Triad winter 2015

THE AWARD WINNING JOURNAL OF THE MICHIGAN OSTEOPATHIC ASSOCIATION

WINTER 2015

VOLUME 26

ISSUE 1

OSTEOPATHIC EDUCATION:THE CArEfUl CUlTIvATIONOf OSTEOPATHIC lEADErS

•Perspectives in Curriculum

•Unique Approaches to Well-rounded Physicians

•Transforming the Doctor- Patient relationship

•Admissions, CMEs, Diversity

WINTER 2015

VOLUME 26

ISSUE 1TrIAD

TrIAD

FEATURES

10 Osteopathic Education:

The Careful Cultivation of Osteopathic Leaders

20 The Doctor’s Company

DEPARTMENTS

5 Editors’ Notebook

6 President’s Page

7 Physician Spotlight:

Peter Gulick, D.O., Devotes Career to HIV Patients

8 New Practitioner Spotlight:

Nicholas VandenBosch, D.O., Mixing Passion With Purpose

9 Student Spotlight:

Lauryn Przeslawsk, From Gymnast to Women’s Health Specialist

19 The Practice Manager

22 Dean’s Column

23 Advertiser Index

TABlE Of CONTENTS

WINTER 2015

VOLUME 26

ISSUE 13

4 TRIAD, WINTER 2015

JOHN SEALEY, D.O., FACOS, AND KEVIN LEIKERT, OMS-II, ARE EDITORS-IN-CHIEF

OF TRIAD AND MEMbERS OF THE MOA bOARD OF TRUSTEES.

T he Michigan State University College of Osteopathic Medicine

is THE osteopathic college of the great state of Michigan. In

this Winter 2015 edition of TRIAD, we take the time to learn

about and honor the incredible work being done across the

state in the name of osteopathic education.

Michigan Osteopathic Association owes much to the innovation and dedication

of the fine faculty, staff and students of MSUCOM. They are carefully cultivating

the next generation of osteopathic leaders. Whether it’s evolving the admissions

process, finding innovation in curriculum, preserving the excellence in patient

care through CME or any other of the robust initiatives we explore in the

following pages, MSUCOM truly exudes and inspires excellence in osteopathic

education and research.

It’s with gratitude that we invite you to read on about the incomparable Michigan

State University College of Osteopathic Medicine.

TrIAD

JOHN SEALEY,D.O., FACOS

KEVIN LEIKERT,OMS-II

ED I TOrS’ NOTEBOOK

TRIAD, WINTER 2015 5

As always, we would like to hear from you!

Did you like this issue of triad?

Please send us feedback by e-mailing:

[email protected].

mailto:[email protected]

MYRAL R.RObbINS, D.O.,FAAFP, FACOFP

A s we prepare for the 116th MOA Annual Spring Convention, there are

not many organizations celebrating over one hundred years of annual

gathering. It is awe inspiring to think of the changes to our society, and

to osteopathic medicine, which have taken place during that time. Com-

puter technology is just one of the advances that has affected our culture and our profession

and allowed us to greatly increase our ability to communicate, collaborate and access infor-

mation. If we look back, it would be hard to imagine where our predecessors would have

envisioned osteopathic medical education to be in 2015.

In this issue of TRIAD, we talk with Michigan State University College of Osteopathic Medi-

cine (MSUCOM) administration, faculty and staff for their perspective of the educational

process. From my MSUCOM student days to the present, it has been my privilege to work

with each of these insightful and influential people in the varied educational roles I have

served within the osteopathic family. Our colleges have been on the forefront of change,

using technology to enhance and expand the educational process. Each person in this issue

has had a role in the process of osteopathic education and has a unique perspective. Our

predecessors would be astounded by the changes in the osteopathic curriculum over the past

ten years. We hope this issue offers a perspective into the educational process: past, present

and future. It is difficult to imagine what the osteopathic students of the next generation will

encounter in their career, but based on the last ten years, the changes will be amazing.

As we enter 2015 I hope we can build upon our educational accomplishments and look to

an ever improving landscape of our osteopathic profession and our communities. Our job is

to pass on our knowledge to the next generation of physicians and be proud of the accom-

plishments of our generation.

“We hope this issue of TRIAD offers a perspective into

the educational process: past, present and future. It is

difficult to imagine what the osteopathic students of the

next generation will encounter in their career, but based

on the last ten years, the changes will be amazing.”

MYRAL R. RObbINS, D.O., FAAFP, FACOFP IS THE PRESIDENT OF THE MICHIGAN OSTEOPATHIC

ASSOCIATION AND MAY bE REACHED AT [email protected].


PrESIDENT’S PAgE


PETER GULICK, D.O.

Peter Gulick, D.O., Devotes Career To HIV PatientsbY CHLOE SEYMOUR

Peter Gulick, D.O.’s early medical career revolved around attempting to

treat an unidentified disease that had taken the medical community by

storm. As an up-and-coming doctor at the Cleveland Clinic in the early

1980s, Dr. Gulick was on the forefront of treating patients for the disease

now known as HIV. More than 30 years later Dr. Gulick is still devoting most of his

time, energy and passion toward caring for HIV patients.

“We were treating people with HIV without even knowing it,” Dr. Gulick said. “When

I moved to Michigan I was designated as the HIV caregiver because I had the most

experience with it. ”

Moving to East Lansing, Mich. in 1984 to teach and research at Michigan State

University’s College of Osteopathic Medicine, Dr. Gulick has been expanding HIV

patient care in Michigan ever since.

After establishing an HIV clinic in Ingham County, which now services more than 400

patients, Dr. Gulick knew there was still an immense need for HIV care and treatment

around the state. With clinics now open in Saginaw, Mich. and Harrison, Mich., Dr.

Gulick provides care for more than 800 patients. With this impressive number and

through his extensive efforts, Dr. Gulick is now the largest HIV care provider in the

state of Michigan.

He advocates that a D.O. approach is vital in attempting to care for patients who are

suffering from HIV and its many side effects.

“I approach them with a whole patient concept because HIV is not just about treating

the immune system, it’s also about focusing on preventative care,” Dr. Gulick said. “We

have to realize that HIV patients have other conditions that they’re dealing with. You

have to be looking at the entire self rather than just one area - that’s the D.O. philosophy.”

Whether they are pursuing a specialty in infectious diseases or any other realm of

medicine, Dr. Gulick sees a fruitful future for those now entering the osteopathic field.

“With the way medicine is going now, I think we’re sitting much better off than our

counterparts that focus on just one disease or body part,” Dr. Gulick said. “For good

medical care, it’s about treating the whole patient. That’s where medicine is heading and

that’s the way D.O.s have always been trained.”

D.O. SPOTlIgHTPrESIDENT’S PAgE


NICHOLAS VANDENbOSCH,

D.O.

NEW PrACTITIONEr SPOTlIgHT

Nicholas Vandenbosch, D.O., Mixing Passion With PurposebY CHLOE SEYMOUR

For Nicholas VandenBosch, D.O. a Muskegon, Mich. native, football is

not just a pastime. Now a practicing D.O. at Westshore Family Medicine

in Muskegon, Dr. VandenBosch has returned to his hometown to use

his medical expertise to benefit the West Michigan community and

regional high school athletes.

Completing his undergraduate education at Adrian College, where he also played

football, Dr. VandenBosch attended Michigan State University’s College of Osteopathic

Medicine. During his medical training, Dr. VandenBosch found his calling in family

medicine, which has positioned him to care for patients in a way he finds truly

rewarding.

“I was drawn to things in the ER that are more acute and situations where you can

see results quickly,” Dr. VandenBosch said. “I like that there is care continuity and the

fact that I am able to develop relationships with my patients.”

Many doctors in their residency struggle to make time for even basic needs, such as

sleeping and eating. Defying these expectations, while in his residency at McLaren

Macomb Hospital, Dr. VandenBosch was able to establish his own nonprofit

organization, The WV Foundation. The foundation aims to provide Muskegon-

area high school athletes with learning and leading opportunities, scholarships and

beneficial athletic experiences.

Since 2011, The WV Foundation has awarded more than $23,000 in scholarships to

West Michigan student-athletes.

Dr. VandenBosch’s philanthropic efforts did not go unnoticed. Nominated by his

residency director, he was awarded the prestigious 2014 Resident of the Year Award

through the Michigan Association of Osteopathic Family Physicians.

Through his medical practice and nonprofit work, Dr. VandenBosch has effectively

found a way to mix what he calls a “passion for high school sports” with purpose.

NEW PrACTITIONEr SPOTlIgHT


LAURA PRzESLAWSKI

Lauryn Przeslawski, from gymnast to women’s health specialist bY CHLOE SEYMOUR

C ompetitive gymnast? Check. Michigan State University cheerleader?

Check. And now, Lauryn Przeslawski is working to check Doctor of

Osteopathic Medicine off of her bucket list.

A current fourth year student at Michigan State University’s College of

Osteopathic Medicine, Przeslawski’s interest in osteopathic medicine was spurred by her

years of involvement in competitive sports.

With injuries plaguing her, Przeslawski struggled to get through her last competitive

season of gymnastics. Bouncing from specialist to specialist, Przeslawski was told that her

days of competitive sports might be over.

“All the doctors I had seen told me to let gymnastics go and to go live the normal teenage

life,” Przeslawski said. “It was so discouraging because I didn’t want to give it up yet.”

Przeslawski’s first appointment with Dr. Larry Nassar, a DO and the USA Gymnastics’

National Team physician, changed not only her future in athletics, but her career goals

as well.

“I had such an incredible experience with him. He looked at me as a whole person rather

than just at my specific injuries,” Przeslawski said. “He was the first physician to look

at me and say ‘I don’t think you need to completely quit’ and he suggested competitive

cheerleading. He had an incredible, inspiring effect on me.”

After completing her undergraduate degree at Michigan State University, Przeslawski

moved on to medical school at MSUCOM’s Macomb campus. With her background

in athletics, Przeslawski assumed her dream job would include sports medicine, but

through experience has found her path has been changed.

“OBGYN was my first rotation as a third year and I absolutely fell in love,” Przeslawski

said. “It’s not originally what I thought I wanted to go into but I realized my passion was

women’s health.”

With a special interest in infertility, Przeslawski is currently interviewing for an OBGYN

residency. She hopes that her passion for her specialty will enable her to make the most

out of her time with patients.

“I’m in this field to be with people during pivotal moments in their lives.”

STUDENT SPOTlIgHT



The relationship between

the Michigan Osteopathic

Association and Michigan

State University College

of Osteopathic Medicine (MSUCOM)

can best be described as symbiotic.

Between the array and diversity of

collaborations, the board and committee

seats and service opportunities,

there is no question of the value both

organizations have to the other. Perhaps

though, less well known are the finer

details of the great work being done in

the trenches at the college.

In this issue of TRIAD, we talk with

MSUCOM administration, faculty

and staff – Michigan’s only college of

osteopathic medicine.

fIrST, A fEW fACTS:• Morethan300osteopathicstudents

graduateeachyearfromMSUCOM

• Eachyearmorethan400first-and

second-yearstudentstakeclassesin

EastLansing,andabout100eachat

theDetroitMedicalCenterandMacomb

UniversityCenter.Third-andfourth-

yearstudentsareinclinicalrotationsat

partnerhospitalsacrossthestate.That’s

1,272osteopathicstudentsstatewide.

• MSUCOMstudentscomefromevery

communityfromDetroitandwestMichi-

gantotheUpperPeninsula,fromacross

theUnitedStates,andfromcountries

aroundtheglobe.83%ofthe2014

enteringclassareMichiganresidents.

• Two-thirdsofMSUCOMgraduatesstay

inthestatetopracticepatient-centered

careinalmostallofMichigan’s83

counties.

• MSUCOM’sStatewideCampusSystemis

oneofthenation’slargestgraduate

medicaleducationconsortiawith1,752

physicians-in-trainingin224internship,

residencyandfellowshipprograms.


All ABOUT ADMISSIONSKatherine M. ruger,Director of aDMissions,MsucoM

What’s the current state of osteopathic medical school admissions?Applications to U.S. osteopathic medi-cal schools have increased by 67% since 2010. Within the last year, MSUCOM’s applicant pool has increased by 20%. With the increasing number of applicants, the MSUCOM admissions office contin-ues to enhance the way in which appli-cants are evaluated. Just as the profession’s approach to patient care is holistic, osteo-pathic medical schools employ a holistic approach to application review. We strive to select the most qualified applicants to best serve the needs of a diverse and patient population in a country that is fac-ing a physician shortage.

how has the admission process changed over the years?Historically, the admissions process has been paper-based, yet the approach to review has remained similar in regards to the philosophy of holism. Most recently, many osteopathic medical schools have employed electronic application systems and new interview processes to better ensure that the selection of applicants fits with the osteopathic philosophy. Inter-view processes more frequently include a unique evaluation of a student’s personal characteristics, such as self-actualization skills, empathy, ethics and cultural compe-tence; all characteristics deemed essential by patients. MSUCOM was the second U.S. osteopathic medical school to go paperless with our admissions process. In the age of technology, the process has resulted in more satisfied applicants, an ease of com-munication and reporting capability, and environmentally friendliness.

how has online admission changed admission processes and outcomes?Online admission has created a streamlined system of review, increased the applicants

level of ease with the process, reduced overhead costs of a paper-based process, enhanced the opportunity to spend more time reviewing each application, provided the reporting structure needed to measure outcomes and improved communication transparency between the process and our applicants.

What does the future look like for online admissions?An online admission system seems to be a popular and efficient method of admissions management. Applicants are demand-ing online admissions processes and now have applications for status checks, etc. In the often stressful and ambiguous world of admissions, applicants crave transparency and information, and online admissions tools seem to be a vehicle to drive greater transparency. Additionally, recruitment efforts can reflect the online admissions through the use of webinars, mobile apps and social media.

how does admissions fit into the osteopathic education community andlater in the professional osteopathic community? Admissions could be considered the front line of the profession. We work to select students who will become the next gen-eration of compassionate physicians and will proudly represent the institution and the profession while serving their commu-nities. It’s crucial that the osteopathic com-munity remain involved in helping select stellar applicants to represent and grow the profession. Involvement could include participating in admissions interview pro-cesses, mentoring prospective applicants and offering shadowing opportunities, and participating in career day events.

What else should osteopathic professionals know about admissions?The osteopathic community has a great opportunity to work together to recruit and retain the most highly qualified applicants. Our admitted students are the future of the profession and will influ-ence osteopathic medicine throughout the world.


how do you relate curriculum to professional/health care outcomes?Patient safety and quality outcomes are increasingly important. Metrics of success include reductions in patient 30-day read-mission rates and higher rates of compliance with evidence-based therapeutic / patient management protocols. The curriculum will add more of this material in the future to better prepare medical students and resi-dent-physicians for entry into practice.

What else should osteopathic professionals know about curriculum?Competency-based assessments will be-come a more significant factor in medical education in the future. Medical school curricula will morph and progressively align more tightly with these assessments and continue to instructional methods that promote the development of compe-tency more effectively and efficiently.

r. taylor scott, D.o., Director, Pre-clerKshiP curriculuM, MsucoM

in your experience as director of pre-clerkship curriculum, what is the current state of osteopathic curriculum?Osteopathic curriculum at is always in flux. Recently, this appears to be focused on curricular revision in many osteopathic medical schools. Many schools are under-going curricular revision with similar prin-ciples. Some of these principles are ‘”flipped classroom”-based and focus on greater cur-ricular integration. This integration of sub-jects has the intended outcome of greater retention of the knowledge base that stu-dents are exposed to during their training.

The basic premise of the flipped classroom is for students to learn at home and come to class to apply their new knowledge, the so-called ‘homework at school and school-work at home’ approach. This style is also intended to foster increased retention of knowledge and a quicker learning curve to practical application in a clinical setting.

PErSPECTIvES IN CUrrICUlUM


DonalD sefciK, D.o.,senior associate Dean,MsucoM

in your experience as senior associate dean, what is the current state of osteopathic curriculum?Osteopathic medical education is a dynamic and multifaceted subject. In the face of a projected shortage of physicians in Michigan as well as nationally, medical educators are scrambling to accommodate the growing numbers of medical students and residents. Medical education has his-torically spanned three segments of train-ing – medical school (commonly referred to as undergraduate or pre-doctoral), postgraduate (residency and sometimes fellowship training in various specialties) and the ongoing professional develop-ment of practicing physicians (continuing medical education or CME).

Currently, there is a movement afoot attempting to better align and integrate these three segments into one, longitudi-nal process. Some training programs are considering a reduction in total training time if competency can be adequately demonstrated based on clinical ability (qualitatively) not simply years of educa-tion (quantitatively).

how has curriculum changed?Beginning in 1892 with the establish-ment of the American School of Oste-opathy by Andrew Taylor Still, M.D., D.O., in Kirksville, Mo., the osteopathic curriculum has emphasized wellness. Two distinct aspects of the osteopathic curriculum are the inclusion of Osteo-pathic Principles and Practice (OPP) and Osteopathic Manipulative Medicine (OMM). OPP espouses the dynamic unity of anatomy (structure) and physi-ology (function); interrelated at all levels. OMM includes the aspects of palpatory diagnosis and various hands-on techniques to treat patients, Osteo-pathic Manipulative Therapy (OMT).

Over time, more than forty different OMM techniques have been established and refined. Osteopathic medical schools include hundreds of hours of course work often beginning with orientation that develop competencies in OPP, OMT and OMM so that graduates can provide osteo-pathically-focused patient-centered care.

What does the curriculum of the future look like?The delivery of the curriculum is becoming more technologically based. Lectures, small group activities, and even faculty-led case-based sessions can be streamed live so that students can attend from remote sites or record for viewing at a later time.

Students will increasingly be required to preview lecture content prerecorded by faculty and posted online prior to attending classroom sessions. This will promote deeper learning and student mastery of content though faculty-led discussions; this model of education is known as the “flipped classroom”.

Additionally, it is likely that the training of resident-physicians and the educa-tion of medical students will increas-ingly occur in more outpatient settings. As over 95% of all health care is cur-rently delivered in ambulatory settings, medical education will transition away from the hospital and into outpatient-based facilities.

“…delivery of the curriculum is

becoming more technologically

based. Lectures, small group

activities, and even faculty-

led case-based sessions can be

streamed live so that students

can attend from remote sites

or record for viewing

at a later time.

saroj Misra, D.o., facofP, Director, clinical clerKshiP curriculuM, MsucoM

in your experience as director of clinical clerkship curriculum, what is the current state of osteopathic curriculum?Osteopathic curriculum has been under-going significant change over the last five to 10 years, as more schools strive to develop educational curricula that provide both traditional scientific knowledge as well as integrated clinical concepts to bet-ter pair the ‘book learning’ with the ‘prac-tice’. The goal has been to create students who are not only more knowledgeable on a wider variety of topics, but who can also apply this knowledge in clinical settings earlier on.

There has also been some increased focus on developing psychomotor skill sets as part of both the pre-clerkship and clerk-ship experience during medical school, ensuring students have basic procedural skills familiarity, if not competency.

What does the curriculum of the future look like?As the profession becomes more sophis-ticated and more validated, standardized measures of competency are becoming more prioritized. Schools have looked to not only identify such standards, but to develop learning goals and objectives that speak to these elements.

We are seeing a greater emphasis on lon-gitudinal curricular design (planning for four years, not year-by-year and revisit-ing topics in different years from differ-ent perspectives) as well as new learning initiatives.

how do you relate curriculum to professional/health care outcomes?Dr. Hershey Bell once said: “Medical education exists to fulfill a covenant that our profession has made with society - to provide the best and most effective care to all people.”


how has curriculum changed over the years?The changes in curriculum over the years, in my opinion, are moving from a fact-based approach to an application-based approach for instruction. The many and varied learning styles are also a consid-eration for curriculum change. Distance learning as well as increased access to sim-ulation and other technologies are opening up instructional and learning possibilities that didn’t exist not too long ago. These changes not only provide increased access to learning, but also options for creativity in learning that students and faculty really enjoy.

how do you relate curriculum to professional/health care outcomes?We measure curricular success in many ways, from board performance to class grades to residency selection. The out-comes of our osteopathic colleges’ curricu-lum are often held to a standard of creating the best physician our students can be. This outcome is influenced not only by the college curriculum but also Graduate Medical Education (GME) and personal motivation of the student.

At MSUCOM we strive to produce the student that is best positioned for fur-ther training in the GME environment, fully knowing that this is influenced by a multitude of factors, not just the college curriculum.

how does curriculum fit into the osteopathic education community and later in the professional osteopathic community? Our MSUCOM curriculum seeks to posi-tion students for success in the further GME training environment by equipping them with excellence in osteopathic patient care that reflects not only a well-rounded

knowledge base but appropriate applica-tion of their osteopathic training in a pro-fessional and caring manner.

MSUCOM is well known for producing not only competent physicians but doc-tors who consistently exhibit excellence in osteopathic patient care. Patient-centered care is one of the hallmarks of the osteo-pathic profession and at MSUCOM we strive to have our curriculum reinforce this at every opportunity.

What’s the latest in online-based curriculum?There are many applications of online training - most evidenced in the flipped classroom model of education I men-tioned before. The online learning options available to students through Internet sites such as YouTube and Kahn Academy as well as New England Jour-nal of Medicine videos and other schools and other professions, provide students with multiple and varied opportunities for leaning.

Sometimes a picture is worth a thousand words and an online module is worth a thousand pictures. If a student needs fur-ther clarification of a concept other than their classroom lecture, often there are online resources that help to explain con-cepts that enhance the lecture setting.

What else should osteopathic professionals know about curriculum?At MSUCOM we are constantly evaluating and revising our curriculum for the best interest of student learning and perfor-mance. This process involves faculty and student feedback, as well as input from the medical community at large. We welcome opinion and interest in curricular develop-ment at MSUCOM and encourage mem-bers of the greater medical community to let us know their thoughts.

“Patient-centered care is one of the hallmarks of the osteopathic

profession and at MSUCOM we strive to have our curriculum

reinforce this at every opportunity.”


This is the primary driving force behind medical education, both undergradu-ate and graduate. If we assume this to be true, then education must be paired to health outcomes, with an eye to evidence-based learning that sup-ports doing specific activities, which are proven to benefit the patient. As we recognize that society (in the form of HMOs, hospitals and the government) has created its own outcome measures, we must direct our teaching towards both influencing and meeting such measures.

how does curriculum fit into the osteopathic education community and later in the professional osteopathic community? Curricula (especially that provided dur-ing the clerkship experience for medi-cal students) must be integrated into the clinical rotation experiences stu-dents undergo during their third and fourth years. The only way this can be accomplished is if a wide body of well-educated preceptors - who value the educational curriculum and can pair it with their clinical experience - are willing to train our students. As edu-cation becomes more longitudinal, we see students forming relationships with physicians well before reaching their clerkship experience and this, in turn, engenders a greater desire on the part of our clinicians to be educators.

What’s the latest in online-based curriculum?MSUCOM has recently revised the clerkship curricular experience to one focused on two distinct sections. The core of both the C3 and R2 modules is accessing articles, videos and train-ing documents through our new online portal, Desire2Learn (D2L). D2L has been instrumental in helping the col-lege to meet the logistic challenges of delivering media-rich curricular content to both trainees and preceptors while simultaneously allowing for remote test-ing and evaluation of the learner. For MSUCOM, which has approximately 320 students at 25 hospitals around the state, the ability to deliver and evaluate electronically has allowed us to inno-vate in ways that would not have been possible even five years ago.

What else should osteopathic professionals know about curriculum?Clerkship curriculum depends on the willingness of our preceptors in the trenches to adapt and teach it to students. As a profession, we can-not perpetuate excellence without the involvement and dedication of those physicians who take the time and effort to teach the next generation of physi-cians. If you are currently a clinical preceptor for MSUCOM or, indeed, any osteopathic medical school, you have my undying thanks. If you are not, con-sider this: becoming a clinical precep-tor allows one to do what doctors are called to do twice - to not only care for the patient, but to also care for the next doctor who will care for that patient. In the end, what better reward is there than that?

PErSPECTIvESIN CUrrICUlUM(CONTINUED)

“Osteopathic curriculum has been undergoing significant change

over the last five to 10 years, as more schools strive to develop edu-

cational curricula that provide both traditional scientific knowledge

as well as integrated clinical concepts to better pair the ‘book learn-

ing’ with the ‘practice’. The goal has been to create students who are

not only more knowledgeable on a wider variety of topics, but who

can also apply this knowledge in clinical settings earlier on.”

jonathan rohrer, Ph.D., D.Min.,associate Dean,stateWiDe caMPus systeM, MsucoM

tell us a bit about the statewide campus system… The Statewide Campus System was formed in 1989 as Consortium of Osteo-pathic Graduate Medical Education and Training (COGMET) to build a continuum of training between pre-doctoral and post-doctoral education, to improve the qual-ity of postdoctoral education, to provide faculty development to program directors, and to decrease the number of trainees who were leaving osteopathic residencies for allopathic residencies.

In 1996 the consortium was approved as an Osteopathic Postdoctoral Training Institute (OPTI) by the American Osteo-pathic Association and changed its name to the Statewide Campus System.

sara carson,Director of continuingMeDical eDucation,MsucoM

give us a cMe refresher…All osteopathic physicians licensed in Michigan are required to complete, dur-ing the 3-year period prior to the date of renewal of the license, 150 hours of continuing medical education. The goal of the MSUCOM Continuing Medical Education office is to provide profes-sional development opportunities that will enhance the physician’s ability to care for their patients.

CONTINUINg MEDICAl EDUCATION ON THE CUTTINg EDgEWe recognize the important role CME plays in the preservation of excellence in patient care and the enhancement of the well-being and the health of individual patients as well as the public. Our con-ferences are designed to provide quality education to health care professionals across the state and the United States.

tell us about the online Principles of Manual Medicine Program…Our new Principles of Manual Medicine online pilot program is a combination of online video lectures and hands-on experience sufficient to enable par-ticipants to understand the principles involved in diagnosing and treating musculoskeletal disorders amenable to

manual medicine methods. Emphasis will be placed on integrating manual medicine into total health care.

There are 15 hours of video lecture to be watched online. In July, the clinical hands-on segment of the course is being held in East Lansing. The dates are July 11-12, 2015. All 15 hours of video, plus relevant quizzes must be done prior to attendance at the hands-on segment.

how has cMe changed over the years?CME has changed over the 17 years that I have been involved with educa-tion and I am excited that we are now able to offer more cutting edge CME for the busy physician and continue to offer the quality manual medicine courses.

EDUCATIONAl EXCEllENCE WITH THE STATEWIDE CAMPUS SYSTEMhow does the scs fit into the osteopathic education ecosystem?The impact of the Statewide Campus System on the profession was recognized when the AOA used the COGMET struc-ture as the guideline for development of the OPTI standards and mandated that all GME training programs in the U.S. become members of an OPTI in 1996.

In 2012 the AOA mandated that OPTIs become the sponsor of all osteopathic postdoctoral training programs. As pro-gram sponsors, SCS became responsible for monitoring and assisting programs in meeting AOA accreditation standards. Currently SCS has 1,854 trainees, 2,455 approved training slots and 225 training programs that are monitored for continu-ous quality improvement. SCS has become one of the largest training consortia in GME, both allopathic and osteopathic.

What does the scs address in terms of needs in the osteopathic community?The Statewide Campus System provides more than 200 daylong educational events for interns, residents and fellows, as well as research assistance to trainees and faculty

development programs to program direc-tors. SCS provides research assistance for residents, training in research develop-ment for community-based training pro-grams and consultation for training sites in developing new GME programs.

What else should osteopathic professionals know about the scs?The Statewide Campus System is cur-rently in the process of applying for Accreditation Council for Graduate Med-ical Education institutional sponsorship and providing professional development for faculty so that consortium members can transition into the new accreditation system. New programming for train-ees and program directors will follow ACGME requirements while maintaining AOA requirements through 2020 when all programs will be accredited through the ACGME. SCS currently has more than 100 M.D. trainees who attend edu-cational events and appreciate the value of the osteopathic component. The tran-sition to a single accreditation system is an exciting opportunity that SCS has embraced as the new future for all Grad-uate Medical Education.


What does this initiative address in terms of needs in the osteopathic community?This program helps to educate future physicians on the variance that exists in the field they will soon engage with. Many of our MSUCOM students have identified a want to contribute their time and talents to communities that are underserved and under-resourced. Because the population of their edu-cational community is not reflective of the population of chosen engagement it becomes increasingly vital that students develop culturally sensitive and relevant practices that will help them relate to, and understand their future patients. Our osteopathic physicians are only as good as their training; the Joy Initiative helps our students to better serve them-selves so they can better serve others.

Leadership Academy for Compassionate Care

celia guro, Ph.D, executive Director, leaDershiP acaDeMy for coMPassionate care, MsucoM

john MeulenDyK, D.o., associate Professor anD counselor, MsucoM

What is the leadership academy for compassionate care?The Leadership Academy aims to improve the health and well-being of our world by educating students in compassionate care and empowering them to become future leaders of healthcare institutions, medi-cal schools and government agencies. The Leadership Academy identifies and men-tors students in developing ethical and compassionate leadership skills both in the academic as well as clinical arenas. The Leadership Academy instructs in the art of caring while promoting the science of medicine and the power of touch.

In addition to the more traditional approaches to education, MSUCOM offers a variety of non-traditional ini-tiatives and supplemental education programs that help MSUCOM students stand out from the rest both in their aca-demic and professional lives.

The Joy Initiative alyse ley, D.o., resiDency Director, DePartMent of Psychiatry, MsucoM

What is the joy initiative?The Joy Initiative is a retention tool to aid in the successful matriculation of current MSUCOM students. It is impor-tant to create a venue where students can openly discuss issues that affect their performance and that endorse a sense of belonging within the institution. When students do not feel connected to their academic institutions, their performance suffers and distractions from absorbing critical information ensue. According to U.S. News & World Report, as many as 50 percent of medical students suffer burnout, a problem that can sometimes carry into their post-graduate practices. The Joy Initiative is a measure to help combat burnout and is a strategy to support the needs of a growing multi-cultural and ethnically diverse student population.

how does this initiative fit into the osteopathic education ecosystem?The Joy Initiative provides a form of sup-plemental education to the culture and academic curriculum at MSUCOM. As students within the medical school envi-ronment often move through the experi-ence in a silo, the Joy Initiative helps to provide an opportunity for a perspective shift and challenge not just the students; but also faculty, staff and administra-tors to recognize there are experiences outside of their realm of familiarity, and that those different worldviews are just as valuable.

UNIQUE APPrOACHES TO WEll-rOUNDED PHYSICIANSWhat does the academy address in terms of needs in the osteopathic community?It grew out of an interest in pallia-tive care and improving doctor-patient relationships.

The relationship between the doctor and the patient is crucial. Compassionate care is about treating people with dignity. Diagnosis is important, but it’s also criti-cal to be thoughtful and to listen to your patients.

Why does the college value leadership training in compassionate care?The osteopathic profession is working to preserve a fundamental osteopathic belief that the human person functions as a unit in terms of mind, body, and spirit. In a contemporary society that is becoming increasingly fragmented in terms of workloads and productivity, a loss of compassion may be one of the emerging tragedies that we face. The col-lege strongly promotes the formation of empathetic and caring physicians; and the Leadership Academy for Compas-sionate Care is one way of insuring that compassion remains a focal part of the doctor/patient relationship.

how does the academy prepare osteopathic professionals for the future or provide an edge in their professional lives?The LACC prepares osteopathic profes-sionals in a unique way by fostering self-care through the use of arts, meditation, music, and self-reflective papers. Issues of ethics and morality are discussed in an attempt to articulate the various view-points to which students and patients ascribe – some of which are markedly distinct. To address the complexity of our health care system, lectures are given that explore some of the emotional and economic hurdles that emerge when implementing policy changes. And finally, students interact directly with patients who are in the process of dying or embracing a life-threatening situation and then reflect on those experiences.


sanDy Kilbourn, executive Director for external PrograMs, MsucoM

how does the college address diversity in osteopathic education?From pre-admission through residency programs, MSUCOM maintains a com-prehensive scope of recruitment, educa-tion, advocacy and curricular integration relative to diversity.

What are 2014 program highlights?The award-winning civil rights lectures, the Dr. William G. Anderson Lecture Series: Slavery to Freedom continued to bring dynamic and thought-provoking speakers to the college.

The MSUCOM OsteoCHAMPS program, more than a decade old, brings more than 50 select high school students to campus during the summer for two weeks of

Pat grauer, Public relations coorDinator, MsucoM

What is the transforming the Doctor-Patient relationship program?A partnership between the Michigan State University Federal Credit Union Institute for Arts & Creativity at MSU’s Wharton Center, Stuart Pimsler Dance & Theater and MSUCOM, Transform-ing the Doctor-Patient Relationship is a unique annual three-day workshop that uses participation in the arts to help students and faculty better understand themselves and others in human rela-tionship. It’s a basic tenet of the program that music, dance, song, painting, poetry, theatre and the other arts can flow into human emotional spaces we usually defend, and provide a safe space for self-reflection.

TrANSfOrMINg THE DOCTOr-PATIENT rElATIONSHIPAs participants understand how to create a hospitable space for intimate conversa-tion, how to position their bodies in ways that are welcoming and not threatening, how to create a patient-centered office, and most importantly, how to listen to their patients, they become more effec-tive physicians. The workshop is also a rejuvenating retreat, and very fun.

how does this program fit into the osteopathic education ecosystem?As the practice of modern medicine elevates money and systems above the human needs of patients, the program helps to conserve the osteopathic values that honor the patient as the focal point of medicine. To survive in this environ-ment, doctors have to learn how to lis-ten and communicate as effectively and efficiently as possible. To encourage heal-ing, this communication must express the care and concern the doctor has for the patient – the whole patient. In addi-tion, the workshop teaches self-care, a

much-needed skill for physicians who must work hard and long in stressful sit-uations at a job that demands their best.

What does this program address in terms of needs in the osteopathic community?It helps to ensure that the profession will continue to produce the kind of caring, compassionate and communicative doc-tors that have been a hallmark of osteo-pathic medicine.

DIvErSITY IN MSU COllEgE Of OSTEOPATHIC MEDICINEeducational and motivational programs to help make them more competitive for health professions admissions. The pro-gram’s mission is to broaden the health care interests of participants to enable them to achieve their career goals.

Bringing together Muslims and non-Mus-lims, mental health professionals and lay people to improve care and access to ser-vices among the Muslim community was Dr. Farha Abbasi’s primary goal in orga-nizing the sixth annual Muslim Mental Health conference. The conference was sponsored by the MSU Department of Psychiatry and MSUCOM in collabora-tion with the Arab Community Center for Economic and Social Services Com-munity Health and Research Center.

Why does the college value diversity/diversity training?We know that by the year 2020, no sin-gle racial or ethnic group will constitute a majority of children under the age of 18. In three decades, no single group

will constitute a “majority.” Future phy-sicians more than ever before, in order to provide quality care for their patients, will require a skill set to interact and treat diverse populations with knowledge and sensitivity to their differences.

how do the various diversity initiatives prepare osteopathic professionals for the future or provide an edge in their professional lives?Key tenets of the osteopathic approach to patient care are patient-centered medi-cine, cultural intelligence and celebration of diversity and inclusion. MSUCOM is committed to providing numerous opportunities within the curriculum, as well as the life and culture of the college to focus the attention of faculty and stu-dents on the importance of diversity and its impact on medical care.


“…music, dance, song,painting, poetry, theatreand the other arts canflow into human emotionalspaces we usually defend,and provide a safe spacefor self-reflection.”

CrEATINg lEADErS MSUCOM alumni are medical school deans, nationally recognized researchers, top-ranking military leaders, persons recognized for their work with the poor and medically underserved, a nationally recognized forensic psychiatrist, sports physicians for collegiate and professional teams, and consultants involved in high-profile medical care.

They are the future of osteopathic medicine in our state and the nation. With a college committed to excellence in osteo-pathic education, research and service, we are confident the future could not be in better-equipped hands.

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“Medical education exists to fulfill a

covenant that our profession has made

with society – to provide the best and

most effective care to all people.”

—Dr. HersHey Bell


EMPLOYMENT AGREEMENTS AND ATTORNEY REPRESENTATION

I received a call recently from a young family practice physician very upset about what had just happened to him. Let’s call him “Bob.” The situation he described is, unfortunately, not uncommon.

Bob took his first job at a private practice a year and a half ago and had just been termi-nated. No reason was given for the termination and he claimed it came without warning. His suspicion was that the practice was not growing as rapidly as expected and that his termination was due to him taking business away from the other physicians in the group who owned the practice. No advanced notice was given and he was asked to leave the same day he got the news.

I was asked all the usual questions. Can they terminate me for no reason? Should I not have gotten some notice? Is my covenant not to compete (5 years and 30 miles) binding? I just bought a house – do I now have to move to find another job? He told me that the employment agreement he signed came from the employer. He did not hire an attorney to review. He was told by the practice that it was the same as the one signed by the prac-tice’s other employed physicians. This is unfortunately typical. I began to address his questions knowing he was not going to like the answers.

An employer can terminate an employee without cause if the employment agreement gives the employer that right. Almost all employment agreements the employer first offers a prospective employee will not contain rights in favor of the employee. Often they are added only after being requested by an attorney representing the prospective employee. Without specific details, whether the “non-compete” will be enforced is a dif-ficult question to answer, but once you sign an employment agreement the employer has the high ground. Litigating these issues routinely costs $25,000 or more.

With attorney representation when the employment agreement was entered into, the covenant not to compete might not have applied at all in this situation. It is unreasonable for an employer to have the right to terminate an employee for no reason the day after the employment agreement is signed and then restrict the employee from finding new employment when there is no harm of chance of harm to be suffered by the employer. Had this been negotiated at the outset, an attorney likely would have gotten this excep-tion to the application of the covenant not to compete in your employment agreement.

Do not be Bob. Do not make the mistake of signing an employment agreement with-out attorney review. Your MOA in partnership with its legal counsel offers an Employ-ment Contract Review Service. For a $500 fixed fee you are guaranteed an expert attorney review that covers all the issues raised above and others that you should consider. You should take advantage of this service and protect yourself.

DANIEL J. SCHULTE IS AN ATTORNEY WITH KERR, RUSSELL AND WEbER, PLC

HE CAN bE REACHED AT: [email protected]

DANIEL J. SCHULTE

THE PrACTICE MANAgEr

ElECTrONIC MEDICAl rECOrDSMAY CAST PHYSICIANS IN UNfAvOrABlE lIgHT

DUrINg lAWSUITSContributed by Keith L. Klein, MD, FACP, FASNN

W hile the electronic medical record (EMR) has advan-

tages, it also has introduced liability risks. EMRs can

lead to lawsuits or result in a weak defense by casting

the physician in an unfavorable light.

Examine these exchanges in a recent malpractice trial:

Plaintiff Attorney: Doctor, if the emergency renal consult was called in at 11:30, why did you wait until 6 PM to see the patient, during which time his kidneys became severely damaged?

Doctor: I did see the patient within 30 minutes.

Plaintiff Attorney: Where does it show that in the chart?

Doctor: Uh…it doesn’t, I guess. I saw the patient but wrote the note later.

Plaintiff Attorney: So you claim you saw this critically ill patient in 30 minutes, spent one hour evaluating him, but did not document your findings for another six hours?

And later in the trial:

Defense Attorney: But the lab record shows that the kidney function was declining…

Judge: [interrupting] The physician notes state each day that kidney function was normal. How do you explain that in the face of deteriorating kidney function? Why would a physician write that, unless he hadn’t looked at the lab testing or the patient?

• • •

EMRs can increase malpractice risk in documentation of clinical

findings—copying and pasting previously entered information

can perpetuate any mistakes that may have been made earlier.1

Incorrect information is the most common user-related contrib-

uting factor in malpractice cases involving EMRs, according to

a study by The Doctors Company of EMR-related closed claims

from 2007 to 2013.


In the study, 15 percent of cases involved pre-populating/copy-and-paste as a contributing factor. Copy-and-paste is a necessary evil to save time during documentation of daily notes, but whatever is pasted must also be edited to reflect the current situation. Too often the note makes reference to something that happened “yesterday.” For example, the sentence “Patient presented to ED with chest pain yesterday…” is pasted over the next two weeks in the daily prog-ress note. An even more telling example is a sentence like “Patient’s admitting lab is normal…” being perpetuated while the actual cre-atinine levels rise every day.

coPy-anD-PasteIn one case, the judge commented about copy-and-paste issues: “I cannot trust any of the physician notes in which this occurred and the only conclusion I can reach is that there was no examina-tion of the patient…it means to me that no true thought was given to the content that was going into ‘the note.’”

checKboxesCheckboxes, particularly those that pre-populate, can be a physi-cian’s nemesis. It’s easy to click on checkboxes, and often they are pre-checked in templates. EMRs have been presented in court that show, through checkboxes, daily breast exams on comatose patients in the ICU, detailed daily neurological exams done by cardiologists, and a complete review of systems done by multiple treating physi-cians on comatose patients. Questioning in court as to how long it takes to do a review of systems and a physical examination, the patient load of the physician for that day, and how many hours the physician was at work cast doubt on the truthfulness of the testify-ing physician. A time analysis showed that there was no way the physician could have accomplished all that was charted that day.

In one case that typifies how to impeach a doctor, it was clear that the doctor spent eight hours at work and, accounting for lunch, spent a little over seven hours seeing patients. But the total time


it was documented that he spent on each patient would have required his time at work to be 15 hours.

As one judge stated in court: “This medical record is simply not believable. I don’t know whether to fault the hospital, the company that wrote the software, or the physician, but the only one on trial here is the physician. In medical malpractice, the record must speak for itself, but this record is worse than silent. It is egregious.”

notesNotes can also be problematic. One issue that frequently comes up is the actual time the patient was seen. It is the accepted practice, especially on teaching rounds, to see all patients and then write notes at the end of the day. The EMR will automati-cally date and time-stamp the physician’s note as the time the note was created. This gives a misleading impression of when the patient was actually seen, and in a rapidly changing clini-cal situation, the note may not accurately reflect the patient’s clinical condition at the time the physician actually saw him. Therefore, it’s important to state in the note the specific date and time that the patient was seen and examined.

Reading an EMR is like taking a drink out of a fire hydrant—it is bloated with repetitive data, and critical findings can easily be missed. Copying information such as entire x-ray reports and lab data into notes only adds to this problem. Because the details of the chest x-ray can easily be looked up, the x-ray should only be summarized in the note, such as, “chest x-ray normal except for right upper lobe infiltrate consistent with a viral pneumonia.”

The fundamental mantra when writing a note in an EMR is to show that you put thought into the record. Discrete data, though strongly favored by IT professionals and insurance companies, does not accomplish this. Free-text entry of three or four sentences can convey far more information than several pages of template-driven notes and will reflect that you saw the patient and put thought into the note.

All these common EMR issues—incorrect information, copy-and-paste, and poor note-taking—cast doubt on the integrity of the doctor and the medical record. While the doctor may not have committed a clear-cut act of malpractice, these types of issues in the medical record cast the doctor in an unfavorable light in front of a judge or jury.

REFERENCES1Mangalmurti S, Murtagh L, Mello M. Medical malpractice liability in the age of electronic health records. N Engl J Med. 2010: 363:2060-2067.http://www.nejm.org/doi/full/10.1056/NEJMhle1005210?viewType= Print&. Accessed December 8, 2014.

Keith L. Klein, MD, FACP, FASN, is Clinical Professor of Medicine, David Geffen School of Medicine at UCLA.

116 Annual SpringScientific Convention

th

Thursday, May 14 - Sunday, May 17

Greetings from

Greetings from

Home of the Home of the Michigan Osteopathic Association116 Annual SpringScientific Convention

th

Thursday, May 14 - Sunday, May 17

We are back!

An opportunity to network with your colleagues, experienceoutstanding lectures and engage with exhibitors while reinforcing your commitment to the osteopathic profession.

For more information and to registervisit: mi-osteopathic.org/spring2015

http://www.nejm.org/doi/full/10.1056/NEJMhle1005210?viewType=Print&

http://www.nejm.org/doi/full/10.1056/NEJMhle1005210?viewType=Print&

DEAN’S COlUMN

bY WILLIAM STRAMPEL, D.O.

OSTEOPATHIC EDUCATION IS OUR THEMEEVERY DAY

This issue of TRIAD is very timely. Its focus on osteopathic education and the

future of our profession comes at a time when everyone is looking ahead

to a new year and continuing change as we move forward toward a unified

graduate medical education system.

I hope that as you read this issue and learn about

the many excellent facets of osteopathic education

in Michigan that you’ll share my strong sense of

optimism about where we are headed, both in this

coming year and into the future.

It’s especially gratifying to see how this issue will highlight some of the many facets that

make me proudest of osteopathic medicine in Michigan. There are outstanding faculty

members who are working every day to ensure that our MSU College of Osteopathic

Medicine students have the absolute best experience in their four years.

Whether it’s making sure that our curriculum provides the most thorough and relevant

information available, teaching classes, administering programs or guiding students

through their clerkship years, I’m immensely proud of the work that is done at MSUCOM

every day at our three sites, at dozens of hospitals and clinics across Michigan and

ultimately, in the amazing work of our alumni.

Learning does not stop when a student crosses the stage at graduation. The extensive

Statewide Campus System supports a network of clinical faculty (many of whom volunteer

their time) to train our graduates and supports young physicians as they continue their

education. We also contribute to lifelong learning through continuing medical education

and our long-running Healthy Lifestyles and Preventive Care course (formerly known as

Seminar in the Sun).

We value our partnership with the Michigan Osteopathic Association and the many ways

that we work together to promote osteopathic education across Michigan. Here’s to a strong

future our state, our students and our profession.

WILLIAM STRAMPEL, D.O., IS DEAN OF THE MICHIGAN STATE UNIVERSITY COLLEGE

OF OSTEOPATHIC MEDICINE. HE CAN bE REACHED AT [email protected].


ADvErTISEr INDEX

TRIAD STAFF

John Sealey, D.O, FACOS &

Kevin Leikert, OMS-II, Editors-in-Chief

William Strampel, D.O., Contributing Editor

Kris T. Nicholoff, CEO and Executive Director

Lisa M. Neufer, Director of Administration

Todd Ross, Manager of Communications

Cyndi Earles, Director, MOA Service Corporation

Marc A. Staley, Manager of Finance

Wendy Batchelor, Manager of Physician Advocacy

Carl Mischka, Advertising Representative

Stacia Love, reZüberant Design, Layout and Cover Design

2014-15 BoARD oF TRuSTeeS

Myral R. Robbins, D.O., FAAFP, FACOFP, President

Robert G.G. Piccinini, D.O., President-elect

Bruce A. Wolf, D.O., Secretary/Treasurer

Michael D. Weiss, D.O., Immediate Past President

Lawrence J. Abramson, D.O., MPH, &Craig Glines., D.O., MSBA, FACOOG, Department of Insurance

John W. Sealey, D.O., &Kevin Leikert, Department of Public Affairs

Lawrence L. Prokop, D.O. &Adam Hunt, D.O., MHS, Department of Education

Jeffrey Postlewaite, D.O. &David Best, D.O., Department of Membership

Patrick Botz, D.O., Department of Judiciary & Ethics

The osteopathic profession in Michigan is made up of osteopathic physicians, osteopathic hospitals and an osteopathic medical school. This TRIAD stands together to serve our patients and one another. TRIAD, the official journal of the Michigan Osteopathic Association, serves Michigan’s osteopathic community, including its osteopathic physicians, hospitals, medical school and patients.

The Michigan Osteopathic Association will not accept responsibility for statements made or opinions expressed by any contributor or any article or feature published in TRIAD. The views expressed are those of the writer, and not necessarily official positions of MOA. TRIAD reserves the right to accept or reject advertising. The acceptance of an advertisement from another health institution or practitioner does not indicate an endorsement by MOA.

TRIAD (ISSN 1046-4948; USPS 301-150) is published quarterly by the Michigan Osteopathic Association, 2445 Woodlake Circle, Okemos, MI 48864. Periodical postage paid at Okemos, MI 48864 and other post offices. Subscription rate: $50 per year for non-members. All correspondence should be addressed to: Communications Department, Michigan Osteopathic Association, 2445 Woodlake Circle, Okemos, MI 48864. Phone: 517.347.1555. Fax: 517.347.1566. Website: www.mi-osteopathic.org. Email: [email protected].

PoSTMASTeR: SeND ADDReSS ChANgeS To TRIAD,2445 WooDLAKe CIRCLe, oKeMoS, MI 48864.

©2015 MICHIgAN OSTEOPATHIC ASSOCIATION

fOr ADvErTISINg INQUIrIES,PlEASE CONTACT CArl MISCHKA

AT 888.666.1491Or vIA EMAIl AT

[email protected]


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DOES YOUR DOES YOURDOES YOUR MEDICAL MALPRACTICE MEDICAL MALPRACTICE MEDICAL MALPRACTICE MEDICAL MALPRACTICE INSURER INSURER INSURER KNOWKNOWKNOW WHICH PROCEDURES ARE MOST WHICH PROCEDURES ARE MOST WHICH PROCEDURES ARE MOST FREQUENTLY LINKED TO FREQUENTLY LINKED TOFREQUENTLY LINKED TO FREQUENTLY LINKED TO CARDIOLOGYCARDIOLOGY CARDIOLOGYCARDIOLOGY CLAIMS?CLAIMS? CLAIMS?CLAIMS?CARDIOLOGY CARDIOLOGYCARDIOLOGY CLAIMS?CARDIOLOGY CARDIOLOGYCARDIOLOGY

A5144_MI_MOA_EIS_Cardio_010715_v3.indd 1 1/7/15 1:57 PM

Triad winter 2015

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