MARCH 2021 • COVERING THE I-4 CORRIDOR
UCF Lake Nona Medical Center Expanding Access to Care in Orlando’s Medical City
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contents 4
MARCH 2021 COVERING THE I-4 CORRIDOR
COVER STORY
PHOTO: PROVIDED BY UCF LAKE NONA MEDICAL CENTER
After breaking ground in 2018, UCF Lake Nona Medical Center opened to the public this month, providing full-service healthcare to Lake Nona and surrounding communities in southeast Orlando and Osceola County. Located at 6700 Lake Nona Blvd., adjacent to the UCF College of Medicine in Orlando’s Medical City, Lake Nona’s new hospital provides 24/7 emergency care and an array of inpatient and outpatient hospital services and is expected to serve more than 17,000 patients in its first year.
ON THE COVER: UCF Lake Nona Medical Center
The establishment of the new hospital was a $175 million investment toward creating an immediate access point to acute inpatient care for adults. Previously, that level of care was only available in the Lake Nona area for children (at Nemours Children’s Hospital) and veterans (at Orlando VA Medical Center at Lake Nona). Now, adults of all ages have immediate, convenient access to a full-service hospital featuring 64 inpatient beds, a 20bed emergency department, four operating rooms, a cardiac catheterization lab, comprehensive imaging and laboratory services, and six private birthing suites.
PHOTO: PROVIDED BY UCF LAKE NONA MEDICAL CENTER
3 CANNABIS USE DOES NOT DIMINISH COGNITION IN OLDER ADULTS 10 YOUR PATIENT IS NOT HAPPY WITH THEIR KNEE OR HIP REPLACEMENT. WHAT’S NEXT?
DEPARTMENTS 2
FROM THE PUBLISHER
7 DERMATOLOGY 8
HEALTHCARE LAW
12 PHARMACY UPDATE
15 MARKETING YOUR PRACTICE
FLORIDA MD - MARCH 2021
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FROM THE PUBLISHER
I
am pleased to bring you another issue of Florida MD. Sometimes a patient may have the opportunity to participate in a clinical trial. Sometimes a patient may need specialized treatment that is not available in Central Florida. And sometimes there’s no money for that patient to get to those places. Fortunately there is Angel Flight Southeast to get those patients where they need to go. I asked them to tell us about their organization and how you, as physicians, can help. Please join me in supporting this truly wonderful organization. Best regards,
Donald B. Rauhofer Publisher
ANGELS ON EARTH HELP PATIENTS GET TO LIFESAVING MEDICAL TREATMENT Everyone knows angels have wings! But did you know in Florida and many parts of the nation they have engines and tails with dedicated volunteers who donate lifesaving services every day? Leesburg, Fla.-based Angel Flight Southeast is a network of approximately 650 pilots who volunteer their time, personal airplanes and fuel to help passengers get to far-from-home medical care. A member of the national Air Charity Network, Angel Flight Southeast has been flying passengers since 1993. Almost all of its passengers are chronic-needs patients who require multiple, sometimes 25-50 treatments. Passengers may be participating in clinical trials, may require post-transplant medical attention or are getting specialized treatment that is not available near home. Each passenger is vetted to confirm medical and financial need and is often referred to Angel Flight Southeast by medical personnel and social workers. Angel Flight Southeast “Care Traffic Controllers” arrange flights 24 hours a day, 365 days a year. In the event of a transplant procedure, the Care Traffic Controllers have precious minutes to reach out to its list of volunteer pilots who have agreed to be prepared on a moment’s notice to fly a patient to receive his or her potentially lifesaving organ. The organization is completely funded through donations by individuals and organizations. A typical Angel Flight Southeast pilot donates $400 to $500 in services-per-trip. In fact, Angel Flight Southeast has earned the Independent Charities of America Seal of Approval as a good steward of the funds it generates from the public. Each $1 donated generates more than $10 worth of contributed services by Angel Flight Southeast. The charity always seeks prospective passengers, volunteer pilots and donations. For additional information, please visit https://www.angelflightse.org or call 1-888-744.8263.
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Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: John “Lucky” Meisenheimer, MD, Sonda Eunus, MHA, Julie Tyk, JD, Michael Patterson NHA, OTR/L, CEAS, George J. Haidukewych, MD, Juan Lopez, Pharm D, John Meisenheimer, VII 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 2021, Sea Notes Media. All rights reserved. Reproduction in whole or in part without written permission is prohibited. Annual subscription rate $45.
Cannabis Use Does Not Diminish Cognition in Older Adults By Michael Patterson, NHA, OTR/L, CEAS Based on a recent review of applicable studies published in the journal: Archives of Clinical Neuropsychology, Cannabis exposure appears to have no significant adverse impact on the cognitive function of older adults. A link to the article is below: Effects of Cannabis Use on Cognitive Function in Healthy Aging: A Systematic Scoping Review | Archives of Clinical Neuropsychology | Oxford Academic (oup.com) Adults over 50 years old represent the fastest-growing population of people who use cannabis. Given healthy aging and cannabis use are associated with cognitive decline, it is important to establish the effects of cannabis and cognition on healthy aging. A team of researchers with the University of California at San Diego reviewed human studies and animal trials specific to the potential impact of cannabis on cognition. For the analysis, researchers analyzed six databases (PubMed, EMBASE, PsycINFO, Web of Science, Family and Society Studies Worldwide and CINAHL) and discovered over 1,000 relevant studies as of September 2019. In the human trials, cannabis exposure revealed “predominantly null findings” in adults ages 50 and older. In animal models, cannabinoid dosing was associated with “improved cognition” with small amounts of THC and more potent amount of THC as well. The authors suggested to use caution in interpreting the studies’ results because of their limited number and heterogeneity. However, the authors concluded, “This systematic scoping review examined current research on the relationship between cannabis use and cognitive function in healthy aging and provides a starting point for future research.” “Ultimately, given the recent increase in cannabis use among older adults, future human research should examine the relationship between both early and later-life cannabis use on cognitive function within more homogenous, older adult samples of people who use cannabis.”
ANALYSIS As more Seniors look to cannabis as a medicine to help with multiple ailments, it is important for us to use as much research and data as possible to assist this demographic in feeling comfortable using an all-natural medicine in proper dosages to have a consistent result. In the largest medical cannabis market in the world (Florida-almost 500,000 patients), the average age of patient is 52 years old. The number of patients in Florida is increasing by 5,000 each week! The average Senior Citizen in the United States takes 13 prescription medicines per day. From my experience in working in the US post-acute healthcare system for over 20 years (Nursing Homes, Rehabilitation centers, Pharmacies, Laboratories), I saw first-hand how over medication can be just as detrimental to health as not being treated for an ailment. With our bodies containing
a Endocannabinoid system (ECS), we are naturally are predisposed to accept cannabis as a medicine. Therefore, I expect more and more Seniors globally will begin to use cannabis as a medicine to decrease symptoms of many diseases, decrease use of other prescription drugs due to no longer needing them, and to not have harsh side effects from certain prescription drugs, and for a better quality of life. Michael Patterson NHA, OTR/L, CEAS is CEO of US Cannabis Pharmaceutical Research and Development LLC. (uscprd.com). Mr. Patterson is a healthcare executive with over 25 years experience in the following areas: Cannabis-Hemp investment, Law, Regulation, Compliance, Operations, and Management, Skilled Nursing, Pharmacy, Laboratory, Assisted Living, Home Healthcare, and Healthcare Analytics. Michael is a subject matter expert in the Global Cannabis and Hemp Industry with Gerson Lehrman Group (glg.it) and Guidepoint. Mr. Patterson is an editorial board member of the American Journal of Medical Cannabis, licensed Nursing Home Administrator, and licensed Occupational Therapist in 4 states..
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COVER STORY
UCF Lake Nona Medical Center – Expanding Access to Care in Orlando’s Medical City After breaking ground in 2018, UCF Lake Nona Medical Center opened to the public this month, providing full-service healthcare to Lake Nona and surrounding communities in southeast Orlando and Osceola County. Located at 6700 Lake Nona Blvd., adjacent to the UCF College of Medicine in Orlando’s Medical City, Lake Nona’s new hospital provides 24/7 emergency care and an array of inpatient and outpatient hospital services and is expected to serve more than 17,000 patients in its first year. The establishment of the new hospital was a $175 million investment toward creating an immeUCF Lake Nona Medical Center’s Family Birthing Unit features six private birthing diate access point to acute inpatient care for adults. suites, offering all the medical technology mom and baby may need for a safe delivPreviously, that level of care was only available ery – including a dedicated operating room for C-sections. Each suite is comfortably in the Lake Nona area for children (at Nemours furnished with space for a guest to stay overnight. The hospital supports each mom’s Children’s Hospital) and veterans (at Orlando VA birth plan and preferences, and provides a nurturing environment to support the family in bonding with baby following delivery, including rooming in, skin-to-skin care Medical Center at Lake Nona). Now, adults of all immediately following birth and personalized breastfeeding instruction. ages have immediate, convenient access to a fullrealization of a vision that will impact the community for years service hospital featuring 64 inpatient beds, a 20-bed emergency to come,” said Wendy H. Brandon, FACHE, Chief Executive department, four operating rooms, a cardiac catheterization lab, Officer. “With the rapid growth in Lake Nona, this community comprehensive imaging and laboratory services, and six private needed a hospital close to home. Our team looks forward to birthing suites. working with our medical staff to deliver innovative, patient“The grand opening of UCF Lake Nona Medical Center is the centered care to every patient and support Lake Nona’s commitment to health and UCF Lake Nona Medical Center well-being.”
PHOTO: PROVIDED BY UCF LAKE NONA MEDICAL CENTER:
Established in one of the state’s fastgrowing regions, UCF Lake Nona Medical Center was strategically designed and planned for with the future in mind – meaning the hospital intends to grow with the community. Currently, the facility has 64 inpatient beds. The facility’s shell space has immediate capacity to grow to 80 beds, and the hospital and campus are designed to grow to 500 beds, as 4 FLORIDA MD - MARCH 2021
PHOTO: PROVIDED BY UCF LAKE NONA MEDICAL CENTER:
By Staff Writer
needed. Looking ahead, Brandon expects the hospital’s first targets for expansion to be inpatient beds, as well as the ER, Family Birthing Unit and operating rooms. Since the hospital was designed to accommodate expansion in these areas, such additions would be completed without disruption to current services or care.
PHOTO: PROVIDED BY UCF LAKE NONA MEDICAL CENTER
In addition to expanded access to care, the new hospital will also provide innovative treatments not previously available in the area, like incisionless brain surgery to treat patients with essential tremors. The hospital also features the latest technology to support superior quality care and patient safety, including systems to provide enhanced security, communica- UCF Lake Nona Medical Center was thoughtfully designed to create a space that is warm and inviting, putting patients at ease with purposeful color choices, calming patterns, comfortable furniture and tion and experience. Examples functional spaces. The lobby atrium features a gift shop, a quiet room and café complete with outdoor include an interactive nurse call dining. Complimentary Wi-Fi service is available throughout the facility so guests can be notified by text system that alerts care teams when their loved one or a team member is ready for them. Located next door to the University of Central of patient needs in real-time, a Florida’s College of Medicine, some design and architectural elements are repeated as a symbolism of the unique partnership between UCF College of Medicine and HCA Healthcare. real time location system which pinpoints equipment, staff and patient location throughout the hospital, smart hospital beds that collect patient data and communicate with patients in up to six different languages, and electronic information displays in each room, which communicate important information such as a patient’s care team, diet, activity schedule and the names and times of team members entering the room. The community will also benefit from the hospital’s tremendous financial impact on the area’s economy. The new facility employs more than 370 staff members. In addition, more than 330 physicians have joined the UCF Lake Nona Medical Center features a full range of imaging technology for both inpatients and outpatients, including 64-slice Computed Tomography (CT), MRI, nuclear medicine, ultraUCF Lake Nona Medical Center medisound, X-ray, 3-D mammography, DEXA scan and interventional radiology. cal staff, including specialists in primary care, cardiology, colorectal surgery, general surgery, gastroenterology, orthopedic surgery, pulmonology, nephrology, OB/ GYN, gynecologic oncology, infectious disease, nephrology, neurology, neurosurgery, spine and urology. UCF Lake Nona Medical Center is projected to contribute $1.4 million in local and state taxes and provide an estimated $13.8 million for charity and uncompensated care in its first year. Thanks to a unique partnership between HCA Healthcare and the University of Central Florida Academic Health, UCF Lake Nona Medical Center will support community needs and boost the local economy – while simultaneously investing in tomorrow’s healthcare pracFLORIDA MD - MARCH 2021
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PHOTO: PROVIDED BY UCF LAKE NONA MEDICAL CENTER
COVER STORY
COVER STORY
PHOTO: PROVIDED BY UCF LAKE NONA MEDICAL CENTER
health and well-being of our communities,” said Brandon. “We want our community to know they can trust UCF Lake Nona Medical Center to provide safe care, whether it is in a medical emergency, a planned medical or surgical procedure or welcoming a new baby to their family.” UCF Lake Nona Medical Center opened its doors to the community Monday, March 1, hosting a virtual grand opening celebration that morning featuring HCA Healthcare and UCF leadership, hospital team members and community leaders. A recording of the program is available at UCF Lake Nona Medical Center’s Facebook page. To learn more, please visit www.ucflakenonamedicalcenter.com. The hospital invested in the latest technology to support superior quality care and patient safety for its new facility. Every patient room features a smart bed that weighs the patient and collects other important data, notifies care teams of patient movement to help avoid falls, and communicates with patients in up to six different languages. Each room is also equipped with an electronic white board, which communicates a patient’s diet, activity schedule and the names of team members entering the room in real time. Through the integration of cutting-edge technologies like these, the hospital can ensure higher levels of patient care, safety and satisfaction.
6700 LAKE NONA BOULEVARD ORLANDO, FL 32827 • 689-216-8000 UCFLAKENONAMEDICALCENTER.COM
“In addition to providing convenient access to outstanding healthcare services in Lake Nona, this hospital will also provide important educational opportunities for tomorrow’s physicians and support the work of our UCF researchers and scientists from across the country seeking innovative treatments and cures,” said Dr. Deborah C. German, Vice President for Health Affairs and Dean of the College of Medicine at University of Central Florida. “UCF Lake Nona Medical Center is the next step in creating a healthcare hub that will increase economic development and improve health for all.” Designed with education spaces and technology throughout, the new hospital creates an ideal learning environment for future physicians, as well as UCF nursing, social work, pharmacy and physical therapy students and more. These students will be learning not only from the UCF Lake Nona Medical Center physicians but will also be supported by hospital colleagues committed to elevating the standards of care in the Lake Nona community. UCF Lake Nona Medical Center has also partnered with community physicians, as well as UCF College of Medicine physicians and researchers, who share a commitment to developing excellent caregivers and finding cures.
PHOTO: PROVIDED BY UCF LAKE NONA MEDICAL CENTER
titioners. These future healthcare professionals will benefit from the depth and breadth of the HCA Healthcare network, tapping into its extensive clinical knowledge and innovative operating strategies.
UCF Lake Nona Medical Center’s rehabilitation technology includes a car transfer simulator, which allows patients to practice getting in and out of a vehicle during therapy sessions.
UCF LAKE NONA MEDICAL CENTER SERVICES: CARDIOLOGY
NEPHROLOGY
COLORECTAL SURGERY
NEUROHEALTH SCIENCES
24/7 EMERGENCY CARE
ORTHOPEDICS
GASTROENTEROLOGY
PULMONOLOGY
GENERAL SURGERY
ROBOTIC SURGERY
As the hospital’s leadership team celebrated their grand opening milestone this month, they also acknowledged the unique challenges of opening a hospital during the ongoing pandemic – something they’re well-equipped to handle.
GYNOCOLOGIC ONCOLOGY
SPINE CARE
IMAGING
UROLOGY
INFECTIOUS DISEASE
WOMEN’S CARE
“As we’ve seen even more so over this past year, access to quality healthcare and leading medical experts is paramount to the
MATERNITY
6 FLORIDA MD - MARCH 2021
DERMATOLOGY
Things That May Look Malignant But Are Not By John “Lucky” Meisenheimer, MD and John Meisenheimer, VII
PHOTO: JOHN MEISENHEIMER, VII
The rate of the number of skin biopsies performed each year nationally has increased by about 6% a year for the last ten years or so. Part of this increase appears to be due to physician extenders biopsying more lesions. The good news is that although there may be more unnecessary biopsies, we have also had an increase in early detection of melanoma in situ, so overall, we are still saving lives. The difficulty is that there are many benign lesions to the untrained eye that look suspicious for skin cancer. Often, for a trained dermatologist, it is simple to tell benign from malignant lesions. Still, in some cases, it is far more problematic, and a biopsy is needed to make sure you are not missing something important.
Abscess – not an ulcerated squamous cell carcinoma.
In my practice, I never tell a patient, we will “closely watch” something suspicious to see if it looks worse in 6 months. I have had patients on their visits with me point out lesions that their health care provider is “following” as it appeared a little suspicious to them. If it is questionable, then it needs to be biopsied, period, now, not in 6 months when it has had a chance to grow. You only follow lesions that don’t look suspicious. If I am at all suspicious, and of course, being a dermatologist, I have the advantage of intuitive expertise, I will biopsy, and I like other dermatologists have a high rate of success in finding the spots that do need biopsying.
PHOTO: JOHN MEISENHEIMER, VII
Hidrocystoma - not Merkel cell carcinoma.
What about a growth that looks completely benign, but you are mistaken? If I feel that there is nothing clinically wrong with a lesion, I will explain to the patient, “if it should change or become symptomatic, then come back in for a recheck, do not wait for your six or twelve months follow up.” If you don’t give the patients this bit of sage advice, then you will invariably see the following scenario happen.” A patient calls three years after his last exam. “Doc, I had a spot you said was okay, but it started growing about a week after I saw you. I didn’t do anything as you said it was okay. It’s now about the size of a golf ball, do you think I need to come in, it’s been three years now and still growing, what do you think?”
PHOTO: JOHN MEISENHEIMER, VII
PHOTO: JOHN MEISENHEIMER, VII
There are times that I will biopsy a spot just because I have an inkling of a thought that there might be something going on; this is the intuitive expertise kicking in again. Sometimes I biopsy lesions because it is a CTA (Cover Thy Ass) moment. Although I know deep in my heart that the spot is benign, it sure looks funky, and I want to make sure I have not made a mistake. Better to biopsy and prove yourself wrong than trying to explain to the jury why not biopsying the malignancy that appeared benign, was the correct choice, good luck with that challenge.
Chondrodermatitis – not Squamous cell carcinoma.
Benign appearing lesions that, in reality, have gone to the dark side will eventually evolve. The patient will be the first to notice this happening, and they need to know you take changes seriously, even if it occurs days or weeks after their exam. Return checks on sudden changes in benign-appearing growths are your security net for wolves hiding under sheepskins. Lucky Meisenheimer, M.D. is a board-certified dermatologist specializing in Mohs Surgery. He is the director of the Meisenheimer Clinic – Dermatology and Mohs Surgery. John Meisenheimer, VII is a medical student at USF.
PHOTO: JOHN MEISENHEIMER, VII
Herpes – not Basal cell carcinoma.
Pyogenic Granuloma – not Metastatic carcinoma. FLORIDA MD - MARCH 2021
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HEALTHCARE LAW
Understanding Exculpatory Clauses By Julie A. Tyk, JD An exculpatory clause purports to deny an injured party the right to recover damages from a person negligently causing his injury. Cain v. Banka, 932 So. 2d 575 (Fla. 5th DCA 2006). They are disfavored in the law because they relieve one party of the obligation to use due care and shift the risk of injury to the party who is probably least equipped to take the necessary precautions to avoid injury and bear the risk of loss. Applegate v. Cable Water Ski, L.C., 974 So. 2d 1112, 1114 (Fla. 5th DCA 2008). Such clauses are strictly construed against the party seeking to be relieved of liability. Sunny Isles Marina, Inc. v. Adulami, 706 So. 2d 920 (Fla. 3d DCA 1998). Thus, exculpatory clauses are enforceable, only where, and to the extent, that the intention to be relieved from liability is made clear and unequivocal. Tatman v. Space Coast Kennel Club, Inc., 27 So. 3d 108, 110 (Fla. 5th DCA 2009). The wording must be so clear and understandable that “an ordinary and knowledgeable person will know what he is contracting away.” Id. (quoting Gayon v. Bally’s Total Fitness Corp., 802 So. 2d 420 (Fla. 3d DCA 2001). The seminal Florida case on exculpatory clauses is the Florida Supreme Court case of Sanislo v. Give Kids The World, Inc., 157 So. 3d 256 (Fla. 2015). Give Kids the World, Inc. (“GKTW”) provided free vacations to seriously ill children and their families. When applying for the vacation, the Sanislos executed a “wish request” form that contained a waiver of liability, also known as an exculpatory clause. When the parents arrived at the resort village they again signed a liability release form, also an exculpatory clause. The language of the exculpatory clause is reprinted below for reference: I/we hereby release Give Kids the World, Inc. and all of its agents, officers, directors, servants, and employees from any liability whatsoever in connection with the preparation, execution, and fulfillment of said wish, on behalf of ourselves, the above named wish child and all other participants. The scope of this release shall include, but not be limited to, damages or losses or injuries encountered in connection with transportation, food, lodging, medical concerns (physical and emotional), entertainment, photographs and physical injury of any kind.... I/we further agree to hold harmless and to release Give Kids the World, Inc. from and against any and all claims and causes of action of every kind arising from any and all physical or emotional injuries and/or damages which may happen to me/us.... Sanislo at 258-259. While participating in a horse-drawn wagon ride, a rear pneumatic lift designed to allow those in wheelchairs to participate failed, and Ms. Sanislo was injured. The Sanislos brought suit and GKTW filed a motion for summary judgment arguing that the signed releases precluded an action for negligence. The Sanislos filed a motion for partial summary judgment against GKTW’s affirmative defense of release. The trial court granted the Sanislo’s motion and denied GKTW’s motion. The jury found for the Sanislos and GKTW appealed. Id. 8 FLORIDA MD - MARCH 2021
The Fifth District reversed, finding the lower court erred in denying GKTW’s motion for summary judgment because the release signed by the Sanislos was unambiguous and did not contravene public policy. It ruled the exculpatory clause barred the negligence action despite the lack of a specific reference to “negligence” or “negligent acts” in the exculpatory clause. The Fifth District reasoned that exculpatory clauses are effective if the wording of the exculpatory clause is clear and understandable so that an ordinary and knowledgeable person would know what he or she is contracting away, and that the court had previously rejected “‘the need for express language referring to release of the defendant for “negligence” or “negligent acts” in order to render a release effective to bar a negligence action.’ ” On the public policy argument, the Court said the relative bargaining power of the parties should not be considered because it was outside of the public utility or public function context and the Sanislos were not required to request a vacation with GKTW or go on the vacation. Id. In affirming the Fifth District’s decision, the Supreme Court wrote that the conflict for the Court’s resolution was “whether an exculpatory clause is ambiguous and thus ineffective to bar a negligence action due to the absence of express language releasing a party from its own negligence or negligent acts.” Id. at 260. The Florida Supreme Court wrote: .... we are reluctant to hold that all exculpatory clauses that are devoid of the terms “negligence” or “negligent acts” are ineffective to bar a negligence action despite otherwise clear and unambiguous language indicating an intent to be relieved from liability in such circumstances. Application of such a bright-line and rigid rule would tend to not effectuate the intent of the parties and render such contracts otherwise meaningless. Id. at 270. The Court found that the GKTW liability release form released GKTW and all of its agents, officers, directors, servants and employees from “any liability whatsoever in connection with the preparation, execution and fulfillment of said wish…” The release then provided that the scope of the agreement included “damages or losses or injuries encountered in connection with transportation, food, lodging, medical concerns (physical and emotional), entertainment, photographs and physical injury of any kind . . . .” The Court found that the release clearly conveyed that GKTW would be released from any liability, including negligence, for damages, losses, or injuries due to transportation, food, lodging, entertainment and photographs. Id. The determination of whether an exculpatory clause is enforceable will be determined by the Judge, as the enforceability of a pre-injury release is a question of law. The enforceability there-
HEALTHCARE LAW fore, will depend on the Judge assigned to the matter. Physicians should not assume that because a patient signed a liability release form the patient does not have a viable cause of action. Physicians should consult with an experienced attorney who can examine the facts of the case and help you determine the best path forward. The Health Care Practice Group at Pearson Doyle Mohre and Pastis, LLP is committed to assisting Clients in navigating and defending medical malpractice claims. For more information and assistance, please contact David Doyle and Julie Tyk at Pearson Doyle Mohre & Pastis, LLP. Julie A. Tyk, JD, is a Partner with Pearson Doyle Mohre & Pastis, LLP. Julie concentrates her practice in medical practice defense litigation, insurance defense litigation and health care law. She has represented physicians, hospitals, ambulatory surgical centers, nurses and other health care providers across the state of Florida. She may be contacted by calling (407) 951-8523; jtyk@pdmplaw.com.
FLORIDA MD - MARCH 2021
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Your Patient Is Not Happy with Their Knee or Hip Replacement. What’s Next? By George J. Haidukewych, MD According to the Agency for Healthcare Research and Quality, more than 790,000 knee and 450,000 hip replacements are performed in the United States each year. While these numbers declined somewhat over the past year due to obvious reasons and events related to the pandemic, experts project a significant upward trend in medically indicated joint replacement surgeries over the next 10 years. More than 85-90 percent of patients who undergo total knee or hip arthroplasty (TKA/THA) surgery experience a favorable outcome, with a decrease in pain, an increase in mobility and an overall improved quality of life. And with advances in technology, patients can expect their replacement joint to function well for 20 years or longer. But not all joint replacement surgeries are successful. Complications and failures can occur, and patients who expected dramatic pain relief and function after a knee or hip replacement may present with persistent pain, as well as considerable frustration and unhappiness. About a third of patients will still have some aches and pains following knee or hip replacement. Early problems can be due to technical factors involving the surgery, inadequate rehab, or more serious problems such as infection or loosening. Problems can also occur years after surgery as the ceramics and plastics start to wear through. A joint replacement that had previously been functioning well for several years can suddenly start hurting or swelling. The most common complaints following TKA include swelling, activity-related pain and mechanical symptoms, like a crunching behind the kneecap and even clicking when the patient walks. With THA, common painful symptoms include persistent pain around the tendon or bursa on the side of the hip.
knee or hip replacement. Sometimes patients have unrealistic expectations of their replacement, because of what they’ve been told or seen on TV or social media. Expecting the joint to be normal versus artificial is a common source of dissatisfaction. They may not follow proper rehab or activity levels. These patients require a comprehensive evaluation of their overall fitness level, including other joints like the shoulders and ankles. Patients need to focus on total body fitness and understand what a replacement joint can and cannot do. An overall aging population, a rise in the prevalence of risk factors such as obesity, and the popularity of maintaining active lifestyles not only contribute to the increasing number of joint replacement surgeries, but also the inevitable consequential increase in complications or failed joint replacements. We also have seen an increasing number of joint replacements in a younger patient population whose active lifestyles place added stress and wear on their original and replacement joints. With normal use and activity, every joint replacement implant begins to wear over time, and excessive activity or weight may increase the rate of this normal wear, causing the replacement joint to loosen and become painful. Evaluation by an orthopedic specialist may determine that a painful knee or hip replacement does need any further surgical intervention. It may simply be something that indicates additional physical therapy, weight loss or activity modification. But there is an increasing number of patients who will require a joint replacement revision (redo).
WHEN IS REVISION SURGERY NECESSARY?
WHAT DO YOU DO IF YOUR PATIENT EXPERIENCES PERSISTENT PAIN AFTER JOINT REPLACEMENT SURGERY?
Revision, or redo, surgery is a complex procedure that involves removing and replacing the original joint implant, usually due to a complication from the initial replacement.
Sorting out what is a normal discomfort for a prosthetic joint and what is a more serious problem is not always straightforward. What may seem like a minor ache or pain could be a sign of a more serious underlying problem. Problems such as instability or loosening of the knee or hip, or even more unusual problems like corrosion or metal sensitivity, can be easily misdiagnosed; ruling out infection and instability is critical.
Overall, complication rates following TKA or THA surgery are low. Serious complications, such as a joint infection, occur in fewer than 1-2 percent of patients. Instability can occur in 2-3 percent of knee replacements, and 2-3 percent of hip replacements can have a dislocation or similar problem. These percentages are small, but given the large number of surgeries performed, it adds up to a significant number of people experiencing undue discomfort and pain.
The optimal plan of care for those patients who continue to experience ongoing joint pain after TKA or THA is an evaluation referral with an orthopedic specialist. Specialized tertiary referral centers like Orlando Health Jewett Orthopedic Institute offer expert specialist care and advanced technology, including leading-edge imaging, such as MRI scanning with metal artifacts suppression, to diagnose reasons for persistent symptoms after a 10 FLORIDA MD - MARCH 2021
Typically, more women than men undergo knee replacement, with hip replacements being about even between men and women. Overall, men place more wear on replacement joints than women, due both to more body weight and slightly more activity, resulting in a slightly higher need for revision surgery. Data from Medicare shows that the average rate of revision
surgery within 90 days is 0.2 percent but increases to 3.7 percent within 18 months. These are usually due to infection or mechanical complications of the implant. While surgical techniques and implant designs and materials continue to advance, implant surfaces can wear down and the components can loosen over time. Research suggests that long-term wear and loosening affects 6 percent of people after 5 years and 12-15 percent after 10 years. Only a handful of centers in Florida specialize in diagnosing and treating conditions associated with problematic joint replacements. Specialists with the Orlando Health Jewett Orthopedic Institute perform hundreds of successful revisions of knee and hip replacements every year for patients throughout Florida and the Southeast. These complex, long procedures can be challenging and require multidisciplinary and subspecialty care, including infectious disease experts and plastic surgeons, as well as advanced surgical, intensive care, recovery and rehabilitation facilities that provide a higher level of care. Backed by all the resources of the Orlando Health system, Orlando Health Jewett Orthopedic Institute offers this advanced level of care. And, expected to be completed in 2023, a new, state-of-the-art orthopedic complex on Orlando Health’s downtown Orlando campus will usher in the next generation of orthopedic care. Ultimately, the basic message for your patients is “Don’t give up hope!” An orthopedic surgeon who specializes in complex knee and hip revision work can provide a comprehensive evaluation to determine how to best correct a persistent joint replacement problem. Internationally recognized for joint replacement surgery and trauma, George J. Haidukewych, MD, serves as Orlando Health’s director of orthopedic trauma and chief of complex joint replacement, practicing at the Orlando Health Jewett Orthopedic Institute. Dr. Haidukewych specializes in total hip and total knee replacements as well as orthopedic trauma. He brings extensive experience in the management of failed and infected total hip and total knee replacements and in reconstruction of the joints after trauma. Up to half of his practice is dedicated to solving these challenging problems from around the Southeast. Dr. Haidukewych completed his residency training at the Mayo Clinic in Rochester, Minnesota, as well as a fellowship at Florida Orthopaedic Institute in the Tampa Bay area.
Check out our newly redesigned website at www.floridamd.com! FLORIDA MD - MARCH 2021 11
COVER STORY
PHARMACY UPDATE
Nature-Throid® & WP Thyroid® Recall By Juan Lopez, PharmD, FAPC Having difficulties filling your prescription thyroid therapy for Nature-Throid® or WP Thyroid®? RLC Labs, the manufacturer of Nature-Throid® and WP Thyroid® products, announced that it is voluntarily recalling all unexpired lots of Nature-Throid® and WP Thyroid® to the consumer level. See RLC Labs’ September 2, 2020 statement below: “RLC Labs, Inc. is voluntarily recalling a total of 483 lots of Nature-Throid® and WP Thyroid® in all strengths, all counts of product within current expiry to the consumer level. The products are being recalled because testing of samples from six (6) lots by the U.S. Food and Drug Administration found the samples to be sub potent. The product may have as low as 87% of the labeled amount of Liothyronine (T3) or Levothyroxine(T4). Risk Statement: Patients being treated for hypothyroidism (underactive thyroid), who receive sub potent Nature-Throid® or WP Thyroid®, may experience signs and symptoms of hypothyroidism (underactive thyroid) which may include, fatigue, increased sensitivity to cold, constipation, dry skin, puffy face, hair loss, slow heart rate, depression, swelling of the thyroid gland and/or unexplained weight gain or difficulty losing weight. There is reasonable risk of serious injury in newborn infants or pregnant women with hypothyroidism including early miscarriage, fetal hyperthyroidism, and/ or impairments to fetal neural and skeletal development. In elderly patients and patients with underlying cardiac disease toxic cardiac manifestations of hyperthyroidism may occur, such as cardiac pain, palpitations or cardiac arrhythmia. RLC Labs, Inc. has not received any reports of adverse events related to this recall. Nature-Throid® and WP Thyroid® (thyroid tablets, USP) are composed of liothyronine and levothyroxine, and are used to treat hypothyroidism (underactive thyroid).” Patients who are currently taking Nature-Throid® and WP Thyroid® should not discontinue use without contacting their healthcare provider for further guidance and/or a replacement prescription. You are encouraged to contact your prescribing health care provider to discuss next steps. The recall of all lots may lead to a supply shortage of this thyroid therapy. In 2017 patients faced similar shortages of Nature-Throid® and WP Thyroid® due to a world-wide shortage of pharmaceutical grade Thyroid USP. NP Thyroid® (Acella Pharmaceuticals) and Armour Thyroid® (Allergan) are two commercially available alternatives that patients and their practitio12 FLORIDA MD - MARCH 2021
ners may consider if appropriate. NP Thyroid® and Armour Thyroid® are standardized using a different thyroid USP quantity as compared to NatureThroid® and WP Thyroid® (60mg vs. 65mg). To facilitate patients converting between these different products, the amount of therapy as grains (gr.) (i.e. ¼ grain, ½ grain, 1 grain, etc.) can be used to express the strength of the patient’s thyroid therapy and ensure the patient receives the same amount of T3 and T4 supplementation. Patients suffering from hypothyroidism symptoms may be sensitive to particular fillers commonly found in medications. Each brand of thyroid medication uses different fillers during the manufacturing process. Pharmacists can review inactive ingredients of each formulation with patients to help determine tolerability. It is not uncommon that patients who are unable to find their thyroid medication due to availability issues may have their therapy changed from desiccated thyroid, which supplies a standardized amount of levothyroxine (T4) and liothyronine (T3), to products that only supply T3 and/or T4 alone. The only commercially available T3/T4 combination tablet not derived from desiccated porcine thyroid was sold under the brand name Thyrolar (Liotrix). In De-
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PHARMACY UPDATE cember 2018, the Food and Drug Administration (FDA) announced the manufacturer made a business decision to discontinue production of Thyrolar tablets.
PERSONALIZED THYROID REPLACEMENT THERAPY Pharmacy Specialists can help patients and physicians design appropriate thyroid replacement therapy. We stock the pure chemical forms of desiccated thyroid (Thyroid USP), levothyroxine (T4) and liothyronine (T3), so that we can create a custom blend of hormones at an ideal ratio to meet patients’ individual needs and maintain their hormone balance. Desiccated thyroid, levothyroxine or liothyronine can be compounded as single ingredient or combination capsules designed to release immediately or over a prolonged period of time. When we compound customized dosages, we have the ability to omit any problem-causing inactive ingredients such as corn, gluten, starch, soy or animal by-products and substitute with non-reactive fillers. Commercially available thyroid replacement products may not be the best fit for a patient when: (1)
There is a lack in availability due to drug shortages.
(2)
They contain undesirable fillers.
(3)
They are only available as immediate-release dosage forms.
(4)
Patients require a different strength than what is available.
(5)
Patients require a unique ratio of T3 and T4 supplementation.
(6)
Patients require non-porcine derived products and would benefit from both T3 and T4 supplementation.
When changing thyroid medications from one manufacturer to another, the dose may need to be optimized to meet individual needs, this is also true for a compounded personalized thyroid prescription. We can prepare a variety of strengths and combinations of thyroid therapy providing patients with a larger choice of therapy options. A little more or a little less is no problem based on your symptoms and you healthcare prescriber’s professional judgment. Our goal as personalized medicine pharmacists is to meet the individual needs and circumstances of patients and physicians. Without the ability to create customized thyroid replacement therapy patients may be at risk for suboptimal or nonexistent thyroid therapy while these medications are in short supply. REFERENCES AVAILABLE UPON REQUEST.
Juan Lopez, PharmD, FAPC, is a personalized medicine pharmacist with Pharmacy
Specialists
Compounding
Pharmacy in Altamonte Springs, FL. For more information on how personalized medicine can help you, please call (407) 260-7002, or email us at Info@ MakeRx.com.
Check out our newly redesigned website at www.floridamd.com! FLORIDA MD - MARCH 2021 13
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MARKETING YOUR PRACTICE
Facebook Marketing for Medical Practices By Sonda Eunus, MHA, CMPE For a medical practice, as for any business, it is now crucial to have a strong presence on social media platforms. However, it is often hard for medical practice leaders to know which social media platforms to focus on to get the greatest results. Whereas there are multiple great options to choose from, Facebook should always be the #1 platform to start with and to invest the most time on.
WHY FACEBOOK SHOULD BE #1 ON YOUR LIST: Facebook is currently the largest social media platform, with 2.6 BILLION monthly active users worldwide as of the first quarter of 2020 – with 1.73 billion of those using Facebook daily (1). Facebook is now the world’s 3rd most-visited website, after Google and Youtube (2). There are 90 million Facebook Business pages (2). This shows that 90 million businesses have found it beneficial to have a Facebook presence. Not only is it important because you are getting additional exposure to Facebook users, but it will also improve your online credibility and boost your search engine optimization. Social Media accounts show up in search results when someone searches for your practice – so make sure that your page is active, that you are sharing valuable content, and that you have a good amount of page followers for social proof that your business is liked and respected in the community. If you are not sure that your target audience is on Facebook, consider this: 71% of American adults use Facebook, as compared to Instagram’s 38%, and Twitter’s 23% (2). The percentages of people in specific age ranges that are active on Facebook look like this: • 18-24: 76% • 25-29: 84% • 30-49: 79% • 50-64: 68% • 65+: 46% This is a good audience for any medical practice, as you can reach both young parents with newborns, older patients, and anyone in between.
OPTIMIZE YOUR FACEBOOK PAGE: To get started, make sure that your Facebook Business page is optimized. Here are some key steps to focus on: • You want to add as much information as possible and fill out all the sections available. • Upload a clear copy of your logo as your profile picture. • Add a nice cover photo – this could be a picture of your clinic, your staff, or another image that is relevant to your clinic and your target audience. • Make sure that there is a clear way to contact you, visit your website, etc. and add the services that you provide • Add as many photos as possible, such as pictures of your waiting room, exam rooms, doctors, staff, etc.
• Ask your existing patients to add Facebook reviews to your page
GROW YOUR FACEBOOK AUDIENCE: Here are the best ways to start growing your Facebook audience: • Invite all your friends to like your new Business page • Ask the other page Administrators that you add to invite their friends to like your page • Ask your friends on Facebook to invite their friends to like your Facebook page After you have acquired an initial following by using these strategies, you will need to start focusing on more long-term strategies to engage with your existing audience and to grow your following. To do so, you will need to: • Post quality content regularly, at least once a day – you can use funny (tasteful) memes, motivational quotes, informative articles, etc. • Invite the people that engage with the content you share to like your page, respond to any comments that you receive on your page • Use engaging posts to increase engagement, such as contests, raffles, photo share requests, etc. • Share blog posts that you write • Ask your friends, staff, and business partners to share your posts • Be active in local Facebook groups • - Start your own Facebook group
LEVERAGE FACEBOOK GROUPS TO GROW YOUR AUDIENCE: There are over 10M+ groups on Facebook, and over 1.4 billion people now use Facebook Groups every month (1). It is a good idea to start a Facebook group in addition to your Facebook Business page in order to grow your following and get more page likes. To grow your group, post valuable resources and information relevant to your target audience – and, every now and then, make announcements regarding your practice, new services that you are offering, or other updates. However, make sure that you are not using this group solely to promote your practice, or you will lose group members. What is great about groups, is that when you share a post in a group, all of your members get a notification that you have posted in the group. This way, your posts get seen by more people than the posts that you share on your Business page. Aside from creating your own Facebook group, make sure that your page also joins as many relevant local groups as possible. There are groups for everyone, and you need to find the ones that FLORIDA MD - MARCH 2021 15
MARKETING YOUR PRACTICE will help you gain exposure to your target audience. For example, a pediatric practice can join groups for local moms, or a specialist can join groups related to a specific ailment that they treat at their clinic. To summarize, a Facebook presence is important for any medical practice. By utilizing the steps outlined below, you will be on your way to growing your practice exposure and building up your credibility as an expert in your field. If you would like to outsource your Social Media Marketing to a team of Marketing experts, Leading Marketing Solutions can help you bring these strategies to life and grow your audience and social presence for you. Visit www.lms-plus.com for more information. References: 1. https://zephoria.com/top-15-valuable-facebook-statistics/ 2. https://blog.hootsuite.com/facebook-statistics/ 3. https://www.websitehostingrating.com/facebook-statistics/
Sonda Eunus is the CEO of Leading Marketing Solutions, a Marketing Agency working with Medical Practices and other Businesses to help them identify the best marketing strategies for their business, create a strong online presence, and automate their marketing processes for a better return on their Marketing budget. Learn more about Leading Marketing Solutions at www.lms-plus.com.
16 FLORIDA MD - MARCH 2021
2021
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.
JANUARY –
Digestive Disorders Diabetes
FEBRUARY –
Cardiology Heart Disease & Stroke
MARCH –
Orthopaedics Men’s Health
APRIL –
Surgery Scoliosis
MAY –
Women’s Health Advances in Cosmetic Surgery
JUNE –
Allergies Pulmonary & Sleep Disorders
JULY –
Neurology / Neuroscience Advances in Rehabilitation
AUGUST –
Sports Medicine Robotic Surgery
SEPTEMBER – Pediatrics & Advances in NICUs Autism OCTOBER –
Cancer Dermatology
NOVEMBER – Urology Geriatric Medicine / Glaucoma DECEMBER – Pain Management Occupational Therapy
Please call 407.417.7400 for additional materials or information. FLORIDA MD - MARCH 2021 17
Celebrating YOU on National Doctors’ Day March 30, 2021
21-CHN-00952
Because you are incredible.
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