Florida md september 2015

SEPTEMBER 2015 • COVERING THE I-4 CORRIDOR

Digestive and Liver Center of Florida, P.A. Celebrating 10 Years of Excellence in Medical Care SPECIAL FEATURE:

Celebration Orthopaedic & Sports Medicine Institute Next-Generation Destination for Orthopaedic Care

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FLORIDA MD - SEPTEMBER 2015 1

FROM THE PUBLISHER

I

t is my pleasure to bring you another issue of FloridaMD. As parents, we try to give our children the very best we can. But sometimes our best isn’t enough when a child is seriously ill or grieving over the loss of a loved one or family member. That’s where New Hope for Kids comes in. I have invited them to tell us about programs they have for seriously ill and grieving children.

If you have a patient that you feel could use their services, please pass along the information discussed below and join me in supporting New Hope for Kids.

Children and adolescents process grief, like they process everything else, according to their developmental level. One of the most important things to remember about the pediatric grieving process is the natural (and incredibly healthy) tendency for children to dive deeply into challenging emotional topics for a short period of time, and then return to play or normal activities. In the home setting, this may come across as alarming. A child who has very recently lost a loved one may verbalize questions regarding the death and express emotions, perhaps even cry, then shortly after ask to go outside, go play, or have a friend over. It may seem like they are in denial or even not “sad for long enough” but this is in fact their coping style. Children are normalizing their environment in the only way they know how in the wake of horrible loss.

New Hope for Kids has this process down pat, and that is why children are able to heal. “I was a grief facilitator who at one point or another worked with every age group (ages 3-18) and even the Special Circumstances group (Death impacted by Homicide + Suicide), states Michelle Preston, CCLS and former New Hope for Kids Grief Facilitator.

“Those children, like all children who come to NHFK, are brave enough to immerse themselves into the grief activities because they know that there is play at the end, there is joy, there is expression, and most importantly of all, every kid sitting next to them is in the same boat. As a Certified Child Life Specialist, I have worked extensively with siblings who experienced the loss of a new baby brother or sister. Watching children heal from loss is one of the most rewarding things I get to do and New Hope for Kids is our community’s’ answer to this healthy healing.” visit www.newhopeforkids.org Best regards,

Donald B. Rauhofer Publisher

COMING UP NEXT MONTH: The cover story will be about the proton therapy program available at The Proton Center at UF Health Cancer Center – Orlando Health. Editorial focus is on Cancer and Dermatology

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Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: Heidi Ketler, Sajid Hafeez, MD, Tracy Bilski, MD, Daniel T. Layish, MD, Harleen Anderson, MD, Jennifer Thompson, Jeff Holt, Susan T. Spradley, Esq, Craig F. Novick, Esq, Marni Jameson, Corey Gehrold 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.

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contents

COVERING THE I-4 CORRIDOR

 COVER STORY

From the spectacular ambience to the compassionate, leading-edge medical care and community outreach– everything about Digestive and Liver Center of Florida, P.A, is designed to improve quality of life for patients by providing the most advanced, safe and proven medical and surgical treatments.

“We are passionate about improving quality of life through health care delivery and policy making,” says gastroenterologist Harinath Sheela, M.D, who is also the chairman of Gastroenterology at Florida Hospital. He, along with fellow gastroenterologists Srinivas Seela, M.D., and Seela Ramesh, M.D., founded Digestive and Liver Center of Florida in Orlando in 2005. “Our vision was to create a sophisticated medical practice that emphasizes in equal parts state-of-the-art medical care and a warm and caring environment for our patients.”

This year Digestive and Liver Center of Florida (DLCFL) is celebrating 10 years of providing comprehensive onsite diagnosis and treatment for all conditions associated with the gastrointestinal tract, liver and related processes at every age – pediatric, adult and geriatric.

The Orlando-based practice has thrived on patient-focused principles.

ON THE COVER: Left to right– Sergio Larach, MD, Srinivas Seela, MD, Seela Ramesh, MD, Ritu Walia, MD, Harinath Sheela, MD

SPECIAL FEATURE 

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The high-tech, high-touch, high-energy team of orthopaedic surgeons at Celebration Orthopaedic & Sports Medicine Institute represents the next generation of orthopaedic care and medical leadership. “One of the things that distinguishes our practice is innovation. Our group is now primarily made up of fairly young surgeons who are technologically smart,” says President Brad Homan, DO, president of Celebration Orthopaedic & Sports Medicine Institute and Medical Director of Sports Medicine at Florida Hospital Celebration. “We provide a fresh perspective on the latest advances.

We are skilled in minimally invasive techniques, so our patients return to their lives as quickly and comfortably as possible.”

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MEET THE FEMALE ATHLETE TRIAD TEN WAYS INDEPENDENT DOCTORS CAN STAY THAT WAY NEW TRAUMA CENTER KEEPS PACE WITH OSCEOLA COUNTY’S EXPLOSIVE GROWTH ALLERGIC RHINITIS, ASTHMA, AND FOOD ALLERGY

PHOTO: DONALD RAUHOFER / FLORIDA MD

PHOTO: DONALD RAUHOFER / FLORIDA MD

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SEPTEMBER 2015

DEPARTMENTS 2

FROM THE PUBLISHER

10 PULMONARY & SLEEP DISORDERS 12 CANCER

21 MARKETING YOUR PRACTICE 22 BEHAVIORAL HEALTH 24 ORTHOPAEDIC UPDATE 28 HEALTHCARE BANKING, FINANCE AND WEALTH

32 HEALTHCARE LAW

FLORIDA MD - SEPTEMBER 2015 3

COVER STORY

Digestive and Liver Center of Florida, P.A. – Celebrating 10 Years of Excellence in Medical Care

By Heidi Ketler

Compassionate, Caring, and Sophisticated Medical Care

PHOTO: DONALD RAUHOFER / FLORIDA MD

From the spectacular ambience to the compassionate, leadingedge medical care and community outreach– everything about Digestive and Liver Center of Florida, P.A, is designed to improve quality of life for patients by providing the most advanced, safe and proven medical and surgical treatments.

“We are passionate about improving quality of life through health care delivery and policy making,” says gastroenterologist Harinath Sheela, M.D, who is the chairman of Gastroenterology at Florida Hospital. He, along with fellow gastroenterologists Srinivas Seela, M.D., and Seela Ramesh, M.D., founded Digestive and Liver Center of Florida in Orlando in 2005. “Our vision was to create a sophisticated medical practice that emphasizes in equal parts state-of-the-art medical care and a warm and caring environment for our patients.”

This year Digestive and Liver Center of Florida (DLCFL) is celebrating 10 years of providing comprehensive onsite diagnosis and treatment for all conditions associated with the gastrointestinal tract, liver and related processes at every age – pediatric, adult and geriatric. The Orlando-based practice has thrived on patientfocused principles.

Dr. Seela recalls their first years of private practice in Orlando.

“We were new to the area. We didn’t know anyone and had few resources. We were determined to work hard and provide care to patients in the community. Our goal was to facilitate the develop-

ment of advances in patient care that would provide high-quality, cost-effective and compassionate care to patients in Central Florida.”

Ten years later, Dr. Seela and his brothers have a vibrant practice that is determined to cater to the needs of all the patients who walk through their door. He further adds that “Nothing is more fulfilling or offers a more priceless experience for us than medicine and helping our patients.”

Since its start, DLCFL has expanded to include the East Orlando location that includes a surgical center and two satellites offices: one in downtown Orlando and one in Altamonte Springs.

In 2011 the main office moved into a new, state-of-the-art facility at 100 N. Dean Road in East Orlando, a location carefully chosen for its surroundings, safe and free parking with easy access to Highway 408 and also Highway 417.

The new location includes the freestanding Endo-Surgical Center of Florida, which is a state-licensed, JCAHO-certified, outpatient, ambulatory surgical center, equipped to handle many procedures on site. The DLCFL physicians are proud as their ambulatory surgical center has surpassed the standards required by Medicare for licensure and has received this accreditation from JCAHO (Joint Commission on Accreditation of Healthcare Organizations). Dr. Sheela further adds “Our team of endoscopists, medical assistants, nurses, and anesthesiologists use state-of-theart procedures and equipment to provide Dr. Seela reviews a patient’s chart with director of operations Noemi before a procedure. superior care and the highest level of clinical expertise in a safe environment.”

The endoscopy suite is outfitted with advanced optics and superior visualization systems and it is equipped to handle all kinds of diagnostic and therapeutic cases. This equipment permits rapid, accurate, and painless examination of the entire digestive tract and adjacent structures.

Their brand-new, state-of-the-art facility provides an environment that is comfortable for patients before, during and after their procedures. Their goal is to provide patients with the best medical care from their endoscopic examination to treating or preventing any gastrointestinal problems.

The Endo-Surgical Center of Florida provides a memory drive to their patients with reports and photos of their procedures In 2013 the Endo-Surgical Center of Florida became the first and only in Orlando to achieve the American Society of Gastrointestinal Endoscopy (ASGE) En4 FLORIDA MD - SEPTEMBER 2015

doscopy Unit Recognition Program (EURP). To date only 500 units across the United States have been awarded the ASGE recognition for meeting rigorous criteria that demonstrate a commitment to patient safety and quality in endoscopy.

The doctors at DLFCL are highly specialized and have completed their training from schools that are recognized among the best in their specialty.

Drs. Seela and Sheela completed their gastroenterology fellowship at Yale University School of Medicine. Dr. Ramesh did his fellowship in gastroenterology from the Medical College of Virginia, which is known for its outstanding gastroenterology and hepatology programs. Interestingly, prior to earning a medical degree, all three of them had degrees in engineering. However their desire to help others to improve their health has led Dr. Sheela enjoys helping patients to understand their health issues and to overcome them so they can enjoy their lives and pursue their goals. them to enter the field of medicine.

Dr. Ramesh states that essentially it is disorders. Clinical care service areas include: their educational background in engineering coupled with their • Adult obesity and GI health knowledge of the medical sciences that has helped them devise • Colon cancer prevention and diagnosis such sophisticated, cutting-edge medical care that caters to all age • Diagnostic and therapeutic endoscopy groups in the field of gastroenterology.

• Digestive health counseling Drs. Seela, Sheela and Ramesh are assistant professors at the • Digestive disorders prevention and treatment University of Central Florida School of Medicine and teaching • Esophageal cancer prevention and diagnosis attending physicians at both the Florida Hospital Internal Medi• Gastrointestinal disorders cine Residency and Family Practice Residence (physician and osteopathic medicine physician) programs. They also share their • Inflammatory bowel disease expertise as contributing writers for several publications.

• Irritable bowel syndrome They are board certified in Internal Medicine and Gastroen• Liver disease, including hepatitis B and hepatitis C terology.

• Stomach ulcers Dr. Srinivas Seela was recognized as one of the top 125 gastroThe Endo-Surgical Center of Florida is equipped with adenterologists in the United States by Becker’s ASC Review. vanced technology to support the latest outpatient medical and Dr. Sergio Larach is the medical director of the GI Motility surgical options, as well as innovative screening and diagnostic Clinic and he joined DLCFL in 2014. He sees patients with anotechnologies. It also adheres to strict ASGE guidelines on privirectal problems and does endoscopy procedures. leging, quality assurance, and endoscope reprocessing. The EndoSurgical Center of Florida follows the Centers for Disease ConDr. Ritu Walia completed her fellowship in pediatric gastroentrol and Prevention (CDC) for infection control guidelines and terology from the prestigious Cleveland Clinic. She also served as endoscopy staff competency. the chief of pediatric gastroenterology at the West Virginia UniThe following procedures can be performed at the Endo-Surgiversity School of Medicine. She is the director of the pediatric cal Center of Florida: program at the DLFCL and is board-certified in pediatrics and pediatric gastroenterology. Dr. Walia joined the practice early this • Upper Endoscopy summer.

• Barrett’s epithelium ablation, using Barrx (radiofrequency ablation system) SPECIALIZED GASTROINTESTINAL DIAGNOSIS • Colonoscopy AND TREATMENT • Hemorrhoid band ligation The Digestive and Liver Center of Florida physicians are rec• HET non-surgical hemorrhoid treatment ognized authorities in the field of gastroenterology. They provide comprehensive care for common and complex digestive and liver • Anorectal surgery FLORIDA MD - SEPTEMBER 2015

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PHOTO: DONALD RAUHOFER / FLORIDA MD

COVER STORY

COVER STORY

Dr. Larach is the medical director for the DLCFL motility clinic. Dr. Larach is a clinical associate professor at the University of Central Florida and Florida State University. He has published numerous articles on colon and rectal surgery, authored book chapters in his specialty and is a reviewer for Surgical Endoscopy.

Dr. Larach is also pioneer in performing laparoscopic surgical procedures, and he has been instrumental inthe development of the TAMIS (transanal minimally invasive surgery) procedure for the treatment of rectal tumors.

The GI motility clinic diagnoses and treats such disorders as: • Achalasia (difficulty swallowing food) • Gastroesophageal reflux (heartburn) • Gastroparesis (weak stomach) • Intestinal pseudoobstruction (abdominal bloating and pain) • Small intestinal bacterial overgrowth • Fecal incontinence • Constipation • Pelvic floor disorders The motility program offers: The Bravo pH Monitoring System, a catheter-free instrument that measures acidity levels in patients suspected of having gastroesophageal reflux disease (GERD). A small capsule is attached to the wall of the esophagus. It transmits data to a pager-sized

PHOTO: DONALD RAUHOFER / FLORIDA MD

GI MOTILITY CLINIC

Dr. Larach evaluating a manometry study at the GI Motility Clinic.

receiver, which is worn by the patient for 48 hours.

The SmartPill Capsule is a new technology available at only about a dozen medical centers around the country. The ingestible, wireless capsule measures pressure, pH and temperature as it moves through the GI tract, allowing physicians to identify where abnormalities in intestinal transit are located.

Impedance monitoring is a catheter-based system that enables doctors to diagnose non-acid reflux. The patient wears the monitoring system for 24 hours, and pushes a button whenever he or she experiences symptoms. Physicians then download and analyze the data to determine whether the reflux is acidic or nonacidic and whether the symptoms corDr. Ramesh reviews a patient’s results at the Endo-Surgical Center of Florida. He was recently relate with incidents of reflux. appointed by Governor Rick Scott to the Florida Board of Medicine.

Other motility tests offered by the program include: • High-resolution esophageal manometry for evaluation of swallowing difficulty.

• Anorectal manometry/EMG with biofeedback for the evaluation and treatment of constipation and fecal incontinence.

PEDIATRIC GASTROENTEROLOGY PHOTO: DONALD RAUHOFER / FLORIDA MD

Dr. Walia started the new pediatric gastroenterology program at the DLCFL. Prior to joining DLCFL, Dr. Walia worked as an assistant professor in the department of pediatrics and was the chief of pediatric gastroenterology at West Virginia University in Charleston.

She is a reviewer of various international journals and has authored many articles published in Pediatric Gastroenterology.

6 FLORIDA MD - SEPTEMBER 2015

She provides specialized diagnosis and treatment of conditions that can impact young patients, from birth through their teenage years. Among these conditions are: • Abdominal pain • Acid reflux • Celiac disease • Constipation • Diarrhea • Failure to thrive • Inflammatory bowel disease • Lactose intolerance • Pancreatic disease • Pediatric enteral access Dr. Walia’s procedural interests include diagnostic and Dr. Walia is dedicated to improving the quality of life of her patients and provides gastroenterology care therapeutic endoscopy as well for infants, children and adolescents. as wireless capsule endoscopy.

She also has advanced experprove the experience of receiving treatment for conditions that tise in fecal microbiota therapy for the treatment of chronic C. can wreak havoc on patient quality of life and can be difficult to difficile infections. She is a prolific writer and has authored sevdiscuss. eral publications in national and international medical journals.

From the administrative staff to the medical team, all recognize She has also been an invited speaker to many national and interthe challenges for patients and want to help minimize any disnational symposiums in the medical field. Other prominent roles comfort. “The quality of the work they do shows how much they include member of the professional educational society for the care for the patients. They love what they do here,” Dr. Sheela National Association of Pediatric Gastroenterology and Hepatolsays. ogy. She is a member of the minority affairs committee at the Simple conveniences in the lobby are designed to minimize prestigious American College of Gastroenterology and has been distractions, inconveniences and frustrations. All phone calls to a recipient of various awards in the field of medicine throughout the office are answered by a live operator 24-7, rather than a reher career. She is also the co-founder of the South Asian Pediatcording. ric Gastroenterologists that serves to connect physicians of South Asian origin all across the globe.

MAKING A DIFFERENCE Her research interests include: Optimizing the ideal bowel “We want to be on the forefront of advancing health care in preparation for pediatric colonoscopies, chronic constipation and Florida.” – Dr. Srinivas Seela encopresis. She has a special interest in the gut microbiome and “We are able to do three times more for the patient,” says Dr. fecal microbiota therapy.

Sheela of practicing medicine with his brothers, all of whom are Pediatric patients are currently being enrolled in this clinical first-generation physicians. trial: A Prospective, Placebo Controlled, Double-Blind, CrossRaised in a close-knit family and close in age, Dr. Ramesh says, over Study on the Effects of a Probiotic Preparation (VSL#3) on he and his brothers often followed similar paths. And so it was Metabolic Profile, Intestinal Permeability, Microbiota, Cytokines with their decision to switch careers. At the time, the eldest and and Chemokines Expression and Other Inflammatory Markers the youngest brothers, Srinivas Seela and Harinath Sheela, were in Pediatric Patients with Crohn’s Disease. civil engineers. Seela Ramesh was a mechanical engineer.

COMPASSION REFLECTED IN ATTENTION TO DETAILS

“Most people have anxiety when they come to a medical facility and we try to make them comfortable and feel at home by offering a welcoming environment. When you see our offices, you just know we’re trying to make a difference in patient care.” – Seela Ramesh, M.D. The Digestive and Liver Center of Florida is designed to im-

Their interest in medicine, they say, was rooted in wanting to improve the human condition around the world.

“We were happy with our jobs, but we noticed we were reaching a plateau and wanted to do something that would make a difference in global health and make lifespans longer,” says Dr. Sheela.

Today they are actively engaged in leadership that is charged with advancing health care policy. This year, Dr. Ramesh was apFLORIDA MD - SEPTEMBER 2015

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PHOTO: DONALD RAUHOFER / FLORIDA MD

COVER STORY

COVER STORY pointed by Gov. Rick Scott to the Florida Board of Medicine, a term that began Aug. 10, 2015 and continues through Oct. 31, 2018.

Dr. Seela is serving a term this year on the Orange County Medical Society board of directors. Dr. Sheela was recently nominated to serve as its political action committee chair.

PHOTO: DONALD RAUHOFER / FLORIDA MD

A free hepatitis C support group is offered at Digestive and Liver Center of Florida.

ADVANCING MEDICINE AND COMMUNITY HEALTH “We touch patient lives by trying to help them overcome disease and lead as normal a life as possible. Getting to know patients and seeing them enjoying their lives more fully – sometimes having kids – is our reward.” – Harinath Sheela, M.D. Patients coming in to see Dr. Walia enjoy the beautiful, bright waiting room set up Part of the mission within the Digestive and Liver with books and toys and everything needed to make them feel at ease at the office.

Center of Florida is to improve the health of the surrounding community. This is done through a variety of ways. duct its second annual health fair at the main office in November 2015.

Last November, the practice provided more than 200 free flu

shots and 100 free hepatitis C screenings. The practice will conEmployees love to help patients and patients love them back.

Medical assistant Norma received flowers from a thankful patient for her dedication.

Digestive and Liver Center of Florida works with the Orange County Specialty Clinic to provide free colonoscopies and upper endoscopies to those who have no insurance and are deemed eligible by the Orange County Clinic.

PHOTO: DONALD RAUHOFER / FLORIDA MD

The practice also supports the medical community through is contributions to the Florida Hospital Foundation and the Orlando Regional Foundation. It works to advance the next generation of medical professionals, by sponsoring one student enrolled at the University of Central Florida School of Medicine.

Appointments with DLCFL specialists can be made by calling (407) 384-7388. For more information visit the practice website at www.dlcfl.com. 

100 N. Dean Rd., Ste. 101, Orlando, FL 32825 (407) 384-7388 • www.dlcfl.com 100 N. Dean Rd. Ste 102, Orlando, FL 32825 www.escfflorida.com facebook.com/dlcfl • twitter.com/digestive1 youtube.com/dlcfl1 8 FLORIDA MD - SEPTEMBER 2015

Meet the Female Athlete Triad: The New Challenge for the Active Woman

By Will Felix, MD, CAQSM The participation of women between the ages of 35-50 in high-performance sport has grown exponentially in recent years. Probably, this increase reflects the many campaigns from multiple health-related organizations to encourage a more active life style for women in this age range. Unfortunately, athletes who abuse physical activity thinking they will reach their physical goals faster by increasing the frequency of exercise can trigger medical complications typically only seen in adolescent girls and younger adults. These complications, known as “female athlete triad syndrome” include three common symptoms: loss of periods before menopause (amenorrhea), osteoporosis and eating disorders.

WHAT HAPPENS TO THE BODIES OF WOMEN WITH THIS SYNDROME? The stress related to excessive exercise affects the secretion of estrogen, the hormone responsible for regulating menstrual cycles.

The irregularity in estrogen levels in turn affect its secondary function, the reabsorption of calcium in the bone. This alteration increases the risk of women to experience pathological fractures secondary to a weak and fragile bony structure (osteoporosis).

The root of this disorder is the result of excessive physical activity that is not compensated in proportion to the necessary caloric intake. Therefore, this triad is completed with the presentation of underweight women.

DIFFICULT DIAGNOSIS The female athlete triad is a challenge for the health care professional; diagnosis is difficult in the early stages.

Multiple factors combine to complicate diagnosis, particularly the desire of the patient to continue with a rhythm of intense exercise driven mostly by psychological need to maintain the “perfect body” in response to the growing social pressure. Initially, this seems to be possible without apparent health consequences.

for any perceived defect in body image, whether real or imagined.

WHAT CAN AN ACTIVE WOMAN DO? Fortunately, this triad can be solved without major implications as long as it is diagnosed early and various medical specialties are integrated as part of a collaborative effort.

Exercise should be regulated and supervised by a certified fitness trainer, together with proportional physical activity and nutritional food intake. Exercise will always be beneficial at any age, as long as it is done moderately and not excessively.

William Felix, MD, CAQSM, is a fellowship-trained, board-certified physician focusing on the treatment of sports injuries as well as acute and chronic injury care for patients of all ages. A medical consultant with the National Basketball Association and CNN Networks, Dr. Felix is one of only 125 physicians in the United States board-certified in both sports medicine and emergency medicine. Treating athletes and nonathletes, including children with special needs, Dr. Felix is uniquely qualified to provide emergency orthopedic services in the office, in the emergency room and on the sidelines. Dr. Felix was fellowship-trained at Duke University School of Medicine’s prestigious sports

New forms of exercise regimes that emphasize aerobic exercise, such as “Crossfit,” make this a very complex condition with an alarming increase of incidence. Patients usually present the doctor with unexplained symptoms or nonspecific pain. During the medical evaluation and analysis of patient records, the absence of menstrual periods before formally entering a period of perimenopause is often discovered.

medicine program and went on to serve as a team physician

Part of the assessment also includes documentation of weight and height. These two variables are used to calculate body mass index, which is regarded as normal parameter values between 20 and 25. Female athlete triad patients usually present with lower body mass index of 20.

local and national events, including the 2012 Olympic

at Rollins College in Winter Park, FL. Since 2010, he has served as the Medical Director Global Games Clinical Consultant for the National Basketball Association during

Games in London. Be sure and check out Dr. Felix’s website at SportsMedicineLakeNona.com

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A psychological evaluation is highly recommended due to the possibility of body dysmorphic disorder or exaggerated concern FLORIDA MD - SEPTEMBER 2015

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PULMONARY AND SLEEP DISORDERS

Pulmonary Rehabilitation

By Daniel T. Layish, MD, FACP, FCCP, FAASM Pulmonary rehabilitation can benefit patients with a wide variety of lung diseases including COPD, pulmonary fibrosis, cystic fibrosis, and sarcoidosis (among other chronic respiratory illnesses). Pulmonary rehabilitation does not replace standard medical and/or surgical treatments for these lung diseases. Rather, it supplements and complements standard therapy.

Patients with COPD (and other chronic lung diseases) develop shortness of breath with activity. This leads to the tendency to avoid activity, which in turn leads to deconditioning. It is felt that one of the main benefits of pulmonary rehabilitation is to break the cycle of deconditioning. Pulmonary rehabilitation programs typically include two or three outpatient sessions per week for 10 to 12 weeks. Typically, a pulmonary rehab program will include aerobic exercise, strength training, patient education in management of lung disease - including nutrition, energy conservation, medication compliance, bronchial hygiene, and breathing strategies. The component of group support is also felt to be a significant contributor to the success of these programs. The group support motivates the patient to attend the pulmonary rehab sessions. It also allows the patient to realize that there are other people suffering from chronic respiratory illness and to see how they are able to overcome these obstacles. Pulmonary rehabilitation is considered to be critical both before and after lung transplantation. Occasionally, a patient will have such a significant functional and symptomatic improvement after pulmonary rehab that transplant can be delayed.

Pulmonary rehabilitation programs are typically multidisciplinary in nature and may include a respiratory therapist, registered nurse, exercise physiologist, nutritionist, physical and/ or occupational therapists. The staff is trained to encourage the patient’s self management and coach them to adopt healthier habits through lifestyle modification. To enroll in a pulmonary rehabilitation program requires a medical referral. Pulmonary rehabilitation is covered by most third party payors. Pulmonary rehabilitation is appropriate for any stable patient with a chronic lung disease who is disabled by respiratory symptoms.

The pulmonary rehab program should involve assessment of the patient’s individual needs and creation of a treatment plan that incorporates realistic goals tailored to each patient. Evidence based analysis consistently reveals improvement in health related quality of life after pulmonary rehabilitation as well as improved exercise tolerance. Pulmonary rehabilitation has been shown to improve the symptom of dyspnea and increase the ability to perform activities of daily living. Pulmonary rehabilitation has also been shown to reduce health care utilization (including frequency of hospitalization) and decreases length of stay (when hospitalization is required). Pulmonary rehabilitation has not been demonstrated to improve survival.

The benefit from a pulmonary rehabilitation program may decline over time if the individual does not maintain their con10 FLORIDA MD - SEPTEMBER 2015

ditioning. Some pulmonary rehabilitation programs will therefore include a “graduate” or maintenance program after the patient finishes the initial program.

Patients who develop shortness of breath often become anxious which in turn exacerbates the sensation of dyspnea and this can become a vicious cycle. Pulmonary rehabilitation can be very helpful in addressing this problem. Sometimes pulmonary rehabilitation will require supplemental oxygen with exercise.

Although the strongest evidence regarding pulmonary rehabilitation programs is in the setting of COPD, it has been shown to be beneficial in a variety of disease states. Pulmonary rehabilitation has been shown to be a cost effective tool in the fight against chronic lung disease. It is currently felt to be underutilized.

Daniel Layish, MD, graduated magna cum laude from Boston University Medical School in 1990. He then completed an Internal Medicine Residency at Barnes Hospital (Washington University) in St.Louis, Missouri and a Pulmonary/Critical Care/Sleep Medicine Fellowship at Duke University in Durham, North Carolina. Since 1997, he has been a member of the Central Florida Pulmonary Group in Orlando. He serves as Co-director of the Adult Cystic Fibrosis Program in Orlando. He may be contacted at 407-841-1100 or by visiting www.cfpulmonary.com.

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Veronica Schimp, DO, FACOG

Rosa Ovarian Cancer Survivor

Comprehensive Gynecologic Cancer Care Complex gynecologic cancers such as cervical, uterine, ovarian and vulvar require the care that only a comprehensive facility like UF Health Cancer Center – Orlando Health Gynecologic Cancer Center can provide. Our specialists are experts in their field and will guide you through genetic counseling, diagnosis and treatment.

Contact us for a next-day appointment.

Call 321.843.7775 or visit OrlandoHealth.com/gyncancer FLORIDA MD - SEPTEMBER 2015 11

CANCER

September Is National Thyroid Cancer Awareness Month By Steven Blanchard Thyroid Cancer Awareness Month runs through September and the disease is on track to be the No. 1 diagnosed cancer in women by the year 2030. According to one study, it is already the second most common cause of medical bankruptcy. However, doctors at Moffitt Cancer Center say it is possible to effectively treat the disease in an affordable way, by minimizing over-diagnosis and evaluating patients in a cost-sensitive, evidence-based way.

Approximately 50 percent of women and 10 to 20 percent of men over the age of 50 have a nodule, or lump, on their thyroid gland, a small, butterfly-shaped gland in the base of the neck.

These nodules are often discovered by chance, either on physical examination, or during scans performed for some other reason.

“These thyroid nodules are very common, and most are not cancerous” says Bryan McIver, M.D., Ph.D., leader of the Endocrine Oncology Program at Moffitt. “For that reason, it is very important that we evaluate these nodules rapidly, efficiently and accurately, while causing a minimum of pain, worry and expense to our patients”.

At Moffitt, McIver and his team have developed a highly efficient diagnostic clinic for patients with thyroid nodules. Based conveniently at our Moffitt Cancer Center at International Plaza outpatient facility, Moffitt’s Thyroid Clinic is one of only a handful of places in the country that offers same-day evaluation of thyroid nodules, permitting clinical assessment, ultrasound imaging, biopsy procedures, and result reporting all within just a few hours, as well as access to state-of-the-art molecular testing for nodules that cannot be diagnosed on biopsy alone. And Moffitt is almost the only location in the country in which the patient can also be seen – on the same day – by a highly specialized thyroid surgeon, if surgery proves necessary.

“Most thyroid nodules are benign and do not need any treatment.” comments McIver, “But if the nodule turns out to be cancer, it’s really important to offer the patient rapid access to an entire team of specialists and to move ahead with the treatment as soon as possible ”. Fortunately, the survivorship for thyroid cancer is very high¬—more than 99 percent in stage 1 cases.

“Thyroid cancer is often called a ‘good’ cancer,” McIver says. “But there is no such thing as a ‘good’ cancer. What is true is that Thyroid cancer is slow-growing and responds very well to treatment, at least when it is found early. The problem is that, even then, the impact on a patient’s quality of life can be huge, and we as physicians need to be aware of that.”

Fortunately, most cases of thyroid cancer are caught in early stages, because the thyroid nodule can often be seen or felt in the front of the neck. The best way to detect the disease early is to know about the common symptoms of thyroid cancer, “check your neck” and see a physician right away if you notice anything that looks (or feels) like a lump or swelling in the front of your neck.

Treatment of thyroid cancer involves surgery to remove the thyroid gland. “Although there are risks of Thyroid surgery, those 12 FLORIDA MD - SEPTEMBER 2015

risks are low in expert hands” says Kristen Otto, M.D., assistant member of the Head and Neck, and Endocrine Oncology Program at Moffitt. “At the cancer center, our surgeons are highly specialized and use advanced techniques, including nerve monitoring, to maximize safety. Plastic surgical techniques also ensure the scar heals well – usually, it becomes almost invisible in just a few months.”

Beyond surgery, treatment includes thyroid hormone – which acts as a form of chemotherapy in thyroid cancer – and sometimes radioactive iodine, a form of internal radiation therapy. “In the past, we have used far too much radioactive iodine in this country.” says McIver, “Our studies have clearly shown that most patients do not need that treatment and that careful, selective use provides the right balance between controlling the cancer, controlling the complications, and controlling the cost.”

Long-term follow-up is necessary to ensure thyroid cancer is driven into remission, but “doing this well means being thoughtful and careful about what tests we choose and how often we use them” says McIver. After effective treatment, most patients need to be seen in the cancer center only once a year, though often for 10 years or more, before they can be considered cured of their disease. “’Cure’ is a hard word” notes McIver, “I prefer the term remission, stable remission, and long-term stable remission, because we have to remember that our testing can never be perfect”.

For those patients with more advanced disease, disease that has spread into other parts of the body, and for whom the standard treatments prove ineffective, Moffitt offers patients the latest diagnostic techniques, and a wide range of treatment options, including the newest tyrosine kinase inhibitor drugs – a targeted, technologically advanced chemotherapy approach for thyroid cancer. “We are also deeply involved in research in thyroid cancer, looking at outcomes, improving treatment options, and developing clinical trials.” says Jeffery Russell, M.D., Ph.D., a medical oncologist in Moffitt’s Endocrine Tumor Program. “Our clinical research programs at Moffitt have been recognized by the National Cancer Institute, which has designated Moffitt a Comprehensive Cancer Center— the only one based in Florida. Our cancer survival rates consistently outrank national averages, and our ultimate goal is to provide our patients with better outcomes and higher-quality lives.”

“Fortunately, most of our patients do well with treatment” McIver says. “Using the skills of our endocrinologists, surgeons, medical oncologists, radiologists and pathologists – offering multidisciplinary care in one of the best cancer centers in the country - we quickly develop and institute a comprehensive treatment plan, ensure the patient is free of the disease, and then use minimal check-ins so the patient can enjoy her quality of life for years and decades to come.”

Steven Blanchard is Media Relations Coordinator at Moffitt Cancer Center in Tampa, Florida. 

SEPTEMBER 2015 • COVERING THE I-4 CORRIDOR • SPECIAL FEATURE

Celebration Orthopaedic & Sports Medicine Institute

Next-Generation Destination for Orthopaedic Care FLORIDA MD - SEPTEMBER 2015 13

SPECIAL FEATURE

Celebration Orthopaedic & Sports Medicine Institute – Next-Generation Destination for Orthopaedic Care

By Heidi Ketler The high-tech, high-touch, high-energy team of orthopaedic surgeons at Celebration Orthopaedic & Sports Medicine Institute represents the next generation of orthopaedic care and medical leadership.

“One of the things that distinguishes our practice is innovation. Our group is now primarily made up of fairly young surgeons who are technologically smart,” says President Brad Homan, D.O., president of Celebration Orthopaedic & Sports Medicine Institute and Medical Director of Sports Medicine at Florida Hospital Celebration.

“We provide a fresh perspective on the latest advances. We are skilled in minimally invasive techniques, so our patients return to

their lives as quickly and comfortably as possible.”

Celebration Orthopaedic & Sports Medicine’s surgeons complement each other with expertise in every aspect of orthopaedic diagnosis, treatment and care. In addition to general orthopaedics, each has specialized fellowship training: − Sports medicine and arthroscopy – Brad Homan, D.O. − Joint replacement surgery – Matthew Johnston, D.O. − Hand and upper extremity disorders and microsurgery – Joseph E. Robison, M.D. − Spine surgery, including minimally invasive techniques – Maahir Haque, M.D.

PHOTO: DONALD RAUHOFER / FLORIDA MD

Dr. Brad Homan discusses Total Knee Arthroplasty with his patient. This minimally invasive procedure is performed on a weekly basis by Dr. Homan and his team and he has perfected his skills. Dr. Homan specializes in Total Joint Replacement, Sports Medicine Injuries and minimally invasive surgery.

14 FLORIDA MD - SEPTEMBER 2015

PHOTO: DONALD RAUHOFER / FLORIDA MD

SPECIAL FEATURE

Dr. Brad Homan (right) reaches out to Dr. Matthew Johnston (left) on his opinion of a patient’s hip condition. The two often collaborate on what steps need to be taken in the treatment of patients to ensure they are receiving the proper care they deserve. Dr. Johnston specializes in minimally invasive total hip and knee arthroplasty. .

The world-class physicians balance the technical aspects of their practice with personalized care. Making personal connections with patients enables them to prescribe treatment plans that are holistic and realistic. Along with age and overall health, they take into account such things as priorities, concerns, hopes and dreams and lifestyle characteristics, like occupation and level of activity.

HIGH TOUCH: PERSONAL CARE AND HOLISTIC TREATMENTS “I take a lot of pride in caring for my patients as if they were my friends and family. When they are struggling, I’m struggling, so I provide as much hands on care as possible,” says Matthew Johnston, D.O. In addition to general orthopaedics, Dr. Johnston has extensive training in the diagnosis and treatment of arthritis, failed total joint replacement and osteonecrosis. He joined Celebration Orthopaedic & Sports Medicine Institute in 2009.

“It’s important for me and my partners to see patients as individuals, not just X-rays or test results. We really try to connect with patients on a personal level,” says Joseph E. Robison, M.D. “I try to match the treatment to the patient’s needs. For example, treatment for somebody who knits for fun and experiences symptoms once or twice a week may be different than for someone who uses their hands a lot, doing heavy work and are bothered by symptoms every minute of the day.”

Dr. Robison is Medical Director of the Florida Hospital Kissimmee Hand & Wrist Clinic and is the Assistant Chief of Staff at Florida Hospital Kissimmee. His special interests are carpal tunnel syndrome, Dupuytren’s contracture, ulnar nerve surgery, distal radius fractures, arthritis of the hand and peripheral nerve surgery. He joined the practice in 2011.

Maahir Haque, M.D., is new to the practice, having moved from Providence, R.I, in August, after completing his fellowship at Brown University. A Florida native, Dr. Haque says Celebration Orthopaedic & Sports Medicine’s patient-centered approach mirrors his own.

“My treatment plans are specifically tailored to each patient. Even though two patients may share the same problem, their activities, physical demands or simply their life goals may be completely different. One might choose surgery, while the other might prefer to avoid surgery. I look to find the right answer for the patient.”

The emphasis in health care today is quality, not quantity, says Dr. Homan, who joined the practice in 2005. “We recognize that, and we’re focusing on benchmarks and clinical best practices with the goal of improving patient care and satisfaction.” The practice, Dr. Homan says, is at the 95th percentile or higher of meeting national benchmarks, including those produced by the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) patient satisfaction survey, and established best practices. Day to day, “positive FLORIDA MD - SEPTEMBER 2015 15

feedback and patient referrals tell us we are doing a good job.”

Celebration Orthopaedic & Sports Medicine Institute has been recognized for leading-edge, compassionate care since it opened in 1998. Practice founder David D. Dore, M.D., retired in 2014, but his philosophy and his compassion are reflected in the team that he assembled.

HIGH TECH: THE NEXT BIG THING IS HERE Today Celebration Orthopaedic & Sports Medicine Institute includes a well-established alliance with Florida Hospital Celebration Health.

Dr. Joseph Robison reviews a hand x-ray with his patient. Dr. Robison involves his patients in every aspect of “Our practice is in a unique their care and ultimately leaves the option of surgery up to them. Dr. Robison’s special interests are Carpal position to partner with the Tunnel Syndrome, Dupuytren’s Contracture, and Arthritis of the Hand. hospital and offer services other orthopaedic surgery practices typically cannot,” like robotic LESS IS OFTEN MORE surgery, says Dr. Homan.

“Our main focus is on minimally invasive techniques, getting “The hospital is an internationally recognized ‘destination’ hosthe surgeries done using smaller incisions, with less tissue dampital, with an orthopaedic surgery center of excellence and the age, and controlling post-operative pain to speed up the recovery Global Robotics Institute. We are not only part of that, but we process,” says Dr. Homan. help the hospital achieve that status,” he says.

Minimally invasive spine surgery techniques are designed to The Florida Hospital Orthopaedic Institute was the first in the give equivalent relief as more traditional techniques. The signifistate to perform total knee and arthroscopic surgery. Today it is cant advantage comes from using smaller incisions and doing less ranked a Top 10 hospital for knees and hips by AARP Magazine. tissue damage. Surgical complications, blood loss, pain, recovery time and scarring are reduced.

The institute is equipped with the latest imaging and treatment technology. Its orthopaedic team of nurses, surgical staff, radioloThe key to surgical success, says Dr. Haque, is knowing what gists and licensed therapists is dedicated to caring for the mustechnique to use for each patient. “I am challenging patients’ exculoskeletal system. Their multidisciplinary approach promotes pectations. My patients are surprised how quickly they are able individualized treatment plans that get patients back to normal to recover.” activity as quickly and painlessly as possible.

Dr. Haque returned to his home state with game-changing exCelebration Orthopaedic & Sports Medicine Institute has ofpertise in evidence-based, minimally invasive techniques to allevifices on the campus of Florida Hospital Celebration and Florida ate neck and back pain, after conservative measures don’t improve Hospital Kissimmee. Both locations provide easy access to the symptoms. advanced imaging technology, comprehensive physical therapy Among them are: and rehabilitation services. − Endoscopic discectomy − Total disc replacement “At Celebration and Kissimmee, we are fortunate to have state− Endoscopic decompression − Kyphoplasty of-the-art equipment and facilities, as well as a staff that is spe− Endoscopic fusion − Lateral fusion cifically trained to handle all of our patients’ orthopaedic needs,” “Not every patient is a candidate for outpatient, minimally insays Dr. Johnston, who is Director of Orthopaedics at Florida vasive surgery, but many are,” says Dr. Haque. “I pride myself on Hospital Kissimmee. “Because of the facilities that we have at our finding the best treatment for each individual patient.” disposal, we can offer state-of-the-art nonsurgical approaches for ROBOTIC SURGERY many chronic conditions.”

“The advantage of robotic surgery is a new level of precision and “It’s important for us to recognize that the majority of the paaccuracy, which can improve surgical outcomes,” says Dr. Homan. tients in our office can be treated nonsurgically. We pride ourFor certain spine surgeries, Celebration Health Robotics Instiselves on making sure we provide appropriate nonsurgical treattute is the only adult hospital in central Florida equipped with ment and manage recovery without surgery when we can,” says the Mazor Robotic Renaissance system. For partial knee or total Dr. Homan.

16 FLORIDA MD - SEPTEMBER 2015

PHOTO: DONALD RAUHOFER / FLORIDA MD

SPECIAL FEATURE

SPECIAL FEATURE

PHOTO: DONALD RAUHOFER / FLORIDA MD

hip arthroplasty, RIO Robotic Arm Interactive Orthopedic System technology, or MAKOplasty, is an option for the appropriate patient.

A study reported that MAKOplasty is four-to-six times more accurate than manual techniques for implant placement.1 Results from a multicenter trial indicate that 84 percent of implants placed with MAKOplasty robotic arm technology are in an acceptable range, compared to only 47 percent of implants placed manually.2 “I would say, across the country the majority of (orthopaedic centers) do not have this technology,” says Dr. Homan.

that can give excellent results with a low complication rate, reduced discomfort and decreased time for recovery in the majority of patients,” says Dr. Johnston.

After joint replacement, the patient should eventually be able to return to his or her former level of activity. While impact activity that includes running and jumping should be avoided, patients should be able to do low-impact activities, like hiking, gardening, swimming, playing tennis, cycling and golfing.

SPINE SURGERY

Eight out of 10 people will have back pain at some point in their lives, making it one of the most widely experienced health problems in the world and a main reason for work absences and KNEE AND HIP SURGERY doctor visits.

More than 500,000 people in the United States have knee reIn 2000, the five-year Spine Patient Outcomes Research Trial placements each year.

(SPORT) compared surgical and nonsurgical treatments for three Debilitating primary osteoarthritis is the major indication for of the most common conditions of the lower back: intervertebral knee and hip replacement operations. “The positive effect of redisc herniation, degenerative spondylolisthesis and spinal stenoplacement on quality of life for patients age 60 and older is sigsis.3 In all three cases, the study found the group that underwent nificant and well established,” says Dr. Johnston. standard surgery had a more rapid improvement and reported Hip and knee replacement is not usually done in younger peobetter physical function and satisfaction eight years after the opple, because the average life expectancy of artificial bearings is eration than did the group that received nonsurgical treatment. about 20 years, and younger people tend to put more strain on A 1999 study found approximately the same outcomes betheir new hip or knee. tween endoscopic (arthroscopic) and open discectomy tech“It’s important that the orthopaedic surgeon have significant niques.4 However, the patients who had the video-assisted arexperience in performing hip and knee replacement procedures throscopic microdiscectomy had shorter postoperative disability and keep up to date with developments in order to give the best and narcotics use. medical advice and get the best results,” says Dr. Johnston. “Total Dr. Haque is experienced in the latest advances in microscopic knee and hip arthroplasty produces excellent results in the propsurgery, disc replacement and minimally-invasive spinal fusion. erly selected patient.”

For example, XLIF, or eXtreme Lateral Interbody Fusion, is an Dr. Johnston and Dr. Homan have performed several hundred advanced, minimally invasive approach for spinal fusion that prototal knee arthroplasties (TKA) and more than 1,000 total hip vides access to the spine from the side of the body instead of from arthroplasties (THA). the front or back. Dr. Haque performs XLIF to treat a variety of “Total hip arthroplasty is a safe and reproducible procedure spinal conditions, including Dr. Maahir Haque discusses a patient’s treatment with a member of the staff. Dr. Haque is the newest degenerative disc disease, spimember of the staff and performs many impressive outpatient treatments allowing patients to go home nal stenosis, spondylolisthesis, immediately after surgery. Some of the procedures he specializes in are Endoscopic discectomy, Total disc recurrent disc herniation and replacement, Endoscopic decompression Kyphoplasty, Endoscopic fusion and Lateral fusion. scoliosis.

“I am trained in a wide variety of techniques. I can do whatever the patient needs to have done, whether it’s traditional open surgery or lessinvasive procedures,” says Dr. Haque. “Many of the newer minimally invasive procedures do improve outcomes in the long term, and they are not yet done with great frequency here in the Orlando community. I’ve brought my training from the northeast with me for the benefit of my community.”

HAND SURGERY Dr. Robison treats all forms FLORIDA MD - SEPTEMBER 2015 17

SPECIAL FEATURE of injuries and disorders of the hand and elbow, including upper-extremity arthritis, scaphoid and distal radius fractures, and peripheral nerve injury. He says he gets special satisfaction treating carpal tunnel and cubital tunnel syndromes and Dupuytren’s contracture, conditions that can be easily mistreated or overtreated by those without specialized training.

Like most orthopaedic conditions, hand surgery is considered only after conservative measures have failed. Conservative treatment may include anti-inflammatory medications, splinting and change in habits, such as using tools and technology to reduce repetitive motion at work or amending athletic technique. Physical therapy that includes ultrasound and range-of-motion exercises, as well as corticosteroid injections to reduce swelling also may be options.

Most mild cases of carpal tunnel syndrome usually can be managed with conservative treatment, says Dr. Robison. Surgery should only be considered if symptoms persist, there is nerve damage, or risk of irreversible nerve injury. Surgery involves dividing the transverse carpal ligament to relieve pressure on the median nerve in the wrist. Nowadays, this procedure can often be performed endoscopically.

Cubital tunnel syndrome, or ulnar neuritis, is the second most common reason for peripheral nerve entrapment neuropathy in the upper limb. The condition is more common in certain occupations. It also can be associated with previous elbow trauma, elbow arthritis and diabetic neuropathy.

Symptoms include pain, numbness, tingling and sometimes weakness in the ulnar side of the hand and can greatly inhibit athletic performance that requires strong hand or wrist action. In most cases, cubital tunnel syndrome can be managed conservatively, but more severe cases may require surgery to decompress the tunnel and/or transpose the nerve. A newer endoscopic approach allows for more complete release and decompression, without a large incision and lengthy recovery time, according to Dr. Robison.

Dupuytren’s contracture is a hand deformity caused by thickening tissue under the skin of the palm. Thick, collagenous cords may eventually develop and pull one or more fingers into a bent position. The condition can make it difficult or impossible to grasp and perform routine tasks. Biochemical factors that affect the palm’s connective tissue are thought to be the cause.

Some people have no dysfunction and need monitoring only.

If the condition interferes with daily activities, treatment may help. Conservative measures may include ultrasound and local cortisone injection to reduce prominence of the cords. A newer nonsurgical treatment option to relax fingers that are bent is collagenase clostridium histolyticum injection to weaken the cords.

When dysfunction is significant, surgery to remove or cut scar tissue may restore use of the hand. Needle fasciotomy may be performed to divide the cord and release tightness. As many as 60 percent of people who have a needle fasciotomy experience a return of symptoms within three to five years.

Open fasciotomy is sometimes used to treat more severe cases.

It is a more extensive operation, with a slower recovery but longer-lasting results, with the rate of recurrence as low as 8 percent.

18 FLORIDA MD - SEPTEMBER 2015

HIGH ENERGY: DOCS HUSTLE ON AND OFF THE SIDELINES Celebration Orthopaedic & Sports Medicine Institute is a vibrant practice with patients of all ages, conditions and backgrounds, some of whom are even familiar athletes – including high school and college standouts and semi-pro and professional celebrities. As team physicians for seven local high schools, Drs. Homan and Johnston often can be found after hours providing orthopaedic coverage on the sidelines. In the spring, they conduct sports physicals, the cost of which is donated back to the respective athletic departments.

Dr. Homan also is team physician for Impact Wrestling and Tom Shaw Performance Camps, and he provides orthopaedic coverage for the NCAA football bowl games at the Orlando Citrus Bowl and for Disney endurance events.

Dr. Homan was even “at the right place, at the right time” to surgically repair the fractured humerus of a baby gorilla at Disney’s Animal Kingdom. Surgery for a broken arm in a gorilla is almost always indicated, he says, because they use their arms like legs, and casting a gorilla is not an option. A veterinarian who takes care of the gorilla recently reported that follow-up X-rays “looked amazing.”

The commitment of Dr. Homan and his partners to sports medicine extends to academics. He and Dr. Johnston work closely with the physician resident program at Florida Hospital as well as other health care professionals. They regularly teach advanced arthroscopy skills to residents and practicing orthopaedic surgeons. They write articles and continue to develop and work on research projects.

Dr. Haque is actively involved in the national and international spine surgery community. He has published a number of peerreviewed articles in spine surgical journals, including the leading journal Spine. He speaks before professional audiences, including at the prestigious Scoliosis Research Society. He also was a clinical instructor at Brown University and continues to instruct other surgeons in advanced spine surgical techniques.

For more information about Celebration Orthopaedic & Sports Medicine Institute, visit www.celebrationorthopaedics. com. Appointments can be made online or by calling (321) 939-0222. Celebration Orthopaedic & Sports Medicine Institute is also on Facebook, Twitter and Instagram. 

410 Celebration Place, Suite 106 • Celebration, FL 34747 2400 N. Orange Blossom Trail, Suite 100 • Kissimmee, FL 34744

(321) 939-0222 • celebrationorthopaedics.com

Ten Ways Independent Doctors Can Stay That Way-- Practice Managers Share Best Tips

By Marni Jameson The pressure on independent doctors to join a hospital can be great, especially if they’re not well insulated against acquisition.

The more vulnerable providers feel in the face of that pressure, the more likely they are to succumb to it. Yet, if you ask most doctors, most would say they would rather work for themselves not for the hospital. As one practice manager put it, when I asked why the doctor she worked with was so staunchly independent: “Because he gets to run the practice the way he wants want to run it, and he doesn’t have to ask anyone’s permission to take a day off.”

Not every doctor is so fortunate. To have the luxury of being your own boss, and practicing medicine the way you – not a group of hospital administrators – want to, takes savvy practice management. Recently, I invited several administrators of thriving independent practices to meet with me and share their inside tips on how they helped their doctors stay successfully independent. Here are some of their best practices: 1. Stay positive. Attitude is everything, they universally agreed.

It’s easy to get discouraged, but believing you will survive is half the battle.

measures, patient satisfaction scores and what your practice is worth to them. Then negotiate for more because ultimately your practice’s success rides on reimbursements.

6. Make the patient experience over the top. Patients are still your best referral source. If your patient has a good (or bad) experience, he or she will likely tell five people. Train your team to make patients feel like they’re first, and not just the next patient in line. Also strive to make the patient’s visit as efficient from check in to check out. If the doctor is running behind, tell the patient how much longer it will be. Don’t keep the patient in the dark.

And lose the phone tree. One practice administrator said her patients appreciated that when they call, they never call into a phone tree or get a recording. A live human being answers the phone.

2. Keep your community presence strong. Hospitals promote their employed doctors into the community often through media outreach and community education. Non-employee physicians rarely get that support, so they need to take the initiative to get out into the community to create a strong positive presence. Give health talks on your area of expertise.

Support a local sports team. Make yourself available to the media.

3. Shore up your referral base. Know where your patients come from, and reach out to your referral sources, including other physicians, therapists, and employers. Don’t just send a fruit basket. Go out and talk to them. Business, including the business of medicine, is still about relationships.

4. Look for alternatives to the hospital. One Central Florida practice took advantage of office space becoming available next door. They took over the space, and turned it into a procedure room, where they now perform services they used to do in the hospital. The practice now receives the technical fee that would have gone to the hospital. The technical fee helps boost practice revenue, and also helps patients, since the fee to the independent practice is less than the fee to the hospital for the same procedure.

5. Don’t say yes to the first contract. When working with insurance companies, don’t take the first offer they give you. Sell them on your practice. Let them know what differentiates you, your quality FLORIDA MD - SEPTEMBER 2015 19

7. Educate your patients. Unfortunately, most consumers don’t understand the differences between an independent doctor and a hospital-based practice. They don’t know that seeing an independent doctor will save them hundreds, if not thousands of dollars. Those who do understand have trouble knowing which practices are independent. To help educate them, many members of the Association of Independent Doctors display signs in their lobby stating that their practice is “A proud member of the Association of Independent Doctors.” Some providers go further and give patients a letter in new patient packets explaining why that matters. Here’s an excerpt from one: “We would like to reassure our patients that we have not been acquired, nor do we have any intention of being acquired, by a hospital system. When a physician’s practice is bought by a hospital system the costs to patients increase significantly…. This results in higher expenses to Medicare, private insurers and most importantly individual patients...

As an independent practice … the only partnership we seek is with our patients.”

8. Make it easy to refer. To streamline referrals, provide referral sources with a Fast Fax form. They fax you a referral before the patient leaves their office, and within a few hours, your office has called that patient, scheduled an appointment, and reported back to the referring provider, assuring that their patient is getting prompt attention.

9. Be sure your stars align. Love them or hate them, star grades on sites such as Health Grades, and on various insurance

company websites hold enormous sway with patients, many of whom get their information from the Internet. Even if these scores are based on a small, random sampling, where one disgruntled patient can have an outsized impact, they count. To keep your star rating high, survey patients as they check out. Ask how their visit was, and whether you could do anything to improve. If they express a concern, follow up and ask what went wrong, and how you could make up for it. Nip dissatisfaction before patients let out their frustrations online.

Some practices hire a reputation management consultant to manage their social media. When a doctor goes down a star, the consultant finds out why, and works to get his or her reputation back up.

10.

Connect with other independent doctors. Camaraderie among independent practice managers and providers is critical to insulating practices from being acquired. So is joining an organization like the Association of Independent Doctors (www.aid-us.org), a national nonprofit with members coast to coast that gives independent doctors a voice. When independent doctors don’t feel isolated, and feel they’re part of a greater whole, they can practice better medicine with greater confidence.

Marni Jameson is the executive director for the Association of Independent Doctors. You may reach her at 407865-4110 or marni@aid-us.org. 

Central Florida Pulmonary Group, P.A. Serving Central Florida Since 1982

Specializing in: • • • • • • • •

Asthma/COPD Sleep Disorders Pulmonary Hypertension Pulmonary Fibrosis Shortness of Breath Cough Lung Cancer Lung Nodules

Our physicians are Board Certified in Internal Medicine, Pulmonary Disease, Critical Care Medicine, and Sleep Medicine Daniel Haim, MD, FCCP

Eugene Go, MD, FCCP

Jorge E. Guerrero, MD, FCCP

Daniel T. Layish, MD, FACP, FCCP

Mahmood Ali, MD, FCCP

Roberto Santos, MD, FCCP

Francisco J. Calimano, MD, FCCP

Steven Vu, MD, FCCP

Jean Tan Go, MD

Francisco J. Remy, MD, FCCP

Ruel B. Garcia, MD, FCCP

Hadi Chohan, MD

Ahmed Masood, MD, FCCP

Tabarak Qureshi, MD, FCCP

Syed Mobin, MD, FCCP

Kevin De Boer, DO, FCCP

Downtown Orlando:1115 East Ridgewood Street East Orlando:10916 Dylan Loren Circle Altamonte Springs: 610 Jasmine Road

407.841.1100 phone | www.cfpulmonary.com | Most Insurance Plans Accepted 20 FLORIDA MD - SEPTEMBER 2015

MARKETING YOUR PRACTICE

If You Aren’t Listening to Podcasts Yet, You’re Missing Out

By Jennifer Thompson By now, you have probably heard of podcasts; but what exactly are they and why should you care?

In 2005 podcasts were referred to as “the future of radio” and then they sort of disappeared for a long time. Today however, many industry insiders and marketers are again referring to these downloadable pieces of audio content as the next great thing to entertain, educate and consume.

With Apple recently surpassing 1 billion subscriptions for podcasts via iTunes, it may be time to listen to some and find out what you’ve been missing.

WHAT IS A PODCAST? First, some basics. Podcasts are essentially radio shows delivered on-demand over the Internet as opposed to the airwaves.

Users download the episodes they want to hear and play them back on their computers, MP3 players and mobile devices.

navigation tab. Oftentimes you can just navigate to one of the episode pages and listen to an episode.

However, the most common way to consume podcasts is by subscribing and then having the episodes automatically download to your device of choice.

HERE’S WHAT YOU’LL NEED TO DO TO GET STARTED: • A podcast app on your mobile device or a working iTunes account • Search for the podcast you’d like to listen to and press “Subscribe” • Download the episode to avoid any sort of buffering or interruption • Press play and enjoy at your desk, on your ride home or wherever you have a few minutes

Podcasts range in style, content, length and format in just about every way you can imagine. Some are just a singular host and a few minutes long while others are done in an interview format and last for an hour and 40 minutes.

PODCASTS TO CHECK OUT

The podcast format allows you to listen to long-form content from industry personalities and professionals you won’t hear anywhere else. Oftentimes, this creates loyalty between the listener and the host(s) because you spend so much time with them. It’s unique, it’s useful and it’s downright fun.

• The Tim Ferriss Show

Once you’re all set up, it’s time to really dig in. Below are a few of the podcasts we listen to regularly around the office we think you may enjoy.

• Get Social Health • The EntreLeadership Podcast

Plus, listening to podcasts gives you a competitive advantage over your competition since they aren’t mainstream just yet.

As mentioned above, you spend a lot of time with the hosts of shows diving deep into issues that matter to your industry or interests. They also serve as a means to stay up on current industry trends and topics and provide detailed discussions and education at a price that can’t be beat: free.

• Social Media Marketing

You can find a podcast on just about whatever you’re interested in from marketing your medical practice (like ours) to technology, business, fashion, television, sports, finance and on and on and on until you’re blue in the ears (get it?). There really are podcasts about everything, so just pick an interest, search and you’re bound to find something you want to listen to.

• What Ashley Madison Can Teach You About Reputation and HR

Business or cat grooming - we won’t judge.

HOW CAN YOU LISTEN TO PODCASTS? Podcasts are becoming more mainstream, but listening to podcasts isn’t as easy as tuning into your favorite FM station just yet. Many of your favorite websites with podcasts attempt to make it as easy possible to listen to their podcasts by putting the link to their episodes on their front page or a dedicated

• Dr Marketing Tips (this is a shameless plug for my podcast) If you do decide to try out podcasts and you would like to listen to the Dr Marketing Tips Podcast we have put together, here’s a few of our more popular episodes you can look forward to listening to:

• Boring to Soaring: Creating Social Media that Works • Do Changes at Yelp Mean More Headaches for Doctors?

• The Importance of Hospital Partnerships To find the podcast, head to DrMarketingTips.com or search for it in the iTunes store. Happy listening!

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 - SEPTEMBER 2015 21

BEHAVIORAL HEALTH

The Nature of the Affliction

By Sajid Hafeez, MD “So… How long do I have to take the medication?” If a psychiatrist had a dollar for every time he has been asked this question, he’d be set to retire a few years after med school. It is a question that bears investigation in a larger context of how psychiatric care is understood by the general patient.

Generally speaking, the shorter the duration of a medication, the higher the compliance on behalf of the patient. When medications are required to treat chronic issues, the patient is less likely to see them as a cure and more as a burden. Antibiotics to treat an infection have a finite conclusion when the infection is cleared.

Yet, illnesses such as diabetes or hypertension are afflictions that will likely persist through the rest of most patient’s lives.

Often times the public naively see mental illness as a transient problem. At some point in life, every person will know sadness in one form or another. More often than not, most people will recover and move on. When a person struggles from depression, this mirrors what they experienced when they were sad, but with lasting effects. The hope is that psychotropic meds act like an antibiotic to “cure the blues,” and once that sickness is cured, life will continue as normal. Part of the explanation to this could be explained by linguistics

As a society, “depressed” and “sad” are often used interchangeably. A person may say that he or she is “depressed because the Denver Broncos lost the Super Bowl,” whereas another may say that he or she is “sad because the Denver Broncos lost the Super Bowl. A large part of mental health care is in educating the patient that sadness is a temporal emotion that relates to situational and environmental factors. Depression is a lasting condition that persists independent of situational and environmental context, which is related to the physiological make-up of the bodies’ chemistry. It is because of this chemical origin, that it can be treated with medications that adjust the levels of chemistry or how the body absorbs them.

Unfortunately, there is no dipstick in the back of the head that the doctor can check to measure the serotonin levels and top them off with a quart when needed. Patients are educated that rather these levels must be discerned by the clinical presentation of the patient, his affect, mood, and own subjective self-assessment of these. When set against lab values, history of recurrence, and environmental context the doctor is then best able to hone in on the issue and treat it accordingly.

Some patients will be diagnosed with an Adjustment Disorder or Stress Response Syndrome, which is essentially a sadness caused by a specific event. A doctor may or may not choose to start a medication to help the patient through the event, in conjunction with therapy that will help the patient to deal with the psychological aspects of the event. These are the patients who may not need to stay on medication once appropriate coping skills and philosophies are established which allow them a certain level of mental resilience against future stressors.

However for those whose afflictions are the results of the body’s physical biochemistry, therapy and coping skills are typically not enough to overcome the chemical imbalance.

It is through medication that these levels are corrected and that patient begins to feel the depression lifting. Unfortunately, this point of “feeling better” is what is responsible for much of the relapse in patients.

Often, once a patient begins to feel better, he or she incorrectly assumes that the affliction has been cured and medication is no longer needed. Inevitably some will attempt to wean themselves off the medication. However

22 FLORIDA MD - SEPTEMBER 2015

BEHAVIORAL HEALTH because the root of the affliction is chemical and not psychological, no matter how mentally stable and prepared he or she may feel, without the medication to maintain the stable chemistry, these patients will drift back into the affliction.

Ultimately a large part of treating the patient is educating him or her as to what is causing the issue and teaching that psychiatric medications are not cures to a sickness, but rather stabilizers of a chronic condition. In much the same way that a patient with hypertension requires beta blockers so too do those with mental illness need their medication to function at an optimal level. When a patient truly understands why the medications are important and how they work, the compliance ultimately increases, which as a result will improve the patient’s overall quality of life.

Sajid Hafeez, M.D. is a child and adolescent psychiatrist who is serving as a Medical Director of the Acute Care Baker Act Unit at the University Behavioral Center. He also served as the Center’s Medical Director of the long term Residential Units: ASAPP Unit (for adolescent boys with inappropriate sexual behaviors), Solutions Unit (for adolescent boys with behavior problems), Promises and Stars Unit (for adolescent females with behavioral problems as well as victims of sexual abuse), and Discovery Unit (for children ages 5-13 with behavioral as well as inappropriate sexual problems). In addition, Dr. Hafeez also Served as an Assistant Professor of Psychiatry at the University of Central Florida (Voluntary Position). He was also the Chief of the Adolescent Psychiatry Unit, an Attending Psychiatrist of the Comprehensive Psychiatry Emergency Program and of the Mobile Crisis Team at the Westchester Medical College. At Vassar Brother’s Medical Center in New York. Dr. Hafeez was the Director of Outpatient Child & Adolescent and Adult Psychiatric Clinic as well as Director of Consultation and Liaison Psychiatry . Dr .Hafeez received his adult Psychiatry and Residency Training at the University of Kansas Medical Center in Kansas City. He received his Child and Adolescent Psychiatry fellowship training at the New York Medical College New York and at Children’s National Medical Center of George Washington University in Washington, D.C. Dr. Hafeez can be reached at 407-281-7000 or by visiting www.universitybehavioral.com.

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NOW IN LAKE NONA’S STARTING LINE UP Dr. William Felix is a fellowship-trained, board-certified physician focusing on the treatment of sports injuries as well as acute and chronic injury care for patients of all ages. Treating athletes and non-athletes, including children with special needs, Dr. Felix provides traditional orthopedic care along with the latest cutting-edge, minimally-invasive techniques to heal chronically injured tissues.

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FLORIDA MD - SEPTEMBER 2015 23

ORTHOPAEDIC UPDATE

Stem Cells Help Patient Avoid Surgery, Return to the Slopes

By Corey Gehrold For Steven Appelblatt, M.D., there’s nothing better than carving down the side of a mountain after a fresh snowfall. The exhilaration. The grace. The...toll on his knees?

Regenerative medicine includes the use of stem cells and platelet-rich plasma (PRP) therapy to treat patients of all ages and activity levels without Bryan L. Reuss, MD surgery, allowing them to get back to what they love with little to no restrictions.

“Everything I tried didn’t significantly improve my knee for sports function” he says. “I was pretty much told I was heading toward a total knee replacement, and I didn’t want that because I am not ready to give up skiing.”

After discussing the pros and cons of surgery and stem cell therapy with Bryan L. Reuss, M.D., a board certified orthopaedic surgeon specializing in sports medicine at Orlando Orthopaedic Center, Dr. Appelblatt was ready to start his stem cell treatment.

Steven Appelblatt, MD, an avid skier plagued with chronic knee pain, underwent stem cell therapy several months ago in the hopes of returning to his passion. Today he is able to ski full days again and he credits stem cell therapy for providing him relief without surgery.

After spending as much of his life as possible on the slopes, Dr. Appelblatt’s knee joints have endured continued use, stress and trauma. With knee replacement surgery out of the question if he wants to continue the high-level, fast-paced skiing he has come to love, Dr. Appelblatt turned to regenerative medicine to reduce his pain and allow him to hit the slopes with regularity once more.

Today, two treatments and several months later, he says he is skiing full days again and he would recommend the procedure to anyone.

“Before, I was typically only able to ski two or three hours on my knee,” he says. “The biggest benefit for me is that I can now ski full days again without pain and I don’t limp at night after skiing. I’m walking like normal - it has just been great.”

WHAT IS STEM CELL THERAPY?

Stem cell therapy uses healthy regenerative cells found throughout the body to make tissue regeneration a reality. These stem cells actually allow the body to heal on its own Once the blood is aspirated from the pelvis a trained nurse uses specifically designed equipment to concentrate the stem cells before giving them back without the use of drugs, and in some cases, they may to the doctor to be injected at the injury site. reduce or eliminate the need for surgery altogether.

“The term ‘stem cell’ actually includes different kinds of cells found naturally in the body that can renew themselves, becoming virtually any cell in the body,” says Dr. Reuss. “These new cells are harvested from your body, so there is no chance of them being rejected. They are then injected at the site of injury to restore and generate damaged or aging cells.”

WHAT HAPPENS DURING STEM CELL THERAPY TREATMENTS? In Dr. Appelblatt’s case, his stem cells were injected into his ailing right knee. The procedure was performed at the Orlando Orthopaedic Center Outpatient Surgery Center and he was on his way home later that day after recovering from the mild anesthesia.

24 FLORIDA MD - SEPTEMBER 2015

23

ORTHOPAEDIC UPDATE During the harvesting procedure, Dr. Reuss removes (or aspirates) stem cells from the pelvis, one of the richest, most convenient sources of stem cells. A trained nurse then uses specifically designed equipment to concentrate the stem cells before giving them back to the doctor.

“From there we implant the cells at the site of the injury and monitor the patient for a bit before releasing them to return home and rest for the day,” says Dr. Reuss.

WHAT IS THE RESULT OF STEM CELL THERAPY?

Bryan L. Reuss, M.D., says stem cells allow the body to heal on its own without the use of drugs, and in some cases, may reduce or eliminate the need for surgery altogether.

“The first [injection] was approximately eight weeks ago, and I got, what I would classify as, a 70 percent improvement in the function of my knee,” says Dr. Appelblatt. “I went back for a second injection because I wanted to see a 100 percent improvement in my knee.”

Although healing and improvement varies for each patient, most generally report positive improvement in function and a decrease in pain. Dr. Appelblatt says he didn’t notice significant improvement until the three month mark following his first stem cell therapy session.

“After that the amount of swelling in my knee started to reduce dramatically and I found I could go up and down steps without any pain,” he says. “In four months, I went skiing and I could ski about four to five hours without pain and within six or seven months I could do full days again whereas prior to the stem cell treatments I could make it just an hour or two.”

Although Dr. Appelblatt was originally hesitant to recommend stem cell knee injections to his friends and colleagues with similar knee injuries, he says he would certainly support the procedure to others with injuries who want to avoid surgery.

“Eight months out from my first injection, I feel comfortable recommending it to anybody with a cartilage injury in their knee,” he says.

If you would like to learn more about stem cell knee injections or see if they can help improve your knee injury, request an appointment with one of our knee specialists or call 407-254-2500. 

COMING NEXT MONTH: The cover story will be about the proton therapy program available at The Proton Center at UF Health Cancer Center – Orlando Health.

Editorial focus is on Cancer and Dermatology

22

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Orlando Orthop�dic Center

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Treating Central Florida for over 25 years Major Services include: • Allergy Injections • Allergy Testing • Asthma Therapies • Flu Shots (during Flu season) • Pulmonary Testing • Food Challenge • Drug Challenge • Exercise Challenge Helping Patients with: • Asthma • Chronic Cough • Drug, Insect and Food Allergies • Eczema • Hay Fever • Hives • Immunodeficiency • Sinus Conditions • And More!

Our physicians hold faculty appointments at the Florida State University School of Medicine and the University of Central Florida School of Medicine and are members of Florida Hospital Kid’s Doc’s

Board Certified Allergy, Asthma & Immunology & Board Certified Pediatrics Steven Rosenberg, MD Carlos Jacinto, MD Harleen Anderson, MD Winter Park

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FLORIDA MD - SEPTEMBER 2015 25

New Trauma Center Keeps Pace with Osceola County’s Explosive Growth Critically Injured Patients Can Now Receive Treatment at Osceola Regional Medical Center

By Dr. Tracy Bilski, MD, FACS It wasn’t long ago that Osceola County had more cattle than people. And while this sprawling landscape on the doorstep of Walt Disney World retains much of its rural character, massive growth is turning a once-quiet community into one of Central Florida’s most highly populated regions.

Today, about 300,000 people call Osceola County home – a 12-fold increase since 1970. By the middle to latter half of the 21st century, planners expect nearly 1 million residents.

As you might imagine, it’s an ongoing challenge to keep pace with this community’s rapidly evolving needs, especially when it comes to health-related services.

At Osceola Regional Medical Center – where our coverage area stretches from southern Orange County to northern Polk County – we’re doing our part by making a number of improvements. In the past two years, we’ve opened a behavioral health center and freestanding ER, expanded our pediatric department, added a

$60 million patient tower, renovated our emergency department and partnered with the UCF College of Medicine to launch a residency program.

Our most recent accomplishment – being designated a Provisional Status Level II Trauma Center by the Florida Department of Health – addresses the county’s long-standing need for quicker, more centrally located access to life-saving medical care.

THE CLOCK IS TICKING …

Until now, critically injured patients in Osceola County – Florida’s sixth-largest in land size – had to be transported more than 20 miles to the nearest trauma center. That didn’t bode well during life-and-death situations such as car accidents, severe burns, shootings and stabbings.

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As all ER doctors know, the sooner care is given within the crucial “golden hour” – a 60-minute window for bringing patients to a designated trauma center – the better the outcome for survival. Indeed, every second counts.

When Osceola Regional began accepting Level II trauma patients on May 1, it marked a milestone in our mission to save lives. Under this new designation, the hospital now provides the following 24/7 services: in-house coverage by a trauma surgeon; on call-neurosurgeons; access to specialty and non-specialty surgeons and physicians; an anesthesia provider; a surgical services team and trauma-trained nurses.

Our commitment to enhancing critical care for such a wide geographic footprint is especially relevant because trauma is the leading cause of death among Floridians under the age of 44. Plus, the state’s death rate for trauma remains higher than the national average, and only about 50 percent of Florida’s trauma patients receive treatment in a designated trauma center.

To drive progress in these areas, we’ve

joined the state’s first and largest network of trauma centers, developed in affiliation with the University of South Florida. When compared to statewide averages, hospitals in the HCA Florida Trauma Network post higher survival rates for critically injured patients and have shorter lengths of stay. By transforming Osceola Regional into a Level II Trauma Center, we can also keep local families closer to their loved ones, which further speeds the recovery process.

LESSONS FROM NAVAL SERVICE As Osceola Regional’s new trauma medical director, I’m honored to be leading a team of highly skilled professionals filling a major need in our community.

It takes heart and dedication to thrive in this field, a reality I experienced first-hand as a trauma surgeon in the U.S. Navy. Working alongside some of our country’s finest, bravest citizens, I had the honor of treating military personnel at Camp Pendleton in California and the National Naval Medical Center in Maryland. Deployments in Egypt, Afghanistan and Iraq also allowed me to treat critically injured patients in the most intense environments.

These days, I’m glad to be back in the Sunshine State, where I’ve served as assistant professor of surgery at UCF and USF. And I’m even more excited to be leading a newly created department that holds such promise for the future of Osceola County.

Just like this region of Florida, our hospital is expanding at a rapid pace.

Having the ability to treat trauma patients is a major step in Osceola Regional’s commitment to providing the kind of lifesaving medical care this community needs and deserves Dr. Tracy Bilski, M.D., F.A.C.S is the trauma medical director at Osceola Regional Medical Center, a 321-bed hospital located in Kissimmee. She holds a doctorate from Jefferson Medical College and is a former trauma surgeon for the U.S. Navy, having been deployed to Egypt, Afghanistan and Iraq.

Dr. Bilski is a member of the American Association for the Surgery of Trauma, Society of Critical Care Medicine, Surgical Infection Society, and American College of Surgeons. She can be reached at 407-518-3800 or Tracy.Bilski@hcahealthcare.com.

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FLORIDA MD - SEPTEMBER 2015 27

HEALTHCARE BANKING, FINANCE AND WEALTH

What Does Chip Card (EMV) Processing Mean for Your Practice?

By Jeff Holt, VP, Senior Healthcare Business Banker with PNC Bank Is your practice prepared for processing chip cards from your patients starting in October, 2015? We are now only a month away from this deadline and still many medical practices have not yet upgraded their equipment and software to the new improved EMV technology.

It is important for all medical practices to understand the history of how and why this technology has evolved, and then to consider what is best for your patients and practice before properly implementing and utilizing EMV technologies.

A chip card enhances card security for electronic payments when inserted in the chip card reader (not swiped) of a chipenabled terminal. The chip generates a unique transaction code, which is shared with the merchant, instead of your card information. This makes the card difficult to copy. Your chip card provides an additional layer of security at chip-enabled terminals; however, perpetrators continue to look for new opportunities to commit fraud.

Starting in October 2015, financial liability for card-present counterfeit card losses will shift from the card-issuing banks to merchants if merchants receive chip-enabled cards but have not yet installed chip card capable terminals. This liability shift will apply to all merchants, regardless of size. As a card processor, your medical practice will need to ensure your point-of-sale (POS) system is capable of accepting chip cards due to this fraud liability shift. Now is the perfect time to review your processing needs, and upgrade to a chip card capable system.

“For healthcare professionals, the need to protect patient information goes beyond desire - HIPAA / FIPA compliance, regulations, and reputation demands it,” explains Dylan Floyd, regional account executive with PNC Merchant Services. “EMV utilizes a European-based chip and pin technology that has decreased fraud by over 90 percent worldwide for face-to-face transactions.”

BY THE NUMBERS Let us first cover some of the staggering statistics that will show you why this technology came to be needed: • The total cost of fraud in the U.S. is estimated at $8.6 billion per year, according to an Aite Group report from 2010; so preventing fraud growth is of the upmost importance.

• A recent USA Today article ranked Florida as the #1 state in the U.S. for number of identity theft complaints, with the average amount paid of $2,104.

• An analysis by Visa® found that small merchants account for 28 FLORIDA MD - SEPTEMBER 2015

more than 80 percent of data security breaches.

• Major insurance companies like, AIG and Great American, proclaim that the average cost of a data breach in 2012 was more than $38,000.

• And security experts affirm that the sale of credit card information is still thriving on the black market.

In the end, security breaches may not only expose your practice to fines from bank regulators and the card associations, but they also can rob you of your patient’s trust.

HOW COULD YOUR PRACTICE BE FINANCIALLY AT RISK WHEN NON-COMPLIANT? A data breach can already have a very negative impact on your practice and your patients, but a breach while out of compliance could result in card association fees and penalties up to $10,000 per occurrence and $500,000 in total; monthly non-compliance fees; damage to the reputation of your practice; and worst case scenario - be possibly driven out of business.

“Non-compliance with PCI-DSS requirements provides banks and the credit card companies the means to recoup lost funds, as well as levy penalties,” said Tatiana Melnik, a healthcare attorney based in Tampa. “But losing the trust of your patients could have a greater negative financial impact on the practice than the fines.”

When considering the unfortunate possible combination of both the fines and loss of patient trust, the resulting total financial impact could be difficult to recover from. So how should your practice prepare for implementation? Initially, identify all credit card collection points and systems used by your organization and talk to your merchant services provider to understand their strategy for chip cards. Then, assess your practice’s potential risks based on credit card volumes, current fraud experience and areas of potential exposure.

This process could require an initial investment, so you need to budget for new credit terminals and/or system upgrades, as well as training for your staff.

If your practice is unable to meet the October 2015 deadline, you may want to investigate whether potential losses due to fraudulent card transactions will be covered by corporate insurance policies.

HEALTHCARE BANKING, FINANCE AND WEALTH Basic Payment Card Industry Data Security Standard (PCI DSS) data security requirements should still be implemented for security and compliance reasons. Twice a year, complete a PCI DSS Self-Assessment Questionnaire (SAQ) to self-evaluate your compliance with PCI DSS. (Visit https://www.pcisecuritystandards.org/ to learn more about what you need to do to become PCI compliant).

Please ask your healthcare business banker for assistance to get your practice in the best possible position to be EMV compliant at all times.

Jeff Holt is a Senior Healthcare Business Banker with PNC Bank’s Healthcare Business Banking and can be reached at (352) 385-3800 or Jeffrey.holt@pnc.com.

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DID YOU KNOW?

EMV stands for Europay, MasterCard® and Visa®, and is interchangeable with the name Chip Card, and evolved in the mid 1990’s.

Currently, more than 1.55 billion EMV-compliant cards are now being used at 20 million EMV acceptance terminals. As of October 1st 2015 the implementation of EMV makes the United States the last major world economy to migrate to EMV. Fortunately, that does allow us to adopt existing best practices and learn from mistakes other countries have made.

The United Kingdom was one of the earliest adopters of Chip and PIN technology based on EMV. While total card purchase volume in the UK grew 32 percent between 2005 and 2010, total card fraud decreased by 17 percent. In addition, lost, stolen and counterfeit card frauds in the UK are now at their lowest levels since the 1990s.

HOW DOES EMV MAKES PROCESSING MORE SECURE?

The new Chip cards are nearly impossible to duplicate, and when combined with additional layers of security—such as encryption, tokenization and other strong authentication techniques — EMV significantly reduces opportunities for card payment fraud.

THE SECURITY DIFFERENCE BETWEEN CARDS:

Traditional Credit/Debit Cards – The magnetic strips contain data that does not change. This data gives thieves all the information that they need to steal thousands of dollars from your patients.

Chip (EMV) Credit/Debit Cards – When a chip card is used for a payment, a unique code for each transaction is generated and stored on the chip. That newly created code cannot be used again, and therefore is useless to thieves. The chip technology gives criminals unusable data only when properly used with the coinciding compliant merchant service equipment.

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Email: info@floridamd.com or call 407.417.7400 FLORIDA MD - SEPTEMBER 2015 29

Allergic Rhinitis, Asthma, and Food Allergy: Undiagnosed and Undertreated

By Harleen Anderson, MD

THE BURDEN OF ALLERGIC DISEASE We as providers can do better for our patients with allergies and asthma.

Allergies are one of the most common diseases afflicting our country-- approximately 40% of the US population suffer with allergic rhinitis. In Florida, allergic rhinitis is more common because of our temperate climate. In Burlington Vermont, I practiced for 4 years. Seasons are shorter and patients symptoms were relieved after months. Here, patients have symptoms year round.

Common seasonal allergens, including grasses, trees, and weeds, are sustained and therefore our patients suffer longer with more severity. After relocating to Florida, I was thoroughly surprised how severe, how early and how often my patients suffer from their allergies. I now regularly care for 2 year old children with moderate to severe allergic rhinitis; something uncommon in Vermont.

Primary care providers are dealing with many medical issues, such as uncontrolled diabetes and hypertension, which can lead to severe co morbid conditions and mortality. With all the changes to medical reimbursement, there is increase pressure to see more patients and time is of the essence. Understandably, many providers may not be able to completely address their patient’s allergic rhinitis. However, uncontrolled allergic rhinitis certainly leads to a decrease in quality of life and often results in other complicating conditions such as recurrent otitis media, uncontrolled atopic dermatitis, and asthma exacerbations.

One such consequence is the affect on sleep. Sleep is absolutely fundamental to our physical and mental health. Up to 60% of patients feel their sleep is being adversely affected by their allergies. Many studies have demonstrated how allergies detrimentally affect our sleep. It appears nasal congestion is the leading reason for insomnia, micro-awakenings, fatigue, and overall decreased quality of sleep. Lower quality of sleep causes decreased learning ability, decreased work productivity, and a resultant decreased quality of life. Additionally, uncontrolled allergic rhinitis is significant risk factor for sleep apnea. I strongly believe sleep disturbance from asthma, atopic dermatitis, and/or allergies is an indicator of uncontrolled allergies and we should be routinely asking our patients if their asthma or allergies are affecting their sleep in order to take the proper steps to improve their health.

Likewise, at least 30% of allergic rhinitis sufferers have asthma with a significant component of reversible obstruction. Therefore 30 FLORIDA MD - SEPTEMBER 2015

providers treating children with allergic rhinits should ask questions about chest tightness, cough, and wheezing, such as asking parents if their children with rhinorrhea or congestion, cough with exercise or at night. Patients often do not equate these symptoms with asthma because they have never had an asthma “attack”. Each diagnosis requires a very detailed history and often spirometry is needed to confirm the diagnosis of asthma.

In our office, Dr. Rosenberg, Dr. Jacinto, and I educate our patients on the symptoms of their asthma and allergic rhinitis and discuss the definition of control, the etiology, identifying triggers which often include allergens, and finally determine the ideal treatment options for each patient. Encouraging patients to be proactive in their treatment and resolving issues with compliance are key to being successful in control of allergies and asthmatics.

Fortunately, treatments, such as immune modulators and allergy immunotherapy, make it possible for effective treatment of allergies and asthma and subsequent improvement in our patients’ quality of life and health.

FOOD ALLERGY. A GROWING PROBLEM Food Allergy is on the rise. I have a special interest in the diagnosis and treatment of food allergy. Food allergy is on the rise therefore more questions are being asked. One possible reason for the increase in food allergy is the “Hygiene Hypothesis” The following is a simplistic view on the hygiene hypothesis.

Our IgE, our allergic antibody, is now bored in industrial societies because there are less infections to fight. Instead of spending time fighting parasitic infections, IgE spends its time fighting seemingly innocous antigens such as peanut protein and environmental allergens such as mold spores and pollens. There has also been a increase in awareness which could be playing a role in increase rate of diagnosis. As the prevalence and incidence increases research moves rapidly in pathophysiology, diagnosis, and treatment.

We are learning more everyday. In the past we thought delaying highly allergenic foods such as peanut could help delay the developement of food alelrgy but this is not the case. We now do not tell parents to avoid particular foods if there is no history of food allergy.

The average person does not distinguish between food intoler-

ances and IgE mediated food allergy. The diagnosis becomes more complex and it is our job at Allergy and Asthma Associates of Central Florida, to arm our patients with the accurate information. The first step is determining if in fact there is an IgE mediated food allergy and this starts with a very detailed history of food ingestion, symptoms and the temporal relationship between the two. If a misdiagnosis of a child occurs, the child could be unecssarily avoid a particular food, develop food aversions, and can develop anxiety surrounding the diagnosis. The diagnosis of food allergy can lead to a great deal of anxiety on the family as well. Because food allergy can be deadly causing angioedema or anaphyalxis, parents often become anxious about sending their children to school, going out to dinner, or going to someone house to play. It is my mission to appropriately diagnosis patients and address all surrounding issues. One such way to make the proper identification of food allergy is through percutaneous skin testing which is more sensitive and specific than RAST testing. In certain cases a food challenge is neccesary to rule out food allergy. This is done in a very controlled environment with close observation but it allows for the diagnosis to be ruled out and for patients and their families to feel certain it is safe for ingestion of foods in question. If the diagnosis of food induced anaphylaxis, urticaria, or angioedema has been made Dr. Rosenberg, Jacinto and I provide action plan and arm our patients with a life saving epinephrine auto injectors. We want our patients to fully understand their diagnosis.

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At Allergy and Asthma Associates, we can make an impact on those who suffer from atopic and immunologic disease.

Harleen Anderson, MD, is a graduate of Tufts University. She is board certified in allergy and immunology as well as Internal Medicine. She completed her training at Albert Einstein University in New York, New York with an emphasis on pediatric allergy and immunology. She has participated in numerous research trials has presented complex cases at many national conferences. She is active in her community in raising awareness of food allergy and asthma and is on staff at Florida Hospital.

She is committed to providing expert care for her patients. Dr. Anderson currently practices at Allergy and Asthma Associates of Central Florida located at1890 SR 435, Suite 215, Winter Park, FL and can be contacted at (407) 678 4040 or by visiting www.aaacfonline.com.

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COMING UP NEXT MONTH: The cover story will be about the proton therapy program available at The Proton Center at UF Health Cancer Center – Orlando Health. Editorial focus is on Cancer and Dermatology.

FLORIDA MD - SEPTEMBER 2015 31

HEALTHCARE LAW

NLRB Expands Test Used to Determine Joint Employer Status

By Susan T. Spradley, Esq and Craig F. Novick, Esq On August 27, 2015, the National Labor Relations Board (“NLRB”) issued a ruling in which it expanded the test it will use to determine joint employer status for purposes of interpreting the National Labor Relations Act (“NLRA”). In a case commonly referred to as the Browning-Ferris case, the NLRB addressed the issue of whether Browning-Ferris Industries of California, Inc. d/b/a BFI Newby Island Recyclery (“Browning-Ferris”) and FPR-II, LLC d/b/a Leadpoint Business Services (“Leadpoint”) were joint employers. Browning-Ferris, the owner and operator of a recycling facility, staffed its facility with workers provided by Leadpoint, a staffing agency. The NLRB ruled that BrowningFerris and Leadpoint were joint employers.

In making its ruling, the NLRB announced an expanded test which overruled years of prior precedent. This new test uses a two prong analysis to determine whether two or more entities are joint employers: 1) whether the entities are both employers within the meaning of common law; and 2) whether the entities share or codetermine those matters governing the essential terms and conditions of employment. The new test looks at whether an entity possesses the authority to control the terms and conditions of its workforce, whereas the prior precedent required an entity to actually exercise its authority over its workforce to be considered a joint employer.

Entities that use staffing agencies or subcontractors to supply their workforce should be cognizant of this new rule, as they may be considered joint employers for purposes of the NLRA. This new rule could impact hospitals and other healthcare facilities who use staffing agencies or other outside sources to staff their facilities. Further, other agencies, such as the Occupational Safety and Health Administration (“OSHA), the Department of Labor (“DOL”), and the Equal Employment Opportunity Commission (“EEOC”) may adopt the NLRB’s expanded joint employer test in the future.

Be sure and check out our website at www.floridamd.com!

32 FLORIDA MD - SEPTEMBER 2015

Susan T. Spradley, Esq. is a Shareholder in GrayRobinson’s Orlan-

Susan T. Spradley

do office and is chair of the firm’s Employment and Labor Practice Group. She focuses her practice in all aspects of management employment law, including litigation, general advice and training. She can be reached at 407-843-8880 or susan. spradley@gray-robinson.com.

Craig F. Novick, Esq. is an As-

Craig F. Novick

sociate Attorney in GrayRobinson’s Orlando office. He represents employers in all areas of employment law, including, but not limited to: discrimination; retaliation; the Fair Labor Standards Act; the Family and Medical Leave Act; and the Americans With Disabilities Act. He can be reached at 407-843-8880 or craig.novick@ gray-robinson.com.

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2015

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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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> WELCOME RITU WALIA, MD < — Pediatric Gastroenterologist — The Digestive and Liver Center of Florida is pleased to announce the addition of a pediatric gastroenterologist to our practice. Dr. Walia is Board-Certified in Pediatrics and specialized in Pediatric Gastroenterology.

Dr. Walia completed her fellowship at the Cleveland Clinic.

Her interests include Acid Reflux, Inflammatory Bowel Disease (IBD), Abdominal Pain, Chronic Constipation/Impaction, Motility Disorders and Irritable Bowel Syndrome (IBS). She also specializes in Fecal Transplants for the treatment of Recurrent C. difficile Infections in Children.

Please join us in welcoming Dr. Ritu Walia to our community.

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