M.D. Update Issue #87

THE BUSINESS MAGAZINE OF KENTUCKY PHYSICIANS AND HEALTHCARE PROFESSIONALS ISSUE #87

A Team Approach with a Shared Vision for Excellence

SPECIAL SECTIONS PLASTIC SURGERY AND HAND & FOOT SURGERY

Dr. David Cowen masters oculoplastics and builds a practice as the “Go-To Eye Plastics Guy” in the region.

ALSO IN THIS ISSUE VOLUME 5, NUMBER 5

 PLASTIC SURGEON JOINS OWENSBORO HEALTH  PEDIATRIC UROLOGIST OPENS LOUISVILLE OFFICE  FOOT & ANKLE HEALTH  HAND CARE AT THE VA  DERMATOLOGY PRACTICE IN BOWLING GREEN  TRIMIX FOR MEN’S SEXUAL HEALTH

life

With each new first, we give more people a second chance at

KentuckyOne Health was first in Kentucky to perform open heart surgery, first with transcatheter aortic valve replacement, first with ventricular assist devices, first with MitraClip procedure. We perform the most technologically advanced heart procedures in the region, because with each new first, we give more people a second chance at life.

See all of our firsts at KentuckyOneHealth.org/heart.

Saint Joseph Heart Institute and Jewish Heart Care are now known as KentuckyOne Health Heart and Vascular Care.

KentuckyOne Health. The one name in heart care.

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771 771 Corporate Drive Suite 460, Lexington, KY 40503Pho Phone: 859-219-0299 Toll free: 866-882-6936 ww

www.davidcowenmd.com

LETTER FROM THE EDITOR

Reflections on the All-Star Game and Doctor/Patient Relationship Change is coming.

Change is here.

It’s Tuesday night, July 15, 2014 and I’m watching the MLB All Star game with watering eyes as Derek Jeter, Yankee shortstop who is retiring at age 40, in case you didn’t know, receives two standing ovations.

Retiring at 40, that’s a young doctor’s age and the upside of a career for the rest of us.

I’ve been a baseball fan for more than 50 years, although I hardly know any current (L-R) Jimmie Foxx, Hall of Fame, major league players. For the last 10 years my with publisher at age 16 and baseball passion has been fed by watching youth Sammy Dell Foxx, Jimmie’s and high school baseball where my son and his brother, July 1966 on Kent Island, teammates play the same game as Jeter does, but Md. Foxx was born on Maryland’s with a lot more emotion, frustration, joy and Eastern shore and came to visit sometimes tears.

Dunn’s father, Gil Sr. So, I’m thinking that after Derek Jeter leaves baseball this season, which major league player will I know or care about or follow all summer long and into the fall? It’s a very short list. Time will tell.

The next day I read that Tuesday, July 15 was the beginning of implementation of 2014 Senate Bill 7, the APN Collaborative Agreement legislation, which Dr. Tracy Ragland, among others, diligently worked on in Frankfort. I invite you to read Dr. Ragland’s essay on page 5 where she describes the process and outcome of the Kentucky Academy of Family Physicians advocacy for extending primary care throughout Kentucky. We applaud her work on behalf of Kentucky physicians and all the people of Kentucky who need healthcare. The un-intended consequences of the compromise bill remain to be seen.

Dr. Damian “Pat” Alagia, III, knows something about change. He is the chief physician executive at KentuckyOne Health. He told us that every day is full of the challenges of merging three legacy organizations into one with over 15,000 associates, staff and individuals PLUS patients. See the Q & A with Dr. Alagia on page 14 and you’ll find out something you probably didn’t know about his family.

And MD-UPDATE is growing and changing too with the launch this fall of MD-UPDATE.COM. Learn how “Inbound Marketing” works for physicians from MD-UPDATE Digital Publisher, Megan Campbell Smith. Kentucky physicians can change how other doctors and patients find them on the internet. Be one of the first to get on board. Until next issue...

All the Best, Gil Dunn Jr. Publisher, MD-UPDATE Send your letters to the editor to: jnewton@md-update.com, jennewton01@gmail.com, or (502) 541-2666 mobile Gil Dunn, Publisher: gdunn@md-update.com or (859) 309-0720 phone and fax 2 M.D. UPDATE

Volume 5, Number 5 ISSUE #87 PUBLISHERS

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James Shambhu art@md-update.com

CONTRIBUTORS: Jan Anderson Sarah Charles Wright Camille Oliver Scott Neal

CONTACT US:

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CONTENTS

ISSUE #87

COVER STORY 4 HEADLINES 5 PHYSICIAN VIEWPOINT 7 FINANCE 8 LEGAL 10 ACCOUTING 12 ONLINE MARKETING 14 Q&A 16 COVER STORY 20 SPECIAL SECTION: PLASTIC SURGERY

22 SPECIAL SECTION:

A Team Approach with a Shared Vision for Excellence Dr. David Cowen masters oculoplastics and builds a practice as the “Go-To Eye Plastics Guy” in the region.

BY TIM CORKRAN, COVER PHOTO BY JOHN LYNNER PETERSON PAGE 16

SPECIAL SECTION  PLASTIC SURGERY

20 FILLING THE VOID: PLASTIC SURGEON JOINS OWENSBORO HEALTH

21 COMING FULL CIRCLE: PEDIATRIC UROLOGIST OPENS LOUISVILLE OFFICE

HAND & FOOT SURGERY 25 DERMATOLOGY 26 MEN’S HEALTH 27 COMPLEMENTARY CARE 28 NEWS 32 ARTS/EVENTS

SPECIAL SECTION  HAND & FOOT SURGERY

22 BEST FOOT FORWARD: DR. NICOLAS VIENS AT LEXINGTON CLINIC

24 HEAVY-HANDED: HAND CARE AT LOUISVILLE VA

ISSUE#87 3

HEADLINES

LINX®, an Update

First surgical procedure for permanent GERD relief performed in Kentucky at Saint Joseph Hospital

BY TIM CORKRAN PHOTOGRAPHY BY GIL DUNN

LEXINGTON Jason Harris, MD, completed the first successful LINX® surgery in Kentucky on June 5, 2014 at Saint Joseph Hospital in Lexington Harris places LINX device and established LINX as an to encircle the esophagus. option for GERD (gastroesophageal reflux disease) patients in the region.

(See MD-UPDATE #85 (April 2014), pg.

21, for more discussion of LINX.) LINX, a Torax Medical product, is a band of rare earth magnets placed around the base of the esophagus to restore the body’s natural barrier to reflux. Following the laparoscopic procedure, Harris’s first

patient, a middle-aged female, described her immediate post-op comfort level, “I can’t even believe I’ve had surgery.”

LINX has an FDA indication for patients with intractable reflux who, despite medication, continue to exhibit symptoms.

The LINX device was created to provide patients with a suitable alternative to both the long-term use of proton pump inhibitors and conventional surgery for GERD. The magnets have a high degree of Rare Earth Elements, so their magnetism is enduring; one implant should last the 4 M.D. UPDATE

remainder of a patient’s life. The procedure is also considered for GERD sufferers who have prohibitive medication side effects or simply are uncomfortable with-long term medications.

Harris says his first patient found him through internet research. A Louisville resident, she was interested in obtaining a LINX band and learned that he was the sole provider in the Commonwealth. He reports that the procedure, which can be performed on an outpatient basis, was done under general anesthesia and went fully as expected.

ABOVE (L-R) Jon Gould, MD, FACS, chief of division of General Surgery, Medical College of Wisconsin, was preceptor for first LINX surgery in Kentucky with Jason Harris, MD, FACS, Bluegrass Surgical Group, who performed the surgery at Saint Joseph Hospital in Lexington.

Harris with surgical assistant, Kathy Nord, sizes the device prior to placement while Gould observes.

LEFT

BELOW LINX uses a band of rare earth magnets around the base of the esophagus to restore the body’s natural barrier to reflux.

While the patient had taken no postop pain medications other than over-thecounter pain relievers, Harris predicts that from two-to-eight weeks post-op, she can expect some chest pain with meals. This is a natural consequence of the bodies acclimation to the device. Harris explains that not reverting to a liquid diet – a soothing temptation – is contra-indicated at this point. He expects to work with his patient on tactics for moving through this uncomfortable stage without discouragement or regression and contends that personalizing the post-op protocol is standard with LINX emplacement. “Just like a knee replacement, LINX surgery requires some physical therapy to ensure maximum effect,” he adds, noting that, “Ninety percent of patients have resolution of this by eight weeks.”

Kentuckians with GERD now have another option, and Harris says, “LINX is going to take away a lot of the current outcome challenges of traditional anti-reflux surgery.” ◆

PHYSICIAN VIEWPOINT

Lessons Learned

An individual physician perspective on the advanced practice nurse-physician collaborative agreement compromise BY TRACY RAGLAND, MD The article in MD-UPDATE Issue #85 that focused on the recent legislation on collaborative agreements for nurse practitioner prescription writing was informative. As an individual physician who was directly involved in the process that led to the compromise, I would like to share a few more important details.

Since 2010, the Kentucky Coalition of Nurse Practitioners and Nurse Midwives (KCNPNMW) has been very successful in lobbying the Kentucky legislature to eliminate the requirement for an Advanced Practice Nurse (APN) to maintain a collaborative agreement with a physician in order to write prescriptions for non-controlled drugs. This proposal steadily became accepted by many lawmakers as a way to counter inadequate access to primary care physicians in many underserved areas of the state. The KMA historically opposed the elimination of the requirement, citing patient safety concerns. Since most legislators had come to believe that the issue was purely a turf battle, the APN-backed legislation would have become law during the 2013 session if not for a handful of Senators who were deeply concerned about the issue and the Kentucky Academy of Family Physicians (KAFP) which, together with several individual physicians, lent “credibility,” according to many legislators, to the physician argument. In April 2013, the three organizations were asked by legislative leaders to work out a compromise during the interim.

A large and diverse group of nurses, physicians, lobbyists, and legislative staff met several times between May and November 2013. Most of us agreed that simply eliminating the requirement for collaboration would not significantly improve access to primary care across the state. We began by looking closely at how the collaborative agreement requirement in Kentucky was reportedly limiting access to care in some instances. According to the KCNPNMW: the collaborative agreement, with no stan-

dardized feature, added no value to patient care; some APN’s were in danger of losing their practices if their collaborating physician retires, moves, or dies; and some physicians were charging excessive fees for signing these agreements. After lengthy discussions, it became apparent that these problems represented the extremely rare exception, not the rule.

In July of last year, the Joint Licensing and Occupations committee heard a progress report from the group. Physicians revealed the general trend of APN’s working increasingly in non-primary care specialties while generally being no more likely to practice in rural and underserved areas than primary care physicians. We reiterated the importance of the substantial educational gaps between nurse practitioners and physicians (especially with the recent development of “fast tracks” toward RN and advanced practice degrees) and shared that every state surrounding Kentucky continued to maintain stricter collaboration laws than ours. Further discussion drew atten-

tion to the fact that non-controlled drugs include extremely potent medications that have complex interactions and potential side effects that are less predictable than controlled substances. Physicians finally presented how physician-led team-based care, along with efficient applications of technology, can dramatically reduce the impact of physician shortages. We offered to develop a clearinghouse of physicians willing to work with nurses who lose their collaborating physicians through no fault of their own, and we recommended building on previously proposed legislation regarding standardization of the collaborative agreement.

After further discussions revealed that the KCNPNMW was committed to eliminating rather than improving the collaborative agreement, and proposals to develop a Joint Medical/Nursing Board while holding independently prescribing APN’s and physicians to the same professional liability standards were deemed non-starters for further discussion, physicians proposed the following: (a) form a Joint Advisory Committee made up of equal parts Kentucky Board of Nursing and Kentucky Board of Medical Licensure and charge it with monitoring APN-written prescriptions, developing a standardized collaborative agreement form, and advising each Board on the issue; (b) develop a process for APN’s who wish to practice and prescribe independently that includes a requirement to complete several years of meaningful collaborative practice with a physician who specializes in the APN’s area of focus and allows for a grandfather clause; (c) incentivize APN’s to serve in one of Kentucky’s approximately 80 medically underserved areas by establishing a rural/underserved area carved out for nurses who opt to prescribe without a collaborative agreement; and (d) allow APN’s to maintain the protection of their existing collaborative agreements as the default.

The final agreement that is now law was made within the confines of a smaller ISSUE#87 5

PHYSICIAN VIEWPOINT

group that I was not a part of. In essence it establishes a requirement for a newly graduated APN to maintain a collaborative agreement for four years, after which time the APN may opt to prescribe independently in any part of the state with no stipulation about his or her area of practice. At this point, there is no requirement for meaningful collaboration. The Joint Advisory Committee will be established with no definitive authority to make recommendations regarding collaborative agreements or prescribing. It may, however, develop a standardized collaborative agreement form, and hopefully it will opt to do that in a manner that provides transparency and guidance without being unnecessarily restrictive. (See 2014 Senate Bill 7.)

Many lessons can be learned from this imperfect yet rewarding experience. First, it offers proof that when groups and indi-

MANY LESSONS CAN BE LEARNED FROM THIS IMPERFECT YET REWARDING EXPERIENCE. FIRST, IT OFFERS PROOF THAT WHEN GROUPS AND INDIVIDUALS WHO HAVE BEEN AT ODDS ON ISSUES CAN ACTUALLY SIT DOWN IN THE SAME ROOM AND HAVE A DISCUSSION, GOOD THINGS CAN HAPPEN. viduals who have been at odds on issues can actually sit down in the same room and have a discussion, good things can happen.

It also shows that political advocacy is very

important, as ultimately the group that had been the most active in Frankfort was the most satisfied with the outcome. It is exciting to think what could happen in the future if multiple physician groups sat down regularly with other providers, insurers, and attorneys, as well as our leaders in government, academics, and business. Together we could realistically eliminate chronic provider shortages, grow local economies, and, most importantly, improve the health and well-being of all the citizens of this great Commonwealth.

Dr. Tracy Ragland is a partner in Internal Medicine & Pediatric Associates in Crestwood, KY. She is vice chair of the Greater Louisville Medical Society Policy and Advocacy Committee and legislative liaison for the Kentucky Chapter of the American College of Physicians. â—†

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6 M.D. UPDATE

FINANCE

Social Security and You Planning for social security benefits has apparently become a hot topic for many readers. Buying into the idea that social security will be broke in x number of years, some people discount the future value of their benefits. For others, it will be such a small part of their overall retirement success that it doesn’t warrant much ink. But I suppose that because there are many readers getting close to retirement age, questions regarding social security appear frequently in my inbox.

The most common question, and the one that has the greatest long term impact, is “When should I start my benefits?” Just as a reminder, you can start a reduced benefit at age 62; the age for receiving “full” retirement benefits is set by the year of birth and can range from age 65 to age 67; and one can receive an increased benefit up until age 70. It makes no sense to go past 70 to start benefits. For married couples, spouses have so many potential yearly combinations of individual start dates that careful and complete analysis is in order.

THE MOST COMMON QUESTION, AND THE ONE THAT HAS THE GREATEST LONG TERM IMPACT, IS “WHEN SHOULD I START MY BENEFITS?” A few years ago, Wharton School of Business published a research paper on the choice of a start date. They concluded that the selection of start date was often behaviorally determined and directly related to how the problem was framed. Not too surprisingly, those prospective recipients who viewed the question from a break-even analysis almost always opted for an earlier start date. Comparing age 62 to age 70, the breakeven age is generally about 78. Those for whom the question was posed around lifetime benefit chose a later start date. We are of the opinion that a better analysis is quantitative and optimizes start date for both spouses down to the month and year.

One of the first things to understand when you are thinking about starting ben-

efits is that after the death of the higher-earning spouse, the higher benefit will transfer to the surviving (lower-earning) spouse. The surviving spouse’s own benefit will then stop. Thus,

BY Scott Neal the start date of the higher-earning spouse will determine the lifetime benefit for both of them.

Choosing a later start date is like procuring a life insurance policy that will pay out over the lifetime of the surviving spouse.

This points to one fallacy of a breakeven analysis. Many people look at the breakeven date and conclude that because their life expectancy is not much greater than the breakeven date, they should opt for an earlier start date. They do this without considering the impact to the surviving spouse.

When you are married, you should consider the potential life expectancy of the longerlived spouse. This could become especially important for couples with an age-gap between them and where the younger spouse is the lower-earner. Remember, the higher earner’s benefit will prevail regardless of who dies first—that benefit should be maximized. The lower earner’s life expectancy becomes the controlling factor if the financial security of the surviving spouse is your concern.

Obviously, there is a cost to waiting to start benefits. If both spouses die early, the delayed claiming strategy would cause them to have foregone the benefit that could have been received between age 62 and the later start date. This amount is the “cost” of the longevity insurance (if the higher earner lives to a very old age) and life insurance (if he or she dies early). Worth noting that this cost goes away if the lower-earner lives past the breakeven point.

In many cases, the optimized solution reveals that the higher-earning spouse should file for benefits and suspend their receipt in order for the lower-earning spouse

to collect spousal benefits. Yes, this can actually be done. Also if, like me, you were older when your child was born, filing and suspending may enable a minor child to collect a benefit until he or she reaches age 18. In both cases, the benefit of the one who suspended continues to grow. The bottom line is that family demographics matter and each spouse should carefully consider the life-expectancy of the other before claiming his or her benefits.

So far, we have dealt with the cumulative benefits of Social Security and it’s easy to dismiss the large numbers that are included in such an analysis; but in reality most benefits are not accumulated, they are spent on living expenses throughout retirement. To a surviving spouse, the income is likely to be the factor that ultimately matters the most.

Imagine if you will, 40 years from now, your spouse is sitting with his or her friends in the retirement community comparing social security checks. As tempting as it was to start earlier, the impact of delaying the start of benefits is clearly evident as the one who delayed the start date has nearly twice as much in benefit as one who started at age 62. The survivor benefit includes all the delayed credits accrued between full retirement age and age 70 plus the cost of living increases that compounded on the higher starting amount. It’s hard to value the peace of mind that comes from a having a source of lifetime income as one gets older.

Your financial advisor should routinely build this analysis into your financial plans and make recommendations regarding the optimized start date. The analysis can also be performed on a stand-alone basis with a minimum amount of data. In any event the final decision is a very personal one, uniquely tied to individual circumstances, and the impact can be big. It should not be left up to rules-of-thumb, and certainly not to mere chance.

Scott Neal, CPA, CFP is President of D. Scott Neal, Inc., a fee-only financial planning and investment advisory firm with offices in Lexington and Louisville, KY. Email questions to scott@dsneal.com. ◆ ISSUE#87 7

LEGAL

Treating Patients by Telehealth in Kentucky You may already be practicing telehealth, or considering it, if you have patients who cannot be seen in your office due to physical limitations or transportation issues.

Kentucky was one of the first states to pass telehealth laws, by authorizing physician use of telehealth in 2000 and creating the Kentucky Telehealth Board to develop the Kentucky Telehealth Network (“KTN”).

Health plans are now prohibited by law from excluding coverage of telehealth if the service is otherwise covered and the telehealth consultation is conducted through the Kentucky Telehealth Network or is otherwise approved by the health plan.1 The use of telehealth by Kentucky providers is growing, and it is important for physicians to be familiar with the basic “dos” and “don’ts” of practicing telehealth.

Last year, Kentucky Medicaid amended its telehealth regulations expanding the types of health care providers and services available through telehealth.2 This article provides an overview of the current state of telehealth law for physicians in the Commonwealth.

Telehealth Under Kentucky’s Physician Licensure Laws

Kentucky defines “telehealth” for physicians as “the use of interactive audio, video, or other electronic media to deliver health care. It includes the use of electronic media for diagnosis, consultation, treatment, transfer of medical data, and medical education.”3 Physicians may practice telehealth in Kentucky but only if the physician (i) first obtains the patient’s signed informed consent to telehealth treatment, which explains the limitations of telehealth treatment absent a physical exam and the inherent security and confidentiality risks of electronically transmitting a patient’s health information; and (ii) has policies and procedures to protect and maintain the confidentiality, privacy, and security of the health information received via telehealth.4 A physician cannot prescribe medication in response to a patient email or telephonic request, unless the physician already has a proper physician-patient relationship 8 M.D. UPDATE

with the patient.5 This means the physician has already diagnosed the patient’s condition through “accepted medical practices” and verified the patient’s identity, and has a

BY Sarah Charles Wright current medical record for the patient in which the diagnosis is documented, as should be the prescription request.6 An initial patient evaluation performed by internet or telephone questionnaire is not acceptable. Prescribing in violation of the statute constitutes dishonorable, unethical, and/or unprofessional conduct subject to KBML disciplinary action.

Practicing telehealth across state lines is problematic. Physician licensure laws

in other states risk violating the licensure laws of the other states unless they are also licensed to practice in those states.

Kentucky Medicaid and Telehealth

Last year, Kentucky Medicaid updated the Medicaid telehealth regulations to expand the types of providers and Medicaid covered services available by telehealth.8 To be reimbursed by Medicaid for a telehealth consultation:9  the physician must be a Kentucky Medicaid provider;  the patient must be referred by another provider for a telehealth consultation;  the patient must sign a Medicaid compliant informed consent for telehealth treatment;  the telehealth consultation must be performed via the KTN;

MEDICAID COVERS MEDICALLY NECESSARY PHYSICIAN TELEHEALTH CONSULTATIONS PERFORMED AT APPROVED LOCATIONS IF THE SAME SERVICE PROVIDED IN-PERSON WOULD BE COVERED. TELEHEALTH CLAIMS MUST BE PROPERLY CODED AND INCLUDE THE “GT” MODIFIER. REIMBURSEMENT FOR TELEHEALTH WILL TYPICALLY BE AT RATES COMPARABLE TO EXISTING RATES FOR THE SAME SERVICE PERFORMED INPERSON IN THE APPLICABLE SETTING. vary from state to state. The KBML’s policy7 is that physicians in other states actively practicing medicine on patients in Kentucky should also be licensed to practice in Kentucky. Otherwise, the KBML cannot effectively enforce Kentucky licensure laws and regulations against them to protect Kentuckians. Most states with telehealth laws have similar law or policy.

Consequently, Kentucky physicians practicing telemedicine from Kentucky on patients

 the physician must be a member of the KTN and perform the consultation pursuant to its standards.10 The consultation must be conducted through a secure live two-way interactive audio-visual telecommunication line;11 The telehealth hub site where the physician is located, and the spoke site where the patient is located, must use authentication and identification protocols to ensure confidentiality.12

Medicaid covers medically necessary physician telehealth consultations performed at approved locations if the same service provided in-person would be covered. Telehealth claims must be properly coded and include the “GT” modifier.

Reimbursement for telehealth will typically be at rates comparable to existing rates for the same service performed in-person in the applicable setting.13 Physicians should carefully document the referral and medical necessity of any telehealth consultation they perform, the resulting diagnosis and treatment plan, and furnish this information to the referring provider.14

Telehealth Under Federal Law

Medicare pays for some Part B services performed by an approved practitioner when the Medicare eligible patient is located in a rural HPSA15 outside a Metropolitan Statistical Area.16 Like Medicaid, Medicare requires physicians to perform telemedicine face-to-face by live, interactive audio-video telecommunication. Services that do not require a face-to-face patient encounter, and are most often performed by asynchronous “store and forward” telecommunication, such as teleradiology or telepathology, are not considered telehealth by CMS and instead reimbursed as if they were physically performed at the patient’s location.

The Affordable Care Act further promotes using telehealth in various ways, some of which are still being developed.

Examples include directing the Center for Medicare and Medicaid Innovation to explore a new care model to facilitate inpatient care at local hospitals through remote electronic monitoring by specialists; requiring Accountable Care Organizations to use telehealth to promote evidence-based medicine, report quality and cost measures, engage patients and coordinate care, and by allowing physicians to use telehealth to certify the need for home health services or DME for Medicare patients.17 FOOTNOTES K.R.S. §304.17A-138.

2 See generally, 907 Ky.Admin.Reg. 3:170.

3 K.R.S. § 311.550(17). Unlike Kentucky, federal Medicare and Medicaid regulations differentiate between “telemedicine,” which requires real-time, interactive telecommunication between physician and patient by use of audio-visual equipment, and “telehealth,” which generally refers to the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision, and information across distances. See e.g., 42 C.F.R. § 410.78, and http://www. medicaid.gov.

4 K.R.S. § 311.5975 See also, AMA Ethics Opinions 5.025 and 5026 (2002).

5 K.R.S. §311.597(1)(e) 6 Id. 7 KBML “Telemedicine Policy Statement” (1997).

8 In addition to physicians, examples of Medicaid authorized telehealth practitioners now include APRNs, optometrists, chiropractors, licensed men-

tal health professionals, and licensed physical and occupational therapists, subject to various restrictions imposed by regulation. See 907 Ky.Admin.Reg. 3:170, Section 3.

9 A telehealth consultation under Kentucky Medicaid law is a medical or health consultation to diagnose or treat a patient “that requires the use of advanced telecommunication technology, including compressed digital interaction interactive video, audio or data transmission; clinical data transmission via computer imaging for teleradiology or telepathology; and other technology that facilitates access to health care services. K.R.S. § 205.510(15).

10 See generally, 907 Ky.Admin.Reg. 3:170.

11 907 Ky.Admin.Reg. 3:170, Sections 2(6).

12 Id. at Sections 2(6) and 3(2).

13 Medicaid managed care organizations are not obligated to do the same. Id. at Sections 2(1)(a) and (b).

14 Id. at Sections 7 and 8.

15 Federal Health Professional Shortage Area 16 As determined by the HRSA. 17 http://www.cms.gov/Medicare/MedicareGeneral-Information/Telehealth; see also Telemedicine in the patient Protection and Affordable care Act (American Telemedicine Association, 2010).

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

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

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

ISSUE#87 9

ACCOUNTING

Business Disaster Plan: The Essentials

BY CAMILLE OLIVER You already know you should have a disaster plan for your practice. Every time you read about a bad tornado, flood, or fire, you wonder how your practice would cope. But how do you begin? What should a disaster plan include? The good news is that getting the basics in place is easier than you might think.

Emergency management professionals base state- and county-level plans on the emergency management cycle. You can use the same principle when creating your own plans. The cycle has four phases: Mitigation, Preparedness, Response, and Recovery.

Mitigation refers to the things you do now to reduce the impact of future incidents.

Preparedness entails creating a plan and testing it to see how it works. The Response

phase occurs when there is an actual emergency, and it’s what you do to protect life and property at that time. Recovery happens after the fire is out or the waters have receded, when you take the actions needed to get back to normal operation.

Although most people consider a disaster plan to be one thing, you really need two. Your emergency operations plan (EOP) is your Response, while your business continuity plan (BCP) covers Recovery. You can have one comprehensive document to encompass both of these, or you can develop them separately.

Planning starts with a brainstorming session, where you’ll make a list of the risks your practice faces and the types of emergencies that may happen in your area.

Most people think of natural disasters like tornadoes, floods, or ice storms. Those

will certainly go on your list, but don’t stop there. What if one of the firm’s key personnel was in a major car accident? Would it be a small problem or a large problem if one of your computers was stolen? Also think about risks specific to your location.

If your practice is near a highway, could a tanker truck crash lead to an evacuation order in your area?

Once you have your list of emergencies, think about what you might do now to make those emergencies less problematic.

The most critical one for most practices today is establishing an off-site data backup.

Other mitigation tools include having a sprinkler system in your building and crosstraining personnel on key tasks.

This is the point at which you need to decide if you are creating an EOP, a BCP, or both. Assuming that you start

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with your EOP, you need to decide how to respond if one of the risks you’ve identified actually occurs. Many emergencies will require one of three actions immediately: shelter in place, evacuate the building, or evacuate the area.

Now begin to nail down specifics – if you evacuate the building, which exits are available, and where will you tell staff to meet so everyone can be accounted for?

Who is responsible for the head count? If you need to shelter in place, where are the safest places in your building? If you must leave the area, who will lock the door once everyone is out?

Don’t forget to build flexibility into your plan. Who has access to keys and key-codes, and is it possible they might be absent when an emergency occurs? It’s fine to put the receptionist in charge of the

company head-count…but what if she is out sick? In that example, your plan might say, “The staff member acting as receptionist when the emergency occurs is in charge of the head count.”

Once you’ve gotten a plan in place for responding to immediate emergencies, you can move on to longer-term concerns – the BCP. This document will be organized a little differently than your EOP. Think about your assets that could be lost or damaged in any disaster. For each one, ask yourself what you would need to do to fix it in order to resume operations. If your building is damaged, it doesn’t matter whether it was due to fire, flood, or civil disorder – you just need to plan for how to acquire a temporary location and know who to call to begin repairs. If your server fails due to water damage or a malevolent

hacker, either way you’ll need to know what steps to take to restore normal network operation as soon as possible.

Once your plan is complete, communicate the plan to all staff and test it! Many of us last did a fire drill when we were in high school. When an emergency happens and your adrenaline skyrockets, you don’t want to think, “What do I do now?” but rather, “I know what to do…it’s just like the drill.” By having plans in place to deal with any emergency, you will be protecting your practice.

Camille Oliver is IT manager and a member of the Medical Services Group of Barr, Anderson & Roberts, PSC in Lexington. Ky. For more information, contact L. Porter Roberts, Jr., CPA via email at lproberts@barcpa.com or via telephone at (859) 268-1040. ◆

ISSUE#87 11

ONLINE MARKETING

How Inbound Marketing Works for Physicians Do you remember the last time you googled your name? Did it leave you seeing stars, wondering how you can be on the web so patients and colleagues can find you while retaining your reputation and integrity?

Until very recently, search engine queries about health care providers and their practice yielded a cacophony of results: Ratings, rankings, and all sorts of dubious resources crowding out the first page of search results and making it difficult for internet users to gain meaningful information about the health care options available to them. Adorned but insubstantial, the rating sites that search engines kept serving up simply lacked professional integrity, and put off, doctors stayed away.

There’s good news for physicians (and other professionals whose business is based on their expertise). Search engines have changed. They recognized the quality issues

keting, a hybrid advertising and communications strategy based on search engine algorithms that scour web-based resources for specific programmed and interconBY Megan Campbell Smith nected data that demonstrate pertinence to the user. For the medical industry, search engine users are patients (and referring colleagues), and health care providers are the advertisers.

Advertising, via inbound marketing, establishes cachet among experts in the information economy. This value is generated when people query search engines and you respond with professionally-crafted blogs, videos, checklists, or whitepapers.

marketing in my next column, but let’s use the following example to see how it all works together.

Let’s say your cardiology practice has invested in a new procedure that can significantly reduce post-operative pain and recovery time. There’s some buzz about it - someone told you they heard about it on the morning talk shows - and you want to make sure people in your community know you provide that same service locally.

A marketer trained in inbound marketing will write a short article about the procedure and post it on your website in the form of a beautiful practice brochure. Next, she will contact highly-relevant media properties to have the article placed in their content marketing platforms. If the story is newsworthy, she will pitch for coverage in regional newspapers.

Once the story is published, your marketer works to distribute it to your targeted

TODAY, RELEVANCE MATTERS, AND HEALTH CARE PROVIDERS CONTROL HOW SEARCH ENGINES DISPLAY INFORMATION ABOUT THEIR PRACTICE. of their old algorithms and tuned them to make the web, via search result, a much more harmonious space.

At their core, search engines are businesses that balance the information and entertainment needs of users with the advertising revenues from businesses competing for users’ attention. They exchange access for information. In the past, their algorithms favored sites with lots of traffic – like those physician ratings sites that are engineered not to provide anything substantive but rather to compel people to click, click, click - with distasteful results.

Today, relevance matters, and health care providers control how search engines display information about their practice.

This is accomplished through inbound mar12 M.D. UPDATE

The most effective advertising of our era emphasizes content placed within established media outlets, including online magazines, newspapers, and social media. The more targeted your approach and the more synergy you establish - i.e. doctors posting to a medical information site instead of a home and garden site - the more highly ranked you are on search engines.

Advertising, via inbound marketing, yields greater relevance and trust.

Because of high average lifetime customer value, health care providers can benefit greatly from professionally-executed inbound marketing whenever an improvement is made in clinical care or the overall operations of the practice (new procedure, new hire, new location, new coverage benefit). I will focus on cases for inbound

readers. She emails all of your (opted-in) patients about the coverage including a link to the brochure version you posted on your website, and she emails the physician community through your local medical media and medical society eNewsletter. The readers are captivated and convinced, so they click to share with their social media connections.

Then, a local resident having just heard that he will be getting a referral for a cardiologist, googles his condition and…

Voila. There you are, page one of the search results. That’s how inbound marketing works for physicians.

Megan Campbell Smith is the digital publisher of MD-UPDATE. Contact her at mcsmith@md-update.com. ◆

PROMISES

Made PROMISES Kept

Nearly two decades ago, we made a promise to help our members live healthier lives. Now we’ve expanded that promise to include Kentuckians throughout the commonwealth.

We invite you to become part of our growing network of healthcare providers helping us improve the health and quality of life of all Kentuckians.

Contact our Provider Contracting department at 502-585-8357 or 800-578-0775 ext. 8357.

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ISSUE#87 13

Q&A

Q&A with Dr. Damian P. “Pat” Alagia

MD-UPDATE Editor Jennifer Newton talks with KentuckyOne Health Chief Physician Executive Damian P. “Pat” Alagia, III, MD. MD-UPDATE: Tell us a little about yourself.

ALAGIA: I am a native Kentuckian born on the Fort Campbell army base --my father was JAG corp -- and then grew up in Louisville. After graduating from St. X, I attended Georgetown University in Washington, DC, for both undergraduate and medical school. I had the good fortune to work under the direction and guidance of Dr. Hiram Polk for three years as a general surgery resident before deciding to transfer to Georgetown to complete my residency training in OB/GYN. After my training was finished, I started a private practice in Washington, DC, which grew into a group practice. During the early years of the practice, I was able to finish an MBA in finance at Johns Hopkins University in Maryland.

I was very fortunate to grow up in a close family with great parents and siblings. I married a wonderful woman, and we have three children of our own.

Describe the complexities of the job as Chief Physician Executive.

First and foremost, we focus on our patients, potentially threeand-a-half million people in the Commonwealth. We have more than 15,000 physicians, nurses, medical, and administrative support staff working to integrate the deeply rooted and proud cultural heritages of the UofL academic health system with the Jewish and Catholic health care systems into one organization.

Even though we are in transition as an organization, and like others, are constantly managing changing funding sources in the new world of health care, we are working hard to provide the highest level of care to the people of our communities.

14 M.D. UPDATE

At the end of the day it comes down to focusing on the patient, communicating with our physicians and encouraging all staff members and providers to contribute in a meaningful way.

What are your priorities?

Quality, safety, and service are our top priorities, followed by physician engagement and physician leadership. Doctors need to feel that they have a voice in the

system. The physician enterprise, known as KentuckyOne Health Medical Group, must provide an exceptional experience for both the patient and the physician. We also need to integrate the hospital practice, the ambulatory practice, and the Center for Innovation and Research (CIRI) into the vision of providing the highest quality of care to our patients.

Every day is exciting and surprising and challenging. It is wonderful to see the determination and commitment among the doctors and all the stakeholders to get this right, in the face of changing business and health care delivery models.

Talk about quality, safety, and service.

Those concepts are buzzwords. What do they mean in practice?

Quality, safety, and service comprise a cultural mindset. In the past, if there was a problem, we might have thought the problem was caused by one or two bad apples on the team.

There was a “gotcha” mentality that created tension and mistrust. The new way of thinking focuses on the processes or the context surrounding a situation in which there was a bad or less-than-desired outcome.

Instead of asking “Who let that happen?” we ask, “How did that happen?”

We’ve established a culture of accountability, not a culture of blame; and we listen. Then we solve problems as a team. That’s what great teams do.

When you work in a hospital, instead of assuming it’s a safe and stable environment where nothing can go wrong and nothing bad can happen, you have to realize that it is a highly complex, highly functioning but inherently unstable environment. People are seriously ill and we often have to act quickly with limited or incomplete amounts of information. We have set up mechanisms to ensure accurate, appropriate care despite the pace of our work and the acuity of our patients. Our ability to successfully manage this complexity while providing a safe environment for our patients distinguishes KentuckyOne from the rest.

Quality, safety, and service are not just events or just a bunch of boxes we check off.

It’s how we think about the quality, safety, and service that we’re delivering every day that defines the culture we are creating.

What do you see in the next two-to-three years at KentuckyOne? We’re here to stay. We’re here to be great.

The future of the health care model is still unclear. We know that in the future hospital admissions and lengths of stay will go down, while outpatient care will go up. Only the

care doctor without using our emergency rooms or ambulatory care centers?”

Anywhere Care was the answer. It’s no surprise that younger people are adopting it more quickly than the rest of us. They’re more comfortable with digital media. We do track the number of calls being made to the service, and the numbers are increasing steadily every month. I’m a little surprised by how quickly it’s been adopted, but happy with the results. You have to con-

WE’RE HERE TO STAY. WE’RE HERE TO BE GREAT. THE FUTURE OF THE HEALTH CARE MODEL IS STILL UNCLEAR. WE KNOW THAT IN THE FUTURE HOSPITAL ADMISSIONS AND LENGTHS OF STAY WILL GO DOWN, WHILE OUTPATIENT CARE WILL GO UP. ONLY THE REALLY SICK WILL BE ADMITTED INTO THE HOSPITAL AND WILL BE CARED FOR BY THE FULL COMPLEMENT OF HOSPITAL RESOURCES.

really sick will be admitted into the hospital and will be cared for by the full complement of hospital resources.

Growth will be in the acute setting caring for the very sick and in the ambulatory setting with physician-led teams of extenders, physician assistants, and nurse practitioners. We’ll become much better at chronic disease management because it’s the right thing to do and we’ll be incentivized to do so.

Our focus will be on keeping people out of the hospital. We will change the paradigm, and that is really exciting.

Tell us about the 24-hour Anywhere Care.

Where did that idea come from and how is it working?

It was an idea that came from CHI. The question was asked, “How can we serve a larger patient population who does not have immediate access to a primary

stantly be trying different and innovative things -- knowing that some of your efforts will not be successful-- if you are going be competitive, relevant, and sustainable in the marketplace.

You’ve been here since September 2013, talk about merging three different health care systems.

It comes down to communication, transparency, and trust. It takes time to create a culture where all three are present and embedded. As long as we remember that “It’s not about us, it’s about the people of the Commonwealth,” we’ll be ok. We need to keep focused on the vision and the purpose of the work we are doing and keep building trust.

What do doctors need to know about KentuckyOne? We are working to make KentuckyOne

the best place for physicians to practice. We must give them the authority, the venue, and the resources to excel in the work they are trained to do. If we, in any way, marginalize or diminish the physician’s voice, then the system falls apart. When physicians lead, we win.

We’re finding a balance and creating alignment; the physician’s interest is focused on taking care of the patients and the business interests support them in this endeavor.

It goes back to keeping our focus on our mission: to bring wellness, healing, and hope to all.

Is KentuckyOne in a practice acquisition mode?

We are always looking for great physicians and great practices committed to providing the highest level of quality and service to patients and their families.

Are there any misconceptions in the marketplace that you want to address?

We are absolutely here to stay. As a group of physicians, nurses, support staff, pharmacists, technicians, chefs, and administrators, we don’t commit to something this big if we don’t believe in our hearts that we can make a difference. We’re a young company, merging three legacy systems from across the state. That takes time. If there is any misperception out there that I need to address, it is that KentuckyOne is committed to our mission, our patients, and our clinicians. We’re here to stay.

You have some interesting siblings and family relatives, I hear?

They’re all interesting. My brother is a major record producer. He produced the first Dave Mathews Band CD and won a Grammy with John Mayer. I have three wonderful and successful sisters, and a father-in-law who was a Navy test pilot and the first head of the FAA. My sisterin-law is the Queen of Jordan. As I said at the beginning of our discussion, I am very fortunate, and of course, very grateful. ◆ ISSUE#87 15

COVER STORY

A TEAM APPROACH WITH A SHARED VISION FOR EXCELLENCE

PHOTOGRAPH BY JOHN LYNNER PETERSON 16 M.D. UPDATE

Dr. David Cowen masters oculoplastics and builds a practice as the “Go-To Eye Plastics Guy” in the region.

BY TIM CORKRAN

David E. Cowen, MD, FACS, has a commitment to the region that is as deep as his passion for eyes. By embracing innovation in oculoplastics and challenging the status quo, he serves his patient constituency and his legion of referring colleagues. His Lexington-based practice, Oculoplastic & Orbital Consultants, has a reach extending well beyond the Bluegrass and provides both reconstructive and aesthetic services. His independent practice has been built with a simple value: “Taking care of my patients and referring doctors in a manner that is excellent and makes them feel important and valued.”

LEXINGTON

LEFT: Cowen

injects local anesthetic prior to the graft.

He works with many Mohs trained surgeons for grafts from skin cancer resection.

CENTER: Cowen and team harvesting a skin graft.

RIGHT: “There is an element of artistry in the procedures that can make something function well and look really good,“ says David Cowen, MD. PHOTOS BY GIL DUNN

Oculoplastics is both art and science, says Cowen, because “we preserve the form and function of the areas surrounding the eyes, particularly the eyelids, eyebrows, eye sockets, and tear ducts.” Respecting the delicate nature of these tissues and honoring the significance of their appearance is Cowen’s daily work. For him there is nothing that attracts our attention more than a person’s eyes, so the value of safeguarding their appearance is paramount. Oculoplastics’ draw for Cowen was two-fold, “There is an element of artistry in the procedures that can make something function well and look really good.”

Interest and Commitment Build a Practice

Cowen graduated, with distinction, from the University of Kentucky College of Medicine in 1988. After an internship in general surgery, he returned to UK for ophthalmology residency because he enjoyed the “very delicate, precise nature of the surgery.”

He then completed two fellowships, one in ophthalmic plastic and reconstructive surgery at the University of Toronto followed by a fellowship in craniofacial plastic surgery in Toronto, Canada.

It was during his fellowship program in ophthalmic and plastic reconstructive surgery that Cowen says he “expanded the scope of what I focused on to broader areas around the eyelids, eye sockets, and to a lesser degree, the face.” After Cowen joined the faculty at UK in the mid-90s, he developed an entire oculoplastic service there. This led to building a similar service at the VA hospital, “which is a place that I have always loved and enjoyed.”

Cowen’s next move grew out of his commitment to the people of the region. He says, ISSUE#87 17

COVER STORY

“I realized very quickly that my real heart and passion was for the people of Kentucky – and bringing the excellence of my subspecialty to them.” As such, he focused on developing a surgery practice that would reach the underserved in Eastern Kentucky and central Appalachia. To do this effectively, Cowen needed to go to these places and establish relationships with physicians there. Over the next seven years, he developed relationships with clinics and doctors across a broad spectrum of medicine in that region. Cowen’s hard work has produced an extensive network of clinics and physicians across central Appalachia who know him as their go-to guy for oculoplastic needs.

The “Go-To Eye Plastics Guy” for Babies to 90-Year-Olds

“My patient population spans from babies to 90-year-olds,” says Cowen. Patients come to him with issues related to eyelids, tear ducts, and tumors.

His pediatric population usually has life-impacting birth deformities and congenital defects, such as ptosis or droopy eyelids. Cowen notes, “Correcting a congenital ptosis that could affect vision as a child grows is a key procedure.”

Most of his patients are in the 50- to 80-year-old range. Ptosis (droopy eyelids and brows) accounts for the largest percentage of his overall patient population. He

cancers is a particular interest of Cowen’s.

Many doctors who normally address cancers of the face are reluctant to work on the sensitive tissues around the eye, so this is where his skills are highly valuable.

To effectively address skin cancer reconstruction, Cowen often works hand-inhand with Central Kentucky’s Mohs surgeons. Just hours after a Mohs surgeon removes a lesion through layered ablation, Cowen comes in to do the reconstructive work. Whether it was simply a biopsy or a full tumor removal, the reconstructive work can be critical. As he says, “A resulting defect on the eyelid the size of your thumb is unacceptable: the eyelid will not function properly, and the eye will be lost. The loss of an eye is a 25 percent disability to a patient.

My personal opinion is that you want to save every millimeter of eyelid possible.”

Cowen has lectured nationally and internationally on state-of-the-art techniques for eyelid reconstruction and published articles in Ophthalmic Surgery, Current Ocular Therapy, and The Journal of the American Society of Ophthalmic & Reconstructive Surgery.

Cosmetic procedures are an important and growing segment of Cowen’s patient population. Pharmaceutical grade products and non-surgical services complement procedures such as eyelid surgery, brow lifting, and laser resurfacing.

Putting Surgery Second for Graves’ Disease Cowen’s mission work has taken him to remote leprosy villages in China, where he collaborated with local eye surgeon Dr. Tang Xin. PHOTO COURTESY DR. DAVID COWEN

also sees many people with tear duct issues and considers himself a “plumber of the eye,” as he has become adept at reconstructing tear drain systems.

Cancers around the eye account for 15 to 20 percent of his adult patients. Some of these are orbital tumors, but addressing skin 18 M.D. UPDATE

Another particular concern is thyroid eye disease, aka, Graves’ disease. Treating Graves’, the troubling manifestation of an autoimmune disease in the thyroid that results in secretion of excess thyroid hormone, comprises about 10 percent of his practice. Swelling around the eyes, bulging eyes, tear duct malfunction, and eyelid retraction are prominent symptoms that oculoplastic surgeons address. For Cowen, managing Graves’ disease, preventing vision loss, and correcting its resulting deformities is a complex and engaging challenge. “My goal is to stabilize the condition and avoid surgery, whenever possible,” he says.

Cowen knows he bucks the surgery-first trend, noting that, “There are a lot of things you can operate on, but you don’t have to.”

He utilizes steroids, anti-inflammatories,

and even radiation in an attempt to hold down the painful and extremely unattractive swelling that can afflict Graves’ sufferers during the most acute stages of the disease.

His preference for exhausting all options before surgery has earned him an excellent reputation among endocrinologists, who are the primary referrers of Graves’ patients.

Moving Forward: Oculoplastics and the Independent Doctor

Cowen has a fervor for the dynamism of his field, which he has combined with his business acumen to establish the premier independent oculoplastics service in the region. He knows he is the beneficiary of the trend in medicine towards subspecialization. He attributes the expertise that has evolved in his field, and the high expectations of referring doctors, to “the advancement in fellowship and subspecialty training and the development of new techniques.” The increase in the quality of reconstruction, which relies largely on precision, has been greatly enhanced by the advent of lasers. He also cites close work with other specialists as a key to developments in oculoplastics, particularly with regards to complex cases like Graves’ disease. Innovation in cosmetic services is quite robust these days, he notes.

Staying focused on a subspecialty has allowed Cowen to devote considerable energy to how his practice could be maximally effective and broad reaching. His decision to stay independent has been justified by careful development of a professional network, enduring commitment to regional service and charitable work, and cultivation of a comprehensive office experience.

Early on, Cowen established a presence in Hazard, Whitesburg, Harlan, and Springfield. He was always asking, “Where are the patients and doctors that need me?”

Now he has settled on a permanent presence in Prestonsburg, London/Corbin, and Ashland, as these are the population centers that make his travel cost effective. But his early efforts have assured that many local doctors elsewhere seek him out for the oculoplastic needs of their patients.

Cowen has an enthusiasm for helping those in need. His love for people has sent him to China, Haiti, and Thailand. His

desire once led him to Haiti for an emergency surgery on a young girl that was unable to leave the country. He also participates with Surgery on Sunday, World Medical Mission, and His Servant’s Hands programs.

Cowen with a patient post-operatively.

“Taking care of my patients in a manner that is excellent and makes them feel important and valued” is his philosophy and one that has made his practice successful for over 20 years. PHOTO BY GIL DUNN

Success Comes from a Shared Vision for Excellence

Cowen’s model for success starts with his desire to serve the citizens of the Commonwealth and his appreciation for the delicate importance of the human eye.

Staying independent has allowed him to honor both passions successfully for over 20 years, performing over 47,000 surgical procedures.

Serving patients, their families, and their local doctors, with the help of employees devoted to his vision, fuels the long hours and drives his commitment: “We have a unique ability to take care of and pay attention to both our referring doctors and our patients,” he says. The staffers who support him at his Lexington office – he calls them his “five amazing women” – comprise a well-oiled machine. He is proud to say, “I allow all these women to bring their strengths to my practice, which provides a unique experience for our patients and doctors.”

Cowen’s desire for excellence with his yearning for mastery unites the two aspects of his work. He concludes, “To take the principles and practices of general plastic surgery and apply them to an area as dynamic and delicate as the eye, so that it functions and is aesthetically pleasing, is why I love what I do.” ◆ ISSUE#87 19

SPECIAL SECTION  PLASTIC SURGERY

Filling the Void

Dr. Janae Maher brings plastic surgery services to Owensboro Medical Health System BY JIM KELSEY OWENSBORO Filling a void is nothing new to a plastic surgeon. “Plastic surgeons always consider themselves the surgeon’s surgeon,” says Janae Maher, MD. “Whatever hole the surgeon makes to get rid of a cancer, it’s my job to find a way to fix it and improve function and appearance.”

But as a new addition to Owensboro Health, Maher is filling a gap of a different sort – an overall lack of plastic surgery providers at the Owensboro hospital. In the past, plastic surgery patients at the hospital have faced trips to the nearest provider.

Maher’s presence fills that void, whether patients are seeking reconstructive procedures or cosmetic.

Particularly dear to her heart are breast cancer survivors seeking breast reconstruction. “Right now, breast cancer patients who want to undergo reconstruction have to travel two hours away for some of those procedures,” Maher says. “Whether they choose to do implant-based reconstruction or use their own tissue (autologous), a plastic surgeon focused solely on their reconstruction has just not been available here. Those patients already have a lot going on in their life, and I hate for them to make choices because they don’t want to have to drive two hours away for those types of consultations, procedures and follow ups.”

A Kansas native, Maher attended the

Plastic surgeon Dr. Janae Maher joins Owensboro Health in August 2014, filling a gap in reconstructive and cosmetic surgery services.

a magazine and it opened right to an article about mission trips doing cleft lip and cleft palate repair,” Maher says. “Reading how the surgeons were able to change the lives of those kids, I just knew I wanted to have that kind of impact on my patients’ lives.”

RIGHT NOW, BREAST CANCER PATIENTS WHO WANT TO UNDERGO RECONSTRUCTION HAVE TO TRAVEL TWO HOURS AWAY FOR SOME OF THOSE PROCEDURES. – DR. JANAE MAHER University of Kansas School of Medicine and completed her residency in plastic surgery at Texas A&M earlier this year. She was drawn to Owensboro by the proximity of family, the size and culture of the area, and the opportunity to provide life-changing services. It was the ability to make a difference that drew her to plastic surgery while she was still in high school. “I was flipping through 20 M.D. UPDATE

PHOTO COURTESY OWENSBORO HEALTH

As a hospital employee with the Owensboro Health Medical Group, Maher will be able to offer hospital-based reconstructive procedures such as breast reconstruction. In addition, Owensboro Health is opening a cosmetic and reconstructive surgery clinic in the nearby Breckenridge Medical Office Building, which also holds an outpatient surgical center.

Maher says the presence in both the clinic and the hospital will provide her and the group the capacity to offer a wide range of procedures and expert advice in a convenient location. “When people think of plastic surgeons, they think of cosmetics initially,” Maher says. “But the field of plastic surgery is very broad and we have a unique opportunity by partnering with Owensboro Health’s medical group to offer not only cosmetic surgery –both surgical and nonsurgical procedures to reshape normal body structures to improve appearance and selfesteem – but also the reconstruction part of plastic surgery. That can be congenital defects, developmental abnormalities, trauma, infection, tumors, and disease – we will be able to offer assistance with those patients as well.”

Initially, only implant-based breast reconstruction will be offered in Owensboro.

It will take some time to make autologous tissue reconstruction a local option, but it is high on Maher’s priority list. Until then, she says, being able to examine the patients and inform them about their options will be a valuable first step in their treatment, regardless of whether they choose to have implantbased reconstruction in Owensboro or go elsewhere for autologous tissue reconstruction. “I would love to be the first person to evaluate them and talk to those patients about that option,” Maher says of the autologous procedure. “They will now have someone close to home to talk to them about their breast reconstruction options.”

That same sort of patient connectivity is what Maher hopes to bring to the cosmetic and reconstructive clinic as well. “I think it’s beneficial to have a woman doing cosmetics,” Maher says. “Ninety-one percent of the people coming for plastic surgery are women. I think the vast majority feel comfortable talking about these types of issues with another woman who understands what they are going through, what they are looking for and what they are trying to achieve.” ◆

SPECIAL SECTION  PLASTIC SURGERY

Coming Full Circle, Again

A Lexington pediatric urologist with old ties to Louisville opens an office in downtown Louisville. BY GIL DUNN LOUISVILLE Dr. Cameron S. Schaeffer is back in Louisville. Again. The Lexington-based pediatric urologist recently opened a satellite office in Louisville in partnership with Ann Muth, APRN, a stable and trusted presence in the world of Louisville pediatric urology.

Schaeffer was born in the old Norton Infirmary in downtown Louisville and moved to Lexington as a child. After graduating from Henry Clay High School in 1980, he pursued his education across the country- Dartmouth College (BA- English), University of Virginia (MD), University of Utah (General Surgery and Urology), and Duke University (Pediatric Urology). In 1995, he returned to Kentucky for a residency in plastic surgery at the University of Louisville. He is the only surgeon in the United States certified by the American Board of Medical Specialties in urology, plastic surgery, and pediatric urology.

After finishing his residency in plastic surgery in 1997, Schaeffer practiced urology, pediatric urology, and plastic surgery in Denver. “I developed an interesting niche practice in pelvic and genital reconstruction when I lived in Denver, but I got a little burned out. I did a lot of trauma work, so I felt like a urologist by day and a plastic surgeon by night. I knew I needed to focus my practice. My OR days at Denver Children’s Hospital were always my favorites, and it became increasingly clear that pediatric urology was my passion and my calling.” In 2000, Schaeffer was recruited by the University of Kentucky to become its first formally trained pediatric urologist. Twelve years ago, he opened a private practice on the campus of Central Baptist Hospital.

Describing the process of establishing his new Louisville partnership, Schaeffer

Cameron S. Schaeffer, MD, FACS, FAAP LEFT Ann Muth, APRN ABOVE

says, “Ann and I have known each other for almost twenty years. I met her when she worked as an OR nurse at the University of Louisville Hospital. She was an exceptional nurse, extremely bright. When I heard she had become a nurse practitioner, I was not surprised. When I heard she had decided to pursue pediatric urology, I was very happy for her. Urology is the best kept secret in medicine, and pediatric urology is the best kept secret in urology.”

Schaeffer and Muth stayed in touch with each other over the years, and at various times discussed teaming up. “A number of things came together for both of us professionally this summer, so we decided it was time,” explains Muth.

Initially, Schaeffer and Muth will have

an office at the Louisville Surgery Center, a downtown facility owned by Dr. Mark Chariker and Dr. Gerry O’Daniel. “Mark preceded me as a plastic surgery resident at the University of Louisville, and I accompanied him on one his trips to the Philippines to do cleft surgery. Gerry had just emerged from a long training experience and was a new plastic surgery attending at Kosair when I started my plastics residency. We’ve all been good friends over the years. They’re just as passionate as I am about taking care of kids, and I greatly appreciate their support and vision for pediatric surgical care in Louisville,” says Schaeffer.

The new office is open daily for consultation on the full spectrum of pediatric urologic disease. All children less than 18 years of age are welcome, as are young adults still under the care of their pediatricians.

Schaeffer says he will consider seeing adult patients with specific genitourinary reconstructive problems, but only if referred by either an adult urologist or a plastic surgeon.

“Ann and I are very excited about the level of care we think we can provide to the children of Louisville and the surrounding counties,” says Schaeffer. “I am particularly looking forward to renewing old friendships and developing new relationships in the place of my birth and my specialty training.

This should be fun.” ◆ FOR PATIENT REFERRALS

(502) 410-4700 444 South 1st Street, Suite 200 Louisville, KY 40202 Lexington (859) 275-5437 (KIDS) (866) KIDSURO Fax (859) 275-5434 (BOTH LOCATIONS)

www.pediatricurology.com

TOP PHOTO BY GIL DUNN, BELOW PHOTO PROVIDED BY ANN MUTH

ISSUE#87 21

SPECIAL SECTION  HAND & FOOT SURGERY

Best Foot Forward

Dr. Nicholas A. Viens champions foot and ankle health at Lexington Clinic BY JIM KELSEY LEXINGTON Balance. Stability. Mobility. Taken for granted and underappreciated, they are essential to most of our daily activities.

But what’s a common response when someone twists an ankle playing basketball or tripping on a curb? “Walk it off. It’s just a sprain.” That attitude, says Nicholas A. Viens, MD, is a potential problem for the long-term health and strength of feet and ankles.

Viens, who received his medical degree from the Duke University School of Medicine and completed a residency in Orthopedic Surgery at Duke University Medical Center, specializes in orthopedic services and sports medicine focusing on the foot and ankle. His professional interests involve foot and ankle athletic and traumatic injuries, ankle instability, foot and ankle arthritis and treatment of degenerative conditions of the foot and ankle, including total ankle replacement.

After completing his fellowship training in Orthopedic Surgery of the Foot and Ankle at The Steadman Clinic and Steadman Philippon Research Institute in Vail, Colo., Viens joined the Lexington Clinic Orthopedics – Sports Medicine Center in September 2013 as the foot and ankle specialist.

“We know that ankle instability can be a chronic, disabling problem,” Viens says.

“We believe ankle instability is one of the most common reasons patients ultimately develop arthritis.

“We don’t like hearing, ‘It’s just a sprain.’

Ankle sprains are significant injuries, and downplaying them really can do a patient a disservice.”

Viens believes that aggressive treatment is essential to the recovery and long-term stability of the ankle. Treatment often begins by immobilizing the ankle in a neutral or dorsiflexed position that allows the ligaments to heal with appropriate tension, followed by functional rehabilitation with physical therapy focusing on balance, gait training, range of motion and strengthening 22 M.D. UPDATE

Nicholas A. Viens, MD, Lexington Clinic orthopedic foot and ankle surgeon, performs Achilles tendon surgery.

of the peroneal tendons. It is important that patients keep up with their exercises.

“Just saying, ‘Oh, you’ll be fine.

Walk it off, take some anti-inflammatories and use an ankle wrap’ … that frequently doesn’t work,” Viens says.

Neither does assuming that every ankle injury is truly an “ankle sprain.” An injury might have all the characteristics of a sprain but actually be something quite different or more complex. Better understanding of the ankle anatomy, the damage that can occur and higher quality diagnostic tools are helping identify the exact type and degree of

PHOTOGRAPHY COURTESY OF LEXINGTON CLINIC

injury much more quickly and accurately. That allows for more targeted, and hopefully more effective, treatments.

“It can be a little bit of a diagnostic challenge,” Viens says. “Patients are often told that they have an ankle sprain, but that’s sort of a wastebasket term for some. A lot of patients don’t really have a typical ‘sprain’ at all, referring to a tear of the lateral ankle ligaments.

They sometimes have a fracture that they were told was a sprain. Sometimes they have a sprain with other problems, such as a cartilage injury or tendon tears – or all of these things together. That’s a common occurrence that I see in my clinic.”

While a course of immobilization and functional rehabilitation are often very effective, there are times when more complex treatments are called for. Patients with more severe cases, a history of frequent injuries or inadequate response to the appropriate rehabilitation can become surgical candidates.

“Sometimes we’re able to tighten up the ligaments that are still there but stretched out, and then start the patient in rehab after protecting the ligament repair for a time, “ Viens said.

While the standard repairs are relatively widespread, there are nuances, including a growing trend to focus on anatomic

repair. At the Steadman Clinic, Viens was mentored by Dr. Thomas O. Clanton who recently researched the quantitative anatomy of ankle ligaments in an effort to improve surgical techniques for problems such as these. Dr. Viens worked with Clanton and others to study anatomic ligament repair and reconstruction techniques that can be used when the standard repair has failed or is unlikely to be sufficient. For instance, their published research demonstrates that

WITH THE NEWER GENERATION IMPLANTS, IN THE RIGHT PATIENT POPULATION, ANKLE REPLACEMENT CAN BE A GREAT SURGERY. – DR. NICHOLAS A. VIENS an anatomic tendon graft reconstruction closely approximated biomechanical properties of the normal ligament early on and supported their clinical experiences about the value of such procedures for certain patients.

Irreplaceable? Not Necessarily

Although Viens and others hope better and more aggressive treatments for ankle injuries will help patients avoid arthritic problems down the road, patients with ankle arthritis are another group he enjoys seeing in the office. “Many patients have been told ‘there’s not much they can do’ for ankle arthritis, which simply isn’t the case.” Shoe wear modifications, bracing, medications and injections can all play a very helpful role in caring for patients with ankle arthritis.

When those treatments no long help a patient’s pain, surgical options exist, depending on each specific patient’s problem and goals. “Ankle fusion can be a very

effective treatment for a lot of patients,” Viens says. Ankle replacements don’t have as long a history as hip and knee replacements and they are certainly not as common or known about – even among orthopedic surgeons. But the impression that ankle replacements aren’t effective is slowly changing, says Viens.

“Many older ankle replacements had issues,” he says. “So suffice it to say a lot of orthopedic surgeons remember, or have heard stories about, the old one and think, ‘You can’t replace ankles. They don’t do well.’ That’s not necessarily accurate. With the newer generation implants, in the right patient population, ankle replacement can be a great surgery.”

Viens stresses that the relatively short history of the newer replacements means there are no long-term data, such as that which exist for hip and knee replacements, but says mid-term data suggest that ankle replacements are now more viable options than ever before.

That, more than anything, exemplifies the general path of modern foot and ankle care. Orthopedic surgeons are focused more than ever on reducing the severity and long-term impact of foot and ankle injuries.

Through improved understanding of anatomy and injuries, advanced diagnostic tools and more aggressive treatments, Viens and his colleagues hope they are making significant strides toward that goal every day. ◆

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ISSUE#87 23

SPECIAL SECTION  HAND & FOOT SURGERY

Heavy-Handed

Plastic Surgery practice at the VA specializes in treating hand injuries and diseases BY JENNIFER S. NEWTON LOUISVILLE At the Robley Rex VA Medical Contrary to what you might think, Common diseases Kasdan sees include Center (VAMC) in Louisville, the Plastic Kasdan saw more hand injuries in private skin cancers, Dupuytren’s contracture, nerve Surgery Section has a different focus from practice than he does at the VAMC today. entrapments, and inflammatory tendon conwhat you might first think of when you While you may associate Veterans with ditions. The most common surgical proceconsider a plastic surgery practice. There injury, or trauma, Kasdan says, “I’ve only dures he performs are carpal tunnel release are no rhinoplasties or breast augmenta- seen four combat injuries in the 10 years I’ve and excision of skin cancers. Many of the tions here. In fact, there are no cosmetic been here.” They had received excellent care treatments are non-surgical. For example, procedures at all. According to Morton down range. He attributes the greater num- injections are used for some conditions.

L. Kasdan, MD, FACS, chief of Plastic ber of hand trauma cases he saw in private One area where Kasdan’s Veteran Surgery for the VA, “All of our surgery is for practice to the industry Louisville once had. patients do differ from the general popufunctional reasons,” and more specifically, At the VA, Kasdan sees “mostly diseases of lation lies in his research interest – factifocused heavily on the hand. the upper extremity,” rather than injuries. tious disorders. Defined as a condition Kasdan estimates more than half his practice is devoted to hand surgery. He was inspired to subspecialize in hand surgery CONTRARY TO WHAT YOU

by Dr. Harold Kleinert, a pioneer in the MIGHT THINK, KASDAN SAW field whom Kasdan trained under at the University of Louisville (UofL). Kasdan MORE HAND INJURIES IN completed medical school and took his PRIVATE PRACTICE THAN HE general surgery residency at UofL, then completed a fellowship in plastic and DOES AT THE VAMC TODAY. reconstructive surgery at Duke University Medical Center. A Veteran himself, Kasdan was a Lieutenant Colonel in the United States Air Force and served as where someone deliberately creates chief of the Division of Plastic Surgery at or exaggerates symptoms to feign a Wright-Patterson Air Force Base in Ohio physical illness, factitious disorders from 1971-1973 before starting in private are not as prevalent among Veterans practice. as compared to private practice.

Ten years ago, Kasdan left private When it comes to plastic surgery, practice to join the VA because he wanted there is one misconception Kasdan to get back to teaching. His position would like to dispel. “All incisions at the VAMC allows him to practice leave scars,” he says. While equipclinically and surgically, publish, ment and techniques have and teach. Kasdan has over 150 advanced over the years published articles, includand there are things that ing editing 12 books. you can do to hide or Currently a clinical prominimize scarring, there is fessor at UofL, he teaches no such thing as a scar-free medical students and plasincision. tic surgery residents who Ever the teacher, rotate at the VAMC. In Kasdan is grateful to be addition, Kasdan teaches practicing among a physiphysician assistant students cian group at the VA he for the US Army and hosts considers top-notch and Dr. Morton L. Kasdan, FACS, is the chief of Plastic Surgery at the Robley a suturing class on Sundays to be doing what they Rex Medical Center in Louisville, Ky. for medical students. love. ◆ 24 M.D. UPDATE

PHOTO BY TOM DOWNS, ROBLEY REX VAMC MEDICAL MEDIA PHOTOGRAPHER

DERMATOLOGY

From Scratch

Dr. John Cowan established Bowling Green Dermatology & Skin Cancer Specialists as a champion of skin cancer detection and treatment and as a model for independent practitioners BY JENNIFER S. NEWTON BOWLING GREEN Fresh out of dermatology residency at Emory University in Atlanta, Ga., in the summer of 2008, John Cowan, MD, knew he wanted to be an independent practitioner. “Instead of joining any other practices, we decided to start our own practice from scratch,” he says. The “we” are Cowan and his wife Amy, who serves as the practice’s office manager. The couple settled in Bowling Green, where Cowan says they found a similar feel to his hometown of Somerset, Ky., and a community that fit their family’s personality. In fall 2008, Bowling Green Dermatology & Skin Cancer Specialists opened its doors.

Cowan attended medical school at the University of Kentucky and took his internal medicine internship at New York University, before completing his residency at Emory. Dermatology was a natural fit for Cowan, who says, “I was always drawn toward the procedural side.” He also relishes the opportunity to see patients of all ages and the chance to stay out of the hospital.

The main focus of Bowling Green Dermatology & Skin Cancer Specialists is diagnosis, treatment, and long-term management of skin cancers. “I’ve had a skin cancer myself, and it’s something I’m passionate about – to help patients overcome the diagnosis and get proper treatment and move on with their lives,” says Cowan.

Because it’s focused on skin cancers, the practice heavily favors surgical dermatology, although they do offer medical, pediatric, and cosmetic dermatology services. Cowan performs surgery three to four days a week and holds general dermatology clinic two days a week.

All surgical procedures are performed in-office. “The beauty of dermatologic surgery is that you’re able to do it in the outpatient setting and in your office,” he says, and contends in-office procedures benefit patients by being less expensive and safer, as they avoid the risks of general anesthesia and hospital infections.

ber of melanomas each year. He has also seen more unusual cancers, such as verrucous carcinoma and merkel cell carcinoma.

In order to ensure there are appointment slots available to evaluate suspicious lesions on a timely basis, the practice holds designated slots for acute patients, a service that is well received by referring physicians.

Leading by Example

Cowan readily admits that there have been hurdles along the journey of establishing and maintaining a solo practice, but he is a staunch advocate for independence and physician leadership.

“I think if I were to give anyone starting this process some advice, I would say number one, have the courage to do it because in this environment, with all the health care changes going on, Dr. John Cowan is the sole practitioner and owner of some of the individual physiBowling Green Dermatology & Skin Cancer Specialists. cians do not want to take on the responsibility of being a business Cowan is trained in Mohs Micrographic person and a good doctor, and I think that Surgery and is a fellow for the American is to the detriment of the field of medicine Society for Mohs Surgery. “In my opinion, in general,” he says. “We have, in many I think every dermatologist should have ways as physicians, ceded our power to knowledge of doing Mohs surgery,” he says. what I call the “suits.” The “suits” or health Calling it the “gold standard” for skin can- care administrators are not in a position, in cer removal, particularly for head and neck my opinion, to really stand up for what the lesions, Cowan values the ability to evaluate principles of medicine should be about.”

Running a successful practice that 100 percent of a cancer’s margins. demands excellence of its staff and fosters a While Mohs training is part of the core personal touch with its patients is Cowan’s competencies of dermatologic residency, way of leading by example. some programs focus on it more than othAs for his formula for success, Cowan ers. Cowan says he was fortunate to attend a program at Emory that was “weighted says his business philosophy is pretty simvery heavily towards the surgical part of ple. “I think the important thing for growth is to try to do right by each patient, try to dermatology.”

Of the skin cancers Cowan sees, the establish a good reputation … We think majority are basal cell and squamous cell, patients will find us if we do a good job,” but he notes they do see a remarkable num- he says. ◆ PHOTO PROVIDED BY BOWLING GREEN DERMATOLOGY & SKIN CANCER SPECIALISTS

ISSUE#87 25

MEN’S HEALTH

Trimix

The gold standard for ED treatment BY BART GOLDMAN, MD Tri what? … The gold standard? Never heard of it. Well, me neither until last November. Trimix has been around since the 1980s, but there is no pharmaceutical company with a multi-million dollar advertising budget marketing Trimix. Its contents are generic meds: papaverine, phentolamine, and alprostadil. These agents act together to dilate smooth muscle, increase arterial inflow, and restrict venous outflow.

With an aging male population, erectile dysfunction (ED) is becoming more common, with an estimated 30 million cases occurring in men aged 40-70. Trimix works regardless of age or the cause of ED. Trimix is administered by injection into the corpora cavernosa at the base of the penis using an insulin syringe and an autoinjector similar to that used by diabetics.

The skin at the base is about the same sensi-

tivity as the arm. Many patients are amazed that the injection is painless. Patients are instructed as to landmarks for proper injection. Often the partner of the patient also undergoes injection instruction. Trimix begins working generally five minutes after injection with full effect in about 10 minutes. Increasing circulation further increases results of the injection.

In comparison to the five phosphodiesterase inhibitors, Trimix is a direct acting agent causing vasodilation in the penis. It does not have the side effects of the PDE5i agents – no blood pressure changes, blurred vision, headaches, back aches, flushing, nausea, etc. Trimix can, however, cause priapism, which is typically reversed by oral administration of pseudoephedrine or injection of phenylephrine.

Trimix is safe for patients with heart

disease, whether they are on nitrates or not, lung patients, and kidney patients.

Contraindications to Trimix include obese abdomen, vaso-vagal response, dexterity problems, uncontrolled hypertension, concurrent use of MAO inhibitors, predisposition to priapism due to hematologic disorders such as multiple myeloma and leukemia, Peyronie’s disease, marijuana, and penile prosthesis.

At the Louisville Men’s Clinic, the majority of the patients we see are diabetic and/or hypertensive cardiac patients and those who have undergone prostatectomy.

Virtually all of them have tried the PDE5i’s and treatment has failed or the side effects are too extreme. This is very common as studies have shown failure rate as high as one-third compared to five percent failure rate for Trimix. Trimix has also been found effective in treating ED from depression, performance anxiety, widower syndrome, and as a side effect of prescription drugs – antihypertensives, oral hypoglycemics, beta blockers, etc. Office evaluation includes a test dose of Trimix to measure patient response. Each patient’s dose must be customized for their desired duration and firmness. We carry 12 formulations of Trimix and three formulations of Quadmix (Trimix with atropine) to accomplish this task.

Dr. Bart Goldman is a staff physician with Louisville Men’s Clinic. Neal Berryhill is Clinic Director. ◆

FOR PATIENT REFERRAL

Dr Bart Goldman A Joint Commission accredited private surgery center where our physicians perform diagnostic and surgical procedures for the treatment of pain, to include:

502-259-9160 info@louisvillemensclinic.com www. LouisvilleMensClinic.com 6420 Dutchmans Parkway, STE 390, Louisville, KY 40205

26 M.D. UPDATE

COMPLEMENTARY CARE

Is That All?

Five surprising things I’ve learned about men BY JAN ANDERSON, PSYD, LPCC When I asked my husband to review the list below, he asked, “Is that all? You’ve just learned five things about men?” and promptly referred me to Dave Barry’s The Complete Book of Guys. In the meantime, I’m standing by the few things I’ve learned about men, all of which I wish I had known sooner.

If a man is interested in you, you will know it. If a man is interested in you and ready for a relationship, he will pursue you. Many women get caught up in psychoanalyzing a man and making excuses for his lack of initiative or follow-up. But it’s actually very simple (and painful, wherein lies the problem). Whether it has anything —or nothing — to do with you, if he’s not calling you, assume that he’s just not that into you. My observation jibes with an interesting survey reported in John Molloy’s Why Men Marry Some Women and Not Others. One of the questions asked the men was why they didn’t call a woman back after two or more dates. Many of the men had a hard time coming up with a specific reason for why they didn’t call. The most common answer was that the woman was really nice, but there was no chemistry. It appears that a man doesn’t need a reason not to call. But he does need a reason to call.

During a conflict, a man tends to perceive himself as trying not to react and as listening in a neutral way. He may not be aware that his wife tends to interpret his behavior as emotional withdrawal or even hostility. His intention is to avoid a fight by looking away or down, or saying nothing or avoiding the subject. Unfortunately, this behavior gives his wife no indication that he is paying attention to her or cares about what she is saying. As the man reacts less and less, his wife becomes more and more emotional. When a woman learns how to better maintain her emotional equilibrium during difficult conversations with her husband, it invites him to be able to

hear her and respond.

When a husband learns to give more cues to his wife that he is listening - such as eye contact, head nodding and verbal cues such as “uh huh” - it invites her to feel heard. His wife then doesn’t have to get more and more dramatic in an effort to get a reaction from him.

Men don’t respond to words.

They respond to action.

This is a hard one for many women because we usually need to talk things out. In great detail. For hours. My female clients usually get this immediately if, rather than citing research, I simply offer a man’s comment from Why Men Love Bitches: “Women talk too much. If she’s upset, she’ll go on and on. I’d rather get into a ring with Mike Tyson for six rounds than hear a woman repeat herself over and over.” What seems to work better? Besides abstaining from TMI, women seem to fare much better when they engage in something I call “behavioral communication.” This simply means that you talk less and act more.

If a man refuses to attend counseling sessions with his wife, don’t assume there’s no hope for the relationship. I have observed a number of men who got their counseling through their wives — an excellent application of Learning #3 above.

There’s a saying in counseling that it only takes one person to change a relationship.

“Just do your own work,” I say. “It’s your best chance of improving the relationship.

Regardless, you’ll still end up in the best possible position.” When a woman starts working on herself and her own issues, the changes in her behavior become a powerful and appealing invitation for her husband to join her in renegotiating the relationship.

Men and women are from the same planet after all. In one of the most reliable surveys ever done on divorce (the Divorce

Mediation Project by Gigy and Kelly) 80 percent of divorced men and women said their marriage broke up because they gradually grew apart and lost a sense of closeness, or because they did not feel loved and appreciated. According to marriage researcher John Gottman, the determining factor by far (70 percent, to be exact) in whether wives feel satisfied with their marriages is the quality of the couple’s friendship. The determining factor by far (again, 70 percent) in whether husbands feel satisfied with their marriages is the quality of the couple’s friendship. As it turns out, we want the same thing after all.

Dr. Jan Anderson is a Licensed Professional Clinical Counselor with a Doctorate in Clinical Psychology. Her private practice includes over 15 years of experience counseling individuals, couples, and families. ◆

ISSUE#87 27

NEWS  EVENTS  ARTS

Ayoub Joins Lexington Clinic

LEXINGTON Lexington Clinic is pleased to announce the association of Walaa Ayoub, MD, PhD, with the Lexington Clinic Endocrinology Department.

Ayoub received his medical degree from the University of Cairo Faculty of Medicine and completed an internship and residency in internal medicine at Cairo University Hospitals. He completed another residency in internal medicine at Fairview General Hospital, a Cleveland Clinic Hospital, and most recently completed a fellowship in endocrinology at the Henry Ford Health System.

Ayoub is board-certified in internal medicine and is board-eligible in endocrinology. He provides services in general endocrinology and metabolism, diabetes mellitus, obesity and lipid-related disorders, thyroid and parathyroid disorders, pituitary disease, osteoporosis, and adrenal disorders.

His professional interests include diabetes mellitus, obesity and lipid-related disorders, and osteoporosis and other bone and mineral-related disorders.

Baptist Health Medical Group Names Leadership

Isaac J. Myers II, MD, has been named president of the Baptist Health Medical Group, part of Baptist Health. The

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Baptist Health Medical Group brings together the system’s employed physicians, including occupational medicine and urgent care physiIsaac J. Myers II, MD cians.

Prior to joining Baptist Health in early 2014, Myers served as president of Saint Francis Medical Group (Central Indiana Region), part of Franciscan Saint Francis Health in Indianapolis. Myers’ group included 205 employed physicians, 40 advanced practice clinicians and 1,400 employees, in addition to hospitalists and immediate care clinics managed by Franciscan Physician Network.

Myers began his health care administration career as a family practitioner in 1991, but left private practice in 1996 to begin a 20-year career in administrative roles. His extensive experience spans all aspects of health care delivery, including a physician hospital organization, management service organization, and health insurance companies. He was also an executive leader at Wishard Health Services, one of America’s five largest safety net health systems, and was an adjunct faculty member for Indiana University in Indianapolis, teaching Healthcare IT in the Health Care Administration master’s program.

Catherine A. Zoeller has been chosen

Catherine A. Zoeller

its strategic goals.

Zoeller was named interim vice president of operations for the Baptist Health Medical Group in 2013 and vice president in 2014. She was previously vice president of physician integration for Baptist Health Louisville. Under her leadership, 150 physicians were added to the physician network in Louisville and La Grange and two significant outpatient departments were established: Louisville Cardiology Group and the CBC Group (hematology/medical oncology).

In addition, Zoeller helped to add Baptist Health Urgent Care facilities on Westport Road and at Holiday Manor.

Two New Cardiologists at Saint Joseph Mount Sterling

MOUNT STERLING Two cardiologists with KentuckyOne Health Cardiology have opened a new office at Saint Joseph Mount Sterling, part of KentuckyOne Health.

Michelle Morton, MD, and Thomas Goff, MD, are board-certified cardiologists

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as vice president of operations for the Baptist Health Medical Group, working closely with Myers, to provide support for employed physician practices and help the group accomplish

NEWS

Michelle Morton, MD

specializing in nonsurgical procedures to diagnose and treat several forms of cardiovascular disease, including coronary artery disease, congestive heart failure, hypertension, peripheral vascular disease,

and heart valve disease.

Morton is a graduate of the University of Kentucky School of Medicine. She completed medical residency and cardiac fellowship training, University of Kentucky School of Medicine/Chandler Medical Center. She also sees patients at the Women’s Hospital at Saint Joseph East, also part of KentuckyOne Health.

Goff is also a graduate of the University of Kentucky School of Medicine. He Thomas Goff, MD completed fellowships at The Ohio State University Medical Center and Linder Center of Christ Hospital in Cincinnati.

Cao Joins KentuckyOne Health Primary Care Associates

Dr. Luyen Van Cao joined KentuckyOne Health Primary Care Associates on July 1. He is fluent in Vietnamese and very active in the Vietnamese-American community.

The physician earned a BA in chemistry with honors from Grinnell College in Grinnell, Iowa. He received his MD from Rush Medical College in Chicago, Illinois, and completed his internship and residency in internal medicine at the University of Missouri-Columbia School of Medicine in Columbia, Missouri.

SHEPHERDSVILLE

Cao, who is board-certified in internal medicine, has worked in many areas, including private practice, as a hospitalist, as an emergency department physician, and as a senior internist for National Health Corp Physicians, where he was a proctor for medical, pharmacy, and nurse practitioner students.

Cao is a member of the Indiana State Medical Association and board member of the Vietnamese-American Community in Louisville. His past community leadership experience has included membership in the Monitoring Committee of the Jefferson County Board of Education in Louisville from 1992-1993 and was on the board of the Americana Activity Center in 1992.

He has received a Louisville Community Service Award from Mayor Jerry Abramson.

Cao will practice at KentuckyOne Health Primary Care Associates (formerly Saleem Family Medicine) on the campus of Medical Center Jewish South at 1905 Hebron Lane, Suite 103.

UofL Adds 18 Pediatric Specialists

The University of Louisville Department of Pediatrics is adding 18 physicians to its faculty roster, bringing the total number of pediatricians and pediatric specialists to 186 as of July 1.

Pediatric Cardiology – Ashley E. Neal, MD, assistant professor in pediatric cardiology, completed a residency in general pediatrics at the Children’s Hospital of Philadelphia and a fellowship in pediatric cardiology at Boston Children’s Hospital.

She received her medical degree in 2004 at Yale University.

Pediatric Emergency Medicine – Brit Anderson, MD, assistant professor in pediatric emergency medicine, completed a pediatric residency at Northwestern University’s Children’s Memorial Hospital (now known as Lurie Children’s Hospital of Chicago) and a pediatric emergency medicine fellowship at Cincinnati Children’s Hospital Medical Center. She received her medical degree in 2008 at Northwestern University Feinberg School of Medicine.

Laura Voegele, MD, assistant professor and mid-level clinician in pediatric emergency medicine, completed a pediatric residency at the University of Louisville. She received her medical degree in 2007 at the

University of Louisville.

Tracey Wagner, MD, instructor and clinician in pediatric emergency medicine, completed a pediatric residency at the University of Louisville. She received her medical degree in 2011 at The Ohio State University.

Anita Yalamanchi, DO, instructor and pediatric emergency department clinician, completed a pediatric residency at University of Louisville. She received her medical degree in 2011 at The University of Pikeville Kentucky College of Osteopathic Medicine.

Pediatric Endocrinology –Sara Watson, MD, assistant professor in pediatric endocrinology, completed a pediatric residency at the University of Louisville and a pediatric endocrinology fellowship at Indiana University. She received her medical degree in 2007 at the University of Louisville.

Pediatric Forensic Medicine – Vinod Balakrishna Rao, MD, has joined the Kosair Charities Division of Pediatric Forensic Medicine as an assistant professor. Rao completed a pediatrics residency in 2011 at Pitt County Memorial Hospital/East Carolina University Brody School of Medicine and a child abuse pediatrics fellowship in 2014 at Westchester Medical Center/New York Medical College. He received his medical degree in 2008 at the Northeastern Ohio Universities College of Medicine.

General Pediatrics – Matthew D. Kinney, MD, assistant professor in general pediatrics, completed a pediatric residency at Northwestern University/Children’s Memorial Hospital in Chicago. He received his medical degree in 2008 at the University of Louisville School of Medicine.

Kendall Purcell, MD, MPH, instructor in general pediatrics, completed a pediatric residency at Children’s National Medical Center. She received her medical degree in 2011 at the University of Louisville School of Medicine.

Jennifer Stiff, MD, instructor in general pediatrics, completed a pediatric residency at the University of North Carolina. She received her medical degree in 2011 at the University of Louisville.

Hematology/Oncology & Bone Marrow Transplant – Michael Angelo Huang, MD, assistant professor in pediatric hematology/oncology & bone marrow transplant, completed a pediatric hematology/ oncolISSUE#87 29

NEWS ogy fellowship in 2012 at Penn State University. He received his medical degree in 2004 at the University of the Philippines and completed his pediatrics residency in 2009 at Albert Einstein Medical Center in Philadelphia.

Pediatric Hospital Medicine – Cindy DeMastes-Crabtree, MD, has joined the UofL Department of Pediatrics as chief resident and physician on the Pediatric Hospital Medicine service. Crabtree completed a pediatric residency at the University of Louisville. She received her medical degree in 2011at Pikeville School of Osteopathic Medicine.

Prasanthi Pasala, MD, has joined UofL Department of Pediatrics as an instructor and will practice primarily at Memorial Hospital and Health Care Center in Jasper, Ind. Pasala completed a pediatric residency at Kosair Children’s Hospital. She received her medical degree in 2011at the University of Cincinnati.

Aurelia C.H. Wood, MD, has joined the UofL Department of Pediatrics as chief resident and physician on the Pediatric Hospital Medicine service. She completed a pediatric residency at UofL in 2014 and she received her medical degree in 2011 at the Wright State University Boonshoft School of Medicine.

Pediatric Infectious Diseases – Victoria Statler, MD, instructor in pediatric infectious diseases, completed a pediatric residency and a Kosair Charities fellowship in pediatric infectious diseases at the University of Louisville. She received her medical degree in 2007 at the University of Louisville.

Neonatology – Sarah Korte, MD, assistant professor and neonatal hospitalist, completed a pediatric residency at University of Louisville. She received her medical degree in 2010 at the University of MissouriColumbia.

Bethany Woomer, MD, instructor and neonatal hospitalist, completed a pediatric residency at the University of Louisville.

She received her medical degree in 2011 at the University of West Virginia School of Medicine.

Weisskopf Child Evaluation Center – Maria Romelinda L. Mendoza, MD, has joined Weisskopf Child Evaluation Center as an assistant professor. Mendoza completed a pediatric residency at Penn State 30 M.D. UPDATE

Children’s Hospital and a developmental and behavioral pediatrics fellowship at Cohen Children’s Medical Center of New York. She received her medical degree in 2005 at the University of the Philippines.

UofL Pediatricians Reorganizing Primary Care Operation

The University of Louisville Department of Pediatrics is reorganizing its general pediatrics division, positioning itself to respond better to the new health care marketplace and needs of the community’s children.

The division provides primary care services to children in Louisville and Campbellsville, Ky., and helps train many of the university’s student doctors, nurses, dentists, psychologists and social workers. In 2013, its 22 pediatricians were responsible for more than 22,000 patients.

Approximately 12 percent of the total pediatric population in metro Louisville identifies a UofL pediatrician as their primary care provider.

“Healthcare reform has placed a greater emphasis on primary care, where providers can promote health and safety,” said Gerard Rabalais, MD, MHA, chairman, University of Louisville Department of Pediatrics.

“Pediatric programs like ours may be the best place to achieve success with health care reform since we have the longest runway to influence attitudes about prevention and healthy lifestyle.”

A number of changes are planned for the coming months: The department is closing its office at Floyd St. and Broadway on July 1 and creating a single expanded downtown practice, the Children & Youth Project (C&Y), located a few blocks away.

Not only will C&Y offer all of the services previously offered at the Broadway office but the expanded downtown clinic will serve as a medical home with a wider array of onsite ancillary services: social work; psychology; dental care; home health; speech therapy; WIC nutrition services; and legal counseling.

This summer, the UofL Department of Pediatrics will partner with an east Louisville pediatric practice, bringing the number of general pediatricians and nurse practitioners in the department to 36.

LOUISVILLE

The department will also expand its Campbellsville, Ky., practice later this summer, partnering with Taylor Regional Hospital to open a satellite office in Columbia, Ky. Plans are also underway to provide general pediatric care in the West End of Louisville.

All of the Louisville pediatric practices will soon operate as a network. That means patients will have a medical home for routine visits as well as access to urgent care at any of the other Louisville general pediatric practices. The network also will enable families to access ancillary services headquartered at C&Y and specialty care by UofL pediatric specialists.

The department’s reorganization also ensures that residents, medical students and trainees from other programs will have places to learn primary care pediatrics.

Historically, trainees have spent time in community pediatric practices but these practices may struggle to continue hosting students because of changes in the health care landscape.

KentuckyOne Health Primary Care Associates Adds Nurse Practitioner

Gina Laughlin, APRN-C, advanced practice registered nurse, is now practicing at KentuckyOne Health Primary Care Associates, formerly Sun Valley Family Care, located at 9616 Dixie Highway.

Laughlin has 14 years of nursing experience.

She became a nurse practitioner and completed her master of science degree in nursing at the University of Louisville in 2012. She also holds a bachelor of science degree in nursing from the University of Louisville.

She previously worked as a nurse practitioner with First Urology in Louisville.

Nurse practitioners are advanced practice registered nurses who diagnose and treat a wide range of health problems.

LOUISVILLE

NEWS

Shelbyville’s MaxCare Urgent Treatment Center joins Baptist Health

LOUISVILLE Baptist Health has added a Shelbyville urgent care center to its family of services, strengthening and broadening its scope of health care in the Louisville area.

MaxCare Urgent Treatment Center, 101 Stonecrest Road, Suite #1, Shelbyville, became Baptist Health Urgent Care and Occupational Medicine, effective May 30.

A leader in the Shelbyville medical community, MaxCare has provided urgent care and occupational medicine since 2006, seeing more than 17,000 patients a year.

Led by Steven W. Smith, MD, Ronald E. Creque, MD, and Paul A. Goodlett, MD, MaxCare provides health care services with no appointment needed for treatment of minor illnesses and injuries such as lacerations, broken bones, sore throat or flu.

The center also provides pre-employment services (physicals, drug screenings and vaccinations) and work-related injury treatment to many of the area’s employers.

MaxCare is the only urgent care center in Shelby, Henry, and Spencer counties, and its physicians and nurse practitioners see patients from each of those communities, as well as from Anderson and Franklin counties.

Smith, who serves as medical director for MaxCare, said that joining Baptist Health is a positive change for his practice and for the people of the Shelbyville area.

Having worked in the emergency room at Baptist East (now Baptist Health Louisville) for 10 years, Smith has strong ties with Baptist Health.

Smith is board-certified in emergency medicine and as a Medical Review Officer (MRO) with expertise in drug and alcohol testing. He serves as a clinical instructor of emergency medicine at the University of Louisville and as the physician for the Shelby County Fire Department. He received his medical degree from the University of Louisville School of Medicine, did training in diagnostic radiology at Indiana University Medical Center in Indianapolis and completed an emergency medicine residency at the University of Louisville, where he served as chief resident.

Creque received his medical degree from the University of Louisville and completed his residency at University of Alabama

Birmingham in 2001. Dr. Goodlett, who is a graduate of Shelby County High School, received his medical degree from the University of Louisville and completed his residency at St. Mary’s hospital in Evansville, Ind.

UofL Professor Honored for Research by German Society

LOUISVILLE Mariusz Ratajczak, MD, PhD, DSci, has been selected to receive the prestigious Karl Landsteiner Prize from the German Society for Transfusion Medicine and Immunohematology. Ratajczak holds the Henry M. and Stella M. Hoenig Endowed Chair at the University of Louisville.

T h e Landsteiner Prize is given by the society to a doctor for outstanding achievements and research in the fields of transfusion and/or immunology. The prize is named after Karl Landsteiner, an Austrian biologist and physician. In addition to distinguishing the main blood groups, Landsteiner also discovered polio along with several other researchers and received the Nobel Prize in Physiology or Medicine in 1930. Landsteiner is recognized as the father of transfusion medicine. Previous recipients of the Karl Landsteiner Prize include Nobel Prize laureate Rolf Zinkernagel (Basel), Karl Blume (Seattle) and Stephanie Dimmeler (Frankfurt).

Ratajczak was honored for his outstanding achievements in the characterization of mechanisms involved in the mobilization of hematopoietic stem cells and the discovery of very small embryonic like stem cells in the adult tissue.

An internationally known specialist in the field of adult stem cell biology, his 2005 discovery of embryonic-like stem cells in adult bone marrow has potential to revolutionize the field of regenerative medicine.

The discovery may lead to new treatments for heart disease, eye disease, diabetes and neurodegenerative disorders, as well as provide insight into the development of many forms of leukemia.

In addition to his endowed position, Ratajczak is a professor in the Department of Medicine and the director of the Developmental Biology Research Program and of the Research Flow and Sorting Core Facility at the University of Louisville’s James Graham Brown Cancer Center.

In addition to receiving the Karl Landsteiner Prize, Ratajczak has also been invited to deliver an opening lecture on Sept. 9 during the society’s annual meeting in Dresden, Germany.

UK, Norton Expand Research and Educational Collaborations

LEXINGTON UK HealthCare and Norton Healthcare are building upon their history of collaboration to expand research and educational collaborations between the two institutions, with the goal of improving health and health care for all Kentuckians.

Beginning July 1, educational and research initiatives between UK and Norton will be led by Dr. Stephen Wyatt, who most recently served two successful terms as the founding dean of the University of Kentucky College of Public Health. Wyatt will return to the UK College of Medicine, with joint appointment as vice president for research at Norton Healthcare.During Wyatt’s tenure as dean, the College of Public Health experienced tremendous growth in faculty, staff, students, extramural funding, and reputation, with the college now ranked 25th nationally by U.S. News and World Report. Wyatt will leverage his expertise in collaborative research and education to guide the partnership efforts between UK and Norton Healthcare.

Facilitating collaborative research is a key component of the partnership and will benefit Kentuckians by expanding access to novel clinical trials only available at academic medical centers that, like UK, have major federal research designations in cancer, aging and translational science, while simultaneously expanding access to industry-sponsored trials at Norton Healthcare.

The collaboration will also allow researchers at both institutions to combine expertise and resources and better recruit diverse research participants from a larger area of Central Kentucky. ◆ ISSUE#87 31

EVENTS

Baby Health LEXINGTON On May 31, 2014 Baby Health Service celebrated at the Keene Barn at Keeneland Race Track 100 years of providing free health care to low income children whose families were not eligible for government assistance nor could they afford private health care. Since 1914 Baby Health Service has evolved into a complete medical clinic providing free immunizations, diagnostic testing and medications for children birth through 17 years. Over 400 people who have volunteered, donated or connected to Baby Health Service came together to celebrate this milestone of care to over 120,000 children in the Lexington community. BHS has expanded its mission of care by providing a dental clinic, Wende’s Healthy Habits Program and a Community Garden. ◆

Board President Kathleen Eastland and husband Carl Matlacola, director of UK Athletics training program, were thrilled with the success of the 100 celebration event of Baby Health Services.

Ashley Robbins, board member and husband Earl Robbins, MD, Central Kentucky Gastroenterology, said “It’s an to honor to support such a great organization as Baby Health Services.”

Bill Underwood, MD, FAAP, retired from Lexington Clinic and UK professor of Pediatrics, was honored at the 100 year celebration of Baby Health Services.

Ron Shashy, MD, and wife Evie, board member of Baby Health Services, who said “It was a wonderful evening.”

COME PLAY

Baby Health board member Kristin Sajadi and Dr. Kaveh Sajadi of Kentucky Bone & Joint Surgeons attended the 100 year celebration of Baby Health Services.

32 M.D. UPDATE

(L-R) Barney

Hunter, MD and John Cronin, MD

Cindy Campbell & Rob Revellte, MD, PhD, FAAP, Pediatric & Adolescent Associates, were among the 300 who gathered to support the long-time community health organization.

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All proceeds to benefit the Lexington Medical Society Foundation. Each year the LMS Foundation distributes grants to several local organizations, including Baby Health Service, God’s Pantry Food Bank, Faith Pharmacy, Mission Lexington, Ronald McDonald House and Surgery on Sunday.

Get your team together, sponsor a hole and register to play!

Golf Committee:

Format:

Shamble Tournament (Play best drive then play own ball to the hole)

Patrick Cashman, SIS

teams:

Put together own Foursome or Committee will help form teams

Wendy G. Cropper, M.D.

GOLF – INDIVIDUAL PLAYERS: $100.00/person

Kenneth V. “Tad” Hughes, III, M.D.

HOLE SPONSORSHIP: $500.00 (Includes signage and newsletter recognition)

HOLE SPONSORSHIP WITH 4 PLAYERS: $800.00 (Includes signage and newsletter recognition)

WHITE TEE SPONSORSHIP: $2000.00

John W. Collins, M.D., Chairman

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Jon H. Voss, M.D.

GOLD TEE SPONSORSHIP: $6000.00 – BB&T

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To Sign Up: Please contact a committee member or Jaime Verba (jverba@lexingtondoctors.org) or at LMS office 859-278-0569 with questions or to sign up.

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