The Business Magazine of Kentucky Physicians and HealthCare Administrators August 2011
Special Section
Sleep Medicine
A
The
wakening
Volume 2, Number 7
After 15 years as a rogue specialty, Sleep Medicine Comes to The Physicians’ Center for Sleep Disorders at Graves-Gilbert Clinic in Bowling Green.
Also inside
Q&A with David Laird Local Insight into Practice Merger
Saint Joseph Sleep Wellness Center
Sleep and Your Heart Snoring not only prevents you from getting a good night’s rest but snoring also can lead to serious health problems over time, including high blood pressure and heart disease. Treating an underlying sleep disorder, however, improves heart function and your quality of life. If you have been told you snore or think you have a sleep-related disorder, contact Saint Joseph Sleep Wellness Center where our dedicated board-certified physicians and credentialed specialists will provide you with the highest quality care based on your individual needs. The Center offers diagnosis and treatment of sleeping and waking disorders, including: • Insomnia • Narcolepsy • Obstructive Sleep Apnea (OSA) • Periodic Limb Movement Disorders (PLMD) • Restless Legs Syndrome (RLS) • Shift–work Disorders
MORE INFORMATION OR AN APPOINTMENT, CALL SAINT JOSEPh SLEEP WELLNESS CENTER AT 859.967.5044. www.SaintJosephSleep.org
6 CONVENIENT LOCATIONS Saint Joseph - Berea Saint Joseph East Saint Joseph - London Saint Joseph - Martin Saint Joseph - Mount Sterling Flaget Memorial Hospital
Contents
August 2011 Volume 2, Number 7
2 From the Desk of
cover story
4 Headlines 5 Finance 6 Practice Management 7 Law 11 Cover Story 14 Special Section
A
The
Sleep MEDICINE Grand Rounds 26 News 31 Events
wakening
Sleep Medicine Comes to
32 Arts
On the Cover:
Representing the multispecialty Physicians’ Center for Sleep Disorders at the Graves-Gilbert Clinic in Bowling Green: (seated l-r) Otolaryngologist James L. Salmon, Jr., MD; Sleep specialist Michael J. Zachek, MD; (standing l-r) Neurologist Wesley H. Chou, MD; and Pulmonologist and sleep medicine specialist J. Randall Hansbrough, MD, PhD.
Featured professionals
4 David Laird
6 Stephen F. Schulz
14 Pell Ann Wardrop
16 Ryan Wetzler
18 J.F Pagel
20 B.T. Westerfield
21 Pamela Combs
22 Barbara Phillips
24 Ron Shashy
24 Chad Ahn August 2011 1
Letters
FROM THE DESK OF
Megan Campbell Smith, editor-in-chief Over the last four years, we have shared the stories of over one thousand Kentucky physicians. In this time, I have never heard such consensus among a medical specialty's practitioners about their work being "fun" and "exciting" as I did this summer with our participating otolaryngologists. In architecture, from which I draw many analogies to keep abreast of physicians as they describe their work to me, the original critic Vitruvius defined the profession as a practice of firmness, commodity, and delight (firmitas, utilitas, venustas).
It occurs to me now that physicians, who similarly practice both science and art, experience a similarly tripartite profession. In Firmness lies the restoration of anatomical structures and their functions; Commodity employs research and best practice; and Delight - the pursuit of health for oneself and one's patient. As we wrap up the summer season and get back into our long, studious season of labor, I hope to linger on the delight and wish much the same for you in your practice. â—†
Submit your Letter to the Editor to Megan Campbell Smith at mcsmith@md-update.com
Kentucky Issue Volume 2, Number 7 August 2011 Publisher
Gil Dunn gdunn@md-update.com Editor in Chief
Megan Campbell Smith mcsmith@md-update.com Associate Editor
Greg Backus gbackus@md-update.com John Cowgill Photographer
Kirk Schlea kirk@ md-update.com Liz Haeberlin Writers
Jennifer S. Newton Robert Hadley Graphic Designer
James Shambhu art@md-update.com
Contributors:
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For advertising information contact Gil Dunn, Publisher (859) 309-0720 or gdunn@md-update.com 2 M.D. Update
Lisa English Hinkle Scott Neal Stephen F. Schulz
Send your Letters to the Editor to: mcsmith@md-update.com
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921 Beasley Street, Suite 210 Lexington, KY 40509 (859) 309-9939 phone and fax Mentelle Media, LLC is locally owned and operated. Mentelle Media strives to produce top quality referral and marketing resources for Kentucky’s professionals by welcoming the participation of our readers. For more information about how your business or medical practice can get involved, contact Gil Dunn at (859) 309-0720. Standard class mail paid in Denver Co. Postmaster: Please send notices on Form 3579 to 921 Beasley Street, Suite 210 Lexington, KY 40509 M.D. Update is peer reviewed for accuracy. However, we cannot warrant the facts supplied nor be held responsible for the opinions expressed in our published materials. Copyright 2010 Mentelle Media, LLC. Contact Mentelle Media for information on obtaining reprints. Individual copies of M.D. Update are available for $7.95.
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headlines
Adapting to Change
CEO David Laird of JHSMH leads Louisville-based providers as the evolution of the state’s newest health system develops. By Megan Campbell Smith LOUISVILLE After nearly two years of costcutting under the interim leadership of Janice James, Jewish Hospital and St. Mary’s HealthCare (JHSMH) prepares for reform era medicine under a new consensus building CEO, David Laird. Laird, who was previously senior vice president of planning for the hospital, is a key negotiator in the merger of Saint Joseph Health System, UofL Hospital and the James Graham Brown Cancer Center, and JHSMH. While some speculate that reform medicine will revolve around the accountable care organization, Laird leaves little speculation what kind of position the new company will take. When I asked Laird about this up on the fifteenth floor of the Rudd Heart and Lung building in Louisville, he leaned back and said, “It’s a merger. We can talk about ACOs, but this is not an ACO.” Laird explains that the new company, taking shape in a decentralized, consensusbuilding process, comprised of many different organizations and legal entities. The formulation he says has been consistent, in part due to the fact that the transition board launched each meeting reading the mission statement of the merged entity. Alternately referred to as New Co or the Kentucky State Network, at least until the official name is released perhaps as early as this summer, the merged entity will link the latest research and best practices from the academic medical center in Louisville into the comprehensive network of providers statewide. According to Laird, merger planning and negotiations have focused thus far on defining what kind of entity they were forming, and the next phase of development will provide the how.
It’s Definite
Over months of talks, a transition board largely populated by the same people selected to serve on the New Co’s 18-member community board of trustees board drafted and executed the Definitive Agreement and announced the merger in a Frankfort press conference on June 14, 2011. The Definitive Agreement started with last November’s Memorandum of 4 M.D. Update
Understanding in which the three health systems outlined the principles under which they would operate, and it concluded with the Consolidation Agreement, or merger agreement, more recently completed. “We were at a very high level of defining how we would be coming together,” says Laird. Other agreements that emerged out of the consensus-building process were the academic affiliation agreement with the University of Louisville School of Medicine, and various lease agreements since property ownership is not changing due to the merger. “The things that are going to be merged together are the businesses,” explains Laird. “So it is not so important who owns what. It is more important to assure that there are agreements for people to use each other’s property as we plan and go forward. We have five or six agreements and side letters trying to define all of the relationships to be con- David Laird sistent with the Memorandum of Understanding that we signed last year.” Developing stepwise with a high level of consensus is essential, says Laird, to avoid having to back up because new agreements break older ones. After two years of negotiations, Laird believes that clearly defined organizational relationships will help manage expectations within New Co and to service the relationships with its outside organizations. “One of the things that is abundantly clear to me and to everyone who has been a party to this,” says Laird, “is the very high level of respect, trust, and consensual agreement for this merger. This is not a win-lose deal; this is a five way win. It is a win for the three organizations, for the community, and for the physicians within the community.”
Preparing for Change, They Play to Their Strengths
The centrally-planned ACO model for achieving increased healthcare efficiencies is widely viewed as too speculative for many healthcare systems. Based on the assumption that how efficiencies will be achieved is known, the
ACO must conform to a master plan. Now that the Wall Street Journal reports that fewer than seven percent of health systems have chosen to form an ACO, it’s of little surprise that UofL, Saint Joseph, and JHSMH would instead seek to define their own way to change and in that process use the character and intellectual assets of the merged organizations as their foundation for change. Laird emphasizes that their consensusdriven talks so far have enabled the New Co to adapt to market demands rather than adopt the first experimental protocol proposed to accomplish it. It remains to be seen how the organizations will distribute service lines and consolidate expenses, but if it works, there is one group certain to profit. It’s the community of patients, says Laird, who will benefit from the mechanism of efficiency. “If we can arrive at a critical mass of patients, then we will have more physicians who will want to work in this system, more physicians participating in the academic medical center, and we’ll attract better medical students into the residency programs,” says Laird. “There is a synergy with better faculty, better residents, better medical students, and better research. While we are in competition with a lot of other academic programs for resources, we have to build more research capabilities and produce more clinical volume. We have to make sure that we are improving in all of the variables that are important to the medical school. “And the way to do that is to make sure that the hospitals are improving as well. We will create opportunities for private physicians to work side-by-side. We are not trying to control anybody, we are trying to create opportunities for people to participate if they want to. This is about creating fair opportunities for everybody.” Be sure to check out the expanded coverage of our interviews with David Laird and Charles Hoopes at M.D. Update Online Edition md-update.com ◆
finance
Debt Miscellany Although it is more practical and less magical than that of the government, you and I have a debt ceiling. At our firm, we believe that one’s ceiling for debt is predicated primarily by cash flow considerations. Nearly every time we hear somebody say that money is tight, or there is more month than bank account, we can point to a debt service that is greater than 20%. The debt service percentage is the amount of interest and principal payments on debt divided by the total gross income (that is, income before taxes). The calculation of the ratio should consider all forms of debt, including the mortgage on one’s house, and all forms of income. Think about your cash flow. As I have said many times before, there are five things - and only five things - to do with your gross income. Pay taxes, pay debts, give some, save some, and spend the rest. Taxes generally take 30-35% of gross income. Therefore, if debt service is 20% or more, that only leaves 45-50% for discretionary items: giving, saving, and spending. Hopefully, you know by now that it is spending that determines your family’s living standard, and spending more than is sustainable is what we call “living beyond one’s means.” See www.esplanner. com for a more thorough discussion of maximum sustainable living standard. There is much criticism being leveled today toward those who have an outstanding mortgage balance that is greater than the value of their house. In and of itself, this is only a problem if one is planning to move or needs to tap the equity for some reason. We advise against using a home equity loan as emergency funds because when an emergency hits is likely the worst time to add debt since many emergencies carry added cash flow burdens. We do advocate accelerating debt reduction as soon as you realize that you are upside down, at least until equilibrium is achieved. Cash flow still reigns supreme. We have previously written much about the outlook for the economy and have derived why we are constrained to slow growth. The Congressional debate around the August deadline for raising the debt ceiling focused the world’s attention on
the dysfunction of our legislative body if not upon the problems we face. If our elected authorities cannot deal effectively with a stagnating economy, sooner or later the bond BY Scott Neal market will also stagnate. It will not be pretty. Interest rates will go up, unemployment will rise, and asset prices (investments and houses) will likely fall further and harder. In past articles we have introduced our readers to why this is so. Unfortunately, the debt ceiling debate locked onto two points: raising taxes or reducing spending. Ironically, both of these affect the practicing physician and the economy in negative ways. This “dialogue of the deaf ” fails to recognize some very good
ket would respect would be to exclude true investment, those that have an expected return, from the current operating deficit of the federal government. The resulting operating deficit would be much smaller and people would be put back to work on bridges that actually lead somewhere. Another good way of handling what appears to be an irresolvable conflict in Congress (or around the dinner table) is to figure out where we agree. I was encouraged briefly when Congress agreed that we need government to help care for the truly needy. Of course, the devil is in the detail of defining who, exactly, are the needy. As an example, I offer my own case as a veteran of the U.S. Army. Few would refuse benefits to a needy veteran, but to paint us all as needful of governmental assistance is absurd, and to refuse to reduce benefits for those of us who do not need them is an exercise in futility. There has also been much debate about the future of social security. We ran the numbers on a case of a 40-some-
We advise against using a home equity loan as emergency funds because when an emergency hits is likely the worst time to add debt since many emergencies carry added cash flow burdens.
solutions that go beyond the broad brush painting that goes on the halls of Congress. If Congress is successful in cutting a trillion dollars out of the economy either by raising taxes or cutting its own spending (both of which depress the economy), we will surely head back into recession, if not worse. Perhaps what is needed is to use physicist’s way of dealing with intractable problems: redefine the terms. Let’s start with the word deficit. When you and I make an investment in a piece of equipment we recognize the hit to income over some period of time (e.g. depreciation expense); however, the current federal deficit includes all spending of all types, operating and investment. A measure that the bond mar-
thing year-old who is expected to pay the maximum into social security for the next twenty years. We determined the detriment if there were no social security benefits for her when she reached full retirement age. The answer was that her standard of living was reduced by 6% now and in the future. This was a quite specific case, but the effect is ascertainable for each of us with the right inputs. Today, more than ever it is a scenario that we must all consider. Scott Neal, CPA, CFP is the President of D. Scott Neal, Inc. a fee-only financial planning and investment advisory firm. Reach him at scott@ dsneal.com or by calling 1-800-344-9098. ◆ August 2011 5
Practice management
Medical Practice Mergers
Physician practice mergers are a way for physicians to maintain their private practice model while creating a truly professionally run business. Two roads diverged in the wood, and I took the one less traveled by, and that has made all the difference ~Robert Frost Long gone are the uncomplicated days of private medical practice operations. It used to be that a doctor knew coming out of residency that the future was a lifetime in private practice. Sure, there would be the challenges of running a medical practice, but there wasn’t the pressure applied on practices by payers and government regulation like there is today. The future was pretty well mapped out and seldom if ever did a doctor find herself at a crossroads about the organization or structure within which he or she would practice medicine. Privately practicing physicians now face major decisions about the structure within which they will practice medicine in the future, and the question they face is no longer whether to consider these options, but which option to select. The fork in road travels in three disparate directions: hospital employment; practice combination or merger; and stay the course. This author believes the road less traveled – practice merger – is the road of choice. Many market forces have created this dilemma for physicians. One market force is the steady decline in physician reimbursement. Since the introduction of the Resource Based Relative Value System in the early 90’s, Medicare and private payer reimbursement has
LOUISVILLE
been deteriorating. The emphasis on IT in medical practice operations is another factor. Practices are faced with the requirement to move into the IT age, which is both operationally and financially BY Stephen F. Schulz challenging. To avoid this difficult transition, some practices have chosen hospital employment. Another market force – the emphasis on quality – is also applying pressure on physicians. Failure to comply with the quality standards of the future will result in a reduction of Medicare reimbursement.
Impact of Health Care Reform
Health Care Reform is a major driver and market force placing physicians at a crossroads in their careers. There is great uncertainty as to the role physicians will WHY MERGERS FAIL
Lack of Champion Deal Fatigue Good of a few overshadows
the good of the whole Allow distractions and obstacles to dominate Don’t invest the time to finish the job
play in the world of Accountable Care Organizations and bundled payments. Some physicians believe independent physicians will be vulnerable in this environment. However, other physicians believe that properly aligned physician groups of significant size resulting from merger can control their future in the world of Health Care Reform. While the resurgence of hospital employment of physicians is another significant market force, not all physicians see hospital employment as the only redemption from today’s challenging private practice model. Hospitals are paying little or nothing for the assets of practices while offering employment as a way for physicians to escape the complications of today’s private medical practice. However, many physicians believe that they are better equipped to structure a practice model that gives them the same benefits, or better, than hospital employment. Practice merger is a better solution for these physicians.
Investigating the Practice Merger Option
For physician ownership groups that do not see hospital employment as a solution to this problem, mergers are an opportunity to create the critical mass that allows the larger practice to properly leverage operating costs and maintain competitive physician compensation levels. Market share is a major driver for physicians to investigate practice mergContinues on page 8
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law
The New Duty to Refund Overpayments One of the most important changes created by the Health Care Reform Act is the establishment of an explicit duty to refund Medicare and Medicaid overpayments within 60 days of identification. While this “60 day rule” sounds simple, it is anything but, as all providers and suppliers struggle to determine both how and when this rule applies without regulatory guidance from the Centers for Medicare & Medicaid. Physicians and provider groups should pay particular attention to the 60 day rule as billing responsibilities are generally delegated to staff. In the normal course of business, a physician may not even be aware that his or her office staff has received and deposited an overpayment due to a simple mistake in billing. Failure to refund an overpayment within 60 days now constitutes an “obligation” under the Federal False Claims Act, which means that the overpayment may be considered to be a false claim. False claims, of course, can be the subject of qui tam lawsuits, government investigations, MAC/RAC audits, among others, and, if liability is found, then damages can be assessed at three times the amount of the claim and civil monetary penalties.
What does the law provide?
In general, the Patient Protection and Affordable Care Act, PPACA Section 6402(d) provides that when a person has received an overpayment, the person shall report and return the overpayment to the Secretary, the State, an intermediary, a
carrier or a contractor and notify the recipient in writing of the reason for the overpayment within 60 days of identification. “Overpayment” is defined as any funds that a perBY Lisa English Hikle son receives or retains under Medicare or Medicaid to which the person, after applicable reconciliation, is not entitled to. While this requirement seems straightforward, it is anything but.
What is an overpayment?
The statute defines an overpayment as a payment that a person is not entitled to. This could mean that services were billed for but not rendered, that the services provided were not medically necessary, that the services were billed at a higher code than actually provided, that the services were provided in violation of the Stark Laws, or that the services were not of a sufficient quality. In short, there are many ways for physicians and their staff to make mistakes in billing that would mean that they were not entitled to receive payment. Identification of a billing problem, however, does not always mean that an overpayment has been received. Careful review and inves-
tigation may be necessary to determine whether an overpayment exists.
What does it mean to identify an overpayment?
One of the most difficult problems that physicians and other providers face is determining when the 60 day time limit is triggered. What does it mean to identify an overpayment? Does the 60 day clock start when a report is received by one physician that another physician in the group has improperly billed for evaluation and management of a particular patient? Does the 60 day clock start when the allegation is confirmed for one of the physician’s patients? Does it start when the practice begins to investigate the physician’s billings for the past year? Does it start only after the investigation has been completed and a determination weighing all the facts has been made by the physician group’s inhouse or outside counsel has made a legal opinion considering all possible defenses that an overpayment has been received? As these questions illustrate, thorny issues are presented when an overpayment is alleged to have been received, and there is no federal regulatory guidance that addresses how an overpayment is identified. Taking a very aggressive stance, New York’s Office of Medicaid Inspector General has said that a provider does not have to know the amount of the overpayment to trigger the 60 day time frame, but that an overpayment Continues on page 9
August 2011 7
Medical Practice Mergers Continued from page 6
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ers. Physicians of all specialties need market share for a flourishing private practice model. Market share provides for access to more patients, which is the foundation for growth and financial success. Mergers are challenging because there is no single template for ensuring the process is a success. Some experts will tell you, “If you’ve seen one merger, then you’ve seen one merger.” The legal, accounting, tax, and financial aspects of a merger are comparatively easy to negotiate by the professionals engaged to get the deal done. Otherwise, the challenging aspects of a merger are subjective and rely more on physician involvement and leadership than the technical prowess of accountants, lawyers, and consultants.
The Difference Between Success and Failure
A practice merger will only succeed if it involves physician members of like mind, common purpose, and aligned vision. It must have one or more champions for the cause or the deal will die an early death due to fatigue and lack of direction. If done properly, it gives physicians all the perceived advantages of hospital employment while retaining independence and opportunities to make more money—not to mention the ability to stay in control of their own destiny. Mergers succeed and fail for a variety of reasons, all unrelated to the strength or weakness of professional advisors. They are mostly process driven and subjective factors. Mergers succeed because they are committed to the vision and because they commit sufficient time to the process. In successful mergers, communication and expectations are managed while the group works around obstacles. Importantly, the good of the whole is placed ahead of the favor of a few. If practice merger is the road of choice, recognize it is the road less traveled today. But in the end, if successfully done, it can make all the difference in providing the highest level of professional job satisfaction possible. Stephen F. Schulz, CPA, CMPE is a partner with Mountjoy Chilton Medley and is based in their Louisville office. Steve provides broad based practice management consulting services for physician practices. He can be reached by telephone at (502) 749-1900 or by email at Steve.Schulz@mcmcpa.com. ◆
8 M.D. Update
The New Duty to Refund Overpayments
law
Continued from page 7
was received1. A more reasonable position may be that a provider’s 60 days is not triggered until the group has a reasonable time to investigate the facts and determine the amount of the overpayment if any. The real problem is that determining whether an overpayment has been received probably involves complex reimbursement questions, which may be of a legal nature and involve significant factual questions that may both include reviewing medical records as well as interviewing staff and possibly patients.
How is an overpayment returned?
Assuming that a physician has determined that an overpayment has been made, another important question is to whom and how is a payment returned. The statute permits the report and return of an overpayment to be made to the Secretary, the State, an intermediary, a carrier, or a contractor, as appropriate, at the correct address. It is important to also note that the statute requires that the provider explain in writing the reason for the overpayment. One of the most difficult decisions that a provider must make is deciding whether it has made a simple
billing error that merely requires a repayment or whether evidence of other wrongdoing exists that could expose the provider to criminal or civil False Claims Act violations or administrative sanctions. This decision should influence how and to whom the report and refund should be made. Compliance with the overpayment statute does not guarantee that the provider will not face other sanctions related to the overpayment when it is a serious violation. For serious violations that involve false claims or Stark violations, a provider may want to use the Office of Inspector General’s Self-Disclosure Protocol. While there are substantial requirements for the disclosure that include repayment of double damages, this may be attractive when false claims are apparent. On the other hand, for billing mistakes, repayment should be made to the Medicare or Medicaid contractor. Where there is conflicting guidance, a provider may choose to seek guidance from the Centers for Medicare & Medicaid Services. Where there is possible civil or criminal exposure, there are a number of options that include the local United States’ Attorney’s Office, the Office of Inspector General, and the Kentucky Attorney General’s Office.
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Conclusion
While there has been significant disagreement about when a provider has a duty to refund an overpayment, the Health Care Reform Act created an unequivocal duty to refund overpayments. Because of the complexities of reimbursement and the myriad statutes and regulations regulating the health care industry, physicians and other providers must be alert to this duty and handle allegations of overpayment carefully including the reporting of the overpayment. (Endnotes) 1 www.omig.state.ny.us/data/index.php?opi+comcontent&task (last viewed 7-31-11).
Lisa English Hinkle is a Partner of McBrayer, McGinnis, Leslie & Kirkland, PLLC. Ms. Hinkle concentrates her practice area in health care law and is located in the firm’s Lexington office. She can be reached at lhinkle@mmlk. com or at (859) 231-8780. This article is intended as a summary of newly enacted federal law and does not constitute legal advice. ◆
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August 2011 9
10 M.D. Update
A
The
cover story
wakening
Sleep Medicine Comes To By Megan C. Smith Once described as a rogue specialty, sleep medicine has gone mainstream. Coming under the purview of the American Board of Medical Specialties (ABMS) in 2007, the subspecialty unites physicians across many specialties in an effort to increase awareness of sleep disorders, their diagnosis and proper treatment. More than just sleep apnea, the field unites the members of the American Boards of Otolaryngology, Internal Medicine, Pediatrics, Neurology and Psychiatry, Family Medicine, and most recently Anesthesiology, with a common certificate of qualification to treat conditions such as insomnia, narcolepsy, restless leg syndrome, REM behavior disorders, and parasomnias. Before the new ABMS conjoint board, sleep medicine fell exclusively under the rule of its long-time professional society, the American Academy of Sleep Medicine, and its examination and certification organization, the American Board of Sleep Medicine (see our interview with Dr. Pell Wardrop, p. 28, for more on the new and old boards). Today, AASM continues to advance the profession through its sleep center accreditations and inter-scorer reliability (ISR) programs. These changes are subtle yet serious. They strengthen sleep medicine practitioners’ economic position amidst the runaway markets of the medical device and home health industries, and for future professionals they mean a fellowship and increased barriers to entry. Moreover, the formalization of the subspecialty of sleep medicine recognizes the multifaceted nature of sleep while fulfilling the unmet needs of an under-diagnosed and undertreated patient population.
BOWLING GREEN
Wesley H. Chou, MD, neurologist with the Physicians’ Center for Sleep Disorders at the Graves-Gilbert Clinic in Bowling Green.
August 2011 11
cover story
J. Randall Hansbrough, MD, PhD has a dual career in pulmonology and sleep medicine, splitting his time between the hospital and the sleep center.
(PCSD) provides comprehensive diagnosis and treatment services for all sleep related conditions. The multispecialty composition of the physician staff emerged like sleep medicine itself – a coordinated effort to address sleep disorders, which span traditional medical disciplines in both cause and effect. Dr. Wesley Chou, for example, sees sleep patients with narcolepsy, parasomnias, and REM behavior disorders as a specialized part of his general neurology practice. His colleagues rely on his diagnostic expertise in differentiating suspicions – like parasomnia from epilepsy. Chou replies that the integration of his practice with the group’s sleep study center is invaluable. “I have close communications and can thoroughly monitor how we perform the sleep study tests,” he says. Another example of the multispecialty nature of sleep medicine is the dual career of PCSD’s two physicians specializing in pulmonology and sleep medicine. Douglas B. Thomson, MD, MPH, along with colleague J. Randall Hansbrough, MD, PhD, split their time between the sleep center and the hospital, between sleep apnea and emphysema, so to speak. Thomson says that while the patients for either pulmonology or sleep medicine differ, “it turns out there are often intersections. A patient is more likely to be referred to [Hansbrough or me] due to a lung disease than a sleep condition, but we might be the first ones to think that the patient may have a sleep condition, too.” In those cases, the providers often find attendant sleep disorders. From time to time a patient will present with obstructive sleep apnea in isolaThe Multispecialty Nature of tion, in which case Thomson says he may Sleep Medicine call on colleague James L. Salmon, Jr., Within the Physicians’ Center for Sleep MD, otolaryngologist, to perform uvuDisorders at the Graves-Gilbert Clinic lopalatopharyngoplasty, or UP3 surgery. in Bowling Green, providers approach Generally for patients who fail CPAP, UP3 sleep medicine from the Clinic’s famed is an excellent example of why sleep centers multispecialty perspective. Representing benefit from a multispecialty approach. otolaryngology, neurology, internal mediOne of the more interesting aspects of cine, and the subspecialties of pulmo- sleep medicine is how for some providers nary, critical care, and sleep medicine, the sleep medicine is a subspecialty and for Physicians’ Center for Sleep Disorders others it stands on its own. When chal-
For some providers, sleep medicine is a subspecialty. For others, it stands on its own.
12 M.D. Update
lenged to answer how being a pulmonologist informs his sleep practice, Hansbrough replies, “I am a sleep medicine doctor and the fact that I am a pulmonologist does not influence me. I treat everything from insomnia to narcolepsy. In my mind, that’s like asking how your pulmonary practice would change if you were a republican or a democrat. They are unrelated.” While some providers get involved in sleep medicine because their specialty has a niche there,
James L. Salmon, Jr., MD
Hansbrough points out that providers who are trained sleep medicine specialists should be able to treat just about any sleep disorder. For Michael Zachek, MD, sleep medicine is a full time occupation. His entire practice is located at the Physicians’ Center for Sleep Disorders where he consults patients and monitors sleep studies. His interests lie in the interpretation of sleep studies and the professional development of sleep medicine specialists nationwide. He also performs site visits for sleep centers seeking American Academy of Sleep Medicine (AASM) accreditation. Additionally, Zachek collaborates with providers across the US in the AASM Interscorer Reliability (ISR) program, which seeks to establish a basis for sleep study testing quality. Traditionally, he says, doctors who were boarded in sleep medicine determined the sleep study interpretation standards in their own sleep facilities. Today, ISR engages 1400 US physicians in comparative scoring of monthly case studies to define the national standard. Zachek says, “As I have gone around
Sleep medicine specialist Michael J. Zachek, MD performs site visits for centers seeking AASM accreditation and engages sleep professionals across the country in the Academy’s Inter-scorer Reliability program.
the country inspecting sleep centers, I have found more and more people embracing ISR and, as a consequence, the sleep studies have improved.” Nationwide, he finds sleep studies are being scored in a more uniform fashion. “Sleep medicine doctors come from a lot of different specialties,” says Zachek. “The take home message for me is sleep medicine is very gratifying for the patient and the doctor. In my job now, it happens four or five times a day that a patient tells me I have changed their life. “It is important to me to see that I am doing something for people,” he concludes. “The patients feel better, and when you feel better you are more likely to be healthy and have a more productive life.” ◆
Douglas B. Thomson, MD, MPH
August 2011 13
sleep Medicine
Case Study: The Sleep Medicine Professional
Dr. Pell Ann Wardrop, who wrote the book on sleep medicine, reflects on the specialty and its potential. By Greg Backus and Megan C. Smith In the 1980s before attention deficit hyperactivity disorder was widely recognized, Pell Ann Wardrop, MD, otolaryngologist, observed a correlation between tonsillectomies in her pediatric population and improvements in the symptoms of what would become known as ADHD. Wardrop, who has been practicing in Lexington for over 20 years, recalls how this correlation sparked her careerchanging interest in sleep medicine. “Together with Dr. Thomas Young, a pediatrician in my practice who specialized in school dysfunction, I did some work on school-aged children that really made obvious the connection between sleep disorders and the ADHD-like symptoms brought on by disrupted sleep,” says Wardrop. By the turn of the millennium, Wardrop had immersed herself in sleep medicine training for both pediatric and adult cases. She was first boarded in sleep medicine in 2003 and a year later left ENT surgery in favor of full-time sleep practice. LEXINGTON
Introduction: Sleep Medicine Boards
Recent administrative changes in the specialty of sleep medicine require some explanation. Sleep medicine as a specialty has been around since 1978, when the American Academy of Sleep Medicine (AASM) was 14 M.D. Update
founded. The AASM administered the exams and certifications of sleep medicine doctors until its spin-off organization the American Board of Sleep Medicine (ABSM) took over the boarding responsibilities in 1991. Due largely to economic pressures, sleep medicine came under the purview of the American Board of Medical Specialties (ABMS) in 2007 with the advent of the conjoint Board Certification in Sleep Medicine. The conjoint board recognizes the sub-certification of anesthesiologists, pediatricians, otolaryngologists, neurologist/psychiatrists, and pulmonologists in the practice of sleep medicine. In 2010, Wardrop coauthored Sleep Medicine with a fellow otolaryngologist sub-certified in sleep medicine, Kathleen Yaremchuk. Clinically oriented toward a multispecially review of Sleep Medicine, the book received a positive review in the February 2011 JAMA by critic Denis Rosen, MD. Wardrop points out that the window is practically closed for practitioners boarded in the conjoint specialties to become certified in sleep medicine without embarking upon an ACGME-approved sleep medicine fellowship. Anesthesiology, which was the last ABMS member board to join the conjoint board, is the lone discipline with time remaining for physicians to
be grandfathered in. Today there are many sleep medicine specialists with both the new ABMS and the older ABSM board certifications since physicians who passed the ABSM exam 1978– 2006 retain lifelong diplomat status. Also, the AASM continues to play a key role in the certification of sleep centers across the US.
Case presentation: ENT to Sleep
“Doctors are coming from many different backgrounds to become certified in sleep medicine,” explains Wardrop. “There are many different sleep disorders and different ways to treat each of them – there are more than 200 sleep disorders listed in ICD-10. Some are psychiatric conditions, others are defined neurologically, and some are related to respiratory conditions and the anatomy of the airway.” The diversity of sleep disorders means that treatments have been gathered from many different fields. As an otolaryngologist, Wardrop was initially interested in anatomical conditions that could be corrected surgically, like obstructive sleep apnea (OSA). “Within OSA,” she says, “the specific anatomic abnormality could be a an upper airway mass, large tonsils, or perhaps a nasal obstruction for which I would per-
sleep medicine form the surgery.” As her sleep practice grew, Wardrop developed experience in insomnia, narcolepsy, and circadian rhythm disorders, and with her background in ENT surgery, she is one of just a few local providers seeing pediatric sleep disorders. “So today I am treating the whole gamut of sleep disorders,” she says. In treating patients, Wardrop has come to expect the presence of multiple conditions. “There are very few patients with just one sleep disorder,” she says, adding that what are called sleep hygiene problems are commonly caused by other conditions. Wardrop cautions that “if you successfully treat a sleep apnea patient and do not treat their other sleep disorders, they are not going to feel better. Maybe they have trouble falling asleep, in which case a CPAP will not help so much. “Sleep disorders really do come in mixed bundles,” she remarks, “and I frequently find patients with sleep apnea who initially presented for other sleep conditions.”
Management: CPAP for OSA
If a patient fails CPAP, insurance will usually pay for other procedures such as mandibular advancement devices or oral appliances, which Wardrop finds very helpful with some patients. Surgery, she says, can be very effective with some patients, but it is important to bear in mind that this is a young field. “The development of new treatments is a priority,” says Wardrop. “It is important to identify which patients do best with each of the different treatments available. There are a lot of ongoing studies to figure these things out.” Patient preference is a major issue in managing OSA. While CPAP is highly effective, compliance falls below 50%. Other treatment modalities are less effective. “Surgery is effective less than 50% of the time, and failing that, mandibular devices are worn,” says Wardrop. “We are only at about the 50% treatment level across the board, and we need to make that better.”
Outcome: Better Medicine
Wardrop predicts significant improvements in compliance and effectiveness in the near
future. Home testing promises to make polysomnograms more affordable, CPAP manufacturers are improving the interface with masks, and new techniques and approaches being developed. “One example is a hyperglossal nerve stimulator, which is in the preliminary stages of development. This is an implantable nerve stimulator,” Wardrop explains. “It keeps tone in the airway and stimulates the nerve during sleep. It seems to work so far, but the studies were in very small groups, so more studies need to be done.” There also seems to be greater consensus among practitioners as to the future of sleep medicine. “There is more general agreement developing in hospitals and sleep centers that polysomnograms are going to become less common as home studies becoming easier to accomplish,” she says. “It is a specialty in which diagnostic tests are very expensive, plus CPAP machines average around $2500. We need to spend less on diagnosis, and the easier we can make it for the patient, the better everything will work out.” ◆
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special section Sleep medicine
CBT for Sleep Disorders
Dr. Ryan Wetzler utilizes cognitive and behavioral strategies to cure insomnia and more Chronic insomnia affects an estimated 10 to 15 percent of the population, and yet, according to Ryan Wetzler, PsyD, C.BSM, ABPP, the most effective treatment – cognitivebehavioral therapy for insomnia (CBT-I) – is not the most widely utilized approach. CBT-I is an effective and durable treatment approach of behavioral sleep medicine (BSM), a subspecialty of sleep medicine and health psychology that was first recognized in 2003. Wetzler, who is certified in BSM and board-certified in clinical health psychology, is one of only three certified BSM providers in Kentucky and approximately 160 nationwide. Traditional sleep disorder centers are mainly focused on diagnosing sleep apnea and treating patients with positive airway pressure (PAP). “What certified behavioral sleep specialists are best known for is cognitive behavior therapy for insomnia, which is now recognized by the NIH as a first line LOUISVILLE
16 M.D. Update
By Jennifer S. Newton treatment for chronic insomnia, mainly prevents many from tolerating the therapy. because it has been found to be more effecIdentifying cognitive and behavioral factive than any sleep drug on the market,” tors that contribute to sleep disturbance is one says Wetzler, who is the director of behav- of the core aspects of BSM, which is rooted ioral sleep medicine at Sleep in the cognitive-behavioral Medicine Specialists. model. Accordingly, “The way Behavioral sleep specialists we think determines how we also use non-drug strategies to feel; how we feel determines treat a variety of other sleep what we do; and what we do disorders including parasomleads to improvement or worsnias, hypersomnia, and circaening of symptoms. Cognitivebehavioral approaches seek to dian rhythm sleep disorders. identify counterproductive BSM specialists also work thoughts, feelings, and behavwith patients with difficulty iors which are getting in the tolerating PAP to facilitate way of recovery and teaches optimal management of sleep strategies to restore optimal apnea. For instance, behavfunctioning,” explains Wetzler. ioral sleep specialists may pro- Dr. Ryan Wetzler is the vide desensitization to help a director of behavioral sleep “In short, CBT-I teaches stratepatient overcome a claustro- medicine at Sleep Medicine gies to reset the bodily systems Specialists of Louisville. that regulate sleep.” phobic reaction to PAP which
sleep medicine Wetzler says he is opposed to using medications to treat insomnia because they have limited long-term efficacy, contribute to dependence, and lead to undesirable side effects including memory disturbance, daytime sleepiness, and increased incidence of parasomnias. Chronic insomnia, Wetzler explains, stems from some people’s increased biological susceptibility to sleep disturbances. “The behavioral model of chronic insomnia says that we all have varying levels of vulnerability to sleep disturbance, and people who suffer from insomnia tend to be born with particularly strong vulnerabilities.” We are all born with an internal sleep clock, known as the suprachiasmatic nucleus, which orients us to the natural light and dark cycle. This sleep clock runs on a 24.3 hour rhythm in an average person, slightly longer than a day, meaning people would generally like to stay up late and sleep in. Those who are particularly vulnerable to sleep onset insomnia (difficulty getting to sleep) may have a clock that runs at 25 hours. Should this vulnerable person experience a stressful period of time, they may begin to
have trouble sleeping and they may sleep in on weekends in an attempt to catch up, which can exacerbate the problem by further delaying the circadian rhythm and increasing the likelihood of trouble sleeping the next night. As this continues overtime, “they will begin to experience stress, frustration, irritation, and anger,” says Wetzler. “After enough time, just going to bed will automatically trigger those sleep preventing emotions.” CBT-I helps patients understand their condition, identify what they are doing that perpetuates the problem, and teaches strategies to restore normal function. The evaluation process also includes psychological instruments designed to detect depression, anxiety and underlying psychiatric issues. Recent research suggests that rather than being a secondary condition, insomnia is more accurately considered a co-existing condition that can independently worsen depression, anxiety, pain, and other common conditions. More detailed and systematic than just good sleep hygiene, CBT-I has been found to work as well in the short term and more
LOSING
SLEEP? We can help.
effectively in the long term than medical therapies. Wetzler tested this theory in his own practice, studying not just “perfect” patients but a complex clinical group who exhibited co-existing conditions such as pain, gastrointestinal problems, depression, and anxiety. “After an average of five or six visits, we had put into remission 50-66%, with 90% experiencing some improvement in sleep,” says Wetzler. “We were able to get a great majority, 78%, off of sleep drugs.” Other advantages of CBT include its quick response rate and relative cost efficiency. “We can put a majority of chronic insomnia cases into remission within five visits,” says Wetzler. This is compared to years of drug therapy and follow-up visits for sleep medications which do not actually fix the problem, they just cover it up and when drugs are discontinued symptoms resurface. “The main message,” says Wetzler, “is that sleep drugs are not the answer. There are other, non-drug strategies that are available and the important thing is to get the word out … to providers and patients alike.” ◆
Sleep disorders disrupt and disturb the overall quality of life for more than 40 million Americans and can include obstructive sleep apnea, narcolepsy, insomnia, and restless leg syndrome. Lexington Clinic Sleep Center physicians have expertise in sleep medicine and provide comprehensive medical and surgical care for all sleep disorders. For more information about sleep studies, sleep disorders or appointments, contact the Lexington Clinic Sleep Center at 859.258.4NAP (4627).
Lexington Clinic Sleep Center 1221 South Broadway, Lexington, KY 40504
859.258.4NAP (4627)
LexingtonClinic.com/sleepcenter
August 2011 17
special section Sleep medicine
In Sight of Sleep
National sleep and dream expert Dr. J. F. Pagel lays out the vision for primary care’s engagement with sleep medicine. By Megan C. Smith PUEBLO, Colorado During this September’s conference for the Kentucky Sleep Society, nationally renowned researcher J. F. Pagel, MS/MD, triple board-certified in family medicine, sleep medicine, and behavioral sleep medicine, will present a talk on the evidence basis for the application of sleep medicine into primary care. Pagel, whose practice Rocky Mt. Sleep has sleep labs in Pueblo, Colorado Springs, and Salida, Colorado, was one of the nation’s first family physicians to get boarded in sleep in the 1990s. His thirty years of insights into sleep medicine began when he was an undergraduate at the University of Alabama - Birmingham in the 1970s. There the young Pagel spend nights doing DNA markers just a floor above a sleep lab run by G. Vernon Pegram, PhD, one of the early researchers in the field of sleep science. Though a sufficient chemist by then, Pagel discovered a preference for the biologic systems and soon got involved with Pegram’s experiments on REM sleep and intelligence in mice. In recent years, he has written extensively on sleep apneas and the data evidence supporting the importance of diagnosing and treating it within primary care. “The evidence right now,” says Pagel, “is kind of extreme. There is more evidence that sleep apnea is itself a risk factor for cardiac disease, heart attacks, strokes, and arrhythmias than there is for the classic high cholesterol lipid theory.” s Pagel emphasizes that the patients presenting in primary care with high blood pressure, diabetes, cardiac and pulmonary diseases, and strokes likely have a sleep apnea, too. “There have been a series of recent papers indicating that up to a third of patients at a primary 18 M.D. Update
care practice have sleep apnea,” he explains, “but the number of patients in primary care practice who have gone through the protocol for diagnosis and treatment of sleep apneas is in the range of 1-2 percent.” Nationally, sleep apnea is still is not on the radar for most primary care specialties. From his own practice, Pagel knows that of the list of 27 topics that should be addressed as the focus of primary care practice, “not one of those involves sleep. We’re the Johnny come
National sleep and dream expert J. F. Pagel, MS/MD of Pueblo, CO, will address the conference of the Kentucky Sleep Society in September in Lexington. Pagel, who is triple boarded in family medicine, sleep medicine, and behavioral sleep medicine, focuses on the evidence basis for diagnosis and treatment of sleep apnea in primary care.
lately.” There are many medical schools where student get only an hour or two of sleep training, and still other institutions that make no room for sleep training at all. “So we find ourselves in this situation,”
There is more evidence that sleep apnea is itself a risk factor for cardiac disease, heart attacks, strokes, and arrhythmias than there is for the classic high cholesterol lipid theory. says Pagel, “where we have increasing amounts of evidence on the importance of diagnosing and treating apnea, and still there are a lot of patients out there who have not been addressed.” Professionally, Pagel is of the opinion that the way to get primary care doctors involved in sleep medicine is to bring them into the field, so he got involved in the formation of the ABMS conjoint board in Sleep Medicine. “If members of the field can receive subspecialty certification, more and more people in the field will emphasize sleep. That’s where we are now,” he says. “There is a big lag time we’re the last guys on the block. The data keep getting better and more people keep incorporating the importance of diagnosing and treating sleep apnea in their practice. “In the past 35 years, there have been two major accomplishments in the field of sleep medicine. One is the development of safe and effective medication for treating insomnia, and the second is the identification of the importance of diagnosing and treating sleep apnea in reducing morbidity and mortality, improving comorbid disease processes, and improving patient quality of life.” ◆
Directory of Kentuckiana sleep Centers Baptist HealtH sleep DisorDers Centers Baptist Hospital East aasM accredited Baptist Hospital East, 4000 Kresge Way, louisville, KY 40207 (502) 896-7612 baptisteast.com/sleep
Baptist Hospital NortHEast 1025 New Moody ln., la Grange, KY 40031 (502) 222-8687 subin Jain, MD, pulmonary Medicine, Critical Care and sleep Medicine, Medical Director Mala laCaze, rpsGt, Clinical Coordinator (mala.lacaze@bhsi.com) Central Baptist Hospital sleep DiagnostiC Center aasM accredited 1740 Nicholasville road, Building E suite 503, lexington, KY 40503 (859) 260-4300 fax(859) 260-4319 centralbap.com John r. White, M.D. sleep Medicine, pulmonary Medicine and Critical Care alexander E. tzouanakis, M.D. sleep Medicine, pulmonary Medicine and Critical Care l. Brittany Cobb, rpsGt, Clinical Coordinator, Brittany.cobb@bhsi.com Central KentuCKy sleep Center at FranKFort regional MeDiCal Center aasM accredited 299 King’s Daughters Drive, Frankfort, KY 40601 (502) 226-7691 frankfortregional.com pamela Combs, MD, sleep Medicine, Geriatric, Nuclear, internal Medicine FloyD MeMorial sleep DisorDers Center aasM accredited 1850 state st. New albany iN 47150 (812) 949-5550 floydmemorial.com/sleep-center satish rao, MD, Ms, Neurology, sleep Medicine azmi Draw, MD, pulmonology, sleep Medicine Nuzhat Hasan, MD. pulmonology, sleep Medicine georgetown CoMMunity Hospital sleep Center aasM accredited 1140 lexington road, Georgetown KY 40324 (502) 868 1221 (877) 868 1221 georgetownhospital.com Dr. ronald shashy, MD, ENt, sleep Medicine
JewisH Hospital sHelByville 727 Hospital Drive, Medical annex Bldg shelbyville, KY 40065 (502) 647-4341 JewisH Hospital MeDiCal Center east 3920 Dutchman’s lane First Floor louisville, KY 40207 (502) 259-6566 tHe lexington CliniC sleep Center aasM accredited 1221 south Broadway lexington, KY 40504 (859) 258-4Nap (4627) lexingtonClinic.com/sleep Wayne B. Colin, DMD, MD otolaryngology John F. Dineen, MD, FCCp pulmonary Diseases Craig a. Knox, MD Neurology tHe pHysiCians’ Center For sleep DisorDers aasM accredited Graves Gilbert Clinic the Medical arts Building 350 park street Bowling Green KY 42101 (270) 781-8420 or (270) 781-5111 ggclinic.com/sleepDisorders.php Wesley H. Chou, MD, Neurology, sleep Medicine J. randall Hansbrough, MD, phD, internal Medicine, pulmonary, sleep Medicine Douglas B. thomson, MD, M.p.H, internal Medicine, pulmonary, Critical Care, sleep Disorders James l. salmon Jr., MD, otolaryngology lalith C. Uragoda, MD, internal Medicine, pulmonary Medicine, Critical Care Medicine and sleep Medicine Michael J. Zachek, MD, internal Medicine, sleep Medicine saint JosepH sleep wellness Center Joint Commission accredited saintJosephsleep.org FlaGEt MEMorial Hospital 4305 New shepherdsville road Bardstown, KY 4004 (502) 350-5475 Eugene Fletcher, M.D. Zaka Kahn, M.D. Warren shakun, M.D.
saiNt JosEpH East 160 N. Eagle Creek Drive, suite 302 lexington, KY 40509 (859) 967-5044 pamela Combs, M.D. Jeremiah suhl, M.D. James M. thompson, M.D. pell Wardrop, M.D. saiNt JosEpH - BErEa 305 Estill st., 4th Floor Berea, KY 40403 (859) 986-6524 saiNt JosEpH - loNDoN 1370 West 5th street london, KY 40741 (606) 877-1096 95 Bryan Blvd., suite 102 Corbin, KY 40701 (606) 528-8144 Muhammad iqbal, M.D. aqeel Mandviwala, M.D. saiNt JosEpH - MartiN 11203 Main street Martin, KY 41649 (606) 285-3690 Vijay ammisetty M.D.
saiNt JosEpH - MoUNt stErliNG 50 sterling avenue Mt. sterling, KY 40353 (859) 497-6013 Worawute supaongprapa, M.D. sleep MeDiCine speCialists aasM accredited 1169 Eastern parkway #3357 louisville, KY 40217-1415 (502) 454-0755 4606 Greenwood road, louisville, KY 40258 (502) 937-2209 sleepMedicinespecialists.com David Winslow, MD, internal Medicine, pulmonary, sleep Disorders richard Baker, MD, internal Medicine, pulmonary, sleep Disorders Walter app, MD, internal Medicine- Critical Care, pulmonary, sleep Disorders l. pete Moore, MD, internal Medicine, pulmonary, sleep Disorders George Boatwright, MD, internal MedicineCritical Care, pulmonary, sleep Disorders William owen lacy, M.D. internal Medicine, pulmonary, sleep Disorders Carlos J. ramirez-icaza, MD, internal Medicine, Critical Care, pulmonary, sleep Disorders David Hasselbacher, MD, internal MedicineCritical Care, pulmonary, sleep Disorders ryan G. Wetzler, psy. D., CBsM Julie Etzel, ph.D, Clinical psychologist sts. Mary & elizaBetH Hospital aasM accredited 4402 Churchman avenue, plaza 1 louisville, KY 40215 (502) 361-6555
special section Sleep medicine
Consciousness of Sleep
Pulmonologist and sleep medicine specialist Dr. B. T. Westerfield recognizes some challenges ahead for sleep medicine. By John Cowgill LEXINGTON Sleep medicine and sleep disorders have gained a great deal of attention is the past decade. Be it commercials for sleeping pills, morning talk show discussions of the benefits of the power nap, or public health warnings of the dangers of drowsy driving, one need not go far to see evidence of sleep’s elevated cultural profile. If the importance of sleep is everywhere, one might wonder why sleep disorders including sleep apnea are under-diagnosed and undertreated? Many practitioners in the
field are concern that too few patients are coming in to see a physician for treatment. B.T. Westerfield, MD, medical director of the Sleep Disorder Center of Lexington, who is triple board certified in internal medicine, pulmonary medicine, and sleep medicine, recalls how he got involved in sleep medicine in the early 1990s. Concerned that the field was too often a diagnostic testing mode for hospitals and not a medical practice interested in caring for patients, Westerfield began looking into potential treatments for breathing-related problems in sleep. “My involvement in sleep medicine was always motivated by the goal of treating 20 M.D. Update
my patients,” Westerfield says. “It was not enough to just find out who has sleep apnea - it was about making sure they were fully treated and followed as long as their conditions persisted.”
out a physician present will be under-educated and inappropriately treated,” Westerfield says, adding that “a great deal of interpretation goes into these tests.”
Home Testing
As both a pulmonologist investigating breathing difficulties and an internist looking closely at the effects of medication, Westerfield’s interest is the interworking of sleep apnea and medications that affect sleep is based on his clinical experience. He says, “Any medication that alters the brain for behavioral reasons can also affect sleep. We are a pill society, and many people are taking psychotropic drugs, so I am interested in how these medications may affect sleep.” One interesting example is the relationship between childhood behavior and sleep disorders in children. Many children who are diagnosed with attention deficit hyperactivity disorder (ADHD) are likely to have a sleep disorder too, and Westerfield advises that treatment of their sleep disorder may improve the behavioral disorder. “Rather than labeling children as ADHD and giving them psychotropic medication,” he cautions, “physicians should ensure that a sleep disorder is not the cause of the problem.”
Westerfield’s commitment to improving the practice of sleep medicine is reflected in his involvement with the Kentucky Sleep Society (KSS), which strives to educate patients and physicians about current treatments and issues in the field of sleep medicine. One of the more vexing issues echoed among the KSS constituency is the proliferation of home testing in sleep medicine that eliminates the physician from the diagnostic process. Dr. B. T. Westerfield That patients is medical director seek diagnosis and of the Sleep treatment for sleep Disorder Center of disorders without Lexington. the aid of a physi-
Medications Affecting Sleep
That patients seek diagnosis and treatment for sleep disorders without the aid of a physician is partly due to the great numbers of people who need to be treated. cian is partly due to the great numbers of people who need to be treated. Westerfield estimates that 10% of Kentucky’s adult population suffers from sleep apnea, and pediatric cases of sleep apnea seem to be rising as well. “My concern is that patients who are tested for sleep disorders at home or at a hospital with-
This advice brings Westerfield to the crux of his message. “Good sleep helps in treatment of every medical problem,” he says. “Every patient, no matter what other medical problems they have, will do better if their sleep disorder is addressed by a physician.” ◆
sleep medicine
Sleep Apnea and Heart Disease
Kentucky physicians turn to Dr. Pamela Combs for expertise in diagnosing and treating sleep apnea in cardiovascular patients By Megan C. Smith When Central Kentucky cardiologists have a heart patient who is still experiencing tiredness or fatigue or whose blood pressure is not optimally controlled, they call on Pamela Combs, MD, to evaluate the situation. Combs is an internal medicine specialist with board certifications in sleep medicine, vascular medicine, nuclear cardiology, and echocardiography. For over fifteen years, Combs worked alongside cardiologists in private practice where she provided cardiovascular testing and treatment. It is in this capacity that Combs discovered the integral role that sleep apnea plays in cardiovascular health. “Statistically, about half of all cardiovascular patients with diseases such as heart failure will have sleep apnea,” she says, “and that half does worse. If you look at the failure rate of stents or ablation procedures, many of the group that do not fare as well have sleep apnea.” What’s more, she says, having sleep apnea makes one more likely to develop coronary disease or suffer a stroke than the group that does not have sleep apnea.
PARIS
Sleep apnea & HBP
Evidence points to sleep apnea as a treatable cause of refractory high blood pressure, so Combs cautions that “anyone who is getting on three or four blood pressure medicines should be considered for a sleep study.” Moreover, cardiac conditions and sleep apnea can combine to create new problems, though Combs says that she generally concentrates on sleep apnea with referred patients since their other conditions are already established. “Sometimes you cannot do anything further about the fact that they have a weak heart muscle and they have to be on five drugs for it,” she says, “but half of those people will have sleep apnea, and that part of it you can fix.” For example, of the group failing atrial fibrillation ablation, up to 85% will have sleep apnea. Among stents that do not do as well, sleep apnea may be present in up to
Pamela Combs, MD, internal medicine and noninvasive cardiology testing specialist, is in private practice at Cardiovascular and Sleep Consulting Service in Paris, Kentucky.
one a third of those patients. Additionally, approximately half of all heart failure patients have sleep apnea, too. Treating the root cause means “you almost get a bigger bang with the sleep,” says Combs. “You put them on a CPAP and probably 80-90 percent of them
practice, Combs sees other conditions like edema that could be attributed to sleep apnea. “These conditions occur more frequently than you would expect. We question why people with high blood pressure get to the point where they need a third or fourth drug, or why people with unresponsive edema though their heart pump is okay. These are things that sleep apnea can cause.” Complicating the situation is the possibility that just because a patient is on a sleep apnea treatment does not mean that they are being treated appropriately. Combs explains that this is especially true of heart patients with heart disease and prior strokes who may have central sleep apnea, where the brain does not tell the body to breathe. CPAP does not always trigger breathing, so specialized adaptive servo-ventilator machines are used to trigger breathing. Combs believes that there are many unrecognized cases among this population, and she is passionate about finding them and treating them. “Sometimes, we might write off the tiredness of a heart patient to their age, their medicines, or to other diseases,” she says, “but it is often something correctable. Recognizing that has a signifi-
There are few providers like Combs who are out there trying to link sleep medicine and cardiology together. feel better, so there is a large potential to make them feel better with just air.”
Consulting with Cardiology
In October 2009, she founded Cardiovascular and Sleep Consulting Service in Paris, Kentucky. Combs also directs the sleep labs at Frankfort Regional Hospital, Clark Regional Medical Center, and Bourbon Community Hospital, and she is on staff at Saint Joseph Sleep Center. Because of her noninvasive cardiology
cant impact on their quality of life.” There are few providers like Combs who are out there trying to link sleep medicine and cardiology together. “We do a lot of noninvasive cardiology and a lot of sleep work independently of each other,” she says, “but we are always cognizant that sleep apnea is a risk factor for developing heart problems, and some heart conditions can produce sleep breathing disorders. I view it as another extension of giving my patients the best possible outcome.” ◆ August 2011 21
special section Sleep medicine
Drowsy Driving
UK professor Dr. Barbara Phillips advised transportation industry on dangers of sleep apnea By Megan C. Smith While it’s hard to pin down the percentage of traffic accidents caused by driver fatigue, the issue of drowsy driving has grabbed headlines while shaping commercial driving regulations. According to the Federal Motor Carrier Safety Administration (FMCSA), the division of the US Department of Transportation charged with the mission to reduce crashes, injuries, and fatalities involving commercial motor vehicles, as many as 28 percent of commercial drivers have sleep apnea.1 UK professor Barbara Phillips, MD, MSPH, FCCP, served on the FMCSA Medical Review Board from 2009-2010. During her term, Phillips assisted with the develLEXINGTON
opment and updating of the medical fitness guidelines that medical examiners use to certify drivers’ fitness for duty. They made recommendations on the diagnosis and management of commercial drivers with sleep apnea, including that a diagnosis of obstructive sleep apnea (OSA) should preclude an individual from receiving “unconditional certification to drive a [commercial
motor vehicle] for the purpose of interstate commerce.” Currently, a driver can obtain a CDL provided that they are CPAPadherent. According to Phillips, the FMCSA has yet to act on these recommendations “but many commercial driver medical examiners and trucking companies have adopted them anyway.” The board’s findings were published in both the Journal of Clinical Sleep Medicine 2 and the journal Sleep.3 Phillips believes that integrating sleep apnea into primary care is essential. “As evidence accumulates that sleep medicine results in important consequences and that CPAP treatment can improve outcomes, including blood pressure,
While the FMCSA has yet to act on the Medical Review Board’s recommendations, many commercial driver medical examiners and trucking companies have adopted them anyway. Obstructive Sleep Apnea (OSA) has become a common, preventable risk factor for Heart Disease.
Obstructive Sleep Apnea has been associated with abnormal heart rhythms, high blood pressure, heart failure, increased arterial stiffness, stroke, and type 2 diabetes. If you or someone you care about might have Obstructive Sleep Apnea, see your doctor or contact Sleep Medicine Specialists at 502-454-0755. SleepMedicineSpecialists.com 22 M.D. Update
What is Obstructive Sleep Apnea? - Collapse of upper airway tissue that causes pauses in breathing during sleep - Associated with snoring - Associated with daytime tiredness in many people - May be diagnosed in children and adults - May have a serious affect on medical conditions such as high blood pressure, heart circulation, blood sugar levels, mood, acid reflux and testosterone levels
tHe KentucKy sleep sOciety presents tHe 13tH annual
Sleep Medicine Conference learn frOm tHe experts in sleep medicine. KeynOte presenter:dr marK rOseKind, member Of tHe natiOnal transpOrtatiOn and safety bOard.
Examine sleep from both a clinical and an innovative perspective. The Technical professional tracks will present instruction on technical case studies, interactive scoring scenarios, cardiac challenges identified when recording a sleep study, and breathing disorder management with PAP therapies. The Advanced Seminar will discuss methods to integrate for professional development and increased productivity in the sleep center. The General sessions will provide all of us with updated information about innovative clinical topics.
OctOber 14-16, 2011 HOliday inn HurstbOurne, lOuisville, Ky tO register call 859-312-8880 Or visit Kyss.Org
sleep medicine
mood, coronary heart disease, diabetes control and crash risk, primary care clinicians (and cardiologists and others) are starting to take notice.” Phillips credits both the eligibility of family medicine and internal medicine physicians for the sleep medicine examination and the increasing use and availability of portable testing for bringing more generalists into the fold. “Let’s face it,” she says, “sleep apnea is simply too prevalent and too deadly to be exclusively managed by specialists.” Barbara Phillips, MD, MSPH, FCCP, professor of pulmonary, critical care medicine, and sleep medicine at UK’s Department of Internal Medicine. She was recently honored with the 2011 AASM Excellence in Education award.
ENDNOTES 1. Pack AI, Dinges DF, & Maislin G. (2002). A study of prevalence of sleep apnea among commercial truck drivers. Federal Motor Carrier Safety Administration (Publication No. DOT-RT-02-030). Washington DC: U.S. Department of Transportation, FMCSA. 2. Tregear S, PhD; James Reston J, Schoelles K, Phillips B, Obstructive Sleep Apnea and Risk of Motor Vehicle Crash: Systematic Review and Meta-analysis, JCSM 2009; 5: 573-581. 3. Tregear S, PhD; James Reston J, Schoelles K, Phillips B, Continuous Positive Airway Pressure Reduces Risk of Motor Vehicle Crash among Drivers with Obstructive Sleep Apnea; Systematic Review and Meta-analysis. Sleep 2010; 33: 1373-1380. ◆
August 2011 23
special section Sleep medicine
Striving for Health
Ironman, ENT, and sleep specialist Dr. Ron Shashy reflects on what it takes to succeed in fitness, practice, and life. By Megan C. Smith Dr. Ron Shashy competing in the World Ironman Championships on the island of Oahu, HI in 2009.
GEORGETOWN There’s something infectious about this man’s enthusiasm for fitness. “Doing well in the Ironman or a marathon is no different than doing well in anything,” says Ron Shashy, MD. “You pick something up that you want to do, and if you are passionate about it, you practice at it until what seemed impossible all of a sudden becomes possible.” Witnessing his passion for fitness stirs an excitement in others, and he knows it. “When I speak to groups about being an Ironman, one of the things I talk about is the infectious nature of behavior,” says Shashy. “Behavior is a virus, and normal becomes going to the gym and working out and being healthy.” Shashy, who is an otolaryngologist in private practice at Ear, Nose and Throat Specialists, PLLC of Georgetown, is a fitness enthusiast who promotes health not only in one’s private life but within the medical practice as well. He will be speaking at the Kentucky Sleep Society’s Fall Conference about how providers can create practice habits that excite people about achieving a healthy lifestyle. “In my practice, I think about how I can inspire my colleagues to exercise more or to compete athletically again. I want people who come into my office to know who I am and what I do,” he explains. “When people come into my office they see awards from Ironman Germany, Ironman Austria, the Mercedes Marathon, and the Boston Marathon 24 M.D. Update
Dr. Shashy believes that the solo-practitioner must be more than just a doctor and accept the roles of owner, manager, and provider of the business.
hanging in my office.” Shashy finds he often connects with patients who ask about his races and his experience with personal fitness. “When I am talking to my patients about losing weight or smoking, I immediately carry some authority. They get a sense of who I am beyond the fact that I am a doctor. They see what I have done,” he says, “and
sleep medicine
that I am proud of what I have accomplished.”
Shashy, “because I did not know as many people here and did not have as many connections.”
Honing your skills
Shashy says that one of the most important lessons he has learned is that in private medical practice, “You have to be more than just a doctor.” As owner, manager, and provider of the business, he says that “you have to think about things like what the waiting room looks like, whether patients are being adequately followed in their care. I continue to work on these tasks and do more than just practice medicine.” Shashy wants each person who interacts with his practice to have a quality experience that he or she will tell other people about. He embraces a productized vision for the way he will deliver services based on the famous pie baker in Michael E. Gerber’s book, The E-Myth. Dr. Chad Ahn, otolaryngologist, heads up the Frankfort “Everything about my practice is based office for Ear, Nose and Throat Specialists, PLLC. on quality patient care, cost/benefit analysis, and giving patients a good experience that makes he would succeed. He had left the Mayo them feel like an individual. When you think Clinic and picked a practice in Atlanta about the business of a solo practitioner, I am where he thought he would build a practice really just making pies. But we aren’t talking key and raise a family. “We talked ourselves lime pie; it is Mayo Clinic-Trained ENT, Ron into moving to Atlanta, but we hated the Shashy – that’s the pie. place and moved to Lexington.” “It is not just what I deliver to the patient,” The leap of faith paid off. Shashy dis-
Shashy finds he often connects with patients who ask about his races and his experience with personal fitness. “When I am talking to my patients about losing weight or smoking, I immediately carry some authority,” he says. he says, “It is also what I deliver to each doctor. Often I will call the referring doctor in the middle of my visits to encourage collaboration and to show that I am taking the time right then and there to fix the problem.”
Committing to life
When Shashy started Ear, Nose and Throat Specialists, PLLC at the practice’s Georgetown Community Hospital location in 2006, he admits that he was not sure
covered it was more important that his family live in a quiet neighborhood – not a big city - with quality schools and good people. “I never imagined that I would be living so happily in Lexington with a business partner and second practice in Frankfort,” he exclaims. One year later, ENT Specialists opened its second location at Frankfort Regional Medical Center, led by partner Chad Ahn, MD. “Chad was a home run for me” says
Achieving your goals
As a comprehensive otolaryngology practice, ENT Specialists diagnoses and treats all ear related problems, cancers of the head and neck, sinus, allergy, and facial plastics for pediatric and adult cases. “Patients hear ENT and they just think we look at the ears, nose, and throat, but there are a lot of other things that go along with that,” says Ahn. Advanced services include removal and repair of skin lesions of the face, head, and neck; modified quantitative testing for allergies; Balloon Sinuplasty for treatment of chronic sinusitis; ENG, caloric, hearing, and neurological testing for vertigo and balance; and sleep studies for both children and adults. The providers embrace the mix of medical and surgical care, with a bit of primary care added in. Since they practice in small communities, Ahn says ENT Specialists strives to listen to patients and remain accessible to them, even providing their cell phone numbers to surgery patients. “Ron and I make sure patients know we are always available to them. That can be an issue sometimes at three in the morning, but I think patients really like hearing my voice the day after surgery. That goes a long way.” In addition, both providers take care to reach out to referring physicians and let them know that, when patients come in for a visit, “they are not just getting someone who looks in their ears, they are getting a comprehensive look at the problem,” says Ahn. As for their practice goals, Ahn says, “Ron and I want to provide the highest quality and the most advanced ENT care that patients can get anywhere in the country, and we want to do it locally so patients don’t have to drive into big cities to get that kind of care.” ◆ August 2011 25
NEWS ◆ EVENTS ◆ ARTS
BMA
grand rounds news@md-update.com
Neurologist Joins Baptist Medical Associates
ST. MATTHEWS David Salvatore, DO, has joined Neuroscience Associates, part of Baptist Medical Associates. Dr. Salvatore is a 2007 graduate of Western University of Health Sciences in Pomona, California. He completed an adult neurology residency at Grandview Hospital and Medical Center in Dayton, Ohio, in 2011. While there, he served as chief resident from 2009-10 and received special recognition for excellence in stroke care.
Dr. David Salvatore
Lexington Medical Society Wednesday, 2011 Wednesday,September September 21, 21, 2011 Shotgun start: 1:30 p.m. Lunch at noon provided by Raising Cane ’s Chicken Fingers
$100/person $500/hole sponsor $800/hole sponsor with foursome All proceeds benefit Lexington Medical Society Foundation, Inc. Call 859.278.0569 or email jverba@LexingtonDoctors.org for info. 26 M.D. Update
UK Names Chair for New Department of Otolaryngology-Head and Neck Surgery
LEXINGTON Dr. Raleigh O. Jones Jr., was recently appointed the first chair of the recently created Department of Otolaryngology-Head and Neck Surgery in the UK College of Medicine. The UK Board of Trustees approved the creation of the Department of Otolaryngology-Head and Neck Surgery, effective July 1, 2011, after a committee studying the strengths and weaknesses of the program unanimously recommended that the division become a department. “The creation of the Department of Otolaryngology-Head and Neck Surgery should allow UK HealthCare to continue to grow in its missions of excellence
Golf Golf Tournament Tournament
Means Named Executive Vice Dean of the UK College of Medicine
UK
LEXINGTON Dr. Robert T. Means Jr., professor and senior associate chair of internal medicine and associate dean for veterans affairs, has been appointed executive vice dean of the UK College of Medicine. Means will be responsible for providing
operational guidance to the academic endeavors of the College of Medicine as well as assisting the College of Medicine leadership team in the development and implementation of initiatives. He will continue to serve as associate dean for Veterans Affairs, having primary oversight of the College’s interactions with the Lexington VA Medical Center. JHSMH
UK
news
Dr. Raleigh O. Jones Jr.
in clinical care, education and research,” said Jones. “The Department has 13 faculty members with clinical programs headed by fellowship trained specialists in head and neck oncology, neurology, facial plastic surgery, pediatric otolaryngology, voice and advanced sinus surgery. Our goal is to provide the finest care to all Kentuckians so that there will never be a need to seek care outside Kentucky.”
Dr. Robert Means Jr.
Louis I. Waterman
August 2011 27
JHSMH
news
Jewish Hospital & St. Mary’s Healthcare Announces New Board Chair
Kaelin Named Medical Director of Frazier Rehab Institute
LOUISVILLE Jewish Hospital & St. Mary’s HealthCare has named Darryl L. Kaelin, MD, Medical Director of the Frazier Rehab Institute. Kaelin is also an asso-
28 M.D. Update
CMD Holding has named Jim LeMaster President of New Market Development for ClubMD, the orga-
LEXINGTON
Dr. Darryl Kaelin
CMD Holding
LOUISVILLE Louis I. Waterman, a leading family law attorney in Kentucky, has been elected chairperson of the Jewish Hospital & St. Mary’s HealthCare Board of Trustees. Over the past 13 years, he has served on the boards of the Jewish Hospital Foundation and Jewish Hospital HealthCare Services and was an inaugural member of the Jewish Hospital & St. Mary’s HealthCare Board. An honors graduate of the UK and the University of Louisville Brandeis Schools of Law, he maintains a domestic relations practice in Louisville.
LeMaster Signs On to Lead New Market Development for ClubMD
ciate professor at the University of Louisville and Chief of Physical Medicine and Rehabilitation in the Department of Neurological Surgery. He will oversee inpatient and outpatient services at Frazier Rehab, as well as the rehab division in several areas including spinal cord injury, brain injury, pediatric rehab, pain medicine and outpatient spine and musculoskelatal care. Jim LeMaster
JHSMH
news
nization’s healthcare delivery model. He joins after serving as an attorney at Stoll Keenon Ogden PLLC as Chairman of the firm’s Government Relations Practice. From 1997 to 2004, he was the President of Kentucky Operations and VP of Association Sales for Anthem Blue Cross Blue Shield. He will be responsible for raising awareness among Lexington area employers for ClubMD and provide non-commissioned assistance to agents of record in the sale and service of the CMD Health/ClubMD product and oversee employer relations in Central Kentucky.
New VP of Finance for JHSMH
Jewish Hospital & St. Mary’s HealthCare has named Christopher L. Roszman as Vice President of Finance. Roszman has more than 20 years of pro-
LOUISVILLE
country’s largest accounting and consulting firms. At BKD, he assisted health care providers with audit, consulting and revenue and performance management solutions. “Christopher Roszman has a terrific history of managing the financial interests of a healthcare system like ours,” said Ron Farr, JHSMH Senior Vice President/Chief Financial Officer. “We’re pleased to bring his expertise onto our team.”
Van Nagell Honored by KY House of Representatives
Chris Rozman
gressive health care financial and operations experience. He has served as both a senior vice president of finance in a multi-hospital system and as a public practice CPA. Most recently, he served as partner with BKD, LLP Health Care Group, one of the
Epidurals Facet Blocks
Intrathecal Pumps Vertebroplasty
Main Office: 2416 Regency Road, Lexington
LEXINGTON UK physician Dr. John R. van Nagell Jr. was formally recognized for his years of service in House Resolution No. 23 by the House of Representatives of the General Assembly of the Commonwealth of Kentucky for his “years of dedicated and outstanding service to the Kentucky
Spinal Cord Stimulation Neurolytic & Sympatholytic Denervation Satellite Office: 125 Foxglove, Mt. Sterling Satellite Office: 256 Burkesville Road, Albany
August 2011 29
UK
Ophthalmology and Visual Sciences at the UK College of Medicine, has been selected as one of two junior faculty clinicianscientists to receive the Foundation Fighting Blindness (FFB) Career Development Award in fiscal year 2011. The FFB indicates that the purpose of this award is to “jump-start” the careers of highly-qualified junior investigators to pursue research programs to drive the research to find therapies and cures for retinal degenerative diseases. The award will be given in five annual payments of $75,000 for a total of $375,000.
Georgetown Community Hospital
UK
news
Dr. John R. van Nagell Jr.
medical community as he furthers the cause of better health awareness for the women of the Commonwealth,” according to the resolution. Van Nagell serves as an American Cancer Society Professor of Clinical Oncology at the UK College of Medicine. Thanks in part to his efforts, the UK Markey Cancer Center is a major referral center that is nationally renowned for its treatment of patients affected by gynecologic malignancies. He is also the director of the Ovarian Cancer Screening Program at UK, the largest program of its kind in the US.
Ophthalmologist Wins Career Development Award
LEXINGTON Dr. Mark Kleinman, assistant professor and researcher in the Department of
Neurologist Moves into Georgetown
GEORGETOWN Dr. Ryan Owens has joined Georgetown Community Hospital. Owens is a board-certified neurologist
Dr. Ryan Owens
who sees patients for a variety of neurological problems and disorders such as Parkinson’s disease, multiple sclerosis and migraines, among others. His special interests include sports concussions and stroke. He received his medical degree and completed his residency at the UK Chandler Medical Center. ◆
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Dr. Mark Kleinman 30 M.D. Update
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Lexington | Louisville | Cincinnati 800.344.9098 | D S N E A L . C O M
events
LEXINGTON Nearly 200 of the nation’s top orthopedic-sports medicine physicians, physical therapists, athletic trainers and other professionals attended the 14th Annual Shoulder Symposium, presented by the Shoulder Center of Kentucky on July 29-30 in Lexington. The theme of the Symposium was “The Disabled Throwing Shoulder: 10 Year Update.” Topics ranged from labral and rotator cuff injury, anatomic and physiologic adaptations in the throwing shoulder to surgical and rehabilitation techniques. The Shoulder Symposium brought experts and attendees from around the world, including South Korea, Italy and Argentina, plus a full representation of physicians and other sports medicine professionals from various parts of the U.S.A. Speakers included W. Ben Kibler, MD, Medical Director of Lexington Clinic Orthopedics-Sports Medicine Center, Richard Hawkins, MD, of the Stedman Hawkins Clinic of the Carolinas, Jed Kuhn, Chief of Shoulder Surgery at Vanderbilt Sports Medicine Center, David Linter, MD head team physician for the Houston Astros, among many others.
The Shoulder Center is associated with the Lexington Clinic Orthopedics-Sports Medicine Center. More information is available at 859-258-8575 and www.info@ shouldercenterofky.com.
Kentucky Society of Healthcare Public Relations and Marketing Fall Conference.
consulting. His consulting experience focuses on building better hospital-physician relationships, physician employment, and physician practice management. KSHPRM will be awarding its annual Thoroughbred Award to excellence in recognize Marketing/Public Relations at a luncheon on October 11. Entries are due by September 1. Direct inquiries to questions, Ashley Sides Johnson of Methodist Hospital at (270) 831-7836 or via ajohnson@methodisthospital.net
Kentucky Sleep Society’s 13th Annual Sleep Medicine Conference October 14-16, Holiday Inn Hurstbourne, Louisville, KY
October 10-11, 2011, Louisville
Davis Creech, senior project manager with the Healthcare Strategy Group, LLC, is scheduled to headline the 2011 Fall Conference of the Kentucky Society of Healthcare Public Relations and Marketing (KSHPRM). Creech has over fifteen years’ experience in hospital-physician relations, practice management, and Davis Creech KSHPRM
Shoulder Symposium Meets in Lexington
International experts presenting at the 2011 Shoulder Symposium: ( l-r) Aaron Sciascia, MS, ATC, NASM-PES; Anthony Romeo, MD; Kevin Wilk, PT, DPT; Todd Ellenbecker, PT, DPT, MS, SCS, OCS, CSCS; Felix Savoie, MD; Richard Hawkins, MD; David Linter, MD; W. Ben Kibler, MD; Jed Kuhn, MD; Tim Uhl, PhD, ATC, PT, FNATA; Robin Cromwell, PT; Chuck Thigpen, PhD, PT, ATC.
The Kentucky Sleep Society’s fall conference will address clinical and technical innovations in the practice of sleep medicine. Advanced sessions will cover professional development and productivity concerns. Keynote speaker Dr. Mark Rosekind, chair of the National Transportation and Safety Board, will sleep’s role in national transportation safety issues. Direct inquiries to Kathryn Hansen at 859-312-8880 or kathrynhk@msn.com. ◆
August 2011 31
arts
Art for the Community
Crystal Bader and Bruce Burris are owners and program directors at Latitude Artist Community in Lexington.
Art for All
Latitude creates meaningful, inclusive community interactions for adults with disabilities By John Cowgill LEXINGTON Art is a mysterious thing. It has the ability to confound, to inspire, to energize and even to perplex. At Lexington’s Latitude Artist Community, however, art has the ability to empower a group that is too often marginalized. Owned by local artists Bruce Burris and Crystal Bader, Latitude acts as both a community providing care for persons considered by some to have a disability and as an advocacy group promoting the rights and needs of those with disabilities. Although this mission may seem similar to that of traditional adult day support, Latitude’s approach to disability is anything but ordinary. “At Latitude we create an environment which emphasizes potential and ability. Artists at Latitude explore ways in which they can advocate for themselves and others 32 M.D. Update
and in so doing learn how to navigate the world we all share,” says Bader. To accomplish this goal, Latitude functions as a living, breathing artist community. Burris , Bader, and their team of experienced artists serve as mentors who encourage and guide each of the program’s participating artists in creating art as a form of self-expression. “Working through the arts is the best way to create an environment that is not about disability,” says Burris . “The arts are a creative method and they promote freethinking and acceptance.” Artists at Latitude create an incredibly broad range of art. Drawings, paintings, and sculptures line the walls of the center and artists can be seen working with found materials as well as traditional art supplies in a variety of media. This highly creative, varied approach is a fundamental part of Latitude’s process. “We place a great deal of emphasis on the process we use to create art,” says Burris . “We use avante garde methods and work with our artists to guide them in the right direction.” Burris admits this is often not easy. “Working with these artists requires that we understand the disconnect in their lives in order to understand how we can connect them with the community through art.”
This observation brings Burris to the second part of his mission at Latitude- connecting artists with the community around them. “At Latitude, it is not enough to bring artists in and just have them make art. We are always looking for ways to get our artists out there in a way that they have never been before,” says Burris. Burris and Bader attribute some of their emphasis on community goals to Medicaid, which provides them with the majority of their funding. “One of the things Medicaid harps on, correctly, is the idea that people should have community goals that will be met,” says Bader. Putting artists out in the community is an undertaking that Burris and Bader have found especially rewarding. “When you put our artists work out there in the community, you show people that disabled persons don’t have to be crowded together in a day support and pushed to margins of society,” says Bader.
Art for the Individual
In actively engaging the artists with creative expression and empowering them to connect with their community through art, Latitude Artist Community provides a powerful alternative to the traditional care of adults with disabilities. “People living with disabilities often have a low quality of life. Ninety-nine percent of the people they interact with are paid to care for them. We want to give these people a means of expression and direction that can raise their quality of life,” said Burris . Judging from the reactions of artists in Latitude, it would appear Burris and Bader have achieved their goal. “For a lot of these artists, having their work featured in the community and held up as something that is powerful and important is the most significant community interaction that has ever happened in their life,” Burris says. Norma, an artist at Latitude who recently had her drawings featured in an exhibit in Cincinnati, interrupts him. “I would say that is true,” she says, before turning away and eagerly returning to her art. Learn more about the artist of Latitude latitudeart. blogspot.com or calling (859) 806-0195. ◆
Who undeRstands the financial needs of a Medical pRactice MoRe than a doctoR?
Dr. Gregory Kasten, Founder/CEO Unified Trust
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