Medical Insider 2019

2019

Medical Insider Professionals • Hospitals • Practices • Technology

Meet Pioneers in Patient Care People-driven initiatives and treatments An Award-Winning Roadmap for Surgery Patients (and Staff)

Success Stories in Opioid Addiction Treatment

Breakthroughs in Holistic Dentistry

New Prostate Cancer Support

Telemedicine for Emergency Pediatric Patients

TAVR—A Minimally Invasive Alternative to Open Heart Surgery

A supplement to

LoAnn Vande Leest CEO Copper Ridge Surgery Center MI 1

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LOANN VANDE LEEST, CEO (AKA CHIEF CHEERLEADER) COPPER RIDGE SURGERY CENTER

» Award-Winning Surgical Care

A Roadmap for Compassion and Quality

ON THE COVER AND THIS PAGE: PHOTOS BY MICHAEL POEHLMAN

By Emily Tyra

For over 14 years, Copper Ridge Surgery Center (CRSC) has offered patients in Northern Michigan expert surgical care in a non-hospital setting under a wide umbrella of specialties. Chief Executive Officer LoAnn Vande Leest leads the CRSC team with an ultimate goal: to be recognized both regionally and nationally as the place for outpatient surgery and the place to work.

This last May in Orlando, CRSC’s Patient Experience Initiative was named one of 12 Intalere Healthcare Achievement Award winners. Copper Ridge Surgery Center won in the “Quality/Patient Care Delivery and/or Patient Satisfaction” category alongside health care facilities in Wilmington, North Carolina and Staten Island, New York.

Designed by Mark VanderKlipp from Connect_CX, and displayed prominently in a thoroughfare of the surgery center, the Patient Experience Initiative is a giant navigational tool comprised of every moment

of every patient’s visit. As CRSC Clinical Administrative Assistant, Laurie Olson, notes, “It’s not just the surgery that patients remember, it’s all the little things that happen in between.”

Indeed, every step, from diagnosis to parking, to anesthesia to family waiting has at its center the patient. And the map shows how the patient is supported at every turn by a groundswell of engaged, smart and happy staff.

Case in point: CRSC staffers Stefany Comeaux (Endoscopy Team Leader) and Tricia Wollam (Total Joint Program Coordinator). The duo helped craft the initiative—behind the scenes and above and beyond their regular duties. Vande Leest says Comeaux and Wollam became “patient experience officers" in the process, asking every department for input. Now, each person who works at the surgery center can see precisely where he or she falls in the patient experience. And, says

Vande Leest, “that that they contribute to something bigger.”

Today, the award-winning roadmap is a way of life for the staff. But Comeaux and Wollam didn’t rest on their laurels. They cocreated a staff pledge highlighting personal conduct with patients and with each other.

Each team member signs a detailed promise to: be accountable, show respect, practice stewardship, demonstrate compassion, work as a team and reinforce safety.

“We provide an environment for the health care professionals to apply their skills in a manner that is valued,” Vande Leest says. “We take care of our patients and one another.”

The ripple effects of this cycle of care rise to the surface in the stories the patients tell after their time at CRSC. Says Vande Leest: “Recently after surgery, a patient said to me, ‘You could tell the staff made me feel so cared for because they are so cared for.’ And I think: Yes. Goal made.”

MyNorth Medical Insider is produced by MyNorthMedia. Advertising and editorial offices at: 125 Park St., Suite 155, Traverse City, MI 49684. 231.941.8174, MyNorth.com.

All rights reserved. Copyright 2019, Prism Publications Inc. Reproduction in whole or in part without permission is prohibited.

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» Heart Health

TAVR Success

PHOTO COURTESY OF MCLAREN NORTHERN MICHIGAN

By Emily Tyra

A half-decade ago, the McLaren Northern Michigan Structural Heart Team, led by interventional cardiologist Dr. Jason Ricci and cardiothoracic surgeon Dr. J.D. Talbott, performed the first TAVR procedure in the entire McLaren system. With TAVR— transcatheter aortic valve replacement—the doctor enters an artery in the groin or chest, threads a catheter through the artery to the heart, then guides in a new aortic valve to work inside the old valve.

TAVR is a less-invasive surgery to replace the aortic valve, used to treat aortic stenosis in patients who aren't healthy enough for regular open-heart valve surgery.

(Aortic stenosis a narrowing of your aortic valve that does not allow normal blood flow.) We recently spoke with Dr. Ricci to find out more about this life-changing procedure: At TAVR’s onset, McLaren Northern Michigan was the smallest hospital and one of only a handful of non-teaching hospitals in the nation to offer a fully implemented TAVR program. Tell me more about that: We were one of the first commercial sites to offer this because of McLaren Northern Michigan’s willingness to take it on—the company understanding that with

the staff and resources we had, we could take it on, and saying we are committed to it, even if it’s not to make money. We will support it.

What’s new with TAVR technology?

The valve is on its third generation. And the catheters are much smaller now. When we initially performed the transfemoral approach [via the groin] back in 2012, the catheter was bigger than it is now. We were only able to perform about 70 percent of the procedures because the artery was not big enough. Now, it’s rare that we cannot use a groin approach, which is preferred for the quickest recovery.

TAVR was originally only for the sickest of the sick. How has that evolved?

TAVR is indicated for patients suffering from severe, symptomatic aortic stenosis as an alternative to traditional aortic valve replacement surgery. When we started, it was for those too sick to undergo openheart surgery—for example, a patient who also had advanced lung disease. Today, TAVR can be indicated and reimbursed for those with moderate risk for open-heart surgery. (A team of cardiothoracic surgeons and cardiologists approves the surgery risk.)

Studies are to be done in the next two or

three years determining risk scores, and it may someday be approved for everyone.

How about recovery?

It’s better than everyone imagined.

Recovery time for open-heart surgery is three to six months. With TAVR, patients can go home the next day and are back to full activity in 72 hours. In fact, many are interested in quality of life, living better, and no longer have debilitating symptoms that impact daily activities, such as walking short distances or even climbing stairs. They are back to a quality of life they really desire.

What could open up TAVR to more people?

The great unknown is how long the valves last. We have data at seven to eight years that the valves are holding up. The fact that the valves are holding up—that’s where the excitement is for TAVR in younger, healthier patients.

You are in China right now—can you share why?

I’m actually proctoring physicians just getting started with TAVR here. One of the valve types used in the U.S. is mounted on a balloon. Physicians in China are doing their approval trial to deploy this valve.

I’m here to help with the learning curve.

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» Virtual Pediatrics

Extreme Facetime for Medical Professionals

PHOTO BY MICHAEL POEHLMAN

By Ross Boissoneau

Technology continues to reshape our world, including medicine. For pediatrics patients at Munson Healthcare Cadillac Hospital, it is allowing doctors there to consult with and directly interact with specialists at Munson Medical Center in Traverse City. “The technology is pretty simple. It’s similar to Facetime,” says Dr. Jacques-Brett Burgess, pediatric hospitalist at Munson.

Similar perhaps, but not so simple. Rather than just an app on a smartphone or computer, the technology (known as a telemedicine cart) consists of a wheeled medical grade mobile cart with a video processor, monitor, camera and more.

It provides not only interaction between the physicians and patients, but sharing of medical records. “I can look at the patient’s labs, X-rays, their vital signs. I see the patient on the left screen and the data on the right,” Burgess says.

At this point, it is being used for pediatrics. Burgess said a key element is the product’s security. “It’s personal, private and protected,” he says.

The technology offers several other advantages. The patient doesn’t need to be immediately transferred to Traverse City.

It provides a way for a specialist to see a patient without having to drive to and from another office, providing more actual treatment. It offers the doctor a chance to see how the child responds. It also gives the doctor, child and parents or other caregivers the opportunity to become acquainted. That provides greater comfort for all, especially if it’s determined that the patient does need to be transferred.

Burgess previously worked in Grayling. “I recognized that they (staff) were great caregivers but had limited resources,” he said. That experience helped provide the impetus for telemedicine. “This seemed like a great means to share and expand resources with relatively little cost,” both in terms of financial resources and time.

While it is not inexpensive—Burgess says between the hardware and the necessary broadband connections it runs thousands of dollars—that onetime acquisition cost pales next to paying for multiple ambulance runs. He also said the cost per use will come down as more disciplines utilize it.

Currently the technology is connecting Cadillac and Traverse City. Burgess hopes to expand that to another Munson facility in the region, though those plans have not yet been finalized.

Eventually he’d like to see it in all the Munson affiliates. “My vision is that each would have virtual connections,” Burgess says.

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» Plastic Surgery

Better Outcomes for Breast Reconstruction PHOTO COURTESY OF GREAT LAKES PLASTIC SURGERY CENTER

By Courtney Jerome

For 10 years following her lumpectomy, looking in the mirror was a constant reminder of Judy Matelski’s battle with breast cancer. When the cancer vigorously returned, she was told she needed a double mastectomy. Body image thoughts consumed her. “I had a hard time finding anyone who would take them off and put something in right away,” Judy shares. But then she found Dr. Matthew Smith.

Dr. Smith is Section Head of Plastic Surgery at Munson Medical Center and Founder of Traverse City’s Great Lakes Plastic Surgery Center. He’s been on the national television show The Doctors, and been trusted by thousands of patients over the past 20 years to perform reconstruc-

tive surgeries—including for those fighting breast cancer.

In 2014 Dr. Smith embraced a new technology known as SPY to his practice.

SPY’s specialized camera grants him realtime assessment of blood flow to different tissues of the body. This permits performing breast reconstruction immediately after a mastectomy, allowing women to feel like themselves in just one surgery, with more predictable outcomes.

“The number-one priority is to treat the cancer,” says Dr. Smith. “When a mastectomy is done, breast tissue is removed, and much of the skin is left behind. In the past, it was very subjective to determine if that skin would heal well.

“Now with the SPY we can determine the health of the skin that’s left behind and at that time determine if we can proceed with the reconstruction, or if we need to modify the plan,” explains Dr. Smith.

Before SPY technology there was a 16% chance patients would encounter woundhealing complications, leading to a significant rate of reoperations and additional costs to patients. Now the complication rate is down to only 1 to 2 percent.

“We’ve been able to give women much more hope that they’re going to get back to that body image they had prior to their diagnosis,” says Dr. Smith.

Judy agrees. “People need to know how wonderful he is. I tell everyone!”

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BEAR RIVER HEALTH TREATMENT RESIDENCE ON WALLOON LAKE

» Recovery & Results

Opioid Treatments Offer Hope

By Emily Tyra

» CHRIS FRASZ, OUTREACH SERVICES DIRECTOR

PHOTO COURTESY OF BEAR RIVER HEALTH

BEAR RIVER HEALTH, BOYNE FALLS How does Bear River Health approach treatment for those with opioid use dependence?

Our clinical and medical teams receive continuous training to be up to date with new opioid and substance use treatment modalities—incorporating the latest education of effects of substances on the brain, the role of past trauma related to usage, and clinical treatments to support clients during and after their residential stay.

Bear River Health (BRH) provides a place of support and empathy for those struggling with any addiction, where clients receive a clinical treatment team made up of therapists, case managers, recovery techs and activity directors to get the best care while in treatment and a detailed aftercare plan to give direction to a client's transition back to daily life. And to support the transition, BRH has recently opened an Outpatient Clinic, which provides a continuum of care through outpatient services consisting of individual and group sessions.

Such counseling encourages continued growth and supports the direction that was initiated in residential care.

Bear River is currently applying for the participation with Opioid Health Home pilot program. It is initially being administered through the State of Michigan and

the Northern Michigan Regional Entity, the local Prepaid Inpatient Health Plan for Medicaid funding of substance use disorder dollars. The Opioid Health Home program is a model of care that will coordinate the health and social needs of clients. The program will utilize a team of health care providers to provide full, wrap-around services. Programming will be designed to address substance use, mental health and other medical conditions that might not otherwise be addressed.

What role does the BRH campus and natural surroundings play in rehabilitation?

All clients have regularly scheduled opportunities to enjoy the northern Michigan surroundings. Clients are connected to many of the beautiful areas of Boyne City, Walloon, Petoskey and Harbor Springs and can enjoy beach outings in the summer, ice-skating in the winter, and walks through trails and parks throughout the year. Other activities have included disc golf outings, orchard visits, and potlucks and open talks with local AA and NA groups. The outings show new environments where clients can feel good, build on the connection with others, and engage in various activities that bring enjoyment without using any substances.

Scheduled down time on campus offers

structured time to reflect or relax from the daily programming, off-campus groups, and outings.

Any treatment breakthroughs your staff notes as being especially effective?

Regular mindfulness courses by a specialized therapist also give an evidencebased tool to manage stress and understand the role of thought recognition related to actions and results.

Tell me a little bit about your aftercare model, and how it's a meaningful part of reducing relapse in opioid addiction: All clients leave BRH with an aftercare plan. The aftercare planning starts from day one. We touch on and make plans for every aspect of ones life including: employment, housing, community, sobriety, supports, mental health, physical health, etc. With a client-driven, well-balanced treatment, outpatient counseling maintains connection to solidify new thinking and life patterns that have been learned.

Bear River Health has also initiated an Alumni Program to allow all graduated clients the ability to stay connected. A summer picnic had close to 100 attendees including clients, families, and members of the medical and clinical teams.

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MI 11

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Opioid Treatments Offer Hope, continued

» GWEN WILLIAMS, DIRECTOR OF PROGRAMS NORTHWEST MICHIGAN HEALTH SERVICES, TRAVERSE CITY How has the approach to treatment evolved at your clinic in recent months?

Northwest Michigan Health Services in Traverse City has adopted a model of integrated medical and behavioral health care.

This is provided under the umbrella of primary care services. We have begun offering Medication Assisted Treatment (MAT) using the medication Naloxone (Vivitrol), which reduces cravings and blocks the body’s ability to feel an effect from opioids. Primary care providers—nurse practitioners and physicians—oversee the administration of monthly injections at the health clinic. Our on-site behavioral health therapist also meets with patients in an integrated visit with medical providers, helping to coordinate and assure that the patient is receiving ongoing substance abuse treatment from outside agencies.

Any breakthroughs or treatments your medical professionals are seeing being especially effective?

The integrated approach of providing MAT and behavioral health care within the context of primary care, while connecting

with substance use disorder treatment providers is a model that is proving to be successful. The more that primary care providers can be involved in helping to address the opioid crisis, the more successful we will be in treating it.

What about prevention efforts?

At Northwest Michigan Health Services, we partner with community organizations working on increasing involvement of family members dealing with substance use disorder, disseminating Narcan to reverse overdose, and offer families prescription lockboxes.

Are there specific ways you are able to help uninsured or underinsured people and families battling this addiction?

Northwest Michigan Health Services offers a sliding fee scale that sets fees for services based on family income and size that covers medical, dental and behavioral health care. The sliding fee scale program can also help those who have insurance but are struggling with high co-pays for care.

» COURTNEY WHINNERY, LPC, CAADC, LEAD SUBSTANCE USE DISORDER SERVICES COUNSELOR TRAVERSE HEALTH CLINIC, TRAVERSE CITY How long has the pilot program Opioid Health Home been in action at Traverse Health Clinic ... and what are some of the most crucial ways your team supports the specific needs of your clients?

The official start date of the Opioid Health Home (OHH) was October 1, 2018. We have 6 providers who are able to prescribe medications (Naltrexone or Buprenorphine/Naloxone) to assist in patients’ recovery from opioid use disorder.

Our integrated or wrap-around approach means literally meeting the patients right where they are and surrounding them with the supports they need to get healthy. We have primary care, counseling, and a peer recovery coach all in one spot—which decreases the patient’s need to coordinate transportation, childcare, time off work, etc. In addition to patient convenience, the collaboration that can happen in the moment has been amazing. As a mental health counselor, I don’t have medical expertise but I can peek out my office door and there are 6 providers and even more nurses who do. From on-the-spot blood pressure checks to questions about medication side effects, patients have been able to get immediate answers and solutions to their problems. And the flip side is also true—a patient in the clinic to see a primary care provider has access to counselors for those moments of panic, anxiety or depression.

What are some of the most effective tools to recovery?

Perhaps the most important link in our recovery program is the peer recovery coach. She is able to connect with patients on a level that puts them immediately at ease. She’s been through what they’re going through so they feel understood and often open up

more freely about their needs. The peer recovery coach is able to then connect the patients to different resources that would help (bus passes, gas cards, peer support meeting suggestions, Hep C testing—the list goes on). She really has the opportunity to bridge the gap that so often exists. Patients are able to call/text or meet with her between office visits. She will often remind them of counseling appointments that would otherwise have been missed, or she helps to motivate them to keep appointments that they may have otherwise chosen to skip.

What message would you like to share, shedding light on efforts behind the scenes to help those with opioid use disorder?

We really can’t reiterate enough that people struggling with opioid addiction are just that—people. They are no different than you or me. They have a chronic illness and need help to recover from it just like we all do when we are sick. Instead of judging them, let’s embrace them, support them, love them and help them.

Addiction is difficult enough to deal with, let’s not impose even more barriers for people to get help.

A common misconception is that using Medication Assisted Treatment (MAT) is that it is trading one addiction for another.

When the medications are used as prescribed, patients are not getting high and feeding their addictions. I’ve heard multiple patients use the same word to describe how the medications make them feel: normal. The cravings are reduced enough for patients to be able to focus on underlying issues, strengthening their recovery plans, repairing relationships, and working toward life goals.

Essentially, MAT gives patients a chance at living instead of dying.

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Expanded Access to Proven Addiction Treatment in Northern Michigan Quitting drug or alcohol use is just the beginning of the process of recovery from addiction. In order to maintain sobriety, therapy and new support systems are essential. Like diabetes or other chronic diseases, it’s helpful to think of addiction as a condition that must be actively managed to help prevent or reduce chance of relapse.

Therapy provides those in recovery with new coping techniques to help them avoid high-risk situations, learn new ways to unwind and relax, and recognize and change negative thinking.

Sometimes the alcohol or drugs were used to self-medicate the symptoms of past trauma, depression, anxiety or other behavioral health issue. In nearly every case, the resulting consequences of alcohol and/or drug have damaged the individual’s physical, emotional, financial and familial health.

Addressing these issues with a Certified Addiction Counselor has been proven to increase the ability to not only stay sober, but build a life worth living.

“The Pine Rest Traverse City Clinic has long offered these therapies including cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), mindfulness-based stress reduction (MBSR), and others,” says clinic manager Kristine Wilmoth.

“However, we knew a great many individuals are unable to attend therapy in our clinic due to a variety of reasons such as inability to travel regularly to appointments, no access to transportation, as well as work and family commitments.”

In response to the tremendous need for treatment, Pine Rest has begun to offer therapy for addiction through online video chat similar to Skype or Facetime.

Teletherapy has been proven to be just as effective as traditional in-person therapy. In fact, teletherapy can help address many reasons why individuals might not otherwise be able to attend in person, so that they can get the most from treatment and live a

healthy and productive life. Plus, teletherapy provides additional privacy since the waiting room is avoided.

“In addition to therapy, research has shown that having a peer recovery coach greatly improves recovery success rates,” says Scott Smith, a Certified Advanced Alcohol and Drug Counselor and the supervisor of Pine Rest’s Addiction Teletherapy program.

Peer recovery coaches use their experiences with personal recovery to offer hope, encouragement and reassurance to the people served.

Much of this support is offered in a coaching or mentoring manner, where the recovery coach cultivates and secures a connection with the person served, while teaching personal responsibility and serving as a mentor and role model on the recovery and wellness process.

“Our local peer recovery coaches have at least two years of recovery and have gone through recovery coach training and certification,” says Smith. “The recovery coach works with individuals to outline and achieve meaningful life goals in sobriety.

The relationship is very rewarding and meaningful for both the individual and the coach.”

All addiction treatments at Pine Rest are evidence-based, which means that over time they have been tested and found to provide predictable outcomes and long-term recovery. Therapy is provided

by Certified Advanced Alcohol and Drug Counselors who have met the requirements of the Michigan Certification Board for Addiction Professionals (MCBAP). Recovery coaches are all Certified Peer Recovery Mentors who have met MCBAP requirements.

Learn more about the addiction services available through the Pine Rest Traverse City Clinic including teletherapy and peer recovery coaching online at pinerest.org/recovery. Call 866-852-4001 to set up an initial assessment. Most insurance policies cover the cost of these services. Financial and technology assistance may be available.

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» Innovative Treatment

Caring for Your Wounds is a Science

PHOTO BY MICHAEL POEHLMAN

By Ross Boissoneau

Everybody gets wounds, from scratches to lacerations to burns and more. Treating them is big business. Take a walk through the wound care aisle at your local drugstore, and you’ll find an overwhelming multitude of products—and some 4,000 come to market annually.

Enter Dr. Marc Krakow, the medical director of the Advanced Wound Care Center and Hyperbaric Medicine at Munson Medical Center. “The region needed a wound care physician-run (center),” he said, for procedures such a skin grafts and to treat more serious wounds. “It only became a thing about 15 years ago.”

While the products on store shelves offer some benefits, Krakow is skeptical at best about some of the more common treatments. “Triple antibiotic is terrible.

Hydrogen peroxide is terrible,” he says.

Instead, he say the best treatment for wounds is to keep them moist while they heal. “The most important thing is to keep it clean and keep it moist. Dermatologists like Vaseline. Wound care specialists like hydrocolloids.” These are gel-forming agents in a wafer of dressing which keep the wound clean and moist.

Also vitally important is providing the proper setting for a person’s body to respond to a wound and heal itself. “We want to get our sugars in control, get the (proper) protein levels. Most of us don’t get enough protein.”

Healing also becomes more difficult when the body’s resources are compromised by age or other conditions. “I don’t see 20-year-olds,” Krakow said. Visitors to the wound center are more typically elderly patients and/or those suffering from obesity,

emphysema, or high blood pressure.

Unfortunately, there are some wounds that do not respond to treatment. For those, Krakow also has a potential solution. As a scuba diver, he was familiar with hyperbaric treatment to treat decompression sickness. It is also ideal for getting additional oxygen into cells to treat and heal wounds.

Krakow said saturating those cells with oxygen when under compression creates new pathways for blood vessels and healing.

The body starts growing new tissues and blood vessels.

“Skin grafts can fail in a day or two.

Hyperbaric treatment has been shown to keep them survivable. The same with a diabetic with a wound that is not healing, or a bone infection if antibiotics don’t work,” says Krakow.

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MI 17

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» Personalized Treatment

A Care Team for Prostate Cancer

By Ross Boissoneau

PHOTO BY MICHAEL POEHLMAN

KATHY LARAIA (L), EXECUTIVE DIRECTOR OF ONCOLOGY SERVICES & DANA HOLLISTER, NURSE NAVIGATOR AT MUNSON HEALTHCARE

Prostate cancer is the second-most common cancer among men in the U.S., trailing only skin cancer. The American Cancer Society estimates that more than 164,000 new cases of prostate cancer will be diagnosed each year, and about one in nine men will be diagnosed with prostate cancer during his lifetime.

It is also the second leading cause of cancer death in American men, lagging behind only lung cancer; one in 41 men will die of prostate cancer. Bill Bixby, Frank Zappa, Merv Griffin, and Johnny Ramone are among those who have died from the disease. So yes, it can be deadly. On the other hand, the five-year survival rate is 99 percent, and the ten-year rate is 98 percent; current survivors include Rudy Guiliani and John Kerry.

Enter Donna Hollister, nurse navigator and part of a multi-disciplinary team at the Cowell Family Cancer Center in Traverse City, where teamwork is essential to provid-

ing effective, personalized cancer treatment and support. At the Center, specialists in medical oncology, radiation oncology, urology pathology, genetics and pharmacology as well as nurse practitioners, a research nurse and a nurse navigator such as Hollister gather together as a tumor board to talk about treatment options.

The team is there to treat cancer and ease the journey through diagnosis, treatment, and beyond. Kathy LaRaia, the executive director of oncology services at Munson Healthcare, says in addition to critical medical treatments, the center offers life-affirming health and wellness services that treat the whole body and mind to promote healing. “As the community grew people felt we needed this type of facility,” she says.

Treatment options for those diagnosed with prostate cancer include surgery (robotic or open), radiation therapy, brachytherapy (radioactive seed implants) and external

beam. Alternate treatments are cryosurgery and high-intensity focused ultrasound.

Some cancers can be controlled with a combination of medication, diet and exercise, a treatment called active surveillance.

LaRaia notes the addition of specific technology has also improved cancer services at the Cancer Center. That includes a 3T MRI, which is four times more powerful than Munson’s 1.5 MRI machines and provides clarity that previously was unavailable locally. It can be used to diagnose a variety of disorders, from strokes and tumors to aneurysms and others, but it’s especially effective at detecting areas of concern in the prostate.

When the results are fused with real-time ultrasound, practitioners can take biopsies from areas previously identified as suspicious. That has enabled doctors to offer better treatment with fewer side effects.

“It’s much more precise,” says LaRaia. “It’s been a great advantage.”

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MI 21

JEFFREY WENTZLOFF MD, PETRA VON KULAJTA MD, MATTHEW MADION MD, J. RYAN MCMANUS MD

» Cataract Surgery

PHOTO COURTESY OF GTOC

Optimized Outcomes The femtosecond laser is the newest technology in cataract surgery with many benefits for the surgeon and patient. The laser allows the surgeon to make more precise incisions than are possible with manual techniques. The laser forms a custom 3D map inside the eye, which means the surgeon can create a treatment plan tailored to the patient’s exact eye. The surgeon can also use the laser to soften the hard cataract, allowing for gentler removal. And perhaps best of all, pairing femtosecond laser technology with the correct lens implant can eliminate the need for glasses after the surgery.

We recently spoke with Dr. Jeff Wentzloff, a board certified ophthalmologist specializing in cataract surgery at Grand Traverse Ophthalmology Clinic (GTOC) in Traverse City, about some of the positive outcomes of using the femtosecond laser: How does cataract surgery performed with the femtosecond laser help achieve better vision post-surgery?

Cataract surgery with femtosecond laser can eliminate the need for glasses. This is accomplished by laser reshaping of the

By Emily Tyra

cornea to correct for astigmatism. The laser allows the cataract surgeon to incorporate as much of the glasses prescription into the eye as possible.

What are some of the biggest reasons patients elect to have their cataract surgery performed with the advanced technology of the femtosecond laser?

Patients are interested in the best possible vision after cataract surgery with the least amount of need for glasses. People recognize the benefit of not needing glasses especially for activities like biking, swimming, and skiing. Patients also like the ability to wear non-prescription sunglasses when spending time outdoors or when driving. People choose femtosecond laser for these reasons even though it is not a covered benefit by Medicare or other insurance plans.

What feedback do you have from patients?

I am particularly impressed with the people who come back to see me years after surgery and still thank me for how well they are seeing. The results are long lasting.

Is femtosecond laser surgery available at all three—TC, Petoskey and Sault Ste. Marie—GTOC locations?

Patients in all three GTOC locations have the option of femtosecond laser. The laser machine is located at Copper Ridge Surgery Center in Traverse City so the procedure itself is done at this location. All pre- and post-operative office visits may be done in any of our office locations.

What excites the team at GTOC the most about the femtosecond laser being a part of the available technology at the clinic?

We at GTOC are proud to be able to offer the latest and greatest technology to our patients. This is the same level of excellent care that is offered in large cities and teaching institutions, and we have the ability to offer it to our patients in Northern Michigan. Better vision and reduced dependency on glasses make for a better quality of life for our patients, and nothing excites us more at GTOC than being able to help others reach their full potential.

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MI 23

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» Munson Expansion

New Care Model for NICU Families

By Emily Tyra

PHOTO BY MICHAEL POEHLMAN

Munson Medical Center is preparing for the hospital’s largest expansion project to date—an $80 million project that will include the construction of a $36 million, 110-foot new Family Birth and Children’s Center. The expansion means Munson can house its maternity services, neonatal intensive care unit (NICU) and pediatric services in one central hub.

Munson’s NICU itself will expand from 2,700 square feet to 15,500 square feet, changing the design from an open-floor unit to private and semi-private rooms. We spoke with Annie Hautala, RNC about how the space paves the way for a new care delivery model in the NICU: Tell me the impact the new space will have on how you care for patients?

What we do now is called family-centered care. As soon as families are ready we show them what their baby’s care is like. And as they get close to going home, they do more and more. Sometimes we have 22 to 24 babies in this 2,700-square-foot area, and there is not space for families to be really close to their baby as much as they would like to be.

With the new model of care, called family integrated care (FIC), we take what we are doing now to the next level. Instead of explaining care, we will be teaching family members to take care of the baby themselves as soon as they are able. When they go home they have been there with the baby around the clock and are confident advocates for their baby.

How does this model of care alleviate stress on the parents and baby?

In the NICU, most of our patients don't expect to be there. It can be scary or even traumatic. With a private and semi-private room environment, it is more welcoming, more homelike, with a view to outside and spaces just to be families. There will be room to lie down and rest, so parents can meet their own needs too.

And there will be better care takeaways. Now we might get a call after a family goes home. They’ll say: “We have fed the baby, she's changed, it’s the middle of night—why is she wide awake?” We can reassure them, oh, after she eats, she just likes to be awake and play. Even this

normal progression of behavior can cause concern after such an unnatural growth and development experience. It can be very hard for families to transition from our highly monitored environment to life outside of the hospital. We hope to ease this transition in the new unit.

What is your role in implementing the new care model?

As the family integrated care lead, I am still on the floor. I need to see firsthand what unique needs and opportunities there are to make the model what it needs to be, living with one foot in each world.

We are building a parent advisory council now, because parent involvement is vital to developing and supporting family integrated care. We have so many amazing families and we couldn't make this better without them. My role is also to coordinate implementation of FIC between NICU, Maternity, and Pediatrics. We are hoping to provide a seamless transition from one service to the next and allow families to be the primary caregivers in each of these areas.

MyNorth Medical Insider

MI 25

Tips for Better Heart Health They say an apple a day keeps the doctor away. But Dr. James Fox, an interventional cardiologist at Traverse Heart and Vascular, knows it takes much more than that. Heart health awareness is at a high. We’re hearing about how to eat right. How to exercise more.

And Dr. Fox has great tips for that. However, he also recommends something you might not expect.

“People who are more prone to a higher stress level—who can’t let go of a problem or issue, who internalize and dwell on those things—tend to have worse health outcomes,” Dr. Fox says.

Studies at an advanced level have shown someone with a “Type-A” personality is prone to have more heart issues with worse outcomes. Therefore, Dr. Fox stresses to his patients the importance of learning not to worry and to be more relaxed. But he acknowledges sometimes that’s easier said than done, as he can’t tell patients specifically how not to stress.

Dr. Fox has been treating Traverse City area patients for more than 15 years. He grew up in a household of medical professionals (his father was also a cardiologist). Because of that, he had an early awareness of cardiac disease.

“One of the things that was very clear and emphasized at an early age was taking care of your own health,” he says. His parents believed in “daily exercise and watching your diet and controlling your weight to the best you could.”

His father transitioned from military care to preventative cardiology around the time that cholesterol was recognized as a cause of coronary artery disease and heart-related complications. It was then that Dr. Fox was exposed to the importance of watching dietary fat intake and cholesterol intake. “Some of my earliest memories are sitting around the dinner table hearing conversations about this,” he says.

Now, over half of Dr. Fox’s patients see him for coronary artery disease. When asked how not to become a patient of his—besides managing your stress levels—his answer is simple: Exercise at least a half hour a day, and try to eat healthily. “Mostly eat fresh,” he recommends. “When you can, eat local. Prep the food yourself when you can.”

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Are there any “superfoods” that are best for your heart? Probably not, Dr. Fox says. “There’s this belief that there are these superfoods, and if you eat a hype amount of a particular type of food it will stave off or prevent the development of diseases. And the data that supports that is really not that strong.”

He continues, “It’s more important for people to recognize that they have to eat more of a balanced diet with an emphasis mostly on vegetables, fruits, whole grains, and beans.”

If you are in your 30s, with a family history of poor heart health or high cholesterol, this is particularly important. Dr. Fox urges these people to start paying attention at an age earlier than you’d probably expect. He says to start thinking of, “What am I going to eat that I’m willing to eat for the rest of my life?”

As people get older (middle age/retirement years), he mentions that a lot of people have loss of muscle mass, leading to loss of strength, balance, and heart health.

“This is the age you need to think about protein intake and exercise,” he says. While it doesn’t need to be exercise in a gym, he suggests activities like chopping wood and carrying things— activities that help your heart rate and make your muscles sore.

He recommends doing this two to three times a week. “Even brief bouts of short moderate-intensity exercise, 10 minutes here or there.

People who do more than about 120 minutes of good stamina-based exercise in a week are probably doing a pretty good job.”

Stamina and balance-focused exercises—such as walking and yoga—that help maintain muscle mass are what he advises for those in their 60s, 70s, and older. “Find something you like to do, and add it to your day,” Dr. Fox says.

So, to sum it up: Exercise frequently. Don’t ignore family heart history. Eat fresh. But don’t stress if your crisper drawer is empty.

Just try again tomorrow!

This story was written in partnership with Shape Up North, a community collaboration dedicated to helping northern Michigan residents benefit from healthy eating habits and an active lifestyle. shapeupnorth.com

PHOTO BY ANGELA BROWN

By Courtney Jerome

» Membership Medicine

MDVIP: A Patient’s Perspective

By Shea Petaja

PHOTO BY MICHAEL POEHLMAN

PHILLIP SIEMER, MD (L) & THOMAS LAMMY, MD

It’s 9 a.m. on a Friday morning. I’m in San Diego at a conference for work and I’m having an allergic reaction to a new medicine.

I text Dr. Siemer, my MDVIP doctor, and say, “Please call when you can, I’m in desperate need of help.” He calls immediately and puts me in touch with MDVIP-affiliated physicians in San Diego, gives me the address of the recommended emergency room and suggests meds to help calm the reaction in the meantime. This is modern medicine at its best and it’s available here in Northern Michigan thanks to Dr. Phillip Siemer (Family Medicine) and Dr. Thomas Lammy (Internal Medicine), both primary care doctors in Suttons Bay. “Joining the MDVIP network affords me the valuable time necessary to know my patients well beyond their immediate medical needs so I can manage and anticipate their unique healthcare needs,” says Dr. Siemer.

What is MDVIP? It’s affordable membership-based healthcare that goes beyond concierge medicine services. The network includes more than 900 primary care physicians in 43 states that care for more than 300,000 patients. Since 2000 they have been fine-tuning the patient experience. Both Dr. Siemer and Dr. Lammy participate in ongoing education including functional medicine certification and specialty training. Their combined experience in collaboration with national doctors keep them at the top of the list for healthcare provider, Northern Michigan.

Consider this—the average physician has a patient load of 2,300 or more a year, MDVIP practices are limited to 600 patients or fewer. Medicare patients in MDVIP-affiliated practices were admitted to the hospital 79% less than patients in traditional practices, and commercial patients were in the hospital 72% less often, notes an American Journal of Managed Care study.

WHAT’S INCLUDED?

» An annual wellness plan that is a customized comprehensive yearly health assessment, including advanced diagnostic tests and screenings. » Same- or next-day appointments that start on time and last an average of 30 minutes. Physicians are reachable 24/7 by phone. » If patients have an emergent need while traveling, their physician can help arrange care with a local hospital, pharmacy or doctor, which may include another MDVIP-affiliated physician. » Assistance in managing chronic illness.

So, does the extra cost for membership-based care pay off?

According to The Impact of Personalized Preventative Care Model vs. the Conventional Healthcare Model on Patient Satisfaction, The Open Public Health Journal, 2015, 97% of patients in MDVIP-affiliated practices were satisfied with their doctor relationship versus 58% of those in traditional primary care practices.

MyNorth Medical Insider

MI 27

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»A Step Forward

World’s Smallest Pacemaker

PHOTO COURTESY OF MCLAREN NORTHERN MICHIGAN

By Ross Boissoneau

For those diagnosed with a slow or occasional missed heartbeat, a condition known as bradycardia, the treatment of choice has long been a pacemaker. Implanting a device to keep the heart beating strong and steady has become a nearly routine procedure.

But that doesn’t mean there isn’t room for improvement.

Enter the Micra® Transcatheter Pacing System (TPS). Standard pacemakers generally run about 2 inches by 2½ inches and about a quarter inch thick. Micra is 93 percent smaller than a typical pacemaker, about the size of a large vitamin pill. It was also designed, tested, and approved to be used safely with MRI scanners.

Dr. Daniel Buerkel, electrophysiologist at McLaren Northern Michigan, implanted the

first Micra pacemaker there on December 21, 2017. “Not only is its size advantageous, it’s also leadless,” says Dr. Buerkel. Typical pacemakers have leads that attach to the chambers of the heart; Micra is actually implanted in the heart.

He says the decision as to whether to use the TPS or the standard pacemaker depends on the cause of bradycardia. “It’s for those who only need a single chamber (pacemaker). That’s 5 percent. Most require a dual chamber device,” he says.

But for that 5 percent, the device offers some definite advantages. The surgery to implant it is less invasive. With a lifespan of 12 years, it also lasts longer than the typical pacemaker’s six-to-seven-year average.

Buerkel said that because typical pacemaker

patients are in their 70s, that means they most likely will only need one or two such surgeries in their lifetime. And because of its diminutive size, when it does have to be replaced, the old one is left in the heart and simply switched off.

He says despite the advantages it presents for those who only need a single chamber pacemaker, making it suitable for the majority of those suffering from bradycardia will not be easy. That is where pacemakers with two leads still are preferable. “The next step is two leadless devices that can communicate (with one another). There are still a lot of technology challenges to make it small enough and still communicate, though we are excited about the technological possibilities.”

MyNorth Medical Insider

MI 29

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» Full-Circle Care

Combining Holistic and High-Tech Dentistry

PHOTO BY MICHAEL POEHLMAN

By Emily Tyra

When Dr. Lisa Siddall opened her own dental practice in Lake Leelanau 20 years ago, she dedicated herself to oral care techniques that improve the overall quality of life for her patients.

She considers each patient’s medical background, current health conditions, and risk factors to promote total body wellness.

And indeed, a dentist may be the first health care provider to diagnose a health problem in its early stages. Research from the Academy of General Dentistry shows 90 percent of all systemic diseases—diabetes, pancreatic cancer, kidney disease—have oral manifestations. “Early signs can be picked up by looking in the mouth,” says Siddall. “Bleeding gums can be a sign of diabetes. And when gums are bleeding, it’s like having an open sore. Bad bacteria in the mouth can enter the body this way.”

She notes that when people suffer a heart

attack and they find a clot, “often it has oral bacteria in it.”

She’s also helped patients find a link between their nighttime teeth grinding and inability to get adequate oxygen during sleep.

“Sleep apnea, snoring, and sleep disordered breathing can be caused by oral anatomy,” says Siddall. She discovered this when she started doing dental cone beam computed tomography (CBCT) scans, which make 3-D images of a patient’s teeth, soft tissues, nerve pathways and bone in a single scan.

“We were doing the scans for bone placement for implants,” Siddall says.

“Because we were getting a 3-D picture of the anatomy, we found people who had these worn down teeth and we could see the obstruction that was causing the volume of oxygen to breath to be compromised.

When you are not getting adequate oxygen,

the body goes into a grinding response.

The theory is that you wake yourself up enough to change your jaw positioning.”

To remedy this, Dr. Siddall can make custom oral appliances that naturally open your airway and increase oxygen flow during sleep. The benefits to resolving sleep disorders and associated teeth grinding go on: it can help with migraines, jaw pain and tooth sensitivity caused by enamel loss. “Once you get through the enamel layer, the inner tooth is six times softer, and the teeth begin to shrink and wear down faster.”

And certainly, Dr. Siddall and her team can help with the smile itself. “We rebuild the teeth up to their original height, and can give patients Botox for a mini-facelift around their mouth.”

That makes for confident smiles, and, yes, one more puzzle piece to overall heath.

MyNorth Medical Insider

MI 31

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Working to Make Orthodontics Better Anybody can move teeth. In fact, children do it all the time – when they suck their thumb. And the more aggressively they suck, the more profound is the impact on their teeth.

Dr. Northway

In recent years we are being inundated with the idea that the public can purchase systems (usually on-line) that will facilitate self-correction of an orthodontic problem. While this might save money, it could also be dangerous. In fact, it is illegal to practice dentistry without a license – for a reason. In an effort to protect the public, the American Association of Orthodontists is working with the Federal Trade Commission and the Michigan Board of Dentistry to force on-line providers to conform to standards that protect our citizenry. Just like a thumb, unsupervised appliances might be doing harm.

During the last year the AAO has also moved to a more aggressive position in terms of conscientious practitioners being more explicit about the limitations of treating complex orthodontic cases with clear aligners. The association stresses the importance of educating patients as to their role regarding compliance so that the anticipated goals can be achieved. When that does not happen, it could well be that the inferior results provided are not be attributable to the appliance; just like a child’s thumb, it depends largely upon how effectively it is used. And often clear aligners do not have the potential of fixed appliances.

Appropriate orthodontic treatment involves moving teeth into proper alignment; but, in order that function will occur, the jaws have to be aligned with each other. This is where functional appliances come in. When properly designed, supervised and worn, “enhanced growth” can - in the right cases -accomplish MI 32

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what would only be achievable with surgery. The young lady shown in this case presented with such a short mandible that she drooled constantly and had a difficult time keeping food in her mouth while chewing. She was fitted with functional appliance (Frankel), which she wore with incredible diligence for four years. That was the only treatment rendered, and it is obvious that she out-grew her skeletal deformity. Commitment like this regularly delivers proof that functional appliances work when they are used appropriately.

There are orthodontists who contend that functional appliances do not work, and there are studies that come to that conclusion. Many of the studies are done at universities, where patients are treated in less than ideal conditions; and some patients can’t adapt well to the commitment necessary to provide the proper environment for success. I have had a few of those. Nonetheless, our feeling is that functional appliances provide a superior form of treatment when all parties involved fulfill their responsibilities.

» Healthier Smiles

Familiar Procedures + New Thinking

PHOTO BY MICHAEL POEHLMAN

By Ross Boissoneau

What’s old can be new again in orthodontic care, according to Dr. William Northway of Northway Orthodontics, where time-tested procedures are used for innovative treatments. “What’s new is an increased application of orthodontics beyond what we’ve known for some time,” Northway says.

That means utilizing and–as necessary– modifying the body’s own resources to correct problems. One exciting example: Rather than simply moving teeth to straighten them out, braces can be used to move teeth to account for missing or malformed teeth.

He cites as an example a young man who was missing his two upper front teeth.

Rather than simply giving him a bridge (either fixed or removable) or to replace those teeth with implants, Northway would

prefer to pull the back teeth forward to fill in the gap.

As the teeth each have a particular job to perform and a shape to fit that job, that also means rebuilding the teeth to assume their new task. This involves modifying the canines to more closely resemble the incisors they are replacing, then doing the same with the premolars that are being moved to replace the canines. “You reshape the canine and pull it downward,” says Northway, who then adds orthodontic resin and/or porcelain as needed, so the tooth looks like and acts like the one it replaced.

Using the body’s own resources is also a treatment possibility for patients with receding gums, which can and often do lead to periodontal disease. One procedure involves surgically repositioning the gum

tissue and pulling it up, then suturing it in place. He says that often does not solve the problem on a permanent basis, especially when the teeth are not situated properly.

But using orthodontics to push the teeth more into the bone can create better stability and at a reduced cost.

Such a procedure can also correct sensitivity engendered by recession that leaves the roots exposed. Northway says, for some people, the sensitivity is so great that they feel a need to keep their lips sealed when it’s cold outside.

When asked, “What’s new in orthodontics?” Dr. Northway responds that there are things that are considered new, like invisible aligners and fancy diagnostic tools, but “for me, the newness in orthodontics is generated in vastly improved treatment response.”

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Now on their second decade of offering computerized CAD CAM dentistry, the office is often described by patients as high tech and cutting edge. Dr Holcombe remarks, “Many of our new patients have retired to the area and often are surprised that our Leelanau County office is more advanced than their ‘big city’

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Although technology is important, the biggest point of pride for the doctors is the experienced, caring staff. Seeing a familiar face at appointments helps to establish relationships with the patients thus making visits enjoyable and relaxing.

The most rewarding part of their day is helping patients change their smiles. Drs. Holcombe and Hall have emphasized this in their practice and are thrilled to see a new smile change a patient’s life.

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