M.D. Update Issue #78

THE BUSINESS MAGAZINE OF KENTUCKY PHYSICIANS AND HEALTHCARE ADMINISTRATORS Issue #78

Special Section

Women’s Health

A Mission of Compassion and Equality

Volume 4, Number 3

Common values unite the physicians of Women’s Care and Family Care of the Bluegrass

Also in this issue  The Psychology of OB/GYN  Stem Cell Therapy for

Pelvic Organ Prolapse

 Creating a Niche Urology Practice  Integrating Sexual Medicine with Sex Therapy

We’re improving access to quality health care because you live and work here.

Better care is here. And here to stay.

At KentuckyOne Health, we’re continuing to improve access to high quality health care. We believe that every Kentuckian from the hills of eastern Kentucky to the city of Louisville should receive the same level of care.

As we welcome the University of Louisville Hospital and the James Graham Brown Cancer Center into our system, our more than 200 health care locations from hospitals to home health agencies are more committed than ever to creating healthier communities across Kentucky.

Continuing Care Hospital Flaget Memorial Hospital Frazier Rehab Institute James Graham Brown Cancer Center

Jewish Hospital Jewish Hospital Medical Centers: East, South, Southwest, Northeast Jewish Hospital Shelbyville Jewish Physician Group

Our Lady of Peace Saint Joseph Berea Saint Joseph East Saint Joseph Hospital Saint Joseph Jessamine

KentuckyOneHealth.org

Saint Joseph London Saint Joseph Martin Saint Joseph Mount Sterling Saint Joseph Physicians Sts. Mary & Elizabeth Hospital

University of Louisville Hospital VNA Nazareth Home Care The Women’s Hospital at Saint Joseph East

from the publisher’s Desk

Welcome to Women’s Health, 2013 We often read and hear that the

woman is the guardian of the family’s healthcare system. There is a current

Publishers

Gil Dunn Print gdunn@md-update.com Megan Campbell Smith Digital mcsmith@md-update.com Editor in Chief

advertising campaign from Baptist

Jennifer S. Newton jnewton@md-update.com

Health that makes a statement and

Graphic Designer

asks the question of a woman with her child, “You’re taking care of her,

James Shambhu art@md-update.com

but who’s taking care of you?”

Contributors:

In this issue of M.D. Update, our Woman’s Health issue, we profile Kentucky physicians and health care providers who have dedicated their professional careers to taking care of women and their families. We offer you the opportunity to meet and hear from multiple OB/GYN physicians, a family medicine practitioner, a urologist, midwives, a therapist, a nutritionist and an organic farmer.

We think each has a unique story and valuable insights to share.

Valerie Areaux, MS, LMFT Emily Dial, APRN, CNM Lisa English Hinkle Scott Neal Matthew S. Smith Kathleen Stanley, CDE, RD, LD, MSEd, BC-ADM Mac Stone

Contact us:

Advertising and Integrated Physician Marketing:

Gil Dunn gdunn@md-update.com

Mentelle Media, LLC

Future Issues of M.D. Update Please review the Editorial Calendar on page 31 and look for your specialty among future issues. To participate, give us a call (859) 309 0720, send a text to (859) 608 8454 or email gdunn@md-update.com.

I look forward to hearing from you and telling your story.

All the Best, Gil Dunn Publisher, M.D. Update

Submit your Letter to the Editor to Jennifer S. Newton at jnewton@md-update.com 2 M.D. Update

Volume 4, Number 3 Issue #78

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Contents

Issue #78

cover story 2 FROM THE PUBLISHER’S DESK 4 HEADLINES 5 FINANCIAL AFFAIRS 6 ACCOUNTING 7 LEGAL 8 COVER STORY 13 SPECIAL SECTION:  WOMEN’S HEALTH

22 SPECIAL SECTION:  COMPLEMENTARY CARE:

22 SEXUAL HEALTH 23 NUTRITION - CLINICAL 24 NUTRITION - HOLISTIC 25 NEWS

A Mission of Compassion and Equality

32 EVENTS

Common values unite the physicians of Women’s Care and Family Care of the Bluegrass

By Jennifer S. Newton  page 8

Special Section   Women’s Health 14 PSYCHOLOGY OF OB/GYN 16 NEW TECHNIQUES FOR PROLAPSE REPAIR 20 CREATING A NICHE UROLOGY PRACTICE

 Complementary Care

14

16

20

22

22 SEXUAL HEALTH

Issue#78 3

Headlines

Norton Suburban Hospital, future home of Norton Women’s and Kosair Children’s Hospital LOUISVILLE The campus is in the midst of an $89.7 million conversion to Norton Women’s and Kosair Children’s Hospital.

Many changes have taken place over the past several months, and the next will be a 16-bed adult intensive care unit, planned to open this summer. Other transformations under way include

creating a dedicated inpatient migraine treatment unit, a onestop breast health center, a multidisciplinary pelvic health program, a comprehensive bone health program and specialty programs for eating disorders and integrative medicine. “We will continue to maintain a 373-bed, acute care facility serving men, women and children, but the new hospital will have dedicated women’s programs that cannot be found anywhere in the region,” said Charlotte Ipsan, RNC, MSN, NNP-BC, president of Norton Women’s and Kosair Children’s Hospital. ◆

UofL Center for Women & Infants addresses growing problem with neonatal abstinence syndrome

LOUISVILLE The University of Louisville Center for Women & Infants is on the forefront of helping Kentucky handle a growing problem – babies born with neonatal abstinence syndrome (NAS) as a result of being exposed to drugs in the womb.

Center staff drew attention to the problem in May as the nation observed National Alcohol and Drug-Related Birth Defects Awareness Week and participated in a May 20th meeting on NAS convened by the Kentucky Department of Health’s Division of Maternal and Child Health with director Dr. Ruth Ann Shepherd.

Cases in Kentucky of NAS have increased 11-fold in the past decade – from 67 in 2001 to 730 in 2011. At the CWI, staff began seeing a sharp increase eight years

ago and began developing new treatment models to address it.

“In 2004, we had about six babies born with NAS all year,” said Pauline Hayes, clinical nurse manager for the neonatal intensive care unit (NICU). “That number jumped to nine cases in the first six months alone in 2005.

While some babies exposed to drugs or alcohol in the womb show no signs of NAS or other problems at birth, “we know that 75 percent of babies exposed in utero will require hospitalization and treatment after birth – and the research available now gives us no way to know in advance which babies will be OK at birth despite exposure and which babies will need treatment,” Hayes said.

“Our best evidence-based medicine shows that giving drug-for-drug and gradually decreasing the dose works best for these babies,” Hayes said.

“We do not want any baby to go home from the hospital still on medications.” ◆

Would you rather be here?

Or HEAR?

Engineered for performance.

4 M.D. Update

Financial Affairs

And then there was the FED At this writing the Federal Reserve has just announced a strategy for unwinding the $85 billion-a-month buying spree. What will this move mean to you and me? In case you are not aware, the Fed has been buying bonds on the open market at the rate of $85 billion a month since last September. The bond buying programs, the first of which began in 2008, were designed to push down long term interest rates and to push up sentiment that would hopefully lead to more borrowing, spending, and ultimately more hiring in the broader economy. The economy however has not responded.

When the Fed buys on the open market, it turns to its primary dealers (about 20 large banks) and issues reserves in exchange for those bonds. It is hoped that those reserves will stimulate the economy via loans, by a multiplier of 10 to 1. In order for the desired effect (growth in the economy) to occur, those banks must be willing and able to lend, AND they must find willing and able borrowers. What has happened is

the amount of bond buying left some market analysts scratching their heads. Did such an acknowledgement mean that the economy is actually slowing down and that he Fed believes that

BY Scott Neal more stimulus might be needed? The data from April seemed to bear that out. Employment data were weak and inflation has once again dropped. We, like everybody else, have to wait and see. Meanwhile you and we have to make investment decisions in a highly complex world. Where does this leave us?

Let’s go back to fundamentals.

We happen to believe in the primacy of GDP growth as the principal driver of future prosperity in our society. As you may recall, Federal spending is an additive component of GDP while taxes subtract. But most recently government spending has been reduced as a result of sequestration and taxes were increased for everybody, high earners in particular. Many regarded these as necessary to reduce the national debt; however, the effect on the economy will most likely be shrinkage, not growth, in the not-toodistant future.

In spite of the recent drop in unemployment from 8.1% to 7.5%, and the rapid rise of the stock market to new high, the economy lacks the robustness needed to grow on its own, i.e. without unusual stimulus of some sort. That has to be made up with other components of GDP, notably consumer spending or a reversal in the trade deficit. As we have noted in previous articles, it would take a spending spree, fueled by borrowing, on the magnitude as

The Fed’s actions in the next few months have the potential of a huge impact on all of us that the banks have either chosen or been forced to simply hold the reserves. They have then used their other capital to bolster their investment portfolio, driving the stock market to new heights.

The announcement left the bosses at the Fed plenty of wiggle room. Officials have said that they plan to reduce the amount of bonds they buy in careful steps, leaving room for turning the dial back up or simply holding it at a given level for quite some time. They would not hint at a date for beginning the shift.

Even to suggest that they might increase

that seen in the mid-‘90’s for the kind of growth that we truly need to materialize.

The huge overhang of the as-yet unimplemented provisions of ObamaCare and the ever increasing number of baby boomers entering retirement indicates that the pressure for a pretty serious storm seems to be brewing on the horizon. In other words, the Fed’s actions in the next few months leave us with a potential of a huge impact on all of us, even if we don’t regard ourselves as big investors. This seems to be particularly true if we hold too strongly to one set of beliefs about the market and economy (either that it is bound to keep going up or that it is bound to have a correction).

There is increasing evidence that we all need to morph our market risk assessments into economic policy risk assessments. By that, I mean to say that in the past, the Fed’s actions mattered to you and me much less than they will in the future. Our investment policies should be determined in large measure on whether we think that the Fed (and other policy makers around the world) will adopt the right policies and that those policies will be effective in getting economies growing again.

At the risk of over-simplification, you should become more aggressive if you believe that they will be effective and more conservative if you think they won’t.

Unfortunately, the traditional monetary and fiscal policies are not likely to be enough, so what we really need to be looking for are new and innovative control measures.

Disappointingly, those have not appeared in the recent Fed pronouncements.

We would love to hear from you about what you think about this article or if you have a question or pressing financial issue that you would like us to address in the future. See email below.

Scott Neal is the President of D. Scott Neal, Inc., a fee-only financial advisory firm with offices in Lexington and Louisville and the ability to serve clients anywhere. Questions and comments can be addressed to him via email at scott@dsneal.com or by calling 1-800-344-9098. ◆ Issue#78 5

Accounting

Accountable Expense Reimbursement Plans a Tax Savings for Both the Employee and Employer January 1, 2013 was the effective date for numerous Federal tax provisions geared towards raising additional tax revenue. This article will discuss one tool that may be used to reduce the additional tax burden of these new provisions.

What is an accountable plan?

An accountable plan (“plan”) is a reimbursement or other expense allowance arrangement that allows employees to be reimbursed tax free for business expenses they paid personally. The requirements for a plan to be classified as an “accountable plan” are specific; but in general, the plan must only pay for deductible business expenses, maintain adequate substantiation, and require employees to return excess advances.

This type of plan allows the employer to deduct the amounts disbursed as business expenses and allows the employee to exclude the reimbursements from taxable compensation.

Benefit to Employee

The reimbursements are deductible expenses for the employer. Because the plan reimbursements are not considered employee compensation, the employer benefits by excluding the reimbursements from employer payroll taxes and workers’ compensation insurance premiums.

6 M.D. Update

Without an Accountable Plan A physician signs an employment contract with guaranteed wages of $300,000 but is

BY Matthew S. Smith responsible for paying for his/her business related cell phone, dues, CME, and related travel out of his/her own pocket. If these amounts total $5,000, the physician may claim these items as deductible business expenses but will receive no tax benefit or savings from doing so. This

ness expenses paid by him/her.

With an Accountable Plan As an alternative, the employer could maintain an accountable plan. The physician could sign an employment contract with guaranteed wages of $295,000 and an accountable expense reimbursement plan up to $5,000 per year to be used for his/ her business related cell phone, dues, CME, and travel. The guaranteed salary combined with the expense reimbursement is the same $300,000. Because the expense reimbursement is not taxable income to the employee, the tax savings will result from reduced Federal, state, and local income taxes. Depending on the physician’s tax bracket, this could be a potential tax reduction of $2,000 or more per year.

Furthermore, the employer will not be required to pay employer payroll taxes or workers’ compensation insurance on the expense reimbursements. If the practice utilizes the plan on multiple physicians or other employees, the practice can obtain significant tax savings in exchange for complying with the requirements.

Many practices may have accountable plans already in place. For practices and employers without a documented plan, strong consideration should be given to implementing a plan. Employee physicians should also consider discussing such plans with their employers or potential employers for their personal benefit.

An accountable plan (“plan”) is a reimbursement or other expense allowance arrangement that allows employees to be reimbursed tax free for business expenses they paid personally

The reimbursements for the business expenses are not considered taxable compensation, so employees are not required to pay payroll or income taxes on the reimbursements.

Employees who are not reimbursed for business expenses usually claim the expenses as deductions on their individual income tax returns. Whether they know it or not, most employees do not receive the full tax savings by deducting the expenses on their individual income tax returns due to deduction limitations and the alternative minimum tax.

Benefit to Employer

Tax Savings Example

is because unreimbursed employee business expenses are deductible only when the amounts exceed 2% of their adjusted gross income. If the physician’s only income is from wages, the first $6,000 of unreimbursed expenses is not deductible ($300,000 x 2%). The unreimbursed employee expenses, along with any other Schedule A miscellaneous deductions must exceed $6,000 before there is any tax benefit for the out of pocket expenses.

Even if these items do exceed the 2% adjusted gross income floor, many physicians end up paying alternative minimum tax, and these expenses are not deductible when calculating the alternative minimum tax. Under this scenario, the physician will not receive any tax reduction for the busi-

Additional reporting from L. Porter Roberts, Jr. and Harvey D. Thompson L. Porter Roberts, Jr., CPA, Matthew S. Smith, CPA, CFE, and Harvey D. Thompson, CPA, CVA, CMA, 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 hthompson@barcpa.com and via telephone at 859-268-1040. ◆

Legal

Get Ready to Negotiate

OIG Authorizes Hospitals to Pay Physicians for Call Coverage Since the enactment of EMTALA in 1986, hospitals have struggled with providing sufficient call coverage to meet federal requirements as physicians have been increasingly hesitant to take on the added responsibility, cost, and risk of responding to emergency department requests for consultation.

With patients often presenting in increasingly acute conditions with no health insurance coverage, physicians understandably find themselves between a rock and a hard place as utilization of hospital emergency departments has skyrocketed, particularly in Eastern Kentucky. And, it is becoming increasingly difficult to see these patients in the hospital emergency departments without also seeing the patients for follow-up in private physician offices often without payment. Thus, the movement for hospitals to pay for physician call services started amid a tangled web of intricate financial relationships, power struggles between hospitals and medical staff, and a statutory and regulatory maze of the Stark Law and Anti-kickback Statutes.

Finally, good news is on the horizon as a result of a series of recent Department of Health and Human Services Office of Inspector General’s Advisory Opinions, which essentially give the okay for a hospital to pay a per diem fee to specialists providing unrestricted on-call coverage for hospital emergency departments within certain parameters. For physicians, these OIG Opinions give clear guidance and should be a tool to negotiate payment for call within the parameters of fair market value.

Generally two types of call coverage are provided by physicians including unrestricted call coverage, which allows for a physician to remain off the hospital premises but available to report for duty, and restricted call coverage, which requires a physician to remain on hospital premises. On-call pay is the hospital’s payment for access to physicians providing call coverage and has increased by about 48% from 2007 according to some reports.

The most recent of the OIG’s Advisory

Opinions AO-1215 authorized a non-profit hospital’s arrangement to pay a per diem fee to specialists providing unrestricted on-call coverage under a one year contract that required

BY Lisa English Hinkle the physician to respond within requested times and to provide appropriate inpatient and follow-up care to admitted patients. The favorable review included the following considerations:  The hospital would pay a per diem fee,

may vary based upon the specialty involved, a hospital’s medical staff may be in a good position to advocate for a comprehensive payment methodology. Some of the factors that should be considered include:  On-call pay rates should vary by the specialty and reflect fair market value Generally, surgery areas may be paid more than medical specialties  The frequency of the call coverage and number of available physicians should factor into the rate that is paid  The likelihood that a physician will be called in when providing call coverage  Uncompensated care should be considered when establishing payment rates  Employed physicians may be paid for call subject to the same rates excluding payment for services furnished as part of the employment contract  Compensation for calls per shift provided in excess of a specified number

With the OIG’s Advisory Opinions in hand, physicians are in a good position to demand that hospitals pay for call coverage by developing an equitable mechanism that recognizes the importance and necessity of their services. calculated annually in advance  All specialists on the hospital’s medical staff are offered the opportunity to participate  Physicians agree to provide inpatient care as well as outpatient follow-up care following discharge without additional compensation by the hospital  A uniform method is used by the hospital to equitably allocate call  The per diem rates are commercially reasonable and at fair market value With the OIG’s Advisory Opinions in hand, physicians are in a good position to demand that hospitals pay for call coverage by developing an equitable mechanism that recognizes the importance and necessity of their services. While payment for services

With clear guidance from the OIG about how to avoid statutory and regulatory hurdles, physicians and their respective hospital medical staff bodies now have the opportunity to negotiate compensation for call services. Given shrinking Medicare and Medicaid reimbursement coupled with the ever increasing complications of maintaining compliance with practice requirements like electronic medical records, compensation for the provision of call services could be helpful to physicians as the path is forged through the Accountable Care Act’s changes.

Lisa English Hinkle is a Partner of McBrayer, McGinnis, Leslie & Kirkland, PLLC. Ms. Hinkle concentrates her practice area in healthcare law and is located in the firm’s Lexington office. She can be reached at lhinkle@mmlk. com or at (859) 231-8780.

This article is intended as a summary of newly enacted federal law and does not constitute legal advice. ◆ Issue#78 7

Cover Story

A Mission of Compassion & Equality Common values unite the physicians of Women’s Care and Family Care of the Bluegrass

By Jennifer S. Newton Photography by BRIAN BOHANNON

FRANKFORT These days, the characteristics that come to mind when setting up a medical practice are probably: profitability, stability, employment or independence, and payer mix. But what about: faith, compassion, inclusion, and equality? Those may not be the primary attributes that come to mind when you think of establishing a medical practice, but they are the founding principles of the obstetrics and gynecology practice of Women’s Care of the Bluegrass (WCOTB) in Frankfort, Kentucky.

The practice began in Eastern Kentucky before taking root in Central Kentucky. After completing residency in 1993 at the University of Kentucky (UK), founding partner E. J. Horn, MD, and then partner Steve Roberts, MD, returned home to Eastern Kentucky to set up Women’s Care of Eastern Kentucky in Prestonsburg. As fate, or faith, would have it, Roberts decided to make a life change when he felt called to become a Catholic priest.

“We tried to recruit someone to replace him, but it’s hard to recruit good doctors back home unless you’re from there,” says Horn.

After four years in Prestonsburg, the two decided to move the practice to Versailles in Central Kentucky and enlisted another pal from residency, Stephen K. Hall, MD, to join them in anticipation of Roberts’ departure. Hall had taken a different route and located in Murray in Western Kentucky after residency. With Hall on board, Women’s Care of the Bluegrass (WCOTB) continued 8 M.D. Update

Dr. E. J. Horn founded the practice based on the cifically asks for a particular provider, principles of compassionate care, equality for and that predictability of schedule is physicians, and treating one of the things that attracted her all patients regardless of to the practice. “Honestly, it helps to ability to pay.

preserve our lifestyle to some degree,” says Saxena. At some point, the senior physicians in the group will reach a point where they want to slow down a little, and they will have to address an alternative to the equal call, equal pay philosophy. But for now, it is an approach that has worked for 20 years.

“The other founding principle of the practice is that we wanted to see everyone, whether they had the best insurance, bad insurance, no insurance, or Medicaid, and we’ve continued to do that throughout the years. And hopefully that’s been part of the reason God has blessed us with so much growth,” says Horn. Not only treating all patients regardless of socio-economic status but Dr. Stephen K. Hall’s goal is also treating them with compassion, is "to approach each patient a value shared by all of the providers fresh regardless of whether at WCOTB. “I believe we can make a difference in people’s lives as far as proto grow while recruiting new providers. In 2001, that’s the second patient you’ve seen today or the viding compassionate and skillful care they moved their main office to Frankfort but 30th patient you’ve seen to anyone regardless their walk of life or kept an office in Versailles, in addition to offices today and treat them as economic situation,” says Hall. in Owenton and Lawrenceburg. the most important person From a single location, the pracBoth Horn and Hall cite Dr. John W. Greene, you’ve come in contact with tice has grown to cover multiple counJr. from the UK College of Medicine as the men- that day." ties in the area surrounding Frankfort. tor who helped shape their practice philosophy.

WCOTB’s locations include the clinic in Woodford County “The founding principles of the practice when Father in Versailles, a satellite office in Owen County in Owenton, Dr. Steve Roberts and I started the practice were basically and a presence in Anderson County in Lawrenceburg. treating people with the compassionate care Dr. Green had “Another unique aspect of our philosophy has been to proinstilled in us as residents and the philosophy that we vide care where there is a need,” says Mark A. Wainwright, would take equal call, equal time in clinic, and we would DO, who has been covering the Owenton office since joinall be paid essentially the same,” says Horn. They did so ing the practice in 2001 and has seen its patient base grow because they believed it was “the physician thing to do but over the years, drawing patients from Carrollton, Florence, also the Christian thing to do,” offers Horn. Because they and Gallatin County.

A very rural area, Wainwright says, share call equally, Angela Saxena, MD, says patients in labor “It’s worth the 35-minute drive for me to see 20 or 30 are delivered by the provider on call, unless the patient spe-

Issue#78 9

Cover Story

tune with sensitive situations, and I times spiritually if they are open to that,” think that definitely comes across in says Farley. the way we provide care,” says Hess.

“This way we say, ‘What’s the right Drawn to OB/GYN A unifying aspect for the physicians of thing to do?’ and that’s the way we WCOTB is the way they all felt drawn to run our practice.”

“There are many professions, the specialty of obstetrics and gynecology, but the thing that being a medical even though some of them initially had professional and physician allows other plans. Horn was set on becoming a you to do is, you’re never pitting family doctor, but became enthralled by his a human against a human,” says fascination for surgery when he did his first Horn. “You’re always in a partner- surgery rotation in medical school. “You ship with that patient preventing see a problem, you fix it, and are able to see disease or treating disease. There’s almost immediate results,” he says. “Then never a situation that I choose to I did a rotation in OB/GYN and saw lots help this person more than that of surgery being done. One of the greatest person, whether it be a contractual things a person can do is bring a new life into the world, and that pretty much sold agreement or whatever.”

Family practice physician Dr. Frank Donald Frank Donald Farley, III, MD, me right there,” Horn adds.

Farley, III, says, "Most important to me is to Hall likes the “good blend of taking care family practice physician with be able to take care of patients no matter what Family Care of the Bluegrass, a spinoff of of patients from teenage years through the they can pay. That’s something I’ve always wanted to have the opportunity to do, ever WCOTB that was born out of a need for elderly years,” the mix of endocrinology and since coming out of residency." comprehensive care, believes their com- internal medicine, and the challenging ethimon faith enhances the level of trust cal issues they face.

Thinking she would be a pediatrician patients. It’s been very fruitful.” between the physicians. “I’m fairly open and follow in her father’s footsteps, Saxena According to Wainwright, 99% of with my Christian faith, and I don’t try to says, “As soon as I delivered a baby, I knew WCOTB’s patients deliver at Frankfort push it on people. But I think my patients that was what I wanted to do.” While most Regional Medical Center, although all of know that I’m a committed Christian, and people’s attention follows the baby, “I could their physicians have privileges at Saint I’m able to administer to them not just just tell my draw was more towards that Joseph East and UK in Lexington. Another physically and emotionally but also somefemale that had just delivasset is the level 2 NICU at Frankfort Dr. Mark A. ered,” she says. Saxena also Regional that’s been in place almost four Wainwright says years. “Before, we would have to transfer values the mix of the techthe family practice 34 or 35-weekers to Lexington or Louisville. nical aspects of surgery and aspect and midwifery Women who are 28 weeks actually can the warm, personal interacservices make stay, and we can deliver here in Frankfort. tion with patients.

Women’s Care of the That’s changed the way we’ve practiced and Having trained in Bluegrass unique. is better for families in our community,” Chicago, Hess found the says Wainwright. The neonatologists are practice in Frankfort smaller and the same providers that take care of patients more rural than what she had done at Kosair Children’s Hospital in Louisville. in the past. “I wasn’t sure that was what I wanted to do, but this United in Faith group was just an amazing set of When it comes to religious faith, very kind doctors. Everything they Amanda Hess, DO, says it is a common do has very good values behind it, mindset that helps the physicians practice and that was what brought me to as good people rather than just a business. them,” she says.

“Certainly we’re respective of everyone’s reliWainwright, who also trained gions, but we all kind of keep [our faith] in in Chicago, was initially drawn to mind. It translates into making the providsurgery. “But after my first delivers a little more caring, a little bit more in ery, I was hooked! I found the 10 M.D. Update

years. Katie Isaac, ARNP, CNM, has been with Women’s Care since its early days in Eastern Kentucky. In fact, their midwifery service has been so popular that WCOTB currently employs three midwives. “A lot of patients seek out the midwifery part of our practice because of the holistic type view of midwifery,” says Saxena. Hess agrees, “There are some people that really gravitate towards that low maintenance, minimally invasive type of healthcare.”

Being able to offer all aspects of the spectrum, from natural birth to epidural births or C-sections, WCOTB is able to provide something for every patient.

While the midwives mostly see obstetrics patients, they also see patients for annual visits and routine gynecologic care.

“The comfort level with us and with them is so good. We’re very careful about which providers we have join our practice. We all mesh together very well,” says Saxena.

For more information about WCOTBs midwifery service, see related article by CNM Emily Dial on page 13 of this issue.

Center in 2003. Since then, the group has adapted the technique to their own needs, using two five millimeter port sites and one 10 millimeter port site to do the procedure, which Horn claims are “fewer incisions and smaller incisions even compared to the daVinci machine.” Horn cites a Journal of the American Medical Association (JAMA) study that demonstrated no difference in complications rates between traditional lapDr. Angela Saxena says, "We’re not just aroscopic supracervical hysterectomy and partners, we’re friends, and I think that helps. daVinci robot-assisted surgery. He cauWe socialize with one another as much as we tions, “The only difference was that the see each other in the office and I think that robot was per case over $2000 more. I relationship is unique really." think in today’s environment we need to be more cognizant of the cost of medicine. specialty of OB/GYN to be a perfect blend That’s something that’s often overlooked between primary care and surgery. Joining when we just want to go with the newest WCOTB has helped to validate my chosen thing that’s out there.” career,” says Wainwright.

WCOTB also performs in-office procedures, and contracts with an outside comA Challenging Profession pany to provide nurse anesthetist services.

Like any specialty, there are challenges.

According to Wainwright, this provides a For WCOTB, their Christian faith serves as cost savings that “benefits insurance compaa resource for dealing with today’s challenges nies and patients, and patients can actually and attitudes toward assisted reproduction, get home a little quicker.” abortion, and teenage pregnancy. “A lot of Wainwright has a particular interest issues in today’s climate can be controver- Minimally Invasive Surgery and In-Office Procedures in urogynecology procedures. He persial. I find that challenging,” says Hall. To forms suburethral slings for incontinence address these issues, he says, “I combine my Over the last decade, minimally invasive and traditional anterior/posterior colporown personal beliefs along with my profes- surgery has transformed the way OB/GYNs rhaphy, as well as the Burch procedure for sional responsibilities and try to do what I practice. WCOTB was on the cutting-edge incontinence if a patient is having an open think is best for the patient as a whole.” in Frankfort, says Horn, having performed Coming from a more urban population the first laparoscopic supracervical hys- hysterectomy.

Other in-office diagnostics include bone and infrastructure in Chicago, one of the terectomy at Frankfort Regional Medical density scans, ultrasounds for GYN frustrations for Hess is the “disparand OB patients, and colposcopy to ity as far as [patients] just not having examine the cervix in-depth and take access to things a lot of people take for Mission Statement biopsies for patients with abnormal granted,” one of those being not havWomen’s Care of the Bluegrass and Family pap smears. ing transportation to get to a doctor’s Minimally invasive procedures in appointment.

Care of the Bluegrass are first and foremost the office are available for sterilizaAs the youngest practitioner in the committed to delivering the highest quality tion, endometrial ablation, urodygroup, Hess enjoys connecting with patient care. We pledge to achieve this by namics, hysteroscopy, and treatment teenagers and correcting misinforof pre-cancer or early cervical cancer. mation. “I really like educating and providing compassionate care in all areas of The Essure is a sterilization proceempowering younger women to take prevention, wellness, and treatment of illness dure that forgoes traditional anescontrol of their health and do things to and disease thesia and lessens down time for avoid problems in future,” she says. patients. Endometrial ablation of the We will pledge to respect life, all patients, and uterine lining to combat heavy bleedMidwifery one another. We provide care regardless of ing is also done in office, offering a Midwifery has been an imporsocial or economic background. cost savings and quicker recovery for tant part of the practice for nearly 20 Issue#78 11

cover story

patients. “For treatment of pre-cancer or early cervical cancer we do a LEEP procedure, where you remove a small portion of the cervix,” says Hess. If invasive cancer is discovered or if further treatment is necessary, patients are referred to an oncologist in Lexington or Louisville.

Family Care of the Bluegrass

“One of the issues we had with a philosophy of taking care of all patients regardless of payer, was that we would see patients who, whether obese, hypertensive, or whatever, we would take care of them during pregnancy. Then after delivery we would try to find primary care physicians to take care of them. It became extremely difficult and often impossible to find primary care doctors who were accepting Medicaid at that time,” says Horn. Rather than succumbing to the frustration, WCOTB

99% of WCOTB’s patients deliver at Frankfort Regional Medical Center which has a level 2 NICU.

created its own solution. With prompting from their accountant, Porter Roberts, of Barr, Anderson & Roberts, they established their own primary care center called Family Care of the Bluegrass (FCOTB) in 2008.

They initially recruited one family practice physician and one PA-C to staff the center. When that physician left, WCOTB sought the assistance of Frank Donald Farley, III, MD, who already had an estab12 M.D. Update

that included a large population of elderly patients, many of whom he had been following since middle age.

“Coming into this relationship with Women’s Care, it’s served to give an infusion of youth into my primary care population because we’re seeing more women of childbearing age and more new babies too because when they deliver a baby who doesn’t have a doctor or pediatrician Dr. Amanda Hess traded a more urban already, they refer to us,” setting for the smaller environment in says Farley.

Frankfort because of WCOTB’s valueTrends in his popbased approach. lished practice in town. ulation include a large At first it was a temponumber of COPD rary solution, recalls Farley. “But everything patients, due to the propensity of tobacco worked out so well we became the full time use in the state, and a large number of doctors, and my practice that was across diabetes patients, a nationwide epidemtown became the east location for Family ic. Controlled substance abuse is another Care and the original location here at the problem prevalent in Kentucky. “With us hospital became the west taking Medicaid and Medicare with a lot location,” he says. Now of disabled patients, it’s a fine line we have Farley is the sole physi- to walk, distinguishing those patients who cian servicing both loca- legitimately need controlled substances to tions, with a physician’s treat pain and psychiatric problems versus assistant at each. those who are drug seeking,” says Farley.

It is a reciprocal Because of the Affordable Care Act, in relationship that ben- recent months FCOTB has partnered with efits both practices. Cumberland Family Medical Center, which Among the advantages is a federally qualified health center. While for WCOTB’s patients their business arrangement has changed, dayis that women who are to-day operations have not. Horn offers that often the gatekeepers of the relationship provides them new advantagtheir families’ health, es they did not have as a primary care center, have easy access to care such as a mobile dental unit that visits schools for their entire family. for dental screening and a high school scholThe physicians benefit What makes us unique is our as well. “Communication is half the battle in medicine,” says partnership agreement where we Saxena. “There are many capa- all give equal time and receive ble doctors out there, but if you don’t have the information and equal compensation. communication between physicians and nurse practitioners and between nurse midwives, it’s all lost in arship program. “Now moving into a federal that transition. I think that is a huge value healthcare center status, we are able to take in our practice.” care of those who don’t have insurance and Having practiced in Frankfort for 13 use a sliding scale fee schedule that is much years, Farley had an established patient base more affordable for them,” adds Farley. ◆

Special Section  Women’s Health

Midwifery in Central Kentucky

By Emily Dial, APRN, CNM Midwifery is often considered by some as an art rather than a profession. Certified Nurse Midwives (CNM) offer services to women that make them the sole decision makers of their care, while being carefully guided and advised by providers that are trained to be experts in normal pregnancy, birth, and beyond. We are often considered to be the experts in natural childbirth, and while this is often true, our skills and knowledge extends beyond that of Lamaze breathing and water births. A CNM is trained as an Advanced Practice Registered Nurse (APRN) that counsels women in their childbearing years, as well as provides routine gynecological care to women varying in age, often starting in adolescence and carrying on through their entire life.

I practice dually as a Women’s Health Nurse Practitioner and Certified Nurse Midwife in the heart of the Bluegrass Region in Frankfort, Kentucky. I work at Women’s Care of the Bluegrass alongside five physicians (E.J. Horn, MD, Steve Hall, MD, Angela Saxena, MD, Mark Wainwright, DO, and Amanda Hess, DO)

and two additional CNMs (Katie Isaac, CNM, and Kendra Adkisson, CNM).

This provides me and my cohorts the opportunity to provide a broad spectrum of obstetrical and gynecological care to women in Franklin, Anderson, Owen, and Woodford counties. It is in these smaller communities, that as a healthcare provider, one will often get to know entire generations of families and watch those families expand through the years. Living my entire life in the small town of Lawrenceburg, Kentucky, and providing care locally is perhaps one of the most rewarding aspects of being a nurse midwife.

Care by midwives is seen by our practice as an integral care component and a valued option in the low risk client population.

Women are given the option at their initial meeting with a care provider as to whether she would prefer a midwife or physician for her care and birth. Patients will often meet all of the staff on hand throughout their pregnancy course if no preference is desired. Midwives are skillfully trained in the physiology behind normal pregnancies and are constantly alert for any high risk conditions such as hypertension, diabetes, and a wide array of other maternal/fetal complications that a patient may encounter

Katherine Isaac, ARNP, CNM, affectionately known as “Katie” has been practicing midwifery for over 30 years.

She completed her training at Frontier School of Nursing and Midwifery and has been employed by Women’s Care of the Bluegrass since 997. She has built through the years a large and loyal patient base for not only her obstetrical skills, but her gynocological experience as well. She estimates she has delivered more than 4000 babies, several of whom send yearly pictures and updates to her.

She is also an active Preceptor of midwifery students from across the state and was awarded the coveted “Outstanding Preceptor Award” in 2011 from the American College of Nurse-Midwives. She sees patients at Women’s Care of the Bluegrass office in Versailles as well as the main office in Frankfort.

that could require physician consult. This consult may occur either in the office or in the hospital setting. In the event of any of these situations, care of the patient often becomes a collaborative effort between the midwife and physician.

Perhaps the most often asked question by the public and even medical communities is “What sets midwives apart from physicians?” While there are a multitude of differences and similarities, midwives have a common goal to regard birth as a normal process, while physicians are often sought after when complications arise. Working at Women’s Care of the Bluegrass, these two principals are put into practice while providing a fine balance that allows the highest quality of care.

While unfortunate, Kentucky is a leader at the national level for tobacco use during pregnancy, obesity rates, and diabetes (both during and after pregnancy). While national healthcare reform now requires practices to implement electronic health records, Women’s Care of the Bluegrass has had this technology for nearly 10 years. This allows for the collaboration between midwives and physicians while allowing for more robust educational resources to provide to our patients. It is undoubtedly a favored trait that midwives not only serve as healthcare providers, but excellent educators often giving expert advice on nutritional needs, exercise recommendations, and many other aspects of pregnancy and well-woman care, thus allowing the woman to be more cognizant of her own healthcare needs.

While more common elsewhere in the world, midwifery care is now on the rise in the United States, mostly because women seek the personalized sense of care that a CNM has to offer. Kentucky is growing in the field of midwifery; nestled in Hyden, Frontier Nursing University is one of the most prestigious midwifery training programs in the country. The collaboration that exists between physicians and Certified Nurse Midwives is certainly an excellent and affordable option for any woman seeking a rewarding and memorable healthcare experience. ◆ Issue#78 13

Special Section  Women’s Health

The Psychology of Obstetrics and Gynecology Two new Lexington Clinic OB/GYNs meet more than their patients’ physical needs By Tim Corkran

Preparing for On the Job Training

her osteopathic training prepared her to meet the subtle needs of her patients. right: Dr. Ramon Thomas, MD, received his MBA at the University of Louisville while attending medical school and then spent 4 ½ years in the US Air Force.

Both doctors sought positions at Lexington Clinic because they knew what they were getting: a strong specialty group with regional reputation and the opportunity to train on St. Joseph’s surgical robot. They emphatically agree, however, that their OB/GYN residencies did nothing to prepare them for the counseling aspect of the specialty.

Thomas notes, “When you are a resident, you are working through patient problems quickly. But once you are on your own, these patients are yours. It’s a very personal 14 M.D. Update

of Louisville, Thomas received his MBA because, “You don’t get business education in medical school and understanding the business side in private practice allows me to see the big picture.” Following his residency at St. Louis University, he spent four and a half years in the Air Force. For Arghavani, after she received her DO degree at Des Moines University Osteopathic Medical Center, residency and internship were followed by four years practicing in an underserved area in

eastern New Mexico. “You learn a lot when you are out in the middle of nowhere,” she notes. Her DO training to consider the body as a whole has prepared her well to meet the subtle needs of her patients: “As an OB, often I need to think about how the body is functioning as a whole to figure out how to best help the patient.”

Treating with Honesty and Technology

Like most new OB/GYNs, their patient population is primarily young, healthy woman coming for annual exams or experiencing their first pregnancies. The nature of their work, however, is evolving as the obesity epidemic deepens and more women choose to have children later in life.

Many obese woman experience infertility due to irregular menstrual cycles (as few as two a year) and more hypertension and gestational diabetes when they do get pregnant. Thomas prefers a direct approach, consistent with his counselor attitude, with these patients. He says, “I have no qualms about telling a pregnant woman she is obese.

We have to broach that subject to minimize the many risks that they are already facing.” This is also the first step to truly fixing problems such as infertility, in which the patient must play an active role. He tells his patients: “My job is to identify your issue and give you an adequate plan to fix it; your job is to see that plan through.” High-risk pregnancies have become the norm, according to Arghavani, “We see more hypertension, obesity, gestational diabetes, and multiples. With more older women having children, the number of factors that make a pregnancy high-risk increases.” It’s no wonder then, that both doctors value time to talk with patients,

Photos courtesy of Lexington Clinic

It might not surprise you that relationship. You have to deal with the counmost OB/GYNs perform surgery, but it seling part to get the comfort level, which will likely surprise you how much counsel- allows them to trust you enough to look at ing some perform. Lexington Clinic’s Tracy those most intimate parts of their bodies.”

Arghavani, DO, says “We are marriage Fortunately, flexible thinking about counselors and parental counselors. We are where valuable experiences might lie prea shoulder to cry on, infertility counselors, pared both physicians to recognize and hanand sexual dysfunction counselors.” Ramon dle this revelation about their specialty; each Thomas, MD, adds “I call perceived opportuit ‘psychiatry light.’ If I have nity in non-tra20 minutes with a patient, ditional settings. only five minutes of it is During medical actually examining them; the school at University rest is listening and giving input.” Both bring reflective and personable affects that complement their empathetic and attentive approach to meeting patient needs in the OB/GYN department of Lexington Clinic. Arghavani and Thomas’s willingness to counsel women, coupled with access to St. Joseph East’s da Vinci surgical robot, are furthering Lexington Clinic’s reputation for responsive care and providing a maximally comfortable experience for patients.

ABOVE: Dr. Tracy Arghavani, DO, says Lexington

Where families are born. given the increased number of concerns they bring to the office.

The Surgical Options

The da Vinci surgical robot is an innovation brought to OB/GYN’s practices, and the opportunity to use it at Lexington Clinic helped both doctors choose employment there. Arghavani and Thomas have been proctored in their training by the senior physician of the practice, Tamara James, MD. Arghavani, who complements more traditional laparascopic methods with it, says “the da Vinci has changed gynecological surgery. For major surgeries, such as hysterectomies, because it is minimally invasive, it results in shorter hospital stays and reduces risk of post-operative infection.” Thomas is sensitive to the value of such minimally invasive robotic surgery to his patients, citing, “We do get people who ask ‘Am I going to get a big incision or a small incision?’”

That’s just one more way that patient concerns are being alleviated in this practice.

At the Floyd Memorial Birthing Center, we put your family first. You’ll find luxurious and spacious labor and delivery rooms, and our obstetricians and certified nurse midwife provide whole-family care, education and support throughout your entire pregnancy, labor and delivery. We even personalize your birthing plan to meet your wishes, and provide options including doulas and garden tubs for labor. And after your bundle arrives, we encourage kangaroo care, quiet time for the new family and we provide breastfeeding support from certified lactation experts.

Discover why Floyd Memorial is the first choice for families.

Ensuring Patient Comfort

www.floydmemorial.com/baby

Patient education has primacy for both doctors; it’s another way they build the trust. A full wall in the practice is devoted to informational brochures, and each seeks opportunities to inform patients.

Thomas takes pride in offering troubled patients something that his partners cannot, “Giving them the male perspective provides another slant when discussing relationship and infertility issues.” Arghavani sees empowerment through clear information as valuable. “I love to educate patients,” she says. “They need to understand what the norm is for their body to understand what is abnormal. I want them to understand our reasoning; I think they will be more satisfied if they understand what was done.” In fact, when asked the biggest challenge she faces as an OB/GYN, she quickly responds, “Not enough time. We just don’t have time to do all the education we want.” ◆ MDU Birth_4.8524x10.indd 1

4/11/13 10:56 AM Issue#78 15

Special Section  Women’s Health

left: Dr. Karon credits her team for the success of daVinci robotic surgery.

From left: Karri Doneghy, surgical tech, Chris Arvin, physician assistant, Hope HaginsCornett, surgical tech, Dr. Magdalene Karon Above:Dr. Karon has performed over 450 robotically assisted surgeries below: Dr. Karon uses an acellular matrix sheet for sacrocolpopexy and paravaginal defect repair.

New Techniques Elevate Pelvic Organ Prolapse Repair

By Jennifer S. Newton Pelvic organ prolapse has been a hot topic in the field of OB/GYN over the last five years, in part due to the notoriety of some surgical repair techniques. But from the ashes of problematic methods such as vaginal mesh has risen a phoenix of sorts in the form of new diagnostic and surgical techniques that are producing optimum results.

“For years, some vaginal surgeries have been the standard of care [for pelvic organ prolapse], but we’ve always known vaginal repairs have not been as strong as abdominal approaches,” says Magdalene Karon, MD, an OB/GYN and solo practitioner in Lexington. The downside to the abdominal approach is greater trauma to the patient because it requires a large incision and a much more difficult recovery. “Now

Lexington

16 M.D. Update

that we can do [pelvic organ prolapse repair] laparoscopically and as an outpatient, we are turning more towards abdominal prolapse repair laparoscopy, especially with the da Vinci® Surgical System. The patient will have faster recovery that way and less vaginal trauma,” says Karon.

According to Karon, pelvic organ prolapse “basically involves the descent of different organs in the pelvis, such as the bladder, uterus, and vaginal walls in a downwards direction.” The most common cause of prolapse is obstetrical injuries from the trauma of large babies or multiple deliveries, but family predisposition, lifting heavy objects, obesity, and estrogen deficiency in menopause are also contributing factors.

The most common symptom for women is stress urinary incontinence, which conventional wisdom typically

assigns to elderly women but Karon says is more and more common at younger ages, where women are more likely to discuss problems with their doctor.

Diagnosing Pelvic Organ Prolapse

Listening to a patient’s symptoms during the consultation and doing pelvic exams are still part of the protocol of diagnosing pelvic organ prolapse. In addition to stress incontinence, complaints often include a feeling of a bulging or protrusion in the vagina or pressure when standing up. However, vaginal ultrasound has become an important component in documenting the prolapse and mapping out the anatomy in each individual case. “We can see the angle of the bladder drop that is funneling. We can measure the

Regina Ramsey, surgical tech, has been a key member of Karon’s surgical team for years.

thickness of the bladder, see the cystocele, which is the part of the bladder that drops down. We can see torn muscles such as in the paravaginal defect,” says Karon. “We also use Doppler, which is a vascular flow study, so we can see if a structure has a good blood supply or not or if it’s been devascularized. With 3D and 4D ultrasound, it gives us another dimension to see pelvic floor damage and the relationship of the uterus and the bladder and the other structures.”

Pelvic Organ Prolapse Evaluation Exam representaton based on the Pelvic Organ Prolapse-Quantification (POP-Q) System.

Non-Surgical Treatment

Treatment begins postpartum when nurses advise new mothers to do Kegel exercises to regain muscle control. In some cases, physical therapy and advising patients to stop lifting heavy objects are the least invasive options. For patients where surgery is not an option, especially older patients, Karon still uses pessaries. A rubber, flexible ring that works in principle like a diaphragm, a pessary supports vaginal structures, although it does not provide birth control.

In post-menopausal women, hormone replacement therapy utilizing estrogen can help. “Estrogen is the hormone that helps with vaginal wall thickness and moisture, pinkness and blood supply. The bladder also has a lot of estrogen receptors in it,” says Karon. “The vaginal estrogen does help with the atrophy because after menopause there’s the dryness and thinning of tissues … Supplementing with hormones can help if they’re borderline with prolapse issues. Once the bladder is fallen to a certain point, then it needs to be repaired surgically,” says Karon.

Surgical Prolapse Repair

Because she says women are visual,

Karon uses a computer to map out each patient’s prolapse to see which part is prolapsing and forming the cystocele and help educate patients on the treatments she will use. She no longer uses vaginal mesh because of the complications it has caused, but more importantly, because newer, more effective techniques are available. “I’ve used fascia for prolapse, and most recently I’ve used a product that’s based on tissue regeneration with your own stem cells,” she says.

The product is a sterile, porcinederived, acellular (with all animal cells removed) matrix sheet, absorbable over six months, that attracts stem cells, supports healing, and strengthens and remodels the area. Karon has been using it for about a year and likes the device because the sheets come in different thicknesses and different lengths, so it can be used for sacrocolpopexy, paravaginal defect repair, and in the Burch procedure for bladder lift. The patches are designed to withstand a lot of pressure, which is essential while the tissue is healing.

Taking laparoscopic techniques a step further, Karon utilizes the da Vinci robotic system, which uses wristed-instruments and 3D visualization to enhance surgical precision and dexterity. With it, her patients experience small abdominal incisions enabling shorter recovery times, less trauma, and fewer complications. Dr. Karon has performed over 450 robotically assisted surgeries. ◆

For patient referral contact

Dr. Magdalene Karon 100 North Eagle Creek Drive, Suite 205, Lexington, KY 40509 (859) 277 3135 www.karonmd.com Issue#78 17

Special Section  Women’s Health

Midwifery

More Than Just Labor and Delivery By Jennifer S. Newton “With women for a lifetime,” is the slogan of the American College of Midwives (ACM) and the practice philosophy of Carla Layne, ARNP, certified nurse midwife (CNM) with OB/ GYN Associates of Southern Indiana, PSC, in New Albany. “From adolescence to menopause, my focus is educating women about their choices so that they know that there are alternative therapies,” says Layne.

While the practice of midwifery often brings to mind normal pregnancy care and natural deliveries, certified nurse midwives are trained in deliveries with epidurals and gynecological services as well. In addition to well woman care, Layne sees patients for problems, such as vaginitis, birth control planning, hormone replacement, bioidentical hormone therapy, aromatherapy, and alternative therapies when standard treatments are unsuccessful. She also spends a lot of time counseling adolescents about birth control and sexually transmitted diseases.

New Albany, Indiana

History of Midwifery

Midwifery is often misunderstood because there are different levels of midwife training. Licensed midwives do home births, are trained by other midwives, and do not have any official medical or nursing education. Certified midwives have a degree in midwifery but no background in medicine or nursing. CNMs have a nursing background and undergo two additional

years of study in midwifery. Layne holds a master’s in nursing in addition to her midwifery certificate. Currently she delivers exclusively at Floyd Memorial Hospital & Health Services.

For Layne, making sure her standards are

no matter where you went to medical school or did your residency … so because midwives have a different kind of training, it’s interesting to see the different philosophies and ways they address different issues,” says Heather Lewis, MD, with OB/GYN Associates of Southern Left: Carla Layne, ARNP, CNM, Indiana of her practice’s with OB/GYN Associates of decision to add a midSouthern Indiana, in New wife to its staff.

Albany, IN With OB/GYN below: Heather Lewis, MD, since says midwifery adds a different Associates December 2012, Layne philosophy to the OB/GYN has a growing practice practice. of post-menopausal women seeking bioidentical hormone therapy. Layne works with a compounding pharmacy to provide patients individualized plant-based bioidenticurrent is critical. “Midwifery cal hormone replacehas a long history in the US, ment. While it takes an especially in Kentucky. Mary average of six months Breckinridge started the to find the right forFrontier University in 1925. mula for each patient, So, there’s a lot of research and Layne claims a 95% certified nurse midwives use success rate in her preevidence-based practices just vious practice. like physicians do.”

Aromatherapy is an example of an alternative therapy Layne utilizes to afford Midwife Services her patients a more natural experience.

“I think one of the things we were look- Lavender is used for anxiety and relaxation, ing for is physicians all have similar training either during delivery or during a proce-

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

18 M.D. Update

Special Section  Women’s Health

Just like the doctors all practice differently, they understand that I am a provider and that I practice differently.

– Certified Nurse Midwife Carla Layne

dure. Tea tree oil can be used to combat vaginal bacteria and yeast.

For patients who are opposed to Pitocin, Layne uses the herb clary sage to induce contractions.

When it comes to labor and delivery, Layne estimates about 80% of patients who seek out a midwife want natural childbirth, while 20% want an epidural.

Either way, she spends initial visits educating her patients about pregnancy and what she can do for them during labor. One major difference between Layne and the physicians in her practice is that she labor sits with her OB patients, something physicians simply do not have the time to do. Patients understand that this means their office appointments may be rescheduled if Layne has a patient in labor at the hospital, but they relish the opportunity to have her undivided attention when it is their turn. Techniques Layne

utilizes to assist patients in laboring without pain medication include meditation, hydrotherapy, aromatherapy, and massage.

The flexibility of a midwife’s schedule has other advantages for patients. “I have the pleasure of saying, ‘Okay, schedule my patients every half an hour. Don’t double book me,’” says Layne. While physicians might see upwards of 40-45 patients a day, Layne sees six to 15 in her burgeoning practice, a volume she hopes to build to 15 to 20. Lewis says the ability to spend more time educating patients is another of the reasons they chose to add a midwife to the practice. “I think patient education and teaching is a lot of the practice

of midwifery … I think that’s one of the places medicine falls a little bit short is educating patients. We make an effort to do that, but I think they have more time,” says Lewis.

On her relationship with the physicians in her practice, Layne says, “Just like the doctors all practice differently, they understand that I am a provider and that I practice differently.” She describes her style as conservative when it comes to following the practice guidelines she and the doctors agreed upon, meaning she does not hesitate to consult with or turn a patient over to one of the physicians if they fall outside of her parameters. “We want to look at midwifery as pregnancy being a normal thing. So when it starts to fall outside the realm of normal, then we look at how much of it can be managed by midwifery and how much of it needs to be managed medically,” says Layne. ◆

Issue#78 19

Special Section  Women’s Health

Creating a Niche

The Hubbard Clinic uses in-office procedures to maintain profitability as an independent urology practice By Jennifer S. Newton

20 M.D. Update

Left-right: Patricia Hooker, PA-C; Sandy Nasief, medical assistant; Dr. John Hubbard; Emmy Baker, APRN; Debbie Freeman, administrative assistant; Liz Fields, surgery coordinator; Jill Watts, medical assistant

Patients benefit by paying reduced copays instead of hospital copays, and they have the comfort of seeing familiar faces and not worrying about hospital infections.

Office-Based TVT Sling

For Hubbard’s female patients, incontinence is a common problem. The muscle cradle that supports the bladder can become relaxed with pregnancy and childbirth, causing leakage when the bladder is under pressure. In 1998, Hubbard began doing tension-free transvaginal tape (TVT) sling surgery, which provides a backboard for the urethra and bladder to prevent leakage.

Hubbard prefers the TVT to other tape procedures because it uses one vaginal and two pubic incisions, allowing for a longer tape. “There are no sutures that hold it, so the more tape you have for the body tissue to grab, the longer it’s going to last,” he says.

“I have done right at 1800 [TVTs] since 1998, and I have yet to take one out for pain, infection, or body rejection.”

For patients who have the procedure, Hubbard recommends a six-week muscle training course that uses a vaginal probe to measure patients’ squeezing and muscle strength and provides much better results than simply prescribing at-home Kegels.

With the TVT and some muscle strengthening, patients can avoid future pelvic prolapse surgery, something Hubbard does not do.

Hubbard also does not treat pelvic floor pain without bladder symptoms. For muscle or nerve problems he refers to a physical therapist who specializes in the pelvic floor. “We see more that have pelvic floor pain that have bladder symptoms along with it, and we’ve found the great majority turn out to be interstitial cystitis,” says Hubbard.

Interstitial Cystitis

Not many treatable conditions start with negative test results, but when the patient reports frequent urination and urgency, pelvic pain, and pain with sexual activity but has negative urine cultures and negative local cystoscopy, the diagnosis is often interstitial cystitis (IC).

Often misdiagnosed as recurrent urinary tract infections, IC does not have a known cause. It is characterized by a lack of tightness in the lining of the bladder, resulting in microscopic leakage of urine through the bladder wall, which irritates surrounding muscles and nerves. It affects both men and women but is much more common in women.

According to Hubbard, “70% of the treatment is telling patients, ‘We know what it is. It is not dangerous, and you are not crazy. You have to watch your diet, and we will look at allergies.”

When Hubbard suspects IC, he suggests patients undergo cystoscopy. “We go on how much the bladder will hold, when you’re feeling the pain as we’re filling the bladder, and do you break blood vessels after we fill the bladder?” says Hubbard.

Dietary factors and allergies greatly influence the condition. The first step is educating patients that it is a chronic condition, and avoiding certain foods and beverages can improve symptoms. The second step is to check for allergies. “Part of our

Photography by Brian Bohannon

These days, small, independent practices seem harder and harder to come by. The trend towards hospitals employing physicians in large group practices is undeniable. Certainly, physicians are turning to employment models to combat skyrocketing costs and ensure longevity in a changing healthcare landscape.

However, John Hubbard, MD, urologist and the sole physician at The Hubbard Clinic, says there are profitable ways to maintain your independence. A selfdescribed “country doctor,” Hubbard has capitalized on experience, personal circumstances, and bargaining power to establish a niche practice. “I’ve been in practice a long time. I know what I like. A great staff is a must. I know what I want my patients to have, and I like for my nurse extenders to do the same thing … Because of that I opened my own practice in 2000,” says Hubbard.

The key, according to Hubbard, is choosing in-office procedures that have low risk for infection and performing those only on healthy patients. He uses a nurse anesthetist and performs all procedures under conscious sedation. Patients who are ill or on a lot of medications get referred to someone else, so they can be done in a hospital setting.

Limited from doing big surgeries because of his own back surgery but desiring to grow his practice, Hubbard found his perfect formula in a niche urology practice built around voiding problems in women and men. Wanting to remain a solo practitioner, he uses nurse extenders to help cover his patient load. One ARNP and one PA-C see female patients for routine and followup visits, while Hubbard focuses on male patient visits and procedures for all patients.

Six years ago Hubbard brought most procedures in-office after receiving accreditation for office-based surgery, and he says the benefits are staggering. Insurance companies benefit because it costs them less than the same procedure done in a hospital. Physicians receive a slightly higher reimbursement for in-office procedures than hospital ones.

Louisville

Dr. John Hubbard says, ”Medicine is evolving into a big industry assembly line." He prides himself on his staff’s relationship with patients and their dedication to dealing with problems the same day.

workup when we do biopsies [during cystoscopy] is to check for mast cells to give us an idea if there’s a strong allergic component. If so, we have an allergist that’s very familiar with interstitial cystitis that we work with to help that aspect,” says Hubbard.

Treatment also includes medication. Elmiron is the only medication FDA approved for the treatment of IC, although it has some drawbacks: it takes a long time to work, does not work in every patient, and can be expensive. However, The Hubbard Clinic also employs the use of natural products and

Dr. Hubbard performs office based procedure under monitored anesthesia.

other medications to treat the symptoms.

The newest treatment in Hubbard’s toolbox is Botox. Approved three years ago for use in neurogenic bladders, physicians have begun using Botox in IC patients to help the bladder retain more and hopefully reduce pain.

When all else fails in particularly difficult cases, Hubbard refers for a urinary diversion technique called an ileal conduit.

Other In-Office Procedures

In addition to the TVT sling, Botox, cys-

“A 3D Mammogram Saved My Life” Dawn Slicker, Cancer Survivor

toscopies, and biopsies, Hubbard can also do bladder distensions, correct bladder neck contractures and urethral strictures, and remove small bladder tumors in office. For male patients, Hubbard offers the transurethral needle ablation (TUNA) and transurethral resection of the prostate (TURP) for treatment of benign prostatic hyperplasia (BPH).

Hubbard still does some procedures in the hospital when insurance will not cover office procedures or when the overhead is prohibitive for him, such as the case with Medicare patients. But he is banking on the in-office procedures to help him maintain his independence and the small office feel his patients appreciate. ◆

For patient referrals contact:

The Hubbard Clinic

3924 Dupont Square South, Louisville, KY 40207 (502) 893-3510 hubbard.theharpethgroup.com

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Learn more about the power and promise of 3D mammography Visit womensdiagnosticcenter.com

Dr. Art McLaughlin, Medical Director 4004 DuPont Circle, Suite 230 502.893.1333 Dawn and her husband, Carl

Issue#78 21

Special Section  Complementary Care

Integrating Sexual Medicine with Sex Therapy A Collaborative Treatment Approach By Valerie Areaux, MS, LMFT

It’s no secret that human sexuality is an intri- and relationships. They work collaboratively cate interplay of one’s physiological respons- with physicians to treat a broad range of difes, emotional processes, and relationship ficulties related to sexuality, including erectile issues. Sexual dysfunction is a quality of dysfunction, rapid ejaculation, vaginismus, life problem that may affect an individual’s anorgasmia, and dyspareunia. Sex therapy desire for sexual activity, ability to become can also address individual issues related to sexually aroused, capacity to reach orgasm, sexual identity, trauma, sexual orientation, or to experience sexual activity without pain. problematic sexual inhibitions, undesirable Many individuals who experience sexu- sexual habits, as well as desire discrepancies in al difficulty wait months, sometimes years couples. Although the discussions between before seeking help from a medical or psy- the couple and the therapist in the context chotherapy professional. Others remain too of sex therapy are of an intimate nature, the embarrassed or ashamed to ever seek treat- therapy itself never involves physical examiment for sexual problems, reluctant to dis- nation or contact, of any sort, between the close and discuss intimate or uncomfortable therapist and the patient. information. Instead, they remain silent, Frequently, individuals and couples trusting that their issues will resolve them- bypass a physician’s office and make their selves without professional attention, often at initial contact with a psychotherapist, seekthe expense of their health, self-esteem and, ing treatment for relationship difficulties most certainly, their intimate relationship. and intimacy issues. The therapist begins Those who are experiencing trouble in their work by obtaining a comprehensive the bedroom may make their first contact psychosexual history from the patient and/ with a physician seeking a pill, cream, or or couple, whereby the sex therapist learns lotion in hopes of quickly improving their about the origin of the symptoms and sexual functioning. After a comprehensive related information regarding emotions, evaluation, the physician may identify a past history, and current sexual functioning. cause, or a more significant health con- Through this process, the therapist may discern, and prescribe a course of treatment. cover emerging or persistent symptoms of a Although a prescription may provide some sexual dysfunction, which may or may not relief from their symptomology, it does noth- be a symptom of an underlying disease. In ing to address what else may be going on order to rule out a biological cause, such as emotionally or psychologically within the diabetes, neurological disorders, hypertenindividual and their relationship. sion, endocrine disorders, etc., the therapist In other instances, the physician might determine that the symptom does not Valerie Areaux, MS, LMFT, have a biological origin has 20 years of experience and conclude that the treating relationship and sexual problem may be intimacy issues. best addressed through psychotherapy with the individual and/or couple. The physician then dialogues with the patient and makes an appropriate referral to a mental health professional that has specialized training in the field of sex therapy.

Sex therapists are mental health clinicians who have completed advanced, specialized coursework in the areas of diagnosis and treatment of sexual disorders, human sexuality, 22 M.D. Update

refers the patient to a competent physician for a proper medical diagnosis and course of treatment. Once a diagnosis has been made, or physiological etiology of the dysfunction has been ruled out, the therapist continues their work with the individual or the couple through talk therapy, assigning specific sexual homework tasks to be completed in the privacy of the patient’s home.

By developing collaborative relationships between the sexual health provider and the sex therapist, patients may increase their compliance with prescribed courses of treatment. Those patients, who require the use of prescription drugs such as SSRI’s, antihypertensives, antipsychotics, and anitepileptics, may not use the medication as recommended by their physician due to some adverse sexual side effects. A physician can take a pro-active approach with these individuals by discussing the possibility of sexual side effects and recommend a consultation with a sex therapist to explore alternative practices that may alleviate these difficulties while still maintaining the patient’s prescribed course of treatment.

It is important to recognize that not all sexual dysfunction has an organic cause, yet all sexual dysfunction takes a psychological, emotional, and relational toll on the individual and couple. Whether the patient initially presents in the medical office or in the therapy office, the perceived competency of the providers, as well as the level of trust the patient may feel toward the physician and therapist, can be enhanced by taking a multi-disciplinary approach to the diagnosis and treatment of their sexual dysfunction.

Valerie Areaux, MS, LMFT, owns and operates Bluegrass Family Therapy, LLC with offices in Lexington and Danville, Kentucky. She is a Licensed Marriage and Family Therapist with nearly 20 years of clinical experience providing treatment to individuals and couples with relationship and intimacy issues. She is currently completing a clinical program in Sex Therapy through the Florida Post-graduate Sex Therapy Training Institute located in Palm Beach, Florida. ◆

Special Section  Complementary Care

Nutritional Therapy Enhances Health Outcomes

By Kathleen Stanley, CDE, RD, LD, MSEd, BC-ADM

Specialized nutrition plans are essential term success. components in the treatment of many disWhen counseling patients, the RDs ease and health care conditions. Nutritional utilize evidence-based practice recommentherapy has been proven to help achieve dations from reliable sources such as the therapeutic outcomes for conditions such as American Diabetes Association, Academy cardiac disease, weight imbalance, pediatric of Nutrition and Dietetics, the Celiac issues, diabetes, renal Sprue Association, and dysfunction, allergies, the American Academy auto-immune disease, of Pediatrics, to name and many GI disorders. a few. When a patient Baptist Health has been prescribed a Lexington has had an modified diet, it can be outpatient nutrition overwhelming to the counseling service for patient to change food approximately five habits that have been years to address the in place for a lifetime. needs of the greater Therefore, a stepwise Lexington community approach is implefor medical nutrition mented, and the clinitherapy. The program cian and patient colis located at Lexington laborate on short-term Green Mall, next to and long-term goals.

HealthwoRx fitness To maximize the expefacility. A physician’s rience for the patient, referral is necessary individual instruction for services to confirm Kathleen Stanley says, "nutritional is provided. diagnosis and medical counseling can ease the frustration Instruction will treatment plan. include the purpose of of multiple diagnoses affecting food Patients referred for choices." prescription, identificacounseling – for examtion, or classification ple, those with diabetes or celiac disease of prescribed foods, benefits of nutri– receive specialized counseling from expe- tional intervention, and record keeping. rienced registered and licensed dietitians. Computerized nutritional analysis can also The registered dietitians (RDs) will perform be performed based on food diaries to a thorough nutritional assessment of each provide specific information on macroindividual, including information such as and micro-nutrient intake. Individuals personal food preferences, food tolerances, will also receive reference options such budgetary limits, and cultural and lifestyle as written materials, menus, web-based influences. The RDs believe in a patient- applications, and phone apps to enhance centered approach and encourage patients the learning experience and for postto identify their needs upfront so that instructional support. an individualized educational plan can be During the session, information will developed. be provided on shopping, menu planning, The key to crafting a realistic and effec- cooking, and eating out, which is integral tive meal plan for an individual is listening to an individual’s lifestyle and is lacking in to the patient. The RDs at Baptist Health simple “tear-off ” nutritional prescription Lexington use an established approach plans or typical fad diets found in magazines called motivational interviewing. Food is a and books. very personal choice, therefore, it is essential Follow-up is essential to success, so indito understand the needs of the patient and viduals are given a follow-up appointment incorporate their food preferences for long- within 30 days of their initial appointment

to assess their ability to apply the information and skills learned. This also gives the RD the ability to measure the achievement of personal goals and track clinical outcomes such as weight changes, fasting blood glucose levels, and other biometrics.

It is not uncommon for people to have multiple nutritional challenges, such as hypertension and diabetes, heart disease and obesity, or even diabetes and Celiac disease.

In these situations, nutritional counseling can ease the frustration of multiple diagnoses affecting food choices. RDs at Baptist Health Lexington prefer to emphasize food choice opportunities, rather than provide a restricted food list, which is discouraging and usually temporary for most patients.

All encounters with patients – face-toface sessions, phone calls, follow-up assessment, and other correspondence – are communicated back to the healthcare provider for review and continuum of care. Making nutritional changes that produce positive health outcomes requires knowledge, skills and motivation. RDs are trained professionals that can help your patients achieve desired results that will improve their medical status without negatively affecting their lifestyle or food pleasures.

BH_CMYK_UNCOATED Logo Horizontal_LEXINGTON [Converted].pdf

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Kathleen Stanley is the coordinator of Outpatient Diabetes Education & Nutrition Education Services for Baptist Health Lexington. ◆

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For more information:

Kathleen Stanley, CDE, RD, LD, MSEd, BC-ADM Baptist Diabetes, Health & Nutrition Services Baptist Health Lexington PH: (859) 260-5122 FAX: (859) 277-0616

Issue#78 23

Special Section  Complementary Care

The Truth about Organic Farming

By Mac Stone Many of you may have seen the headline on a report from Stanford University – “Little evidence of health benefits from organic foods.”

(Brandt, 2012) A more accurate headline should have been – “Stanford research confirms health benefits driving consumers to organic.” (Organic Trade Association, 2012) But would we have learned about the study if the positive sentence were the lead one? As one of the owner/operators of Elmwood Stock Farm, a certified organic farm in Scott County, Kentucky, and current chair of the USDA National Organic Program and National Organic Standards Board, it is quite troubling the report chose to sensationalize one aspect of the fundamentals of organics, especially since it is inaccurate.

First, for the record, the report is a review of many different research studies, not its own designed study. It is very difficult to combine studies with differing scopes and draw single strong conclusions.

In conversation with agricultural researchers from the University of Kentucky and Kentucky State University, they pointed out the conservative statistical tests used in the Stanford report brought the variation of each study into the same range, therefore no differences show up, although many of the individual studies do show a positive significant difference in nutrient content of organic foods. There is clear evidence in refereed journals that livestock on foragebased diets have significantly different fatty acid profiles in their meat and milk, considered heart healthy by nutritional experts.

All organic meat and milk production must employ systems that optimize animal welfare and forage intake. Important is not just what the animals eat, but allowing their digestive systems to function properly at the right pH level with an optimum balance of nutrients. This has broader environmental implications as it reduces the need to raise 24 M.D. Update

Mac Stone, Director for Sustainability of Farms and Families, KSU

corn, wheat, and soybeans in other regions of the country and truck them to the animals. A very high percentage of the corn and soybeans are genetically modified, the effects of which are scary. There is increasing evidence a pesticide that is genetically inserted into the chromosomes of the corn plant is the cause of the demise of honeybees, known as colony collapse disorder.

Genetically modified corn pollen is said to have found its way into the ancient maize varieties in Mexico.

Another key aspect of organic production is demonstrated by the plants in an organic system. Insects do not pressure organic crops when they have such a strong balance of nutrients in them to produce the com pounds needed to resist chewing and piercing insect-feeders. The first insect of a particular species to feed from a plant will exude pheromones to others in their species if there is a weak or receptive and tasty food source. This will not happen in a nutrient balanced plant, therefore the insects will move on. Also, a well-balanced plant has a strong immune system to rapidly heal itself if tested by insects or wind damage. It just goes to reason that the produce itself would have a similar balance of micro-nutrients, and those often are not included in studies

like these. The Stanford report does go on to indicate higher levels of antioxidants, those all-important nutrients that contribute to a healthy body and offer disease suppression, are found in organic produce.

One major conclusion of the report showed clear benefits to consuming organic foods due to a reduced exposure to pesticides. Face it, how well can one wash broccoli, or strawberries? All pesticides have a “days-to-harvest interval” after application, but there are serious insecticides, miticides, fungicides, and growth regulators that really do not need to be anywhere near the foods we consume. Check out the Environmental Working Group’s Dirty Dozen annual list.

Not only is organic produce not contaminated with pesticides, but also organic grains are lower in mycotoxins. Mycotoxins are toxic compounds associated with molds on or in grains. They can invade the grains during production or in post-harvest handling and storage. Because most organic grains are handled in smaller lots, not commingled with many other producers’ grains, and often sold locally rather than stored or shipped great distances, they are less prone to coming into contact with these molds.

The report did find that a benefit of consuming organic meat and poultry is the reduced exposure to antibiotic-resistant bacteria, along with the beneficial elevated levels of omega-3 fatty acids. Many nonorganic farms add sub-therapeutic levels of antibiotics to the feed to stimulate growth of their animals. Anyone can walk into a farm supply store and purchase them with no restrictions. These antibiotics are not only showing up in streams and rivers, but also in underground aquifers. There is evidence that now shows human pathogenic bacteria are becoming resistant to treatment because of this indiscriminate use in food animals.

Kentucky is well suited for the production of organic foods. The vast acreage of rolling terrain is ideal for grazing livestock and poultry. The growing season is long enough to produce a wide array of fruits and Continues on page 31

news  events  Arts

Dr. Toni Ganzel named dean of UofL School of Medicine

Toni M. Ganzel, MD, MBA, FACS, has been named dean of the University of Louisville School of Medicine.

Her appointment is effective on or before June 1 and is subject to approval by the UofL Board of Trustees.

Ganzel has served as interim dean since March 2012, replacing Edward Halperin, MD, who stepped down as dean in early 2012.

“Dr. Ganzel was a key member of the team that helped develop the partnership between the University of Louisville and KentuckyOne Health,” said David L. Dunn, MD, PhD, executive vice president for health affairs. “She

LOUISVILLE

Send your NEWS items to M.D UPDATE > news@md-update.com

is critical to the implementation of our strategic initiatives as it relates to attacking many of the health issues we face within Kentucky. Additionally, she led the School of Medicine through the arduous self study and the Liaison Committee on Medical Education (LCME) site visit, the national accrediting body for schools of medicine.

She has worked tirelessly to ensure that our school continues to meet the needs of our faculty, staff and students and that we work to fulfill our mission for the UofL becoming a premier metropolitan research university.

Ganzel joined UofL in 1983 as an assistant professor in otolaryngology. She served as chief of otolaryngology at Kosair Children’s Hospital

from 1989 to 2002 and director of the division of otolaryngology at UofL from 1993 to 2001, when she was named associate dean of student affairs for the School of Medicine. In 2003 she was named senior associate dean for students and academic affairs in the school.

A native of New Mexico, Ganzel earned her bachelor of science and medical degrees from the University of Nebraska. She earned a master’s degree in business administration/medical group management from the University of St. Thomas in Minneapolis.

She completed her residency in otolaryngology at the University of Nebraska Medical Center before joining the faculty at the Creighton University School of Medicine.

She is a fellow of the Executive Leadership in Academic Medicine (ELAM) Program for Women at Drexel University College of Medicine in Philadelphia. ELAM is

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Serving health care providers with integrity.

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news the nation’s only in-depth program that develops the professional and personal skills required to lead and manage in today’s complex health care environment, with special attention to the unique challenges facing women in leadership positions.

Pagni Joins Baptist Surgical Associates

Sebastian Pagni, MD, cardiothoracic surgery, has joined Baptist Cardiac LOUISVILLE

Surgery, part of Baptist Surgical Associates.

Pagni is a 1989 graduate of the National University of La Plata School of Medicine in Buenos Aires, Argentina. He completed his general surgery internship at Yale University in New Haven, Connecticut, in 1992, and his residency

24th Annual

BB&T/Lexington Medical Society Golf Outing

Wednesday, August 28, 2013 | 1:00 p.m.

University Golf Club of Kentucky Format: Shamble Tournament (Play best drive then own ball to the hole)

Teams: Put together own Foursome Or Committee will help form teams

Golf – Individual Players | $100.00/person Hole Sponsorship | $500.00

(includes signage & newsletter recognition)

Hole Sponsorship with 4 Players | $800.00 (includes signage & newsletter recognition) White Tee Sponsorship | $2,000.00

(includes banner recognition, newsletter recognition, hole sponsorship & four players)

Gold Tee Sponsorship | $6,000.00 BB&T Get your team together, sponsor a hole and register to play!

More information will be sent out soon. Please contact a committee member or call Jaime Verba at LMS office 859.278.0569 with questions or to sign up.

Committee Members John W. Collins, M.D., Chairman

James W. Baker, M.D.

Wendy G. Cropper, M.D.

W. Lisle Dalton, M.D.

Kenneth V. “Tad” Hughes, III, M.D.

John Maher, BB&T

David Smyth, Family Financial Partners

Jon H. Voss, M.D. Gil Dunn, M.D. Update

there in 1996, serving as chief resident his final year. He completed a cardiovascular fellowship at Hospital Espańol de Buenos Aires, and a thoracic and cardiovascular fellowship at the University of Louisville, both in 2001. Pagni is board certified in general and thoracic surgery.

Cyrus joins Baptist Medical Associates

LOUISVILLE Jahangir Cyrus, MD, endocrinology, has joined Baptist Medical Associates at 4003 Kresge Way, Ste. 400.

Cyrus is a 1969 graduate of the Tehran University School of Medicine in Tehran, Persia. He completed his internal medicine internship at MacNeil Memorial Hospital in Derwin, Ill., in 1970; and his internal medicine residency at Veterans Administration Hospital in Dayton, Ohio in 1973. Cyrus completed an endocrinology fellowship at George Washington University Veterans Administration Medical Center in Washington, D.C. in 1975. He is board certified in internal medicine.

Williams joins Baptist Medical Associates

LOUISVILLE Lisa Williams, APRN, MSN, CDE, has joined Baptist Medical Associates at 4003 Kresge Way, Ste. 400.

Williams is a 2007 graduate of the Northern Kentucky University adult to family nurse practitioner program. She also holds a bachelor’s degree in nursing from Spalding University and a master’s degree in nursing from the University of Louisville.

She is a certified diabetes educator.

Hoven Selected One of the ‘Top 25 Women in Healthcare’

Dr. Ardis Hoven, internal medicine and infectious disease specialist at

LEXINGTON

All proceeds to benefit the Lexington Medical Society Foundation.

MC-8820 4.8542x7.25 Golf Outing Save the Date.indd 1 26 M.D. Update

4/22/13 11:38 AM

news the University of Kentucky and presidentelect of the American Medical Association (AMA), has been selected one of the “Top 25 Women in Healthcare.”

The selection, made by the editors of Modern Healthcare magazine, honors executives in all fields of health care “for making a positive difference in the industry.”

Hoven, who received her undergraduate degree in microbiology and then her medical degree from UK, will begin her term as American Medical Association president in June, making her the third woman to hold that position.

Hoven, 68, previously served as president of the Kentucky Medical Association, where she first got involved in the 1980s to advocate on behalf of patients with HIV/ AIDS. She has been on the AMA board of trustees since 2005, serving as chair from 2010 to 2011.

Lee Named Medical Director of Stroke Care

LEXINGTON Dr. Jessica D. Lee has been named UK HealthCare Medical Director of Stroke Care. Lee assumes the responsibilities formerly held by Dr. Michael Dobbs.

In her new role, Lee will work with members of the enterprise stroke leadership team on maintaining compliance with stroke core measures, stroke center certification, and other quality initiatives in stroke care.

Over the last three years, the stroke program has excelled in core measure compliance to receive the American Heart Association’s Gold Plus Award three times for quality of care, underwent a successful Primary Stroke Center recertification with The Joint Commission, and has improved to be a national leader in stroke survival, length of stay, and readmission.

Lee attended the University of Mississippi School of Medicine and is a fellowship-trained vascular neurologist with a strong background in patient safety. Since 2009, she has been actively involved in the American Academy of Neurology’s Patient Safety and Education Committees. She

JOINING THE FIGHT AGAINST CHRONIC ILLNESS

YMCA OF CENTRAL KENTUCKY Chronic Health Initiatives Diabetes • Cancer • Heart • Obesity

Learn more at www.ymcaofcentralky.org Issue#78 27

news has spoken regionally and nationally on “Patient Safety 101 for Neurologists” and has worked to develop curricula for neurology residency training programs.

Since coming to UK in 2012, Lee has been leading development of a vascular neurology fellowship training program, as well as a telehealth stroke care clinic within the Stroke Care Network.

Bluegrass Internal Medicine Group, PLLC Joins Lexington Clinic

Lexington Clinic, Central Kentucky’s oldest and largest multi-specialty medical group, announced today the association of Bluegrass Internal Medicine Group, PLLC as part of a strategic alliance to further enhance healthcare service delivery to patients.

Bluegrass Internal Medicine Group, PLLC has offered personalized, comprehensive care to central Kentucky since 2007. “We are pleased to associate with Lexington Clinic,” said Daniel J. Beiting,

LEXINGTON

MD, Bluegrass Internal Medicine Group, PLLC, “because this alliance will enhance our patient care.”

“Bluegrass Internal Medicine Group, PLLC is a welcome addition to Lexington Clinic, and we look forward to the patient care opportunities made possible by this association,” said Andrew Henderson, MD, Lexington Clinic CEO. This association is expected to take effect on June 1, 2013, at which time Bluegrass Internal Medicine Group, PLLC will become a member of Lexington Clinic’s Associate Physician Network. Lexington Clinic and Bluegrass Internal Medicine Group, PLLC are striving to ensure minimal patient impact during this transition.

Lexington Clinic expands outpatient surgical center services

LEXINGTON Lexington Clinic has opened the new Endoscopy and Surgical Center (ESC) of Lexington Clinic to expand procedural and surgical outpatient services for patients.

The Endoscopy and Surgical Center, located on the second floor of Lexington Clinic’s existing Ambulatory Surgery Center (ASC), adds five procedure rooms and one operating room to the facility, and is the first phase of a multi-faceted renovation project at 1225 South Broadway in Lexington. The new center will offer endoscopic and surgical services in more than eight specialties and provide 9,700 square feet of procedural, surgical and office space.

The Endoscopy and Surgical Center’s 20 physicians and 38 staff members will provide gastroenterology, pain medicine, pulmonary, vascular, radiologic, breast surgery, podiatric and general surgeries and procedures. “Patient satisfaction is the hallmark of the ambulatory surgery industry,” says Ashley Karathanasis, MBA, CASC, Lexington Clinic ASC administrator. “The ASC and ESC are service oriented and patient focused and now more accessible to our patients.”

The existing ASC, which occupies the first floor of the facility, offers six operating suites and four procedure rooms, providing surgical services in over 15 different specialties. Lexington Clinic is planning a second phase renovation which will expand the current first floor facility, adding additional operating room space.

The Lexington Clinic Board of Directors approved the renovation plan in response to significant growth and increased demand.

“Choosing the provider and location that is right for you is an important decision,” says Andrew H. Henderson, MD, Chief Executive Officer at Lexington Clinic.

“The demand for outpatient services, which offer advantages like flexibility, cost-savings, convenience and faster recovery, is growing.

This new center will allow us to meet those increasing demands and better serve our patients.”

Dr. David A Dageforde Honored on Doctors’ Day

On March 22, 2013 the GLMS Alliance recognized Dr. David A. Dageforde’s years of service to the medical community by honoring him as physician, leader, educator, missionary and family man.

Dr. Dageforde attended medical school at Indiana University, went to Houston, Texas for a residency in the specialty of Internal Medicine. He then moved to 28 M.D. Update

news Washington, D.C. for fellowship training Cardiology. Dr Dageforde is certified in Internal Medicine, Cardiology, and Interventional Cardiology.

From 1979 until 2012, he worked at Epidurals Facet Blocks

Intrathecal Pumps Vertebroplasty

Spinal Cord Stimulation Neurolytic & Sympatholytic Denervation

Rhonda Rhodes, KMA Alliance presidentelect, Dr. Dageforde, Adele Murphy, GLMSA president

CardioVascular Associates. He was president of the medical staff at Audubon Hospital, and continues as an Assistant Clinical Professor at the University of Louisville School of Medicine.

In service to his community, Dr Dageforde has been a researcher, lecturer, author, and leader. He has been on the Board of Directors for the WHAS Crusade for Children, Founder and President of Shawnee Christian Healthcare Center, and a deacon at Southeast Christian Church.

Since 1994 he has made over twenty medical mission trips overseas to places like Ethiopia, India, China, Zambia, Romania, Gabon, Thailand, Guatemala, and Afghanistan. Included in his list of overseas mission work is his service on the board for MedSend and SOZO International, and he is the founder of the Global Missions Health Conference at Southeast Christian Church.

In 1999, Dr Dageforde was honored with the Community Service Award from the Kentucky Chapter of the American College of Physicians, and in 2004 he received the President’s Heritage Award from the National Christian MedicalDental Association

BMT Program Earns Renewal for Prestigious FACT Accreditation

LEXINGTON The University of Kentucky Markey Cancer Center’s Blood and Marrow Transplant Program was recently grant-

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Issue#78 29

news ed re-accreditation from the Foundation for the Accreditation of Cellular Therapy (FACT).

The BMT Program was accredited for adult allogenieic and autologous, hemtaopoietic progenitor cell transplantation, marrow and peripheral blood cellular therapy product collection, and cellular therapy product processing. The accreditation runs through 2015.

“Achieving FACT accreditation requires the hard work and dedication of all members of the BMT team, including the outpatient clinic, chemo infusion, apheresis, central ambulatory surgery, stem cell processing laboratory, ICU, radiation oncology, and Markey BMT inpatient providers,” said Dr. Dianna Howard, hematologist for the UK Markey Cancer Center. “The expert contributions of each member of the team on a daily basis establishes the high quality of care required to maintain this prestigious accreditation.”

FACT is the only accrediting organization that addresses all quality aspects of cellular therapy treatments: clinical care, donor management, cell collection, cell processing, cell

30 M.D. Update

storage and banking, cell transportation, cell administration, cell selection, and cell release.

FACT accreditation is also a factor in the ranking of “America’s Best Hospitals,” published by U.S. News and World Report. In 2012, UK Albert B. Chandler Hospital was named the No. 1 hospital in the state of Kentucky and earned a ‘high performing’ designation in 10 speciality areas, including cancer treatment.

Hospitals Recognized for Stroke Care

LEXINGTON UK HealthCare’s Kentucky Neuroscience Institute (KNI) Stroke Program has once again received the Get With The Guidelines – Stroke Gold Plus Quality Achievement Award from the American Heart Association. This marks the third year the program has been recognized with a quality achievement award.

Baptist Health Lexington has also received the Get With The Guidelines®– Stroke Gold Plus Quality Achievement Award. This marks the fifth year that Baptist Health Lexington has been recognized with a quality achievement award.

The award recognizes the programs’ commitment and success in implementing a higher standard of care by ensuring that stroke patients receive treatment according to nationally accepted guidelines.

To receive the award, a hospital must achieve at least 85 percent adherence to all “Get With The Guidelines” stroke quality achievement indicators for two or more consecutive 12-month intervals, and achieve 75 percent or higher compliance with at least six of 10 stroke quality measures. These measures include appropriate use of life-saving medications and lifestyle/ behavior modifications, all aimed at reducing death and disability and improving the lives of stroke patients.

KentuckyOne Health and the Mayor’s Healthy Hometown Movement kick-off Walk With a Doc events

KentuckyOne Health and the Mayor’s Healthy Hometown Movement are teaming up this summer to get Louisville area residents to Walk With a Doc. On Saturday,

news May 18, KentuckyOne kicked off monthly Walk With a Doc events at Iroquois Park with Mayor Greg Fischer and LaQuandra Nesbitt, MD, Louisville Metro director of Public Health and Wellness.

Walk with a Doc is a nationwide program that works to empower patients to improve their health through physical activity, exercising side-by-side with their healthcare providers. Walkers have the opportunity to learn about important health topics, ask medical questions in an informal manner and receive free blood pressure screenings, refreshments and giveaways. To help make walking a habit, people who participate in at least three walk events receive a Walk With a Doc t-shirt.

Walk With a Doc events will take place at 10 a.m. every second Saturday of the month at the Egg Lawn in Beckley Creek Park at The Parklands; every third Saturday of the month at Iroquois Park at the shelter near the Amphitheater; and every fourth Saturday of the month at Shawnee Park at the Southwestern Parkway entrance parking lot. ◆

products over many generations, showed increased fertility, improved stress resistance, and longevity over their conventionally fed contemporaries. Fruit flies do not know how to misrepresent themselves.

Board Member 2011-2015; and Vice President, Lexington Farmers Market. He is currently the Director for Sustainability of Farms and Families at Kentucky State University and the owner/ operator of a 375-acre Certified Organic Farm in Scott County, Kentucky.

Mac Stone has a BS in Agronomy and an MS in Animal Science from the University of Kentucky.

He is the former Executive Director, Office of Marketing, KY Department of Agriculture; the Chair, National Organic Standards Board,

References: Brandt, M. (2012, September 3). News: Little evidence of health benefits from organic foods, Stanford study finds. Retrieved from Stanford School of Medicine: http://med.stanford.edu/ ism/2012/september/organic.html Organic Trade Association. (2012, September 4). Newsroom: Stanford research confirms health benefits driving consumers to organic. Retrieved from Organic Trade Association: http://www.organicnewsroom. com/2012/09/stanford_research_ confirms_hea.html

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Continued from page 24

The Truth About Organic Farming vegetables. UK, KSU, and Berea College all have certified organic farms, training the next generation of farmers to raise food the right way.

The study itself has added some fuel to the fire of organic versus conventional production methods. Interestingly, the inaccurate, but attention-grabbing headline for the Stanford research study has generated even more follow up news reports.

Virtually all of these, when properly established, do show a benefit to consuming organic foods, much less the greater environmental good. In many European countries, governments subsidize organic farmers since the citizens value the environmental benefits to their ecosystem.

This begs the question, why do university scientists have to misrepresent the results to get some “airtime”?

The New York Times recently reported a study out of Southern Methodist University. Fruit flies, feeding on organic Issue#78 31

events

T h e J u l e p Ba l l Photos courtesy of the University of Louisville.

Dr. Jeff Bumpous, Physician of the Year; Dr. Donald Miller, director of the James Graham Brown Cancer Center; and Dr. Brad Chaires, Scientist of the Year, pose for photos at the Julep Ball. Dr. Bumpous treats cancers of the head and neck. Dr. Chaires is researching nucleic acid structures that may shut off the production of proteins early in the development of cancer.

Dr. Shiao Woo, chair of radiation oncology at the James Graham Brown Cancer Center, far right, shares a moment with John Howard Shaw-Woo and Kristen Reiss Pellino at the Julep Ball.

Cardinal Hill Telethon Dr William O. Witt, Medical Director of the Cardinal Hill Pain Institute (lower right) takes pledges during the annual Cardinal Hill Telethon on April 21, 2013.

32 M.D. Update

University of Louisville President James R. Ramsey, left, talks with David Klein, a cancer survivor whose generosity has enabled the creation of the Transitions program at the James Graham Brown Cancer Center to help patients navigate the maze their lives become after diagnosis.

Dr. David Dunn, executive vice present for health affairs at the University of Louisville, and Dr. Kelli Bullard Dunn, professor of surgery specializing in colorectal cancer at the James Graham Brown Cancer Center, talk with friends at the Julep Ball.

Photo courtesy TOPS in Lexington/Alex Orlov

The Julep Ball is one of the longest running Derby weekend fundraisers. On Derby Eve, special musical guests Angie Johnson and the iconic party band The B-52s treated guests to an experience like no other from the main floor of the KFC Yum! Center. The evening included a multicourse seated dinner, auction, and dancing.

A portion of the event’s proceeds go specifically to the Harriett B. Porter Endowment to support the health disparities in underserved communities of greater Louisville. A true “Party with a Purpose,” the Julep Ball honors the groundbreaking achievements made by the researchers and physicians at James Graham Brown Cancer Center. Support of this event assures better access to screening and education opportunities in fighting cancer. No matter who the patient is or what type of cancer they have, they are offered a world-class level of care that starts with diagnosis and continues through every phase of disease management and recovery. ◆

Have Your Baby Close To Home!

Pictured above (left to right):

Angela S. Saxena, MD, FACOG Everett J. Horn, MD, FACOG, MBA Amanda Hess, DO, FACOG Mark A. Wainwright, DO, FACOG Stephen K. Hall, MD, FACOG Kendra Adkisson, WHCNP, CNM Emily Dial, WHCNP, CNM Katie Isaac, ARNP, CNM

Specializing in Obstetrics and Gynecology

Frankfort

279 King’s Daughters Dr., Ste. 301

Frankfort, KY 40601

(502) 227-BABY (2229)

Owenton

120 Progress Way Owenton, KY 40359 (502) 227-BABY (2229)

www.wcotb.com

Versailles

360 Amsden Ave., Ste. 401 Versailles, KY 40383 (859) 873-BABY (2229)

You may also call us toll free at 866-861-6157.