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2016 Editorial THE BUSINE

SS MAGAZI

THE BUSINESS

PHYSICIANS

KENTUCKY MAGAZINE OF

RE PROFESSI

AND HEALTHCA

NE OF KEN

ONALS

TUCKY PHY

SICIANS

AND HEA

LTHCARE

PROFESSIO

ISSUE #95

Opportunities* Issue #101, June/July

NALS

ISSUE #94

 MUSCULOSKELETAL HEALTH Cassis Der matolog to growing y & Aesthetics Cen a successful ter forges its own independen t practice path

MATIVE RE heast A TRANSFORT IN CANCERexpeCA to nort MOMEN cer Center expands its lyrtise and globally

ALSO IN THIS

ISSUE

DENT NEW KMA PRESI Q&A WITH TION THERAPY

VOLUME 6•#5



 HAND

NOVEMBER 2015

IN RADIA ERSHIP E OF KENTUCKY PHYSICIA  ADVANCES RCH PARTN GING NS AND ER RESEA HEALTHC DAMAPROFESS  A CANC LESS ARE IONALS RB™ EFFECTIVE, BIOZO MORE THERAPIES BREAST SURGERY AND DETECTION  TARGETED IC PHY ENHANCES  ONCOPLAST 3D MAMMOGRA

VOLUME 6•#6•



ISSUE #93

Issue #102, August/September

IONS

S/ORTHOPE DICS GASTRO ENTERO LOGY HEMATO LOGY VASCULAR

ER 2015

& ONCOLOGY RADIOLOGY

THE BUSINESS MAGAZIN

Physical Medicine SPECIAL SECT

PLASTIC

ONS

SPECIAL SECTI

•SEPTEMB

Can onal ham Brown therapies regi The James Gra ncing access and cancer Louisville, adva

Orthopedics, Sports Medicine,

The Road Less Travel ed

Sports Medicine/BUSINESS MAGAZINE THE Orthopedics Men’s Health

 SKIN DEEP

ISSUE

SURGERY IN THE DIGIT  THE IMPA AL AGE CT OF PLAS TIC SURG  MODERN ERY DAY GAST ROENTERO LOGY  ENDO SCOPIC GI TECHNIQU  THE CHAL ES LENGES OF APLA STIC ANEM  THE DRAW IA OF VASC ULAR SURG ERY

L AGE RY IN THE DIGITA  HAND SURGE SURGERY OF PLASTIC  THE IMPACT Y OENTEROLOG DAY GASTR  MODERN IQUES TECHN GI  ENDOSCOPIC A APLASTIC ANEMI ENGES OF  THE CHALL RY LAR SURGE VASCU OF  THE DRAW

SPECIAL SECTIONS

ALSO IN THIS

 HAND

ICIANS KENTUCKY PHYS

ESSIONA THCARE PROF

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Dermatology, Plastic Surgery,

SURGERY IN THE DIGIT AL AGE  THE IMPA CT OF PLAS TIC SURG ERY  MODERN DAY GAST ROENTERO LOGY  ENDO SCOPIC GI TECHNIQU  THE CHAL ES LENGES OF APLA STIC ANEM  THE DRAW IA OF VASC ULAR SURG ERY

Vascular Medicine

ISSUE #92

Issue #103, October  CANCER CARE



MEET THE TEAM

INE OF KENTUCKY

THE BUSINESS MAGAZ

PHYSICIANS AND

ALSO IN THIS ISSUE

 ONE STOP SHOP FOR SPORTS MEDICINE IN NEW ALBANY  PROBLEM SOLVING FOR MOTIVATED, HEALTHY PATIENTS  FIXING ORTHOPEDIC PROBLEMS IN OWENSBORO  THE PROS OF PROSTATE SCREENING  SEX, POWER, & BOUNDARIES FOR MEN

HEALTHCARE PROFE

Oncology, Hematology, Radiology

ONS

SPECIAL SECTI

The collaboration of specialti at KentuckyOne Health/UofL provides comprehensiveescare Sports Medicine to athletes of all ages

TH WOMEN’S HEAL S AND PEDIATRIC

ISSUE #91

THE BUSINESS MAGAZ

INE OF KENTUCKY

PHYSICIANS AND

 PEDIATRIC

HEALTHCARE PROFE

SSIONALS iSSue #90

LAND OF OPPORTUNITY

Special SectioN

PAIN MEDICINE AND NEUROLOGY

MHA Kendra J. Grubb, MD, on, cardiovascular surge a joins U of L to build

Neurology, Ophthalmology, ENT Pain Medicine, Mental Health Issue #105 – Dec/Jan 2016

Medicine, Pediatrics

LUNG CANCER

 IT’S ALL IN YOUR HEAD

Primary Care, Internal Medicine, Family

SION  MANAGING HYPERTEN EVOLVES  A HEART TEAM GY  PREVENTIVE CARDIOLO G FOR  CT SCREENIN

Volume 6, Number

OGY

OPHTHALMOL

Issue #104, November

PRIMARY CARE AND PEDIATRICS

PATIENT-RESPONS IVENESS, INNOVATION, AND COLLABO

RATION William O. Witt, MD, uses three pillar s toRO’S  REBUILDING OWENSBO enhance the patien t experience at PROGRAM CARDIAC SURGERY Cardi  NEW EP SERVICES nal Hill Pain Institute IN IN NEW ALBANY, ALSO IN THIS ISSUE

VOLUME 6•#2•MA

RCH 2015

AS PRIMARY  OB/GYN ER CARE PROVID

EATING  ADOLESCENT DISORDERS

CARDIOLOGY AND PULMONOLOGY

transcatheter and minimally invasive m heart surgery progra at Jewish Hospital.

ISSUE

HEALTH FROM  WOMEN’S E TO OLD AGE ADOLESCENC & INNOVATION  TECHNOLOGY PRACTICE IN OB/GYN HOSPITAL UNITY COMM  WITH PARTNERS R MEDICAL CENTE

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SSIONALS

SPECIAL SECTIONS

ALSO IN THIS

T TH E PATI EN OUNT IS PA R A M MAY 2015 VOLUME 6•#3•

VOLUME 6•#4•JUNE/JULY

2015

COVERING ALL THE BASES

alSo iN thiS iSSue

 FAMILY APPROAC H TO PAIN MANAGEM ENT  INJECTIONS FOR  ENDOSCOPIC MIGRAINES ENDONASAL SURGERY FOR SKULL-BASE TUMORS  BUILDING AN INTERVENTIONAL NEUROLOGY PROGRAM  NEUROLOGIST FILLS SERVICES GAP IN GEORGETO WN

*EDITORIAL TOPICS ARE SUBJECT TO CHANGE.

TO PARTICIPATE CONTACT: Gil Dunn, Publisher • gdunn@md-update.com • (859) 309-0720 Jennifer S. Newton, Editor-in-Chief • jnewton@md-update.com • (502) 541-2666 SEND PRESS RELEASES TO news@md-update.com

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12 WHEN HIGH RISK IS NORMAL: SAINT JOSPEH EAST

2 MD-UPDATE

14 BRINGING MATERNAL-FETAL MEDICINE TO THE FOREFRONT: OWENSBORO HEALTH

16 IT’S ONLY NATURAL: WOMEN FIRST OF LOUISVILLE

18 THE GENDER GAP: JEWISH HOSPITAL

20 3D TIMES THREE: FLOYD MEMORIAL

LETTER FROM THE PUBLISHER

MD-UPDATE MD-Update.com Volume 7, Number 4 ISSUE #100 PUBLISHER

Gil Dunn gdunn@md-update.com EDITOR IN CHIEF

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

James Shambhu art@md-update.com

CONTRIBUTORS:

Jan Anderson, PsyD, LPCC Scott Neal Shawn Stevison Jamie Wilhite Dittert

ADVERTISING AND INTEGRATED PHYSICIAN MARKETING:

Gil Dunn gdunn@md-update.com

Mentelle Media, LLC

38 Mentelle Park Lexington KY 40502 (859) 309-0720 phone and fax Standard class mail paid in Lebanon Junction, Ky. Postmaster: Please send notices on Form 3579 to 38 Mentelle Park Lexington KY 40502 MD-Update is peer reviewed for accuracy. However, we cannot warrant the facts supplied nor be held responsible for the opinions expressed in our published materials. Copyright 2016 Mentelle Media, LLC. All rights reserved. No part of this publication may be reproduced, stored, or transmitted in any form or by any means-electronic, photocopying, recording or otherwise-without the prior written permission of the publisher. Please contact Mentelle Media for rates to: purchase hardcopies of our articles to distribute to your colleagues or customers: to purchase digital reprints of our articles to host on your company or team websites and/or newsletter. Thank you. Individual copies of MD-Update are available for $9.95.

Welcome to Issue #100 of MD-UPDATE. It’s curious why we celebrate certain milestone events in our lives, so many based on particular numbers, like #10, #25, #50, and in our case #100. Why is that, and why do we celebrate or commemorate events at all? For some insight, I asked our resident mental wellness columnist Dr. Jan Anderson for her thoughts. “It’s about rituals,” she said. “It’s in our emotional and cultural DNA to celebrate or remember transitioning life events.” She posits that since our American culture is still relatively young and so diverse, we don’t have as many rituals as other more long-standing cultures. It seems to me that we celebrate milestones now with homebred American enthusiasm: birthdays, anniversaries, holidays, sporting events, and business milestones. Did you know that in 2015 Facebook celebrated a 10-year anniversary of being “Liked”? Nike celebrated 25 years of “Just Do it!” Starbucks celebrated 40 years of connection with customers and their coffee. Ford celebrated the 50th anniversary of the Mustang, and Motel 6 celebrated 50 years of “Leaving the light on for you.” Trying to strike a balance between self-promotion and recognition of the milestone that MD-UPDATE has achieved, I offer that 100 issues, with 500+ stories, and interviews with thousands of physicians and healthcare providers is a worthy accomplishment to be proud of. We could not have done that without the readers, the supporters, the MD-UPDATE team, and, most importantly, the Kentucky doctors and healthcare providers who participate in each issue. Thank you and here’s to another 100+. All the Best,

Gil Dunn Publisher, MD-UPDATE

Send your letters to the editor to: jnewton@md-update.com, or (502) 541-2666 mobile Gil Dunn, Publisher: gdunn@md-update.com or (859) 309-0720 phone and fax ISSUE#100 | 3

Q&A

Q&A with Stephen Toadvine, MD President of Baptist Health Medical Group Stephen Toadvine, MD, was named president of Baptist Health Medical Group, effective April 4, 2016. As a longtime Baptist Health family medicine physician and leader, Toadvine has served as chief medical officer for Baptist Health Lexington, chief medical officer and vice president for Hardin Memorial Health, and chief medical officer for Baptist Health Corbin. MD-UPDATE Editor-in-Chief Jennifer Newton sat down with Toadvine to learn more about him and his plans for the future.

My transition to full-time administrative work came in the fall of 2006, when John Henson, the hospital’s CEO, asked me to assume the chief medical officer position at Baptist Health Corbin.

LOUISVILLE

What led you to pursue roles in physician leadership?

MD-UPDATE: What led you to specialize in family medicine?

TOADVINE: While in medical school at Northwestern in Chicago, for me it was family practice that offered general breadth of knowledge, with a demand to have some expertise in all the disciplines at a broad level. I was also attracted to continuity of care and longer-term relationships with patients across all spectrums of ages, so it appealed to me very much. The other influence on me was the physicians my family and I had when I was growing up in Florence, Ky. It was the group of Booth, Baird and Poore. They were tremendous examples of the ideal primary care doctor.

How long did you practice family medicine?

Sixteen years altogether. The first few years of that were in Barbourville, Ky. It was really perfect for what I wanted to do. My partners had come from out-of-state with a strong sense of service for an area of high need and also an area that needed the skills that we had. We did lots of obstetrics, including needing to do our own C-sections and epidurals, and care for the infants, including some very critical premature neonates. We did general medicine, critical care, and rounded in the area nursing homes. The practice really matched the interests I had when I had decided during medical school to pursue family practice. 4 MD-UPDATE

When did you first become involved in healthcare administration?

I had practiced for three years in Barbourville and then I went to Pittsburgh to do a fellowship in academic family medicine. After that fellowship, I went to Chicago and joined a hospital-owned practice and then began teaching in a residency program. I would describe that as administrative, as I was the associate program director for a family practice residency that we founded and opened at Rush-Copley Hospital in Aurora, Ill., which was affiliated with Rush University Medical School. I returned to Corbin in 1999 to help open a rural track residency in conjunction with UK at Baptist Health in Corbin. That’s why I left Chicago and returned to Kentucky. We ran that for a few years, but for various reasons decided to close the program. I returned to full-time practice, and we had a total of 10 physicians at the time.

I really enjoy direct patient care, and it’s really impossible to beat that in terms of professional satisfaction. But I also had interest in broader issues in healthcare, and in system and policy issues, and I think that interest was what led me to do the fellowship in Pittsburgh, which was in association with a master’s in public health. While I was practicing in Barbourville and Corbin, I was quite active on medical staff committees, and due to that, I believe, I was asked to take the CMO job. I struggled with that decision, but the CMO who was retiring, Dr. Ross Halbleib, was very encouraging to me. He didn’t see the transition as a move out of the practice of clinical medicine, but really a continuation of it, still carrying out the function, the philosophy, and the ideals of a physician, just in a different role. I went into the CMO position on a trial basis, but what happened quickly was that I began learning so many new things in terms of developments in national healthcare policy, expectations on hospitals and providers from various governmental agencies, and the mechanics of healthcare funding and reimbursement. The new position challenged me with continual learning, which was fun and exciting, and still continues.

What achievements would you like to highlight from your most recent role as CMO for Baptist Health?

I think we’ve made really good progress in bringing the doctors together around the state, beginning to work system-wide in terms of advances in clinical policies and care delivery. I think we have made a lot of progress as well in what we need to do in becoming a physician-led organization. By

that I mean, not any one physician in particular as a leader, but the physicians as an entire group, where our nearly 500 doctors, as partners, help drive strategy for our health system. We have much work to do, but over the last year we’ve made a lot of progress. What’s happened in Kentucky, if you go back 15 years where most doctors were in a private practice setting, the physicians were clearly customers of the hospitals and health systems. That’s shifted now that we have 500 doctors in an “employment” arrangement. In my view, they have ceased being customers of the health system and are now co-owners and partners in the health system. Functionally, the medical group physicians are really key in driving Baptist Health.

What challenges or opportunities do you see as you take on this new role?

The challenges for all of us, especially physicians in healthcare, are to continually be advancing what we’ve been doing, which is delivering care that’s safe, effective, and as cost efficient as possible, with great outcomes, delivering a great patient experience, all while adapting to new technologies that are emerging incredibly rapidly, from diagnostic capabilities to genetic testing to telehealth, and in light of rapidly changing reimbursement models.

What are your main goals as president?

We want to continue to grow. We want to improve patient access. We want to meet patient demand. We want to continue to promote physician leadership across the system. What we really need to work on in terms of safety in all our practices and hospitals is information management and closing any and all open loops in that. Second, is a striving for perfection and speed in diagnostic accuracy. And third is to pay meticulous attention to appropriate utilization and medical necessity.

What’s your take on the family practice shortage and what can be done about it?

We need to keep painting the vision of what can be accomplished through primary care to improve the health of our communities, and the professional meaningfulness and satisfaction that comes through that.

Second, is to still be looking at models of appropriate compensation for primary care doctors. Third, is to look for new models to make primary care more effective and efficient, such as the use of telemedicine. A large percentage of primary care visits could be done through telehealth application, more efficiently, quickly, with good results and good patient satisfaction. The other is the use of nurse practitioners and physician assistants more appropriately.

We’re recruiting primary care everywhere across Baptist Health.

What else should we know about you?

My wife, Ann, and I will have been married for 34 years this summer, and we have six children. I’ve been involved with some international work with several trips to Honduras, and assisting in opening a charity hospital in Iraq. ◆

“As a midwife, I’m at their side through pregnancy and beyond.” “My name is Emily duBois Hollander. I’m a Certified Nurse Midwife. And I recently joined the team at Women First. “The term midwife means ‘with women,’ and I work with women through the entirety of their reproductive lives. Yes, I help with more holistic labor and delivery. But I also work with Women First patients to provide a full range of care, including personalized birth plans, pre- and postnatal care, and contraceptive and nutrition counseling. “I’m very excited to work with the talented physicians at Women First and ‘with women’ who want to take an active role in their own health care.” —Emily duBois Hollander, CNM, at Women First

To learn more about certified midwife services at Women First, or to set up a patient appointment with Emily, go online to womenfirstlouisville.com or call 502.891.8788. Our Women First Physicians, l to r back: Dr. Margarita Terrassa, Dr. Leigh Price, Dr. Kelli Miller, Dr. Holly Brown, Dr. Michele Johnson. Front: Dr. Lori Warren, Dr. Mollie Cartwright, Dr. Rebecca Terry, Dr. Ann Grider, and Dr. Rebecca Booth.

ISSUE#100 | 5

FINANCE

Mirrors and Windshields While practicing as a CPA, our firm ran an ad that compared the relative dimensions of the rear view mirror to that of the windshield and suggested that they should also be used in that proportion. The 100th issue of MD-UPDATE is a good milestone with which to glance into the rear view mirror while still focusing on what lies ahead. You, dear reader, and I have been through a lot together over these past 8+ years, and I feel incredibly privileged to have had many of you along for the entire journey. Some of you have become friends who have regularly challenged me to think more clearly about what I write here. Especially for you who have provided questions and feedback, I remain grateful. Be assured, relevance to you remains my goal. In 2008, before the crisis got underway, you were challenged to think less in terms of relative return, i.e. beating the market, and to focus more on an individual investment strategy tied to your own goals and objectives. I wrote that it was time to “seek, through knowledge, performance that will

cial planning that focuses solely on building a pot of money to meet a future goal, attention is focused on the current spending/saving tradeoff. The method is, in my opinion, far supeBY Scott Neal rior for quantifying current and future financial decisions, such as when to retire, when to take social security, how much to spend on college, downsizing/upsizing a residence, etc. We even went so far in one article to suggest that many of you might be saving too much, a stance labeled as heresy by many financial advisors. We have articles in the archive related to estate planning, tax planning, education funding, long-term care planning, life and disability insurance, and end of life planning. If any of these issues strike a chord

IF YOU HAVE NOT ASSESSED RISK TOLERANCE AND RISK CAPACITY AND ADJUSTED YOUR PORTFOLIO ACCORDINGLY, NOW WOULD BE A GOOD TIME TO DO THAT. be measured against some absolute return benchmark and to remain less than satisfied with anything that falls short.” To support that argument, you were introduced to the concept of endogenous risk (the risk inherent in the market itself ), a theory developed by Stanford’s Mordecai Kurz in 1994 but made more accessible by economist Woody Brock. In this space, you have read about a new way of thinking about financial planning, tagged as the economists’ approach because it was built on a theory of consumptionsmoothing, originally proposed in the early 20th century and fully developed by Boston University economist Lawrence Kotlikoff. Rather than goals-based, traditional finan6 MD-UPDATE

with you today and you would like more current information, write or call. For now, let’s turn our full attention to the current marketplace. The past year has been an especially difficult one for stock investors, especially those who simply buy-hold-and-rebalance. The Dow peaked in May 2015 at 18,351, and at this writing in late May 2016, the index is down nearly five percent since then. Likewise the S&P is down nearly four percent over that same period. The NASDAQ has been even worse; peaking in July of last year, it is down more than 8%eight percent. Dividends have helped push the total return of the S&P into positive territory for the trailing 12 months. Looking solely at those

data points hardly tells the story. The market has been range-bound over the past 12 months, and investor emotions have taken a ride up and down several times. Historically, such activity is indicative of market tops. We need to make decisions today and be ready to move as the market unfolds. By most any measure, today the markets are expensive and earnings are falling. Combined with small business sentiment that is in decline, this sets up for weaker employment numbers in the months to come and does not give the Fed much room for its proposed rate increases. The Presidential election cycle doesn’t help any. Earnings per share outlook has been helped by stock buybacks since 2009, but those have also been significantly reduced this year compared to last. The number of companies that are cutting dividends also appears to be accelerating. All this is putting pressure on corporate balance sheets. An analysis by the Fed’s Board of Governors indicates that delinquencies of commercial and industrial loans are up significantly from Q4 2014. From a technical standpoint, if we examine monthly charts, this market bears significant resemblance to the market tops of 2000 and 2007. In other words, risk is high that we are witnessing the top of this bull market. The great temptation is to succumb to the fear of missing out when strong rallies show up like they did in October of 2015 and February to April of this year or the fear of losing everything in strong declines like we saw in September 2015 or January of this year. At either of those times, it is especially important to take a deep breath, face the fear, and remain true to a strategy that attends to your own individual circumstance. If you have not assessed risk tolerance and risk capacity and adjusted your portfolio accordingly, now would be a good time to do that. Scott Neal is President of D. Scott Neal, Inc., a fee-only financial planning and investment advisory firm with offices in Lexington and Louisville. He can be reached at scott@dsneal. com or by calling 1-800-344-9098. ◆

ACCOUNTING

Expected CMS and OIG Enforcement Targets for 2016 Each year, the Office of Inspector General (OIG) for the department of Health and Human Services (HHS) issues a work plan detailing expected audit areas for the fiscal year. The publication of the work plan provides an opportunity for physicians to look at their current practices and determine whether they may be affected by the enforcement actions. In addition to the OIG work plan, physicians may want to be aware of Department of Justice (DOJ) settlements impacting physicians that result in civil and criminal penalties. At this time, there are three main areas that are under increasing scrutiny: (1) compensation arrangements; (2) coding compliance target areas; and (3) physician prescribing patterns.

Compensation Arrangements

Nearly all physicians are familiar with the

STARK regulations, which have focused on ensuring that compensation arrangements don’t focus on the volume or value of referrals and that the arrangements fall within a desigBY Shawn Stevison nated STARK exception. Historically, litigation on these issues has focused on the hospitals that are initiating the arrangements. That focus has now shifted toward physicians, with the federal government using the Anti-Kickback Statute in new ways. At the end of 2015, the DOJ reached settlements with several hospital entities related to the amount of

compensation paid to physicians compared to the practice’s income. Additionally, physicians were targeted in the settlement based on the type of negotiation comments made in emails and other written communication with the hospital. The hospitals were penalized for paying physicians too much, based on significant losses suffered by the practice as a whole compared to the revenues earned. Many of the physicians had utilized terminology in negotiations referencing the volume of their referrals, the value of their service lines to the hospital, and the like. Physicians should use caution in future compensation negotiations to avoid utilizing this type of terminology. Additional enforcement targets related to compensation are focused on the rates paid for medical directorships; documented evidence that services were provided for the

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ISSUE#100 | 7

ACCOUNTING

ADDITIONAL ENFORCEMENT TARGETS RELATED TO COMPENSATION ARE FOCUSED ON THE RATES PAID FOR MEDICAL DIRECTORSHIPS; DOCUMENTED EVIDENCE THAT SERVICES WERE PROVIDED FOR THE PAYMENTS RECEIVED; AND THAT HOSPITALS ARE NOT EMPLOYING OFFICE STAFF ONLY IN ORDER TO REDUCE PHYSICIAN OVERHEAD. payments received; and that hospitals are not employing office staff only in order to reduce physician overhead.

Coding Enforcement

The OIG Work Plan includes five items that target physician coding: (1) anesthesia services; (2) physician home visits; (3) prolonged services; (4) medication management; and (5) place of service coding. There are specific elements that the OIG is focusing on for each of these items. Anesthesia Services: The OIG is focused on whether the anesthesiologist has billed appropriately for the level of participation. Claims billed with the AA modifier, indicating that the anesthesiologist personally performed the services, will receive the most scrutiny by the OIG. Documentation must be present to support that the services were performed directly by the anesthesiologist and that no part was performed by others. An additional tactic to be utilized will include looking to see how the anesthesiologist was scheduled and for evidence that the anesthesiologist was, in fact, only supervising. Physician Home Visits: In order for a

home visit to be considered reasonable and medically necessary, there is an expectation that documentation will reflect the reason it was not medically appropriate for the patient to be seen in the physician office or other outpatient setting. Prolonged Services: The OIG will determine whether evaluation and management (E/M) services coded as prolonged services were reasonable and made in accordance with Medicare requirements. The additional time beyond the time spent with a beneficiary for a usual companion evaluation and management service must be supported with appropriate documentation in order for the services to be covered. Medication Management: The OIG has noticed an up-tick in the prescribing of medications that cause interactions or complications when utilized in combination by Medicare Part D patients. As a result, the OIG will focus their review on how well physicians are documenting the complete medication list of patients and whether physicians are considering interactions when managing the patient’s medication. Place of Service Coding: Physicians are required to appropriately notate the loca-

tion where services are provided to patients, and to bill for the services accordingly (physician office, outpatient department of a hospital, and inpatient visits).

Prescribing Patterns of Physicians

CMS and the DOJ have growing data analysis opportunities. One of the items that is receiving increased scrutiny via data analysis is the prescribing patterns of physicians. This analysis includes many different medications, with the most recent target being opoid and opiod replacement medications. Physicians who are identified as high prescribers of these types of medications can expect increased scrutiny on the medical necessity of the prescriptions as well as the frequency and volume of prescriptions. As the OIG and CMS identify patterns of high usage of goods and services, the list of target areas will continue to grow. Be alert to enforcement trends. Consider what monitoring may be appropriate within your practice, in order to be appropriately prepared. Take proactive steps to address the known target areas while the opportunity still exists. Shawn Stevison, CPA, CHC, CGMA, CRMA, is the manager of Healthcare Consulting Services at Dean Dorton. She can be reached at 502.566.1066 or sstevison@ ddafhealthcare.com. ◆

Focus on what matters most. We’ll handle the rest. • Revenue cycle assessment and • Reimbursement optimization management • Accounting and financial • Physician coding and documentation outsourcing improvement • Compliance and risk • Managed care contract negotiations management services 8 MD-UPDATE

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LEGAL

The State of Negligent Credentialing in Kentucky Recently, Kentucky courts have considered whether to recognize a new cause of action called “negligent credentialing.” Generally, a negligent credentialing claim involves allegations that a hospital negligently issued or renewed hospital privileges to a physician, resulting in injury to a patient. Under this theory, a patient can seek damages from a hospital based on the hospital’s negligence, which is separate and apart from any claims the plaintiff may make against the physician. A key feature of a negligent credentialing claim is that it is based on the independent actions or omissions of the hospital. It does not depend on a finding that the hospital is vicariously liable for a doctor’s negligent acts. Rather, the claim is that the hospital itself did not act as a reasonably competent hospital in connection with allowing a physician to exercise hospital privileges. While several other jurisdictions recognize neg-

ligent credentialing, some states have enacted statutes to limit or preclude negligent credentialing claims against hospitals. There is no final Kentucky opinion BY Jamie Wilhite Dittert court that adopts the tort of negligent credentialing. In 2014, the Kentucky Supreme Court (the highest court in Kentucky) was faced with the question of negligent credentialing and opted to leave the issue “for another day.” The debate continues, however, to make its way through the Kentucky courts, resulting in divergent opinions from the intermediate appellate court, the Kentucky Court of Appeals.

During the first quarter of 2016, two different panels of the Kentucky Court of Appeals issued contradictory decisions regarding the viability of negligent credentialing as a claim under Kentucky law. In the first decision, Brown v. Trover,1 two judges out of the three-judge panel opined that Kentucky law does not currently recognize the tort of negligent credentialing, declined to recognize the tort, and stated that the Kentucky Supreme Court should decide whether to adopt the cause of action. A third judge dissented, arguing for the adoption of the tort. A few months later, a different Kentucky Court of Appeals panel (with one judge who also served on the Brown case) came to the opposite conclusion in another two-to-one decision, with two judges holding that Kentucky should recognize negligent credentialing in Spalding v. Spring View Hospital, LLC.2

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ISSUE#100 | 9

LEGAL

The Spalding decision is not final, but it may ultimately present the Kentucky Supreme Court with an opportunity to decide whether negligent credentialing is a viable claim under Kentucky law. Several policy-based arguments have been asserted in favor of the tort of negligent credentialing. An ability to seek damages for negligent credentialing is consistent with patient expectations that hospital care is given by qualified staff. Moreover, the potential liability on the part of hospitals could result in an increased sense of accountability for an effective privileging process. In Spalding, one judge connected the ability of patients to assert a claim based on hospital negligence to a shift in hospital ownership from non-profit to for-profit organizations and the notion that a business should be responsible for its own negligence. Further, in the context of Kentucky law, negligent credentialing is similar to and

arguably an extension of other causes of action that have already been recognized in this state, including negligent hiring, negligent supervision, and corporate negligence. Conversely, advocates against Kentucky’s adoption of the tort of negligent credentialing argue that it could have a negative impact on physician and credentialing committee recruitment, particularly in rural areas of the state. Other policy arguments against the tort include that recognition of the tort could add to the rising costs of healthcare, result in the improper admission of evidence regarding a doctor’s past performance issues in medical negligence cases, encroach on the jurisdiction of the Kentucky Board of Medical Licensure, create conflicts between physicians and hospitals in litigation, and impede the candor needed for an effective privileging process. Finally, opponents of the tort have argued that a patient injured through a physician’s negligent care can fully

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recover from the physician and does not need to seek compensation through an extra avenue of recovery. One issue faced by courts is that the parameters of the tort of negligent credentialing differ from jurisdiction to jurisdiction. Generally, a claimant asserting a negligence claim must prove that the defendant owed a claimant a duty, that the defendant breached the applicable standard of care, and that the defendant’s breach was a substantial factor in causing damage to the claimant. In adapting these principles to negligent credentialing claims, jurisdictions differ on several points, including whether the duty owed by the hospital includes evaluating the financial stability of a physician, and whether a plaintiff must prove medical negligence on the part of the physician in order to establish a negligent credentialing claim against the hospital. Courts also need to decide if expert testimony will be required to establish that a hospital’s credentialing fell below the applicable standard of care. Although recent Kentucky opinions on this topic have come to opposite conclusions, a common thread is a request for the Kentucky Supreme Court to decide whether to recognize the tort of negligent credentialing. Medical providers should be aware of the potential addition of another cause of action relating to healthcare. Hospitals wishing to take pre-emptive steps may review existing policies and procedures regarding the extension and renewal of physician privileges to determine whether any updates are merited and to confirm that those policies and procedures are put into practice throughout the credentialing process. Jamie Wilhite Dittert, Esq., is a healthcare and medical malpractice defense attorney with Sturgill, Turner, Barker & Moloney, PLLC. She can be reached at jdittert@sturgillturner. com, 859.255.8581, or via the website www. sturgillturner.com. This article does not constitute legal advice.

1 Brown v. Trover, 2012-CA-001880 (Ky. App. Jan. 8, 2016). 2 Spalding v. Spring View Hospital, LLC, 2013CA-000842 (Ky. App. March 11, 2016). ◆

ISSUE#100 | 11

SPECIAL SECTION  MATERNAL-FETAL MEDICINE

When High Risk is Normal Welcome to the world of Kristine Lain, MD, MS, director of Maternal-Fetal Medicine for KentuckyOne Health at Saint Joseph East in Lexington, KY BY ROBERT BAKER

A college basketball coach once said, “I don’t want a player who can make the easy look difficult, I want a player who can make the difficult look easy.” While bringing mother and baby successfully through a high-risk pregnancy is far more serious than a basketball game, the analogy is fitting for the work of Kristine Lain, MD, MS, director of Maternal-Fetal Medicine at KentuckyOne Health, Saint Joseph Hospital East. When asked to describe her work as succinctly as possible she says, “My goal is to make a high-risk pregnancy as normal as possible from the first confirmation of pregnancy through delivery of a healthy baby.” A simple statement, right? Not exactly. With Kentucky’s high incidence of obesity, smoking, diabetes, and hypertension, there can be treacherous times in pregnancies LEXINGTON

12 MD-UPDATE

PHOTO BY GIL DUNN

Kristine Lain, MD, MS, is the director of Maternal-Fetal Medicine at Saint Joseph Hospital East in Lexington, a part of KentuckyOne Health.

where the mother has one or more of these conditions, even times when the life of the mother or the fetus or both are in serious jeopardy. This is the medical world Lain lives in – to diagnose, treat, and comfort the woman, the fetus, and the family.

From Biomedical Engineering to Maternal-Fetal Medicine

Lain graduated from Southern Methodist University in Dallas Texas in electrical engineering with a focus on biomedical engineering. She attended medical school at the University of Chicago, followed by a residency in obstetrics and gynecology at

the University of Pittsburgh, where she spent a total of 11 years, including a threeyear fellowship in maternal-fetal medicine and four years on faculty at the Magee Women’s Hospital. Highlights of these years include the opportunity to work with James Roberts, MD, a renowned researcher in pre-eclampsia, one of the most frequent complications of pregnancy. Steve Caritis, MD, recruited Lain into clinical research and multi-center trials coordinated by the National Institute of Child Health and Development (NICHD) Maternal-Fetal Medicine Units Network, the largest cooperative of clinical research for high-risk pregnancy and fetal health. After her time on faculty at the University of Pittsburgh, Lain was attracted to the University of Kentucky Medical

Center (UK) because the systems were in place to support young physician-scientists. Plus, living in Lexington brought her family closer to their extended families. After five years on faculty at UK, she had the opportunity to work with a large maternal-fetal medicine group at Norton Healthcare in Louisville, which allowed her to expand her clinical expertise. At Norton, Lain used telemedicine to pursue her passion for providing care for maternal-fetal patients statewide from Paducah to Ashland. Telemedicine remains a very important part of Lain’s practice at KentuckyOne Health. While working in Louisville, Lain lived with her family in Lexington. She ended the daily commut-

cal indication. Ultrasound not only guides the procedures noted above, it is used to diagnose fetal conditions such as slow or arrested fetal growth, too much or too little amniotic fluid, ectopic or tubal pregnancy, unsuspected twins, triplets, or other multiples, and many more less-common conditions. Lain emphasizes that some of the behavioral issues contributing to a high-risk pregnancy, such as obesity and smoking, cannot be aggressively addressed in nine months of pregnancy. Lain counsels her patients regarding behaviors that are risk factors to their pregnancy, but she does not suggest that an overweight patient lose 60 pounds during the pregnancy. Behavior modifications can be tackled aggressively,

MY GOAL IS TO MAKE A HIGH-RISK PREGNANCY AS NORMAL AS POSSIBLE FROM THE FIRST CONFIRMATION OF PREGNANCY THROUGH DELIVERY OF A HEALTHY BABY. – DR. KRISTINE LAIN

ing in 2015 when an opportunity arose to practice maternal-fetal medicine at KentuckyOne Health in Lexington. Lain says she never envisioned a solo practice, but her experiences at UK and Norton prepared her very well for this role. Lain now has in place an experienced team of nurses, ultrasonographers, and counselors to support a robust practice at Saint Joseph East. With this team, she can diagnose and treat conditions early and refer appropriate patients to centers that implement the many innovative techniques for treating a fetus in utero, such as placental laser to treat twin-to-twin transfusion or endoscopic surgery on spine defects. Lain points out that these advances are the result of innovations in ultrasound over the last 30 years. Ultrasound is now one of the most widely used procedures in obstetric care for women with a medi-

but the emphasis is often on things that can be controlled, such as hypertension, blood sugars, and seizure disorders. Being part of a team or network is of utmost importance in providing comprehensive care. Lain has access to three neonatologists at Saint Joseph East, which has a level-two neonatal intensive care unit. Cardiac defects are the most common fetal conditions requiring transfer to a specialized center. Lain works closely with the surgeons and pediatric cardiologists at the neonatal cardiac center at the University of Louisville and Kosair Children’s Hospital. Other conditions that will not affect the timing of delivery but will require immediate surgical attention include gastroschisis and renal abnormalities. Lain determines the appropriate medical facility for each family to receive the best care. Sometimes that location will

be Saint Joseph East, and other times it is Louisville or Cincinnati. A common misconception of highrisk obstetrics and Lain’s practice is the “importance of prevention.” By this, she means identifying risk factors during one pregnancy that can be modified before the next pregnancy. A frequent example is high glucose or glucose intolerance during pregnancy in an overweight patient. Extreme weight loss during pregnancy is not realistic, but exercise and diet modification can result in weight loss before the next pregnancy so that glucose intolerance does not put that pregnancy in the highrisk category. This is a team approach involving a dietician and a primary care physician. With counselling, the patient will understand how obesity puts her and her baby at risk and will therefore have a strong motivator to lose weight. A similar case could involve smoking or non-prescription drug use. As a final reinforcement of her overarching concern Lain says, “I want to manage this high-risk situation in a way that makes the pregnancy and delivery as normal as possible for each family.” Bringing a child into the world is one of the great joys of parenthood. Lain wants to move the issues of high-risk care out of the way of that experience. ◆

KentuckyOne Health High Risk Obstetrics Associates Kristine Lain, MD 170 N. Eagle Creek Drive, Suite 110 Lexington, KY 40509 P 859.263.0141 F 859.263.8669 ISSUE#100 | 13

SPECIAL SECTION  MATERNAL-FETAL MEDICINE

Bringing Maternal-Fetal Medicine to the Forefront

Thomas Tabb, MD, offers pre-conception health awareness and fetal abnormalities prevention for the first time in Owensboro, Kentucky BY MELISSA ZOELLER Recognizing a need is half the battle, and when Thomas Tabb, MD, started traveling to Owensboro, Ky. once a week to practice maternal-fetal medicine, he knew there was much more he could offer. Born and raised in Louisville, Tabb received his B.A. in chemistry from the University of Louisville (U of L), completed his graduate degree at the University of Illinois and earned his medical school degree from the University of Kentucky (UK). His passion for maternal-fetal medicine began after completing his fellowship in the specialty at the University of Memphis. After stents in Ontario, Canada and at the University of Texas and UK, Tabb eventually migrated back to U of L to be the head of maternal-fetal medicine. His trips to Owensboro began in partnership with his work at Norton Hospital. He quickly recognized the need in the area and realized he could fulfill that need. “I liked the area, enjoyed the people, and saw a need there for my services,” states Tabb. “I was the only one offering maternal-fetal medicine in that area – it was a brand new service – so I knew it was the place I should be to make a much needed impact.” Tabb has been providing these much needed services in Owensboro since March 1 of this year, managing the care of infants to 27 weeks gestation with access to a level-three neonatal intensive care unit. His practice offers state-of-the-art ultrasounds that can identify certain abnormalities with the baby, which helps to make appropriate referrals if surgical care is needed after the infant is born. Monitoring of the health and welfare of the baby in-utero is also now available with the use of 3D imaging, fetal heart monitoring, and fetal Doppler studies, identifying risk for fetal death or fetal compromise. Tabb’s true passion though lies in pre-conceptual health awareness, OWENSBORO

14 MD-UPDATE

Dr. Thomas Tabb is a maternal-fetal medicine specialist practicing in Owensboro, Kentucky.

which has been his main focus. “I’m a big believer in pre-conceptual counseling so that women who have diabetes or hypertension are as well controlled as they can be prior to becoming pregnant,” states Tabb. “One area that is a problem here and across the nation is that diabetes patients are poorly controlled at the time of conception, which greatly increases the risk of birth defects. I can’t stress enough how much women, with any type of condition, really need to be seen prior to conception in order to understand how to control these issues before conceiving.” Managing these kind of complications during pregnancy is another facet of his practice. “Diabetics need to be well-monitored during pregnancy – the better you’re controlled, the better off your child will

“The risk of stillbirth, small babies, and abnormalities is higher, as well as diabetes. It becomes a bigger problem with the obesity issue, which is part and parcel the diabetes issue,” states Tabb. “Obesity is a major health problem, and diabetes tags right along. A lot of young women don’t go for healthcare until they are pregnant, and they might have significant uncontrolled diabetes by that time. Hospitals having healthcare screening fairs to check for diabetes and hypertension are so important, because these really are silent killers.” Tabb also notes that women who have significant cardiovascular complications during pregnancy are more prone to have cardiovascular issues later in life. “This is all kind of a continuum of a problem. If it starts when they’re 15 and continues to go

“I’M A BIG BELIEVER IN PRE-CONCEPTUAL COUNSELING SO THAT WOMEN WHO HAVE DIABETES OR HYPERTENSION ARE AS WELL CONTROLLED AS THEY CAN BE PRIOR TO BECOMING PREGNANT.” – DR. THOMAS TABB be all the way throughout adulthood. The gestational environment majorly influences a child’s health later in life with respect to cardiovascular disease. New medications and new technology, insulin pumps, and continuous glucose monitoring can all now be used in pregnancy and can make a difference. We don’t have the complications we once had and outcomes are very good,” says Tabb. Tabb has also seen the cascading effect of tobacco use within the state of Kentucky moreso than other areas of the country in which he’s practiced.

unchecked, at age 55 they will definitely have complications. Pregnancy is a good time to get people to regulate themselves. The majority of moms are willing to do whatever it takes to ensure the health of their baby,” he adds. Thankfully most fetal abnormalities Tabb’s practice sees are minor, and he’s happy to reassure parents that most are easily treatable and won’t impact the child’s long-term health. “I’m happy to provide parents with some type of calmness during their pregnancy, states Tabb. “Most abnormalities

do not require surgical procedures after the baby is born. It’s important to be able to interpret what we’re seeing and give the patient the information to hopefully put them somewhat at ease through the rest of their pregnancy.” Throughout his 30 years of practice, Tabb has seen the attitude towards medical complications change, shifting from a focus only on the beginning of the pregnancy to a more holistic view and a full continuum of care. “We’re now understanding that women who have significant problems during pregnancy will most certainly feel the impact of that later in life,” states Tabb. “We want to take care of our patients’ medical complications while they’re pregnant, and also arrange for them to follow up with a specialist post-partum. This idea of a continuum of care is hard to understand, but so important because it can change these patients’ outcomes for the rest of their lives.” Tabb is looking forward to growing his practice and continuing to establish fetal health awareness in the region, as well as offering comprehensive pre-conception diabetes programs and information to pediatricians and internal medicine physicians in the area. “We all want the same thing for mothers and babies – to see them healthy and happy. Preconception appointments cannot be stressed enough. Everyone needs to be seen before they decide to get pregnant,” adds Tabb. “The incidence of heart defects are extremely high in patients with diabetes if their illness goes unchecked. Rarely do we have a problem that we can actually fix, but if intervention happens early, neonatal complications drop significantly. We can work together to truly change the outcomes for the good, and I’m happy to be fighting for that in Owensboro.” ◆ ISSUE#100 | 15

SPECIAL SECTION  OB/GYN

It’s Only Natural

Women First of Louisville finds certified nurse midwife to be a natural addition BY JIM KELSEY Women First of Louisville has been providing obstetric and gynecological care since 1988. Their motto is “Women First … in all we do.” It was with that mindset that they added a new member to their family of physicians, nurse practitioners, and physician assistants – a certified nurse midwife. “Our practice likes to meet women where they are, to add convenience, to add diversity, to recognize that everyone has individual needs and desires,” says Kelli Miller, MD, FACOG. “We’ve had more women asking about all-natural kinds of experiences, meaning unmedicated deliveries and having options with their childbirth. For some reason, Louisville has been slow to have midwifery care, so it’s not new, but it’s new to Louisville.” In fact, when Emily duBois Hollander, APRN, CNM, joined Women First in November 2015, she became the first certified nurse midwife to practice at Baptist Health Louisville, where Women First exclusively delivers. DuBois Hollander grew up in Connecticut as part of a medical family. With a father who was a primary care physician and a mother who was a nurse, a medical career was only natural. But her journey started as a Peace Corps volunteer in 2009,

you’d be hard pressed to find a physician who would really feel differently. The kind of care that I provide fits really well into the practice philosophy here at Women First.” Common misconceptions often paint the picture that the differing approaches of midwives and physicians can be at odds or that midwives only practice home births. There are different types of midwives, but as a certified nurse midwife, duBois Hollander underwent rigorous training as a nurse and midwife and only delivers in the hospital setting. For Women First, the physician-midwife relationship has been quite complementary. “We work intimately and collabora-

LOUISVILLE

Kelli Miller, MD, FACOG, received her medical degree from the University of Louisville and has been with Women First since 2002. LEFT Emily duBois Hollander, APRN, CNM, spent three years in Rwanda with the Peace Corps before entering the nursing program at Vanderbilt University. ABOVE

OUR PATIENTS HAVE THE BEST OF BOTH WORLDS WITH MIDWIFERY CARE ALONG WITH KNOWING THEY HAVE A GROUP OF GREAT DOCTORS WORKING WITH HER AND BACKING HER UP IN A GREAT HOSPITAL SYSTEM. – DR. KELLI MILLER serving in Rwanda for over three years. When she returned, she went through the nursing program at Vanderbilt University with specialties in nurse midwifery and family practice. Upon graduating in 2015, she returned to Rwanda on a fellowship, working at a maternity hospital. While her path to Women First might 16 MD-UPDATE

not have been the conventional route, duBois Hollander is quick to point out that she and her colleagues have more in common than not. “I don’t think there’s too much of a difference between the way I practice and the way my colleagues practice,” she says. “I believe in the physiologic process of natural childbirth, and I think

tively with Emily, our midwife,” Miller says, noting that the model was patterned after that at Vanderbilt. “Our patients have the best of both worlds with midwifery care along with knowing they have a group of great doctors working with her and back-

ing her up in a great hospital system. We wanted a collaborative model rather than us-versus-them.” Miller explains that the crux of the difference between midwives and physicians comes from the mindset of each. Midwives view pregnancy and childbirth as a normal life event. While physicians acknowledge that they are trained to look for and treat the medical issues that arise. Midwives tend to focus more on patient advocacy, support, and how to naturally manage pain. “As physicians, we don’t focus exclusively on obstetrics,” Miller says. “We’re seeing gynecological patients, surgery patients, and we’re in the operating room. Our midwife can spend more time with the patients, and she’s able to provide a great deal of education on the front side, before the actual childbirth.” The staff at Women First includes 10 physicians, a dozen nurse practitioners and physician assistants, as well as a midwife. Even though the nurse midwife position

is relatively new at Women First, duBois Hollander says that she has been welcomed with open arms and has been quickly blended into the work environment. She sees patients both in the office setting as well as during delivery. She is part of the call rotation along with the physicians. “We can never guarantee who will be on call, so that’s why it’s nice for our patients to get to meet everyone at some point,” duBois Hollander says. “The wonderful thing about Women First is that it’s an incredibly collaborative practice. People who are seeking primarily midwifery care can see me as much as they need to. I don’t think people understand that I am an independent healthcare provider. I can write prescriptions and I work right within the team of all the practitioners here.” “Midwives are trained for the low risk, uncomplicated pregnant patient,” Miller adds. “They are well prepared to take care of that patient and do that delivery with a physician backup.”

She’s one reason Passport is the top-ranked Medicaid MCO in Kentucky.

Hollander also runs Women First’s postpartum support series. The free group is offered to moms for about 90 minutes every Monday with an obstetrician and duBois Hollander providing support and answering questions. Frequently, a guest speaker will provide information on such topics as infant milestones or postpartum depression. The postpartum program is another example of the physicians and nurse midwife working together to provide optimal care to the patients. “We have the opportunity to work with families in some of the most joyous and saddest moments,” duBois Hollander says. “That really is an honor.” That opportunity unifies the staff at Women First to use their respective skill sets for the well-being of the patients. “I love that we’ve been able to offer this to patients,” Miller says. “We see it as a cohesive model and relationship.” Naturally. ◆

We can give you 23,483* more. Passport Health Plan is the only providersponsored, community-based Medicaid plan operating within the commonwealth. So, it’s no coincidence that Passport has the highest NCQA (National Committee for Quality Assurance) ranking of any Medicaid MCO in Kentucky.

Our providers make the difference. *Passport’s growing network of providers now includes 3,720 primary care physicians, 14,014 specialists, 131 hospitals, and 5,619 other health care providers.

Ratings are compared to NCQA (National Committee for Quality Assurance) national averages and from information submitted by the health plans.

MARK-51677 | APP_11/16/2015

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5/2/16 2:59 PM ISSUE#100 | 17

SPECIAL SECTION  WOMEN’S HEART CARE

The Gender Gap

KentuckyOne Health Cardiac Surgeon Kendra Grubb, MD, discusses when and how gender matters in the treatment of cardiovascular disease BY JENNIFER S. NEWTON “What should I be doing about my heart?” It’s a simple question, but one Kendra Grubb, MD, MHA, director of Minimally Invasive Cardiac Surgery for the University of Louisville (U of L) and Jewish Hospital, part of KentuckyOne Health, says is pivotal in turning the tide against heart disease as the number one killer of women (and men) in the United States. Historically, heart disease has been mistakenly thought of as a disease of men. While the prevalence of cardiovascular disease may be higher in men, the American Heart Association (AHA) reports that, in 2013, women accounted for 49.7 percent of all deaths from cardiovascular disease.1 “As a nation, we have done a very good job of raising awareness of breast cancer. But the reality is all cancers combined are not going to take as many women’s lives in a year as heart disease does,” says Grubb. In 2013, one in 4.7 women in the US died of cancer, whereas one in 3.2 women died of cardiovascular disease.i As deadly as heart disease is, Grubb says 80 percent is preventable with behavior modification. “Part of the battle is just getting women to start the conversation with their doctors,” she says. Simply asking, “What should I be doing about my heart?” jumpstarts discussions about healthy lifestyle choices such as not smoking and getting the proper diet and exercise. The other part of the equation is the role primary care physicians play in monitoring heart health, particularly in Kentucky where risk factors are abundant. “We need to put the heart higher on our differential as physicians and not discount the possibility just because the patient is female,” says Grubb. Her advice to physicians is twofold: 1) Discuss heart health with every adult patient at every visit, and 2) Ask the right questions. “If you ask women if they’re having chest pains, they may say no,” says LOUISVILLE

18 MD-UPDATE

Kendra Grubb, MD, MHA, is director of Minimally Invasive Cardiac Surgery for the U of L and Jewish Hospital, part of KentuckyOne Health.

3 ANNUAL LOUISVILLE SYMPOSIUM ON HEART DISEASE IN WOMEN RD

Three years ago, Grubb began the Louisville Symposium on Heart Disease in Women to help educate practitioners on new guidelines and thinking in women’s heart disease. One of her goals has been to increase access to the technology and services available in Louisville and provide practitioners in smaller communities with resources and people they can contact when they have a challenging case or need modalities not available in smaller communities. This year the symposium will be held on June 25 at the Muhammad Ali Center in downtown Louisville. The theme will focus on innovative procedures, devices, and state-ofthe art care, many of which are research efforts coming out of U of L and Jewish Hospital in regards to stem cell therapy, transplantation, and device and medication advancements. The symposium is a CME accredited event for physicians and nurses, although the public is welcome to attend. For more information, visit louisvilleheartdiseasewomen.com. Grubb. “But they may notice when they get stressed or increase their activity, they have abdominal pain. That can be their heart, and it’s just presenting differently.” Women also have a tendency to respond to symptoms of heart failure by decreasing activity. So, a woman may say she does not get short of breath. But the better question is – are you able to do the same level of activity you were doing a year ago? And if not, why?

The Gender Difference

Heart disease does not discriminate based on gender. The disease process is the same in women and men and diagnosis is essentially

HEART DISEASE DOES NOT DISCRIMINATE BASED ON GENDER. THE DISEASE PROCESS IS THE SAME IN WOMEN AND MEN AND DIAGNOSIS IS ESSENTIALLY THE SAME, ONCE THE HEART IS IDENTIFIED AS A POTENTIAL PROBLEM. the same, once the heart is identified as a potential problem. The difference is in the presentation of symptoms and the response to treatment. Men often suffer from classic, crushing chest pain, what Grubb refers to as the “Hollywood heart attack,” while women’s symptoms may present more subtly. It’s those subtle symptoms that physicians may attribute to some other cause, leading to a delayed diagnosis. Data has long shown that women’s outcomes for cardiovascular procedures, including stents and open heart surgery, are worse than those of men. “We don’t necessarily understand why women do not respond to treatment as well as men do. Some of it stems from early research,” says Grubb. In early high blood pressure studies for example, the participants were almost exclusively male, yet those results were extrapolated to the entire population. Additionally, Grubb believes outcomes in women have been lower because, historically, women have been diagnosed and treated later in the disease process than men. The tide is slowing changing. Of promise are improved treatment responses and outcomes for women with new minimally invasive cardiac procedures. “In some cases, like that of the transcatheter aortic valve replacement (TAVR), one of the procedures I do at Jewish Hospital with the team, women actually do much better compared to their male counterparts and certainly do much better than high risk patients when compared to open surgery,” says Grubb. She attributes this in part to better representation of the entire population in clinical trials for these newer modalities and to better timing, as women are beginning to be diagnosed, treated, and followed in a timelier manner. The TAVR program at Jewish Hospital continues to grow. Physicians there have performed over 300 such procedures and

now perform TAVR with the patient completely awake, so they go home the next day. Indications for TAVR are expanding to not only very high risk and inoperable patients, but also intermediate risk patients as part of a registry, and Jewish Hospital has recently begun enrolling low-risk patients in a TAVR trial. While open heart aortic valve surgery is still the most proven, durable treatment for younger patients (65 and under), Grubb has begun recommending transcatheter approaches to patients 80 and up because her results have shown better outcomes and quicker recoveries in this population, particularly for women. The truth is gender does matter when it comes to heart disease. While physicians need to be equally as active in monitoring the symptoms and heart health of male and female patients, all symptoms and treatments are not created equal. Thankfully new technologies with better outcomes for women and educational efforts to increase awareness of gender differences can enable physicians to tailor treatments in the best interests of each patient, and, hopefully, one day close the heart health gender gap. 1 Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, Das SR, de Ferranti S, Després J-P, Fullerton HJ, Howard VJ, Huffman MD, Isasi CR, Jiménez MC, Judd SE, Kissela BM, Lichtman JH, Lisabeth LD, Liu S, Mackey RH, Magid DJ, McGuire DK, Mohler ER III, Moy CS, Muntner P, Mussolino ME, Nasir K, Neumar RW, Nichol G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez CJ, Rosamond W, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Woo D, Yeh RW, Turner MB; on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics 2016 update: a report from the American Heart Association. Circulation. 2016; 133 (4):e38-e360. ◆ ISSUE#100 | 19

SPECIAL SECTION  WOMEN’S IMAGING

3D Times Three

Less than a year after introducing 3D mammography, Floyd Memorial has already expanded its use BY JIM KELSEY When used in relation to cancer, words like “spreading,” “expanding,” and “aggressive” are generally negative. There are exceptions, however. One such case is the recent announcement by Floyd Memorial Hospital and Health Services that it has expanded its 3D mammography screening capabilities to its Diagnostic Imaging Center in Corydon, Ind., located about 30 minutes from Floyd Memorial Hospital. What makes this expansion somewhat aggressive is that Floyd Memorial just began offering 3D mammography in August of 2015. But Sarah Leis, RT(R), (M), RDMS, RVT, radiology manager at Floyd Memorial, says the success of the 3D unit in New Albany made the decision to expand to Corydon much easier. “We saw the benefits of what we were getting from the 3D mammography at the hospital and the service we were able to provide to the women in the local New Albany area,” Leis says. “We wanted to be able to offer that service to the women in Corydon and the surrounding counties. We were excited to be able to expand that service so they don’t have to drive to the hospital.” Diagnostic Radiology and Breast

screenings. The result is greater efficiency and less down time. In addition to the decrease in recalls and increase in cancer detection rates, the 3D units have proven their worth in the actual number of patients served. The 3D mammogram is covered in full by traditional Medicare and has a $60 additional fee for other patients. While the hope is that insurance companies will soon cover the 3D mammograms in full, nearly 60 percent of the women coming in for screen-

Sarah Leis, radiology manager at Floyd Memorial, has over 15 years of radiology experience. LEFT Diagnostic Radiology and Breast Imaging Specialist Laura Barkley, MD, a Louisville native, joined the team at Floyd Memorial in September 2015. ABOVE

NOW THAT MORE COMPANIES ARE PRODUCING THE MACHINES AND ONCE COMMERCIAL INSURANCE CARRIERS GET ON BOARD TO PICK UP THE COST, IT’S JUST GOING TO BE THE STANDARD OF CARE. – SARAH LEIS, RADIOLOGY MANAGER AT FLOYD MEMORIAL Imaging Specialist Laura Barkley, MD, who joined the team at Floyd Memorial in September 2015, says that 3D mammography decreases recall rates due to a greater ability to discern whether or not abnormalities are just a place where the breast tissue is overlapping in a different way. The 3D images also increase cancer detection rates. “When we go through each thin section of the 3D images, we’re able to find signs of cancer such as distortion or pulling in the breast that we would have missed on a regular mammogram,” Barkley says. 20 MD-UPDATE

The value of 3D mammography to both the patients and the medical staff has been so readily apparent, that a second 3D unit has already been added at the hospital. Shortly after acquiring their first 3D mammography unit, Floyd Memorial added 3D breast biopsy capability with the Affirm biopsy guidance system. In the past, a biopsy would tie up the room and the 3D equipment for an extended period of time. Now, with two 3D units, one unit can be used for biopsy, while the other can continue to be used for the standard outpatient

ing are already opting for 3D over 2D. Leis also reports that patient volume has grown from 10 to 15 percent since the addition of the 3D units. The increase in patient volume, patient adoption of the technology, and greater service to the patients generated the needed support for the expansion to Corydon. “I’ve been so excited that Floyd Memorial’s been willing to support the technology and understands that this is what’s best for the patient,” Leis says. “Now that more companies are producing the machines and once commercial insurance

carriers get on board to pick up the cost, it’s just going to be the standard of care. So it’s nice to know we are able to embrace the innovation and change and keep Floyd Memorial on the forefront of patient care.” As soon as a few final pieces of equipment are in place, the staff at Corydon will be able to perform both screenings and diagnostics. Breast MRI and biopsies will still be referred to the hospital. Leis says the Affirm breast biopsy system has helped make the biopsy experience much more pleasant for the patient as well. “The biggest change I’ve seen for the patients is going from the prone stereotactic unit to the Affirm,” Leis says. “With the stereotactic unit, the patients lay on their stomach, the breasts went through the table, and we worked from underneath the table.

The Affirm is upright, making it much more comfortable with a quicker procedure time.” Barkley adds that the biopsy is easier and more accurate for the radiologists using the 3D technology and upright positioning of the patient. “We are able to scroll through while the patient is positioned for the biopsy,” Barkley says. “We are able to target and find the exact location. The images are much clearer and it’s easier for us to see than if we were trying to do it on the regular stereotactic machine. It’s much easier to pinpoint the abnormality and target with the extra information that we get from the 3D images.” Barkley says she also expects an increase in the use of breast MRI. A well-established screening tool for women considered to be at high risk for breast cancer, breast MRI joins

3D mammography as state-of-the-art tools to aid in early detection of breast cancer. Floyd Memorial has demonstrated a commitment to embracing the latest technology and providing optimal care to their patients. They are in the process of renewing their accreditation as an American College of Radiology Breast Center of Excellence, which is based on four elements: breast MRI, stereotactic biopsy, breast ultrasound, and mammography. Leis says having a unified vision of the standard of care has made it all possible. “I’m really grateful for the support of Floyd Memorial and the Foundation for the 3D biopsy system,” she says. “It’s been great for the patients and for the hospital to offer this technology at both locations.” It’s aggressive. And it works. ◆

From health care transactions and compliance to litigation defense, Sturgill Turner’s health care team is committed to providing comprehensive legal services to health care providers, hospitals and managed care organizations.

Find us in Lexington and at STURGILLTURNER.LAW

ISSUE#100 | 21

COMPLEMENTARY CARE

The Role of the Genetic Counselor

As genetic mutations are increasingly identified and linked to cancer, genetic testing and counseling becomes more important than ever BY ROBERT BAKER If the first image that comes to mind when you hear the term genetic counselor is a person who studies and counsels the family of a newborn with an unexpected abnormality, you have missed a lot in the past few years. The revolutionary impact of molecular genetics and the ability to study the human genome in detail has vastly broadened the scope of the genetic counselor. Many forms of cancer have now been linked to specific mutations in the genetic code. Testing and counseling patients and relatives with these kinds of cancer is the focus of the work done by Liz Reilly, MS, genetic counselor at KentuckyOne Health in Lexington. Reilly grew up in Berea and followed in an older sister’s foot-steps to attend Xavier University in Cincinnati where she obtained a B.S. in Biology. She then obtained a Master of Science degree in Genetic Counseling from the University of Cincinnati. Both proximity to family and the wide spread presence of KentuckyOne Health in Eastern Kentucky drew her to her present job as a genetic counselor in the Cancer Care department in Lexington. Most people are familiar with the genetic form of breast cancer caused by mutations in the BRCA1 or BRCA2 genes because some celebrities have opted for a pre-emptive double mastectomy when it is discovered that they carry a mutated gene. This is the form of counseling Reilly does. Clearly, choosing a double mastectomy with no evidence of breast cancer is a major decision for anyone. Reilly’s job is to map-out a family tree, assess environmental exposures, order and review genetic testing to give the patient an accurate prediction of their chances of developing the cancer and also explain the sorts of early detection and treatment available should the patient opt for a wait and see approach. With the BRCA mutations the numbers are quite striking. Breast cancer occurs in about 12 percent of women in the general population over a lifetime, whereas about 60 LEXINGTON

22 MD-UPDATE

PHOTO BY GIL DUNN

Liz Reilly, MS, is a genetic counselor at KentuckyOne Health Cancer Care in Lexington.

percent of women with a BRCA1 mutation will develop breast cancer. Less publicized is the increase in ovarian cancer in carriers of these mutations. In the general population, 1.3 percent will develop ovarian cancer. Nearly 40 percent of those with a BRCA1 mutation will develop ovarian cancer. Reilly is quick to point out that these kinds of population-based studies do not tell the whole story of risk. “Each woman’s risk is different and will be affected by family history of cancer, reproductive history, and the woman’s age at the time of consultation, to name a few,” she says. As important as risk assessment and discussion of treatment options is today, the future will very likely bring molecular and immune modifying therapy that can be individualized for maximum efficacy in treating each type of cancer in each particular patient. The BRCA mutations are only one example

of genetic predisposition to cancer. There are now known genetic mutations for certain types of cancer in almost every organ of the body. Many mutations are linked to more than one type of cancer, and some cancers are linked to several different mutations. Most prominent, but not exclusive, cancers in Reilly’s practice are breast, colorectal, and female reproductive tract. With ever increasing healthcare costs, the question must be asked, is genetic testing of healthy people a good idea financially? To this Reilly gives an emphatic yes. “Preventive and proactive care has been shown to decrease healthcare costs because these patients are not sick and do not need the most expensive kind of healthcare, such as costly cancer drugs, radiation, and prolonged stay in intensive care units, as they would if they were diagnosed after symptomatic tumors had grown,” she says. As an example of proactive care, Reilly points to people with a high risk of colon cancer. Normally colonoscopy is recommended every five to 10 years, but in a high risk patient, the procedure could be done every year to detect tumors early and possibly remove a pre-cancerous polyp. Patients with a high risk of breast cancer can choose to have breast MRI in addition to mammography. Although uterine and ovarian cancer are not screened for in the general population, women at high risk for these cancers can have yearly screening performed or even consider total hysterectomy. Reilly maintains close relationships with oncologists, OB/GYN physicians and with colonoscopy centers. Part of this relationship is education of the primary care providers. Referral on the basis of an abnormal

finding on physical examination is well understood, but Reilly urges doctors to send patients with a normal physical examination if there is a red flag in the family history such as different cancers in the same person, cancer diagnosed under age 50, or a combination of breast, ovarian, uterine or colorectal cancer in a single family. Of course, it is important that physicians question family history for both sides of the patient’s family. In the general population and even among some healthcare professionals, there are some misconceptions about genetic testing and counseling. Some people believe that genetic counseling is a service that only the wealthy or high middle class can afford. The reality is that genetic counseling and testing is available to everyone with a medically legitimate issue, and there are resources to help the uninsured or under-insured. Reilly repeats the mantra, “Cancer has no idea how

much money a person makes or how nice they are. Cancer does not discriminate.” Another fear based on misperception is that if a person gets genetic testing because of family history or as a participant in a research study and a mutation is discovered, they will be unable to get health insurance or even employment. In fact, there is a federal law that has been effective since 2009 that specifically prohibits discrimination by health insurance companies and employers based on “genetic information.” This law is called the Genetic Information Nondiscrimination Act, usually referred to as GINA. It should be noted that GINA does not apply to life insurance and long term disability insurance. These are policies that patients may want to get in place before having genetic testing. As a final message, Reilly reiterates the goal of genetic counseling at KentuckyOne

Health is to identify people at risk before they develop cancer, so they can undertake preventative measures or detect cancers early and be treated proactively when the growth is very small or pre-cancerous. ◆

Liz Reilly, MS 3470 Blazer Parkway, Suite 150 Lexington, KY 40509 P 859.629.7110 F 859.543.1989

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ISSUE#100 | 23

COMPLEMENTARY CARE

A Champion for Pelvic Dysfunction

Dunn Physical Therapy specializes in unique, often life-changing, therapies to improve pelvic health in women, men, and children BY JENNIFER S. NEWTON Sixteen years ago, Susan Dunn, PT, launched her private physical therapy practice and began treating a subset of patients that often go unnoticed and undertreated – those with pelvic dysfunction. Perhaps because conditions such as constipation, incontinence, and painful intercourse are often spoken of in whispers rather than in broad forums and public awareness campaigns, the treatments for these conditions are also lesser known. Dunn did not set out to specialize in pelvic dysfunction in physical therapy school. In fact, it’s not something that is part of any regular PT curriculum, but her work with female athletes soon shed light on a host of pelvic floor issues she was illprepared to treat. She sought out a fellowship in pelvic dysfunction, and it changed the course of her career. Dunn and her fellow therapists have become advocates and champions for these services that can make a tremendous difference in a person’s quality of life. “Every single therapist within the practice will say at least three or four times a week they have a patient say, ‘I didn’t know these services existed.’” Those services include therapy for a variety of pelvic dysfunction, such as pelvic pain, painful penetration, urinary incontinence, fecal incontinence, constipation, and prenatal and postpartum issues, issues that are vastly more common than people realize. “Constipation is epidemic,” says Dunn. “In the United States, we have the worst statistics for constipation and subsequent hemorrhoids, fissures, and prolapse,” says Dunn. Similarly, chronic pelvic pain affects an estimated one in seven women.1 Women make up the largest percentage of the practice’s overall pelvic patient population, but they also treat men and children. The practice also treats general orthopedic rehab needs in addition to pelvic issues. LOUISVILLE

Life-Changing Treatments

Dunn’s practice model has always includ24 MD-UPDATE

PHOTO BY GIL DUNN

It is extremely comfortable, and it’s not as awkward as you would think,” says Dunn. The clinicians are also trained in the practice of ultrasound imaging, which is used to visualize pelvic floor and abdominal wall musculature to help teach patients how to recruit those muscles. “If I’m asking for a particular type of recruitment from the deepest level of their abdominal wall or from the pelvic floor, it’s so hard for these people to proprioceptively get and feel it. To use live ultrasound imaging and be able to point that out on screen so they can see what they’re doing is huge,” she says. Although women may be top of mind when we think of pelvic floor issues, Dunn says children and men are an important part of their population. “We have a program that’s 100 percent dedicated to pediatric pelvic issues,” says Dunn, which can include bedwetting, giggle incontinence, fecal incontinence, constipation, and pediatric pelvic pain. “It’s life-changing for these kids because you have a seven-year-old who wants to do sleepovers, and they can’t because of the symptoms that they’re having,” she adds. Rounding out the practice, Dunn contends they also have the highest concentration of therapists treating male pelvic function in the Louisville area. Male patients include those with prostate issues but also young athletes with pelvic pain or pudendal neuralgia.

Susan Dunn, PT, is the owner of Dunn Physical Therapy with two Louisville locations specializing in pelvic dysfunction not only for women, but also for men and children.

ed individualized, private treatment, in part because of the sensitive nature of her patients’ problems. “Everything is oneon-one with our patients, but that’s not the norm for outpatient rehab unfortunately,” she says. Her passion for serving this population has driven her to keep pace with the latest technology and treatment solutions. She describes her practice as “fully equipped,” including biofeedback, anal manometry balloon training, and live ultrasound imaging. Biofeedback is a form of surface electromyography and pressure perineometry used to assess and strengthen pelvic floor muscles. Anal manometry balloon training was added to the practice a year ago, after one of Dunn’s therapists completed special training at Marquette University. The technique uses a balloon catheter inserted anally to simulate pressure and analyze muscle performance. For those who have bowel dysfunction, it teaches them how to feel when the bowels are full and how to use the muscles to expel. “Amazingly, it is extremely modest.

Growing Her Niche

In the past two years, the practice has grown from six therapists to 10. It currently includes two locations, although their office on Dutchmans Lane will soon move next door to gain 600 square feet for more private treatment rooms. Dunn hopes to add a third location in the next 12 to 18 months

that better serves Southern Indiana and Louisville’s South End. While the need is great, Dunn’s approach to growth is calculated. She refuses to compromise her guiding principle of one-onone care, even when her waiting list begins to grow. But finding qualified practitioners to accommodate increasing volume can be difficult. Therapists must seek out specialized training in pelvic dysfunction, and that takes time. So, Dunn’s hiring process is very selective. “Every PT in the practice specializes; none of us are general practitioners,” she says. Out of 10 therapists, one is dedicated full-time to pediatrics, two are dedicated to lymphedema care, and the remaining seven see adult pelvic dysfunction patients plus a specialized area of orthopedic rehab patients. For instance, Dunn is a pelvic and spine therapist.

Dunn may be a private practice owner, but she is quick to note how important it is to collaborate with referring providers. “Ninety-nine percent of the time this is a team approach. We are always working with other healthcare providers, our care complementing what they’re doing. What they bring to the table is different than what I bring to the table, and most of these patients need a team approach,” she says. It is that carefully cultivated team and their passion for treating a specialized, underserved niche that continues to propel the practice forward successfully. “I’m really so proud of what we have here. I’m 16 years into being a private practice owner, and it’s like raising a child … My name is on the practice, but I’m often giving credit to the crew that surrounds me because they are amazing,” concludes Dunn. ◆

1 Mathias SD, Kuppermann M, Liberman RF, et al. Chronic pelvic pain: Prevalence, health-related quality of life, and economic correlates. Obstet Gynecol. 1996

FOR PATIENT REFERRAL

ST. MATTHEWS OFFICE 4042 Dutchmans Lane Louisville, Kentucky 40207 P 502-899-9363 • F 502-899-9365 SPRINGHURST PROFESSIONAL PLAZA 10321 Champion Farms Drive Louisville, Kentucky 40241 P 502-425-1716 • F 502-425-2258 http://www.dunnptky.com

ISSUE#100 | 25

COMPLEMENTARY CARE

Are Women Really Better at Intimate Relationships? It was with equal amounts of anticipation and dread that I read the R. Chase article “What Men Want” in an old back issue of the Voice-Tribune. I laughed out loud when I read the following exchange between the author and a male friend: “I once had a conversation with a friend of mine about women. We were talking about a girl that, while extremely attractive, was a little vapid. Me: ‘She’s pretty hot, but I want a girl I can talk to.’ Him (with incredulity): ‘Why?’” That’s a lot funnier way of putting it than marriage researcher John Gottman’s description of the classic marital impasse as “a wife seeking emotional connection from a withdrawn husband.” From both my professional and per-

your feelings to someone? Most of the time, we’re doing everything we possibly can to not feel vulnerable — and with good reason. It’s all about BY Jan Anderson, PsyD, LPCC making sure we survive, not just physically, but also emotionally. Although it takes us longer than any other species to mature to adulthood, we humans, even as infants, are intelligent and adaptive when comes to figuring out how to “belong,” first in our family of origin and then into the larger social setting around us.

HOSPICE WORKER BRONNIE WARE AGREES. IN HER BOOK TOP FIVE REGRETS OF THE DYING, WARE NOTED THAT ONE OF THE COMMON REGRETS THAT SURFACED AGAIN AND AGAIN WAS, “I WISH I’D HAD THE COURAGE TO EXPRESS MY FEELINGS.”

sonal observations, I’d say that emotional intimacy isn’t any easier for women than it is for men. I don’t think intimacy is easy for anyone. Here’s why:

Intimacy Requires Vulnerability

How many people do you know who relish the opportunity to make themselves emotionally vulnerable with another person? Do you feel safe and enjoy yourself when you take an emotional risk by expressing

Whether it’s by becoming smart or tough, selfish or self-sacrificing, straightforward or manipulative — whatever it takes — as children we adjust to make a place for ourselves and keep things safe enough that we make it to adulthood. In the process, we grow the necessary “skin” to protect our profound emotional openness and sensitivity. Somewhere along the way, we encounter one of life’s biggest conundrums — it’s impossible for us to have intimate relation-

ships without our vulnerability being part of the equation. In other words, we have to put ourselves at some emotional risk to reap the incomparable reward of emotional intimacy with another person.

Over-Empathy Looks Like Intimacy … But It’s Not

Emotional intimacy isn’t a luxury, add-on, or optional item for a happy life, according to Robert Cummins, a pioneer researcher of subjective wellbeing (aka “happiness”). Cummins’ study identified intimate social relationships as the strongest predictor of life satisfaction — more than material wellbeing, health, or leisure satisfaction. Trying to ignore our need for emotional connection or fill it up with poor (oftentimes addictive) substitutes tends to have a short shelf-life. Hospice worker Bronnie Ware agrees. In her book Top Five Regrets of the Dying, Ware noted that one of the common regrets that surfaced again and again was, “I wish I’d had the courage to express my feelings.” When men acknowledge that they’re not good at intimate relationships, at least they’re upfront and honest about it. What concerns me about women is that we tend to do our “non-intimacy” in a way that looks like we’re loving and intimate. Even more problematic, we genuinely think we’re being intimate. Let me explain. Intimacy isn’t just about being interested in, attuned to, and emotionally “present” with someone else. Intimacy also requires an ability to confide your needs and air your dissatisfactions without fear of losing your partner’s affection. According to Robin Stern, PhD, associate director of the Yale Center for Emotional Intelligence, “Many women are brought up

CHART 1

26 MD-UPDATE

“NO-NO” BEHAVIOR Selfish

HOMEOPATHIC DOSE OF “NO-NO” BEHAVIOR Self-Respect, Self-Responsibility, Self-Reliance, Personal Boundaries

Pushy, Bossy

Persuasive, Challenging, A Leader

Arrogant

Confidence, Self-Esteem, Believing in Yourself

Vain

Self-Care, Well-Groomed, Lives a Healthy Lifestyle, In Good Shape

to believe that empathy, in and of itself, is always appropriate, and it becomes the default mode of responding to others. The high regard in which empathic people are held obscures the fact that they may be neglecting their own feelings.” Over-empathy, codependency, caregiver syndrome, helicopter parenting, all tend to look loving, kind and intimate… but there’re really not.

The Antidote to Over-Empathy

I find that plenty of women “get” it about over-empathy — and the need to dial it back — on an intellectual level, but it doesn’t help them much. Something more than awareness is needed to translate being able to talk about it into being able to do it. The fastest and most effective “something more” I’ve discovered is creating an in-session experience for clients so they get an in-the-moment sense of what it looks like, sounds like, and, most importantly, what it feels like — both physically and emotionally — to try on behavior that may at first seem unfamiliar, awkward, or even unthinkable. The other essential ingredient to lasting behavior change is taking on what I call “homeopathic doses” of the “no-no” behavior, until it starts to feel easy and natural and can be channeled in just the right amount to be effective without being counterproductive. Some examples of what the attitudinal transition looks like are in Chart 1 on page 26.

INTIMACY ISN’T JUST ABOUT BEING INTERESTED IN, ATTUNED TO, AND EMOTIONALLY “PRESENT” WITH SOMEONE ELSE. INTIMACY ALSO REQUIRES AN ABILITY TO CONFIDE YOUR NEEDS AND AIR YOUR DISSATISFACTIONS WITHOUT FEAR OF LOSING YOUR PARTNER’S AFFECTION.

Relationship and Life Strategy Expert Individual & Couples Counseling Relationship & Life Strategy Coaching Mindfulness-Based Cognitive Therapy

complimentary preliminary Consultation 502.426.1616 DrJanAnderson.com Jan Anderson, PsyD, LPCC

SOMETHING TO CELEBRATE Scott Neal is pleased to have been a contributing writer to every single issue of MD Update. CONGRATULATIONS GIL AND STAFF for reaching this publishing milestone, and thanks to MD Update’s editors and readers for finding continuing value in our observations and comments. HERE’S TO THE NEXT 100 ISSUES, AND THE HUNDREDS MORE TO FOLLOW.

The Pay-Off

The most unanticipated, paradoxical, and flat-out exhilarating effect of dialing back over-empathy and integrating some of these traditionally taboo behaviors for women? When you develop some personal boundaries in the form of basic self-respect and selfesteem, you are actually are able to make a better emotional connection with others. Who would have thought? ◆

Thinking clearly. Caring deeply.

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ISSUE#100 | 27

NEWS  EVENTS  ARTS

World-Renowned Hand Surgeon Dr. Joseph Kutz Retires

Joseph E. Kutz, MD, cofounder of the Kleinert Kutz Hand Care Center and w o r l d - re n ow n e d hand surgeon, is retiring at the age of 87. Kutz’s achievements in the medical field have impacted the future of hand surgery, microsurgery, and reconstructive surgery around the world. Patients worldwide, including the king of a middle eastern country, have received hand care from Kutz. Kutz began working with Dr. Harold Kleinert in 1963. The Kleinert Kutz Hand Care Center was later established and remains one of the largest hand care referral centers in the world. At the center, Kutz and his team have developed breakthrough procedures for the repair of digital arteries and flexor tendons, as well as hand, forearm, and upper arm transplantation techniques. More than 1,400 physicians from nearly 60 countries have served as fellows in the center’s accredited fellowship program. The renowned hand surgeon is part of, and at times has led, the Louisville Vascularized Composite Allograft (VCA) program, otherwise known as the hand transplant program, a partnership of physicians, researchers, and healthcare providers from Jewish Hospital, part of KentuckyOne Health; the Christine M. Kleinert Institute for Hand and Microsurgery; the Kleinert Kutz Hand Care Center; and the University of Louisville. The VCA program is the nation’s oldest hand reconstructive transplantation program. Kutz is a past director of the Christine M. Kleinert Fellowship in Hand Surgery, the teaching arm of Kleinert Kutz. He graduated from the University of Michigan Medical School in 1958 and received his postgraduate training at the University of Louisville. Kutz is a Clinical Professor LOUISVILLE

28 MD-UPDATE

SEND YOUR NEWS ITEMS TO MD-UPDATE > news@md-update.com

of Surgery at the University of Louisville School of Medicine. In honor of Kutz’s career and achievements in the medical field, Mayor Greg Fischer proclaimed April 27, 2016 as “Dr. Joseph Kutz Day” in Louisville.

Woods Elected Chair of an AAP Committee

Charles R. Woods Jr., MD, has been elected the incoming chair of the Executive Committee of the American Academy of Pediatrics’ (AAP) Section on Epidemiology, Public Health and Evidence (SOEPHE). His one-year term begins Nov. 1. The SOEPHE supports development of high quality practice guidelines for children’s healthcare and fosters informed use of data to improve the health of children. It is composed of AAP members who practice or have interests in the fields of public health and epidemiology. Woods is board certified in pediatrics and pediatric infectious diseases. He is associate chair of the U of L Department of Pediatrics and director of the department’s Child & Adolescent Health Research Design & Support Unit. He has been at U of L since 2006. He earned his bachelor’s degree from Samford University and his medical degree from Baylor College of Medicine. He completed a pediatric residency followed by a pediatric infectious diseases fellowship at Texas Children’s Hospital. He later earned a master’s degree in epidemiology from Wake Forest University. Woods practices with University of Louisville Physicians-Pediatric Infectious Diseases. LOUISVILLE

Brown Wins Cardiology Award

It stands to reason: If you want to educate large numbers of people, go where large numbers of people go. In Dr. Lorrel E. Brown’s case, that place LOUISVILLE

was the Kentucky State Fair – and the nation’s premier cardiology association has presented her an award for her innovative thinking. Brown, assistant professor of medicine in U of L’s Division of Cardiovascular Medicine, won first place in the category of “Young Investigator Awards in Cardiovascular Health Outcomes and Population Genetics” from the American College of Cardiology earlier this month. The award was presented at the organization’s 65th Annual Scientific Session in Chicago. It also was published in the April 5 issue of the Journal of the American College of Cardiology. Brown headed a group of researchers that included Dr. Glenn Hirsch, associate professor of medicine, cardiology fellows Dr. Wendy Bottinor and Dr. Avnish Tripathi, medical student Travis Carroll, Dr. Bill Dillon, who founded the organization Start the Heart Foundation, and Chris Lokits of Louisville Metro Emergency Medical Services, Office of Medical Direction and Oversight. They tackled the problem of surviving cardiac arrest – the sudden stopping of the heart – by increasing the number of people trained in hands-only cardiopulmonary resuscitation (CPR). Titled “CPR at the State Fair: A 10-minute Training Session is Effective in Teaching Bystander CPR to Members of At-risk Communities,” the research effort brought CPR training to the Kentucky State Fair’s Health Pavilion in August 2015.

Steltenkamp Honored as One of the Most Powerful Women in Healthcare IT

Health Data Management, the information resource for medical and information technology (IT) professionals, executives, and administrators, honored 75 of the Most Powerful Women in Healthcare IT, including Dr. Carol Steltenkamp, professor of pediatrics at the University of Kentucky College of LEXINGTON

NEWS

Medicine and chief medical information officer (CMIO) at UK HealthCare, at the Most Powerful Women in Healthcare IT conference on May 12 in Boston. Steltenkamp is chair of the Kentucky eHealth Board, which successfully launched and maintains the Kentucky Health Information Exchange (KHIE). She also is the principal investigator for more than $10 million in healthcare information technology (HIT) grant funding including the foundational grant establishing the Kentucky Regional Extension Center from the U.S. Department of Health & Human Services’ Office of the National Coordinator for Health Information Technology (HHS/ONC). As the first CMIO at UK HealthCare, Steltenkamp selected and ultimately led implementation of an electronic health record system across the clinical enterprise. She then became a leader for HIT in Kentucky and was named chair of the Kentucky eHealth Board, which successfully launched and maintains the Kentucky Health Information Exchange (KHIE). She also is the principal investigator for more than $10 million in healthcare information technology (HIT) grant funding including the foundational grant establishing the Kentucky Regional Extension Center from the U.S. Department of Health & Human Services’ Office of the National Coordinator for Health Information Technology (HHS/ONC).Steltenkamp also has been an active volunteer member of the Health information Management Systems Society (HIMSS) for many years.

Ephraim McDowell Board Chair Honored by KHA

The Kentucky Hospital Association (KHA) presented several awards during the Association’s Awards Luncheon on May 13, at the 87th Annual KHA Convention in Lexington. KHA’s Health Care Governance Leadership Award, which recognizes individuals who have had a positive and sustainDANVILLE

L–R Dale

Kihlman, Ephraim McDowell board chair, and Kevin Halter, KHA board chair.

able impact on the quality of care in their community, was presented to Dale Kihlman, board chair of the Ephraim McDowell Health Board of Directors in Danville. After serving our country in the U.S. Air Force, earning his bachelor of science in business from the University of Minnesota, and working for Tonka Toys, Kihlman relocated to Stanford, Ky. in 1978 to work for Ceramichrome, a Tonka Toys affiliate. He has more than 20 years of service as a member of various boards, and over 35 years of dedicated service and involvement with civic organizations and local agencies in the Danville and Stanford communities. Kihlman has served the Ephraim McDowell Health System since 1994, when he began serving as a member of the Ephraim McDowell Health Care Foundation Board of Directors, as well as the Central Kentucky Cancer Advisory Board. He served as chair of the Foundation Board from 2009 to 2013 and he has served as chair of the Ephraim McDowell Health Board of Directors since 2014.

JGBCC Enrolling Patients in Recurrent Glioblastoma Trial

For patients with recurrent glioblastoma (GBM), existing chemotherapies have offered limited survival benefit, and new therapies are clearly needed. Eric Burton, MD, is conducting a clinical LOUISVILLE

trial with a new therapy at the University of Louisville’s James Graham Brown Cancer Center that may provide improved results for these patients. Burton, assistant professor in U of L’s Department of Neurology and director of neuro-oncology at JGBCC, is seeking participants for a clinical trial at the James Graham Brown Cancer Center, a part of KentuckyOne Health, to test a new treatment for recurrent GBM that attempts to halt tumor growth by reducing the blood supply to the tumor. Participants will be accepted for the trial over the next year. The therapy to be tested aims to halt tumor growth by limiting the tumor’s blood supply, a process called angiogenesis inhibition, which is a well-established tumor treatment method. It uses VB-111, a modified version of a common virus, that delivers a gene specifically to the endothelial cells that spawn blood vessels for the tumor. The expression of this gene in the blood vessel cell causes cell death, resulting in decreased blood flow to the tumor. The VB-111 virus can be given to patients systemically with tolerable side effects and, based on early trial studies, it may improve survival in patients with recurrent GBM. Avastin is an FDA-approved drug for the treatment of recurrent GBM. In this trial, participants who experience either a first or a second recurrence of GBM will be randomized to be treated with either Avastin alone or Avastin with VB-111. The goal of the study is to determine if the addition of VB-111 to Avastin improves survival over treatment with Avastin alone. The trial is open to adults over 18 years of age initially diagnosed with GBM who have already received upfront standard treatment with radiation and Temodar at initial diagnosis. Patients can only be in their first or second recurrence and may not have received previous therapy with Avastin or any other angiogenesis inhibitor. The Brown Cancer Center currently is the only site in this region participating in the international clinical trial. To learn more about the trial, patients may contact the Brown Cancer Center at 502-562-3429 or email ctoinfo.louisville.edu. ISSUE#100 | 29

EVENTS

MD-UPDATE Celebrates Issue #100

LEXINGTON To celebrate the publication of the

100th issue of MD-UPDATE, team members, writers, photographers, and contributors gathered at The Club at Spindletop Hall in Lexington on Thursday, May 12, 2016. MD-UPDATE Publisher Gil Dunn toasted those assembled and thanked them for “the generous contributions of their time, energy, talents, and intellectual property for the cause of helping physicians across Kentucky connect with each other through MD-UPDATE.” MD-UPDATE Editor-in-Chief Jennifer Newton also addressed the crowd calling MD-UPDATE “truly a collaborative effort joined together for the purpose of serving Kentucky physicians and all healthcare providers.” Newton described the upcoming new MD-UPDATE website, www.mdupdate.com, which will be a searchable collection of articles from the MD-UPDATE archives and current healthcare news in Kentucky. The website, said Newton, will “be open to Kentucky healthcare consumers and decision-makers to give them the opportunity to benefit from the curated, in-depth content of MD-UPDATE, the magazine.” “Kentucky healthcare consumers and decision-makers want to know more about their providers,” said Newton. “And no one has spent more time with more Kentucky doctors than MD-UPDATE.” The website will be launched summer of 2016. PHOTOS BY JOE OMIELAN 30 MD-UPDATE

(l-r) Robert Baker, MD, and Jennifer Newton, MD-UPDATE editor-in-chief, shared a moment together at the party talking about upcoming articles.

Enjoying the celebration of MD-UPDATE #100 were (l-r) Deanna Croucher, Pain Treatment Center of the Bluegrass, Gil Dunn, MD-UPDATE, and Heather C. Wright, CEO of the Pain Treatment Center of the Bluegrass and Ballard Wright, MD, PSC.

(l-r) MD-UPDATE financial columnist D. Scott Neal, Gil Dunn, MD-UPDATE, and mental wellness columnist Jan Anderson, PsyD, shared a joyful moment during the celebration of MD-UPDATE 100 issues. (l-r) The legal and financial wheels were turning when Lauren Parsons, director of Marketing & Client Relations, Sturgill, Turner, Barker & Moloney, PLLC, with Stephanie Wurdock, Esq., Sturgill, Turner, Barker & Moloney, PLLC, and Molly Nicol Lewis, Esq., McBrayer, got together with Richard Coles of D. Scott Neal Incorporated, fee-only financial planner.

EVENTS

Ashland Lawn Party Ashland, the Henry Clay estate, is a National Historic Landmark and a rare treasure in the heart of Lexington. Established in 1926, the Henry Clay Memorial Foundation, a 501c3 non-profit organization, is dedicated to preserving Ashland and operating its educational center. Generous individuals and corporations make the conservation of Ashland, and sharing the legacy of the Great Compromiser, Henry Clay, possible. The annual Ashland Lawn Party supports the foundation and Ashland. The Lawn Party is Ashland’s largest fundraising event of the year and features bourbon tasting, cocktails, music, dinner, and a live and silent auctions. More information is available at www. henryclay.org. LEXINGTON

Every year the sun shines bright on the old Kentucky home of Kentucky statesman Henry Clay for the Ashland Lawn Party. Over 500 guests attend the Ashland Lawn Party to help preserve a piece of Kentucky history.

PHOTOS PROVIDED BY ASHLAND, THE HENRY CLAY ESTATE, COURTESY OF THE RENAUDS

(l-r) Gil Dunn, MD-UPDATE, with Stephanie Sarrantonio, director of Marketing for KentuckyOne Health Central & Southeastern Division, shared smiles reminiscing about many physician stories that have appeared in MD-UPDATE. (l-r) Lauren Parsons and Stephanie Wurdock, Sturgill, Turner, Barker & Moloney, chat with Richard Coles and Scott Neal. ABOVE

Members of the Marketing Department at Lexington Clinic joined MD-UPDATE to celebrate 100 issues. Pictured are (l-r) Laci Poulter, director of Marketing for Lexington Clinic, Gil Dunn, MD-UPDATE, Sarah Wilder, Public Relations specialist, and Taylor Harlon, intern, both with Lexington Clinic Marketing and Public Relations. ISSUE#100 | 31

EVENTS

Kentucky CancerLink Golf Scramble

The 3rd Annual Kentucky CancerLink Golf Scramble presented by UK HealthCare took place on Monday, April 25 at Spring Valley Golf Club. Twenty-four teams took the course for a great cause to raise money for Kentuckians in need of cancer screenings or assistance during a cancer battle. Kentucky CancerLink’s upcoming #UNTIL campaign was also highlighted at the event. The theme of the campaign is: UNTIL there is a cure for cancer, Kentuckians need help today. Kentucky CancerLink is a 501(c)3 nonprofit whose mission is to reduce barriers to screening, treatment, and diagnosis of cancer. Funds raised go toward Kentucky Cancerlink’s mission to help with those needs, such as transportation to and from cancer treatment. Community partners who have accepted the challenge to BE the #UNTIL are: UK HealthCare, WKYT, Lexington HeraldLeader, iHeart Radio, TOPS in LEX, Baptist Health, Town Branch, KentuckyOne Health, MD-UPDATE, and Safe Floors of Kentucky. LEXINGTON

UNTIL Baptist: The Baptist Health Team included Greg Bodger, Jason Potes, Jeff Vella, and Chase Hall. RIGHT Former UK Basketball star Jack Givens joined the cause at the 3rd annual Kentucky CancerLink Golf Scramble. BELOW UK HealthCare Team members were Mark Filburn, Spencer Houlihan, Craig Rogers, and Jeffery Reynolds. TOP

Men’s Health Check at UK Markey Cancer Center

The UK HealthCare Markey Cancer Center (MCC) provided a “Men’s Health Check,” a screening event for 48 men, on April 13, 2016. Men participated in labs that checked their cholesterol, blood sugar, PSAs, and more. They were able to obtain colon cancer and prostate cancer education and to sign up for cancer screenings. Kentucky CancerLink (KCL) offered free at-home colon cancer screening kits to qualified attendees, who then mailed their samples back to KCL for testing. Based on the results of the test, several men were encouraged to contact their family physician to discuss obtaining additional colon cancer screening, including a colonoscopy. This was the first time for Men’s Health Check at UK’s Markey Cancer Center. In previous years, a grant allowed UK LEXINGTON

32 MD-UPDATE

(l-r) Vicki Blevins-Booth, Kentucky CancerLink (KCL) executive director, and Toni Davis, KCL certified patient navigator, attending UK Healthcare’s Men’s Health Check event, which provided colon cancer screening information and free in-home colon cancer screening kits to those who qualified.

to conduct quarterly prostate cancer screenings. The Men’s Health Check provided an opportunity for men to receive a general health and wellness report. Melissa Hounshell, MCC Community Outreach director, said, “There are several events and screenings with women in mind, but there are not that many designed specifically for men. Our results show that men need screenings. The majority of our attendees had one or more labs that were out of the normal range.” Continues Hounshell, “As the only NCIdesignated cancer center in Kentucky, we at the Markey Cancer Center feel like it is our responsibility to educate and screen as many people as possible. Men’s Health Check is simply another opportunity to do that.”

A UK Faculty, Staff and Alumni Club Since 1962

When you choose The Club at UK’s Spindletop Hall

you are not simply choosing a club—you are becoming a Member of the Spindletop family. The Club’s service team works hard to ensure your every need is met, so that your time at the Club is stress-free and just as you expect. We specialize in not only offering all of the amenities of a social club, but accommodations for all of your business and landmark events from meetings to weddings. The history and gorgeous character of the mansion and grounds provide the perfect setting for any event, and our Club is proud to feature a new award-winning chef and culinary team that allows you to relax and enjoy the delicious culinary delights. For those seeking the Club in a class all by itself in the Bluegrass, Spindletop is the choice for you. You will find that we offer a great value, especially compared to other clubs in the area.

Some of the many benefits of a Club membership are: n n n n n n n n n n

Roxie’s upscale casual indoor and al fresco dining Use of the mansion with versatile space for social or business events Discounted golf opportunities at the University Club of Kentucky and other area courses Use of the Hilary J. Boone Center, our sister Club, Monday through Friday for lunch Championship caliber swim and dive teams 10 tennis courts, two chipping and putting greens, Pickleball and croquet courts Easy access to the Legacy Trail with bike rental and storage available Tiki Bar and Grill, picnic areas and outdoor event space Three heated swimming pools, including one with family fun water features, and a baby pool Event programming year-round: Family Events, Book Club, Wine Club, Bourbon Club, Gardening Club and more

Spindletop also offers another valuable perk for Members. Being a part of the Association of College and University Clubs entitles Spindletop Members to reciprocal privileges at nearly 80 university-related clubs across the country and around the globe.

You Belong Here! Joining the Club is a simple process.

Many different membership categories are offered based on age and location. UK Alumni Association Lifetime Members, Golden Seniors, and UK Young Alumni and Students pay no Initiation Fee upon joining the Club. Call today to begin planning for a lifetime of memories! Reach us at 859-255-2777 or email membership@spindletophall.org or holly.clark@uky.edu. Visit us at www.spindletophall.org or in person at 3414 Ironworks Pike, Lexington, Kentucky, 40511. Club membership is subject to approval.