THE BUSINESS MAGAZINE OF KENTUCKY PHYSICIANS AND HEALTHCARE ADMINISTRATORS MARCH 2012
SPECIAL SECTION
Pain Medicine
A Tradition of Leadership, Innovation, and Research The Pain Treatment Center of the Bluegrass is dedicated to pioneering and providing multi-modality treatments for acute and chronic pain.
ALSO INSIDE
Practical Insights into Hospital Medicine and Pathology Physician Q&A with Dr. Jim Roach on Complementary and Alternative Medicine Coordination of Care: Nutrition
VOLUME 3, NUMBER 3
The Leader in Heart Care. Saint Joseph Heart Institute is at the forefront of cardiovascular services in Kentucky, providing the most comprehensive care in the region. But being the region’s leader in pioneering heart care isn’t new to us. Saint Joseph is the site of the state’s first heart cath in 1954 and central Kentucky’s first open-heart surgery in 1959. Our groundbreaking legacy also includes Lexington’s first heart catheterization lab, first balloon angioplasty, first Chest Pain Emergency Center and first da Vinci® heart surgery in Kentucky. Using the most sophisticated equipment and techniques to diagnose and treat heart disease, our unmatched team of cardiologists, heart surgeons, nurses, and other healthcare professionals provides the latest treatments - from common problems to life-threatening conditions. Yes, we’re proud of our many accomplishments. We want you to know why you can trust your heart to the veteran team and staff at the Saint Joseph Heart Institute who performed 951 open-heart procedures last year alone, as well as more than 18,700 procedures in our Cath and EP labs.
SaintJosephHeartInstitute.org
First Row: Second Row: Third Row:
Simply, your heart matters to us.
Richard Blake, MD; Richard DiNardo, DO; S. Michelle Morton, MD; John Thomas, MD; Donald Wakefield, MD; Naresh Anjur-Kapali, MD; Michael Schaeffer, MD; Steve Lin, MD; Jonathan Waltman, MD. John Sartini, MD; Hamid Mohammad-Zadeh, MD; David Cassidy, MD; Lon Keith, MD; William Jeffrey Schoen, MD; Sameh Lamiy, MD; Suresh Rekhraj, MD; Thomas Goff, MD; Nezar Falluji, MD; Dermot Halpin, MD. Michael Sekela, MD; David O’Reilly, MD; M. Jason Zimmerman, MD; Mark Tussey, MD; Richard Floyd, IV, MD; Robert Salley, MD; Theodore Wright, MD; Kiran Saraff, MD; Mubashir Qazi, MD; David Keedy, MD; Paul Randhawa, MD.
CONTENTS
MARCH 2012 VOLUME 3, NUMBER 3
2 LETTERS
COVER STORY
3 HEADLINES 3 COLON CANCER 4 LEGISLATION 5 FINANCE 6 ACCOUNTING 7 PHYSICIAN Q&A 9 PRACTICAL INSIGHT 9 HOSPITAL MEDICINE 10 PATHOLOGY 12 COORDINATION OF CARE 14 COVER STORY 18 SPECIAL SECTION PAIN MEDICINE 27 NEWS 31 EVENTS
A Tradition of Leadership, Innovation, and Research The Pain Treatment Center of the Bluegrass is dedicated to pioneering and providing multi-modality treatments for acute and chronic pain. BY JENNIFER S. NEWTON PHOTOGRAPHY BY LIZ HAEBERLIN PAGE 14
ON THE COVER:
Dr. Ballard D. Wright, founder of the Pain Treatment Center of the Bluegrass and father of PTC’s chief executive officer Heather C. Wright, ESQ, and company president Dr. Peter D. Wright.
SPECIAL SECTION PAIN MEDICINE
20 Revelations from an EMR Journey
17 A New Plan for Pain
18 Neurostimulator Utilizes Motion-Sensing Technology to Combat Chronic Pain
22 Identifying Qualified Pain Management Centers
24 Ultrasound: A New Tool for Diagnosing and Blocking Pain MARCH 2012 1
DEDICATION Volume 3, Number 3 March 2012
This issue is dedicated to Florence M. Dunn (1923-2012) whose strength and compassion were inspiring to all who had the joy of knowing her. _________________
PUBLISHERS
Gil Dunn gdunn@md-update.com Megan Campbell Smith mcsmith@md-update.com EDITOR IN CHIEF
Jennifer S. Newton jnewton@md-update.com SALES MANAGER
Bias Tilford bias.tilford@md-update.com GENERAL MANAGER
Wesley Shears wshears@md-update.com PHOTOGRAPHERS
Liz Haeberlin
GRAPHIC DESIGNER
James Shambhu art@md-update.com
LETTERS
The Future of Healthcare Media Dear Readers, Over the past several years, M.D. UPDATE has traveled the Commonwealth and spoken with thousands of doctors and healthcare professionals about the trends and technologies that shape the practice of medicine today. I must confess that I always leave these encounters inspired by the great accomplishments of Kentucky’s doctors and a renewal of purpose in our media and its power to affect the wellbeing of us all. Over time, as we gathered your feedback about how we could strengthen our mission at M.D. UPDATE, Kentucky’s doctors told us repeatedly, resoundingly, that the biggest improvement we could make would be to get this magazine in the hands of Kentucky’s patients. I confess. At first I thought I’d just print
up a half million magazines and we’d call it mission accomplished. Fortunately, though, my deliberations led me on a different path. Today, I write to you from the City University of New York (CUNY) where I am a fellow in the Tow-Knight Center for Entrepreneurial Journalism. Here I am developing a new digital media platform designed to connect patients to doctors – INSIDE HEALTH – that will help patients to discover the many innovations in quality care pioneered right here by Kentucky physicians. Watch this space for future announcements as we progress toward our launch. Now - let me encourage any Kentucky doctors who wants to be present when INSIDE HEALTH goes live to contact me right away! I have established a short invitation form which is available at NEWMEDIA.MD-UPDATE.COM. Yours truly, Megan Campbell Smith Cofounder M.D. UPDATE, Creative Director, Mentelle Media
SUBMIT YOUR LETTER TO THE EDITOR TO JENNIFER S. NEWTON AT JNEWTON@MD-UPDATE.COM 2 M.D. UPDATE
CONTRIBUTORS: Sandra Meyerowitz Scott Neal L. Porter Roberts, Jr. Matthew S. Smith Dr. William O. Witt
CONTACT US: ADVERTISING:
Bias Tilford bias.tilford@md-update.com
INTEGRATED PHYSICIAN MARKETING:
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Mentelle Media, LLC
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HEADLINES
Putting Colon Cancer Screening Front and Center BY JENNIFER S. NEWTON
LOUISVILLE March is National Colon Cancer Kentucky Colon Cancer Screening Awareness month, and perhaps no other Program (KCCSP), which was state should be more aware of the effects established in 2008 and has never of the disease than Kentucky, which his- been funded. That amount, while torically has had the highest colon cancer not enough to screen the optiincidence and mortality rates in the country. mum amount of 8000 people a However, trends are slowly shifting, accord- year, would cover screening for ing to Whitney F. Jones, MD, founder of 12,000 Kentuckians over the next the Colon Cancer Prevention Project, a two years and is a concession to Kentucky advocacy group, and co-founder the fiscal situation in Frankfort. of the Kentucky Cancer Foundation, a The bill provides for a blended new 501(c)(3) fundraising organization screening program for the uninannounced by Governor Steve Beshear at sured and underinsured, utilizing a press conference on February 28 and sup- fecal immunohistochemical testported by a rally on the state Capitol steps ing (FIT) for normal risk patients Whitney F. Jones, MD on March 1. “Our rates of cancer death and and colonoscopy for symptomcancer incidence are down 16 percent over atic, high risk, and positive FIT are going to be out raising funds to provide the last decade,” says Jones. Kentucky has patients. The bill includes funding for: actual screenings, not policy, not overhead, dropped to the third highest mortality rate Increased public education and awareness to make sure that evidence-based intervenin the U.S., and the state’s screening rates Implementation of screening programs tions happen, and I would include in that have gone from some of the nation’s worst by health departments and community colonoscopy and FIT, mammograms, pap 10 years ago to somewhere between 23rd health centers smears, HPV vaccinations, and anything and 32nd best, all of which Jones credits to Rewards for successfully navigating we can do to help people who are smoking increased education, awareness, and execu- patients to screenings right now to quit smoking,” says Jones. The Treatment tion of colon cancer screening. Foundation will be governed by a board While progress has been made, Jones Data analysis and process improvement of trustees, including Jones, and will be points to an on-going public health issue: tasked with overseeing fundraising and the Kentucky’s disparate populations, including The allocations are based on data from allocation of those funds. There will also those in low socio-economic and geograph- other states that have colon cancer screening be an advisory committee made up of state ically urban areas, are not experiencing programs in place and on lessons learned cancer expects, public health experts, and improvements to the same degree as the rest from breast and cervical cancer screenings. Kentucky stakeholders. In his budget, for the first time ever, Gov. of the population. In addition, Kentucky’s “The pay scale is the exact same wording Medicaid population, while they have access and numbers as the breast and cervical can- Beshear has pledged up to $1 million over the biennium to match funds raised by the to screening, is not any more likely to be cer screening programs,” says Jones. On a parallel plane, Jones has been Kentucky Cancer Foundation to jumpstart screened than the uninsured population. “There are two clear challenges before us: involved in developing the Kentucky Cancer the screening program. “It’s an amazing effort in good faith by Gov. Beshear to raise aware1. How do we increase We hope to push this argument of prevention and early ness on this agenda,” says Jones, one he hopes the message and availability of screenings to detection way up the list and demonstrate through will challenge the legislature to fully fund HB 55. Implementation of the screening prothose who are uninsured success in fundraising that, not only can we meet the grams will happen at a local level through and underinsured? and need but Kentuckians understand the need and expect health departments and community health 2. Since that population overlaps so much, how their legislator to step up. – Dr. Whitney F. Jones centers, but Jones cautions that even if HB 55 is fully funded, there will not be enough do we increase screening with the Medicaid population?” asks Jones. Foundation. Born out of the understanding money to reach every health department in Stakeholders have turned to the state that even with public funds, there will not the first two years. HB 55 has unanimously passed the legislature for help. This year Rep. Jim be enough money to provide cancer screenGlenn (D-Owensboro) and Rep. Bob ings for all Kentuckians, the Foundation’s Health and Family Committee and propoDeWeese (R-Louisville) co-sponsored goal is to raise private money to match pub- nents are in line to testify before the House House Bill 55 (HB 55) that asks for $8 lic funds to make screenings happen. “The Appropriations Revenue Committee, but a million over the biennium to fund the folks at the Kentucky Cancer Foundation date has not yet been set. ◆ MARCH 2012 3
HEADLINES
Kentucky Legislature Tackles Pain Management Facilities In one of the session’s liveliest moments, Wright addressed FRANKFORT Pain Treatment Center of the concerns about how patients Bluegrass CEO Heather Wright testified pay for pain medicine services. before the Senate Judiciary Committee on Some legislators propose to ban the possible consequences of legislation that cash payments altogether. would further regulate pain medicine clinics To this Wright cautioned, and their providers. “Do not restrict patients’ abilAt issue were Senate Bills 42 and 100, ity to use cash as a form of ultimately revised and consolidated into SB2, payment for services; this which propeses legislation to define and reguunnecessarily restricts and burlate pain management facilities in Kentucky. dens patients from using a legal Wright testified that while some of form of tender. the bill’s provisions would be beneficial to “Cash is a legal tenKentucky doctors and healthcare consumder being paid for legitimate Heather Wright testified before Kentucky Senate ers, others still caused concern. Among medical services; practitioners Judiciary Committee on Feb 24. At issue, Senate Bill those - the ownership of pain manageaccepting cash in exchange for 100 (predecessor to SB2) and the legislature’s efforts to ment facilities and whether that ownership prescriptions are already operaddress pill mills and abuse of controlled substances. should be restricted to licensed physicians. ating outside of the law, and Wright said, “We agree that each practice to prohibit pain management facilities from these unscrupulous practitioshould, at a minimum, employ a physician employing previously encumbered physi- ners can and should be prosecuted as such. medical director who actively participates cians. She stated that this was a large con- This places an unnecessary restriction on or consults in the management process, cern as such a statute could “unjustly restrict legitimate patients, particularly those who but to completely exclude non-physicians the ability to practice for any physician have lost their insurance but require ongowho might have previ- ing treatment. “If there is concern regarding “cash In one of the session’s liveliest moments, Wright ously and successfully been treated for their and carry” medications, then cash payment addressed concerns about how patients pay own substance abuse restrictions would be more appropriately problem, and fails to aimed at the medication point-of-sale, i.e. for pain medicine services. Some legislators recognize the important pharmacies or dispensers of controlled subpropose to ban cash payments altogether. and necessary work and stances.” oversight already done The latest version of this legislation, from having any interest in a management, by the KBML and the Kentucky Physicians SB2, is awaiting debate by the Senate. The operations and/or administrative capacity is Health Foundation. Such restrictions Kentucky House created its version of legislaoverly restrictive.” would seem to run afoul of the ADA as it tion, House Bill 4, which has been sent to the Wright also took issue at the bills attempt pertains to individuals who are in recovery.” Senate Judiciary Committee for debate. ◆ BY MEGAN CAMPBELL SMITH
William O. Witt, MD, DABA-PM 2050 VERSAILLES ROAD LEXINGTON, KY 40504
www.cardinalhill.org | www.docwow.com 859.367.7246 (859-FOR-PAIN) 4 M.D. UPDATE
Dr. William Witt specializes in the non-narcotic treatment of chronic pain in association with the innovative physical rehabilitative services provided by Cardinal Hill Rehabilitation Hospital.
FINANCIAL
Time to Stress Test Your Retirement Plan As I am writing this, most of the big banks have just reported the results of their stress tests conducted by the Federal Reserve. The tests are imposed by the regulators to determine if the banks can meet ongoing obligations during a major credit or liquidity crisis. The most serious scenarios used to test the banks are 13 percent unemployment, a 50 percent drop in the Dow Jones Industrial Average, and a 21 percent decline in residence values. Citigroup, SunTrust, MetLife, and Ally Financial were the four, out of 19, that failed the stress tests during March. But today, I want to address a different kind of stress test and no, it does not involve treadmills. Many of you have at least seen The Number from your financial advisor or heard it advertised. You know The Number I am talking about; those seven or eight digits that traditional financial planning has said you need to have invested as you retire in order to have a withdrawal rate that replaces your current income. Actually, it’s more likely the number that the firm who
age x. An achievable steady pace is preferred over one that gets disrupted during retirement when the earning years are over. In the course of performing financial planning for our clients, our firm BY Scott Neal calculates the client’s maximum sustainable living standard. We use age 100 of the youngest spouse as the final year of the plan, but a good stress test would be to test to age 110 or even 120. Each time the relevant answer is the amount of money available to spend. Living longer means that your maximum sustainable living standard goes down. Of course, we don’t think that intentionally living shorter lives is the answer. Another valid stress test to apply to your best laid plan is for the return home of an adult child or the care of an ageing parent.
You know The Number I am talking about, those seven or eight digits that traditional financial planning has said you need to have invested as you retire in order to have a withdrawal rate that replaces your current income. Actually, it’s more likely the number that the firm who advertises it wants you to have invested with them. advertises it wants you to have invested with them. Some of you have even found relief in knowing that you have more than enough to hit that number. But without a good deal of analysis, The Number is not very reliable. There are simply too many moving parts. Online tools that ask three or four questions and spit out the number are not worth the effort. Even if The Number were completely reliable, most people have not even considered subjecting it to a variety of stress tests once they have it. If there ever was a time to do that, it is now. We believe strongly that saving to achieve The Number is really the wrong target. So is developing a smooth withdrawal rate. A better target is a smooth living standard determined by the amount of money one can safely spend each year, adjusted for inflation until
Naturally it takes more to fund a certain living standard when there are more people in the house—thus the maximum sustainable number goes down with the new addition. However, the analysis must recognize the economies of scale that result from cohabiting with other adults. Two cannot live as cheaply as one, but perhaps as cheaply as 1.6. The beauty of looking at financial planning in this way is to model alternative scenarios. It’s a perfect way to stress test a long range plan. One of the chief risks facing all investors today is the risk of sudden loss of assets, remember 2008. Some analysts have suggested that we are reaching the same valuation levels that existed in 2000 and 2007 at those market peaks. Nobody knows for sure, but everybody seems to agree that there is signifi-
cant risk of loss to investing in financial assets today. In a worst-case scenario our stress tests reveal the real-world impact on lifetime living standard if you lost 10%, 20%, or 30% of your portfolio value. Sort of like increasing the elevation on the treadmill, don’t you think? Better to do it now in a test environment than out on the street. Other retirement plan stress tests that should be performed include: future inflation increasing at an increasing rate, deflation, returns staying low for a much longer period than anticipated, or interest rates remaining negligible for an extended period. All of these represent significant loads on living standard. The final question remains: what do you do with the information once you have it? We always look for ways to adjust the controllable inputs in order to improve living standard. Those include: the standards of increasing income, reducing taxes, saving more, spending less, achieving better returns, or lowing volatility just to name a few. We also look at some rather unconventional ways, like moving to a state that has no income taxes or selling a house and renting in later years. It’s important to think about alternatives and to avoid rationalizations. “Oh, I won’t live that long,” is a common rationalization that we hear often. We are constantly looking for ways to help people to improve their living standard, now and in the future. Stress testing the best laid plan is just common practice for us. One mistake that I see a lot of people make in casting a plan is to build in multiple doses of conservatism with the thought of being 100% certain of reaching their goal. Their thinking is that local optima add up to the global optimum. Rarely is that the case. Layer upon layer of conservatism usually results in over-saving and failing to enjoy life. Isn’t a full life what living standard is all about? Comments and questions are welcome. Scott Neal is the President of D. Scott Neal, Inc., a fee-only advisory firm. Reach him at 1-800344-9098 or scott@dsneal.com. The firm’s website is www.dsneal.com. ◆ MARCH 2012 5
ACCOUNTING
The tax credit for small employer health insurance premiums may help offset this cost for your practice. BY L. PORTER ROBERTS, JR. AND MATTHEW S. SMITH LEXINGTON Buried in the mounds of pages meet all of the following requirements: of healthcare reform legislation is a tax (1) The employer employs no more credit available for certain small employ- than 25 full-time equivalent (FTE) ers providing health insurance coverage employees for the tax year. Owners are for their employees. The credit is spe- not considered employees for this requirecifically targeted to help certain small ment. businesses, including medical practices, (2) The average annual wages of the reduce their costs to provide health insur- employees cannot exceed $50,000 for the ance coverage to employees. Several medi- tax year. Again, owner wages are not concal practices we work with have qualified sidered in this calculation. for this tax credit, and (3) The we have used it to save employer has to them thousands of dolcontribute at least lars. Even though the calculation is time consuming, we have found significant tax savings that more than offset the costs and effort required by practices to calculate the credit. In our experience, this credit is most beneficial in a practice where all the physicians are owners and the practice has two or fewer midlevel providers. Because owners are excluded from the calculation, L. Porter Roberts, Jr., CPA (ABOVE) their wages are not taken and Matthew S. Smith, CPA, CFE into account for this credit. However, one or two fulltime physicians, or even several mid-level 50% of the premiproviders that are not owners, can cause ums for the employees’ health insurance covthe average wages of the practice to rise erage on a uniform basis. above the $50,000 average wage eligibility threshold, and thus phase out any avail- The Credit in Action A medical practice (a PLLC taxed as a able credit. Through the end of 2013, the amount partnership) has two physician-owners of the credit is generally 35% of the (who are excluded from the calculation) employer’s non-elective contributions and 10 full-time staff, including front toward the employees’ health insurance office and clinical. Total 2011 wages for premiums. The amount of the credit is the staff are $350,000, giving average subject to a phase-out. An eligible small wages of $35,000. The practice pays 75% employer qualifying for the credit has to of the single-coverage premium costs and 6 M.D. UPDATE
requires the staff to pay the other 25% and any additional coverage (children, spouse, or family). The amount paid by the practice for premiums totals $40,000 (excluding coverage for owners). This amount is multiplied by 35% to determine the potential credit of $14,000. Because the practice has 10 or fewer FTE employees, it is not subject to the FTE phase-out. Since the average wages exceeded $25,000, there is a partial phaseout of the credit. After factoring in the average wage phase-out, the credit works out to be $8,400. Each of the physician-owners will have a $4,200 tax credit that will reduce their federal individual income tax, which may allow them to each keep an additional $4,200 in their pockets. As you can see, this credit can really make a difference for certain practices. If you are a small practice owner and are paying at least 50% of the single coverage premium cost for your employees, you should be discussing the applicability of this tax credit to your practice with your tax preparer. Otherwise, you could be paying more taxes than required. Please note that the IRS will not notify you of the omission of this credit on your tax return and the related tax refund that may be due to you. L. Porter Roberts, Jr., CPA, and Matthew S. Smith, CPA, CFE, are with the Medical Services Group of Barr, Anderson & Roberts, PSC, in Lexington, KY. If you would like more information, they can be reached via email at lproberts@barcpa.com and msmith@barcpa. com and via telephone at (859) 268-1040. ◆
PHOTOS COURTESY OF BARR, ANDERSON & ROBERTS, PSC
Frustrated With the Rising Cost of Health Insurance Coverage for Your Staff?
PHYSICIAN Q&A
CAM: It’s About Patients
With about 40% of US consumers seeking complementary and alternative medicine, doctors can forget about the old “Snake Oil” bit and consider how CAM can broaden their therapeutic repertoire. BY MEGAN C. SMITH LEXINGTON A few weeks ago, I was in Lexington’s Good Foods Coop selecting some must-have organic cosmeceuticals to take back to New York with me. I’m working up there on a new media project to help patients gain access to the physician insights we discover each month in this magazine. We’ll talk more about it in coming issues, but suffice it to say that patients struggle to get the most out of their healthcare experiences. The interesting thing is patients are eager to do so. Take the rising use of complementary and alternative medicine (CAM) for example. If you believe everything you read, you’d think the rising use of CAM correlates with patient dissatisfaction in organized medicine. This is untrue. Research shows that CAM users are no less satisfied with traditional medicine than nonusers. 1 What CAM users certainly are – especially if we encounter them at the Good Foods Coop – is passionately invested in their health outcomes. In this small aisle of organic beauty
products I share with the shoppers of vitamin supplements beside me, I overhear a woman say to her companion, “That’s the one Dr. Jim told me to get when we were in Midway.” She then reaches across her cart to pick up a small bottle of vitamins, turning it deliberately for a few moments. I smile a knowing smile. She’s referring to Jim Roach, MD, founder of the Midway Center for Integrative Medicine. Not only have I enjoyed the occasion to interview Roach for this magazine, I have also attended one of the Healing Young Brains symposia that the Midway Foundation puts on each year. Besides, it seems like every savvy customer around here speaks his name in the vitamin aisle of this popular store. That’s when It
This month we talk with Dr. Jim Roach, founder of the Midway Center for Integrative Medicine, to gain some context on the integration of CAM into medical practice. IN THE DEVELOPED WORLD, WE HAVE THIS PHENOMENON WHERE THE ENVIRONMENTAL TOXINS ARE UP, NUTRITIONAL HEALTH IS DOWN, AND METABOLIC DISEASES ARE UP. WHAT IS HAPPENING TO US?
JR: One big thing that has happened is that our nutrition is diminishing substantially from when I grew up. When I grew up, on the supper plate there were always vegetables and whole foods. Now we eat mostly processed meals. Out of the 21 meals we eat a week, on average 17 of those meals we are eating
out of the house. Those foods are processed and they are low nutrient foods for the most part. It is very difficult to get healthy whole foods that are preserved in a way that can be served at a restaurant. Families are also not sitting down and eating together. Eating on the run you do not digest as effectively; that’s why we encourage our patients to chew their food 30 to 100 times to get it into the liquid form before they swallow it. Also, each of us has hundreds of chemicals in our bloodstream that didn’t exist sixty years ago.
occurs to me that Roach’s handle on the business of patient empowerment and, thus, customer satisfaction is worthy of understanding regardless of a provider’s personal preference on the use of CAM. The fact is CAM use is growing. The most recent measures were in the 2007 National Health Interview Survey (NHIS), which showed 38% of adult healthcare consumers chose CAM therapies either in conjunction or as an alternative to allopathic therapies. The reasons are highly varied, from cultural to economic and beyond. But at $38B in out-ofpocket spending, there is no doubting the consumers’ desire to spend on products and services that meet their goals for integrative health. ◆
raised: do these new toxins literally change some of our DNA? There is an epidemic of brain disorders caused by this. It seems to me that one in Dr. Jim Roach of the Midway Center for Integrative Medicine three children have significant brain These chemicals are primarily issues. In South Korea, stored in brain tissue, and they are now finding that one out we don’t know how they are of 35 children suffer from autism. affecting us. Children are not DESCRIBE FROM YOUR nourished as well as they used to be - 70% of us are magnesium PERSPECTIVE THE CONFLICT BETWEEN TRADITIONAL AND deficient, 50% are zinc deficient. ACADEMIC MEDICINE? Those are very key minerals to our health involving relaxation, JR: It is a very complex and hormone modulation, and disease involved question because there prevention. are so many factors that come We also have these new into play. toxins. The question is being First of all there are economic MARCH 2012 7
PHYSICIAN Q&A
pressures on physicians these days. There was a time when physicians had a reasonable amount of time to interview patients, to really get a deep understanding of what was happening before they prescribed a therapy. Economically, if physicians try to go that approach these days, their income suffers substantially. So the way that the medical system is set up now is that physicians have to see patients in fifteen minutes to maintain the same income level. Physicians are unable to get the information they need to form optimal recommendations. A lot of this information that we find so vital in our practice is nutrition information - what are these patients eating and do you have time to teach them about what they need to be eating. I am continuously gaining a new appreciation about how important, really vital, nutrition is to health. Couple with that what I’ll call spirituality, as your ability to deal with stress is a major factor as well. If you don’t get those two aspects right, regardless of what the acute illness may be, long term those patients are going to suffer. More and more, commercial interests are taking a larger role, and that can have adverse effects. For example, if you have a professor at a medical school, they have to do research to maintain their position as a professor. So they are searching for research dollars and they go to pharmaceutical companies. If you do a study for those companies and your study is not favorable, will a pharmaceutical company offer you research dollars the next time? And if they don’t, does that jeopardize your university job? Does that increase the risk of bias towards a positive result? With the emphasis in medical schools on the growing number of pharmaceuticals, there is less time and likely less emphasis on nutrition. This is despite the fact that nutrition may be more important than ever. Pharmaceuticals should be the last line of defense. Because physicians don’t have time to adequately address health concerns, it is very easy for them to initiate with a pharmaceutical approach as opposed to a lifestyle approach. This becomes a very expensive approach 8 M.D. UPDATE
Research shows that CAM users are no less satisfied with traditional medicine than nonusers. What CAM users certainly are is passionately invested in their health outcomes. relative to a lifestyle approach. Then, there is a centralization of medicine. As doctors in rural Kentucky and other places are financially having a difficult time surviving, these doctors will affiliate with hospitals for financial reasons, and the bigger the organization, typically the less sensitivity to the needs of the patient. The focus increasingly at each higher level is more on the economic impact of treatment interventions as opposed to what might truly be best for the patients. I’m very concerned about the centralization that is occurring and the ultimate impact that will have on health. WHAT ROLE DOES THE FUNCTIONAL MEDICINE ASSESSMENT PLAY IN MEDICINE?
JR: To me, that is the biggest take home message for practitioners. The message is that there are more rocks we can look under. And that is really good news. Currently, physicians do basic testing, but they can learn additional tests to be done that are covered by insurance that would give information that would help more fully explain what is going on. So, the example I like to use is depression. I don’t consider depression to be a diagnosis; I consider it a symptom. It could be a symptom of omega 3 deficiency, vitamin B12 polymorphism, vitamin D deficiency, testosterone deficiency, mercury toxicity, fast food, or stress. The good news is that if we look more comprehensively we can find root causes of these issues and find cures. That is a word that is not often used much in medicine these days.
We use a lot of treatments for symptoms, but when I deal with patients who have chronic fatigue or fibromyalgia, if you try to treat each of their 25-30 symptoms with a medication, then they become toxic. You need to be doing those underlying studies that allow you to connect the dots and find true answers and long term cures.
WHAT SHOULD PHYSICIANS KNOW ABOUT NATUROPATHY?
JR: Physicians understand that there is a danger in naturopathy, in that naturopaths, because of a wide variation in training and clinical skills, can misdiagnose or fail to appreciate the acute gravity of a health problem. That is a very rational concern. Naturopaths, on the other hand, have the ability to teach us something. They figured out ways to help patients without having to write a prescription. A highly skilled naturopathy is what physicians should be doing before they ever write their first prescription – emphasis on nutrition, connection with the patient, some cutting-edge tests, and reasonable nonpharmaceutical interventions. The future is incorporating the very relevant information the naturopaths have learned into a more open, integrative medical approach. Those who categorically say that naturopaths have no beneficial role in health will not learn anything from their success. You have to be open and know that everyone has the ability to teach us something from their life and their life’s work. I think that welding the two concepts together is important. Functional medicine and integrative holistic medicine are doing exactly that - learning those lessons and achieving superior outcomes in chronic disorders. 1 ENDNOTE
Nahin RL, Barnes PM, Stussman BJ, et al. Costs of Complementary and Alternative Medicine (CAM) and Frequency of Visits to CAM Practitioners: United States, 2007. ◆
PRACTICAL INSIGHT HOSPITAL MEDICINE
Filling in the Quality Care Gap
Hospitalist Dr. Hunter Housman sees himself as a steward of quality and patient safety for an increasingly efficient yet fragmented industry. BY MEGAN C. SMITH Hospitalists enjoy a unique distinction. They are members of the fastest growing medical specialty ever. Hospital medicine has been growing hand over fist since Medicare first misaligned hospital and provider incentives with the introduction of DRGs back in the 80s. Payment based on diagnosis shifted the demand for primary care away from rounds and into outpatient care. After DRGs, when patients got really sick, primary care wasn’t around like they used to be, and the coordination of inpatient care suffered under a fragmented system. Hospital medicine emerged to fill the primary care gap between inpatient and outpatient settings. Today, hospitals large and small are machines of efficiency when it comes to managing acute care demand. However, the supply of qualified hospitalists to manage those cases is limited, and in this competitive marketplace, recruiting hospitalists is especially difficult for the small or rural community hospital. Georgetown Community Hospital, managed by LifePoint, is part of the trend of smaller hospitals that contract with hospitalists to perform rounds and manage acute care services. They employ MESA, a Lexington-based emergency and hospi-
GEORGETOWN
tal medicine group practice, to staff both departments. There, MESA hospitalist Hunter Housman, MD serves multiple roles within patient care and hospital management. Hospitalists like Housman are emerging as the new leaders of inpatient care for the way their responsibilities to round on patients integrate with the hospital’s need for standardized quality and patient safety. Their emergence in hospital leadership is reflective of the fact that while inpatient care has become more effective, it has also become more complicated. “As hospitalists, we make sure that things go smoothly and that patients recover sooner and better. With all of the rules inside the hospital limiting their interactions,” says Housman, “some primary care providers feel like they can’t even go into the hospital.” That’s how he comes to see hospitalists as the stewards of more highly regulated medicine. “We own quality and patient safety. We own accountability.” Housman serves on multiple quality and safety committees at Georgetown and nearby Bourbon Community Hospital. At Bourbon, he is currently vice chief of staff. He credits MESA for allowing him to advance his career in his areas of interest. “What drew me to MESA,” he says, “is that as a growing company, I have the chance to develop as a leader and a physician. I see dif-
MESA hospitalist Dr. Hunter Housman makes rounds at Georgetown Community Hospital. He serves on many quality and patient safety committees there, too.
ferent levels of care and different severities of diagnoses, and I am also involved in the quality and safety processes of the hospital.” This is a trend nationwide and one that Housman hopes continues. “In the next several years, I would like to integrate more process into what I do. I am interested in finding the processes that hospitalists are developing across the country that improve patient care. I think process, not just that someone is a good doctor, is why things are improving. That’s what I get excited about.” ◆
MARCH 2012 9
PRACTICAL INSIGHT PATHOLOGY
The Silent Partner
Floyd Memorial Pathologists Are Key to Accurate Breast Cancer Diagnosis and Treatment
BY JENNIFER S. NEWTON NEW ALBANY, IN In breast cancer treatment there is one provider who is integral in the decision-making process yet rarely communicates directly with the patient – the pathologist. “The role of pathologist in breast cancer is about as critical as they come,” says Walter Jones, MD, pathologist with Floyd Memorial Hospital and Health Services. “Obviously the correct diagnosis must be made, and the pathologist is the individual who determines if this is a malignant tumor or a benign process.” Although pathologists might be the silent partner as far as patients are concerned, they work in tandem with a team of radiologists, surgeons, and oncologists
to ensure an accurate diagnosis is made so that individualized treatment can be instituted. A breast cancer case usually originates with an abnormal mammogram or a palpable lump discovered by the patient or the patient’s physician. If the mammogram is abnormal, patients typically undergo a stereotactic needle core biopsy or ultrasound guided needle core biopsy. It is those cores, tiny cylinders on a slide that can be magnified up to 400 times under the microscope, that are the first tissue a pathologist will examine. The radiologists usually perform these biopsies, and the tissue is then sent to the pathology lab for diagnosis. The pathologist is tasked with making a diagnosis and Dr. David Stapp, pathologist at Floyd Memorial, says in gross evaluation of breast cancer tissue, the fatty breast tissue is very soft in contrast to cancer, which is hard and typically a different color with an irregular outline.
10 M.D. UPDATE
ensuring that diagnosis is consistent with the lesion described in the mammogram.
Evaluating the Tumor to Unlock Optimal Treatment
If a malignancy is found, patients are referred to a surgeon for a lumpectomy or mastectomy and sentinel lymph node biopsy. The pathologist will evaluate the excised breast tissue and document the size, grade, margins, lymph node status, and hormone receptor status of the tumor. These findings will determine the stage and treatment algorithm for that patient. “The size of tumor is critical, since most malignancies less than a centimeter do not generally receive chemotherapy.” says Jones. Size is evaluated microscopically and grossly and measured in three dimensions whenever possible. The grade is determined using a Nottingham score. For instance, whether or not a ductal cancer, the most common form of breast cancer, is forming ducts, and to what degree, determines its score. “The higher the score, the higher grade of cancer,” says David Stapp, MD, also a pathologist at Floyd Memorial. “We look for mitoses to see how active it is, to see how rapidly cells are dividing, and then look for nuclear pleomorphism to see if cells are all uniform or if they are haphazard. More aggressive tumors receive a higher grade and may need more aggressive therapy.” Margins are measured by applying ink to the exterior of the specimen and fixing it with a mild acidic solution. When the pathologist takes sections from the specimen and examines them under the microscope, they try to establish the distance between the cancerous tissue and its closest inked margin of resection. This ensures complete local excision of the tumor. Hormonal status is another indicator pathologists measure, which dictates subsequent treatment. “We perform estrogen and progesterone receptors (ER and PR)
institutions. An indepth reporting system is used to communicate their findings to other physicians. “We complete a synoptic report where we list all things According to Dr. Walter Jones, pathologists the person who is takat Floyd Memorial have been reporting breast ing care of the patient cancer findings in a similar manner for 15 Margins are measured needs to know in order years. He thinks the addition of a bi-weekly by applying ink to to make an accurate breast cancer tumor board and a nurse the exterior of the navigator will improve patient care. stage,” says Stapp. This specimen and fixing it report includes all the with acid. on all tumors and HER2 status. The parameters necessary results of those will determine whether the frozen results. Jones estimates that the for a treatment plan to be made by the patients are treated with tamoxifen or other sentinel node frozen section is probably 95 oncologist. The pathologists are quick to anti-estrogen drugs or Herceptin,” says percent accurate. note that in addition to filing a report, Jones. Currently all three tests are sent Immunohistochemical stains may also they are always available to discuss cases by out to another laboratory, but soon Floyd be used with lesions that are difficult to phone with their colleagues. Memorial will be bringing ER and PR test- definitively diagnose as benign or maliging in-house. nant. “In order to be called an invasive Pursuing National During surgical excision, surgeons per- cancer, it has to have demonstrated invasion Accreditation form a sentinel lymph node biopsy to … It should also look very atypical,” says The Floyd Memorial Cancer Center of determine whether lymphatic invasion is Stapp. “Sometimes we get something that Indiana is pursuing accreditation by the present. Utilizing a radioactive tracer and looks a little atypical but still appears con- American College of Surgeons’ National blue dye injected as close to the can- fined to the lobule or duct.” In those cases, Accreditation Program for Breast Centers. cer as possible, they demonstrate “which they can use immunohistochemical stains “In terms of the way we treat the patient, lymph node drains the lesion initially,” to detect whether invasion has occurred or it’s the same standard of care,” says Jones Stapp explains. That sentinel node will be if the cells are still confined. Occasionally of working towards the advanced designaexamined with an immediate frozen section the pathologists will encounter a tough case tion. The main differences, however, are the by a pathologist, while the patient is still that they cannot make a definitive diagnosis addition of bi-weekly breast cancer tumor under anesthesia. If the node is positive, on, so they might send the tissue out to a boards and a nurse navigator, who focuses surgeons typically do a regional lymph node national expert at a reference lab for another solely on breast cancer cases. The breast dissection, removing the entire axillary lym- opinion. “We don’t try to pretend we know cancer tumor board includes pathologists, phatic contents. “Even if it’s negative, we everything. It’s always in the best interest of radiologists, surgeons, medical oncologists, radiation oncologists, and more. The advantage is that the doctors can collaborate When we get an excisional tumor specimen, we ink it, take our sections and on cases from a multi-disciplinary perspecevaluate it under the microscope. From that observation, we’ll be able to tell tive and ensure they have the most upwhether the margins are clear; what type of cancer it is; whether it’s well to-date, accurate information available to differentiated, moderately differentiated, or poorly differentiated; and whether establish the optimal treatment plan for the lymphatic invasion is present and it has a greater potential to metastasize. individual patient. The nurse navigator’s job is to guide each breast cancer patient through the will perform immunohistochemical stains the patient,” says Stapp. to see if there are any cancer cells circulatDespite little-to-no direct contact with sequential process of diagnostic radiology, ing and do a complete exam in this way. patients, pathologists follow them through surgery, and oncology. “To have someone [The patient] may even have small clusters the continuum of care utilizing a comput- to shepherd you through the process is realof cells that are only picked up that way,” er system that inventories each specimen. ly an advantage. It’s a wonderful adjunct says Jones. Subsequently, they examine Stapp also credits their excellent staff, who and value-added service we now provide the them with permanent sections to confirm tracks down patient information from other patient,” says Jones. ◆ MARCH 2012 11
COORDINATION OF CARE NUTRITION
Better Food Choices May Be the Ticket to Reduce Chronic Pain BY SANDRA MEYEROWITZ, MPH, RD, LD, CLT
Nutrition is not the first treatment option that comes to mind for most people battling chronic pain or for their healthcare providers, but maybe it should be. The opportunity to change the chaos within may come from choosing the right foods for the body. Physicians and other healthcare providers are often at a loss for options to help their patients with fibromyalgia, migraines, IBS, and other painful health conditions. Medications, surgeries, and other treatments don’t work in many cases, and the patient is left to their own devices to find some relief. Sometimes it can seem like every avenue has been explored, but what about the diet? Eating reactive foods that stimuNutritionist Sandra Meyerowitz late the immune system to produce mediators that create pain and inflammation throughout the body freely throughout the body, symptoms can can be limited and controlled. We are bom- arise anywhere. barded by food at every turn, and unless we Today we have the scientific ability to know what works for our particular body identify foods and food chemicals in our and we stick to safe items, we could be fuel- food supply that are reactive for individuing an internal storm. Just because a food is als and cause them harm. The patented touted as healthy for the general public does Mediator Release Test (MRT) by Signet not mean it is safe for everyone. Diagnostic Laboratories was created for Unlike food allergy symptoms that this purpose. With this tool, a patient with
LOUISVILLE
Today we have the scientific ability to identify foods and food chemicals in our food supply that are reactive for individuals and cause them harm. occur immediately, food sensitivities have a delayed response. The immune system perceives the ingestion of certain foods or chemicals as foreign and proceeds to unleash a flood of mediators from white blood cells. Humoral and cellular mechanisms can cause this process to happen. The mediators (cytokines, prostaglandins, histamine, etc.) cause tissue inflammation, smooth muscle contraction, mucus secretion, and pain. And because blood flows 12 M.D. UPDATE
chronic pain and inflammation will have a personalized road map of safe foods and chemicals to follow. This eliminates the need for guessing, which is the usual and time-consuming method followed when foods are suspected of causing symptoms. Once trigger foods are identified, it is possible to custom make a diet that is truly tailor fit to an individual’s needs based on their personal immune system. This diet treatment program is called LEAP (Lifestyle
Eating and Performance). At Nutrition Works in Louisville, this is the program I use to help clients get long lasting relief when nothing else has worked. I am a Certified LEAP Therapist who is specially trained and will create a custom elimination diet and carefully develop meal ideas with the patient taking into consideration any other health conditions they are facing. This addition of Medical Nutrition Therapy into the patient’s care plan is well integrated into the whole healthcare team approach. With MRT results as a guide and following the LEAP diet plan, thousands of people have been able to reduce their symptoms to the point where they no longer rely on drugs for relief. They can go back to enjoying their lives as they did before being overwhelmed with pain. Symptoms are often cut in half after the initial seven to 10 day period on the elimination diet. If diet modification were one of the first choices for treatment for chronic pain patients instead of a last resort, then fewer people would continue to suffer needlessly. The LEAP program helps physicians and patients get the results they are looking for so everyone wins. It is an effective treatment option that can be appropriately targeted to patients with hard to resolve chronic pain issues. Sandra Meyerowitz, MPH, RD, LD, CLT, is a nutritionist with Nutrition Works. You can reach her at sandra@smartnutritionworks.com or by calling (502) 339-9202. For more information about the MRT blood test and the LEAP program, visit www.nowleap.com or www. smartnutritionworks.com. ◆
INTERVENTIONAL PAIN ASSOCIATES We treat: · Back and Neck Pain · Headaches · Abdominal Pain · Leg Pain Services provided: · Opioid Management and Consultation · Nerve Blocks and Trigger Points · Pain pumps and Stimulators · Psychological Counseling We are currently accepting new patients. Please call (859) 323-7246 to set up an appointment. Good Samaritan Hospital 1st Floor | 310 South Limestone, Suite 100A | Lexington, KY 40508 | www.WildcatAnesthesia.com
Healing Growth
winner of the 2012 landscaper of the year award MARCH 2012 13
COVER STORY
A Tradition of Leadership, Innovation, and Research
The Pain Treatment Center of the Bluegrass is dedicated to pioneering and providing multi-modality treatments for acute and chronic pain. BY JENNIFER S. NEWTON PHOTOGRAPHY BY LIZ HAEBERLIN
Dr. Ballard D. Wright (seated)is the founder of the Pain Treatment Center of the Bluegrass and father of PTC’s chief executive officer Heather C. Wright, ESQ, and company president Dr. Peter D. Wright.
14 M.D. UPDATE
LEXINGTON – Current studies estimate that 26 percent of Americans suffer from chronic pain, a debilitating disease that can lead to a lifetime of discomfort and a myriad of treatments. At The Pain Treatment Center of the Bluegrass (PTC), the longevity of chronic pain is matched by the lifelong commitment of Dr. Ballard Wright, founder of PTC, established in 1991 and one of the oldest private pain management practices in Kentucky. In addition to the physician practice, Ballard Wright, MD, PSC, the Center has a second division, an ambulatory surgery center called The Stone Road Surgery Center. PTC’s professional staff includes 10 physicians, a psychologist, a physical therapist and physical therapy assistant, registered dietician, and four mid-level providers: three PA-Cs and one ARNP. While both divisions are headquartered in Lexington, the center’s geographic reach extends to satellite clinics in Mount Sterling, Hazard, and Albany, KY. A pioneer in the field of pain management in the Bluegrass, Dr. Ballard Wright, now in his 70s, plays a more emeritus role, seeing clinic patients one or two days a week when he is in town and providing medical direction and guidance in business management. The Ballard Wright tradition of pain management follows a familial path, as his children are also in the practice: Peter Wright, MD, is the president and medical director of Ballard Wright, MD, PSC, the physician practice division of the center, and Ms. Heather Wright, Esq. is its CEO. As president and medical director of the physician practice, Dr. Peter Wright oversees the medical decision making of the clinical staff. According to Dr. Peter Wright, “Our mission is essentially to have a multidisciplinary approach, to tailor the treatment to the individual and their particular pain problem using a multidisciplinary model.” Dr. Peter Wright also works in conjunction with Ms. Wright to run the Center. Ms. Wright’s role is to oversee the administrative staff and functions. Ms. Wright also
shoulders the aspect of social responsibility by taking a leadership role in educating the public regarding pain management, working with legislators, and advocating for pain management doctors and patients. [See “Headlines” this issue, p. 4.]
A Multidisciplinary Model
There is not a cookie cutter approach to treating acute or chronic pain . No two patients experience pain in the same way. By approaching pain management from a comprehensive perspective, using a variety of disciplines, PTC ensures that every patient has access to the most effective treatments for their individual condition. “We use essentially the modalities that are traditionally considered part of pain management but that are often not necessarily associated under a single roof or facility,” says Dr. Peter Wright. Those modalities include: “behavioral medicine; physical therapy and rehabilitation; interventional procedures such as epidurals, facet blocks, or even more aggressive therapy such as spinal cord stimulation or intrathecal pump placement; and of course, medication management, which can be as simple as anti-inflammatory medications or other adjuvant pain medications, but also up to and including chronic opioid therapy for chronic intractable pain.” The PTC physician also use a variety of diagnostic tools housed at the Center, which include CT, x-ray, EMG/NCV and EKG, to examine and treat the pain patient. Moreover, the Center has recently added an ultrasound and laboratory to aid in the treatment . The ultrasound gives physicians the ability to perform same-day injections in the office for some cases that previously required localization through fluoroscopy or x-ray in the operating room. The new lab is a product of the center’s dedication to high ethical standards and compliance monitoring. The lab provides the access to rapid (same day) and accurate screening results, ultimately shortening the cycle of treatment and increasing compliance. PTC is considering adding an MRI in 2012.
Behavioral Medicine Focuses on Well-Being and Risk Assessment
According to Ken Kirsh, PhD, clinical psychologist and director of Behavioral
Medicine at PTC, the department’s goal is to assess every patient that comes through the center. The reasoning is twofold: 1) for risk assessment to protect physicians, patients, and the community and 2) to evaluate for psychological distress. “Risk assessment is the cornerstone of pain management,” says Dr. Kirsh. “We never want to inadvertently give medications to someone who is using them outside of pain management.” Not only does
developed, and one of the challenges for Kentucky physicians is working with other states that may not have efficient systems in place to get good quality information. At PTC, they put other safeguards into place to combat drug diversion, including random urine drug monitoring, pill and patch counts, opioid risk tools, and non-verbal behavior inventories. In terms of psychological distress, the incidence rate of depression in the U.S. is
LEFT
Ken Kirsh, PhD, clinical psychologist and director of Behavioral Medicine at PTC. BELOW
John Peppin, DO, is an internist and director of the Clinical Research Division at PTC.
the center participate in risk assessment, but it is a national leader in the area through research and development of new tools. PTC was a beta site for the Kentucky All Schedule Prescription Electronic Reporting System (KASPER), which Dr. Peter Wright asserts is the best program in the country. “It’s been one of our best tools in following patients and ensuring patient compliance and also attempting to reduce and or eradicate the doctor shopping, which can occur with patients that are interested in drug diversion,” says Dr. Peter Wright. Each patient who comes into the center has an initial KASPER evaluation performed. Follow up KASPERS are performed depending on the patient’s circumstances. NASPER, a national version of the program, has never been fully
between one and six percent of the population and more predominant among women. “When you put a chronic pain population in place, instead of that one to six percent, what you find is pain is the great equalizer. Men and women have equal rates of depression … and most studies show somewhere around a 25 to 45 percent rate of clinical depression, not including anxiety MARCH 2012 15
COVER STORY
or other issues, in chronic pain patients,” says Kirsch. The Center provides acrossthe-board therapy services, and part of Dr. Kirsh’s role is also to recommend medications, as many are indicated for both pain and depression.
Nutrition Counseling Enhances Comprehensive Treatment
The concept is simple: poor diet is linked to weight gain and an increased incidence of diabetes, both of which lead to increased pain symptoms. Dr. Kirsh first began thinking about nutrition from a psychology perspective, considering how diet impacts the way medicines are absorbed, the effects of weight gain, and the correlations between eating habits and depression, anxiety, and addiction risk. Now about a year and a half old, the nutrition counseling program at PTC focuses mainly on diabetes patients because it is one of the few areas of nutrition services covered by Medicare, Medicaid, and private insurers and because diabetes is one of the most prominent co-morbidity issues
Jennifer A. Kouns, MS, RD, LD
of weight gain in Kentucky. Dr. Kirsh estimates the national incidence of diabetes in the general population is seven to eight percent, and of those, 30 to 40 percent will end up with diabetic neuropathy. At PTC that percentage is much higher, 60 to 70 percent, due to the advanced disease state of 16 M.D. UPDATE
their population. Jennifer A. Kouns, MS, RD, LD, is PTC’s resident nutritionist. In addition to diabetes patients, she sees a small number of self-pay weight management patients. Ms. Kouns formulates customized weight loss plans based on in-depth background and data analysis. “What we try to do here at the Pain Treatment Center is to get those patients in here and get them started on a healthier lifestyle, a healthier diet, and hopefully prevent those complications that can happen later on, which in turn can cause more pain from nerve damage or excess pressure on the joints,” says Ms. Kouns.
Research that Rivals an Academic Center
Clinical research and achieving an academic-like environment are critical components of PTC’s comprehensive care approach. “We see it as an important part of our duty as one of the leaders and largest pain centers in the region, that we should be involved in furthering the field,” says Dr. Peter Wright. John Peppin, DO, is an internist and director of the Clinical Research Division at PTC. His role includes research, publishing papers, presenting posters, and giving lectures, as well as seeing patients. Dr. Peppin recently presented three posters at an American Academy of Pain Medicine meeting in Palm Springs: one on nutrition, another on the Zung depression scale in chronic pain patients, and one on a consensus panel making recommendations on who, what, and how often to use urine drug screening, which Dr. Peppin concedes is weak evidence but is valuable because of the lack of literature on the topic. The nutrition study surveyed the eating habits of approximately 200 patients and
evaluated a six-minute walk test applied upon initial intake and after four months in the clinic. Results showed a diet worse than the average American. Additionally, “We found that there was a statistically significant increase in their ability to walk, but of great interest is that they didn’t even reach the low level of normal for 60 year olds,” says Dr. Peppin. Some recent research projects Dr. Kirsh has developed include co-writing a paper that identified and ranked more than 25 risk assessment tools across the country, launching a non-verbal behavior interview that combines psychology and law enforcement techniques to interpret body language, and co-creating the Chemical Coping Index, a middle-of-theroad scale addressing drug misuse that does not qualify as addiction.
Challenges and Advancements
Unfortunately, addiction and drug diversion are part of pain management, especially in Kentucky, but advancements are being made. “There has certainly been improvement in the variety of medications available, in particular in the area of long-acting opioid preparations, and an attempt to make those more resistant to abuse,” says Dr. Peter Wright. He cites a reformulated OxyContin pill that is more difficult to break down, a Butrans® patch that has low addictive potential and higher resistance to tampering, and a new opioid called Nucynta®, which is “less active at the opioid center and helps control pain via avenues other than just acting on opioids receptors in the spine,” says Dr. Peter Wright. Although new drugs and refinements can offer increased benefits, they also tend to pose obstacles regarding cost and insurance coverage that affect not only Medicare and Medicaid patients, but also those with private insurance. The landscape is slowly changing, as payers are beginning to accept preventive care models, such as nutrition services, that are more cost-effective in the long run. In the meantime, PTC continues to look for new ways to advance the knowledge, education, and treatment of pain medicine. ◆
SPECIAL SECTION PAIN MEDICINE
A New Plan for Pain
Physiatrist joins orthopedic group to manage, treat nonsurgical neuromusculoskeletal pain.
are any questions about the diagnostic testing. Continuity - that’s my niche.”
BY MEGAN CAMPBELL SMITH LEXINGTON When patients present with neuromusculoskeletal pain, determining the cause or source of the pain is an essential first step before determining which provider should treat it. Consider the classic example of the automobile accident. After a car wreck, the patient goes to the ER, gets a muscle relaxant, and makes an appointment with their primary care doctor. Primary care refers the patient to a neurosurgeon or orthopedic surgeon. A few short moments into the examination, the surgeon realizes the patient’s condition is nonsurgical, so the patient is prescribed physical therapy and sent back to primary care. Following therapy, the pain persists, but now the patient feels frustrated having been bounced back and forth between providers without ever really addressing the source of the pain. A better model for the diagnosis and treatment of nonsurgical neuromusculoskeletal pain exists in outpatient physiatry, where doctors of physical medicine and rehabilitation (PMR) determine why patients experience these pervasive pain syndromes. When the cause is determined to be nonsurgical, the physiatrist then manages the treatment plan himself. When community need demands it, the number of cases presenting with nonsurgical neuromusculoskeletal pain can be quite high. The vast majority of patients who present to an orthopedic or neurosurgical specialist with pain will ultimately not require surgery, depending of course on the progressive or chronic nature of the underlying disease. An innovative way to address this high volume of nonsurgical cases, and thus freeing surgeons to do what they do best, is to combine outpatient physiatry with the specialty care clinic. That is what Kentucky
Myofascial Pain
George P. Boucher, MD
Orthopedic and Hand Surgeons, PSC (KOHS) did in 2011 when a community needs assessment by Central Baptist Hospital showed a strong demand for physiatry services in the Bluegrass. KOHS’s outpatient physiatry clinic, led by George P. Boucher, MD, is helping to reshape the nonsurgical pain experience for both patients and the primary care doctors who refer them. Similarly, his surgical colleagues also benefit from the physiatrist’s role in stitching together the care continuum for nonsurgical cases. Take for example what happens when a patient comes into KOHS with hand pain. As is tradition, the patient sees Dr. Einbecker, the group’s hand surgeon. After initial examination, the patient travels down the hall to Boucher’s clinic, where he performs EMG and nerve conduction studies as part of the diagnostic workup. “Everyone benefits,” says Boucher. “While I do the EMG, Dr. Einbecker carries on with his patient load. The current patient enjoys the convenience of a one-stop shop for her hand pain, and Dr. Einbecker and I are able to consult on the spot if there
Historically one of the most challenging neuromusculoskeletal pain conditions to treat – myofascial pain – can be treated quite satisfactorily in the outpatient physiatry clinic. Like the patient with whiplash from our car wreck example, myofascial pain is a condition in which muscle and connective tissue are taut and severely contracted. The resulting tender point, or trigger point, is easily identified and reproducible. Many times, myofascial neck pain begins to refer pain down the arm, into the shoulder, or into the head. Headaches may occur. Boucher finds several treatments to be effective in providing lasting relief from this kind of pain. Steroid injections, botox, or a local anesthetic may be considered. Often, Boucher prescribes topical medications made by a compounding pharmacist. “For myofascial situations, I add a muscle relaxant or two, an anti-inflammatory, and a nerve medication or two. The nice thing about these topical compounds is that there is no risk. Even the most benign oral medication, overtime, poses a risk,” he says. “I try to construct a treatment plan with the most benefit and the least risk.” Overall, Boucher finds that his role in PMR is to provide specialized management and TLC. “Chronic pain is like diabetes,” he says. “It is something that patients have to manage every day. Pain reduction is important, however, the more realistic goal also focuses on improved function and quality of life.” Boucher has a prescription. “When I give people time to form a relationship with me,” he says, “it is as helpful as anything.” ◆ MARCH 2012 17
SPECIAL SECTION PAIN MEDICINE
Neurostimulator Utilizes Motion-Sensing Technology to Combat Chronic Pain BY JENNIFER S. NEWTON
programs, requiring a great amount of recall and often resulting in confusion, dissatisfaction, and reprogramming of the device. AdaptiveStim follows the same principles of spinal cord stimulation but is controlled in a revolutionary way. “This is a major advancement in spinal cord stimulation,” says Dunbar. With AdaptiveStim, a programmer initially interacts with the device to apply appropriate amplitude settings for various activities. The difference is, using motion-sensing technology, the device actually learns the patient’s movements, adapts settings based on that information, and begins to remember it. The device is rechargeable and is predicted to last seven to nine years. By her third week of implant, Dunbar’s first AdaptiveStim patient, with just a new battery and new leads and before the AdaptiveStim had even been turned on, was already giving the device rave reviews. Eight years ago she received an implantable spine stimulator after two back surgeries and failed treatment with narcotics, anti-
LOUISVILLE Have you ever thought about the technology that powers wireless, motionsensing gaming systems like the Nintendo Wii or the way your smart phone knows whether you are holding it vertically or horizontally? Now, a far cry from entertainment and social uses, these features are being put to work in the treatment of chronic pain conditions. In November 2011, the Food and Drug Administration (FDA) approved the AdaptiveStim™ with RestoreSensor™ neurostimulation system from Medtronic, the first of its kind to receive FDA approval. Elmer E. Dunbar, MD, pain management specialist with the Baptist Center for Pain Control (part of Baptist Medical Associates), implanted the AdaptiveStim device in a female patient in early February 2012. Neurostimulation therapy has been around since the 1980s and uses an implantable spinal stimulator to send electrical impulses through the spinal cord, interrupting pain signals to the brain, and replacing the pain with a tingling sensation called paresthesia. “The standard of care has been to place electrodes in the epidural space and then connect them to a power source, analogous to a cardiac pacemaker,” Dunbar explains. The conventional devices are not rechargeable and have a battery life of anywhere from three to seven years. Settings correlating to a patient’s position or activity are programmed into the generator, and the patient manually switches programs through a patient programmer. “So with each change of position, the patient In November 2011, needs to adjust the amplitude to comAdaptiveStim™ with pensate for the amount of distance RestoreSensor™ by between the dura and the spinal cord Medtronic became the itself,” he says. The changes can be first neurostimulation almost shocking and uncomfortable, system of its kind to and some patients have as many as 32 receive FDA approval. 18 M.D. UPDATE
inflammatories, anti-epileptic medicines, and physical therapy. She had great results with the older iteration of the device, but says there is no comparison between it and the AdaptiveStim. “I had the opportunity to to ask her today what her pain score was, and she almost cried and said ‘I don’t have any pain,’” says Dunbar. The device is implanted through an outpatient percutaneous procedure with a two-inch incision. Dissecting down to the supraspinous ligament, the pain medicine interventionalist places electrodes into the epidural space through two curve-tipped needles. “I arranged the configuration so we can talk across the electrodes and from top to bottom,” says Dunbar, who performs the procedure at Baptist East. The leads are tunneled under the skin to a generator usually placed in the buttock region. The device is activated and tested in the operating room before the incisions are closed. The ideal patients for this new device are those with back and leg pain or neck and arm pain, and those that have failed other
Pain Management Specialist Elmer E. Dunbar, MD, says AdaptiveStim is a major advancement in spinal cord stimulation.
pain. He emphasizes that caring for the whole patient and interfacing with referring physicians and surgeons is critical to optimal patient care. In addition to implantable stimulators, he offers injections, implantable pain pumps and spinal catheter systems. He is also an associate clinical professor at the University of Louisville and participates in research studies, including an upcoming project seeking to demonstrate that pain management techniques for severe cancer pain can successfully allow patients to withstand more rounds of chemotherapy and radiation, therefore improving survival rates. Dunbar believes in the incredible potential of pain medicine devices given the accelerated rate of technology in medicine today. So what’s next? “I predict they’ll figure out how to program [the neurostimulator] through your cell phone,” he says. ◆
treatments. While this is not typically the first line of treatment, Dunbar says, “We’re moving so quickly now [with the technology] that you have to think about this earlier and earlier in the treatment algorithm, that maybe you shouldn’t wait until they’ve had three spine surgeries and they’re still having pain before you consider stimulation.” One of the contraindications for any implantable stimulator is if the spine is unstable. Dunbar cautions that AdaptiveStim is not a replacement for orthopedic surgery or neurosurgery. One of the major benefits of AdaptiveStim and implantable stimulators in general, is that they are drugless systems. Controlled substances are a hot button issue locally, in the state legislature, and on a national scale. “I write a lot of prescription narcotics, and when I write the first one, I think to myself, ‘I’m never going to get them off those narcotics.’ With the stimulator we have gotten several people off the narcotics, lowered their pain scores, and made them more functional, and they’re our best patients,” says Dunbar. A 30-year veteran in pain management, Dunbar’s practice, the Baptist Center for Pain Control at Baptist Eastpoint, sees patients from ages 16 to 100 with acute and chronic MARCH 2012 19
SPECIAL SECTION PAIN MEDICINE
Revelations from an EMR Journey BY DR. WILLIAM O. WITT LEXINGTON I always wanted to create a medical practice my way, just to see how good I could make it. That is how I came to experience my technological epiphany when, at the age of 62, I left academic medicine and launched a solo specialty career. I had some trepidation about entering solo practice at this time in life, but after meeting with upper management at Cardinal Hill and realizing their enthusiasm for forming a pain institute, the opportunity was too great to miss. At the top of my list of standards was a fully integrated electronic medical record. I had developed an interest in electronic records in the early 80s while I directed the surgical intensive care, respiratory therapy, and cardiac anesthesia services at UK. Back then, I used a Texas Instruments computer to run hemodynamic calculations and print them into patients’ charts. Therefore, when I decided to start my own practice, I never questioned whether
I would use an electronic record. After many consultations with EMR vendors, I decided to purchase WritePad by Addison Health Systems (AHS), a small company just outside Dallas. There were several reasons for the selection, and chief among them is that AHS is a nimble, dedicated company. I met the people involved and got to know the CEO of the company. I found them to be some really sharp young computer “wonks” who are anxious to make the best possible product. Dealing with a smaller company means that I can call up the programmers and make changes to the software over the phone. I have now learned to write screens and edit them any way I want. The ability to customize the EMR for the unique needs of my practice was a strong selling point, but one that came with a price. With 17,323 diagnoses in the database, unless you take the time to refine and organize these, you will spend a lot of time scrolling through long lists with every patient visit. The same is true for all of the William O. Witt, MD, DABA-PM, is a technophile and founder of the Cardinal Hill Pain Institute.
20 M.D. UPDATE
billing codes and other details. Initially, this caused a lot of anxiety over the tedium of entering patient data efficiently. If there had been an easy solution, I would have taken it. Instead I spent two weeks glued to the computer, up to 20 hours a day, cranking through each individual screen and refining it to what I needed for my practice. Ultimately, it was time well spent. The EMR allows me to document every detail of a visit or procedure in just a few mouse clicks. There is no clipboard awaiting my patients when they check in. Rather, they get an iPad and enter their history into their actual record. If patients prefer, they can enter this information before their visit by secure email. Whichever method they choose, at each subsequent visit, my patients’ health information is on the iPad. They note any changes, and their information is then synchronized wirelessly with my laptop for review. When they check out they get a printed summary of their visit. As I look back now, the first six months with EMR were really miserable. Yet, with each use, it got better. Now I may find that I refine a screen every two or three days, but it’s to the point where it is minor stuff. At the end of the day, I send my bills electronically to a Chicago-based clearinghouse, from where they are distributed to the individual carriers. I take the backup cassette out of my server containing the complete updated records of over 9000 patients, some going back twenty years or more, and I go home with no stack of dictation to be done at the end of the day, I can honestly say that the electronic record has made the practice of medicine fun again. I can see more patients now than I could with paper records. And, for providers considering a new EMR, it is worth noting that WritePad is fully governmentcertified and qualifies for incentive reimbursement. One common criticism of EMR – that the records are too verbose– is resolved by the clever technology behind the WritePad system. Being able to edit every screen means that if a report is too lengthy, it is all
my own doing. I can make it as skinny or as fat as I want it to be. EMRs are also criticized for “rubberstamping” medicine, but WritePad has a unique language algorithm that allows doctors to use their own dictated phrases instead of the “boilerplate” phrases that other EMRs may use. As a result, each report is as unique as the provider who creates it.
Computers Love Minutia
Computers are really good at managing the mind numbing coding and billing details that can be very tedious, but absolutely critical, if the doctor is to be paid. In my practice, an electronic record affords me a near-zero denial rate for coding or diagnosis issues. Today I measure denials at less than 1% for coding errors. A rate of 20 to 30% is not unusual with “coding on the fly” with paper records, and while paper claims may eventually get paid, someone will spend a lot of time and overhead correcting and resubmitting them. Just looking at what my anticipated denial rate would have been based on what it had been in years past and what it is now - the system paid for itself in the first year. When billing and diagnosis codes are updated, WritePad sends me an electronic file, I drag it to my server, and everything is updated with no manuals to page through. I don’t even have a CPT or ICD manual in the office. When you add the cost savings of no paper charts, no filing, no record storage
One common criticism of EMR – that the records are too verbose – is resolved by Witt’s customization and the clever technology behind the WritePad system. Being able to edit every screen means that if a report is too lengthy, “it’s all my own doing. I can make it as skinny or as fat as I want it to be.” space, no secretary, no transcriptionist, no coder and no billing service, the system not only pays for itself at the outset, it keeps paying as it goes.
Computers Improve Patient Safety
Not only has the electronic record made it fun to practice medicine again, but it has also improved patient safety in three critical areas: medication management, allergy management, and medical record access. There are many medications that I might never prescribe but that a patient may be taking, so I cannot possibly keep track of all the interactions that may occur. With electronic prescribing, the computer keeps track of all the patient’s medications regardless of what doctor has prescribed them. The system also tracks allergies, interactions and other precautions such that before I can hit “Send Prescription”, a notice might pop up on the screen: “Patient has a sulfa allergy” or “Combining this drug with one that he is already taking could trigger a serotonin syndrome, do you want to prescribe anyway?” This is a great help in preventing errors. Also, WritePad’s encrypted software allows me to access patient records securely
from any place with an Internet connection. Historically, if the medical reviewer for an insurance company called with a question, I would have to look a particular note only to find that the note I needed was in the hospital or surgery center chart. I would then have to copy it, fax it, and wait sometimes days or weeks for a response. It was very frustrating. Now I can find any note in seconds with all outside records automatically incorporated into WritePad, and the question is handled right on the phone. If they want a hard copy I can click it and send it instantly. Patients can have electronic access to their clinical records as well. For any physician contemplating the move to EMR, I recommend just doing it. You will be glad you did - but not for the first six months, mind you. Resign yourself to six months of your professional life as being horrible. Get it behind you, and once it is done you will never believe that you once preferred paper records. You will find that whatever time you spend in the practice of medicine, you spend with your patients instead of alone in your office digging through a bunch of papers. A few years ago, the thought of retirement was attractive. Now, I know that I will practice as long as I am able. ◆
2335 Sterlington Road, Suite 100 Lexington, Kentucky 40517 (859) 268-1040 Fax: (859) 268-6165 Email: lprober ts@barcpa.com www.barcpa.com
MARCH 2012 21
SPECIAL SECTION PAIN MEDICINE
Identifying Qualified Pain Management Centers Dr. David Bosomworth emphasizes interventional procedures and minimizing narcotic use in pain management BY JENNIFER S. NEWTON In this age of drug diversion and abuse, legitimate pain management practices face many challenges, requiring vigilance and perseverance to provide safe, efficient treatment for patients with chronic pain. The son of an anesthesiologist, David Bosomworth, MD, Bluegrass Pain Management, followed in his father’s medical footsteps but soon realized he preferred more interaction with patients. In 1997 Bosomworth went to work for Ballard Wright, MD, at the Pain Treatment Center of the Bluegrass (PTC), fully committing to the subspecialty of pain management. He spent seven years with PTC and served as the surgery center’s medical director, but in 2003, he opted for a smaller practice and opened his solo practice. A significant event in 1996 was the introduction of OxyContin. A sustained LEXINGTON
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release oxycodone, within two years, the drug’s popularity grew significantly due to misuse. “The sustained release component of the medication was based solely on the coating. If the tablet was crushed, it became an immediate release medication, which could be very addictive,” says Bosomworth. In the mid-90s, many physicians refused to prescribe opioids for fear of addiction. Bosomworth stopped prescribing OxyContin in 2001 because he felt the social risks outweighed potential benefits. The abuse of OxyContin also stimulated pain management physicians to put parameters in place to evaluate patients’ social histories. In his own practice, Bosomworth daily utilizes the Kentucky All Schedule Prescription Electronic Reporting System (KASPER), which was
developed during his time at PTC.
Treatment Philosophy
“From a philosophy standpoint, when it comes to the treatment of chronic benign pain, I would not use a malignant dose of medication to treat benign pain,” says Bosomworth. For benign patients, his treatment goal is always functionality, and for malignant patients, the goal is comfort. “One of the things I try and do is not use a dose of the narcotics that’s going to make the people dependent on the medications in the first place,” he says. In the last 15 years, significant advancements have been made in existing treatments and new procedures. Bosomworth cites implantable therapies such as spinal cord stimulation and intrathecal drug delivery systems; kyphoplasty;
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“From a philosophy standpoint, when it comes to the treatment of chronic benign pain, I would not use a malignant dose of medication to treat benign pain,” says Dr. David Bosomworth of Bluegrass Pain Management.
epidural lysis of adhesions; and injection therapies, primarily epidural steroid injections but also facet joint injections and radiofrequency thermocoagulation. His diagnostic approach includes an in-depth patient history and MRIs, nerve conduction studies, and CT scans. “One hundred percent of the folks I see are on a referral basis,” says Bosomworth, which is an asset in identifying legitimate patients.
His primary demographic is back pain patients, ages 35 to 55. While the majority of his patients are private pay, 40 percent are Medicare patients. Bosomworth also estimates that 60 percent of his patients are from outside Fayette County, a statistic he attributes to the availability of interventional services and the desire of physicians in southeastern Kentucky to have someone trained in dealing with prescription narcotics to handle complex or problematic patients.
Identifying Qualified Providers
One of the keys to decreasing drug diversion and increasing access to legitimate pain management services lies in differentiating pain clinics with interventional pain management specialists from “pill mills.” According to Bosomworth, qualified pain management practices are physician-owned, offer individu-
alized treatment through in-depth exams and record keeping, have advanced training in interventional procedures, are attentive to contraindications for opioid analgesics, and bill through insurance providers. The Kentucky legislature is currently considering several items of importance for pain management, including who can call themselves a pain clinic. [Editor’s Note: See Headlines story on page 4.] The proposed legislation also includes increased funding for additional investigators with the Kentucky Board of Medical Licensure, which currently only has five investigators for the whole state. Bosomworth notes that doubling the number of investigators would be helpful, but in his opinion the DEA should take a lead role. ◆ FOR REFERRALS
Dr. David Bosomworth at Bluegrass Pain Management, 1760 Nicholasville Rd., Suite 503, Lexington, KY 40503-1473, (859) 275-5229, Fax (859) 977-2683
Would you rather be here? Or HEAR?
Engineered for performance. MARCH 2012 23
SPECIAL SECTION PAIN MEDICINE
Ultrasound: A New Tool for Diagnosing and Blocking Pain By Gil Dunn
with abdominal pain is that you can actually have one organ causing pain that is felt in a different area. That means you may treat that pain without identifying what the pain generator actually is,” he explains. “One way to approach abdominal pain is from the spinal cord level, with spinal cord stimulation and blocking.
One of the latest trends in pain management has made its way to the Bluegrass. Ultrasound, long used in diagnostic medicine, is one of the latest technologies to be deployed in the battle against pain. In the Central Kentucky clinics of Richard Lingreen, MD, therapeutic injections to treat acute and chronic pain are now made under the guidance of ultrasound imaging. Traditionally, image-guided injections exposed patients to harmful radiation, but today Lingreen’s patients are spared the dangerous side effects of fluoroscopy or x-ray while they reap the benefits and improved performance of the ultrasound-guided approach. According to Lingreen, ultrasound is a versatile tool that gives the pain medicine practitioner many new ways to address chronic pain. “It helps increase Dr. Richard Lingreen analyzes accuracy,” he says, “because I a patient’s shoulder before know the depth of injection, performing an ultrasoundand I can actually see the guided pain injection. medicine go into the proper “Alternately, you area or the proper layers.” can approach it from In both large and small joint applications, an ultrasound level and block the abdomiwhere blind techniques are 65-75% accu- nal musculature to see whether the pain rate, ultrasound-guided techniques increase is actually manifested by the muscles or Lingreen’s accuracy to almost 90%. whether it is generated from an internal In the case of abdominal pain, where organ.” With a more accurate diagnothe pain is diffuse, ultrasound plays both a sis, Lingreen is better able to determine diagnostic and therapeutic role in the per- which treatment modality to use to block formance of diagnostic blocks called TAP, or the pain. transabdominal peritoneal injection. While The net result, for Lingreen, is a new providing some short term pain relief, TAP freedom to approach an old problem. “All allows Lingreen to these many patients analyze the nuances have abdomiUltrasound is a versatile tool who of abdominal pain nal pain for whatthat gives the pain medicine and determine ever reason – panwhich modalities to metastases practitioner many new ways to creatitis, use to treat it. from cancer, spinal address chronic pain. “The problem cord problems,
FRANKFORT
24 M.D. UPDATE
bladder and pelvic pain problems for both males and females – at least now they have a hope that there is something else out there that can help them out.” Ultimately, Lingreen may choose to address the pain at the spinal cord level either chemically, with intrathecal pumps, or stimulatory with spinal cord stimulation and blockade devises. Either way, ultrasound provides an opportunity to improve upon medical management of complex abdominal pain.
Professionalism in Pain Management
“There is a need for this technology,” says Lingreen, “and it helps the primary care doctors across the state by providing an avenue for patients that they didn’t know what to do with before.” Lingreen’s practice, Commonwealth Specialists of Kentucky, Pain Management, works in tandem with referring physicians to help manage pain in a more conductive way and to help patients attain improved functionality. With satellite clinics in Shelbyville, Dry Ridge, Versailles, and Mount Sterling, Lingreen aims to bring advanced pain management tools to underserved areas. The portability of the ultrasound technology provides a freedom to this purpose. “We can take the ultrasound machine to any clinic and provide accurate diagnostic and therapeutic techniques. There is no need for expensive x-ray or fluoroscopy capacity,” he says, “so we can take our goal comprehensive pain management across the state, even in underserved areas.” ◆ FOR REFERRALS
Dr. Richard Lingreen at Commonwealth Pain Specialists, PLLC 279 Kings Daughters Dr STE 100 Frankfort KY 40601 (502) 352-2530, Fax (502) 353-2534 www.cwpain.com
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Commonwealth Cancer Centers of Kentucky becomes the eighth in the state to become a Markey Cancer Center affiliate.
Commonwealth Cancer Center Joins Markey Cancer Network – Commonwealth Cancer Center is the newest member of UK HealthCare’s Markey Cancer Center Affiliate Network. The partnership is established with an emphasis on clinical research, with the goal of providing cancer patients in Commonwealth’s network of centers throughout the state expanded access to new clinical trials and emerging therapies in their own communities, as well as greater exposure to additional specialty and subspecialty physicians. Dr. Dennie Jones, medical director of the UK Markey Cancer Center Affiliate Network, says the relationship between Markey and Commonwealth Cancer Centers also allows the opportunity for Commonwealth physicians to collaborate on this research, combining the center’s clinical expertise with the support of UK academic research. Dr. Thomas Baeker, medical director of Commonwealth Cancer Center, said the partnership is beneficial to all parties involved, especially patients. Commonwealth Cancer Centers of Kentucky becomes the eighth in the state to become a Markey Cancer Center affiliate, but is uniquely the only independent private network of cancer clinics among them. With six full-time medical oncology practices, a radiation oncology center (London), satellite clinics and a mobile PET/CT Scan unit, Commonwealth Cancer Center is committed
DANVILLE
to providing accessible care to communities in central and southeastern Kentucky. CCC offices are located in Danville, Frankfort, Russell Springs, Somerset, Corbin, London, Harrodsburg, and Columbia.
Pearce Named Chair of Dept. of Family and Community Medicine
LEXINGTON Dr. Kevin Pearce has been named of chair of the Department of Family and Community Medicine in the University of Kentucky College of Medicine, effective March 1. Dr. Pearce, who is also professor of family and community medicine, has served as interim chair of the department since Jan. 1, 2011.
Dr. Kevin Pearce
Prior to joining the faculty at UK, Pearce was a faculty member at Wake Forest University School of Medicine in WinstonSalem, NC. He earned his medical degree at the University of Florida College of Medicine and completed his family practice residency training at the Medical College of Virginia, Fairfax, where he was appointed chief resident. He also earned a master of public health degree and completed fellowship training in faculty development at the University of Minnesota, and completed a leadership development course for physicians in academic health centers at the Harvard School of Public Health. He also serves on the faculty of the UK College of Public Health.
Central Baptist Hospital Receives AHA Accreditation for Acute Cardiac Care
According to Central Baptist Hospital, they are the first healthcare facility in the United States to receive the American Heart Association’s Mission: Lifeline® Heart Attack Receiving Center Accreditation. The accreditation program — sponsored by the American Heart Association and the Society of Chest Pain Centers — recognizes centers that meet or exceed quality of care measures for people experiencing the most severe type of heart attack, ST-elevation myocardial infarction (STEMI), in which blood flow is completely blocked to a portion of the heart. Central Baptist Hospital underwent numerous on-site reviews by accreditation specialists from the Society of Chest Pain Centers. Key areas in which Central Baptist demonstrated exceptional quality of care to receive accreditation include: • Activation of the heart attack team as soon as Emergency Medical Services determines a patient may be having a heart attack • Immediate transport of heart attack patients to the Cardiac Catheterization Lab to open the blocked artery or arteries causing the heart attack • Opening of a blocked artery as fast as the top 10 percent of hospitals participating in the American College of Cardiology Cath/PCI registry
LEXINGTON
MARCH 2012 25
NEWS
Jewish Hospital/University of Louisville Medication Protocol Results in LVAD Removal
Some patients with advanced heart failure caused by cardiomyopathy are getting a new lease on life thanks to an innovative treatment program at Jewish Hospital, a part of KentuckyOne Health, and the University of Louisville. Led by Emma Birks, MD, PhD, FRCP,
LOUISVILLE
director of the Jewish Hospital Heart Failure, Transplant and Mechanical Support Program, the program treats advanced heart failure patients who have left ventricular assist devices (LVADs), also known as heart pumps, which help with heart function. Using a specific combination of medications – which includes ACE inhibitors, spironolactone, beta blockers, angiotensin receptor blockers, and digoxin, in combination with the LVAD – the elements work
Feel better.
together to strengthen the patients’ hearts. Birks, professor of medicine, physiology and biophysics at the UofL School of Medicine, monitors the patients closely, and once the heart function improves to normal levels, the LVAD is removed. Once the LVAD is removed, medication therapy remains ongoing for patients, but they are able to function normally and return to work and other daily activities. The program has led to the successful removal of LVADs from 11 patients at Jewish Hospital in just 18 months. The average time on the medication before the LVAD is removed has been six months, but it can be more than a year. Jewish Hospital is the second facility in the country to remove LVADs from patients using the protocol, which was pioneered in England by Birks and her mentor, a wellknown heart surgeon, Dr. Magdi Yacoub.
UK First in Kentucky to Implant Total Artificial Heart
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LEXINGTON On March 5, The University of Kentucky announced the state’s first implantation of the SynCardia Total Artificial Heart as a bridge to transplant. UK is one of 29 medical centers in the country certified to perform this procedure. On February 10, 20-year-old Zack Poe of Maysville, KY, became the state’s first patient to receive the Total Artificial Heart. Poe, diagnosed with heart failure on January 3 at St. Elizabeth Hospital in Edgewood, KY, was referred to UK for consideration of advanced treatment options by Dr. D.P. Suresh. The Total Artificial Heart (TAH) is a device that contains the same components as a real human heart. For patients who are dying of end-stage biventricular failure, the only options are an immediate donor human heart or a TAH as a bridge to transplant. The TAH helps keep patients healthy while waiting on a viable donor heart to become available — which could take weeks, months, or even years. UK surgeons Dr. Charles Hoopes, director of the UK Heart and Lung Transplant Program and the Mechanical Cardiac Support Program, and Dr. Mark Plunkett, chief of Cardiothoracic Surgery and the co-director of the Linda and Jack Gill Heart Institute, have both received certification from SynCardia to perform this procedure. To become eligible to perform the procedure, medical centers
NEWS are required to undergo a stringent four-part certification process. Hoopes and Plunkett led the surgical team during the procedure. Within days of the surgery, Poe was able to get up and move around his room. Poe’s mobility improved greatly when he received the SynCardia Freedom Driver, a wearable, portable device that powers the Total Artificial Heart. The Freedom Driver weighs just 13.5 pounds and is carried in a small backpack or shoulder bag. A second UK patient underwent successful Total Artificial Heart implantation last Wednesday. The patient is currently recovering in the hospital and doing well.
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Women’s Wellness Guide Unveiled at UK Markey Cancer Center
LEXINGTON Kentucky’s First Lady Jane Beshear joined University of Kentucky’s Dr. Mary Lynne Capilouto as well as represen-
Dr. Mary Lynne Capilouto
tatives from the Kentucky Commission on Women (KCW) and the Markey Cancer Center to unveil the Women’s Wellness Guide, a new bilingual, interactive wellness kiosk that provides important health information especially for women. The touch-screen kiosk provides a wide range of information on general women’s wellness and breast health, including symptoms and treatment options for diabetes, asthma, cancer, weight management, smoking cessation, STDs, depression, heart health, domestic violence, breast health and HIV-AIDS. Each topic is programmed with women’s health stories, preventive measures, suggested follow-up questions to ask
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NEWS a health care provider and encouragement to visit a medical professional. The kiosk, located on the first floor of the Marylou Whitney and John Hendrickson Cancer Care Facility for Women at the Markey Cancer Center, also includes a telephone that is programmed to connect the user with immediate assistance if needed or desired.
Kleinert Kutz/Jewish Hospital Perform Eighth Hand Transplant and First US Recipient Celebrates 13 Years
LOUISVILLE Matthew Scott, the world’s most successful hand transplant recipient and the first person in the United States to receive a hand transplant, returned to Louisville for his yearly check-up on Thursday, March 1, 2012. Medical history was made 13 years ago on January 24-25, 1999, when Scott received his new left hand, an event that has greatly impacted the future of both transplantation and reconstructive surgery around the world. The 14 1/2 hour innovative procedure was performed at Jewish Hospital by Kleinert Kutz Hand Care Center and Christine M. Kleinert Institute for Hand and Microsurgery surgeons. During his visit, Scott met with Marion, Indiana, resident Ronald Thurman, the eighth and latest patient to receive a hand transplant by the Kleinert Kutz Hand Care Center team of surgeons at Jewish Hospital, part of KentuckyOne Health. Thurman is receiving an intense physical therapy regiment that will help him gain function in his new right hand. Thurman’s hand transplant took place during a 15 1/2 hour procedure on
28 M.D. UPDATE
Dr. Joseph Kutz
Wednesday, February 15, 2012. At 56 years old, he is the oldest patient to receive a transplant from the Louisville team. Members of the hand transplant team include co-investigators of the Louisville Vascularized Composite Allograft (VCA) Program: Joseph Kutz, MD, partner with Kleinert Kutz Hand Care Center and director of the Christine M. Kleinert Institute for Hand and Microsurgery, and Michael Marvin, MD, chief of transplantation for Jewish Hospital and associate professor at the University of Louisville.
Kosair Children’s Hospital Receives Grant
LOUISVILLE The Children’s Hospital Foundation is pleased to announce a $25,000 grant from the CVS Caremark Charitable Trust, the private foundation created by CVS Caremark Corporation,
whose purpose is to help people on their path to better health by providing funding for health care, education, and community involvement initiatives. The grant to the foundation, in support of Kosair Children’s Hospital, is part of $4.3 million in grants awarded to 98 nonprofit organizations across the country as part of the 2011 grant cycle and includes multi-year grants from previous years. The grant to Kosair Children’s Hospital, when paired with other community funding, will help establish the Bridges to the Future program, an initiative to help children with special health care needs such as cerebral palsy, congenital heart disease, cystic fibrosis, Down syndrome, and sickle cell anemia transition to adulthood.
Livingston Publishes Study on Effects of Concussion
LEXINGTON A study recently published by the University of Kentucky’s Scott Livingston, director of the UK Concussion Assessment Research Lab and assistant professor in the Department of Rehabilitation Sciences, shows that physiological problems stemming from a concussion may continue to present in the patient even after standard symptoms subside. Conducted while he was a graduate student at the University of Virginia, Livingston’s study was just published in the February 2012 issue of the Journal of Clinical Neurophysiology. The study used motor-evoked potentials (MEPs) — an electrophysiological measurement that can provide hard evidence for changes in brain function — to determine if any physiological abnormalities followed a similar recovery
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NEWS pattern to self-reported symptoms and neuropsychological testing. Livingston’s study enrolled 18 collegiate athletes — nine who had been concussed within the previous 24 hours, and nine who had not experienced a concussion. Subjects were evaluated for evidence of concussion based on selfreported symptoms, computerized neurocognitive test performance, and MEPs for a period of 10 days. Post-concussion symptoms were more frequent and greater in severity in the immediate timeframe after the injury (24-72 hours) and decreased in the following days. Some subjects reported no symptoms by day 10, though others did not have complete symptoms resolution by that time. Neurocognitive deficits followed a similar pattern, proving greater just after the injury and returning to normal (or closer to normal) by day 10. MEPs, however, showed delays in response time and smaller MEP size which continued up to day 10, with these physiological changes actually increasing as the concussed athletes’ symptoms decreased and cognitive functioning improved.
“Further investigation of MEPs in concussed athletes is needed, especially to assess how long the disturbances in physiological functioning continue after those initial 10 days post-injury,” Livingston said.
UK Study Provides Insight into Cancer Progression
LEXINGTON The University of Kentucky has announced that Dr. Daret St. Clair, the James Graham Brown Endowed Chair and professor of toxicology, has published the first comprehensive study that provides insight into the relationship between two types of suppressors in cancerous tumors. The results will enhance the understanding of transcriptional mechanisms in carcinogenesis. The study was supported by a National Cancer Institute research grant and was recently published in Cancer Research. St. Clair and her team generated transgenic mice expressing a luciferase reporter gene under the control of human MnSOD promoter-enhancer elements and investigated the changes of MnSOD transcription using the 7,12-dimethylbenz(a)anthra-
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cene (DMBA)/12-O-tetradecanoylphorbol-l3acetate (TPA) multistage skin carcinogenesis model. The results identify MnSOD as a p53regulated gene that switches between early and advanced stages of cancer. These findings also provide strong support for the development of a means to reactivate p53 for the prevention of tumor progression.
Study at UK Evaluates Faster Treatment for Seizures
LEXINGTON Results have just been released from an NIH study conducted at multiple sites, including the University of Kentucky, indicating that an autoinjector pen is a faster and possibly more effective way for emergency medical personnel to treat serious seizures. The study appears in the Feb. 16, 2012 issue of The New England Journal of Medicine. Typically, when paramedics respond to a patient with status epilepticus (a prolonged seizure lasting longer than five minutes), they attempt to start an IV to deliver anticonvulsant medication to the patient. However, starting an IV in a patient who is experiencing seizures can be challenging for paramedics and waste precious time. An autoinjector — similar to the EpiPen used to treat serious allergic reactions — saves time and delivers needed medication in a quick, consistent way. The autoinjector delivers medication directly into the thigh muscle as an intramuscular injection. The investigators, at UK and other institutions, compared two medicines known to be effective in controlling seizures, midazolam and lorazepam. Both are benzodiazepines, a class of sedating anticonvulsant drugs. Midazolam was a candidate for injection because it is rapidly absorbed from muscle. Lorazepam must be given by IV. The study found that 73 percent of patients in the group receiving midazolam via autoinjector were seizure-free upon arrival at the hospital, compared to 63 percent of patients who received IV treatment with lorazepam. Patients treated with midazolam were also less likely to require hospitalization than those receiving IV lorazepam. Among those admitted, both groups had similarly low rates of recurrent seizures. Dr. Roger Humphries, chair of the UK Department of Emergency Medicine, is the principal investigator of the study’s UK site. ◆
EVENTS
GLMS Alliance Membership Announcement
The Greater Louisville Medical Society (GLMS) Alliance provides many benefits to the spouses of GLMS member physicians. Being a member provides volunteer service opportunities and a social network for the unique challenges of living in medical families. The alliance raises funds for health career scholarships and also works to shape the future of medicine through legislative advocacy. The local, state, and national alliances all are important and have similar goals working to support physicians’ families. For more information about joining the GLMS Alliance, contact Adele Murphy (502) 6645925 or adelepmurphy@aol.com.
The Multi–Specialty Foundation For Aesthetic Surgical Excellence (FASE) presents VEGAS
Cosmetic Surgery 2012:
The February GLMS Alliance membership meeting featured Iron Chef Edward Lee, who demonstrated culinary techniques for preparing a “Dinner for Two.”
Lexington American Heart Association’s Heart and Stroke Ball Breaks Fundraising Records – Again! For the second year in a row, Lexington’s Heart and Stroke Ball set an all-time record for in-room donations benefiting the American Heart Association (AHA). This year’s event was held Saturday, February 25 at the Bluegrass BallroomLexington Center, and honoring Coach Joe B. Hall and a special survivor, Jessi Bowman. According to Dr. Sylvia Cerel-Suhl, president of the central Kentucky chapter of the American Heart Association, in-room donations were up 27% over last year, and overall donations were up 14%. The funds raised will be used by AHA to make a difference in the fight against heart disease and stroke in Central Kentucky through research, education, and advocacy. The AHA has given more than $16 million to Lexington-based cardiovascular research over the last 10 years. LEXINGTON
Dr. Dermot Halpin, Mrs. Melanie Simpson Halpin, Mrs. Lisa Tomassoni, Dr. Michael Rukavina, and Mrs. Amy R. Rukavina.
Mrs. Saskia Wright, Dr. Theodore Wright, Dr. Jeremiah Suhl, and Dr. Sylvia Cerel-Suhl.
An international multi-specialty symposium. The Bellagio, Las Vegas June 6-10, 2012 Discount Registration Ends Soon! The Multi–Specialty Foundation For Aesthetic Surgical Excellence (FASE), a 501(c)(3) educational foundation, fosters a spirit of cooperation and understanding between four specialties that are primarily involved in the science, practice, and teaching of facial aesthetic surgery. The foundation’s main objective is the creation and maintenance of a recurring annual symposium that includes the leading educators and teachers from the fields of oculoplastic surgery, dermatology, facial plastic surgery and plastic surgery. The 8th annual Vegas Cosmetic Surgery symposium will feature four tracks: General Session
Covering 120 fifteen minute talks by the world’s leading surgeons and dermatologists on the very latest innovations in rhinoplasty, blepharoplasty, facelifting, injectable treatments, laser technology, and new and emerging technology. Master’s Seminars
These 45-60 minute presentations provide an indepth review of many procedures and techniques with a “How I do It” emphasis. Practice Management and Marketing
Four days with some of the best business and public relations minds in the country. Aesthetic Dermatology
Learn valuable techniques from leading dermatologists around the world. More Reasons to Attend in 2012: • 19 International Faculty Members Representing 9 Different Countries • 100+ Faculty of Worlds Most Renowned Physician • Bellagio Block Rates Starts at Only $149/Night • 4 Day Practice Management and Marketing Workshop • A Minimum of 42 CME Credits Available • Over 80 Companies Will be Exhibiting • The ORIGINAL CORE Multi-Specialty Symposium! Visit: www.VegasCosmeticSurgery2012.com for information and to register. ◆
MARCH 2012 31
APPLAUSE
Dr. Frank Miller leads Malawi training project LOUISVILLE Frank Miller, M.D., trauma surgeon with University of Louisville Physicians and professor of surgery at the University of Louisville, recently returned from overseeing a Physicians for Peace medical training project at Queen Elizabeth Central Hospital in Blantyre, Malawi. Physicians for Peace, an international non-profit based in Norfolk, Va., has recently assumed responsibility for recruiting volunteers to serve as surgical faculty overseeing the Malawi hospital’s Surgical Intern Training (SIT) Project. Dr. Miller was the first volunteer surgeon sent by Physicians for Peace to lead the training at this large (1,000+ bed) hospital. The SIT Project is designed to train interns and registrars (known as residents in the United States) in basic surgical techniques. According to Physicians for Peace President and CEO, Brig. Gen. Ron Sconyers (USAF-Ret.), “Due to the shortage of trained surgeons in Malawi, this project is a critical training ground for recent graduates of the Malawi College of Medicine.” The project has a dedicated clinic and operating space, along with a clinical officer. Physicians for Peace surgical faculty will typically accept a 3-month
32 M.D. UPDATE
Dr. Frank Miller, trauma surgeon with UofL Physicians, volunteers with Physicians for Peace. He is recruiting surgeons to join the Malawi hospital’s Surgical Intern Training (SIT) Project.
volunteer assignment. The role of the volunteer surgeon is to provide hands on training and guidance to the interns through this clinic. Dr. Miller, who has a long history of international medical service in
Tanzania, Vietnam, Ghana, and Nigeria, learned of the Physicians for Peace opportunity through the American College of Surgeons’ Operation Giving Back Program. Operation Giving Back encourages humanitarian service by helping surgeons find volunteer opportunities best suited to their expertise and interests, both in the United States and internationally. ◆
Dr. Stephen Besson Harrison Memorial Hospital & Licking Valley Internal Medicine and Pediatrics
His patients may not remember all the medicines they take. Fortunately, their electronic records do. Dr. Stephen Besson knows just how valuable
avoid ordering unnecessary tests. And it helps me
the Kentucky Health Information Exchange can be.
quickly zero in on the right treatment option,” says
Every day, with just one click of a button, he’s able
Besson. You can enjoy the same benefits. Join our
to learn about his patients’ prescriptions, allergies
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and past medical procedures. “This helps me
how your practice and patients can benefit.
protect them against drug interactions. It helps me For a limited time, there are financial incentives for your hospital or practice to join KHIE. Visit www.khie.ky.gov or call 502-564-7992 to learn more.