M.D. Update September 2011 - Urology

The Business Magazine of Kentucky Physicians and HealthCare Administrators September 2011

Special Section Also inside  Transplant 

Volume 2, Number 8



Economics page 4 Asthma’s Match page 12 Central Kentucky Research Powerhouse page 16

Urology

Now fully integrated, the union of Commonwealth Urology and Lexington Clinic demonstrates that quality care and physician autonomy coincide in the reality of medical practice mergers.

Merger Delivers More

Kentucky’s FIRST HIGH DEFINITION daVinciŽ Surgical Robot System was installed at Saint Joseph Hospital in 2007.

Surgeons at Saint Joseph Hospital have more experience with robotic surgery than any other facility in Lexington.

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Contents

September 2011 Volume 2, Number 8

2 letters

cover story

4 Headlines 9 Finance 10 Practical insight 10 Interventional Nephrology 12 allergy, Asthma & Immunology 14 Otolaryngology 15 Orthopedics 16 Research 19 Cover Story 22 Special Section

Urology 28 News

Merger Delivers

More

On the Cover: Commonwealth Urology joined the Lexington

Clinic on April 1, 2011. Combined, they have 21 urologists serving multiple locations throughout Central Kentucky. (Pictured L-R): K. Eric Ruby, MD (CU); Andrew C. McGregor, MD (LC); Lexington Clinic CEO Andrew H. Henderson, MD; Thomas K. Slabaugh, Jr., MD (CU); Stephen J. Monnig, MD (LC); and Charles G. Ray, MD (CU).

Featured professionals

4 Charles Hoopes, MD

7 Ann Rhoten, AuD, CCC/A

10 Amy Dwyer, MD

12 Farhad Karim, MD

18 Debbie Dyer, RN, BSN

22 Michael Heit, MD, PhD

23 Ganesh S. Rao, MD

24 Dr George W. Privett, Jr

25 Dr Amberly K. Windisch

26 Cameron S. Schaeffer, MD September 2011 1

Letters to the editor Kentucky Issue Volume 2, Number 8 September 2011

Dear Editor:

In reading Lisa English Hinkle’s excellent article on “The New Duty to Refund Overpayments,” I wanted to point out that the duty to refund overpayments is not new. The “60 day rule” is new, but providers had an existing duty to return overpayments. When I served as a federal prosecutor handling health care fraud cases, one of the tools we had to prosecute providers was a federal statute, 42 USC 1320a-7b, that required providers to return overpayments or risk imprisonment. The statute’s relevant part reads as follows: “having knowledge of the occurrence of any event affecting (A) his initial or continued right to any such benefit or payment, or (B) the initial or continued right to any such benefit or payment of any other individual in whose behalf he has applied for or is receiving such benefit or payment, conceals or fails to disclose such event with an intent fraudulently to secure such benefit or payment either in a greater amount or quantity than is due or when

no such benefit or payment is authorized.” In essence, if the provider is aware that he or she has received an overpayment and willfully keeps it, the provider could risk imprisonment of up to five years for the overpayment. The new 60 day rule arguably gives the provider a window of opportunity to return the overpayment within 60 days and avoid the criminal penalty of 42 USC 1320a7b, but, as Ms. Hinkle points out, there are many considerations for a provider who has received an overpayment. The complex web of federal statutes, regulations, and billing rules can become a trap for any provider. Nonetheless, a provider should be aware of a potential criminal penalty, in addition to civil penalties, for an overpayment issue when seeking advice on how to handle the overpayment.

Thank you, C. Dean Furman dean@lawdean.com (502) 245-8883

Submit your Letter to the Editor to Megan Campbell Smith at mcsmith@md-update.com

Publisher

Gil Dunn gdunn@md-update.com Editor in Chief

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Photographers

Kirk Schlea Liz Haeberlin Writers

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September 2011

Special SectioN

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Urology

 Transplant

Economics pagE 4  asthma’s Match pagE 12  Central Kentucky Research powerhouse pagE 16

now fully inTegraTed, The union of coMMonwealTh urology and lexingTon clinic deMonsTraTes ThaT qualiTy care and Physician auTonoMy coincide in The realiTy of Medical PracTice Mergers.

Merger Delivers MoRE

Volume 2, Number 8

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Headlines

Transplant Economics

Why Community Matters in the Reigning In of Healthcare Costs Lexington

Dr. Charles Hoopes, director of UK’s Heart and Lung Transplant and Ventricular Assist

Device programs, joined UK’s faculty in December 2010 and has performed fourteen double lung transplants. Hoopes, who came from UC San Francisco, regularly performs heart transplants, lung transplants, and implants artificial heart and lung devices. M.D. UPDATE editor-in-chief Megan Campbell Smith talks with Hoopes about the costs and benefits of transplant medicine, how doctors and institutions can make a huge impact on healthcare spending, and the reason why it will take community involvement to get it done.

M.D. Update: Dr. Hoopes, help us understand the economic issues behind transplant centers.

Hoopes: The reality of academic medical centers is that your available services and level of care are contingent upon your ability to generate revenue. So, from the hospital’s perspective the service that makes the greater income is the more attractive…more likely to be supported, nurtured…not because it is more important but because it is a revenue stream that can support care of important but less lucrative – in reality, non-procedure based – medicine. This is where transplant medicine can get tricky, because if transplant becomes a significant source of income for a hospital, the hospital can begin to depend on the income from transplants to provide other services to other patients.

Charles Hoopes, MD, is director of UK’s Heart and Lung Transplant and Ventricular Assist Device programs. He has performed 14 double lung transplants since coming to UK in December 2010.

and you compare them to the costs of taking care of an end-stage emphysema patient or a patient with congestive heart failure, the cost of transplant surgery is less than one and a half percent of the total expenditure on health care in the United States. So in the big picture of expense, transplant has a very low cost collectively but is a very big expense and investment in one individual.

How is it decided who gets transplanted?

From the hospital’s perspective, transplants are like a private “fee for service” practice in that you must be able to afford the services to receive the services. That’s why community-based executive boards, at transplant centers and organ procurement organizations, are important -- they help to ensure that the patients who really need transplants are able to get the care they need. The way the system is set up now, if you don’t have insurance or private resources you can’t get on the list to have a transplant (see King et al, 2005, Health insurance and cardiac transplantation: a call for reform. J Am Coll Cardiol 45(9):1388).

This is a big issue with transplant currently: the cost vs. benefit, and for whom. When you look at heart transplant or lung transplant

Access to solid organ transplant is determined by federal allocation policy. However, there are complexities. We have patients on our list that we aren’t going to be able to transplant without significant financial loss because they need double organs – for example heart and kidney - but Medicare and Medicaid currently will only pay for a single organ transplant.

Why a double lung transplant for one person rather than a single transplant for two?

It is widely acknowledged that that double lung transplants are the better longterm operation - better survival curve, better performance at two years. But, it’s been a resource utilization issue whether you should use two singles and have two people who are off oxygen - though their quality and length of life may not be as good - or whether you should try to give one person two lungs with a better long term outcome.

After active debate in the last five years major transplant centers have moved almost exclusively to doubles.

Now, even this new trend is starting to slow with some of the bigger centers starting to perform single organ transplants again for select patients, such a older patients with pulmonary fibrosis where survival advantages of double lungs is less certain. The issue with lung transplants is really about trying to provide quality for life - more so than a long-term survival procedure.

Even for the cystic fibrosis?

No, patients with cystic fibrosis require a double lung transplant and overall survival is quite good (see www.ishlt.org for thoracic organ outcomes).

The challenge with cystic fibrosis is that 4 M.D. Update

headlines

where you get your care has everything to do with your outcome – that is true medically and, as a general rule, true in transplant as well. Pre-operative medical care is the biggest predictor of how patients do in the postoperative transplant setting as it impacts the timing of cystic fibrosis transplants. This has been a major outcomes issue.

Cystic fibrosis tends to be a gene mutation more frequent in the historic Scotts-Irish population common to Appalachia…there is simply a large regional cohort of patients.

Expertise and clinical outcome in cystic fibrosis is in large part a consequence of experience, and experience has to do with your patient referral patterns. In my opinion, UK ought to be a dominant CF referral center.

It can’t be easy to be looking at end-stage disease and still have to adjust with costbenefit analysis.

Well this is the issue; this is why it has become a nationwide discussion.

THIS IS AN ADVERTISEMENT

Transplantation is a public health issue.

There are people who feel very strongly that the first thing we should create is greater – and equitable access. Thoracic transplantation as a clinical entity is very small – 95 percent of the waiting list for organs is for kidney/pancreas or liver transplants.

There is such a need for kidney organs that it is drawing nationwide attention in the New York Times (“New Kidney Transplant Policy Would Favor Younger Patients” February 24, 2011; “One Death Provides New Life for Many” on May 16, 2011). Some people think it is time to readdress the issue of paying for kidneys from healthy donors, where you simply say, “I’ll give you health care for the rest of your life if you’ll give us a healthy kidney.” This issue has been debated multiple times and turned down, but it is being raised again.

What is the climate like for Kentuckians in need of transplant?

If you are in Kentucky you are blessed because we have among the shortest kidney wait list times in the country. Patients from California might come here to get a kidney because they will get it in 3 to 4 months, but if they stay in California they may die on the waiting list given wait list times of more than five years. This is debated nationwide because some people think that organs should go wherever the need is most dire and not be held to geographic restrictions. Others don’t feel the same way. Overall, however, Kentucky does not currently have a sufficient number of organs donated to transplant all the Kentuckians in need of transplant…it probably does have an adequate number of donors…they simply do not come to donation.

Be sure to check out the expanded coverage of our interviews with Charles Hoopes at M.D. Update Online Edition md-update.com ◆

Practicing in All Areas of Health Care Law Long Term Care, Senior Housing and Home Health Physician Contracting Professional Licensure Defense Health Information and Technology Hospitals and Health Systems Fraud and Abuse Reimbursement, Accreditation and Regulation Health Care Reform

THE RESOURCES TO FULFILL ALL YOUR HEALTHCARE LEGAL NEEDS.

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201 East Main St., Suite 1000 | Lexington, KY 40507 | (859) 231-8780 September 2011 5

Headlines

Pediatrics and Psychiatry

Transcending boundaries to meet the needs of a young population By Jennifer S. Newton LOUISVILLE The term crossover has become a buzzword in modern media from automobiles to technology, and medicine is no exception.

While there are many medical specialties that work in tandem, none may be so natural or critical a fit than the evolving partnership of pediatrics and psychiatry. John Gallehr, MD, medical director of the developmental disabilities unit at Our Lady of Peace, is a graduate of the five-year, triple-board combined residency program in pediatrics, adult psychiatry, and child and adolescent psychiatry that began 25 years ago at six sites across the United States, including the University of Kentucky. The program’s goal is to integrate training in biological and behavioral sciences in order to better treat the whole child.

In his role at Our Lady of Peace, Gallehr sees patients with autism, mental retardation, severe behavioral disorders and other developmental disabilities, but he also works one afternoon a week in a pediatrician’s office, seeing a range of routine medical and developmental issues. Gallehr asserts that medical and infectious diseases are becoming a smaller part of pediatricians’ practices, while behavioral problems have increased. “Immunization has decreased the amount of infectious disease we see,” said Gallehr. For example, he cites the decrease in ear infections due to the pneumococcal conjugate vaccine (PCV), furthermore according to the Centers for Disease Control and Prevention, severe pneumococcal disease has decreased by 80 percent in children under age five since the advent of PCV. Gallehr also attributes the trend to families being more sophisticated and treating more at home.

What pediatricians and schools are seeing more of are behavioral problems, including ADHD, oppositional symptoms, and conduct disorder symptoms. One reason for the increase in behavioral problems is the emphasis on test scores in schools.

“Educational issues are much more prominent than they were before,” says Gallehr.

“Kids are more stressed. We’re even seeing depression. More families are requesting evaluations for medications because of test scores.” Another potential cause of school difficulties is bullying, which caregivers have become more attuned to. “One difference I notice is that physicians are more likely 6 M.D. Update

John Gallehr, MD, medical director of the developmental disabilities unit at Our Lady of Peace, is a graduate of UK’s five-year, triple-board combined residency program in pediatrics, adult psychiatry, and child and adolescent psychiatry.

Gallehr integrates biological and behavioral sciences in order to treat the whole child.

to recommend therapy and counseling for behavior problems rather than passing off bullying issues as ‘just part of life,’” he says.

While Gallehr is a product of ◆ the integrated triple-board program, many physicians are taking on roles outside their training.

Managing medications for some psychiatric diagnoses is a part many pediatricians are now playing, in addition to screening for autism, depression, and drug and alcohol use. “Seven percent of youngsters are diagnosed with ADHD, which is a big increase from a few decades ago,” says Gallehr, and pediatricians are handling most of the patient management for that. Depression is more common than was previously understood, and pediatricians Upcoming Community Seminars:

Our Lady of Peace is offering a series of free seminars for parents with schoolage children: Teen Depression:

Warning signs of suicide and how to help your teen - September 20 Addiction and the Adolescent Brain:

What parents need to know - October 25 Setting Boundaries for the Difficult Child

Without Having to Say No (Too Often!) December 6 Registration is free, call (502) 479-4495. The events take place at Our Lady of Peace, 2020 Newburg Rd., Louisville, KY 40205.

are prescribing antidepressants for anxiety disorders such as PTSD, OCD, and major depression and mood stabilizers such as lithium, Depakote, and Trileptal for bipolar disorder. They are also prescribing neuroleptics for behavior issues and autism.

“Pediatricians have always taken care of childhood behavior problems,” says Gallehr.

Howerver this new trend takes pediatricians into a deeper partnership with parents and requires a dual approach of medical and psychiatric principles. One impetus for pediatricians taking on a larger role is, in part, because national organizations are giving doctors the tools to make these diagnoses in children, as in the case of autism. “We are also much more sophisticated with biologic therapies on the psychiatric side,” says Gallehr, understanding that medical issues can cause problems in the brain. Although child psychiatrists could potentially assist families with a larger spectrum of issues including mild school refusal and mild family issues, the reality is they are in very short supply. As a reslut the integration of services with the pediatric community is welcome assistance. The crossover is also being supported by local organizations providing education for physicians and the community.

(See sidebar for further details.)

Going forward, Gallehr believes the most important issue is communication.

“We need to talk to each other so kids get the care they need.” ◆

headlines

Relief for Ringing Ears

Tinnitus patients, long thought to suffer under their untreatable condition, are finding relief with Tinnitus Retraining Therapy. By Megan C. Smith with Photography by Liz Haeberlin Lexington “After saying for twenty years that I couldn’t do anything to help,” she starts, “I’m excited that I can finally help the tinnitus sufferer.”

For Ann Rhoten, AuD, CCC/A, helping patients with tinnitus had been a long term frustration for the lack of satisfactory treatments options.

“For many years, I went to continuing education courses on tinnitus and heard there was nothing new. Then about two years ago,” she recalls, “I learned that we could successfully treat tinnitus and that people didn’t have to just learn to live with it anymore.”

Rhoten’s excitement led to her becoming certified by the Tinnitus Practitioners Association in the treatment of tinnitus and to specialize in Tinnitus Retraining Therapy (TRT), which was developed by Pawel J. Jastreboff, professor and director of Emory University’s Tinnitus and Hyperacusis Center in Atlanta.

TRT consists of two parts – counseling and sound therapy. The counseling focuses on teaching the person with tinnitus about the auditory system and the structures in the brain that are causing them to suffer. “This demystifies the tinnitus and allows for the habituation of the reaction to it,” says Rhoten.

The second component, sound therapy, provides patients with a soundscape where tinnitus slips into the background of more compelling auditory content – like the humming of the computer we can barely perceive above our own conversation.

“When things are quiet,” explains Rhoten, “our ears turn up the gain so they can pick up on soft things. What sound

Ann Rhoten, AuD, CCC/A, provides tinnitus retraining therapy at Kentucky Audiology & Tinnitus Services in Lexington.

therapy does is allow the ears to turn down the gain by reducing the contrast between the tinnitus noise and the background.

Eventually, it recalibrates your ear and your brain such that the tinnitus noise can be put in the background. Like your brain puts the computer sound in the background, sound therapy habituates the patient’s perception to the tinnitus.”

Many tinnitus sufferers are on constant alert and experience anxiety, depression, and sleep problems. Habituation, while not a cure, is an effective treatment. At over 80% effectiveness, TRT is twice as effective as

Before TRT, conventional wisdom said there is no cure for tinnitus, so for decades patients felt like they could never get rid of the ringing in their ears. That’s when the autonomic nervous system and limbic systems get involved, and the negative reaction to the tinnitus becomes a vicious cycle.

other treatment programs.

Sound therapy

There are many theories regarding the source of tinnitus; dysfunction of the cochlear neurotransmitter systems, heterogeneous activation of the efferent system, or central, to name a few. Many believe tinnitus is caused by damage to the ear’s outer hair cells which converge on the auditory nerve in a mismatch of signals from the inner hair cells and their damaged, outer counterparts.

This imbalance causes typically random firing neurons to fire in a recognizable pattern perceived as ringing, roaring, or chirping noise, i.e. tinnitus.

“We all have spontaneous activity in our brains all the time, but we don’t perceive anything until it becomes some recognizable pattern. When we are in a really quiet environment, about 94% of people will experience tinnitus,” explains Rhoten.

“Researchers believe this is just a spontaneous firing of the nerve that, because it is so quiet, the brain recognizes as a pattern in the neural firing.”

September 2011 7

headlines

Sound therapy works by minimizing the contrast between the tinnitus sound and other background noises. It can come from many sources – the din of traffic through an open window, a CD or MP3 playing nature sounds, white noise, or non-harmonic soundscapes called fractals. Sound generating devices can take the form of a pillow, or they can be coupled with hearing aids that utilize the newest

there is no cure for tinnitus, so for decades patients felt like they could never get rid of the ringing in their ears. That’s when the autonomic nervous system and limbic systems get involved, and the negative reaction to the tinnitus becomes a vicious cycle.

“You get in that mode where you are anxious, your heart rate is up and you are really alert, which makes you pay attention to the Rhoten is gratified that tinnitus retraining therapy now offers effective treatment for longtime suffers of the disturbing condition.

open-ear sound technology.

For effectiveness and compliance, an ear level device is the patient’s best option. Rhoten cautions that tinnitus generally becomes louder if you close off the ear, so headphones and ear buds are not always appropriate.

Counseling

Rhoten describes the second mechanism of tinnitus as the difference between someone who experiences tinnitus and a sufferer of tinnitus. Seventy-five percent of people who experience tinnitus don’t react to it. It is like the noise of the refrigerator, it is there but you don’t notice it. It is when the autonomic nervous system and the limbic system get involved that the person who experiences tinnitus becomes the tinnitus sufferer.

Before TRT, conventional wisdom said 8 M.D. Update

tinnitus more,” says Rhoten. “The more attention is paid to the tinnitus, the more anxious the person becomes. The cycle is repeated over and over again.”

Counseling and patient education aims to diminish this cycle and help patients realize that not only are these sounds not harmful, they can be treated, too.

How do patients react to the thought that these sounds are a real perception to a phantom sound, and that there is nothing to be fearful or anxious about? “It doesn’t work to just say it,” says Rhoten. “Patients go through the education process and learn about the whole system repeatedly to reinforce the new information in order for it to be as automatic as the negative thoughts were about tinnitus.”

Other Medical Conditions

Because some medical conditions that cause tinnitus can be treated medically, it is essential that each patient receives a thorough medical evaluation. “Most often, tinnitus is caused by the imbalance in the hair cells,” says Rhoten. “But occasionally the cause is treatable. Hopefully by having a medical evaluation, they will either find a cause that can be treated, or they can be assured that this is not life threatening and that there are methods of treatment.”

Using TRT, says Rhoten, sound therapy and counseling can be highly effective for the person who experiences hyperacusis as well. Patients with hyperacusis have a decreased tolerance for sounds, and 40% of tinnitus sufferers have hyperacusis too. “The sound therapy for hyperacusis patients,” says Rhoten, “is never loud or annoying, but it should be loud enough that eventually the ear turns down the gain in the auditory system and the patient tolerates normal sounds again.”

Other conditions associated with tinnitus, misophonia and phonophobia, cause patients to have either a severe dislike of sound or fear of sound. Sound therapy and education are again the key treatment strategies. Unlike tinnitus and hyperacusis, it is helpful for the misophonia and phonaphobia sufferer’s sound therapy to have meaning and content – like music or television.

Rhoten observes that one’s personality can have a strong influence on their reaction to tinnitus, hyperacusis, or misophonia; like her own husband, she recalls, who had tinnitus for a long time but never sought treatment because it just didn’t bother him very much. “For others, they stay up at night and are distressed by the feeling that there is nothing that can be done about it, even though that is not true.”

Rhoten says she is excited to help patients and their doctors who are frustrated by tinnitus. “I’m excited to relieve people of their reaction and perception to their tinnitus,” she says. “And after working alongside ENTs for twenty years, I am glad to provide a service that has been missing for a long time.” ◆

finance

Buy-and-Hold May Be On Life Support Decades come and go. As I observed the 10th anniversary of 9/11, I realized just how quickly the past ten years have gone by.

That event seems much more recent than its reality. Maybe it’s a sign of our times, my age, or the simple fact that I have never had as much fulfillment as I am presently experiencing that I sense a kind of time-quickening. It is indeed energizing. Spirituality, work, marriage, and parenthood seem to be flowing together rather nicely. I am grateful. But this is a financial column.

One of the most compelling pictures of the last decade (or so) is updated regularly by one of my correspondents Doug Short. He has maintained a chart that illustrates the total return of the S&P 500 since the tech bubble high on March 24, 2000. The chart shows the value as of September 9, 2011 of $1,000 invested in the index, including dividends, but excluding any taxes or fees on March 24, 2000. It looks like this:

com/dshort).

A few months ago, I introduced you to another correspondent, Ed Easterling of Crestmont Research, who keeps track of

BY Scott Neal secular (long term) market trends. He believes that we entered a secular bear market in 2000 and that it continues today. Nobody can say when it will end. In his most recent book, Probable Outcomes, Easterling gives the tools to “project” the expected return of the S&P 500 over the next ten years. He uniquely and compelling ties the expected return to the expectations of GDP growth and Inflation. One’s investment philosophy and strategy Readers can link to this chart via QR Code or www.md-update. com/FINANCE.html. © 2011 Advisor Perspectives, Inc.

Doug says, “This little charting exercise gives credence to the frequent reference to a ‘lost decade’ for investors.” I would add that that only applies to those who follow a buy-and-hold strategy and have remained invested throughout the entire 11 year period. It also places into clear perspective the crisis of 2008. Even more staggering are the losses in real, inflation adjusted, terms.

If you are interested, you can find more of Doug’s work online (advisorperspectives.

should be consistent with one’s beliefs about the future. Proper construction, maintenance, and revision of one’s projections should be accompanied by good research that updates the belief.

Easterling updates his online charts each quarter (www.crestmontresearch.com).

Our firm is incorporating his ideas into its investment strategies. Resting on a decades old strategy is not likely to get you to where you want to go at least for

the duration of the secular bear market.

The answer, to us, lies in a combination of technical and fundamental analysis backed by rigorous ongoing analysis and judgment. There is a lot wrong with economies around the world today. As I write this, Europe remains in the financial news everyday. It is important for us to pay attention to how this story unfolds. Granted, the

This ‘lost decade’ for investors applies only to those who follow a buyand-hold strategy. economy of Greece is a poor comparison to our own; however the principles and outcomes of ever-increasing debt-to-GDP ratios cannot be ignored. We and our more developed neighbors in the G7 need to pay attention.

Reading such news, the temptation is to simply pull the plug on equities, sell out all stock investments, and say that we will let the markets settle down before putting any capital at risk in hopes of attaining a positive return. There is perhaps another way.

Consider what would have happened had you been able to call the major turns in the Doug Short graphic above and participated positively in both the ups and downs. Even if you had only captured a percentage of the trip up or down with an investment in the S&P or a reverse index fund, you would have fared much better than those who simply buy and hold and hope. Our hope rests in solid research, analysis, and action.

We think yours should too, at least for now and maybe for the next decade.

Scott Neal is the President of D. Scott Neal, Inc. a fee-only financial planning and investment advisory firm with offices in Lexington and Louisville. Start a dialogue with him at scott@dsneal.com or by calling 1-800344-9098. ◆ September 2011 9

practical Insight  INTERVENTIONAL NEPHROLOGY

Access is Everything

UofL Interventional Nephrology maintains vascular access for dialysis and defines national standards of excellence in the delivery of care. By Megan C. Smith LOUISVILLE It might surprise you, but the chances for a person with chronic kidney disease to live a long, quality life correlate not only with their dialysis protocol and hypertension control but also with one single yet monumental factor: what kind of vascular access they have.

“The blood pressures and other health problems become less important if you can’t maintain open vascular access,” says Amy Dwyer, MD with UofL Interventional Nephrology (ULIN). “Access is the Achilles’ heel of dialysis.”

Each year, Dwyer and her colleagues maintain vascular access for over 700 patients in Louisville and its surrounding communities. Because most dialysis patients need one to two procedures a year, ULIN is very busy, performing about 100 procedures per month. “All we do is vascular access,” she says.

Dwyer founded the University of Louisville Interventional Nephrology program in 2004, and soon succeeding in achieving every national standard set forth by the National Kidney Foundation’s Dialysis Outcome Quality Initiative (NKF KDOQI) – the Bible for Nephrologists.

Who among her cohorts perform at her level? “We beat all national averages and perform higher than anyone in the state.”

Catheter, Fistula, or Graft

Mortality, Dwyer says, is directly related to the type of vascular access that a patient has when they start dialysis: catheter, fistula, or graft.

“A catheter is the worst type of dialysis access because it has the most complications,” she says. Clots and fibrin sheaths begin to form the moment the catheter is put into the body, which means that catheters require a lot of maintenance. Then there is a heightened chance of infection, especially if they are in place for more than 90 days.

Catheters also significantly limit a patient’s quality of life. Patients with a catheter cannot get them wet thus impacting even their daily bathing needs.

10 M.D. Update

Amy Dwyer, MD with UofL Interventional Nephrology, is a national leader in the creation and maintenance of vascular access for dialysis.

It is important to recognize that patients starting dialysis with a catheter do not start there by choice. “Patients typically get catheters because they don’t have a functioning fistula or graft. It takes about three months to see a surgeon, get a fistula, and have the fistula mature to be usable for dialysis.” This significantly increases infection risk.

Furthermore, most patients in the US qualify for Medicare the day they start dialysis, but it takes 90 days for benefits to kick in. Without insurance, a patient may be looking at six months with a catheter before they have a fistula that works.

That may be the status quo, but Dwyer says UofL surgeons take a different approach. “As soon as we get our hands on the patient, our practice gets them to see a surgeon. Our UofL surgeons are fantastic; they know that the patient’s mortality and quality of life depends on them having a fistula as soon as possible regardless of insurance status.”

Approximately 9% of our patients do not have adequate blood vessels to have a fistula or graft. This low number of patients with a catheter exceeds the national guideline of 10%. “We have the best catheter rates in the state,” says Dwyer. “KDOQI

Guidelines also require that you have 66% of your patients with a fistula, which we have, leading the rates for fistula in the State, region and nationally.”

A fistula is the preferred dialysis access because they have fewer complications and last longer than grafts. Dwyer says, “There is nothing artificial about it. It is natural, and there is a lot of data that shows it is the best type of access.” A fistula can last as long as a patient needs it - ideally, until they get a kidney transplant.

A graft may be implanted if a patient’s veins are too small to get a fistula, but they are not without problems. Both fistula and grafts can develop stenosis in the vessel lumen that may lead to low flows and high pressures on dialysis. Stenosis is treated with angioplasty. Sometimes grafts and fistulas clot, “so we have to fix that as well. We do all of those things to maintain blood flow so that the patient can receive dialysis,” says Dwyer.

Excellence in the Delivery of Care

ULIN was one of the first academic centers in the country to receive American Society of Diagnostic and Interventional

Dr. Dwyer performs angiogram on a fistula that has developed hyperplasia, a condition in which inflow of blood toward the artery is producing high arterial pressures during dialysis.

Nephrology (ASDIN) Training Program Accreditation. “I am one of the first women in the world to be certified and accredited,” says Dwyer, who wrote the national curriculum for interventional nephrology fellowship training. It will soon be available for all training programs to utilize.

Dwyer revolutionized vascular access care in Louisville by establishing protocols for any problem that may occur with fistula, catheter, or graft. At ULIN, the coordination of care is clearly defined. Having a designated Interventional Nephrology Center has increased our fistula

rate from 32% to 66%.

Soon a paper written on their data, “A vascular access coordinator improves the prevalent fistula rate,” will be published in “Seminars and Dialysis.” Included in it are the detailed protocols for other practices to

copy and set up their practice just like ULIN. “We presented this data and this project at the 2011 ASDIN National Scientific Meeting and won second place,” Dwyer adds, “It is going to be fantastic when people can see what we are doing.

Everybody wants to have this; they just don’t know how to get it done.

This paper will tell them how to get it done.”

Dwyer indicates that the future of ULIN includes expanding services for patients with chronic kidney disease to encompass all of their needs. “We plan to add both a diagnostic native and transplanted kidney ultrasound program and a peritoneal dialysis catheter program within the next 12 months,” she concludes. ◆

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September 2011 11

Allergy, Asthma & Immunology

Asthma’s Match

Traditional allergy practice uses aggressive approach to prevent asthmatic hospitalizations. By Robert Hadley and Megan C. Smith LEXINGTON For Drs. Leslie Branch sis on treating asthma aggresand Farhad Karim, asthma is a sively and are therefore well disease that is too often misdiagprepared to meet the needs of nosed, undiagnosed, or else goes their asthma patients. Branch untreated for years. completed an allergy fellowIn their thirty years of private ship at National Jewish, which practice, they have seen countbecame a center for asthma less cases where patients have treatment because of the prisgradually adapted a more sedtine air quality the region once entary lifestyle in response to boasted. “National Jewish was their obstructed airways. Often set up for the severe cases that were steroid dependent and complaining of seasonal allerhad respiratory failure,” says gy symptoms, and sometimes Branch. “They would come concealing the impact of their there and get stabilized and breathing problems on their we would try to wean them off activities, the doctors find upon steroids.” Karim completed pulmonary function testing that his allergy fellowship at La many patients are indeed experiRabida Children’s Hospital, encing the symptoms of asthma.

University of Chicago, Ill., Each day in the US, over Leslie B. Branch, MD, and Farhad Karim, MD, are rooted in the tradition which was an in-patient facil5000 emergency room visits are of their Lexington Ky. practice, which was founded over 60 years ago. attributed to asthma. But, for ity for the treatment and staall but the most severe cases, bilization of severe steroid hospitalization can be avoided by proper ma patients, and I found that challenging.” dependent asthmatics, many of them havmedication and maintenance. That’s why Branch joined the practice in 1993 after ing multiple respiratory failures in the past. an aggressive approach to asthma has been spending 32 years as a military allergist. A “Back when we started we did not a practice tradition at Karim & Branch for graduate of Duke University, Branch com- have the tools and treatments that we have over 30 years. pleted medical school at the University of today,” says Branch. “It was pretty much North Carolina at Chapel Hill and started just theophylline and later on inhaled steactive duty in 1964. He completed his roids back then.” Steroids like Flovent are Practice History The practice history begins in 1952, when pediatric training at Tripler Army Medical still the foundation of treatment, but today Dr. Lloyd Mayer started his allergy prac- Center, Honolulu, Hawaii and allergy fel- they are combined with bronchodilators, as in Advair, to prevent tice with Dr. Maurice airway spasms in people Kaufmann, who started his suffering from asthma practice in 1948. Mayer and other pulmonary formed his own practice diseases. in 1960, and moved to the The doctors recall current location in 1969, how in their early where Karim & Branch practice, both science practice today. and literature supKarim joined the pracported their aggressive tice with Mayer in 1981 approach to treating after completing pediatasthma using inhaled ric residency in Pontiac, steroids, but it took changes in treatment Mich., and an allergy fellowship at the lowship at National Jewish Hospital and guidelines to get the rest of the medical University of Chicago from 1979 to 1981. Fitzsimons Army Medical Center, Denver, community up to speed.

Colorado.

“My mother had asthma, so asthma has Insurance companies, which Karim says Both providers have a similar philosophy always been something I’ve wanted to treat,” used to question the high number of pulin treating asthma because of their training Karim explains. “The training program in monary function tests being performed backgrounds which had a strong emphapediatrics allowed me to treat a lot of asth-

“Patients often see asthma as something like a strep throat,” says Branch. “They think they can take treatment until the symptoms disappear, and they’ll be OK. But for most people, asthma is probably a lifelong condition.”

12 M.D. Update

and about one-third also have asthma. Branch said they see higher rates at their practice, partly because primary care physicians have prescreened the patients they receive as referrals.

The first hurdle doc-

Allergy and asthma treatments teach the body to not react to a substance causing an allergic response. Allergy shots, shown here, and other forms of immunotherapy are effective forms of treatment.

at Karim & Branch, realize now that pulmonary function tests are important for monitoring asthma “Fifteen years ago,” says Karim, “we would be questioned by the insurance companies as to why we were performing so many more pulmonary function tests compared to our peers and the answer was how else can you diagnose and manage asthma without the pulmonary function test? You should be questioning those who are not doing enough tests”. By asking the right questions and screening the appropriate patients with the pulmonary function test, they have been able to identify many asthma patients that would otherwise not have been diagnosed. “We learned that by finding those patients, and treating them aggressively, we are able to keep them out of the emergency room.

This of course benefits insurance companies that are trying to save money.”

Kentucky Allergies And Asthma

Unfortunately, Kentucky offers an environment conducive to the development of severe respiratory disease. Much of it is caused by seasonal allergies, but the prevalence of tobacco smoke also plays a role.

“It is part of living in Kentucky,” says Branch. “Everybody you know has it, and you just learn to live with it. You don’t go out as much in the summer; you stay under the air conditioner.”

Nationwide, it is estimated that 10-30% of the population suffers from allergies,

Karim & Branch, PSC

Seated in the front row (l-r) are: Teresa McKinley, receptionist, Susan Bias, medical transcriptionist, Debra Stapp, LPN; Standing in the center are Linda Frazier, RN, and Cathy Rogers, CMA; and standing in the back row are Lisa Haydon, tech, Leslie B. Branch, MD, Sandy Ferguson, insurance coordinator, Farhad Karim, MD, Marlene Adams, office manager, and TriQuina Roberts, LPN.

tors must overcome is correctly identifying which patients have asthma and which have common allergies. Pulmonary function tests, getting a complete history from the patient, and asking the right questions are keys to a proper diagnosis.

“Patients often see asthma as something like a strep throat,” says Branch. “They think they can take treatment until the symptoms disappear, and they’ll be OK.” Every doctor would like to believe that their patients are compliant, he says, but the fact is that compliance is an issue. When people feel well they do not take medication. The pulmonary function test, Branch observes, is helpful to demonstrate that the patient is not really doing well. This encourages the patient to take their medication, and repeat pulmonary tests with each visit cause compliance to go up.

Treatments differ according to the sever-

ity of the patient’s condition, Branch says.

Mild cases of asthma receive medication and follow-up visits, while severe cases require oral and inhaled steroids and beta agonists, which are medicines that relax bronchial passages. Avoiding cigarette smoke, cleaning bedrooms, and limiting contact with pets are additional measures that might be required.

Treating seasonal allergies can vary depending on symptoms. The goal of both allergy and asthma treatment is to teach the body not to react to a substance that causes an allergic response.

Antihistamines, allergy shots, and other forms of immunotherapy are effective forms of treatment.

“The goal of immunotherapy (allergy shots) is to desensitize an allergic individual by shifting an abnormal allergic response back to a normal response, so that it’s toned down,” explains Karim, “as a result, the production of allergic antibodies and other mediator release responses are modulated thereby causing a reduction of all symptoms and the need for medications.”

Both Karim and Branch believe that effective treatment for allergies and asthma depends on the level of customer service a practice provides its patients. Although one trend in allergy medicine is to open multiple offices and satellite locations, the doctors say that their decision to keep a single office allows them to deliver better care. For example, they boast, there is no automated call director or voicemail screening their calls.

“When patients call here, they talk with a nurse who can take a question to the physician and get an answer right away,” says Branch. “It doesn’t matter where they live in town or far away. They get just as prompt service to their phone calls.”

Offering a high level of customer service is a tradition rooted in the earliest days of the practice.

“One of the things that Dr. Mayer used to say is treat your patients like they’re a king or queen,” says Karim. “They’re the reason we’re here.” ◆ September 2011 13

otolaryngology

The Lure of ENT

Complex anatomy, surgical variety, and clinical practice attract physicians like Dr. Bryan Douglas Murphy to the discipline of otolaryngology. By Megan C. Smith LOUISVILLE Not many physicians admit that they got into their specialty for the fun of it, but that’s exactly the lure that hooked Bryan Douglas Murphy, MD, otolaryngologist with Chmiel, Murphy and Secor, PSC. With Drs. Stanley Chmiel and Chad Secor, this single specialty group provides all ENT services to both children and adults in their Louisville office. They also provide full audiological services with Anita Cronin, AuD, who has been with them for over 20 years.

Murphy recalls how he was turned onto otolaryngology in part because his father is a dentist and because a mentor in high school, an orthopedic surgeon, introduced him to surgery early on.

Later, a medical school rotation would reveal an excitement for the complex anatomy of ENT and its variety of surgeries.

Murphy recalls a friendship with then resident Dr. Mark Hoi who provided Murphy with advice and allowed him to learn more about the field of ENT as a medical student.

Surgical Variety and Complexity

Sometimes Murphy finds humor in the misconception that ENTs don’t perform a lot of surgeries. “Some of my patients ask me when we advise them on surgery, ‘Who will be doing the surgery?’” says Murphy. “On the other hand, unlike many surgical subspecialties, ENTs have a lot of office-based clinical practice.”

Among his adult population, Murphy evaluates diseases of the sinuses and any kind of nasal complaint. Lesions involving the oral cavity, throat, or tongue; masses and growths in the neck including thyroid tumors, parathyroid tumors, and salivary gland tumors; sleep disorders and obstructive sleep apnea; voice and swallowing disorders; and disorders of hearing and balance.

In addition to tonsillectomies and ear tube placements, ENTs, says Murphy, also perform endoscopic sinus surgery, soft tissue surgery in the head and neck area, facial excisions and biopsies, removal of diseased glands and tumors, and vocal chord surgery.

“One of the unique functions we serve,” says Murphy, “is the evaluation of deep throat 14 M.D. Update

care. Dentists, oral surgeons, hearing aid consultants, speech therapists, and other specialist physicians are among the health professionals who seek the assistance and expertise of the Dr. Bryan otolaryngologist-head and neck Douglas Murphy, surgeon. otolaryngologist with Some conditions are discovChmiel and Murphy, ered on imaging for another PSC, of Lousiville, reason. An x-ray or CT scan of enjoys the variety and the head or neck following a complexity of ENT fall at home can reveal a thyroid practice. nodule or an abnormality deep in the throat, necessitating the visit to the ENT for an ultrasound evaluation or endoscopy.

The newest innovations in the field have come in the area of sinus care and rhinology. Lesser invasive techniques have rendered sinus surgery more tolerable and effective.

One technique is balloon sinuplasty symptoms. We perform flexible endoscopy in which expands sinus openings without removour office to allow visualization of the larynx al of tissue or bone. The ENT modificaand the deeper areas of the throat that are not tion employs small catheters and endoscopes otherwise easily seen. In some cases, this leads allowing for the technique to be used in the to the diagnosis of a cancer in that area.” sinuses. Murphy says that the technology is Murphy advises that chronic sore throat new and “we’re still studying it to see how or voice change is often an initial complaint well it might work long term, but it does look for cancer of the larynx or the deep part of promising as a safer way to obtain cultures the throat. A patient may see a primary care and other helpful diagnostic material from the physician with a chronic sore throat that will sinuses without having to formally operate on not respond to normal treatment or therapy, someone.” and because of that symptom and its lack His specialty may boast an understated of response they will be referred to him for intrigue, but Murphy is quick to point out further evaluation. “Then it will be discovered that his practice sees a wide variety of chilthat they have a cancer or a growth on the base dren and adults for a number of different of their tongue or in the deep part of their problems. A lifelong Kentuckian, Murphy throat,” he says, “and we will provide biopsy enjoys the traditions of medicine as well. and further management for that problem.”

“Our practice still operates on the Children are evaluated for speech and model of seeing every patient individually,” language issues relating to their hearing, says Murphy. “We try very hard to develop recurring ear and throat infections and practical treatment plans based on sciensleep disordered breathing that may require tific evidence within our field, and we cola tonsillectomy. Ear tube placement is per- laborate on challenging problems. That has formed to improve hearing and diminish been invaluable to me in my career, having chances for infection. a senior partner and now a younger partner that I can collaborate with.” Murphy says Technology and Tradition the practice strives daily to earn the trust Not all patients come to ENT by primary and support of their referring physicians. ◆

Orthopedics

Hip Arthroscopy

A New Frontier for the Return to Sport By Kris Abeln, MD LOUISVILLE For decades physicians and their patients have had the benefit of a minimally invasive option to treat a wide range of injuries of the shoulder, knee, wrist, and ankle. However, options for the treatment of hip and groin disorders were more limited. Conditions often went undiagnosed, untreated, or worse, treated in fashions that made return to sport difficult.

With the emergence of hip arthroscopy though, there have been dramatic advances in the diagnosis, treatment, and return to play for patients suffering from hip pain.

Through the use of x-ray imaging, surgeons can safely introduce these small instruments into the hip, treat a multitude of issues, and preserve vital muscle and supporting tissue that would otherwise be disrupted through traditionally-used open surgical options.

The most common indication for hip arthroscopy is currently a labrum tear. The labrum, similar to the shoulder, is a ring of soft tissue circling the pelvic side of the hip joint. It serves to deepen the hip socket, provide a tight seal for the joint, and likely serves a role in proprioception, that is feedback to the brain from the hip during various movements. This is provided by small nerve fibers, and is thought to be a reason that tears in this area can be painful.

Normal Hip Anatomy

When injured, patients will typically suffer from mechanical symptoms of the hip such as clicking and catching as well as limited range of motion. Other times the symptoms are less obvious, and only manifest with a dull groin pain with certain activities.

At the time of arthroscopy, some labrum tears will need to be repaired with suture, and others will need to be trimmed to prevent continued symptoms.

Labrum Tear

Coexistent with labrum tears, many surgeons are increasingly recognizing a condition termed Femoroacetabular Impingement, or FAI. This condition refers to a mismatch in the shape of the two bones, the femur and acetabulum, which compose the hip joint.

Deformity can be present in the femur,

Treatment of this condition at the time of hip arthroscopy requires contouring the bone to recreate the natural shape of both bones. This minimizes future trauma to the labrum and articular cartilage, relieves pain, and possibly prevents the onset of osteoarthritis.

Recontoured Femur

Dr. Abeln is a sports medicine specialist at Loeb Orthopaedic Group in Louisville.

In addition to these conditions, hip arthroscopy can successfully treat conditions such as loose bodies, cartilage defects, snapping hip, synovitis, tendon and ligament tears, and in certain cases osteoarthritis. Prior to hip arthroscopy, most patients will require specialized x-rays and MRI where dye is injected into the hip. Most patients will be on crutches approximately two weeks after their arthroscopy, and perform a combination of physical therapy and a home program for their rehabilita-

With the emergence of hip arthroscopy, there have been dramatic advances in the diagnosis, treatment, and return to play for patients suffering from hip pain. the acetabulum, or more commonly both.

When on the femur it is termed a cam type impingement and if on the acetabulum, a pincer type impingement.

At a minimum FAI is felt to be the primary causative factor for labrum tears, and there are some who feel this condition is a significant contributor to osteoarthritis of the hip due to the articular cartilage damage often seen when this condition exists.

tion. Full recovery can be expected to take 3-6 months depending on the conditions present at the time of surgery.

Kris Abeln, MD is an orthopaedic surgeon and sports medicine specialist at Loeb Orthopaedic Group at Jewish Hospital Medical Center Northeast in Louisville. He may be contacted by telephone at (502) 253-4120 or by email at krisabeln@gmail.com. â—† September 2011 15

research

Central Kentucky Research Powerhouse

CKRA’s cofounder and CEO Debbie Dyer and esteemed internist Dr. James Borders reflect on decades of independent clinical research excellence. By Megan C. Smith LEXINGTON When Debbie Dyer met Jacqueline Smith in the late 1980s, they were both Debbie Dyer, RN, BSN, registered nurses working at the University cofounder and CEO of of Kentucky and getting frustrated with Central Kentucky Research the bureaucratic side of medicine. Smith, Associates (CKRA). a critical care nurse, and Dyer, who did research, did not realize that their chance meeting would spark one of Kentucky’s most highly respected companies – and one of the nation’s top independent clinical research companies.

The women, famous self-starters, determined that they could administer private research programs on their own, so they secured investigators, a high blood pressure drug study, and with 50 bucks invested launched Central Kentucky Research Associates (CKRA) in 1991.

Recalling their first days filled with moonlighting and been named the Small rejection, Dyer says Business Association’s drug companies Small Business Person did not want to of the Year; she met work with nurses; President Bill Clinton they worked with in the Oval Office. doctors in private Fortunes changed practice who did course six years ago research on the side. when, at a sponsor’s But CKRA persemeeting in Florida, vered, guided by Dyer lost her friend the belief that the and cofounder to a Internist James L. private sector could brain aneurism. “It was Borders, MD, has served do a better job of drug research. a real adjustment after as principal investigator at Before long, they had hooked up losing Jacquie because CKRA since 2005. with area doctors who felt likewe were together for so wise that they had struck upon a long and went through great idea. the obstacles of being nurses and women In time, CKRA joined the Alliance for together in a man’s world of medicine,” says Multispecialty Research (AMR), a group of Dyer. Their current principle investigator, 18 independently owned sites recognized Dr. James Borders, had joined CKRA only as premier sites in the US. Some spon- a month before Smith’s tragic passing. “Our sors came to work with CKRA exclusively, relationship with Dr. Jim just blossomed and with an improved national profile, since then,” she smiles. “He got more sponsors like the Department of Defense involved in our research, and rather than keep coming back. By 2000, Dyer had having him driving all across the city, we 16 M.D. Update

finally talked him into moving his private patients over here.”

National Leader in Pharmaceutical Research

Today, CKRA is a leading US clinical research organization overseeing about $5 million a year in pharmaceutical trials.

While CKRA is part of the FDA-approval mechanism, they are dedicated to the furtherance of ethical efforts to improve the quality of life, at the same time, valuing the safety and comfort of their patients above all else.

According to Borders, it is their singular focus on clinical research that created their prominent national reputation. “Here we have a person solely dedicated to patient retention and another person who deals solely with data entry,” he explains. “In hospitals or in large practices, it is hard to find staff solely dedicated to these tasks.”

The core work at CKRA extends beyond just pharmaceutical testing for sponsors, says Dyer, and provides a real community service as well. “We provide new and innovative treat-

ments to patients that would otherwise not be available. We will also provide care to patients who are underinsured or indigent,” she says, adding that a lot of patients participate in their trials as their way to give back.

Vaccine research, for example, ties together many of these motivators. Like with H1N1, vaccines have the potential to prevent pandemic effects, so they are the only drugs that are being tested on people at the same time they are being made available to the public. On the matter of economics, Dyer says that there are only about five vaccine-manufacturing plants in the world, which are private. “There is just no money in vaccines because they cure. The money is in chronic care,” she says, which is why the Obama administration allocated over $1 billion for the DOD to set up vaccinemanufacturing plants. Currently, CKRA is working with the DOD on bioterrorism research in plague vaccines, and other recent investigations have focused on bird flu and anthrax vaccines.

CKRA’s recent investigations into pharmasponsored vaccines include work on Gardasil and Tamiflu, and Borders points out that there is a lot of talk about an HIV vaccine.

Patient-driven Research

From time to time, primary care providers may reach an impasse in treatment, at which time Borders says it is a welcome relief to be able to turn a patient toward clinical research as a way to find new therapy options. Recently, fibromyalgia studies have revealed a new optimism for this difficult-to-treat condition.

Says Borders, “Fibromyalgia is a very poorly understood condition, and many physicians don’t even believe in it even though the Arthritis Foundation accepts it as a diagnosis. We do a number of research studies on fibromyalgia, and we have patients come in here and say that they have never had a doctor do a tender point exam, where you touch various parts of the body.”

Patients are responding well to a new fibromyalgia drug that CKRA is testing on them, and Borders recalls several people

Dyer was the national Small Business Person of the Year in 2000. She has seen CKRA grow from a $3000 loss in its first year to an annual budget approaching $5 million. already have told him that this new drug is ‘amazing’. “Sometimes they will tell me that their doctor doesn’t believe in this condition, and they say I have legitimized their condition and made it better.”

It is no surprise that many of the drugs being tested at CKRA are the same drugs being marketed directly to consumers.

This is the new paradigm of patient-driven healthcare – leading patients to educate their physician about what is available on the market. “To me,” says Borders, “that is the most tangible benefit I see in my practice and the practice of other physicians from CKRA’s clinical drug trials.”

Patient recruitment and retention are two critical aspects of CKRA’s ongoing success, especially in today’s marketplace. There are about 29,000 patients in CKRA’s database of previous and prospective study participants.

Local primary care providers, like Borders’s brother and private practice partner Dr. John Borders, also enlist patients into new studies.

Marketing to patients, Dyer says, is essentially important not only for getting patients to participate in the first place – say for the financial compensation or for access to therapies that are not otherwise available or affordable – but is equally vital throughout a study to ensure that patients stick with it until the end. In tough economic times, the retention specialist must find creative ways to keep patients coming, like providing IRB-approved meals and gas cards.

The facility’s Phase I Center boasts 10 private rooms, the accommodations of which rival four-star hotels. A concierge service is available for inpatients when they need someone to let the dog out or go get their mail. From these efforts to put patient needs first come CKRA’s exceptional patient retention rates, further advancing their national reputation for research excellence.

“On occasion,” says Borders, “there is something we are studying at CKRA that might offer a valuable therapeutic alternative for patients. Some projects are cutting edge, for example a recent gout study.

“Gout has very limited treatment options, and we were studying a new treatment option that proved to be a godsend to some of our patients. A couple of those patients were private patients,” he continues, “and several said that it was the first time they had experienced relief.”

And that is when it is fun, says Dyer.

“That is when it is really cool - when you have a patient like that that has never been able to do anything, then they take this medicine, and they experience relief for the first time.” ◆ September 2011 17

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18 M.D. Update

cover Story

Andrew C. McGregor, MD utilizes Lexington Clinic’s Ambulatory Surgery Center.

Merger Delivers More

Now fully integrated, the union of Commonwealth Urology and Lexington Clinic demonstrates that quality care and physician autonomy coincide in the reality of medical practice mergers.

By Megan C. Smith Photos courtesy of Lexington Clinic

LEXINGTON Since the Patient Protection and Affordable Care Act (PPACA) passed on March 23, 2010, physicians across the country have clamored to assert market position in the face of federal regulations that – despite the fact that they haven’t been defined yet – are destined to reshape the delivery of healthcare in America.

Physicians, many of whom feel trapped between the Oath and the Law, seek reassurance that they can retain autonomy and deliver the best care possible regardless of what the future of Healthcare Reform may bring.

If you are a physician who is wondering what market position to stake the future of your practice on, then here is a position worth looking into: On April 1, 2011, the 19 physicians of Commonwealth Urology, working in nine offices across Central Kentucky, went to work for the first time in the practice’s 84-year history as associate physicians of a large, multi-specialty group practice, Lexington Clinic. The partnership, which was initiated the summer before PPACA, is a full-scale experiment in keeping physicians in control of their practice future.

Lexington Clinic CEO Andrew H. Henderson, MD says that the reason Commonwealth Urology (CU) and Lexington Clinic (LC) merged practices is that “physicians should take an active role in running health care to best serve their patients.”

“We are an independent physician organization,” he says, “and we will maintain that.” While government, payers, and hospitals are trying to lead healthcare, the philosophy LC supports is that physicians should fill the leadership role. “With all the challenges that are out there, with the economy and all the regulations,” says Henderson, “there is strength in working together.”

The partnership process required due diligence, but it didn’t take long for CU physicians to realize they shared the LC vision for comprehensive medical delivery.

Once the word “merger” started floating around CU’s offices, Charles Ray, MD, of the Lexington division recalls that the prevailing concern was whether the two groups’ September 2011 19

cover Story

Charles G. Ray, MD, Commonwealth Urology Lexington

philosophies would align. There was also a sense of trepidation amongst the providers “that it would perhaps not be a workable situation. There was a general notion that you couldn’t find a consensus in such a large and diverse group of urologists.”

Others were concerned that a merger could alter the existing referral relationships so significantly as to make a merger impractical or unwise. Ray recalls, “There was not much desire to make a broad scale change in the referral patterns that had already been well established over 50 years’ time.” As a third-generation urologist, those referral patterns descend from the practices of Ray’s father and grandfather. “However, the merger was designed such that we would not sever the relationships we had built with other physicians for so many years.”

Ray says, instead, he was fascinated to discover how quickly the merger idea took off. “I don’t think it was ever received in anything other than a favorable light when we began to iron out details, slowly at first and then much more quickly. It was an exciting process to go through.”

Three months into the merger, CU physicians report that they are better able to deliver quality care and better positioned for the future. “There was a sense that a merger of some sort was going to be somewhat inevitable at some point in time, the question was whether this was the right time” says Ray. “This is not a nuts-and-bolts change. We still see patients like we normally do. However, the merger has given us a great deal of peace of mind and security.”

According to Eric Ruby, MD, with the 20 M.D. Update

Somerset office, one of the clearest advantages of merger occurred to him during a tour of the onsite IT capabilities at LC. At the time he was feeling “frustrated with our offsite IT services and with our EHR vendor’s ability to be adaptable and available.” By the time the merger was official, CU staff were quickly integrated with LC practice management and IT infrastructure, including electronic health records.

From a clinician’s point of view, says Ruby, “We didn’t really skip a beat. Lexington Clinic has helped us become uniform across the board in the way we deliver patient care.”

Ray says that the merger process is now 100% complete. “The current status is that we continue referrals with our previous physicians and long-standing colleagues while working collaboratively with Lexington Clinic. We continue to deliver the same level of quality care that we did in the past,” he says.

among the first physicians to utilize the system when Saint Joseph Hospital purchased the robot four years ago. Since that time, Ray says the patients requiring the work of the da Vinci system “have just flowed naturally into our patient pool as if it were something we have been doing for a long period of time.”

The da Vinci robot has revolutionized urologic care. It is used for nearly 100% of

Uniform Care Delivery across the Board

The merger process did not disrupt the busy schedules of the CU and LC practice’s urologists. In fact the merger brought together three of Kentucky’s earliest adopters of the da Vinci Surgical System. Commonwealth Urology’s Charles Ray, MD and Thomas Slabaugh Jr., MD, along with Lexington Clinic’s Andrew McGregor, MD, were

K. Eric Ruby, MD, Commonwealth Urology, Somerset

prostate cancer surgeries, and in the past two years has been used for renal tumor resection and pyeloplasty for ureteropelvic junction (UPJ) obstructions. A handful of robotic partial cystectomies for treatment of bladder cancer with a bladder sparing approach, Ray says, has been performed with favorable outcomes. Furthermore, in pelvic floor reconstructions, Slabaugh finds that “just like with cancer surgery, the robot aids in precision of movements and in visualization. Because of that, you get more long lasting repairs while minimizing potential problems.”

Moreover, the da Vinci robot has given providers like Slabaugh a new focus in Andrew H. Henderson, MD, oncology, a change in direction he says CEO Lexington Clinic he did not anticipate. Now both pros-

cover Story

The partnership process required due diligence, but it didn’t take long for Commonwealth Urology physicians to realize they shared the Lexington Clinic vision for comprehensive medical delivery. tate cancer and kidney cancer cases are being managed with robotic surgery. Slabaugh adds, “We do a lot of partial nephrectomies and the robot really helps with preservation of kidney tissues and reconstruction of the kidney after we remove tumors.”

McGregor, who with colleague Stephen Monnig, MD was one of two original LC urologists before the merger, reminds us that the practice of urology entails more than men with enlarged prostates who have difficulty passing urine. About 35% of McGregor’s patients are female, and for these patients he provides surgical and medical therapies for overactive bladder,

Stephen J. Monnig, MD, Lexington Clinic South Broadway

stress urinary incontinence, bladder cancer, and kidney cancer.

Treatments for stress urinary incontinence in females have advanced significantly in recent years and contributed new solutions to quality-of-life issues. “We have a lot of technologies that can be used for incontinence,” says McGregor. “For stress incontinence, it is a surgical problem primarily. There is a new technology, called a single incision sling, which is an outpatient procedure that can have a woman back at work in two days.”

Kidney stones are a big part of Kentucky urological practice as well.

Treatment depends on the size and the location of the stone. The lithotripter - a machine that uses sound waves to break up stones from outside the body - transformed stone treatment some 30 years ago. Today, small stones are usually addressed with a laser while large stones are approached from the back for removal. “All of these surgeries are minimally invasive, small incision, and quick recovery,” says McGregor. “That is another example of how far technology has come.”

Kentucky lies square within “the stone belt,” says McGregor. “If you look at the incident of kidney stones nationwide it increases north to south and west to east, and that puts us right in the middle of the increased prevalence.”

“No one really knows for sure why this is the case,” says Monnig, “but we think it is a combination of genetics and diet.

Many people like to blame the water in the

Thomas K. Slabaugh, Jr., MD, Commonwealth Urology, Lexington

Bluegrass, but that has never been shown to be the case. The real problem is sodas, high salt, and high meat.”

Monnig has a special interest the No-Scalpel technique for vasectomies. In this technique, a special instrument that creates a small knick in the skin, allowing him to perform the vasectomy through a very small opening.

He is also one of few Kentucky urologists performing cryotherapy for the treatment for prostate cancer. Cryotherapy involves freezing the prostate tissue as opposed to removing it or radiating it. The technology has been around for decades, but it has been improved in the past 5-10 years to provide greater patient safety in an outpatient surgery.

“It is another option for treating prostate cancer, typically in low to medium grade cancer in older men who are not sexually active,” says Monnig, “since it causes permanent erectile dysfunction.” This less invasive technique allows patients to get back to their regular activities in a day or two, and they have fewer urinary symptoms afterward compared to the radioactive seed implant that is considered a comparable treatment. ◆ September 2011 21

Special Section  Urology

Female Pelvic Medicine and Reconstructive Surgery

Formalized training is changing who can treat pelvic floor disorders By Megan C. Smith LOUISVILLE Pelvic floor disorders affect about one out of every three women, making them more prevalent than breast cancer, but not many people are talking about it.

According to Michael Heit, MD, PhD, a sole practitioner at Louisville Urogynecology PLLC, pelvic floor disorders do not get much attention in the mainstream because they do not have that cancer label. Among medical communities, however, female pelvic medicine has emerged as a guiding light in the treatment of pelvic floor disorders, which include urinary incontinence, pelvic organ prolapse, and anal incontinence, among others.

“Women are often misdirected and misguided about these problems- where to go, whether to their gynecologist, their urologist, or their primary care physician,” explains Heit.

Urogynecologists are the only specialists who deal exclusively with these problems.

Formally, Female Pelvic Medicine and Reconstructive Surgery became the latest board approved subspecialty in April 2011.

Heit, who is based out of Louisville, has been instrumental in bringing the discipline to the state.

In 1994, he became Kentucky’s first fellowship trained female pelvic medicine specialist when he came to build UofL’s urogynecology program. He served as the division director until 2004, when he left research and training to focus on patient care.

Heit says that by the age of 80, one in every eight women will have a surgery for urinary incontinence or pelvic organ prolapse. Thirty percent of the surgical procedures are repeat operations because of the high failure rates of traditional operations.

Newer procedures utilizing mesh grafts to reinforce the pelvic floor tissues have gained popularity because they are associated with higher success rates but may have higher complication rates than traditional repairs when performed incorrectly. High complication rates for the transvaginal placement of mesh grafts for treating pelvic organ prolapse prompted the FDA in 2008, and again in 2011, to issue recommendations to both physicians and patients about the need for specialized training in evaluating and surgi22 M.D. Update

cally treating pelvic floor disorders. cure rate of nearly 90%. He cautions against Heit believes that internists, family practi- the notion that these surgeries are one-andtioners, and even patients themselves – should done treatments for a woman’s pelvic floor be better informed that there are qualified disorder(s) because “ongoing muscle damfemale pelvic medicine specialists who can age, ongoing change in hormones, the provide quality care for women with pelvic addition of medicines that predispose the floor disorders. Fellowship training in female patient to incontinence, and weight gain pelvic medicine and may mean the development reconstructive surgery of additional pelvic floor disgives these specialists the orders over time.” knowledge, experience, Preventing the develand surgical skills necesopment of future pelvic sary through three years floor disorders is an imporof additional training. tant part of Heit’s work.

With its origins in “Minimizing the modifigynecology and obstetable risk factors that are rics, female pelvic medout there,” he says, “is in icine developed out of line with current trends in the understanding that health care. These prevenmost pelvic floor disortion factors include weight ders are related to vagiloss, hysterectomy, and nal childbirth and the poorly performed surgertrauma associated with ies for pelvic floor disorit and/or the hormonal Michael Heit, MD, PhD, of ders. We have also had changes associated with Louisville Urogynecology PLLC many innovations in the menopause. past 16 years, including Over time, Heit observes, urologists the first minimally invasive operations for have become more interested in pelvic urinary incontinence, anal incontinence, floor problems as they recognized the and pelvic organ prolapse beginning in needs of the population were not being 1999. These minimally invasive operaserved. However, urogynecologists or the tions have revolutionized the way we treat more recently accepted term female pelvic women with pelvic floor disorders because medicine specialists, differ from urologists they are associated with less postoperative because they treat only women with pelvic pain, shorter hospital stays, and quicker floor disorders and received their train- recoveries than in the past. Now, we are ing in obstetrics and gynecology prior to implanting pelvic floor nerve stimulaspecialization. Today, the board approved tors and injecting botox in the bladder subspecialty of Female Pelvic Medicine and of women with overactive bladder who Reconstructive Surgery lies within the disci- cannot tolerate medications or have not pline of obstetrics and gynecology, thereby benefited from them,” Heit explains. changing who will be able to treat female Surgeries to correct pelvic floor disorpelvic floor problems in the future. ders, Heit says, are “good, durable operaPelvic floor disorders are treated com- tions. These are not your grandmothers' prehensively and involve medical, behavior, surgeries." ◆ and surgical therapies. Heit offers the examFor Referrals Contact: ple of stress urinary incontinence (SUI), for Michael Heit, MD, PhD which physical therapy can be quite effective.

Louisville Urogynecology PLLC Alternatively, the implantation of a mid-ure4121 Dutchmans Lane, STE 401, thral sling – a strap that supports the urethra Louisville KY 40204 when abdominal pressure increases such as (502) 895-0557 | drheitmdphd.com from coughing or sneezing – has a long-term

Special Section  Urology

Merger Yields Kentucky’s Largest Single Specialty Practice

Metropolitan Urology and Allied Urology, long standing competitors, are now partners in advancing urologic care By Gil Dunn Louisville “It began when a doctor from Metropolitan Urology and I ran into each other,” says Christopher E.W. Smith, MD, urologist and past president of Allied Urology. “There had been conversation about merging the two groups over the years,” he recalls, but when the topic came up again in the context of healthcare reform, the Louisville-based urology practices started taking the talk much more seriously.

It all came together in the early days of January 2011 when the new company formed by the merger of Metropolitan Urology and Allied Urology took the name First Urology.

Spanning 32 offices across Kentucky and Southern Indiana, First Urology is now the largest single-specialty practice in Kentucky.

Enhanced negotiating power may motivate some healthcare mergers, but Smith says that the goal of this merger is better patient care and greater physician satisfaction.

“This merger allows us to expand the number of people we serve and the service lines we provide in a more affordable and convenient way,” explains colleague Christopher G. Schrepferman, MD , secretary/treasurer of First Urology. “We can invest in ancillary service lines that are too expensive for a small practice.”

Combined, First Urology employs three radiation oncologists and two pathologists in addition to the staff of 29 urology specialists.

Not only is patient volume reaching nearly 1000 visits each day, the practice supports advanced imaging, pathology, and a very robust research program managing multiple studies concurrently. First Urology also provides radiation therapy in their Louisville, Kentucky and Jeffersonville, Indiana centers.

Ganesh S. Rao, MD, president of First Urology, observes that the changing face of healthcare makes it harder for smaller groups to survive. “We looked at the horizon and saw a fork in the road where we would either have to work for the hospitals or come together. We decided the hospital employment model was not something we were working towards. We would work bet-

ter together as a group.”

Realizing their new strength, CEO Mike Shannon says they added services following the merger, beginning with the recruitment of pediatric urology specialist David Arnoff, MD, from Lubbock, Texas. Both physician and patient benefit from the improved access to subspecialists within the practice, he says.

“We are able to take advantage of each other’s strengths.”

From Legacy to Future

Between them, Metropolitan and Allied boast over 625 years of experience providing general and subspecialty urologic care, including oncology, female urology, reconstructive urology, male fertility, stone disease, and minimally invasive surgery via robot and laparoscope.

“We have an incredible breadth of accumulated knowledge that we can all tap into,” says Rao. Better outcomes from radiation therapy for prostate cancer are achieved by better managing patients’ care. This is why, he says, having imaging, radiation, and research under one umbrella is essential to their success.

Furthermore, First Urology physicians have access to data from more than 40 centers across the country through a partnership with Vantage Oncology, and they regularly collaborate with local medical oncologists who enroll patients in trials for prostate, kidney, and bladder cancer.

Community Involvement

First Urology physicians and staff “give back to the community in a number of ways,” says Shannon. Many area residents have benefitted from their non-profit foundation Families for Fathers, which organizes free prostate screening events. “We have an annual 5K run walk that is tied to free screenings around the city on Father’s

Christopher G. Schrepferman, MD; Mike Shannon, CEO; and Ganesh S. Rao, MD, president of First Urology

Day weekend,” he says, “and we have provided about 1500 free prostate screenings at the Kentucky State Fair each of the last 10 years.”

During a recent upheaval in leadership within the UofL urology residency program, First Urology stepped to the plate and helped recruit a new chairman and provide the support of two full time urologists.

“We need the public-private partnership there to keep the residency program in force,” says Rao, “and keeping urologists on staff is difficult and expensive in an academic setting. We are committed to help train the next generation of urologists.”

The physicians of First Urology also cover support UofL’s Level One trauma center, providing 24/7 care for all urologic traumas such as abdominal or pelvic injury from car accidents and wounds. “We couldn’t have a Level One Trauma Center without that care,” Schrepferman concludes. ◆ For Referrals Contact: Metropolitan Urology 101 Hospital Blvd, Jeffersonville IN 47130 (812) 282-3899 | www.metropolitanurology.com Allied Urology 3920 Dupont Square, Louisville KY 40207 (502) 721-0117 | www.alliedurology.com September 2011 23

Special Section  Urology

Dynamic Contrast Imaging Aids Urologists Central Kentucky radiologist reports on the first year of implementation

Lexington In the October 2010 issue of M.D. Update, we reported having a new imaging technique for evaluation of prostate cancer at Lexington Diagnostic Center & Open MRI. This test known as Dynamic Contrast Enhanced (DCE) MRI of the prostate uses Computer Assisted Diagnosis (CAD) is helping urologists, internists and radiation oncologists to determine the existence of and the location of cancer(s) and whether or not a cancer may have spread outside of the prostate.

We are happy to report on our first year of experience with prostate DCE MRI. We have performed 42 DCE-MRI scans ordered by 7 Urologists, 4 Internists and 2 Radiation

Oncologists.

There were no complications.

In one case CAD analysis was not possible due to technical problems.

Following are the scan findings (through August

BY Dr George W. Privett, Jr 28, 2011) according to the reasons doctors have for ordering DCE-MRI. Readers may view slides at www. md-update.com/DCE-MRI.html.

(A) Rising/High PSA for Pre-biopsy Planning

There were 12 cases and the findings were: 4 Negative, 2 Suspicious, 4 Positive for cancer, and 1 Positive for cancer with extra-capsular extension.

(B) Rising/High PSA and Negative Biopsy

There were 16 cases in this category and the findings were: 5 Negative, 1 Suspicious, and 10 Positive for cancer with suggested area(s) to target a biopsy.

(C) Positive Biopsy for Pre-treatment Planning & Staging

There were 11 cases in this category and the findings were: 0 Negative, 1 Suspicious, 7 Positive for Cancer, and 3 Positive for Cancer with extra-capsular extension.

(D) Post Treatment for Rising PSA or Re-staging

ENHANCED CONTENT NOW AVAILABLE AT M.D. UPDATE ONLINE Readers, you can now access expanded content at M.D. Update Online, including image slides, white papers, and more, by keying in the URL’s provided alongside the text or using your smart phone’s QR reader for immediate access.

Access Dr. Privett’s slides using your smart phone.

24 M.D. Update

There were 3 cases: 2 Negative and 1 Positive for Cancer.

In categories A and B the treating internists and urologists reported that positive DCE-MRI has been helpful in biopsy planning and a negative DCE-MRI has been helpful in reassuring the patients that their elevated PSA is not due to prostate cancer. In categories C and D the treating urologists and radiation oncologists have reported that DCE-MRI has given helpful information for performing targeted biopsies, determining treatment modalities and evaluating the possibility of performing nerve sparing procedures.

As our radiologists and referring urologists, oncologists and internists get more experience with this procedure and their confidence grows, DCE-MRI should become even more useful in the evaluation and treatment of prostate cancer.

Dr. George Privett Jr., medical director at Lexington Diagnostic Center & Open MRI, can be reached at (859) 278-7226 and gwprivett@aol.com. ◆

Special Section  Urology

The Elusive Nature of Chronic Pelvic Pain Pathways Georgetown We all have them, the patients who cause you to cringe when realizing that they are on the schedule for the day. Why? Because they are in pain and not only is it unclear as to why they are in pain, but you are at a bit of a loss as to how to go about helping them.

Thankfully, research has discovered new treatment options on how to manage chronic pain, but more importantly, we are learning more and more regarding the etiology of how chronic pain begins.

I see many patients with elusive symptoms of pelvic pain. I am presented with tales of chronic prostatitis, scrotal pain, discomfort while sitting, pain in the bladder, vagina, and even the rectum. Eliciting details of how the pain is perceived is helpful. Terms such as “burning,” “sharp” or “cramp-like” can provide important clues to the etiology of the pain, whether neural, muscular, or something else.

Nerves of the pelvis are located within a web-like set of plexuses that typically follow along the course of blood vessels. There is a complex peripheral processing system in between these plexuses. The primary afferents of these plexuses which encode both mechanical, such as stretch, and chemical stimuli, are profoundly sensitive to inflam-

is non-specific.

Tim Ness, an anesthesiologist at the University of AlabamaBirmingham, continues to work in this area, focusing on sensations and contractions within the bladBY Dr Amberly K. Windisch der.

Visceral afferents project diffusely, often to numerous levels of the dorsal horn in the spinal cord. Compare this to a typical cutaneous nerve which has a single or limited number of contacts in the dorsal horn. Neurons receiving input from the urogenital area use intensity coding with convergent inputs from the colon, uterus, and bladder. This results in a perceived generalized pain or discomfort, a pain that is not easily localized and often very difficult to treat. Because of the convergent nature of the neurons, endometriosis or colitis, typical sources of discomfort in the lower pelvis, may cause neighboring systems to fire off signals of inflammation. These may include symptoms of a UTI such as dysuria, urgency or frequency.

Studies have confirmed that pain in the pelvis, in particular of the visceral organs, is non-specific.

Neurons receiving input from the urogenital area use intensity coding with convergent inputs from the colon, uterus, and bladder. This results in a perceived generalized pain or discomfort, a pain that is not easily localized and often very difficult to treat. matory events. In fact, it has been estimated that as many as 50% of said neurons lie silent, awaiting an event of inflammation.

Studies have confirmed that pain in the pelvis, in particular of the visceral organs,

Generalized mental states also impact a patient’s perception of pain, such as stress and anxiety which can augment pain.

Functional MRIs performed during urodynamics have revealed that patients with

detrusor hypertonicity, or “overactive bladders,” have increased activity in the parahippocampal gyrus, an area known for its role in emotional states. Likewise, individuals without hypertonicity, had deactivation within the parahippocampus.

Chronic pain often can be tied to an initial acute event. Acute pain serves to get our attention so that we remove ourselves from the source of pain. Unfortunately, the pain can linger, sometimes for weeks, months, years, or even decades after an injury or inflammation. The plasticity of the nerves in such cases is lost. How to restore this plasticity is truly a million dollar question.

I will often see patients with a previously documented bacterial urinary tract infection. Although the infection has been treated, the pain and symptoms often remain.

As the initial inciting event is gone, the goal becomes to control symptoms and prevent the development of a chronic pain pathway.

This can be achieved at times using an anticholinergic, as well as a local analgesic or muscle relaxant for 30 to 60 days. It is not unheard of for such patients to have repeat events in the future. However, having pinpointed the most effective treatment algorithm, the patient now feels empowered, and the emotional magnifiers of anxiety and panic are gone, thereby lessening symptoms and their duration.

I do my best to keep an open mind and a discerning ear when faced with such patients. The stories are never as simple as they may sound. Oftentimes multiple steps of action and attempts at treatments are necessary to determine what will work best for a patient. Until there is a way to eliminate the formation of chronic pain pathways, treatment of symptoms with no possibility for a cure must suffice. May current research continue to bring to light the dark recesses which remain in the development of chronic pain.

Amberly K. Windisch, MD is sole practitioner at Landmark Urology, PSC of Georgetown.

Contact Dr. Windisch at (502) 868-9748 and online at www.landmarkurology.com. ◆ September 2011 25

Special Section  Urology

Q&A with Cameron S. Schaeffer, MD M.D. Update publisher Gil Dunn sits down

(c) Kirk Schlea 2009

LEXINGTON

with Dr. Cameron S. Schaeffer, pediatric urologist and plastic surgeon, a solo practitioner based out of Lexington’s Central

Baptist Hospital with clinics at Rockcastle Hospital in Mount Vernon and at Flaget Hospital in Bardstown.

MD UPDATE: You have a unique blend of specialty training and are board certified in three specialties. I have heard you describe your work as “pediatric urology with a smattering of adult reconstructive urology and general plastic surgery.” What led you on this path?

Dr. Cameron Schaeffer: As the cliché goes, life is what happens while you are making other plans. When I started my urology training in Salt Lake City in 1989, I thought I would eventually practice as a general urologist somewhere in the Montana or Idaho. I figured most days I would do a couple of TURPS and go fly fishing.

Early on, I became interested in the small subspecialty of reconstructive urology, so towards the end of my residency I began to research additional training possibilities.

I got some very good advice from a reconstructive urologist. Rather than do a two year fellowship in reconstructive urology, he advised me to do a residency in plastic surgery. However, I had missed the application period for plastic surgery, so I decided to do a pediatric urology fellowship first.

I was always a bit of a hospital rat- so what’s another few years of surgery training, right? Instead of taking and maintaining one ABMS board exam, I ending up taking three, which I maintain- general urology, pediatric urology, and plastic surgery.

I started my practice in 1997 in Denver, Colorado. I was a urologist by day and a plastic surgeon by night. One tends to do the work that comes his way. By the time I left Denver in 2000, a substantial portion of my practice was general plastic surgery. I suppose if I had stayed in Denver I would now be full-time plastic surgeon 26 M.D. Update

with a focus on genital reconstruction.

How did your training lead to your unique formula for patient care?

When I finished training I had a perspective that other urologists, including pediatric urologists, just don’t have. I am not aware of another pediatric urologist in this country who is also a board-certified plastic surgeon. Plastic surgery training teaches you surgical techniques and problem solving at a level you don’t get in other surgical disciplines. Reconstructive plastic surgeons are the physicians other surgeons call when they need help.

We are a full-service pediatric urology practice. We treat everything from bedwetting to major congenital malformations requiring long, complex operations. You are correct that I do some adult reconstructive urology work, but only if the patient is referred by an adult urologist. I also do some general plastic surgery to keep up my skills. The vast majority of what I do, and what I love the most, is pediatric urology.

Which hospitals and surgery centers do you regularly utilize and why?

I have been based at Central Baptist Hospital for almost ten years, and I use several of the surgery centers in town. Central

Baptist Hospital far and away delivers most of the babies in this region and it has strong Neonatal and High Risk OB programs, as does Saint Joseph East, where I consult. We also have excellent pediatric anesthesia and pediatric nursing at Central Baptist Hospital.

Our patients get very good care here.

I started doing outreach clinics at Rockcastle Hospital in Mount Vernon and at Flaget Hospital in Bardstown when the price of gas went through the roof. It didn’t make much sense to have a bunch of patients drive all the way to Lexington when I could easily see them closer to home.

Last year I was asked to obtain privileges at Kosair Children’s Hospital, and I just finished that process.

Does pediatric urology utilize the da Vinci surgical robotic?

Some pediatric urologists have been experimenting with the Da Vinci system. I currently do laparoscopic surgery without the robot, so I have not see much indication for it given the extra associated costs and the longer operative times. When you can reconstruct the kidney through a one inch retroperitoneal flank incision, it doesn’t make much sense to make three half inch incisions and violate the abdominal cavity.

While many of your peers are merging and consolidating their practices, what motivates you to remain a sole practitioner?

I have remained solo. In fact, I think I am the last fully-independent, private, surgical urologist based in Lexington. I think that is sad for a city this size. I’ll be frank with you. The consolidation we have seen in medicine, both on the hospital side and on the provider side, is being driven by fear and uncertainty coming out of Washington.

I was quite vocal and public in my opposition to Obamacare, as I see it as a further erosion of traditional Hippocratic medicine.

Patients should have complete freedom to choose their physicians, and physicians should be free to provide care in the settings they feel their patients will get the best results. Of course doctors should be free to pursue whatever professional situations they want, but I believe a man cannot serve

two masters. When the money gets tight, and it will get tight, employed physicians may be asked to choose between what is best for their patients and what is best for their employers or “society.” I have seen this already happening.

We are overturning 2500 years of Hippocratic medicine, based on the doctorpatient relationship, and replacing it with the doctor-patient-accountable care organization relationship. But history is pretty clear. The human desire for freedom cannot be suppressed, and central planning eventually collapses.

Obamacare will collapse, either at the hands of the Supreme Court, where it should, or under its own economic weight and market distortions. As long as physicians are the ones with the talent, and as long as people seek that talent, the doctorpatient relationship will endure, despite the best efforts of those who take it upon themselves to meddle with that relationship. Are there challenges? Sure. And they all seem to be business and regulatory in nature, not clinical. The government is waging war on private medicine, but private medicine will eventually win because it is the most nimble and cost-effective way to deliver care.

away? Ultimately, private physicians are small businessmen. Their capital resides in their heads and in their hands, dearly bought in time, toil, and tuition. The act of opening and maintaining a private medical office is an act of faith in oneself and a gift to one’s patients, no different than the acts of faith and giving made daily by entrepreneurs and capitalists all over this country.

You must first believe in your heart that you have skills that other people will want, then you must act on it.

There are a few physician organizations dedicated to private medicine, like the American Association of Physicians and Surgeons. Most specialty societies also have resources for physicians seeking to establish private practices. If you have faith in yourself and your talent, get some advice from a private physician, hire a good accountant, and have at it.

I think physicians need to reflect on the Oath that they took upon graduating from medical school. They should reread it in the original, not the sanitized version read at some medical school graduations these days, and really think about what they are doing for themselves, for their patients, and for the future of their profession. ◆

To maintain autonomy, physicians must first recognize that they are the ones with the talent- the ones the patients are coming to see. Why give that talent and value

For Referrals Contact: Cameron Schaeffer, MD 1760 Nicholasville Rd, STE 601, Lexington KY 40503 (859) 275-5437 | www.pediatricurology.com

What can physicians do to start or continue in solo practice in 2011 and beyond?

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September 2011 27

28 M.D. Update

news

Retina Associates of Kentucky

Lexington Clinic

New Physicians with Lexington Clinic

Send your NEWS items to M.D UPDATE > news@md-update.com

Baptist Medical Associates

with Retina Associates of K e n t u c k y, has once LEXINGTON Lexington again won Clinic announces the American the association of S o c i e t y Robert Owen, MD of Retina with the Lexington S p e c i a l i s t ’s Clinic Neurosurgery p r e s t i g i o u s Robert D. Owen, MD Department. Owen Rhett Buckler John W. Kitchens, MD received his medi- Award.

His cal degree from Indiana University School film, entitled: Drainage of Choroidals with of Medicine. He completed an internship a Guarded Needle Technique: An Insider’s in General Surgery and a residency in View was judged according to originality, Neurological Surgery at the University of educational content, audiovisual quality, Kentucky College of Medicine. He also script writing, editing quality and effectivecompleted a fellowship at Indiana University ness. The coveted Rhett Buckler Award will School of Medicine. He is board-eligible be presented at the ASRS’s annual meeting in Neurological Surgery. His professional on October 3rd. Co-authors were: Drs. interests include general neurosurgery.

Carey Pate and Daniel Prescott. Kitchens Lexington is the President of Kentucky Academy of Clinic also welEye Physicians and Surgeons and is an comes Chad internationally recognized authority on disHarston, MD eases and surgery of the retina, macula and to the Lexington vitreous.

Clinic Center for Breast Care.

New Physicians with Baptist Medical Associates Harston, a fellowship-trained LOUISVILLE Jamie D. Kemp, MD, cardiology, mammograhas joined Louisville Cardiology Group, pher, received part of Baptist Medical Associates. She is a his medical 2004 graduate of the Washington University Chad Harston, MD degree from School of Medicine in St. Louis. She comBaylor College of Medicine. He completed pleted her internal medicine internship his residency in radiology at San Antonio and residency at Brown University School Uniformed Services Health Education of Medicine in 2007. She Consortium and a fellowship in mammogcompleted a raphy at Brigham and Women’s Hospital fellowship in and Harvard Medical School. Harston is cardiovascular board-certified in Radiology. His profesmedicine at sional interests include, include radiology, the University breast imaging, breast cancer, disease of the of Louisville breast and women’s imaging.

School of Repeat Honors for Doctor Medicine in Filmmaker 2011.

Dr. LEXINGTON John W. Kitchens, MD, partner is Jamie D. Kemp, MD Kemp

board-certified in nuclear cardiology, echocardiography and internal medicine and is board-eligible in cardiology.

Shiela Rhoads, MD, gastroenterology, has joined Baptist Medical Associates Gastroenterology, with locations at Baptist Hospital Northeast in La Grange, Baptist Hospital East in Louisville and Baptist Eastpoint near Anchorage.

She is a 2000 graduate of the Shiela Rhoads, MD University of Louisville School of Medicine. She completed her internal medicine internship at University of Louisville Hospital in 2001, and her internal medicine residency and gastroenterology fellowship at Detroit’s Henry Ford Hospital in 2003 and 2007, respectively. Dr. Rhoads is board-certified in gastroenterology and internal medicine.

LA GRANGE

Grand Opening for Cardinal Hill

LEXINGTON Cardinal Hill Rehabilitation Hospital celebrated the opening of the new Patient Care Building on September 13, 2011. The expansion brings more private rooms, larger

therapy gyms, a new aquatic center, larger patient rooms, and a new ventilator program.

September 2011 29

news

Nanobiotechnology Expert Joins UK Faculty

Peixuan Guo, director of the National Cancer Institute Cancer Nanotechnology Platform Partnerships Program at the University of Cincinnati and considered one of the top three nanobiotechnology experts in the world, will join the university in the fall, bringing the national program with him. Guo will bring more than $10 million in research funding to UK. He will serve as a Peixuan Guo professor in the College of Pharmacy’s Department of Pharmaceutical Sciences and will hold the William S. Farish Fund Endowed

LEXINGTON

Chair in Nanobiotechnology for the UK Markey Cancer Center. The appointment will strengthen collaborations between the College of Pharmacy and the Markey Cancer Center, thanks to a nanotechnology cancer program grant that he received from the National Cancer Institute last year.

This grant – combined with other experts on UK’s campus in cancer, pharmacy and engineering – places UK among the nation’s leaders in cancer nanotechnology, providing UK the ability to deliver novel cancer therapeutics and advanced diagnostic capabilities.

National Fellowship for UK CNE

LEXINGTON Colleen Swartz, chief nurse executive at UK HealthCare, has been named one of just 21 Robert Wood Johnson Foundation (RWJF) Executive Nurse Fellows for 2011.

Swartz joins a select group of nurse leaders from across the country chosen to participate in this world-class, three-year leadership development program designed

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Main Office: 2416 Regency Road, Lexington

30 M.D. Update

to enhance nurse leaders’ effectiveness in improving the US health care system.

Swartz is UK HealthCare’s first chief nurse executive, taking on the position in 2009, with the objective of ensuring professional nursing practice across the organization. Her progressive leadership roles include serving as trauma nurse coordinator, in which she successfully established a Level-One Trauma Center program; director of emergency/trauma services; and chief nursing officer at a 100-bed nonprofit community-based hospital. She plans to focus at least part of her work with the RWJF Executive Nurse Fellows (ENF) program on using electronic medical records to identify and provide early intervention to patients whose conditions are dete- Colleen Swartz riorating clinically.

Spinal Cord Stimulation Neurolytic & Sympatholytic Denervation Satellite Office: 125 Foxglove, Mt. Sterling Satellite Office: 256 Burkesville Road, Albany

JHSMH

news

New JHSMH Senior VP will Lead Sts. Mary & Elizabeth Hospital

Jewish Hospital & St. Mary’s HealthCare (JHSMH) has named Jim Parobek as senior vice president of clinical innovation and president of Sts. Mary & Elizabeth Hospital.

In these roles, Parobek is the senior officer responsible for the service line development and clinical integration across the Jewish

LOUISVILLE

Kirk Schlea

Jim Parobek

Hospital & St. Mary’s HealthCare system, oversight of the operations of the Jewish Physician Group and all activities related to Sts. Mary & Elizabeth Hospital. Parobek has more than 20 years experience in healthcare leadership. He most recently served as the president of the Saint Joseph Health System Physician Enterprise. In this role, he was responsible for the establishment and implementation of physician affiliation and integration. He also served as CEO of the former Gateway Rehabilitation Hospital in Louisville.

New Chief of UK Cardiovascular Medicine

LEXINGTON Susan Smyth, MD, PhD is the new Chief of Cardiovascular Medicine within the UK College of Medicine’s Division of Internal Medicine. Smyth, who holds a doctorate in pharmacology and a medical degree, both from the University of North Carolina at Chapel Hill, came to

Susan Smyth, MD, PhD

September 2011 31

UK

news UK in 2006. Smyth is a tenured professor in the Division of Cardiovascular Medicine, as well as a joint appointee to the Departments of Physiology, Behavioral Sciences and Molecular and Biomedical Pharmacology.

She is also a Summa cum Laude graduate of Mount Holyoke College.

At UK, Smyth also directs the MD/ PhD program and a cardiovascular research training program for fellows. She is the co-director of education and training programs for the UK Center for Clinical and Translational Science (CCTS), and chairs the research and developmental committee for the Lexington Veterans Affairs Medical Center. Smyth also serves as an attending physician at the Lexington VA, UK Chandler Hospital and UK Good Samaritan Hospital.

New Chief Administrator for Good Samaritan

Leslie Crofford, MD

International Scientist Awarded

LEXINGTON UK’s Leslie Crofford, MD, PhD was the recipient of this year’s Woman in Inflammation Science award from the International Association of Inflammation Societies (IAIS). Crofford received the award

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32 M.D. Update

at the 10th biennial World Conference on Inflammation held in Paris this past June.

The IAIS award is given to recognize and honor an individual female scientist who has demonstrated scientific excellence in the field of inflammation research and who has, either through leadership or by example, promoted the advancement and development of women in this field.

Crofford has authored more than 150 publications on subjects in rheumatology and women’s health. The main focus of her work is inflammation and pain in rheumatic diseases. She is known for her contributions to developing new anti-inflammatory drugs and analgesics. ◆

UK

LEXINGTON Willem de Villiers, MD, PhD has been named chief administrative officer of UK HealthCare’s Good Samaritan

Hospital effective immediately.

De Villiers follows Frank Beirne who recently Willem de Villiers, MD, PhD left the post for a position in California. De Villiers joined UK HealthCare in 1996 and currently serves as president of the UK HealthCare Medical Staff and is chief of the Division of Digestive Diseases and Nutrition in the University of Kentucky College of Medicine’s Department of Internal Medicine. He most recently earned a master’s degree in health care management from Harvard University in 2008.

Feel better.

if you’ve ever been a smoker, what’s it worth to finally breathe easier?

Over 80% of lung cancers have a chance to be cured if detected at an early stage. Lung CT screening can give you that chance.

© 2011 Baptist Healthcare System, Inc. / Member, Baptist Healthcare System

If you’re a current or former smoker, early detection of lung cancer is key to preventing more serious problems later. A new, low-dose lung CT screening now available at Baptist Hospital East and Baptist Eastpoint gives you the ability to take that positive step to safeguard your health.

Even if you aren’t currently experiencing symptoms, taking action now may make all the difference. The cost for this progressive screening is $185*, but the advantage to current or ex-smokers is invaluable.

Consult your physician or call the Baptist Health Information Center at (502) 897-8131. Visit baptisteast.com/earlydetect for more information. * This screening is not covered by insurance.

Participants must be 55-75 years old.

baptisteast.com/earlydetect

Who undeRstands the financial needs of a Medical pRactice MoRe than a doctoR?

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Today, Unified Trust is a national trust company. We’re located in Lexington, Kentucky and are one of a handful of companies in the country that offer true fiduciary responsibility.

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