THE BUSINESS MAGAZINE OF KENTUCKY PHYSICIANS AND HEALTHCARE PROFESSIONALS ISSUE #90
SPECIAL SECTION
PAIN MEDICINE AND NEUROLOGY
PATIENT-RESPONSIVENESS, INNOVATION, AND COLLABORATION William O. Witt, MD, uses three pillars to enhance the patient experience at Cardinal Hill Pain Institute
VOLUME 6, NUMBER 1
ALSO IN THIS ISSUE FAMILY APPROACH TO PAIN MANAGEMENT INJECTIONS INJECTIONS FOR FOR MIGRAINES ENDOSCOPIC ENDOSCOPIC ENDONASAL ENDONASAL SURGERY SURGERY FOR FOR SKULL-BASE SKULL-BASE TUMORS BUILDING BUILDING AN AN INTERVENTIONAL INTERVENTIONAL NEUROLOGY NEUROLOGY PROGRAM NEUROLOGIST FILLS SERVICES GAP IN GEORGETOWN
We give you more primary care options.
Whether you’re sick or need a wellness check-up, KentuckyOne Health has more primary care options. Your primary care physician is your first choice when you’re sick, and for annual visits. Anywhere Care is a live 24/7 phone or video chat service. Emergency Care is where you turn for immediate emergency treatment. Urgent Care is close-by for minor illnesses and injuries. Workplace Care partners with employers to promote a healthier workforce. To find the right door for you, visit ChooseYourDoor.org or call 888.570.8092 for a provider near you.
Chronic Pain is Real. We Can Help.
CONDITIONS TREATED INCLUDE:
Spinal metastases, Vertebral Compression Fractures, Complex Regional Pain Syndrome-Types I & II (RSD and Causalgia), Spinal Stenosis, Neuropathy, Low Back Pain, Radiculopathy, Post-thoractomy Pain, Failed Back Surgery Syndrome, Carpal Tunnel Syndrome, Thoracic Outlet Syndrome, Shingles and Post Herpetic Neuralgia, Sciatica, Whiplash, Sports Injuries, Work Injuries, Cancer-related Pain
THERAPEUTIC OPTIONS INCLUDE
Kyphoplasty, radio frequency lesioning of spinal metastases, radio frequency vertebral augmentation, injective treatment, physical therapy, spinal cord stimulation, minimally invasive lumbar decompression (MILD®), TENS, physical training, nutritional counseling, aquatic therapy, cognitive behavioral therapy, non-narcotic medication management, consultations, second opinions, independent medical evaluations
William O. Witt, MD, DABA-PM, Medical Director Cardinal Hill® Pain Institute Board certified in Pain Management, Anesthesiology & Critical Care Medicine MEDICAL SCHOOL: University of Minnesota RESIDENCY: University of Colorado APPOINTMENTS: Chairman Emeritus, Anesthesiology/ University of Kentucky PROFESSOR EMERITUS , Anesthesiology, Neurosurgery and Hematology-Oncology, Founding Director Emeritus, Pain Management Fellowship MEMBER: Lexington Medical Society, Kentucky Medical Association, International Association for the Study of Pain, American Pain Society, American Academy of Pain Medicine, North American Neuromodulation Society
859-367-7246 (859-FOR–PAIN) 2050 Versailles Rd, Lexington KY 40504 Fax: 859-254 5715 www.docwow.com • www.cardinalhill.org
LETTER FROM THE PUBLISHER
Welcome to LIFESTYLE RE-HABITUATION©! You’re hearing it here first: I’m coining a new term, “Lifestyle Re-habituation.” Sure, it’s another way to say: New Year’s Resolution, Turning over a New Leaf, A Fresh Start to New Year, The New Me, etc. Those terms are so last century, before “lifestyle” was a catch-all phrase for how and where we live and what we do for work, family, and fun. I grew up in an Irish, Catholic, middle-class family. If we had a “lifestyle,” it was the same as everyone else around us. Why Lifestyle Re-habituation? Because after numerous conversations with Kentucky doctors and healthcare professionals that revolve around “integrative and preventative medicine,” “obesity, poor diet, and lack of exercise,” and “prescription drug abuse, misuse, and addiction,” it’s obvious that some changes are needed. I’m 100 percent convinced that by changing some of the small things we do numerous times each and every day, we can effectively alter our mental and physical health and the health and wellness of the people we come in contact with. I remember as a child that the word “habit” was usually associated with something “bad,” and “bad habits” were to be avoided. Now, as an adult, I know that there are good habits as well as bad habits, and I have both. Look up the word “habit” and you’ll see definitions like: “an acquired behavior pattern regularly followed until it has become almost involuntary,” “a routine of behavior that is repeated regularly and tends to be unconscious,” “a fixed way of thinking or acting.” Involuntary, unconscious, fixed. Those are uncomfortable words when describing human behavior. Physicians across Kentucky have told us that the health and future welfare of the people of the Commonwealth depend on cognitive change. In this issue of MD-UPDATE we share some of these “lifestyle” conversations with Dr. Preston Nunnelley, Dr. William Witt, Dr. Danesh Mazloomdoost, and Dr. Deborah Ballard. I invite you to read what they have to say on the subject. And here’s one final cliché: “Old habits are hard to break.” That’s why we need “Lifestyle Re-habituation.” Until next issue, 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 2 MD-UPDATE
Volume 6, Number 1 ISSUE #90 PUBLISHERS
Gil Dunn PRINT gdunn@md-update.com Megan Campbell Smith DIGITAL mcsmith@md-update.com EDITOR IN CHIEF
Jennifer S. Newton jnewton@md-update.com GRAPHIC DESIGNER
James Shambhu art@md-update.com
CONTRIBUTORS: Jan Anderson, PsyD. Molly Nicol Lewis D. Scott Neal Calvin R. Rasey
CONTACT US:
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 M.D. 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 2013 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 M.D. Update are available for $9.95.
CONTENTS
ISSUE #90
COVER STORY 4 LEGAL 5 INSURANCE 7 FINANCE 8 Q&A 10 COVER STORY 14 SPECIAL SECTION: PAIN MEDICINE 18 SPECIAL SECTION: NEUROLOGY
Patient-Responsiveness, Innovation, and Collaboration
25 MENTAL HEALTH 28 NEWS
William O. Witt, MD, uses three pillars to enhance the patient experience at Cardinal Hill Pain Institute
30 EVENTS
BY TIM CORKRAN
PHOTOGRAPHY BY JOHN LYNNER PETERSON PAGE 10
SPECIAL SECTION PAIN MEDICINE
14 FAMILY VALUED: PAIN MEDICINE AND MANAGEMENT
16 IT NEVER HURTS TO CARE: BUX AND BUX PAIN CLINIC
SPECIAL SECTION NEUROLOGY
18 COMBATING THE PAIN: LEXINGTON CLINIC NEUROLOGY
20 A REVOLUTION IN BRAIN SURGERY: UOFL HOSPITAL
22 PAVING THE ROAD TO INTERVENTION: BAPTIST NEUROSCIENCE ASSOCIATES
24 NEW DOCTOR TO LEAD NEUROLOGY DEPARTMENT: GEORGETOWN COMMUNITY HOSPITAL ISSUE#90 3
LEGAL
Changes Proposed for Anti-Kickback Statute It has been said before—healthcare is changing. Most often providers must adapt their practices to comply with governing regulations. Sometimes, governing regulations must be revised to adapt to providers practices. And on occasion, governing regulations must be revised to be consistent with other governing regulations. This is one of those occasions. On October 3, 2014, the Office of Inspector General (“OIG”) published a Proposed Rule (“Rule”) that would make changes to the safe harbor regulations under the federal anti-kickback statute (“AKS”). Much of the Rule codifies changes to the AKS that were already established by the Affordable Care Act and the Medicare Modernization Act of 2003. It also, however, proposes two new safe harbors.
Codification of Pre-Existing Safe Harbors
Part D Cost-Sharing Waivers by Pharmacies: The Rule would protect certain cost-sharing waivers, including pharmacy waivers for financially needy Medicare Part D participants. Generally, cost-sharing waivers are prohibited by the AKS. To meet the safe harbor, pharmacies would need to meet three criteria: (1) the waiver/reduction is not advertised or part of a solicitation; (2) the pharmacy does not routinely wave cost-sharing; and (3) before waiving a cost-sharing obligation, the pharmacy determines in good faith that either the beneficiary has a financial need, or the pharmacy fails to collect costsharing amounts after making a reasonable effort to do so. Federally Qualified Health Centers and Medicare Advantage Organizations: This Rule would protect certain remuneration between federally qualified health centers and Medicare Advantage organizations pursuant to a written agreement requiring that the Medicare Advantage organization pay the contracting health center no less than the level and amount that the plan would pay for the same services to another type of entity. Medicare Coverage Gap Discount 4 MD-UPDATE
Program: To implement another existing exemption in the AKS, one that was added in 2010 with the Affordable Care Act, the OIG would add a safe harbor protectBY Molly Nicol Lewis ing brand drug discounts provided by drug manufacturers to Part D enrollees in the coverage gap under the Medicare Coverage Gap Discount Program. The safe harbor would incorporate the definitions of “applicable beneficiary” and “applicable drug” which are set forth in the Affordable Care Act.
New Safe Harbors
Local Transportation: The OIG would establish a new safe harbor protecting free or discounted local transportation made available to patients by an eligible entity, provided that the following criteria are met: (1) the availability of the transportation services is not determined in a manner related to the past or anticipated volume or value of referrals; (2) the transportation does not take the form of air, luxury, or ambulance-level transportation; (3) the services are not marketed or advertised, no marketing of healthcare items and services occurs during the course of the transportation, and drivers or others arranging for the transportation are not paid on a perbeneficiary basis; (4) the eligible entity that makes the transportation available bears the costs of the transportation services and does not shift the burden onto other payors; and (5) the distance from the patient’s location to the provider is no more than 25 miles. Entities that supply health care items (such as pharmaceutical companies and durable medical equipment suppliers) and laboratories are excluded from the definition of “eligible entities.” Cost-Sharing Waivers for Emergency Ambulance Services: This Rule would
establish a safe harbor to protect reductions or waivers of cost-sharing amounts for emergency ambulance services furnished by providers owned by states or municipalities. Generally, items and services provided free of charge by a governmental entity are not reimbursable. The providers would be required to offer the reduction or waiver on a uniform basis, without regard to patient-specific factors. The OIG is also seeking an express prohibition against claiming the amount reduced or waived as bad debt for payment purposes under Medicare or a state health care program, or otherwise shifting the burden of the waiver to other payors.
Technical Correction
Finally, the Rule would also amend the existing safe harbor for referral services to clarify that the safe harbor precludes protection for payments from participants to referral services that are based on the volume or value of referrals to, or business otherwise generated by, either party for the other party. The “either party for the other party” language was inadvertently changed in a 2002 revision, but appeared in the 1999 Rule. In addition to proposed changes to the AKS, the Rule also proposes changes to the civil monetary penalty rules. These changes would allow providers greater flexibility to enter into beneficial arrangements that are not in violation of the statute. The OIG is soliciting comments on how to best implement the changes. Comments on the Rule are due by December 2, 2014. If you are in the health care industry and would like more information contact a health care law attorney today. Molly Nicol Lewis is an Associate of McBrayer, McGinnis, Leslie & Kirkland, PLL Ms. Lewis concentrates her practice in healthcare law and is located in the firm’s Lexington office. She can be reached at mlewis@mmlk. com or at (859) 231-8780. This article is intended as a summary of federal and state law and does not constitute legal advice. ◆
INSURANCE
Disability Definitions: Don’t Be Fooled
For over 18 years I have been advising physicians to make sure that when purchasing disability protection that it has a true “own occupation” or “specialty specific” definition of disability for the entire benefit period of the contract. Recently, this advice has been challenged by one well known disability provider. Traditionally, total disability means that, due to an injury or illness, as a physician you are unable to perform the material and substantial duties of your occupation. The best contracts go in more detail and state that if you have limited your practice to a recognized specialty in the medical community that specialty would be deemed your occupation. This means if you could not see patients in the same manner you do today, you would be entitled to receive full disability benefits. If you decided to work in another specialty or even another job outside the medical community earning the same amount or even more than you did prior to your disability, you would still collect full benefits. A true own occupation or specialty specific definition of disability does not allow the physician to profit, however it does allow the physician to utilize not only his/her education, but also his/her training and experience, to find joy within the workforce without being penalized for being intelligent, motivated, resourceful individuals. Some would argue that this is a form of “double dipping” or “profiting” from a disability, but that is just nonsense. Every physician has sacrificed time, money, and energy to build a career in the medical community. There are also student loans that may be lingering and possibly new debt due to the disability. Suffering a disability is difficult and your disability plan should protect your specialty without limiting your future mental and financial well-being. A well-known insurance company which markets heavily to the medical community switched from true own occupation or specialty specific definition of disability in 1997 to what they now label as “medi-
cal occupation” definition of disability. Don’t be fooled by the clever wording, because things always aren’t what they seem. The medical occupation definition hinges on the fact BY Calvin R. Rasey that as a physician you may have several duties, and in order to collect full benefits, you would have to be unable to do all of those duties. For example, an OB/GYN who may not be able to do procedures or work in the delivery room, but would see limited patients in the office would not be considered totally disabled. This makes the case that since most physicians will not satisfy the own occupation definition of total disability, they will be viewed as proportionally disabled and would only receive partial benefits. This is also true if a physician is working in any capacity, inside or outside the medical community. There is a widely accepted court case, Dowdle v. National Life Insurance Company, tried in the 8th Circuit Court, which set precedent between the two definitions: own occupation or specialty specific and medical occupation. Dowdle, an orthopedic surgeon, purchased an own occupation plan. Prior to his unfortunate disability he devoted 3 full days a week to surgery and 2 half days of office consulting, seeing 15-20 patients each half day. Due to his disability he was unable to stand in the operating room for an extended period of time, making him unable to perform orthopedic surgery. Although he could still see patients in the office, he claimed total disability because he could not perform surgery. Unsurprisingly, his disability carrier argued that he was not totally disabled because he could see still see patients in the office. After hearing the case, the court agreed with Dowdle that he was totally disabled and should receive full benefits. They ruled that orthopedic surgery was his
primary function and any non-surgical tasks were secondary. Using this court case is a great way to compare the own occupation/specialty specific to the medical occupation definition of disability. Under the medical occupation definition Dowdle would have needed to either discontinue working altogether or continue working earning less than 20% of his pre-disability earning to qualify for full benefits. However with the own occupation or specialty specific definition Dowdle had the ability to continue working in or out of the medical community and could earn unlimited income as long as his disability renders him unable to perform orthopedic surgery. The devil is in the details, and after a disability has occurred is the wrong time to learn that your coverage is not what you thought it was. The ability to earn a living doing what you love is a wonderful gift which should be protected at all costs. Calvin R. Rasey is president of Physicians Financial Services II, LLC. You can reach him (502) 893-7001 or 1-800-928-8834.
REFERENCE Dowdle v National Life Insurance Company, NO 04-2628, US 8th Circuit Court, May 19, 2005 Securities Offered Through Securities America, INC.*Member FINRA/SIPC • Calvin R. Rasey • Registered Representative Advisory Services offered through Securities America Advisors, INC.• A registered Investment Advisor Calvin R. Rasey • Investment Advisor Representative Physicians Financial Services II, LLC and Securities America Companies are NOT UNDER Common Ownership Representatives of Securities America do not offer tax or legal advice The opinions and forecasts expressed are those of Calvin R. Rasey, are general in nature and cannot be guaranteed. Securities America and its representatives do not provide legal advice. For questions about a specific situation please consult your legal advisor. ◆ ISSUE#90 5
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6 MD-UPDATE
FINANCE
Outlook 2015 Except during our periodic meetings with clients in which we parade out their recent and long term performance, I almost never get a question related to what happened in the investment market or the economy yesterday, last month, last quarter, or last year. Yet, I get tons of questions framed around what’s going to happen next month, next quarter, next year. It’s as though people think that investment advisors in general, and I in particular, have some sort of crystal ball. Well, guess what? I don’t, and for that matter, neither does anybody else in this busines . That does not mean, however, that we don’t have some insight into what can probably help our clients, and you our dear reader, achieve a higher level of well-being over the course of 2015 and into the future. That prospect is what keeps me going yeaafte- year, or in the case of this column, mont- afte- month. In response to such questions, advisors are prone to drag out reams of data quantifying the past in an effort to satisfy the seeker. Many assert or at least imply, with an air of certainty, that they can predict what is going to happen. For instance over the last decade, a legion of otherwise intelligent voices cried out that housing prices could never go down; that financial Armageddon was at hand in ’08 and ‘09; that the Fed’s zero interest rate policy would definitely
or the recordsetting prices of stocks for which the prediction is a fall or complete collapse. My caution here is to be especially alert when anybody, especially a financial advisor, BY Scott Neal uses the words: “Certainly,” “Surely,” or “Everybody knows.” Over the past three years, we have followed a path of seeking to participate in growth but with a relatively high degree of caution. As the U.S. markets are hitting all-time highs (as of this writing at least) it is not time to totally throw caution to the wind. However, one does not have to become imprudent to adopt a more optimistic stance and to become more aggressive toward the accomplishment of goals and objectives—even investment objectives. That is our intent in 201 . Many would take such a statement to be my prediction that 2015 will produce another year of stellar returns for financial assets. It might, but if that is what you heard, please go back and re-read the first paragraph. What this market calls for is some clear thinking about risk, not just return.
… BE ESPECIALLY ALERT WHEN ANYBODY, ESPECIALLY A FINANCIAL ADVISOR, USES THE WORDS “CERTAINLY,” “SURELY,” OR “EVERYBODY KNOWS.” bring robust economic growth; that its quantitative easing programs were tantamount to money printing and would surely result in hyperinflation; that interest rates could not go any lowe . We all know, in perfect hindsight, the fallacy of each of thes . Yet the cacophony continue . presently it’s either about the price of oil for which they say “everybody knows it can’t go lower”
The problem is that most people have a disconnection, often unconscious or unspoken, with their advisor when it comes to defining risk. You see, most advisors and academics still think of risk as volatility or fluctuation. However, most of our clients have told us that some volatility is acceptable, but the loss of capital is not. Howard Marks of Oaktree Capital Management
wrote extensively about this in a 2006 memo and in his subsequent book, The Most Important Thin . He believes, like us, that volatility is the preferred measure of risk among academics because it is quantifiable. He calls it “machinable.” We have said over and over that volatility is a type of risk that we must befriend and even use to our advantage when present, but that it is not the chief concern of most clients. On behalf of our clients, we are most concerned with making enough return to warrant risking permanent loss to capital, while at the same time minimizing that loss whenever it is possible to do so. Some risk, so defined, has to be tolerated but should not be allowed to become large and permanent. That often requires some psychological adjustmen . I am hoping that you resolve to address this in your investment planning for 2015. We can model the probability of this kind of loss, and we do, using some very sophisticated tools, but let’s be certain about one thing: even the true probability of permanent loss is unknowable. So what is one to do? Adopting an appropriate investment strategy that matches one’s outlook on risk / return, and to an even greater extent one’s rational beliefs about the market, is paramount. So the key question to ask yourself as you embark on 2015 is not what is the market going to do in 2015; but rather it is what is my goal for 2015? Does my advisor know what it is? Do we have a strategy that is matched to the goal? And does my advisor have the tactical expertise to implement and maintain the portfolio in accordance with my strategy? Just as importantly, one should ask: What is my plan for dealing with surprise? After all, one does not know what one does not know. Our hope for each of you is that 2015 will be your Best Year Yet! Scott Neal, a CPA and CFP, 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 toll free at 1-800-344-9098. ◆ ISSUE#90 7
Q&A
Q & A with Dr. Preston Nunnelley, VP and Chief Medical Officer for Baptist Health Lexington For over 40 years, Preston P. Nunnelley, MD, has been in private OB/GYN practice, a leader in Kentucky medicine and in hospital administration. Dr. Nunnelley is retiring in February, 2015 from his position at Baptist Health Lexington. To gather some of his wisdom, MD-UPDATE publisher Gil Dunn had an extended conversation with Dr. Nunnelley which will run in two parts. This is Part 1.
MD Update: Preston, tell us about your personal and professional background and influences.
Nunnelley: My grandfather was a civil engineer and I would spend summers with him. Because of his influence, I started college at UK majoring in civil engineering in 1960. During that time I made friends with George Prewitt, a hospital administrator, and Jack Lewis, a family practice physician. I’d go to the hospital with them and see what they were doing. Through this association I developed an interest in medicine and switched my major to pre-med. After my first year of college at UK, I met and married my wife Lucille and transferred to Eastern. While I was attending Eastern, I worked nights as an orderly at Pattie A. Clay Hospital doing whatever needed to be done. The more I was around healthcare the more I wanted to be a physician. I’ve been blessed in my career, because somehow I made the right decisions. When I look back, there is very little that I’d change.
I’ve been blessed in my career, because somehow I made the right decisions. When I look back, there is very little that I’d changePreston P. Nunnelley, VP and Chief Medical Officer for Baptist Health Lexington
he delivered. He would number his birth certificates. When he gave up OB, he was just short of 10,000 deliveries. You don’t get anywhere close to that now.
How did you decide to specialize in OB/GYN?
After medical school I was interested in a residency in surgery. I also loved OB. One day, the doctor in charge of rotating internships and the residencies program said he “had to know today, are you going to go into OB/GYN or not?” For some reason I said, “I am.” It was the right thing to do at the right time, and I never looked back.
Never?
OB/GYN gave me the opportunity to do both surgery and OB. Obstetrics is stressful, but rewarding. Sometimes when 8 MD-UPDATE
I’m out in public someone comes up to me and says, “Dr. Nunnelley look who you delivered seven years ago, 20 years ago.” That really makes you feel good.
What was the name of your first practice?
Initially, it was Ellis, Jenkins and Nunnelley. Dr. Ellis, my senior partner, was always interested in how many babies
How many babies did you deliver? About 6,000.
You practiced OB/GYN for over 30 years. How has it changed?
There have been many changes in both obstetrics and gynecology. The major change in obstetrics is the ability to make an early diagnosis of fetal abnormalities and other complications. We now have
ultrasound, particularly 3D ultrasound, and amniotic fluid analysis which provide us with a lot of diagnostic information on the status of the baby. We have evolved to the point of a specialty practice including maternal-fetal medicine and neonatology. And now we have telemedicine. If you’re in a rural area and you’re delivering babies, you can have a specialist look at the ultrasound or even up to the point of labor.
Talk about changes in gynecology.
It’s a totally different world. When I did a hysterectomy, it would take four-to-five days before the patient went home. Now, with the da Vinci robot and laparoscopic surgery, the patient is discharged the same day or after a 24-hour stay. We have more non-invasive management techniques to reduce hospital stays and decrease complications. The patients are more satisfied; they have less postoperative pain. The easier you make the surgery, the easier to get satisfaction.
What’s next in the advancement of OB or GYN?
In obstetrics, it’s advances in infertility treatment. In my mind, there’s nothing worse than a couple that wants to start a family but can’t conceive. The treatments for endometriosis and our monitoring techniques are getting better, so we’ll have more healthy babies. Unfortunately, there are just certain things that happen in pregnancy that can’t be resolved, but perinatologists and neonatologists give us better options. It is a real team approach. From a GYN standpoint, there’s more medical management as newer drugs are developed. There will be refinements in
robotic surgery. Probably the most significant improvement will be the treatment of GYN cancers like ovarian, uterine, and cervical cancer with newer medications and surgical techniques.
Who is "we"?
Public health. It hurts me to have to use the word, but that means government. That’s where the funding has to happen and that’s a big challenge for medicine in Kentucky.
What are the challenges for Kentucky OB/GYN doctors?
What do you consider your legacy, your proudest accomplishments?
The biggest challenges are the lifestyles of our population. Weight, obesity, smoking, diabetes, heart disease – all of those affect pregnancy and GYN because they are risk factors in surgery. We have a very high population of smokers and patients with pulmonary disease. Kentucky has to do more in preventative healthcare because the future of medicine is prevention. We need patient population and disease management. We are a proud people in Kentucky, and patients don’t like to admit that they can’t afford their medicine. Many of our patients, because of travel cost and other issues, don’t get good prenatal care. It is not because it isn’t available; it’s because they don’t have the money. When you get them in for prenatal care, you can talk about preventative care. It takes time and resources to deal with issues of diet management, smoking, and more. We need a lot more resources. The biggest thing we are dealing with in prenatal care is prescriptive drug abuse. That is huge. When you see the number of babies that are influenced by that, it is heartbreaking. Now, we are getting a handle on prescriptive drug abuse, but we are trading that off for heroin. We don’t have enough resources to treat addiction. You have to treat the addiction. You can stop one drug, but they will find something else until you cure the problem. We need more sites for addiction treatment.
The simple word would be that I care, I cared about my patients. I made every effort to treat them as individuals and made sure that they had the best quality of care that I could provide.
As you prepare to retire, any unfinished business?
No, I really don’t think so. The unfinished business is to finish out the positions that I am in now. I started about two years ago getting into that. I think that after I retire, there will be opportunities that I don’t recognize today. There will be things that I will get involved in that will be different than what I have done in the last 41 years. I’m excited about that. I want to further my education, maybe be a Donovan Scholar, take some classes. I think it is extremely important to keep your mind working. You can be productive as long as you’re doing that. I worry about retirement and not having the challenges that I have on a daily basis here, which stimulates you and keep you going. For more on Nunnelley’s work in organized medicine and his role at Baptist Health Lexington, check out Part 2 of this Q&A in the next issue of MD-UPDATE. ◆
CALL FOR PARTICIPATION 2015 Editorial Opportunities * TO PARTICIPATE, PLEASE CONTACT:Gil Dunn, Publisher / gdunn@md-update.com / (859) 309-0720 Jennifer S. Newton, Editor-in-Chief / jnewton@md-update.com / (502) 541-2666 THE BUSINESS
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ISSUE#90 9
COVER STORY
William O. Witt, MD, uses three pillars to enhance the patient experience at Cardinal Hill Pain Institute
PATIENT-RESPONSIVENESS, INNOVATION, AND COLLABORATION BY TIM CORKRAN WITH PHOTOGRAPHY BY JOHN LYNNER PETERSON From rheumatic fever as a child through his graduation first in his medical school class, Dr. William O. Witt’s plan had always been to be a pediatric cardiac surgeon. When chronic pain following a skiing accident in 1978 nearly ended his then planned career, little did he know that it was creating a new one as a pain specialist. “It was a surprise ‘gift’ for which I never would have thought to ask,” says Witt. Accordingly, Witt’s creation of the Cardinal Hill Pain Institute (CHPI) in 2009 was the culmination of several decades of experience both as patient and as physician, and a strong commitment to improving it. Witt has benefitted from the convergence of three forces: Cardinal Hill Rehabilitation Hospital’s vision for patient-centered treatment and their consequent facilities expansion; his own continued innovation and collaboration; and his enduring commitment to “help my patients have better pain relief and better function as well as to feel better about the process.” For Witt, who is board certified in anesthesiology, critical care LEXINGTON
10 MD-UPDATE
The main procedure room at CHPI includes an OEC 9900 cardiac fluoroscope and a six-axis Morgan table with modern ultrasound imaging and optimum sterility. ABOVE
RIGHT The
CHPI waiting room has hardwood floors, overstuffed seating, high-fidelity spa music, a soothing waterfall, and flat screens that scroll inspirational and educational messages to enhance a positive patient experience.
medicine, and pain management, the attention to patient experience is a pillar of his practice. This attracted him to Cardinal Hill with its impeccable reputation in the region and its patient-specific, optimistic culture. From the region’s only super-heated therapy pool to the abundant natural lighting, Cardinal Hill has the amenities consistent with those Witt has documented to benefit patient attitudes and perceptions. Cardinal Hill also has facilities for balance training, gait training, strengthening, and ready access to many other outstanding professionals. “The entire culture at Cardinal Hill is how we focus on our patients’ remaining abilities rather than their disabilities,” he says. When the hospital’s expansion allowed him to design his own facility in 2011, “It resulted in the perfect facility for this kind of practice.”
The Optimal Space for Patient Comfort
There is much about Witt’s facility and approach that maximizes a patient’s sense of convenience, comfort, and overall well-being, such as its reserved CHPI parking, its drive-up entrances, and its beautiful three-story glass atrium. Once in the facility, the positive patient experience continues. His waiting room has hardwood floors, overstuffed seating, high-fidelity spa music instead of television blather, a soothing waterfall, and flat screens that scroll inspirational and educational messages. Family members often accompany patients, and they are given wireless pagers so they can be free to stroll through the sunny glass atrium, view the donated art gallery, or to just move around and still be available when the patient is done. “My staff is the face and the soul of the practice,” says Witt. Each patient is greeted, treated, and followed by highly skilled, professionally uniformed, and always friendly individuals who have a personal stake in and a commitment to the culture of the practice. Witt is particularly proud of his procedure and examination rooms. The main procedure room contains the best equipment of its
ISSUE#90 11
kind available, including optimum sterility, an OEC 9900 cardiac fluoroscope, a sixaxis Morgan table, and modern ultrasound imaging. His examination rooms have windows to allow relaxing natural light in, with the comfort of privacy glass. “Whenever I go to any kind of medical facility, I make a mental list of what I like and what I don’t like, and after most of my 68 years, this makes for a very long list that I have fully incorporated into the practice,” he says.
Serving Patients Thoughtfully and Thoroughly
Witt serves patients from all over Kentucky, numerous other states, and from abroad. Some out-of-state patients travel to CHPI, and his proximity to Bluegrass Field is appreciated. While he uses many approaches to alleviate pain, all patients benefit from his holistic philosophy that eschews opioids and promotes nicotine cessation, sleep hygiene, weight loss, behavioral counseling as needed, and favors long-term healing as well as management of pain. Witt says that, “Even if you cannot relieve all the pain for every patient, you can improve every patient’s function and outlook. The word 12 MD-UPDATE
Dr. Witt and his assistant performing a radiofrequency vertebral augmentation procedure.
‘doctor’ from its Latin root means ‘to teach,’ and most patients are eager to learn not just what we can do, but what they can do to get better; part of my job is to teach them.” Witt also works with other physicians who do not need a comprehensive consultation but only a specific procedure as part of their diagnostic or therapeutic plan. Accordingly, he provides time-sensitive accommodation, within a couple of days, to “any physicians who want to refer patients for procedures only, such as kyphoplasty, radiofrequency lesioning of spinal metastases, or the injection or lesioning of particular structures.” CHPI offers a large menu of services, concisely summarized by Witt as handling “pain from virtually any structure in the spine or musculoskeletal system, by injection, augmentation, ablation, or neuromodulation with surgically implanted pain
control devices.”
Innovation and Connection
Witt stays at the forefront of pain management innovation with CHPI’s most recent acquisition of the STAR® system for tumor ablation and the Radiofrequency StabiliT® vertebral augmentation system. The Star system allows for an outpatient procedure that does not interrupt chemotherapy or radiation, is performed under local anesthesia with light sedation, and can provide permanent pain relief within two hours. This single steerable probe eradicates vertebral tumors with heat, then, allows for the injection of cement through the same cannula to fill the cavity created by the vaporization of the tumor. CHPI is the only facility in the region with this system. The StabiliT system is also a single steerable probe for the treatment of verte-
COVER STORY
bral compression fractures that allows Witt to finely manipulate the point of cement injection. As a result, all cavities and fracture lines are filled while vertebral height is restored. Earlier systems for treating compression fractures cannot be targeted in this fashion. CHPI has always fully embraced EMR technology, and Witt continues to tout its value and tweak its uses. Beginning in 2009, he worked with Addison Healthcare Systems to develop an EMR that would be optimal for his practice (March 2012, MD-UPDATE). The laborious startup process was validated, and today he has over 8,500 patient records going back over a decade in a fully secure, encrypted system, accessible from anywhere with internet access, even on his iPhone! Patients can input their medical history online prior to an appointment or with simple check
Even if you cannot relieve all the pain for every patient, you can improve every patient’s function and outlook. – Dr. William O Witt
boxes on an iPad when they arrive. For Witt, developing a comprehensive and customized EMR system removed tedious, time-wasting work from his practice. Most
While waiting, patients and family can stroll in the sunny atrium of Cardinal Hill Hospital with wireless pagers, an idea Witt borrowed from restaurants.
importantly, it allows him and his staff to stay focused on their patients. He highly recommends adopting an EMR system, stating, “You will find that whatever time you spend in the practice of medicine, you will spend it with patients, not alone in your office digging through a bunch of papers and dictating charts.” Witt is now a consultant with Addison. He brings the clinical perspective that allows the software developers to update the product to work most effectively and efficiently. Witt highly values the many professional relationships he has cultivated over his 38 years as a physician, including a number of peers in Kentucky with whom he collaborates. He also works on national and international consensus panels regarding neuromodulation therapies. One of these panels of particular interest is on preventing surgical infection during the implantation process, drawing on his degree in microbiology, his previous experience as a reference bacteriologist with the Minnesota State Health Department, and his implantation of well over a thousand such devices and many thousands of related intraspinal procedures.
A Forward-Moving Field Demands a Forward-Thinking Practice
Witt finds this to be an exciting time in pain management. He cites neuromodulation as one of the more rapidly developing aspects of the field, noting that Boston Scientific Corporation was just awarded a 2014
Popular Mechanics “Breakthrough Award” for its unprecedented neurostimulation technology, made all the more significant in that these awards are not just for medical technology, but for all fields of technology. “This has brought tremendous attention to our field from experts in all areas of science and technology,” he says. Witt is poised to lead and inspire regarding non-narcotic pain management, and CHPI has garnered interest from several outside groups who have come to study his model. He also lectures around the country about his approach and its success. Although his success is timely, he is quick to say that he did not originate this approach. It began with his pain management training in 1978-79, when using opioids for chronic nonmalignant pain was anathema, and excellent results were obtained with an inpatient rehabilitative model in many ways similar to what he now does on an outpatient basis. With virtually no published data to support the efficacy of opioids for chronic nonmalignant pain and a large amount of published data showing deleterious effects and the actual production of pain through opioid-induced hyperalgesia, he smiles while reading a recent article from the American Academy of Neurology entitled: “Potential Dangers Overshadow Advantages of Opioids for Chronic Non-cancer Pain.” Witt comments on the article: “If you practice medicine long enough, not that much is really new when it comes to how the body works!” Through his patient-responsive setting and practices, his innovation, his local and international collaboration, and his congruence with Cardinal Hill, Dr. William O. Witt has crafted CHPI into a highly successful practice. It has kept him innovating to drive his field and practice forward. In sum, these attributes are what assure that his patients not only get better, but feel better during the process as well. ◆ ISSUE#90 13
SPECIAL SECTION PAIN MEDICINE
Family Valued
Pain Medicine and Management maximizes familial bonds to offer a comprehensive approach to pain management BY TIM CORKRAN LEXINGTON When Manoochehr Mazloomdoost,
MD, (Maz) founded Pain Management Medicine (PMM) in 1992, he did so with a vision to help pain sufferers, of which he saw many in society. He says he remembers thinking, “If I can help them, I will be a great achiever.” He would also have to be a pioneer, as pain medicine and pain management was not yet a recognized specialty. It became one in 1998. The comprehensive approach Maz has developed at his highly successful clinic is grounded in three sentiments: one, that pain is a messenger, not the disease. Two, that the intensity of chronic pain is exacerbated when it is combined with depression: both aggravate each other. And three, that familial collaboration is the source of great strength. As such, his partners are his wife, Camillia Shirazi, MD, their son, Danesh Mazloomdoost, MD, (Danesh) and their prospective daughter-inlaw Andrea Omidy, Psy, PhD. Maz was educated in Iran and has been practicing medicine for 50 years. Following anesthesiology experience there and in the US, he settled in Lexington, where, in 1988, he became director of the Lexington VA Pain Clinic. Shirazi met Maz while she was doing her anesthesiology training at Shiraz University, in Iran. She switched to psychiatry following their move to the US, aiming to better address the mental health impact of immigration and other life transitions. She spent 10 years practicing at the VA while PMM was getting established. Her observation that, “Most of the patients that Dr. Maz was treating for chronic pain were also suffering from depression,” opened the door for their merging of the two practices. Danesh attended medical school and completed residency in Anesthesiology at
(L-R) A
true family practice - Camillia Shirazi,MD, Manoochehr Mazloomdoost,MD, (seated), future daughter-in-law Andrea Omidy, Psy, PhD, and Danesh Mazloomdoost, MD.
Johns Hopkins in Baltimore, followed by a fellowship in Interventional Pain at MD Anderson in Houston in 2010, joining PMM after that.
Listening: The First Line to Better Diagnosis
PMM’s main office is in Lexington, with satellite facilities in Corbin and Winchester that take clinic one day a week. The practices see an adult population largely between
IT’S A MATTER OF EDUCATING PEOPLE ABOUT WHAT PAIN MANAGEMENT MEANS. MANY OF THE PATIENTS I SEE ARE COMPLETELY UNAWARE OF WHAT WE CAN ACTUALLY PROVIDE. – DR. DANESH MAZLOOMDOOST 14 MD-UPDATE
PHOTOGRAPHY BY JOHN LYNNER PETERSON
the ages 30 to 60. Most patients come to them for chronic, neuropathic, or cancerrelated pain. Most of the procedures offered are minimally invasive, same-day, and rarely leave a mark. These treatments are far more sustainable than chronic opiate maintenance. Psychiatric care is available at the Lexington office, as they have found that some patients develop a better response to pain management when they also receive counseling support. Shirazi treats many of her patients for mood disorders, which she says are very common among chronic pain sufferers. The value added for the Pain Medicine and Management patient comes from both the presence of the extended Mazloomdoost family and the utilization of the best attributes of a caring family: PMM has a culture of listening, communicating, and sharing information. The physicians regularly “curbside” each other, so informal
exchanges help inform their approaches to PMM’s satellite office in Corbin has their patients. With patients, they employ given them a window to the front line of the an unhurried approach to seek out the epidemic. Danesh finds that the population source of problems. there has been exposed to such high levels of Shirazi’s observation of Maz’s style is, medication in the past that a pervasive atti“He pays attention to his patient’s prob- tude ranks opioids on par with Tylenol. He lems. He talks to them, finds out the source of the problem. Many of our patients complain that other physicians they visited did not give them nearly as much personal attention.” Danesh considers this attribute of paramount value, noting, “a really good pain doctor is a really good diagnostician: we are the first line of understanding why someone hurts.” Such attention goes hand-in-hand with having therapists in the practice. Shirazi continues, “We were not educated about the connection between pain and depression. I began treating some of these (l-r) Manoochehr pain patients for depression, and Mazloomdoost, MD, says, “They are unfortunately amazingly, their ability to tolerate known as "Doctor used to an availability that is pain increased.” She uses both anti- Maz", with son Danesh unrealistic.” He adds, “Our depressants and counseling because, Mazloomdoost Corbin practice is as much a “Most of the time, just medication social program as a medical is not enough. You have to listen to your office because the resources we provide are patient to see what the main problem is.” otherwise non-existent in the community.” Maz has been involved in this battle Communication: more on the national level, helping promote The Key to Challenges and KASPER to Congress a few years ago. There Future Frontiers is the national version in development, The primary challenge in the field of pain called NASPER, which is yet to be funded. management has evolved substantially. When Danesh is thoughtful on the future of Maz began PMM, insurance companies did pain medicine. Not surprisingly, he sees not know the field existed, which led to many communication as the primary frontier. billing problems. Today, those demands are He says, “It’s a matter of educating people replaced by the hydra of opioid abuse. about what pain management means. Many
of the patients I see are completely unaware of what we can actually provide.” PMM approaches its future expansively. Maz has developed a website devoted to the intersection of pain and nicotine addiction called Smokingpain.com. It also details a simple, practical formula for gradually eliminating nicotine addiction, one that puts self-control and reasoning at the forefront. PMM recently brought on Omidy as a psychologist who practices part-time in the clinic. She has a PhD in Psychology from Oklahoma State University and completed a post-doctoral fellowship at Harvard Medical School. While she specializes in disordered eating (both over and under-eating), she sees a spectrum of disorders and plans a comprehensive therapeutic approach for the clinic on coping skills. Danesh notes, “She currently has patients on a wait list given her popularity.”
Family: Engine and Anchor
The PMM approach places family as engine and anchor. That perspective allows its physicians to collaborate effectively and bring a sum greater than its parts to their patients. It also extends to what is promoted to patients. For Shirazi, she says of their patients, “Those who have family support can tolerate their pain much better.” And for Maz, it is summarized in a point of obvious pride: “I believe I have prevented many divorces. I believe that by decreasing chronic pain in a healthy way, I have helped people go back into a good life, a good family. That is why I became interested in this.” ◆
IS YOUR PRACTICE FINANCIALLY HEALTHY? Contact us for a complimentary benchmark analysis of 10 key performance indicators for your practice compared to other practices in your specialty. 2335 Sterlington Road, Suite 100 Lexington, Kentucky 40517 (859) 268-1040 Fax: (859) 268-6165 Email: lproberts@barcpa.com www.barcpa.com
ISSUE#90 15
SPECIAL SECTION PAIN MEDICINE
It Never Hurts to Care
Bux and Bux Pain Clinic treats patients like family BY JIM KELSEY When you’re dealing with chronic pain patients, the patients want treatment, of course. They want relief from the symptoms. And sometimes they just want someone who understands. It’s that third element, says Dr. Anjum Bux that sets apart the Ephraim McDowell Pain Management Center, operated by father Madar Bux, MD, and son Anjum Bux, MD, from many other pain management clinics. “What makes our practice unique is that we treat our patients like family,” Anjum says. “They come in here and not only are they receiving care, but it’s also a social visit. They come in and we talk about kids and the family. They feel well taken care of here because it’s more of a family-type atmosphere.” He continues, “That’s part of the treatment as well. It’s a form of psychological treatment where they want to feel somebody is listening to them and understands that they have pain. So in addition to treating them pharmacologically or with injections, we’re also treating them psychologically.” DANVILLE
The Journey to Danville
Madar graduated from medical school in India in 1962; then moved to England in 1963, where he performed surgery for three years. He was not fully satisfied with the practice of surgery and eventually changed to emergency medicine. “I ended up doing anesthesia because I was in the ER and there was a young female patient with facial injuries, and I didn’t know how to intubate,” Madar says. “So I did a tracheotomy, and it saved her life. But after that I went from learning intubation to learning anesthesiology. I liked it, and they offered me a job. That was in 1969. Here I am still doing anesthesia and have never regretted a day. I love it.” Madar accepted a position at the 16 MD-UPDATE
PHOTOGRAPHY GIL DUNN
Father and son team (l-r) Madar Bux, MD, and Anjum Bux, MD, operate Bux and Bux Pain Clinic at Ephraim McDowell Regional Medical Center in Danville, Ky.
University of Louisville in 1973 before moving to Danville in 1977 as only the second anesthesiologist at the Danville Anesthesia Associates. The program grew over the years, and in 2002 it was ready for a fifth anesthesiologist. Anjum, who attended Centre College and graduated from St. George’s University School of Medicine in St. George’s, Grenada, in 1998, completed his residency at the University of Kentucky in 2002 and joined the Danville Anesthesia Associates team as its fifth physician. “My father at that time stopped doing anesthesiology and went just to pain management,” says Anjum, who is the managing partner for Danville Anesthesia Associates. “At that point the pain management part was separated from Danville Anesthesia
Associates and has operated as Bux and Bux Pain Clinic at Ephraim McDowell Pain Management Center.” Madar continues to work at the age of 79, despite undergoing a complicated heart surgery just three years ago. “There was a 98 percent chance that I was going to die,” Madar says, noting that the opportunity to work with his son is what motivates him to continue to practice. “That’s the reason I decided to continue to work. Otherwise I could have retired, but it was fun to work with my son. It’s just a different feeling when you’re working together.”
A Multidiscipline Approach to Pain
It should come as no surprise that father and son have developed a symbiotic relationship in their practice, complementing each other’s skills and expertise to the maximum benefit of their patients. Madar’s time is completely devoted to pain management, primarily through epidural injections and joint injec-
tions. In cases in which those injections are not enough, they are referred to Anjum. “I’m doing more of the invasive procedures, the intrathecal pain pumps and the spinal cord stimulators,” Anjum says. “My practice is made up of some of the patients that he’s already seen and done injections on, and they need more interventional pain management, including implanted pain pumps or spinal cord stimulators or rhizotomies.” A large part of their practice is patients with intrathecal pain pumps and spinal cord stimulators. According to Anjum, “These treatments are reserved for patients who have failed all conservative therapies, including physical therapy, medications, injections, and are not candidates for surgery or have failed previous surgery.” They have one of the largest intrathecal pump practices in the state with over 400 pumps under management. In addition, they are one of the few practices that utilize a spinal cord stimulator system that is MRI compatible and has adaptive stimulation, which is described as stimulation that automatically adjusts with different positions. Anjum says that, “With this system, patients love not having to worry about getting an MRI in the future and having their stimulator automatically adjust itself to different positions from lying down to sitting to walking.” As expected, the Buxes treat many patients suffering from back pain, neck pain, or arthritis. Recently, they have also become a leader in treatment of shingles. Anjum says their strategy is to take a very aggressive approach, employing the use of nerve blocks, oral medications, antiviral pain cream, and injections. Utilizing these various procedures and techniques demonstrates the growing diversity and expertise present in the field of pain management. Employing these different strategies is slowly helping change a once negative perception that many had of pain clinics. “Pain clinics have always had a bad connotation because people think that a chronic pain clinic means narcotics,” Anjum says. “But it’s much more than that. We have a multidisciplinary way of treating patients.
It involves physical therapy, occupational therapy, psychological treatment with Dr. Johnathan Cole in Lexington, oral medications other than narcotics, and injections. I think people just don’t understand everything that is involved in chronic pain treatment.” Anjum himself had much to learn – even after his formal education ended. Working with his father, Anjum received top-notch instruction every day. “I couldn’t ask for better training,” he says. “It was good to have him nearby. He would let me try things my way, and he would always tell me, ‘you will see.’ And he was right. I’d try it my way, and inevitably I changed.” One thing that hasn’t changed from the early days of the Danville Anesthesia Associates to today is the family atmosphere that makes patients so loyal and satisfied with the care they receive. That level of
compassion and understanding is a trait that runs through both father and son, who might soon welcome a third family member to the practice. Anjum’s wife Faezah is in her second year of residency in anesthesia at UK. There’s little doubt she’s already immersed in the social, familyfriendly atmosphere that sets the Ephraim McDowell Pain Management Center apart. “Often we cannot eliminate the source of the pain,” Anjum summarizes. “We cannot cure degenerative disk disease or degenerative arthritis. So we basically are treating patients to decrease their symptoms and pain level so they can learn to manage and live with their pain. It’s basically treating them psychologically to validate, ‘Yes, you have pain, but here’s how we can help you can live with this pain and go on with your daily life.’” ◆
Danville Anesthesia Associates Providing Anesthesia and Pain Management Services to the Patients of Central Kentucky for over 35 years
Anjum Bux MD Madar Bux MD Perry Majors MD Bill Barnett MD Khursheed Siddiqui MD Scott Fisk MD
ANESTHESIA
Tammy Higgins CRNA Roland Laswell CRNA Eric Gosser CRNA Susan Adams CRNA Amelie Yates CRNA Crystal Carpenter CRNA
PAIN MANAGEMENT Anjum Bux MD, Madar Bux MD Conditions Treated: Treatment Methods: Chronic Back & Neck Pain Pain & Steroid Injections/ Nerve Blocks Degenerative Disc Disease Pain Pumps/ Neurostimulators Fibromyalgia & Myofacial Pain Radiofrequency Ablation Shingles/ Post Herpetic Neuralgia Pain TENS unit and Bracing Cancer Pain Physical Therapy & Occupational Therapy Hip/ Sacroiliac Joint Pain Nutrition Counseling Reflex Sympathetic Dystrophy Family Education & Stress Management
Bux & Bux Pain Clinic
859-236-3726 230 West Main Street Suite 200 Danville, Ky 40422 ISSUE#90 17
SPECIAL SECTION NEUROLOGY
Combating the Pain
Injections for Chronic Migraines BY SARAH WILDER The approach to patients with chronic intractable migraine typically reaches well beyond the medicine bottle. These patients, by definition, are suffering from frequent, moderate to severe headaches, accompanied by symptoms such as photophobia and nausea, and the sufferer is often left disabled. When these migraines are intractable, medical management has already proven ineffective and other means are necessary to gain control of the migraines, according to Eliza E. Robertson, MD, PhD, Lexington Clinic Neurologist. “The neurological evaluation of the patient with chronic migraine must incorporate a multisystem assessment of the patient to include psychological health, stress, sleep, diet, allergy and sinus disease, dentition, musculoskeletal disorders, movement disorders, underlying neurological and medical comorbidities, medications, work environment, and lifestyle. In this light, a multidisciplinary approach to migraine management is typically necessary and may involve referrals for physical therapy, cognitive behavioral therapy, sleep studies, dental treatment, allergy and sinus treatment, diet counseling, and at times pain management,” Robertson says. “Among the most common comorbidities in this group of patients whom I see in my practice are hormonal disturbances, sleep disorders, obstructive sleep apnea, psychiatric disorders, myofascial pain, fibromyalgia, spasticity, cervical disc disease, spinal deformities, sinus disease, food or environmental allergies, bruxism, and temporomandibular dysfunction (TMJ).” As for treatments for patients with chronic intractable migraine, Robertson recommends a relatively new treatment – neurolysis with botulinum toxin injections. Robertson, who completed a residency in neurology at Vanderbilt University Medical Center, learned the techniques of occipital nerve blockade and neurolysis with botulinum toxin during her residency. Both approaches can be very effective at gaining pain control in the medically-refractory migraine patient. Botox-brand botulinum toxin was LEXINGTON
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approved as a treatment for chronic migraines in 2010. A randomized placebocontrolled trial, PREEMPT, released earlier that year demonstrated the positive effects of botulinum toxin within a large population of chronic migraine sufferers. After six months, or two cycles of treatments, patients experienced eight fewer migraines per month, on average. After one year, the
Lexington Clinic Neurologist Eliza E. Robertson, MD, PhD
study showed even greater success with the treatment: 70 percent of patients regularly treated experienced at least 50 percent reduction in migraines. “Nerve blocks in conjunction with trigger point injections can be particularly helpful for migraine sufferers with myofascial pain, spasticity, spinal deformities, and cervical disc disease, as well as for patients with status migrainosis, medication overuse headaches, cluster headaches, and occipital neuralgia. I often combine these treatments with scheduled botulinum toxin injections and as-needed nerve blockade and trigger point injections for breakthrough,” Robertson says. “This new treatment of botulinum toxin seems especially suited to patients suffering with myofascial pain, fibromyalgia, cervical disc disease, TMJ,
PHOTO BY KIRK SCHLEA. PROVIDED BY LEXINGTON CLINIC
and bruxism for whom modification of the standard protocol of injections is often beneficial.” Since the publication of the PREEMPT trial, the use of botulinum toxin for chronic migraine has become a popular treatment offered by neurologists. Although the specific reasons for why these injections reduce the occurrences and intensity of chronic migraines is not currently known, Robertson provides some insight into the matter. “We know that the toxin inhibits the release of acetylcholine across the neuromuscular junction, thereby rendering flaccid paralysis of the target muscle,” Robertson says. “However, we think there may be an additional effect targeting pain-mediating neurotransmitters that are associated with migraines.” For patients with chronic migraines who would like to explore the option of botulinum toxin injections as treatment, Robertson advises they first consult with a physician who currently performs this procedure to verify a diagnosis of chronic intractable migraine and to ensure the patient’s insurance will cover the injections. “Appropriate screening of patients for referral to a physician who performs the procedure should include establishing the diagnosis of chronic intractable migraine, that is, for more than three months the patient experiences at least 15 headache days per month lasting at least four hours and has failed to improve with at least two prophylactic agents from different medication classes. Referral should be to a physician who performs the FDA-approved injection site protocol, which is 31 injections in seven muscles around the head, neck, and shoulders,” Robertson says about the process. “The protocol can be modified, if necessary, to each patient’s needs with subsequent injections based on tolerability and symptoms,” she adds. “While Botox, just one of the three types of botulinum toxin, funded the trials and obtained FDA approval for the treatment of chronic migraines, there are three forms of botulinum toxin type A: Botox, Dysport, and Xeomin. Within my
clinical experience, all three brands of the toxin work equally well in the treatment of chronic migraine,” says Robertson. Regardless of which form of botulinum toxin is used, Robertson recommends the injections as a treatment option to chronic migraine patients because the positive effects of the treatment greatly outweigh the costs. “The potential benefits of this type of treatment include a reduced number of migraines, increased hours of productivity, huge savings in cost, decreased ER visits, and the avoidance of side effects from previously or too-frequently used migraine medications. Given the potential overall improvement in well-being and quality of life, botulinum toxin for chronic migraine is often the best option available,” Robertson says. “Besides, the procedure goes relatively fast and, for most, is well tolerated.” ◆
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THIS IS AN ADVERTISEMENT ISSUE#90 19
SPECIAL SECTION NEUROLOGY
A Revolution in Brain Surgery
U of L neurosurgeon uses highly specialized Endoscopic Endonasal Approach for skullbased tumors BY JENNIFER S. NEWTON We have all heard and perhaps even used the idiom, “It’s not brain surgery,” regarding an easy and uncomplicated task. But what if it is brain surgery? Neurosurgery is a relatively small specialty, with approximately 4,300 neuroLOUISVILLE
surgeons in the US as of January 2009, compared to 20,000 orthopedic surgeons and 16,000 ophthalmologic surgeons1. Of those neurosurgeons, only approximately six percent are women. Narrower still is the number of physicians who have been trained in endoscopic endonasal skull-base procedures of the brain. Mary Koutourousiou, MD, assistant professor of neurosurgery at the University of Louisville (U of L) and director of the skull base program for U of L Hospital, part of KentuckyOne Health, belongs to this elite group. Koutourousiou’s expertise is bolstered by her passion for her work. “I’m always excited by a challenge,” she says. “I believe women are very adept at fixing things with their hands. There is also a kind of artistic 20 MD-UPDATE
involvement in microsurgery, and I found that could be a very good option for me.” Koutourousiou joined U of L in July 2014 to begin building their skull-base program, after spending four years at the University of Pittsburgh Medical Center
(UPMC) completing a clinical fellowship in extended endoscopic skull-base surgery and open skull-base surgery. UPMC has a 25-year history of tackling skull-base tumors and pioneered the Endoscopic Endonasal Approach (EEA). Prior to her time at UPMC, Koutourousiou attended medical school and residency in Greece and completed an endoscopic surgery fellowship in the Netherlands. Referring to the EEA as “revolutionary,” Koutourousiou believes the most important aspect is that it leads to fewer surgical and post-op complications because the brain is not retracted during the procedure. “In traditional open surgery, after we remove the bone, we have to retract the brain in order to get to these deep structures. When we go through the nose, we approach the lesion from below, and actually we don’t have to touch the brain,” she says. Beyond fewer complications, patients enjoy shorter hospital stays (two to three days as opposed to up to 30 days), quicker recovery, and no scarring. The EEA was originally used to treat pituitary adenomas beginning 15 years ago and was adapted for neurosurgical tumors 10 years ago. It can be utilized on any lesion located deep in the skull base, according ABOVE Dr. Mary Koutourousiou is director of the skull base to Koutourousiou. For neurosurgery program at U of L Hospital. PHOTO BY GIL DUNN. BELOW Due to the wide exposure and incredible visualization example, ENT tumors provided by the Expanded Endonasal Approach, this allows the such as nasopharyngeal surgical removal of tumors sometimes considered "inoperable" malignancies and neuroby traditional techniques. IMAGE PROVIDED BY KARL STORZ. surgical tumors such as skull-based meningiomas, chordomas, chondrosarcomas, craniopharyngiomas, trigeminal schwannomas, and dermoids/epidermoids, among others. Since July, Koutourousiou has done 12 pituitary adenomas with the EEA and four extended procedures with more complex cases. As is quickly becoming the mantra in
comes data is scarce. Only UPMC has published extensively on the subject and Koutourousiou is one of the main authors of the most recent outcome publications. Based on this experience, Koutourousiou believes the EEA outcomes are at least Koutourousiou utilizes KARL STORZ’S TAKE-APART® Bipolar Forceps equivalent to those of for endoscopic endonasal surgery. IMAGE PROVIDED BY KARL STORZ. open craniotomy and medicine today, Koutourousiou says the that outcomes will Endoscopic Endonasal Approach is a team increase as more surgeons gain experience effort. She performs each operation in con- with the technique. “The learning curve is junction with ear, nose, and throat (ENT) long. I think outcomes are going to be even specialist Welby Winstead, MD, whose role better in the future,” says Koutourousiou. is to do the initial approach, open the corWith such a small volume of cases approridor for tumor removal, and prepare the priate for the EEA, the University’s investnasoseptal vascularized flap for skull base ment in the endoscope is being maximized repair. The team also includes neuroradiol- by utilizing the equipment for endoscopicogy, neuro-oncology, neuro-anesthesia, and assisted open surgeries. “It’s very important interventional services. because what we do with the endoscope is Because the procedure is still new, out- to bring the light inside the surgical field
and bring our own eyes inside the surgical field, so we can have a closer look at the anatomy and look under direct visualization areas that would not be accessible with the microscope alone,” says Koutourousiou. On November 21, 2014, Koutourousiou completed another extended endoscopic procedure for the resection of a skull base epidermoid tumor that was a first in Kentucky. Certainly one cannot solely credit the technology for revolutionizing brain surgery in Kentucky without tipping a hat to the unique skills, passion, and vision of the surgeon that is making it happen. “I find all these things fascinating, and I’m really in love with what I’m doing,” Koutourousiou says. REFERENCES 1 American College of Surgeons (ACS) Health Policy Research Institute. (2010, April). The Surgical Workforce in the United States: Profile and Recent Trends. Retrieved from ACSHPRI: http://www.acshpri.org/ documents/ACSHPRI_Surgical_Workforce_in_ US_apr2010.pdf ◆
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2/27/14 9:23 AM ISSUE#90 21
SPECIAL SECTION NEUROLOGY
Paving the Road to Intervention
Dr. Alex Abou-Chebl helps pioneer the field of interventional neurology and seeks to build a worldclass stroke program at Baptist Health Louisville BY JENNIFER S. NEWTON If you ask Alex Abou-Chebl, MD, interventional neurologist with Baptist Neuroscience Associates, part of Baptist Health Louisville, the secret to changing the status quo in medicine, his answer will probably be stubbornness and the refusal to accept “no treatment available” as an answer. Five minutes into a conversation with him and his passion and persistence about stroke care are immediately evident. “I actually think stroke is the most important disease known to mankind because it affects the very organ that makes us who we are, that makes us human,” he says. Stroke is the fourth leading cause of death and the leading cause of adult disability in the United States. “The reality is that the majority of patients in the stroke belt, where Kentucky is, do not get adequate stroke care. I want to solve that,” he contends. LOUISVILLE
A Diagnosis without Treatments
It was the complexity of the brain and the lack of effective treatments for stroke while he was in medical school in the 1990s that drew Abou-Chebl to the field of neurology. But the road from education to stroke intervention was an uphill climb. In addition to the lack of therapies, neurologists also faced a misconception about their role. “I refused the notion because I was a neurologist I could not intervene,” says Abou-Chebl. “We could diagnose where the problem was but we were viewed as not being able to offer treatment to patients.” He persevered 22 MD-UPDATE
PHOTO COURTESY BAPTIST HEALTH
neurologists are not the only physicians who can treat stroke and that building a better program necessitates a team approach. “The ideal program, which is what I think we have here at Baptist, is where neurologists, neurosurgeons, and neuroradiologists work together to deliver the best Dr. Alex Abou-Chebl, with Baptist Neuroscience Associates, was one of possible care.” Each the first interventional neurologists in the world. of these specialties because he believed the clinically trained can perform stroke interventions and each neurologist is the best person to manage brings different tools and skills to the table, patients through all phases of care. he posits. In 1999, Abou-Chebl began a fellowship With the right team in place, the next in interventional neurology at Cleveland part of Abou-Chebl’s mission is to conClinic, a training program he helped cre- tinue to expand effective stroke treatments. ate. He completed that fellowship and two “Every stroke patient has to be given a others, in stroke and critical care neurology, chance to receive some treatment, and this concurrently at Cleveland Clinic over the means we cannot stop until we prove that next three years. In 2002, he became the there’s no brain tissue worth saving, for first interventional neurologist on staff at every individual,” he says. Cleveland Clinic and “one of the first interFor example, Abou-Chebl refused to ventional neurologists in the world,” he says. accept there were no treatment options Fortuitously for Abou-Chebl, his pursuit for the acute stroke patient who presents of comprehensive stroke care overlapped beyond six hours after onset. After doing with the advent of effective stroke treat- a few anecdotal cases, he set about creating ments, such as thrombolysis and mechanical the scientific evidence to back his position. embolectomy, in the late 1990s and early “One way we can garner that evidence is by 2000s. “The development of the field of doing advanced multimodal imaging – scans neurology really coincided with the avail- that look at how much brain tissue is dead, ability of new treatments,” he says. how much brain tissue is at risk of dying, By 2006 there were 14 interventional and what brain tissue is not at risk of dying,” neurologists in the world, and they formed he says. By working with neuroradiologists the Society of Vascular and Interventional to do CT and MRI perfusion scans, they Neurology, of which Abou-Chebl was the established a protocol for screening patients. founding vice president and is still a board The neuroradiologists then interpret the member. scans to identify patients with large penumbras, brain tissue that is at risk of dying, to Building a Better Program see who could benefit most from mechaniAbou-Chebl joined Baptist Health Louisville cal embolectomy, removal of the clot, or in August 2014 after seven-and-a-half years thrombolysis, clot-busting medication. as director of Interventional Neurology Abou-Chebl then performs the procedure. at the University of Louisville. Because of In the case that the procedure is not successBaptist Health’s large patient population ful or there is already too much damage, a and gap in comprehensive stroke services, neurosurgeon may be called in to consult. he says, “I saw an opportunity here to help build a world-class stroke program.” Ever-Evolving Treatments He is quick to note that interventional Because acute stroke treatments are still
relatively new, they are still being tested and fine-tuned. Intravenous tissue plasminogen activator (IV tPA) is still the gold standard for ischemic stroke, the most common type of stroke, when administered within three to four hours of stroke onset. However, AbouChebl says, “Generally across the country, only five percent of patients are being treated with IV tPA. We have to do better.” National guidelines for door-to-tPA time are under 60 minutes. Abou-Chebl says Baptist Health Louisville’s quickest door-totPA time has been 15 minutes, and they do a “substantial amount” under 30 minutes because of the protocols they have in place. Beyond tPA, the good news is that in mid-November 2014, two randomized clinical trials showed mechanical embolectomy to be effective at improving stroke outcomes for the first time. “I think now the standard of care is going to shift so that within 12 hours of stroke onset, if a person has major stroke, and a CT scan doesn’t show a lot of dead brain, they should be offered mechanical embolectomy,” says Abou-Chebl. The success rate for opening an artery with this procedure is 80 to 90 percent, and AbouChebl says up to 60 percent of patients walk home from the hospital. In hemorrhagic stroke, there is a new Pipeline stent for subarachnoid hemorrhages, available at Baptist, which is employed in the normal artery to block blood flow to the aneurysm. Regardless of stroke presentation, for Abou-Chebl the path is clear: “The days of therapeutic nihilism are gone. We’ve got to get rid of this notion that you can’t treat stroke patients … and we’ve got to do better at educating our patients on the symptoms of stroke. If they don’t come in, we can’t treat them.” ◆
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ISSUE#90 23
SPECIAL SECTION NEUROLOGY
Georgetown Welcomes New Doctor To Lead Neurology Department Neurology is one of several new service lines at Georgetown Community Hospital BY JIM KELSEY
When William Haugh, CEO of Georgetown Community Hospital (GCH), met with his staff regarding the community needs and service lines offered at their hospital, one consistent theme was voiced. “We asked the medical staff what services were needed here, and which services they saw being transferred out,” Haugh says. “Neurology was always one of the top areas identified.” The solution to that need came September of 2014 with the addition of Dr. Melissa Smith, DO, who practices general neurology. Initially, when GCH started the neurology department it performed ancillary testing and it was not a very formal department, Haugh says. “Now with the addition of Dr. Smith, our neurology department has been strengthened to meet the community need. Our overall goal is to keep the patients in their community instead of having to transfer to other facilities.” Dr. Smith, whose husband Eric is a surgeon at Georgetown Community Hospital, has provided the hospital with the service they were looking for. Smith, who attended West Virginia School of Osteopathic Medicine, credits extensive practical training with preparing her for running her own practice at Georgetown Neurology and Neurodiagnostics. Smith trained at the Dayton Center for Neurologic Disorders and credits her residency director Dr. Michael Valle in particular for helping her gain the experience and exposure she needed to succeed. Five years in Dayton were followed by eight and a half in Ashland, Ky., before Georgetown Community Hospital came calling. “All of my osteopathic training was volunteer,” she says. “Their trainers are not paid university trainers. They are in private practice and they’re in the communities. Therefore I think you get hands on experience and a more real world experience early on. I think that helps rather than being in an academic university setting.” 24 MD-UPDATE
It hasn’t taken long for Smith to make her presence felt. Her growing patient population ranges from ages 18 to 80-plus and she sees patients presenting with the acute management of back pain to more chronic neuro-degenerative diseases such as dementia and Parkinson’s.
with meeting with the patient and their family during the initial diagnosis. From there, the focus turns to day-to-day activities, outof-the-norm activities, and maintaining an overall quality of life. Home health care is a big component of the treatment plan of these progressively degenerative disorders. While Alzheimer’s continues to evade effective cures and treatments, another major neurological disorder has seen dramatic changes in recent years. “One significant advancement in is in treatment for multiple sclerosis,” Smith says “From the time I started until now, we’ve had more than triple the amount of medications available now and options for patients. The outcome is that we’re seeing
Melissa Smith, DO, has filled a need for neurology at Georgetown Community Hospital. ABOVE
PHOTO BY GIL DUNN
William Haugh, CEO, Georgetown Community Hospital restores service line to fill community needs. PHOTO COURTESY GEORGETOWN RIGHT
COMMUNITY HOSPITAL
Treating patients with dementia disorders such as Alzheimer’s is especially challenging. “The dementias are a struggle because we don’t have any real effective treatments. It’s also hard on the family,” Smith says. “There’s an overall perception with many of these neurological diseases that we can’t help patients, because there aren’t cures. But there are things we can do. There’s support and education we can give, such as getting patients and families involved in home health programs, that can significantly improve quality of life. Frequently we can help improve the situation, even if we can’t cure the problem.” Improving the situation typically begins
patients with much less disability and much more improved quality of life.” As she gazes into the future of neurological disorders, Smith believes the attention and public support for research into disorders such as Parkinson’s and Alzheimer’s will lead to finding treatment options that will slow – or even cure – the diseases. And her own future is focused on doing what Haugh brought her to Georgetown for – to fill a community need. ◆
SPECIAL SECTION MENTAL HEALTH
Evaluation and Consultation
Frazier Rehab Institute’s Neuropsychology Services offers diagnostic evaluation and consultation to neurologic patients and their physicians BY JENNIFER S. NEWTON Neurologic events, such as traumatic brain injury, stroke, and dementia, require multi-faceted care. Frazier Rehab Institute, a part of KentuckyOne Health, is well-known for its inpatient and outpatient rehab services. At Frazier, rehabilitation is about recovering not just physical deficits, but also improving cognitive functioning and quality of life. In addition to rehab therapists, Frazier employs psychologists and neuropsychologists whose services supplement inpatient and outpatient rehab. “Our focus is on adjustment to disability and facilitating recovery postinjury,” according to Brandon C. Dennis, PsyD, neuropsychologist with Frazier. He adds, “Neurologic injury often comes with psychological, behavioral, and cognitive changes. We work with the patient, family, physician, and treatment team to maximize recovery.” But how is that cognitive recovery measured? And when can a patient return to normal activities? That’s where neuropsychological evaluation can help. LOUISVILLE
A Unique Subspecialty
In contrast to typical psychologists, the neuropsychologist’s job is primarily assessment. Their services are sought out when, “There is a suspected or confirmed condition, and a physician has a question about diagnosis, severity, functioning, treatment, or whether other factors are contributing,” says Dennis. He adds, “Our job is focusing on neurologic function, the cognition, as opposed to the purely psychiatric.” Dennis, whose father is a clinical psychologist, says he initially resisted following in his father’s footsteps, but his aptitude led him into the field. “I always loved neuropsychology because it allowed me to see the complex brain-behavior relationships from both psychological and neurological perspectives,” he says. “Practicing in a physical rehab setting is especially rewarding because everything is focused on the positive and improving outcomes.” Dennis’ primary focus is acquired brain injury, as in traumatic brain injury or stroke. Dementia and memory disorders are a close second, followed by movement dis-
The Power of Pen and Paper
Dr. Brandon Dennis, neuropsychologist with Frazier Rehab Institute, part of KentuckyOne Health, says his role is about assessment, patient education, improving outcomes, and enhancing quality of life.
orders, epilepsy, and other conditions with a cognitive component. In addition to rehab, Dennis sees patients in a variety of contexts. He does preand post-surgical assessment for patients undergoing deep brain stimulation surgery with U of L Physicians. He consults with Jewish Sports Medicine on sports-related concussion, and he works closely with KentuckyOne neurologists on a variety of conditions. Although many of his referrals
Most patients have never encountered a neuropsychologist, and thus do not know what to expect from an evaluation. The tools neuropsychologists use are mostly pencil and paper, Dennis says, adding, “All of what we do is individually administered. It’s one-on-one, face-to-face, and we don’t use any needles or electrodes. It’s answering questions and performing tasks to see how well they can remember new information, sustain attention, or solve problems.” An analogy Dennis often uses is, “Neuropsychological assessment is kind of like radiology. The MRI scan will give you the structure of the brain, but our testing tells us how those areas are functioning. We look at scores compared to what we expect, and send our findings back to your physician for ongoing treatment.” He adds, “In addition, we are trained in cognitive intervention and have experience with learning/attention problems and psychiatric or behavioral issues, so we are in a unique position to help.” The most common “treatment” Dennis provides is patient education. “Education goes a long way and that’s a lot of what we do. Studies have shown patients with brain injury have better outcomes when they understand their injury and know what to expect in recovery,” he says. Consistent with that idea, Dennis teaches a family and patient education group at Frazier, does regular lectures and support group talks, and is active with research efforts. When making a referral, Dennis says the best thing a physician can do is communicate clearly what neurologic symp-
OUR JOB IS FOCUSING ON NEUROLOGIC FUNCTION, THE COGNITION, AS OPPOSED TO THE PURELY PSYCHIATRIC. – DR. BRANDON DENNIS are internal, Dennis is quick to note that the department is happy to accept outside referrals and, in fact, up to half of their current referrals come from outside the KentuckyOne network.
toms he/she is seeing that would necessitate evaluation. “What are yours or the patient’s concerns? Are there skills we can measure or questions we can answer? That’s where we can really be most helpful,” he concludes. ◆ PHOTO COURTESY KENTUCKYONE HEALTH
ISSUE#90 25
MENTAL HEALTH
The Other Talk
Have your patients had “The Conversation”? I would certainly count myself among the 90 percent of Americans that say it’s important to talk about their endof-life care wishes, but like many others (70 percent, to be exact) I had not actually had “The Conversation” with my loved ones — until recently. There are a million reasons to avoid or put off having the conversation, but you and I already know the primary reason: Whether you’re doing the asking or the telling, it’s hard. The Conversation Project, co-founded by Pulitzer-Prize-winning syndicated columnist Ellen Goodman, can make it a whole lot easier for your patients to talk with their loved ones about the rest of their lives. It offers the tools, guidance, and resources — as well as motivation — needed for patients to get their thoughts together, gather around the kitchen table, and have one of the most important conversations they’ll ever have. There’s also a patient’s guide for how to talk to their doctor – and there’s even a guide for doctors about how to talk to patients and their families about end-of-life care wishes. The conversation isn’t so much about filling out advance directives or other medical forms. According to author Tim Prosch, it’s more about navigating how and when to give up the car keys, where patients want (and where they’ll be able) to live, and how patients want their loved ones to start taking over decision-making when they no longer can — including their preference for cure versus comfort and who will advocate for their medical needs. According to Goodman, “Elderly parents and adult children often enter into a conspiracy of silence. Parents don’t want to worry their children. Children…worry their parents will think they’re expecting or waiting for them to die. We often comfort ourselves with the notion that doctors are ‘in charge’ and will make the right decisions. And we all think it’s too soon to speak of death. Until it’s too late. In the last years of my mom’s life, I started talking with other people I knew LOUISVILLE
26 MD-UPDATE
who had been through similar experiences … The difference between a good death and a difficult death seemed to be whether the dying person had shared his or BY Jan Anderson, PsyD, LPCC her wishes. So a group of my friends and colleagues—about a dozen of us in medicine, media, and the clergy—decided to come together and try to get people talking about this subject.” Like Goodman, Prosch’s motivation for writing The Other Talk: A Guide to Talking
1
2
3
Grief program. But I wasn’t prepared for the emotional wallop I encountered as I wrestled with questions like the ones in the Conversation Starter Kit as illustrated in the chart below.
Or pondering questions like:
• Are there any circumstances you would consider worse than death? (Long-term need of a breathing machine or feeding tube, not being able to recognize your loved ones, etc.) • When would it be okay to shift from a focus on curative care to a focus on comfort care alone? It’s a lot to think about.
4
I want my doctors to do what they think is best 1
5 I want to have a say in every decision
2
3
4
Ignorance is bliss.
5 I want to know how long I have to live
Questions from the Conversation Starter Kit
with Your Adult Children About the Rest of Your Life, came from his personal experience of caring for his parents during the last part of their lives. “Certainly the most challenging was the role reversal that I found myself in … becoming my parents’ parent … with no planning, no expertise, inadequate resources and, most significantly, no direction and no ‘buy-in’ from my parents. It brought me to the same conclusion as all those Boomers that I’ve interviewed over the last decade: I’ll never put my kids through what just happened to me!” I didn’t expect the conversation to be very hard for me — I have a living will, an advance directive, and a health care proxy. One of the electives I chose in my doctoral program was Death and Dying. For 15 years I co-facilitated the Hosparus Living Through
And then there’s how to bring the subject up, whether you want to tell someone your wishes or ask someone about theirs. Goodman suggests some ways patients or their loved ones can break the ice: • “I was thinking about what happened to ______________, and it made me realize…” •“Even though I’m okay right now, I’m worried that ____________, and I want to be prepared.” • “I just answered some questions about how I want the end of my life to be. I want you to see my answers. And I’m wondering what your answers would be.” She emphasizes, “Whether you’re sharing your wishes or need to hear from your parents, start by bringing up a memory, a statistic, an article (like this one). Try
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to remember these are not Grim Reaper talks. They’re not discussions about what’s the matter with you. They are about what matters to you. How you want the end of your life to reflect the whole of it. As many people have told us, these conversations produce rich moments of emotional connection. They bring us closer together. What’s more, people who have had them tend to choose less aggressive care and leave their survivors less regretful and depressed. What a gift!” Or as Tim Prosch says, “That’s why your kids will love you for it!” Dr. Jan Anderson is a licensed professional clinical counselor with a doctorate in clinical psychology. Her private practice includes over 15 years of experience counseling individuals, couples, and families. ◆
Issue #91 – Feb – HEART & LUNG CARE Cardiology, Pulmonology, Sleep, Medicine / Eating Disorders Issue #92 – March/April – INTERNAL SYSTEMS, Urology, Gastroenterology, Nephrology, Pathology / Organ Donation, Forensic Medicine Issue #93 – May – WOMEN’S HEALTH, Women’s Health, Pediatrics, Endocrinology / Genetics/ Sexual Health Issue #94 – June/July –MEN’S HEALTH, Dermatology, Plastic Surgery / Sports Medicine, Fitness Issue #95 – August/September MUSCULOSKELETAL HEALTH Orthopedics, Physical Medicine, Rheumatology / Occupational Health Issue #96 – October – SURVIVING CANCER, Oncology, Radiology, Imaging / Hospice, Home Health Issue #97 – November – IT’S ALL IN YOUR HEAD, Neurology, ENT, Pain Medicine / Mental Health, Smoking Cessation Issue #98 – December/January 2016 PREVENTION AND SENIOR HEALTH, Internal Medicine (including Hospitalists and Concierge Medicine), Family Medicine & Geriatrics, Ophthalmology / Physician Extenders, Residential Care
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ISSUE#90 27
NEWS EVENTS ARTS
Two U of L Researchers Named Fellows of the NAI
Two researchers at the University of Louisville (U of L) were named Fellows of the National Academy of Inventors (NAI). LOUISVILLE
Dr. Joshua Huffman (left), and Christina Huffman, Suzanne T. Ildstad, MD, director of U of L’s Institute for Cellular Therapeutics, and Kevin M. Walsh, PhD, director of the Micro/Nano Technology Center, were among 170 new fellows named. They will be inducted by Deputy U.S. Commissioner for Patent Operations Andy Faile, of the United States Patent and Trademark Office, during the 4th Annual Conference of the National Academy of Inventors on March 20, 2015, at the California Institute of Technology in Pasadena. Those named bring the total number of NAI fellows to 414, representing more than 150 prestigious research universities and governmental and non-profit research institutions. To qualify for election, NAI fellows must be academic inventors named on U.S. patents and nominated by their peers for outstanding contributions to innovation in areas such as patents and licensing, innovative discovery and technology, significant impact on society and support and enhancement of innovation. Ildstad is the Jewish Hospital Distinguished Chair in Transplantation and professor in the Department of Surgery in the U of L School of Medicine. She also holds associate appointments in the school’s Department of Physiology and Biophysics and Department of Microbiology and Immunology. Ildstad has 20 patents related to her research and is the founding scientist of Regenerex LLC, a biotechnology company. 28 MD-UPDATE
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Her research is being translated into the clinical arena with FDA approval to enroll patients in six different research protocols to treat autoimmune disease (multiple sclerosis), red blood cell disorders (sickle cell anemia and thalassemia), and inherited metabolic disorders, and to induce tolerance to organ transplants (kidney). Walsh is a professor and holder of the Samuel T. Fife Endowed Chair in the Department of Electrical and Computer Engineering at the J.B. Speed School of Engineering. He also is founding director of the Micro/Nano Technology Center (MNTC), home of the nationally-ranked, class 100, $30 million, 10,000-square-foot cleanroom in which dust particles are totally eliminated so one can successfully design and prototype ultra-miniature devices and systems for a variety of fields including microelectronics, health care, consumer products, and defense. Walsh has 12 awarded patents and is cofounder of four technical start-up companies – Assenti, Intellirod Spine, UltraTrace Detection, and Simon Sounds. He has published more than 150 technical papers in the areas of micro/nanotechnology and micro-electro-mechanical systems (MEMS), and his research group has won over $35 million in external research funding from the National Science foundation, NASA, National Institutes of Health, and others. He has twice been presented with the school’s top Research Award for the threeyear periods of 1998-2000 and 2007-2009.
Baptist Health Elects New Board Members
A Paducah attorney has been named chairman of the Baptist Health Board of Directors. R. Christion “Chris” Hutson, who previously served as vice chairman, was elected chairman by fellow board members during the board’s December meeting in Louisville. Hutson’s term begins Jan. 1. Hutson, who already was a director of the Baptist Health Paducah and Baptist Health Madisonville boards, is a member (partner) with the law firm of Whitlow, Roberts, Houston & Staub, PLLC, in Paducah. Allen Rudd, president of Rudd Insurance Inc. of Madisonville, will now serve as vice
chairman. Rudd is chairman of the Baptist Health Madisonville board. In other board news, two physicians were appointed to four-year terms: Ramsey N. Nassar, MD, of Nephrology Associates of Kentuckiana, PSC, in Louisville; and Randal W. Owen, MD, president/managing partner for Lexington OBGYN Associates. “We believe it’s very important to include the perspective of practicing physicians on the Baptist Health board of directors,” said Baptist Health CEO Stephen Hanson. “Physicians help ensure that decisions we make have a sound basis in real-life medicine.”
Louisville Team Performs Hand Transplant on Bowling Green, Kentucky Man
A Bowling Green, Ky., man was the ninth patient to receive a hand transplant by the Louisville Vascularized Composite Allograft (VCA) surgical team at Jewish Hospital during a 16-hour procedure on November 25. The Louisville VCA team is a partnership of physicians, researchers, and health care providers from Jewish Hospital, part of KentuckyOne Health; the Christine M. Kleinert Institute for Hand and Microsurgery (CMKI); the Kleinert Kutz Hand Care Center; and the University of Louisville. The hand transplant recipient, Jim Ray, is recovering and resting comfortably at the hospital. Joseph Kutz, MD, with the Kleinert Kutz Hand Care Center, is co-principal investigator of the hand transplant clinical LOUISVILLE
LOUISVILLE
Kleinert Kutz surgeon, Tuna Ozyurekoglu, MD, and Christine M. Kleinert Institute fellows Benjamin Wei, MD, and Colleen Calvey, MD, identify structures and prepare for bone work while Joseph E. Kutz, MD, oversees the operation.
NEWS trial. He led a team of 26 hand surgeons to perform the procedure. Michael Marvin, MD, director of transplantation at Jewish Hospital and associate professor of surgery at the University of Louisville, is also a coprincipal investigator.
New "Super Accelerator" Truebeam™ Radiotherapy System at Baptist Health Louisville
Greater precision in targeting tumors and reducing treatment times to just a few minutes are just some of the benefits of the new Truebeam™ radiotherapy system recently installed at the Charles and Mimi Osborn Cancer Center at Baptist Health Louisville. The equipment is from a new line of super accelerators by Varian Medical Systems. “This is cutting-edge radiation therapy technology providing treatment precision measured in less than a millimeter,” said Carole Scharf, MD, radiation oncologist and program medical director. “Its engineering reduces the number of steps required in both imaging and patient position, therefore greatly reducing overall treatment time, which results in greater patient comfort and convenience.” The technology uses non-invasive radiation to target cancer tumors and preserve healthy surrounding cells with most treatment times only lasting a few minutes. In addition, Truebeam performs both intensity-modulated radiotherapy (IMRT) and image-guided radiotherapy (IGRT). The Center started treating patients with the Truebeam system on December 1. LOUISVILLE
ical center will continue to be a first-line stroke treatment center. The collaboration will allow for the sharing of best practices and outcomes data to promote continuous quality improvement in stroke care. The Medical Center is the first hospital that was already designated as a Primary Stroke Center by The Joint Commission before joining the network. Other hospitals in the network obtained their Primary Stroke Center designation after becoming affiliates of the network.
Baptist Health Sports Medicine to Partner with Louisville City FC
When Louisville’s first professional outdoor soccer team takes the field for preseason games in February, players will have the support of the Baptist healthcare system. In Louisville City FC’s first official sponsorship, Baptist Health Sports Medicine will provide the team with its comprehensive, multidisciplinary services, including dedicated team physicians, sports performance, LOUISVILLE
athletic training, and physical therapy. Baptist Health Sports Medicine is located in Baptist Health Louisville’s Eastpoint Parkway outpatient center. The 11,000-square-foot sports medicine facility offers diagnostic technology including digital X-rays, MRI, CT, and advanced ultrasound, as well as a physical therapy/training gym, indoor running track, climbing wall, and a turf field. Services also include onsite orthopedic surgeons, a neurologist specializing in concussion management, and a sports nutrition counselor. Christopher Pitcock, MD, and Mark Puckett, MD, will serve as team physicians, with Scott Ritter serving as the team’s athletic trainer. Nick Sarantis, practice manager for Baptist Health Sports Medicine, will head up the team’s sports performance training. In the coming months, Baptist Health Sports Medicine will work with the team to host events introducing players to the community, drum up excitement for the team, and get the word out about their services as well. ◆
The Medical Center at Bowling Green Joins UK HealthCare Stroke Network
UK HealthCare has announced that The Medical Center at Bowling Green has become the newest member of the Norton Healthcare/UK HealthCare Stroke Care Network, a community-based stroke initiative providing the highest quality clinical and educational programs to hospital staff and the community. The Medical Center is the only hospital in south-central and western Kentucky to join the network that includes 25 affiliate hospitals. As part of the Norton Healthcare/UK HealthCare Stroke Care Network, the medLEXINGTON
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EVENTS
26th Annual Saint Joseph Hospital Foundation Evening with the STARS Gala The 26th annual Evening with the STARS Gala, November 15, 2014, at the Embassy Suites in Lexington, raised a record amount of more than $100,000 for the Saint Joseph Hospital Foundation, part of KentuckyOne Health. Proceeds from the event are used to further the success of Saint Joseph Hospital’s, Saint Joseph East’s, and Saint Joseph Jessamine’s healthcare initiatives. This award recipients were: David Blake, MD - The President’s Award for Physician of the Year at Saint Joseph Hospital; Kimberly Stigers, MD - The President’s Award for Physician of the Year at Saint Joseph East; Helen O. Hamilton - Outstanding Community Volunteer of the Year Others who were recognized at the event, including nominees for the President’s Award for Physician of the Year at Saint Joseph Hospital, were: Jon Bowen, MD, Grant Breazeale, MD, Dermot Halpin, MD, Joshua Huffman, MD, Charles Kennedy, MD, Samer Kseibi, MD, Scott Pierce, MD, John Stewart, MD, and Jeff Weaver, MD. Nominees for the President’s Award for Physician of the Year at Saint Joseph East were: Marta Kenney, MD, Hossam Zohary, MD, and Yasser Zohary, MD. The Evening with the STARS Gala has raised over $1.2 million for projects such as the Patient Family Assistance Fund, nursing scholarships, transportation for cancer patients, and services for the underserved, including screening mammograms for uninsured or underinsured women. Most recently, the Saint Joseph Hospital Foundation provided a portion of the funding for the $1 million expansion of KentuckyOne Health Breast Care at Saint Joseph East. ◆ LEXINGTON
Dr. Kimberly Stigers, St Joseph East winner, Dr. David Blake, SJH winner, and Helen Hamilton, Outstanding Community Volunteer.
Dr. Dermot and Melanie Halpin.
Dr. Kimberly Stigers and Dr. David Stigers. Christina Huffman, Dr. Joshua Huffman, and Meredith Huffman, daughter.
Dr. Magdalen Karon and Dr. John Stewart.
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Dr. and Mrs. Charles Kennedy.
PHOTOS COURTESY OF THE SAINT JOSEPH HOSPITAL FOUNDATION
Dr. and Mrs. Richard Budde.
EVENTS
"Mindfulness" Workshop Presented at State Conference of Counselors BY GIL DUNN LOUISVILLE- Jan Anderson, PsyD, LPCC,
sole practitioner at LifeWise by Dr. Jan, presented a “Mindfulness and Resilience” experiential workshop at Anderson the 2014 conference of the Kentucky demonstrates for patients having MRIs Counseling Association (KCA) in rhythmic and non-sedated procedures Louisville on November 7, 2014 at movements and and examinations. Anderson the Crowne Plaza Hotel. The presen- breathing, which noted, “Mindful breathing tation was entitled “How to Focus have a calming, techniques such as these Your Attention, Reduce Emotional centering effect, have also been found to help Reactivity and Connect to an Inner both mentally and improve sleep and energy, physically. Wisdom” and focused on two aspects reduce blood pressure, lower of mindfulness: “Mindful Breathing” cholesterol and blood gluand “Mindful Movement.” cose, and even correct heart arrhythmias.” Anderson described mindfulness as “the Anderson led participants through “The ability to focus in a receptive, relaxed way Calming Breath Part 1,” which is a 1:2 ratio on present moment experience.” To give breath (Inhale to a count of 4 and exhale to attendees an actual experience of mindful- a count of 8). “The calming effect comes ness, Anderson led participants through a from extending the length of the exhalaseries of simple mindful movements that tion,” explained Anderson. After mentioncan be done in a standing or seated posi- ing conditions for which “The Calming tion. “Rhythmic movement integrated with Breath Part 2” might be contraindicated, rhythmic breathing has been found to have Anderson then introduced this 1:1:2 ratio a calming, centering effect, both mentally breath, which includes breath retention. and physically,” according to Anderson. Anderson concluded by mentioning Anderson then focused specifically on that both mindful movement and mindful The Calming Breath, an effective anti- breathing can be a preparation for, or alteranxiety technique that she recommends native to, mindfulness meditation. “These
simple practices are powerful ways to help ourselves and our patients achieve focus, calm, and center.” In addition to mindfulness-based therapies, Anderson specializes in relationship and life strategy counseling. One difference in her approach is that in addition to training in counseling psychology, she draws on 20 years of experience in the corporate business world and holistic expertise in the mind-body connection. Anderson notes, “The diversity of my background, training, and experience puts me in a unique position to be able to focus on the well-being of the whole person – whether it relates to relationships, life transitions, wellness, or work.” As an additional resource, Anderson referred participants to podcasts of The Calming Breath available on her website at www.DrJanAnderson.com. Each podcast takes two-to-three minutes, so it makes the calming, centering effect quickly and easily accessible to her clients. Over 500 professionals attended the KCA conference where sessions were designed to strengthen skills, provide new information, and encourage professional development. The KCA is a nonprofit, professional organization having over 1,300 members and is an affiliate of the 40,000 member American Counseling Association. For more information contact Karen Cook, KCA executive director, at karen.cook.kca@ gmail.com or 1-800-350-4522. ◆
Go Red For Women Luncheon raises funds, awareness for heart disease prevention. Go Red For Women (GRFW)) is the American Heart Association’s national call to raise awareness of heart disease as women’s No. 1 killer, and empower women with the knowledge they need to take charge of their health. The Lexington GRFW event was November 14, 2014 and featured Central and Eastern Kentucky women with ties to heart disease and stroke. Keynote speaker was Bonnie St. John, a former Olympian and best-selling author, LEXINGTON
"In competitive skiing, everyone falls down. The winner is the one who gets up faster." Bonnie St. John
(L-R) Stephanie Sarrantonio, Director of Marketing, KentuckyOne Health Central/Southeastern KY with Dr. David Blake at Go Red For Women.
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Walkers making a little noise included Kate Stevens, RN, clinical coordinator, third from left in the black toboggan; Greg Brislin (red Jacket), exercise physiologist and phase I coordinator, and Deborah Ann Ballard, MD, MPH (far right), medical director of Integrative Medicine at Healthy Lifestyle Centers.
EVENTS
Bluegrass MGMA Annual Vendor Fair
The Bluegrass chapter of the Medical Group Management Association held its annual Vendor Fair at the Red Mile Clubhouse on Thursday, November 13th, 2014. A diverse group of vendors participated including: KORT – Kentucky Orthopedic Rehab Team Elucidate Financial Solutions Credit Bureau Systems SecureStream, a Waste Solutions Company Intellisuite Technologies: IT Services & Tech Support Professionals Insurance Agency State Volunteer Mutual Insurance Company RH Clarkson Insurance Group Soterion Medical Services MD Update Magazine Representatives for each company were on-site to answer questions and provide information, including brochures and other materials, on their services. Vendors offered giveaways and drawings for prizes were held at the end of the fair. It was an excellent opportunity to discover new vendors and check with representatives for updates. ◆ LEXINGTON
ABOVE LEFT Shannon
Helton, Lexington Clinic, president BGMGMA, welcomes over 80 attendees and members to the annual vendor fair and luncheon, ABOVE RIGHT Tracey Burchell, Danville Orthopaedics & Sports Medicine, was co-moderator of panel discussion on current coding and re-imbursement issues.
KentuckyOne Health Louisville celebrates second anniversary of Walk with a Doc at the Parklands of Floyds on November 8, 2014 Walk with a Doc is a free, nation-wide, non-profit program for people interested in taking steps for their health. Physicians and other healthcare professionals from KentuckyOne Health answer participants’ questions while walking in a beautiful setting. During the months of December, January, and February, the walks are held indoors at the Mall St. Matthews on Shelbyville Road in Louisville. Walk with a Doc is part of KentuckyOne Health’s ongoing efforts to engage people in healthy lifestyle habits that prevent disease and promote wellness. Deborah Ann Ballard, MD, MPH, an internist and integrative medicine specialist, is the physician champion for the Walk with a Doc program in Louisville. As an integrative medicine specialist, Ballard encourages lifestyle strategies such as diet, exercise, stress LOUISVILLE
Broadway live
reduction, and toxin avoidance to treat or reverse many common conditions such as type 2 diabetes, hypertension, and coronary artery disease. KentuckyOne Health physicians affiliated with Flaget Memorial Hospital walk through historic downtown Bardstown with participants there. More information on other locations of the Walk with a Doc program is available at www. walkwithadoc.org/our-locations/ louisville. Old Courthouse Building 10am 2nd Saturday of Each Month at the Old Courthouse Building Downtown Bardstown, KY Parklands of Floyds - 10am 2nd Saturday of Each Month At the Egg Lawn Louisville, KY Iroquois Park 10am 3rd Saturday of Each Month at the shelter near the amphitheater,Louisville, KY Shawnee Park- 10 am 4th Saturday of each month at the middle concourse Parking Lot just north of the Bandstand Louisville, KY
JAN 23-25 CO-PRESENTED BY
(859) 233-3535 • LEXINGTONOPERAHOUSE.COM
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