Med Monthly October 2011

Med Monthly October 2011

BONE DENSITY SCREENING

THE

s ’ n e m o W Health ISSUE

Why it’s important for your practice

THE PAIN

down there

And new treatment options

I think I want a lab in my practice Information on how to get started

View all

51

Medical boards

COACHING WOMEN TO BE WELL P. 30

20

contents

So you want a lab in your practice?

features 30 COACHING WOMEN TO BE WELL

Using positive psycology to guide patients to self-care accountability

34 BONE DENSITY SCREENINGS

And why you need them in your practice

38 CAPITALIZING ON CHANCE OBSERVATIONS subehead goes here

16

Google for neurologist

research and technology 10 THE PAIN DOWN THERE 14 ENDOMETRIAL ABLATION 16 GOOGLE FOR NEUROLOGISTS

your practice 20 I THINK I WANT A LAB FOR MY PRACTICE 22 SEO OPTIMIZATION 24 MIND BODY CONNECTION

legal 28 HEALTH CARE REFORM

the kitchen 40 TROPICAL SMOOTHIE

in every issue 4 editor’s letter 8 news briefs

48 classified listings 52 top nine

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editor’s letter

W

omen’s health is Med Monthly’s theme for October. We have explored a range of topics that can enhance the physical and psychological well being of women.

One article explores Vulvodynia, a gynecological pain for which there seems to be no cause or treatment. We interviewed Denniz Zolnon MD, who has developed a multi-disciplinary approach for its management that has greatly decreased patients’ pain.

Another feature discusses the importance of bone density screenings. There are new strategies to identify and reduce bone loss in females to prevent deterioration, which may lead to fractures and osteoporosis.

Andrea Lukes, MD explains NovaSure Endometrial Ablation. This is a new five minute procedure that improves heavy bleeding and PMS by using radiofrequency energy.

We also have an article detailing the benefits of having a laboratory in your practice. Labs can enhance patient care by providing immediate results with little training for employees to perform simple procedures.

We are pleased to announce that our November issue will contain a Resource Guide including medical vendors and suppliers from across the country. Keep Med Monthly handy as a list of useful resources. If you would like to have your medical support company listed, please e-mail us at medmedia9@gmail.com.

Enjoy our October issue!

Ashley Austin Contributing Editor

4 | OCTOBER 2011

contributors

Med Monthly October 2011

Publisher Contributing Editor Creative Director Contributors

Marketing Manager

Philip Driver Ashley Austin

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.

Courtney Flaherty Edward Logan, D.D.S. Kimberly Licata Libby Knollmeyer, B.S., MT Elizabeth Witherspoon Lani Kee Andrea Lukes, M.D. Denise Hanson, PSY.D. Ashley Acornley, R.D., L.D.N. Bree Sullivan Alice Osborn Will O’Neil

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.

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

Edward Logan, D.D.S. 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.

Elizabeth “Libby” Knollmeyer, B.S., MT (ASCP) has over 40 years experience in the laboratory industry. She specializes in financial, operational management and compliance issues for hospital and physician office laboratories. Libby has a wide variety of experience with her areas of special expertise including financial review and management, compliance and regulatory assistance and lab design. She can be reached at eknollmeyer@triad.rr.com.

Ashley Acornley, R.D., L.D.N. holds a BS in Nutritional Sciences with a minor in Kinesiology from Penn State University. She completed her Dietetic Internship at Meredith College and is currently working on completing her Master’s Degree in Nutrition. She is also an AFAA certified personal trainer. Her blog can be found at: ashleyfreshfromthefarm.wordpress.com.

Andrea S. Lukes, M.D., MHSc, FACOG is the founder and lead investigator at the Carolina Women’s Research and Wellness Center and is now in private practice at the Women’s Wellness Clinic in Durham, North Carolina. Two years ago she received a grant to begin the OB-GYN Alliance, a peer-to-peer network of medical professionals whose goal is to improve health care for women.

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news briefs

Women’s heath new study

global health

Chemotherapy effective whether given before or after breast cancer surgery

BREAST CANCER RISING AMONG YOUNGER WOMEN IN DEVELOPING COUNTRIES Although women in industrialized countries have been able to survive breast cancer, women in developing countries don’t have the screening and treatment resources. In a study done by the University of Washington, published in “The Lancet,” global breast cancer incidence increased from 641,000 cases in 1980 to 1,643,000 in 2010, which is an annual rate increase of 3.1 percent. Cervical cancer worldwide rose from 378,000 cases a year in 1980 to 454,000 in 2010, an 0.6 percent annual increase. The study also showed that younger women are being diagnosed with both breast and cervical cancer. “More policy attention is needed to strengthen established health-system responses to reduce breast and cervical cancer, especially in developing countries,” the researchers wrote.

Young women with BRCA mutation are more likely to develop breast cancer than their moms.

Young women who carry the BRCA mutation will get breast cancer eight years earlier than their older female relatives who had breast cancer, according to study done at the University of Texas MD Anderson Cancer Center. In the study, the median age for the older generation at diagnosis was 48, while the median age for the younger generation was 42. A BRCA mutation is a mutation in the genes BRCA1 and BRCA2 which account for five to ten percent of all breast and ovarian cancer cases. Having the mutation does not mean cancer will develop and if you are male your chances for developing breast cancer is higher than for other men, but still low.

In 2011, it is estimated that among U.S. women there will be 230,480 new cases of invasive breast cancer. (includes new cases of primary breast cancer among survivors, but not recurrence of original breast cancer) 8 | OCTOBER 2011

Chemotherapy before a lumpectomy or chemotherapy after a lumpectomy is just as effective because the results depend upon the tumor’s characteristics, not the timing of the chemotherapy. Those who had more aggressive cancers had the chemotherapy before the surgery because in some cases chemotherapy given before a lumpectomy can shrink the tumor.

These are the results of a study done with 3,000 women who underwent lumpectomies and radiation therapy from 1987 to 2005 and were presented at the 2011 Breast Cancer Symposium.

RISK FACTORS FOR BREAST CANCER • being female

in

women will be diagnosed with breast cancer

• getting older • having an inherited mutation in the BRCA1 or BRCA2 breast cancer gene • lobular carcinoma in situ (LCIS), a rare condition where abnormal cells form in the milk glands

global health

Former president takes on women’s health in developing countries

• a personal history of breast or ovarian cancer • a family history of breast, ovarian or prostate cancer • having high breast density on a mammogram

SOURCE: THE SUSAN G. KOMAN FOR THE CURE PHOTOS COURTESY ISTOCKPHOTO.COM

• having a previous biopsy showing atypical hyperplasia • starting menopause after age 55 • never having children • having your first child after age 35 • radiation exposure, frequent X-rays in youth • high bone density • being overweight after menopause or gaining weight as an adult • postmenopausal hormone use (current or recent) of estrogen or estrogen plus progestin

SOURCE: THE SUSAN G. KOMAN FOR THE CURE

With public and private sources, the Bush Foundation has secured $75 million in pledges to help women in developing countries gain access to cancer screenings and care. The focus will be on cervical cancer prevention since great numbers of women in these countries are HIV-positive, and they are four to five times more likely to develop an aggressive form of this cancer. This is the first major initiative for Bush since leaving office in 2009. The initiative will use existing clinics in Africa and Latin America to offer screening and treatment for cervical cancer. Both Merck and GlaxoSmithKline, the makers of the HPV vaccines have made significant donations. This Bush initiative will not help those affected by breast cancer as much, but clinicians will be supported with patient education about detection and treatment. “In some ways, where we are in breast cancer in many of these places is where we were with HIV many years ago; the infrastructure isn’t there,” says Dr. Eric Bing, the director of global health for the Bush Institute.

MEDMONTHLY.COM |9

research & technology

The

By Elizabeth Witherspoon

P

ain is bad enough, but when a doctor cannot find the cause, nor provide a known treatment that will cure it, sufferers can start to lose hope. Add to that the difficulty of the pain being in a private part of the body—not in a place one is comfortable speaking freely about—and the patient suffers in isolation. This combination of pain and hyper-vigilance to when the next pang will come, coupled with isolation and sexual difficulties, can lead to emotional and psychological issues too.

Vulvodynia is just such a pain. It is localized or widespread discomfort in a woman’s vulvar region, the genital area around the opening to her vagina. It can be chronic or intermittent. Its diagnosis comes after physicians rule out cancer or other causes—that is, when there is no other explanation. According to the National Institutes of Health, as many as 18 percent women will at some point experience vulvodynia.

Yet the condition has remained so obscure, NIH launched a national awareness campaign about it in 2007.

In fact, the experts are not in complete agreement on use of the term

10 | OCTOBER 2011

pain

down there vulvodynia itself, which underscores how uncharted the territory is for research and effective treatment.

The cause of vulvodynia is not well understood. Researchers speculate about injury to nerves, genetic susceptibility to widespread pain, elevated levels of inflammatory substances in the vulvar tissue, or an abnormal response to environmental factors, such as infection or trauma.

The National Vulvodynia Association says vulvodynia is not simply a gynecological condition, and that many experts favor a multi-disciplinary approach to its management.

This may include treatment by a gynecologist, dermatologist, neurologist, pain management specialist, urogynecologist, or even a physical therapist. Because the condition typically affects a woman’s sexual relationships and emotional well-being, she may be referred to a psychologist or a couples or sex therapist as well.

Ultimately, since the cause remains unknown, treatment, or the combination of treatments, focuses on alleviating symptoms.

Denniz Zolnoun, M.D., M.P.H., an OB/GYN at University of North Carolina at Chapel Hill School of Medicine and director of the vulvar clinic, has spent over a decade researching causes and treatments for vulvodynia. She recently won a national award from the Society for Women’s Health Research for her work in gynecological pain. Her pioneering spirit seems to come naturally. Zolnoun, of Turkish and Iranian descent, came to the United States at age 16, learned English and eventually got herself into medical school.

Her work has included “reverse engineering” as patients describe symptoms to trace nerve pathways back to the source of the pain and to locate the targets for treatment. She looks for answers among the work

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Sufferers of the complicated illness, vulvodynia, find hope and a champion

Denniz Zolnoun, M.D. is a crusader for vulvodynia and helping women get relief from constant pain

of nationally known researchers in areas of medicine where pain is better understood: dentistry, neurology, gastroenterology and orthopedics.

She is currently working on a large research project at UNC with researchers specializing in Complex Persistent Pain Conditions (CPPCs), such as fibromyalgia, episodic

migraine, vulvar pain, irritable bowel syndrome and temporomandibular joint (TMJ) disorders. Their hypothesis is that multiple genetic factors, when coupled with environmental exposures (e.g. injury, infections, physical and psychological stress), increase a patient’s susceptibility to CPPCs by enhancing pain sensitiv-

ity and/or increasing psychological distress.

Her multidisciplinary work with some of these same experts in pain research grows out of prior work during a training program, called the Bridging Interdisciplinary Research Careers in Women’s Health (BIRCWH) Scholars at UNC. It is administered by the North Carolina Translational and Clinical Sciences (NC TraCS) Institute, UNC’s NIH Clinical and Translational Science Awards (CTSA), which is part of a national consortium created to more quickly turn discoveries into practical solutions for patients.

“When I began, there was simply no construct in gynecology for what patients were experiencing, because it had been marginalized as a cognitive disorder,” said Zolnoun. “We never tell someone who has a hyperthyroid problem it is all in their head. It is a chemical abnormality with different manifestations in different patients … pain is pain.”

A big part of her research, clinical work and mentoring of other clinician-researchers is closing the knowledge gap about differences between men and women with regard to pain perception, as well as their anatomical differences.

“One of the nerves involved wasn’t even mapped out for women in the textbooks when I was in medical school,” said Zolnoun. In fact, it was these gaps in knowledge about the health needs of women that led her into gynecology, where she thought she could make a difference by moving the science forward with research.

Two patients’ stories Often, women experiencing vulvar pain have endured silently for years.

Layered on top of that silent suffering can be shame and isolation, along with frustration and despair.

MEDMONTHLY.COM |11

12 | OCTOBER 2011

her reverse engineering she identifies which nerves are involved and administers nerve blocks via injection for relief. Patients differ in how long the relief lasts or how many injections are needed, but, as Zolnoun explains, it is a process of quieting the nerve over time and is unique to the individual. In Jurek’s case, the nerve mapping revealed involvement of nerves running down her leg. She said it was very mysterious to her, but “it made perfect sense when Dr. Zolnoun explained it.”

“My goal is to be pain free,” said Ballard, who says she is now having pain-free pleasurable sex for the first time at age 45. “I am not giving up.

Dr. Zolnoun has given me relief and given me hope, more than anything else.”

‘‘

Dr. Zolnoun instinctively zeroed in on the precise source of my pain, I was never so elated to have someone hurt me! I thought, ‘She knows. She knows what hurts, and she knows why.’ If she knew that within five minutes, I knew she could guide me to some degree of relief. She is not just knowledgeable; she’s passionate and tenacious in a way I imagine our suffragette sisters were in their day.

Because of her crusade, many women are regaining hope for a normal, productive life.”

Furthermore, the work continues through those she enthusiastically mentors as they continue to break new ground in research and treatment.

“She is a rare breed within academic medicine, in that she wants those she’s mentoring to be successful because she sees the bigger picture of it pushing forth the state of the science and providing better care,” said Elisabeth Dinkins, FNP, a nurse practitioner being mentored by Zolnoun and who soon will have her Ph.D. in nursing. She is specializing

I never let this condition stop me; it’s just that now I can make plans and carry them out without fear of pain every minute. I used to plan around the pain — even the simplest thing like getting in and out of the car took immense courage. Now, I can live without that cloud overshadowing every move.”

— Noreen Jurek Jurek added: “There’s no describing the moment I finally felt that someone understood the real physiological issue and was willing to administer targeted treatment. As

in biological, psychological and social correlations of pelvic pain. They plan to continue working together on a number of research grants and in treating patients with vulvar pain.

PHOTO COURTESY DENNIZ ZOLNOUN, M.D.

Noreen Jurek, a marketing professional in Cary, N.C., who suffered a nerve injury in a prior routine pelvic surgery, has described the “searing pain” and the misery of sitting for long plane rides for business travel. Coupled with the endurance it took to maintain a “happy face” at work, despite her discomfort, she said it was extremely difficult to concentrate.

“It felt like a fish hook there all the time and every move made it dig in a different way,” said Jurek.

Sandy Ballard, of Raleigh, N.C., spoke of almost two decades of chronic pain that felt “like a hot poker in the vaginal area.” She was diagnosed in her 20s with a yeast infection by her family physician and said the pain never went away.

To add insult to injury, she sought help from a series of physicians who in their ignorance about this issue suggested it must all be in her head, that she was “super sensitive” or asked whether she was ever molested. She has found relief from the constant pain from a combination of medications, including dextromethorphan (an ingredient in cough syrup), Lyrica® (a fibromyalgia drug), Mirapex® (used to treat restless leg syndrome), Wellbutrin® (an antidepressant) and others.

These women and others also have sought help in Zolnoun’s monthly pain clinic, where she maps the type and location of pain and other sensations they are having. Then through

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research & technology

Endometrial ablation improves heavy bleeding and PMS Five minute NovaSure procedure relieves suffering

By Andrea Lukes, M.D.

H

eavy periods can cause cramps, nausea and headaches making women miss work and social events, and can lead to depression and anxiety.

Ten million women suffer from heavy bleeding, but this number can be decreased through NovaSure Endometrial Ablation, a five-minute procedure in a doctor’s office that gently removes the lining of the uterus. The procedure is well-tolerated and safe.

The one year amenorrhea rates (no bleeding) is between 44 to 56 percent; whereas, the five year amenorrhea rates climbs to 58 to 75 percent.

Seven out of ten endometrial ablations are done using NovaSure.

On average the discomfort during the procedure ranges from two to six, on a scale from zero up to ten. Most women rate the discomfort similar to menstrual cramps. Women who are not planning for any more children, who have a normal endometrial biopsy and who want relief from their heavy periods are good candidates for the NovaSure procedure.

How does it work?

The science behind NovaSure involves radiofrequency energy. Via 14 | OCTOBER 2011

the cervix, the energy is delivered through a slender wand that extends a triangular mesh device into the uterus that conforms to the contours of the uterine cavity. This energy is applied to the endometrium (or lining of the uterus) for an average of 90 seconds. The muscle of the uterus has less water content compared to the lining, so the muscle of the uterus serves as an impedance to stop the energy from spreading. After the procedure, the mesh device is pulled

‘‘

heavy menstrual bleeding, but that it improves symptoms of premenstrual syndrome (PMS). Although how it benefits PMS is not known, recent research at CWRCW shows the symptoms of PMS did improve. We had a prospective cohort of 36 women from several practices who completed two validated daily questionnaires, the Daily Symptoms Report (DSR) and the Daily Record of Severity of Symptoms (DRSP). This was done at baseline and then four to six months

Ninety-seven percent of women reported improved PMS symptoms [after having NovaSure endometrial ablation].”

back into the wand, and both are removed from the uterus.

NovaSure improves the symptoms of PMS Research coordinated by Carolina Women’s Research and Wellness Center (CWRWC) has shown that the Novasure Endometrial Ablation is not only highly effective for

after the NovaSure Endometrial Ablation. We also had patients do a selfrating of PMS before and after having a NovaSure Endometrial Ablation.

Ninety-seven percent of women reported improved PMS symptoms.

It is interesting to determine what associated symptoms women suffer from who have heavy periods. In a survey of 906 women with heavy

periods, the most common associated symptoms included pain, mood changes and feeling tired, which are all part of PMS. The diagnosis of PMS includes prospective recording of symptoms that are restricted to the luteal phase of the menstrual cycle which impair some facet of a woman’s life (with the exclusion of other diagnoses). The symptoms of PMS can be divided into mood (affective) or physical (somatic). Remarkably, up to 85 percent of women have one or more symptoms of PMS.

Final Word Although Novasure Endometrial Ablations are not indicated for PMS, it is important for health care providers and women undergoing the procedure to consider the impact on symptoms of PMS. As we counsel women on treatments for heavy periods, the fact that PMS symptoms may improve may help them make a more educated decision regarding their options.

The impact of the endometrial ablation treatment for heavy periods has not yet decreased the hysterectomy rate within the United States, but it has in England. Many experts expect that with the growing number of ablations, there will be a decline in hysterectomy rates within the United States.

Many women who have had a Novasure Endometrial Ablation procedure love having more energy and confidence and no longer dread that time of the month.

More information for providers and patients can be found at novasure.com.

Andrea S. Lukes, M.D., MHSc, FACOG is the founder and lead investigator at the Carolina Women’s Research and Wellness Center (CWRWC) and is now in private practice at the Women’s Wellness Clinic in Durham, North Carolina.

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research & technology

New app could help doctors care for their Alzheimer’s patients

J

aved Mostafa, Ph.D., is an information junkie. As a professor with joint appointments in Information Science and the Biomedical Research & Imaging Center at UNC-Chapel Hill, Mostafa likes to explore innovative ways to dig up data, documents and images.

His latest project is a computerbased tool that could help physicians analyze the brain changes associated with Alzheimer’s disease. The program searches for brain scans with similar patterns of damage to give doctors a

16| OCTOBER 2011

basis of comparison when diagnosing, treating and predicting the course of each patient’s disease. Think Google for neurologists.

The standard approach employed by neurologists doesn’t take such a “cohort” of similar patients into account.

Rather, physicians typically address brain scans one patient at a time for atrophy or loss of brain cells. Mostafa’s system—called Viewfinder Medicine— tries to change that paradigm by giving physicians an automated system that could guide them in decision-making with regard to their patients.

As one neurologist, Daniel Kaufer, M.D. sees it the realm of Alzheimer’s disease diagnosis could use the help.

Kaufer, director of the Memory and Cognitive Disorders Program at

UNC-Chapel Hill, says that MRIs are primarily used to rule out strokes or tumors or other structural lesions. The changes associated with Alzheimer’s are rather subtle, and, as a result, it can be difficult to make a reliable diagnosis based on the MRI alone.

“Currently there are limitations with regard to how much a brain scan can predict the clinical picture,” Kaufer said. “These automated systems are trying to improve the ability to take what is a very subjective process and make it more objective.”

The Viewfinder Medicine system presents neurologists with relevant images on the computer screen in a pattern known as a “fisheye.” By placing a patient’s brain scan in the center or “eye” of the screen, the physician can

PHOTO COURTESY ISTOCKPHOTOGRAPHY.COM

Google for Neurologists

prompt the system to retrieve a cohort of similar patients, which it scatters around that center focal point. Importantly, it uses not just brain scans but also age group, gender, cognitive scores and other supporting data to determine the best matches for the patient.

“I am not a physician, I am an information retrieval guy, so my interest in this project is to study how both visual images and textual information can be combined to make searching an effective process,” explained Mostafa, who also serves as one of the deputy directors at the NC Translational and Clinical Sciences Institute (NC TraCS).

“This is a domain where it is very important to be accurate. The more clues about a patient you can use to determine their diagnosis and treatment, the better.”

Mostafa was first drawn into this domain by the ADNI (Alzheimer’s Disease Neuroimaging Initiative), an NIH-funded project that has developed a database of images from 200 elderly controls, 400 subjects with mild cognitive impairment and 200 subjects with Alzheimer’s disease. Such comprehensive databases are hard to come by, so when Mostafa heard of ADNI he was eager to sign up for access to the

collection.

“In medical science it is very hard to find image collections that can support a research project like this,” said Mostafa. “I could do it on my own, but that would mean I would have to get IRB approval, access MRI scans, make sure they are consistent, then I would have to store it somewhere, maintain it, manage it, make sure that the cognitive score data is available. Everything needs to be curated; this notion of having good data for research becomes a huge barrier for a researcher. There is a reason people call this kind of data gold standard—it is because they are expensive to produce!”

Mostafa’s research was also aided by funding from NC TraCS, UNC’s home of the NIH Clinical and Translational Science Awards (CTSA). The national consortium was created to make biomedical research faster, cheaper and more efficient. Mostafa says having NC TraCS, with its grants support and programs like Carolina KickStart, which helps commercialize and move discoveries into the marketplace for potentially widespread use, has been key to his success.

“I couldn’t say enough positive things about them,” he said. “I am a

A screenshot of Viewfinder Medicine courtesy NC TraCS.

pragmatic type of a scientist, if my work just got published and cited, I wouldn’t consider that my most valuable contribution. It has to get out to the world, and someone, hopefully someone, will find it useful. NC TraCS has been fabulous about making that happen.”

Translating scientific advances into health care improvements is a passion for Mostafa, who presented the vfM system at the 9th International Workshop on Content-Based Multimedia Indexing held in June in Madrid, Spain. He and his co-author Mayank Agarwal found that the “classification performance” of their computer-based tool matched the best result reported in the medical imaging literature, with up to 87 percent of patients correctly classified in their respective groups of normal, mild cognitive impairment or Alzheimer’s disease. Mostafa and Agarwal, who recently graduated with a doctorate from the School of Information and Library Science, are now making modifications to the system in hopes of getting its accuracy closer to the 100 percent mark.

“We are not sure if physicians are going to like this way of analyzing, but we hope they do,” said Mostafa. “For us, this is not an image analysis project; it is an image retrieval project. We didn’t invent any new image analysis algorithms or software, we invented a new way of searching and browsing MRI images and analyzing those images from a physicians’ perspective.

The goal is to help create a tool that helps the physician to understand and analyze the information.”

The tool could prove particularly useful to physicians who are not just focused on memory disorders but who see different types of patients every day. Kaufer thinks that automated programs like Viewfinder Medicine could improve the care of such patients who aren’t seen at a specialized clinic.

“My advantage is I can look at the MEDMONTHLY.COM |17

brain scan and, based on experience of looking at thousands of them, I can extract subtleties that help inform my differential diagnosis,” said Kaufer the neurologist. “These automated programs could help operationalize that expertise so that it would be more widely available.”

Mostafa believes automation could also lead to earlier detection of Alzheimer’s disease. Though there is currently no cure and few effective treatments for the illness, diagnosing it early in its progression could give physicians a better chance of testing new interventions and buying patients more time. Mostafa hopes to develop his application so that it could enable physicians to stage a patient’s disease on image data alone, without having to wait for the results of cognitive testing.

But Kaufer thinks that may be overreaching a bit.

“There is so much overlap between groups, it makes it difficult for these imaging techniques to accurately classify a single subject every time,” said Kaufer. “I see people with terrible memory whose brains look normal, and other people whose brains look pretty atrophic, but their memory is still preserved. We are never going to get to a point where pure imaging can detect a diagnosis, but I do think that in the next five years, quantitative brain imaging methods are going to play a larger role in helping to facilitate the diagnosis of dementia in conjunction with other clinical factors.”

Mostafa, who with the support of NC TraCS recently co-founded a company concentrating on patient-centric decision support (Keona Health), thinks this latest project has commercial potential. But first the researchers will have to test the merits of the system with doctors in the Alzheimer’s domain, like Kaufer, who says he is more than willing to serve as a guinea pig.

This article was reprinted from NC TraCS Institute (North Carolina Translational & Clinical Sciences Institute) newsletter.

18| OCTOBER 2011

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I think I want a lab for my practice And what kinds of testing you should be offering to your patients

By Libby Knollmeyer B.S., MT (ASCP)

20 | OCTOBER 2011

W

hile there are multiple levels of laboratory complexity, it is possible to have a lab in your practice with very little fuss and administrative burden. The level of complexity of any lab is determined by the testing being performed, and the complexity level of each test or test system is assigned by the FDA.

What is Waived Testing?

The waived category allows physicians to do simple testing in their offices to facilitate diagnosis and enhance patient care with on-the-spot results. A test or test kit gets classified as waived if it:  is extremely easy to perform  has built-in safeguards, and  requires little education or training to do and interpret correctly.

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your practice

Urine dipsticks, rapid Strep A kits, urine pregnancy test kits, and rapid Mono Test kits are examples of waived tests. In addition, there are also some Point of Care (POC or POCT) tests/ instruments that have been granted waived status, including glucose monitors and hemoglobin instruments. There is a wide variety of testing available to the practitioner without having to bear the administrative burdens of the moderate or high complexity laboratory.

Of the various types of laboratories defined, the waived lab has the least regulatory oversight. CLIA (Clinical Laboratory Improvement Amendments) does not have personnel requirements for waived labs other than requiring there be a lab director, which any physician in the practice can fulfill. It is common for the lab director to receive a monthly stipend of $300 to $500 per month for fulfilling this simple role.

The only regulations that apply to waived testing are:  requirement to have a CLIA ID # and pay the certificate fee every two years, and  to follow the manufacturers instructions for any test performed.

Laboratories are not required to subscribe to proficiency testing for waived tests, and there is generally no inspection of waived laboratories every two years as there is for moderately and highly complex labs. CLIA has the right to come in and inspect at any time, and they are trying to inspect about two percent of the waived labs each year. Generally, though, they are short-staffed and these waived lab inspections are not the priority that the more complex labs are unless there has been a complaint filed.

What does following the Manufacturer’s Requirements/ Recommendations mean?

Following the manufacturer’s requirements/recommendations means following all the instructions that come with the test kit in the form of a package insert. This insert will include instruc-

tions on quality control, how to perform the test, interpretation of the test results, and environmental conditions suitable for performing the test. Because there are usually temperature requirements for storage of the tests and for performing them, refrigerator temperatures and room temperature will need to be monitored and recorded each day of testing.

If the package insert includes humidity specifications, then the room humidity will need to be monitored and recorded also. Hardware stores and medical supply companies both sell devices for measuring the temperature and humidity of a room. The device hangs on a wall and is frequently a digital read-out, but some are dial read-outs.

I want to start with dipstick urine tests in my practice— how do I accomplish this?

Start by submitting an application to CMS (Centers for Medicare and Medicaid Services) for a CLIA certificate. This is done by filling out the CMS116 form and mailing it to the CLIA office in your state.

Once the CLIA Certificate and ID number have been issued (and any state licensure completed if required) you are free to begin testing. At some point you will receive a bill from CMS for the CLIA Certificate Fee. Don’t overlook this because failure to pay it will inactivate your CLIA ID number.

Competency Testing Now you will identify and train the personnel who will perform the testing.

Almost anyone in your office can do this once you have them pass a urine dip competency which will include: Performing controls. Control materials for urine dips are purchased separately and dipped as though they were a patient specimen. Two levels (negative and positive) are tested, but most manufacturers only require Quality Control (QC) when a new lot number is

opened or a new shipment (even if the same lot number) is received.

Patient Communication. Explaining to the patient the instructions for providing a urine sample. Although many offices provide written instructions in the rest room, remember that not all patients read well or read English.

Timing the test.

Recording results. I recommend having a log sheet that has a place for the patient I.D. and results for each analysis on the strip. Another alternative is to get an automated strip reader, which can be obtained without purchasing it if enough vials of test strips are purchased.

This has a printed report that is generated and also standardizes the reading so variations from one person to another don’t play a part in results.

Cleaning. Clean after each test, and documenting daily cleaning on a log sheet.

Final Words I recommend you purchase the test strips (almost all medical/surgical supply vendors carry waived testing kits and strips), and develop a mechanism to get the results to the provider (entry into an EMR [Electronic Medical Record] or paper chart or via a paper document). You will need a little space on a counter somewhere, preferably close to a sink, and good light to read the strip under. Urine is not considered a biohazardous material unless it is contains visible pus or blood, so disposal of the urine when testing is complete is easy: pour it down the sink or flush it down a toilet.

And voila! You have a lab.

Consultant Elizabeth “Libby” Knollmeyer, B.S., MT (ASCP) has over 40 years experience in the laboratory industry and has set up many laboratories. She can be reached at eknollmeyer@triad.rr.com.

MEDMONTHLY.COM |21

What do dentists need to know about SEO? How easy it is for your potential patients to find you online is crucial to your practice’s success

By Edward M. Logan, D.D.S.

22| OCTOBER 2011

T

he importance of appearing on the first page of search engine results was highlighted in iProspect’s 2006 Search Engine User Behavior Study of 2,639 Internet users. The study’s results revealed that 62 percent of users stated that they do not look past page one for results.

Over 90 percent of users reported that

they never look past the first three pages for results. As this study bears out, if your website is not appearing on the first page of results, it is highly unlikely that it will be found by potential patients. Therefore, it is critical to maintain a high ranking with the search engines, and this needs to be accomplished my putting in place sys-

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your practice

tems to ensure maximal search engine optimization of your website.

First, let’s explain in simple terms what happens when a potential patient searches for a new dentist online.

The patient will choose a combination of words, such as “Dentist in Austin,”

‘‘

increasing their websites’ optimization and visibility. This to me is a clear display of the backward logic being employed by the marketing factions of these companies. Therefore, if we know that the overwhelming majority of patients searching for you online

Making our websites relevant to search engines in a natural rather than a paid manner will provide us the greatest return on investment.” and click “Search.” The listings which appear on the results page will generally be in one of three formats: Organic, also called natural listings, that appear in a search because a search engine such as Google determines their website content to be relevant to the words entered into the search query.

Local listings which appear on a Google map, as well as within the list of results returned in a search query.

With a recent redesign in how Google delivers local search results these local listings now appear higher on the first page in many cities.

Pay per click (PPC) also called sponsored listings. These companies have paid to have their websites appear high in the ranking for specific keyword search phrases.

A recent study by the website tracking company, Eightfold Logic, determined that for the 5,000 companies it monitors, people were 8.5 times more likely to click on an organic listing than they were to click on a sponsored listing. Despite this data, these same companies spent nearly 80 percent of their Internet marketing dollars on pay per click advertisements, and less than 10 percent on

will be drawn to the organic listings they find, it behooves us to market to this area much more than to the area of sponsored ads. We can conclude that making our websites relevant to search engines in a natural rather than a paid manner will provide us the greatest return on investment.

Google protects the information on its search results algorithms and nobody can say for certain what factors the most heavily in boosting a website’s results in searches. However, from my experience, I have learned that the following steps should have a positive effect on your dental website’s results in Google searches for a local dentist.

If you haven’t already, claim your Google Places listing. Fill out all of the requested listing information and consider adding photos and videos to your listing. Use the status update option to promote special events. If you offer a discount of any kind, Google will allow you to create a coupon on your listing as well.

Make sure you use consistent business name and address information in EVERY reference to your business online. Make a choice whether you will use the dentist’s name or practice name when registering your office with online directories.

If you choose the dentist’s name, list it the same each time. For instance, do not list it as Dr. Edward Logan one place while listing it as Edward M. Logan, DDS in another. One dentist brought to my attention that it is not always possible to have consistent information since every website or directory formats its information form differently, but whenever given the opportunity try to keep your information consistent.

Check to make sure Google has not created duplicate Google Places listings for your business. This can occur as a result of using different forms of your business name or address in online citations. Duplicate listings will hinder your efforts to promote your Google Places listing.

Seek online patient reviews from patients who have made positive verbal comments about their experience in your dental office. There are a large number of online review sources, including Angie’s List, Merchant Circle and Insider Pages. Many dentists are nervous about the possibility of a negative review harming their online credibility. However, seeking positive reviews from happy patients is always a good idea.

Seek out online citations for your dental office through inexpensive directories, such as The Dentist Search. A website and business will appear more relevant to Google with a large number of references online.

Perform a Google search on your practice name to see which websites and directories refer to your practice. Check to ensure that your business name and address information is listed correctly. If you find errors, contact the website for correction.

To learn more and to order book copies, visit www.DentistrysBusinessSecrets.com MEDMONTHLY.COM |23

your practice

MINDBODYCONNECTION A couples practice is a recipe for success

By Denise Hanson, PSY.D.

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W

hen I decided to open a private practice in Wilmington, N.C., in March of 2000, the community embraced not only a new and unique model of medical and mental health care, but also embraced me. This was a welcome surprise as I had recently relocated from Boston, Mass., and felt very much an “outsider.” Today, eleven years later, The Center for Integrated Health Care, PC (CIHC) has a difficult time keeping up with the volume of referrals we receive. It has been an inspiring and rewarding venture and we have grown tremendously as a result of the positive response from the patients and clients we serve. My practice has been shaped by my passion for and commitment to making a difference in this world and to help others to do the same.

CIHC was founded by my husband, Russell H. Gerry, Board Certified Internist, and myself, a Licensed Clinical Psychologist. After many visits to Wilmington, we concluded that this city was truly a unique place due to its location, beauty, resources, and most of all, its people. We decided that Wilmington was exactly the type of community we could call “home,” and also a community that would be open to our long-standing vision of health care. For many years, we looked forward to establishing a health care practice that was founded on a model of integration. Although the “MindBody Connection” has long been accepted as a theoretical model of health care, our experience was that most practices continued to treat them as separate entities.

We wanted our delivery of physical and mental health care to be centered on the premise that the mind and body are truly interdependent. We are proud to say that the care we deliver at CIHC does, in fact, center on the premise that mind and body are to be treated as an integrated entity. The

medical and mental health team of professionals at CIHC is concerned about the whole patient or client, recognizing that each individual’s unique health care needs involve multiple factors, including their physical health, emotional or behavioral health, spiritual beliefs, family, environment, and community. Dr. Gerry and his medical team provide general internal medicine care, including preventive, acute and chronic health care, while the mental health team I lead provides mental health care to children, adolescents, adults, and families. Not all patients receive care from both the medi-

‘‘

of care that other members of my community provide. I believe that our efforts at interdisciplinary networking and education have served as a vital foundation for the comprehensive care we strive to provide for our patients. I am grateful that so many local practitioners, each with a unique and invaluable skill set, have welcomed and accepted my efforts at integration.

Our practice continues to grow through our relationships with both our patients and the professional community. Our community partners include pediatricians, general practitioners, internists, physician assistants,

We wanted our delivery of physical and mental health care to be centered on the premise that the mind and body are truly interdependent.” cal team and the mental health team at CIHC, but for those that do, the medical and mental health teams work closely together with their patients.

Marketing a practice through collaborative relationships When I opened my practice, I decided to market my services to several different groups, as well as to medical and mental health professionals. I reached out to schools, both private and public, social service agencies, physical therapists, occupational therapists, speech and language pathologists, tutors, and agencies that support individuals with disabilities, such as vocational rehabilitation. In addition to marketing my services, one of CIHC’s primary goals in reaching out to other professionals was to expand our network of integration by partnering with other disciplines in the Wilmington community. Working alongside other disciplines has been, and continues to be, a very important part of my practice.

In addition to educating others about CIHC’s model, I learn unique aspects

nurse practitioners, schools, tutors, occupational therapists, speech and language therapists, medical specialists, mental health practices, parents, and of course, our patients. They are not only our partners, but also support the growth of CIHC through referrals.

Getting in the driver’s seat of your own health One major observation that our clients and patients make is that our practice model empowers them to take ownership over their own care. They report feeling heard and understood by our clinicians, and most importantly, they report feeling respected.

Our clients are encouraged to learn everything they can about their health care needs and to work collaboratively with our health care providers towards optimal health and well being. These patients share with us that this has not been the case with many of their previous medical and/or mental health care experiences. One common perception is that they were not encouraged to MEDMONTHLY.COM |25

work collaboratively with their doctors, but rather told what to do or not to do. Their take-home message was “the doctor knows best, so do what is recommended and don’t ask questions.” Most patients and clients come to us with this very expectation, and they are initially perplexed over our expectation that they are a team member, just as important a player, and with as much control over their care as their health care provider. Over time, however, they begin to embrace the idea that it is their health and their right to make important decisions regarding their health. When they come to accept their role fully, we see a big difference in the way patients and clients take care of themselves. Without a doubt, they do it better.

For example, a patient contacted CIHC in 2002, reporting long-standing multiple physical and mental health problems. He had been seen by several medical and mental health providers prior to being seen at CIHC. Over time, at CIHC, he learned that many of his medical problems, such as his bleeding ulcer, sleep disturbance, and gastrointestinal symptoms were related to his mental health diagnosis, posttraumatic stress disorder. He had never been told that he had PTSD. He was unaware of the symptoms and their relationship to the medical problems he had endured for so many years. Together, Dr. Gerry, and myself, worked closely with this patient to help him not only understand his medical and mental health needs, but to develop and implement a plan of care that would address his complex health care needs. The patient has made significant behavioral changes in his life, in addition to taking charge of his health care by asking questions and learning about treatment options and medications. Other than his sleep, which is still not regulated completely, this patient’s medical problems have significantly abated. This patient has 26| OCTOBER 2011

participated in therapy since 2002, with fewer and fewer medical visits due to his improved physical health.

Empowering patients who need mental health care As a mental health provider, empowering my patients to become experts on their conditions is of utmost importance. The stigma of having a mental health disorder continues to lurk in the lives of most clients who seek mental health care, and lack of knowledge and awareness only serves to exacerbate their feelings of shame and vulnerability. Educating clients about their mental health disorder is an integral part of the treatment process in my practice. Over time, my clients develop a new “narrative” about their illness, one that bridges the mind with the body. We view mental health illness the same way that we view physical illness. Brain chemistry is at the root of many mental disorders. Physical chemistry is at the root of many physical disorders. The mind affects the health of the body and the body affects the health of the mind.

The stigma of mental illness is difficult to overcome, but many of my patients are able to rid themselves of the shame that has caused them so much emotional pain. In doing so, they feel much less powerless. This is a huge and important step in becoming emotionally healthy. In order to help our clients accomplish this, their team of health care providers needs to convey the same message. In my practice, this is what we strive to do.

My practice has expanded to include an affiliate, “Mentoring Minds for Mental Health” (MMMH), a company that serves a special population of children, adolescents, and adults through neuropsychological, psychological, and learning evaluations. The clients of MMMH are not suffering from a mental health disorder; rather, they are suffering predominantly from

a learning disorder and/or attention deficit disorder. Diagnosis of a learning disorder and/or attention deficit disorder is the first step in helping an individual realize their cognitive and academic potential. Once a diagnosis is made, an academic plan for success can be developed and implemented.

The MMMH team now consists of teachers, parents, school guidance counselors, pediatricians, occupational therapists, speech therapists, and myself. I spend a good deal of my time at local schools, working with a child’s academic team in the interest of addressing the child’s unique learning needs. Helping an individual develop a love for learning in the face of many obstacles, has been, and continues to be, the most inspiring part of my work.

DENISE HANSON, PSY.D. Dr. Hanson has been providing psychological services since 1977.

She strongly supports an integrated model of health care that includes collaborating and partnering with other professionals in her community towards optimizing health care for her patients. Dr. Hanson is currently licensed in both Mass. and N.C. and is a member of The National Register of Health Service Providers in Psychology, The American Psychological Association, The North Carolina Psychological Association and The Cape Fear Psychological Association. As a result of her work in the Wilmington community, Dr. Hanson was nominated for membership to the National Association of Professional Women, and has been nominated twice for the YWCA Women of Achievement Award. She currently serves on the board of directors for the Hill School of Wilmington, a private school serving children with learning difficulties.

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legal

Where is health care reform headed?

Government seeks increased transparency and changes through tax credits and payment reform

By Kim Licata

28| OCTOBER 2011

If only there were an “easy button” for reform

through various agencies. The most recent changes have included: The Center for Medicare and Medicaid Innovation (“Innovation Center”) announcing the Bundled Payments for Care Improvement Initiative. Under this program, providers can apply to participate in certain bundled payment programs ranging from a payment bundled for an episode of care defined alternatively to include: (i) all inpatient acute care, (ii) all inpatient acute care and post-acute care, (iii) post-acute care only, or (iv) a prospective bundled payment for in-

patient care. Applying providers have some flexibility depending on which initiative they want to participate.

The Internal Revenue Service (“IRS”) issuing news release IR-201190 to encourage small employers and professional service providers to review the new Small Business Health Care Tax Credit to see if the tax credit applies to them.

Health and Human Services (“HHS”) announcing a joint state-federal review of double digit health insurance rate increases, which includes the creation of consumer-friendly

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P

resident Obama signed the Patient Protection and Affordable Care Act (“P-PACA”) almost 18 months ago in March 2010. Many articles have been written about it. Many more opinions have been shared. Congress continues to debate health reform, while health care and the economy are taking center stage in the upcoming elections.

Where is health care reform today and what has the government been doing this summer?

Answer: Payment reform and quality incentives continue to be the direction in which health care reform is headed.

In spite of the ongoing constitutional challenges to P-PACA in the federal court system, the federal government spent its summer continuing to implement health care reform

insurance information on the website HealthCare.gov relating to proposed rate increases.

The Centers for Medicare and Medicaid Services (“CMS”) published multiple final rules, including on the hospital value-based purchasing program (Aug. 18, 2011), quality reporting program for long-term care hospitals (Aug. 18, 2011), hospital readmission reduction program (Aug. 18, 2011), quality reporting for hospices (Aug. 4, 2011) and for inpatient rehabilitation facilities (Aug. 5, 2011), as well as the hospice face-to-face requirement (Aug. 4, 2011).

These recent actions demonstrate the federal government’s commitment to achieve increased transparency between payors, providers, and consumers, to incentivize changes through bonus payments or tax credits, and to implement substantial payment reform. Unfortunately, P-PACA was a highly partisan effort and the fallout from this has been significant in terms of understanding and expectations. Consumers have expressed mixed emotions on health care reform; most recognize that change is necessary, even inevitable. Providers and insurers have viewed health care reform both as an opportunity to be incentivized to be cost-efficient and cost-effective and yet as a likely loss of revenue over time.

Under P-PACA, health care reform attempts to change fundamentally how health care services are provided by health care providers by shifting the focus from reimbursement based on the quantity of services provided to reimbursement on the basis of the quality of the services provided.

Payment reform takes two primary forms in P-PACA: bundled or valuebased payments and accountable care.

The first is bundled or value-based payments. By aligning caregivers and providers with a financial interest in working together and manag-

ing costs through a single payment, the government hopes that bundled payments will help shift the focus to quality care. Bundled payments and its kin are insurance and reimbursement based efforts to shift payment.

In contrast (but to the same end), the second payment reform is through accountable care. Accountable care is intended to be a patient-centered approach to deliver coordinated care to improve quality and reduce the total cost of care for a defined patient population. Accountable care requires buy-in from providers and patients and coordination among all involved in care delivery.

P-PACA’s lack of focus on the role of the consumer, aka the patient, in driving health care costs has been considered a significant weakness of the current health care reform efforts. Most if not all recognize patient access to care and health care information to be very important.

Notwithstanding this, for systemwide changes to occur and “stick,” health care reform is dependent on buy-in from insurers, providers, and consumers with each bearing some responsibility in the process. The government continues to encourage a dialogue between insurers, providers, and consumers through regulations, websites, even “town hall” or open forum discussions.

Most agree that our health care system needs an overhaul. Consumers feel they are overcharged, while providers frequently complain about operating in the red. The last 18 months of reform have made changes to the system with many more to come. The next few years promise to provide us all with a wild ride. Stay tuned and hold onto your hat!

There isn’t an app for this.

Live, learn, and work with a community overseas.

Be a Volunteer.

peacecorps.gov

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

MEDMONTHLY.COM |29

feature

Coaching women to be well

Using positive psycology to guide patients to self-care accountability

By Lani Kee Kathryn Fisher is a 50-year old registered nurse case manager, whose job is to provide disease management (diabetes, hypertension) for the members of a large health insurer* in the Southeastern U.S. market. She came to my office as a result of having to earn “wellness incentives,” which the company offers to employees who

want a discount on their health insurance. To get her discount, she had to schedule two sessions with a registered dietitian, log 12 exercise sessions within a calendar month, and meet with me for two sessions of stress management coaching. She had 11 months to ac-

complish this, plus submit to a biometric screening and an online health risk appraisal. If she accomplished all this, she would get a $750 discount off her health insurance the following year. The company wins by hoping to lower their health care costs when they motivate employees to engage in their self-care at a deeper level.

For Kathryn, she held off doing anything about her health until the last minute because she smokes a pack of cigarettes a day and has been a smoker since she was 15 years old. During the biometric screening, the employees are tested for cotinine, a substance found in nicotine, which would then flag her, and she would incur a “smoker’s surcharge” of $250, which

From weight loss goal to quitting smoking, wellness coaches can do it all.

30| OCTOBER 2011

WELLCOACH RESOURCES would be deducted from her $750 discount. If she attempted to quit before the screening, she could earn the full discount. This is where Kathryn presented herself to me, understandably stressed over it all.

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What does a wellness coach do for someone like her?

My job as a wellness coach is to partner with Kathryn in a co-active approach that helps her to become self-empowered and self-sufficient in addressing and striving for a better quality of life in all dimensions of her wellbeing: physically, spiritually, emotionally, intellectually, socially, occupationally and environmentally. Through practices using positive psychology, appreciative inquiry and wellness goalsetting, my aim is to guide Kathryn to get back in the driver’s seat of self-care accountability.

By identifying Kathryn’s stress triggers and stress symptoms, I can find an entry point to move her into a plan that is realistic and drives her motivation to change in baby steps.

The coach focuses on what is working well instead of what is broken. For example, if a client wishes to find more time for exercise but struggles with competing time constraints, a coach will explore with the client what has worked well in the past, ask the client to explain what they want this routine to look like and brainstorm ways to introduce new behaviors. Allowing the client to rate their confidence in achieving their goals, and not asserting my expert opinion, is important to co-active coaching.

I consider myself a professional “nudger,” guiding clients gently within a conversation that allows them to feel safe, motivated and to bring about a readiness to change, otherwise known in the coaching world as “generative moments.”

A new mindset in patient care In today’s managed care settings, some of these coaching opportunities are lost and unaddressed.

The current trend is telephonic health coaching executed by doctors, nurses, therapists, health educators, fitness professionals, and counselors.

Few companies have adopted the more costly (yet more effective) model of face-to-face coaching as the company I work for has implemented. Health/ wellness coaching barely existed 10 years ago, but as physician practices are beginning to experience the limitations managed care has toward patient care, they are seeing the need for coaching.

Health care management is beginning to realize it is not enough to just dictate care to patients. According to Ewa Matuszewski, CEO of Medical Network One, a Rochester-based physician group, “Physician practices are moving from the ‘I’ approach to the ‘we’ approach,” incorporating a team of experts that address the whole person, body, mind, and spirit. This integrated effort may include dietitians, diabetes educators, health educators, exercise physiologists, physical therapists, nurses and wellness coaches.

If their budgets are prohibitive to add a full-time coach, then many times providers train themselves to coach in the exam room. As a part of a team of practitioners in the medical clinic where I work, I have provided coaching tip sheets for the providers. Included in those tip sheets are questions the doctor can ask (aside from their usual questions) that may uncover underlying factors in why a patient is not compliant in taking the prescribed medications or in following the treatment plan. A question such as “what stress do you think is getting in the way of your treatment?” or “what do you think caused you to not take

POSITIVE PSYCHOLOGY See Dr. Martin Seligman’s website on positive psychology http://bit. ly/hfSflF APPRECIATE INQUIRY For an in-depth view of appreciative inquiry (AI) refer to this article including samples of AI in a conversation. http://bit.ly/ojkpWF WELLCOACHES The organization trains and certifies professionals credentialed in physical and mental health as wellness, health and fitness coaches. They were the first coaching organization to be endorsed by The American College of Sports Medicine (ACSM). Core topics covered in the training: Understanding human behavior change Leveraging the science of Positive Psychology so clients flourish and thrive Utilize Motivational Interviewing techniques which support a client in uncovering internal motivation Overcoming the resistance to change and uncovering self-efficacy The coach training programs are drawn from the core coaching competencies explored fully in the Lippincott, Williams, & Wilkins Coaching Psychology Manual.

Visit the website wellcoaches.com MYPLATE MyPlate is part of a larger USDA communications initiative based on 2010 Dietary Guidelines for Americans to help consumers make better food choices. It has replaced the USDA’s Food Guide Pyramid that consumers still found to be confusing. MyPlate illustrates the five food groups using a familiar mealtime visual, a place setting.

Visit their website section for professionals: http://www.choosemyplate.gov/professionals/index.html MEDMONTHLY.COM |35

your medicine?” can motivate the noncompliant patient. Making the time for this additional level of care can provide additional revenue for a physician practice. By using the CPT code under “preventive medical counseling” between 15-60 minutes, a provider can take the time to uncover other barriers to treatment. Another option due to time constraints in the exam room is to schedule an additional office visit and provide a separate preventive coaching visit which can be provided by a trained nurse as well. The extra time taken to enhance the level of care as well as the patient experience can reap many benefits for the physician practice. There are currently a few gold-standard certifications out there to provide that training. I am certified through Wellcoaches. The scope of

care given by the coach will depend on the credentials and experiences of the coach and the coach should be careful to stay within their boundaries.

Coaching as it relates to the path of self-efficacy for women Because women are historically the natural caregivers, they typically put themselves last in the nurturing cycle, and as a result, they tend to delay their own self-care until health conditions become chronic, and they use the healthcare system more. The typical approach of prescribing exercise three to five times per week, taking medications as prescribed, and following the USDA’s Food Guide Pyramid (which has finally been traded in for MyPlate), has not been effective as evidenced by the obesity in our country and the

increasing health care costs. Coaching attempts to get to the “root causes” in clients’ behavior patterns. Since women typically are more emotional and readily welcome face-to-face conversations, the coaching approach works well.

I have coached over 2000 employees at my company in a two-year period, with 80 percent of them being women. The accepting, non-judgmental, non-intimidating approach offered by coaching creates a clearer path to their wellness. In the coaching conversation, the roots of dis-ease are gently pulled up and discarded for plantings of new seeds that produce new growth.

I am thankful that I have the opportunity to till that toil and plant the seeds. *Names have been changed

GROW YOUR PRACTICE

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32| OCTOBER 2011

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IMAGINE THAT!

Our secret weapon against smoking?

Each other.

I first lit up a cigarette when I was 9. I started smoking at 16 and smoked for 15 years. When I wanted to quit, I found out the average person takes 3-4 efforts to quit because nicotine is so powerful. I learned that if you pick it up again, it’s part of a process. It’s not that you failed, that’s just how it works. When I finally quit, I had more weapons to help me — my pills, my support and my nurse practitioner to talk to. Now we have Tobacco Free Nurses to help, too.

Photo: Todd Pickering

— Maria, RN Tobacco Free Nurses is a one-stop shop for all nurses, especially nurses who want to help their patients quit smoking and nurses who want to quit themselves. We are nurses who want to benefit nurses and patients, and promote a tobacco free society. Please visit our website or call for further information.

Toll Free: 877-203-4144 | www.tobaccofreenurses.org Support for the Initiative was provided by a grant from the Robert Wood Johnson Foundation in Princeton, New Jersey, to the School of Nursing, University of California, Los Angeles in partnership with American Association of Colleges of Nursing, American Nurses Foundation / American Nurses Association, and National Coalition of Ethnic Minority Nurse Associations.

MEDMONTHLY.COM |33

feature

And why having a DEXA screening tool is a must for your practice

By Ashley Acornley 34 | OCTOBER 2011

PHOTO COURTESY ISTOCKPHOTOGRAPHY.COM

A

dding bone density screenings with the DualEnergy X-Ray Absorptiometry (DEXA), the most widely used bone mineral density test for the spine and hip, is smart business for your practice. Savvy physicians realize that with more screenings, patients are more likely to stay with a practice and use more offered diagnostic interventions. Plus patient volume will increase when the practice is known as a health care site of choice within the community.

The physicians who offer bone screenings include women’s health clinics, primary care physicians as well as specialists such as gynecologists, radiologists, rheumatologists and clinical endocrinologists. Women’s clinics who offer bone density screenings as well as mammography screenings recognize that these patients overlap and that they all want a one-stop shop to save their time and money. Another plus is that revenue can be boosted in these clinics without the burden of hiring additional staff since mammographers, nurses and RTs can be trained to perform the DEXA test.

According to the National Institute of Health (NIH), females are at greater risk for low bone mass, fractures and osteoporosis than males. Remind patients that every woman begins losing bone mass after the age of 30, and bone loss continues to accelerate after menopause. Health practitioners can help female patients learn the risks for osteoporosis so they can incorporate appropriate lifestyle changes to live a fuller, healthier life.

Benefits of offering the DEXA Screening Tool The DEXA screening tool can

identify bone loss by as little as two percent in one year, which is necessary for diagnosis since there are no obvious symptoms of low bone mass.

In comparison, a traditional X-ray machine would be unable to spot a change in bone mass unless it had deteriorated 20 to 30 percent. It concentrates its reading on the spine and hip, which are the two most prone areas for fractures.

‘‘

The DEXA screening tool can identify bone loss by as little as two percent in one year, which is necessary for diagnosis since there are no obvious symptoms of low bone mass.”

After the patient lies down on the examining table, the DEXA scans two X-ray beams with two different energy levels at the patient’s bones.

After the soft tissue is subtracted, the bone mineral density (BMD) can be seen. The DEXA is non-invasive and requires very little preparation from the patient, plus it is a quick test. The average patient throughput time is 20 minutes. The test itself costs around $200 with Medicare covering the test in all 50 states and the District of Columbia. The Health Care Financing Administration covers the DEXA test once every two years and will cover additional tests when medically necessary. Medicare and insurance company reimbursement covers the test under CPT codes 77080, 77081,

76977, 77078, 77082 (find more CPT code explanation in our sidebar) When bone mass declines In addition to the DEXA tool physicians can use other screening tools and education in their practices in order to identify bone loss in females at an earlier stage and counsel them with strategies to prevent rapid deterioration of the bone, including diet and exercise. The U.S. Preventive Services Task Force recently issued new recommendations for bone mass screening with a risk profile tool called the WHO Fracture Risk Assessment Tool (FRAX).

The Task Force suggests screening for all women older than 65, and also for younger women who have a high risk profile. The FRAX helps predict an individual’s risk of bone fracture over the next 10 years and takes into consideration several risk factors, including age, race, smoking, diet, activity, medications, and age of menopause.

According to Dr. Susan Fisher, a graduate level nutrition professor at Meredith College in Raleigh, N.C., a female’s peak bone mass is accrued from the onset of adolescence until about 28 years old. Approximately 45 percent of bone is formed during this growth stage, so the need for calcium and Vitamin D is particularly important at this time. Dr. Fisher states that after the late 20s, “Bone mineral density slowly declines until menopause, and bone loss accelerates for approximately five years after this phase.” Bone becomes less dense and weaker over time due to a lack of estrogen in the body, which causes calcium to be removed and not fully replaced from the bones. Therefore, if a woman hasn’t built strong, dense MEDMONTHLY.COM |35

FAST FACTS CPT CODES FOR DXA BONE DENSITY STUDY TEST  77080 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton  77081 Appendicular skeleton, peripheral DXA  76977 Ultrasound bone density measurement and interpretation, peripheral site(s), any method  77078 Computed tomography, bone mineral density study, 1 or more sites; axial skeleton  77082 Dual-energy X-ray vertebral fracture assessment TIPS FOR YOUR PATIENTS: Take the following steps to maintain strong bones and to prevent a future occurrence of low bone mass or osteoporosis: 1. Eat a calcium-rich, balanced diet 2. Get plenty of weight-bearing exercise. Try to exercise at least three days per week, at least 30 minutes per session for optimal results 3. Get 5-15 minutes of daily sun exposure on hands, arms, and face 4. Quit smoking 5. Limit alcohol and phosphorus and caffeine-rich foods and drinks (coffee, soda, energy drinks) 6. Consider taking a vitaminmineral supplement that includes calcium and Vitamin D. For More Information: Office of Dietary Supplements http://ods.od.nih.gov/ factsheets WHO Fracture Risk Assessment Tool www.shef. ac.uk/FRAX

36| OCTOBER 2011

bones by the time she is in her late twenties, she risks having weak, brittle bones in the future. This can increase the risk for fractures, broken bones, and the diagnosis of osteoporosis later on in life.

Recommendations for Your Patients Exercise Remind your patients to:  Build bone through weightbearing exercises. Chad Golding, a NASM Certified Personal Trainer and boxing instructor residing in Raleigh, N.C., states, “Bone is our support system for working muscles and is the living tissue that responds to increased tension and work by building and repairing new cells quicker than living cells die, therefore increasing bone density.”  For the lower body: walk with hand weights, do jumping jacks, hike and dance.  For the upper body: use free weights or resistance bands to help improve the upper body.  Yoga, tai chi, and Pilates can help increase bone density and improve strength, balance, and coordination, which can reduce risk of falls and fractures.  If injured, swimming is a great workout that builds strength and is easy on the joints. To avoid injury when starting an exercise plan, it is best to work with a personal trainer or physical therapist that works with specialized populations.

Nutrition Remind your patients to:  Get plenty of calcium in their diets through yogurt, milk, cheese, salmon, tofu, almonds, spinach, broccoli, and kale. Lactose intolerant women can include soy beverages and fortified orange juice in

their diets as well. Taking a supplement can help if a woman’s calcium intake is inadequate. As of 2010 the Institute of Medicine recommends teenage girls ages 13-18 get 1,300 mg/day of calcium, while adults ages 19-51 require 1,000 mg/day.

For women aged 51 and older, the RDA is 1,200 mg/day.  Get plenty of Vitamin D in their diet by spending 5-15 minutes daily in sunlight and consuming rich sources such as dairy, eggs, salmon, sardines, and tuna.

If dietary intake or sun exposure is low, a supplement is recommended. Recommend a limited intake of salt, alcohol, caffeine, and soft drinks, as they can weaken bones over time when consumed in excess. The current RDA for adults is 600 IU/day, the equivalent of two cups of milk.

Who should be tested?

Before testing with the DEXA, women need to be aware of their risk factors for having low bone mass. These include being a woman, increased age, small frame, ethnicity, family history, and sex hormones.

Older females of white or Asian ethnicity have the greatest risk for low bone mass. As do small, thinframed women who have infrequent menstrual cycles and estrogen loss due to menopause. However, there are many behaviors that women can change, such as smoking, a sedentary lifestyle, medication use, consuming excess alcoholic beverages, and having a diet low in calcium and Vitamin D. If women find that they have at least three of these risk factors above, they are most vulnerable to fractures and osteoporosis.

Although osteoporosis involves many risk factors that women cannot control, research shows that there are many lifestyle changes females can make to keep their bones healthy.

It is important that physicians stress the importance that females over the age of 35 receive a proper bone density screening to identify the symptoms of low bone mass or osteoporosis at an early stage. Doctors should encourage their female patients to schedule an annual visit to discuss the risks of low bone mass, and ways to prevent this from occurring. This includes reviewing current diet, exercise regimen, and calcium and Vitamin D supplement use. If the patient has an increased number of risk factors, a DEXA screening once every two years should be recommended. More bone screenings are desirable for female patients, and savvy practices should implement these screening tools into their business to demonstrate value and quality of care, which will in turn increase traffic and revenue.

A example of the DEXA scan, courtesy Ashley Acornley.

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feature

Capitalizing on chance observations And a doctor’s first encounter with a chronic disease

By Marla Broadfoot

38| OCTOBER 2011

research centers in the world.

Boucher’s first encounter with CF, one of the most common chronic lung diseases in children, was as a parent, not a clinician. One of his daughters had multiple pneumonias when she was just a baby, and was tested for CF. She did not have the disease, but Boucher says he didn’t realize how lucky he was then because he knew so little about the illness.

He had never even seen a kid with CF when he was in medical school because those patients were kept in “mist tents” to maintain moisture in their lungs.

“There was always so much condensation on the plastic that you never saw the children inside,” explained Boucher. “It was almost like plants in there, it

was so weird.”

Despite those early experiences, Boucher was still determined to study another illness, asthma, which affects a greater number of children and young adults. He developed a test to quantify the stickiness and dehydration of mucus secretions in his asthmatic patients.

Then his colleague Michael Knowles, M.D., borrowed the technique for his CF patients. The results were so striking, so abnormal, that Boucher felt compelled to understand them.

“I found a new direction and I never went back,” recalls Boucher. “In this line of work, you have to take advantage of chance observations. It is a bit of luck, and a bit of just keeping your eyes open.”

PHOTO COURTESY ISTOCKPHOTOGRAPHY.COM

T

hough Richard Boucher, M.D., has viewed thousands of chest X-rays in his career, one stands out in his mind. Boucher (rhymes with touché) was doing a year of medical service in Eagle Butte, S.D., when an X-ray revealed dozens of opaque spherical objects lodged in the chest of one of his patients. At the time, tuberculosis was endemic among the Native Americans living in the area, and doctors would cut out lung tissue damaged by the disease and fill the space left behind with ping pong balls.

“I figured this field must be pretty interesting,” deadpanned Boucher, recounting the oddball moment that led him to become a pulmonologist.

Thirty-some years later, Boucher is a leader in the field, serving as a Kenan Professor of Medicine at UNCChapel Hill and helping to oversee the management of the NC Translational and Clinical Sciences (NC TraCS) Institute, UNC’s home of the Clinical and Translational Sciences Awards (CTSA), as a PI extender (a top-level position shared by four to assist the principal investigator in managing the institute). He also directs the Cystic Fibrosis Center, which in recent years has evolved into one of the largest CF

That ability to look at every anomaly with a curious mind has led Boucher to a number of discoveries revolutionizing the treatment of CF. Despite his singular accomplishments, he maintains that his greatest achievement is leading a multidisciplinary center that takes advantage of people’s collective knowledge, insight and hard work.

“We have essentially created a platform where we can begin to understand how the dominoes fall to produce lung disease in patients missing a functional CF protein,” Boucher said with pride.

CF is caused when patients have two defective copies of the gene coding for a protein called cystic fibrosis transmembrane conductance regulator, or CFTR. When the protein doesn’t work properly it affects the way chloride ions move across the surface of the lungs, making them clog up with sticky mucus that is prone to infection.

With the help of mouse-modeling gurus Oliver Smithies, Ph.D., and Beverly Koller, Ph.D., Boucher made a “knock-out” mouse with a defective CFTR gene. This small animal model of the disease mimicked many of the intestinal issues of human patients, but oddly enough possessed none of the lung problems. The finding pointed the researchers to factors that could offset the lung disease, and paved the way for new therapeutic options for CF. The CFTR protein mainly functions as a “chloride channel,” controlling the flow of ions that keep the mucus on the outside of the airways hydrated. But there are also other chloride channels that are quiescent, being called into action by hormones and other stimuli in the lung only when needed.

“The idea is that there is a local regulation system that serves as a sort of back-up, that we all need to flush out insults from the outside world, such as viruses or pollutants,” explained Boucher. “What we learned in the mouse has led us to ways to turn on this whole second set of chloride channels, picking up the slack for CF patients.”

One way to kick this back-up channel into gear is through exercise, which is why doctors recommend that their patients work out at least 30 minutes a day.

As CF patients exercise, they breathe in a lot of dry air, forcing the body to come up with alternative ways to hydrate their airway surfaces. They can also add the use of devices such as “flutter vests” to their daily routine, which can trick their lungs into thinking they are exercising, again turning on these other chloride channels and helping to clear the chronically infected mucus secretions out of their lungs. Both approaches are decidedly low-tech, and are now part of the standard of care for CF patients.

‘‘

have access, but was quickly informed that unless the discovery was patented, no one would back it because there would be no return on their investment.

“You do think not to patent it, then it will be easier for everyone to get it, but it turns out that that is just not how the world works,” said Boucher.

“Though patenting goes against one’s natural instinct, it is the best way to push it forward.”

In his role as PI extender at NC TraCS, Boucher is helping to accelerate the translation of similar discoveries, especially in terms of commercialization.

“Our number one challenge is changing the mindset on campus so faculty

In this line of work, you have to take advantage of chance observations. It is a bit of luck, and a bit of just keeping your eyes open.”

The third piece of standard treatment came from another chance observation, initially made by Boucher’s colleagues Scott Donaldson, M.D., and William Bennett, Ph.D. Because the main manifestation of the disease is caused by a lack of salt and water in the lungs, the researchers wondered if they could simply add salt water to the airway surfaces by having patients inhale hypertonic saline. The saltwater solution would draw water from the tissues in the secretions and liquefy them, making it easier to clear mucus from the lungs.

Boucher, who was brought in for some of the proof-of-concept studies and clinical trials, says the safe, effective and cheap approach went from an idea to a treatment in under five years.

Boucher holds 76 patents for such medical interventions and diagnostics, though he is too busy inventing to bother keeping a tally. The importance of patenting ideas was imparted on him long ago by the CEO of the CF foundation. Boucher was about to publish a paper on a potential therapy and had decided not to patent it so everyone could

understand that commercializing our advances is actually something we ought to be doing,” said Boucher, who also helps lead NC TraCS’ Carolina Kickstart initiative, which guides scientists as they commercialize their drug compounds, therapies or devices. “Then we can show them that there are clear-cut rules for how to do it and that there are clear resources to help them along the way.”

Boucher, who through his own scientific contributions has helped to extend the life expectancy of CF patients from the age of 12 to 37, is optimistic that pushing academic research to the next level could one day make CF as easy to treat as asthma.

“Currently there are a lot of scientists investigating both low-tech approaches and high-tech biophysics and molecular biology approaches for CF,” stated Boucher. “Personally, I would be happy if we could put some drugs that would hydrate CF secretions in an aerosol vial.

Then we could just tell our patients to take two puffs in the morning and two puffs in the evening and that they will be fine. I think that is very possible.”

the kitchen

Tropical Smoothie With fruit and yogurt

By Ashley Acornley, R.D., L.D.N.

T

his quick and easy yogurt smoothie is the perfect breakfast to drink on your way to work or to give your kids as an after-school snack. Yogurt is also a great source of calcium and Vitamin D, to help build and maintain strong bones! Blend in other fruits for a variety of flavors. Try incorporating a refreshing smoothie into your daily diet to keep your bones healthy!

Smoothie Recipe Yield: Makes 5 cups (serving size: 1 cup)

Preparation: smooth, Process all ingredients in a blender until immediately. stopping to scrape down the sides. Serve

40| OCTOBER 2011

Nutritional Information Amount per serving

Calories: 180 Calories from fat: 4 percent Fat: 0.8g Protein: 6.5g Carbohydrate: 37g Fiber: 2.2g Cholesterol: 4mg Iron: 1mg Sodium: 93mg Calcium: 227mg

PHOTO COURTESY KEENAN MILLIGAN

Ingredients: 2 cups fat-free milk urt (soy 1 (8-ounce) container vanilla low-fat yog ose yogurt can be substituted if vegan or lact intolerant) concentrate 1/2 cup thawed pineapple-orange juice 2 cups frozen strawberries 1 banana, coarsely chopped 1 tbsp. ground flax seed (optional)

ď‚Ą Research and technology articles

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Resource Guide * Opportunity *And the best part is, it’s FREE! Introducing the FREE Med Monthly Medical Resource Guide!

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Physicians needed

Physicians needed

North Carolina

North Carolina (cont.)

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

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, Email: 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 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 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

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 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.

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.

Internal Medicine practice located in High Point, North Carolina, has two full time positions available. This well-established practice treats private pay as well as Medicare/Medicaid patients. There is no call or rounds associated with this opportunity. If you consider yourself a well-rounded IM physician and enjoy a team environment, this could be your job. You would be required to live in or around High Point and if relocating is required, a moving package will be extended as part of your salary and incentive package. BC/BE MD should forward your CV, and copy of your North Carolina Medical License to physiciansolutions@gmail.com View this and other exceptional physician opportunities at www.physiciansolutions.com or call (919) 845-0054 to discuss your availability and options.

MEDMONTHLY.COM |45

Hospice Practice Wanted

MedSpa Located in North Carolina

Hospice Practice wanted in Raleigh/ Durham area of North Carolina.

We have recently listed a MedSpa in N.C. This established practice has staff MD’s, PA’s and Nurses to assist patients. Some of the procedures performed include; Botox, Dysport, Restylane, Perian, Juvederm, Radiesse, IPL Photoreju Venation, Fractional Laser Resurfacing as well as customized facials. There are too many procedures to mention in this very upscale practice. The qualified buyer will be impressed with the $900,000 gross revenue. This is a new listing and we are in the valuation process.

Medical Practice Listings has a qualified physician buyer that is ready to purchase. If you are considering your Hospice practice options, contact us for a confidential discussion regarding your practice.

Contact Medical Practice Listings today to discuss the practice details.

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: d e t Wan Hospic

in Dalla e Practice

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s, TX

We have a qualified buyer that is looking for an established Hospice practice in the Dallas,Texas area.

To review your Hospice practice options confidentially, contact Medical Practice Listings at 919-848-4202 or e-mail us at medlistings@gmail.com.

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Wanted: Urgent Care Practice Urgent Care Practice wanted in North Carolina.

Qualified physician is seeking to purchase an established Urgent Care within 100 miles of Raleigh, North Carolina.

If you are considering retiring, relocations or closing your practice for personal reasons, contact us for a confidential discussion regarding your Urgent Care. You will receive cash at closing and not be required to carry a note.

Medical Practice Listings Buying and selling made easy

To view our national listings visit www.medicalpracticelistings.com 46| OCTOBER 2011

Call 919-848-4202 or e-mail medlistings@gmail.com www.medicalpracticelistings.com

Classified To place a classified ad, call 919.747.9031

Physicians needed

Practice sales

North Carolina (cont.)

North Carolina

Locum Tenens Primary Care Physicians Needed If you would like the flexibility and exceptional pay associated with locums, we have immediate opportunities in family, urgent care, pediatric, occupational health and county health departments in North Carolina and Virginia. Call us today to discuss your options and see why Physician Solutions has been the premier physician staffing company on the Eastern seaboard. Call 845-0054 or review our corporate capabilities at www.physiciansolutions.com

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

Virginia

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

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

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

MEDICAL PRACTICE LISTINGS Are you looking to buy or sell? We can help you!

View national practice listings by visiting our website or contact us for a confidential discussion regarding your practice options. We are always ready to assist you.

919.848.4202

medlistings@gmail.com | medicalpracticelistings.com in-house practice experts and attorney

Classified To place a classified ad, call 919.747.9031

Practice for sale

Practice for sale

North Carolina (cont.)

South Carolina (cont.)

Internal Medicine Practice located just outside Fayetteville, North Carolina is now being offered. The owning physician is retiring and is willing to continue working 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

your own boss and make the changes you want, when you want. Physician will to stay on for smooth transition.

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, 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 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 48| OCTOBER 2011

Practice wanted North Carolina Pediatric Practice Wanted in Raleigh, North Carolina Medical Practice Listings has a qualified buyer for a Pediatric Practice in Raleigh, Cary or surrounding area. If you are retiring, relocating or considering your options as a pediatric practice owner, contact us and review your options.

Medical Practice Listings is the leading seller of practices in the US. When you list with us, your practice receives exceptional national, regional and local exposure. Contact us today at (919) 848-4202.

Wanted: Classified ads for Med Monthly!

Call our Advertising Department today to find out about all the advertising opportunities available with Med Monthly.

919.747.9031 Visit us online anytime at

medmonthly.com

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.

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

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

List price: $435,000.

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

MD STAFFING AGENCY FOR SALE Great opportunity for anyone who wants to purchase an established business.  One of the oldest Locums companies  Large client list  Dozens of MDs under contract  Executive office setting  Modern computers and equipment  Revenue over a million per year  Owner retiring  List price is over $2 million

Please direct all correspondence to mdstaffingforsale@gmail.com.

Only serious, qualified inquirers.

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.

Listing price is $625,000.

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

MEDMONTHLY.COM |49

Buying or selling? We can help!

Listing Benefits • • • • •

Buying Benefits

Maintain confidentiality Professional representation National and regional marketing Maximize your practice value BizScore Valuation assessment

• Accurate practice pricing • Detailed reports and financials • Largest selection of healthcare facilities • Work one-on-one with an experienced team of qualified professionals

Medical Practice Listings Scan this QR code with your smartphone to learn more

A Philip Driver Company

medicalpracticelistings.com

Exceptional North Carolina Primary Care Practice for Sale Established North Carolina Primary Care practice only 15 minutes from Fayetteville, 30 minutes from Pinehurst, 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

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

For more information call Medical Practice Listing at (919) 848-4202.

To view our other listings, visit medicalpracticelistings.com.

Pediatrics Practice Wanted Pediatrics Practice wanted in N.C. Considering your options regarding your Pediatric Practice? We can help.

Medical Practice Listings has a well qualified buyer for a Pediatric Practice anywhere in central North Carolina.

Contact us today to discuss your options confidentially.

Medical Practice Listings Call 919-848-4202 or e-mail medlistings@gmail.com www.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.

MEDMONTHLY.COM |51

the top BE POSITIVE Compliment the people

around you to include your staff and patients. Make an effort to speak to each person you see and smile at them even if you are busy.

Contributed by Alice Osborn, Bree Sullivan and Ashley Austin

2

FOUNTAIN BY THE DOOR If

you have the space, trickling water from a table fountain can help to keep the flow of energy moving in your practice. A fish tank with lots of colorful fish has been proven to instantly zap stress.

3

ART Use framed prints,

posters or paintings of matching shades to pull the room together in a positive way.

Also consider wall murals of city or natural landscapes.

52 | OCTOBER 2011

Healthy, welltended plants create peace while they cleanse the air. Place hanging plants by the entrance and disguise any sharp corners with a jade, ficus, bamboo or peace lily. When shopping for flowers, try varieties with the brightest blooms such as orchids.

8

OFFER SIMPLE REFRESHMENTS

Water with fresh lemons, tea, peppermints and fruit can greatly enhance your office environment.

7

PLANTS

LIGHTING Natural light

is always best, but if you are in a windowless office, try using table lamps and floor lamps with good wattage. Instead of fluorescent overhead lights, use full spectrum “grow” lights.

5

ENTRANCE

Pay attention to your entrance to see if it’s wide enough so that chairs, tables or couches don’t block passage. Walk through the patient entrance to make sure the doors don’t squeak and they fully open inside the office.

DE-CLUTTER. Take the time to get rid of

old magazines, piles of papers, and stacks of files within view.

9

COLOR Adding splashes

of color to your office space can really impact your surroundings as well as your mood.

Turn to happier, brighter shades of color. Whites combined with gold or silver can relax the spirit as well as pinks, greens and lighter shades of blue. Purples bring about mental awareness and healing.

PHOTOS OF THUMB COURTESY: ISTOCKPHOTOGRAPHY.COM, TEA: RAPHAEL PINTO, PLANT: SANJA GJENERO, OFFICE: CATHY BEL, PAINT: JENNY KENNEDY-OLSEN

If you’re like most, you experience a bit of stress in your practice office.

Stress has become an inseparable part of our lives so here are 9 quick fixes which will improve the Feng Shui of your office so you are relaxed and ready to give great care.

ways to de-stress your practice office

needs.

We’ve got a lot of bright ideas Let us show you how MedMedia9 can market your practice.

Visit us online at medmedia9.com or call 919.747.9031 to learn more.

Scan this QR code with your smartphone to learn more.

IMAGINE THAT!