July/August ECMS Bulletin Newsletter

www.escambiacms.org JULY/AUGUST 2013

BULLETIN

VOLUME 43, NO. 4

President’s Message

Upcoming Events July 26, 27, 28 FMA Annual Meeting Orlando, Florida August 13 Fall Risk & Prevention People’s Home Health 5:30 p.m.

September 29 Women in Medicine Hemingway’s Bimini Bar 11:00 a.m.

RSVP: 478-0706 info@escambiacms.org

Founded in 1873

Making a Difference in our Community How does a physician in Pensacola Florida make a difference and potentially change the legal system in Florida? I am proud to announce that one of our local physicians, Dr. David Turner, has done just that by creating a resolution that will be presented and voted upon at the Florida Medical Association’s Annual Meeting this July.

Dr. Turner, a gynecologist in Pensacola, was in a situation where a patient of his, who had in the past been noncompliant with care and follow up, went to the ER complaining of breast pain. A mammogram ordered by the ER physician in his name was abnormal. When he received the abnormal mammogram report he looked through his records on this patient and it had been a while since he had seen her in the office. He knew he was responsible for contacting this patient and following up with her on her abnormal mammogram. Keeping in mind her history of noncompliance, Dr. Turner called the FMA and his medical malpractice insurance carrier and asked if there was any law in place that made a doctor nonliable for a patient if the patient had not had contact with that physician for years. He was informed there is no such law in Florida. This inspired him to write Resolution 13-313 which was endorsed by our medical society. (Please see page 6 to read Resolution 13-313.)

Every November the Escambia County Medical Society holds an election for the following positions: President, President-Elect, Vice-President, Secretary/ Treasurer, (3) Members at Large, Delegates to the FMA and Alternate Delegates. Each July we take those delegates to the FMA Annual Meeting so our two counties have a voice. A resolution may be written by a county or specialty medical society, individual delegates, or special sections. Once all resolutions have been proposed and written the FMA sends out a handbook of all the resolutions to all delegates prior to attending the FMA annual meeting in July.

This year our medical society will host our annual resolutions review meeting on Wednesday July 17, 5:30p.m. at 1549 Airport Blvd. Pensacola, Florida, 32504. The FMA Annual Meeting will take place Friday, July 26- Sunday, July 28 in Orlando, Florida. If you are interested in attending the local

ECMS resolutions review meeting please contact Erica Huffman, Executive Director to RSVP (850-478-0706 x2).

Wendy Osban, D.O. The FMA Annual Meeting has a packed schedule. Each ECMS delegate has an opportunity to attend FREE CME courses and leadership classes Friday followed by an open reception. Friday night the North Florida Delegates including Duval County Medical Society, Capitol Medical Society, Bays County Medical Society, and Escambia and Santa Rosa County Medical Society will gather and discuss late resolutions, political business, nominations for FMA board positions, and other business.

The schedule continues early Saturday and Sunday mornings with the Northwest Florida Caucus Meeting. In this meeting delegates from Capitol Medical Society, Bays County Medical Society, and Escambia & Santa Rosa County Medical Society will discuss all approved resolutions set forth in the FMA handbook. The day will proceed with the FMA House of Delegates, Reference Committee Meetings, and the FMA Installation Ceremony.

Each year FMA delegates have an opportunity to nominate themselves for a reference committee.

Every resolution is assigned to a reference committee. This year Dr. John Lanza will be serving on Reference Committee I: Health, Education, and Public Policy. The purpose of a Reference Committee is to provide FMA members the opportunity to appear and be heard and have a voice in the business of the Association.

In years past the Escambia County Medical Society has had resolutions approved. Dr. Branhorst and Dr. Lanza both wrote resolutions that have been approved. I encourage any physician in the community to become active in this aspect of medicine.

If you are interested in becoming a leader or if you would like more information about how you may become more involved next year please contact one of our board members or our Executive Director.

E.C.M.S. Bulletin

The Bulletin is a publication for and by the members of the Escambia County Medical Society. The Bulletin publishes six times a year: Jan/Feb, Mar/Apr, May/ Jun, Jul/Aug, Sept/Oct, Nov/Dec. We will consider for publication articles relating to medical science, photos, book reviews, memorials, medical/legal articles, and practice management.

Vision for the Bulletin:

路 Appeal to the family of medicine in Escambia and Santa Rosa County and to the world beyond. 路 A powerful instrument to attract and induct members to organized medicine.

Views and opinions expressed in the Bulletin are those of the authors and are not necessarily those of the directors, staff or advertisers.

Editors: Brian Kirby, MD Erica Huffman, Executive Director

Ad placement Contact Erica Huffman at 478-0706 Ad rates 1/2 page: $300 路 1/4 page: $150 路 1/8 page: $100

2013 ECMS officers President - Wendy Osban, D.O. President-Elect - Susan Laenger, M.D. Vice President - Christopher Burton, M.D. Secretary/Treasure - Brian Kirby, M.D.

Contents Page 3 - New Members/ ECMS Young Physicians Section Page 4 - Corrections to 2013 Pictorial Directory/ Updated Calendar Page 5 - Reporting your ECMS CME to CE Broker Page 6 - Resolution 13-313 Page 7 - Why Healthcare Reforms Will Inevitably Create More Lawsuits Page 8 & 9 - Diagnosis & Treatment of Acute Pulmonary Embolism Page 10 - In the Community News

Membership

ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY

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NEW MEMBERS Ana Antonetti, M.D. FSU COM OB/GYN 5045 Carpenter Creek Drive Pensacola, FL 32503 (P) 850-416-2400 (F) 850-475-5964 Alexander Coleman, M.D. Andrews Orthopaedic & Sports Medicine Hand and Wrist Surgery 1040 Gulf Breeze Parkway Gulf Breeze, Florida 32561 (P) 850-916-3700 (F) 850-916-3710 Welcome Juliana Matthews, FSU COM M3 who will be joining Rick Sims, FSU COM M4 on the ECMS Board as the Student Liaison’s.

Caitlin Dunham, M.D. FSU COM OB/GYN 5045 Carpenter Creek Drive Pensacola, FL 32503 (P) 850-416-2400 (F) 850-475-5964 Carie Fletcher, D.O. Gary Gotthelf, M.D., PA Family Medicine 4511 N. Davis Highway Suite 1C Pensacola, FL 32503 (P) 850-477-3252 (F) 850-477-2659

Heba El Goweni, M.D. Navarre Pediatrics, P.L. Pediatrics 8880 Navarre Parkway Suite 102 Navarre, FL 32566 (P) 850-939-5550 (F) 850-939-5445 Eric Kujawski, D.O. Sacred Heart Orthopedics Family Medicine, Primary Care Sports Medicine 4541 A North Davis Highway Pensacola, FL 32503 (P) 494-9000 (F) 474-4123 Lindsey McAlpin, M.D. FSU COM OB/GYN 5045 Carpenter Creek Drive Pensacola, FL 32503 (P) 850-416-2400 (F) 850-475-5964 Omaima Mousa, M.D. Navarre Pediatrics, P.L. Pediatrics 8880 Navarre Parkway Suite 102 Navarre, FL 32566 (P) 850-939-5550 (F) 850-939-5445

Brittney Williams, M.D. FSU COM OB/GYN 5045 Carpenter Creek Drive Pensacola, FL 32503 (P) 850-416-2400 (F) 850-475-5964 Kevin Yan FSU COM, M3 5045 Carpenter Creek Drive Pensacola, FL 32503 (P) 850-416-2400 (F) 850-475-5964 Updated Physician Information: Barry Callahan, MD Pensacola Hand & Microsurgery Hand Surgery 9400 University Parkway Suite 406 Pensacola, FL 32514 (P) 850-916-8711 (F) 850-916-8629 Retiring Dr. Troy Tippett will retire from practice on August 1, 2013. Dr. Tippet was ECMS 123rd president in 1996.

We appreciate his involvement and service throughout the years. Dr. Tippett was also the Florida Medical Association President in 2005-2006.

ECMS Young Physicians Section

(left) Dr. John Katopodis explains Organized Medicine at the state and local level. (right) Dr. Fred Mixon talks about how to prevent physician burnout

The Escambia County Medical Society hosted the first annual Young Physicians Section Meeting on Tuesday July 9th at Cactus Flower. Topics included Organized Medicine at the State and Local Level, Prevention of Physician Burnout and Debt Management.

Our first presentation of the evening was given by Dr. John Katopodis. Dr. Katopodis is an Interventional Cardiologist practicing in Tallahassee, Florida. Dr. Katopodis has been a member of the Florida Medical Association since 1987 and is currently serving as the District A Representative. Our second presentation was given by Dr. Fred Mixon. Dr. Mixon is a local Family Practitioner and has been involved in Physician leadership and management roles at Sacred Heart Medical

Group for almost 30 years. Our final presentation of the evening was the Debt Management presentation which was given by North Florida Financial representatives Richard McCool and Bessann Watson. Richard and Bessann provide advanced services to businesses and families across the country in developing broad based financial strategies including retirement income strategies, and asset protection.

We would also like to thank our sponsors for helping to make this night possible Financial Design Associates, McMahon & Hadder Insurance, and Underwood Anderson & Associated, Inc. For a complete list of ECMS events visit our website: www.escambiaCMS.org

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Membership Corrections to the 2013 Pictorial Directory

ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY

Win Hansen, M.D. Ophthalmology 2020 Langley Avenue Pensacola, Fl 32504 (P) 850-476-8467 (F) 850-476-8468

Christopher E. Burton, M.D. Physical Medicine & Rehabilitation 8333 N. Davis Highway Pensacola FL, 32514 Phone: 850-969-2563 Fax: 850-969-2564

Leo Carney, D.O. Family Medicine 6000 W. Highway 98 Pensacola, Florida 32512 Phone: 850-505-6380 Fax: 850-505-6501

Ken Garrett, M.D. Pain Management, Anesthesiology 4624 N. Davis Highway Pensacola, Fl 32503 Phone: 850-494-0000 Fax: 850-494-0001

Updated Calendar July 26, 27, 28, 2013 FMA Annual Meeting Orlando, Florida 2013 ECMS Event Calendar

November 2013 | Strategic Health Intelligence Summit General Membership Meeting Sponsor (social|dinner): Underwood Anderson | Caduceus

August 13, 2013 | People’s Home Health |5:30p General Membership Meeting [1 AMA PRA Category 1 Credit™] Topic: “Fall Risk & Prevention” Speaker: Stephen Slobodian, M.D. Sponsor: People’s Home Health

December 10, 2013 | Hancock Bank |5:30 General Membership Meeting [2 AMA PRA Category 1 Credit™] Topic: Medical Errors Speaker: TBA Sponsor: Hancock Bank

September 29, 2013 | Hemingway’s Bimini Bar |11:00a Women in Medicine Brunch Sponsors: Baptist Healthcare | Emerald Coast Hospice | Fisher Brown Bottrell Insurance

January 25, 2014 | TBD ECMS Inaugural Ball President-Elect Susan Laenger, M.D.

October 8, 2013 | Pensacola Yacht Club | 5:30p General Membership Meeting Topic: Asset Protection/Wealth Management/Comprehensive Planning

Speaker: Jason Dyken, MD Sponsor: MAG Mutual Insurance & McMahon Hadder Insurance

DOCTOR’s OFFICE FOR RENT Gulf Breeze on Highway 98 FURNISHED Available now 1/2 or Full Day any day except Wednesday Contact: John Garner, M.D. 516-3274/3273

Practice Management

ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY

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Reporting your ECMS CME to CE Broker Dear ECMS Members: For all future license renewals, the state of Florida will require that physicians report at least 40 CME credits (including their required courses) to its endorsed system, CE Broker.

Please visit cebroker.com to login or to set up your account.

The Basic Account for self-reporting is free, and allows you to upload your MECOP transcript in just a few simple steps.

There are also other account options where CE Broker will report on your behalf. Note that there are fees associated with these account options.

To upload your MECOP CME transcript, you simply log in to your account, and report your CME by hospital/association transcript. This allows for a mass upload of your transcript.

It should take only a few minutes and there is no need to do this on an ongoing basis. Just do so a few weeks before license expiration to ensure all of your credits and requirements are accounted for.

Note that if you are directly employed by Sacred Heart Hospital, they will upload your MECOP transcript as an employee courtesy if you contact the Medical Staff Services Department and provide your CE Broker username and password.

Any questions regarding the upload process must be directed to CE Broker. If you have other questions relating to CME reporting and the new requirement, please visit ceatrenewal. com, or contact CE Broker at 1-877434-6323, as the Medical Educational Council of Pensacola is not affiliated with the state or its licensing board.

We are a national provider and are only required to report to the AMA and the ACCME. Reporting to the state and to individual licensing boards is a responsibility of each the individual physician licensed in this state.

Sincerely, Jenna Coleman, MA, CCMEP Executive Director Medical Educational Council of Pensacola 850.477.4956 (option 1) office

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ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY

Medical/Legal

Medical/Legal Why Healthcare Reforms Will Inevitably Create More Lawsuits

ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY

The one conclusion we can all agree upon as healthcare reforms begin is that by definition change is happening in medicine. With change comes potential for an explosion of lawsuits against doctors and hospitals if we are not careful. As we all know very early in the debate leading to the healthcare reform package passing President Obama crushed any hope of tort reform so our help will only come from bottom up action, not from the top down. So where do we start is the question.

The answer comes from the fact that a majority of malpractice lawsuits stem from some sort of communication failure, not from surgical or diagnostic errors. As the alignments change in the medical industry we must keep in mind that if we do not set up the right communication links and systems then things on the liability front could get ugly quickly given the shifting sands of practice profiles. The concept of the medical home and its promise of a seamless continuum of care is a great idea and will surely drive up patient satisfaction in the end. Satisfied patients sue less, but it is the complex process of realigning the existing practices to get to the medical home that could become the issue. Just think of all of the challenges of just unifying the IT systems in every practice involved in a medical home as one element of the needed changes to come and you will realize what a critical but problematic link this is to better communications and thus less lawsuits. Layer on top of those realignment issues a severe doctor shortage and then thirty million new patients and the problems begin to take on a new importance to liability concerns. According to a recent Harvard study only 1.5% of patients harmed by malpractice actually sue, so if we end up in our medical realignment process for some years before working through the kinks we can only expect more and more lawsuits from more frustrated patients. Then add one more layer onto these issues: the inevitable change in the malpractice insurance

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By Matt Gracey, Danna-Gracey Insurance Agency

market cycle from being very favorable to doctors for the last six or seven years to a tougher market. The last few years the malpractice insurers have lowered profit margins to fend off competitors. Most of the insurers have even been able to even lower their claims reserves in what they call “reserve takedowns, and this has boosted their profits enough to maintain the lower rates, but that trend will end soon. In addition many believe that a number of recent tort reforms will be overturned like recently happened in Illinois and Georgia.

So as we hike through the foothills toward the mountains of change coming in our healthcare system doctors should expect to pay a good bit more for their malpractice insurance coverage as more lawsuits are filed and the market cycle changes.

Should you like to speak to a local representative regarding this article please feel free to contact Julie Danna, at the newly established Danna-Gracey Panhandle office, at 850-530-3924 or 877-720-0144.

Medical/Legal 8 David B. Troxel, MD, Diagnosis and Treatment of ByMedical Director, Board of Governors, The Doctors Company Acute Pulmonary Embolism ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY

In a review of 363 consecutive closed claims from January 2004 through January 2006 at The Doctors Company, 3 percent involved deep venous thrombosis (DVT) and pulmonary embolism (PE). Most malpractice claims of this type result from the failure to recognize patients at high risk for venous thromboembolism (VTE) and implement appropriate prophylaxis, failure to diagnose DVT in patients who subsequently have a PE, and failure to rule out PE in patients with nondiagnostic pulmonary symptoms. When VTE is seriously considered in the differential diagnosis, it should be confirmed or excluded by appropriate testing.

In the fourth quarter 2008 issue of The Doctor’s Advocate, I reviewed the risk factors for VTE, the prevention of VTE, and the diagnosis of DVT. The discussion in this issue will focus on the diagnosis and treatment of acute pulmonary embolism.

Diagnosis of Acute PE Without treatment, pulmonary embolism has a mortality rate of 30 percent, resulting largely from recurrent embolism. Most emboli are multiple, primarily involve the lower lobes, and cause pulmonary hemorrhage. Only 10 percent of emboli cause pulmonary infarction. The symptoms and signs of PE are relatively nonspecific and include dyspnea, pleuritic pain, cough, hemoptysis, tachypnea, and tachycardia. Fewer than one-third of patients have symptoms or signs of DVT. Lab tests often show leukocytosis and elevation of lactate dehydrogenese (LDH) and aspartate aminotransferase (AST) with normal bilirubin. Troponin 1 and troponin T are elevated in 30 to 50 percent of patients with moderate to large PE, due to right ventricular strain. Arterial blood gases (ABGs) may show hypoxemia, hypocapnia, and respiratory alkalosis; however, these changes are often absent, so ABGs have limited diagnostic value. ECG and chest x-ray abnormalities are usually nonspecific and are seldom helpful diagnostically. Echocardiograms show abnormalities suggestive of PE in 30 to 40 percent of patients (increased right ventricular size, decreased RV function, and tricuspid regurgitation). Clinical assessment and these studies alone are usually not sufficient to reliably confirm or exclude the diagnosis of PE—and further testing is required.

•

• •

•

Ventilation/perfusion lung scan (V/Q scan) is the best validated noninvasive approach to evaluating patients with suspected PE. However, a high percentage of scans are nondiagnostic, and scans are most useful when they are either negative or indicate a high probability of PE. • Patients with both a high clinical and high V/Q scan probability have a 95 percent likelihood of PE. • Patients with both a low clinical and low V/Q scan probability have a 5 percent likelihood of PE. • A normal V/Q scan virtually excludes PE. Pulmonary angiography is the definitive diagnostic test. When negative, the diagnosis of clinically significant PE is excluded.

Spiral (helical) CT scanning with intravenous contrast (CT pulmonary angiography, CT-PA) is an increasingly available noninvasive approach, although results vary depending on the experience of the person interpreting the images: • 83 percent of patients with PE have a positive CT-PA (sensitivity).

• 96 percent of patients without PE have a negative CT-PA (specificity).

CT-PA in conjunction with the modified Wells score.

• If the CT-PA is positive, the likelihood of PE in patients with high, intermediate, or low clinical probability is 96, 92, and 58 percent, respectively.

• If the CT-PA is negative, the likelihood that PE is absent in patients with low, intermediate, or high clinical probability is 96, 89, and 60 percent, respectively.

A Practical Approach to the Diagnosis of Acute PE 1.

CT experienced institutions: • If PE is suspected, apply the modified Wells criteria (clinical criteria used to estimate the probability of PE).

• If a patient is classified as PE unlikely, proceed to the D-dimer test. A negative test (<500 ng/ml) excludes PE. • Patients classified as PE likely or who are PE unlikely with elevated D-dimer levels (>500 ng/ml) should undergo CT-PA. A positive CT-PA confirms the diagnosis of PE; if negative, PE is excluded.

2.

CT inexperienced institutions: • If PE is suspected, apply the modified Wells criteria and obtain a V/Q scan.

• A normal V/Q scan regardless of clinical probability excludes PE. • A low probability V/Q scan plus a low clinical probability excludes PE. A high probability V/Q scan plus a high clinical probability confirms PE. • For all other combinations, obtain either pulmonary angiogram or serial lower extremity venous ultrasound examinations.

Medical/Legal Diagnosis and Treatment cont.

ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY

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Treatment of VTE Most deaths from PE occur within the first few hours due to recurrent PE. Therefore, if there is high clinical suspicion or a diagnosis of PE, anticoagulant therapy is promptly initiated—usually with subcutaneous low molecular weight (LMW) heparin or intravenous unfractionated heparin with the goal of achieving a therapeutic level within the first 24 hours. Heparin should be continued for at least five days. For most patients, oral anticoagulation can be started simultaneously with the heparin and overlapped with heparin for at least four to five days. Heparin can be discontinued on day five or six if the internationalized normalized ratio (INR) has been therapeutic for two consecutive days. Persistent hypotension due to PE is an accepted indication for thrombolytic therapy. However, due to the risk of major hemorrhage, anticoagulation must be temporarily discontinued during infusion.

Hospital medical staff protocols for the treatment of VTE should be followed.

Additional Resources Each of the following references is from UpToDate, Rose BD (Ed), UpToDate, Waltham, MA 2008. Copyright 2008 UpToDate, Inc. Accessed on November 28, 2007. For more information, visit www.uptodate.com.

Thompson BT, Hales CA. Overview of acute pulmonary embolism.

Thompson BT, Hales CA. Diagnosis of acute pulmonary embolism.

Tapson VF. Treatment of acute pulmonary embolism.

The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.

The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.

The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

The Doctor’s Advocate is published quarterly by Corporate Communications, The Doctors Company. Letters and articles, to be edited and published at the editor’s discretion, are welcome. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of The Doctors Company. Please sign your letters, and address them to the editor.

Reprinted with permission. ©2013 The Doctors Company (www.thedoctors.com). This article originally appeared in The Doctor’s Advocate, first quarter 2009.

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In the Community

ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY

Hospital News - Sacred Heart Hospital Patient-Tower Construction Update From the busy intersection of Ninth Avenue and Bayou Boulevard, Sacred Heart’s very visible five-story patient-care tower appears nearly complete. As of early July, Greenhut Construction crews were completing the roofing, windows and the exterior finish on all four faces.

Two floors in the new tower will be dedicated intensive care units, each with 20 patient rooms, for a total of 40 ICU beds. Two more floors of the tower will be dedicated for Medical/Surgical patient units. The 50 total private rooms on these floors will ultimately allow Sacred Heart to convert existing semi-private patient rooms in the main hospital to private patient rooms. The top floor of the new tower will provide 22 beds for a new Total Joint Replacement Center and will include an 800-sq.-ft. rehab area.

The new tower’s 112 all-private patient rooms are scheduled to be complete Spring of 2014 and will open to patients July 2014. The addition will allow Sacred Heart to improve patient experience, expand services and meet the community’s need for more beds for critically ill patients.

Bedside Delivery of Prescriptions Available at Sacred Heart Hospital Patients at Sacred Heart Hospital now can have their prescriptions quickly filled and delivered directly to their room by the Walgreens pharmacy that is located on Sacred Heart’s Pensacola campus. Patients will receive their prescriptions prior to being discharged, eliminating an extra stop between hospital and home.

Beyond providing an easy, time-saving option for obtaining prescriptions and supplies, the bedside delivery service can also help improve patients’ compliance with medication therapy prescribed by their physicians, which in turn, can help speed recovery and help prevent unnecessary readmission to the hospital.

The bedside-delivery service is available to patients from 8 a.m. to 6 p.m., Monday through Friday.

ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY

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www.escambiacms.org

8800 University Pkwy., Suite B Pensacola, FL 32514 Ph: 850-478-0706 Fx: 850-474-9783 Email: info@escambiacms.org Executive Director: Erica Huffman

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Member Benefit: The Health Care Attorney On Call Hotline (561) 306-5699 View and opinions expressed in the Bulletin are those of the authors and are not necessarily those of the board of directors, staff or advertisers. The editorial staff reserves the right to edit or reject any submission.