Med Monthly July 2011

Med Monthly July 2011

Breast surgery

Dr. Becker helps women feel better about themselves

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contents

44

features 18 CODING FOR THE REST OF US

Why everyone needs to know some coding

22 NEW “ACCESS REPORTS” New reporting rules for HIPAA

27 SHARING YOUR GIFTS

Dr. Kobs volunteers for international organization

30 MEDICAL SCHOOL TAKES A VACATION Medical schools on the beach

36 MAYO ONE & DONE

The men and women of Mayo One

research and technology 10 DR. BECKER HELPS WOMEN LOOK THEIR BEST 13 BEATING TUMORS AT THEIR OWN GAME

careers 14 THE NURSING SHORTAGE

your practice 16 MAKE YOUR PRACTICE KID-FRIENDLY 20 WHY YOU SHOULD USE IPADS

healthy living 42 ASTHMA: THE HYGIENE HYPOTHESIS

the kitchen 44 SUSTAINABLE GOURMET

in every issue 6 editor’s letter 24 book review

20

iPads for your practice

47 for sale 54 top nine

Cover photo of Mayo One pilot Jeffrey Sterns courtesy Mayo Clinic.

editor’s letter

W

e have an international theme this month at Med Monthly, which is perfect since July is an ideal time to embark on a long overseas vacation, perhaps to a locale with sun, sand and cool drinks. July is also halfway to Christmas, but I don’t want to think about that!

In this issue, you’ll find George Cox’s feature where he shares the benefits American students gain when they decide to attend a Caribbean medical school education.

You’ll also learn about the fascinating and never-ending work of Dr. Jeff Kobs of Raleigh, N.C. who is the president of COAN Health, a nonprofit group of orthopedic doctors and health practitioners who travel regularly to Nicaragua to serve the local population. You’ll also meet Dr. Hilton Becker, a cosmetic and reconstructive breast surgeon based out of Boca Raton, Fla. who shares his innovative talents and skills in almost every continent. You’ll also find in our July issue Megan Cutter’s book review on “The Healing of America: A Quest for Better, Cheaper and Fairer Health Care” by T.R. Reid, Mary Pat Whaley’s informative article on medical coding and how the Mayo helicopter team fights against the clock on a daily basis. You’ll also know the best vacation deal overseas and what the price of drugs is in other countries after reading this issue.

I’m looking forward to my new position as managing editor of Med Monthly as we bring you more stories of the unsung heroes who save lives every day and generously give back and care about their communities. We’ll also share tips to make your practice successful on all levels, as well as cooking and healthy lifestyle strategies. Next month we’ll focus on pediatrics and learn about the human-centered approach to healing at the Duke Center for Integrative Medicine in Durham, N.C. Our goal here at Med Monthly is to give you inspiring stories that you won’t find anywhere else. Send us a note at medmonthly.com to let us know how we are doing and give us feedback on what stories you want to see in this magazine. Also take a minute to visit our updated website at MedMonthly.com and “Like” on us on Facebook.

Enjoy our July issue!

Alice Osborn Managing Editor

6 | JULY 2011

Med Monthly July 2011

Publisher

Philip Driver

Managing Editor

Alice Osborn

Creative Director

Courtney Flaherty

Contributors

Advertising Director

George Cox Dr. Edward Logan Cathy Warschaw Kimberly Licata Mary Pat Whaley Megan Cutter Shauna Smith Duty Bill Turner

Subscription Information Subscriptions are $69 for one year or $89 for two years. Individual copies are $5.95 each. To subscribe call 919.747.9031 or visit medmonthly.com

Med Monthly is a national monthly magazine committed to providing insights about the health care profession, current events, what’s working and what’s not in the health care industry, as well as practical advice for physicians and practices.

We are currently accepting articles to be considered for publication. For more information on writing for Med Monthly, check out our writer’s guidelines at medmontly.com/writersguidelines.

contributors Dr. Edward Logan is a general and cosmetic dentist practicing in O’Fallon, Missouri. Dr. Logan graduated from the University of Washington School of Dentistry. After years of learning the business side of dentistry, Dr. Logan decided to write a book. Dentistry’s Business Secrets was published late last year. You can read more articles by Dr. Logan at his website DentistrysBusinessSecrets.com.

George Cox moved to Raleigh, NC in 1983 and obtained an MA from NC State in 1990. He has ghostwritten two novels and a collection of blogs and short articles. Currently, George is preparing his own novel for publication, and enjoys the opportunity to write freelance in his spare time. Besides writing, working, and raising two teenagers, George still finds time to fingerpick a few original compositions on his classical guitar.

Kimberly Licata is an attorney at Poyner Spruill, who practices health law and participates on the Firm’s Emerging Technologies and Privacy and Information Security teams. She may be reached at klicata@poynerspruill.com or 919-783-2949.

Mary Pat Whaley, FACMPE is Board Certified in Healthcare Management and a Fellow in the American College of Medical Practice Executives. She has worked in healthcare and healthcare management for 25 years. She can be contacted at marypatwhaley@gmail.com.

Megan Cutter P.O. Box 99488 Raleigh, NC 27624 medmedia9@gmail.com Online 24/7 at medmonthly.com

is a professional writer, editor and creative journaling instructor. In addition to providing writing, editing, coaching for writers and public relations services, she facilitates creative writing workshops, specifically in the areas of writing for health and wellness. To find out more about Megan, visit her at cuttersword.com.

MEDMONTHLY.COM |7

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research & technology

Dr. Becker helps women look and feel their best Breast surgery inventor and innovator

By Alice Osborn

D

r. Hilton Becker uses his passion and skills at breast reconstructive and plastic surgery to help patients when they are the most vulnerable: after mastectomies and after botched cosmetic operations. “Some of the most gratifying parts of my work are treating patients who have had complications with breast implants, multiple operations or previous breast problems where we can help them with our new advanced techniques and correct them in one operation.” Dr. Becker’s experience in reconstructive breast surgery greatly enhances his ability to perform cosmetic surgery of the breasts.

“I combine my knowledge of reconstruction and cosmetics to benefit both populations,” he states.

Originally from South Africa, and now practicing in Boca Raton, Florida at the Hilton Becker Clinic of Plastic Surgery, Dr. Becker is recognized both nationally and internationally as an expert in breast reconstructive surgery with over 25 years of experience in the field. He has lectured and taught surgeons all over the world and is extensively published on the subject of breast

10 | JULY 2011

surgeries and reconstruction of the breast.

The Becker Adjustable Breast Implant After experiencing the emotional and physical toll breast cancer took on his patients early in his career, Dr. Becker was determined to help these patients who underwent mastectomies maintain their femininity and self-esteem following the loss of their natural breasts. He soon invented the Becker Adjustable Breast Implant in 1984. The implant enables the woman to have a one-stage reconstruction at the time of the mastectomy, which is also called primary reconstruction. How it works is that the double-lumen saline-gel implant is a combination tissue expander and a breast implant in one, so the implant can be stretched to stretch the breast tissue. The saline is in the inner chamber for tissue expansion and the gel is in the outer for a softer-feeling implant. Dr. Becker explains, “Once you’ve stretched and shaped the tissue sufficiently then the tissue expander is removed and the implant remains behind. The patient doesn’t need to go back for a second operation as you do

when a traditional tissue expander is used. Now that the surgeons are doing less invasive mastectomies and saving more and more skin, this implant is getting more use.”

The implant allows a woman to regain her confidence and figure immediately and achieve her desired results as the implant is shaped and sized when fluid is added through a port which is removed once healing has taken place. This one-stage reconstruction is suitable for a high percentage of patients and not only does the adjustable implant reduce scarring and surgery complications, the size and shape of the breasts can be modified through the implants. This is especially important if one breast has had radiation or another trauma.

Besides reconstructive surgery, the Becker adjustable implant is useful for women who want an augmentation and a lift (here the volume can be fine-tuned and the breasts can be better shaped), for those who have asymmetrical breasts or who have had previous complications with implants.

The Scarless Breast Lift Dr. Becker is the pioneer of the sub-areolar (circum-areolar) or scar-

less breast lift which he performs with the adjustable implant. The lift is done around the outer edge of the areola where the scar can be camouflaged.

The areolar tissue is elevated and all of the tension is placed under the areola instead of on the skin so the scar doesn’t stretch and is less noticeable than traditional techniques. The lift is enhanced with the use of the Internal Mesh Bra, which was first used in reconstructive surgeries.

Continuing his mission to help women have healthy breasts Dr. Becker donates his time by lecturing about his highly sought-after surgical skills for physicians in South Florida and around the world. Dr.

Becker continues his mission to help breast cancer patients by performing free surgeries in Thailand, China, Brazil, Croatia, Mexico, Germany, and Panama as well as other countries.

He has helped many patients who have had reconstructive surgery done overseas because it’s cheaper and have later developed problems at home.

Dr. Becker says, “Many times you don’t stay overseas for three months and you can develop problems weeks or months after the surgery that you don’t anticipate. The areas where we see the complications are with patients going overseas or patients running to the cheapest possible surgeon.”

Visit beckerbreastimplants.com for more information about Dr. Becker and his practice.

DR. BECKER’S TIPS FOR CHOOSING A COSMETIC SURGEON:  Be very careful about advertising because anyone can advertise that they’re the greatest authority on earth. They need to be board certified in their specialty.  Speak to other patients who have been treated by the surgeon you’re seeking.  View the surgeon’s Before and After pictures.  Research that the surgeon has treated complications.  Do your due diligence and don’t rush into surgery.  Don’t elect to get the cheapest surgery because it won’t come with warranties for the implants, or guarantees to help with problems after the first few months and you may not get the best type of surgery for your condition.

Courtesy istockphoto.com

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research & technology

Beating tumors at their own game Surgical oncologist works to create pancreatic cancer vaccine

S

urgical oncologist Barish Edil is working with colleagues on a pancreatic cancer vaccine.

Tumors are tricky things, and pancreatic tumors especially so.

With an ability to deceive and ultimately thwart the body’s immune system, pancreatic cancer has long held the upper hand against physicians and patients fighting the disease.

Even in those rare cases when surgeons successfully remove the tumor, the cancer often returns in full force.

Consequently, a diagnosis of pancreatic cancer is often tantamount to a death sentence, if not in the first goround then the next, usually less than a decade after the initial diagnosis.

Now, though, a vaccine developed by Johns Hopkins researchers could potentially weight the fight in the immune system’s favor.

During a clinical trial 10 years ago, a group of Hopkins researchers led by oncologist Elizabeth Jaffee distributed an experi-

Photo by Brian Hoskins

mental pancreatic cancer vaccine to 10 patients. As is often expected in pancreatic cancer diagnoses, several of those patients eventually suffered recurrences and died. But today, three remain alive and cancer-free, and all signs point toward the vaccine as the cause.

“With pancreatic cancer, that’s exceedingly rare,” says surgical oncologist Barish Edil. “The five-year survival rate for this disease is only around 20 percent, and the 10-year rate, well, that is quite rare.”

Edil, joined by a group of oncology colleagues, has taken the helm of the clinical trial’s second phase, which is now in its second year. He’s also altered the approach.

In the trial’s first incarnation, the vaccine was distributed only after patients had undergone a Whipple operation and received chemotherapy. Now, however, patients receive one vaccine dose before surgery and right after, followed by four more vaccinations after chemotherapy.

The pre-surgery vaccinations offer several advantages in treating the disease, Edil says. First and most obviously, the body receives an immune boost that could prove helpful as patients deal with the threefold challenge of fighting the cancer, undergoing major surgery and coping with chemotherapy and radiation.

And, of course, there’s the hope that the tough vaccine regimen will fight off cancer recurrence. But there is a third benefit that’s

proving most exciting for Edil and his colleagues: the chance to reach out to patients before surgery allows physicians to observe the effects the vaccine has on the tumor postoperatively.

Since the trial opened, 22 patients have received the vaccine. Examinations of the patients’ tumors have shown that each has developed disease-fighting lymph nodes, a sure sign that the immune system is battling harder and more effectively than has ever been possible before.

“We have the immune system working to kill the cancer cells,” Edil says.

“This is the first time we’ve ever seen that, plus we have long-term survivors now, which is especially unique. Our hope is that the body is revved up so that when the cancer comes back, which it does with pancreatic cancer quite often, the immune system will be able to kill those cells as well.”

Of course, there are still improvements to be made.

For instance, despite any immuneboosting effects the vaccine may have, chemotherapy and radiation treatments ultimately thwart the immune system all over again.

“We’ve shown that even after we give the vaccine, once we start giving patients chemo and radiation therapy, certain cells that attack cancer go down again,” Edil explains. “We have to figure out how to integrate the two treatments so that they work well together.”

Reprinted from Cutting Edge, a publication for the department of Surgery Johns Hopkins Hospital MEDMONTHLY.COM | 13

careers

Over the last 12 months, health care has added 283,000 jobs, or an average of 24,000 jobs per month.

Nursing shortage means opportunity for those interested in health care

D

espite a slow economy, the health care industry continues to thrive. This is partially due to growing demand from the aging baby boomer population, who require additional health care services today and into the future.

These same boomers are retiring, leaving many areas of the health care field open for new professionals looking to get involved in helping others.

Nurses, in particular, are in high

14 | JULY 2011

demand. Many areas of the country are experiencing major nursing shortages. Those with a degree and certification are valuable to employers, and it’s not uncommon for experienced nurses to have a number of opportunities to choose from.

Jobs in health care are increasing despite losses in other major industries.

Over the last 12 months, health care has added 283,000 jobs, or an average of 24,000 jobs per month. As the larg-

est health care occupation, registered nurses will likely fill many job openings in the future. With above average growth numbers projected through 2018 and a national median wage of $62,450, there is a unique opportunity for registered nurses.

The majority of nurses work in a hospital — approximately 60 percent — but nurses are also needed in other places. Some alternative workplaces include offices of physicians, home

health care services, government agencies and educational services. Because complicated procedures, once only performed in hospitals, are now being performed in physicians’ offices and in outpatient care centers, demand for qualified nurses with strong leadership skills at these locations is increasing.

Whether just starting down the nursing career path or looking to take on a leadership role and influence the delivery of care, education and training are highly valued by employers in this field. Higher education helps practitioners become more skilled and knowledgeable nurses, thus allowing them to step forward as leaders, while helping improve health care delivery and patient outcomes.

How can you become a nurse?

Getting the right education is key.

Employers expect nurses to keep their skills current and be able to handle multiple tasks and an increasing num-

ber of patients. There are a variety of options for those considering a nursing degree. Typically nurses get a two-year associate degree or a fouryear bachelor’s degree that includes coursework and clinical training. For those that wish to expand their skillset and become leaders in this field, higher education programs prepare nurses for the increased responsibilities and challenges facing today’s health care practitioners.

Many nursing students today are considered non-traditional students.

This means these working learners have full-time jobs, are parents, spouses or active members of the military.

If you fit into this category, you can still pursue a nursing degree through a flexible online school like University of Phoenix, which has one of the largest nursing schools in the United States with more than 30 years of experience.

For nurses who have a two-year

degree and want to advance to a fouryear degree, the RN to BSN program (registered nurse to bachelor’s of science in nursing) provides students the opportunity to advance their credentials, knowledge and skills on their own schedule, allowing time for family and other work obligations.

Nurses help those in need both emotionally and physically. Some nurses choose to specialize in a type of patient, such as children or the elderly, or they specialize in a certain area of treatment, such as in the emergency room or during surgery.

No matter what your personal interest, the demand for nursing continues to grow and offers a once in a lifetime opportunity for those looking for job security, career growth and the ability to make a difference in other people’s lives.

Reprinted courtesy of ARA content

If you offer medical or dental care to children, you need to make the kids adore you.

Courtesy istockphoto.com

your practice

Think of the children How to make your practice more kid-friendly

By Shauna Smith Duty

I

n 1979, McDonald’s rolled out an innovation that revolutionized marketing in the fast food industry: the Happy Meal. Since then, the Happy Meal has become iconic across the globe, and some connoisseurs are serious Happy Meal toy collectors.

There is no denying that the Happy Meal was one sensational idea.

Dentists and physicians can learn something from McDonald’s. Please the kids, and the parents will become loyal customers. We know that mothers usually choose the family health care providers. Logic tells us to target our marketing efforts towards moms.

We also know that moms give their children’s doctor and dental care visits top priority, usually over the parents’ own care. That initial visit is your opportunity to please the kids and thus please the parents.

What’s Your Happy Meal?

Whether you’re a pediatrician, pediatric dentist, or family healthcare provider, if you offer medical or dental care to children, you need to make the kids adore you. Prove your dedication, concern, and genuine compassion to the children, and the parents will become loyal patients.

After a visit to your office, what do you think Mom asks her child? “Did

you like the doctor?” It’s the same type of question you would ask your child after a first day at school. “Did you like your teacher?”

So what do you want the child’s answer to be? Develop a marketing plan to make your goal a reality. With good, well thought out marketing, you can determine your future. Here are a few Happy Meal ideas to get you started:  Big Success Club Everyone appreciates recognition for a job well done.

Rewarding good grades in school is an obvious success to honor, but you might also recognize accomplishments in Boy Scouts, Girl Scouts, Awanas (a faith-based organization for children), and other clubs. Dentists should have a cavity-free club, and doctors can recognize children for healthy habits, like exercising and eating right.

Create a promotion for kids and parents to share successes on your Facebook page and blog. In addition, tangible rewards may include: stickers, candy, gift certificates for frozen yogurt, movie tickets, or a Wall of Fame in your lobby.  Kid-Friendly Surroundings Stage your office so that parents don’t have to tell their children, “No! Stop!

Be quiet! Don’t touch!”

Set up an area in your lobby with contemporary toys and games.

Modern kids are tech savvy, so equip your office with WiFi, as well. You might also incorporate television and video games into the children’s area.

Your bathroom and treatment rooms should be kid-friendly, as well.

Don’t forget, Mom sometimes has to spend thirty minutes in a treatment room entertaining her children. Both kids and mother may feel apprehensive, anxious, or scared. A distraction would be wonderful. Make sure the kids have something fun to do in the treatment room so that Mom can relax during the wait.  A Team Who Loves Children From your receptionist to your nurses, everyone in the practice must not only tolerate but like children.

When interviewing perspective employees, ask how they feel about children — even kids who have ADHD and don’t take medication. During team meetings, share tips and tactics for pleasing children and parents or handling difficult situations with children. Set the expectation that your team members will make children feel welcome and secure in your office so you’ll be that much closer in finding your practice’s Happy Meal.

MEDMONTHLY.COM | 17

your practice

Coding for the rest of us And why everyone in your practice needs a basic knowledge of coding

By Mary Pat Whaley, FACMPE

T

here is no one, and I do mean no one, in your medical practice who does not need to know the basics of coding. Here is why this is important:

Providing services to patients is the business of health care.

Every person who relies on health care for their living should understand something about the business they are in. This should not outweigh the fact that we are privileged to care for patients, but as the saying goes, “No money, no mission.”

It takes a team to produce care The silos of front desk, billing, nursing and scheduling must come together to share their knowledge and produce a high-quality, reimbursable patient visit. Here are the roles each member of the team plays:  The patient calls for an appointment and the scheduler matches the patient’s problem to an appropriate appointment type. The scheduler finds out if the patient is new or established and why the patient wants to be seen.  The patient arrives for the appointment and the front desk assures that all current demographic and insurance information is collected.  The nurse rooms the patient, tak18| JULY 2011

ing vitals, reviewing medications and reviewing the reason for the visit – the chief complaint.  The physician or mid-level provider cares for the patient, documenting the visit and choosing the appropriate service and diagnosis codes.  The patient completes the visit by paying any deductibles or co-insurance due and making any future appointments needed. The checkout staff enters the payments and/or charges if the service codes have not already been posted via the EMR.  The biller “scrubs” the claim, checking for any errors and electronically submits the claim to the payer. The hope is that the claim is clean and will be accepted and paid immediately (within 30 days.)

When staff understands how important their contribution is to the financial viability of the practice and how all the pieces fit together, they are more incentivized to perform.

“Coding” means two things: service codes and diagnosis codes. Service codes describe office visits, surgery, laboratory, radiology, pathology, anesthesia and medical procedures that are provided by physicians, nurse practitioners, and physician assistants. Diagnosis codes describe signs, symptoms, injuries, diseases, and conditions. The critical relationship between a service code and a diagnosis code is that the diagnosis supports the medical neces-

sity of the procedure.

Service codes are called either CPT codes or HCPCS (pronounced “hickpicks) based on the payer/insurer who uses them. Most commercial insurers use CPT (Current Procedural Terminology) codes, but Medicare and Medicaid use HCPCS (Healthcare Common Procedure Coding System.)

Codes are globally grouped into Level I and Level II:  Level I codes include the 5-digit numeric CPT (Current Procedural Terminology) codes. These were developed by the American Medical Association (AMA) in 1966 and remain proprietary to the AMA. The codes are updated in October and become effective as of the next calendar year. They are available as a printed manual or as an electronic file.  Level II codes are national codes developed by the Centers for Medicare and Medicaid Services (CMS) to describe medical services and supplies not covered in the CPT. They consist of alphabetic characters (A through V) and four digits.

There are two ways that patient services are coded so they can be billed to insurance companies. The first is through the use of a preprinted coding sheet, which goes by many different names: superbill, encounter form, routing sheet, patient ticket, or billing form. The physician or mid-level

provider indicates which services were provided and maps specific diagnosis codes to the services.

The second is abstraction from the medical record. A coder reads the documentation provided by the physician or mid-level provider, and matches codes to the services described in the record. Computerized coding abstraction via an electronic medical record (EMR) is also an option.

Basic coding rules for every practice  Always have the latest edition of CPT and HCPCS. Service codes change annually and it is important to use the correct code for the calendar year.

Check new, revised and deleted codes annually and change your encounter form and codes in your billing system to match.  Attend webinars or seminars annually to stay up-to-date on large-scale coding changes for your specialty or for all specialties. For instance, tobacco

cessation counseling is reportable to and payable by Medicare for the first time in 2011 – see a handy guide here (http://www.aafp.org/online/en/home/ clinical/publichealth/tobacco/reimbursement.html) and every specialty can bill it. You may also want to subscribe to coding newsletters for your specialty or check your physician’s specialty society to see what they offer.  Utilize the National Correct Coding Initiative (NCCI) to make sure which codes are to be submitted individually versus being bundled. Many practices do not know about or use the NCCI information for the simple reason that it is complex and confusing and changes regularly. Someone in the field who offers great (free) information on the NCCI edits is Frank Cohen at www.frankcohen.com.  Have an in-house crosswalk for provider abbreviations to make sure that they have signed off on what their abbreviations mean. The best of all worlds is requiring the physician or mid-level provider to supply a code as

opposed to a description.  Use scrubbing software tools to check service and diagnosis code mismatches, Local Coverage Determinations (LCDs) for Medicare, any services without appropriate diagnosis codes and any diagnoses without standard accompanying services.  Audit your documentation regularly to ensure it matches your level of service (“if you didn’t document it, you didn’t do it”) especially if you are not documenting electronically with decision support tools. Audit yourself or hire a firm to audit for you and document lessons learned and any corrective action taken. This should be part of your practice compliance plan. Note that physician regulatory insurance is now available (Google it) for around $1500 per physician per year.  It is always the physician or midlevel provider’s ultimate responsibility to choose the codes that best correlate with what s/he did. When in doubt, always defer to the provider of the service.

your practice

Why you should be using iPads in your dental practice Consumer technology aids practices, patients

By Edward M. Logan, DDS

M

y business manager recently purchased an iPad for her family’s use to replace a laptop and provide a communication device for her son who has a communication disorder. It has been fascinating to see the role that this iPad technology is playing in the lives of people with Autism Spectrum Disorders and communication disorders. Her enthusiasm over its usefulness has led her to look into the uses of an iPad within a dental office.

Patient Education Tool With the iPad’s ability to quickly display pictures it can serve as a patient education tool, providing your patients with the opportunity to view photos of their smile in the palms of their hands. Yes, the display of these pictures can also be accomplished on a laptop, computer monitor or mounted TV so this usage alone certainly doesn’t justify the purchase of an iPad. However, some dentists have noted that their patients seem to react better to the “cool factor” of holding an iPad while viewing their photos.

Useful Dental Apps The main reason to purchase any of 20 | JULY 2011

Apple’s iProducts is to take advantage of the applications available for virtually every area of life. Are there any iPad apps designed for dental practice management or patient education?

A quick browse of the iTunes store displays several dental specific apps, but you can rest assured that many more apps are in the works. One app that is receiving great reviews is DDS GP which was created by a practicing dentist to be used for patient education. This app includes demonstrations of many common dental problems and their treatments. The demonstrations include drawings, but no video or sound, which allows the dentist to explain the patient’s specific case while showing possible treatments. The DDS GP app allows dentists to add their own photographs and design treatment plans which can be printed or e-mailed. Dentists who use this app for patient education are raving about its effectiveness.

Charting Tool Many doctors, and a large number of dentists, have transitioned to using tablets for their medical and dental charting. With the release of the iPad in 2010, several dental practice management software distributors have been working on an iPad based chart-

ing app. EdgeEHR, which offers dental practice management software for use with the Mac operating system, has launched a touch based charting application that integrates with edgeDMS. The edgeDMS app allows for dentists to use the iPad to chart and check patient history. This app integrates with the edgeDMS software and can share information with other Mac computers running edgeDMS.

Potential Pitfalls As I consider whether this new technology would be helpful to my office, I have a few concerns. The first concern is about durability of the iPad and the possibility that it could get bumped or dropped in a dental office.

To decrease my worries, I believe I would want to purchase an Otterbox Defender series case before introducing the iPad into my office. The Apple Warranty does not cover drops, bumps or spills, but other companies offer extended warranties that cover these occurrences. I’ve never been one for expensive extended warranties, but I might consider a warranty from a company like Square Trade to cover these possibilities.

For more information visit dentistrysbusinesssecrets.com.

Courtesy istockphoto.com MEDMONTHLY.COM | 21

your practice

Health and Human Services modifies HIPAA’s accounting disclosures

By Kimberly Licata

F

or months we’ve waited and wondered what the government was going to say about what many have called the least used right under the Health Insurance Portability and Accountability Act (HIPAA), the right to an accounting of disclosures. Back in 2009, Congress passed the Health Information Technology for Economic and Clinical Health Act (HITECH), which significantly expanded the disclosures that need to be listed in an accounting of disclosures, which caused concern

panded right. Most commenters told the government that the accounting of disclosures would offer little to no value to a patient while costing providers substantial time and expense to produce. The government not only failed to reduce the potential hardship of the HITECH changes, but further expanded this right into a new right: a patient’s right to an “Access Report.”

You won’t find the definition of an “Access Report” in the HIPAA statute or the HITECH Act. An “Access Report” is something that is brand new

user. This must be provided within 30 days of a patient’s request (subject to a single extension). Patients will get one free access report per twelve (12) month period. After that free report, providers may charge a patient for subsequent reports on a per cost basis.

For many, the most alarming aspect of the NPRM is that OCR believes the HIPAA Security Rule requires that this detail about access to information be tracked, maintained, and monitored.

Many experts in the field had not interpreted the Security Rule so broadly,

The Office of Civil Rights of the federal Department of Health and Human Services issued a Notice of Proposed Rulemaking to modify HIPAA’s standard for the accounting of disclosures as required by HITECH among providers. You may be asking where are we now? On May 31, 2011, the Office of Civil Rights (OCR) of the federal Department of Health and Human Services (HHS), the agency that enforces HIPAA, issued a Notice of Proposed Rulemaking (NPRM) to modify HIPAA’s standard for the accounting of disclosures as required by HITECH. Because of the concerns of the provider community, many wrote OCR in advance of the NPRM about the ex22 | JULY 2011

and was created by OCR. This report is OCR’s attempt to provide patients with what OCR thinks patients really want, namely, a list about who is looking at their information. An access report must include all disclosures and uses of protected health information in an electronic designated record set.

An access report must be understandable to the individual and provide date and time of user’s access, user’s name, description of information accessed, and action taken by

and currently, few providers and business associates keep this level of access information for three (3) years as proposed by the NPRM. Many providers have never had a patient request an accounting of disclosures since implementation of this HIPAA standard in 2003. This is despite providers having notified patients of this right in their HIPAA-mandated Notice of Privacy Practices. Back in the old days (before HITECH), the accounting had to

include all disclosures (but not uses), except for those that were specifically excluded from the list. Pre-HITECH, providers did not have to account for disclosures made to carry out treatment, payment and healthcare operations (so-called TPO uses or disclosures); to the individual himself or herself; incident to a permitted or required use or disclosure; pursuant to an authorization; for the facility director or individuals involved in the patient’s care; for national security or intelligence purposes; to law enforcement or correctional facilities; as part of a limited data set; or that occurred prior to the compliance date for the provider. This was a situation where the exceptions did swallow the rule.

HITECH removed many of these exclusions. Of particular interest to many providers was HITECH’s removal of the exception for uses or disclosures to carry out TPO. The NPRM details what HIPAA requires of the

accounting of disclosures from specific facts about each use or disclosure to the three (3) year period covered.

The accounting need not include disclosures or uses of which the provider has already notified the individual (such as any breach notification).

There are a few positives about the NPRM. First, it only applies to electronic records. This is a change from the prior rule. Second, the government thinks electronic health records (EHRs) should be able to do this for you without significant effort.

While this may not be true today, this will likely encourage EHR vendors to make this an easier process for Stage 2 Meaningful Use. Remember EHRs certified under Stage 1 did not have to provide an accounting feature, but this feature will be required for later Stages. Third, providers are up in arms about this expansive right(s) and some softening may occur although it is unlikely to be completely re-

moved. A lawsuit may be filed about the constitutionality of the right to an access report. Fourth, the proposed rule identifies explicitly the seven (7) categories of disclosures that must be listed in an accounting. Interestingly, these do not appear to include disclosures for TPO. Finally, the government is soliciting your comments on or before August 1, 2011 about the NPRM. What you say about how this will impact you and your practice (positively or negatively) helps OCR make the final rule more palatable.

To review the notice of proposed rulemaking, go to OCR’s website: www.hhs.gov/ocr/privacy/index. html where you will find links to the May 31st NPRM and the related press release.

Editor’s note: These comments are not intended to establish an attorney-client relationship and are not intended to be legal advice.

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your practice

The Healing of America: A Quest for Better, Cheaper and Fairer Health Care Review by Megan M. Cutter

W

e all know that our health care system is failing individuals and communities across the United States, but how can we begin to change it? Before stepping into the current political battlegrounds over health care, understanding global health care structures can provide an educational foundation to build upon in order to address our current health care crisis.

“The Healing of America: A Quest for Better, Cheaper and Fairer Health Care” by T.R. Reid looks at other health care models around the world from France and Germany to Japan and Canada.

T.R. Reid then dives right into the United States health care crisis with an example of a young woman who dies from a curable illness, but who was unable to work and therefore denied the health care she needed. Providing many statistics, Reid reports that over twenty thousand Americans die each year because they cannot afford health care costs.

24| JULY 2011

Interweaving personal accounts of visiting doctors across the world, global statistics and historical details on four different health care models, the reader gathers a wealth of knowledge about the current state of the

nation’s health care crisis, the benefits and drawbacks of other health care models and questions we should all be putting forth, whether we are physicians, administrators, or individuals.

We learn that the United States has one of the highest infant mortality rates in the world, and that as leader in the industrialized world, our health care systems time and time again rates as one of the worst. In fact, it was shocking to learn that “the average American can expect a shorter life than people in relatively poor countries like Jordan.”

This implores the question, are other health care models any better? T.R. Reid dissects four different models- The Bismark Model (Germany, Japan, Belgium, Switzerland and Latin America), The Beveridge Model (Great Britain, Italy, Spain and Scandinavia), The National Health Insurance Model (Canada) and The Out-ofPocket Model (Africa, Cambodia, India and Egypt) providing an overview, historical references, benefits as well drawbacks and comparisons to the US healthcare system.

In looking at these four models, Photo by Courtney Flaherty

T.R. Reid evaluates quality, cost, choice and effectiveness, in addition to comparing them to the American health care system. T.R. Reid dispels many myths about other global heath care models including socialized heath care, rationed care, bureaucracy within systems or that these systems are just too foreign to be used within the US. T.R. Reid also mentions the com-

have no insurance coverage.

“The Healing of America: A Quest for Better, Cheaper and Fairer Health Care” breaks down what a unified health care system would look like and what universal coverage would mean. Though he only touches on the recent changes in health care reform from 2010, the reader will understand why it is so difficult to change.

Instead of finding the jumbled and

even individuals in the community can make in their everyday decisions, “The Healing of America: A Quest for Better, Cheaper and Fairer Health Care” provides concrete information that every health care organization should grasp in order to ask questions that can move the nation’s health care system in the right direction.

Health care providers and administrators can see why individuals walk

Reid reports that over twenty thousand Americans die each year because they cannot afford health care costs. bination of systems that we use in the United States citing veteran, military, and Native America as a British model; senior care as being similar to the Canadian model; working individuals who receive insurance through their employers as similar to Germany or Japan; and the millions of individuals who pay out of pocket because they

confused argument slanted toward a politician’s agenda, readers will come away with a clear and focused overview to create their own perspective with questions to take beyond the pages of the book.

While T.R. Reid is unable to give concrete steps that physicians, health care administrators, organizations or

into their offices frustrated or why individuals must wait until their illness becomes an acute crisis to seek help.

Understanding the systemic problem gives recognition to the many facets of the health care system, so that whether you are a large health care facility or a private doctor’s office, you can provide the best care to your clients.

MEDMONTHLY.COM | 25

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When most doctors are asked what their practice is worth, the answer is usually, “I don’t know.”

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feature

By Alice Osborn

A Mural, created by volunteers now decorates the children’s ward of the Nicaraguan facility.

Photos courtesy Dr. Kobs.

MEDMONTHLY.COM | 27

I

t’s been said that serving others through your passion can lead to health, happiness and abundance. If this is true then Dr. Jeffrey K. Kobs, the president of COAN (Cooperación Ortopédica Americano Nicargüense) is a very wealthy man indeed.

Since 1993 Kobs has practiced at Raleigh Orthopedic Clinic, in Raleigh, North Carolina, his “day job” while volunteering for COAN, a not-forprofit organization committed to optimizing the orthopedic health care and well-being of the Nicaraguan people. “I get more out of it sometimes than they do. I have friends down there so going down and working with colleagues in a different country who really need the help is extremely rewarding,” says Kobs. “It’s its own reward. I see patients who are so incredibly appreciative and they know that if we weren’t there they may not get any care. We’re preventing poverty.”

Nicaragua is the second poorest country in the Western Hemisphere after Haiti. COAN’s patient base is made up of low-income people, mainly families and children, who need emergency treatment and longer term orthopedic care. “We are trying to change the orthopedics of Leon and then hopefully all of Nicaragua over time and we’re starting to make some headway,” says Kobs.

Founded in 2002, with the help of Robert Pontz, the vice president and managing partner of Progress USA, Inc., COAN is a group of orthopedic doctors comprising of all different practices that travel four times a year in January, April, July and October to the Heodora teaching hospital in León for one week at a time. The team leaves on a Saturday and returns on the following Saturday.

However, in COAN’s first year the doctors only visited one week in a year. Kobs remarked that there wasn’t enough impact and COAN couldn’t keep the hospital supplied. “We wanted to do more educational support, give

28 | JULY 2011

them technology upgrades and start an anesthesia program, which goes down twice a year.”

At this teaching hospital there are residents and attending surgeons so when the COAN team performs surgery there’s always follow-up care.

The U.S. doctors train Leon doctors and expect their skills to improve after each subsequent visit. Because of the regular visits, the hospital knows when the American team is coming back.

“We’re getting the right patients to the right surgeons,” remarks Kobs. “I’ll see 20-30 patients during the clinic on Sunday, our first day, for broken bones, club foot, shoulders, and knees. I also perform a lot of tertiary orthopedics where patients had a fracture and it wasn’t treated right and I have put it back together.”

There are a few challenges Challenges to serving the residents of Leon for orthopedic care include the language barrier, the lack of equipment, and education.

To overcome miscommunications, Christina Dees, of Carolina Beach, North Carolina, was the group’s liaison with the Nicaraguan government and the team of doctors.

Using her business background and fluency in Spanish she served as the COAN team’s translator, bookkeeper, webmaster and fundraising coordinator for many years.

She also found a way others could contribute to the hospital’s needs by raising money to paint a mural in the pediatric ward, improving the nurse’s station and installing ceiling fans. Dees and her husband also started a grant program for participants so the cost of $1500 per trip would be lessened. Now on maternity leave, she says, “It was

my dream job,” and that Dr. Kobs was wonderful to work with.

Dees continues, “Working with COAN, its doctors, and volunteers, has given me unique life experiences I will forever remember as vividly as the day I saw them. I traveled the country of Nicaragua with doctors Bob Caudle and Ed Campion, seeking out new hospitals that needed our help. It didn’t matter to them that these places had no state-of-the-art operating rooms or fancy equipment; what mattered was that there were people who just needed treatment, some who needed life changing surgeries. Simple treatments and supplies weren’t affordable or available. Seeing the love and passion the COAN doctors have for helping others is truly addictive. It is a dedication that changes people’s lives forever.

That same contagious passion can be seen in the volunteers of COAN. Volunteers like nurses and lay people who selflessly give up their vacation time each year to go and change lives no matter what the cost.”

Dr. Kobs adds, “We’ve taken infrastructure missions, with three in January where we took laypeople to paint, fix sinks and toilets; to help the hospital do what it won’t do for themselves, since this is sometimes a last priority for the hospital.

It makes a big difference for the staff and doctors.”

“When something breaks, they don’t have any money to fix it. So they put in a governmental request and they don’t get to it that fast,” Kobs says.

In order to stretch the COAN equipment budget, medical reps give COAN implants and sometimes COAN receives grants and supply donations from medical equipment companies.

“When we first started going our drills came from Sears to use in the OR and were very hard to keep sterile, but now

we have battery-powered regular OR grade drills.”

COAN also brings English to the hospital. Two times a week COAN pays for an English teacher to give a lesson for the residents and attendings for an hour and a half. “All of the orthopedic literature that’s worth anything at all is in English,” Kobs states. “The same applies with papers in that the paper needs to be English and most of the published data is in English.” Monday through Friday the COAN team works in the OR and then in the morning they conduct lectures.

One day of that week the residents are expected to give the COAN team lectures in English. At first there wasn’t any place for the orthopedic team to meet. “There was one room that was too hot so what we did we spent $2,000 to fix up a storage space on the roof that includes A/C and a library. That’s where we give our talks and lectures and the entire department can fit there.

We have them set up with the Internet too,” Kobs adds.

Another challenge is that the hos-

pital doesn’t have enough of the right equipment or they use older methods that American orthopedists abandoned sixty years ago. “We’re working very hard at getting people out of traction,” states Kobs. He continues that he used to see a bunch of patients up on traction in open, common wards with tibia and femur fractures. Of course their leg fractures could not heal properly.

To solve this problem, Kobs involved the help of Dr. Lou Zirkle of Richland, Washington, who runs a program called SIGN (Surgical Implant Generation Network) that provides rods (which are orthopedic implants that heal fractures) to underdeveloped nations. COAN bought $25,000 worth of rods and took them down on a mission to teach the residents how to do the rodding. “We don’t see people in traction anymore because of the rods,” Kobs remarks. “They do substandard work by our standards because they don’t have the right equipment and the other part is that they don’t know the exact right way to treat patients.

Learning is gained through repeti-

tion and they’re not learning proper methods because they’re not trained.”

He says that American doctors learned in the last century to rod and clean the wound the same day and not put the patient up in traction. In contrast, Nicaraguan doctors have been trained that patients must remain in traction until the skin closes.

Sometimes the innovation that’s inexpensive can save lives. Take the case of healing open wounds with a wound V.A.C. (Vacuum Assisted Closure) costing $10,000. Rising to the challenge, the longtime fish owner made his own wound V.A.C. out of an aquarium aerator pump for $35 and dubbed it the “Turtle” or officially, the Negative Pressure Wound Therapy System. It helps extract the fluid from the wound using pressure and tubing so doctors can stitch the skin on both sides. “You can do this procedure at the bedside and not in the OR. It took a year for me to develop and I want to make it open source so it’s more readily available. In Leon we’ve used it on two patients so far and I want to make as many as I can for the next trip,” Kobs describes.

What’s next for COAN? Right now Dr. Kobs and his team are busy working on fundraising, enrolling more members, building awareness and preparing for the next mission.

Through his and COAN’s efforts, men are back at work providing for their families after a broken leg, a boy with club foot can walk again and Leon’s hospital’s residents practice what they learned in the far reaches of Nicaragua.

Kobs often tells his Nicaraguan colleagues, “You do have what you need and you should perform surgeries in the more modern way. You have to believe in yourselves and do it the right way.” He adds, “We all want these techniques to migrate from Leon and spread to the rest of the country.” With his determination, generosity and leadership this wish will become a reality.

MEDMONTHLY.COM | 29

feature

Medical school The Caribbean isn’t just for vacation anymore. From Ross University to the American University of the Caribbean, now you can find quality medical schools in paradise.

By George Cox

30 | JULY 2011

takes a vacation

Not a bad place to study.

St. George’s, Grenada is home to St. George’s University.

Courtesy iStockphoto.com

P

opular for its vacation hotspots, the Caribbean also offers excellent opportunities for medical students desiring an affordable alternative to universities in the United States. Since St. George’s University, the first Caribbean medical school, was founded in 1977, sixty more medical schools have been founded throughout the islands.

Schools like the American University of the Caribbean in St. Maarten, Ross University in Dominica, West Indies, and others are dedicated to challenging prospective students as they build a secure foundation in medical scholarship. Qualified students attending these schools will develop high standards of professionalism and proficiency in their medical specialty, paving the way to an invaluable career

United States, making wonderful contributions to the healthcare industry.

American University of the Caribbean in St. Maarten Located on the magnificent island of St. Maarten, American University of the Caribbean (AUC) was founded with one simple goal—to produce “visionary, skilled, compassionate doctors.”

The AUC campus overlooks Simpson Bay Lagoon and allows students access to a variety of spectacular beaches and island activities like diving, sailing, golf, and shopping. First class restaurants and live entertainment enhance students’ living experience.

Academically, the school maintains state of the art facilities, ultra-modern classrooms and laboratories, a virtual

Compared to the first-year tuition and living costs at some U.S. schools, such as Harvard Medical School ($66,000) and East Carolina Medical School ($31,889), AUC’s fees are definitely very competitive.

Spacious on-campus dormitories feature fully equipped kitchens, air conditioning, and cable TV and Internet availability. Of course, students and families may opt to enjoy these amenities in a more tranquil residence in one of the nearby towns, such as Beacon Hill, Pelican Key, and Simpson Bay. Campus organizations at AUC include Alpha Omega Phi (Honor and Service Society), the American Medical Student Association (AMSA), and the Student National Medical Association (SNMA). Other campus groups

When not in class, students have access to a campus fitness center and sport fields for soccer, football, tennis, and volleyball. in public health care.

However, some medical professionals claim that Caribbean medical schools have too easy entrance requirements and less than rigorous curricula to adequately prepare graduates to become quality physicians. Furthermore, low tuition could suggest poor or inadequate facilities, substandard laboratories, and insufficient clinical research opportunities. Critics also argue that Caribbean graduates practicing in U.S. hospitals may not be taken too seriously by their Americaneducated colleagues. Ultimately, these critics suggest that the medical schools of the Caribbean are nothing more than a secondary choice for students who failed the entrance requirements for U.S. medical schools.

While some of these naysayers may have legitimate points, prospective medical students considering a Caribbean school should take a closer look at some of the more reputable ones before making an informed choice. Many physicians from Caribbean schools are practicing medicine successfully in the 32 | JULY 2011

imaging anatomy lab, and a technologically advanced medical library.

Students develop skills through challenging instruction and meticulous training from an experienced faculty pool of over 500 dedicated physicians, scientists, teachers, and scholars. Since its founding in 1978, AUC has graduated more than 4,000 fully licensed physicians who practice medicine in many different countries around the world.

Fully accredited by the Accreditation Commission on Colleges of Medicine (ACCM), AUC models its curriculum after U.S. medical schools, providing students with five semesters of medical science training at the St. Maarten campus before clinical studies at hospitals in the U.S. and England. To be considered for enrollment, entering students must have a baccalaureate degree from an accredited university and have recently passed the MCAT. Tuition and fees range from $32,000 to $34,400 for the first year, with living expenses varying from $10,000 to $14,000 per year.

include religious-oriented organizations as well as a Student Government and a Diversity Council.

Modern learning facilities housed in a culturally diverse environment give AUC students an unsurpassed educational experience at an affordable price.

Ross University in Dominica Nestled on the mountainous volcanic island of Dominica, Ross University offers students a solid foundation in medical training in a classical Caribbean environment. The entire campus is wireless, with high-quality multimedia technology in the classrooms and laboratories, a comprehensive modern library, and two Learning Resource Centers.

Enthusiastic students benefit from the advanced facilities and dedicated faculty, acquiring the quality foundation in medical science necessary for the required clinical rotations at affiliated U.S. teaching hospitals. In its thirty years of committed service,

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Ross University has graduated over 7,700 students, with over 600 physicians successfully placed in U.S. residencies.

Many Ross graduates have specialized in various areas of medicine, including invasive cardiology, endocrinology, geriatric medicine, plastic surgery, and oncology. Whether Ross graduates go into private practice or research, they are among the most diverse and successful medical professionals in the world.

A 2006 graduate of Ross, Dr. Challie Minton says the university gave him the “opportunity to get into school quickly, and get into a residency program” that allowed him to “become a highly respected physician in North Carolina.”

A U.S. Navy Corpsman, Dr. Minton was a bit older than a typical medical student in the U.S., but at Ross he met other Corpsmen and Army medics who “were over thirty years old and had at least 5-10 years medical experience.” Many of his colleagues have been accepted into top residencies programs and Fellowships across the country, including Sylvia Marcos M.D., a Ross graduate who was the Chief Resident at Kings County Hospital in Brooklyn, New York, one of the top Internal Medicine programs in the country.

Students must meet standard acceptance requirements and be financially prepared for entrance in to Ross.

According to the school’s published tuition rate for the 2010-2011 academic year, each Basic Science semester costs $15,600, with the each semester of Clinical Sciences averaging $17,500. Financial assistance is available through governmental and private loans.

When not in class, students have access to a campus fitness center and sport fields for soccer, football, tennis, and volleyball. Brimming with a rich, diverse culture, Dominica offers a variety of outdoor activities for residents, including hiking, scuba diving, and snorkeling in the eastern Caribbean. To pay for these activities, students may have to exchange their currency for Eastern Caribbean (EC) 34| JULY 2011

currency; however, most businesses accept the U.S. dollar.

Whether from the United States, Canada, or anywhere in the world, incoming medical students to Ross University will gain access to a superb teaching facility, highly accredited teachers and researchers, and an island paradise they will love to call home. Dr. Challie Minton credits Ross with his success as a physician, from the opportunity “to rotate at great hospitals across the country to finishing as a visiting student at Duke University and passing with honors.”

Final Word While the Caribbean hosts high quality, affordable medical schools, a student must do adequate research before making an informed decision.

While the school’s location may be exotic and tempting, its U.S. accreditation, rigorous course work, and accessibility to prestigious research clinics should be significant factors in a prospective student’s decision to attend.

If the goal is to practice at a particular U.S. hospital, students would be wise to do a little homework first. Before applying to the Caribbean school of their choice, students should find out if the school in question is accredited by the LCME (Liaison Committee

on Medical Education which accredits medical schools in the United States).

They should be aware that in order for them to do rotations in hospitals in the U.S. that the individual school must first be reviewed and approved by some licensing boards, especially in California, Florida, New Jersey, and New York.

Students should know when was the school established, its percentage of students that are U.S. citizens, and the credentials of its faculty. Student’s premed advisors should provide good information about the advantages and disadvantages of attending a particular Caribbean medical school. Finally, students must research the school’s accreditation, ultimately choosing the school with the most rigorous curriculum and access to the most prestigious clinics for rotations.

While medical schools in the Caribbean present a viable alternative to the U.S based institutions, serious students should be able to narrow down the optimum candidates. Performing a little research and asking the right questions will help them make the best choice to start their career in the medical field.

Other reputable medical schools in the Caribbean include St James in Bonaire and St. George’s University in Grenada.

READY TO ENROLL? For more information about these schools, visit their websites:  American University of the Caribbean aucmed.edu/  Ross University rossu.edu  St. George’s University sgu.edu/  St. James University at Bonaire bonaire.sjsm.org/

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MEDMONTHLY.COM | 35

feature

MAYO ONE & DONE Christoper Russi, D.O., is an emergency medicine specialist and chair of Mayo’s emergency medical services research committee.

All photos courtesy Mayo Clinic

The Mayo Clinic’s Mayo One helicopter has to beat the clock to save lives.

By Marie Zhuikov

MEDMONTHLY.COM | 37

M

edical helicopter transport has become much more. Thanks to research and rigorous training, the Mayo One staff delivers stateof-the-art care as soon as they reach patients.

A tour bus veers out of control across an Interstate highway in southern Minnesota, rolling on its side, injuring and trapping passengers.

Moments later a school bus collides with another vehicle, sliding off a state highway.

Kathy Berns story It was a busy evening for the crews of Mayo One. The pilot, flight nurse and flight paramedic land in fields or roadways to get as close as they safely can to patients. It’s emergency transportation, yes, but Mayo One is also a modern medical care delivery system.

This means treatment begins the moment the team in the blue flight suits reaches patients.

“The situations you encounter in emergency services are exciting, but also gratifying,” says Kathy Berns, a certified Clinical Nurse Specialist and flight nurse with Mayo One. “You make a difference for people during the worst day of their life.”

Mayo flight crews also make a difference because they are constantly improving, through training, and also through research in this specialty environment.

Shock in the Sky Mayo Clinic conducts research to ensure its patients are getting the best care anywhere and that includes at 2,500 feet in the air. Even in the extreme conditions Mayo One encounters, flight crews are doing scientific research for the same reason.

Take shock, for instance.

Medical shock is a life-threatening emergency in itself, and one of the 38 | JULY 2011

most common causes of death for the critically ill because it may lead to a lack of oxygen in arterial blood or multi-system organ failure. Determining what type of shock a patient is experiencing can save their life. Mayo One crews often see patients before the classic signs occur. “The ability to recognize shock can be elusive,” says Christopher Russi, D.O., emergency medicine specialist and chair of Mayo’s emergency medical services (EMS) research committee.

The National Institutes of Health is funding a Mayo study on flight crews’ ability to assess medical shock and its impact on patient care. As with many of the EMS and Mayo One research projects, this one studies patient care delivered by the crew. Other projects involve review of the medical record or hospital outcomes. Few of these research projects involve traditional clinical studies because it is challenging to obtain patient consent at the time of transport, says Dr. Russi.

Through part of his role, Dr. Russi develops educational programs to help improve the diagnosis of shock by flight teams and to evaluate the program’s effectiveness. Dr. Russi describes the four types of shock as falling along a spectrum: Hypovolemic shock is most often due to blood loss or dehydration.

Cardiogenic shock is caused by a heart attack or congestive heart failure.

Obstructive shock occurs when the ability of the heart to pump blood is restricted. This could be due to a heart attack or severely collapsed lung.

Distributive shock happens when there’s been a spinal cord injury or from overwhelming infection (sepsis).

The blood vessels lose their tone and circulation stops.

A related project of Dr. Russi’s investigates the effectiveness of a non-invasive tissue oxygen monitor to detect the first stages of hypovole-

mic shock. The tissue oxygen monitor, called an InSpectra StO2 Tissue Oxygenation Monitor developed by Hutchinson Technology Inc. uses a sensor that fits in a patient’s hand.

The sensor emits four beams of near infrared light to test the underlying muscle tissue for oxygen saturation.

The InSpectra monitor detects low oxygen levels before the classic signs and symptoms of shock manifest.

Dr. Russi is looking at the feasibility of using the monitor in a helicopter environment and hopes to develop treatments correlating to the StO2 values in future studies.

Dr. Russi finds research in the EMS field particularly satisfying. “There are a lot of questions left to ask and dogma to refute. I like to design a way to find answers. If you can gain better outcomes for patients, that’s number one.”

OTHER MAYO ONE RESEARCH  Evaluating effectiveness of Airtraq optical device, which uses prisms and mirrors to help proper placement of breathing tubes  Study on ventilator masks significantly decreased necessary intubation rates, improved patient comfort, reduced complications and shortened hospital stays  Retrospective records study helped improve ventilator settings by crew members  Mayo One crews obtained patient blood samples to help better identify those who may develop blood clots

Improving Patient Outcomes Two other Mayo One studies have already improved emergency care for patients. They involve changing how helicopters are dispatched to a scene and what equipment they carry.

Helicopters were previously dispatched only after an ambulance crew or law enforcement had arrived and deemed it necessary. Now at Mayo, that decision is in the hands of the 911 dispatchers. That practice is called Autolaunch.

“When a call comes into a dispatch center, the dispatcher sends the helicopter at the same time as the ambulance,” says Berns. “This can save 10 to 15 minutes, which is vital for a victim in an emergency.” The dispatcher considers key medical criteria, the situation at the scene of injury and the likelihood of serious injuries.

Examples include vehicle rollovers, head-on collisions, pedestrian-vehicle accidents, and other major sources of trauma.

Shortening the time it takes to get a helicopter launched means quicker medical response at the patient’s side and earlier arrival at the trauma center. Berns says their research demonstrates that Autolaunch saves lives and improves patient outcomes. The Mayo One findings were published in Air Medical Journal in 2002 and were later presented at the Aeromedical World Congress in Norway and Switzerland.

The study has also been shared at several venues across the United States.

Few emergency helicopter services carry blood for en route transfusion, and even fewer carry both blood and plasma. Administering blood during transport can be critical to avoiding complications from shock. Mayo One conducted research on the feasibility of having blood on board and those findings were published as early as 1998 in the Air Medical Journal and

presented at several conferences in Austria and Germany in addition to the U.S. All Mayo One helicopters are equipped to carry blood, and the Mayo One aircraft in Rochester also carries plasma. Research on the benefits of carrying plasma is currently being conducted. The helicopters are also equipped with special warming compartments for saline solution and other fluids.

Seeing at Night Flight nurse Jeffrey Stearns is based at Eau Claire, Wis., but his research efforts are impacting care and safety throughout Mayo One’s five-state flight area.

“Let’s say it’s a new moon night and you’re descending into a landing zone,” Stearns says. “What you see are flashes of red and blue, but even

with our landing lights on, around that scene it’s a black hole. Are there trees? Where are the tree lines? Are there telephone poles or power poles with lines? All those are potential obstacles.”

In 2006, Mayo became only the third civilian air medical service in the country to have all crew members use night vision goggles on all flights at night.

By wearing night vision goggles, crews can see objects nearly as though it were daylight, says Stearns. Stearns and Mayo Clinic’s transport division have also been involved in discussions with the Federal Aviation Administration and the National Transportation Safety Board on how the entire air medical transport industry can provide the highest amount of safety.

“From our viewpoint, it’s hard to MEDMONTHLY.COM | 39

A crew from Mayo One.

imagine working without night vision goggles. They’re a critical piece of equipment for safety,” Stearns says.

He’s awaiting word on a research grant designed to collect data on the safety benefits of night vision goggles. Stearns plans to work with Fort McCoy in Sparta, Wis., to use their multi-purpose flight operations area to create different landing zone situations.

“We’ll film them with one camera using a night vision goggle and one camera without,” Stearns says. “We’ll test our crews on the landing zones and, using simple geometry, calculate the time to obstacle avoidance on a standard rate of descent. We’ll be able to quantify the difference between aided and unaided night vision for the emergency medical 40 | JULY 2011

transport environment.”

Jeff Stearns was recently named International Medical Crew Member of the Year by the Association of Air Medical Services for his work to promote the improvement of patient care in the emergency medical transport community.

Coordinating EMS Research Dr. Russi oversees all these studies and assists anyone who wants to conduct EMS research projects. Research coordinator, Luke Myers, a registered paramedic, is also a vital committee member. He assists with data entry and reports outcomes. Myers says the

group logged 17 publications last year involving research conducted through Mayo Clinic Medical Transport, which includes the four Mayo One helicopters, Mayo MedAir jet ambulance and Gold Cross ground ambulance.

“The field of EMS is relatively new,” says Myers. “It started in the 1960s.

Most of the information available is hospital-based research, but we are developing our own knowledge base now for emergency transport.”

Stearns adds, “Mayo gives us the ability to conduct research and the tools needed to help a patient that are far beyond what other helicopter services can provide. Mayo does it right. Not everyone has Mayo Clinic’s standards for quality and value.”

Cancer robbed my family.

Please protect yours.

Cancer took my dad Michael Landon’s life when I was only 8.

Today we know a lot about preventing this disease. If you smoke, quit. Eat more vegetables, fruits, and vegetarian meals.

These steps are powerful for you and your whole family.

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healthy living

Asthma: The Hygiene Hypothesis Do clean enviroments provide enough exposure to germs?

By Ronald Rabin, MD

W

hat do clean houses have in common with childhood infections?

One of the many explanations for asthma being the most common chronic disease in the developed world is the “hygiene hypothesis.” This hypothesis suggests that the critical post-natal period of immune response is derailed by the extremely clean household environments often found in the developed world. In other words, the young child’s environment can be “too clean” to pose an effective challenge to a maturing immune system.

According to the “hygiene hypothesis,” the problem with extremely clean environments is that they fail to provide the necessary exposure to germs required to “educate” the immune system so it can learn to launch its defense responses to infectious organisms. Instead, its defense responses end up being so inadequate that they actually contribute to the development of asthma.

Scientists based this hypothesis in part on the observation that, before birth, the fetal immune system’s “default setting” is suppressed to prevent it from rejecting maternal tissue.

Such a low default setting is necessary before birth—when the mother is providing the fetus with her own antibodies. But in the period immediately after birth the child’s own immune system must take over and learn how to fend for itself.

42| JULY 2011

The “hygiene hypothesis” is supported by epidemiologic studies demonstrating that allergic diseases and asthma are more likely to occur when the incidence and levels of endotoxin (bacterial lipopolysaccharide, or LPS) in the home are low. LPS is a bacterial molecule that stimulates and educates the immune system by triggering signals through a molecular “switch” called TLR4, which is found on certain immune system cells.

The science behind the hygiene hypothesis The Inflammatory Mechanisms Section of the Laboratory of Immu-

Are cleaner homes giving us asthma?

nobiochemistry is working to better understand the hygiene hypothesis, by looking at the relationship between respiratory viruses and allergic diseases and asthma, and by studying the respiratory syncytial virus (RSV) in particular.

What does RSV have to do with the hygiene hypothesis?

RSV is often the first viral pathogen encountered by infants.

RSV pneumonia puts infants at higher risk for developing childhood asthma. (Although children may outgrow this type of asthma, it can account for clinic visits and missed school days.)

RSV carries a molecule on its surface called the F protein, which flips the same immune system “switch” (TLR4) as do bacterial endotoxins.

It may seem obvious that, since both the RSV F protein and LPS signal through the same TLR4 “switch,” they both would educate the infant’s immune system in the same beneficial way. But that may not be the case.

The large population of bacteria that normally lives inside humans educates the growing immune system to respond using the TLR4 switch.

When this education is lacking or weak, the response to RSV by some critical cells in the immune system’s defense against infections—called “T-cells”—might inadvertently trigger asthma instead of protecting the infant and clearing the infection. How this happens is a mystery that we are trying to solve.

In order to determine RSV’s role in triggering asthma, our laboratory studied how RSV blocks T-cell proliferation.

Studying the effect of RSV on T-cells in the laboratory, however, has been very difficult. That’s because when RSV is put into the same culture as T-cells, it blocks them from multiplying as they would naturally do when they are stimulated. To get past this problem, most researchers kill RSV with ultraviolet light before adding the virus to T-cell cultures.

However we did not have the option of killing the RSV because that would have prevented us from determining the virus’s role in triggering asthma.

Our first major discovery was that RSV causes the release from certain immune system cells of signaling molecules called Type I and Type III interferons that can suppress T-cell proliferation (Journal of Virology 80:5032-5040; 2006).

must be educated so it will function properly during infancy and the rest of life. One of the key elements of this education is a switch on T cells called TLR4. The bacterial protein LPS normally plays a key role by flipping that switch into the “on” position.

Prior research suggested that since RSV flips the TLR4 switch, RSV should “educate” the child’s immune system to defend against infections just like LPS does.

But it turns out that RSV does not flip the TLR switch in the same way as LPS. This difference in switching on TLR, combined with other characteristics of RSV, can prevent proper education of the immune system.

One difference in the way that RSV flips the TLR4 switch may be through the release of interferons, which suppresses the proliferation of T-cells. We still do not know whether these interferons are part of the reason the immune system is not properly educated or simply an indicator of the problem. Therefore, we plan to continue our studies about how RSV can contribute to the development of asthma according to the hygiene hypothesis.

Further research This finding that Type I and Type III interferons can mediate the suppression of T-cells caused by RSV generated two significant questions that our laboratory is now addressing: Interferons are important molecules that enhance inflammation, so why—in the context of RSV—do they suppress T-cells?

Interferons are clearly not the only way RSV suppresses T-cells. What are the other mechanisms that may depend upon T-cells coming in direct contact and communicating with other immune cells?

Conclusion The hygiene hypothesis suggests that a newborn baby’s immune system

Article reprinted courtesy of the US Food and Drug Administration

Finally!

A prescription with side effects you want.

Blueberries and red beans are powerful remedies against cancer. Research shows that fruits, vegetables, and other low-fat vegetarian foods may help prevent cancer and improve survival rates. A plant-based diet can also lower cholesterol.

For a free nutrition booklet with cancer fighting recipes, call toll-free 1-866-906-WELL or visit www.CancerProject.org

MEDMONTHLY.COM | 43

the kitchen

Gourmet, simple, sustainable A meal perfect for summer entertaining

S

ummer is all about enjoying nature at its finest. On a sunny afternoon or a warm, starlit evening, a grilling get-together is the perfect way to celebrate both the beauty of the season and the bounty of fresh foods that it brings.

Building a gourmet menu doesn’t mean that you’ll have to spend hours in the kitchen preparing before guests arrive. By keeping the menu simple and focused on the foods and flavors that are perfectly in season, you can showcase what makes summer special without sacrificing time spent with your guests.

When it comes to the ingredients you’ll use, take a sustainable approach by visiting local farmers markets or your own garden plot, if you have one. It’s important to remember that ingredients other than vegetables can still be sustainable and environmentally friendly. Blue cheese varieties from Salemville, for instance, are rBGH free, contain no preservatives or chemical additives, and are sustainably produced by an Amish community in Cambria, Wisc., where cows are hand-milked twice daily without the use of machines or electricity.

44| JULY 2011

And since steak is the perfect main dish for a grilling get-together, look for steaks with labels with identifying information, letting you know that it is grass-fed or pasture-raised.

Plan on serving at least four dishes: a salad, a side, a main dish and a dessert. A green salad topped with rich blue cheese and herb dressing is a wonderful, fresh start to the meal.

Follow it with a side dish of seasonal vegetables and cheese-topped steak.

Depending on the vegetable you

choose, it’s possible to prepare both your side and main dishes on the grill, allowing you to spend more time outside with your guests. Complete the meal with a sweet treat of ripe summer fruits baked into a rustic French galette or tossed with fresh mint as a topping for a light sorbet.

Try these recipes for your salad and steak courses and you’ll be preparing sustainable dishes that perfectly capture the essence of summer. For more recipes and grilling tips, visit salemville.com.

Article reprinted courtesy ARA content

Blue Cheese Salad with Blue Cheese Dressing INGREDIENTS: Dressing: 1/2 cup plain nonfat yogurt 1/4 cup skim milk 1/2 cup green onions (including green tops), thinly sliced 1/4 cup Salemville Amish Blue or Salemville Smokehaus Blue cheese, crumbled 1/2 clove garlic, pressed 1/4 teaspoon basil 1/4 teaspoon rosemary, crushed Dash salt, to taste Salad: 1 large head iceberg lettuce 6 slices thick-cut bacon 1 cup Salemville Amish Blue or Smokehaus Blue cheese, crumbled Black pepper, to taste Chopped pears, walnuts, red onion and/or tomatoes, to taste

DIRECTIONS: In small bowl, stir together yogurt and milk. Mix in onions, cheese, garlic, herbs and salt. Cover and chill 30 minutes or more to blend flavors.

Cook bacon until crisp and crumble into large pieces. Cut lettuce into four to six wedges. Pour blue cheese dressing over the top. Sprinkle bacon over dressing. Add additional crumbled cheese, freshly ground black pepper, chopped pears, walnuts, red onion and/or tomatoes, if desired. Makes four servings.

Steak with Gorgonzola Thyme Crust INGREDIENTS: 2 teaspoons Worcestershire sauce 2 beef tenderloin or small rib eye steaks (about 6 ounces each), cut 3/4-inch thick

1 large or 2 small cloves garlic, minced 1/4 teaspoon freshly ground black pepper 2 teaspoons fresh thyme, chopped, or 1/2 teaspoon dried thyme 1/2 cup Salemville Amish Gorgonzola cheese, crumbled DIRECTIONS: Preheat broiler. Spoon Worcestershire sauce over both sides of the steaks and let stand five minutes.

Sprinkle garlic and pepper over steaks.

Place steaks on rack or broiler pan. Broil 3 to 4 inches from heat source three to four minutes per side for medium rare steak.

Remove pan from broiler. Sprinkle thyme, then cheese over steaks.

Return to oven and broil two minutes, or until the cheese is golden brown.

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the sales

Classified To place a classified ad, call 919.747.9031

Seminars and Courses

Physicians needed

South Carolina

North Carolina (cont.)

Pediatric Update

Methadone Treatment Center located near Charlotte, North Carolina has an opening for an experienced physician. You must be comfortable in the evaluation and treatment within the guidelines of a highly regulated environment. Practice operating hours are 6:00 a.m. till 3:00 p.m. Monday through Friday. Send copies of your CV, NC Medical License, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, E-mail: physiciansolutions@gmail.com

July 11-14, 2011 Kiawah Island, SC Make plans to join us for our 34th Annual Pediatric Update Conference with topics including: Pediatric Gastroenterology, Lice and Bedbugs, Genetics for primary care, and a special presentation about how implementing patient-and familycentered care into your practice has been proven to improve the quality of care (MCG Health and the MCG Children’s Medical Center have been recognized as national leaders in Patient and Family Centered Care). Concurrent Breakout Sessions will return, with Dr Bill Lutin presenting his problem cases in pediatric cardiology, (with Dr Bill’s Rhythm Review) and Dr. Chris White’s always popular interactive “Rash Decisions”! We are also pleased to have Dr Jatinder Bhatia, Chair of the AAP Committee on Nutrition presenting “need-to-know” updates on nutrition. We will also continue to offer Breakfast Roundtables - small group discussions of problem cases, with each table led by one of our Faculty. Finally, we will have a whole morning dedicated to coding and reimbursement which will more than pay for itself in improving your practice’s bottom line. Visit our web site for additional conference information and on-line registration: http://www.georgiahealth.edu/ce/pedupdate2011.html

Physicians needed North Carolina Occupation Health Care Practice located in Greensboro, North Carolina has an immediate opening for a primary care physician. This is 40 hours per week opportunity with a base salary of $135,000 plus incentives, professional liability insurance provided and an excellent CME, vacation and sick leave package. Send copies of your CV, NC Medical License, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, E-mail: physiciansolutions@gmail.com Family Practice physician opportunity in Raleigh, North Carolina.

This is a locum’s position with 3 to 4 shifts per week requirement that will last for several months. You must be BC/BE and comfortable treating patients from 1 year of age to Geriatrics. You will be surrounded by an exceptional, experienced staff with beautiful offices and accommodations. No call or hospital rounds. Send copies of your CV, NC Medical License, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, E-mail: physiciansolutions@gmail.com

Family Practice physician is needed to cover several shifts per week in Rocky Mount, North Carolina. This high profile practice treats pediatrics, women’s health as well as primary care patients of all ages. If you are available for 30 plus hours per week for the remainder of the year, this could be the perfect opportunity. Send copies of your CV, NC Medical License, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, E-mail: physiciansolutions@gmail.com Cardiology practice located in High Point, North Carolina has an opening for a Board Certified Cardiovascular physician. This established and beautiful facility offers the ideal setting for an enhanced life style. There is no hospital call or invasive procedures. Look into joining this 3 physician facility and live the good live in one of North Carolina’s most beautiful cities. Send copies of your CV, NC Medical License, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, E-mail: physiciansolutions@gmail.com Family Practice Physician needed for full time employment in established primary care practice in High Point, North Carolina. Salary with full benefits and production incentive for an energetic Board Certified FP. The ideal candidate can begin practicing as early as June 2011. Please send a copy of your current CV, North Carolina medical license, DEA certificate and NPI certificate with number along with your detailed work history and CME courses completed to; Physician Solutions, P.O. Box 98313, Raleigh, NC 27624. E-mail: physiciansolutions@ gmail.com or phone with any questions, PH: (919) 845-0044.

Board Certified Internal Medicine Physician position is available in the Greensboro, North Carolina area. This is an out-patient opportunity within a large established practice.

The employment package contains salary plus incentives.

Please send a copy of your current CV, North Carolina medical license, DEA certificate and NPI certificate with number MEDMONTHLY.COM |47

ď‚Ą Research and technology articles

the sales

Classified To place a classified ad, call 919.747.9031

Physicians needed

Practice sales

North Carolina (cont.)

Indiana

along with your detailed work history and CME courses completed to; Physician Solutions, P.O. Box 98313, Raleigh, NC 27624. Email: physiciansolutions@gmail.com or phone with any questions, PH: (919) 845-0054.

Pain Management Practice located in Indiana is now listed for sale. The main practice has been serving the community with two satellites located about 30 miles from the main practice. All three practices are being offered for $785,000 with the main practice building offered for $950,000. The two satellite practices being leased for a very reasonable monthly rent. If you are interested in a Pain Management practice that will generate impressive profits from month one, this could be your opportunity.

Contact Medical Practice Listings at (919) 848-4202 for more information. View additional listings at; www.medicalpracticelistings.com

Locum Tenens opportunity for Primary Care MD in the Triad Area, North Carolina. This is a 40 hour per week on-going assignment in a fast pace established practice. You must be comfortable treating pediatrics to geriatrics. We pay top wage, provide professional liability insurance, lodging when necessary, mileage and exceptional opportunities. Please send a copy of your current CV, North Carolina medical license, DEA certificate and NPI certificate with number along with your detailed work history and CME courses completed to; Physician Solutions, P.O. Box 98313, Raleigh, NC 27624.

E-mail: physiciansolutions@gmail.com or phone with any questions, PH: (919) 845-0054.

Virginia Urgent Care opportunities throughout Virginia. We have contracts with numerous facilities and 8 to 14 hour shifts are available. If you have experience treating patients from Pediatrics to Geriatrics, we welcome your inquires. Send copies of your CV, VA Medical License, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, E-mail: physiciansolutions@gmail.com Pediatric Locums Physician needed in Harrisonburg, Danville and Lynchburg, Virginia. These locum positions require 30 to 40 hours per week, on-going. If you are seeking a beautiful climate and flexibility with your schedule, please consider one of these opportunities. Send copies of your CV, VA Medical License, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, E-mail: physiciansolutions@gmail.com

MEDICAL PRACTICE LISTINGS View national practice listings or contact us for a confidential discussion regarding your practice options.

919.848.4202

medlistings@gmail.com | medicalpracticelistings.com

North Carolina Impressive Internal Medicine Practice in Durham, NC; The City of Medicine. Over 20 years serving the community, this practice is now listed for sale. There are 4 well equipped exam rooms, new computer equipment and a solid patient following. The owner is retiring and willing to continue with the new owner for a few months to assist with a smooth transition. Contact Medical Practice Listings at (919) 848-4202 for more information. View additional listings at: www.medicalpracticelistings.com Modern Vein Care Practice located in the mountains of North Carolina. Booking 7 to 10 procedures per day, you will find this impressive vein practice attractive in many ways. Housed in the same practice building with an Internal Medicine, you will enjoy the referrals from this as well as other primary care and specialties in the community.

We have this practice listed for $295,000 which includes charts, equipment and good will. Contact Medical Practice Listings at (919) 848-4202 for more information. View additional listings at: www.medicalpracticelistings.com Family Practice located in Hickory, North Carolina. Well established and a solid 40 to 55 patients split between an MD and physician assistant. Experienced staff and outstanding medical equipment. Gross revenues average $1,500,000 with strong profits. Monthly practice rent is only $3,000 and the utilities are very reasonable. The practice with all equipment, charts and good will are priced at $625,000. Contact Medical Practice Listings for additional information. Medical Practice Listings, P.O. Box 99488, Raleigh, NC 27624. PH: (919) 848-4202 or E-mail: medlistings@gmail.com Internal Medicine Practice located just outside Fayetteville, North Carolina is now being offered. The owning physician is retiring and is willing to continue working MEDMONTHLY.COM |49

Practice for Sale in Raleigh, NC

EXCELLENT FAMILY PRACTICE FOR SALE

Primary Care practice specializing in Women’s care

North Carolina Family Practice located about 30 minutes from Lake Norman has everything going for it.

Raleigh, North Carolina The owning female physician is willing to continue with the practice for a reasonable time to assist with smooth ownership transfer. The patient load is 35 to 40 patients per day, however that could double with a second provider. Exceptional cash flow and profitable practice that will surprise even the most optimistic practice seeker. This is a remarkable opportunity to purchase a well-established woman’s practice.

Spacious practice with several well-appointed exam rooms, tactful and well appointed throughout. New computers and medical management software add to this modern front desk environment.

List price: $435,000.

Call Medical Practice Listings at (919) 848-4202 for details and view our other listings at www.medicalpracticelistings.com

Medical Practice Listings For more information call (919) 848-4202. To view other practice listings visit medicalpracticelistings.com

Gross revenues in 2010 were 1.5 million and there is even more upside. The retiring physician is willing to continue to practice for several months while the new owner gets established.

Excellent medical equipment, staff and hospital near-by, you will be hard pressed to find a family practice turning out these numbers.

Listing price is $625,000.

Exceptional North Carolina Primary Care Practice for Sale Ensure Optimal Performance of your Global PACS System “With PACSHealth™, I finally have an easy way to monitor our PACS system 24/7. I can rest assured that system data is clean and consistent across the board and errors, if any, are quickly repaired. I can do my job in a fraction of the time that it used to take with better results.”

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• PACS Status Reporting • System Monitoring Dashboard • Audit Log Management/ HIPAA Compliance Tool

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Established North Carolina Primary Care practice only 15 minutes from Fayetteville, 30 minutes from Pine Hurst, 1 hour from Raleigh, 15 minutes from Lumberton, and about an hour from Wilmington. The population within 1 hour of this beautiful practice is over one million. The owning physician is retiring and the new owner will benefit from his exceptional health care, loyal patient following, professional decorating, beautiful and modern free standing medical building with experienced staff.

The gross revenue for 2010 is $856,000 and the practice is very profitable. We have this practice listed for $415,000. Call today for more details and information regarding the medical building.

Our Services: • Primary Health • Well Child Health Exams • Sport Physical • Adult Health Exams • Women’s Health Exams • Management of Contraception • DOT Health Exam • Treatment & Management of Medical Conditions • Counseling on Prevention of Preventable Diseases • Counseling on Mental Health • Minor surgical Procedures For more information call Medical Practice Listing at (919) 848-4202.

To view our other listings, visit medicalpracticelistings.com.

the sales

Classified To place a classified ad, call 919.747.9031

Practice for sale

Practice for sale

North Carolina (cont.)

South Carolina (cont.)

for the new owner for a month or two assisting with a smooth transaction. The practice treats patients 4 and ½ days per week with no call or hospital rounds. The schedule accommodates 35 patients per day. You will be hard pressed to find a more beautiful practice that is modern, tastefully decorated and well appointed with beautiful art work. The practice, patient charts, equipment and good will is being offered for $415,000 while the free standing building is being offered for $635,000.

Contact Medical Practice Listings for additional information. Medical Practice Listings, P.O. Box 99488, Raleigh, NC 27624. PH: (919) 848-4202 or E-mail: medlistings@ gmail.com

Hospital support is also an option for up to a year. The listing price is $395,000 for the practice, charts, equipment and good will. Contact Medical Practice Listings for additional information. Medical Practice Listings, P.O. Box 99488, Raleigh, NC 27624. PH: (919) 848-4202 or E-mail: medlistings@gmail.com

Primary Care practice specializing in women’s care.

The owning female physician is willing to continue with the practice for a reasonable time to assist with smooth ownership transfer. The patient load is 35 to 40 patients per day, however that could double with a second provider. Exceptional cash flow and profitable practice that will surprise even the most optimistic practice seeker. This is a remarkable opportunity to purchase a well-established woman’s practice. Spacious practice with several well-appointed exam rooms, tactful and well appointed throughout. New computers and medical management software add to this modern front desk environment. This practice is being offered for $435,000.

Contact Medical Practice Listings for additional information. Medical Practice Listings, P.O. Box 99488, Raleigh, NC 27624. PH: (919) 848-4202 or E-mail: medlistings@ gmail.com

South Carolina

Med Monthly Med Monthly is the premier health care magazine for medical professionals.

By placing an ad in Med Monthly you’ll reach: family medicine, internal medicine, physician assistants and more!

Call us today to place your classified!

919.747.9031 Also available online 24/7

medmonthly.com

Lucrative E.N.T. practice with room for growth, located three miles from the beach. Physician’s assistant, audiologist, esthetician, and well-trained staff. Electronic medical records, Mirror imaging system, established patient and referral base, hearing aids and balance testing, esthetic services and Candela laser. All aspects of Otolaryngology, busy skin cancer practice, established referral base for reconstructive eyelid surgery, Botox and facial fillers. All new surgical equipment, image-guidance sinus surgery, balloon sinuplasty, nerve monitor for ear/parotid/ thyroid surgery. Room for establishing Allergy, Cosmetics, Laryngology & Trans-nasal Esophagoscopy. All the organization is done, walk into a ready-made practice as your own boss and make the changes you want, when you want. Physician will to stay on for smooth transition.

MEDMONTHLY.COM |51

Physician Solutions MD STAFFING Locum tenens Permanent placement

When your physician can’t work tomorrow do you have a plan B? With an extensive network of healthcare providers and over 20 years of experience in physician staffing, Physician Solutions is a leader in the industry. We specialize in primary care and place doctors in facilities such as familly practices, urgent cares, pediatrics offices and occupational health.

Short term or long term, Physician Solutions has your covered

P.O. Box 98313, Raleigh, NC 27624 phone: 919.845.0054 fax: 919.845.1947 e-mail: physiciansolutions@gmail.com www.physiciansolutions.com

PRACTICE FOR SALE

OCCUPATIONAL HEALTH CARE PRACTICE FOR SALE Greensboro, North Carolina Well-established practice serving the Greensboro and High Point areas for over 15 years. Five exam rooms fully equipped, plus digital X-Ray. Extensive corporate accounts as well as walk-in traffic. Lab equipment includes CBC. The owning MD is retiring, creating an excellent opportunity for a MD to take over an existing patient base and treat 25 plus patients per day from day one. The practice space is 2,375 sq. feet. This is an exceptionally opportunity. Leased equipment includes: X-Ray $835 per mo, copier $127 per mo, and CBC $200 per mo. Call Medical Practice Listings at (919) 848-4202 for more information.

Asking price: $385,000

To view more listings visit us online at medicalpracticelistings.com

Practice For Sale

Large Louisiana Pediatric Practice This Louisiana Pediatric Practice treats an average of 30 plus patients per day and is open 4 ½ days per week. The owner/MD treats patients and she has a part time physician assistant that provides a second provider 2 to 4 days per week. Fully equipped and staffed, this practice is ready for the new owner to accept a full patient load. The MD that owns the practice will be moving to join her husband in California during the summer or as soon a proper transfer in ownership takes place.

She is more than willing to continue with the practice for a few months to assist with a smooth transfer.

Asking price: $165,000 Call Medical Practice Listings today and we will be happy to provide more details regarding this pediatric practice opportunity!

(919) 848-4202 | MedicalPracticeListings.com

Practice at the beach Plastic Surgery practice for sale with lucrative E.N.T. specialty Myrtle Beach, South Carolina Practice for sale with room for growth and located only three miles from the beach. Physician’s assistant, audiologist, esthetician, and well-trained staff. Electronic medical records, Mirror imaging system, established patient and referral base, hearing aids and balance testing, esthetic services and Candela laser. All aspects of Otolaryngology, busy skin cancer practice, established referral base for reconstructive eyelid surgery, Botox and facial fillers. All new surgical equipment, image-guidance sinus surgery, balloon sinuplasty, nerve monitor for ear/parotid/thyroid surgery. Room for establishing Allergy, Cosmetics, Laryngology & Trans-nasal Esophagoscopy. All the organization is done, walk into a ready made practice as your own boss and make the changes you want, when you want. Physician will to stay on for smooth transition. Hospital support also an option for up to a year. The listing price is $395,000.

For more information call Medical Practice Listing at (919) 848-4202. To view our other listings, visit medicalpracticelistings.com.

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top

best places for medical jobs

Working in the health care industry is a surefire way to get and keep a job, but if your looking for a new job or just a career change, check out the top 9 best states for health care jobs.

1

California

The aging Baby Boomers are to blame for the need for more health care workers in California. According to allhealthcare.com there are roughly 4 million California residents over 65.

2 3

4 5

7

Massachusetts Massachusetts has some of the best hospitals to work for in the country, including Mass General and Brigham & Women’s open positions in the health care industry continue to increase.

8

Michigan

Florida Another state with a high number of boomers is Florida.

With an estimated 3 million residents over 65, Florida needs health care workers to care for the aging population.

Illinois The government gave home heath aids a raise in this state to encourage more people to enter the health care industry but other health care workers have also seen pay increases.

54 | JULY 2011

The state government has invested in health care training programs and has spent millions to promote nursing programs in schools. They are also experiencing a shortage in specialty physicians.

6

New Jersey Registered nurses are in high demand in New Jersey. While the need increased by 7,000 there is an 18% vacancy rate in the New Jersey nursing field.

9

North Carolina Nursing shortage estimates for NC were at just over 8,000 in 2010 ranking NC 19th for nursing needs.

Ohio This state created a health care shortage task force to address changes to be made in health care encourage more people to become health care professionals.

Pennsylvania

With over 17,000 health care related job opportunities, Pennsylvania created the Pennsylvania Center for Health Careers to help fill hospitals and health care facilities with the employees it needs.

Source: allhealthcare.com Photos by Keith Syvinski, Danie Pratt and Sam LeVan.

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