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MAY 2016 • COVERING THE I-4 CORRIDOR

Common Misconceptions about Gastroesophageal Reflux Disease (GERD)

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FLORIDA MD - MAY 2016 1

FROM THE PUBLISHER

am pleased to bring you another issue of Florida MD. I can only imagine the emotional and physical trauma that a woman goes through when she has a mastectomy. The procedure affects not only her body, but her mind and her self-esteem. Now add in the inability to not be able to reconstruct her breasts and give that part of her life back, because she’s uninsured or under insured, and it becomes an unthinkable crushing blow. Fortunately there is My Hope Chest to help women who are unable to afford reconstructive surgery. I asked them to tell us about their organization and how you, as physicians, can help. Please join me in supporting this truly wonderful organization.

COMING NEXT MONTH: The cover story focuses

Best regards,

on board-certified vascular and endovascular surgeon Adonis Lysandrou, MD of Vascular Associates of St. Cloud and St. Cloud Regional Medical Center. Editorial focus is on Allergies and Sleep Disorders.

Donald B. Rauhofer Publisher

MY HOPE CHEST — Making Women Whole Again In 2010, more than 22,000 uninsured women lost their breasts to cancer and were left disfigured, deformed and feeling “less than whole.” How many years has this figure been growing? Many organizations raise funds for research, education and “awareness” of breast cancer. Most have no idea there lies a huge gap in assistance for delayed reconstruction and co-pays for survivors wanting this surgery. My Hope Chest is the ONLY national 501c3 non-profit organization focused on funding breast reconstruction for the uninsured and under insured survivors. Our services “pick up” where other breast cancer organizations leave off… providing the “final step in breast cancer treatment. ” My Hope Chest is about addressing the needs of survivors now. Through wonderful surgeon partnerships we are able to transform the lives of breast cancer survivors who otherwise have no hope of reconstruction. We hope to hear from you to learn how we can work together to eliminate our wait list and take action to help every woman who desires reconstruction after mastectomy and feel restored in body, mind and spirit. Wish List • Surgeons to create awareness for My Hope Chest and to identify new clients • Doctors of Distinction- Surgeon partners nationwide to join our program. • Corporate partners, interested in Win-Win, Commercial- coventure marketing campaigns promoting their product or service by sharing our vision to make sure there is always coverage for reconstruction surgery. For additional information on how you can help or refer a patient please go to www.MyHopeChest.org.

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Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: Sajid Hafeez ,MD, Daniel T. Layish, MD, Adonis Lysandrou, M.D, Jeremiah Nelson, MD, Veronica L. Schimp, DO, Jeff Holt, Jennifer Thompson, Timothy M. Cerio, Michelle Bilsky, Saloni Agarwal, Jennifer Campbell, Anita White, Dorothy Mowbray, 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. Advertising rates upon request. Postmaster: Please send notices on Form 3579 to P.O. Box 621856, Oviedo, FL 32762. Although every precaution is taken to ensure accuracy of published materials, Florida MD cannot be held responsible for opinions expressed or facts expressed by its authors. Copyright 2012, Sea Notes Media. All rights reserved. Reproduction in whole or in part without written permission is prohibited. Annual subscription rate $45.

contents 4

MAY 2016 COVERING THE I-4 CORRIDOR

 COVER STORY

PHOTO: PROVIDED BY FLORIDA HOSPITAL TAMPA

Reflux of gastric contents to the esophagus is an event than can be put on a spectrum ranging from physiological to severely pathological leading to life threatening consequences. When reflux is pathological, it is referred to as gastroesophageal reflux disease (GERD). Due to little agreement as to what this term exactly includes, the Montreal Working Group issued a consensus statement defining GERD as a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications; “troublesome symptoms” are defined as mild symptoms occurring two or more days a week, or moderate to severe symptoms occurring one or more days a week.

PHOTO: PROVIDED BY FLORIDA HOSPITAL TAMPA

ON THE COVER: Dr. Alexander Rosemurgy and Dr. Sharona Ross of the Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery at Florida Hospital Tampa

13 VARICOSE VEINS 15 TYPE 1 DIABETES: THEN AND NOW 21 TAKE THE MEDICAL OFFICE RESOURCES OF FLORIDA CHALLENGE! 24 THE MONEY IN MEDICINE - HYPOCRITE OR HIPPOCRATIC?

DEPARTMENTS 2

FROM THE PUBLISHER

HEALTHCARE LAW

HEALTHCARE BANKING, FINANCE AND WEALTH

10 CANCER

12 MARKETING YOUR PRACTICE 14 ORTHOPAEDIC UPDATE 17 INPATIENT REHABILITATION 18 BEHAVIORAL HEALTH

20 PULMONARY & SLEEP DISORDERS 22 INSURANCE FLORIDA MD - MAY 2016 3

COVER STORY

Common Misconceptions about Gastroesophageal Reflux Disease (GERD) By Alexander S. Rosemurgy, MD, FACS, Forat Swaid, MD, and Sharona B. Ross, MD, FACS

INTRODUCTION Reflux of gastric contents to the esophagus is an event than can be put on a spectrum ranging from physiological to severely pathological leading to life threatening consequences. When reflux is pathological, it is referred to as gastroesophageal reflux disease (GERD). Due to little agreement as to what this term exactly includes, the Montreal Working Group issued a consensus statement defining GERD as a condition that develops when the reflux of stomach contents causes troublesome symptoms and/ or complications; “troublesome symptoms” are defined as mild symptoms occurring two or more days a week, or moderate to severe symptoms occurring one or more days a week. According to a review that included 15 epidemiological studies of GERD with strict inclusion criteria, GERD prevalence is 1020% in the Western world, with an incidence of 0.5% per year.

PHOTO: PROVIDED BY FLORIDA HOSPITAL TAMPA

Alexander S. Rosemurgy, MD, FACS Director, GERD and Digestive Disorders Surgery Center; Director, HPB Surgery Center; Co-Director, Advanced GI & HPB Surgical Fellowship Program, Florida Hospital Tampa

4 FLORIDA MD - MAY 2016

Not surprisingly, a steep increase in the incidence of esophageal adenocarcinoma, the most dreaded complication of GERD, has been observed. According to data from the Surveillance, Epidemiology, and End Results (SEER) Program, there has been a 56-fold, not 56%, but a 56-fold increase in the incidence of adenocarcinoma of the esophagus between 1984 and 2010. This high prevalence has led to enormous research about GERD and its optimal management options. There are clear, and potentially dangerous, misconceptions regarding this disease, and the purpose of this report is to address some of them.

OVERVIEW OF GERD SYMPTOMS, DIAGNOSIS, AND MANAGEMENT The most common symptoms of GERD are heartburn, regurgitation and dysphagia. Other, less common symptoms of GERD include chest pain, hypersalivation, odynophagia, bronchospasm, laryngitis and chronic cough. GERD can be asymptomatic until complications reflecting advanced disease occur. Untreated or undertreated, GERD can lead to esophageal complications including erosive esophagitis, esophageal strictures as a result of chronic inflammation and healing, and Barrett’s esophagus, in which metaplastic columnar epithelium replaces the stratified squamous epithelium that normally lines the distal esophagus, predisposing to the development of esophageal adenocarcinoma. In addition, extra-esophageal complications may develop, including asthma (GERD is present in 34-89% of asthmatics), chest pain (i.e., noncardiac angina), hoarseness, globus pharyngeus (sensation of a lump or foreign body in the throat), chronic cough, and nonproductive throat clearing. Longstanding reflux can also lead to recurring pneumonia, chronic sinusitis, and voice changes. The diagnosis of GERD can often be made empirically, based on a convincing clinical presentation with a good response to anti-acid therapy, making extensive radiologic and endoscopic investigations seemingly superfluous. Additional testing is needed to objectively confirm the diagnosis and severity of GERD, to assess for complications of GERD, and / or to establish alternative diagnoses. The American Gastroenterological Association (AGA) recommends that endoscopy should be done for patients with GERD that have “alarm features” (e.g. dysphagia, odynophagia, gastrointestinal bleeding, anemia, weight loss) and for patients who have not responded to an empirical trial of twice-daily PPI therapy. Ambulatory pH monitoring is a “first-line” test to confirm or rule-out GERD in patients with or without symptoms, including those with symptoms persisting after initiation of PPI therapy and those who do not have evidence for mucosal damage on endoscopy. Ambulatory pH monitoring should be undertaken if

COVER STORY proton pump inhibitor (PPI) therapy is considered for beyond the short-term. We have developed techniques to undertake endoscopy and Bravo pH probe placement in the office without sedation. This means patients do not lose control and are able to drive home or return to work immediately following the procedure.

• Antacids, which neutralize gastric acid on contact, thereby decreasing (for a short time) the exposure of the esophageal mucosa to gastric acid during episodes of reflux. • Surface agents, such as sucralfate, which adhere to and protect the gastric mucosal surface and protect it from peptic injury. • Histamine - 2 receptor antagonists (H2RAs, H-2 blockers) decrease the secretion of acid by inhibiting the histamine 2 receptor on the gastric parietal cell, thereby reducing acid secretion. • Proton pump inhibitors (PPIs) work by short-term irreversible binding to and inhibition of the hydrogen-potassium (H-K) ATPase pump of the gastric acid producing cells. They are the most potent inhibitors of gastric acid secretion. PPIs at standard doses for eight weeks relieve symptoms of GERD and heal esophagitis in up to 86% of patients with erosive esophagitis. Traditionally, definitive control of reflux through surgical and/ or endoscopic interventions were reserved for patients with complications of reflux such as recurrent or refractory esophagitis, stricture, Barrett’s metaplasia, persistent symptoms despite acid suppression, patients with GERD-induced asthma, as well as for patients unable to tolerate medication, noncompliant with medication, or unwilling to take lifelong medications The most commonly used endoscopic intervention are Transoral Incisionless Fundoplication (TIF) and Stretta. We use these techniques selectively in patients that are not good surgical candidates because of serious medical comorbidities, for patients with a notable history of abdominal / gastric surgery, and for patients meeting strict eligibility requirements (e.g., a hiatal hernia of ≤ 2cm. Laparoscopic anti-reflux surgery (e.g., laparoscopic Nissen fundoplication) is associated with very encouraging results from multiple centers across the United States. We have undertaken more than 2,000 of these operations over 25 years and have been very pleased by their efficacy and durability, and low complication rate. In recent years, robotics has been applied to anti-reflux surgery allowing surgeons with limited laparoscopic skills to safe-

PHOTO: PROVIDED BY FLORIDA HOSPITAL TAMPA

Once GERD is diagnosed, lifestyle and dietary modifications are recommended, including weight loss, elevation of the head of the bed, avoidance of meals 2-3 hours before bedtime, selective elimination of dietary triggers that cause a relaxation of the gastroesophageal sphincter (such as fatty foods, caffeine, chocolate, alcohol, and peppermint), as well as smoking cessation. In a systematic review of six randomized trials, notably only weight loss and elevation of the head of the bed improved esophageal pH-metry and/or GERD symptoms. The next step in treatment usually involves anti-acid medications; the most commonly used being:

Sharona B. Ross, MD, FACS Director, Minimally Invasive Surgery and Surgical Endoscopy; Director, Advanced GI & HPB Surgical Fellowship Program; Director and Founder, FHT Women in Surgery Initiative, Florida Hospital Tampa

ly undertake anti-reflux surgery through 4 to 5 small incisions. This is not our preference. Our preference is a “scarless” laparoscoic approach: LaparoEndoscopic Single Site (LESS) surgery. This approach allows for conventional laparoscopic operations to be undertaken through only one 12mm incision at the umbilicus, itself a scar. This approach has been very well received and results in less pain and a quicker recovery with a truly superior cosmetic outcome. Symptom control after LESS fundoplication is salutary, significant, and durable (note figure). “Scarless” anti-reflux surgery is possible only through this approach. We embraced this approach very early and have undertaken more anti-reflux operations using this approach than any other center in the United States, now more than 350 such operations. As experts in this surgical approach, we remain excited about the salutary benefits with outstanding cosmetic outcomes.

MISCONCEPTIONS ABOUT PPI’S AS A TREATMENT FOR GERD Despite documented efficacious outcomes after anti-reflux surgery, skeptics remain and promote the open-ended use of PPIs. However, enthusiasm regarding PPIs has led to their downsides being overlooked, and many misconceptions about them have spread, notably: • Misconception #1: “PPIs stop reflux.” Fact: They don’t. When used properly, they effectively eliminate gastric acidity in most people, but the reflux FLORIDA MD - MAY 2016

PHOTO: PROVIDED BY FLORIDA HOSPITAL TAMPA

COVER STORY

Drs. Ross and Dr. Rosemurgy undertake a pancreaticoduodenectomy on a patient who has undergone extensive neoadjuvant therapy for pancreatic adenocarcinoma.

of gastric contents, which contain bile salts, continues. PPIs do not affect structural, mechanical, and motility abnormalities at the gastroesophageal junction responsible for gastroesophageal reflux (i.e. hiatal hernias, decreased lower esophageal sphincter pressure, transient lower esophageal relaxation). Therefore, PPIs do not decrease reflux; they simply change the acidity of the refluxate. With PPI therapy, patients do not reflux acid, but rather bile salts and conjugated acids. These can cause heartburn and esophageal injury. In addition, because they still reflux, patients treated with PPIs still experience and suffer from some of the aforementioned extra-esophageal complications of reflux, such as asthma, pneumonia, laryngitis, chronic cough, dysphonia/hoarseness, globus pharyngeus, and nonproductive throat clearing. • Misconception #2: “PPIs are harmless.” Fact: They are not. Long-term PPI therapy is associated with several complications: 1. Community acquired colonic Clostridium difficile infections 2. Community acquired and hospitalization-associated pneumonia 3. Magnesium malabsorption leading to hypomagnesemia has been documented in patients on prolonged PPI treatment, and an FDA safety alert has been issued in this regard. 4. Calcium malabsorption resulting from hypochlorhydria has been documented, with an associated increased risk of low bone density (osteoporosis) and hip fractures. This is particularly a problem in postmenopausal women and men over 50 years of age. 5. Vitamin B12 malabsorption. 6 FLORIDA MD - MAY 2016

6. Iron malabsorption and iron-deficiency anemia. 7. Acute interstitial nephritis. 8. Dementia: a number of studies have found a significant association between use of PPIs and dementia 9. Drug interactions: PPIs are metabolized via hepatic cytochrome P450 enzymes, with CYP2C19 having the dominant role. The activity of CYP2C19 is determined by gene polymorphism, and two known inactivating mutations which occur most commonly in Asian populations have been described. Five percent of Caucasians are homozygous for this mutation; as a result, the metabolism of drugs by this route may be delayed in these individuals, leading to higher plasma levels of PPIs in these patients with extended acid-suppression. While the latter sounds great, deleterious consequences may ensue, such as altered metabolism or activation of many drugs that are metabolized by the same pathway, including warfarin, diazepam, clopidogrel and phenytoin. In addition, PPIs may decrease the absorption of certain HIV protease inhibitors. Furthermore, the decreased acid environment of the stomach may limit pill or capsule degradation of some medications limiting their absorption. 10. The reflux of unopposed bile salts and acids, possible because of acid suppression, can cause injury to the esophageal lining and predispose to adenocarcinoma of the esophagus, in part explaining the tremendous increase in the incidence of esophageal adenocarcinoma over the past 35 years. • Misconception #3: “PPI’s are cost effective.” Fact: They are a huge economic burden. It is estimated that 11 billion dollars are spent annually on both prescribed and over the counter

PPIs, an average cost of 60-160 dollars/ month per patient. Moreover, a large proportion of the patients taking these drugs lack objective documentation of excess gastroesophageal reflux, and it is estimated that 30% of PPI prescriptions are appropriately prescribed. In summary, GERD imparts a tremendous morbidity on our health system and our citizens. The indiscriminate and extended consumption of PPI therapy is not a solution, just a way to ‘kick the can down the road’, often to the tremendous detriment of the patients. Objective testing for reflux should be undertaken early to appropriately apply therapy, which should be definitive therapy for patients in need of ‘open-ended’ therapy or those with complications of reflux. Antireflux surgery is underutilized: it is efficacious, durable, and salutary.

PHOTO: PROVIDED BY FLORIDA HOSPITAL TAMPA

COVER STORY

Dr. Rosemurgy discusses an upcoming procedure with a patient during an office visit.

Dr. Rosemurgy has been a surgeon in the Greater Tampa Bay for almost 30 years. He has operated on over 27,000 patients and provided care and treatment to countless more from across the country. He is a thought leader in American Surgery, and has been a pioneer in minimally invasive surgery and Surgery of the foregut including esophageal cancer, reflux, achalasia, portal hypertension, liver tumors and pancreatic cancer. For more information or to refer a patient, please contact us at 813-615-7030. 

PHOTO: PROVIDED BY FLORIDA HOSPITAL TAMPA

Dr. Ross and Dr. Rosemurgy undertake a laparoscopic anti-reflux operation.

More than 70 million Americans suffer from digestive disorders such as reflux, esophageal cancer, pancreatic cancer and many more. The Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive and Robotic Surgery at Florida Hospital Tampa treats a wide variety of digestive conditions that include: • GERD (Acid Reflux) • Paraesophageal Hernias • Achalasia • Esophageal Cancer • Stomach Cancers and Tumors • Small Bowel Disorders • Gallbladder Disorders • Hernias (Incisional and Inguinal) • Pancreatic Cancer • Cholangiocarcinoma • Bile Duct Disorders • Liver Tumors (Hepatocellular Carcinoma and Metastatic Tumors) • Portal Hypertension • Complex Abdominal Disorders The practice offers the most extensive experience in treating digestive disorders and pancreatic cancer in the Southeastern United States. We provide comprehensive care through a broad range of surgical techniques, including endo-lumnial, minimally invasive, robotic and open procedures. Pioneers and experts in LaparoEndoscopic Single Site (LESS) and robotic surgery, Dr. Ross and Dr. Rosemurgy can provide patients with the most minimally invasive surgical procedures available today, many of which are “scarless” operations. Through innovative applications of anesthesia, they are able to operate on patients without the use of general anesthesia. FLORIDA MD - MAY 2016

HEALTHCARE LAW

Health Care Legislation to Note From 2016 Session By Timothy M. Cerio This year’s Florida Legislative Session concluded on Friday, March 11, 2016. Lawmakers passed an $82.3 billion budget – a 5% increase over last year’s spending plan. $34.3 billion of this amount was allocated to health care. The Agency for Health Care Administration will receive $26.6 billion of this amount, with $25.7 billion earmarked for Medicaid services. The Legislature provided approximately $607 million in Low Income Pool funding, and appropriated $227 million for the Disproportionate Share Hospital Program for the poor and uninsured. The budget also invests $13.3 million for the Alzheimer’s Disease initiative which includes an increase of $1.6 million to provide respite services for approximately 133 individuals. Each Session, hundreds of health care bills are filed and few make it through for final approval by the Governor. The following is a summary of three of the more high-profile pieces of legislation that passed this year.

TRANSPARENCY IN HEALTH CARE (HB 1175) House Bill 1175 seeks to provide consumers with more information about health-care prices and quality. The bills were filed at the request of the Governor, who has been a vocal critic of the hospital industry for not providing enough transparency about prices and accusing some of “price gouging” patients. The bill creates pre-treatment transparency obligations on hospitals and ambulatory surgery centers licensed under Chapter 395, Florida Statutes, and health care practitioners licensed under Chapter 456, Florida Statutes, who provide non-emergency services. Facilities must post online the average payments and payment ranges received for bundles of health care services defined by the Agency for Health Care Administration (AHCA) and the information must be consumer friendly. Facilities must also provide to prospective patients information on the facility’s financial assistance policy, as well as the names, addresses, and telephone numbers of the health care practitioners with which it contracts. Patients may request a posttreatment itemized bill from a facility or practitioner, which must be provided within seven days. The personalized estimate must also inform the patient of the practitioner’s financial assistance policy, charity care policy, and collection procedures, but provides that the estimate does not preclude the actual charges from exceeding the estimate. Failure to timely provide the estimate shall result in a daily fine of $1,000, not to exceed $10,000 for facilities, and a daily fine of $500, not to exceed $5,000, for practitioners. AHCA is required to contract with a vendor to provide the internet-based platform through a competitive procurement process.

controlled substances to the extent authorized under their supervising physician’s protocol. The bill also subjects ARNPs and PAs to administrative disciplinary actions, such as fines or license suspensions, for violating standards of practice in law relating to prescribing and dispensing controlled substances. The bill prohibits ARNPs and PAs from prescribing controlled substances in pain management clinics. After years of opposing this legislation, the Florida Medical Association registered its support after amending the bill to allow prescribing authority only under a supervising physician’s protocol.

BALANCE BILLING (HB 221) One of the most heavily lobbied health care bills of the Session dealt with balance billing. House Bill 221 prohibits providers from balance billing patients with PPO and EPO health insurance plans in emergency rooms and scheduled inpatient procedures at an approved in-network hospital. Hospitals, ambulatory surgical centers, and urgent care centers are also prohibited from balance billing. The bill establishes standards for determining reimbursement based upon the current balance billing prohibition in the HMO statute, which is the lesser of the provider’s charges, the usual and customary provider charges for similar services in the community where the services are provided, or the charge mutually agreed to by the insurer and the provider within 60 days of claim submission. House Bill 221 authorizes providers and insurers to settle disputed claims under the statewide provider and health plan claim dispute resolution program. The legislation also requires insurers to publish a list of their network providers on their websites, and to update the list monthly. Hospitals must also publish information on their websites regarding their contracts with plans and providers of hospital-based services. The bill will take effect July 1, 2016. Timothy M. Cerio is an attorney in the Tallahassee office of GrayRobinson, P.A. Until recently, Tim served as General Counsel to Florida Governor Rick Scott, and he previously served as General Counsel to the Florida Department of Health. Tim focuses his practice on regulatory and health care law; administrative law, including

PRESCRIBING OF CONTROLLED SUBSTANCES (HB 423)

representation of clients in regulatory, administrative and

Florida was the only state that did not allow advanced registered nurse practitioners (ARNPs) to prescribe controlled substances, and was one of two states that did not allow physician assistants (PAs) to prescribe these medications. House Bill 423 now allows ARNPs and PAs to prescribe, dispense, order, and administer

and federal courts. He may be contacted by calling (850)

8 FLORIDA MD - MAY 2016

quasi-judicial proceedings; and complex litigation in state 577-9090; tim.cerio@gray-robinson.com or by visiting www.gray-robinson.com.

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HEALTHCARE BANKING, FINANCE AND WEALTH

Your Roadmap for Future Financial Success – Some Key Points for Financial Projections! By Jeff Holt, CMPE, VP, Senior Healthcare Business Banker with PNC Bank As medical practices moves deeper into healthcare reform the focus on financial stability becomes even more important. What tools can a practice utilize to plan for the future? Cash is the lifeblood of any business, and healthcare practices are no exception. Forecasting your cash inflows and outflows can help you foresee potential shortfalls and give you enough time to put a solution in place. Here’s how to create a cash-flow projection and use it effectively.

CASH VS. PROFITS First, it’s important to understand that if your practice uses the accrual accounting method, a cash-flow statement will look different from a profit-and-loss statement. The former records a transaction when money is exchanged (similar to a bank statement), while the latter registers when a sale is made and expense occurs.

PROJECT YOUR INFLOWS There are a number of ways to find data for projections. Depending on how far ahead your schedule is booked, you may be able to draw directly from your appointment calendar. To look farther into the future, however, consider drawing on the same period as the previous year, if your income fluctuates predictably, or you can use a monthly average, if it is relatively consistent. [1] You will also need to have an understanding of how much revenue you will see from each type of visit, what payment you expect immediately, how long various insurers take to pay and at what percentage of the amount billed you will be paid. If, for example, your insurers reimburse you in 30 days on average, you would use January’s billings to forecast February’s inflows.[2

PROJECT YOUR OUTFLOWS Many of your expenses, such as rent or mortgage payments, salaries and insurance, are fixed—they’re the same every month. Others, such as disposable supplies, depend on your patient volume. Again, you must consider when you actually pay bills, not when you incur them.[3]

MATCH THE SOLUTION TO THE ISSUE If you foresee potential shortfalls, you might consider financing. Generally speaking, it’s best to match the term of the financing to the term of the need.[4] A revolving line of credit can help you bridge short-term, unexpected or seasonal shortfalls. You can draw down as needed up to your credit limit, and pay off just the amount of debt used. Any principal you pay back is available for a future drawdown.[5] A term loan, by contrast, is a set amount with fixed monthly payments. Such a loan may make sense for large purchases, first to avoid a sharp cash outflow, and second, to align the length of the loan term to the life expectancy of the equipment itself.[6]

While hardly a crystal ball, cashflow forecasts can help you make decisions about the direction of your practice as well as make it more resilient to unforeseen downturns. Consult with your financial advisor and healthcare consultant for their valued input in order to have the most accurate financial plan in place. Remember… good financial projections combined with a good business plan are the best roadmaps to the financial success of a practice and its owners. Important Legal Disclosures and Information: (1) http://www.sba.gov/community/blogs/guest-blogs/industryword/how-project-your-basic-business-numbers (2) http://medicaleconomics.modernmedicine.com/medicaleconomics/news/how-physicians-can-improve-cash-flowaccounts-receivable-financing?page=full (3) http://www.inc.com/encyclopedia/fixed-and-variableexpenses.html (4) http://www.wbsonline.com/resources/filling-cash-flowshortages/ (5) ibid. (6) ibid. The third-party trademarks referenced in these articles are owned by and are the registered trademarks of their respective third-party owners. There is no affiliation, sponsorship or endorsement relationship between PNC or its affiliates and any such third party. PNC is a registered mark of The PNC Financial Services Group, Inc. (‘‘PNC’’)

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

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CANCER

The Gynecologic Cancer Center: Treating the Whole Woman By Veronica L. Schimp, DO As women, we’re often taught to shy away from discussions about our gynecological health, so when something is seriously wrong it can be difficult to talk about it. Gynecologic cancers affect thousands of women each year, and dealing with these diseases is often an intensely private experience for women. While many clinics and oncology centers do an excellent job of providing care, it’s critical to provide women with a safe place where they feel comfortable seeking treatment. That is why we created the Gynecologic Cancer Center in 2012. We treat various gynecological conditions and all forms of women’s cancer, including cervical, peritoneal, ovarian, uterine, and vulvar cancers. Our goal is to create a calming environment for patients who are going through one of the hardest times in their lives and treating the whole woman emotionally and physically so she feels supported throughout her cancer journey.

A HAVEN FOR FEMALE PATIENTS

Many patients tell us that the center doesn’t look like a typical hospital or doctor’s office. That is by design. We created everything in the Gynecologic Cancer Center with female patients in mind — from the names of the chemotherapy rooms (Rose, Begonia and Hibiscus, for example) to the pictures

and paint colors on the wall. The overall feel of the center is more like a spa, albeit one governed by hospital rules. Not only is the center’s look and feel different, but also our approach. We try to do more than just manage patients from a traditional clinical standpoint; we also incorporate Eastern medicine into our philosophy. Many patients are very anxious before surgery, so we have an Eastern medicine physician on staff, who helps them with stress management. We offer acupuncture and acupressure to reduce patients’ need for medication and to help with chemotherapy-induced nausea and vomiting. We also provide these services to patients’ spouses to help reduce their stress levels. It’s been encouraging to see how well these techniques work. For example, one patient had high anxiety as she got closer to surgery, but our physician did acupuncture and several visual techniques to calm her fears. The result was that the patient felt more comfortable with the entire process, did not have as many post-operative concerns and had better recovery. We have many discussions with patients about their intimate life. This is really important because when a woman is told she has a gynecologic cancer, she feels like her reproductive organs have betrayed her. It’s very hard to come to terms with this, especially because it affects a patient’s sexual life and their relationship with their spouse. It’s why we make it a point to talk about ways to make sex and intimacy more comfortable, given their diagnosis and treatment. We work as a team to support every patient and our 30-person staff also helps ORTHOPAEDIC SUBSPECIALTIES us deliver a very personal approach, with the goal that patients feel listened to, respected • SPINE and part of their treatment process. • ELBOW

HELPING YOUR PATIENTS

GET BACK TO WHAT THEY LOVE

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TREATING THE WHOLE WOMAN

We work with colleagues across disciplines to provide the best care and individualized treatment for each patient. We do a lot of prophylactic surgery at the center, as well as treat patients with a long history of endometriosis, pre-invasive diseases of the lower genital tract and people with genetic abnormalities such as BRCA or Lynch syndrome. All four of the physicians at the center are trained in laparoscopic procedures, vaginal procedures and robotic surgery, which allows us to add a different dimension to patient care and decrease a patient’s hospital stay to between six to eight hours, on average. This is very impactful for treating certain cancers. Treatment for uterine cancer, for example,

CANCER has included a large surgical incision on the abdomen, but now 80 percent of patients with this cancer will be treated with a minimally invasive approach and often can go home the same day or the day after surgery. They can also return to their normal life much more quickly. Another procedure we perform is the trachelectomy (removal of just the cervix, not the uterus) to treat cervical cancer, which allows us to give women who still want children the opportunity to do so in the future. Women with gynecologic cancers diagnosed during pregnancy also receive treatment at the center. We focus on treating both mother and child, even as a female patient undergoes chemotherapy. We work with a multi-specialty team of obstetrical experts to achieve the best outcomes. Our goal is to make sure the patient has successful treatment and delivers a healthy baby. Many of our patients have achieved this and have gone on to have subsequent healthy pregnancies. While our center has a unique approach, being part of a larger cancer center also helps us give patients the best care. We typically have access to two or three clinical trials for different types of cancer, which gives patients more options and access to drugs they wouldn’t otherwise get. As a community cancer center, we’re fortunate to offer this option to patients. Women wear a lot of hats — they’re mothers, grandmothers, sisters, providers and caretakers. But when a woman is diagnosed with a gynecologic cancer, the role she must focus on is that of survivor. At the Gynecologic Cancer Center, our ultimate goal is to help women not only survive cancer, but thrive after it. Giving them hope, encouragement and a supportive environment throughout therapy is a critical part of their treatment process. Our center has been successful in helping patients over the last four years because every person who works here is committed to the idea that any woman who walks through our doors could be Danna-Gracey Danna-Gracey Lead Lead Agent, Agent, Orlando Orlando Office Office their own mother, sister or best friend. An estimated 98,000 women were diagnosed Danna-Gracey is pleased to introduce Michelle Bilsky our newwith gynecologic cancers last year, according to est team member. Heading up our Orlando office, Michelle the Foundation for Women’s Cancer. I hope brings over 26 years in the insurance industry to Danna-Gracey. our center will continue to be a small part of reducing those numbers and increasing survivorMichelle holds a Bachelor of Science degree from the ship. I would love to walk down the halls of our University of Central Florida and an Executive Leadership office one day and see less cancer. Until then, Certificate from The Wharton School in Philadelphia, PA., as we’ll continue to help women in their fight.

Introducing Michelle Bilsky

Veronica L. Schimp, DO is expert in minimally invasive surgery, is chief of Gynecologic Oncology at UF Health Cancer Center – Orlando Health and chair of the Robotics/Minimally Invasive Surgical Quality Committee at Winnie Palmer Hospital for Women and Babies. She is board-certified in obstetrics and gynecology as well as gynecologic oncology. Dr. Schimp earned a bachelor’s degree in biology and chemistry from Lake Superior State University in Michigan and a doctorate in osteopathy from Michigan State University. She went on to complete residencies in general surgery at St. John/ Oakland General Hospital and in obstetrics and gynecology at Hutzel Hospital/ Wayne State University, both in Michigan, as well as a fellowship in gynecologic oncology at The University of Texas MD Anderson Cancer Center in Houston. Dr. Schimp may be contacted at 321.841.8393. 

well as certifications in behavior analysis, risk management, HIPAA and OSHA. Michelle is also a frequent and highly rated speaker on industry related topics and has been recognized and approved to provide CME credits for her lectures.

For a no-obligation assessment of your current malpractice coverage, or for more information on additional coverages designed to protect your practice, such as workers’ compensation, cyber liability, medical directorship, employment practices liability (EPLI), and investigatory coverage, contact Michelle today at 888.496.0059 or michelle@ dannagracey.com to see what she can do for you.

888.496.0059

michelle@dannagracey.com • dannagracey.com FLORIDA MD - MAY 2016 11

MARKETING YOUR PRACTICE

4 Ways You Can Get More Patients via the Internet This Week (No, Seriously!) By Jennifer Thompson Having an optimized online presence to attract patient referrals is of the utmost importance for today’s medical practices. According to a study conducted by Google and Compete, Inc., 84 percent of patients use both online and offline sources for medical practice and hospital research.

sites compared to non-search visitors, according to a study by Google and Compete, Inc.. Again, keywords play an important role with SEO. Be sure to use keywords in your titles, your content, URLs and image names. Be sure not to “stuff” your page with keywords, as using a lot of keywords on your page can get your site labeled as spam; and this will result in a negative SEO impact.

UNDERSTAND CONTENT IS KING Content marketing refers to creating quality content relating to your medical practice’s services and expertise. This can help with SEO, as it creates unique content to be shared on social media or in a newsletter and gives your patients content to associate with your practice. Rework content you have already created and use it for various mediums. One of the first steps to attracting the patients you want online is by creating an online patient acquisition strategy. Here are four strategic ways to draw in potential patients online.

USE PAY PER CLICK ADVERTISING Pay per click (PPC) advertising is a marketing tool that allows businesses and individuals to buy listings in their search results. When you search Google, Bing or Yahoo for something, the suggested sites that appear first are pay per click advertisements. Using PPC advertising can help generate site traffic, impressions of your name and potentially attract new patient referrals. When searching for health information, 81 percent of people click on a sponsored link, or PPC advertisement, according to Geonetric. The key to using PPC advertising is in the keywords. Choose keywords that you think people would use to find your facility. This includes services, location(s) and your name. The more specific you are the better. If your office has a niche service, it may be helpful to include it as a keyword. After you have chosen your keywords, test them in a keyword tool to see the estimation of how much traffic that keyword will generate.

STOP IGNORING SEARCH ENGINE OPTIMIZATION (SEO) SEO is a way of improving a website for ranking in the search engines to increase the number of visitors the site receives. Search drives about three times as many visitors to medical and hospital 12 FLORIDA MD - MAY 2016

Make sure the content you’re producing relates to your practice. The unique content you create doesn’t just have to be a blog post. It can be an infographic, a podcast or even a video. Remember that you don’t have to reinvent the wheel when it comes to content – meaning, a video you record of a physician speaking on a subject can also become a blog post, an infographic, a social media post, etc.

FINALLY START USING EMAIL MARKETING After building a patient database, keep in touch with them with an email newsletter. In the newsletter include news about your practice or content from your blog. Also, use email to remind your patients of upcoming appointments. One of the best services for e-newsletters in our opinion is MailChimp.com (and no, we weren’t paid to say that…it really is pretty good). 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. 

COMING NEXT MONTH: The cover story focuses on board-certified vascular and endovascular surgeon Adonis Lysandrou, MD of Vascular Associates of St. Cloud and St. Cloud Regional Medical Center. Editorial focus is on Allergies and Sleep Disorders.

Varicose Veins

By Adonis Lysandrou, MD

Spider Veins. Varicose Veins. Whatever you call them and training in both medical and surgical regardless of their location on your body, they are considered treatments options. He attended the a cosmetic nuisance for those who have them. However, it is Medical School at Indiana University, important to realize varicose veins can be the source of more completed surgical residency at St. serious complications. Francis Medical - University of Veins are blood vessels that return deoxygenated blood from the Illinois and completed a Vascular outer parts of the body back to the heart and lungs. Recognizing Surgery fellowship at the University when these veins become abnormal may help aid your awareness of Iowa. Dr. Lysandrou has more than 16 years of vascular of possible chronic venous disease. Spider veins are usually red or and endovascular surgical and cosmetic vein care experience. purple dilated venules about one millimeter in diameter, while He is currently a member of the Medical Staff at St. Cloud varicose veins are larger, raised, elongated veins that are usually Regional Medical Center  over three millimeters in diameter. Pain and swelling are the most commonly reported symptoms of varicose veins. The pain cited can include aching, heaviness, fatigue or burning. Swelling of the legs or ankles and even numbness in the legs are also possible symptoms of varicose veins. Varicose veins do occur more often in women than in men and are caused by a number of possibility. Family history is always a large indicator of your potential health risks, but also increasing age, obesity and standing or sitting for long periods of times can lead to vein abnormalities. If left untreated, varicose veins can cause chronic venous disease and venous insufficiency. Chronic venous disease occurs when the venous wall or valves in the leg veins are not working properly, making it difficult for blood to return to the heart. It causes blood to pool and clot in the veins and hinders proper blood flow. Chronic venous disease can lead to further complications and problems such as ulcerations, which are wounds that do not heal, bleeding and blood clots. If diagnosed with varicose veins, the treatment options vary based on each patient’s symptoms and conditions. Likely treatments can include compression stockings, sclerotherapy, venous ablation, vein ligation and/or phlebectomy. It is recommended to see a vascular specialist if you have any of the To learn more, call 407 587-8600. signs or symptoms of varicose veins. A vein screening will be conducted and treatments A Higher Level of Care® options discussed. Vascular Associates of St. Cloud is currently running a pricing special for a vein screening and 30-minute sclerotherapy treatment option. If signs or symptoms of varicose veins go ignored or untreated, you are 831 South State Road 434 • Altamonte Springs, FL 32714 leaving your health at risk and your body in danger of further complications. healthsouthaltamontesprings.com Adonis Lysandrou, M.D., is board-certified ©2015 HealthSouth Corporation 1110525 in vascular and endovascular surgery with

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FLORIDA MD - MAY 2016 13

ORTHOPAEDIC UPDATE

Meet Orlando’s Newest Sports Medicine Specialist By Corey Gehrold

WHAT DOES IT TAKE TO BE A GREAT SURGEON? “That’s the hardest question I’ve had to answer all day,” jokes Aaron M. Burgess, M.D., Orlando Orthopaedic Center’s newest surgeon. When asked about anatomy of the shoulder, elbow, hip and knee - his specialty areas - Dr. Burgess delivers lightning quick, accurate responses. But here, he pauses. “I think being a great surgeon involves so many things. To be ‘good’ you have to be knowledgeable, confident, precise; but, to be great, you have to have empathy. You have to put yourself in the shoes of your patients to understand their issues and what recovery means for them as an individual. When you combine that with the skill and compassion to take them to where they need to be, that’s what makes you great, ” he says with a smile. “You have to always want to learn, always want to get better and always want to connect with the person who is trusting you to ‘fix’ them.”

“I am very honored to join the Orlando Orthopaedic Center family,” he says. “As I pursued my interest in sports medicine and joint replaceAaron M. Burgess, MD ment surgery, I always wanted to join a comprehensive, family-centered practice like Orlando Orthopaedic Center. I look forward to becoming a staple in the community, the office and beyond.” Fellowship trained in sports medicine and specializing in knee, elbow and shoulder surgery, Dr. Burgess is now accepting new patients out of the practice’s SoDo (downtown), Sand Lake and Lake Nona locations. Born and raised in Charleston, WV, Dr. Burgess attended Ohio University where he earned his Bachelor of Science Degree in Biology with a special focus in Exercise Physiology. He went on to graduate from West Virginia University School of Medicine, where he was president of his medical school class. He completed his Orthopaedic Surgery Residency at Orlando Health and decided to pursue additional fellowship training in Sports Medicine at Allegheny General Hospital in Pittsburgh, PA. During his fellowship, Dr. Burgess was an assistant team physician for Major League Baseball’s Pittsburgh Pirates, the United Soccer League’s Pittsburgh Riverhounds, Robert Morris University’s basketball and hockey teams, as well as several local high school football teams. Additionally, Dr. Burgess was a team physician for the United States Men’s rugby team, providing care for the athletes during their 2015 South American Tour. Dr. Burgess is a member of the American Academy of Orthopaedic Surgeons, The Arthroscopy Association of North America, and the American Orthopaedic Society for Sports Medicine. For more than 40 years, the team of physicians and support staff at Orlando Orthopaedic Center have been getting Central Floridians back to work, back to play and back to making a difference in the community. Since 1972, Orlando Orthopaedic Center has grown to include 21 physicians across multiple orthopaedic subspecialties, many of whom are recognized leaders amongst their peers nationwide. Orlando Orthopaedic Center has six locations throughout Central Florida plus a state-of the-art outpatient surgery center at the heart of its downtown campus located in the SoDo Shopping District. 

Dr. Burgress performing an ACL replacement surgery at the Orlando Orthopaedic Center Outpatient Surgery Center.

In that moment, it becomes abundantly clear why Dr. Burgess recently became the 21st physician at Orlando Orthopaedic Center: he shares the same desire to help patients and continue learning as the rest of the staff. 14 FLORIDA MD - MAY 2016

Type 1 Diabetes: Then and Now By Jeremiah Nelson, MD While we at the Florida Center for Pediatric Endocrinology, Diabetes & Metabolism celebrate every advancement in the research and technology used to treat Type 1 Diabetes Mellitus, it’s good to take a look back to see how far we’ve come in the treatment of this condition that is, while still not curable, far more manageable than ever before.

STARVATION IN THE MIDST OF PLENTY

dedicated professionals to mention here, but one such leader was George Eisenbarth who, among others such as Emil Unanue, Jeffrey Bluestone, Diane Mathis, Mark Atkinson and many more, have intricately studied many of the immunologic aspects of T1DM. Neil White, Janet Silverstein, John Malone, Irl Hirsch, Stephen Ponder and Richard Guthrie are among the many physicians who have dedicated

Before 1922, Type 1 Diabetes Mellitus (T1DM) was a terminal illness. In those days, children diagnosed with this condition -- also previously called Juvenile Diabetes, now more commonly referred to as Type 1 Autoimmune Diabetes Mellitus or Type 1 Diabetes -- were not able to replace insulin. Another phrase used to describe this same condition was: “starvation Serving Central Florida Since 1982 in the midst of plenty.” Children would eat and drink, consuming large amounts, but Our physicians are Board Certified in Internal Medicine, were not able to keep and store fuel approPulmonary Disease, Critical Care Medicine, and Sleep Medicine priately, typically becoming very thin and frail prior to losing their individual battles Specializing in: with ketoacidosis. • Asthma/COPD

Central Florida Pulmonary Group, P.A.

While still crude by today’s standards, technology advanced far enough so that a glucose level could be measured within a shorter period of time allowing more successful interventions. Early Type 1 researchers set the table regarding some fundamental questions.

GIANTS IN THE FIELD In Toronto, it was Frederick Banting an orthopedic surgeon, and Charles Best, a medical student who, while utilizing the lab of John MacLeod and the biochemistry expertise of James Collip, were able to support their hypothesis regarding insulin. This led to administering insulin to patients, saving their lives and the lives of many people to come. The physicians of St. Louis are of particular note as early adopters of this intervention. The results across North America were remarkable. The use of insulin to treat T1DM came to be considered one of the most significant advances in the history of medicine. Dr. Richard Guthrie advocated for optimizing glycemic control and also administered the first dose of recombinant insulin to a human being in 1980, another huge step into the future. Additional advances in understanding T1DM have included too many

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FLORIDA MD - MAY 2016 15

an overflow of their clinical experience and wisdom to other healthcare professionals attempting to understand this disease. I am fortunate to have had the opportunity to study the work of, meet or work with some of these giants in the field, among many others.

T1DM TODAY The precision of control regarding insulin kinetics continues to improve. Medications sometimes called “designer insulins” were made available during the 1990s. Additional technological advances have included insulin pumps, some of the earliest models of which were originally designed for use during pregnancy, but soon gained popular use with additional refinements over time. Sensors have helped to connect the dots between glucose meter checks. And, with better and more frequent use of dilated eye exams and additional interventions when necessary, there has been a substantial reduction in blindness for those diagnosed with T1DM. The fifth person to ever receive insulin replacement was a small child. He lived into his 80s. Today, there are many people with T1DM who not only survive with T1DM, but thrive. Mary Tyler Moore is an example among many in the entertainment industry. There have also been many Olympic and professional athletes who have lived and competed with diabetes. Miss America 1999 Nicole Johnson set an impressive example, winning while wearing an insulin pump. I, myself, was diagnosed in 1986. Diabetes camps such as the Clara Barton Camp in Massachusetts, the Central Ohio Diabetes Association’s Camp Hamwi in the Columbus area, and nearby Camp Winona in Florida are examples of the many camps that have provided additional education as well as camaraderie for many generations of individuals living with T1DM.

LIVING WELL WITH T1DM Those of us with Type 1 Diabetes are very grateful to be able to replace insulin. T1DM, however, remains a perpetually lifethreatening condition. Without timely and effective insulin replacement we would be subjected to the same fates as those diagnosed prior to 1922. There remains substantial risk for shortterm and long-term complications that must be reduced through individual efforts on a daily basis. It is plausible that Type 1 Diabetes could be prevented in our lifetimes. Those that are most passionate about this goal must stay focused on this multi-dimensional autoimmune puzzle while still keeping an open mind and thoughtful ear to new ideas shared by the next generations. Continued substantial advances in T1DM could also offer practical solutions to other autoimmune conditions. At our own Florida Center for Pediatric Endocrinology, Diabetes & Metabolism in Orlando and Celebration, we prioritize empowering patients and families with a focus on preservation and protection, while working toward prevention of both short-term and long-term complications of T1DM and other forms of Diabetes Mellitus. Although this is the best time in history to have T1DM, we still look forward to putting it in the history books for good. Until then we will continue to tailor our approaches to 16 FLORIDA MD - MAY 2016

each individual child and family afflicted with T1DM, helping them in as many ways as possible.

ABOUT DR. NELSON Jeremiah Nelson, MD, is nationally recognized as an expert in Pediatric Diabetes. Dr. Nelson chose to become a diabetologist after he was diagnosed with Type 1 autoimmune diabetes mellitus in 1986. He began medical school at age 18 after being selected for the accelerated Bachelor of Biology and Doctor of Medicine six year dual degree program at the University of Missouri-Kansas City. Following graduation from medical school, Dr. Nelson completed six additional years of specialty and subspecialty training including board certification in pediatric medicine, and three years of pediatrics-focused residency in Orlando. He then completed a three-year diabetes-focused fellowship at Washington University in St. Louis. Dr. Nelson has extensive experience treating Diabetes Mellitus in all its forms, working with patients of all ages.

ABOUT FLORIDA CENTER FOR PEDIATRIC ENDOCRINOLOGY, DIABETES & METABOLISM The Florida Center for Pediatric Endocrinology, Diabetes and Metabolism is an integral part of Florida Hospital for Children. The team provides expert care to young patients from around the state and across the country. To learn more or to make an appointment, call 407.896.2901 or visit FloridaPediatricEndocrinology.com. 

INPATIENT REHABILITATION

May Is National Stroke Awareness Month Stroke Rehabilitation Recovery Considerations By Saloni Agarwal & Jennifer Campbell According to the Centers for Disease Control and Prevention (CDC), approximately 795,000 people suffer a stroke annually within the United States. Stroke is the leading cause of serious long-term impairment. Yee Sien, et. al (2007), found that patients post stroke made significant functional gains after intensive rehabilitation such as in an inpatient rehabilitation facility (IRF) like HealthSouth Rehabilitation Hospital of Altamonte Springs. Early intervention and intensive rehabilitation are vital with evidence indicating that maximum recovery is expected within the first three months after onset.

RECOVERY: TIMING, INTENSITY AND TECHNOLOGY Stroke rehabilitation is a coordinated use of medical, therapeutic, social, educational and vocational approaches to facilitate maximum recovery from stroke. Evidence supports that early initiation of therapy services favorably influences stroke recovery. When therapy is delayed, patients can develop avoidable secondary complications, such as contractures and de-conditioning. In addition, many studies show that intensive stroke rehabilitation can improve functional ability even in patients who are elderly, medically ill, or have severe neurologic, functional deficits. Rehabilitation services enable patient neurologic functioning recovery and improve activities of daily living (ADL). The ability to perform ADLs can improve through adaptation and training in the presence or absence of natural neurologic recovery, the element of recovery where rehabilitation exerts the greatest impact. It is important to note that although a person’s greatest stroke recovery takes place in the first three months, and only minor additional measurable improvement occurs after six months following onset, recovery may continue over a longer period of time in patients who have partial return of voluntary movement. Rehabilitation services within an IRF such as HealthSouth, which are initiated within the first 24 hours of admission, are comprehensive, intensive, and use foundational technology to maximize functional outcomes. Each plan of care is tailored individually to each patient and guided by physiatrists*. Patients receive at least three hours of therapy five days a week. HealthSouth Altamonte Springs’ state-of-the-art rehabilitation gym includes fundamental technologies such as the Biodex®, RT-200, Dynavision™ and FreeStep. Criteria for a patient’s admission to a comprehensive rehabilitation program may include the following: • Stable neurologic status • Significant persisting neurologic deficit • Identified disability or functional decline affecting at least two of five ADL functions such as mobility, self-care activities, communication, bowel or bladder control, and swallowing

• Physical ability to tolerate intensive program

WHY CHOOSE HEALTHSOUTH ALTAMONTE SPRINGS FOR YOUR FAMILY MEMBER, FRIEND OR PATIENT WHO SUFFERED FROM STROKE? At HealthSouth our multidisciplinary therapeutic approach involving physiatry, physical, occupational, speech therapy and nursing amongst other disciplines focuses on patient-centered goals and family needs. Dr. Dana Clark, rehabilitation physiatrist, indicates that rehabilitation at HealthSouth Altamonte Springs includes, “Access to advanced technology and skilled therapists in the rehabilitation setting that allow my patients to achieve maximum functional recovery post stroke. It also allows for alternative methods of treatment for post stroke complications such as tone and pain.” *The hospital provides access to independent physicians.

Saloni Agarwal is a physical therapist at HealthSouth Rehabilitation Hospital. She earned her Bachelor’s of Physical Therapy from Srinivas College of Physiotherapy, India and MHA from National University in California. Saloni completed internships at acute in patient hospital settings such as USCD and Scripps Memorial to learn about rehabilitation in the US before serving as a Lead PT at Bishops Glen, in Ormond Beach, Florida in 2011. In addition to providing physical therapy, Saloni underwent training to become a certified Vestibular Rehabilitation therapist. She is currently serving on the committee working towards Joint Commission disease specific certification for Stroke. She can be contacted at Saloni.Agarwal@healthsouth.com. Jennifer Campbell is the Senior Speech Language Pathologist at HealthSouth Altamonte Springs. She received her Master’s Degree from Florida State University in 2006 and has been practicing for the past ten years with a focus in Adult Neurological Disorders and Stroke. She has worked in Acute Care and Inpatient rehabilitation settings and has helped lead rehabilitation programs in Stroke Program Development. She has achieved a Neuro Clinical Specialist designation and her passions are cognitive communication disorders and functional implications, staff development and education, teaching and mentoring and Neuro Program development. She can be contacted at Jennifer.Campbell@HealthSouth.com. 

FLORIDA MD - MAY 2016 17

BEHAVIORAL HEALTH

Treating the Spirit By Sajid Hafeez, MD A safe assumption is that when a patient is involuntarily admitted to an acute crisis unit, he or she is probably not having a good day. Even those who are admitted there on a voluntary status are doing so because they see treatment as a last result. They are hopeless. They are helpless. Maybe their meds have stopped working. Maybe they have lost someone. Maybe they have been arrested. Maybe depression just slowly snuck up on them. While medication can treat the chemistry, and therapy can teach coping skills, a large part of recovery is treating the spirit. As any doctor will tell you, a vital part in the patient recovery is the restoration of hope. When a patient can see that there is the potential to return to a state of mental wellness, that patient begins to take an active investment in his or her treatment, which is a great indicator of success. The question is, how exactly does one conjure optimism where none exists? It starts by first validating the patient. Stigma against mental health runs deep through society, and often times those who struggle with issues compare themselves to people they feel are successful and without problems. The patient must be treated with the dignity and respect due any person, regardless of his or her behavior or condition. In showing common courtesy, understanding, and empathy, it helps the patient to feel like less of a failure or outcast. A trained staff of nurses, therapists, and techs understand that most people in crisis will act as they do out of fear, the avoidance of pain, or to gain a sense of control over a new and potentially frightening environment. With this understanding it is easier to accept without judging so that together the staff and patient can focus on what can be instead of what is. A major part of hopelessness is the unknown. The patient is often completely unaware of how to begin the path to wellness. As such, a second facet of restoring hope is education. In conversation with the doctor, a patient is educated on the causes of his or her affliction, and what medicines can be used to treat it. Each potential plan of treatment or medication acts as an arrow to fill the patient’s quiver. Now unfortunately, some of these may miss the mark. Yet as long as that quiver remains full of different medications, ideas, and approaches, there always exists a chance to hit the bull’s-eye. In this the combined knowledge and optimism of the doctor translate to an optimism for the patient. Hope is amazing in that it can be borrowed by one in need from someone who has excess. This is also emboldened by a trust in the confidence of the doctor’s ability, trustworthiness, and knowledge. As such even if a doctor has doubts, it is vital to focus on the best potential in order to lend out that optimism.

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BEHAVIORAL HEALTH Next, it falls upon the techs and the therapists to buff the patient’s self esteem. Through guided existential evaluation, any patient can be walked through a path to discover what it is that he or she likes best about his or her self. In doing so, the staff is effectively breathing life back into a fading ember before it goes out. When that patient begins to recognize that there are aspects of life that they do enjoy, it is possible to fan those embers to glow a little brighter and a little hotter. While the process may not happen all at once, over time, this ember can be rekindled into a small flame of purpose. When a patient is able to regain a sense of purpose, it represents a turning point wherein a patient is able to cross that bridge of hopelessness into hopefulness. The solution to this problem is making the patient feel he or she is the star of his or her own story of recovery, and not just a supporting role. It is then that the patient can draw the connections between what it is that defines hope, and make a promise to his or her self that he or she does have value and that they have a sense of control in the outcome. Those patients who develop this understanding are those who are most likely to succeed. However, a hospital is a temporary escape from the real world where stressors, and problems often are temporarily placed on hold. It then falls upon the duty of the facility to provide a plan of action at discharge as opposed to releasing the patient with nowhere to go. Patients are then recommended to the next level of care. For some it may be a day program. For others it may simply be a follow-up therapy with med management. What is known is that success rates are shown to be higher when the follow up is carried out as soon as possible. With a plan in hand, a patient has less to fear of the unknown. As of yet, medical science has made no discoveries of how to put hope and optimism into a pill. Until that time, medical professionals will continue to use the kindness, empathy, and compassion to achieve the same results. Ultimately, when all is said and done these are the best medications that we as health professionals have to offer. 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 PsychiaOften times the stress of everyday life can be overwhelming. A particutry Emergency Program and of the larly traumatic event can change your life in an instant. We are here. Mobile Crisis Team at the Westchester Let us help you navigate through life’s sometimes unpredictable turns. Medical College. At Vassar Brother’s UBC is a 112 bed psychiatric inpatient and substance abuse/detox hosMedical Center in New York. Dr. pital. UBC offers children, adolescents, and adult programs and accepts Hafeez was the Director of Outpamost insurances including Medicare and Tricare. We offer specialized tient Child & Adolescent and Adult treatment based on the individual and treat the following common diPsychiatric Clinic as well as Director agnoses as well as others: of Consultation and Liaison Psychia Anxiety/Phobias  Trauma Related Issues try. Dr. Hafeez received his adult Psy Depression  Substance Abuse Treatment chiatry and Residency Training at the (Adult)  Bi-polar Disorder University of Kansas Medical Center  Detox services (Adult)  Co-occurring Disorders in Kansas City. He received his Child  Intensive Outpatient- Substance  Phobias and Adolescent Psychiatry fellowship Abuse (Adults)  Grief training at the New York Medical  Intensive Outpatient and Partial  Adjustment Disorders College New York and at Children’s Hospitalization- Mental Health  Anger Management National Medical Center of George (Adults)  ADHD Washington University in Washington, DC. Dr. Hafeez can be reached TO SCHEDULE A FREE AND CONFIDENTIAL ASSESSMENT at 407-281-7000 or by visiting www. CALL 407-281-7000 or FAX REFERRAL TO 407-282-5410 universitybehavioral.com.  2500 Discovery Drive Orlando, FL PLEASE PLACE STAMP HERE

FLORIDA MD - MAY 2016 19

PULMONARY AND SLEEP DISORDERS

Orexin Antagonist Therapy:

A New Option for the Pharmacologic Treatment of Insomnia By Daniel T. Layish, MD and Kathleen Summo RN, MSN Insomnia can be divided into two categories: difficulty initiating sleep and/or difficulty maintaining sleep. Approximately 30 percent of the adult population is affected by insomnia at some point, thus creating a major risk factor for anxiety, depression and/or substance abuse. Current pharmacologic therapy options for insomnia include benzodiazepines and non-benzodiazepine gamma-amino butyric acid (GABA) acting hypnotics such as zolpidem and eszopiclone. Other options include antihistamines, sedating antidepressants and melatonin agonists. Orexin, a neurotransmitter (also known as hypocretin) was discovered in 1998. There are approximately 15,000 orexin neurons in the brain, primarily located in the perifornical lateral hypothalamus. Hypocretin deficiency is associated with decreased levels of epinephrine and histamine, important chemicals in promoting arousal, alertness and wakefulness. Ninety percent of patients with narcolepsy have been found to have decreased levels of orexin in their cerebrospinal fluid. Cataplexy, (the most common form of narcolepsy) causes sudden, transient episodes of muscle weakness triggered by emotions (such as crying or laughing). Seventy percent of narcoleptics have cataplexy, which is caused by the autoimmune destruction of orexin. The FDA recently approved suvorexant, a duel orexin receptor antagonist, as the first in a new class of pharmacologic agents for the treatment of insomnia. This new medication blocks both 0X1R and OX2R, has been shown to improve both sleep onset as well as sleep maintenance. One major advantage of suvorexant is its low potential for addiction or rebound. In gaining FDA approval, three Phase III studies were conducted. Two of these studies lasted three months and the largest evaluated more than 1200 elderly and non-elderly subjects for safety and efficacy. Plasma concentrations were unchanged in patients with moderate hepatic or renal dysfunction. However, suvorexant should be avoided in individuals with severe hepatic impairment. At doses of 15-20 mg, Suvorexant reduced latency to persistent sleep by about 10 minutes as compared to placebo. By the third month of therapy this was down to 5 minutes. Wakefulness after sleep onset (WASO) was about 35 minutes less than placebo (verified by polysomnography) at the 15-20 mg dose. This effect also lessens over time to a 23 minute improvement in WASO (versus placebo) by month three. Suvorexant may cause daytime sleepiness as well as some daytime confusion. The daytime sleepiness is dose dependent. There is also a potential for next day driving impairment at the higher doses. Suvorexant should be used cautiously in the setting of other moderate CYP3A medications and is contraindicated with severe CYP3A inhibitors. It is recommended that this medication be taken within 30 minutes of going to bed and by those ready to stay in bed for at least seven hours. Many of the studies that led to the FDA approval of suvorex20 FLORIDA MD - MAY 2016

ant looked at higher doses than were eventually approved. This fact should be kept in mind when interpreting Daniel T. Layish, MD these clinical studies. Suvorexant is now available under the brand name BelsomraÂŽ in 5, 10, 15, and 20 mg tablets. Suvorexant is a controlled substance (Schedule lV) and is contraindicated in narcolepsy. In addition to pharmacologic therapy for insomnia, it is important to remind patients about cognitive behavioral therapy, sleep hygiene, and other non-pharmaceutical treatments of insomnia (such Kathleen Summo RN, as avoidance of caffeine, nicotine, MSN alcohol, etc.). Perhaps in the future, there will be an orexin agonist available to treat excessive daytime sleepiness, as this is currently an active area of clinical research.

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. Dr. Layish may be contacted at 407-841-1100 or by visiting www.cfpulmonary.com. Kathleen Summo RN, MSN, CCP is the Clinical Director of Research and Cystic Fibrosis at the Central Florida Pulmonary Group, PA. She has a Masters degree in Nursing with a minor in Clinical Research and fifteen years of experience conducting clinical trials. î Ž

Take the Medical Office Resources Of Florida Challenge! By Jeffrey Holt MOROF Education Chairman and Dan O’Connell MOROF Ambassador Chairman With all of the challenges that the Healthcare industry faces: Marketing, Compliance, Revenue Generation, Billing/Coding, Insurance/Medicare Changes, etc., MOROF understands the need for better supporting the education of our healthcare practitioners and fellow healthcare business professionals. Take the MOROF challenge! Give us your 3 top burning pain points in the healthcare industry and challenge our ability to properly address the major areas of concern, and offer helpful guidance to you and your counterparts over the next several issues of Florida MD Magazine. Our expansive resources enable us to reach out to key industry specialists, and get the answers that you and many others need in a timely manner. The following video presentations are available through our website www.mor-of.net and are some historical examples where healthcare practitioners have requested additional education support from MOROF on timely industry topics: • 5/26/2016 : Florida Legislative Healthcare Update

• Medical Practice Revenue Generation & Stabilization

• Physician Relationships: From a Business & Medical Perspective

• Telehealth: Opportunities/Obstacles

• MACRA Payments : APM vs MIPS - What it means for Your Medical Practice

• Getting Your Practice’s Credit Ready for the Storm

• Networks : The Future of Healthcare Delivery • First Aid for Your Online Reputation • The Growing Popularity of Integrative Medicine • The Surprising Truth About Physician Burnout & Why We Should Care • Medical Community Building : Bringing Florida Medical Organizations & Societies Together

• Medical Coding and Billing Review • Healthcare Insurance, Medicaid & ACA Updates • New Year, New Changes: Getting Your Practice Ready • HR: Understanding Recruiting, Training & Compliance • Medicare, Medicaid Audits: Ready or Not, Here They Come • Are You Ready for ICD10? • PCMH: Redesigning Primary Care

• Why Medical Data is so Valuable to Criminals & Why We Must All Be Compliant

• Lean Six Sigma & Healthcare

• Diabetes is on the Rise: But, What’s Race Got to do with it?

• HIPAA Omnibus Video Presentation

• Transformation of Healthcare to Home Care and Everywhere

• Healthcare Marketing in a Changing Environment

• Achieving Better Patient Satisfaction: An Emerging Issue

• Solutions Using Nurse Practitioners

• Top Healthcare Privacy & Security Developments to Watch

• What are ACOs?

• Preparing Your Medical Practice for the Triple AIM

• Solo & Small Practice Compliance Issues

• GPOs : a “Costco” for Medical Offices

• How Embezzlement Looks for Medical Practices

• The State of Healthcare Reform

At Medical Office Resources of Florida, we’re here to serve you, as being your reliable Resource for important healthcare industry information and insights. What are your 3 challenging questions you feel need to be addressed by the healthcare industry? Please email us your three questions to info@mor-of.net For MOROF meetings, times and locations please visit our events page on www.mor-of.net - Healthcare professionals are always welcome as guests. Also check out archived presentations, a member directory and more resources on this same website and on our YouTube Channel.  FLORIDA MD - MAY 2016 21

INSURANCE

How to Protect Your Data and Avoid Being Hacked by Michelle Bilsky The government hack of an iPhone used by the San Bernardino killer serves as a reminder that phones and other electronic devices aren’t impenetrable vaults. While most people aren’t targets of the NSA, FBI or foreign governments, hackers are looking to steal the financial and personal information of ordinary people. Your phone stores more

than just selfies. Your email account on your phone, for example, is a gateway to resetting banking and other sensitive passwords. Like washing your hands and brushing your teeth, a little “cyber hygiene” can go a long way toward preventing disaster.

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22 FLORIDA MD - MAY 2016

LOCK YOUR PHONE WITH A PASSCODE Failing to do so is like leaving your front door unlocked. A four-digit passcode – and an accompanying self-destruct feature that might wipe a phone’s data after too many wrong guesses – stumped the FBI for weeks and forced them to bring in outside help. Using six digits makes a passcode 100 times harder to guess. And if you want to make it even harder, you can add letters and other characters to further increase the number of possible combinations. These are options on both iPhones and Android. The iPhone’s self-destruct feature is something you must turn on in the settings, under Touch ID & Passcode. Do so, and the phone wipes itself clean after 10 failed attempts. But the 10 attempts apply to your guesses, too, if you forget your passcode, or if your kids start randomly punching in numbers. Android has a similar feature. Both systems will also introduce waiting periods after several wrong guesses to make it tough to try all combos. Biometrics, such as fingerprint scanners, can act as shortcut and make complex passcodes less of a pain.

USE ENCRYPTION Much to the FBI’s displeasure, iPhones running at least on iOS8 offer full-disk encryption by default. That means that the information stored on the phone can’t be extracted – by authorities or by hackers – and read on another computer. If the phone isn’t unlocked first, any information obtained would be scrambled and unreadable.

INSURANCE With Android, however, you typically have to turn that on in the settings. Google’s policy requires many phones with the latest version of Android, including its own Nexus phones, to offer encryption by default. But, according to Google, only 2.3 percent of active Android devices are currently running that version.

SET UP DEVICE FINDERS Find My iPhone isn’t just for finding your phone in the couch cushions. If your device disappears, you can put it in Lost Mode. That locks your screen with a passcode, if it isn’t already, and lets you display custom messages with a phone number to help you get it back. The app comes with iPhones, but you need to set it up before you lose your phone. Look for the Find iPhone app in the Extras folder. Meanwhile, Activation Lock makes it harder for thieves to sell your device. The phone becomes unusable – it can’t be reactivated – without knowing its Apple ID. The feature kicks in automatically on phones running at least iOS 7. If all else fails, you can remotely wipe the phone’s data. While your information will be lost, at least it won’t end up in the hands of a nefarious person. There isn’t anything comparable built into Android phones, but Google’s Android Device Manager app, along with a handful of others made by third parties, can be downloaded for free from the Google Play app store. Michelle Bilsky is a medical malpractice insurance specialist with Danna-Gracey. She can be reached at or (888) 496-0059 or Michelle@dannagracey.com.. 

COMING NEXT MONTH: The cover story focuses on board-certified

vascular and endovascular surgeon Adonis Lysandrou, MD of Vascular Associates of St. Cloud and St. Cloud Regional Medical Center. Editorial focus is on Allergies and Sleep Disorders. O F F I C I A L LY L I C E N S E D ®

2016 ANNUAL MEETING Hyatt Regency Grand Cypress Hotel

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JUNE 18-19, 2016 - ORLANDO, FLORIDA

Florida Hospital Cancer Institute’s Best of ASCO® Meeting

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The Florida Hospital Cancer Institute is proud to bring the highlights of the ASCO Annual Meeting to Orlando, Florida through its licensed Best of ASCO® meeting, to be held at the Hyatt Regency Grand Cypress, Orlando, Florida.

Florida Hospital is accredited by the Florida Medical Association to provide continuing medical education for physicians. Florida Hospital designates this live activity for a maximum of 8 AMA PRA Category 1 Credit(s)™. Each physician should claim only those hours of credit commensurate with the extent of their participation in the activity. Florida Hospital is committed to making its activities accessible to all individuals. If you have a disability, please submit a description of your needs, along with your registration, to assure that you will be able to participate in the activity. ASCO is not the CME provider for this activity.

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Each year, the ASCO scientific committee selects the highest-rated abstracts from the Annual Meeting to be available for licensed Best of ASCO meetings around the world. Florida Hospital Cancer Institute will choose specific, highest-rated abstracts for presentation. Sponsored by:

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FLORIDA MD - MAY 2016 23

The Money in Medicine - Hypocrite or Hippocratic? By Anita White, MBA

The degree to which a Physician can enrich the community by contributing to the long-term health of patients is predicated on a financially healthy business. Financial profitability in healthcare is often seen as hypocritical not “hippocratical”. How do you put cancer and profits in the same sentence? Forget for a moment the seemingly vast difference in disciplines, human sentiment compels us to reject the notion of profitability as it relates to medicine. The basic human right to health care, the moral obligation to administer care saturate our souls to overflow. Because we love to love each other, the following must be said: Physicians, you are passionate, compassionate individuals who are skilled in enhancing the quality of life for those we love but you are not volunteers. You are well-educated members of our communities, you have a noble aspiration to help others. This doesn’t make you missionaries. It makes you an integral part of assisting families and communities in maintaining an acceptable quality of life. Without you and the supportive ecosystem that encompasses you, our daily experiences would be filled with significantly more tragedies. When your practices thrive our lives are more fully enriched. The practice of medicine doesn’t always feel like a business. It can feel more like a battle between your heart and your head. Think about these scenarios. Doctors, you provide a service, in some cases, whether or not the patient can pay. Few, if any, service firms operate this way. If they did, they wouldn’t be in business very long. You are the expert at your specific craft but you don’t always get to make the decisions on what is the best care for your patients. Most of the revenue in medicine is paid from a third party, so the pricing model is imposed on you versus strategically planned by a group of selected business leaders. Clearly, there are specific dynamics that surround medicine that are substantially different from other service firms. However, the practice of quality medicine and running a profitable business are not mutually exclusive. Healthcare providers, you run a business and like a going concern, there are revenue and expense management duties. You employ healthcare professionals that require payroll and benefits that must be processed. There are intake and exit protocols for members of your staff. There are suppliers to pay and receivables waiting to be satisfied. If debt was secured to purchase equipment, then loans need to be serviced. Just as traditional businesses need to keep up with technological advances, medical practices are also required to keep up specific technological advances that meet regulatory requirements and legal standards, such as HIPAA. Private medical practices and other service firms have distinct differences but as pointed out here, there are striking similarities. This awareness has motivated prestigious institutions of higher learning to offer programs where the role of Doctor and CEO/President intersect. Indiana University, Kelley School of Business offers MD/ MBA credentials – The Business of Medicine MBA program. Harvard Business School and Stanford University also offers a MD/MBA program. The additional credentials after “MD” may feel a little awkward, even counterintuitive but let me reassure you that you are running a business. No one is suggesting that you suspend practice to get an MBA. It may be prudent, however, to get an overview of how to read financial statements, paying special attention to those line items that are key financial and operating performance indicators. Such monthly insights would go a long way in setting the foundation for a healthy practice. I don’t know anyone who decided that during their second year of undergraduate school that medicine would be an interesting pursuit. For most of you, helping others, giving others the gift of hope and life is a lifelong dream, a passion. Remember when you played doctor as a kid, using your siblings as patients, business terms like financial and operational dashboards more than likely did not come to mind. Times are changing. The health of patients, the joy that you bring the community are preceded by the overall health of the business of medical practice. Whether you realize it or not you are running a business. Treat it accordingly. Your ability to enrich the community by contributing to the long-term health of patients is predicated on a financially healthy business. Yes, it would seem a bit of an oxymoron, financial profitability in healthcare. I strongly suggest that a financially healthy business provides the platform that allows the Hippocratic Oath to come alive. Anita White, MBA, is the Principal Consultant with Enfusion, Inc, specializing in Business Financial Intelligence. She obtained MBA at Crummer Graduate School of Business, Rollins College, with a concentration in Finance. In addition, she has extensive international experience across five continents. For inquiries she can be reached at anita@enfusionfinance.com. 

24 FLORIDA MD - MAY 2016

2016

EDITORIAL CALENDAR

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

JANUARY –

Digestive Disorders Diabetes

FEBRUARY –

Cardiology Heart Disease & Stroke

MARCH –

Orthopaedics Men’s Health

APRIL –

Surgery Scoliosis

MAY –

Women’s Health Advances in Cosmetic Surgery

JUNE –

Allergies Pulmonary & Sleep Disorders

JULY –

Imaging Technologies Interventional Radiology

AUGUST –

Sports Medicine Robotic Surgery

SEPTEMBER – Pediatrics & Advances in NICU’s Autism OCTOBER –

Cancer Dermatology

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

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

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