Dallas Medical Journal

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Medical Education

I n t h i s i s s u e :

Resident Spotlight - Michael Lee, MD

ICD-10 Implementation - Are you ready for the transition?

8 4 • M a y 2 0 1 3 • D a l l a s M e d i c a l J o u r n a l

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A Texas Original

submit letters to the editor to [email protected]

87 President’s Page Leading Your Own Life

92 Photos f rom First Tuesday

93 ICD-10 Implementation Information

94 Legis lat ive Update Tracy Casto

97 Medical Student Debt Facts and Repayment Options

98 Resident Spotl ight Michael Lee, MD

101 Photos f rom Spring Events Residents/Young Physicians Happy Hour/ Retired Physicians Club

103 TMLT Pol icy Changes William Malamon, ABC

About the Cover PhotoLes Secrest, MD, and State Rep. Kenneth Sheets (R-Dallas) discuss healthcare legislation outside the House chamber in Austin on the First Tuesday in April.

Dallas County Medical SocietyPO Box 4680, Dallas, TX 75208-0680Phone: 214-948-3622, FAX: 214-946-5805www.dallas-cms.orgEmail: [email protected]

DCMS Communications CommitteeRoger S. Khetan, MD ............................................. Cha i r Gene Beisert, MDSuzanne Corrigan, MDSeemal R. Desai, MD Gordon Green, MDRobert Gross, MD Steven R. Hays, MDC. Turner Lewis III, MDDavid Scott Miller, MDClifford Moy, MD

DCMS Board of DirectorsCynthia Sherry, MD ......................................... PresidentJeffrey E. Janis, MD .................................President-ElectJim Walton, DO ...............................Secretary/TreasurerRichard W. Snyder II, MD ........ Immediate Past PresidentMark A. Casanova, MDWendy M. Chung, MDChristopher A. Hebert, MDMichelle Ho, MDTodd A. Pollock, MDKim M. Rice, MDHampton Richards, MDErin Roe, MDChristian Royer, MD

DCMS StaffMichael J. Darrouzet .................. Chief Executive OfficerLauren N. Cowling ............................... Managing EditorSteven Harrell ............................. Asst. Managing EditorBearett Wolverton ...............................Advertising Sales

Articles represent the opinions of the authors and do not necessarily reflect the official policy of the Dallas County Medical Society or the institution with which the author is affiliated. Advertisements do not imply sponsorship by or endorsement of DCMS. ©2013 DCMS

According to Tex. Gov’t. Code Ann. §305.027, all articles in Dallas Medical Journal that mention DCMS’ stance on state legislation are defined as “legislative advertising.” The law requires disclosure of the name and address of the person who contracts with the printer to publish legislative advertising in the DMJ: Michael J. Darrouzet, Executive Vice President/CEO, DCMS, PO Box 4680, Dallas, TX 75208-0680.

Dallas Medical Journal(ISSN 0011-586X) is published monthly by the Dallas County Medical Society, 140 E. 12th St, Dallas, TX 75203.

Subscription rates$12 per year for members; $36, nonmembers; $50, overseas. Periodicals postage paid at Dallas, TX 75260.

PostmasterSend address changes to:Dallas Medical Journal, PO Box 4680 Dallas, TX 75208-0680.

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Correction: In April, we credited Diane K. Shaw as the author of the Legal FAQ on page 79 concerning medical record retention, release and storage. In fact, Susan Murphy wrote this article, in addition to the adjacent article on page 78.


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Lead your life, don’t simply live it! This advice is paraphrased from Sheryl Sandberg, COO of Facebook, in her recent book, “Lean In.”

The phrase captures an element of truth relevant to physicians. Physicians are burdened by red tape and hassle factors related to practicing medicine in today’s tedious environment. Add to this the recurring payment cutbacks and the reactive

continuous pressures to increase daily productivity, and we have a recipe for widespread burnout across the medical specialties. As a consequence of living life with our feet squarely planted in the present, we, as a group, have become oriented toward evaluating our day as successful based on whether we’ve been able to work our way through a long list of tasks. As a result, we are in danger of losing sight of any higher purpose or life goal we might once have felt was worthy of a sustained effort. We have become entrenched in the details of the present and in putting out brush fires that require our attention, and less focused on the pursuit of endeavors beyond those that lead to the immediate gratification of crossing off a list. This means, in essence, that we live our life instead of lead our life.

Our task-oriented lifestyle is ingrained and perpetuated by the very structures upon which our medical and healthcare systems are built, and this constant barrage of urgent tasks and bureaucratic compliance requirements puts us at high risk for burnout. Burnout is characterized by a loss of enthusiasm for work (emotional exhaustion), feelings of cynicism (depersonalization), and a low sense of personal accomplishment. It has been theorized that burnout in physicians erodes professionalism, degrades quality of care, increases medical errors, and promotes early departure from the healing profession. Burnout also has been linked to negative personal consequences, including divorce, substance abuse and suicide.

A recent study1 shows that burnout is more common among physicians than among other US workers. Physicians at the front line of care seem to be at greatest risk. The study confirms what we have long suspected — that physicians work longer hours and have greater struggles with work-life integration than do other US workers. According to the study, burnout can be traced to several sources, including an excessive workload, loss of autonomy, inefficiency due to excessive administrative burdens, a decline in the sense of meaning that physicians derive from work, and difficulty integrating personal and professional lives.

In addressing burnout, most techniques center on promoting greater self-awareness and a greater sense of meaning in life. Although such interventions are promising, they require investment of time and effort, which already are in short supply for physicians.

This proposal is not limited to the psychosocial world; it also permeates the academic business and leadership realms. For example, Clayton Christenson, professor of business administration at Harvard Business School and author of “Innovators Dilemma,” admonishes in a recent article, “Don’t reserve your best business thinking for your career.” In his article “How will you measure your life?”2 he advises readers also to use their best thinking to design their life plan. In his class at HBS, he teaches about business models of good management from the perspective of stimulating innovation and growth. At the end of his course, he asks students to turn that theoretical lens upon their own lives and to ask themselves questions such as, “How can I be happy in my career?” “How can I be sure that my family life is an enduring source of happiness?” Finally, he says, “Think about a metric by which you would like your life judged, and make a resolution to live every day so that in the end, your life will be judged a success.” It is clear that Christenson is focused on the importance of leading one’s own life, not simply living it, in a meaningful and purposeful way.

To take the point one step further, John Maxwell, another Harvard Business School professor and widely read author, declares similarly in his article “To Lead Others, First Lead Yourself.“3 He says, “Effectively leading your own life is one of the most important things you’ll ever do as a leader. If you don’t look at yourself realistically, you will never understand where your personal difficulties are coming from.”

Physicians could benefit from taking this advice from the business world. Doing so could help relieve symptoms of burnout and re-establish a higher meaning in our lives; furthermore, it could improve patient care. We as a group need to “lean in,” as the Facebook COO puts it, and be more aggressive about retaking control of our lives. We should not allow ourselves to be so consumed by our list of daily tasks that we overlook the healthy value of leading life with a higher purpose.

Cynthia Sherry, MD

Leading Your Own Life... to avoid losing sight of our higher purpose as physicians and people.

1Shanafelt T, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012 Aug 20; 1-9.2Christenson C. “How Will You Measure Your Life?” (Harvard Business Review May 15, 2012).3Maxwell J. “To Lead Others, First Lead Yourself,” accessed on-line Jan. 13, 2013, www.sermoncentral.com.

8 8 • 8 8 • M a y 2 0 1 3 • D a l l a s M e d i c a l J o u r n a l

Power Up Your Practice. Contact the professionals behind the professionals.

Accountant (CPA) / Tax ServicesPaula Allgood, CPA……Beaird Harris & Co, P.C.972.503.1040……[email protected]

Lori A. Eads, CPA……Bland, Garvey, P.C.972.231.2503……[email protected]

Design / Build Medical & Dental ContractorGrady Herzog……Structures & Interiors Inc.817.329.4241……[email protected]

Electronic Medical RecordsLeslie Warren……EMR Advisory Group972.898.5671……[email protected]

Employee BenefitsAmy Rickman……Lockton Dunning Benefits940.384.2720……[email protected]

Financing / BankingGary West……BB&T (Branch Banking & Trust)469.791.4502……[email protected]

Healthcare Interior DesignerLaura Ginsberg……Medical Space Design, Inc.972.566.6771……[email protected]

Legal ServicesMichael H. Saks……Wright, Ginsberg, Brusilow, PC972.788.1600……[email protected]

W. Darrell Armer*……Looper, Reed & McGraw, PC469.320.6021……[email protected]*Board Certified-Health Law by The Texas Board of Legal Specialization

Marketing / Public RelationsBarbara Steckler……Concepts in Medical Marketing972.490.7636……[email protected]

Medical Malpractice / Commercial InsuranceJames Patterson, CIC, AAI……Agapé Healthcare Partners817.329.4200……[email protected]

OSHA ComplianceJessica James, LLC 469.360.1367……[email protected]

Personnel RecruitmentJan Harris……J. Harris Co. Personnel Services Inc.214.369.9545……[email protected]

Practice Management / Billing / ConsultingDavid Loomis……The Health Group972.792.5700……[email protected]

Real Estate (Healthcare)M.W. (Hugh) Resnick……Pizel & Assoc. Commercial Real Estate 972.404.0008……[email protected]

Telecommunications / IT / Computer ServicesCharlie Hubbard, PMP……HUBCO Communications, Inc.469.293.3081……[email protected]

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They went. They fought. They triumphed.

This Memorial Day, honor the heroes who fought for freedom and laid down their lives. Whether a family member, of�ice staff, or colleague, make a donation in their honor to DCMS Foundation at www.active.com/donate/dcmsfoundation.


a c a rd i o l o g i s t i n C o pp e l l , a radio logist in Richardson, an onco log i s t i n Oak C l i f f , a surgeon on Swiss Avenue, an in fec t ious d i sease spec ia l i s t in I r v ing, a hosp itali st in H ighlan d Park , an anesthesiologist in Addison, a g e r i a t r i c p h y s i c i a n i n G r a n d P r a i r i e , a m ic rob io log i s t i n Mesqu i t e , an endocr ino log i s t in East Dal las , a gyneco log ist in Gar land, a laboratory spec ia l i s t in Lancaster, a psych iat r ist i n Su nnyva l e , a d e r m a t o l o g i s t i n D u n c a n v i l l e ,a fami ly doctor in Farmers Branch , a rheumatologist in Rowlett , a p las t i c surgeon in P lano, an allergist in the Arts District, a pediatric Hematologist in Preston Hollow, or a uro logis t in Univers i ty Park,

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In addition to scheduled meetings, DCMS members talk with lawmakers as they leave the House chambers. State Rep. Kenneth Sheets (R-Dallas) meets with Drs. Sue Bornstein, Lee Ann Pearse, Deborah Fuller, Steven Hays, Sarah Helfand, and Les Secrest.

Drs. Lee Ann Pearse and Steven Hays buttonhole State Rep. Stefani Carter (R-Dallas) outside the House chambers.

First Tuesdaysat the Capitol April 2, 2013

During the third First Tuesday of the 2013 legislative session, more than 300 TMA physicians, medical students and TMA Alliance members met with legislators to encourage laws that benefit medicine and patients across the state.

Still smiling and ready for their next appointment— Drs. Deborah Fuller, Lee Ann Pearse, Sarah Hefland,

and Dee Whittlesey

Drs. Cliff Moy, Les Secrest, Brett Stauffer, Steven Hays, and Martin Giesecke

State Rep. Dan Branch (R-Dallas) talks with Sue Bornstein, MD, about her support of funding for preceptorships.


On Oct. 1, 2014, the data foundation of the US healthcare system will undergo a major transformation. All healthcare providers and payors will transition from the decades-old Ninth Edition of the International Classification of Diseases (ICD-9) set of diagnosis and inpatient procedure codes to the 10th Edition of those code sets — ICD-10. ICD-10 allows for greater specificity and detail in describing a patient’s diagnosis and in classifying inpatient procedures, so coding can more thoroughly represent the patient’s condition and diagnostic needs.

In December, TMA joined the AMA and other state medical societies to ask the Centers for Medicare & Medicaid Services to stop the switch from ICD-9 to ICD-10, and work with all interested parties to find a better replacement for ICD-9. They said ICD-10 “will create significant burdens on the practice of medicine, with no direct benefit to individual patient care, and will compete with other costly transitions associated with quality and health IT reporting programs.”

In February, CMS executives rejected that request and made Oct. 1, 2014, the official implementation date.

This transition will have a major impact on anyone who uses healthcare information that contains a diagnosis and/or inpatient procedure code. The ICD-9 coding system has about 14,000 codes; ICD-10 will include nearly 70,000. The ICD-10 code set is so much larger because it includes more characters to designate the differences between left and right side, initial encounter and subsequent encounter, and other clinical information. As an example, ICD-10 has 480 codes for variations of a fractured patella.

The TMA has estimated that ICD-10 implementation will cost about $83,000 per doctor for a three-physician practice and $28,500 per doctor for a 10-physician practice.

TMA recommends that practices plan for the transition to a new code set, both financially and operationally. Making the switch to a new coding system will be the most challenging initiative since the inception of medical coding.

To ease the transition, TMA is offering an “ICD-10 Essentials” seminar during which TMA’s coding experts help physicians and their staffs understand the foundation and background of ICD-10, and learn the documentation requirements for increased code specificity. The seminar will be from 1–4 p.m. June 3 in Dallas and costs $129 for TMA members or their staff. Registration is available at www.texmed.org/ICD10now.

TMA is offering discounts on GEMs software, a downloadable tool created to quickly identify which ICD-10 codes replace the ICD-9 codes physicians use every day. For a one-time purchase price with no ongoing subscription fees, physicians and office staff can:

• Search by code, code description or key words.• Create and save a “favorites” list of common codes.• Develop and print quick reference lists. For more information, including videos, software

links, press releases, timelines, and practice checklists, visit www.texmed.org/ICD10.

Are you ready for the transition to ICD-10?

This information is compiled from information made available by the Texas Medical Association, www.texmed.org/ICD10, and the CMS ICD-10 Fact Sheet, www.cms.org/medicare/coding/icd10.


Legislative Updatecompiled by Tracy Casto, director of public affairs and advocacy

THE BUDGETThe House and the Senate passed their budget bills

earlier in the session than usual, even after considering 267 amendments. Senate Bill 1 is in a 10-member conference committee to work out details. Members are not allowed to change the bottom line, so for every amount added, they must find a corresponding cut.

The budget bills for 2014–2015 provide critical funding to expand graduate medical education and restore the Physician Education Loan Repayment Program. Increased funding also was allocated to the Family Medicine Residency Program and the Joint Admission Medical Program.

The House and Senate versions are close. The House budget has $193.8 billion in state and federal funding, including $93.5 billion in general revenue; the Senate budget has nearly $195.5 billion in state and federal money, and $94.1 billion in state funds.

Both bills continue to fund the Women’s Health Program and create funding for the Department of State Health Services primary care expansion. The program provides primary care for uninsured women 18 years or older, and screenings for diabetes, heart disease and cancer. SB 1 proposes an additional $100 million to women’s health services, including family planning. This is in addition to the $114 million starting point. The additional money would fund the Community Primary Care Services Program, which contracts with community health clinics and nonprofit organizations to perform services for poor Texans who do not qualify for other state health programs.

SB 1 also proposes adding more than $230 million toward mental health and substance abuse for expanding education, treatment and housing. Funding would increase spending on community-based mental health and treatment programs; train teachers to identify children at risk of major behavioral health problems; help adults who cycle in and out of state mental hospitals; and spend $4 million to help Texans view mental illness as a physical disease.

LAWMAKERS SEEK “TEXAS SOLUTION”Republicans who want to draw down billions in federal

dollars to expand Medicaid have been trying to find commonalities between Gov. Rick Perry and the Obama administration to come up with a “Texas Solution” to the uninsured crisis.

If Texas spends some $15 billion to expand Medicaid over the next 10 years, the state could receive up to $100 billion from the federal government and insure an additional 2 million people. Local governments and hospitals are putting pressure on state lawmakers to take the federal offer.

The governor can veto any legislation that would expand Medicaid. So far, he has said only that he would accept a no-strings-attached block grant that would allow the state to redesign Medicaid without the intervention of the Obama administration.

Rep. John Zerwas, MD (R-Simonton), has offered HB 3791, which the House Appropriations Committee has approved. The legislation creates a “Texas” solution for covering the working poor in Texas. The bill consists of four key components:

• Structure: First choice for coverage for low-income Texans would depend on the state receiving an unrestricted block grant from the federal government to run Texas’ current Medicaid program.

• Funding streams: If the state cannot obtain a block grant, the Texas Health and Human Services Commission would funnel the money in concert with the Texas Department of Insurance to purchase private health insurance policies for people under 133 percent of federal poverty guidelines. • Payment: The bill includes reforms that Texas can implement concurrently with a block grant, such as cost-sharing, which means Medicaid recipients would pay a percentage of the coinsurance and/or deductible. • Oversight: The bill creates a committee, appointed by state leaders, to oversee program implementation.

Rep. Zerwas said, “This is not expansion of Medicaid. This is creation of a new program that leverages our partnership with the private sector. This is not an entitlement program.” He added, “I understand the political radioactivity surrounding this bill. This would have a profound impact regarding the provision of care ... and ultimately benefit the taxpayers.”

OTHER ISSUESEnd of LifeSB 303/HB 1444 provide legal safe harbors for physicians

involved in end-of-life care. The bills amend the Texas Advance Directives Act to allow patients to make their care preferences known before they need care, and to protect patients from discomfort, pain and suffering due to excessive medical intervention in the dying process. The bills maintain protection against forcing physicians to violate their religious beliefs, moral conscience and professional ethics. In an amendment, the number of days of treatment that can be provided after an ethics decision increases from 14 to 21 days. New language prohibits discrimination in the ethics review process against the disabled, elderly or those with limited financial means; the focus is on the medical appropriateness of the treatment. The Texas Catholic Conference, TMA, Catholic Health Association-Texas, Texas Alliance for Life, and Christian Life Commission support it. The bill passed out of the Senate and now is in House Public Health.

Scope of PracticeSB 406 firmly establishes a “physician-led medical team.”

The legislation is the result of months of discussions among TMA, the Texas Academy of Family Physicians, advanced practice registered nurses, and physician assistants. It establishes a more collaborative, delegated practice that allows members of the healthcare team to practice to their level of education and training. The bill increases the number of APNs a physician can supervise from four to seven. Passed by the Senate and referred to House Public Health for a hearing.

TMA opposes two bills that expand the scope of practice beyond the nonphysician practitioner’s expertise, education and skills. HB 1039 allows physical therapists to treat patients without a physician referral. HB 3183 allows a chiropractor to conduct mental and physical examinations of school bus drivers. The heart, lungs, vision, reflexes, hearing, and mental health all should be evaluated in a prospective school bus driver,

The legislative session continues, with a more collegial atmosphere than in the 2011 session, but major discussions— including a revisit of redistricting — still on deck. Out of the more than 6,000 bills filed, TMA and DCMS are following about 1,100 of them. The 140-day session adjourns on May 31, but Gov. Perry can call 30-day special sessions to consider issues he designates.


and chiropractors do not have the statutory scope of practice or the training to analyze, examine or evaluate such components.

A bill moving through the House and Senate requires healthcare providers in a hospital to wear photo ID badges clearly stating to patients their name, license, level of training/education, and the person’s status as a student, resident or intern if the practitioner doesn’t have a license. Some practitioners with doctoral training refer to themselves as “doctors,” which can mislead patients to think a physician is treating them.

Health Insurance ReformA few bills reduce paperwork tremendously. HB 1032/

SB 644 require the Texas Department of Insurance to design a standard prescription drug prior authorization form applicable across all payers, including Medicaid, the Children’s Health Insurance Program, and workers’ compensation.

SB 1216/HB 1604 require TDI to design a standard request form for prior authorization of healthcare services.

SB 166 allows physician offices to check in patients using the electronic strip on the back of their Texas drivers license.

SB 822 would regulate silent PPOs — companies or networks that sell, lease or share physician discounts without the physician’s knowledge or consent.

Medicaid OIG ReformThe Senate unanimously approved SB 1803, which takes

numerous steps to improve due process, transparency and the expediency of the Office of Inspector General process when a provider is accused of a credible allegation of fraud or Medicaid overpayment. The bill includes a provision relating to the preliminary finding of fraud, defines “credible allegation of fraud,” and requires the OIG to provide detailed information and material on its processes and findings to providers and the public.

The House Human Services Committee approved four bills that are part of TMA’s legislative effort to reduce hassles from the OIG:

HB 1536/SB 785 gives physicians who treat Medicaid patients a right to an administrative hearing when the OIG takes action to recover overpayments of $50,000 or more.

HB 3452 gives physicians and other healthcare providers a right to a contested hearing to dispute unreasonable Medicaid or HMO payments.

HB 2731 aims to reduce administrative hassles in Medicaid HMOs by standardizing credentialing and prior authorization forms, requiring HHSC to more actively oversee HMO contract compliance, and ensuring prompt payment of claims.

HB 3158 requires HHSC to develop and implement one or more Medicaid managed care contracting pilot(s) using a healthcare collaborative.

TaxesHB 1310 by Rep. Angie Button (R-Garland) allows

physicians to deduct vaccine purchase cost from their taxable revenue. This bill is expected to cost the state about $3 million to $4 million annually, not a big part of the larger tax bill. The language has been rolled into the tax franchise bill, HB 500, so we’ll have the bill in two major avenues. HB 1310 is in Calendars.

Patient ProtectionTMA opposes HB 1806, which removes the requirement

that a physician and patient have a face-to-face visit to establish a patient/physician relationship, allowing the relationship to be established by telephone. The TMB would not be able to regulate those situations, and it would allow vendors and others to treat patients without ever seeing them in person. In Calendars.

Texas Medical BoardPassage of SB 1193/HB 2343 could undermine the

beneficial effects of our tort reform victories and interfere with the Texas Medical Board’s and hospital peer review process. The bills require the TMB to notify a physician of a complaint filed with the board, provide a copy of the complaint, and identify who filed the complaint and what physician reviewers are involved.

TMA contends that these bills weaken the medical board and could signal a return to the days when far too many physicians were subjected to civil lawsuits, courtroom proceedings and overly ambitious trial lawyers. SB 1193 could keep good doctors from providing quality peer review of TMB complaints. Any observation that threatens patient safety must be reported in a manner so that the complainant is protected from retaliation. SB 1993 is pending in Senate Jurisprudence.

Public HealthTMA opposes SB 1013, which allows pharmacists to

vaccinate children 7 years of age and older, contending the bill undermines the purpose of medical homes, which are essential for children in this age group. A medical home can ensure children have proper screenings, health evaluations and preventive counseling. Without such health evaluations, problems such as type-2 diabetes, hypothyroidism, hip and spine problems, and depression can go undetected. TMA has offered to work with the bill’s supporters during the interim to determine whether pockets of need exist and how to address them. Pending in Senate Health and Human Services.

The Senate approved SB 63, which allows a minor who is pregnant or is a parent to consent to his or her own immunizations. In House Public Health.

The Senate approved SB 64, which requires licensed childcare facilities to develop and implement an immunization policy for their employees to protect the children in their care from vaccine-preventable diseases. House version is in Public Health.

SB 40/HB 772 changes the state’s immunization registry (ImmTrac) from an opt-in system to an opt-out system. Most people choose to be included in the registry anyway. In Calendars.

WorkforceSB 301 prevents off-shore medical schools from buying

clinical clerkships for their students. TMA believes the accreditation of Texas medical schools would be jeopardized by allowing off-shore, for-profit, unaccredited medical schools to use Texas’ clerkships. TMA objects to substituting clerkships in the United States for the core clinical curriculum of foreign medical schools. Texas clerkships are limited and must be reserved for Texas medical students. Voted out of Senate 30-0.

House Joint Resolution 109 protects physicians’ right to practice private health care. This amendment to the state constitution says that no act of government or agency could ever limit a physician’s right to practice private health care. In Calendars.

Women’s HealthTMA supports HB 2945, which removes the requirement

to include information on the possibility of increased risk of breast cancer after an abortion in the state-mandated “Women’s Right to Know” booklet. More than two dozen states dictate information that a woman seeking an abortion must have before she gives informed consent. Of these, Texas is the only state with a booklet that includes inconclusive and unclear statements on an association between abortion and an increased risk for breast cancer. Pending in House State Affairs.

To follow these bills, visit the Texas Legislature Online at www.legis.state.tx.us


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The debt that burdens medical students affects the entire healthcare system. It creates a system with fewer primary care physicians as students with high debt may be less likely to pursue family practice, and instead seek specialties with higher income or more leisure time. The cost of tuition can prevent low-income/minority students and those with other financial responsibilities from attending medical school. Physician diversity is necessary to address the needs of heterogeneous, multicultural patient populations. Residents with high debt are more likely to moonlight, and increasing debt leads to more cynicism and depression among residents.

Loan Repayment OptionsStandard 10-year repayment plan Repayment under a standard 10-year plan always is

an option; however, due to most residents’ low income relative to their high debt, standard repayment is not a realistic option. (The standard monthly loan payment for the average resident would consume well over half of his or her after-tax income.)

Forbearance Residents who cannot or choose not to make the

required minimum payment under income-based repayment can request forbearance. They are not required to make monthly payments while loans are in forbearance; however, interest continues to accrue on all loans (both subsidized and unsubsidized), and any unpaid interest is capitalized at the end of the forbearance period. As a result, forbearance can be an expensive option. For example, three years of forbearance on $156,000 at a 6.8 percent interest rate will cost nearly $44,000 in additional interest over the life of the loan. Also, note that forbearance is granted at the discretion of the lender, so this option is not guaranteed.

Income-Based RepaymentThe income-based repayment program has been

an option since 2009. Instead of a loan deferment plan, IBR structures reduced payments (i.e., partial deferment) for borrowers who demonstrate partial financial hardship.

Eligibility — The ability to repay loans under IBR depends on whether a resident demonstrates a “partial financial hardship,” which exists when the monthly loan payment under a standard 10-year repayment plan exceeds 15 percent of the difference between the resident’s adjusted gross income (AGI) and 150 percent of the federal poverty guidelines

for his or her family size. For example, a single resident earning $46,717 per year (the national average) is eligible for repayment under IBR if his or her total monthly loan payment exceeds $380, which corresponds to a total debt burden of approximately $33,000 at 6.8 percent interest. Most residents with student loans are eligible for repayment under IBR.

Calculating your monthly payment — For residents who are eligible for repayment under IBR, their loan principal is irrelevant. Monthly loan payments, which are recalculated every year they participate in IBR, depend on their AGI and on federal poverty guidlines for their family size. For example, for a single first-year resident with a salary of $46,717, the monthly loan payment under IBR is approximately $380. For more information about the IBR formula and monthly payment determinations, see www.IBRinfo.org.

Interest — Under IBR, interest continues to accrue on both subsidized and unsubsidized loans. Unfortunately, the reduced monthly payment under IBR will not be sufficient to cover the interest that accrues each month — interest on $156,000 at 6.8 percent accrues at a rate of nearly $900 per month. If the monthly payment is not sufficient to cover accrued interest, the federal government will pay any remaining accrued interest on subsidized loans for the first three years. Any unpaid interest on unsubsidized loans (as well as any unpaid interest on subsidized loans after the first three years) continues to accrue and is added to the principal when the resident leaves IBR or no longer demonstrates a partial financial hardship. Consequently, it is possible that, despite making payments throughout residency, the loan principal will be higher upon leaving IBR than it was when the resident entered the plan.

Comparing OptionsA standard 10-year repayment plan is not a realistic

option for most residents, so, most residents will have to choose between IBR and forbearance. Because each resident’s financial situation is unique, it is not possible to make an across-the-board recommendation for loan repayment options. It is possible, however, to make one useful generalization: When choosing between IBR and forbearance, remember that lower payments today mean higher payments tomorrow, and more interest paid over the life of the loan. Residents must decide whether the additional long-term cost of forbearance is a good trade-off for additional discretionary income during residency.

$161,290 – Average educational debt of indebted 2011 graduates78% of indebted graduates have debt of at least $100,000.

59% of indebted graduates have debt of at least $150,000.86% of graduating medical students carry outstanding loans.

Medical Student Debt• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

This information is compiled from AMA resources on student debt, www.ama-assn.org.


DCMS Resident SpotlightMichael Lee, MDby Steven Harrell, communications manager

Michael Lee, MD, may not have put the small town of Clinton, La., on the map, but he’s well on his way to leaving his mark. Clinton is about 45 minutes north of Baton Rouge and boasts a population of less than 2,000. Fans of campy 1970s TV might recognize the main street and surrounding back roads as the shooting location for the 2005 movie remake of “The Dukes of Hazzard,” while others may know it as the fictional small town of Bon Temps, setting for HBO’s show “True Blood.” Dr. Lee, outgoing chief resident of plastic surgery at UT Southwestern and Parkland Health and Hospital System, recognizes it as something else — home.

Lee was born in Baton Rouge and raised in Clinton, the oldest of four sons of a welder and a homemaker. He learned the value of hard work by watching his parents, and their example made him determined to pursue a college degree.

“It was very important for me to be successful in college. No one in my family had ever obtained a college degree,” he says.

By the time he was a junior in high school, he had set his sights on medical education and was determined to make his dream become reality. Unlike medical students who inherit their desire to become a physician by being the children and even grandchildren of physicians, Dr. Lee was attracted to the medical profession by its prestige as a “noble profession” and the opportunity to become a leader in a well-respected field.

After high school graduation, he moved away from his close-knit family and small community to enroll at Louisiana Tech University in Ruston. He had the grades, the academic aptitude and the motivation to earn his undergraduate degree. The only problem? Money.

“My parents couldn’t afford to give me money for school, even for a smaller state school like LA Tech,” he remembers. “So, I worked out a system of short-term loans. Because the academic calendar was divided into quarters, I went to the bank at the beginning of each quarter and borrowed just enough money for that term’s tuition and books.”

To be eligible for another loan by the time the next tuition bill came due and to minimize his long-term debt, Lee paid off every loan within the term. During the first three years of his undergraduate degree, he worked six days a week at a local Chinese restaurant, bussing tables and washing dishes. He spent weekends maintaining equipment at a poultry processing plant outside of town. In his senior year, he got a steadier job at the Louisiana Tech Dairy.

Despite his extremely tight schedule, Lee made time to serve as president of Alpha Epsilon Delta, a pre-med honor society, during his junior and senior years. Not only was this good leadership experience, but it also allowed him the opportunity to get to know Stacy, a fellow pre-med student only one year behind him, who served as secretary of the organization. The two began dating, and in 2000 Stacy cheered as Michael became the first person in his family to cross the college graduation stage, graduating with honors and receiving a bachelor of science in animal studies with a minor in chemistry.

Lee’s next step was medical school. He enrolled at Louisiana State University in New Orleans, where he continued his leadership training as the first-year medical school class president. The following year, Stacy joined him at LSU. They dated throughout medical school and later married.

Having a desire to pursue facial surgery, he next completed both an internship in general surgery and a residency in otolaryngology, head and neck surgery, at the University of Texas Southwestern Medical School in Dallas. Concurrently, Stacy was completing her radiology residency and Women’s Imaging Fellowship at Parkland Hospital. During this season of life, Dr. Lee was again balancing multiple jobs: husband, surgeon and student. With that first year of residency came a new job title — father. Michael and Stacy’s first child, Abigail Lee, was born in 2006 and brother, Hayden, followed in 2008.

“Stacy blew me away during those years,” Dr. Lee recalls. “She was just as busy as I was, but also managed to bring these children into our family and be an excellent mother to them. She was remarkable.”

Because both parents worked long shifts at the hospital and were required to be on-call on the same nights and weekends, the only way for them to guarantee childcare was to hire a live-in nanny. Michael’s aunt, Gayle, moved from Louisiana to live with the Lees for the next seven years. Gayle had experience with children; she had raised six of her own.

Dr. Lee emphasizes the importance of his role as a father, despite their hectic circumstances. “My busy schedule didn’t change the responsibility I had to teach my children. You want your children to learn foremost from their parents, and in order for this


to happen you have to maintain a heavy presence in their lives.”

During his first residency, influenced by many of the leaders in the Dallas medical community, Dr. Lee felt the desire to become a plastic surgeon. “Dallas is the mecca of plastic surgery in the United States,” he says, then refers to the recent Rhinoplasty Society meeting in New York, where he presented a research paper. “This was an international gathering of the top plastic surgeons in the world, and Dallas was easily the most well-represented medical community there. Dallas doctors make a visible, unmistakable impact.”

Because plastic surgery is one of the most competitive specialties in medicine, the normal course of action would have been for Dr. Lee to send applications to a multitude of training programs and open himself up to a variety of opportunities. Instead, Dr. Lee chose a different route.

“UT Southwestern, in my opinion and the opinions of most other people, is absolutely the best plastic surgery program in the country. I only applied to this one program.” When asked about the risk of not matching, Dr. Lee just smiles.

Really? Only one? “Well, it turned out pretty well.”That’s hard to argue. In 2010, he was accepted to

the UT Southwestern plastic surgery training program and started his second residency. As chief resident under DCMS President-elect Jeffrey Janis, MD, Dr. Lee has been thrilled with the opportunities that have come with being part of the plastic surgery community in Dallas. Dallas physicians have been at the forefront of pushing plastic surgery and rhinoplasty past the developmental stages, and furthering the technology and techniques now being used around the world. During the past eight years at UT Southwestern, he has strengthened his commitment to become a leader in his specialty.

“My generation, as a whole, seems to be less focused on advancing our specialty compared with past generations,” Dr. Lee says. “While balance in life is important, it is crucial that we grow the specialty. Moving forward will require us to innovate, to undertake groundbreaking research, and to seek out leadership roles in our professional societies.”

In addition to working closely with Dr. Janis, Dr. Lee considers himself fortunate to be able to learn from doctors like 2013 ASAPS Lifetime Achievement Award winner Fritz Barton, MD, and the chairman of the Department of Plastic Surgery at UT Southwestern, Rod Rohrich, MD.

“Drs. Barton and Rohrich have been influential in my desire to pursue a leadership role in plastic surgery. Furthermore, Drs. Jeff Kenkel and Jeff Janis have been significant figures in my education and serve as profound role models.”

In Dr. Lee’s next move, his ability to balance his passion for his specialty and his passion for his family will be critical. In the next few months, the Lees will move to Shreveport, where Stacy will join the breast-imaging faculty at LSU Shreveport. Michael will join The Wall Center for Plastic Surgery to work alongside Simeon Wall Jr., MD, a leading expert in body contouring. This move will allow Dr. Lee to establish himself even more firmly as a leader in aesthetic plastic surgery and rhinoplasty, and will allow the Lees to live near family for the first time in their marriage — Michael’s brothers Ben and John live near Shreveport and Stacy’s parents live two hours away.

As for the rest of his family, back in picturesque Clinton? Dr. Lee’s three younger brothers followed his example and earned college degrees. In fact, his youngest brother, Matthew, will begin law school at Louisiana State University this fall.

Drs. Fritz Barton and Michael Lee

Drs. Michael and Stacy Lee, cheering on their favorite LSU Tigers at Cowboys Stadium in 2011

1 0 0 • 1 0 0 • M a y 2 0 1 3 • D a l l a s M e d i c a l J o u r n a l

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On March 27, more than 40 residents and young physicians met at Mattito’s Tex Mex in Dallas to network with colleagues.

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A woman claims that her male employer (a physician) made several sexually suggestive comments to her during her six months of employment, and he once tried to trap her in an exam room and “proposition” her.

A physician disciplines a pregnant employee. The employee sues, claiming her employer was trying to “force her out” in violation of the Family Medical Leave Act.

A dispute between a physician and nurse about the treatment of a patient turns into a profanity-laden screaming match. The nurse files a lawsuit against the physician for creating a hostile work environment.

The area of law that deals with these kinds of events is called Employment Practices Liability. Harassment, discrimination, FMLA violations, hostile work environment, and wrongful termination are typical allegations in employment practices lawsuits. Employment practices claims not only are embarrassing, but can be expensive to defend or settle.

The good news for physicians insured with Texas Medical Liability Trust is that Employment Practices Liability Insurance has been added to all policies at no extra charge. Policyholders will receive information about this new coverage as they renew their policies.

EPLI claim statisticsApproximately 100,000 employment-related claims

were filed through the Equal Employment Opportunity Commission in 2012, and $364 million was paid to claimants, excluding awards through litigation. Approximately 30,500 discrimination claims were filed with the EEOC and Fair Employment Practices Agencies in 2012.1

Regarding the types of claims, three increases were notable in the last two years: a 9 percent increase in discrimination based on religion, a 4.6 percent increase in discrimination based on national origin, and a 3 percent increase in retaliation.

The cost of settlements and verdicts from employment-related claims can be huge. For example:• In 2009, Wal-Mart settled a race bias suit for $17.5 million.2

• In 2008, New York City paid more than $20 million to settle a racial discrimination suit filed against its Department of Parks and Recreation.3

• In 2003, California’s public pension fund paid $250 million to settle an age discrimination suit.4

TMLT’s EPLI coverage All TMLT policies now include an EPLI endorsement

which covers several kinds of alleged, wrongful employment practices, including:• violation of any federal, state, local, or common law, prohibiting any kind of employment-related discrimination;• harassment, including any type of sexual or gender harassment as well as racial, religious, sexual orientation, pregnancy, disability, age, or national origin-based harassment and including workplace harassment by non-employees;• abusive or hostile work environment;

• wrongful discharge or termination of employment, whether actual or constructive;• breach of an implied employment contract or promissory estoppel (an understanding based on a previous action or statement);• breach of an actual or written employment contract as long as another wrongful employment practice also is alleged;• wrongful failure or refusal to hire or promote, or wrongful demotion;• wrongful failure or refusal to provide equal treatment or opportunities;• employment termination, disciplinary action, demotion, or other employment decision that violates public policy, the FMLA, or similar state or local law;• defamation, libel, slander, disparagement, false imprisonment, misrepresentation, malicious prosecution, or invasion of privacy;• wrongful failure or refusal to adopt or enforce adequate workplace or employment practices, policies or procedures;• wrongful, excessive or unfair discipline;• wrongful infliction of emotional distress, mental anguish or humiliation;• retaliation, including retaliation for exercising protected rights, supporting in any way another’s exercise of protected rights, or threatening or reporting wrongful activity of an insured;• wrongful deprivation of career opportunity, negligent evaluation or failure to grant tenure;• negligent hiring or negligent supervision of others, including wrongful failure to provide adequate training, in connection with training.

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For more information about EPLI coverage, visit www.tmlt.org or call the Underwriting Department at 800-580-8658.

TMLT Policies Now Cover Employment Practices Liability

1US Equal Employment Opportunity Commission. Statistics. www.eeoc.gov/eeoc/statistics/index.cfm. Accessed Oct. 1, 2012.

2NBCNews.com. Judge OKs Wal-Mart race bias suit settlement. www.msnbc.msn.com. Accessed Oct. 3, 2012.

3Cardwell D. New York Times. Feb. 27, 2008. www.nytimes.com. Accessed Oct. 3, 2012.

4Greenhouse S. New York Times. Jan. 31, 2003. California pension fund to pay $250 million age bias settlement. www.nytimes.com. Accessed Oct. 3, 2012.

The information and opinions in this article should not be used or referred to as primary legal sources nor construed as establishing medical standards of care for the purposes of litigation, including expert testimony. The standard of care is dependent upon the particular facts and circumstances of each indi-vidual case and no generalization can be made that would apply to all cases. The information presented should be used as a resource, selected and adapted with the advice of your attorney. It is distributed with the understanding that neither Texas Medical Liability Trust nor Texas Medical Insurance Company is engaged in rendering legal services. © Copyright 2013 TMLT.

by Will iam Malamon, TMLT Communications Supervisor

1 0 4 • M a y 2 0 1 3 • D a l l a s M e d i c a l J o u r n a l

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Documents

Dallas Medical Journal