CHESAPEAKE
Physician YOUR PRACTICE. YOUR LIFE.
Maryland/DC/Virginia
ATTACKING ADDICTIONS LEANA WEN, MD: BATTLING FOR BETTER HEALTH IN BALTIMORE TAILORING CARE FOR SENIORS ON THE ROAD TO ENTREPRENEURSHIP
chesphysician.com VOLUME 5: ISSUE 6 NOVEMBER/DECEMBER 2015
Contents 8
VOLUME 5: ISSUE 6 NOVEMBER/DECEMBER 2015
20
F E AT U R E S
14 Addictions Under Attack 24 Tailoring Healthcare to Seniors
D E PA R T M E N T S
Cases Policy
| 7 | Spinal Cord Stimulation: Alternative to Pain Medication | 8 | Fighting for Better Health: An Interview with Dr. Leana Wen
Solutions HIT
| 12 | Remedies for Physician Burnout
| 20 | Lessons on the Road to Entrepreneurship
Our Bay
| 30 | Celebration of the Chesapeake Bay
On the Cover: Leana Wen, MD, Commissioner at Baltimore City Health Department
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CHESAPEAKE
When a disease rapidly spreads to many people, it becomes an epidemic. Sadly, the U.S. has an epidemic of opioid abuse today, and doctors have been part of the problem. According to IMS Health, a healthcare information company, more than 219 million prescriptions for opioids were written in 2014 with sales of $8.85 billion. The Substance Abuse and Mental Health Services Administration (SAMHSA) estimates that the market for addiction treatment is about $35 billion per year. The numbers are staggering and they don’t even reflect the wider impact of addiction on the individual’s friends, family and employer. It’s an epidemic that is everywhere. An epidemic usually does not stop without medical intervention and assistance. Every primary care physician in America spends at least 20 percent of their time dealing with the consequences of substance abuse (see Addictions Under Attack page 14). The need to medicalize addiction and the mental health issues that often underlie the addiction is our editorial theme throughout this issue. We spoke with some leading healthcare providers and stakeholders, spotlighting the key needs as well as the treatments and advocacy work that we all, including physicians, can do to stop this epidemic. We learned how we can change the way we think about and act on mental health disease and addictions, including training more doctors in a new specialty – addiction medicine (Solutions page 12 and HIT page 20). Many of us have a story about mental health disease and addiction to share, whether it’s our own, a family member’s, a colleague’s or a patient’s. We all need to be agents of change to destigmatize mental health disease and addiction. Dr. Leana Wen, Baltimore City health commissioner, patients’ rights and community advocate, believes that every doctor should think through what they’re doing, rather than being complacent. As she states, “We have to say, over and over, that addiction is a medical illness and not a moral issue.” (Policy page 8). The ACA’s parity law requires that coverage for mental health ailments must be comparable to coverage for physical ailments. This is an urgent need with an incredibly slow pace of adoption. Busy ERs can be ill-equipped to manage patients requiring treatment for a mental health crisis, and hospitals often lack beds to accommodate patients. It can take weeks to secure an appointment with a psychiatrist for outpatient care, then patients often must pay out-of-pocket for the visit. The cycle of selfmedication with street and/or prescription drugs begins, and sometimes unfortunately ends, with heartbreak for the families left in the wake of no treatment, a misdiagnosis and/or the “treat and street” approach to care. When it’s time to change behaviors, there are basically two approaches: change your own thinking and hope this leads to new behavior, or change your behavior and hope this leads to new thinking. And, act. Wishing you and yours a healthy and joyful holiday season,
Jacquie Cohen Roth Founder/Publisher/Executive Editor jroth@chesphysician.com @chesphysician
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Chesapeake Physician — Your Practice. Your Life.™ is published bimonthly by Mojo Media, LLC, a certified Minority Business Enterprise (MBE). Mojo Media, LLC PO Box 949 Annapolis, MD 21404 443.837.6948 mojomedia.biz Subscription information: Chesapeake Physician is mailed free to licensed and practicing physicians and a select group of healthcare executives and stakeholders throughout Maryland, Northern Virginia and Washington, DC. Subscriptions are available for the annual cost of $52. To be added to the circulation list, call 443.837.6948. Reprints: Reproduction of any content is strictly prohibited and protected by copyright laws. To order reprints of articles or back issues, please call 443.837.6948 or email sjenkins@ mojomedia.biz Chesapeake Physician — Your practice. Your life. Advisory Board: An advisory board comprised of medical practitioners and business leaders in diverse practice, business and geographic scopes provides editorial counsel to Chesapeake Physician. Advisory Board members include: RANDY M. BECKER, MD Advanced Radiology HARRY BRANDT, MD Sheppard Pratt Health Systems PATRICIA CZAPP, MD Anne Arundel Medical Center HOLLY DAHLMAN, MD Green Spring Internal Medicine, LLC MICHAEL EPSTEIN, MD Digestive Disorders Associates STACY D. FISHER, MD University of Maryland Medical Center MICHAEL FREEDMAN, MD Evolve Medical Clinics GENE RANSOM, JD, CEO Maryland Medical Society (MedChi) CHRISTOPHER L. RUNZ, DO Shore Health Comprehensive Urology VINAY SATWAH, DO, FACOI Center for Vascular Medicine THU TRAN, MD, FACOG Capital Women’s Care Although every precaution is taken to ensure accuracy of published materials, Chesapeake Physician and Mojo Media, LLC cannot be held responsible for opinions expressed or facts supplied by authors and resources. Printed on FSC certified, 100% PCW, chlorine-free paper
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CHESAPEAKE
Physician YOUR PRACTICE. YOUR LIFE.
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2016 CLINICAL EDITORIAL CALENDAR JANUARY/FEBRUARY n Cover Story: Advances in Cardiovascular Care n Feature: Diabetes & Co-morbidities n HIT: Direct Primary Care Model — An Alternative to Fee-for-Service
MAY/JUNE n Cover Story: Chesapeake Female Healthcare Innovators n Feature: Women’s Health & Pediatric Care n HIT: Independent Practice Models That Work
SEPTEMBER/OCTOBER n Cover Story: Progress in Cancer Care n Feature: Advances in Imaging n HIT: Telehealth — A New Standard of Care
MARCH/APRIL n Cover Story: Digestive Disease Update n Feature: 3D Printing & Prosthetics n HIT: Connected Health
JULY/AUGUST n Cover Story: Progress in Orthopaedics n Feature: Podiatrists — Partners & Referrers n HIT: Reputation Management in Social & Digital Media
NOVEMBER/DECEMBER n Cover Story: Brain Medicine n Feature: The Biology of Depression n HIT: Integrated Care Delivery Platforms
IN EVERY ISSUE AND ONLINE
Cases x Solutions x Compliance x Policy 6|
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Jacquie Cohen Roth Founder/Publisher/Executive Editor jroth@chesphysician.com
CASES
Spinal Cord Stimulation: Alternative to Pain Medication By Sudhir R. Rao, MD
CASE: A 51-year-old woman presented with severe lower-back and leg pain that had been taking a toll on her life since she had fallen down a flight of stairs nearly five years earlier. Despite multiple treatments with NSAIDs, physical therapy and lumbar spine surgery, she continued to report intolerable pain. While under the care of our pain management practice, she underwent epidural steroid injections and radio frequency ablation, which only provided temporary relief. The patient complained that her pain medication regimen was not providing her adequate relief, and was causing untoward side effects resulting in altered cognition. Since multiple treatments had been tried and failed, Spinal Cord Stimulation (SCS) was discussed with her as the next appropriate plan of action. After consideration, the patient decided that since all options had been exhausted, she was willing to proceed with the trial. After a four-day trial period, the patient followed up to report 90-percent relief from pain. She was immediately scheduled for a permanent SCS placement with a surgeon. Her relief as a result of the permanent SCS was so remarkable that she no longer needs to take her pain medication, and has not been prescribed opioids for nearly a year. After surgery in 2014, she has had to follow up only twice in the two months after her surgery. She is now able to continue her active lifestyle with her family without needing pain intervention or limitation in her daily activities. She is one of many patients who have reported significant relief from the use of SCS.
DISCUSSION: The use of opioids can have a negative effect on the body and brain after long-term use. Physicians are always looking for long-term solutions to help treat their patients. SCS, which has been available for therapeutic use for more than 40 years, continues to improve, and is one of those modalities that can treat pain permanently and safely. This implanted device sends electrical impulses to the spinal cord, transforming severe, neuropathic pain symptoms into a more pleasant, tingling sensation (paresthesia). With this device, the patient uses a wireless remote control to obtain total control over the intensity of these pulses. While considered a permanent intervention, SCS is a reversible therapy in which the implanted parts can be turned off or removed, if desired. The ideal candidates for the SCS are those suffering from burning, throbbing or shooting pain. These symptoms can be a result of failed back surgery, diabetes, disc herniations, neuropathy, radiculopathy, and/or complex regional pain syndrome (CRPS). Ideal patient candidates are those whose pain is not related to a malignancy, those who have failed conservative treatment, or those who do not have medical contraindications such as a defibrillator. For SCS candidates, the first step is to undergo a three- to five-day trial before anything is permanently implanted. What is so unique about this surgery is that patients have the ability to ‘test drive’ it to make sure that it has the ability to provide relief for their individual type of pain. If the patient experiences significant relief from the trial, the patient is then referred for the permanent implantation with a surgeon. Permanent implantation is minimally invasive and requires little recovery time. Once the device is implanted, the patient also has the ability to re-program the device as their pain patterns may change over the course of time. As SCS allows for improved functionality, a decrease in opioid dependency in a sub-set of this population is being recognized. As prescription drug abuse continues to plague American society, the medical community strives to find alternatives that provide long-lasting pain relief and improved functionality. SCS is one such modality that has the proven ability to provide a long-term solution to chronic pain. Sudhir R. Rao, MD, an anesthesiologist who specializes in pain management, is the founder of Pain and Spine Specialists of MD in Mount Airy, Md.
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POLICY
Fighting for Better Health An Interview with Dr. Leana Wen, Commissioner at Baltimore City Health Department
Q:
You note that a quote by Dr. Martin Luther King, Jr., explains your core vision: “Of all the forms of inequality, injustice in healthcare is the most shocking and most inhumane.” What are the greatest injustices in Baltimore healthcare today, and what do you see as the greatest health challenges for residents of Baltimore City? Baltimore
is a microcosm of other places across the country. When I first moved here, I did a listening tour of our key stakeholders – hospital CEOs, community members, faith leaders, people across the city, federally qualified health centers, etc. They identified three key needs: Caption.
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Baltimore City Health Commissioner Leana Wen, MD, has a level of energy and passion matched only by her ability to tackle critical health issues. Chesapeake Physician recently asked her about her many health initiatives and her views on everything from medical education to prescribing naloxone. BY LIN DA H ARDER • PH OTOGRA PH Y BY TRAC EY BROW N
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Youth health and wellness. If our children aren’t born healthy, don’t have glasses to read, have such severe dental pain they can’t concentrate, or have undiagnosed and untreated mental health problems, then how can we help them grow, learn and excel? Substance abuse and mental health. It’s estimated that about 19,000 people in the city use heroin, and that likely far more use prescription drugs like opioids, benzodiazapines, alcohol or a combination thereof. It’s so important for us to focus on this issue, and we can’t talk about employment or crime without also addressing this need. Nationwide, only 11 percent of those who are addicted get treatment. We would never accept this rate for those suffering from diseases such as cancer. Population health. In Maryland, with global budgeting, there is tremendous opportunity to align the goals of hospitals and insurers, together with public health goals such as prevention. How can we make sure we’re taking care of the most vulnerable while keeping everyone healthy and saving taxpayers money?
Q
: You’ve advocated for better programs for drug-addicted and mentally ill people in Baltimore as one way to reduce incarceration rates. What are your specific recommendations? Just recently, we brought insurers, hospital CEOs, foundation leaders, government officials, and other partners together to talk through the major challenges and opportunities. Specifically, we focused on behavioral health issues. We talked about care coordination. Every hospital has its own list of high utilizers, with the vast majority of these patients having underlying behavioral health concerns. We discussed creating a city-wide, high-utilizer dashboard, coming up with some wrap-around services for these patients, and working with our fire department, which oversees the EMS system, to address this issue together.
for people with acute medical concerns, and getting these individuals the right care for them.
Q
: What should physicians be doing to address these problems? Three major things: First, physicians need to ask the questions. Let’s use violence as an example. There is often a ‘Treat and Street’ mentality, where someone has a violent injury and you fix their problem and send them home, instead of asking what led them to be there in the first place. We’ve developed a number of campaigns, including “Words Not Weapons” that is asking physicians to take the time to ask a question, and to know what resources they can turn to. Second, we have to recognize that prescription opioid abuse is something that started with doctors and drug
We have to recognize that prescription opioid abuse is something that started with doctors and drug companies. Another area that we’re working on is a Stabilization Center, also known as a Sobering Center. In the ED, we often see individuals who come in with the same issues, to the point where we can recognize not only the individual, but the same scars over and over. We give them naloxone but we know we’re not providing everything they need. Instead of taking up a bed and care resources in the ED, these patients would be brought to a separate center with specialized resources including social work and addiction counseling – a centralized, citywide facility. We secured $3.6 million from our state legislature for capital costs, and now we’re looking to our hospitals for help. It’s in everyone’s best interest to help people get the best care possible, at the time they need it. We don’t want to dis-incentivize people from getting needed care, but we can provide a very strict protocol to divert the right people, freeing up beds
companies. I never thought about my role as being somehow complicit in this until I started realizing how we turn to opioids as first line for pain relief. We prescribe 250 million opioids every year in America — one for every adult American. We’re five percent of the world’s population but over 85 percent of its opioid prescriptions. Every doctor should think through what we’re doing and how we can change our practice. Is it really necessary to prescribe, for example, 100 Percocet for a rotator-cuff tear? Third, doctors have to speak up. We are the ones who interpret science, who are trusted advocates for our patients. We need to speak up to legislators, to our community. We have a really powerful voice. There is such stigma around mental health and substance abuse. There is such misunderstanding about the role of doctors and the challenges we face in order to provide the best care possible.
We have to say, over and over, that addiction is a medical illness and not a moral issue. We have to advocate for our profession and for our patients. We become complacent when we as physicians feel that there isn’t anything we can do. I understand that we’re pressed for time, and that there are many other pressures on us, but that lack of sense of control leads to burnout. Doctors can speak up at a dinner party or the nail salon or the barbershop. We can say, ‘This is what I’ve experienced. This is the science. These are the facts. This is what we must do.’ And there are specific actions we can take. We can be on the lookout for those who may have opioid disorders, or who use prescription pain medications, and also prescribe them naloxone. We would never think twice about discharging someone with a severe food allergy with an EpiPen, because they could die from anaphylaxis, so why would we not do that with naloxone? That’s something doctors can do with every patient at risk.
Q
: How do you think you can best work with your colleagues in this region to implement similar programs? DC and Virginia have different laws than Maryland, but all physicians, regardless of where we are, can coprescribe naloxone with opioids. The standing order we created here in Maryland is so that I can give naloxone to someone even when (s)he is not my patient. I have issued a standing order to all pharmacies in Baltimore. This should encourage all residents to train to use naloxone and they can carry it to save lives.
Q
: With heroin overdose deaths increasing nearly 50 percent from the first quarter of 2014 to 2015, you’ve had staff and volunteers demonstrate how to use naloxone and got the maker of Evzio, a convenient form of the drug, to donate 3,000 kits to the city. You’ve also urged Baltimore physicians to prescribe naloxone whenever they prescribe opiates. Some doctors expressed concern about liability and what message NOVEMBER/DECEMBER 2015
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they’re sending their patients. How do you respond? And what impact on heroin deaths are your actions having? The issue of liability is
dependent on best practices, and the best standard of care is that you should be prescribing naloxone to patients. If we have said in Baltimore City that this is the best practice, and you don’t prescribe naloxone to a patient and they overdose, that is your liability. And if I were giving fentanyl to a patient in the
from overdoses. The fastest growing demographic is white, middle-aged suburban women. I’m glad we finally have traction and that we’re working on naloxone and that I’m now the socalled “prescriber in chief” because we’ve issued a standing order in my name, but we’re all just treading water unless we get people into treatment. I’d love for all primary care providers to be trained for buprenorphine. With methadone, you have to go to
We have to say, over and over, that addiction is a medical illness and not a moral issue. We have to advocate for our profession and for our patients. ED or the OR, I would always have naloxone available — it would be malpractice to not do that. So why would we send a patient home with dozens of opioids but without naloxone? Or if someone has overdosed already, they should get naloxone to go, and training to use it; that’s equivalent to sending someone who has had anaphylaxis home with an Epi-Pen. It’s also very possible that, if you told your patient that they could overdose or become addicted to a narcotic, they would decide to use another method of pain relief instead. It’s our job as doctors to save lives and to provide education to our patients. We are turning the tide in some respects, because at least we’re talking about the problem. We know that there are 25,000 deaths across the country 10 |
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the clinic every day to get your dose, which is not only inconvenient, but could be stigmatizing to patients. On the other hand, if you get buprenorphine, you can go to your doctor’s office, just as you would for high blood pressure or diabetes. The problem is that there’s federal legislation that limits the number of patients any doctor can have on buprenorphine. But every primary care physician could be trained through a one-day training course that provides CME credit.
Q:
Describe your recent “Words, Not Weapons” campaign and what role physicians and other healthcare providers can play in furthering the goals of that campaign. WORD stands
for Walk away, Organize your thoughts, Reach out for help and Decide not to fight. We’re just starting to give the WORDS cards to people in emergency departments, rec centers, youth groups – people throughout the city. This is not the only solution by any means, but it’s one thing we can do. My chief medical officer and I are both ED physicians who have worked in busy trauma centers. We understand the pressures on a physician’s time. But we also understand that violence is a communicable disease and that there’s a cycle of violence. For example, I saw a 17-year-old who died of gunshot wounds, but he had been there on multiple previous occasions with lesssevere injuries. The perpetrators are often the victims of violence, and vice versa. We need to see every opportunity as a point of intervention. We may not be able to do everything that one time, but we need to think about what we might have done that could work. Words Not Weapons encourages physicians and nurses to ask questions, and to refer to resources. We also encourage everyone in the community to speak up because we all play a role. After a tragedy, we always look back and note that all the warning signs were there. Why didn’t anyone speak up sooner? I want healthcare providers not to look back, but instead, to intervene before it’s too late. We have a 24/7 crisis line that we just started. We want one source for anyone to call, whether for mental health, addiction, violence or overdose. It’s been too complicated to have multiple
numbers that depend on time of day, insurance status, and other factors. We consolidated existing phone lines. These are staffed not just by an operator at the end of a phone, but also by addiction counselors and social workers who physically go out to see patients in crisis.
Q:
You’ve noted that the Words Not Weapons campaign will be run out of the city health department's Office of Youth Violence Prevention, which also operates such programs as the recently expanded Safe Streets, to have outreach workers combat violence in their own neighborhoods. Tell us more about that program.
These are citizens who literally walk the streets and mediate violence where it occurs. There are only four sites that serve a total of about 1.5 square miles. Just in those four sites alone, we have had tremendous progress. Last year, our workers mediated 880 conflicts. Some 80 percent of those conflicts mediated were deemed to be “likely” or “very likely” to result in gun violence, which is really remarkable. How many lives saved is that, how many injuries prevented is that? The sites were identified by certain criteria to target the most vulnerable individuals where they are. We just obtained a grant to develop a fifth site that will likely be in the SandtownWinchester area.
Q:
Speaking of that, how can the issue of physician burnout and insufficient numbers choosing primary care be addressed? I see people lose
their sense of why they’re in medicine. Pre-med students get that they are here to help people. But we are not fostering that in our medical training. I think the burnout has to go all the way back to our training, and we need to educate students that there is more to being a doctor than typing on a computer or doing a procedure. Medical students hear that they need to go into the highest paid professions, rather than working in underserved areas in primary care. If we give them the opportunity to serve in the way that they should, that’s how we can avoid burnout. Medicine is a service profession, and we have to keep that orientation throughout the course of our training. We’re only accepting one in three
qualified candidates in medical school. So we should choose the ones from underrepresented groups, who are interested in primary care, and we should improve the pipeline so that we are drawing from individuals who are committed to returning to the communities they come from. Rather than selecting students by test scores, select those who understand what it means to be a public servant. I was part of a group that wrote a report calling for an overhaul in how we think of our medical education. Specifically, we wanted every medical student to commit to one or two years of national service. If you’re using federally or state subsidized dollars for your education, you have an obligation to give back. If you’re not willing to take on that obligation, you should consider a different career. Leana Wen MD, Baltimore City health commissioner
Q
: What advice do you have for physicians? First, focus on what you can do now, because you can often feel disempowered when dealing with a complex patient, such as someone who’s homeless with diabetes. But if you had someone in front of you with cancer, you would never give up. Start where you can and do what you can now. Second, advocate for your patient. You have a powerful voice and it needs to be heard. Third, go back to the fundamentals. We entered medicine to help people, to heal. Studies show that 80 percent of diagnoses can be made just by listening to patients. It also helps to alleviate physician burnout by focusing on why we went into medicine. NOVEMBER/DECEMBER 2015
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SOLUTIONS
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HEN A PHYSICIAN consistently feels unenthusiastic or cynical about practicing medicine, or driven to despair by the administrative burdens of caring for patients, they may be suffering from burnout. A 2012 article published in the Archives of Internal Medicine by T.D. Shanafelt, MD, et al., attempted to measure and report the rate of burnout among physicians. It noted that the negative consequences of burnout may erode the quality of care, increase medical errors, contribute to early retirement and substance abuse, and adversely affect physicians’ personal relationships and mental health. A 2015 Medscape survey revealed that physician burnout rates today range from 37 percent (in dermatology) to 53 percent (in critical care medicine). The highest rates are typically among those in primary and emergency care, with half or more of these physicians reporting burnout. A 2014 Physician Compensation report from Medscape found that family physicians and internists were among those most likely to choose medicine as a profession again, but unlikely to choose primary care as their specialty.
2013 RAND survey commissioned by the AMA found that doctors were dissatisfied with current EHR systems, but still believed in the potential of electronic communications to improve care. Physicians are taking different approaches to prevent and address burnout, described below. Improve Existing Practices
Improvements in working conditions, such as creating an environment in which physicians have more decision-making autonomy and a better work-life balance, can help. Using stress-reduction techniques can also help. A 2014 Cochrane review found that cognitivebehavioral training and mental and physical relaxation reduced stress in healthcare workers. Medical societies also are getting involved. Launched in June 2015, the AMA’s STEPS Forward™ program, a partnership with MGMA, is designed to help physicians address some of the key causes of burnout that were uncovered in a 2013 survey conducted by RAND. Physicians can access a
Be intentional about making the space to work on your life. It’s okay to do what you want, but don’t quit without a plan or putting your financial house in order before you leave. – Jattu Senesie, MD Of no surprise to physicians is that the growing administrative burden they shoulder is a key cause of burnout. “Too many bureaucratic tasks” topped the list in both a 2015 and 2013 Medscape survey of the causes of physician dissatisfaction, followed by “too many hours at work,” “insufficient income” and “increasing computerization.” A 12 |
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Remedies for Physician Burnout
growing collection of interactive, online educational modules to help address common practice challenges at STEPSforward.org while earning CME credit. By the end of 2015, the AMA expects to have 25 modules that include steps for implementation, case studies and downloadable videos and other resources.
Direct Primary Care, Concierge Medicine and PCMH
Direct primary care is a practice model that is gaining momentum across the country. Examples of this model, which typically charges a monthly fee and bypasses insurance, can allow physicians to eliminate insurance headaches, spend more time with patients and have greater control over their medical practice, include Evolve Medical Clinic in Annapolis, Iora Health in Boston, Qliance in Seattle, and R-Health in Philadelphia. Some are B-to-B while others are B-to-C models, and some cater to both. Look for more information on this model in Chesapeake Physician’s January/ February 2016 issue. The concierge medicine model also has been adopted by many physicians who want to practice medicine outside the walls of insurance, allowing them to avoid many of the hassles of billing for their services and devote more time to their patients. A disadvantage of this approach is the high monthly cost to patients. See “Alternative Care Delivery Models” at chesphysician.com/2012/ 06/28/alternative-care-delivery-models/. Many physicians who have adopted the Patient Centered Medical Home (PCMH) model also report feeling re-energized about practicing medicine.
This model, which emphasizes more accessible, coordinated care, is now expanding to encompass urgent care centers and some specialties. Physicians typically are assisted by care coordinators and work with a team of caregivers that are performing at the ‘top of their paygrade’ to deliver care. See Chesapeake Physician’s articles, “The Medical Home Gets a Neighborhood� chesphysician.com/ 2015/07/01/the-medical-homegets-a-neighborhood/ and “PCMHs and ACOs: Are They Working?� chesphysician.com/2014/06/30/pcmhsand-acos-are-they-working/ for more information on this model. Changing Careers
Some physicians are addressing the burnout issue by leaving their medical practices – if not abandoning helping other people. Jattu Senesie, MD, FACOG, a former OB/GYN in private practice in the Washington, DC, area, found that she was unable to design a life she enjoyed while practicing medicine, even after changing a number of variables in both her professional and personal life. In 2008, she stopped
working for 100 days, then tried reducing her work-week to four days, to no avail. “I realized in retrospect that I did everything I was supposed to do, but still wasn’t happy, and I had no Plan B,� she admits. The problem wasn’t that she didn’t love helping patients or didn’t find OB interesting, it was the need to spend most of her day dealing with administrative issues that she said sucked the joy out of medicine. She recalls, “People always told me throughout my training that when I got to the next step – whether my clerkships, residency or private practice – it would get better. It did get better, but it was never good.� Fortunately, being single and having savings allowed her to take the frightening step to stop practicing in 2010. Dr. Senesie hired a life coach to help her decide what to do next, and found that she was attracted to coaching other physicians in self-care and wellbeing. After pursuing certification from an International Coaching Federation (ICF)-accredited coach-training program, she is now working with a master certified coach until she
completes 175 hours of supervised training. To supplement her income while her business is taking off, she performs medical chart reviews and does some speaking and workshops on the weekends. Dr. Senesie believes that many doctors don’t value their own well-being as much as they do the health of their patients. Her advice to other physicians is, “If you’re really not happy, get over the brainwashing from our medical training and recognize that it’s not normal to feel miserable. Be intentional about making the space to work on your life. It’s okay to do what you want, but don’t quit without a plan or putting your financial house in order before you leave. And don’t be shy about reaching out to people in other fields.� She adds, "Have a clear vision of what you want to do that can get you through the hard days. Don't limit yourself to what seems obvious and reasonable. Start with a broad vision and narrow it down.� Jattu Senesie, MD, FACOG, former OB/GYN and current personal trainer and professional life coach at Essence of Strength, LLC, in the greater Washington, DC, area
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ADDICTIONS UNDER ATTACK
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BY LINDA H ARDER
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Physicians are beginning to tackle the growing addiction rates in our society by creating a new medical subspecialty, treating comorbid substance abuse in patients with eating disorders, and avoiding opioids when treating
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DDICTIONS typically get their start in the teenage years. According to CASAColumbia, a national nonprofit research and policy organization dedicated to improving the understanding, prevention and treatment of substance use and addiction, over 90 percent of people with addiction began smoking, drinking or using other drugs before age 18. Worse, one-quarter of those who start young become addicted, compared to only four percent of those who started using at age 21 or older. The disease is overshadowing other chronic conditions. In 2010, roughly 40 million Americans had an addiction, compared to 27 million with heart disease, 26 million with diabetes and 19
million with cancer. An additional 80 million Americans are considered risky substance users – those who use them in a way that threatens public health and safety. Tobacco, alcohol and other drugs also cause an estimated 580,000 deaths in the U.S. each year – nearly 20 percent of the total. SUBSPECIALTY RECOGNITION ATTACKS ADDICTIONS The rise of addiction in American society underscores the need for medical professionals who are fully trained to diagnose and treat these disorders, and who can serve as faculty and change agents in addressing this chronic disease. No specialized medical training programs existed until 2007, when the American Board of Addiction Medicine (ABAM) was incorporated. “The purpose of all medical boards is to review eligibility and bestow certification in specialty or subspecialty fields, and to have a process for maintaining certification at the highest standards,” ABAM Executive Vice President Kevin Kunz, MD, MPH, declares. “Within the next year, we anticipate the recognition of the addiction medicine subspecialty by the American Board of Medical Specialties, bringing attention to this disease within mainstream medicine.” Becoming certified in addiction medicine presently requires passing a certification exam after either a) completing 1,920 hours of work as an attending physician in the field, or b) completing a one-year fellowship at a participating program. By the end of 2015, some 37 programs across the country will offer this fellowship. A total of 3,800 physicians have been certified by ABAM. Dr. Kunz notes that making addiction medicine a medical subspecialty should focus more attention on the problem and create more resources to treat it. “What changes the equation is recognition and accreditation,” he explains. “You don’t have a “real” credential or get paid as a physician unless the subspecialty is recognized.” He adds, “While addiction medicine
doesn’t have bells and whistles, it’s a very intimate specialty, where patientphysician and family-physician relationships are essential. It’s also very rewarding to understand the trajectory of the disease, and to see patients recover with the care of a knowledgeable and skilled physician. And these subspecialists become the teachers of others in medical school and in communities, just as cardiologists or other subspecialists do.” Shining Light on a Silent Problem “Medicine has become expert at treating the complications of substance abuse, but we need to do far more to treat the problem. Society tends to focus on the drug of the day or the decade,” Dr. Kunz complains. “We think it’s great to reduce abuse of a given drug over time, but in the meantime, the abuse of other drugs takes off. We need instead to pay attention to the whole scope of substance abuse in our society, not just the current drug of choice.” “There’s no primary care physician in America who doesn’t spend at least 20 percent of their time dealing with the consequences of substance use,” says Dr. Kunz. “And some 40 percent of cardiovascular deaths involve alcohol or other drugs, such as nicotine. It’s the same story for cancers, trauma and a host of other conditions. We tend to think of the problem clustering in cities like Baltimore or Miami, but the truth is that all cities have an epidemic. It’s a national problem and a silent one. Physicians must be part of the solution.” He says, “Every physician needs to know some basics about addiction so he or she can screen patients and know where to refer them. Addiction can be a terminal disease if untreated, but we have evidence-based treatments, including cognitive behavioral therapy and effective medications. Encouraging patients to delay drug use is ideal. Physicians also need education on the proper prescription of opioids.” Dr. Kunz concludes, “Becoming recognized as a legitimate field of medical practice changes the world. We’re on the verge of that. And this will
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cause more physicians to sharpen their knowledge and skills in dealing with America’s most devastating disease.” ADDICTIONS AND EATING DISORDERS LINKED The facts are startling: Half of those with eating disorders also abuse alcohol or drugs, and their risk of substance abuse is five times that of the general population. Irene Rovira, PhD, director of Psychology Postdoctoral Program, and Psychology coordinator at the Inpatient/ Partial Hospitalization Program, The Center for Eating Disorders at Sheppard Pratt, says, “Some 35 percent of those with substance abuse also have eating pathology.” A shared characteristic between both disorders is its development in early-mid adolescence. The usual age of first drinking is 15, similar to that of dieting onset. In fact, early adolescent girls who are worried about their weight are two times more likely to start drinking. Teens who start drinking 16 |
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under age 15 are two-to-three times more likely to develop Alcohol Use Disorder. For this reason, early intervention for both eating disorders and substance abuse is key." Dr. Rovira notes "Multiple factors have been identified linking these disorders, including common brain chemistry, family history, social pressures and personal risk factors, such as low self esteem, depression, anxiety, trauma, and personality disorders. There is evidence that both groups share deficits in expressing negative affect and controlling impulses. These illnesses, although destructive to the person, may serve a purpose, such as coping with negative affect." The Role of Neurotransmitters A growing body of research is uncovering the role of neurotransmitters in the cycle of addiction. A review article published in Neuropharmacology in July 2012 suggested that alterations in dopamine, acetylcholine and opioid systems in reward-related brain areas
occur in response to binge-eating of palatable foods. Dr. Rovira states, “Low dopamine is seen in individuals with substance abuse, bulimia, and binge eating disorder, while higher dopamine is seen in those with anorexia. Serotonin and norepinephrine have been linked to both disorders as well. Having this knowledge could translate to better prescription of appropriate medications.” Treat Comorbid Conditions Concurrently “It’s surprising that many eating disorder programs won’t accept those who also abuse substances,” she adds. “Only a handful of programs in the country, including ours, will treat both. We’ve expanded in the last years to include a substance abuse track within our eating disorders center. It’s important to treat both at the same time to avoid symptom-substitution, such as switching from drug abuse to binging and purging.” Continues Dr. Rovira, “We offer
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behavior modification, cognitive behavior therapy and an expressive art component. You have to treat the symptoms first in order to achieve stability. This allows treatment to then focus on additional difficulties, such as body image, mood intolerance, trauma, and self esteem." A key component of successful treatment is preparing patients to return home without resuming their addictive behaviors. Dr. Rovira explains, “To address these comorbid conditions once they’re in the ‘real world,’ we start planning while they’re still inpatient or in our partial hospitalization program. For example, we’ll have them attend AA meetings, find a sponsor, and eliminate drugs and alcohol in their home or car before they leave our center.” Advice for Primary Care Physicians Dr. Rovira advises, "As our first line of defense in identification, primary care physicians should ask patients very specific questions, such as what they ate yesterday from the time they woke up until they went to sleep, rather than a general question about their eating habits. While patients can be secretive about these disorders, asking direct questions are more likely to get a more useful answer. Don’t ask, ‘Do you drink?’ instead ask, ‘How much alcohol do you drink?’” For those whose eating disorder and substance use disorder coexist, the data suggests that patients with bulimia usually develop their eating disorder first, and then substance abuse. Those with anorexia tend to have substance abuse problems before they develop an eating disorder. Individuals with anorexia often restrict food in order to save calories for alcohol later. As former U.S. Secretary of Health, Education and Welfare, Joseph A. Califano, Jr., said, “Where there’s the smoke of eating disorders, look for the fire of substance abuse and vice versa.” Caffeine, tobacco and stimulants, such as cocaine, can be used by those with eating disorders to control their appetite. Those with bulimia, compared to anorexia, tend to use a heavier and wider variety of drugs, including amphetamines, barbiturates and heroin, reportedly to assist in vomiting. "Primary care physicians should also be aware of 'atypical' substance abuse of
Irene Rovira, PhD, director of Psychology Postdoctoral Program and Psychology coordinator at the Inpatient/Partial Hospitalization Program, The Center for Eating Disorders at Sheppard Pratt
over-the-counter medications such as diet pills, diuretics and laxatives, which may lead to dangerous abnormal electrolytes. For example, low potassium and high carbon dioxide levels may indicate purging, and the physician ought to suspect self-induced vomiting or laxative abuse. Ordering lab reports to test these values can help uncover hidden eating disorder symptoms," Dr. Rovira notes.
DO OPIOIDS WORK? Some physicians might be surprised to learn that high-quality studies on opioids for chronic pain management have found little evidence of efficacy compared with other pain medications. Kurt Hegmann, MD, MPH, editor-inchief for the ACOEM Occupational Practice Guidelines published by Reed Group, Ltd., and professor, University of Utah, notes, “After a careful review of NOVEMBER/DECEMBER 2015
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28 well-conducted studies, we cannot find one showing that opioids are superior to anti-inflammatories, antidepressants or placebos. All of the opioid approaches decreased pain by only one to two points on a scale of one to 10 compared with placebo. While opioids obviously do have a limited role in acute and post-operative pain, even then they do not work as well as commonly thought. In one example, ketorolac outperforms the opioids for adverse effects while providing equivalent pain relief.” He continues, “A study of chronic low back pain found that giving patients oxycodone 5mg managed pain no better than 250mg of naproxen, despite potentially handicapping the naproxen at half the dose of a prescription. Given that our body adapts to opioids so quickly, with rapid dependency and dose escalation, and the risks involved, it’s clear that there are better things to prescribe than opioids. They have no demonstrable role in non-terminal chronic pain management. First prescribe functional restoration via a tailored, functional exercise program plus perhaps limited NSAIDs, antidepressants or anti-convulsants.”
Avoid Opiates for Safety-Related Jobs The American College of Occupational and Environmental Medicine (ACOEM) Practice Guidelines: Opioids and SafetySensitive Work, published in the Journal of Occupational & Environmental Medicine in July 2014, recommended avoiding acute or chronic opioid use for patients who perform safety-sensitive jobs such as operating motor vehicles or other heavy equipment. According to Dr. Hegmann, quality studies have shown that acute or chronic use of opioids can double the risk of traffic accidents. He says, “There’s an elevated risk, even with weak opioids such as codeine and tramadol.” Regarding overdose and fatality risks, “We now have clear evidence that risks of overdoses and fatality are significantly increased at a 50mg morphineequivalent dose. Prescriptions shouldn’t go above that dose without a demonstrable increase in function. Even starting a patient on an opioid should be undertaken only on a trial basis. If you don’t get functional benefits within two to three weeks, stop. Further, many prescribers don’t have good programs to monitor these patients.” In December 2014, ACOEM
Mental Health/Addiction Resources ‰ National Alliance on Mental Illness (NAMI) 800.950.6264 nami.org
‰ Addiction Hotline Washington DC 855.219.5600 addictionhotlinewashingtondc.com
‰ Baltimore Crisis Response 410.433.5175 bcresponse.org
‰ Mental Health Association in Talbot County 888.706.9902 mhamdes.org
‰ American Foundation for Suicide Prevention 800.273.TALK (8255) www.afsp.org ‰ District of Columbia Department of Mental Health 888.7WE.HELP dbh.dc.gov ‰ Bethesda Community Crisis Center 301.656.9161 communitycrisis.org ‰ CrisisLink – Arlington, VA 703.527.4077 prsinc.org/crisislink ‰ ACTS Helpline Prince William County, VA 703.368.4141 actspwc.org/
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‰ Suicide Prevention Education Awareness for Kids 410.377.7711 speakforthem.org ‰ Mental Health Association of Maryland 800.572.6426 mhamd.org ‰ Naloxone Training (Baltimore City Health Department) 410.637.1900 dontdie.org ‰ Maryland Youth Crisis Hotline Network 800.422.0009 Help4MDYouth.org More online at chesphysician.com
published updated “Guidelines for Opioids for Treatment of Acute, Subacute, Chronic, and Postoperative Pain” in its journal. After reviewing 157 studies of high and moderate quality addressing pain treatment, it found no quality studies demonstrating that opioids were superior to other treatments for treating chronic noncancer pain or improving functional outcomes long-term. The recommendations also encouraged physicians to use informed consent, get a treatment agreement, track functional benefits, use drug screenings, and attempt tapering of the dose if opioids are prescribed. Medical Education: Part of the Problem Dr. Hegmann believes that medical education is a part of the problem. “Pain management is not well taught in medical education,” he says. “Some physicians under-recognize the problem opioids cause, and their contribution to the growing addiction rate. In a sense, we need to turn back the clock to the way we treated pain 30 years ago, perhaps supplementing antiinflammatories with the use of opioids on a very limited basis. We should also be emphasizing functional restoration to treat chronic pain-related impairments.” He adds, “Even though we have prescription drug registries as a tool that’s fast and easy to use, many physicians still aren’t using them. It would help if each state’s laws would allow medical assistants to review a patient’s registry data for the physician at the start of the clinic workday, to provide organizational structure and save time.” The fact that some 25 to 45 percent of patients misuse opioids is sobering. Clearly, it’s long overdue for physicians to make sure they’re doing everything possible to be part of the solution to addictions.
Irene Rovira, PhD, psychology coordinator, Inpatient/Partial Hospitalization Program, The Center for Eating Disorders at Sheppard Pratt, Baltimore Kevin Kunz, MD, MPH, president, American Board of Addiction Medicine Kurt Hegmann, MD, MPH, editor-inchief for the ACOEM Occupational Practice Guidelines published by Reed Group, Ltd., and professor, University of Utah
Clinical Features In each issue, Chesapeake Physician interviews some of the region’s top specialists to spotlight the latest clinical developments, including leading-edge diagnostic and treatment options.
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HEALTHCARE IT
ISTOCK©BLOSSOMSTAR
USING SMARTPHONES TO FILL APPOINTMENTS
lessons on the road to
entrepreneurship BY LIN DA H ARDER
A growing number of doctors find that being an entrepreneur can enrich their lives. Two physicians who continued practicing medicine while founding a company, and one who decided to quit his day job as an interventional cardiologist to consult on medical devices, share the lessons they learned. 20 |
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On a cold gray day in February 2013, Brian Kaplan, MD, an otolaryngologist at Ear, Nose & Throat Associates at GBMC in Glen Burnie, Md., suddenly realized that one of his greatest frustrations might present a business opportunity. When a patient cancelled with only 30 minutes notice, he realized that his smartphone might be able to solve this frequent last-minute drain on his revenues. Recognizing that some patients cancelled on short notice, while others waited weeks or months to get an appointment, Dr. Kaplan had the germ of an idea that became Everseat. “Most of your day as a physician is not under your control,” he says. “Government agencies, payers, corporations and often your patients command the structure and organization of your practice. The only freedom you have is how to structure your day to increase your professional enjoyment. You can’t use differential pricing or do balance billing to increase your revenue. But you can make better use of your day. That is the impetus behind Everseat.” It took until May 2014 for his idea to become reality, when he and CEO Jeff Peres launched the app that notifies patients seeking appointments that a slot has become available that day or the next. The approach also works for other businesses that book appointments, including hairdressers, physical therapists, acupuncturists and dentists. “Until now, the appointment process hadn’t really changed in 50 years,” comments Dr. Kaplan. “Everseat lets physicians and healthcare organizations send a list of cancellations to people on their cell phones and usually within 30 seconds we have at least one response to fill that slot.” “We charge our providers a flat fee for unlimited bookings, and the service is always free to their patients and customers,” he continues. “Patients often say, ‘I’ve been waiting for my physician to do this.’ We even had one patient in Baltimore who felt Everseat saved her life by freeing up an appointment that found an aggressive skin cancer.” For Everseat to succeed in a practice,
Dr. Kaplan notes that patient engagement is critical. “If you don’t get the app into patients’ hands, it doesn’t work. When patients make an appointment, Everseat sends out a notice as if they are from the physician’s office. Staff can confirm that the patient has the free app before they leave the office, and use postcards, email blasts, mailers, digital newsletters and website postings to spread the word. It doesn’t take a lot of time, but you have to build it into your workflow.”
think is intuitive may not be to other people,” he cautions. Finding a partner with complementary skills – perhaps including a business or financial background – is also critical. “You need to show investors that you
is a practicing orthopaedic surgeon as well as president and founder of Suspension Orthopaedic Solutions. His path to entrepreneurship was a bit more lengthy and rocky than Dr. Kaplan’s, perhaps because his business idea
You need to show investors that you will spend their dollars wisely, and have someone who can focus on the business full-time. – Brian Kaplan, MD
THE BIRTH OF A COMPANY Dr. Kaplan describes how Everseat evolved. “My parents both own businesses in the Boston area and worked 80 hours a week – it was just what you did. And I have a business idea every three days. I had been friends with Jeff for over 12 years. Luckily, when I approached him with my idea, it proved to be the right time for him to take on a new project. Lawyers nixed my initially more grandiose plans, but everyone recognized the inefficiencies in medicine and the huge supply and demand for this service. “We funded the first year ourselves, and contracted the initial development and graphics work,” he recalls. “Then we raised the seed money to start the company. Next, we underwent a second round of financing for growth, sales and development. We had to vet a lot through various attorneys and undergo several rounds of financing, with the latest over $3 million round closing in the fall of 2015.” Today, Everseat is in 35 states with nearly 2,000 providers, including several large systems such as Baystate Health, The Centers for Advanced Orthopaedics (CAO) and LifeBridge Health.
ADVICE FOR PHYSICIAN ENTREPRENEURS Dr. Kaplan notes that, “Every annoyance is a business opportunity. If it’s causing you a problem, it’s likely causing millions of other people problems too. Uber was created by two guys who couldn’t get a cab in San Francisco.” He advises physicians to clearly articulate the simplest solution to the problem and vet that idea, expecting it to take several iterations. “What you
will spend their dollars wisely, and have someone who can focus on the business full-time. Jeff works 18 hours a day on the company. We’re also different in almost every way – you want to find a compatible relationship, not a clone. I enjoy the strategic element of growing the business the most, while Jeff also focuses on operations.” “Fortunately, the Baltimore-DC corridor is currently a hotbed for technical development,” Dr. Kaplan believes.
ORTHOPAEDIC INVENTOR Like Dr. Kaplan, Jeffrey Gelfand, MD,
involved the more regulated field of medical devices. But like Dr. Kaplan, the idea for his company arose from a problem. “In 2007, I had a patient with a fracture of their distal clavicle,” he remembers. “A company had recently developed a new arthroscopic device to treat the more common shoulder injury of AC [acromioclavicular] separation, and it occurred to me that I might try that device for my patient. Unfortunately, the AC device had insufficient mechanical support, so I paired it with another already-commonly-
top tips for Would-Be entrepreneurs z z z z z z z z z
Network, network, network – there’s something to be learned from everyone you speak to It’s never too late to change your career Remember that you have a right to be happy and you don’t have to put yourself second Find a partner that complements your skill set – e.g., one with business experience if you don’t have it – and who’s compatible, not a clone Expect the process to take far more time and dollars – and legal advice – than you originally thought Every annoyance is a business opportunity. Identify a problem that’s driving you and/or your patients crazy – then find the simplest solution For new devices, seek advice from a patent company Fund as much of the initial development yourself as you can You don’t need an MBA or special credentials – being an MD buys you credibility
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down this road and had a successful exit, and he put me in touch with a medical device design firm in Connecticut,” he explains. “They worked with me to refine the concept, determine the feasibility and make some initial prototypes. I funded the initial stage with $150,000 of my own money. Then I partnered with an attorney, formed the company, created additional prototypes and secured $4 million in outside funding, chiefly for R&D. We received three FDA clearances and commercialized three products with the initial funding, which was remarkable considering the average cost to get a product through FDA clearance is about $25 million. “I was naïve initially about how much it would cost,” admits Dr. Gelfand. “I expected that initial investment to make us cash-flow positive. We had great clinical success and sold our initial inventory in six months, but we needed more capital to continue funding the company. Until that point, everything had come surprisingly easily, but all start-ups should expect to have issues. In late 2012, we were running out of cash, which forced us to undergo some restructuring. I was able to purchase all the assets of the company, allowing me to pursue the current licensing deal.”
ADVICE FOR ENTREPRENEURS
Brian Kaplan, MD, an otolaryngologist at Ear, Nose & Throat Associates at GBMC, in Glen Burnie, Md., launched the app, Everseat, which notifies patients seeking appointments when a slot has become available that day or the next.
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used device, rigged the two together, and it worked for a problem that was challenging to treat. We reported our encouraging results in a small group of four patients and thought we might be onto something.” Before presenting the results at a national meeting, Dr. Gelfand applied for a patent. He then called a major device company to determine their interest. They passed on his idea, but a friend urged him not to give up. “I reached out to another orthopaedic entrepreneur in Florida who had been
Dr. Gelfand’s advice? “Stick to it and take your idea as far as you can with your own resources rather than just presenting an initial idea to others. That’s the only way to build value in the company. Also think about your intellectual property in the broadest terms possible, to make it harder for larger companies to take your idea.” He adds, “Understand the size of your market. For my initial device, there are about 19,000 potential users annually, making it a somewhat smaller market than some investors might find attractive. However, if it is a higher-cost device, or more importantly, a device with a higher gross margin, it will have more appeal to investors.” Dr. Gelfand concurs with Dr. Kaplan that finding complementary partners is key. “Orthopaedic surgery remains my passion. The only way for me to keep my full-time practice was to find day-to-
day partnerships with reliable business partners with connections to bankers and investors.” Although launching a company is time consuming, Dr. Gelfand managed to pursue his dream while being married to another busy orthopaedic surgeon and having four children. “I was pretty good about being physically present for all the important ‘non-work events’ but I was often distracted,” he recollects. “I definitely have the entrepreneurial bug,” he exclaims. “It’s exciting to close this new deal and I have begun work on some other good opportunities. I
He adds, “It can be hard at first, because you mostly bump into other people who’ve made the same career choices as you. But as you get further into exploring the options for physicians, you realize there are other ‘dropouts’ out there. I found networking was key. One call leads to another and another. That’s not a natural instinct for most doctors, though.” Dr. Brooks pursued an MBA from Johns Hopkins University – Carey School of Business, going to class one night a week from 2007 to 2011.
Stick to it and take your idea as far as you can with your own resources rather than just presenting an initial idea to others. That’s the only way to build value in the company. – Jeffrey Gelfand, MD
plan to stay in the innovation game. Many doctors today lament all of the challenges with the changing healthcare environment and reform, but there are billions of dollars being thrown at healthcare today and with more insured patients as a result of healthcare reform, the opportunities are out there. Doctors know best where the needs are.”
FROM MEDICINE TO MEDICAL DEVICES In contrast, Steven Brooks, MD, MBA, FACC, a former interventional cardiologist in the Baltimore area, took a path away from the daily practice of medicine. He recalls, “By 2007, I was miserable. I enjoyed the procedural side of medicine and getting to know my patients, but I was tired of fighting with insurance companies. I had a series of appeal letters to insurers and was feeling pressured to do tests and procedures I thought were unnecessary, for fear of malpractice. I was conservative in my practice whereas it seemed like referring physicians often wanted you to be aggressive. I also had three children I barely saw, so I started to ask, ‘What else can I do with my medical degree?’”
“We had some incredible discussions,” he recalls. “Then an opportunity opened up at the FDA related to drugcoated stents. I read an essay by Andy Farb, a medical officer at FDA, about the current stent thrombosis crisis, and FDA opinions past and present on this issue. I googled him, and a week later I had a job. I took a significant pay cut, but I would make that decision 100 times over again.” While at the FDA, Dr. Brooks was part of the Entrepreneur in Residence program, which brought in healthcare experts to find inefficiencies in the FDA process, exploring approaches to decreasing pre-market data requirements to get products out earlier and test them in the real world. He also was one of the charter members of the FDA’s Reimbursement Task Force. That task force connected payers with companies creating novel products. helping them to design their clinical trials to ease the reimbursement process after market approval. “Lots of companies go to Europe to have their products CE marked first
because its EMEA has a ‘bar’ that’s lower than the U.S. FDA,” he explains. “We’re currently lowering the bar here while maintaining the highest standards in patient safety in a way that’s good, because the U.S. has often used firstgeneration devices while Europe is on their second or third generation. One problem here is the huge liability issue given our legal system.” Looking to build on his experience and interests, Dr. Brooks left to join Sage Growth Partners and teach at Johns Hopkins. Today, he works with Ablative Solutions, Inc., which focuses on device-based approaches to decrease hypertension, and Popper & Co., a medical technology-oriented consulting firm.
ADVICE FOR ENTREPRENEURS “If you don’t have a reimbursement scheme, the product will die on the vine,” Dr. Brooks cautions would-be entrepreneurs. “I also learned that FDA decisions were different than insurers’ decision-making process, but that the common currency was data. A combined approach to identify the optimal market, regulatory pathway and the means to reimbursement is critical at the earliest stages of product development. Data must then be generated to support this path and demonstrate the value propositions for all stakeholders.” He concludes, “Remember that it’s never too late to change your career. A single conversation can take you in a different direction. I think most doctors have an entrepreneurial bent because they’re trained to recognize problems and look for the best solution.”
Brian Kaplan, MD, otolaryngologist at Ear, Nose & Throat Associates at GBMC, and co-founder, Everseat Jeffrey Gelfand, MD, orthopaedic surgeon and president and founder of Suspension Orthopaedic Solutions Steven Brooks, MD, MBA, FACC, VP of Regional Affairs and Health Economics, Ablative Solutions, Inc., and senior advisor, Popper & Company
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Stephanie Trifoglio, MD, internist and geriatrician at Maryland Geriatric Medicine, Greenbelt, Md.
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TAILORING HEALTHCARE TO SENIORS
Susan Peeler, MD, MBA, co-founder of the Comprehensive Gynecology Center in Gambrills, Md.
From primary care to specialized emergency departments and surgical screenings, the healthcare industry is beginning to do a better job of recognizing the special needs of seniors – in meaningful ways. BY LI NDA H A RDER • PHOTO GRA PH Y BY TRAC EY B ROW N
SUCCESSFUL AGING STARTS IN MIDLIFE Stephanie Trifoglio, MD, an internist and geriatrician at Maryland Geriatric Medicine, Greenbelt, Md., believes that physicians can help patients age successfully by starting to work with them in midlife. “You can help them take steps now to be healthy and hiking in the Galapagos in their 90s,” she exclaims. “People are now aging well. Prevention is a luxury and a new science that was never on a physician’s horizon in the past. However, Millennials are on a trajectory to a shorter lifespan than Baby-Boomers,
with a higher prevalence of diabetes and other chronic diseases.”
Active Aging The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) study published online in March 2015 in the Lancet, reported the results of a two-year, multi-domain use of diet, exercise, cognitive training, and vascular risk monitoring, compared to a control group, to see if these interventions could prevent cognitive decline in at-risk elderly people. The findings indicated that these actions could improve or maintain cognitive functioning in this group significantly more than health education alone. Dr. Trifoglio states, “Exercise is
the true fountain of youth. It helps to maintain bone density, range of motion and mental status, while delaying the onset of dementia and decreasing osteoporosis. It also has been proven useful in reducing or preventing multi-infarct dementia. “Tai chi helps protect against falls, and swimming provides fabulous aerobic and muscle-tone benefits, even though it’s not weight-bearing,” she adds. “Women especially are guilty of not focusing on themselves. It takes just a little time to invest in oneself. For example, I have three-pound barbells under my desk. I encourage my patients to stand and pace while on the phone or while thinking, or to take a fiveminute break at work and run up the stairs. If you can incorporate exercise NOVEMBER/DECEMBER 2015
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into your life and not make it a separate item on your ‘to do’ list, you’re ahead.” She counsels her patients against watching too much television. “It’s passive and doesn’t promote social interaction. Laughing and being with friends, on the other hand, is ideal. And reading or playing a board game are better for promoting brain activity.” Dr. Trifoglio also is a proponent of learning a new musical instrument, dancing to improve motor coordination, or doing simple weight-bearing activities. Dr. Trifoglio advocates for protecting eyesight by wearing sunglasses to decrease cataracts, and getting an eye exam at least every two years to detect dry macular degeneration and other diseases. The National Eye Institute’s Age-Related Eye Disease Study (AREDS) found that high levels of antioxidants and zinc can cut the risk of advanced age-related macular degeneration by one-quarter. Protecting hearing by wearing earplugs at concerts, races, construction sites and other noisy venues is another simple preventive measure she advocates.
Common Sense Approach to Nutrition A systematic review of 12 eligible studies published in Epidemiology in July 2013 found that higher adherence to a Mediterranean diet was associated with better cognitive function, lower rates of cognitive decline, and reduced risk of Alzheimer’s disease in nine of the studies, whereas results for Mild Cognitive Impairment (MCI) were inconsistent. The authors recommended further studies to explore the connection between diet and MCI and vascular dementia. Dr. Trifoglio recommends that her patients get a wide variety of nutritious foods, and only take supplements if they have a targeted medical problem. She explains, “The exception is vitamin D, which is not absorbed as well by the skin as people age. Taking supplements can help while we’re learning more. The salad bar can be a great resource, because they can get small quantities of a large array of fruits and vegetables.” The NIH Office of Dietary Supplements notes that older adults also are at higher risk for insufficient vitamin D levels because they spend more time indoors and their diet may not incorporate foods containing the 26 |
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vitamin. They estimate that some 50 percent of U.S. adults with hip fractures may have inadequate serum vitamin D levels, at less than 12 ng/mL.
Help Patients Set Reasonable Goals It’s important for physicians to review the risks and benefits of over-the-counter medications with their patients,” Dr. Trifoglio advises. “Avoiding NSAIDs may help decrease the risk of peptic ulcer disease, while those at risk for colorectal cancer may benefit from them.
Exercise is the true fountain of youth. It helps to maintain bone density, range of motion and mental status, while delaying the onset of dementia and decreasing osteoporosis. – Stephanie Trifoglio, MD
Each patient needs individualized recommendations that fit their health history. We’ve learned that it’s not so much the physical itself, but the annual review of individual risks and benefits that is valuable in improving patients’ health. A good doctor should talk to overweight and obese patients about losing just 10 percent of their body weight, and help smokers quit. Helping patients set reasonable goals is important.” What works varies, but she notes that simply getting a doctor’s ‘prescription’ to exercise more or stop smoking is surprisingly powerful.
A Community Geared to Aging in Place Dr. Trifoglio feels fortunate to live in Greenbelt, Md., a community developed by Eleanor Roosevelt. A number of factors make it a great place for older
adults to age in place. “I can walk everywhere,” she enthuses. “Young professionals move in because Goddard Space Center is nearby. GIVES, the Greenbelt Intergenerational Volunteer Exchange Service, was created to help those who need assistance to stay in their homes independently. You can earn a life chip, for example, for helping someone clean their gutters. There’s a senior center across from the preschool, and the interaction for aging in place is amazing. Those who join can take or give help, for everything from getting transportation for doctors’ visits to housework, meals, pet care, computer, laundry, or yard work. The hundreds of participants fill out an application, without paying any fee.”
AN ED DESIGNED FOR SENIORS Emergency departments (EDs) haven’t been senior-friendly, but that may be changing. Take Saint Agnes Hospital’s new ED designed for seniors in Baltimore. After recognizing that not only were 10 percent of its emergency patients seniors, but that half of the visits from that population resulted in admissions, it decided to create a specialized area that could better meet the unique needs of this population, while decreasing repeat visits and hospitalizations. Fortunately, Trishena Jones, MD, an emergency medicine attending physician at the hospital, was eager to play the role of physician champion, and other ED employees were equally enthusiastic. She notes, “We’re the 73rd geriatric ED in the country, the second in Maryland, and the only one in Baltimore.” Susan Mathers, director of the Emergency Department at Saint Agnes, recalls, “Starting about a year before we opened, we engaged the Erickson School at UMBC as consultants, and conducted a five-day, multidisciplinary team planning retreat. Erickson was phenomenal; they’ve done a lot of this work across the country. It was so rewarding and enlightening for the team to come together and focus on meeting our seniors’ needs. We brought in a large group up front that included registrars, radiologists, nurses, doctors, and others, to identify the barriers for older patients. Dr. Jones really took this project and ran with it. She was very collaborative with everyone from the beginning.” “EDs are very busy, noisy places,”
Mark Katlic, MD, MMM, FACS, chief of the Department of Surgery and surgeon-in-chief at Sinai Hospital, and director of the Sinai Center for Geriatric Surgery
acknowledges Dr. Jones, “and older adults can be pushed aside. We looked at new ways to provide excellent care to seniors with their unique needs. We conducted focus groups of our techs, nurses and registrars to solicit their input.” The ED team then met frequently to operationalize their plans, and still meets on an ongoing basis to continue making changes.
Environmental Changes Dr. Jones explains, “We constructed a separate zone with seven rooms, paying attention to lighting, flooring and sound proofing, along with hearing-assistive devices for those who didn’t bring their hearing aids, and white boards to facilitate communication.” Mathers adds, “We made changes that included installing handrails, using softer paint colors, and making blanket warmers available. The quiet environment and lighting really have made a difference.”
Up-Front Screenings Beyond a more calming environment that promotes better communication, the
ED team took a comprehensive care approach that addressed key issues up front with a series of screening tools. “We use screening tests for ADL, falls risk, cognition, nutrition, depression, and polypharmacy,” notes Dr. Jones. “When our screening identifies a patient who needs help at home, we can get a case manager, social worker and/or pharmacist involved up front. We don’t want to admit the person, then find out that the same issues exist at discharge.”
Staff Education A third critical component of the new senior ED involved educating the entire team. “All of the ED staff, not just the ones in the senior unit, received additional training to better meet the needs of older adults,” notes Dr. Jones. “We helped them appreciate how much anxiety being in the ED can create, and to become more aware that older adults sometimes can’t speak up as much as younger patients.” Mathers contributes, “As soon as patients enter the ED, they’re greeted by a ‘quick look’ nurse who assesses them to determine if they’re appropriate for
the senior ED. We don’t put the more acutely ill patients in this unit. As the project progressed, our goal was also to make all staff aware of ageism. For example, we educated them that if someone can’t hear well, you don’t just yell louder. You want to instead adjust your pitch to preserve their dignity.”
Early Results While the early results are anecdotal, Dr. Jones notes that feedback from patients and their physicians is extremely positive, and that seniors appreciate the calm environment and increased attention. “It’s been very successful,” she notes. “In the next few months, we’ll begin to get statistics through the Schumacher Group. I didn’t realize there could be so many resources available from the ED until we undertook this initiative.”
A GERIATRIC SURGERY CENTER If there are only 70-some EDs geared to seniors across the country, the number of surgery centers tailored to their needs is far smaller, with Sinai’s Center for Geriatric Surgery in Baltimore, NOVEMBER/DECEMBER 2015
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still the only one in the U.S. This center was started in the fall of 2012 by Mark Katlic, MD, MMM, FACS, chief of the Department of Surgery and surgeonin-chief at Sinai Hospital, and director of the Sinai Center for Geriatric Surgery. Dr. Katlic, a thoracic surgeon, has had a 30-year interest in geriatric surgery. “The principal behind our center is that the conditions requiring surgery all increase in prevalence with age,” explains Dr. Katlic. “However, it is possible to get identical surgical outcomes in the elderly population. We asked, ‘What can we teach everyone so that we can do it better?’ We also built a computerized database.” The center gives pre-op elderly patients a comprehensive evaluation that involves: z z z z z z z z z z z
The Mini-Cog™ test Timed Up and Go (TUG)™ test Oral health screening Hearing screening A Caregiver Strain Index (CSI) PRIME-MD PHQ (A two-question depression screening) Mini-Nutritional Assessment (MNA)® – a brief nutrition screening BMI calculation Falls risk assessment CAGE alcohol assessment Frailty test including a handgrip device
Dr. Katlic explains, “We evaluate anyone over age 75 who is scheduled for a surgical procedure, and we have screened about 1,000 people to date. We want to show that it’s predictable to determine who is an appropriate candidate.” Available to patients of any surgeon performing procedures at the hospital, the screening is completed in a standard pre-op testing area, supplementing the standard heart and lung screenings that are performed for all pre-op patients. What if a prospective surgical candidate ‘fails’ some of the tests? Dr. Katlic states, “I don’t know that anyone has cancelled surgery as a result, but they have modified it and instituted special post-op measures. For example, some 20 percent of patients fail the mini cognitive test even though they have no apparent mental deficiencies when they walk in. We know, however, that they’re at risk for post-operative delirium if they 28 |
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fail this test, which increases their risk of complications, a long length of stay and even death.” To prevent post-op complications, the center notifies all staff caring for the patient and institutes measures that include: z z z z z z z
Allowing the patient to sleep through the night Permitting the family to be at the bedside Frequently orienting the patient to date/time Removing catheters Avoiding restraints wherever possible Getting them up and moving as soon as possible Begin working immediately on rehab plans rather than assuming the patient can be discharged to home
for Geriatric Surgery is an educational one for healthcare providers. Along with nearly 50 other hospitals in Virginia, Maryland and DC, Sinai has been designated a NICHE (Nurses Improving Care for Healthsystem Elders) hospital for its quality care of older adults. Dr. Katlic also has participated in the Chief Resident Immersion Training in the Care of Older Adult (CRIT), which provides case-based training in geriatrics principles to chief residents to improve care coordination and quality for hospitalized, at-risk older adults. Further, he notes, “The American College of Surgeons, with whom we’re working, just received a $3 million grant from the Hartford Foundation to develop a standards and verification program similar to the one used for cancer centers.”
Avoid Ageism
Don’t be an ageist. Don’t base your treatment and surgical decisions on a patient’s chronological age. – Mark Katlic, MD, MMM, FACS
He continues, “We can get good results with elective surgery in the elderly, whereas performing emergency surgery in this group can endanger their health. For example, a patient with a large hernia that has been trapped should be operated on before it becomes a crisis, because the elderly lack the reserves of a younger population. They can handle stress, but not severe stress, and they can’t handle post-op complications well. The best centers are doing a thorough evaluation of older adults and paying great attention to details. “We put all of the information in a database, with a goal to develop a standardized test that’s predictive of outcomes.”
Educating Medical Professionals The second component of the Center
Dr. Katlic provides this advice to physicians: “Don’t be an ageist. Don’t base your treatment and surgical decisions on a patient’s chronological age, but on their functional age. I’ve successfully operated on a woman who was 104 years old and recently operated on two 90-year-olds.” He notes that studies have found that older adults are less likely to be taken to a dedicated trauma center or receive aggressive treatment than younger patients with the same level of injury. “They also are less likely to receive surgery for breast cancer, for example. Even if hypothetical patients are presented to doctors, studies found that they had different referral patterns compared to younger patients. We need to be aware of our own potential for bias.”
Mark Katlic, MMM, FACS, chief of the Department of Surgery and surgeonin-chief at Sinai Hospital, and director of the Sinai Center for Geriatric Surgery, Baltimore Trishena Jones, MD, attending emergency medicine physician at Saint Agnes Hospital, Baltimore Susan Mathers, RN, director of Emergency Services at Saint Agnes Hospital, Baltimore Stephanie Trifoglio, MD, internist/ geriatrician, Maryland Geriatric Medicine, Greenbelt, Md.
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