M.D. Update Issue #77

THE BUSINESS MAGAZINE OF KENTUCKY PHYSICIANS AND HEALTHCARE ADMINISTRATORS ISSUE #77

SPECIAL SECTION

PAIN MEDICINE PSYCHIATRY

MESA Founders Dr. James Foster and Dr. John Mullins

RAISING STANDARDS TO A HIGHER PLATEAU

VOLUME 4, NUMBER 2

MESA Medical Group evolves from two doctors with a single idea to a regional EM/HM powerhouse that’s busting borders  GLMS PROMOTES OPIOID PRESCRIBING ESSENTIALS

 ARE YOU ELIGIBLE FOR PATIENT CENTERED MEDICAL HOME?  SUBSTANCE ABUSE TREATMENT FOR MEDICAL PROFESSIONALS

Better care is here.

Better care is here.

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All we’re ca for theKentucky, underserved programs suchadvancing as our Appalachian Outreach Program. All across we’rethrough finding new treatments, new care models, introducing innovative cancer treatments, training medical professionals, expanding research introducing across Kentucky, we’re finding newnew treatments, advancing new care models, programs minimizing hospitaltraining stays. The healthier communities that result are all research part of innovativeand cancer treatments, new medical professionals, expanding our 200-year commitment improvingstays. the health of Kentuckians. programs and minimizingtohospital The healthier communities that result are all pa

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Flaget Memorial Hospital Frazier Rehab Institute James Graham Brown Cancer Center Jewish Hospital Jewish Hospital Medical Center East Jewish Hospital Medical Center South Jewish Hospital Medical Center Southwest Jewish Hospital Medical Center Northeast Jewish Hospital Shelbyville Jewish Physician Group Our Lady of Peace Saint Joseph Berea

Saint Joseph Jessamine Saint Joseph London Saint Joseph Martin Saint Joseph Mount Sterling Saint Joseph East Saint Joseph Hospital Saint Joseph Physicians Sts. Mary & Elizabeth Hospital University of Louisville Hospital VNA Nazareth Home Care The Women’s Hospital at Saint Joseph East

CONTENTS COVER STORY 3 4 6 7

HEADLINES LEGAL FINANCIAL AFFAIRS COVER STORY

12 SPECIAL SECTION 

12 PAIN MEDICINE



17 PSYCHIATRY

20 NEWS 24 EVENTS

Volume 4, Number 2 ISSUE #77 PUBLISHERS

Gil Dunn PRINT gdunn@md-update.com Megan Campbell Smith DIGITAL mcsmith@md-update.com EDITOR IN CHIEF

Jennifer S. Newton jnewton@md-update.com GRAPHIC DESIGNER

James Shambhu art@md-update.com

CONTRIBUTORS: George P. Boucher, MD Tim Corkran Scott Neal Sarah Charles Wright

CONTACT US:

ADVERTISING AND INTEGRATED PHYSICIAN MARKETING:

RAISING STANDARDS TO A HIGHER PLATEAU

Gil Dunn gdunn@md-update.com

Mentelle Media, LLC

MESA Medical Group evolves from two doctors with a single idea to a regional EM/HM powerhouse that’s busting borders PAGE 7 SPECIAL SECTION  PAIN MEDICINE

12 ULTRASOUND-GUIDANCE IMPROVES DIAGNOSIS AND TREATMENT

 PSYCHIATRY

13 GENETIC TESTING FOR PAIN PATIENTS

17 TMS OFFERS DRUG-FREE OPTION FOR POSTPARTUM DEPRESSION

SUBMIT YOUR LETTER TO THE EDITOR TO JENNIFER S. NEWTON AT JNEWTON@MD-UPDATE.COM 2 M.D. UPDATE

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HEADLINES

Dr. James Patrick Murphy leads the ROPE study group where he recommends physicians "start low and go slow" when prescribing medications.

LEFT

GLMS Promotes Responsible Opioid Prescribing Protocols

Pain Specialist Gives ROPE to Practitioners

BY GIL DUNN LOUISVILLE House Bill 1, (HB1) the Pill Mill Bill from 2012 did not only impact anesthesiologists and pain medicine doctors.

The restrictions and requirements of HB1 are felt by any Kentucky physician who prescribes controlled substances for pain or other medical conditions.

Responsible Opioid Prescribing Essentials (ROPE) is a study group created and led by James Patrick Murphy, MD, pain specialist and president–elect of the Greater Louisville Medical Society (GLMS). His program is based on the writings of Scott M. Fishman, MD, Responsible Opioid Prescribing, A Clinician’s Guide, 2ndedition, which is one of the approved CME sources that meets the requirements of HB1.

Murphy presented ROPE twice in February, 2013. Dates for future ROPE

courses will be listed on the GLMS website, www.glms.org.

The goal of the program, says Murphy, is “to facilitate physicians obtaining the required CME credits and to give them the tools, education, and confidence they need to prescribe chronic pain medications according to current Kentucky law.”

Differentiating “aberrant behavior, abuse, and addiction” is an important factor for physicians, says Murphy. Of the total pain patient population, 40% may demonstrate some measure of aberrant behavior; 20% may abuse their drugs, but only 2%-5% are addicted. In fact, Murphy states “the biggest misconception in pain medicine is that addiction is prevalent among chronic pain patients. It’s not true.” The key for responsible prescribing of opioids by physician is screening for the risk factors, such as past history of abuse, mental health status, family history, peer group, culture, and social environment, he says.

Drug abuse, not taking medications as prescribed, is the most common drug problem in Kentucky. The ROPE program teaches a series of aids for physicians who

BELOW Dr. Murphy greets Deepak Azad, MD, presidentelect Indiana State Medical Association and Nanine Henderson, DO, at the February 28 ROPE study group.

must “decide to treat or not to treat,” says Murphy, including prescribing a less risky treatment first, employing screening for abuse tendencies and checking KASPER. Developing a pain treatment plan which addresses the patient’s goals and functionality is critical, says Murphy, and “start low and go slow” with the medications. An “Exit Strategy” and “Function Plan” need to be part of the original plan and discussed in advance with the patient, he says.

The ROPE program addresses many more issues facing physicians who treat patients with chronic pain. The overarching message is for “physicians not to feel alone in this situation,” says Murphy.

“There is a way to prescribe opioids and chronic pain medicine safely and correctly that will let you sleep at night,” he says. “I do these things, and I sleep well at night.”

Murphy can be reached at Murphy Pain Treatment Center (502) 736 3636 and dr.m@mpcky.com. ◆

William O. Witt, MD, DABA-PM 2050 VERSAILLES ROAD LEXINGTON, KY 40504

www.cardinalhill.org | www.docwow.com 859.367.7246 (859-FOR-PAIN)

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.

ISSUE#77 3

LEGAL

Patient-Centered Medical Homes— Are you eligible?

You may be familiar with the Patient(ACP) in a 2006 Centered Medical Home (PCMH) practice position paper.3 model. If you practice primary care, you may In 2007, these even be part of a PCMH or in the process organizations of establishing one. Primary care practices together with are consolidating with each other, affiliating the American with hospital organizations and establishing Osteopathic contractual relationships with specialty pracAssociation tices, all in a move toward creating PCMHs (“AOS”) puband providing accountable care. A PCMH lished the “Joint has the interdependent goals of improving Principles of

BY Sarah Charles Wright the quality of primary care for better patient the Patientoutcomes and a healthier patient popula- Centered Medical Home” with a new emphation with the anticipated results of reduced sis on quality delivery of “patient-centered” patient utilization of certain services and primary care.4 The National Committee on controlling healthcare costs. These goals are Quality Assurance (“NCQA”) working with achieved through patient-centered whole- these same professional organizations pubperson coordinated care across care settings. lished an initial set of standards for NCQA PCMHs embody the core primary recognition of PCMHs in 2008 and revised care components of an Accountable Care PCMH Standards in 2011 that incorporate Organization or “ACO” as described in Medicare/Medicaid EHR Incentive Program the Affordable Care Act. Both PCMHs Meaningful Use of EHR Stages I and II and ACOs models are based on deliver- core requirements.5 Each of the five PCMH ing quality coordinated whole-person primary WITH MANY PRIMARY CARE PRACTICES care. An ACO, however, will necessarily have SEEKING RECOGNITION AS PCMHS, multiple PCMHs workPHYSICIANS IN OTHER SPECIALTIES HAVE ing together and relationships with specialty pracQUESTIONED WHETHER NCQA RECOGNITION tices, hospitals, and other health care providers to AS A PCMH IS RESTRICTED TO PRIMARY CARE? offer fully-integrated care to a large patient population. Healthcare sysTHE ANSWER IS A QUALIFIED “YES.” tems are moving towards forming private ACOs and preparing to qualify for participation in the Medicare Shared Savings Standards has multiple Elements. Achieving Program. 1 The American Academy of Pediatrics a designated number of points for spe(AAP) first used the term “medical home” in cific Elements within each the Standards is 1967 to describe a practice model for pedia- required for NCQA recognition.6 tricians to coordinate all aspects of care for With many primary care practices seekspecial needs children in a family centered ing recognition as PCMHs, physicians in and culturally sensitive way.2 The practice other specialties have questioned whether model was later revised by the American NCQA recognition as a PCMH is restricted Academy of Family Practitioners (AAFP) and to primary care? The answer is a qualified envisioned as a means for healthcare reform “yes.” NCQA clarified in the 2011 PCMH by the American College of Physicians Standards that eligibility for recognition is 4 M.D. UPDATE

limited to “primary care practices” which are described as one or more clinicians practicing primary care together in one geographic location. NCQA defines “primary care” as the practice of internal medicine, family medicine or pediatrics with the intention of serving as the personal and primary clinician(s) for their patients.7 Clinicians include physicians/osteopaths, nurse practitioners and physician assistants, as long as they are providing primary care and a patient can select them to be the patient’s primary care provider.8 This limitation to primary care is understandable considering the conceptual basis of the model which is to provide “whole-person care” across care-settings.

However, NCQA has indicated that it will consider recognizing a non-primary care specialty practice as a PCMH if the practice can demonstrate that it provides wholeperson care and satisfies the other elements of the Joint Principles for at least 75 percent of its patients. Using an example from the NCQA webpage, an HIV clinic may be considered a PCMH even though the patient population is limited to patients with HIV or AIDs. HIV treatment and AIDs impact multiple organs and systems within the body and require whole-person care. By contrast, an oncology practice would not be able to demonstrate that it is the primary source of ongoing comprehensive health care for 75 percent or more of its patients.9 The oncology practice may provide a degree of whole-person care for the period of time the patient is undergoing treatment. But, if that treatment is successful, the patient will not continue seeing their oncologist for their primary healthcare needs.

The parameters of what constitutes whole-person care become less clear with some specialties that have many but not all of the core elements of a primary care medical home as, for example, a women’s clinic.

The American College of Obstetricians and Gynecologists even issued its own medical home policy statement in 2009 supporting the application of the PCMH Joint Principles by its members to develop women’s medical homes. But, whether NCQA would find an OB-GYN or other specialty

Pain

Management Medicine

practice eligible for PCMH recognition is still questionable. To address the desire of specialty/subspecialties for recognition and because better coordination of care is a fundamental component of the PCMH, NCQA is scheduled to release recognition standards for a new “Patient-Centered Specialty Practice Recognition Program” this March. NCQA describes the new Program as one that reinforces the need for strong connections between primary and specialty care. The program encourages support of care coordination by recognizing specialty practices that successfully coordinate patient-care with the patient’s primary care provider and with other specialists for timely access to care, continuous quality improvement and a reduction in duplication of services.10 (Endnotes) 1 An ACO must be able to accept a minimum of 5,000 Medicare beneficiaries as patients to participate in the MSSP. See 42 U.S.C. 1395jjj.

Danesh Mazloomdoost, MD ABA Board Certified Anesthesiologist ABA Board Certified Pain Specialist Fellowship Trained: Johns Hopkins Medical Center MD Anderson Cancer Center  

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2 See e.g., L.G. Pawlson, MD (NCQA); B. Bagley, MD, (AAFP); M. Barr, MD, (ACP); X. Sevilla, MD, (AAP); P. Torda, (NCQA); S. Scholle, Dr. PH, (NCQA); The Patient-Centered Medical Home From Vision to Reality, (NCQA 2011) p. 3.

3 Id. at p. 4.

4 AAFP, AAP, ACP, AOA (March 2007). The Joint Principles are: personal physician, physician directed medical practice, whole-person orientation, care coordination and/or integration, quality and safety, enhanced access to care, value based payment including for primary care coordination.

5 See generally, Standards and Guidelines for NCQA’s Patient-Centered Medical Home (PCMH) 2011 (11/21/2011) and “NCQA’s PatientCentered Medical Home (PCMH) 2011- Changes and Clarifications” (11/16/ 2012). www.ncqa.org/Programs/ Recognition/ atientCenteredMedicalHomePCMH.aspx .

6 Id. 7 Id. pp. 11-12.

8 Id. 9 http:// www.ncqa.org/Programs/Recognition/ PatientCenteredMedicalHomePCMH/ BeforeImConsideringPCMH/ PCMHEligibility.aspx.

10 http://www.ncqa.org/Programs/Recognition/ PatientCenteredSpecialtyPracticeRecognition.aspx and http://www. ncqa.org/Portals/0/Public Policy/Improving_Specialty-Care.aspx.

This article is intended as a summary of newly enacted state law and does not constitute legal advice.

Sarah Charles Wright is a partner with Sturgill, Turner, Barker & Moloney, PLLC. Ms. Wright advises health care entities and providers on corporate compliance with state and federal laws and regulations. She can be reached at swright@sturgillturner. com or (859) 255-8581. ◆

ISSUE#77 5

FINANCIAL AFFAIRS

On Alert My military service happened right in the the monetary middle of the Cold War. Serving with the tools to reverse Army’s 1st Armored Division in Nurnberg, the course before Germany, it was not uncommon to be catastrophe hits, rousted out of bed at 2:00 a.m. by a ringthere is no historing telephone. The voice on the other end ical precedent for of the line would simply report, “Sir, we that. My point is are now on alert.” That’s all that needed that the infusion to be said. We were expected to report to of $85 billion a duty within 20 minutes of receiving that month into our call and to remain at a heightened state of system is a key defensive readiness until the commanders ingredient for rishad decided that we could “stand down.” ing asset prices which can lead to complaThere was no discussion of whether the alert cency. Don’t let it happen to you. was a readiness drill or if it was in response to a very real threat from the enemy. Nor So exactly where is was there any indication as to how long we the real threat? would remain “on alert.”

From a technical standpoint, the curWhile I am not suggesting that there is rent price levels of stocks should be viewed a plausible comparison between the threat as a point of resistance. Only time will of nuclear war and that of losing money in tell if the resistance is strong enough for a the stock market, there is at least one useful reversal. A breakout above the high could parallel as we now consider managing the be bullish indeed and the rally could conthreat of the latter. Namely that compla- tinue. However, the market has pushed cency is not an option. We are On Alert. high enough to be “stretched.” The realIf you are reading this, you probably have more than a passing FROM A FUNDAMENTAL PERSPECTIVE interest in matters financial. You THERE IS NOT MUCH EVIDENCE OF A are undoubtedly aware that the U.S. stock market, as measured by BUBBLE IN THE STOCK MARKET the S&P 500, has had a significant rally in Q1 2013. That the venerable index is approaching a record high is probably not a surprise at all. Financial news channels are counting ity is that a correction, while perhaps not down the distance to the record number immediate, will eventually come. And due much like the Times Square ball drop on to the artificial fuel injected by the Fed, it New Year’s Eve. As you may recall, the last could be as ugly, or even more so, as the last two. Being aware of the risks and remainrecord high was in October 2007.

“But this high is different,” you say. And ing on alert is paramount to one’s future you would be right on many fronts. Never financial well-being.

From a fundamental perspective there before have we witnessed such infusions of liquidity into our financial system. In late is not much evidence of a bubble in the February and again in March, Mr. Bernanke stock market. At least that was what Mr. gave testimony that the Fed is going to B. told Congress recently. He, as well as continue its current programs for as long as many others, seems to focus on corporate necessary to achieve at least one of its end profitability to support the claim. Certainly goals: full employment. Okay, he said 6.5% corporations have stockpiled cash and have unemployment is his target but even that paid down debt, bolstering their balance is considered full employment by many. sheets. From my training as an accountant, And while Mr. B. indicates that they have I am leery of how the accounting rules 6 M.D. UPDATE

have changed since the last recession and wonder if we are really seeing comparative results of operations. In any event, as Lance Roberts of streettalklive.com points out, more important than the level of profitability is the relative growth trend of profits.

He points out that recently “50% of those reporting have missed estimates [of profitability] and most have guided estimates lower in the coming year.”

The threat is that a correction is coming. When? Nobody can say for sure. It has been said that the stock market climbs a “wall of worry.” It is when the worry ends that we should all become truly concerned.

Being lulled into a sense of complacency by the rise in asset prices is not where you want to be in the face of that threat. We are On Alert. Are you?

So what do you do?

If you are a traditional investor of the buy-hold-rebalance variety then you should probably be aggressively rebalancing your portfolio. Take some profits, in spite of the bad feeling that you will get from selling those assets that are fueling everybody’s excitement, and buying those that are out of favor. Consider selling losers that could fall even further. Cash would even become a valuable asset if a correction becomes reality.

If you are an active investor, more concerned with losing the capital that you have than with beating the market, risk controls are the order of the day. Trailing stop losses can work well. We do not place automatic stop loss orders on managed positions.

Instead, we set “alerts” that fire when the price drops to a predetermined level. At that point we take an even closer look, make a risk assessment, and decide the next step for that asset.

We are On Alert. Are you?

Scott Neal is President of D. Scott Neal, Inc. a feeonly financial planning and investment advisory firm with offices in Lexington and Louisville, Kentucky. These are his opinions. Comments and questions are welcome and may be addressed to him via email at scott@dsneal.com ◆

COVER STORY

RAISING STANDARDS TO A HIGHER PLATEAU MESA Medical Group evolves from two doctors with a single idea to a regional EM/HM powerhouse that’s busting borders

BY GIL DUNN PHOTOGRAPHY BY MAGNUS LINDQVIST OF GLINT STUDIOS

LEXINGTON, KY The year was 1997. Two young doctors, James Foster, MD, and John Mullins, MD, were working for various large, national staffing companies in emergency rooms at small community hospitals throughout Central and Southeastern Kentucky. Both had attended medical school at the University of Kentucky, College of Medicine and at the time, one was on a career path to orthopedic surgery and the other was interested in general surgery.

Mullins recalls being hired over the telephone by a non-clinical person working in St. Louis, Missouri.

“I was hired. I showed up. I worked. I went home. I was paid. The companies I worked for provided no management of the department or feedback on my performance. To them, I was truly a ‘warm body.’”

In September 1999, Foster and Mullins started a two man group practice. Mullins recalls, “I think we can do this better.”

Fast forward to 2013. Those same two doctors, Mullins and Foster, founders of MESA Medical Group (MESA), now employ more than 300 emergency medicine and hospital medicine physicians, 100 advanced practice providers and over 100 support staff, in addition to managing emergency and hospital medicine ISSUE#77 7

COVER STORY

MESA Founder Dr. James Foster says one of their secrets has been hiring physicians who agree to equal shifts in the ER.

programs at over 30 hospitals throughout Kentucky, Ohio, and West Virginia.

Neither Mullins nor Foster anticipated MESA growing into a regional or multistate EM/HM powerhouse. “We grew because there is an unlimited need for what we know how to do and hospitals keep hiring us,” says Mullins. “Our growth was born out of our commitment to providing quality patient care. Our guiding principles of integrity and accountability along with our passion for healthcare and raising standards resonated to our hospital partners.”

Hospitals were unable to fill their emergency room schedules while holding the doctors accountable to their performance.

According to Foster, “The ER climate in Kentucky was very fragmented at the time.”

Staff members were spending extraordinary amounts of time trying to find qualified emergency medicine physicians which placed undue stress on administration and staff members at the hospitals.

“We took the approach that everybody, including ourselves, will work their fair share of nights, weekends, and holidays. We hired doctors who were like-minded, and many of those that disagreed left. The situation improved immediately for both the hospitals and the physicians,” says Foster.

Familiarity, Feedback, and Passion

MESA is committed to maintaining the culture of a small group practice. “Even though we now have over 400 providers in our group,” Mullins exclaims, “we talk regularly about the desire to maintain the flavor of our vision to remember our past as we embrace the future. I am on a first name basis with each member of our group and I am available to anyone 24/7.”

“If anyone calls us a staffing company, I correct them. We are a group practice!” emphasizes Mullins.

Rarely do hospitals contact MESA when their ER is running smoothly, so MESA’s expertise is in the turnarounds of underperforming emergency departments. When entering a new hospital operating agreement, Mullins and Foster do the evaluation 8 M.D. UPDATE

themselves. They typically walk into situations that have been mismanaged by other groups in geographical areas that are difficult to recruit to.

“Although a complete turnaround can take several months,” Foster is confident in the organization’s proven ability to vastly improve the hospitals overall performance. “We’ve done it so many times we know what to look for and how to fix it. That’s what sets us apart,” says Foster.

Accountability for performance and outcome is both the carrot and the stick for emergency medicine physicians where speed and quality patient care often conflict.

MESA providers are held to higher standards of care that have been developed by Foster and Mullins over their years of firsthand experience and learning from other emergency medicine groups. “We focus on performance metrics that are 100% aligned with the hospitals. The time it takes for the patient to see the doctor after arrival and the time it takes for the patient to be discharged from the department or admitted to the hospital are closely tracked,” says Foster.

MESA Founder Dr. John Mullins says, "If anyone calls us a staffing company, I correct them. We’re a group practice."

scorecard.” “We want our fellow physicians to know how they are doing,” says Mullins.

“What does it mean to be a good doctor? I can tell you that being smart isn’t the biggest measuring stick. Are you compassionate?

Are you efficient? Do your patients feel satisfied with their care? Do you meet the standards of the profession?”

Mullins believes passion cannot be forced, and it is the key ingredient both he and Foster share and also look for when bringing new physicians into the MESA organization. “What we do, we do without notes or a business plan. We do what we do because we passionately believe that patients deserve the best.”

CMO of Hospital Medicine Dr. TJ Richardson says, "Listening to patient feedback is a major part of what we do."

MESA Adds Hospital Medicine

ELECTRONIC MEDICAL RECORDS GIVE US REPORTING PRACTICES AND METRICS THAT TELL US EXACTLY WHAT THE ‘DOOR TO DOCTOR’ TIME IS, THE ‘DOOR TO DISCHARGE OR ADMIT’ TIME, AND THE OUTCOMES. WE GIVE OUR DOCTORS QUANTIFIABLE, OBJECTIVE FEEDBACK ON THEIR PERFORMANCE, THE GOOD AND THE BAD. – DR. JAMES FOSTER

“These indicators are very important factors in patient satisfaction. We give our physicians quantifiable and objective feedback, both good and bad, to improve performance and enhance the patient experience.”

Hospital administrators now know that the emergency room is their front door and the path to more admissions, although that has not always been the case. According to Foster, traditionally, the ER was the “red-headed stepchild” of the hospital that continually lost money. MESA raises the emergency room experience and physician’s accountability to a higher standard by calling every single patient that is discharged from their hospitals to conduct a patent satisfaction survey. “We have a hospital specific survey, a team of interviewers, and a reporting system that give us immediate feedback from the patients that we share with our hospital partners and providers. It’s enormous, a monumental task, but we do it for the feedback and because it’s the right thing to do,” says Foster.

The patient surveys fuel the physician feedback machine. All MESA doctors receive a monthly and a quarterly “physician

Hospital medicine is the flip side of the same coin of hospital-based patient care.

It was only natural that MESA developed a hospital medicine program in October 2008 when TJ Richardson, MD, joined the group as Chief Medical Officer for Hospital Medicine. Richardson was a founding partner of Central Kentucky Medical Group, an internal medicine practice in Lexington.

He was familiar with MESA partners Foster and Mullins through their work at common hospital emergency department locations.

“I realized that my passion was for inpatient care,” says Richardson of his decision to head up MESA’s hospital medicine program. “I knew that John and Jimmy were committed to quality patient care.

They were sound physicians, and I was impressed with their high energy and commitment to the highest standards. And I like that MESA is an independent group.

Independence is a good thing.”

Richardson and MESA now oversee 12 hospitalist programs in Kentucky and one in Ohio with 40 physicians under his supervision and tutelage. Richardson says he demonstrates the MESA Best Practice strategies of raising standards of patient care by providing in-patient care that is timely, efficient, caring and scientifically proven with peer review, patient satisfaction surveys, and MESA’s unprecedented patient call back program after discharge by trained ISSUE#77 9

COVER STORY

medical assistants. “Listening to patient feedback is a major part of what we do,” says Richardson.

Aside from the challenge of providing quality patient care, Richardson acknowledges that physician retention and prevent-

WE GREW BECAUSE THERE IS AN UNLIMITED NEED FOR WHAT WE KNOW HOW TO DO AND HOSPITALS KEEP HIRING US. – DR. JOHN MULLINS ing burnout are his top priorities. MESA addresses each issue head on with “sustainable scheduling and a commitment to our doctor’s mental and physical health,” says Richardson. The standard MESA hospitalist works seven 12-hour days followed by seven off days. This schedule allows the group’s hospitalist physicians their important time-off to enjoy life and their families.

Additionally, “Our size and physician pool allows us to create even more flexible scheduling when necessary.”

It is often beneficial for hospital administrators to partner with MESA for both emergency and hospital medicine programs.

Mullins expressed that the natural synergy and efficiencies are obvious “because ER doctors want to admit patients through the path of least resistance, so admitting a patient to your colleague is more efficient.”

Mullins believes that MESA “not only saves hospitals money, but we make them money when we manage both the emergency and hospital medicine programs.

Hospitals save by only paying a subsidy to one group rather than two competing groups. If having EM and HM doctors talking to each other can reduce hospital stays beyond what’s necessary by even half a day, it saves money. Plus increasing ER visits, which MESA does, is additive to hospital admissions.”

Mullins confidently states, “There’s no doubt, we can document it. Hospitals are proven to be more profitable because of our 10 M.D. UPDATE

efficiencies, our performance based outcomes, and our accountability.”

Physician Recruitment

Director of Physician Recruitment, Doug Smith, MD, serves as the physician liaison for MESA Medical Group’s recruitment team. He credits MESA’s recruitment department for “consistently doing a fantastic job. They are matchmakers, not salespeople.” Smith claims his role in meeting with potential MESA physicians is to understand what is important to the physician, such as proper support staff and coverage in the hospital or a flexible schedule that allows providers to determine where and how much they work and the ability to have a balanced lifestyle and pursue outside interests.

According to MESA CEO Larry Director of Physician Kraska, the to MESA’s Recruitment key Dr. Doug success will be geographic Smith says the physician density anddepartment a core groupis of recruitment cross-credentialed physicians. more like matchmakers than salespeople.

The physician shortage makes finding the best suited matches imperative to the stability and growth of MESA, which Smith believes is what sets them apart from their competitors. “MESA’s commitment is to make our physicians happy. Every physician matters to us.”

According to MESA CEO Larry Kraska, the key to MESA’s success will be geographic density and a core group of cross-credentialed physicians.

Maintaining physicians’ work schedules “is like working a Rubik’s Cube,” according to Smith. “Changing a physicians schedule will impact another physician’s schedule, maybe more, but we have the ability to match a provider with the hospital they want to work at and the schedule they want to work. Our schedulers work tirelessly to accommodate the individual physician’s needs.”

When recruiting physicians to join the organization, Smith points out that MESA is a physician-friendly group that is designed from a physician’s viewpoint.

They do not have non-compete clauses, and physicians have the option to work part-time, full-time, or be an independent contractor. Smith advised, “Our ultimate goal is to have providers who want to live and work in the community where they practice.”

Smith graduated medical school from the University of Cincinnati College of Medicine and completed his residency in emergency medicine at the University of Kentucky. Before joining MESA in 2005, he served as a Naval Flight Surgeon with the US Marine Corps based at Camp Lejeune.

Future Growth Fueled by Need

The ever-changing landscape of today’s healthcare reform initiatives will continue to impact the delivery of patient care. Rapid changes in coverage criteria and limits have a direct influence in the way hospitals and physicians deal with the financial challenges of patients.

This is no more acute than in a hospital’s emergency department.

There is a very large population of underinsured and uninsured people in this area. “Many of these patients go to the emergency room for their care because they have nowhere else to go. I strongly feel that this situation is underappreciated,” says Foster. “The economic situation is very challenging and will be more difficult in the future.”

In October 2011, MESA made the

proactive decision to invest in additional executive leadership to manage the challenges of their continued growth. MESA brought in its first Chief Executive Officer to oversee the organization’s operations and growth throughout Kentucky, Tennessee, West Virginia, and Ohio. Larry Kraska came on board with 25-years of executive level healthcare experience and is an expert in extensive large physician group management and hospital administration. Kraska understands the key to MESA’s success will be geographic density and a core group of cross-credentialed physicians.

Kraska describes why a regional emergency and hospital medicine group like MESA is needed because it solves two major challenges. “One is the imbalance in the supply and demand equation of a physician shortage. The second is the increasing demand for ER and hospitalist services as the result of the Patient Protection and Affordable Care Act.” “Clearly, MESA Medical Group is the leading provider group in Kentucky because of our unique approach to raising standards,” Kraska continues. “It’s due in large part, to the strength of our physician and executive leadership team and to our mission of constantly enhancing the ways we recruit the best emergency and hospital medicine physicians, along with the resultsfocused contract services we offer our hospital partners. Doing so ultimately leads to better patient care—and that’s job one for all of us.” ◆

PHYSICIAN RETENTION AND PREVENTING BURNOUT ARE TOP PRIORITIES IN HOSPITAL MEDICINE. MESA ADDRESSES THE ISSUES WITH SUSTAINABLE SCHEDULING AND DOCTORS’ MENTAL AND PHYSICAL HEALTH IN MIND. ISSUE#77 11

SPECIAL SECTION  PAIN MEDICINE

Ultrasound-Guided Imaging for Diagnosis & Treatment in Pain Management Cardinal Hill Pain Institute Advances Safety and Efficacy

BY GIL DUNN LEXINGTON William O. Witt, MD, founder and Medical Director of the Cardinal Hill Pain Institute began using ultrasound-guided imaging for diagnostic and therapeutic purposes in 2012. He sought a safer and superior imaging technique for the injection of medications into soft tissue for his patients. The implementation of ultrasound-guided imaging has “exceeded my expectations,” says Witt. “It allows me to perform the same procedures as before, but with greater accuracy and safety.”

Ultrasound is not new technology, but its use in pain management has evolved recently as pain medicine specialists seek more precision and better diagnostic capabilities. “There is no other technology that allows me to do what ultrasound-guided imaging does,” affirms Witt.

Witt has used fluoroscopically-guided imaging for injections for years and for many procedures this is the best or even the only appropriate technique. Fluoroscopy shows the bony structures that he needs to see in spinal injections. The advantage of ultrasound is the soft tissue imaging. “Ultrasound allows me to see the actual muscle fibers, tendons, ligaments and nerves so I can inject them very accurately,” Witt says. “I use it for diagnostic purposes to image abnormal anatomy and for therapeutic reasons such as injecting medication into a nerve sheath, tendon sheath, muscle or joint.”

Ultrasound imaging has proven beneficial in multiple other applications such as trigger point injections where the individual muscles can be identified. This is particularly important for the injection of Botox or Myobloc, neurotoxins that break spasm. It is also very useful in the thoracic area as the pleura can be visualized and the risk of accidental pneumothorax reduced as a result.

Accuracy in the filling of implanted pumps is also improved and confirmation that the medicine all went into the pump also eliminates the greatest risk otherwise associat12 M.D. UPDATE

Dr. Witt uses ultrasound to identify the access port and to confirm that all of the injected medication went into the pump.

ed with implanted pump refills. Furthermore, ultrasound allows Witt to show his patients, in real time, what he is accomplishing for them. “Patients who are educated about what we are doing are more relaxed and reassured.”

“Another advantage of ultrasound imaging is that I can use it as often as necessary on the same patient without radiation safety issues assuming the procedure can be done with ultrasound instead of fluoroscopy” says Witt.

The Cardinal Hill Pain Institute

Dr. Witt founded the Cardinal Hill Pain Institute in 2009 after a 29-year career at the University of Kentucky College of Medicine and Medical Center, where he was Chairman of the Department of Anesthesiology and Director of the pain management program and fellowship. Both at the University and in his current practice, Dr. Witt does not use controlled substances in the treatment of chronic pain. Dr. Witt was trained in this approach in 1978, a time when opioids were rarely, if ever used in treating chronic pain. “There were only two pain programs in the Country at that time, Denver, where I was trained, and Seattle. We had excellent results with this approach then and we still do today,” says Witt.

Combined with the outstanding therapy available at Cardinal Hill, including

physical therapy, balance training, gait training, multiple other treatments and the only heated therapy pool in Kentucky, Witt is able to provide a truly comprehensive approach. “I want my patients to not just feel better, but to actually get better.” A program of abstinence from nicotine, weight loss, appropriate exercise, behavioral counseling and other modalities, combined with non-opioid medications, targeted injections and minimally-invasive surgical procedures accomplishes this goal with most patients.

Patient Population and Education

The Cardinal Hill Pain Institute sees a wide variety of patients with all types of chronic pain. The youngest patient is 17 and the oldest is 99. The majority of younger patients seek relief from pain caused by trauma such as automobile accidents or sports injuries. The more mature patients usually suffer chronic pain from degenerative conditions.

Dr. Witt also has a “fast track FAX referral” system for referring physicians or other providers who do not need a comprehensive evaluation and treatment program but only need a specific diagnostic or therapeutic procedure. For these patients, the procedure can be done within just a few days and the referring practitioner will have a printed report by FAX or electronic submission the same day. Also, because of the way the practice is structured there is no facility fee associated with injective treatment in the Cardinal Hill Pain Institute. ◆

Cardinal Hill Pain Institute 2050 Versailles Road Lexington KY 40504 (859) 367 7246 (859 FOR PAIN) www.cardinal.org www.docwow.com

SPECIAL SECTION  PAIN MEDICINE

Genetic Testing: Tailored Medicine for Pain Patients

Frankfort Pain Specialist Adopts New Technology with Positive Results

BY GIL DUNN FRANKFORT Genetics-based Personalized Medicine has long been the medicine of the future – looming forever, it seems, one medical breakthrough from standard of care.

Promising though it has been, it is only recently that physicians have decided the time is now for incorporating Personalized Medicine into practice and those who don’t understand the genetics of their patients are likely to be left behind.

Nowhere is the individual more unique and important than in the treatment of pain. Fully 48% of patients presenting in pain clinics have genetic variations that indicate changes in dosing or drug selection. In addition, the entirely subjective nature of pain leaves physicians vulnerable to regulatory problems, since it has been impossible, in the past, to separate people who are really suffering from those who are merely seeking drugs.

Richard Lingreen, MD, of Commonwealth Pain Specialists in Frankfort has being employing genetic testing for his patients since the fall of 2012 with impressive results. “I can perform a simple cheek swab and within a week, or few days, have results that allow me to tailor the dosage of my patient’s pain medicine that will give us the highest accuracy possible for optimum results,” says Lingreen.

“Some call it Personalized Medicine. I prefer Tailored Pain Medicine,” he says.

The genetics of pain is based, like most pharmacogenetics for Personalized Medicine, on variations in the Cytochrome P450 (CYP) family of enzymes. It is now possible to detect genetic variations in the genes that control CYP. Those variations affect the pace at which the body uses the drug: how it is metabolized, transported, and received by an individual patient.

The tests are not hard to administer. For the clinician, it’s a simple swabbing of the

Dr. Lingreen takes a cheek swab from a patient whose CYP450 receptors had been found to be “poor.” Lingreen then tailored the most advanced & effective pain program possible.

patient’s cheek and sending it to a pharmacogentic diagnostic laboratory. The lab will test the set of genes that govern the effectiveness of medications used to treat pain.

It’s important that the lab chosen supply not just raw genetic data, but an interpretive report that gives physicians and patients the information they need to design an optimal treatment path: medications that will work and those that won’t, as well as dosage parameters and alternative treatment paths.

Lingreen says when the lab results come back, “the conversation changes. I have a much more informed, scientific, evidencebased reason for prescribing certain drugs for my patients, based on their DNA.” The treatment of pain often overlaps with treatment of other kinds. Here, again, genetics can simplify what has been almost impossibly complicated. Balancing the polypharmacy of pain and, for example, cardiology, takes a deft touch under the best of circumstances. Many of the cardiac patients

seen in pain clinics can also be managed better with genetic testing.

There are genetic tests that improve the treatment of patients taking anti-platelet and bloodthinning medications.

Understanding patient genotype can identify those in need of higher dosing, to safely anticoagulate, or lower dosing to avoid bleeding incidents.

But it is in the treatment of the combined effects of pain and depression where physicians like Lingreen use pharmacogenetics to truly tailor and personalize medicine. There are dozens of drugs available for the treatment of depression, and choosing between them is as much art as it is science. It can take months to find the right combination of drug and dosage, a compounding cycle of pain and depression. Lingreen says he has given lab results to primary care physicians who are treating his patients for depression.

While the application of pharmacogenetics to Personalized Medicine is science in its infancy, the results are helpful enough that Medicare and most private insurers reimburse the tests. There are newly developed and more specific tests coming along as well, promising physicians a transformational new tool in the treatment of their patients. Genes are being identified that govern not just the metabolism of drugs, but the transporters and receptors that heavily influence a drug’s effectiveness.

Researchers recently developed tests that determine which of the variant (10) different mu receptors the patient may have.

It’s no wonder, given the rapid evolution of pharmacogenetics and the increasingly obvious benefits of Personalized Medicine, ISSUE#77 13

SPECIAL SECTION  PAIN MEDICINE

Interpretation of CYP450 Test Results GENETIC TERMINOLOGY

ENZYME TEST RESULTS

COMMENTS

Extensive

Normal

The enzyme can metabolize a wide variety of drugs in a timely manner.

Rapid/Ultra-rapid

Defective/Abnormal

The enzyme metabolizes opiods too fast

Poor

Defective/Abnormal

The enzyme has almost zero metabolism

Intermediate(Slow)

Defective/Abnormal

The enzyme is about 30%to 70% less active

GOAL: Determine whether a defective CYP450 enzyme is present and should be avoided. These parameters are specific to Genelex laboratories (Seattle Washington) Reprinted with permission from Tennant F. Interpretations and actions following cytochrome P450 testing. Pract Pain Manage. 2013;13 (1):47-50.@2013 Vertical Health Media,LLC

that Lingreen and physicians in other specialties are incorporating genetics into their practices. It may not be long before genetics is as commonly a part of medical practice as blood typing and CBCs. It will take hold

first in specialties where the need is most desperate, where existing standards have the most room for improvement.

Genetic testing will spread, and as it does, it will provide both doctor and patient

confidence that the treatments administered are the best possible. “Personalized and tailored medicine means that my patients have the most technologically and medically advanced pain treatment plans,” says Lingreen. “It’s the ultimate in evidencebased medicine. It’s my patient’s DNA and it doesn’t get any more personalized or evidenced-based than that.” ◆

Commonwealth Pain Specialists, PLLC 279 King’s Daughters Dr. Suite 100 Frankfort, KY 40601 (502) 352 2530 Fax (502) 352 2534 www.cwpain.com

Community Supported Agriculture (CSA) members receive 22 weeks of the finest, freshest foods grown in Central Kentucky. Over 300 acres certified organic.

14 M.D. UPDATE

Personalized Medicine 201 E. Jefferson St., Suite 200 Louisville, KY 40202 502 569 1584 Visit www.PGXLab.com twaller@pgxlpartners.com

SPECIAL SECTION  PAIN MEDICINE

A Physiatric Approach to Chronic Pain Management marginally effective treatment plan usually requires a combination of treatment modalities, such as: physical therapy, exercise, injections, psychotherapy, and topical and oral medications. The risks and benefits

optimize physical functioning, despite pain.

This goal re-setting, however, requires As a doctor of Physical Medicine and time, the development of a sound doctorRehabilitation (Physiatrist), many of the patient relationship, patient education, and patients that I see in my clinic have some a shift in the mindset of the patient who kind of chronic pain complaint. may still believe that becoming “pain Joint pain, myofascial pain/fibrofree” is likely. It requires the patient myalgia, nerve pain, neck pain, lowto come to terms with a new paradigm back pain – that states that optimal, as good as posany, all, or a combination of sible, physical functioning – at home these, even in the same patient, is not and at work and during community uncommon. and recreational activities – is now at Rarely am I the first physician the center of the treatment plan. The that a particular patient has seen for complete elimination of pain is no their chronic pain. longer the ultimate goal. Function As such, they often present with is now the focus. The patient’s pain, an extensive treatment history. Some as a result, simply becomes one of treatments are ongoing while others the many potential variables that can have been tried and failed. Some influence how a person is able to funcpatients have undergone surgery. tion. That is not to say that the level Sorting out this history is time conof a patient’s pain is not addressed, suming but important. monitored, and treated. It is, but for In the eyes of these patients, the sake of functional goals, the treatand as soon as I introduce myself, ment of pain is a means to a functional I become their new “Pain Doctor.” end.

Patient expectations are high From a physiatric and functional George P. Boucher, MD, physiatrist, because, unlike all the other standpoint, patients can be reached at Kentucky physicians they have seen in the Orthopaedic & Hand Surgeons, (859) with chronic pain are OFTEN TIMES, THERE past for their pain, they seem not unlike patients 278-3481 and www.kybones.com ARE EMOTIONAL AND to think that I have the “magic who have suffered a wand” that will make it all better. of any treatment PSYCHOSOCIAL INFLUENCES spinal cord injury, Often times, there are emotional and “ingredient” need to stroke, or ampuTHAT SIGNIFICANTLY psychosocial influences that significantly be considered. tation.

Patients weigh upon the physical manifestation of Although com- WEIGH UPON THE PHYSICAL who suffer from a person’s pain. For some patients, this plete resolution of a chronic pain are emotional “baggage” may have been pres- patient’s pain would MANIFESTATION OF A also impaired and ent before the onset of the physical pain. appear to be the goal PERSON’S PAIN. disabled. However, For other patients, it has come to the sur- of “pain manageand similar to those face since, or because of, the pain. Either ment,” more times patients whose lives way, this mind-body relationship cannot than not, and the more chronic the pain are altered by other neuromusculoskelatal be ignored and as a result, it is pointless becomes, this is unrealistic. Remember, injuries, a chronic pain patient’s impairto attempt to treat, or even understand, these are patients who have been symptom- ment and disability does not need to result chronic physical pain without delving into atic for years despite having been involved in a handicap. Remember, a handicap is the a patient’s “person.” It is no doubt easier in “pain management.” limitation of the fulfillment of a role that and much less time consuming, but this Rather than an unrealistic goal of pain is normal for a person. A handicap keeps approach is incomplete and ultimately less elimination, or even a significant reduction a person from accomplishing life’s basic successful. You just need to open up that in pain, a more appropriate and poten- activities.

Patients with chronic pain do not need “can of worms.” tially achievable goal in the management In the end, an effective, sometimes only of patients with chronic pain is to try to to be handicapped. ◆

BY GEORGE P. BOUCHER, MD

ISSUE#77 15

SPECIAL SECTION  PAIN MEDICINE

Feeling Good About Pain Management

A Lexington Clinic Doctor Moves the Treatment of Acute and Chronic Pain Forward

BY TIM CORKRAN As a medical student, Lexington Clinic’s Michael E. Harned, MD, board-certified in anesthesiology and interventional pain medicine, glimpsed a possible future for pain management. A University of Kentucky mentor was moving away from narcotics as the default treatment for chronic and acute pain, using devices and injections instead.

Harned says “He made a big impact on me as far as what a pain physician could actually achieve.”

That impression compelled Harned towards interventional pain management, which relies on a broad range of techniques and abundant communication between consulting physicians. Harned calls it “comprehensive pain management,” where he offers interventional techniques, while caring for the patient’s whole Michael E. Harned, MD, boardneeds. If non-narcotic medications certified in anesthesiology and can be used first, he employs those interventional pain medicine took coordinating care. his fellowship in chronic pain at UK. before moving to controlled mediMore of my time cations. Harned’s inclinations about pain is spent delivering care.“ management have evolved into a modern, And it’s working. Having harnessed the collaborative approach that serves patient twin attributes of his generation, willingness and Lexington Clinic alike. to collaborate and comfort with technology, Harned’s practice at Lexington Clinic is seeing more patients than ever, and he enviRefining the Vision sions expanding it.

After a general surgery internship at UT Medical Center in Knoxville and residencies in anesthesiology at UK, Harned took Modern Pain, Modern Tools a fellowship in interventional chronic pain As evidenced by Harned’s patient popuat UK. He chose to join Lexington Clinic lation, the growth of pain management in December of 2011. Lexington Clinic’s needs in Central Kentucky is the result of appeal was the opportunity for collaboration two phenomena: aging boomers who insist that Harned sees as integral to effective com- on staying active and trauma in athletes prehensive pain management: “I feel that in the 16-25 demographic. “Most of my Lexington Clinic offers an amazing oppor- patients come to me for back and leg pain tunity to care for patients in a model way. due to lumbar disc herniations, neck and You have easy access to their family physi- arm pain due to cervical disc herniations, cians, their neurologists and surgeons so that and low back pain due to musculo-skeletal everyone is moving in the same direction.” disorders. I see a fair amount of postherHarned’s youthful energy- he replaced petic neuralgia in our older population,” three outgoing pain physicians– was bol- Harned says. stered by deft usage of clinic-wide EHR. Increasingly, Harned sees a steady stream “Within Lexington Clinic,” he says, “I use of cancer patients, many from Lexington the EHR to know exactly what the primary Clinic’s John D. Cronin Cancer Center, care physician for any one of my patients is who suffer from chronic cancer-related thinking, so I spend less time on the phone pain. He explains, “cancer treatments have 16 M.D. UPDATE

come so far, but while they are more effective in fighting cancer, they oftentimes leave patients with pain.”

Complex regional pain syndrome and auto-immune diseases like lupus also contribute to his patient-load.

Only a small percentage of Harned’s treatment plans use narcotics. Instead, he employs interventional treatments such as neuroablation and neurostimulation to manage pain at its point of origin and pain pumps that deliver steroids and opioids where applicable. Harned also uses ultrasound-guided injection when appropriate to reduce the radiation risk of fluoroscopy.

Seeing the Future of Pain Management

Like many pain specialists, Harned looks forward to a more sophisticated approach to dosing and ultimately less dependence on opioids. Pharmacogenetics could be the answer. Practitioners can utilize genetic testing to know what to expect pharmacologically from patients who are reporting higher dosaging needs than are normally expected. Genetic testing is costly and challenging for patients now, but he expects that will change.

A critical advancement in pain management that Harned foresees is the evolution of injected material. He opines that “our injections will be to the same places but will be of platelet rich plasma that has been spun down from the patient’s own blood.” With this, Harned believes “that steroids will be a thing of the past.” He knows that nerve stimulation and drug delivery have room for evolution also.

While Harned is energized about the future of pain medicine, its present is vibrant at Lexington Clinic. For him, “tailored individual therapy is what we need to do” and his interventional approach at Lexington Clinic, with a robust EHR system and family physicians and specialists close at hand, is effectively moving him towards that future he envisioned in medical school. ◆

SPECIAL SECTION  PSYCHIATRY

Integrative Psychiatry Participates in Study of Transcranial Magnetic Stimulation for Postpartum Depression

BY JENNIFER S. NEWTON Drs. Randy Schrodt, Jr., Chris Schrodt, and Robyn Stinnett of Integrative Psychiatry in Louisville (profiled in M.D.Update, January 2012) continue to expand the use of transcranial magnetic stimulation (TMS) in their psychiatric practice. TMS, an FDAapproved therapy for depressed patients who have failed to benefit from prior antidepressant therapy, is a noninvasive form of focused brain stimulation that uses rapid, repetitive, high energy magnetic pulses comparable in strength to MRI. The magnetic pulses generate an electrical field and cause neuronal depolarization in a small area of the adjacent cortex, as well as distal effects in other brain regions involved in depressive disorders. Unlike electroconvulsive therapy (ECT), TMS does not involve general anesthesia or seizure induction, and no impairment of cognitive function is encountered.

Integrative Psychiatry is one of 42 clinical practice sites, both university and private practice, that participated in a recently completed and published “real world” study, “Transcranial Magnetic Stimulation for Major Depression: A Multisite, Naturalistic, Observational Study of Acute Treatment Outcomes in Clinical Practice” (Carpenter et al, Depress. Anxiety, 29:587-596). The results show that response and adher-

ence rates are similar to those observed in research populations.

In this study, clinician-assessed response (>50% improvement) rates were 58%, with 37% of previously treatment refractory patients achieving full clinical remission.

This spring, the results of the follow-up 3, 6, 9, and 12-month assessments will be pub- Standing from left Dr. Robyn S. Stinnett, Dr. Chris lished, which Schrodt and will provide Dr. Randy Schrodt (seated) i m p o r t a n t partners in Integrative information Psychiatry about the durability of antidepressant benefit with TMS. Integrative Psychiatry has also been selected as a research site for a new study on the use of TMS in postpartum depression.

Postpartum depression (PDD) has been reported in 10-15% of women following delivery. It is the most common complication of childbirth, and 20% of deaths in the postpartum period are due to suicide. PDD is strongly associated with lower quality

of maternal-infant bonding, early discontinuation of breastfeeding, higher risk of impaired cognitive and emotional development in the child, as well as negative impact on other members of the family. Although antidepressant medications are commonly used in the treatment of PPD, they are usually excreted in breast milk. Many nursing mothers wish to avoid exposing their infants to these antidepressants, and the unknown future effects. In addition, a significant number of depressed woman do not adequately respond to antidepressant medication, and many experience intolerable side effects. Transcranial magnetic stimulation is unique compared to other somatic therapies for depression because there are no systemic side effects that would interfere with child care, and no risk of exposure to the infant through breastfeeding.

Physicians or patients interested in more information about transcranial magnetic stimulation or eligibility for the postpartum depression study can check louisvilleTMS. com, or contact Randy Schrodt, Jr., MD at (502) 327-7701. ◆

2335 Sterlington Road, Suite 100 Lexington, Kentucky 40517 (859) 268-1040 Fax: (859) 268-6165 Email: lprober ts@barcpa.com www.barcpa.com

ISSUE#77 17

SPECIAL SECTION  PSYCHIATRY

When Physicians Become the Patients

The Morton Center provides substance abuse treatment for health professionals

BY JENNIFER S. NEWTON LOUISVILLE As health professionals, you know Kentucky is suffering from a substance abuse epidemic, particularly when it comes to opioids. In fact, Forbes ranked Kentucky as the fourth most medicated state in the nation in 2010. But, did you know the number of health professionals with substance abuse problems is on the rise in Kentucky?

According to the Kentucky Physicians Health Foundation, a not-for-profit foundation whose charge is to assist and monitor licensed healthcare professionals with addictive, emotional, or mental illnesses, 125 to 160 physicians are monitored annually with an average of 40 new cases per year.

However, Priscilla McIntosh, CEO of The Morton Center in Louisville, says her organization can help. The biggest misconception about The Morton Center, according to McIntosh, is a lack of knowledge about their services. The Morton Center treats adults, adolescents, and children, including health professionals affected by substance abuse and chemical dependency, and their services are available not only to patients but also to family, loved ones, and co-workers.

Recovery Services

The Morton Center provides outpatient chemical dependency treatment in four locations in Kentucky: Louisville, Lexington, Paducah, and Ft. Mitchell. “Many of the physicians I work with who refer to us are shocked to find out the Intensive Outpatient Program is really the highest level of care that most third-party payers will recognize to reimburse,” says Claude C. Drouet, M.Div., ACSW, LCSW, health professional recovery counselor in Louisville.

He contends inpatient programs can be very costly and are not typically covered by insurance. McIntosh emphasizes that all the 18 M.D. UPDATE

allow for gradual return to functional living.

Group therapy and expressive therapy are also vital parts of the program.

Health Professional Recovery Program

Priscilla McIntosh, CEO, The Morton Center

organization’s services are billable through third-party payers, and because they are privately funded, they have resources for assistance. “We want to make sure [potential clients] get the help they really do need and not let that financial burden stop them,” McIntosh says.

For Drouet, a major component of treatment is helping the individual understand that recovery is a life- Greg L. Jones, MD, long endeavor. KPHF Medical Director Treatment services at The Morton Center begin with a thorough assessment from a licensed psychotherapist. Each participant is assigned an individual counselor and undergoes individual sessions, as well as family sessions, throughout treatment. The Intensive Outpatient Program (IOP) includes four phases designed to decrease in intensity and

The Morton Center’s Health Professional Recovery Program is focused exclusively on the needs of physicians, nurses, allied health professionals, and anyone who holds a license to practice medicine.

Drouet and his co-worker Karen L. Smith, CADC, are the two primary health professional recovery clinicians at the center. According to Drouet, chemically dependent physicians are oftentimes blindsided by their dependency. “It almost always used to be their patient loads and family responsibilities at home, Claude C. but let’s face it, more and Drouet, M.Div., more doctors are feeling ACSW, LCSW the crunch of the business model impinging on them, more and more doctors are employed and are not accustomed to that … So many doctors have to deal with patient satisfaction surveys, and many times satisfying a patient is not necessarily the same thing as good medicine, so doctors are just getting caught every which way,” says Drouet.

Physicians typically come to the center because they are under contract with the KPHF. KPHF Medical Director Greg L. Jones, MD, acts as an intermediary between The Morton Center and the Kentucky Board of Medical Licensure. “We have had a long and fruitful relationship with The Morton Center. Our participants all over Kentucky benefit from this relationship.

The level of professionalism and caring

our participants are shown has resulted in improved long term outcomes,” says Jones.

At The Morton Center, catering to the needs of health professionals is key.

Meetings are held in the evening and at times convenient for those who are still working. To maintain confidentiality, the center has a back entrance and is developing a connected treatment area. This is particularly important for some physicians who do not want to chance seeing their own patients in the waiting area.

Abstinence Alone is Not Recovery

Typically physicians who are on a multi-year contract with KPHF are required to undergo random drug screening, group therapy for one to three years, and individual therapy, which may include the physician’s family or spouse. “[The boards] are interested in whether a person is understanding the principles of recovery because recovery is far more than just being abstinent of the substance of choice,” says Drouet. Abstinence means avoiding the behavior. However, a psychoactive substance, whether legal or illegal, such as alcohol or opioids, changes the brain’s emotional, reasoning, and cognitive processes. “A lot of our treatment is

know someone affected by substance abuse?

WE ARE HERE TO HELP. We offer specialized counseling for adults and adolescents, as well as education for individuals and families struggling with the effects of substance abuse and addiction.

Louisville • Lexington • Ft. Mitchell • Paducah Phone: (502) 451-1221 • Toll Free: (888)421.4321 www.themortoncenter.org www.facebook.com/TheMortonCenter • @TheMortonCenter

RECOVERY IS MORE THAN JUST ABSTINENCE. identifying these emotional changes and how to deal with them,” says Drouet. For instance, if a patient brings their leftover Oxycontin back to the doctor because they are feeling better, it can be a trigger for someone with chemical dependency.

In recovery, The Morton Center addresses many situations and provides a repertory of responses to deal with the triggers of their unique situations.

“I think we’ve been very successful in treating health professionals. Health professionals tend to get better in the context of group work,” offers Drouet.

Their success is also measured empirically by the number of health professionals who complete their contracts, however even those not on contract are on a treatment plan that can be reviewed, evaluated, and fine-tuned as necessary. ◆ ISSUE#77 19

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Oldham joins Baptist Surgical Associates

John S. Oldham Jr., MD, FACS, FASMBS, bariatric surgery, has joined Baptist Surgical Associates, along with Nurse Practitioners John S. Oldham Jr., Sarah K. Kinser, MD, FACS, FASMBS APRN, and Jeannie C. Mattingly, APRN. Oldham is a 1995 graduate of the University of Louisville School of Medicine. He completed his general surgery residency at Wright State University in Dayton, Ohio, in 2000, serving as chief resident his final year. He is board certified in general surgery, and performs a variety of minimally-invasive weight-loss procedures.

Kinser is a 2011 Sarah K. Kinser, APRN graduate of the acute care nurse practitioner program at the University of Kentucky. She holds a bachelor’s degree in nursing from the University of Kentucky, and will graduate from the Madisonville Community College certified surgical first assist program in May. Mattingly is a 2011 graduate of the Spalding University acute care nurse practitioner proJeannie C. Mattingly, APRN gram. She holds a bachelor’s degree in nursing from Spalding University.

Their office is located at 3900 Kresge Way, Suite 42. They are accepting new patients.

LOUISVILLE

20 M.D. UPDATE

Kerri Remmel, Director of University Hospital’s Stroke Center

University Hospital named first Comprehensive Stroke Center in Kentucky, 20th in the U.S.

LOUISVILLE University of Louisville Hospital has become the first facility in Kentucky, and the 20th in the nation, to earn Advanced Comprehensive Stroke Center (CSC) designation from The Joint Commission. CSC is the newest and highest level of Joint Commission certification for stroke centers; formerly, Primary Stroke Center certification was the most distinguished level, which University Hospital obtained in 2004.

CSC designations recognize those hospitals with the most advanced equipment, infrastructure and staff, and physicians, making it possible to treat complex stroke cases. University Hospital met those standards as determined by Joint Commission surveyors following a two-day site visit.

The impact of CSC certification will reach many cities in Kentucky considering 50 hospitals in western and central Kentucky and southern Indiana transferred patients to University Hospital’s Stroke Center from 2011-2012.

“Stroke is the fourth-leading cause of death and the leading cause of longterm adult disability in the United States.

Additionally, Kentucky ranks above the national average in the prevalence of many stroke risk factors (high blood pressure, smoking, diabetes, lack of exercise, obesity, high cholesterol),” said Kerri Remmel, Director of University Hospital’s Stroke Center.

“Kentucky needs the best stroke care, and University

Dr. Warren Boling, Chief of Neurological Surgery at University Hospital

Hospital becoming a Comprehensive Stroke Center is the next step in advancing that care in our region and state.”

A primary emphasis of CSC guidelines is to demonstrate collaboration between neurology and neurosurgical services.

Though neurologists treat a vast majority of stroke patients at University Hospital, there are cases in which neurosurgical services are needed. The teamwork between the two is

FROM LEFT TO RIGHT: Dr. Warren Boling, Chief of Neurosurgery at University Hospital; Dr. Kerri Remmel, Director of University Hospital’s Stroke Center; Jim Taylor, University Hospital CEO; Angela Krohn, stroke survivor and former University Hospital patient; Angela’s son, Andrew; Angela’s husband, Brad; Congressman John Yarmuth; James Ramsey, UofL President

critical in managing complex stroke cases.

“University Hospital’s CSC designation signifies our commitment to providing multidisciplinary stroke care,” said Dr. Warren Boling, Chief of Neurological Surgery at University Hospital. “This means that our neurology and neurosurgical teams are working together to provide individualized stroke care. We are able to determine as a team which treatment is best for each patient.”

Kyprianou named to Johns Hopkins Society of Scholars

LEXINGTON Professor Natasha Kyprianou, the James F. Hardymon Chair in Urologic Research at the University of Kentucky College of Medicine, has been elected to the Johns Hopkins Society of Scholars.

The society was established in May 1967 by the trustees of the University to honor former Johns Hopkins postdoctoral fellows and junior or visiting faculty,

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Intrathecal Pumps Vertebroplasty

Spinal Cord Stimulation Neurolytic & Sympatholytic Denervation

The achievement award is based on continued high scores in a number of areas including: aggressive use of medications, such as antithrombotics, anticoagulation therapy, deep vein thrombosis prophylaxis, cholesterol reducing drugs and smoking cessation, all aimed at reducing death and disability and improving the lives of stroke patients, including risk-factor education.

In addition to the Get With The Guidelines-Stroke award, Jewish Hospital has also been recognized as a recipient of the association’s Target: Stroke Honor Roll, for the quick and effective administration of tissue plasminogen activator (tPA), or clotbusting agent, within 60 minutes of arriving at the hospital (for eligible ischemic stroke patients.) These are the only drugs approved by the Food and Drug Administration for the urgent treatment of ischemic stroke. If given intravenously within the first three hours after the onset of symptoms, tPA has been shown to significantly reverse the effects of stroke and reduce permanent disability.

Baptist Health announces two cardiology pilot programs

Baptist Health, the Louisville Cardiology Group (part of Baptist Medical Associates) and regional EMS services have formed a regional network to help ensure that patients experiencing a major heart attack are taken directly to the nearest properly equipped facility and receive a cardiac catheterization within the 90-minute national standard.

Two pilot programs were announced in late February to activate the Cath Lab from the ambulance. Activating the Cath Lab before arriving at the hospital cuts the patient’s risk of dying in half.

One pilot allows EMTs to perform electrocardiograms (now restricted to paramedics). If successful, this could improve heart attack care throughout Kentucky as many rural areas have few – if any – paramedics.

LOUISVILLE

TAKE ON SUMMER YMCA Healthy Kids Day™ Fun Fest

Sunday, April 21, 2013 2-5 p.m. • UK Nutter Field House Free and open to the community!

Games, activities, inflatables, relays ... Fun for all ages! www.ymcaofcentralky.org 22 M.D. UPDATE

Alltech Symposium to Explore Major Human Health Challenges, Medical Advances of Next Seven Years

Advances in medical science have extended life yet present humanity with a new set of challenges - diseases of old age. In addition, increasingly sedentary lifestyles add another layer of “modern”

LEXINGTON

NEWS ailments to the mix, such as metabolic syndrome and Type 2 diabetes. The Life Sciences session at GLIMPSE 2020, the 29th Annual Alltech International Symposium in Lexington, Ky., USA, from May 19-22, will explore how lifestyle changes, genomics, diagnostics and nutrition can be merged to better manage and prevent the diseases of the modern era.

“We will have to take radical steps in the next decade if we hope to avoid twin pandemics: Alzheimer’s disease and Type 2 diabetes,” said Dr. Ronan Power, vice president of Life Sciences at Alltech and chairperson of the Life Sciences session at the 2013 Alltech Symposium. “A great deal of prevention can be achieved by convincing at-risk individuals to alter their behavior, for example, through diet and exercise. However, it’s likely that this approach will, at best, be only moderately effective so we have to look at the other tools we have at our disposal - early diagnosis and warning as well as direct biological intervention to counter the effects of poor lifestyle habits. Alltech’s 2013 Symposium will provide a forum for discussing these challenges with colleagues and leading experts.”

New in 2013, Alltech International Symposium delegates will have the opportunity to select breakout session tracks.

These tracks, as opposed to traditional species or subject breakouts, will offer attendees a more holistic experience in which they take part in discussions ranging from algae and agriculture’s carbon footprint to nutrition and marketing.

For more information, or to request an invitation, contact a local Alltech representative, visit www.alltech.com/symposium or email symposium@alltech.com. ◆

To learn more about working with MESA, contact us today.

1-877-601-6372 MESAMedicalGroup.com

ISSUE#77 23

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"Bottoms Up Bash" Raises Awareness for Colon Cancer Prevention

Regan Judd, Dr. Sylvia Cerel-Suhl, Board president AHA Central KY chapter and artist Andre Pater

Organizers of the 2nd annual “Bottoms Up Bash” a fundraiser for the Colon Cancer Prevention Project, (CCPP) founded by Dr. Whitney Jones, report that over 500 people attended the event on March 1st 2013 at the Mellwood Art Center in Louisville, KY. More than $40,000 was raised through

Photo 1: David Cassidy, MD, Commonwealth Cardiology Associates, with wife Karma and Bill Harris, MD Pikeville Medical Center Heart and Vascular Institute.

24 M.D. UPDATE

Photo 2: Gil Dunn, MD Update, Robert Salley, MD, Executive Director of Cardiovascular Services for Saint Joseph Hospital and Calvin Rasey, Physicians Financial Services

Bruce Belin, MD, Thomas Slaybaugh, Jr MD, Larry Cunningham,Jr. MD, LMS president and Danesh Mazloomdoost, MD were speakers and presenters at the march LMS meeting.

AMA President-elect Speaks at Lexington Medical Society Dinner Meeting

Central Kentucky Heart Ball Sets A New Record, Honors Jim Host

The 25th annual Central Kentucky Heart Ball, held on Saturday, February 16, 2013 drew record crowds and raised more than $250,000 to support cardiovascular research and preventative education in the local community. This event, chaired by Terry and Ann McBrayer, featured musical selections performed by the UK Opera Theatre. The evening also honored Jim and Pat Host for their contributions to Kentucky.

Proceeds from the Heart Ball go to the American Heart Association, which funds public and professional education, advocacy, and cardiovascular research. The goal of the association is to reduce the risk of heart disease and stroke by 20% by the year 2020, while reducing the number of deaths from heart disease and stroke by 20%.

EVENTS

Attendees at the Bottoms Up Bash decorated underwear that will hang in the Mellwood Art Center in Louisville throughout March to raise awareness of colon cancer screening.

ticket sales and a silent auction.

The CCPP, a 501 (3)(c), is an independent not for profit dedicated to eliminating preventable colon cancer in Kentuckians through education, advocacy and health system improvements. It was founded in 2004

by Jones, a Louisville gastroenterologist.

In eight years since the CCPP began, Kentucky has improved its rank of states with colon cancer screening from 49th to 32nd and the colon cancer incidence and mortality rates have declined 16%.

In 2012, the CCPP successfully led the advocacy effort to fund the Kentucky Colon Cancer Screening Program, and is a partner in the Screening Program for low-income, uninsured individuals in Louisville. “We are continually overwhelmed by the number of people who are committed to the Colon Cancer Prevention Project,” says Jones, “and we are grateful for their support.”

Dr. Whitney Jones and his The Bottoms mother Wanda Jones, a Up Bash event CCPP volunteer, celebrate was presented by the success of the Colon K e n t u c k y O n e Cancer Prevention Project.

Health.

Ardis Dee Hoven, M.D., president-elect of the American Medical Association, spoke briefly at the Lexington Medical Society meeting March 12. Hoven discussed her approaching inauguration as president of the AMA, and she said she is implementing a bidirectional communication effort to listen to physicians across the country. She applauded members of LMS for their leadership, saying that leadership at the local level is much more difficult, and she thanked members for their support in helping her rise to the AMA presidency.

Fo l l o w i n g Hoven, preDr. Ardis Dee Hoven, sentations were AMA president-elect given on changes encouraged doctors to be in medical treatengaged in local medical ments by Bruce societies.

Belin, MD, on colon cancer, Danesh Mazloomdoost, MD, pain management, Thomas Slaybaugh, Jr, MD, on psa screening for prostate cancer and Thomas Wayne, Jr, MD on cardiology.

Larry Cunningham, Jr, MD, LMS president presided. ◆

Bruce Broudy, MD, LMS past president with B.T. Westerfield, MD and Marty Luftman, MD, at the March meeting of the Lexington Medical Society.

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