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AUGUST 2016 • COVERING THE I-4 CORRIDOR

Celebration Orthopaedic & Sports Medicine Institute New Physicians Elevate Medical Team’s Game

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AUGUST 2016 COVERING THE I-4 CORRIDOR

 COVER STORY

PHOTO: DONALD RAUHOFER / FLORIDA MD

Three new physicians have joined Celebration Orthopaedic & Sports Medicine Institute, enhancing the depth and breadth of expertise and complementing the patient-focused approach. Orthopedic surgeon Jose Amundaray, M.D., was recruited from Clearwater, where he was widely known for joint replacement. Foot and ankle surgeon and podiatrist Joshua Britt, D.P.M., represents a new generation of specialists who embrace the latest in treatment and pain management. Many of Celebration Orthopaedic’s patients now find comfort in speaking their native Spanish with Dr. Amundaray and Dr. Britt, both of whom are bilingual. Primary care sports medicine physician Douglas McDonald, M.D., brings a non-surgical perspective to treating orthopedic problems and great experience with athletes and team sports.

16 SELF-DIAGNOSE YOUR PRACTICE WITH THE SUPPORT OF MEDICAL OFFICE RESOURCES OF FLORIDA 21 A SPORTS MEDICINE APPROACH TO REHAB 23 STELLAR LINEUP OF SPEAKERS POSITIONS AID’S INDEPENDENCE IN ACTION AS ‘MEETING OF THE YEAR’ FOR INDEPENDENT DOCS

PHOTO: DONALD RAUHOFER / FLORIDA MD

ON THE COVER: (Left to right): Douglas McDonald, M.D. Jose Amundaray, M.D. Matthew Johnston, D.O. Joseph Robison, M.D. Brad Homan, D.O. Maahir Haque, M.D. Joshua Britt, D.P.M.

DEPARTMENTS 2

FROM THE PUBLISHER

PULMONARY & SLEEP DISORDERS

MARKETING YOUR PRACTICE

10 HEALTHCARE BANKING, FINANCE AND WEALTH 11 ORTHOPAEDIC UPDATE 12 CANCER 14 INPATIENT REHABILITATION 17 DIGESTIVE AND LIVER UPDATE

FLORIDA MD - AUGUST 2016 1

FROM THE PUBLISHER

am pleased to bring you another issue of Florida MD. If you think about it, breathing is something we take for granted. We don’t consciously think about every breath we take. We hear a lot about breast and prostate cancer, but lung cancer is the number one cause of cancer death for both men and women in the United States. Please make any of your patients aware of the Lung Force Expo coming up in October. Best regards,

Donald B. Rauhofer Publisher

DETECTING LUNG CANCER EARLY MAY SAVE YOUR LIFE Lung cancer is the number one cause of cancer death for both men and women in the United States. The five-year survival rate for lung cancer patients is a dismal 16 percent. The good news is that new screening guidelines could dramatically improve lung cancer survival rates by finding the disease at an earlier, more treatable stage. The U.S. Preventative Services Task Force estimates that if physicians screen everyone who is at high risk for lung cancer, lung cancer deaths will be reduced by 14 percent. The Task Force recommends an annual screening for lung cancer in adults age 55 to 80 years old with a heavy smoking history who are current smokers or who have quit within the past 15 years. Talk with your patients about the risk factors for lung cancer, including their age and history of smoking. To learn more about lung health, attend the American Lung Association in Florida’s LUNG FORCE Expo on Friday October 21, 2016 at SeaWorld Orlando. The LUNG FORCE Expo brings together healthcare professionals, patients and families to discuss advances in lung cancer and lung disease research, treatment options and patient resources. For more information and to register, visit LUNGFORCE.org/Expo. What you learn may help save your life.

COMING NEXT MONTH: The cover story focuses on John R. T. Monson, MD, Medical Director for Colorectal Surgery Florida Hospital System, and his vision for the comprehensive Colorectal Surgery program at Florida Hospital. Editorial focus is on Pediatrics and Advances in NICU’s. ADVERTISE IN FLORIDA MD

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Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: Heidi Ketler, Harinath Sheela, MD, Daniel Landau, MD, Richard C. Senelick MD, Hadi Chohan, MD, Jeff Holt, CMPE, VP, Jennifer Thompson, Julie Sexton, PT, CSCS, Corey Gehrold, Marni Jameson Carey Art Director/Designer: Ana Espinosa Florida MD is published by Sea Notes Media,LLC, P.O. Box 621856, Oviedo, FL 32762. Call (407) 417-7400 for more information. Advertising rates upon request. Postmaster: Please send notices on Form 3579 to P.O. Box 621856, Oviedo, FL 32762. Although every precaution is taken to ensure accuracy of published materials, Florida MD cannot be held responsible for opinions expressed or facts expressed by its authors. Copyright 2012, Sea Notes Media. All rights reserved. Reproduction in whole or in part without written permission is prohibited. Annual subscription rate $45.

PULMONARY AND SLEEP DISORDERS

The Unexplained Chronic Cough By Hadi Chohan, MD The origin of the word cough can be traced to a German word kuchen which translates to “breathe heavily” and French old English cohhian which means “to shout.” The symptom of cough is a significant health burden and is one of the most common complaints leading to outpatient evaluations. Specifically, the evaluation and management of cough can account for up to 40% of outpatient pulmonary practices. Persistent cough of an unexplained origin can occur in 5-10% patients with chronic cough. The cough reflex is a complex pathway and much has been researched recently (FIGURE 1). Cough receptors exist not only in the epithelium of the upper and lower airways but are also present in the esophagus, stomach, diaphragm, and pericardium. Chemical receptors can trigger the cough reflex through activation of ion channels with response to multiple exposures including acid, cold, heat, and chemical irritants. Mechanical cough receptors are also triggered by touch or other pressures. The impulses from these stimulated cough centers send signals through an afferent pathway via the vagus nerve to a “cough center” in the medulla. The production of a cough is generated as the response through the efferent pathway back down to the vagus, phrenic, and spinal motor nerves to the expiratory muscles. The initial evaluation of cough is to determine its duration to obtain the most accurate differential diagnoses. A cough that is present for up to three weeks is acute, with subacute cough defined as symptoms present between three and eight weeks. Much of the differential diagnoses for these two categories are infectious in nature or medication-induced such as angiotensin converting enzymes (ACE) inhibitors. Any cough that persists past eight weeks is a chronic cough. 90% of etiologies of chronic cough can be attributed to three conditions: upper airway cough syndrome, asthma, and gastroesophageal reflux (GERD). These can occur alone or in combination. One study has shown that in patients who are nonsmokers, not on an ACE inhibitor and have a normal chest radiograph 99.4% of chronic cough can be attributed to the three most common etiologies. For this reason, empiric treatment options for chronic cough include: bronchodilators, intranasal and inhaled corticosteroids, antihistamines, and reflux treatment (pharmacologic and non-pharmacologic.) Less common etiologies such as malignancy and non-asthmatic eosinophilic bronchitis can occur and should be sought if clinical history for these conditions are present. Despite efforts to treat patients with chronic cough, symptoms can persist and are then classified as the unexplained chronic cough (UCC). These are usually patients that have cough persisting for six months despite treatments to address the most common causes. Recent guideline statements have addressed management algorithms for UCC. Neuromodulatory therapies have been found to have significantly improved quality of life in three randomized control trials. These include gabapentin, amitryptiline, and morphine. These agents act on the enhanced neural sensitization that is a key component of the cough reflex arc. Carefully

monitored uptitration is crucial. The side effect profile of these agents needs to be discussed with the patient prior to initiation. These include confusion, dizziness, dry mouth, nausea and headache. Speech therapy has also been shown to improve quality of life and cough severity in UCC. Interestingly, studies have shown no improvement of UCC with high-dose proton pump inhibitors (in patients without symptoms of GERD) as well as no improvement of quality of life with macrolide therapy. UCC is often a clinical dilemma for health-care providers. Despite an exhaustive work-up and empiric treatment trials, the cough persists in a small subset of patients. New studies have shown promise using neuromodulatory treatments that may help patients suffering from this challenging problem. While not life threatening, UCC can be embarrassing and can be associated with other problems (such as stress incontinence, headache, musculoskeletal pain,hoarseness and rib fractures) that are very debilitating to patients and utilize extensive health care resources.

FIGURE 1 The Lancet Volume 371, No. 9621, p1364–1374, 19 April 2008

Hadi Chohan, M.D attended medical school at St. George’s University in Grenada, West Indies and completed an internship and residency in Internal Medicine at East Carolina University Brody School of Medicine in Greenville, North Carolina. He then went on to obtain further fellowship training in Pulmonary/Critical Care Medicine at Virginia Commonwealth University/Medical College of Virginia in Richmond, Virginia. Dr. Chohan joined Central Florida Pulmonary Group in 2014. He may be contacted at (407) 841-1100.  FLORIDA MD - AUGUST 2016 3

COVER STORY

Celebration Orthopaedic & Sports Medicine Institute – New Physicians Elevate Medical Team’s Game By Heidi Ketler Three new physicians have joined Celebration Orthopaedic & Sports Medicine Institute, enhancing the depth and breadth of expertise and complementing the patient-focused approach. Orthopedic surgeon Jose Amundaray, M.D., was recruited from Clearwater, where he was widely known for joint replacement. Foot and ankle surgeon and podiatrist Joshua Britt, D.P.M., represents a new generation of specialists who embrace the latest in treatment and pain management. Many of Celebration Orthopaedic’s patients now find comfort in speaking their native Spanish with Dr. Amundaray and Dr. Britt, both of whom are bilingual. Primary care sports medicine physician Douglas McDonald, M.D., brings a non-surgical perspective to treating orthopedic problems and great experience with athletes and team sports. The new physicians join the elite team of Brad Homan, D.O.; Maahir Haque, M.D.; Matthew Johnston, D.O.; and Joseph E. Robison, M.D. Dr. Homan is president of Celebration Orthopaedic & Sports Medicine Institute and Medical Director of sports medicine at Florida Hospital Celebration Health. Dr. Johnston is Medical Director of the Joint Replacement Center at Florida Hospital Kissimmee. Dr. Robison is Medical Director of the Hand and Wrist Clinic Maahir Haque, MD and assistant chief of staff at Florida Hospital Kissimmee. Dr. Haque is actively involved in the national and international spine surgery community. Completing the Celebration Orthopaedic medical team are its experienced physician assistants, Crista Hays, P.A.-C., and Michael Taylor, P.A.-C. Celebration Orthopaedic & Sports Medicine Institute provides Joseph E. Robison, MD 4 FLORIDA MD - AUGUST 2016

comprehensive care and advanced expertise in sports medicine, joint replacement, hand and upper-extremity disorders and microsurgery, spine surgery and foot and ankle surgery. The goal is to return patients to their normal functioning, whatever their age or activity level. From the front desk to the exam room, compassion for individual patients and team spirit run deep. Numerous patient testimonials on the celebrationorthopaedics.com website express gratitude.

JOINT RECONSTRUCTION POWERHOUSE A specialist with the expertise of Jose Amundaray, M.D., was needed after practice founder, David D. Dore, M.D., retired in 2014, according to Dr. Homan. “Dr. Amundaray was the perfect fit.” Dr. Amundaray has considerable expertise in treating degenerative conditions of the hip and knee and in performing partial knee replacement surgery. Since the start of an accomplished career some 15 years ago, Dr. Amundaray has performed thousands of joint replacements on the Gulf Coast and more partial knee replacements than most surgeons in the United States. He also is adept in the use of other orthopedic minimally invasive and surgical procedures, such as arthroscopy. Knowing of Dr. Dore’s retirement and the large Spanish-speaking population in Osceola County, Dr. Amundaray remembers thinking, “Celebration Orthopaedic would be a perfect spot for me.” After joining Celebration Orthopaedic & Sports Medicine Institute, Dr. Amundaray also accepted the position of director of the Joint Reconstruction Program at Florida Hospital Celebration Health, a post formerly held by Dr. Dore. A native of Puerto Rico, Dr. Amundaray earned his bachelor of science and medical degrees from the University of Puerto Rico, where he also finished his orthopedic surgery residency. He then completed a general surgery residency at Mount Sinai Medical Center and an adult reconstruction fellowship at the University of Texas School of Medicine at San Antonio.

BEST FOOT FORWARD Joshua Britt, D.P.M., is Celebration Orthopaedic’s first podiatrist and foot and ankle surgeon. Born in Hattiesburg, Miss., and raised in Baton Rouge, La., Dr. Britt earned his undergraduate degree in biochemistry from Southeastern Louisiana University and his medical degree from Barry University School of Podiatric Medicine in Miami. He completed his residency in the Florida Hospital East Orlando Podiatric Medicine and Surgery program. Dr. Britt specializes in trauma, sports medicine, reconstructive foot and ankle surgery, pediatric foot issues and general foot

health care. He partners with running clubs, serving as a resource for prevention and treatment of running-related injuries. Dr. Britt’s practice is enhanced by his ability to speak fluent Spanish, which he learned during two years of missionary service in Mendoza, Argentina. Celebration Orthopaedic had been on Dr. Britt’s radar. “I’ve wanted this job ever since I was halfway through residency. When it became available, I jumped on it. This is a good group of professional, forward-thinking doctors, and central Florida is a great area,” Dr. Britt says. “Dr. Britt has a great personality and sincerely enjoys giving his patients the best foot and ankle care possible. He prides himself on formulating Dr. Amundaray (left) discusses a patient’s knee X-ray and condition with Dr. Britt. Dr. long-lasting relationships with his patients, so he Amundaray has over 15 years experience in partial knee replacements; something not many physicians in Central Florida can perform. may give them the quality of care they deserve,” says Dr. Johnston. “Adding Dr. Britt to our team was a very easy decision, and we are lucky to have him.”

EXCELLENCE WITHOUT SURGERY “A large percentage of orthopaedic conditions and injuries have nonsurgical treatment options, and Dr. McDonald possesses a high level of expertise in those areas,” says Dr. Robison. “Having Dr. McDonald as a part of our practice allows us to provide a new level of patient accessibility to our services when other providers are in the operating room.” “Not every orthopaedic practice has someone who specializes in nonsurgical conditions so we are fortunate I can bring that expertise,” says Dr. McDonald. “I often say, ‘I treat all people like I do an athlete, whether the patient participates in an actual sport, or their sport is shopping.’” Dr. McDonald grew up in Colorado and earned his medical degree from the University of Colorado. He completed his residency in family medicine at Swedish Medical Center in Denver and a primary care sports medicine fellowship at Michigan State University. Dr. McDonald came to Florida in 2002 to become a team physician for the University of Florida Gators athletics. Most recently he was a faculty physician with Florida Hospital’s family medicine residency program in Winter Park. He continues to teach medical students and residents of the University of Central Florida and Florida State University colleges of medicine. Dr. McDonald also works as a team physician for the Atlanta Braves during spring training and its minor league teams at Disney’s ESPN Wide World of Sports. He was team physician for the University of Florida Gators for six years, during which time the Gators won four national championships including in football and men’s basketball. He also has been the head team physician for the Orlando Solar Bears hockey team and Rollins College and Winter Park High School. Dr. McDonald has past patients currently in the NFL, NBA, and MLB and others who will be competing in the 2016 Olympic Games in Rio de Janeiro, Brazil.

PARTIAL KNEE RESURFACING Celebration Orthopedic & Sports Medicine Institute gives patients access to the most beneficial treatments available for orthopedic conditions. Among them is total and partial joint replacement as a treatment for osteoarthritis (OA) in the hip and knee. Total joint replacement used to be the most common treatment. Today, however, the improved accuracy of image-guided surgery is making the technically challenging partial knee replacement easier. Also called joint resurfacing or unicompartmental knee replacement, partial knee replacement is increasingly the choice when a portion of the knee needs to be replaced. Hip resurfacing has similar benefits and associated risks. As with any surgery, expertise plays a strong role in minimizing the risks, first, by understanding what they are and how they might be mitigated; and, second, by having the technical skill to produce the best possible outcomes. The patient should be properly educated, so his or her decisions are informed. Dr. Amundaray’s fellowship training and expertise give him keen insight into understanding when a patient would best benefit from a total knee replacement and when it would be better to do a partial knee replacement. “I begin by understanding their complaints and tolerances. You could have the same X-ray of another person, but your expectations may be different. You may not want surgery. You may not be able to take certain medications.” OA often leads to lifestyle limitations as a result of pain and decreased function. Symptoms include: • Knee pain while walking short distances, standing or climbing stairs. • Stiffness or discomfort in the knee when getting up from a chair or bed. • Knee ache with activity. FLORIDA MD - AUGUST 2016

PHOTO: DONALD RAUHOFER / FLORIDA MD

COVER STORY

CONCUSSION MANAGEMENT Dr. McDonald has extensive experience in concussion diagnosis, testing and management to assure the patient’s safe return to play (RTP) and to normal functioning. He works with athletic trainers and the Florida Hospital concussion management program to help athletes with concussion concerns. The program offers baseline tests that evaluate verbal memory, visual memory, reaction time and mental-processing speed, which can guide evaluation and recovery after a suspected concussion. He works closely with patients, parents, trainers and coaches, providing them with information on recovery, danger signs and risk reduction. A concussion is a type of traumatic brain injury that occurs when the brain is jolted, disrupting normal brain function. Concussions can be caused by a forceful blow to the head or other part of the body that causes the brain to move rapidly back and forth. It can occur even when an athlete is wearing protective headgear. Even though concussions may be diagnosed as a “mild” brain injury and not life threatening, all are serious and should be 6 FLORIDA MD - AUGUST 2016

evaluated by a doctor. Still, many go undiagnosed and unreported, according to Dr. McDonald. The symptoms of a concussion vary according to individual. Most concussions do not involve a loss of consciousness. Many can affect one’s memory, mood, balance and sleep. Severe cases or repeat concussions before symptoms of a prior concussion are reBrad Homan, DO solved can result in longterm neurological symptoms or even, in rare cases, death. Concussions usually appear normal on a computed tomography (CT) or magnetic resonance imaging (MRI) scan because these studies show the structure of the brain and not how it functions. For athletes, a preseason baseline neuropsychological test can be compared to post-injury testing to help gauge the postinjury neurological effect and Matthew Johnston, DO help determine when the brain has healed and the athlete can most safely return to play. Depending on the severity of the injury, full recovery from a concussion can take hours, days or weeks. Children may not recover as quickly as adults. Physical and mental strain can delay recovery, so rest without external stimuli, such as loud noises, bright lights, TVs, computers, video games and reading, is recommended. Medical clearance is recommended before physical activity is resumed for recreational athletes. It is required by state law for Dr. McDonald discusses shoulder pain with his patient. Dr. McDonald is a sports medicine specialist and handles everything from fracture care, concussion management, joint and muscle pain and more.

PHOTO: DONALD RAUHOFER / FLORIDA MD

• Knee swelling. • A crunching or grating feeling when moving the knee. “There are additional problems that occur,” says Dr. Amundaray. “People get depressed. They tend to gain weight. They don’t want to do things any more.” Therapy for degenerative joint disease is individualized based on the degree of arthritis, disability and comorbidities. It typically starts conservatively with activity modification, weight loss, physical therapy, oral medication, orthotics and corticosteroid or hyaluronic acid intra-articular injections. Physical therapy modalities include manual therapy, aquatic therapy, strength training, electrical stimulation and balance and proprioception training. When physical therapy is not possible because of cost, transportation, inconvenience and/or other reason, a self-management program can be effective. Simply walking is helpful. When conservative treatment has not worked and the OA seriously limits mobility and quality of life, surgery may be the next option. “Most of the people who have had a partial knee replacement on one knee and a total knee replacement on the other typically say the partial knee feels more natural,” says Dr. Amundaray. In addition to better mobility, minimally invasive partial knee replacement typically results in less pain and faster recovery. Whereas, recovery from total knee replacement can take as long as six-to-12 weeks, partial knee replacement requires little if any physical therapy and some can recover within four to six weeks. Recovery depends on a patient’s fitness prior to surgery, determination and pain tolerance, according to Dr. Amundaray. Dr. Amundaray’s goal is to help patients regain their quality of life. “Every soul I touch, I try to improve their quality of life. I want to see them get around again without pain. If they feel great when they come to the office, you can see it in their face that it’s not hurting that much.” Drs. Homan and Johnston also perform total joint replacements and partial knee resurfacing using MAKOplasty.

COVER STORY

CONSERVATIVE AND SURGICAL PODIATRIC TREATMENT

ankle surgery. He uses the latest in reconstructive techniques for: tendon repair/transfer, fusion of bone, joint implantation, bone grafting, skin or soft-tissue repair, tumor excision, amputation and/or the osteotomy of bone. It may involve bone screws, pins, wires, staples and other fixation devices, as well as casting to stabilize and repair bone. Fueled by compassion and dedication to his field, Dr. Britt approaches treatment with a technical eye, always seeking opportunities for hardware improvement. In his spare time he reengineers devices, which he submits to manufacturers/investors for consideration. He also creates YouTube podcasts discussing podiatric advances.

A TEAM THAT CLICKS Teamwork is important on and off the field, including within Celebration Orthopaedic & Sports Medicine Institute. In the words of a patient in March: “… I would like to thank the entire office for making my visit very pleasant. The employees at the front desk went out of their way to help me with my paperwork and gladly answered my questions. …To Dr. Britt, thanks for being informative and taking your time to make sure I understood what it would take to get better and stay well.” Patients are seen at Celebration and Kissimmee locations. Appointments at the Celebration office can be made by calling (321) 939-0222. Appointments in the Kissimmee office can be made by calling (407) 201-3934. Regular business hours are from 8 a.m. to 5 p.m.; extended hours are available. For more information visit celebrationorthopaedics.com. 

The foot and ankle is an intricate network of bones, ligaments, tendons and muscles that often endure injury and overuse. The list of causes for inflammation and pain is long and includes arthritis, bone spurs, plantar fasciitis and tendonitis, to name a few conditions. Those who are unsure of the cause of intense foot pain, who are diabetic or who have widespread pain that involves both feet should seek immediate medical attention. Often, however, foot pain responds well to rest and cold therapy at home. If discomfort persists after several weeks, consultation with a physician is advised. Dr. Britt (left) discusses the next steps in patient care with a staff In true Celebration Orthopaedic & Sports Medicine form, Dr. member. Dr. Britt is a foot and ankle specialist/podiatrist and handles all sprains, fractures, diabetic foot care, and other foot conditions. Britt motivates his podiatric patients through understanding and education. So they enter care with realistic goals, they understand their options, they know what to expect and they become actively engaged in their recovery. “My main goal is to ease anxiety and pain during the recovery process,” he says. Understanding the progression of healing and the expected outcome is key. “Rather than leave a patient open to speculate and be anxious and worry, if they are educated properly from the beginning, they are better able to see the end game.” In appropriate cases, conservative treatment, using a combination of physical therapy and anti-inflammatory medication, works. Personalized conditioning programs for strengthening and stretching the muscles that support the lower leg, foot and ankle are incorporated to help reduce pain and increase range of motion. Dr. Britt also is skilled in traumatology, reconstructive foot and ankle surgery, wound care/limb salvage and elective foot and FLORIDA MD - AUGUST 2016

PHOTO: PROVIDED BY FLORIDA HOSPITAL

all high school athletes and required for many sanctioned team sports. An 11-year study published in 2011 in the American Journal of Sports Medicine found that the high school sports with the highest concussion rates are football, soccer, lacrosse and wrestling. Potential complications of a concussion include: • Epilepsy – A concussion doubles one’s risk of developing epilepsy within the first five years after the injury. • Post-concussion syndrome – Symptoms such as headaches, dizziness and difficulty thinking may occur a few days after a concussion and continue for weeks to a few months after a concussion. • Post-traumatic headaches – Headaches may occur within a week to a few months after a brain injury. • Port-traumatic vertigo – A sense of spinning or dizziness may occur for days, weeks or months after a brain injury. • Second-impact syndrome – A second concussion before signs and symptoms of a first concussion have resolved may result in rapid and usually fatal brain swelling. It is important to keep records of all concussions and report them to the appropriate personnel before participation in competition. Prevention should be a priority, according to Dr. McDonald.

MARKETING YOUR PRACTICE

10 Tips for Making a Great Practice Brochure By Jennifer Thompson Do you want to know how to create a gorgeous practice brochure that people actually want to pick up and read? As a general rule, people like pretty things. Put yourself in the shoes of a patient. You’re at a crowded, cramped community event and there’s a few medical offices there as part of their grassroots marketing efforts. All of the booths look basically the same; so you grab a brochure from each as you walk around and try to find your child… who has run off either to the cotton candy guy at the end of the row or the bounce house at the complete opposite side of the event. Kids.

for a long time in a practice. PA’s, office managers and coordinators? Not as much. If you’re going to list staff, keep it to the doctors so you don’t have to redesign brochures annually to keep up with the new faces. 7. Put your logo and relevant photo on the cover. Sounds like a no-brainer, right? You’d be surprised. As we mentioned in tip #4, also be sure to put your phone number and web address on the cover as well.

Anyway, in this scenario the patient will, first, find their child – thank goodness. Then, when they get home, they might look through the pile of material they’ve collected and start throwing out the junk. You’ve got a split second to make a lasting impression on them. Your material either looks better than your competitors… or it doesn’t. They flip through both brochures, read about 8 words total, and keep the one that looks prettier. If that’s yours, odds are they’ll put it up on the fridge and remind themselves to make an appointment Monday. So, how can you ensure your brochure winds up on some prime fridge real estate? 1. Use big, happy photos. Always remember that you want to show the end result, not the pain in photos. Patients are experiencing discomfort; so all that matters is that they can get back to smiling and enjoying activities like riding a bike or sitting on the beach as soon as possible. 2. Keep the word count down. People do not want to read so don’t make them read more than they have to. Think of simple statements. Keep your services listed in bullet form and speak to the pros of coming to your office first and foremost. No one will read the rest and it makes your brochure look intimidating. 3. Use benefit-oriented headlines. When opening up the brochure for the first time, your patient will skim the headlines. Make sure your headlines grab their attention and help them down the page and through the copy. 4. Headshots should be (somewhat) current. You can’t talk about all of your state-of-the-art, minimally invasive procedures and options right next to a headshot that was clearly circa 1987 (especially if your doctor has lost a few inches of hair since then). Keep headshots current to at least 5-6 years. 5. Put your phone number and website everywhere. You want this information to be easy to find no matter where the brochure is seen. Front cover (in case it makes it to the fridge), inside while reviewing the content and on the back while it’s flipped over. 6. Be careful whom you list. Typically, physicians stick around 8 FLORIDA MD - AUGUST 2016

8. Keep the look consistent with your website. Keeping the same look is known as a brand image. You want the same brand image across all of your marketing material. So, if you redesign your brochure and love the look, make sure your website follows closely behind. 9. Use the right colors. Stick with colors that are often associated with medical practices like blue, green, white and light purple. Stay away from reds, blacks and grays whenever possible. 10. Hire a good designer. “You get what you pay for” is especially true in the world of design. Do not try to do this in Microsoft Publisher in your spare time or use a staff member’s cousin. To really make an impact and keep the same design for multiple years, you’ll want to spend the extra few dollars and have it professionally done. There you have it. Regardless of the size of your practice or your resources, the tips found above will assist you in creating a brochure that properly represents your practice, impresses potential patients and earns you a spot on their fridge… all for being pretty. Jennifer Thompson is co-founder and chief strategist for DrMarketingTips.com, a website designed to help medical marketing professionals market their practice easier, faster and better. 

FLORIDA MD - AUGUST 2016

HEALTHCARE BANKING, FINANCE AND WEALTH

Why Utilize Healthcare Professional Organizations? Taking the time to network with peers can relieve stress and improve your practice! By Jeff Holt, CMPE, VP, Senior Healthcare Business Banker with PNC Bank How much extra time do you have these days to fit additional meetings and activities into your schedule? I know when I spend time with my clients at their practice it gets pretty crazy, and even thinking about adding another activity to their day would not be welcomed at all. I feel that most practice owners and managers greatly misunderstand the true value of healthcare professional organizations (physician, practice manager, and healthcare business professional based), which can negatively impact their quality of life at work and the level of success of their practice. If you’re not a very social person, you may look on professional organizations with a bit of uncertainty. Cocktail parties, awards dinners and other demands on your already hectic schedule may seem like more trouble than they’re worth. Yet local and national healthcare organizations are much more than glorified social groups: They can provide valuable resources and tips for making your practice more efficient, keep you abreast of emerging trends in your field and even give you a voice in issues that affect your profession.

STAY UP TO DATE Education is a key benefit of membership in [made this change to fill in white space in first line] any professional organization. Though you may already attend conferences in your specialty, professional groups usually provide access to a substantial number of free resources: speakers, papers, books, gatherings, etc. Learn from your colleagues what new technologies they’re finding most useful in their practices and what equipment investments you may be able to safely avoid. Professional organizations may also provide access to continuing education courses that you need to stay current and licensed in your field.[1]

experiences and meet people who may become partners or associates down the road. Professional organizations offer a variety of ways to meet people and stay in touch.[2] Of course, just joining an organization won’t make much of a difference in your professional life unless you make an effort to become actively involved. Sign up for committees, attend functions and introduce yourself. As you begin to realize the benefits, you may find yourself becoming not only a member of such organizations, but also one of their most enthusiastic supporters. In Central Florida there are many great healthcare professional organizations who are ready to welcome you in and be that “phone a friend” that we all need many times. If you need help with identifying which groups you are able to be part of just ask me for assistance! References: 1. http://aapp.org/2014/02/04/how-a-professional-association-membershipbenefits-doctors/ 2. http://www.physicianspractice.com/mentoring/why-physicians-should-joinprofessional-organization The third-party trademarks referenced in these articles are owned by and are the registered trademarks of their respective third-party owners. There is no affiliation, sponsorship or endorsement relationship between PNC or its affiliates and any such third party. PNC is a registered mark of The PNC Financial Services Group, Inc. (‘‘PNC’’)

Jeff Holt is a Senior Healthcare Business Banker and V.P. with PNC Bank’s Healthcare Business Banking and is a Certified Medical Practice Executive. He can be reached at (352) 385-3800 or Jeffrey.Holt@pnc.com. 

SHARE YOUR VOICE Clinical issues — ranging from potential regulations to billing and insurance requirements to new technologies and treatment methods — may impact how you treat patients and earn your living. Professional organizations can help you stay current on changes and what you need to know. They may also enable you to play an active role. Keep in mind that healthcare professionals are an important part of local and national conversations on many issues. Joining a professional organization may give you a podium to be heard by decision-makers and reporters seeking comments on important issues.

NETWORK WITH OTHERS A network of professionals is a way to connect with others in your field, learn from their best practices, share your own 10 FLORIDA MD - AUGUST 2016

Sea Notes Photography Donald Rauhofer – Photographer Head Shots • Brochures • Meetings Events • Portraits • Arcitectural

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ORTHOPAEDIC UPDATE

Live Surgery Event Offers Glimpse Into Operating Room for Knee Meniscectomy By Corey Gehrold Attendees of this year’s Workers’ Compensation Educational Conference are invited to attend the 9th Annual Orlando Orthopaedic Center Live Surgery Event on Tuesday, August 23, from 8:45 - 9:45 a.m.

To complete the procedure, Dr. Van Travis B. Van Dyke, MD Dyke will use the latest minimally invasive techniques to ensure the patient experiences:

WHAT IS THE LIVE SURGERY EVENT?

• Faster recovery time

The Live Surgery Event is a live, interactive look into an operating room with one of Orlando Orthopaedic Center’s board certified surgeons, Travis B. Van Dyke, M.D. Orlando Orthopaedic Center’s Lawrence S. Halperin, M.D., will moderate the procedure and provide step-by-step explanations and commentary discussing what’s taking place on-screen. Attendees will even be able to ask questions to Dr. Van Dyke live as he completes his procedure. Everyone at the conference is encouraged to attend.

WHAT PROCEDURE WILL BE PERFORMED? This year’s live surgery event will showcase a relatively common workers’ compensation surgery performed by Dr. Van Dyke: knee meniscectomy. Dr. Van Dyke will perform a knee menisectomy at this year’s Live Surgery Event at the Workers’ Compensation Educational Conference on August 23.

• Less pain • Shortened rehabilitation schedule • Smaller scars When the meniscus cartilage in the knee is torn, and when all nonsurgical methods of treatment have been prescribed and failed, arthroscopic meniscectomy may be prescribed by a patient’s orthopaedic surgeon to return them to their pre-injury level of activity and workload. The minimally invasive outpatient surgical procedure, known as a knee meniscectomy, is used to remove the torn portion of the meniscus. Surgery for a torn meniscus is usually required when there is constant swelling of the knee, accompanied by severely limited mobility (a locking of the knee), and when the patient is unable to pursue normal daily activities or work duty. This method of surgery involves inserting an arthroscope (small camera) into the knee joint. The images returned from the camera are viewed on a large monitor and used to guide small surgical instruments to remove the torn meniscus and complete the procedure. Being an outpatient procedure, the patient can return home after the anesthesia has worn off, usually within 1-2 hours after closure. Some patients may work with a physical therapist in the weeks following surgery to restore complete function. The average time to resume light duty is 2-4 weeks after surgery with a full recovery within 4-6 weeks.

ABOUT ORLANDO ORTHOPAEDIC CENTER This is the ninth year Orlando Orthopaedic Center has presented the Live Surgery Event. Since 1972 the practice has grown to include six locations, a state-of-the-art outpatient surgery center and 21 board certified physicians across multiple orthopaedic subspecialties. In the fall of 2016 Orlando Orthopaedic Center will open downtown’s only orthopaedic injury walk-in clinic, located in the SoDo Plaza across the street from Target at 45 W. Crystal Lake St., Ste. 197, Orlando, FL 32806. To learn more about Orlando Orthopaedic Center, visit OrlandoOrtho.com. 

Be sure and check out our website at www.floridamd.com! FLORIDA MD - AUGUST 2016 11

CANCER

Next-Day Appointments Help Patients Navigate Potential Cancer Diagnosis By Daniel Landau, MD According to the American Cancer Society, an estimated 1.6 million Americans were diagnosed with cancer last year. Though millions battle this disease every year, the process for receiving a cancer diagnosis is still harrowing and fraught with anxiety for most patients. When a GP tells his or her patients that they need to be referred to an oncologist, the first reaction is fear and uncertainty. Waiting adds to this anxiety. In some countries, the wait is too long. In the UK, for example, the government has set targets so that patients with suspected cancer must see a specialist within 14 days after referral. It also sets targets so that patients wait no longer than two months between the date a hospital receives an urgent referral for suspected cancer and the date they begin treatment. One Canadian study involving men with prostate cancer indicated that 70 percent of patients felt their care had been delayed due to the health care system or factors related to their physicians. Longer waits for diagnosis and treatment are also associated with added distress for patients and their families and may be correlated with a worse prognosis, the study found.

NEXT-DAY APPOINTMENTS: FASTER ACCESS TO SPECIALISTS, PEACE OF MIND FOR PATIENTS

Some patients have come to us to see a hematologist after a referral from their GP. They’ve scheduled next-day appointments, and in some cases, received a diagnosis of severe anemia rather than cancer. You can’t imagine the peace of mind a patient in this situation has after quickly getting this diagnosis. Next-day appointments also have helped several patients receive an earlier cancer diagnosis. This can be lifesaving for many people, especially those with a diagnosis like acute myeloid leukemia, which doesn’t have any tests that can detect the cancer early.

RESULTS OF NEXT-DAY APPOINTMENTS We’ve seen that next-day appointments have been successful in helping patients see a specialist or doctor more quickly, get an earlier diagnosis of their condition and earlier treatment plans. We also believe that these appointments allow patients to have better outcomes and a better experience. Roughly 67 to 75 percent of patients being referred to the UF Health Cancer Center are offered next-day appointments. Of patients who are offered an appointment, approximately 67 percent of them accept, which speaks to the fact that diagnostic delays are sometimes patient-driven and that we in the medical community need to make patients more comfortable with seeing a doctor. However, patients who do come in for a next-day appoint-

When cancer is suspected, it’s critical to see a doctor as soon as possible. At UF Health Cancer Center – Orlando Health, we don’t want anyone to have to live with the fear of a diagnosis a moment longer than necessary. It’s why we’ve begun to offer next-day appointments for any new patient who calls in or who receives a referral from his or her doctor. Upon calling us, patients are offered a next-day appointment with one of our specialists. The specialist will arrange for imaging tests and other necessary blood work. However, there are frequent occasions where the workup happens immediately. For example, I recently met with a young woman who had a large abdominal mass that her doctor noticed after a Save Thousands Instantly On CT scan for another purpose. Because she came to Credit Card Processing me so quickly, I was able to set her up to meet with me, a surgical specialist and a radiation specialist — all within one day. We were able to put together information to come up with a definitive plan almost Secure Supporrt instantaneously, whereas she couldn’t get an appointment with anyone else for essentially weeks after the scan was done. Free Savings Analysis At Fattmerchant.com/Florida-MD Since we launched the program, we’ve heard sevOr Call 407-204-9657 eral stories from patients about how being able to see a specialist as soon as possible made them feel more in control and better able to cope with a potential diagnosis — whether it was a malignancy or benign.

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12 FLORIDA MD - AUGUST 2016

CANCER ment have faster access to a specialist, less worry and anxiety and a quicker diagnostic workup. We’ve also had patients come to the clinic, undergo a bone marrow biopsy and initiate chemotherapy before they were able to get in to see another physician. The turnaround time in this situation is remarkable, but for many patients it can make a big difference in their prognosis and approach to treatment.

LOOKING TO THE FUTURE When a primary care doctor tells a patient that there is a lump that needs to be biopsied or that the results of a blood test may indicate cancer, patients are unsure of what is happening and want answers quickly. Patients tell us that seeing a specialist right away allows a weight to be lifted off their shoulders — even when they

are unsure of their diagnosis and are awaiting test results. Next-day appointments have an impact far beyond a patient’s initial visit. If a patient is symptomatic and does have cancer, we may be able to detect it early because of these appointments. This expands a patient’s treatment options and potential survivorship. It also has an impact on patients with advanced cancers. I frequently meet patients in our next-day program who have very aggressive cancers, including testicular cancer or lymphomas. When I get these patients, I do whatever test I can instantaneously and have treatment started within days of our appointment. This can make a huge difference with aggressive malignancies that can grow and spread by the day.

Better Outcomes. Quality Care.

Stroke. Trauma. Brain Injury.

Our goal with next-day appointments is to help every patient who comes into our center feel empowered and to ease some of their worry and anxiety, regardless of their diagnosis. We know that this program will save many lives — in fact, we’re already starting to see the results. We will continue to offer next-day appointments, but it’s our hope that more patients beyond the current 67 percent take advantage of this program. Doing so could be lifesaving. New patients who need next-day appointments can call 321.843.7770 to schedule a visit with a specialist or fill out the form on the UF Health Cancer Center at Orlando Health website to request an appointment.

To learn more, call 407 587-8600. A Higher Level of Care®

Daniel Landau, MD, is board-certified in internal medicine, medical oncology and hematology for the Medical Oncology and Hematology Specialty Section at UF Health Cancer Center – Orlando Health. He has been with Orlando Health for 7 years. Dr. Landau received his medical degree from the University of South Florida College of Medicine, where he also completed his residency. Dr. Landau completed his medical oncology and hematology fellowship at MD Anderson Cancer Center Orlando, serving as chief fellow. Dr. Landau has been recognized as a top oncologist by SmartestOncologist. comthree consecutive times. He is currently a member of the American Society of Clinical Oncology and the American Society of Hematology. To schedule an appointment with Dr. Landau, please call 321.841.7219. 

FLORIDA MD - AUGUST 2016 13

INPATIENT REHABILITATION

After a Stroke: One of Your Most Important Orders OR Rehabilitation: Are You Making the Right Decision? By Richard C. Senelick MD Mr. Babinski was sitting with his granddaughter when his right arm and leg became weak. He tried to tell her there was a problem, but he couldn’t speak. He promptly arrives at your hospital and you expertly navigate the decision to give him tPA, manage his hypertension and call upon the diabetes educator to improve his diet, but when it is time for his transfer for rehabilitation, do you give this decision the same amount of care and consideration you gave to your other medical decisions? It is important that physicians approach the prescription of rehabilitation care as carefully as they consider which anti-hypertensive medicine to choose. We often abdicate this responsibility to the family or a case manager, yet this decision is just as important as the decision to give tPA or change a person’s diabetic medication. Here are a few things you should consider.

THE GLASS CEILING The glass ceiling effect still exists in many aspects of our society. Many women still do not have the same opportunities as men. Likewise, children who are deprived of a proper education have fewer opportunities. The same concept is true for the disabled. If we assume that a stroke survivor or other rehabilitation candidate is too impaired to participate in rehabilitation, we are creating a glass ceiling for that individual. Without the right kind of rehabilitation, patients will likely not reach their full potential. The decision to refer a patient for rehabilitation may be the first -- and the last -- chance for them to get the type of rehabilitation that will lead to their maximum recovery. A decision to withhold access to aggressive therapy creates a self-fulfilling prophecy: • Someone doesn’t think the patient will get better • So, they do not offer them the intensive therapy they need • Since they didn’t get the therapy they needed, the patient confirms their theory by showing little improvement.

ing to walk again or learning to transfer from a bed to a chair. She may need to learn to read again, speak clearly or improve her memory. Rarely is it easy and I always tell patients and families that it will be the hardest thing they will ever do. Like school or learning a new skill there are certain principles that make a difference. If rehabilitation is like school, then the “school” you go to makes a big difference.

DOSE MATTERS When we order a medication for a medical problem, we carefully adjust the dose. Too little or too much antibiotic and the infection gets worse or you create additional problems. The same is true of rehabilitation. The intensity and amount of therapy matters. Much like it takes hours of practice to learn and improve playing a musical instrument, it takes hours of therapy to retrain the brain, nervous system and muscles. Typically, an inpatient rehabilitation hospital will provide 3 hours of therapy a day. Many lesser facilities, such as skilled nursing facilities do not. You do

HELPING YOUR PATIENTS

GET BACK TO WHAT THEY LOVE

JUST LIKE SCHOOL Going for therapy and rehabilitation is just like going back to school, because your patient may have to learn new information. If you are going back to school later in life, you may have to “relearn” information that you had previously acquired. In therapy, there are tasks that may require physical activities like learn14 FLORIDA MD - AUGUST 2016

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INPATIENT REHABILITATION not want to “under dose” your patient.

FUNCTION MATTERS If you want to learn to play a piano, you need to practice on a piano and not just read about it. The same is true for rehabilitation. If you have had a stroke and have lost the use of your right arm, you will need to practice tasks and therapies that require the use of your right arm. Performing these specific tasks will help rewire your brain. The more “functional” the tasks that you perform, the more you will improve and more positive changes will take place in your nervous system.

1A) they conclude that “the consistency of the findings in favor of IRF( Inpatient Rehabilitation Hospital) suggests that stroke survivors who qualify for IRF services should receive this care in preference to SNF-based care ( Skilled Nursing Facility).” So, don’t forget: Where you send your patient for rehabilitation does make a difference. You wouldn’t send your child to an inferior school, make the same type of choice for your patients.

MOTIVATION MATTERS

CM RE E CEI CR VE ED IT S

The person who is motivated and works harder has a better chance of getting better. It is not always the brightest student who is the most successful: hard work can make a huge difference. People undergoing rehabilitation are motivated by their physicians, caregivers, therapists, but also by their surroundings. Think of working in a brightly lit office or hospital with a great view versus one in the basement with no windows. . Where you send your patient for rehabilitation does make a difference. Are you referring your patients to a place that specializes in rehabilitation or is it just part of a nursing home or facility that does other things? The medical literature, including the latest May, 2016 American Heart Association/American Stroke Association “Guidelines for Adult Rehabilitation and Recovery,” (http://stroke.ahajournals.org/content/early/2016/05/04/STR.0000000000000098. full.pdf ) addresses this issue After reviewing the highest level of scientific evidence (Class

Dr. Senelick is a neurologist who specializes in neurorehabilitation. For 30 years he was the medical director of HealthSouth Rehabilitation Institute of San Antonio (RIOSA) and is currently the editor- in- chief of HealthSouth Press. 

Walt Disney World Swan & Dolphin Resort, Orlando, FL Saturday, Nov. 5, 2016

*This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical education through the joint providership of the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) and the Association of Independent Doctors (AID). ABQAURP is accredited by the ACCME to provide continuing medical education for physicians. The American Board of Quality Assurance and Utilization Review Physicians, Inc. designates this live activity for a maximum of 6 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

FLORIDA MD - AUGUST 2016 15

Self-Diagnose Your Practice with the Support of Medical Office Resources of Florida By Dorothy Mowbray, MOROF Media Committee Chair and Board Member Medical Office Resources of Florida (MOROF) rallies around independent doctors who desire to stay independent. For doctors who run their own medical practice, the ever-changing compliance regulations and challenges of running the business don’t have to be overwhelming. Through a network of professional healthcare business associates, MOROF provides the resources and expertise for most any compliance or business concern. The table below divides a practice into categories to allow you to evaluate each aspect to determine if everything is on course or if there is an area needing improvement. Place a check next to the items that need some attention. Or use Ben Franklin’s method of A, B, C to grade which areas are most important and then correspond with those most urgent by numbering 1, 2, 3, etc. within each letter grade. No matter how you want to prioritize it, just consider what aspect of your business needs some attention. PATIENTS

EMPLOYEES

REVENUE

Attracting

Deposit Preparation

Attracting

Seeing

Getting Collections Liquid

Interviewing & Clearing

Billing

Monitoring & Reconciliation

Onboarding

Collecting

Expense Payments

Keeping

Expense Items

Paying

Quality Care

Saving and Investing

Accountability

Other

AT RISK

PRACTICE GOALS

OWNER’S GOALS

Compliance

Short Term

Work / Life Balance

Legal

Long Term

Family

Fraud & Embezzlement

Strategies to Accomplish

Retirement Preparation

Mismanagement

Monitoring and Support

Exit Strategy

Lost Opportunities

Other

Other Once you have your most important and most urgent area(s) identified, go to www.mor-of.net. You’ll find a resource of upcoming educational topics and an archive of past video presentations that will most likely address your concern. MOROF’s educational events provide an opportunity for you to attend or send someone within your practice that would benefit most from a given topic. Each archived video from a past presentation is painstakingly broken into about three minute chunks of information so that you can drill down to precisely the information that you are searching to answer your question at whatever day or time fits into your schedule. If neither of these resources answers your question or if you are looking for a more customized solution, search the MOROF member directory. You can contact then speak directly with a professional healthcare business associate in whatever area of expertise you need. These vetted professionals can work with you to tailor a customized solution that works for your specific practice. Since not every student had the time to learn all the aspects of the business of healthcare in med school, MOROF is there to fill in the gaps. At MOROF, you’ll also find other doctors, medical society partners, and healthcare professional members. MOROF provides camaraderie with peers for a more well-rounded resource. With all this knowledge and experience, you are bound to find someone willing to swap stories of how they have found success in various areas. MOROF provides a tremendous resource for those willing to tap into it! Medical Office Resources of Florida provides educational resources for existing practices online through www.mor-of.net, on LinkedIn MOROF (open group), and their YouTube Channel MOROForlando. MOROF also meets the fourth Thursday of each month from 7:30 a.m. to 9 a.m. at the Venue On The Lake at the Maitland Civic Center. The address is 641 South Maitland Ave., Maitland, FL 32751. Healthcare professionals are always welcome as guests. RSVP at www.mor-of.net.  16 FLORIDA MD - AUGUST 2016

DIGESTIVE AND LIVER UPDATE

Nonalcoholic Fatty Liver Disease (NAFLD) Part 2 By Harinath Sheela, MD In the June issue, we covered Part 1 of Nonalcoholic fatty liver immunity to guide future immunizadisease (NAFLD). The article went over definition, epidemioltions. We also rule out other chronic ogy, pathogenesis, and clinical manifestations of Nonalcoholic liver diseases such as autoimmune hepfatty liver disease (NAFLD). In part 2 of the article, we will conatitis and hemochromatosis. tinue to cover Nonalcoholic fatty liver disease (NAFLD), and We obtain the following tests in all patients: we will go over diagnosis, which patients to biopsy, differential • Anti-hepatitis C virus antibody diagnosis, and screening. • Hepatitis A IgG DIAGNOSIS — The diagnosis of nonalcoholic fatty liver dis• Hepatitis B surface antigen, surface antibody, and core antiease (NAFLD) requires all of the following : body • Demonstration of hepatic steatosis by imaging or biopsy • Exclusion of significant alcohol consumption • Exclusion of other causes of hepatic steatosis In those undergoing a radiologic evaluation, radiologic findings are often sufficient to make the diagnosis if other causes of hepatic steatosis have been excluded. While not indicated for the majority of patients, a liver biopsy may be indicated if the diagnosis is not clear or to assess the degree of hepatic injury. In addition, liver biopsy is the only method currently available to differentiate nonalcoholic fatty liver • Analytics & Reporting • Newsletter (NAFL) from nonalcoholic steatohepatitis (NASH). • Branding • Responsive Web Design LABORATORY TESTS — Laboratory • Content Marketing • SEO tests, such as the serum aminotransferase and ferritin levels, are often abnormal in • Digital Marketing • Social Media NAFLD. However, these abnormalities are • Reputation Management • Traditional Advertising neither required nor sufficient for making the diagnosis, as laboratory tests may be • Graphic Design • Video normal in patients with NAFLD and may be abnormal in patients with numerous other conditions. However, laboratory testing is required 321.228.9686 to evaluate for other conditions in the differential diagnosis of hepatic steatosis. InsightMG.com RULE OUT OTHER DISORDERS — DrMarketingTips.com Differentiating NAFLD from the other items in the differential diagnosis begins with a thorough history to identify potential causes such as significant alcohol use, Subscribe to Our Weekly starvation, medication use, and pregnancyPodcast on iTunes related hepatic steatosis. We test all patients with hepatic steatosis for hepatitis C virus infection. We also test for hepatitis A and B. We do this to both to rule out these infections in patients with elevated aminotransferases and to determine

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FLORIDA MD - AUGUST 2016 17

DIGESTIVE AND LIVER UPDATE • Plasma iron, ferritin, and total iron binding capacity • Serum gammaglobulin level, antinuclear antibody, antismooth muscle antibody, and anti-liver/kidney microsomal antibody-1 Other disorders that should be considered based upon the patient’s history, associated symptoms, and family history include Wilson disease, thyroid disorders, celiac disease, alpha-1 antitrypsin deficiency, HELLP, and Budd-Chiari syndrome. RADIOGRAPHIC EXAMINATIONS — Various radiologic methods can detect NAFLD, but no imaging modality is able to differentiate between the histologic subtypes of nonalcoholic fatty liver (NAFL) and nonalcoholic steatohepatitis (NASH) . Our approach in patients who have not already undergone imaging is to obtain an ultrasound. However, computed tomography (CT) and magnetic resonance imaging (MRI) can also detect hepatic steatosis. We consider a radiographic diagnosis to be sufficient for diagnosing NAFLD if all of the following conditions are met: • Radiographic imaging is consistent with fatty infiltration • Other causes for the patient’s liver disease have been excluded • The patient does not have signs or symptoms cirrhosis • The patient is not at high risk for advanced fibrosis or cirrhosis (eg, a younger patient who does not have diabetes and has a normal serum ferritin is at lower risk for having fibrosis or cirrhosis) If these criteria are not met, patients will typically require a liver biopsy to make the diagnosis or to assess the degree of liver injury. ULTRASOUND — Ultrasonography often reveals a hyperechoic texture or a bright liver because of diffuse fatty infiltration. A meta-analysis of 49 studies with 4720 patients found that the sensitivity and specificity for ultrasound were 85 and 94 percent, respectively, when using liver biopsy as the gold standard [. However, the sensitivity appears to be decreased in patients who are morbidly obese . In a study of 187 morbidly obese patients undergoing bariatric surgery, hepatic steatosis was present histologically in 95 percent but was only detected by ultrasound in 49 percent . CT, MRI, and magnetic resonance spectroscopy — Both CT and MRI can identify steatosis but are not sufficiently sensitive to detect inflammation or fibrosis. Magnetic resonance spectroscopy (MRS) has the advantage of being quantitative rather than qualitative or semiquantitative, but it is not widely available . One of the difficulties in determining the sensitivity and specificity of CT and MRI for diagnosis of hepatic steatosis is that not all patients undergo confirmation by liver biopsy. In a study that did use histology as the gold standard, the sensitivity of CT scan for detecting hepatic steatosis was poor, whereas MRI had low specificity. It included a total of 131 patients who had a radiologic evaluation with noncontrast CT, contrast-enhanced CT, or MRI before undergoing a partial hepatectomy, usually for malignancy. The sensitivities of noncontrast CT, contrast-enhanced CT, and MRI for detecting hepatic steatosis were 33, 50, and 18 FLORIDA MD - AUGUST 2016

88 percent, respectively. The specificities were 100, 83, and 63 percent, respectively. In addition, the accuracy of noncontrast CT fell with increasing body mass index. Unlike CT and MRI, MRS allows for quantification of hepatic fat, and may be particularly helpful in patients with small amounts of hepatic steatosis 2. A study that compared MRS with liver biopsy in 12 patients found a close correlation between the measurement of intrahepatocellular lipid by MRS and the histologic assessment of cirrhosis (r = 0.94) . However, not all scanners have the capability of obtaining spectroscopic sequences, and it is not routinely used. ROLE OF LIVER BIOPSY — While liver biopsy is the gold standard for diagnosing NAFLD, in many cases a presumptive diagnosis can be made based upon the patient’s history, laboratory tests, and imaging findings, provided other disorders have been excluded. However, some patients will continue to have an unclear diagnosis following a noninvasive evaluation. In such cases, a liver biopsy is indicated. In addition, imaging studies and laboratory tests do not reliably differentiate patients with NAFL from those with NASH, or predict the severity of liver disease. The only way to definitively confirm or exclude the diagnosis of NASH and to determine disease severity is with a liver biopsy. This information can be used to guide patient care and may motivate patients to enact lifestyle modifications. As examples, patients found to have cirrhosis will require screening for esophageal varices and hepatocellular carcinoma, whereas patients with early fibrosis may be motivated to lose weight to decrease the risk of progressing to cirrhosis. A potentially useful non-invasive method for excluding advanced fibrosis is measurement of liver stiffness with transient elastography. However, the approach is not widely available and has not been extensively studied in NASH. Other indirect markers of cirrhosis such as the aspartate aminotransferase to platelet ratio index are also being studied to identify patients with fibrosis. WHICH PATIENTS TO BIOPSY — There is no clear consensus about which patients require a liver biopsy . We obtain a liver biopsy in patients with suspected NAFLD if the diagnosis is unclear after obtaining standard laboratory tests and hepatic imaging, if there is evidence of cirrhosis, if the patient wants to know if inflammation or fibrosis is present, or if the patient is at increased risk for advanced fibrosis or cirrhosis. Specifically, we obtain a biopsy if the patient: • Has peripheral stigmata of chronic liver disease (suggestive of cirrhosis) • Has splenomegaly (suggestive of cirrhosis) • Has cytopenias (suggestive of cirrhosis) • Has a serum ferritin >1.5 times the upper limit of normal (suggestive of NASH and advanced fibrosis) • Is >45 years of age with associated obesity or diabetes (increased risk of advanced fibrosis) HISTOLOGIC FINDINGS — Histologic findings in NAFLD include steatosis, inflammation, cell injury, and fibrosis. The min-

DIGESTIVE AND LIVER UPDATE imum criterion for a histologic diagnosis of NAFLD is >5 percent steatotic hepatocytes in a liver tissue section. The extent of steatosis can be described as mild (5 to 33 percent of hepatocytes are steatotic), moderate (34 to 66 percent of hepatocytes), or severe (>66 percent of hepatocytes) . Patients with NAFLD typically have macrovesicular steatosis, though mixed steatosis may also be seen. Pure microvesicular steatosis is uncommon. In adults, steatosis is typically first seen in acinar zone 3, though when severe it may occupy the entire acinus. Patients with NAFL may have foci of lobular inflammation, mild portal inflammation, and lipogranulomas, but features of steatohepatitis (ie, hepatocellular injury and fibrosis) are absent by definition. Patients with NASH have liver biopsy findings that may be indistinguishable from those of alcoholic steatohepatitis. A diagnosis of NASH requires the findings of steatosis, hepatocyte injury (typically ballooning degeneration), and lobular inflammation (typically in acinar zone 3). Fibrosis is not a required diagnostic feature, but may be seen. Histologic findings of NASH include • Steatosis • Hepatocyte swelling or ballooning degeneration • Apoptotic (acidophil) bodies • Mild lobular inflammation (acute, and less often, chronic) • Mild chronic portal inflammation (inflammation that is severe or is disproportionate to the acinar lesions is suggestive of con-

current hepatitis C) • Perisinusoidal collagen deposition that may result in zone 3 accentuation in a “chicken wire” pattern (related to the deposition of collagen and other extracellular matrix fibers along the sinusoids of zone 3 and around hepatocytes) • Portal fibrosis without perisinusoidal or pericellular fibrosis • Cirrhosis, which is typically macronodular or mixed • Mallory-Denk bodies (previously called Mallory bodies or Mallory’s hyaline) • Megamitochondria • Glycogenated (vacuolated) nuclei in periportal hepatocytes (rarely seen in alcoholic steatohepatitis) • Lobular lipogranulomas • PAS-diastase-resistant Kupffer cells • Hepatic siderosis (typically mild) involving periportal hepatocytes or panacinar reticuloendothelial cells As fibrosis progresses to cirrhosis, steatosis and inflammation may not be reliably identified, resulting in a diagnosis of “cryptogenic” cirrhosis . It is possible that portal fibrosis alone may represent a variant of NASH . In biopsy specimens from children, portal inflammation may be more prominent than in adults. NASH may exist concurrently with other liver diseases, though diagnosing NASH in that setting can be difficult. As an example, patients with NASH may also have alcoholic liver disease, but there is no way to differentiate the relative contributions of the

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FLORIDA MD - AUGUST 2016 19

DIGESTIVE AND LIVER UPDATE two processes from a liver biopsy]. In a series of 3581 liver biopsies from patients with various chronic liver diseases, concurrent steatohepatitis was found in 5.5 percent of patients with hepatitis C (some with significant alcohol use) . Among patients with other chronic liver diseases of nonalcoholic etiology, the prevalence ranged from 1.6 percent (autoimmune hepatitis) to 7.9 percent (alpha-1 antitrypsin deficiency). None of the patients with steatohepatitis with chronic liver disease from a cause other than hepatitis C had significant alcohol consumption. NAFLD ACTIVITY SCORE — The NAFLD activity score (NAS) is a validated score that is used to grade disease activity in patients with NAFLD. The NAS is the sum of the biopsy’s individual scores for steatosis (0 to 3), lobular inflammation (0 to 2), hepatocellular ballooning (0 to 2), and fibrosis (0 to 4). An NAS of 1 or 2 corresponds to NAFL, 3 to 4 corresponds to borderline NASH, and a score ≥5 corresponds to NASH. Noninvasive assessment of hepatic fibrosis — There are now several noninvasive methods to detect fibrosis in patients with liver disease. One of the scores, the NAFLD fibrosis score, is specific to NAFLD. The score takes into account the patient’s age, body mass index, hyperglycemia, aminotransferase levels, platelet count, and albumin. Studies suggest that higher NAFLD fibrosis scores may be associated with increased mortality from cardiovascular disease.

DIFFERENTIAL DIAGNOSIS Alternative causes of hepatic steatosis — There are multiple causes of hepatic steatosis that should be considered in a patient with suspected nonalcoholic fatty liver disease (NAFLD). Causes of hepatic steatosis in addition to NAFLD include • Alcoholic liver disease • Hepatitis C (particularly genotype 3) • Wilson disease • Lipodystrophy • Starvation • Parenteral nutrition • Abetalipoproteinemia • Medications (amiodarone, methotrexate, tamoxifen, glucocorticoids, valproate, anti-retroviral agents for HIV) • Reye syndrome • Acute fatty liver of pregnancy • HELLP (hemolytic anemia, elevated liver enzymes, low platelet count) syndrome • Inborn errors of metabolism (LCAT deficiency, cholesterol ester storage disease, Wolman disease) Significant alcohol consumption — Several definitions have been proposed for what constitutes significant alcohol consumption . We define significant alcohol consumption as an average consumption of >210 grams of alcohol per week in men or >140 grams of alcohol per week in women over at least a two-year period, a definition that is consistent with a 2012 joint guideline 20 FLORIDA MD - AUGUST 2016

from the American Gastroenterological Association, the American Association for the Study of Liver Diseases, and the American College of Gastroenterology. A standard drink in the United States (12 oz [360 mL] of beer, 5 oz [150 mL] of wine, 1.5 oz [45 mL] of 80-proof spirits) contains approximately 14 grams of alcohol , so the limits above roughly translate to >15 drinks per week for men and >10 drinks per week for women. One finding that suggests alcoholic fatty liver disease rather than NAFLD is an aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio >2 (it is typically <1 in patients with NAFLD). The alcoholic liver disease to NAFLD index (ANI) is a model that has been developed to predict the probability that steatohepatitis is due to alcoholic liver disease . The model is based upon aminotransferase levels, mean corpuscular volume (MCV), body mass index (BMI), and sex: ANI = -58.5 + 0.637 (MCV) + 3.91 (AST/ALT) – 0.406 (BMI) + 6.35 for men An ANI greater than zero favors a diagnosis of alcoholic liver disease, whereas an ANI less than zero favors a diagnosis of NAFLD. The probability of the patient having alcoholic liver disease rather than NAFLD is then calculated using the value obtained for the ANI: Probability = eANI/(1+eANI) The ability of the model to accurately categorize patients ranged from good to excellent in validation cohorts . SCREENING — One issue that arises is whether to screen patients for nonalcoholic fatty liver disease if they are at increased risk because of an associated condition such as diabetes or obesity. Currently, the American Association for the Study of Liver Diseases guidelines do not recommend screening because there are uncertainties around which diagnostic test to use (since liver enzyme levels may be normal in patients with NAFLD), how to treat NAFLD if discovered, and whether screening is cost-effective. Harinath Sheela, MD moved to Orlando, Florida after finishing his fellowship in gastroenterology at Yale University School of Medicine, one of the finest programs in the country. During his training he spent significant amount of time in basic and clinical research and has published articles in gastroenterology literature. His interests include Inflammatory Bowel Diseases (IBD), Irritable Bowel Syndrome (IBS), Hepatitis B, Hepatitis C, Metabolic and other liver disorders. He is a member of the American Gastroenterological Association (AGA), the American Society for Gastrointestinal Endoscopy (ASGE) and the American Association for the Study of Liver Diseases (AASLD) and Crohn’s Colitis foundation (CCF). Dr. Sheela is a Clinical Assistant Professor at the University of Central Florida School of Medicine. He is also a teaching attending physician at Florida Hospital Internal Medcine Residency and Family Practice Residence (MD and DO) programs. 

A Sports Medicine Approach to Rehab By Julie Sexton, PT, CSCS When applied with the appropriate fundamental principles, a sports medicine approach to care can maximize outcomes and expedite return to play in all types of patients. From the rehabilitation perspective, these fundamental principles include a team approach with skilled and experienced physical therapists, biomechanical and functional movement assessments to address the whole person, incorporation of evidence based practice and outcome measures, and innovative technology to support objective treatment progression. To create a cohesive team approach, the physical therapist must work closely with the orthopedic surgeon or sports medicine physician. Depending on the patient, the physical therapist may also work with a team of certified athletic trainers, strength and conditioning coaches, and/or personal trainers to maximize the rehabilitation process. The goal is not only to rehab the injury, but also to examine the athlete as a whole and maximize his or her fitness level to support return to high performance. A team approach with highly trained sports medicine experts is vital to achieving this goal and to ensure the best outcomes and quickest return to play.

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At Florida Hospital Sports Medicine and Rehab, our team of experts include numerous physical therapists who have completed Orthopedic and Sports Residency Training. Many have also earned specialization as Board Certified Orthopedic Clinical Specialist and Board Certified Sports Clinical Specialist. Out of the approximately 210,000 physical therapist nationwide, only 16% have achieved this designation. Florida Hospital Sports Medicine and Rehab has one of only 5 Orthopedic Residency Programs for physical therapy in Florida. Biomechanical and functional movement assessments (SFMA) are an integral part of the physical therapy evaluation in order to identify dysfunction and abnormal movement patterns that may have contributed to the injury or could potentially inhibit full recovery. This approach ensures the treatment plan is addressing not only the injury, but also the cause. Incorporating manual therapy techniques along with targeted exercise will improve functional movement and restore normal biomechanics. By utilizing research supported objective measures of progress, such as isokinetic (Biodex) testing, we are able to use evidence based medicine as the paradigm of our treatment progressions. Isokinetic testing can be used both via open and closed kinetic chain, functional tests, outcomes measures, video analysis, and movement screens (FMS). Isokinetic testing is a valuable tool for a therapist throughout the rehab process to objectively assess strength and compare the affected to

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FLORIDA MD - AUGUST 2016 21

the non-affected sides, as well as to known norms. This technology is utilized for injuries affecting the shoulder, knee and ankle. By using these objective measures, the physical therapist can ensure the patient is at a minimum standard before they start adding on performance and fitness exercises. This approach ensures we will not create movement dysfunctions and thereby delay or inhibit recovery. Developing a treatment plan and progression that is sport specific is another fundamental criteria to successful rehab outcomes. Utilizing the biomechanical and movement screens, our injury prevention programs screen the athlete through the full kinetic chain. One of the many injury prevention programs that we implement is Sportsmetrics for ACL injury prevention. This has been found to prevent ACL ruptures in adolescent athletes by 4-7 times when compared to those who do not receive this specialized training. With our baseball injury prevention program, screenings are done to identify possible musculoskeletal weaknesses and deficits that may contribute to the pitcher’s overall injury risk. Factors such as arm fatigue, deviations during the 5 phases of pitching, year-round playing, pitch counts, position specific factors, and others are all addressed. Biodex isokinetic testing of the rotator cuff musculature is utilized to determine interior rotation/exterior rotation strength ratios. A sports specific rehab program and/or general strength and conditioning program with a personal trainer or strength and conditioning coach is implemented to work on improving these deficits. This biomechanical approach is also applied for runners to identify areas of weakness or anatomical factors that contribute to overuse injuries. Weaknesses and limitations throughout the kinetic chain that affect the running mechanics are addressed in a targeted exercise prescription to correct specific muscle imbalances. Video analysis is used to fully assess each phase of gait. Focus on hip stability is a key factor in minimizing overuse injuries in runners by preventing excessive adduction, interior rotation, and pronation. Shoe wear recommendations are provided to put the runner in a shoe with the correct level of support and shock absorption for their foot-type and running distance. Where necessary, a custom foot orthotic can be provided. Utilizing innovative technology such as the AlterG, anti-gravity treadmill is crucial to achieving the best outcomes. AlterG’s patented differential air pressure (DAP) technology, developed by NASA, applies a comfortable and uniform lifting force to the body. By using air pressure as the lifting force, the AlterG DAP technology feels comfortable, while allowing the athlete to run or walk normally with full range of motion. At Florida Hospital, we have made this technology available for athletes with benefits that include: the ability to continue training while recovering from an injury, over-speed training, adding long-distance training workouts to the runner’s schedule without adding stress to joints, and strengthening and conditioning exercises with reduced impact. In order to maximize outcomes for each patient treated in our program, Florida Hospital Sports Medicine and Rehab has implemented evidence based practices. Our physical therapists are trained in diagnosis specific published Clinical Practice Guidelines and utilize them in every case. Patient reported outcomes tools such as LEFS, DASH, NDI, MODI and GROC are collected on every patient and analyzed to improve delivery of care by the therapist as well as to ensure satisfaction for our patients. With over 200,000 patient visits per year, Florida Hospital Sports Medicine and Rehab is utilizing this data to publish our findings and contribute to the advancement of evidence based practice across the country. The Florida Hospital Sports Medicine and Rehab team has experience with hundreds of athletes of all levels and sports, from youth to professional to the weekend warriors. Florida Hospital’s network of 16 outpatient centers offers convenience and ease of access across the tri-county market. Providing a cohesive and innovative approach to sports medicine from a rehabilitation standpoint is vital to ensure the best outcomes and fastest return to play for all athletes and weekend warriors.

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Julie Sexton, PT, CSCS currently serves as the Senior Director for Florida Hospital’s 16 outpatient Sports Medicine and Rehabilitation centers. She graduated with her Bachelors of Science in Physical Therapy from Ohio University where she played NCAA Division I volleyball for the Bobcats. A short stint with Health South Rehabilitation led Sexton’s career to the Mission of Florida Hospital in 1993 as a staff Physical Therapist and later as a center manager at the RDV Sportsplex site. Sexton accepted a leadership role in 2003 to support operations and growth of the then 11 outpatient rehab sites. 14 years as a passionate therapist with an orthopedic and sports medicine area of specialty, she focused her early career on program development. Sexton’s persistent focus on clinical excellence has driven her career decisions from clinician to administrator 

Stellar Lineup of Speakers Positions AID’s Independence in Action as ‘Meeting of the Year’ for Independent Docs Attendees to receive 6 CME Credits By Marni Jameson Carey

Forbes and Wall Street Journal contributor Dr. Scott Gottlieb, a practicing physician and resident fellow at the American Enterprise Institute, is the most recent addition to an all-star lineup of nationally renowned presenters set to speak at the Association of Independent Doctors’ first meeting this November. The meeting is already being hailed as the nation’s most significant meeting of the year for independent doctors. As if hearing the terrific speakers and networking with other independent doctors weren’t enough, those attending the oneday conference Saturday, Nov. 5, at the Walt Disney World Swan & Dolphin Resort, in Orlando, may now receive 6 continuing medical education credits. * AID recently received approval to offer the credits (6.0 AMA PRA Category 1) from the American Board of Quality Assurance and Utilization Review Physicians, Inc., which is accredited to provide CME for physicians. In a talk titled Uncle Sam, MD: The Federal Regulation of Medicine, Dr. Gottlieb, who previously served as FDA deputy commissioner for medical and scientific affairs, will discuss the

events and trends that have led to the dramatic cultural change in the relationship between the government and the practice of medicine. He will shed light on why federal authorities believe they not only have a legal right to regulate medical practices, but also, somehow, an obligation. Finally, he will explore how doctors can reclaim a tradition of self-regulation, and regain a culture of professional authority that is better for patient care and public health. Those attending Independence in Action 2016 will also hear the following speakers:

• FOLLOW THE MONEY -- DR. GERARD ANDERSON A leading authority on health-care payment reform, Dr. Anderson will discuss how pricing decisions made by physicians and hospitals influence profits, revenue and quality of care. His talk will examine the characteristics that allow doctors and hospitals to have the greatest bargaining power and reveal who is most like-

Compassionate, Caring & Sophisticated Medical Care

• Radiofrequency Ablation (for Patients with Barrett's Esophagus) • Colonoscopy

FLORIDA MD - AUGUST 2016 23

ly to use that power to their advantage. Dr. Anderson is professor of health policy and management, Bloomberg School of Public Health, Johns Hopkins University, and director of the Center for Hospital Finance and Management.

• THE VIRTUES OF INDEPENDENCE -- DR. RICHARD GUNDERMAN

In our era of increasing oversight, consolidation and physician employment, independent doctors appear to be going the way of the dinosaurs. What are the virtues of independence, and what steps can physicians and practices take to promote independence for the benefit of patients and communities? A philosopher and physician, Dr. Gunderman will make the case for doctor independence with his trademark grace, humanity, authority and reason. A professor of radiology, pediatrics, medical education, philosophy, liberal arts and philanthropy, Dr. Gunderman also serves as vice-chair of the radiology department at Indiana University and is a contributing writer to The Atlantic.

• GAMES HOSPITALS PLAY -- DR. MICHAEL REILLY

Orthopedic surgeon and whistleblower, Dr. Reilly was the force behind the second largest hospital false claims settlement in U.S. History. The case Michael T. Reilly, MD vs Broward Health culminated in a landmark $70 million Stark Law settlement last year. In his talk, Dr. Reilly will share his 12-year journey as he battled the ninth largest health-care system in the country – and won. He will discuss what lay behind the fight: the detrimental dynamic created by hospital-physician employee contracts, which has local and national ramifications. Dr. Reilly will cover the salient points of Federal Stark Law and anti-kickback law, as well as how to mount a challenge when violations occur.

• THE FIGHT AGAINST FRAUD -- MARLAN WILBANKS Nationally recognized for his work on Stark Law violations and false claims, attorney Marlan Wilbanks has championed cases that have resulted in more than $2 billion in settlements being returned to the U.S. Treasury. Sharing lessons learned from fighting fraudulent claims on behalf of the American taxpayer, Mr. Wilbanks will discuss recent settlements he’s won, how these cases impact providers, and the scope and potential impact of current cases. He will also discuss current cases and the vital and perilous role of the whistleblower. Over lunch, Dr. George White, Orlando orthopedic surgeon and founder of Integrated Independent Physicians Network, LLC, will discuss The Role of the IPN in Maintaining Independence. If you are a doctor concerned with the future of the practice of medicine, or the administrator of an independent medical practice, you will want to be a part of this landmark conference. To register go to www.aid-us.org/conference. Marni Jameson is the executive director of the Association of Independent Doctors, a national nonprofit dedicated to helping reduce health-care costs by helping consumers, businesses and lawmakers understand the value of keeping America’s doctors independent www.aid-us. org. You may reach her at marni@aid-us.org.

Patient Assistance Resources The CF Foundation is committed to improving the lives of all people and families with CF. We can help you with: •Insurance coverage and benefits •Resources to pay for therapies and medications •Legal information •Other concerns Tell us your issue. We will help you find a solution. 888-315-4154 • parc@cff.org • www.cff.org

24 FLORIDA MD - AUGUST 2016

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2016

EDITORIAL CALENDAR

Florida MD is a four-color monthly medical/business magazine for physicians in the Central Florida market. Florida MD goes to physicians at their offices, in the thirteen-county area of Orange, Seminole, Volusia, Osceola, Polk, Flagler, Lake, Marion, Sumter, Hardee, Highlands, Hillsborough and Pasco counties. Cover stories spotlight extraordinary physicians affiliated with local clinics and hospitals. Special feature stories focus on new hospital programs or facilities, and other professional and healthcare related business topics. Local physician specialists and other professionals, affiliated with local businesses and organizations, write all other columns or articles about their respective specialty or profession. This local informative and interesting format is the main reason physicians take the time to read Florida MD. It is hard to be aware of everything happening in the rapidly changing medical profession and doctors want to know more about new medical developments and technology, procedures, techniques, case studies, research, etc. in the different specialties. Especially when the information comes from a local physician specialist who they can call and discuss the column with or refer a patient. They also want to read about wealth management, financial issues, healthcare law, insurance issues and real estate opportunities. Again, they prefer it when that information comes from a local professional they can call and do business with. All advertisers have the opportunity to have a column or article related to their specialty or profession.

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NOVEMBER – Urology Geriatric Medicine / Glaucoma DECEMBER – Pain Management Occupational Therapy

Please call 407.417.7400 for additional materials or information. FLORIDA MD - AUGUST 2016 25

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