

i congratulate all of our counties on their successes and thank each and every member for the time and energy devoted to building our communities in the name of the alliance.

the fma alliance recently adopted a new mission

statement: “the florida medical association alliance advances health-

related endeavors and engages in legislative advocacy.” these words

were chosen to reflect the actions and interests of our members.

the wording may be updated, but the efforts of our members, as they

reflect our mission, are hardly new. the fma alliance has existed from

its beginning as a partner to the fma. as a partner, the alliance often

has been the heart and hands extended to the communities in which

we live. through efforts large and small, alliance members have given

substance to the words associated with the mission.

workINg together throughout

FlorIDaby Diane R. Andrews, PhD, RN, FMA Alliance President

www.fmaonline.org

“hospitals have put the responsibility of covering their emergency rooms solely on their physicians.”

state oFemergeNcY


state oFemergeNcY

on october 1 letters were sent to the staff physicians of the Venice regional medical center (Vrmc). the message was simple: on-call shifts in our emergency room are now voluntary. for Vrmc, it is a significant change. until now, they, like most other hospitals across florida, have enforced mandatory er on-call coverage, using hospital privileges as leverage.

“Mandatory on-call coverage is discriminatory, pure and simple,” says robert raymond lastomirsky, Md of Venice, who serves on the by-laws committee at VrMc. “Many physicians respond to it by dropping their hospital privileges altogether or acting strictly as consultants.”

Hospitals have required mandatory on-call coverage in response to the emergency Medical Treatment and active labor act (eMTala), which was implemented in 1986. eMTala ensures that patients who seek treatment in emergency rooms will receive treatment, regardless of their ability to pay.

although eMTala places responsibility on hospitals to provide care, physicians are feeling the pressure themselves. “Mandatory on-call coverage is not reflected in any laws or regulations,” says Steven r. West, Md, FMa President and practicing cardiologist from Fort Myers. “instead, hospitals have put the responsibility of covering their emergency rooms solely on their physicians.”

by John Tyler


The choice used to be simple, according to nabil el Sanadi, Md, MBa, FaceP, chief of emergency Medicine for Broward Health. “There was a time,” he says, “twenty or thirty years ago, when specialists were fighting over being on-call in the er.” dr. el Sanadi attributes the advent of mandatory call to several issues. “First of all, there simply are not enough specialists in Florida, period. The environment is just too hostile.” He also attributes the shortage to the increased physical, emotional, and mental strain placed on physicians in emergency rooms. “Today, you have an increasing number of patients coming through the doors, many of them uninsured, with acute emergencies and, of course, the highest expectation of care. That’s a wild amount of risk.”

The risk of professional liability only compounds the problem. Physicians willing to provide care to emergency patients are vulnerable to litigation, no matter the odds of a positive outcome. This double threat of not being paid while becoming entangled in litigation is more than most physicians are willing to bear. “The situation right now is most unfortunate,” says Jennifer Forshey Hinson, esq., FMa regulatory affairs counsel. “Physicians often must decide between protecting their careers and caring for patients in real need.” although hospitals receive considerable federal funding to comply with eMTala,

their subsequent mandates are unfunded, often putting physicians in a difficult professional situation. “caring for indigent patients is important,” says Michael Patete, Md, an otolaryngologist from Venice, who was instrumental in passing VrMc’s new bylaws. “But when caring for them is mandatory, it takes away time from patients in my private practice. it eliminates my ability as a physician to choose.”

Meanwhile, emergency physicians continue to deal with the consequences. “We’re patient brokers,” said dr. el Sanadi. “We don’t know these patients before they come in or follow up once they leave. We’re completely reliant on specialists, so the current situation is tough.”

VrMc is not the first hospital in Florida to implement a voluntary call system. Manatee Memorial Hospital in Bradenton was the first to offer voluntary call to physicians. However, some argue that the area allows for it in a way that others do not. larry Hobbs, Md, Medical director of the emergency department at Southwest Florida Medical center in Fort Myers, and immediate Past President of the Florida college of emergency Physicians, believes many parts of Florida do not have the resources to afford it. “Manatee county has several nearby hospitals, covering multiple specialties,” he says, “but there are places with just

“today, you have an increasing

number of patients coming

through the doors, many of

them uninsured, with acute

emergencies and, of course, the

highest expectation of care.

that’s a wild amount of risk.”


one hospital. Without sufficient specialists on-call, patients would have to travel out of county or even out of the state.”

dr. Hobbs suggests that it is in the best interest of patients for each hospital to determine its call system according to specific community needs. “But, this requires an independent medical staff,” he says. “Physicians alone should draft the bylaws, always with patients in mind. We have to remember that this isn’t just about hospitals and physicians.”

at VrMc, dr. Patete believes the voluntary on-call system will prove successful. “it functions not only to the benefit of our physicians,” he says, “but to the benefit of our community.” early on, physicians will have to pay their dues. VrMc requires new staff physicians to take shifts on-call through their first two years of service, which will provide consistency. after that, on-call coverage is completely voluntary. “Physicians are humanitarians first,” said dr. Patete. He happily admits that many of VrMc’s physicians will continue to volunteer in the emergency room, even without reimbursement.

“it’s all a matter of negotiation, and finding the best outcome for the hospitals, physicians, and patients,” said dr. el Sanadi. “But no matter

what the circumstances are, physicians should never be forced into providing care.”

Don’t miss important information from your Florida medical association. Submit or update your email address today at [email protected]

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“but when caring for them is mandatory, it takes

away time from patients in my private practice.

It eliminates my ability as a physician to choose.”


by John Tyler

14

w h e r e t o s t a r t

“a major problem is that it’s fragmented,” says Michael Wasylik, Md, an orthopedic surgeon from Tampa. “each managed care organization has its own set of criteria – aetna’s is different from Humana, Humana’s is different from United, and so on. none of it is transparent to patients or physicians.” Physicians have no way of knowing how or why they receive a certain ranking, which is broken into two components – cost of care and quality of care.

“as for the costs,” he says, “there is physician skepticism about whether or not the available data is accurate.” insurance companies determine a physician’s cost in two ways. The first is utilization. For example, a physician who orders ten Mris, compared with one who orders five, has an overall higher imaging cost. Second, and most troubling, are episode Treatment groupers. These determine cost according to how long a patient undergoes treatment from beginning to end. “There are so many variables involved with this method, including appropriate physician attribution,” says Wasylik. “We just don’t know their accuracy.”

Whatever the numbers show, some physicians will never score well. Those who treat high-risk or chronically ill patients are especially susceptible. “These are patients who are either unlikely to recover or simply never will recover completely. To group their physicians in with the rest, and score them the same, is unfair by design,” says Jeff Scott, esq., FMa director of governmental affairs.

the consumer-Purchaser disclosure Project began in 2001, and marked the beginning of a new era in medicine. its goal – to provide patients with information regarding the different costs and quality of care of physicians – seemed reasonable. unfortunately, the reality has become a sore subject for physicians in florida and across the united states. as lawsuits are filed and legislation is drafted, physicians are left to wonder who exactly is making the grade.

makINg the graDe

“we want managed care

organizations to use

methods that are fair,

well-founded, and easy for

physicians to understand.”


w h o I s l o o k I N g o u t F o r Y o u

although these grading systems have a tremendous impact on physicians and their practices, currently they do not fall under any regulation or clear criteria. as a result, several states have taken action, with Florida close behind. “a properly constructed physician rating system may prove useful,” says Scott, “but a system without clear criteria available to physicians and patients is unjust at best, and at worst, a danger to public health.”

new York attorney general andrew M. cuomo agrees. last year, he settled a claim against cigna Healthcare, after thoroughly investigating the plan’s physician ratings. during the case, cuomo repeatedly drew attention to the economic interest that managed care organizations have in leading patients to less expensive physicians, as well as the importance for including accurate clinical information. “accurately measuring physician performance is an evolving and complex practice,” said cuomo in a written statement to the New York Times. as a result of this case, cigna is revising its system with an outside monitor and oversight from the attorney general’s office.

earlier this year, colorado also passed legislation that sets new standards for physician ratings. it emphasizes clinical quality over cost, and mandates that managed care organizations disclose all data and methodologies on request by either a physician or the commissioner of insurance. according to a recent article in Colorado Medicine by edie Sonn, the colorado Medical Society’s director of Public affairs, the legislation “[imposes] rigorous standards of transparency, fairness and accountability in health plans’ profiling of physicians.” The bill provides physicians the ability to take civil action, in contract, against managed care organizations, should they ever violate its standards.

b a c k l a s h

This year the consumer-Purchaser disclosure Project, in response to physician backlash, implemented the Patient charter for Physician Performance Measurement. Modeled after cuomo’s settlement in new York, its primary objective is to unify the criteria used by all managed care organizations and provide a national standard. The charter is to include physician input and

be monitored by an impartial third party, but both have yet to be determined.

This year, the FMa is drafting related legislation for the 2009 Session. “our fundamental goals are simple,” says Fred Whitson, esq., FMa director of Medical economics. “We want managed care organizations to use methods that are fair, well-founded, and easy for physicians to understand.” To accomplish this, the bill will seek to define the requirements of medical quality and efficiency. “We understand that a universal standard is impossible,” said Whitson, “but by reaching a national consensus among each specialty and using evidence-based standards in cooperation with physicians, it is possible to develop fair standards based on reliable data.”

Until then, physicians are left to wonder what criteria is being used to develop their scores. “We can’t turn back the clock,” says dr. Wasylik. “now we have to focus on protecting ourselves and our patients.”

“but a system without clear criteria available

to physicians and patients is unjust at best, and at worst,

a danger to public health.”


Since 1992, the number of people abusing prescription painkillers in the United States has increased by nearly 100 percent – five times greater than new users of cocaine; 60 times greater than heroine. in Florida, where prescription drug legislation is among the weakest in the nation, the epidemic is spreading even faster.

Meanwhile, Florida’s physicians stand at a troubling crossroads. “it’s an absolute paradox,” said Sanford Silverman, Md, a pain management physician from Pompano Beach. “We run the risk of under-treating patients, hoping to curb the use of pain medication, or over-treating and bearing all of the liability.”

t h e Q u I e t e P I D e m I c

by John Tyler

for decades, millions of americans have died or faced incarceration because of the

abuse of illicit drugs. however, a growing majority of today’s victims are abusing medications

commonly prescribed by physicians. few realize the devastating impact of prescription painkiller

abuse. despite this, every day seven people in florida die from an overdose of legitimate narcotics.

those living with the addiction face an incredible struggle, no different from people hooked on

heroin or cocaine.


With your support, the American Medical Association made news with its stunning victory in Congress that secured $1.3 billion in reimbursements to Florida physicians, preserved access to care for Florida’s seniors, military families and people with disabilities, and set the stage for groundbreaking health care system reform in 2009.

More news!For 2009, your AMA membership dues will be billed directly from the AMA, not through the Florida Medical Association. Watch your mailbox for your 2009 AMA dues invoice. Your prompt payment will ensure your access to all AMA member bene�ts and will support our continued efforts to create a better health care system for all.

Call AMA Member Relations at (800) 262-3211 or visit www.ama-assn.org to join the AMA or renew your membership today.

The AMA: Helping doctors help patients.

(Actual headlines in support of the AMA’s efforts)


Statewide Prosecutor William Shepherd leads the fight in Florida against prescription drug abuse.

19

efforts in the state legislature to suppress prescription painkiller abuse have floundered, and federal laws have not been implemented successfully or enforced in Florida. it is a battle in the “War on drugs” that no one saw coming, and few know how to confront.

t h e g o o D F I g h t

Statewide Prosecutor William Shepherd is leading the fight in Florida against prescription drug abuse. “The problem here is widespread,” said Shepherd. “in terms of fraudulent activity, criminals are finding ways to exploit pharmaceuticals on multiple levels. But opioids are by far the most pressing, and the most lethal.” last year, 110 people in Florida died from heroin, while more than 2,100 died from prescription opioids, such as oxycodone.

Shepherd attributes a majority of prescription drug proliferation to what he calls “signologists,” – corrupt physicians who provide no treatment and merely sign-off on prescriptions. “Unfortunately,” he says, “there are plenty of them operating in Florida.” These physicians typically work out of walk-in clinics, which only accept cash payments, limiting their potential oversight.

last year in Jacksonville, undercover detectives infil-trated one of these facilities, the S&P Medical clinic. The investigation began after pharmacists started com-plaining about a number of questionable prescriptions, all of them for controlled substances, called in by an unfamiliar physician. detective W. W. Moore of the Jacksonville Sheriff’s office narcotics Unit visited the clinic. Upon arrival, he was told by a front desk clerk that “dr. Sandy lindstrom” would be seeing him.

according to state records, Sandra lindstrom obtained a physician’s assistant license in 2006, and a registered

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Statewide Prosecutor William Shepherd leads the fight in Florida Statewide Prosecutor William Shepherd leads the fight in Florida Statewide Prosecutor William Shepherd leads the fight in Florida


nurse practitioner’s license in 2005. She never at-tended medical school and was not qualified to inde-pendently issue or authorize written prescriptions for controlled substances.

The clinic claimed to staff one physician, david Maurer, Md, a clinical pathologist. However, neither det. Moore nor any other undercover officers were ever seen by dr. Maurer. They were seen exclusively by lindstrom, who performed no medical examinations and often required no medical records. according to the arrest affidavit, lindstrom remarked to the undercover officer during a visit, “Unfortunately, [i need to have] some documentation in your chart that shows you have a health problem. That way the dea doesn’t come and arrest me.”

More often than not, lindstrom simply took orders. during the investigation, the closest thing to an examination came when lindstrom asked one of the detectives to lift his legs for a few seconds while she walked behind him. Paying cash, because the clinic did not accept insurance, the detectives received prescriptions for 120 each of Soma, Xanax, and Hydrocodone.

dr. Maurer was never seen in person. When pharmacies called the clinic to confirm prescriptions with dr. Maurer, they were denied. according to dea records, 8,896 prescriptions were filled under Maurer’s dea number between 2005 and 2007. Prior to his affiliation with the clinic, dr. Maurer never once wrote a prescription.

Between april and September of 2007, the clinic deposited more than $1 million into its account. of this, $896,013 came in the form of cash deposits. Financial records also showed that lindstrom supplied $50,000 prior to the clinic’s opening, suggesting that it was originally intended to operate as a pill mill.

t h e c o s t o F D o I N g b u s I N e s s

although reports from concerned pharmacists often lead to these successful investigations, other factors can lead to a successful bust. “often it’s just foot traffic,” says Shepherd. “one case involved a pediatrician in Jacksonville who was seeing a

considerable number of adults. concerned parents called it in.”

Shepherd refers to the case of Sergio rodriguez, Md, of West Palm Beach, who was arrested in July of this year in a case being handled by the State attorney’s office. Several of his patients died of drug overdoses mere days after their visits. in each case, the medical examiner ruled the cause of death to be oxycodone toxicity, along with polydrug synergism. The drugs found in each of the deceased were exactly those prescribed by dr. rodriguez – oxycodone, Xanax, and methadone.

“it’s absolutely an epidemic,” says Shepherd. “Just ask the parents and loved ones of those who’ve died.” When the mother of one of rodriguez’s deceased patients called and asked for a copy of her son’s records, she was given multiple excuses, told to call back another time, and ultimately denied. Her son was in good health with no documented medical problems. He was just 25 years old.

t e l l m e w h e r e I t h u r t s

even legitimate patients suffering from chronic pain often consider pain medication as a cure, rather than legitimate medical care. “The problem is, not all pain is bad,” said dr. Silverman. “Simply removing pain is not in a patient’s best interest, because the pain is merely symptomatic of the problem. My job is to treat problems, not mask them.” He believes this problem stems from a general cultural belief that medication is preferable, even superior, to medical treatment. “Some people don’t want care,” says albert ray, Md, a pain management physician from Miami. “They want a pill.”

The current pain treatment model, which has brought considerable amounts of opioid painkillers into the market, originated with cancer patients. For decades,

“my job is to treat problems, not mask them.”


people with cancer were treated with narcotics. cancer pain researchers modeled their prescription plans to provide patients with regular doses to control pain, and statistically these patients did well. in the mid-1990s, this prescription treatment model was applied to non-cancer chronic pain patients. The idea was that pain management was not aggressive enough in prescribing narcotics, and based on the cancer model, the statistics made the drugs appear entirely safe. “But there was a problem with the numbers,” says lora Brown, Md, a pain management physician from Bradenton. “Most of these patients were terminal and died within six to eight weeks. addiction was never an issue.”

all of these factors combine to create one dangerous social misconception – prescription drugs are safe. “People, particularly young people, seem to think that anything prescribed by a doctor, anything they find in a medicine cabinet, can’t hurt them,” says dr. Silverman. This has led to a frightening cultural phenomenon among teenagers, called “pharm parties.” during these parties, teenagers empty their parents medicine cabinets of all prescriptions – painkillers, antibiotics, cough medicine, and anything else they can find. “They dump the pills into a bowl and pass them around like candy,” says dr. Silverman.

I N Y o u r o w N

b a c k Y a r D

although no legislative effort will ever put an end to individual abusive behavior, current Florida prescription drug laws are among the nation’s most lenient. Thirty-two states have passed legislation that monitors prescriptions of

controlled substances. Florida is the largest state currently without comparable legislation. “Kentucky’s drug monitoring program is probably the nation’s strongest,” says dr. Brown. “But what we’re seeing now is people traveling from Kentucky to Florida, visiting our pill mills, and bringing the drugs back to sell.”

“People, particularly young people, seem

to think that anything prescribed

by a doctor, anything they find in a

medicine cabinet, can’t hurt them.”


For several years, a prescription monitoring bill has been presented to the legislature. The bills would have created a password-protected online network between physicians, pharmacies, and pharmacists, granting them access to patients’ medication histo-ries. The bill presented last year was referred to five committees in both the House and Senate, and never made it to either floor. in 2005, President Bush signed into law the national all Schedules Prescription electronic reporting act (naSPer), which provides grants to help states either establish or improve exist-ing prescription monitoring programs. However, Florida has yet to receive any funding. “We simply cannot afford to wait any longer,” says dr. Brown.

another weakness of the federal legislation is that it targets rogue physicians rather than troubled patients. “corrupt physicians need to be taken out of practice,” says dr. Brown. “But the law does nothing to prevent legitimate doctors from unknowingly prescribing narcotics to addicted patients.” legislation that dr. Brown hopes to see pass in Florida would grant network access to physicians, enabling them to know what prescriptions their patients have filled and where. However, the idea is

controversial among patients who feel it would be an unconstitutional violation of their privacy.

w h a t h a P P e N s N o w

as the epidemic continues, both physicians and law enforcement will continue to do all they can to stop it. “Most physicians just want to provide the best care for their patients,” says Bill Shepherd. “Honest physicians prescribe narcotics because they’re trying to provide relief from often unbearable pain.” Shepherd will continue prosecuting physicians who operate and supply pill mills, bringing them to justice one offender at a time.

Meanwhile, physicians in organized medicine will continue to pursue legislative action in Tallahassee. combating the narcotics epidemic will be a priority issue for the FMa in 2009. We will support legislation that could strengthen the efforts of both law enforcement and physicians to reduce crime and save lives. “There’s no singular solution to this epidemic,” says dr. Brown. “There are too many factors, too many variables, but that doesn’t mean we can’t make improvements or that we should cease to do everything we can.”

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FL-SW81180 FLMedMag.indd 1 9/24/08 2:52:07 PM


PolIce reQuests For PatIeNt NarcotIcs agreemeNts: Placing Physicians between a rock and a hard Place©

by Robert I. Rubin, JD

detective shows up at your

medical office and tells you that

he is investigating one of your “pain management” patients for “doctor shopping.” he

produces a pharmacy printout with your prescribing information and demands a copy of

your “narcotics agreement” with the patient in question. this is a situation that my client,

a respected neurologist, faced recently. my client, who was unsure of his legal rights and

responsibilities, asked the detective if he was required to turn over the agreement. the

detective threatened there was a “florida statute” mandating disclosure and my client

could be “liable” for failure to cooperate.

aagreemegreemegreemegreemegreemegreemegreemegreemegreemeNNts:ts:ts:ts:ts:ts:

Florida Medical Magazine Fall 2008 www.fmaonline.orgwww.fmaonline.org

acting under duress, and without the advice of counsel, my client turned over to the detective the “narcotics agreement.” Using the narcotics agreement and prescription information he had obtained from the pharmacy, the detective obtained an arrest warrant from the State attorney’s office and charged the patient with fraudulently obtaining a prescription, commonly referred to as “doctor shopping.” The patient heard a rumor concerning possible criminal charges filed against her and contacted an attorney. The attorney called the detective to setup a meeting because the patient claimed she was not guilty of doctor shop-ping; all of her prescriptions were legal. The attorney also agreed to voluntarily surrender his client when an arrest warrant was issued, all on the condition that the patient was willing to “confess.” Because the patient asserted her innocence, the meeting never took place. Several months later, the patient was arrested at home in front of her young children. The patient was brought to a

public location and paraded before the media along with numerous other individuals who were arrested under war-rants for fraudulently obtaining prescription narcotics. Shortly thereafter, the patient’s counsel succeeded in persuad-ing the State attorney that there was insuffi-cient evidence of a crime, and the charges were dropped. The patient then sued the law enforcement agency for false arrest and malicious prosecu-tion, and sued my client for breach of fiduciary duty. although my client’s action in

turning over the narcotics agreement was understand-able, the court indicated that it was inclined to grant a “summary judgment” against my client prior to trial on liability, based on his breach of the statutory duty of confidentiality to his patient. This would leave only issues of causation and damages for the jury. in other words, the plaintiff still had to establish that the breach of confidenti-ality was a substantial contributing factor to her arrest and incarceration. The patient likely could establish this, however, because the narcotics agreement was a key element of the charge. The jury also would decide the issue of damages. This would entail placing monetary value on mental and physical pain and suffering from the arrest and incarceration, as well as the legal fees associ-ated with having the criminal charges dismissed. as a result of the court’s ruling, the case was settled for a minimal sum, with the consent of my client. interestingly, at the time i was defending my client in this matter, i represented an internist who also was sued by his patient for breach of confidentiality. The internist appropriately reported to the police that his patient had violated her narcotics agreement, be-cause she was obtaining narcotics from two prescrib-ers at the same time and fraudulently attempted to cover this up. i obtained a defense verdict for my client before a jury in 2007. The key difference be-tween the case involving the neurologist and the case involving the internist is that the internist’s narcotics agreement specifically authorized the physician to contact the authorities if the patient violated the narcotics agreement, whereas the neurologist’s did not. The jury agreed that the patient violated the narcotics agreement; therefore, the internist was within his rights to report his patient to the police. w h a t I s a N a r c o t I c s a g r e e m e N t ?

There are many patients who suffer from legitimate intractable pain, including the pain associated with cancer. These patients are entitled to compassionate pain management, usually with narcotic pain medica-tion. in both cases described above, the physician used a “narcotics agreement” with the patient. in the majority of cases, manufacturers of narcotic pain medications furnish these agreements. However, some physicians draft their own narcotics agreements, often with the assistance of counsel. in addition, some

www.fmaonline.org Florida Medical Magazine Fall 2008www.fmaonline.org Florida Medical Magazine Fall 2008 25

meDIcal recorDs are coNFIDeNtIal uNDer FlorIDa statute §456.067a patient’s medical records are confidential under Fla. Stat. §456.067 and can be provided to law enforcement investigating a patient for “doctor shopping” only if one or more of four legal requirements have been met: 1. An AuthorizAtion from the pAtient; 2. A vAlid subpoenA for the medicAl records; 3. A seArch wArrAnt for the records; or, 4. A court order. as a practical matter, it is extremely unlikely that a patient would sign an authorization allowing their physician to release medical records to a law enforce-ment agency. if the medical records are sought under

a subpoena, as opposed to a search warrant, the law requires that the law enforcement agency issuing the subpoena give notice to the prospective defendant. This notice allows the patient/prospective defen-dant’s legal representative time to challenge the va-lidity of the subpoena in court before the records ac-tually are subpoenaed.

a criminal search warrant requires that the law enforce-ment agency make a showing to a judge of “probable cause” that a crime has occurred. However, unlike the request for records under a subpoena or authorization, the patient/prospective defendant normally would not be on notice of the police application for a warrant.

law enforcement agencies provide sample narcotics agreements to physicians in their areas. a narcotics agreement is a written contract between the physician and the patient. although the form of the narcotics agreement varies, it has some similarities to an informed consent, in that it usually warns that narcotics have risks and benefits, can be addictive, and should not be abused by the patient. a narcotics agree-ment generally sets forth rules that the patient must follow, which can include an agreement to obtain narcot-ics from only one prescribing physician, to fill the narcotics prescription at only one pharmacy, to refrain from “losing” or “destroying” the prescription and asking for a dupli-cate, to refrain from obtaining narcotics by illegal means, to not sell any prescriptions, and to take the prescriptions in accordance with medical instructions, etc. one purpose of a narcotics agreement is to protect the physician from liability for patient abuse of the prescriptions. a narcotics agreement also pro-tects the patient because the patient must understand

and acknowledge his or her obligations under the agreement, which are implemented for their therapeu-tic and legal benefit. it is extremely important that the narcotics agreement contain language that, if a physician has reason to believe that the patient has violated the agreement, the physician has the right to notify and cooperate with law enforcement. Thus, a physician can obtain important protection if the narcotics agreement contains this provision. I s a N a r c o t I c s a g r e e m e N t

a m e D I c a l r e c o r D ? My neurologist-client testified that he thought the narcotics agreement was an “administrative docu-ment,” not a “medical record,” and, he did not believe that he was giving the police a confidential medical record. With this in mind, we investigated a potential defense that the narcotics agreement was not subject to the confidentiality provisions of the statute. The statute delineates dozens of categories that would constitute medical records, including progress notes, radiology reports, patient histories,

1

2

Florida Medical Magazine Fall 2008 www.fmaonline.orgFlorida Medical Magazine Fall 2008 www.fmaonline.org

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lab work, insurance information, medication records, etc.

interestingly, however, there is no mention of the phrase “narcotics agreements” in Florida Statute §456.067. Because the statute was silent, we looked to other legal sources to determine whether we could support our argument that the narcotics agreement was not a medical record. Specifically, we researched the case law interpreting the statute and the legislative history behind the statute. Both were silent on the issue. However, the Florida administrative code, written by the Florida department of Health Board of Medicine, titled “Standards for the Use of controlled Substances for Treatment of Pain” provides: The physician is required to keep accurate and com-plete records to include, but not be limited to. . . (5) Discussion of risks and benefits . . . (8) instructions and agreements [emphasis added]. a narcotics agreement is an “instruction” or an “agree-ment.” although Florida Statute §456.067 is silent

concerning whether a narcotics agreement is a medical record, the Florida administrative code clearly states that it is a medical record, and thus is subject to confi-dentiality protection. F I N a l t h o u g h t s

absent an authorization, subpoena, court order, or search warrant, it is illegal for a physician to produce medical records or discuss a patient’s medical condi-tion with law enforcement investigating the criminal act of “doctor shopping.” it can be intimidating to the physician when a law enforcement officer appears and demands medical information or a patient’s medical record, but this does not mean the officer is aware of your rights or your patient’s rights. nevertheless, when faced with this situation, a physician must advise the law enforcement officer that the records cannot be turned over, nor can the patient’s medical information be discussed, until the due process requirements have been satisfied. otherwise, the phy-sician could be liable for civil damages for breach of fiduciary duty.

Robert I. Rubin is a shareholder in the West Palm Beach office of Becker and Poliakoff. He has more than 25 years of experience representing

physicians in medical malpractice, administrative and business matters. He can be reached at [email protected]

Q: : I am a cardio-thoracic surgeon who has developedherniated discs in my cervical spine region at C4-C5and C5-C6, and am experiencing numbness in my fin-gers as well as difficulty in holding my head down forthe time required to do open procedures. I would like tomaintain my office practice and perhaps do some endo-vascular procedures — should I file for partial/ resid-ual or total disability benefits?

A: The biggest mistake clients make when filing a dis-ability claim either on their own or with the assistanceof a disability attorney is minimizing job duties on thefirst interaction with the insurance company. Manysimply put “medical doctor” and maybe add the specialtythey practice. If this happens, you will be playing frombehind the rest of the game. It is crucial when filing ini-tial claims and in any discussions with the representa-tive of the insurance company that you highlight thedifferent things you do on a daily, weekly or monthlybasis. Furthermore, you need to identify those job dutiesthat are primary, and those which are more secondaryin nature. For example, if the bulk of your office practicecurrently stems from either pre-op or post-op consulta-tions and the make-up of your patient base will change,you may have been rendered [or may be considered ormay meet the definition of] totally disabled from youroccupation. If, however, you have always had a mixedpractice and you will be cutting out a portion of thatpractice, then you are more likely to fall in the residualor partial disability definition.

It is important to file a claim for total disability ben-efits if it is applicable for numerous reasons. Often insur-ance companies attempt to persuade you from filing atotal disability claim because the economic calculationsallow you to receive the exact same monthly amount in

benefits. What they may not tell you is that most resid-ual claims end at age 65, even if you have a policy thatpays life-time benefits for total disability — cutting ahuge financial obligation from their books and leavingyou without benefits when you need them the most.

There may be other ramifications for residual claim ver-sus a total claim, such as cost of living increases occurring atdifferent rates, and requirements to provide the insurancecompany with numerous financial documents that theywould not otherwise be entitled to, such as tax returns.

Another common mistake is not fully documentingthe early stages of your medical problems. Prior to anymention of disability claims, it is important that doctorsyou have consulted with, even in corridor consults, havesome record to give an adequate timeline, if possible.Disability insurance policies all require that in additionto suffering a disability, you must be treated by a doctorother than yourself.

Also, watch out for the many policies that pay life-time benefits for medical conditions that are caused byaccidents, but limit those caused by illness to age 65.Finally, remember that filing an insurance claim is at itsessence a commercial matter. The paperwork must betreated with extreme care and the insurance company’srequests for information must be placed in the context ofwhat they are entitled to receive — and how that maybenefit them should your claim be forced into litigation.

Too often claimants rush through the initial paper-work and interviews, believing their medical condition isclear regardless of its documentation. There are manyland mines in a claim for disability, from an insurancecompany wanting all of your accountant’s records for fish-ing expeditions to payment of claims under a reservationof rights. It’s important to get proper consultation beforeembarking on this road.

BEFORE EVEN CLAIMING DISABILITY, MAKESURE YOUR BASES ARE COVERED

By Kirk Wagar

Kirk Wagar is managing partner at the disability and life insurancefirm Wagar & Feit in Coconut Grove

Phone: 305-443-7772 | Fax: 305-443-19693250 Mary Street, Suite 302 | Coconut Grove, FL 33133

1-888-812-0393 | www.wagarlaw.com

FMA_WAGAR 9/18/07 1:30 PM Page 1


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a D V e r t o r I a l


america has a litany of exceptional women who’ve helped shape its course. reviewing the national Women’s Hall of Fame (www.greatwomen.org) is a heartwarming experience; in fact, a spiritual one. in common, its members are women who worked to overcome

discrimination and succeeded in the fulfillment of their ambitions. The “glass ceiling” still exists, however, and affects many career options.

it took medical schools 80 years to admit a woman for studies. The door opened slowly, well into the 20th century. Fortunately, women now have established their role as doctors, and most of those barriers have fallen. in 2007, women represented 48.3 percent of the incoming medical student body. However, there are still issues of equity with academic appointments and residency selection.

This issue of the Florida Medical Magazine includes leading women in medicine, but i would like to remember an outstanding physician who paved the way for their success – elizabeth Blackwell, Md.

The courageous dr. elizabeth Blackwell overcame enormous barriers in pursuing medicine. She was born in england in 1821, but financial reverses brought her family to the United States. Her father believed men and women should have the opportunity for an equal education. initially a teacher, Blackwell found the work unfulfilling and realized that her true passion was in medicine.

She was rejected from 29 medical schools. However, Blackwell was admitted to the small geneva Medical college in new York. Her acceptance involved an

admissions committee that considered her work equal to other applicants and put her acceptance to a vote by the student body. Students, believing the request was an administrative hoax, voted unanimously to accept her. When she arrived for classes, students and professors were shocked and encouraged her to leave. instead, she stayed.

despite initial ridicule, she graduated at the top of her class. Becoming a licensed, practicing physician, however, would prove an even greater challenge. even after moving to Paris for further medical studies, she found the social barriers were severe and so she returned to america. Unable to secure an appointment, she opened a clinic for the poor in new York and established the new York infirmary for indigent Women and children, which even today serves the public. at this facility, she also established the Medical college for Women, where she trained her sisters, who carried on her work after she left the country again in 1869.

dr. Blackwell returned to england and there, with Florence nightingale, opened another Women’s Medical college where she taught gynecology until retirement. She then authored several books and advocated for women’s rights. in 1910, dr. elizabeth Blackwell died at 89 years of age.

along with dr. Blackwell in the national Women’s Hall of Fame are others in and out of the field of medicine: clara Barton, who late in life was able to see her dream fulfilled with the establishment of the american red cross; Susan B. anthony, who paved the way for women’s right to vote; rachel carson, a zoologist who wrote the classic, Silent Spring, and The Sea Around Us, both catalysts for today’s environmental movement.

PaVINg the waY Women in Medicine: elizabeth Blackwell, Md, america’s first

by Marc J. Yacht, MD, MPHeditor-in-chief


LOR

IDA

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other accomplished women include: dorothy dix, who advocated for the mentally ill; gertrude Belle elion, who spent a lifetime developing drugs against leukemia; alice Hamilton, a physician pathologist who forced safety regulations in the workplace; Mary Jacoby, who founded the association for the advancement of Medical education for Women; antonia novello, the first woman U.S. Surgeon general, who used her position to address the worldwide suffering of women and children. i recall the efforts of eleanor roosevelt, who advocated for social reform and continued her many efforts after Fdr died. i would describe her as the first visible and active First lady to establish a standard of service for other women to follow.

Still other outstanding women showcased there include: Harriet Tubman, who became known as “Moses” during the civil War because of her efforts to free slaves; Florence Wald, the dean of nursing at Yale and the founder of the hospice movement in america; Mary Walker, Md, who crossed the lines in the civil War to treat civilians and later was captured and imprisoned (and became the first woman to receive the congressional Medal of Honor); rosalyn Yalow, the first american physician to win the nobel Prize for Medicine; and many more.

Today’s physicians, both women and men, face numerous professional challenges. Those who practice medicine often are brilliant, committed, empathetic, independent, and even downright troublesome at times. although battering the profession from a number of quarters seems to be the fashion, today’s courageous

men and women practicing medicine continue to relieve pain and suffering, despite a difficult environment. We must continue to fully open the door for capable women challenging the political and corporate sectors, and yes, even in the medical establishment. These courageous women will have a strong voice in advocating for health care equity and coverage and strengthening our profession to the benefit of all physicians and their patients.

today’s courageous men and women practicing medicine continue to relieve pain and

suffering, despite a difficult environment.

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lthough battering the profession from a number of quarters seems to be the fashion, today’s courageous

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throughout florida’s outstanding community

of physicians, these women are

among its finest leaders. coming from a variety of backgrounds and locations across

florida, each of these physicians offers a unique set of talents, achievements,

and ideas about the future of medicine in the sunshine state. the florida medical

association welcomes you to take a look at some of our best and brightest physicians

and their efforts to make florida a better place to practice medicine.

by John Tyler

Florida Medical Magazine Fall 2008ANA

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ana viamonte ros, mdTallaHaSSee

Many years after graduating from the University of Miami Miller School of Medicine, ana Viamonte ros, Md returned to academia to pursue another degree under unusual circumstances. She enrolled at Harvard University, studying public health, at the same time her two children were enrolled as undergrads. “Fortunately for them, we were on opposite ends of campus,” says dr. Viamonte ros, laughing, “otherwise, it may have been a bit too embarrassing for them.”

all laughter aside, dr. Viamonte ros was proud to return to graduate school and to set a positive example for her children. as a public health student concentrating on family and community health, she became active in Jamaica Plains, a small community just outside of Boston, working with the underprivileged and largely dominican population. For her efforts there, she received the garreth green award, the highest student honor. “i wanted to show my kids what you can accomplish at any point in your life if you set your mind to it.”

Her grandfather, a radiologist and former chair of radiology at the University of Havana, set this example for her. after retiring and emigrating to south Florida, he decided to retake his board exams and recertify in an effort to help the community. “My brother and i are fifth generation physicians,” says dr. Viamonte ros. “We’re continuing a family legacy not just in medicine, but in serving others.”

after returning to Florida from Harvard, she pursued opportunities that would allow her to do both. dr. Viamonte ros became involved in correctional health care, joining armor correctional Health Services. applying skills and experiences that she acquired working in Jamaica Plains and elsewhere, she helped to bring better care into correctional facilities. dr. Viamonte ros also oversaw the development of medical discharge programs and even traveled to Haiti in an effort to prevent the spread of HiV among inmates in correctional facilities.

as Florida’s first State Surgeon general, she is committed to improving and preserving the health of all Floridians. “i’ve traveled to all 67 counties,” says dr. Viamonte ros. “i’ve met with individuals who are serving on the front lines and witnessed the incredible work that is being done.” Her initiative, the 3P’s Tour, which stands for Prevention, Preparedness, and Personal responsibility, has moved across Florida in an effort to prevent disease and prepare for disasters. “What has always been apparent, and further emphasized during my tenure, is the importance of providing quality, accessible care to Floridians. There is so much need, and we’re doing all that we can to meet it.”

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madelyn butler, mdTaMPa

Born in cuba, dr. Butler and her family emigrated to the United States when she was very young. “coming from cuba,” she says, “it wasn’t unusual to see women going into medicine. it was going on there long before it became common in the United States.” dr. Butler attributes her determination and professional success to several of the women in her life, whom she considers tremendous role models. Her aunt grace, a physician in cuba, set a powerful example of how to achieve balance between career and family – a balance which dr. Butler, her husband, Bill, and their three children, olivia, christian, and donovan, strive for every day.

“My family is a big part of my career,” says Butler. “They’re even a part of our involvement with the FMa. My kids have a significant advantage over their peers in their knowledge of politics, for example, and how campaigns are run. it’s all a complement to their education.” When they can get away from work and school, the Butler family spends as much time as they can traveling.

dr. Butler believes it is essential to get away from daily distractions, to learn about the natural beauty life offers and build enduring memories. “Traveling is one of my passions,” she says. even on vacation, however, dr. Butler and her family often are hard at work. “For all the places my family has been, the best trips we’ve taken are our missions in Haiti, working in the medical clinics.”

Back home, dr. Butler spends her days caring for the women of Tampa. She is the founder and senior partner of the Woman’s group, a practice run entirely by women for women. it is one of the top gynecological practices in Tampa and considered a model medical office by practice management consultants. “it’s such a personal kind of medicine,” said Butler. “My staff and i believe women are more comfortable seeing women for their oB/gYn care and we strive to offer the experience to our patients that we ourselves would want.”

For dr. Butler, seeing patients every day is her strongest motivation. “There’s a unique bond,” she says, “an amazing level of trust, which to me is the greatest part of being a physician. it should never be taken for granted.”

dr. Butler’s future plans include staying in Tampa and continuing in her practice and her involvement in FMa, where this year she was elected Vice President. She is also currently Vice President of the FMa Pac and will serve as its President starting in February of 2009. Family, practicing medicine, and being a voice for Florida’s physicians are among dr. Butler’s greatest passions. “My life will always focus on pursuing my passions,” she says. “and learning everything that i can.”

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deborah german, mdorlando

deborah german, Md has always wanted to do two things – help people and make a difference. “My decision to become a doctor really evolved from these desires,” she said. dr. german was also personally influenced by her childhood pediatrician, who provided care regardless of her mother’s ability to pay. “it really impressed me, even as a child,” says dr. german. “He put my needs above his own, because my health mattered.”

Today, as she prepares to welcome the inaugural class of the University of central Florida college of Medicine, it is easy to see the impact this experience continues to have. UcF will bestow scholarships – which will cover all tuition, fees, and room and board – to every member of the college’s first class in 2009.

dr. german was a leader in generating support for the scholarships, which were funded by nearly $7 million in broad-based community donations from across the orlando area. although it will be a new medical school, UcF already has made its mark – the association of american Medical colleges says UcF will be the first medical school ever to provide full scholarships for four years to an entire class.

“i personally received a similar scholarship,” dr. german recalled. “it enabled me to put all of my focus on medicine and avoid the anxiety and other distractions that come with taking on that kind of debt.”

dr. german attributes it all to an effort to build a medical school that would stand out in a nation filled with strong programs. “We have over 100 medical schools in this country,” she said. “all of them are great in their own right. The only way i could justify a new school was to take a step forward, take what has worked for others, and find ways to make it work even better.”

dr. german believes the future doctors that UcF will train will help change the lives of others through their careers, much as she has done in hers. “With passion, compassion, and ambition, they will become part of something greater than themselves,” she said. “i am so grateful to be a part of this wonderful opportunity to create what we expect will become the 21st century’s premier medical school.“

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ADVERTORIAL

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alma littles, mdTallaHaSSee

as a student in the second grade, alma littles, Md received an almost prophetic suggestion from her teacher. “after class one day she approached me,” said dr. littles, “and told me that i should become a doctor when i grew up.” From that moment forward, littles began a lifetime pursuit that has made her one of Florida’s strongest leaders in medicine.

over the years, dr. littles’ desire to become a physician became more personal. Her father died of a heart attack when she was just fourteen. Her sister died of a blood clot shortly after giving birth. “all around me, people were either suffering or dying from things that seemed preventable,” said dr. littles. “it strengthened my resolve to help those who need it most.”

as a child in rural Quincy, alma littles rarely saw a doctor herself because “there simply weren’t enough to go around.” it’s no wonder that dr. littles developed a passion for providing care to underserved regions like northwest Florida, as her career reflects. Today, she is a part of the Florida State University college of Medicine faculty, serving as Senior associate dean of academic affairs, a program dedicated to providing access to care for rural Florida. Before this dr. littles practiced family medicine in Quincy and also in Tallahassee as director of the Family Medicine residency Program at Tallahassee Memorial Hospital (TMH).

Her tenure at TMH showed dr. littles the rewards of working with students, but when FSU offered her a faculty position the decision wasn’t easy. “i love what i do now, but when i see former patients, people i cared for personally, it’s hard not to miss private practice,” said littles. Still, dr. littles is proud of her role in medical education. “i was one physician in the community. This year FSU will graduate 120 physicians who will be prepared to go out and care for far more patients than i could alone.”

dr. littles is also active in organized medicine. as a member of the Florida Medical association, capital Medical Society, and the Florida academy of Family Medicine, she hopes to give physicians greater control over medicine. “i’ve been involved in organized medicine since i was a medical student,” said littles. “in the short period of time between my first year of medical school and my last year of residency, efforts to streamline health care have eroded a lot of what made the relationship between physicians and patients so special. i believe the patients feel it just as much as we do.”

at home, dr. littles spends most of her free time with her husband and their son, a year-round athlete. She also attends church every Sunday in her hometown of Quincy. “i’ve been fortunate,” said littles. “My heart has always been at home, in my community. Throughout my medical career, i’ve been blessed to stay close by.”

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as an academic pediatrician, onelia lage, Md lives the best of both worlds. “i get to care for my patients, while helping to create the health care workforce of tomorrow. as a child, i never dreamed of such a satisfying career.” However, as a child, she did dream of a career in medicine after developing a profound respect and admiration for her own pediatrician. “i didn’t just want to be a physician,” said dr. lage. “i wanted to be a pediatrician.”

Her mother also served as a strong role model, emphasizing the pursuit of education and career opportunities. as a wife and mother of two, dr. lage hopes to provide similar encouragement to her own children. She never misses an important school function or personal event. “They’re so forgiving of my professional responsibilities,” said dr. lage. “i believe it’s because they know they come first for me.”

dr. lage’s passion and influence for young people extends beyond her family. as a pediatrician, she predominantly sees adolescent patients who struggle with everything from eating disorders to depression. This has shaped dr. lage’s resume in organized medicine, leading her be nominated to local and national groups addressing the needs of young women, and minority women. in addition to serving on the Florida Board of Medicine and HHS office on Women’s Health/Minority Women’s Health Panel of experts, she is taking part in the latter’s new girls health initiative, which addresses everything from emotional health to nutrition.

“it’s the day-to-day that makes it worthwhile,” said dr. lage. “if i can make a lasting impression on my patients and benefit their lives so they walk out of my office feeling better, there’s nothing more rewarding.” While she hopes this personal element of her career will continue, in years to come dr. lage aspires to further develop her already impressive academic resume and become a full professor. an associate professor of pediatrics at the University of Miami Miller School of Medicine, she plays an integral part in developing future generations of physicians to come.

She also hopes to have a great influence on health care policy. a founding advisory board member of the national Hispanic Medical association, and one of its leadership fellows, dr. lage personally understands the power of physicians uniting with one voice. “Times are changing for medicine,” said dr. lage. “Together we can take action to help preserve the essence of the doctor-patient relationship and increase awareness of the true sacredness of our profession.”

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www.fmaonline.org

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Shel

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shelley glover, mdclerMonT

For Shelly glover, Md, things rarely have gone according to plan. Shortly after completing her graduate medical education in california, dr. glover joined a group oB/gYn practice in Virginia, only to move to rural Florida within a few short years and hang her shingle. “My husband and i moved to clermont, which was hardly the busy suburb it is today,” says glover. “There were few full-time physicians in the area and certainly no full-time oB/gYns.” To meet the needs of her community, dr. glover opened a solo practice, specializing strictly in gynecology. “Sometimes i miss the camaraderie of the group practice,” says glover, “but i knew i was making an investment in my community, building lasting and rewarding relationships with patients.”

as a physician and owner of a growing business, dr. glover remains passionate about providing care to patients who need it most. in part, she attributes her dedication to community service to her knowledge of public health. dr. glover received a Master of Public Health degree from the University of california at Berkeley, before completing her medical residency. “it gave me an opportunity to step back and view health care as a whole,” says glover. “it’s a true eye-opener; far more complicated than i anticipated coming out of medical school.”

This knowledge also led dr. glover into organized medicine. She is the immediate Past President of the Florida Medical association Foundation and the current President of the lake-Sumter Medical Society. She is also the President and Medical director of “We care of lake county, inc.” which provides health care to indigent patients. With her leadership, We care has provided referrals for donated specialty care to more than 30,000 disadvantaged residents of lake county. “i think i have a unique perspective,” says glover. “i understand what health care costs and how much need there really is. i also understand what patients deal with to receive treatment. This provides me with a great motivation to reach out.”

in the future, dr. glover will continue caring for her patients and her community. “i never imagined i’d move to rural Florida or be running a solo practice,” says glover. “You never know what opportunities the future holds. But, i know that taking care of patients is not something i’ll ever be willing to give up.”

Shel

ley

40


andrea trescot

andrea trescot, mdgaineSVille

during her first medical school interview, andrea Trescot, Md was bombarded with questions about an unlikely topic – politics. “i was very active in student politics as an undergraduate at the University of Florida,” says Trescot. “They asked me why i wasn’t pursuing that. i asked them in all seriousness: ‘What, are there no politics in medicine?’”

in fact, before deciding to pursue medicine, dr. Trescot intended to become a marine biologist. after an entire summer of waiting tables in her hometown, Palatka, Florida, she enrolled in a marine science seminar only to discover its bleak economic potential. “My father kept encouraging me to pursue medicine,” she says, “and i kept doing everything i could to convince myself that it wasn’t what i wanted, until my passion for medicine was unavoidable.”

dr. Trescot graduated from the Medical University of South carolina in charleston and went immediately into the navy. “as a medical student, the financial benefits were great,” says Trescot, “and i was looking forward seeing the world.” Unfortunately, dr. Trescot did not travel very far. The navy stationed her in Jacksonville, Florida. after completing her service, she began practicing and teaching medicine in Florida. However, her role as a medical educator extends far beyond the Sunshine State, allowing her to travel extensively throughout the world. as an examiner for the World institute of Pain, she has worked in Budapest, cairo, and london. “i was able to see the world after all,” she says.

For all her accomplishments, dr. Trescot’s proudest moments are often personal. “i’m frequently able to give people back their lives,” she says. “When patients come in and tell me they were able to play on the floor with a grandchild for the first time or sit through their child’s football game, that makes it all worthwhile.”

in the future, dr. Trescot hopes to become more involved in academia, pulling away from private practice. “it is a very difficult decision,” she says. “i can either continue to see the same group of patients or i can teach the techniques i helped develop and encourage generations of new physicians to care for many more patients.”

despite her busy schedule, she is able to find balance and support at home with her family. “My husband is extremely supportive,” says dr. Trescot. “He has helped tremendously with our kids and afforded me the professional freedom to become the physician i am today.”

ndrea rescotndrea rescotndrea

41


SHAZIA ZAFARFlorida Medical Magazine Fall 2008ZAFARFlorida Medical Magazine Fall 2008

shazia zafar, mdForT laUderdale

For Shazia zafar, Md, the dream to become a physician began when she was a little girl. When her grandmother was diagnosed with cancer, she witnessed firsthand the unwavering care of physicians and developed what would become a lifelong passion for cancer research and treatment. “i wanted to do what they do,” says zafar. “i intended to be an oncologist from the very beginning.”

during her medical education in Pakistan, zafar took two years off and traveled to the United States. during this time, she married her husband and gave birth to their first daughter. She also conducted breast cancer research at the Baylor college of Medicine in Houston, Texas. after graduating with her medical degree in 1999, dr. zafar moved to Florida to complete her residency in internal medicine. This year she began her private practice at Broward general Medical center (BgMc) in Ft. lauderdale, specializing in hematology and oncology.

“as a new physician, practicing medicine is exactly what i hoped and anticipated it would be,” says zafar. She has taken a proactive approach, joining numerous medical organizations to protect and improve medicine in Florida. in addition to her membership in the FMa, dr. zafar is also involved with the association of clinical oncologists (aSco) and the association of Physicians of Pakistani-descent of South Florida (aPPSF).

Her affiliation with these organizations has enabled dr. zafar to further pursue her passion for oncology, particularly breast cancer research. in 2007, she gave several lectures to both physicians and laypersons regarding breast cancer treatment and awareness. This year she will perform lectures before the physicians at BgMc. “Breast cancer research is my passion,” says dr. zafar. “Whether i’m treating patients or spreading awareness, in the future i want to be at the forefront.”

For now, dr. zafar continues to work hard establishing her practice, providing care for her patients, while finding time to spend at home, caring for her husband and their three children. in the future, she also hopes to develop a breast cancer center at BgMc, to offer specialized treatment and clinical trials. “Most oncology departments treat all forms of cancer,” says zafar. “Sub-specialties are becoming a trend, and i want to be a part of developing ours and providing the best possible care for breast cancer patients.”

42

www.fmaonline.org Florida Medical Magazine Fall 2008www.fmaonline.org Florida Medical Magazine Fall 2008Florida Medical Magazine Fall 2008

talk to many

of florida’s physicians, and chances are you’ll

find someone who knows and admires dr. kamel

elzawahry. few physicians have had a greater or

more personal impact on the lives and careers

of physicians than he. although his professional

contributions are great, he’ll be the last person to

tell you about them. “there’s no one more humble,”

says neal dunn, md, urologist from Panama city,

“and, arguably, no one with less of a reason to be.”

43

a gIFteDphysician

kamel elzawahrY, mD


Born in 1944, dr. elzawahry was raised on the other side of the world, as one of 15 children in cairo, egypt. His father, a professor of language, ultimately became the dean of arabic Studies at alazhar University in cairo. This legacy of academic excellence led all 15 children into the sciences, resulting in careers as medical doctors, dentists, and doctors in other scientific disciplines.

dr. elzawahry grew up excelling in many things. While an outstanding student, he also developed into an adept athlete. Prior to entering medical school, he was faced with a difficult choice. a skilled gymnast, elzawahry was approached by the egyptian national gymnastics team to compete in the vault competition in the 1960 olympic games in rome. “His father talked him out of it,” says dr. dunn. “He convinced him that medical school was the better decision.”

I m P r e s s I V e b e g I N N I N g s

in 1969, dr. elzawahry graduated from the ain Shams University in cairo with a medical degree. Since then, he tirelessly has continued his education, obtaining seven board certifications, ranging from internal medicine to neurology. “i have one,” says dr. dunn, “and i’m proud to have it. earning seven is difficult for me to comprehend.” despite his numerous certifications, dr. elzawahry currently practices as a neurologist and is a senior partner with the Brain and Spine center in Panama city.

after completing his internship and residency in internal medicine at al azhar in cairo, dr. elzawahry traveled to the United Kingdom. There he served as Senior House Surgeon for leicester general Hospital, oxford University and edinborough University. during this period, dr. elzawahry met the woman who would become his wife

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“there’s no one more humble, and, arguably, no one with less of a reason to be.”


and mother of his two children, Joan elzawahry, who currently practices anesthesiology. They have been married for 34 years. From the United Kingdom, dr. elzawahry traveled to Jamaica, where he served on the medical staff at the University Hospital of the West indies. after brief residencies in Philadelphia and new Jersey, in 1980 he began his private practice in Panama city, where he has lived and worked ever since. That year he also joined the Bay county Medical Society (BcMS) and the Florida Medical association (FMa).

“His record of service in our community is unparalleled,” says dr. dunn. dr. elzawahry has served on the BcMS executive committee for more than twenty years. He served as president in 1993, and for the past sixteen years as director of continuing Medical education. “He’s got a gift for working with young physicians and medical students,” says dunn. “i’m honored to call dr. elzawahry my mentor, but i am just one among countless others.”

a c a r e e r m e N t o r

earlier this year, the FMa Specialty Society Section (which dr. elzawahry chairs) and the council on Medical education developed a mentorship program, which will provide guidance and additional support to young physicians and medical students. “dr. elzawahry understood the need for mentoring the next generation of physicians,” says Melissa carter, FMa director of education. “He knew they needed to be exposed to organized medicine and poised for leadership, but he also knew this would take considerable funding.” Without hesitation, dr. elzawahry donated the seed money necessary to develop the FMa mentorship program.

“That’s the thing about my father,” says Hoda elzawahry, Md, his eldest daughter. “He is incredibly generous, and he gives without ever asking for anything in return.” She claims his example has led her and her younger sister, Hebah elzawahry, Md, a family practice

resident in chicago, to find ways to give more. “My father is, and always has been, an incredibly hard worker,” says Hoda, who is currently a neurological resident in Tampa. “i currently work fourteen hours a day or more. But my father has worked just as many hours a day for as long as i can remember.” Hoda also recalls the impact her father’s reputation had on her life growing up. “i couldn’t get away with anything,” she remembers, laughing. “anytime someone heard my name, people would always say, ‘oh! You must be dr. elzawahry’s daughter!’ They all knew me because they all know my father. He’s a big part of our community.”

grace Schifley, dr. elzawahry’s office manager, certainly agrees. “He holds a special place in the heart of Bay county. His care and advocacy on behalf of our indigent patients has been incredible.” around the office, Schifley always is impressed with the example dr. elzawahry sets. “He’s the first to arrive in the morning, and the last to leave in the evening. He’ll take any patient who walks through our doors. He’s the kind of person you meet maybe once in your life.”

The influence of dr. elzawahry’s dedication and generosity extends far beyond his practice. in 1992, he co-founded the BcMS Bay cares program, which provides care for indigent patients in the Bay county area with cooperation from local hospitals and physicians. Under his guidance, the Bay cares program has provided millions of dollars of free

he’ll take any patient who walks through our doors. he’s the kind of person you meet maybe once in your life.”


medical care. The proceeds are comprised entirely of voluntary contributions from physicians and the medical community. “There are no state or federal reimbursements at work here,” says dr. dunn. “What makes it special is the spirit of cooperation. We’ve got physicians from different faiths and public and private hospitals, all coming together to provide the best care.”

For all dr. elzawahry has done for Florida’s patients, his efforts to improve the lives and careers of Florida’s physicians are equally impressive. in 1991, he began a series of programs that have set the standard for continuing medical education in northwest Florida. “He’s done the lion’s share,” says dr. dunn. “He designs, directs, recruits, and moderates several cMe events, including the BcMS Spring Meeting, which is attended by more than a hundred physicians.

a l I F e o F a c h I e V e m e N t

although his own achievements in medical education are substantial, dr. elzawahry has become adept in areas outside of medicine, including the political arena. “He was one of the first in BcMS to recognize the need for active involvement in the electoral, legislative, and regulatory processes,” says dr. dunn. dr. elzawahry began lobbying throughout Florida on behalf of patients and physicians. He also became a member of the FMa Pac Board of governors, as well as the Md 1000 club. “our state legislators and congressmen all rely on dr. elzawahry’s judgment and advice,” says dr. dunn. “He was instrumental in transforming our county society into an active participant in politics and in further strengthening the FMa’s reputation.”

in addition to his political prowess, dr. elzawahry also is recognized for his accomplishments within his profession. He has achieved fellow status with the american college of Physicians (acP) and the american

academy of neurology (aan). The aan nominated him for recognition as the Most outstanding neurologist in america and last year honored him with the Kenneth M. Viste, Jr., Md, Patient advocate of the Year award. in 1999, the FMa awarded dr. elzawahry with the certificate of Merit. it is the highest honor awarded to a physician by the organization.

“dr. elzawahry is amazing to all of his patients,” says grace Schifley. “He never will turn a patient away simply because the patient is uninsured or unable to pay. dr. elzawahry is not just a great physician. He is a great man.” after only 28 years, dr. elzawahry has left a greater mark on the patients and physicians of Florida than most could hope to leave in a lifetime, and his legacy will only continue. “He hasn’t lost any of his momentum,” says Hoda elzawahry. “in everything that he does, he sets an amazing examples for others.” an amazing example, that is sure to inspire many for years to come.

“he is incredibly generous, and he gives without ever asking for anything in return.”

Florida Medical Magazine Fall 2008www.fmaonline.org 47

“i stayed active in politics,” says cannon. “i supported campaigns at the local and state levels and remained involved in the process, but it was never my intention to run.” in addition to his growing legal practice, cannon became the president of the orange county Young republicans. Then, in 2003, something happened.

“it was a perfect storm, really,” says cannon. an incumbent representative from the 35th district decided not to run, leaving the door wide open. With support from his numerous local political ties, and years of personal campaign experience, dean cannon decided to run and was elected to the Florida House of representatives in 2004. That same year, his peers in the House selected him to serve as the Speaker, beginning in 2010.

you might say representative dean cannon’s political

career began in an unlikely place – the

lakeland ymca youth legislature.

however, these early beginnings in the

political arena only spurred an interest

that would grow into a passion for

public service. in college, dean

cannon became involved in student

government at the university of

florida, and ultimately was elected

student body president. oddly enough,

after graduating from the university of

florida college of law and moving to

orlando, dean cannon had no plans to

run for office.

gettINg to kNow DeaNcaNNoN


w h o ’ s t h e N e w g u Y ?

during dean cannon’s initial campaign for the Florida House, alan Mendelsohn, Md, an ophthalmologist from Hollywood, Florida and FMa Pac Board member, received several phone calls. “legislators were calling me,” said Mendelsohn. “They were telling me i needed to check out this new candidate. in particular, House appropriations chair, Joe negron told me that dean cannon was exactly what physicians were looking for. You have to understand, legislators rarely make calls for other legislators.”

naturally, at first, dr. Mendelsohn was skeptical. “Physicians are tough characters,” he said. “When legislators speak on health care issues, there’s a pretty narrow margin of error. after about an hour on the phone with him, i felt i might as well have been speaking to Karl altenburger, Md, or Steve West, Md. issue after issue, he hit the bull’s eye.”

The first time rep. cannon and dr. Mendelsohn spoke, Mendelsohn was so impressed with cannon’s eloquence and conviction, he almost didn’t believe what he was hearing. “i asked him,” said Mendelsohn, “How do

you know all of this? i mean, everything from scope of practice to reimbursement, he knew it all. Then he told me about his brother.” cannon’s brother, an ophthalmic surgeon, currently practices in georgia. “He told me that if he didn’t practice what he preached, if he didn’t stand up for Florida’s physicians, he probably wouldn’t be invited for Thanksgiving dinner.”

if you ask rep. cannon, he’ll tell you that having a physician in the family has offered a greater awareness and passion for protecting and improving the practice of medicine in Florida. “it’s a matter of safety,” says cannon. “We have a duty as lawmakers to create policy that secures the public health. For instance, no one, other than medical doctors, should perform medical procedures. anything else is certainly a threat.”

F a c I N g t h e I s s u e s

rep. cannon understands the unfavorable liability climate in Florida. “My brother considered practicing in Florida,” he says, “but the liability costs were far too high.” He believes that many of these issues stem from the Florida constitution. “Unfortunately, a lot of the dysfunction we have, in terms of liability and regulation, is embedded in it. However, there are limits to what the legislature can do.” rep. cannon believes the best solution will involve cooperation from everyone involved, in the halls of the capitol and beyond. “one of my hopes is that all of the stakeholders – the doctors, the patient care advocates, the lawyers – can sit down and acknowledge that the system we have is not ideal.”

“Issue after issue, he hits the bull’s eye.”



49

Well aware of Florida’s physician shortage, rep. cannon understands that a fair system is a must. “Patients deserve reasonable protection, and so do physicians. But we’re not there yet. That’s why we’ve got to work together.”

Physician reimbursement is also one of rep. cannon’s priority issues for the 2009 session. “We ask a lot of our physicians already,” he says. “We should not and cannot ask them to function as banks.” acknowledging the high cost of overhead and liability coverage in Florida, cannon realizes the financial difficulties physicians are facing. “it’s not complicated. When a service is rendered, it should be paid for. Unfortunately for physicians, it’s rarely this easy.”

although his political resume is growing, rep. dean cannon is already a great leader among Florida’s

legislators, with a growing reputation among Florida’s physicians. “i held an event for him at my office in Hollywood back in august,” said dr. Mendelsohn. “it was on a Thursday night, after a long, exhausting workday. even so, more than 200 physicians and their spouses attended – the kind of crowd you might expect for a gubernatorial candidate! i’m telling you, dean cannon is a rock star.” This rock star status, born from his strong, personal resolve to help physicians, makes him a great ally and friend of medicine – certainly one to keep an eye on.

“we ask a lot of our physicians already. we should not and cannot

ask them to function as banks.”

Each election cycle will bring new challenges to how you practice medicine. FMA PAC support can make the difference between victory and defeat.

SPecial PracTice ManageMenT SUPPleMenT www.fmaonline.org

PractIce maNagemeNt

suPPlemeNt

www.fmaonline.org SPecial PracTice ManageMenT SUPPleMenT

Plan for success learn how to write an outstanding business plan.

finding the funds learn ways to build capital for your budding practice.

starting a Practice What to consider before hanging up your shingle.

Joining a Practice What to consider before you sign on the dotted line.

Permits and licensure a list of necessary permits and licenses for practicing physicians.

recruiting and maintaining staff Put together an all-star staff.

develoPing your brand create and project the image you want for your practice.

reaching (and keePing) Patients Make a lasting connection with new patients.

making imProvements learn how to take your practice from good to great.

emr The future of health care information.

closing a Practice get prepared before making your final rounds.

imPortant contacts important contacts for you and your medical practice.

fma Preferred vendors learn what discounts and other benefits you can receive as an FMa member

c o N t e N t s


l o o k s h a r P

Presentation is vital. Your goal is to prepare a plan that is easy to read and easier to understand. it should exhibit a comprehensive and professional knowledge of where you are and where you’re going. assemble your plan in a loose-leaf binder. The size is perfect for quick revisions or for passing across a lender’s desk to review. The binder should have a sharp cover sheet including your basic information: name, location, telephone number, and email address.

t h I N k F a s t , g e t o r g a N I z e D

The key to any successful business plan is having an authoritative knowledge of your ultimate goals. You should know your objectives and strategies well enough to summarize them to a stranger. an executive

summary grants you this opportunity in writing. Your plan should lead-off with this brief summary (one-or-two pages), exploring everything from your practice’s specialties, finances, marketing strategies, and management technique.

in addition to a thorough summary, the business plan should be organized like any other complex manuscript. Starting with a table of contents, your plan should be organized in a logical manner with specific sections and appendices.

r e a c h a N u N D e r s t a N D I N g

around the world, a medical degree is inherently valuable; however, depending on where you choose to practice, its marketability may vary. certain markets

to obtaIN aDeQuate FuNDINg For Your Future PractIce, you must be able to present prospective lenders with a strong business plan.

a guIDe to PreParINg Your meDIcal PractIce’s

busINess PlaN


throughout Florida may be saturated with your particular specialty. Starting a practice in a saturated market can prevent you from joining local provider networks and severely limit the number of patients you see. Your business plan must demonstrate your value, not just as a physician, but as a physician within a chosen community.

even in an unsaturated market, your target demographic and benefits must be clear. describe your specialty and services as you would to a potential patient. Keep it simple, but thorough.

b e P r e P a r e D although the main objective of a business plan is to get your practice started, your focus always should be on the future. Beginning with the end in mind, it’s a good idea to set goals for your practice as far as five years ahead. How many patients do you hope be seeing by then? How much revenue do you hope to generate? Will you expand and acquire greater cost? When you set clear and reasonable goals, your practice is far more likely to meet, and even exceed them.

h o N e s t Y I s t h e b e s t P o l I c Y The greater your goals are, the greater the obstacles you’ll face. Building and leading a successful medical practice in Florida is a formidable challenge. a business plan provides you with an opportunity to address many of these challenges beforehand, and to develop the necessary solutions. a willingness to face and overcome obstacles with a proactive attitude will increase your credibility with lenders and provide you with a greater sense of control.

l e a r N I N g t h e r o P e s even if you didn’t attend business school, numerous academic resources exist on campuses across Florida to assist with new business ventures, including medical practices. Many MBa programs offer free business plan consultations, conducted by experts. For instance, the Jim Moran institute at Florida State University (www.cob.fsu.edu/jmi/) and the gator nest at the University of Florida (www.gatornest.net) offer comprehensive entrepreneurial advising to meet your business needs.advisors can help you write a plan, revise a current draft, or offer additional consulting. These programs work to reach entrepreneurs throughout Florida and

can provide most services by phone, the internet, or via video-conferencing.

if you’d rather “do it yourself,” there are numerous business planning resources available on the internet.

THe SMall BUSineSS adMiniSTraTion (www.sba.gov/smallbusinessplanner/index.html) website offers a small business planner, which includes tools to create a plan of your own and tips on how to start, manage, and when you’re ready, close your business.

enTrePreneUr Magazine (http://www.entrepreneur.com/businessplan/) offers an entire online library of articles on business plans and strategies as part of their Start-Up Kit.

THe Wall STreeT JoUrnal (http://wsj2.miniplan.com/) offers online troubleshooting software, called MiniPlan. There, you can develop and sharpen ideas for your practice. it is completely free, and offers a glance at sample business plans drafted using the MiniPlan software.

Presentation is vital.


FINDINg the FuNDs

whether You are startINg a PractIce or looking to expand, you will need planning, execution, and of course, financing. like any business,

you have several opportunities to acquire funds for your future plans.


I t ’ s u P t o Y o u

Before pursuing lenders, you should consider your per-sonal financial situation. either on your own, or with the help of others, it is possible to build a significant pool of resources to begin or expand your practice without setting foot in a lending office. How much can you put together on your own?

a s o u N D I N V e s t m e N t

You’re a physician, and your services will always be nec-essary. Finding private investors to support your prac-tice can be difficult, but far from impossible. local phy-sicians and group practices who believe in your vision may be willing to buy in and help you get over the hump.

g I V e Y o u r s e l F s o m e c r e D I t

although not the soundest option, credit cards can help you through the early stages of your venture. if you choose to open business credit accounts, make sure you choose cards with low interest rates. it is also es-sential that you fully understand the terms and condi-tions and that you make your monthly payments in a timely manner.

s a V e Y o u r s e l F

no one should have greater confidence in your future than you. Putting personal savings toward your practice not only will eliminate the challenge of dealing further

with lenders, but it shows commitment and faith in your decision. Wherever you can draw the necessary funds, now is the time to do it.

h o s P I t a l s

Most hospitals offer income guarantees to physicians who are new to the area. if you’re planning to put down roots, these guarantees will provide you with supple-mentary income to help build your practice. However, to take advantage of these funds, you must remain local for the time allotted in the contract agreement. if you decide to practice elsewhere before then, you’re obli-gated to pay it all back.

t a k e I t t o t h e b a N k

choosing and building a relationship with a bank is im-portant to the success of any business. a medical prac-tice unlike other start-ups, provides an almost guaran-teed income, which will improve relations with any bank and provide you with far greater lending opportunities. Banks like regions, a FMa preferred vendor, offer a wide variety of options from checking to lines of credit. The criteria for obtaining a business loan at a bank vary widely by institution. Make an appointment with a variety of bank loan officers and find out what is best suited for you. additionally, the Small Business association (SBa) offers many generous lending oppor-tunities. You can read more about these loans in the next article.


oNce Your PersoNal resources are tapped, you can pursue a loan for your practice from the u.s. small business administration (sba). there are several sba loans available, for varying amounts to suit individual business needs.

7 ( a ) b u s I N e s s l o a N s – m a x I m u m o F $ 2 m I l l I o N

The 7(a) business loan is the SBa’s primary lending option. These funds can be used for fixed assets, working capital, and even to refinance debt in certain situations. The interest rates will vary, but are limited by SBa maximums. These are attached to the Prime rate.

c o m m u N I t Y e x P r e s s – m a x I m u m o F $ 2 5 0 , 0 0 0

This option is available to physicians looking to start a practice in an underserved community. it is also available to women, minorities, and veterans. These loans come with technical and management assistance and do not require proven collateral for loans up to $25,000.

s b a e x P r e s s – m a x I m u m o F $ 3 5 0 , 0 0 0

in general, obtaining an SBa loan is a lengthy process. an SBaexpress loan cuts through most of the paperwork and hassles, allowing lenders to use their own forms and processes. Turnaround times for these loans are, at the most, 36 hours. For physicians who are financially stable and looking to act fast, this can prove to be a solid option.

P a t r I o t e x P r e s s – m a x I m u m o F $ 5 0 0 , 0 0 0

if you served, or continue to serve, in the United States armed Forces, this may be the loan option for you. an SBa Patriot express loan provides veterans, reservists, and others with revolving lines of credit for up to seven years. To take advantage of this loan, you must own at least 51 percent of your practice.

c D c / 5 0 4 l o a N P r o g r a m

if you’re looking to finance long-term, the cdc/504 program can be a great choice. it offers fixed-rate loans for up to $1 million for financing land, buildings, and equipment. These loans are typically financed 50 percent by a bank and 40 percent by a non-profit certified development company. The remaining 10 percent is up to you. The purpose of these loans is to create and maintain jobs, allowing the economy to grow along with your practice.

sbaloaNs


b a c k t o b a s I c s

Whether starting a hardware store or a large group medical practice, the same basic business skills apply. Physicians intending to take an entrepreneurial leap must understand the fundamentals of management, finances, and maintaining records. even if you choose to hire a practice administrator, knowing these elements of business will help you maintain leadership and determine the ultimate course of your new practice. also, a firm understanding of the tax regulations and legal framework at every level of government is key. To address all of these needs, you should assemble a professional advisory team. Many accountants and attorneys specialize in dealing with health care issues and can provide counsel through the unique challenges of a budding medical practice.

l o c a t I o N , l o c a t I o N , l o c a t I o N

Whatever your professional reputation, starting a practice in the wrong location can make things difficult. as a rule of thumb, it is best to avoid areas with a large physician population, particularly those in your specialty. This immediately puts your services in low demand. it also makes you less attractive to insurance carriers, who may be unable or unwilling to add you to their local provider

networks. getting in touch with your local county medical society and area hospitals is a great way to become acquainted with an area and make sure it is the right for you.

l I c e N s e D t o P r a c t I c e

a medical license is only the beginning. Business licenses, issued by your city or county, are a necessary part of any new enterprise. For medical practices, the list doesn’t end there. Physicians must register with or obtain a license from the Board of Medicine, the drug enforcement agency, and others. For a detailed list of licensing requirements for physicians in Florida, see “Permits and licensure” on the next page or contact the FMa Medical economics department by calling 850-224-6496.

l e N D I N g s u P P o r t

Starting a practice is expensive. like any other business venture, obtaining outside financial support is often a necessity. For budding medical practices, the challenges of taking a business loan are not unusual. The key is planning, and making your plan presentable. any bank or other lending institution will want to know your projected start-up costs, and anticipated income see “Plan for Success” at the beginning of this supplement.

JoININg a PractIce


I t ’ s a l l b u s I N e s s

You’re licensed to practice medicine, but this is only the beginning. If you’re looking to start a medical practice, a business license is also necessary. Depending on where you’re located, the city or the county will issue one to you. Your local medical society can often point you in the right direction.

N P I

The federal National Provider Identifier (NPI) is the health care provider identification system adopted by the U.S. Department of Health and Human Services (HHS) as part

of the implementation of the Health Insurance Portability and Accountability Act (HIPAA). This is the number used by Medicare/Medicaid, as well as many managed care organizations, to identify you for reimbursement. Applying for your NPI should be one of your top priorities, and can be done by visiting http://www.cms.hhs.gov/nationalprovidentstand/03_apply.asp or calling 1-800-465-3203.

m e D I c a r e a N D m e D I c a I D

To care for Medicare and Medicaid patients, you first must register with the Centers for Medicare and

For aNY small busINess, the local, state, and federal governments all require a series of permits. For medical practices, the list is even longer.

PermIts & lIceNsure

m a k e I t l e g a l

Physicians looking to start a practice must first determine its structure. Starting a solo practice is becoming increasingly difficult. The professional and financial liabilities can be overwhelming, in comparison with a those of a group practice. However, when it comes to group practices, the structural possibilities are numerous. The organizational structure you choose will determine your taxes and overall professional liability. Physicians looking to start a group practice should consult with their potential partners, as well as an attorney, and determine a course that best suits your unique circumstances.

w h o ’ s I N c h a r g e h e r e

The kind of practice you start will determine your amount of administrative responsibilities. Solo practitioners are

responsible for everything, just like any small business owners. in the beginning, they often cannot afford the services of a full-time practice manager or support staff. aspiring solo practitioners should prepare to spend considerable hours handling business affairs or consulting with outside experts.

Starting a group practice enables the physicians to share the amount of administrative work. in sharing space and expenses, group practices also are able to afford administrative tools and staff they couldn’t otherwise.

Whatever you decide, starting a practice in Florida is a difficult but worthy challenge. With proper planning, consideration, and execution, there is tremendous opportunity for success.


Medicaid Services (CMS) and obtain Medicare and Medicaid provider numbers. Visit the Payment Advocacy section of the FMA’s website (www.fmaonline.org) or contact either organization directly:

meDIcare: 1-800-MEDICARE www.floridamedicare.com

meDIcaID: 1-800-239-7560 http://www.fdhc.state.fl.us/medicaid/about/about4.shtml

D e a r e g I s t r a t I o N u N I t

If you’re writing prescriptions, you must obtain a DEA license. The DEA Registration Unit offers a 24-hour service, available by phone at 1-800-882-9539, and online at www.deadiversion.usdoj.gov.

F l o r I D a D e P a r t m e N t o F b u s I N e s s

a N D P r o F e s s I o N a l r e g u l a t I o N

Anyone who opens a business in the state of Florida must have a DBPR license. You can do this by visiting http://www.myflorida.com/dbpr/SSNNotice.html or calling 850-487-1395.

b o a r D o F m e D I c I N e

Whether you’re just starting out or relocating your practice, you must notify the Florida Board of Medicine of your new address as well as your medical licensure number. This should be done in writing, and sent certified mail with a receipt requested, to:

Department of health, Florida board of medicine 4052 Bald Cypress Way, BIN # CO3, Tallahassee, Florida 32300-1753

Failure to notify the Board of Medicine within 30 days of opening or moving your practice can result in significant fines and penalties. You can also reach the Board by phone, at 850-245-4131.

P r o F e s s I o N a l l I a b I l I t Y c o V e r a g e

In Florida, professional liability insurance is not required. However, physicians choosing to “go bare” must demonstrate considerable personal finances. You can establish and maintain an escrow account or obtain and maintain an unexpired, irrevocable letter of credit in the same amounts that base liability would cover.

This includes $250,000 per claim, with a minimum annual aggregate of at least $750,000. Even in doing this, you run the risk of scaring off managed care organizations, many of whom forbid “going bare.” With Florida’s current tort system, obtaining coverage is the responsible choice. The FMA endorses First Professionals Insurance Company (FPIC) which provides FMA members with a discount on their professional liability coverage.

t a x I D e N t I F I c a t I o N N u m b e r

As an employer, you will need an Employer Identification Number (EIN) from the IRS. You can apply for one by filling out a Form SS-4. If you will be providing taxable services or selling taxable items out of the office, you also will need a state tax number. You can contact the Florida Department of Revenue Application Acceptance Department at 850-487-7000 to learn more.

N I c a All physicians licensed in Florida are required to pay into the Neurological Injury Compensation Association (NICA). To ensure that you make your payments and receive invoices, you can register with NICA either by calling 850-488-8191, or by visiting them on the web at www.nica.com.

c l I a If you will be performing any laboratory services in your practice, rather than using outside sources, you must comply with Clinical Laboratory Act of 1998 (CLIA), and all other state requirements. To learn more about CLIA standards, visit www.cdc.gov/clia or call the Agency for Health Care Administration Laboratory Licensing Unit at 850-487-3109.


recruItINg & maINtaININg staFF

t h e w e b

Today, where else would you start? The FMA Online job board (www.fmaonline.org) features listings of physicians and medical professionals throughout Florida. It is advertised in medical publications around the state, reaching a wide and diverse number of potential hires. You also can visit additional online employment resources, such as Monster.com, CareerBuilder.com, and HotJobs.com.

I N t h e N e w s

No matter how good you are with search engines, it is always a good idea to use local newspaper and medical literature to find potential staff members. Advertise in the classified sections. If you’re looking for experience, search within your specialty. Many newspapers are also online, allowing you to shop and compare advertising rates.

s o c I a l I z e w I t h s o c I e t I e s

Don’t underestimate word of mouth. Your local medical society is a great place to network. Ask members you trust about their staffing process. Also, if you’re looking for a young physician or someone fresh out of residency, contacting the chief residents of Florida’s medical schools might help.

I t ’ s t h e l a w

In addition to Equal Opportunity Law, your practice must comply with Florida’s other labor laws. Be sure your staff wages fall within federal minimum wage parameters. Finally, Florida law requires that any employers outside of the construction industry, with four or more employees, must provide their employees with worker’s compensation coverage. For these and any other legal concerns, it is best to consult with your attorney first.

s e t e x P e c t a t I o N s

The value of detailed job descriptions should not be overlooked. There is no better way to maintain and effectively delegate leadership than by knowing precisely who will be doing what and why. Whether you’re looking to hire an office manager, a nurse, or a medical coder, it is essential to understand the job and the knowledge, skill sets, and other characteristics necessary to complete it. Make sure you include a brief outline of the job duties in your classified ad to weed out applicants who do not qualify. A more detailed job description should be developed before you make the hire and shared with your new employee in order to set clear expectations of the individual’s supporting role in your practice.

k N o w w h o Y o u ’ r e h I r I N g

When hiring, background and reference checks should be a top priority. Negligent hires, such as unlicensed physicians or nurses, leave you and your practice entirely liable. It is also important to have a strong, personal sense of all potential employees, to determine whether they are fit for the job. Proper staffing is an investment in the success of your practice, and it is crucial that anyone you hire is a good fit and has potential to grow in his or her position, making lasting and increasing contributions. Three references are standard, and either you or your office manager should contact these references by phone or in-person. This can provide a sense of what employers have experienced in working with an individual, allowing you to assess strengths, weaknesses, and overall potential.

a F a I r w a g e

An important aspect of attracting quality staff members is ensuring that your compensation packages


are competitive. The Medical Group Management Association website, MGMA.com, offers salary surveys for hiring new physicians, practice managers, and other medical personnel. Websites such as Payscale.com or Salary.com offer a wide array of resources, providing detailed demographic information on every conceivable occupation. However, most physicians agree that the best way to find out the typical wages in your area is to call other local physicians. Speaking with colleagues can offer a more personal perspective and ensure that your salary offerings are both consistent and competitive.

o N F u r t h e r r e V I e w

There is no better way to determine the morale and effectiveness of your practice than with regular meetings and performance reviews. Maintaining honest, open communication among staff members not only will keep everyone on the same page, it enables you to address the strengths and weaknesses of your practice. Plan frequent staff meetings. Also, hold performance reviews annually or biannually. These will give you and your staff members an opportunity to observe their growth and discuss how they may continue to grow as part of your practice.

r e t r e a t !

Meetings not related to work also can benefit staff morale and improve relationships between you and your employees. Breakfast or lunch socials can rejuvenate and bring a sluggish staff back to center, allowing everyone to relax and enjoy themselves. However, make sure the time is well spent. Teambuilding exercises can offer fun challenges for you and your staff, allowing you to work together, improving communication and confidence in one another.

www.fmaonline.org SPecial PracTice ManageMenT SUPPleMenTwww.fmaonline.org SPecial Prac

w h a t ’ s I N a N a m e ?

More than you might think. The right name for your practice will convey a simple and positive image to patients. Many solo or small group practitioners choose to name their practices after the physicians involved. However, this can create future branding chal-lenges if physicians leave or join, or if the nature of the practice changes. Be sure to avoid a name similar to surrounding practices or medical facilities. Your name should be unique, enabling your practice to stand out from the rest.

Y o u l o o k F a m I l I a r

One of the most powerful forms of branding is the use of a logo. Although medical prac-tices don’t require the mass-marketing impact of symbols like Golden Arches or an ath-letic Swoosh, a sharp, recognizable logo has significant advantages. It gives your practice an air of professionalism and business savvy. Most importantly, a strong logo can leave a lasting impression on patients, making them more likely to pick up your business card or remember your advertisements.

o N a m I s s I o N

A firm mission statement can be a powerful asset to any business. Although some busi-nesses choose short, simple statements, others develop theirs in a longer, more compli-cated form. Whatever you decide, conveying your mission with a quick and memorable tagline will help you stand out and stay fresh in patients’ minds.

I t ’ s e V e r Y w h e r e

Once you have chosen the right logo and tagline for your practice, it’s time to put them to work. Everything – including letterhead, brochures, business cards, your website, and advertisements – should be redesigned to include your new brand.

t h e t o t a l P a c k a g e

Your practice environment, from the waiting room to the exam room, should reflect your branding imagine. Everything, from office décor and lighting to the staff dress code, should convey the image and atmosphere you want patients to experience. Are you going for upscale or an at-home feeling? Chic or conservative? The look and feel of your office should be consistent with your brand from top to bottom.

most busINesses, INcluDINg meDIcal PractIces, can benefit from effective branding. once your practice has established its mission and core values, there is no better way to communicate the essence of your practice to patients than with strong branding. branding conveys your practice’s image; it gives patients a sense of who you are even before they walk through the door. here are a few ways to make a great first impression.

DeVeloPINg Your braND


®l o g o N

There is currently no better way to reach patients than via the internet. These days, it is more likely for a patient to search the web for a physician, before checking the phone book or asking for a referral. Your website will likely be a potential patient’s first impression of your practice. Make it a good one.

A well-designed, informative website can provide patients with an understanding of who you are and what you can do for them. Brief biographical information about physicians in your practice, their professional experience and accolades, and the services your practice provides will give patients a sense of understanding and perhaps the desire to make an appointment.

s t a r t Y o u r e N g I N e s

Even with a great website, it’s easy to be lost in the shuffle of search engines. How do certain websites always make their way to the top of the list? By using a technique called “search-engine optimization” (SEO). Adding certain words to your web content will increase your chances of receiving top-billing. However, effective SEO is a complicated and evolving process, and may require professional assistance until you or someone in your practice has a firm grasp of how it works. There are numerous resources on the web to learn more about SEO, such as www.seo.com, which can provide further understanding of the process and how to take advantage of it.

s t a N D I N g o u t

In addition to a website, advertising can give your practice an edge on the competition; however, advertising a medical practice is not like advertising most businesses. You aren’t just selling your services; you’re looking to build lasting relationships with patients. Successful advertising not only will showcase your brand, see the previous article, “Developing

Your Brand”, but also will emphasize a personal touch, showing potential patients who you are as a person as much as a physician. After creating listings in the local yellow pages, you should consider mailing postcard announcements throughout your practice area. These should show patients who you are and offer a glimpse of the care you can provide. The point is not just to be seen, but to stand out.

w o r D o F m o u t h

For most practices, a significant number of patients originally were referred by a friend or family member. But new physicians or those who’ve changed practices or locations haven’t established the reputation necessary to draw these referrals. For them, or for any physician looking to increase their number of referrals, a proactive approach can provide a significant increase. Meeting local established physicians personally, or getting involved with your the local county medical society, is a great way to start.

g e t I N t h e N e t w o r k

Once you’ve joined an insurance provider’s network, follow up and make sure your information in the printed and online provider directory is correct. Incorrect phone numbers or an old practice address can stifle your business. Quarterly visits to these directories can give you the peace of mind that your information is correct and accessible to potential patients.

e N J o Y Y o u r s t a Y

A welcoming practice environment can make all the difference for your patients. Whether they’re in the waiting room or the exam room, comfort is key. In the conventional sense, avoid making your office feel like a doctor’s office. Decorate and arrange everything to suit your patient demographic and make them feel at home. Doing so will provide a sense that your practice is not just a clinical environment, but a warm place of comfort and care.

wIth aN eFFectIVe braND, you’re ready to take on the market. You’re in the business of providing quality care to patients. to accomplish this, patients need to know who you are and where to find you. here are some ways to get started.®reachINg (aND keePINg) PatIeNts


k N o w t h e m a r k e t

As you plan financially, it is imperative that you know market trends. Having a strategic business plan matters. When you plan financially for the future of your practice, knowing the market will allow you to anticipate and man-age potential problems. Conducting research in your scope of practice and location affords you important knowledge that you can use to predict the marketability of your practice.

g e t c r e a t I V e

Currently, income is going down and the cost of business is going up because of poor reimbursement rates and a troubled economy. Nevertheless, physicians need to find ways to stand out. Simply adjusting the look and feel of your office attracts more patients. Warm offices that pro-vide a positive experience for patients will maintain and even increase your numbers. Entrepreneurial creativity may sound foreign to medicine-minded ears, but creat-ing new forms of income and fighting the constraints of managed care reimbursements are critical to your future success and eventual retirement.

b u r N c a l o r I e s

Consider your practice a patient in the intensive care unit with the clock ticking. Exercise your creativity to treat your practice-patient. Tap new markets, find new streams of income (such as opening medical facilities) and realize that demands for non-need-based care are high and growing. People do not get sick only between the hours of 8:00 a.m. and 5:00 p.m. Make your practice exercise its body and resources and boost its metabolism. You may want to consider remaining open during some off-hours, or on weekends, and using the equipment that otherwise would be sitting idle.

c o N s I D e r a c o N s u l t

Whether or not you consult your colleagues for rare cases, you should consider hiring a consultant to save you time and give you expert advice on managing your practice and keeping it financially viable. Results will be most helpful and cost-effective if you know what you want to accomplish. Use a practice management consultant judiciously. Some practices have consultants in varying fields of expertise come in annually to provide useful advice, for example, on inter-physician relations or general accounting.

Consulting services can be worth your while, especially for small practices that seem to need the most help. Purchase consulting on an as-needed basis and develop a program that suits your financial needs. Consider calling a prac-tice management consultant or an independent practice association (IPA), that offers a cost-effective solution to a smaller practice. Depending on your location, you can ob-tain research from a local medical school or chief resident on medical issues and prospective associates.

Providing the best care available depends on the growth and success of your practice. There are several ways to achieve balance. Adaptability is a necessary component to marketability and the key to succeeding in the future.

b e w I l l I N g t o c h a N g e

No matter which option you choose, being open to change with the needs of your practice and the eco-nomic climate is vital. If you can build an adaptable practice, and find ways to overcome or work around unforeseen challenges, your practice can grow stronger and more successful.

usINg exPert aDVIce to run your business is similar to using evi-dence-based medicine to practice. until medical schools start teach-ing business basics, learning to run a practice is up to you. luckily, there is help.

makINgImProVemeNts


take that first step and honestly

decide if the organization is ready

for electronic medical records.

eNsure a successFul emrImPlemeNtatIoN

www.fmaonline.org SPecial PracTice ManageMenT SUPPleMenTleMenTSUPP

Unfortunately, eMr implementation failure rates are higher than they should be. often, these failures can be attributed to the practices: they were not ready for this automation, they did not plan properly, or they failed to allow enough time for training. Take that first step and honestly decide if the organization is ready for electronic medical records. if the answer is “no,” but the desire is there, create a plan to take steps to correct the deficits so the organization can reassess and, in the near future, de-termine that it is ready for an eMr system. if the answer is “yes,” congratulations! Move on to the next steps.

e s t a b l I s h g o a l s a N D o b J e c t I V e s

establish goals and objectives important to your practice that need to be achieved with implementing an eMr. a critical step in this phase is to obtain a consensus from the group; this will help ensure the success of your project. review and update these as necessary.

another important decision that has to be made is whether you plan to retain your existing practice man-agement (PM) system or replace it with a new applica-tion. converting your existing PM system to a new appli-cation and training your staff on a different system may seem overwhelming to think about; however, it may be the best decision to make. Using two vendors (one for PM and one for eMr) can be a challenge and can cost more money to create and maintain an interface. in most situations, it is better to go with the same vendor and with an integrated system. each practice needs to review the pros and cons of the various options. D e V e l o P a s e l e c t I o N c o m m I t t e e

it is critical to obtain input from your staff and create a positive level of excitement for your upcoming technol-ogy project. each staff member contributes unique skills

and knowledge to the success of your practice and it is essential to tap into this wealth of knowledge as you prepare to move forward with your eMr.

The primary objective of the selection com-mittee is to develop the list of requirements and the vendor selection tools. Then, using these requirements and tools, the committee will identify vendors that ini-tially qualify and later select the final vendor. once the selection committee has defined its requirements and developed its vendor selection tools, it is time to move on to the next phases in the project. a physician champion is essential to the success of any eMr implementation. a leader can motivate others through his/her values, visions, and attitude. The physi-cian champion should express the importance of the project from his or her perspective and communicate a vision for how the project fits into the organization’s goals and objectives. The champion will be the driving force for the other physicians to follow for the imple-mentation plan and commit to the timeline to ensure a successful deployment.

D e V e l o P a P l a N , t I m e l I N e , a N D b u D g e t

The plan begins after you have determined that you are indeed ready for an eMr. The goals and objectives

ProbablY the most ImPortaNt FIrst steP in considering electronic medical records (emr) is

determining if the practice is ready to undertake a project of such magnitude and commitment. Your

organization needs to look inwardly at the culture, technology skill sets of current staff, financial

situation, current practice management system, and infrastructure. survey the providers and

determine their level of comfort with eliminating paper charts from their lives. are they currently

using Pcs? are they ready to look at a computer screen to review history, obtain lab results, order

tests, and electronically submit a prescription? are the physicians intimidated by computers?

sometimes it is difficult to take a hard look and make the first decision about readiness.

selectIoN commIttee tYPes

an individual from each office/department who has been with the practice for at least one year (Md or staff)

a practice administrator

The physician champion(s)

an information technology consultant or a consultant ex-perienced with PM/eMr se-lection and implementation

1

2

3

4


will drive the plan, along with the staff’s needs and the culture of the organization. The plan should outline steps from vendor selection through product demos, reference checking, contracting, implementation, and “go live.” The timeline will outline the various benchmarks along the way with applicable dates. Keep in mind peak treatment seasons and avoid those times of year for deployment. Staff members can be

overwhelmed with trying to perform their daily jobs, while trying to manage an eMr project. it may be

beneficial to hire a health care consultant with experience in

project management of eMr implementations.

Before you begin the vendor selection

process, create a budget for the

entire project. remember to consider “soft”

expenses such as lost productiv-

ity for training time, learning curves, etc. remember also that paper charts are not free and truly do cost your practice money, especially in salary expenses to file, maintain, search for them, etc. When the right system is chosen and implemented properly, a return on investment (roi) should be achieved.

N e t w o r k w I t h o t h e r P r a c t I c e s

learning from the experiences of others can be very en-lightening. Typically, the most verbal people are those who are dissatisfied with their eMr or who encountered challenges during the implementation. However, there are many success stories. With these successes came bumps in the road and those experiences can provide tremen-dous learning opportunities. network with practices within your local medical organizations and talk to a wide range of practices, including those who are happy and those who are unhappy or had failed implementations. ask a practice what they would have done differently to improve the success of their eMr implementation.

r e s e a r c h V e N D o r s

Part of your vendor research will be accomplished during your discussions with other practices. contact the Florida Medical association or review their eMr section online at www.fmaonline.org to review our recommen-dations and preferred vendor listing. Use the internet and health care publications. remember when you visit a vendor’s website that it is one of their strongest market-ing tools and they have developed that site to sell their products and services.

c o N s I D e r u s I N g a N I t h e a l t h c a r e

c o N s u l t a N t

a health care consulting firm with extensive experience in practice management/electronic medical records im-plementation can be an excellent resource for you. There are hundreds of vendors in the eMr arena, and it could take a practice several months to research many of them. an experienced iT consultant has done the research and can help narrow the field for you. if you choose to enlist the aid of a consultant, you should thoroughly research their background and references. ensure that the consul-tant is independent and has no financial or business rela-tionships with any vendors – you need them to give you unbiased input. and, make sure the consultant is experi-enced with all phases of an eMr project.

m a N a g I N g V e N D o r D e m o s

looking at the various products offered in the eMr in-dustry is a very important phase and can be challeng-ing. First, separate the sales pitch from the product presentation. it is recommended that you conclude your vendor research, including corporate background, finances, number of installations, maturity of product, etc., before you move into the demos. Value your staff’s time in the demos; they don’t need to listen to marketing propaganda.

h e r e a r e a F e w P o I N t s t o F o l l o w :

all selection committee members should be included •in the vendor demos, and additional staff as applica-ble. ensure that the presentation area is private and everyone has blocked their calendars so they can be dedicated to these important product demos.

create a vendor rating card for the attendees to use as they review and analyze each system.


do not allow the sales rep to give a sales pitch •during the demo. The presentation needs to focus on the products.

limit the demos to two or two and a half hours per •vendor because your participants can only focus on demos for a limited length of time.

establish a script or scenario that depicts a typical •patient encounter for your practice and give it to the vendor’s representative when they arrive. You want to ensure that you don’t get a fully “canned” demo and that the system can indeed handle your nuances.

create a vendor rating card for the attendees to use as •they review and analyze each system.

after the final presentation, the committee should •meet to discuss all presentations, compare notes, and begin the process of choosing the final vendor. it is important to hold this meeting immediately after the presentations so that the information is fresh in every-one’s mind.

r e F e r e N c e c h e c k s

once you have narrowed your vendor options to the top two or three; it is time to perform reference checks. of course, vendors will give you clients who are satisfied, so the key to obtaining valuable information from these ref-erences is asking the right questions. review your list of goals and objectives and incorporate some key items in your inquiries.

ask open-ended questions, rather than yes or no ques-tions, so they can explain in detail. Question the quality of training, how the vendor managed the implementa-tion, and whether the timeline was met. Were there cost overruns that exceeded the contracted amount?

s I t e V I s I t s t o o t h e r P r a c t I c e s

Visiting other practices that have installed systems from the vendor under consideration can be a very beneficial step in your selection process. You may not find compa-rable practices in your geographic area; however, it still could be beneficial to visit one or two practices to see the live application. develop a list of questions to ask the

various departments and be prepared to observe and listen during your visit. Watch for manual “work-arounds.”

V e N D o r c o N t r a c t I N g

This section could be an entire chapter on key points in managing the vendor contracting. remember that time is on your side, so ensure that you obtain a performance-based, shared-risk contract with sound financial arrange-ments to protect the practice.

Here is brief list of some items that you need to address during your contract negotiations:

Watch for front-loaded fees, and negotiate a stepped •payment plan based on implementation milestones.

ensure that the contract allows the practice to assign •all licenses and not incur any additional fees if the practice is sold, acquired, or merged.

examine the termination clause and watch for any •penalties for exiting the agreement; ensure that the data belongs to the practice and will be downloaded into a universally usable format (e.g., aScii) for use by future vendors during conversion.

request clauses to protect your practice from copy-•right infringement by the vendor.

negotiate the price for purchase of future licenses to •be locked in at the same license rate for two to three years from the original contract.

s u m m a r Y Selecting a vendor for an eMr system can be a time-consuming and challenging project. However, the rewards of an automated, nearly paperless system can be very beneficial. creating a plan and following that plan will help ensure a successful implementation that can lead to satisfaction and a return on investment.

Sue Hertlein, Senior Associate, Coker Group, 1000 Mansell Exchange

West, Suite 310, Alpharetta, GA 30022; phone: 678.832.2000; email:

[email protected]. Copyright © 2008 by Greenbranch

Publishing LLC, phone: 800.933.3711; website: www.mpmnetwork.com.

Used by permission.



l o N g l I V e s r e Q u I r e l o N g - t e r m P l a N s

Whether retiring early or late, you should plan on having ample time before your expiration date. Physicians must begin developing an exit strategy years before turning in their scrubs. First, you need to establish your post-practice goals, involving your family in the process. Second, you need to assess your current finances and invest in your future. Make sure you account for unexpected bumps along the way. Third, you should find and maintain suitable health and life insurance, as well as post-practice liability coverage. Keep in mind that your retirement date depends on your ability to afford the reasonable post-practice life you desire.

s e l l , s e l l , s e l l

Shutting down is a last resort. Unless there are no buyers or you must exit immediately, you never should just walk away. All of your medical records will need to be stored or transferred at your expense. If you have no other choice but to shut down, make arrangements to sell the office space and equipment. The purchase price will be higher if you sell equipment to another practice, but experts advise that you shouldn’t expect more than 20 percent of your purchase price. Even a relatively small profit can provide you with a substantial cushion for your future.

Identifying potential buyers a couple years in advance will make for an easier transition. Knowing your buyer is an

retIrINg From meDIcINe means more than just attending a farewell party. You need to protect your assets, transition your patients and staff, secure continued liability coverage, and fulfill your legal obligations. here are some things to consider as you plan.

closINg a PractIce


integral part of selling your practice. Finding a buyer who shares your level of expertise and commitment is difficult and takes time, but your transition will benefit from a productive relationship. If your buyer is a young physician who will take over when you take off, he or she should begin working in your office as an associate in order to transition smoothly and gradually. A quickly executable plan may be hammered out between the persons involved if transferring care to a hospital or familiar colleague.

t I m I N g I s e V e r Y t h I N g

Selling your practice demands a certain degree of sensitivity to your patients and staff. Placing them into the hands of a trustworthy colleague or buyer will ease their transition. However, announcing that your practice is on the market prematurely could lower its value. You may find your patients and staff leaving and your referral sources diminishing. To prevent the decrease in value, develop a plan to keep your practice attractive and marketable. Notify your networks after you have created an organized, tailored plan.

Making decisions ahead of time is an integral component to your exit. You eventually will need to begin cutting down on the number of patients you see and stop accepting new patients. Whether you choose to close your practice gradually or go strong until the end, planning allows you to exit in a manner that suits you and it cannot be done smoothly at the last minute. No matter how stable you are as a person, you will be affected by leaving. Working out the logistics ahead of time affords you the ability to spend time with patients without too much administrative anxiety.

s P r e a D I N g t h e N e w s It’s time to notify your networks when you are ready to set your plan in motion. Keep your staff in the loop. Give them incentive to stay with your practice and provide them with details concerning benefits, etc. Carefully arrange for their futures and minimize panic.

Knowing that your patients and staff are in good hands may ease your mind. Your staff, especially your office manager, is critical to implementing this transition. Public relations, patient care, and dealing with business issues are important components to leaving a practice in which your staff takes part.

Inform your patients and the general public. Publish a notice in your local newspaper once a week for four consecutive weeks. Include your exit date, how medical records may be obtained, and if applicable, the name of the physician taking over the practice. Sending personal notifications to patients by mail maintains your positive relations with them. Ask the patients who have been with you from the outset if they would like to reschedule upcoming appointments before your set retirement date. You also must notify insurance companies with which you have contracts, affiliated hospitals, medical societies, the DEA, and the Board of Medicine.

l a s t o r D e r s o F b u s I N e s s

Protect yourself from a malpractice suit. Double-check your numbers and legal information. Store medical records legally and make sure that you have liability coverage extending as long as needed. Finally, calculate any remaining accounts receivable. Another option is to increase the price of your practice by what you are owed in accounts receivable and sell the practice for that amount.

Finish your paperwork and stop seeing patients on a predetermined date to ensure that you have all lab work complete by the day you retire. Perhaps you should ask a friend, staff member, or family member to help you clear out your office. Make sure you have plans to look forward to, groups to join, and activities you are excited to begin or continue. Devote yourself increasingly to your personal life so that, by the time you retire, you’ve developed more of your identity that exists outside of work.

announcing that your practice

is on the market prematurely

could lower its value.


FlorIDa meDIcal assocIatIoN123 South adams StreetTallahassee, Fl 32301(850)224-6496www.fmaonline.org

legal aND goVerNmeNtal aFFaIrsJeffery M. Scott, esq.director of legal and governmental [email protected]

Michelle e. Jacquisassociate director of governmental [email protected]

regulatorY aFFaIrsJennifer Forshey Hinson, esq.regulatory affairs [email protected]

PaYmeNt aDVocacYFred Whitson, esq.director of Medical [email protected]

Susan FranzMedical economics [email protected]

leslie Barbercertified Medical [email protected]

member serVIcesTeri Shaferdirector of [email protected]

Teresa ScanlonMembership [email protected]

eDucatIoNMelissa carterdirector of [email protected]

FlorIDa emr graNt ProJectglenn FielderProject [email protected]

other ImPortaNt coNtactsamerIcaN meDIcal assocIatIoN515 n. State Streetchicago, il 60610800-621-8335www.ama-assn.org

ceNter For meDIcare aND meDIcaID serVIces7500 Security BoulevardBaltimore, Md 212441-800-Medicarewww.cms.hhs.gov

Dea regIstratIoN uNIt1-800-882-9539www.deadiversion.usdoj.gov.

Drug eNForcemeNt aDmINIstratIoN (Dea)drug enforcement administrationMailstop: aeS8701 Morrissette drive, Springfield, Va 22152202-307-1000www.usdoj.gov/dea/contactinfo.htm

FlorIDa aDmINIstratIVe coDes oNlINewww.flrules.org

FlorIDa boarD oF meDIcINedepartment of Health, Florida Board of Medicine4052 Bald cypress Way, Bin # co3, Tallahassee, Fl 32300-1753850-245-4131www.doh.state.fl.us/mqa/medical

FlorIDa boarD oF osteoPathIc meDIcINe4052 Bald cypress Way, Bin # c01 Tallahassee, Fl 32399 -1701850-485-0595www.doh.state.fl.us/mqa/osteopath/os_home.html

ImPortaNtcoNtactsbeloW are some helPful contacts every physician practicing in florida should have.


FlorIDa DePartmeNt oF busINess aND ProFessIoNal regulatIoN1940 north Monroe StreetTallahassee Fl 32399850-487-1395http://www.myflorida.com/dbpr/SSnnotice.html

FlorIDa statutes oNlINewww.leg.state.fl.us/statutes/

FooD aND Drug aDmINIstratIoN5600 Fishers lanerockville, Md 20857-00011-888-inFo-Fda (1-888-463-6332)www.fda.gov

INterVeNtIoN ProJect For NursesP.o. Box 41930Jacksonville Beach, Fl 32240904-270-1633www.ipnfl.org

NeurologIcal INJurY comPeNsatIoN assocIatIoN (NIca)P.o. Box 14567Tallahassee, Fl 32317-4567850-488-8191www.nica.com

ProFessIoNals resource NetworkP.o. Box 1020 Fernandina Beach, Fl 32035-10201-800-888-8Prn (8776)www.flprn.org

Fma PreFerreD VeNDorsbaNk oF amerIcaFMa Member Benefits: no annual Fee american express, Mastercard and ViSa credit card programs.contact: Pete Ferrieremail: [email protected] site: www.bankofamerica.comPhone: 302-432-1369

FIrst ProFessIoNal INsuraNce comPaNY (FPIc)FMa Member Benefits: Professional liability insurance at a 5% discount.contact: angie nykampemail: [email protected] site: www.firstprofessionals.comPhone: 800-741-3742, ext. 3071

graDuate eDucatIoN FouNDatIoNFMa Member Benefits: online cMe programs at dis-counted price, with over 125 lectures covering 18 medical topics.contact: Michelle cassidyemail: [email protected] site: www.cmelectures.orgPhone: 877-263-5400

I.c. sYstemFMa Member Benefits: collections assistance for medical practices at a discounted price.contact: Jim rosevearemail: [email protected] site: www.icsystem.comPhone: 800-279-6711, ext. 1280

meDrecoVerFMa Member Benefits: audit and claim reviews to assist physicians in identifying and collecting on potentially un-derpaid health insurance claims.contact: Jonathan gaddemail: [email protected] site: www.medrecover.comPhone: 800-355-0466

mercer aDVIsorsFMa Member Benefits: Fee-based financial consulting firm providing investment opportunities for medical profes-sionals.contact: Howard rochestieemail: [email protected] site: www.merceradvisors.comPhone: 800-258-1559

oPtacomP (formerly CompOptions)FMa Member Benefits: Workers’ compensation insurance program with an annual dividend paid to participating physicians.contact: Jo anne Tatumemail: [email protected] site: www.optacomp.comPhone: 904-828-7900

PhYsIcIaNs aDVaNtageFMa Member Benefits: caPS+ Program (comprehensive asset Protection Solutions), which provides solutions for growth, tax reduction and defense.contact: Shane Huntemail: [email protected] site: www.physiciansadvantage.comPhone: 866-362-3627

regIoNs baNkFMa Member Benefits: discounts on business and per-sonal loans, as well as mortgage lending.contact: Mike Wilsonemail: [email protected] site: www.regions.comPhone: 850-523-4619

staNDarD regIsterFMa Member Benefits: Secured medical prescription pads or electronic prescriptions at discounted pricing and in compliance with required cMS approved security features.contact: John Hardenemail: [email protected] site: www.standardregister.comPhone: 877-287-1585

fma magazine fall, 2008

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