Welcome to the FMCH Tuesday Talk. Please continue to send us your announcements, celebrations, and accomplishments to FMCHtuesdaytalk@umassmed.edu.
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Table of Contents
Upcoming Events
Focus of the Week - Research
Announcements
Faculty Presentations/Publications
Department Member Recognition
Frankly Speaking Podcast
Clinical Services Spotlight
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Upcoming Events
Faculty Development Workshop
Thursday, February 24th, 7:30 - 8:30 am. "Building Speed Buttons".
Please RSVP to Jennifer Masoud at jennifer.masoud@umassmemorial.org
Faculty Development Workshop
Thursday, March 3rd, 7:30 - 8:30 am. "Optimizing Epic During a Live Patient Encounter".
Please RSVP to Jennifer Masoud at jennifer.masoud@umassmemorial.org
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Focus of the Week - Research
Social Support, Diabetes Distress, and A1C:
Using Causal Mediation to Untangle a Causal Web
Socially based interventions like group-administered diabetes self-management (DSM) education can affect real health outcomes like A1C. However, the pathways by which such interventions shape health outcomes may be complex, multiple, contingent, or difficult to measure. This work in progress uses data from a recent randomized control trial testing the effectiveness of group-based in-person versus virtual world diabetes self-management education for improving disease management amongst minority women with uncontrolled type 2 diabetes to untangle the relationship between social support, diabetes distress, and actual A1C. We illustrate how new tools for identifying causal mediation, which are becoming increasingly popular in biostatistics and the social sciences, can be used to parse and estimate specific pathways by which a complex, socially-based intervention like this one exerts causal effects. Matthew Reichert (mreichert@g.harvard.edu) is a Ph.D. candidate in the Department of Government at Harvard University. His research asks about the origins national identity in Eurasia, and about the ways that identity shapes health behaviors in the United States. His co-authored work has been published in The Lancet Digital Health, The Annals of Family Medicine, Politics and Society, and elsewhere. You can read more about his research and teaching at www.matthewreichert.com.
Research Ethics Meets the New Marketplace
As in-person shopping returns, imagine that you enter a clothing store to refresh your wardrobe. You pick out several shirts and two jackets to try on. The helpful salesperson brings you several more, pointing out their special features. After spending a half hour in the store, you don’t purchase anything. When you leave the store, you are handed a $300 bill for the salesperson’s time and the store’s expense in restocking the garments. This is a joke, right?
No Laughing Matter
A similar experience was not a joke for John Mathna, a 58-year-old man from Chattanooga, Tennessee, who contacted a Mayo Clinic doctor to find out about a clinical trial for which he might be eligible. According to an article in Axios, by reporter Bob Herman, Mathna has a brachial plexus avulsion injury (nerve damage at the point of connection to the spinal cord) and suffers severe chronic pain. The Mayo trial is investigating whether electrical stimulation could help ease the pain in injuries like his. He reached a Mayo doc and had a video call that lasted about 20 to 30 minutes. Mathna talked about the study with his wife and decided not to participate.
Imagine his surprise when he got a bill for $476 from the Mayo Clinic. And a further surprise when Cigna, his insurer, reviewed the bill and said that the consultation was out-of-network and not covered at all. Mathna says that he submitted personal and insurance information before the call but was never advised that he would be billed for anything. This was, after all, not a call about treatment or care but about participating in a clinical trial. He was being charged for the investigator’s time in seeking to recruit him to a study.
The Mayo Clinic’s response to the Axios reporter’s inquiries was the standard, “No comment on specific patient circumstances.” But, it added, “participation in studies are [sic] handled differently from clinical appointments or consultations.”
That comment led us to ask: Even if this was a solitary incident (and we have not identified others), what does it say about the difference between asking about participation in clinical trials and asking about treatment? Has research ethics begun to follow the money and charge prospective subjects just for finding out about a trial? Does the “out-of-network” insurance denial mean that only in-network participants are eligible for clinical trials that involve some treatment expenses? Has the effort to reduce disincentives to enroll in trials succumbed to bottom-line considerations?
Ethical Considerations in Research Ethics
Starting with the Nazi abuses, and the revelations about unethical studies in the United States, research ethics has been a major field of study. Among the many articles published in the past 75 years, there are dozens about incentives to prospective subjects–when, how much, and what kind are appropriate. The kinds of costs that patients are expected to pay for the care included in the trial is another topic. Yet to our knowledge, there are no articles that consider the Mayo Clinic case: expecting a prospective subject to pay for learning about the study before deciding whether to participate or not.
This case might (hopefully) be an anomaly. But it is also possible that it is a sign of broader trends in health care. Health care is big business, and big business operates on different moral grounds than service to individuals in distress. Costs must be recovered in some way; the prospective subject has taken the investigator’s time and expertise but has declined to enroll. That cost must be recovered, and the prospective research volunteer, from a business point of view, is the logical person to bill. Since the inquisitive person has insurance, it is not going to be their problem. A billable hour is billable hour no matter what the reason for taking the doctor’s time. While this way of thinking may not be widespread yet, it could become more common. The federal No Surprises Act of 2020, in effect since January 1, 2022, is a bipartisan effort to protect consumers from just such unjustified costs in out-of-network care. It does not mention research studies. Considering the research participant as a “partner” rather than a “subject’ is another trend that, while based on admirable goals, may lead to expectations that partners share not only the experience but also the costs. The early HIV/AIDS studies of the 1980s pioneered including prospective subjects, mainly gay men, in trial organization and outreach. So far, the discussion has focused on involving patients in aspects of the study, including compensation. But it’s not a big leap to involving them in bearing the costs of the study. Including recruitment. Being billed for asking for information about clinical studies can have a negative impact on the person’s financial and credit status. Mr. Mathna’s bill, which he refused to pay, was sent to a collection agency before Mayo Clinic finally withdrew it. Studies of bankruptcy point to health care costs as a leading factor. Adding another problem to the already tenuous financial position of many people with costly chronic conditions is a very bad thing.
Finally, many research studies, particularly those addressing difficult conditions like dementia or chronic pain, appeal to people who believe or become convinced that participating in a study will help them personally. That may happen but it is not the primary goal of studies, which is to gain knowledge that can lead to better care. Believing that a study is the path to cure for themselves and knowing that slots in a study are limited may lead some people to pay an entry fee. Or they may want to please the investigator, who may be someone they know and trust, making it hard to say no to a bill that has nothing to do with their care. Subjects or partners make a gift of their time and their bodies to allow knowledge to advance. Charging a fee just to find out the basics of a trial is an egregious violation of that partnership.
Human Subjects Research
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Studies involving human subjects typically require review by the Institutional Review Board (IRB). If you are unsure whether your study requires review, contact the UMMS IRB for a determination. Information about the IRB and how to submit applications is available at the following link: https://umassmed.edu/ccts/irb/.
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Our department requires that all IRB applications be submitted for internal review prior to their submission to the IRB. You can find information on the Department’s policies and procedures for review and where to go for questions about your application here. https://umassmed.edu/fmch/research/irb/. This also include applications that are being submitted by a medical student or resident that you’re working with and the hosting department is FMCH.
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All members of the research team involved in the design, conduct, or reporting of human subjects research must complete training. Online training is provided through the Collaborative Institutional Training Initiative (CITI) human subjects training program. Information about the CITI exam and links to training modules are available here: https://umassmed.edu/ccts/irb/CITI-GCP/.
- CITI training must be renewed every three years. We urge all potential research team members to begin CITI training well before submitting an IRB application to avoid delays in approval of your application.
Research Support
Trying to Keep Up with the Literature?
The department pulls together the tables of contents (TOCs) for about 15 medical journals and distributes this bundle monthly to a select listserve that people can easily sign up for. The TOCs include 4-5 FM journals, JAMA, NEJM, AJPH, Health Affairs, Medical Care, JGIM, Am J Prev Med; etc. – lots of great articles that can easily be accessed through links within the bundle. We are also open to adding more journals if there’s an interest expressed! Take a look at what's been posted in the past several months by going to the department's web pages under the section on Research. You will see a tab in the left-hand margin for these TOC bundles that we post monthly: https://www.umassmed.edu/fmch/research/journal-table-of-contents/. Id you would like to be on the distribution list, please send an email to Judy Savageau (judith.savageau@umassmed.edu).
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Announcements
We are seeking nominations for the Putterman Visiting Professor for 2022. The Professorship honors the memory of faculty member Steven Putterman, MD, who died in 1999. Steve was a gifted physician who worked on many fronts to improve health care and education, especially health care for vulnerable populations.
Areas of interest include when considering a potential visiting professor include:
- Addictions Medicine/Research
- Promoting Real Change in Health Care Systems
- Global Health Care and Education
- Health Equity/Reducing Health Disparities
- Novel models of family medicine education, etc.
- LGBTQ + Health
- Other suggestions?
Please send your nomination(s) of potential speakers directly by completing this survey for review by the Leadership Team no later than February 28th.
100 Million Mouths Campaign as part of the work of the Center for Integration of Primary Care and Oral Health, a joint venture between Harvard Medical/Dental School and our UMMS Department of Family Medicine and Community Health.
We have selected nine new state oral health education champions to add to our current five state champions in year 2. Work will be ongoing this year to assess the efficacy of Champions engaging health schools in these 14 states to produce graduates of primary care residencies and medical and nursing schools who have improved their knowledge, skill, and attitude around oral health.
SAVE THE DATE! March 11th at 10:00am Research Meeting Guest Presenter
Please join the FMCH Research Meeting on March 11th at 10:00am for a special guest presentation on "Mediator and moderator analysis for the Women in Control 2.0 virtual world diabetes group visits clinical trial". Our guest presenter will be Matthew Reichert, PhD-Candidate, Harvard University. Matt is a health equity and social science researcher who will present findings from his innovative approach to mediator/moderator analysis of clinical trial data. It will be a great learning experience for all - no prior research experience required. Look forward to seeing you on March 11th.
Passcode: 746997
SAVE THE DATE! March 18th at 12:00pm Research Meeting Guest Presenter
Please join the FMCH Research Meeting on March 18th at 12:00pm for a special guest presentation on "Addressing Social Determinants of Health: The Promise of Integrated Intervention Models". Our guest presenter will be Alison Karasz, PhD, Albert Einstein College of Medicine. Dr. Karasz is an expert in the areas of culture, health, and mental health. She has conducted numerous NIH-funded studies with South Asian immigrants in New York and in South Asia. Currently, her research focuses on the development of structural interventions to address social determinants of health. It will be a great learning experience for all. Look forward to seeing you on March 18th.
https://umassmed.zoom.us/j/92137290142?pwd=YUc5RStnV0piUWtCNVU4MEI2OWxDdz09
Passcode: 746997
Spring Department of Family Medicine and Community Health Retreat:
Vision 2030 - The Next Chapter for FMCH
Save the Date: Friday - May 20, 2022
8:00am-6:00pm
Plan for in-person retreat at South Street Campus, Shrewsbury
(with virtual event as back-up)
Volunteers needed for WFCC
Worcester Free Care Collaborative is always in need of volunteer family physicians and family nurse practitioners to support its mission to address needs of the uninsured and underinsured of our community. We also need help with pediatric vaccine program management. You fill find it fulfilling to address needs for vulnerable patients and work with highly motivated student volunteers. Contact student leader Tyler Healy (tyler.healy@umassmed.edu) for needs across the 6 programs or Danielle Heims-Waldron (danielle.heimswaldron@umassmed.edu) for Monday night’s Epworth program.
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Faculty Presentations/Publications
Lisa Morris, director of cross cultural initiatives at Commonwealth Medicine facilitated a national panel on the professionalization of healthcare interpreters for the Certification Commission for Healthcare Interpreters on February 16th. You can review here: https://youtu.be/MkjW-QWDtnI.
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Department Member Recognition
Hugh Silk, MD, MPH, FAAFP, was a Panelist on February 15th at the Transforming Veteran Oral Health - Illuminating Equity and Sustaining Impact Conference. The conference was hosted by the American Institute of Dental Public Health on the topic of Advancing Medical-Dental Integration for Veterans and was moderated by Assistant Surgeon General, Tim Ricks, DMD, including an interprofessional panel.
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Frankly Speaking Podcast
A weekly Podcast series covering newsworthy topics in primary care medicine.
Please join us for an overview: The FDA's recent emergency use authorization (EUA) for oral agents to treat COVID-19 means that primary care provider (PDPs) will be on the frontline of treating patients with COVID-19. Therefore, PCPs must understand who is eligible for such treatments and how to prescribe them We will discuss the results of the recent FDA EUA for Pfizer's Paxlovid and Merck's molnupiravir antiviral agents and give you the information you need to confidently prescribe them . Guest: Robert a. Baldor, MD, FAAFP, presents: "Oral Anti-COVID-19 Medications-a Game Changer?". - Frankly Speaking Ep 263.
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Clinical Services Spotlight: |
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COVID-19 UPDATES
COVID Updates- US and Global
- President Biden has extended the National COVID Emergency Powers Edict.
- Many countries are ending COVID restrictions including mask requirements.
COVID Update MA
- Current confirmed cases, 1,529,953.
- The 7-day percent positivity rate is 2.74%.
- There are 719 hospitalizations with 139 in the ICU and 71 intubated.
- Total confirmed deaths 22,408.
MA Mask Requirements
- A fully vaccinated individual should wear a mask indoors if you have a weakened immune system, or if you are at increased risk for severe disease because of your age or an underlying medical condition, or if someone in your household has a weakened immune system, is at increased risk for severe disease or is unvaccinated.
- Masks are required on public and private transportation vehicles, healthcare facilities, congregate care facilities, Emergency Shelter programs, Corrections, Home health care facilities, and healthcare and day service programs.
COVID Update UMMMC
- The current confirmed case count in the inpatient setting is 85.
- Of those, 65% are fully vaccinated.
- Of the ICU patients with COVID, 8/13 (62%) are fully vaccinated.
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The 7-day positivity rate is 5.5%.
ED and ambulatory providers for providing therapy to patients:
The patient is diagnosed with COVID by an ED provider or an Ambulatory Provider.
Two options for outpatient treatment (Options 1 and 2 Below):
- The provider can create a referral order to the COVID Treatment Center (CTC) – which already exists in EPIC (see below). The CTC team will review all referral orders and charts, reach out to the patient and recommend a course of treatment if appropriate depending upon the clinical situation. This could include infusion or PO treatments. In the current state – depending upon availability – PO treatment could be picked up at the CTC, or a Rx sent to a local pharmacy.
- ED or ambulatory provider – if they feel confident and comfortable prescribing therapy, could write a prescription to be picked up at a local pharmacy.
Scheduling instructions in the AMB REF TO COVID Treatment Center
This is a referral for treatment with the following COVID Therapeutic Agents
- Monoclonal Antibody (Sotrovimab) – Ideally within 7 days of symptoms onset (can be as much as 10).
- Oral anti-viral Agents (Paxlovid and Molnupiravir) – Pt should be within 5 days of symptom onset
- Remdesivir 3-day course - Pt should be within 7 days of symptom onset.
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Providers can prescribe oral Paxlovid directly to the following Walgreens locations in Worcester or can request the same from our treatment center by completing the above referral order. The Treatment Center can also determine the best therapy option after reviewing labs, drug-drug interactions, and days from symptom onset.
- Walgreens, 320 Park Avenue, Worcester, MA (508) 767-1732
- Walgreens, 220 Grafton Street, Worcester, MA (508) 755-4196
Patients should be within 5 days from symptom onset to be eligible for the oral Paxlovid. Please review the drug-drug interactions and the exclusion criteria (contraindicated for use in patients with severe renal impairment). Please contact Sandeep Jubbal by email (Sandeep.Jubbal@umassmemorial.org), Epic Secure Chat, or Pager #1275 if you have any questions.
Congratulations to the Inpatient Family Medicine Service for reaching a milestone of their lowest readmission rate of all time! This is well below the fiscal year goal of 18%. Many thanks to the leader of the A3 project, Dr. Patricia Seymour.
Team members:
- Jason Numbers
- Iftikhar Khan
- Henry Delrosario
- Pankaj Ksheersagar
- Mohammed Alhabbal
- Tracy O’Donnell
- Anne Zetteksumner
- Lori Peasley
- Lyndsey Stadtmueller,
- Josephine Fowler,
- Erika Zimmons,
- Laurel Banach,
- Katherine Price
- Dr. Lisetta Shah
- Bridget Yang
- Maxwell Sharkey
Burnout Rates 2021*
Twenty-Nine physician specialties were rated for burnout in 2021. Emergency Medicine was ranked number 1 with 60 percent of physicians reporting burnout. The lowest burnout rate was seen for public health and preventive medicine. The top 10 are below:
- Emergency Medicine ( 60%)
- Critical Care (56%)
- Family Medicine and Infectious Disease (51%)
- Physical Medicine and Rehab and Diabetes and Endocrinology (50%)
- Radiology and Pediatrics (49%)
- Pulmonary, gastroenterology, Internal Medicine and Urology (48%)
*(Source: Becker's Hospital review)
Keywords and phrases to think about: wellness, health integration, healthy mind- healthy body, I can do this, grateful, energy, I am strong, we win.
The next wellness meeting is Friday, February 25, from 12:00 - 1:00 pm.
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Wellness Resources
The Caring for the Caregiver Program provides resources such as the Caregiver Support Line (508-334-HELP) and The Employee Assistance Program (EAP) which offers a variety of services and supports (including virtual peer support and wellness tips. EAP can be accessed at 866-263-3525, or www.LiveandWorkWell.com, [company code UmassMemorial]. More information is available on the Caring for the Caregiver page.
Wellness
You are invited to become a member of the Department Wellness Committee. Key goals for this year include improving the efficiency of use with the Electronic Health Record. Watch your email for future training sessions.
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Yoga Classes with Dr. Liz Erban
New Yoga Link!
Our Yoga class hit the 1 year anniversary - which in zoomland means we need a new link. Happy anniversary yogis and much gratitude to our fearless leader, Liz!
Also, a great time to join, new members always welcome. Start your mid week with some relaxing yoga!
Please join department members for early morning gentle yoga, Wednesday mornings 6:30am via Zoom.
Join Zoom Meeting ID: 923 9393 3653 Passcode: 764113
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Zumba with Dr. Anna Zheng
Thursdays 6:15pm: In-person or ZOOM
Please join department members Thursday evenings at 6:15pm**(30 Anna Street: tall & spacious indoor location) and get moving with Zumba. Please note details and any changes via webpage: http://annazheng.zumba.com/. ZOOM still possible for all classes.
Much appreciation to Dr. Anna Zheng for hosting these outstanding classes. New to the class? Please email Dr. Zheng at ZumbawithAnnaZheng@gmail.com to register, complete brief health screen if it's your first class and the ZOOM link.
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