KentuckyDoc Summer 2021 by Rockpoint Publishing

summer 2021 • volume 13• issue 2

THE IMPACT OF

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CONTENTS INFLUENZA PANDEMIC: Lessons For The COVID-19 Coronavirus Pandemic? • PAGE 5 Observations of a Physician Regarding Mental Health Effects Related to COVID-19 • PAGE 8 The Brain: Psychiatric, Neuropsychiatric, and Neurological Faces of Covid-19 Infection • PAGE 14 COMMUNITY NEWS Announcements & Awards • PAGE 20 Impact of COVID-19 on Medical Students • PAGE 24 COVID_19: Education of Medical Students Globally and at UKCOM • PAGE 26 BUSINESS Grow Your Practice by Thinking of Yourself as a Brand • PAGE 30

EDITORIAL

BOARD MEMBERS Robert P. Granacher Jr., MD, MBA, editor of Kentucky Doc Magazine Terry Clark, MD John Patterson, MD Tuyen Tran, MD Thomas Waid, MD Nicholas Coffey, M2 at UK College of Medicine Bowling Green Campus

STAFF Brian Lord Publisher David Bryan Blondell Independent Sales Representative Jennifer Lord Customer Relations Specialist Barry Lord Sales Representative Anastassia Zikkos Sales Representative Kim Wade Sales Representative Janet Roy Graphic Designer Aurora Automations Website & Social Media

FROM THE

EDITOR Robert P. Granacher Jr., MD, MBA, Editor-in-Chief, Kentucky Doc Magazine

Welcome to the summer edition of the LMS magazine, KentuckyDoc. We are not out of COVID yet, so this issue is devoted to COVID in a little different fashion than those you have seen previously. We start off with a review of the 1918 influenza pandemic by Terry Clark, MD, LMS member. Terry provides us with significant historical information that since none of were alive then, is very valuable. Terry notes that this review of the 1918 pandemic was based upon a book by John M. Berry. The warning in that book is striking: “The final lesson of 1918, a simple one, yet the most difficult to execute, is that those in authority must retain the public’s trust.” Where have we have seen breakdowns of this prescient warning? Tuyen Tran, MD, LMS member, provides us “Observations of a Physician Regarding Mental Health Effects Related to COVID-19.” This turns out to be a day in the life of Dr. Tran and the issues that he wrestled with in caring for his patients. He also gives us excellent epidemiology about COVID-19 based on recent data. A third article in our series is by Robert P. Granacher, Jr., MD, MBA, LMS member. Dr. Granacher looks at the impact of COVID19 upon the brain from a psychiatric, neuropsychiatric, and neurological standpoint. Neuropsychiatric, psychiatric, and neurological aftereffects are the second most common problems from COVID-19 at this time. Be sure and read “Community News” starting at page 20 of KentuckyDoc Summer 2021. Brian Lord has put together a significant overview of recent medical news in the Lexington area, including the new edition of Dr. Erika Boyd at Lexington Clinic Beaumont. She is a new pediatrician trained at the University of Arkansas School for Medical Sciences. She received her medical degree from the University of Kentucky. By now, most of the readers should be familiar with the Physician Wellness Program,

which was begun by the Lexington Medical Society and is now starting its fifth year of mental health care. This article is written by the two psychologists, Sandra Hough, Ph.D. and Steven Smith, Ph.D. Those individuals at the Woodland Group here in Lexington head up management of this important mental health provision available through the Lexington Medical Society for members, medical students, and residents. The penultimate article in our summer series is by Robert P. Granacher, MD, MBA and is titled, “COVID-19: Education of Medical Students Globally and at UKCOM.” Dr. Granacher spoke with Dean Griffith at the University of Kentucky, College of Medicine and learned that unlike third and fourth year students in 2020, for the 2021-2022 College of Medicine year, students will be allowed to function with COVID patients the same way physicians do. I encourage you to read this, because it has fascinating information not only about UKCOM, but also fascinating information about global issues for medical students. Lastly, Jim Ray writes, “Grow Your Practice by Thinking of Yourself as a Brand.” Jim is a specialist in business marketing, and he has written a very concentrated short article on how physicians can brand themselves. As always, the Editor in Chief wishes you the best. Enjoy the reading of KentuckyDoc for this summer quarter, and look forward to the fall edition of KentuckyDoc. Stay well, Bob

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INFLUENZA PANDEMIC LESSONS FOR THE COVID-19 CORONAVIRUS PANDEMIC? By Terry Clark, MD The COVID-19 pandemic erupted in early 2020. The cause, the SARS-CoV-2 virus, was a new, highly infectious virus. It had an early lethality in the range of 2 to 8%. There were no drugs or vaccine to combat it. Until these could be developed, quarantine and other mitigation practices were our only weapons against spread. Many experts have analyzed the deadly 1918 Influenza Pandemic in hopes of identifying previously successful practices. I hope to answer some of the important questions in this article. Can we really compare the two pandemics?

Historians strongly disagree about many details of the pandemic, with global cases estimated anywhere from 20-100 million. This makes almost all comparisons of mitigation practices speculative. In 1918 no national influenza health statistics were systematically compiled. Infection control practices were widely variable from city to city and were instituted at dramatically different

phases of the pandemic. Deaths eventually became so frequent that the names of the dead were not even entered in some records, just the body count. For instance, much has been made of reports that “masks” were of no use in controlling infection in 1918. Gauze, 4 layers thick, was used as respiratory masks. They had been important in control of tuberculosis within medical wards, but did not prevent influenza spread. There can be no comparison to the two-layer, snug, tightly knit cloth masks recommended for public use by CDC today. Similarly, mitigation efforts for COVID-19 have been no more organized or enforced on a national scale than those in 1918. How similar is the biology of the viruses?

Both are variants that arose from viruses that are endemic in other species and through mutation achieved the ability to spread among humans. Influenza pandemics have been frequent but rarely as lethal as 1918. The exact origin for the COVID-19 virus is under intense scrutiny, but Its origin is of no current importance

in relation to U.S. mitigation and won’t be discussed here. Are the time frames of the two pandemics comparable?

No, they are hugely different. It is still too early to write the history of the COVID-19 pandemic. While we are somewhere between at least 18 months to perhaps 24 months since the origination of human transmission by the virus, we have really seen only one “phase” in virus biology. Different areas of the world have seen surges of infection at different times. In the U.S. surges generally followed holidays that stimulated travel, family gatherings, and loosening of various mitigation restrictions by some states. The worst was the Thanksgiving-New Year period which began from a high baseline and occurred during the optimal winter respiratory illness season. That surge has only abated as vaccine distribution progressed and the spring weather came. The time course of the 1918 pandemic was shorter, but also much more Continued on Next Page

1918 continued from Previous Page

complicated. The unusual nature of the 1918 influenza infections was first reported in February 1918 to the U.S. Public Health Service (and included in only one issue of its weekly publication) by Dr. Loring Minor of rural Kansas. He recognized a cluster of perhaps 30-50 cases as an influenza of unusual severity and rapid spread, with deaths often occurring in young, healthy adults. By the end of March the local rural epidemic had run its course. However, a visiting soldier carried it to the nearby Camp Funston Army Base overflowing with 56,000 draftees/ enlistees. Their first case was diagnosed on March 4th and by the 25th, about one thousand cases were hospitalized and thousands more were sick in their barracks. Eventually 38 soldiers died in March. The physicians at the camp implored the Army command to isolate the camp, but ingress and deployments of soldiers continued. By mid-April most of the military in the U.S. as well as the European theater were seeing debilitating disease. About 40% of the soldiers were unable to leave their barracks. Front line Allies and European civilians had even more cases. Fortunately, the German army was also suffering from the disease and this may have saved a retreating Allied Army from a third German offensive that could have ended the war that spring. Deaths were more frequent than seen with

the usual influenza epidemics, but still below 2% of cases. By the end of August 1918, the epidemic in the armed forces also had seemed to run its course. Through the 1918 winter and summer the virus spread in U.S. civilian populations as scattered outbreaks occurred, largely in coastal or rail centers near military camps. Toward the fall, the virus spread inland to more isolated areas and increased rapidly. This pattern of spread is similar to what has been seen with COVID-19. The first waves hit crowded cities and trade centers like New York City, New Orleans, Detroit, Seattle and San Francisco while somewhat sparing smaller cities and rural populations until fall and winter 2020-21. Prior to mid-September 1918 outbreaks resulted in only moderately more deaths than seasonal influenza of the period. However, occasionally highly fatal outbreaks were present. Louisville, KY saw an outbreak over the summer with 40% fatal infections. As had been observed by Dr. Loring, the deaths were largely in healthy adults instead of the usual victims, children and the elderly. In October, a second wave of epidemic infections occurred around the world with increased mortality. Death rates from the new strain were often in the 40% range and occasionally even higher.

Are the viruses similar in lethality?

The answer to that question depends on which variant of the 1918 influenza virus you use for comparison. In 1918-20 about 675,000 influenza deaths occurred in a U.S. population of about 100 million. This would proportionally be about 2 million Americans dead in 2020-21. In the 1918 influenza two-thirds of all U.S. deaths occurred between October and December 31st, 1918. The U.S. lost about 100,000 soldiers to combat death in “The Great War” and 47,000 military influenza deaths. The German influenza deaths in October were probably a major factor in Germany’s unconditional surrender on November 11. In this second phase symptoms came on within 24-72 hours of exposure and death was usually within 4-7 days, but occasionally within hours. Patients died with fulminant cutaneous cyanosis, hemoptysis, purpura, headache and high fever. Patients had an appearance similar to descriptions of the dreaded “Black Plague” that decimated Europe in the 1300’s. Recovered patients often suffered lasting cognitive issues. This may have included President Wilson, who was infected during the peace negotiations in the spring of 1919. The “new” influenza virus spreading in the fall of 1918 is perhaps the deadliest virus

Experts fear a mutation that produces more fatal disease such as was seen in the fall 1918 influenza, particularly if it occurs as a second mutation in a vaccine resistant strain.

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ever recorded, essentially equal to Ebola in death rates. Luckily, it burned itself out by the end of 1920. Similar serotype H1N1 influenza virus appearing in 2009 was much less dangerous. The current contagion and mortality rates of COVID-19 are more comparable to the early 1918 virus seen in the winter through the summer of 1918. Current deaths run about 1-2% of infections in the U.S. Even the somewhat more aggressive COVID-19 variants do not reach the extreme mortality of the fall 1918 influenza, but is of an order well beyond the “usual” influenza strains in the world today (about 10-15-fold more deadly). Do experts believe any public health practices could have lessoned the U.S, death rate in the 1918 pandemic?

The answer is a “probably” if the world hadn’t been at war. We had controlled polio, measles, small pox and diphtheria epidemics with quarantines. Unfortunately, throughout the pandemic the Wilson government and many newspapers down-played the domestic epidemic as well as the military disease. Troop deployments were not affected. The U.S. population was confused and fearful throughout the pandemic. Political authorities, both local and national, decried anyone writing about the disease as traitors to the war effort (government medical professionals were ignored and often relieved of their duties). Liberty Bond Rallies continued in most cities with the traditional parades, drinking and dancing in the beer halls. Spain (it was neutral) was about the only government to not distort news coverage of the disease and to Americans it became the “Spanish Flu”. Hispanic and Italian immigrants were harassed and occasionally attacked. Some residents were so afraid of the disease they refused to leave their homes and starved to death. Most citizens refused to help with the sick. Nurses and doctors were overwhelmed and many died. The Temperance Movement claimed the infected were cursed as punishment for

their sinful lifestyles and this undoubtedly helped pave the way for later Prohibition legislation. Food and factory supply lines failed for lack of willing workers as much as workers lost to disease. Still, Wilson insisted on keeping factories of the war industry going. In 2020 our government’s response was hauntingly similar. In summary, what can we learn from study of the 1918 Influenza Pandemic?

First of all, the most important difference between the two pandemics lies in the fact that we have yet to see a truly game-changing mutation in the COVID-19 virus strains. The current vaccines, although less effective in some strains, have significantly slowed virus spread. Still, there is danger from the emergence of a strain that the vaccines do not recognize. Even more, experts fear a mutation that produces more fatal disease such as was seen in the fall 1918 influenza, particularly if it occurs as a second mutation in a vaccine resistant strain. If so, COVID-19 death rates could exceed even the worst seen in the 1918 pandemic. As global infections surge in countries with little vaccine availability, the conditions are ripe for these mutations to develop. For this reason, it is critical that U.S. vaccine participation is high and global vaccine distribution occurs as rapidly as possible. Current estimates are 2 years or more to achieve global vaccination levels of greater than 70%. Additionally, even if moderate U.S. death rates can be tolerated as a tradeoff to avoid severe economic damage, a persistent endemic level of infection will also increase the odds of a more deadly phase of the pandemic may occur. Secondly, governmental withholding of accurate information from the public can amplify the morbidity and mortality of the disease. In 1918 a few isolated cities and islands were able to avoid the second influenza phase by almost complete closure to outside persons and trade as well as enforcing bans on group activities. St. Louis is often touted as an example of policies that resulted in “control”, even

though they saw an eventual rate of 358 influenza deaths per 100,000 population (about 1/2 the national rate in 1918-20 and about double the COVID-19 U.S. mortality rate to date). St. Louis was fortunate in that they had no influenza cases until October of 1918. Still, it shows that early planning and enforced control measures had some chance of mitigating death rates. They instituted many of the policies promoted by the 2020 CDC, but didn’t completely shut down the city and were flexible according to the infection rates as time went by. Independent community leadership worked closely with business and the medical community. Boston and Philadelphia on the other hand saw large outbreaks in the summer and early fall; and were major ports of military deployments to Europe. Local political authorities in those cities did very little to control the spread, yet their few mitigation efforts are often compared to St. Louis. Most of the information in this article was obtained from the book by historian John M. Barry entitled The Great Influenza. The original publication came out in 2005. A more recent digital version includes an Afterword put out about 1918, a couple of years before the COVID-19 disease outbreak. It includes this warning: “The final lesson of 1918, a simple one yet one most difficult to execute, is that those in authority must retain the public’s trust. The way to do that is to distort nothing, to put the best face on nothing, to try to manipulate nothing, to try to manipulate no one. Lincoln said that first and best. ‘A leader must make whatever horror exists concrete. Only then will people be able to break it apart.’ “ There are many additional facets of the 1918 Influenza Pandemic that deserve discussion but are beyond this article. These include economic effects of the disease, the direct and indirect influence on the war, post-1918 political movements, immigration, and subsequent medical advancements.

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OBSERVATIONS OF A PHYSICIAN REGARDING

MENTAL HEALTH EFFECTS RELATED TO COVID-19 By Tuyen Tran, MD After a year of experience with the pandemic, at the financial cost of $10 trillion dollars worldwide per Finance & Economics ( Jan 2021), human lives cost of 139 million infected people and 2.9 million deaths worldwide (600,000 deaths in the US) per Johns Hopkins Coronavirus Resource Center, we have learned a lot about the multi-systemic effects of the SARS-CoV2 infection. For some individuals, the infection is very similar to a bad cold. For others, the infection wreaks havoc, causing pneumonia, severe respiratory failure, heart inflammation, blood clotting abnormalities leading to strokes, limb ischemia, and disseminated bleeding. Additionally, there are growing reports of neurological and mental health symptoms (anxiety/depression) which may persist after the acute infection. Of note, the negative mental health impacts related to CoVID-19 (stress, anxiety, depression) also affect people who were not infected. Continued on Next Page

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There are growing reports of neurological and mental health symptoms (anxiety/depression) which may persist after the acute infection.

MENTAL continued from Previous Page

As a clinician in an acute hospital setting, I have unfortunately seen my share of the medical devastation associated with the CoVID-19 infection, particularly in the elderly population. In hospitalized patients afflicted with CoVID-19, delirium is much more prevalent than typically expected. The patient may present with generalized respiratory symptoms, mentally alert, but ill-appearing. However, within hours, the patient may quickly deteriorate to respiratory distress followed by ventilator dependency. And just as rapidly, the patient may become disoriented, agitated, and paranoid, often with hallucinations. (Delirium is associated with additional complications to include prolonged hospitalization and increased risk of death.) There are reports of other neurologic sequela to include encephalitis, spinal cord infection, seizures, neurodegeneration, and neuroinflammation. This inflammation of the brain may impact memory loss, cognition, and/or depression which may persist for a significant time after the acute infection. Depending upon sources, up to 45% of hospitalized patients and about 33% of non-hospitalized patients reported some residual neurologic symptom (headaches, dizziness) or new neuropsychiatric condition within six months. Per study in The Lancet Psychiatry (Taquet, April 6, 2021), the incidences of anxiety (17.4%), substance use disorder (6.6%), and insomnia (5.4%) were all increased. In the outpatient setting of an addiction clinic, patients who had contracted CoVID-19 seem much more anxious and depressed. Despite the outward appearance of recovery from

the infection, many manifest difficulty concentrating, memory loss, brain fog, and sleeping disturbances. Patients relate that their CoVID-19 symptoms linger (“long-haul CoVID”) despite recovery from the illness. Granted, these patients often have similar issues related to their addiction illness. However, the severity of the anxiety or depression seems worse despite successful treatment of their addiction. In regards to the memory loss and/or difficulty concentrating, these observations are apparent only because I know these individuals. After months of treatment, I have a good idea of their cognitive baseline before CoVID-19 and there is a clear decline post-CoVID-19 infection. There is insufficient data to ascribe a direct causal relationship between CoVID-19 infection and these mental health symptoms; but, the current literature is full of similar reports. While waiting for our scientific scholars to work out the details regarding how the infection causes these symptoms, I encourage you to be mindful of these complications and support those patients who develop these symptoms. More importantly, please also pay attention to the mental health of our patients who did not contract CoVID19. The coronavirus pandemic has dramatically altered our lives. Stresses related to fear about contracting the virus, coupled with isolation, job losses, loss of childcare, and the devastating effect of the loss of a loved one to CoVID-19 have negatively impacted our mental health. A July 2020 Kaiser Family Foundation (KFF) Health Tracking Poll reported 4 in 10 adults in the US reported symptoms of anxiety or depression, up from 1 in 10

adults when compared to the previous year. In addition, the poll also showed difficulty sleeping (36%) or eating (32%), increases in alcohol use or substance use (12%), and worsening of chronic conditions (12%). It would be interesting to compare and contrast the mental health consequences of the CoVID-19 pandemic to the 1918 pandemic (an avian H1N1 virus, also known as the Spanish Flu); but sadly, there is very little data from the Spanish Flu. We do know that there was an increase in first-time psychiatric hospitalizations in the six years following the 1918 pandemic (Eghigan, Psychiatric Times). Specific symptoms described include sleep disturbances, anxiety, depression, mental distraction, dizziness, difficulty coping at work, and suicides. And for those who did not succumb to the pandemic, symptoms of chronic helplessness, anxiousness, and grief of the loss of loved ones were common. Most disturbing symptoms were from health professionals who reported that they were haunted for years by frustration and guilt. Thus, I encourage you to share your observations of the mental health impacts due to CoVID-19. I think it will become valuable to document CoVID19’s impact on patients who contracted the illness, people who coped with the virus, and the healthcare providers who cared for the patients with CoVID-19. I strongly suspect that these observations will predict and prepare us for CoVID19’s healthcare consequences: anxiety, depression, suicide, substance use, and neurologic/cognitive issues.

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THE

BRAIN PSYCHIATRIC, NEUROPSYCHIATRIC, AND NEUROLOGICAL FACES OF COVID-19 INFECTION By Robert P. Granacher Jr., MD, MBA

Introduction: Infectious Pandemics are a Risk Factor for Psychiatric, Neuropsychiatric, and Neurological Diseases Pandemics have shaken the foundation of society and turned the course of history and the mindset of humanity for centuries. Typhoid fever attacked and devastated Athens in 490 B.C. giving the military society of Sparta upper hand in the Peloponnesian War. The Black Death caused by Yersinia pestis killed a third of the population of Europe and instigated drastic changes in economic relations that ultimately disposed of serfdom and feudalism and laid foundations of Renaissance. The last global epidemic of Spanish Flu responsible for 20 to 50 million deaths coincided with First World War and resulted in conflicts and the birth of Bolshevism. This brought great confusion to mankind.1

Continued on Next Page

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There is ample evidence now in the world literature that COVID-19 causes inflammation of the brain, and thus there appears to be at least a linkage to COVID-19 and the induction of depression in humans.

BRAIN continued from Previous Page

The COVID-19 pandemic has changed the world and is changing the culture and human interactions in the US, possibly forever. COVID-19, also known as SARS-CoV-2 can linger for a long time at both upper and lower respiratory tracts.2 SARS-CoV-2 enters the body through various routes and causes systemic and tissue inflammation. This in turn, compromises the blood-brain barrier of the brain and floods it with pro-inflammatory factors. This leads to an increased production and secretion of other pro-inflammatory factors. The combination of systemic inflammation, hypoxia resulting from respiratory failure, and neuro-inflammation may trigger or exacerbate psychiatric, neuropsychiatric, and neurological diseases.1 COVID-19 and Psychiatric Illness

Major depressive disorder is one of the most frequent neuropsychiatric disorders linked to inflammatory injury to the brain. There is ample evidence now in the world literature that COVID19 causes inflammation of the brain, and thus there appears to be at least a linkage to COVID-19 and the induction of depression in humans. Systemic infection has been shown to trigger major depression in elderly patients because of age-dependent decreases of immune homeostasis.3 A review of COVID-19 and bipolar disorder does not give us the same types of literature sources, and the issue is not settled as to what relationship, if any, there is between COVID-19 and bipolar disorder. COVID-19 is increasingly implicated in mental complications, such as psychosis. There is a potential causal link between

COVID-19 infection and psychotic symptoms. However, case reports to this date have been incomplete, as the patients described had known psychiatric histories. One case in the world literature recently reported late-onset psychosis in a middle-aged man with no prior psychiatric history who tested positive for COVID-19 on admission to hospital. He presented with delusions, hallucinations, and disorganized thought and behavior, which subsequently led to inpatient psychiatric hospitalization where he was successfully treated by standard means.4 This 57-year-old man had an abnormal Montreal Cognitive Assessment ClockDrawing Test on initial presentation at hospital which improved as his psychosis improved. Two general mechanisms of central nervous system involvement have been proposed to explain neuropsychiatric symptoms of COVID19 infections: 1. Direct viral invasion of the central nervous system by way of the olfactory bulb across the cribriform plate or by hematogenous spread across the blood-brain barrier1 2. As a sequela of the severe systemic inflammation commonly seen with COVID-195,6 There is a large body of literature that reports the occurrence of obsessions and compulsions in patients who have recently recovered from viral encephalitis. Obsessive-compulsive disorders (OCD) were recognized and linked with von Economo’s encephalitis. To date, OCD has not been reported with COVID-19,

but since it has been reported in other viral infections of the brain, it is suspected that COVID-19 may therefore trigger OCD in surviving subjects.1 A recent international article by Shah et al. (2020) has reviewed mental health during the Coronavirus pandemic and applied that to information from past outbreaks in pandemics. These authors noted substantial evidence from past studies of the impact of SARS, MERS, influenza, and Ebola epidemics; the at-risk population showed neuropsychiatric linkages.7 Neuropsychiatric Complications of COVID-19

It has recently been proposed that not only is the COVID-19 pandemic a significant psychological stressor, but it is also noted to cause significant neuropsychiatric symptoms associated with potential immunologic mechanisms.8 As far as psychological stressors, there are unsettling case reports of suicide deaths related to fears of contracting or spreading COVID-19. The following have also been reported recently in association with infection of the COVID-19 virus: encephalopathies, anosmia, ageusia, chronic neuropsychiatric sequelae such as depression, anxiety, and traumarelated disorders, psychotic disorders, demyelinating and neuromuscular complications, and neurodegenerative disorders.9 There is a case report of a 69-yearold Caucasian female with no prior psychiatric history who developed excited catatonia 1 month after acquiring Continued on Page 18

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BRAIN continued from Page 16

COVID-19. She was seen in the emergency department of a University hospital in San Diego and presented with bizarre behavior, confusion, and paranoid thoughts for four to six weeks. She thought the government was tracking her and thought her husband had drugged her and bugged her phone. Upon presentation, her Glasgow Coma Scale score was 15, and she had a blood pressure of 174/87 with a pulse of 85.

Other vital signs were within normal limits. During the first few days of hospitalization, she remained alert and oriented but displayed extreme agitation and aggression that intermittently necessitated restraints. She displayed some rigidity on physical examination, was extremely restless and agitated, demonstrated poor eye contact, and had a flat affect with echolalia and loose associations. She was not thought to be demented nor delirious, because she

remained alert and oriented to time, place, and person. She was diagnosed with excited catatonia occurring in association with COVID-19 infection and successfully treated with Lorazepam. What made this patients’ presentation and case history dramatic compared to reports of other studies was that hers was so delayed and appeared more than a month after her original infection. Frequent delirium has been associated with COVID-19 infection. It is recognized

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Delirium appears to be common in COVID-19 infection. that delirium in patients with COVID-19 has many possible etiologies, and catatonia is a potential outcome. Delirium appears to be common in COVID-19 infection.10 The authors of this article recommend that the practices of previous delirium studies should be followed, and they suggested using the well-validated Delirium Rating Scale-Revised-98 (DRS-R98) for serial assessments. A recent neurological and neuropsychiatric surveillance study of 153 patients was presented in Lancet Psychiatry (2020).11 This study is touted as the first nationwide, cross-specialty surveillance study of acute neurological and psychiatric complications of COVID19. Altered mental status was the second most common presentation, also comprising encephalopathy or encephalitis and primarily psychiatric diagnoses, often occurring in younger patients. Neurologic Complications of COVID-19

The findings of numerous studies show that beyond the acute pulmonary illness, nervous system and neurocognitive disorders, psychiatric disorders, and neurologic disorders, often appear as delayed manifestations of COVID-19.12 In particular, neurological presentations of COVID-19 may reveal themselves as encephalitis, Guillain-Barré syndrome, and acute disseminated encephalomyelitis,13 among other neurologic disorders. A preprint from Wuhan, China reports 36% of 214 patients with confirmed COVID19 manifested neurological disorders.14 It is not yet fully clear how SARS-CoV-2 virus infects the brain. Little of the virus is found in CSF, yet oligodendrocytes are susceptible and COVID-19 encephalitis usually is a white matter disease. Patients with neurological complications often require prolonged ICU stays.14 Neuroinflammatory crises often are seen but use of IV immunoglobulins increases risk of thromboembolism

and is often associated with increased D-dimer levels15 and may be avoided in some. Delayed neurological side effects of COVID-19 remain to be fully elucidated and diagnostically verified. References

1. Steardo L Jr, Steardo L, Verkhratsky A. Psychiatric Face of COVID-19. Translational Psychiatry, 10: 1-12 (2020). doi.10.1038/s41398-20000949-5 2. To KK, Tsang OT, Leung WS, et al. Temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by SARSCoV-2: an observational cohort study. Lancet Infectious Disease; 20(5) 565574 3. Diger RN, Johnson RW. Aging, microglial cell priming, and a discordant central inflammatory response to signals from the peripheral immune system. Journal of Leukocyte Biology, 84: 932-939 (2008) 4. Parker C, Slan A, Shalev D, Critchfield A. Abrupt late-onset psychosis as a presentation of Coronavirus 2019 disease (COVID-19): A longitudinal case report. Journal of Psychiatric Practice, 27: 131-136 (2021) 5. Baig AM. Neurological manifestations in COVID-19 caused by SARSCoV-2. CNS Neuroscience Therapeutics, 26: 499-501 (2020) 6. Desforges M, le Coupanec A, Dubeau P, et al. Human coronal viruses and other respiratory viruses: underestimated opportunistic pathogens of the central nervous system? Viruses, 12: 14 (2019) 7. Shah K, Kamrai D, Mekala H, et al. Focus on mental health during the Coronavirus (COVID-19) pandemic: applying learnings from past outbreaks. Cureus, 12(3): e7405. doi.10.7759/cureus.7405

8. Troyer EA, Kohn JN, Hong S. Are we facing a crashing wave of neuropsychiatric sequelae of COVID19? Neuropsychiatric symptoms and potential immunologic mechanisms. Brain, Behavior, and Immunity, 87:3439 (2020) 9. Zain SM, Muthukanagaraj P, Rahman N. Exited catatonia – a delayed neuropsychiatric complication of COVID-19 infection. Cureus, 13(3): e13891. doi.7759/cureus.13891 10. Beach SR, Praschan NC, Hogan C, et al. Delirium in Covid-19: A case series and exploration of potential mechanisms for central nervous system development. General Hospital Psychiatry; 65:47-53 (2020) 11. Varatharaj A, Thomas N, Ellul MA, et al. Neurological and neuropsychiatric complications of COVID-19 in 153 patients: a UK-wide surveillance study. Lancet Psychiatry, 7:875-882 (2020) Published online June 25, 2020, https://doi.org.10.1016/s22150366(20)3087-X 12. Ziyad AA, Xie Y, Bowe B. Highdimensional characterization of postacute sequelae of COVID-19. Nature; Published online: 22 April 2021, https//doi.org/10.1038/s41586-02103553-9 13. Needham EJ, Chou, SH-Y, Coles AJ et al. Neurological implications of COVID-19 infections. Neurocritical Care; 32: 667-671 (2020), https//doi. org/10.1007/s12028-020-00978-4 14. Mao L, Wang M, Chen S et al. Neurological manifestations of hospitalized patients with COVID19 in Wuhan China: a retrospective case series study, https//doi.org/10. 1101/2020.02.22.20026500 15. Zhou F, Yu T, Du R, et al. Clinical course, and risk factors for mortality of adult inpatients in Wuhan, China: a retrospective cohort study. Lancet; 395: 1054-1062 (2020)

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COMMUNITY NEWS A N N O U N C E M E N T S , AWA R D S , E V E N T S & M O R E

Lexington Clinic Beaumont is excited to welcome Dr. Erika Boyd Dr. Boyd completed a residency at Dr. Erika Boyd University of Arkansas for Medical Sciences and received her medical degree from the University of Kentucky. She provides pediatric services, including well-child checkups, sports physicals and visits for acute and chronic illnesses for children of all ages. Event: Effective Communication Strategies for Dementia Communication is more than just talking and listening – it’s also about sending and receiving messages through attitude, tone of voice, facial expressions and body language. As people with Alzheimer’s disease and other dementias progress in their journey and the ability to use words is lost, families need resources to help dementia caregivers learn to decode verbal and behavioral messages from people with dementia. The program will be held online on Tuesday, July 13th 6:30pm EDT/5:30pm CDT. To register for this program, please call 1-800-272-3900. Registration is required. Program provided by the Alzheimer’s Association. Join us to explore how communication takes place when someone has Alzheimer’s, learn to decode the verbal and behavioral messages delivered by someone with dementia, and identify strategies to help you connect and communicate at each stage of the disease.

Event: Understanding and Responding to Dementia-Related Behavior Behavior is a powerful form of communication and is one of the primary ways for people with dementia to communicate their needs and feelings as the ability to use language is lost. However, some behaviors can present real challenges for caregivers to manage. Join us to learn to decode behavioral messages, identify common behavior triggers, and learn strategies to help intervene with some of the most common behavioral challenges of Alzheimer’s disease. The program will be held online on Tuesday, July 6th at 6:30pm EST/5:30pm CDT. To register for this program, please call 1-800-272-3900. Registration is required. Program provided by the Alzheimer’s Association. Event: Rural Caregiver Telehealth: You Can’t Control Your Future But You Can Plan for It The diagnosis of dementia makes planning for the future more important than ever. Join us as an attorney from Bluegrass Elderlaw teaches about important legal and financial issues to consider and how to put plans in place. We want to virtually connect with people who are impacted by Alzheimer’s disease and dementia to provide education and supportive services across the state of Kentucky. Bring your questions about memory disorders, brain health, and care and treatment for your loved ones. We look forward to engaging with you. Please

register in advance at https://tinyurl.com/ RuralCaregiving072021 or if you prefer to register by phone, call Tyler at (859) 257-6507. Brought to you by the UK Sanders Brown Center on Aging and The Alzheimer’s Association. This event is free and open to rural areas. Date: July 22, 2021. Time: 6:30-8pm EST/5:30-7pm CST Event: Dementia Conversations This program will offer tips on how to have honest and caring conversations with family members about: deciding when to stop driving, going to the doctor, making legal and financial decisions and reducing stress by building a strong care team. This webinar will be held on Wednesday, July 7th at 2pm EDT/1pm CDT. Registration is required by calling 1-800-272-3900. Program provided by the Alzheimer’s Association. Event: Young Adult Children of People With Younger-Onset Dementia Support Group Support groups create a safe, confidential, supportive environment and a chance for participants to develop informal mutual support and social relationships. They also educate and inform participants about dementia and help participants develop methods and skills to solve problems. This virtual group is for people ages 18-25 who have a parent who is diagnosed with dementia at age 65 or younger, who are at any stage of dementia. This group will meet on Wednesday, July 14th at 6:00 p.m.

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SHARE YOUR STORY WITH THE COMMUNITY. E M A I L B R I A N @ R O C K P O I N T P U B L I S H I N G . C O M T O H AV E Y O U R N E W S P U B L I S H E D.

CDT/7:00 p.m. EDT. No screening is required. Call 1-800-272-3900 to register. Event: Memories at The Museum: Speed A-RT Join us for a special program designed for those living with early- and middlestage memory loss and their care partners. Memories at the Museum will meet virtually on Saturday, July 24th at 1pm EST/12pm CDT, combining a tour of a gallery or special exhibition with a handson art-making activity. Designed for people with memory loss and their caregivers; please no professionals. Registration is required through the Alzheimer’s Association. Please call 1-800-272-3900. Program provided by the Speed Art Museum, AARP, and the Alzheimer’s Association. Event: Young Onset Dementia Care Partner Support Group Support groups create a safe, confidential, supportive environment and a chance for participants to develop informal mutual support and social relationships. They also educate and inform participants about dementia and help participants develop methods and skills to solve problems. This virtual support group is for care partners of people diagnosed with Mild Cognitive Impairment or any form of dementia prior to age 65, who are at any stage of dementia. This support group is an opportunity for spouses, adult children, siblings, and other caregivers of those with Younger Onset

dementia to meet together. This group will meet via zoom on Wednesday, July 28th at 7:00 pm CDT/8:00 p.m. EDT. No screening is required. Call the Alzheimer’s Association at 1-800-272-3900 to register. Baptist Health Corbin Among Nation’s Top Performing Hospitals for Treatment of Heart Attack Patients Award recognizes high standards of patient care. Baptist Health Corbin has received the American College of Cardiology’s NCDR Chest Pain – MI Registry Silver Performance Achievement Award for 2021. Baptist Health Corbin is one of only 132 hospitals nationwide to receive the honor. The award recognizes Baptist Health Corbin’s commitment and success in implementing a higher standard of care for heart attack patients and signifies that Baptist Health Corbin has reached an aggressive goal of treating these patients to standard levels of care as outlined by the American College of Cardiology/American Heart Association clinical guidelines and recommendations. To receive the Chest Pain – MI Registry Silver Performance Achievement Award, Baptist Health Corbin has demonstrated sustained achievement in the Chest Pain – MI Registry for four consecutive quarters during 2020 and performed with distinction in specific performance measures. Full participation in the registry engages hospitals in a robust quality improvement

process using data to drive improvements in adherence to guideline recommendations and overall quality of care provided to heart attack patients. “As a Silver Performance Award recipient, Baptist Health Corbin has established itself as a leader in setting the national standard for improving quality of care in patients with acute myocardial infarction,” said Michael C. Kontos, MD, FACC, chair of the NCDR Chest Pain – MI Registry Steering Subcommittee, and cardiologist at Virginia Commonwealth University Medical Center. “Our goal is to provide our patients with state-of-the art cardiovascular care during the critical window of time (symptom onset to reperfusion) when we can preserve the integrity of the heart muscle. This is another step in our continuing efforts to provide the ever-improving care to our patients, and to make Baptist Health Corbin the best it can be,” stated Anthony Powers, President.

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IMPACT OF COVID-19 ON

MEDICAL STUDENTS The unprecedented events of the past year that were brought about by Covid-19, impacted every aspect of our personal and professional worlds. The medical field, in particular, was greatly affected by this pandemic. Not only were front line workers pressed to work beyond their physical and emotional capacities, but residents and medical students had to make huge adjustments to their professional and personal lives due to the pandemic.

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By Sandra Hough and Steven Smith One of those adaptations required learning remotely. Missing the stimulation of being in classrooms and interacting with a “live” person made maintaining a focus a challenge for some. They found it much harder to look at a screen for hours on end than to be able to break up the monotony with live person interaction. Isolation from faculty made it more difficult to ask questions and discuss the material they were learning. As therapists working with this population, we too had to experiment with new ways of connecting and communicating with our clients. With very little prior experience using teletherapy, there was a learning curve for both clinicians, residents, and medical students. By most reports, this new digital avenue for dialogue proved to be not only workable, some actually preferred it. With no travel time required, the session could take place from the comfort of a home environment, perhaps with a cup of hot tea. There were many and various challenges that residents and medical students reported as a result of the pandemic. This population is normally at risk for psychological distress such as burnout, but with the added impact of COVID-19, they experienced an even greater degrees of stress. Residents reported trauma reactions to heartbreaking work in Covid units early into the pandemic. The unpredictability of the course of the disease was particularly difficult for them, especially so for first year residents. The emotional impact was particularly challenging. Experiencing patients’ long-term hospital stays, the resulting attachment to their patients, and then helplessly seeing them worsen, and sometimes dying, was traumatizing for some. Some clients reported seeing multiple members of the same family simultaneously hospitalized for Covid, and the understandable heartbreak those family

members felt because of their inability to be together. They were so very close— and yet so far. Some found it profoundly difficult to give heart-breaking news to patient families so early in their career. Social isolation was difficult for all but the most extreme introverts. First-year medical students were unable to meet their classmates and create new friendships. They were in a new cohort, but separated from one another in ways that did not allow for a connection. It was like going to a party with a blindfold on. It was disorienting. In addition to being cut off from their peer group, most felt it unsafe to visit their parents and extended family. Some couples who were not living together, but in a committed relationship, were forced to stay apart for many months until they were vaccinated. Those who had just recently moved to the area experienced the greatest disorientation, isolation, and difficulty focusing. Couples who are married with children had a much harder time finding resources for childcare during the pandemic, faced with the indefinite closure of daycares and schools across the country. Some immigrants and those of minority status, already facing the challenges of fitting into a white dominant culture, experienced the strains of their previouslystretched social support system. Doubts about career choice arose for some residents and medical students. Some developed because of anxiety about the pandemic and the uncertainty about whether they wanted to deal with something of this scope going forward; others because they were suffering from social isolation, particularly those who were living alone and far away from family. Sleep deprivation magnified stress reactions and limited hours off-duty prevented the utilization of usual coping methods. Those who had a history of anxiety and depression, even when they

hadn’t had problems for a long time, were surprised at the recurrence of these issues. Not expecting to ever have to deal with it again, they were dismayed and felt like failures. Reframing their experience helped. It was useful to recognize that these reoccurrences were just like having a weak ankle that gives way again under too much stress. With no access to gyms, many exercise routines came to a halt, resulting in a more sedentary lifestyle. Those who adapted and found other ways to exercise and move their bodies, seemed to navigate the stress with greater ease. For those who did not, the resulting weight gain, lethargy, and sleep issues were further complications that added to their experienced stress levels. Some residents were concerned because the reduced patient volume during the pandemic limited their opportunities to perform essential inpatient procedures. They were apprehensive about not achieving proficiency in essential medical procedures. In general, levels of anxiety were heightened, not only by the many factors already mentioned, but also by being forced into situations that were not of their choosing. One such example were residents who were trained to step into front-line roles should the system become overwhelmed with Covid patients. Not all residents were psychologically prepared to deal with dying patients and in some cases, they had specifically chosen specialties that would spare them of that experience. Fearing having to do so raised their anxiety levels. As you can see, there were many challenges during the past year and we are very grateful that the University Kentucky College of Medicine offers psychological support for their fellows, attendings, graduate students, residents, and medical students. Serving those who reached out to us during this trying time has been an honor and privilege.

This population is normally at risk for psychological distress such as burnout, but with the added impact of COVID-19, they experienced an even greater degrees of stress.

| Summer 20212021 | www.kentuckydoc.com | www.kentuckydoc.com docdoc| Summer

26 Kentucky Kentucky

COVID-19:

EDUCATION OF MEDICAL STUDENTS GLOBALLY AND AT UKCOM

Robert P. Granacher Jr., MD, MBA, Editor-in-Chief, Kentucky Doc Magazine

Introduction

The COVID-19 pandemic has thrown our world a serious curve. The necessary focus of international physicians has been to care for patients and communities, because of the emergence of severe, acute respiratory syndrome coronavirus2. This disease has disrupted medical education and will require intense and prompt attention from medical educators. This article is designed to share light on the global situations for our medical students, and lastly to explore the needs of University of Kentucky College of Medicine students from the Class of 2021. COVID-19, for the years 2020-2021 has had a profound impact upon medical students worldwide. It had

the potential to affect students adversely throughout their educational process. Global Impact of COVID-19 upon the Training of Medical Students during 2020-2021

The first COVID-19 tough pandemic issue to face medical instructors throughout the world was getting their students vaccinated. It is interesting that vaccine hesitancy has been a significant pressure point for moving students through their medical education in a safe manner. For instance, a recent research article from the Oakland University School of Medicine in Rochester, Minnesota notes that nearly all participants in their study of medical student attitudes about vaccination, revealed positive attitudes towards vaccines. However, when push came to shove, 23% of students at this institution

were unwilling to take COVID-19 vaccines immediately upon FDA approval.1 This was the first study the author could find about vaccine hesitancy among U.S. medical students. On the other hand, COVID-19 vaccine hesitancy was also seen among medical students in India. This data comes out of the All-India Institute of Medical Sciences and consisted of an online questionnaire that was filled out by 1,068 medical students across 22 Indian states and Union territories from 2 February – 7 March 2021. Vaccine hesitancy was found among 10.6% of the students.2 Thus, there is evidence of substantial variance between an Asian country the size of India and medical students in the United States on this topic. Medical student education in the time of COVID-19 has been explored

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at the Perelman School of Medicine at the University of Philadelphia.3 Dr. Rose notes that in response to COVID19, medical education MANY STUDENTS faculty have quickly REPORTED transitioned MORAL DISTRESS the entire ASSOCIATED pre-clerkship curriculum to WITH WATCHING online formats PATIENTS BE that included ISOLATED FROM content in the basic sciences, LOVED ONES... health system sciences, and even in behavioral sciences. Small group formats convene in online virtual team settings, and clinical skills sessions may occur online, or in some cases,

may be deferred. Examinations have also transitioned to online settings. Dr. Rose concluded, “It is crucial that the academic educational community learns from the experience and prioritizes a forward-thinking and scholarly approach as practical solutions are implemented.” She also opined, “The COVID-19 epidemic may represent and enduring transformation in medicine with the advancement of telehealth, adaptive research protocols, and clinical trials with flexible approaches to achieve solutions.”3 Gallagher and Schleyer4 explored student and trainee responses to the COVID-19 pandemic. These professors of medicine are associated with the University of Washington School of Medicine. Drs. Gallagher and Schleyer noted that the high probability that medical students in the hospital would

be exposed to COVID-19 and the need to conserve personal protective equipment (PPE) seemed to outweigh the educational benefits of student participation. This prompted University of Washington senior leaders to remove medical students from clinical rotations on March 16, 2020. To learn more about how COVID-19 is affecting our students and trainees, Drs. Gallagher and Schleyer conducted a brief anonymous survey and received responses from 316 third year and fourth-year medical students, interns, and residents in Internal Medicine and Emergency Medicine, and fellows in Pulmonary and Critical Care at that institution. These doctors learned that students and trainees felt anxious and vulnerable to COVID-19, and these fears were amplified for trainees serving on the pandemic’s front lines. Many students Continued on Next Page

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EDUCATION continued from Previous Page

reported moral distress associated with watching patients be isolated from loved ones and be described feeling distant from patients while wearing PPE. Especially for fourth year students, apprehension about “being rusty” and maintaining skills that would be required when they began their internships shortly, loomed large. The United States’ experiences among its medical students are similar with those in other countries. A British Medical Journal article5 noted significant impact of the COVID-19 pandemic on final year medical students in the United Kingdom following a national survey. The overall conclusion of this study was that the impact on medical student education had been significant and particularly affected the transition from student to doctor. In this study, a total of 440 students participated per medical school from 32 out of 33 UK medical schools. The medical schools were represented throughout England, Scotland, and Ireland. Almost all respondents to this study (93.9%) felt that the changes that had been made were necessary measures during this pandemic. There were 77.3% respondents that had electives canceled. Although these were disappointing to many of the students, they recognized that worldwide travel restrictions were necessary. The medical system in the UK is a bit different than that in the United States. Those students in the final year of medical education go on to assistantships, these are a transition from student to doctor. They noted that 25.5% of students had no change in their assistantship as they completed their medical education; 16.8% reported that their assistantship had been formally canceled, and 43% reported that assistantships were postponed. Further, 59.3% of students felt less prepared for their assistantships, while 22.7% felt much less confident. This is an exhaustive study,5 and it is worth reading

by medical students. The authors noted that the impact of COVID-19 on final year medical student education had been significant in the United Kingdom. Most students felt less prepared for beginning work as a doctor, and the disruptions to assistantships had a significant impact on preparedness. The authors opined those changes in force by this pandemic provided a key opportunity to evaluate alternative models of medical education and assessment, including novel online summative assessments.

of course, is not the same in the third and fourth years as face-to-face clinical education and patient responsibility. However, this author believes that student safety was justifiably paramount and like most US and global medical students at UKCOM. Going forward, medical educators will have to individually judge Class of 2021 students entering residencies regarding their COVID-19 pandemic knowledge and skills and provide further training where needed.

Local Impact of COVID-19 upon the Training of Medical Students at UKCOM

References

The author of this article contacted Charles Griffith, III, MD, MSPH, Vice Dean for Education at UKCOM. He advised this author that all medical students had now been vaccinated, and there was sufficient PPE for all. The guidelines for M3-M4 UKCOM students are no different than for physicians. They will take care of COVID-positive patients with appropriate PPE, including N-95 masks with no restrictions. Thus, incoming students to the 2021-2022 M3 and M4 years will be function similarly prior to the pandemic with full attending and senior resident supervision. They will be allowed to function the same as physicians with-regard-to interaction with COVID-19 patients. As the author has reported in a prior article in KentuckyDoc, he assists three M3 mentees and one M4 mentee at the UKCOM. Of course, this is by no means a proper statistical sample. They shared they have not been allowed to have faceto-face interactions with patients known to be positive for COVID-19. Thus, in general, they have missed most of the face-to-face interaction with COVID-19 patients. While they have been able to receive education through online video training, observing attending physicians at a distance and didactic lectures, this

1. Lucia VC, Kelekar A, Afoniso NM. COVID-19 vaccine hesitancy among medical students. Journal of Public Health (2020); pp. 1-5. doi:10.1093/ pubmed/fdaa230. Online ahead of print. PMID:33367857 2. Jain J, Saurabh S, Kumar P, et al. COVID-19 vaccine hesitancy among medical students in India. Epidemiology and Infection (2021); May 20: 149e 132. doi:10.1017/ S0950268821001205. Published online. 3. Rose S. Medical student education in the time of COVID-19. JAMA (2020); 323: 2131-2132. Published online: March 31, 2020. doi:10.1001/ jama.2020.5227 4. Gallagher TH, Schleyer AM. Perspective: “We signed up for this!” Student and trainee responses to the COVID-19 pandemic. New England Journal of Medicine (2020); 382 e96(1)-e96(3), June 18, 2020. 5. Choi B, Jegatheeswaran L, Minocha A, et al. Research article: The impact of the COVID-19 pandemic on final year medical students in the United Kingdom: A national survey. BMC Medical Education (open access), (2020); 20:206. https://doi. org/10.1186/s1209-020-02117-1

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| Summer 2021 | Business Section | www.kentuckydoc.com

Grow Your Practice by Thinking of Yourself as a Brand By Jim Ray

For years, the given way a physician grew a practice was through referrals from colleagues and associations with certain hospitals and/or insurance plans. The environment is changing. While these traditional channels remain important, the consumer is more empowered to seek out information about a specific physician. That shift is impacting how physician groups and individual practioners grow their respective practices. Today’s consumer is much more inclined to read online reviews, visit websites and even online physician directories. The need to establish and monitor information has become increasingly more important to a successful practice. Rather than referring a patient to a colleague from medical school, physicians may be encouraged (even pressured) to refer that patient to another member of the hospital network. Overtime, this may erode the traditional flow of new patients to your practice. I encourage professionals to begin thinking of themselves as brands.

This may alter your perspective on how accessible you are to the general public. Let’s consider a few of the implications. Brands such as GE, Apple, Starbucks and even Littmann (the company which may have made the stethoscope you use) all focus on producing great products. More importantly, these brands seek to instill a distinct image in your mind about the product and/or service offered. It’s about the “experience.” The same applies to you and your practice. That’s why you’ve invested so heavily in your education and training. You’re providing a service and you want your patients and their families to be happy with the care they receive. Ultimately, you hope they were

satisfied enough to recommend you to friends and family. This is simple brand positioning. Consider how many times your patients are given the opportunity to complete surveys about their experience. While we want to know that the care provided was effective and met expectations, there’s another reason we ask those questions. We want to know if there was a problem that needs to be addressed and/or resolved. This fact alone provides insight into an interesting fact. When it comes to effective branding, it’s the market, not the company (e.g. physician), that determines the brand’s value. While we may have logos and color schemes those aren’t your brand. They’re merely representations of it. Your brand is based on the value attributed to it by the patients and families who interact with you. Many of us are aware that a happy patient may tell a few people.

On the other hand, a dissatisfied patient will tell everybody. The Internet has become a repository for information about anything and everything. It includes tools consumers can use to tell others about their experiences through ratings and online reviews. If you haven’t taken time in the last few months to research how the market is reporting about you, it may be time for you to do a dive deep. A few negative reviews can have a significant impact on your practice. If you have an office manager, discuss setting up a periodic review of various online properties to monitor comments. When you think of yourself as a brand, your much more focused on the market, the value it attributes to you and how it positions you vis-à-vis your colleagues. Today’s consumers know they have access to information and they’re not afraid to use it. This fact provides an interesting opportunity for you. If you’re in private practice, have a

concierge practice, or may be thinking about transitioning back into a private practice, here are a few simple marketing tips to consider: First, how easily can people find information about you and your practice? While online directories are one component, you should give some thought to a professionally developed website. The advantage is that you control the content. A website provides you and your staff with the means to influence the market and attract new patients. More importantly, you may be able to outrank those ubiquitous online directories. This enables you begin influencing your brand’s perception. While some prospective patients are interested in your CV, many more will be interested in learning about what they should expect from you. Remember, it’s about the experience. A professionally developed website can convey the messages and images you intended. Second, how current is the information about you, your location & contact information? There are tools that can be used to standardize this information across various online properties. Interestingly, when that simple data (Name, Address and Phone) are consistent across the Internet, your website is usually rewarded with higher search rankings. This is especially important for new practices or physicians who have moved to different locations and/or groups. Third, consider adding social media as a way for you and/or your staff to better connect with existing and prospective patients. A well-designed and maintained Facebook page and result in massive exposure for your practice. Social media is a terrific tool for providing helpful information about your office, general information about conditions and/or treatments, new services or procedures, etc. Used effectively, it can reinforce your position as the subject matter expert. I’m not recommending you try to

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Start a Blog. A blog enables you to demonstrate your expertise. For example, you might begin providing updates and answers to common patient questions.

become pop-medicine’s next Dr. Oz or Dr. Phil. Consider, however, why major brands implement social media campaigns. They can have a positive impact on the bottom line. Fourth, explore the option of starting a blog. Blogging is an extremely effective way to provide information about your specialty. If done properly, blog posts can appear in Google search results, just like websites, directories and other sources of information. A blog enables you to demonstrate your expertise. For example, you might begin providing updates and answers to common patient questions. An office manager can easily upload a “Question of the Week” to your blog. That information can be disseminated to your social media properties and featured prominently on your website. The time needed to do this is surprisingly brief. The impact, however, can be significant. Finally, for those of you who like to push the envelope, implement a video component to your marketing campaign. The power of video is astonishing. The information in a video allows people to feel

connected to you in ways plain text simply can’t match. Surprisingly, video content can show up in Google search results, can be included in blog posts and uploaded to your social media channels. Some interesting facts about video: • Videos will soon be 90% of all Internet traffic (Robert Kyncl, YouTube VP) • Videos show up in 65% of the Google search results (Search Metrics) • Videos have a 41% higher click-through rate vs. plain text (Econsultancy) • 60% of visitors will watch a video before reading site text (Diode Digital) • Cisco predicted online video to become 75% of all mobile data traffic by 2019 • The retention rate for video can reach 65% vs. 10% for text-based information (Social Media Today) Over the years, I’ve written many industry articles and provided seminars designed to help professionals with business development issues. I’ve spoken on a local, regional and national basis to audiences in

highly-competitive environments. There are business fundamentals that some have been able to ignore up until now. The market is evolving and how professionals chose to adapt will determine their success rate. Thinking of yourself as a brand is a key step in developing a strategy to increase your exposure to new and prospective patients. It also puts into place processes that will help to protect and influence your reputation. About the Author

Jim Ray earned a BA in Business and his MBA. He managed two multi-million dollar businesses before transitioning into Internet consulting. He later launched his regional consulting practice to help professionals operate more effectively and more profitably. Jim presents an ongoing seminar series and contributes business development articles to a variety of professional publications. He has been invited to speak at national meetings for Internet marketing and has lead several, national webinars on various marketing topics. For more information, visit www.JimRayConsultingServices.com or connect with him on Linkedin.

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