Kentucky Doc Winter 2019 by Rockpoint Publishing

winter 2019 • volume 10 • issue 4

Telehealth Reconciling the tremendous gap in patients’ access to physicians

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CONTENTS Telehealth PAGE 5 PHYSICIAN HEALTH AND WELLBEING Body Scan Meditation PAGE 11 Telepsychiatry PAGE 15 PROFILE IN COMPASSION Being Kind, Being Humble and Serving PAGE 20 Learning the Signs of Elder Abuse PAGE 24 PROSTHETICS Team Hi-Tech PAGE 29 TRAVEL Things to See and Do in Chiang Mai, Thailand PAGE 30

EDITORIAL

BOARD MEMBERS Robert P. Granacher Jr., MD, MBA editor of Kentucky Doc Magazine Tuyen Tran, MD Lowell Quenemoen, MD Tom Goodenow, MD John Patterson, MD Thomas Waid, MD Danesh Mazloomdoost, MD

STAFF Brian Lord Publisher David Bryan Blondell Independent Sales Representative

FROMTHEEDITOR • WINTER 2019 Robert P. Granacher Jr., MD, MBA, Editor-in-Chief, Kentucky Doc Magazine

Welcome to the winter 2019 edition of KentuckyDoc magazine. Like it or not, telemedicine is here. Patients who use it seem to like it, and it is hoped that this edition of our magazine will provide important information to those physicians who may be using telehealth or anticipating incorporating it into their practice. Dr. Tran, LMS member and Past President, has written a wide-scoped article about telehealth in general and the applications and types of this emerging clinical tool. He provides us a succinct overview of telemedicine applications into ordinary medical practice for the benefit of both doctor and patient. LMS member, John Patterson, M.D. provides us practical information about mindfulness skills for physicians and patients. This is a therapeutic outgrowth of introspection. William James, M.D., the father of American psychology, defined introspection as “the looking into our own minds and reporting what we there discover” ( James 1890, p. 185)*. Modern psychology, psychiatry, and medicine have advanced this to a significantly useful part of behavioral medicine. Dr. Patterson’s treatise is useful for most primary care medical specialties. In my own professional life, telepsychiatry is being driven by the developing acute shortage of psychiatrists in the United States. We are expected to have a shortfall of 15,000 psychiatrists by 2025, and telepsychiatry is emerging as one way to address this lack of practitioners. I have personally found it quite useful when I practiced in Mt. Vernon, Kentucky

and provided telemedicine services to patients in the mountains at McKee. It was particularly useful when people were housebound due to illness or weather. Dr. Patterson provides us another article about one of our own, Stephanie Stockburger, M.D., a pediatrician who has focused her practice on the treatment of adolescents. She is portrayed center stage in Dr. Patterson’s Profile in Compassion, which he usually provides in our magazine. We on the LMS Editorial Board wish all of our readers a happy, fruitful, and professionally rewarding New Year. Many of you may find that by incorporating telemedicine into your current practice, not only can you broaden your mission to serve others in your specific area of medicine, but you may find a new and rewarding niche for your personal life and practice. *James, W. (1890). The principles of psychology (Vol. 1). New York: Dover Publications.

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Like it or not, telemedicine is here. Patients who use it seem to like it.

© Copyright Kentucky Doc Magazine 2019. All rights reserved. Any reproduction of the material in this magazine in whole or in part without written prior consent is prohibited. Articles and other material in this magazine are not necessarily the views of Kentucky Doc Magazine. Kentucky Doc Magazine reserves the right to publish and edit, or not publish any material that is sent. Kentucky Doc Magazine will not knowingly publish any advertisement which is illegal or misleading to its readers. Kentucky Doc Magazine is a proud product of Rock Point Publishing.

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Telehealth

By Tuyen T. Tran, MD, MBA One of the major challenges in healthcare is reconciling the tremendous gap in patientsâ&#x20AC;&#x2122; access to physicians. This is particularly true for our patients who reside in Eastern Kentucky. The Appalachian Regional Commission recently issued a very somber report showing that the Appalachian region has significantly higher mortality rates, increased incidence of heart disease, cancer, diabetes, depression, and more health risk factors (obesity, smoking, fewer physicians, drug use) than the rest of the country. More concerning, Eastern Kentucky has even higher morbidity and mortality. (See Figure 1 for comparison details.)1 Although there are many contributing factors to the access gap, physicians can positively impact the access problem by incorporating telehealth modalities into their practice. Understandably, there are many doubting Thomasâ&#x20AC;&#x2122; who want to know if there is any legitimacy to telehealth. AHRQ (Agency for Healthcare Research and Quality) recently TELE Continued on Page 6

Figure 1. Comparison of Mortality Rates. Data from Health Disparities in Appalachia Report, 2017

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TELE continued from Page 5

conducted a diligent systematic review to examine the value of telehealth and remote monitoring of patients with the intention of expanding access to care and contain costs. (Senators Bill Nelson and John Thune requested the study.) The study reported improvements in outcome metrics such as mortality, quality of life, and reductions in hospital admissions. These benefits were consistently noted for counseling or remote monitoring of chronic conditions such as cardiovascular and respiratory disease. The authors recommended future research to broaden implementation and address barriers.2 Telehealth is a collection of modalities which incorporates information and communication technologies to deliver healthcare services and public health remotely. There are four major categories: 1) Clinical Video Telehealth (CVT, Live Video, synchronous): This is real-time, remote, two-way interaction between physician and patient using audiovisual telecommunications technology. With the aid of specific equipment (see Figure 2) located at the patient site, the physician can conduct a limited exam of the patient. (To facilitate discussion, the encounter is traditionally described as Physician site and Patient site.) A technician and equipment such as the one shown in Figure 2 will reside at the Patient site. At the Physician site, there is a typical computer, a monitor (two are recommended), and a headset. The technician, located at the Patient site, will place the electronic stethoscope at the appropriate positions on the patient for the physician to remotely auscultate the heart and lungs. The technician has a small mobile camera (size of a small microphone) with 4K resolution which will allow physicians to visually inspect various body parts to include otoscopic and oropharyngeal cavities. And of course, there is live audiovisual interaction between the physician and patient. In addition to the diagnostic capabilities, this modality also facilitates consultative encounters. For example, the physician, located in Lexington, wants to discuss a very complex treatment plan with the patient located in Eastern Kentucky. But the patient wants to involve the daughter who is in Florida. Simply incorporate all members into a

videoconference call. (To avoid security and HIPAA issues, establish a secure virtual room and only allow invited members to join the virtual conference room. The VA has created such a structure, called VA Video Connect.) 2) Store-and-Forward Telehealth (SFT, asynchronous): This is transmission of recorded health information such as pre-recorded videos (Echo, Ultrasound, gait analysis, neurologic exam) , digital images such as radiographs (X-Rays, CT, MRI, retinal scans), and photographs (skin lesion, rash, wounds, chronic ulcer monitoring) through secure electronic communications to a remote physician for evaluation. The value of this modality is analogous to text messaging. The patient, at his/her convenience, arrives at the Patient site for the technician to capture the respective video, image, or photo. The physician, located remotely and at his/her convenience, can review the transmitted health information to provide diagnostic and treatment recommendations. 3) Remote Patient Monitoring (RPM): This modality facilitates convenient and accurate collection of personal health and medical data which is transmitted via secure electronic communications to the provider. Depending upon the need, there are wearable devices for monitoring heart rate, blood pressures, EKG tracings for dysrhythmias, and even implantable devices for monitoring CVP in patients with severe heart failure. 4) Mobile Health (mHealth): This modality essentially supports communication between physician and patients using any device (cell phone, tablets, computers, PDA’s). Think “Facetime.” Obvious uses include quick follow-up with patients when you need to see something. Office staff can conduct medication reconciliation and see the medication bottles instead of guessing what the yellow pills are. Office staff can triage the patients more appropriately with visual aid, “No, please go to the Emergency Room for that.” There are several major barriers to the implementation of telehealth. First, there must be adequate bandwidth to support this technology. High-speed internet is a struggle in large cities such as Louisville and Lexington. The infrastructure is

sadly inadequate in rural Kentucky. While waiting for the development of internet infrastructure throughout Kentucky (please do not hold your breath), physicians can creatively partner with local businesses that already have internet access. For example, we can negotiate with the local Walmart, RiteAid, or CVS Pharmacy to provide medical services remotely. (These businesses are already contemplating on providing Urgent Care or Walk-in clinics.) Second, there are inherent technical, financial, HIPAA, and security issues (malicious viruses and hacking) which will require standardization and solutions. And finally, reimbursement for telehealth services will need attention. Dr. Alvarado has successfully introduced SB 112 – Telehealth Services which will require equivalent reimbursement of telehealth visits to face-to-face visits. This is a huge step for successful implementation of telehealth. Now, physicians need to assist our legislators with drafting proper regulations to prevent over restriction of our ability to practice. Telemedicine is upon us. We can choose to view this new method of healthcare delivery as a challenge or opportunity. Regardless of our choice, the future practice of medicine will involve the use of telehealth. Kaiser Permanente reported that over 52% of their visits are via telehealth. Contrary to TELE Continued on Page 8

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current myth that telehealth visits are for the easy runny noses, most of the benefits as evidenced by quality metrics are from management of complex chronic diseases. And with threats such as increasing numbers of older patients who will most likely have more chronic illness, significant physician

shortage forecasts, and rising cost of healthcare, the gap to healthcare access in Kentucky will worsen. References 1. Health Disparities in Appalachia. Marshall et al. Appalachian Regional Commission. https://www.arc. gov/research/researchreportdetails.

asp?REPORT_ID=138 Published August 2017. Accessed August 15, 2018. 2. Telehealth: Mapping the Evidence for Patient Outcomes From Systematic Reviews. Totten AM, Womack DM, Eden KB, McDonagh MS, Griffin JC, Grusing S, Hersh WR. Rockville (MD): Agency for Healthcare Research and Quality (US); 2016 Jun.

Figure 2. Example of Telehealth cart

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PHYSICIAN HEALTH AND WELLBEING

Body Scan Meditation A Practical Mindfulness Skill for Physicians and Patients

“Mindfulness of the body is considered the first foundation of mindfulness practice.” By John A. Patterson MD, MSPH, FAAFP Behavioral medicine research confirms the value of mind-body approaches for both physician self care and patient care. Physician adoption of such lifestyle approaches is a key ingredient in our professional well-being, helping us promote resilience, manage stress, prevent burnout and cultivate compassion. Stepping off the daily treadmill of hurry and worry is a critical component of our personal strategy to live an ethical, effective and compassionate life in medicine. It also gives us the authenticity with which to counsel or refer patients for such training as a means of staying well or intervening in chronic disease. The National Center for Complementary and Integrative Health at NIH has extensive resources for consumers and health professionals, emphasizing research and evidence-based recommendations.1

Mindfulness-based stress reduction (MBSR) is among the leading mind body approaches world-wide and has demonstrated efficacy in many chronic physical and emotional conditions, especially anxiety, depression and chronic pain. MBSR includes several distinct and interrelated practices, including the foundational practice of body scan meditation.

and contentment in our personal and professional lives. The mind can also be in some other place besides where the body actually is. For these reasons, mindfulness of the body is considered the first foundation of mindfulness practice. The body is always dependably in the present moment and in this place. The body is always here and now. We train the mind to ‘be here now’ by paying attention to the body.3

What is mindfulness? Researchers who study mindfulness emphasize the following componentshaving the conscious intention to direct attention to immediate experience in the present moment with the attitudes of openness, curiosity, acceptance, nonjudging, patience, non-striving and selfkindness.2

The under-appreciated sense of interoception The body scan meditation emphasizes interoception, shifting from cognition to somatic perception of the gross and subtle “sensing” or “feeling” of the interior of the body- musculoskeletal, visceral, cardiovascular, neural and energetic. This is very different from thinking about the body or imagining the body. It is also different from exteroception (perception of external stimuli in contact with the body)

What is the body scan meditation? The mind is often in the past or the future. This can be useful but it can also be a real obstacle to effectiveness

SCAN Continued on Page 12

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“Beginning with the feet and sequentially progressing throughout the entire body, one focuses on the felt sense in each body part while nonjudgmentally accepting all experience.”

SCAN continued from Page 11

and proprioception (perception of the body’s position, movement, equilibrium and balance). We know from clinical practice and from our own experience, that some people can “feel” their heart beating fast/slow or regular/irregular- while others have trouble with this interoceptive perception. Interoception is important for recognizing changing physiologic cues such as hunger, satiety, hypoglycemia, migraine or epileptic aura, fever, bowel and bladder fullness, heartbeat and the full range of emotions. Interoception is essential to emotional intelligence. Interoceptive training can help those who are unable to distinguish tension from relaxation, safety from fear, pleasant from unpleasant, comfort from pain, anxiety from peacefulness, sadness from happiness, anger from empathy and other emotional states as they come and go. Links between emotions and physical sensations in the body can help identify emotions and anchor emotional intelligence in the body. How to do the body scan meditation? This practice can be done very quickly or very slowly. I have provided 5 minute and 40-minute recorded versions on my website4. Lying down or reclining are ideal positions. Taking three deep breaths, bring full attention to your breathing. Feel relaxation spreading throughout the entire body as each deep breath ends with a long slow outbreath that dissolves into stillness.

Beginning with the feet and sequentially progressing throughout the entire body, one focuses on the felt sense in each body part while non-judgmentally accepting all experience (pleasant, unpleasant and neutral). It is important to let go of any expectations, the need to change or fix anything and the temptation to become fixated on a particular sensation. Letting go of thinking and conceptualizing, one just notices thoughts arising and gently escorts the attention back to the body. As you place your awareness on a body part, tune into what you feel there- comfort, discomfort, pain, itching, numbness, tingling, lightness, heaviness, warmth, coolness, etc. Recognizing any emotions that arise can refine one’s interoceptive sensitivity, affective recognition and emotional intelligence. Allowing emotions to be just as they are during body scan can lead to acceptance of emotions in daily life. Try using the body scan to help you calm the racing mind and fall asleep at night. Try it in the morning, paying close attention to your body as you wake up, beginning your day with the intention of alertness, awareness, presence and paying close attention to your family, patients, staff and colleagues. Tune in to your body throughout the day, noticing how it feels interoceptively to be hungry or thirsty, rushed or relaxed. Notice how you communicate with your tone of voice, facial expression, body posture, silence- while interacting with those who test your patience and those that touch your heart.

Resources 1. NIH Resources for Mind Body Domain https://nccih.nih.gov/health/mindbody 2. Shapiro, S. L., & Carlson, L. E. (2017). The art and science of mindfulness: Integrating mindfulness into psychology and the helping professions (2nd ed.). Washington, DC, US: American Psychological Association 3. Body scan meditation https:// palousemindfulness.com/docs/ bodyscan.pdf 4. Body scan audio recordings, a 5 minute and 40 minute version, I created for patients and students http://www. mindbodystudio.org/?page_id=1594 About the Author Dr. Patterson Chairs the Lexington Medical Society’s Physician Wellness Commission, is past president of the Kentucky Academy of Family Physicians, is board certified in family medicine and integrative holistic medicine and is a certified Physician Coach. He teaches Mindfulness-Based Stress Reduction for the UK Health and Wellness Program and Saybrook College of Integrative Medicine and Health Sciences (Oakland). He owns Mind Body Studio in Lexington, where he offers integrative mind-body medicine consultations, specializing in stress-related chronic conditions and burnout prevention for health professionals. He can be reached through his website at www. mindbodystudio.org

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Telepsychiatry Psychiatric practice in the Information Age is rapidly changing

Part of this is being driven by the developing acute shortage of psychiatrists in the United States. As of April 2017, there were about 45,000 psychiatrists in the United States, with an estimated shortfall of about 6,000, which is projected to increase to 15,000 by 2025.1 By Robert P. Granacher Jr., MD, MBA, Editor-in-Chief, Kentucky Doc Magazine

Due to the obvious shortages in psychiatric manpower, more and more patients requiring psychiatric care are being seen in primary care as part of a “patientcentered medical home.” In this scenario, the primary care physician becomes the coordinator of care, and this relationship is occurring partially in response to the shortage of psychiatrists.2 The role of psychiatrists in particular, is expected to change as these practitioners increasingly take on roles as clinical leaders, teachers, and mentors for teams of providers. This will be as both

seeing individual patients and managing populations of patients while using mobile, easily accessible systems that are patientcentered and flexible.2 A new concept of specialty care using telemedicine concepts is that of the medical virtualist.3 However complete replacement of the traditional clinical encounter will not occur. “Bricks and clicks” will prevail for patients’ convenience and value. Physicians will lead teams with both in-office and by rote monitoring resources at their disposal to deliver care. This model could be enhanced in the future with digital assistance or avatars.3 The medical virtualists will need specific core competencies from curricula that are beginning to be developed at some

institutions. Psychiatrists lag behind compared to some other specialties in the development of this technology in residency training programs. A 2014 survey of 183 U.S. residency training programs found that only 21 offered any training or experience in telepsychiatry, and often this was only an elective offering.4 The author of this article is currently developing a new concept in psychiatric outpatient treatment at St. Joseph East Hospital in Lexington. This is spearheaded by Anna Bennett, RN, Director of Surgical Growth Opportunities at St. Joseph Health System, and Edwin Nighbert, M.D., Chief Medical Officer. The new PSYCH Continued on Page 17

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PSYCH continued from Page 15

clinic is called Transformation Care and will include services of neuropsychiatry, psychiatry and addiction medicine. It will also provide consultation services to numerous outpatient clinics at St. Joseph East Hospital, including neurology, pain medicine, oncology, and high-risk obstetrics. Deborah Burton, Ph.D. acting as Manager of Telehealth in the Strategy and Business Development Section of Kentucky One Health, is assisting the Transformation Care Clinic with integration of telepsychiatry into its services. The new clinic is expected to have a mobile communication system for telepsychiatry, which can be used in group therapy rooms as well as physician’s offices. For instance, one anticipated program is to assist obstetricians with the management of opioid addicted pregnant women. It is hoped that the high-risk pregnancy service will be able to identify these women clinically, manage them through their

pregnancy with buprenorphine, while at the same time providing them counseling services with clinical social workers. This program also provides consultation and clinical management to obstetrical clinics in Eastern Kentucky. It probably will be too cumbersome for women in far eastern counties to come to Lexington on a regular basis for group therapy treatment. Our plan is to engage these women in telepsychiatry and enable them to participate in group therapy on a virtual basis. For instance, we plan to install a large wall monitor in the group room, which will interconnect to a referring obstetrician’s office. At the obstetrician’s office will be a dedicated computer linking into the proprietary telepsychiatry system managed by Dr. Burton. It will be used in the Transformation Care Clinic so that women in outlying counties can be seen virtually during the group therapy sessions taking place in the Transformation Care Clinic. It is also expected that physicians at the St. Joseph East campus will be able

to obtain psychiatric consultation in real time using telepsychiatry. For instance, we plan to install telemedicine rooms in the clinics that we serve so that physicians and clinicians can interact with the psychiatrist, psychologist, social worker or addiction medicine doctor in the clinic in real time and in virtual space. The Clinic staff hopes that the Transformation Care Clinic, in an effort to assist the St. Joseph Hospital East campus with the opioid crisis, will have telemedicine as an integrated part of this movement. We will integrate our telepsychiatry offerings within the guidelines of the new law approved by President Trump allowing telemedicine prescribing of controlled substances using DEA special registration. That legislation has been written by Congress and signed by the President. The remaining offerings of telepsychiatry through the Transformation Care Clinic are expected to develop on an ad-hoc PSYCH Continued on Page 18

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PSYCH continued from Page 17

basis as the clinic develops and moves forward in providing clinical care to patients. Telepsychiatry at St. Joseph Hospital East is a work in progress, which will follow contemporary guidelines being developed at other academic sites in the United States.2 We anticipate the provision of telepsychiatry to enlarge and improve the quality of outpatient services at St. Joseph Hospital East and to be part of the general movement in the United States to develop telemedicine as a concept in many medical specialties to provide care to those who are underserved and at great distance from specialists.

References 1. National Council Medical Director Institute: The psychiatric shortage: causes and solutions, March 28, 2017. Washington DC, National Council for Behavioral Health, 2017. Available at: https://www.thenationalcouncil.org/ wp-content/uploads/217/03/PsychiatricShortage_National-Council-.pdf. Accessed December 2, 2018. 2. Yellowlees P, Shore JH (eds). Telepsychiatry and health technologies: a guide for mental health professionals. Arlington, VA: American Psychiatric Association Publishing: 2018

3. Nochomovitz M, Sharma R. Is it time for a new medical specialty: the medical virtualist. Journal of the American Medical Association. 2018: 319(5): 437-438. doi: 10.1001/jama.2017.17094 4. Hoffman P, Kane JM. Telepsychiatry education in curriculum development in residency training. Academic Psychiatry. 39(1): 108-109, 2015, 24477901.

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PROFILE IN COMPASSION

Being Kind, Being Humble and Serving Pediatrician Stephanie Stockburger MD By John A. Patterson MD, MSPH, FAAFP Pediatrician Stephanie Stockburger MD majored in music/French horn performance at Eastern Kentucky University. As she walked across campus one day, she had “a God moment” and realized she wanted a job where she could make a difference and help others. She wanted to be a doctor. Why pediatrics? “Just being with children makes me happy. I love their joy and spontaneity- it’s kind of contagious. When I was applying to medical school, I was thinking about pediatrics. I almost chose family medicine but eventually realized I really enjoyed the children the most. Also, the pediatric residents were the happiest residents that I encountered as a medical student.”

Why adolescents? “I enjoyed my rotation in the Adolescent Medicine clinic as a resident. The people in the clinic cared so much about their patients. When I was completing my residency in pediatrics, a job became available in the Adolescent Clinic. I applied and they accepted me. We have a compassionate team that cares very much about our patients and each other.” “Adolescents are so interesting because they are at a crossroads and are making choices that can impact the rest of their lives. They need a lot of support. Their parents often view them as all grown up but they truly need a great deal of support to navigate young adulthood. Without that support, they can lose sight of their goals. I try to remember that each patient I see is incredibly special and unique and has so much potential. I try my best to help them and their parents see that.”

“We use a strength-based approach to patient interviewing and counseling. Some teens excel at academics or sports while others have persevered through rough times. Some are creative and artistic. Others listen well, make good friends and care for others. They all have strengths.” Have you ever been burned out or felt your cup of kindness nearly empty? “Definitely. There are days when it seems like all the patients and families are ‘in crisis.’ There are times when I don’t feel I can do anything to help them. These days are often near the end of the academic semesterNovember and April- when stressors are high.” How did you manage it? How do you refill your cup of kindness? “It depends. Sometimes I just need a nap or a good night’s sleep. Talking to colleagues and family members helps me

Just being with children makes me happy. I love their joy and spontaneity- it’s kind of contagious. – Stephanie Stockburger MD

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reconnect. Nature always seems to ‘refill my cup.’ I spend time with my children, ages 6 years and 4 months, and do my best to be fully present with them.” “Sometimes I have to consciously count my blessings. I like to notice the beauty around me. When I drive my son to school in the morning, we look at the sunrise and talk about the colors in the sky and the beauty of the stark tree branches. When I pick him up after school, sometimes the sun is setting and we do the same thing.” How do you approach whole person care, mind/body/spirit medicine, dealing with mentally/emotionally troubled teens and ethnically/ religiously diverse families? “I find that the key is to listen and do my best to be fully present. This is a skill I learned in the Healer’s Art elective as a student and then co-teaching the course for several years. I find that our teenagers are much more likely to open up and talk about what is going on with them when they feel that you truly care. I learned from my mentor, Dr. Hatim Omar, that our listening and our caring helps teens feel comfortable opening up and talking to us.” “I also like to help the teens identify at least one adult support person in their life that they feel they can go to when they are having a problem. This is true for those teens at low risk as well as those at high risk. We also talk about getting enough sleep, drinking enough water, eating regularly throughout the day and basic self-care. Many of our teens are not getting enough sleep and this can affect their mood and decision making capabilities.” KIND Continued on Page 22

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KIND continued from Page 21

“When dealing with ethnically or religiously diverse families, I keep in mind that we are all humans with the same basic needs including the need to be listened to and cared for. At the basis of most religions is belief in a higher power, something that is bigger than ourselves.” “ We are all children of God. We all need love and care and attention- and we are all called to help other children of God. Medicine is a calling. We are called to be humble and serve. We have to take good care of ourselves in order to fully and actively listen and be fully present with our patients. This is a work in progress for me.” How can we help learners and colleagues in medicine maintain their compassion and prevent burnout? “We can pay attention to our colleagues and check in with them. When something seems off, we can take the time to ask how they are doing. We can offer to be there if they need anything or want to talk. We can also help our colleagues if they need time off to take care of their own health or a family member.” “Attendings can make medical students and residents feel they are part of the care team. Attendings can teach and model

real caring and listening to patients. They can also take time for themselves, model personal self-care and support these behaviors in learners, who are their future colleagues. They can show concern if something seems off with a student or resident. Just being kind and caring can go a long way.” Stephanie Stockburger is helping patients, physicians and physicians-intraining by being kind, being humble and serving. About the Author Dr. Patterson Chairs the Lexington Medical Society’s Physician Wellness Commission, is past president of the Kentucky Academy of Family Physicians, is board certified in family medicine and integrative holistic medicine and is a certified Physician Coach. He teaches Mindfulness-Based Stress Reduction for the UK Health and Wellness Program and Saybrook College of Integrative Medicine and Health Sciences (Oakland). He owns Mind Body Studio in Lexington, where he offers integrative mind-body medicine consultations, specializing in stress-related chronic conditions and burnout prevention for health professionals. He can be reached through his website at www.mindbodystudio.org

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Learning the Signs of

Elder Abuse

By Dr. Dani Vandiviere Physicians and other medical professionals are often on the front line due to their accessibility to elderly patients. Sometimes being the only individual to see an elder other than their caregiver, the ability to recognize the signs of abuse is vital. According to the Administration on Aging in Washington, D.C., each year hundreds of thousands of older persons are abused, neglected, and exploited. Many victims are people who are older, frail, and vulnerable and cannot help themselves and must depend on others to meet their most basic needs. Abusers of older adults are both women and men, and may be family members, friends, or “trusted others” at home or in a senior living community. It is often a private home situation, but abuse can take place anywhere. In general, elder abuse is a term referring to any knowing, intentional, or negligent act by a caregiver or any other person that causes harm or a serious risk of harm to a vulnerable adult. Legislatures in all 50 states have passed some form of elder abuse prevention laws. As a medical professional you may not be privy to all types of elder abuse, but you will see the signs of most abuse. Whereas, a single sign may not be enough to determine abuse, if you see clusters of signs the possibility of abuse must be considered. Abuse can be characterized as: Physical Abuse (inflicting physical pain or injury on a senior) • Slapping, bruising, punching, hitting or kicking • Bruises and scar not consistence with age related falling • Can be restraining by physical or chemical means • Under or over medicating • Being kept in seclusion away from friends and family and other visitors Sexual Abuse (non-consensual sexual contact of any kind) • Bruises around breasts or genitals • Unexplained venereal disease or genital infections • Unexplained vaginal or anal bleeding • Torn, stained, or bloody underclothing

Neglect (the failure by those responsible to provide food, shelter, health care, or protection for a vulnerable elder) • Unusual weight loss, malnutrition, dehydration • Untreated physical problems, such as bed sores or other preventable conditions • Unsanitary living conditions: dirt, bugs, soiled bedding and clothes • Being left dirty or unbathed • Unsuitable clothing or covering for the weather • Unsafe living conditions (no heat or running water; faulty electrical wiring, other fire hazards, trash and waste within the living area) • Desertion of the elder at a public place Emotional Abuse (inflicting mental pain, anguish, or distress on an elder person.) • Verbal or nonverbal acts, e.g. humiliating, intimidating, or threatening. Self-neglect (characterized as the failure of a person to perform essential, self-care tasks and that such failure threatens his/her own health or safety.) You may notice: • Frequent arguments or tension between the caregiver and the elderly person • Changes in personality or behavior in the elder • Has trouble sleeping • Seems depressed or confused • Loses weight for no reason • Displays signs of trauma like rocking back and forth • Acts agitated or violent • Becomes withdrawn • Stops taking part in activities enjoyed in the past • Changes in the behavior of the caregiver to the elderly patient Additional types of abuse: Abandonment (desertion of a vulnerable elder by anyone who has assumed the responsibility for care or custody of that person.) Exploitation (the illegal taking, misuse, or concealment of funds, property, or assets of a senior for someone else’s benefit.) Initially you may not recognize or take seriously indications of elder abuse. The elderly patient may present with what may

appear to be symptoms of dementia or signs of frailty. Caregivers may explain or dismiss possible signs of abuse in such a manner that may raise alarms and require further investigation. In fact, many of the signs and symptoms of elder bullying or abuse do overlap with symptoms of mental deterioration, but that doe not mean you should dismiss them based upon the perspective of the caregiver alone. The abused or bullied individual typically has trouble defending him or herself and does nothing to cause the abuse. They are an easy target due to being weak physically and perhaps unable to recall conversations or events. This inability to remember is what the abuser counts on to get by with the abusive behavior because when questioned the inconsistency of the memory can render doubt to the incidents. It is acceptable to ask probing questions when you suspect possible abuse, but it is important to note that it is not your role to verify that abuse is occurring, only to alert others of your suspicions. There are investigators employed by the state responsible for verification. It is your responsibility, morally and legally, to be alert and vigilant of the possibility. It is the law to report. Kentucky is a mandatory reporting state. (Reference KRS 209.030). To report call 1-800-752-6200, calls can be made anonymously. The Office of the Attorney General of Kentucky operates an Elder Abuse Hotline, 1-877 ABUSE TIP (1-877-228-7384). The Child/Adult Abuse Hotline at 1-877-597-2331 or 911 if it is an emergency. About the Author Dr. Dani Vandiviere is a conflict and bullying specialist and CEO of Summit Conflict Resolutions and Trainings. She is the President of the Bluegrass Continuity of Care Association, a founding member of KY Association of Senior Services, a member Association for Gerontology, and an Elder Care Conflict Trainer and Mediator. She also offers training programs for the workers in the Eldercare industry, medical professional, elder’s families, organizations and businesses. To learn more contact Dr. Dani at www.summitcrt.com, dani@summitcrt.com or 859-305-1900.

“Sometimes being the only individual to see an elder other than their caregiver, the ability to recognize the signs of abuse is vital.” – Dr. Dani Vandiviere

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ANNOUNCEMENTS AWA R D S N E W S TA F F EVENTS AND MORE

EMAIL brian@rockpointpublishing.com TO SUBMIT YOUR NEWS

Baptist Health Lexington receives American Heart Association accreditation for acute cardiac care Baptist Health Lexington has received the American Heart Association’s Mission: Lifeline® Heart Attack Receiving Center Accreditation. The hospital is one of only two facilities in Kentucky to currently hold this accreditation; sister hospital Baptist Health Louisville is the other. The accreditation program — provided by the American Heart Association — recognizes centers that meet or exceed quality of care measures for people experiencing the most severe type of heart attack, ST-elevation myocardial infarction (STEMI), in which blood flow is completely blocked to a portion of the heart. The accreditation identifies healthcare facilities that meet specific criteria for lifesaving heart attack treatments that restore blood flow. This is the third consecutive Mission: Lifeline® Heart Attack Receiving Center Accreditation for Baptist Health Lexington. The hospital was the first in Kentucky to receive the accreditation in 2012. “Baptist Health Lexington is dedicated to improving the quality of care for our patients who suffer a heart attack, and the American Heart Association’s Mission: Lifeline program continues to help us accomplish that goal through internationally respected clinical guidelines,” said Susan Mobley, RN, BSN, MBA, NE-BC, vice president of cardiovascular services. “We are pleased to be recognized for our dedication and achievements in cardiac care, and I am very proud of our team.” Baptist Health Lexington underwent reviews by accreditation specialists from the American Heart Association. Key areas in which the hospital demonstrated exceptional quality of care to receive accreditation include: • Expertise, facilities and equipment

to perform percutaneous coronary intervention (PCI), where a small balloon is inserted through a catheter to open narrowed or blocked blood vessels in the heart (coronary arteries) • PCI readiness on a 24/7 basis • Coordination with emergency medical services (EMS) and referring centers (non-PCI) to prepare for immediate treatment when STEMI patients arrive Facilitation of STEMI patient transport participation in a multidisciplinary team with representatives from EMS, cardiac catheterization lab, quality improvement, coronary care unit, physician and nursing staff, meet regularly to identify challenges and make continuous care improvements. The American Heart Association’s overall goal for Mission: Lifeline® Heart Attack Receiving Center Accreditation is to significantly reduce cardiac death in patients by teaching the public to recognize and react to early symptoms of a heart attack, reduce the time it takes to receive life-saving treatment and increase the accuracy and effectiveness of treatment administered.

Lexington Clinic’s Direct-ToEmployer Program, "Provider Employer Pathways” has been nominated for the Hosparus Health Innovation Award. The Hosparus Health Innovation Award is presented to an organization that has developed a new procedure, device, service, program or treatment that improves the delivery of care for patients. The award is a part of the MediStar awards presented by Medical News. Lexington Clinic is one of eight finalists for the award, and the winner will be chosen and announced at the end of October. Congratulations to the Lexington Clinic Direct-To-Employer program!

Lexington Clinc Announces Dr. Trevor Wilkes, of Lexington Clinic Orthopedics — Sports Medicine Center, has served as the associate editor and content provider for The Journal of Bone & Joint Surgery Continuing Medical Education program. Dr. Wilkes provided the testing content in his area of specialty — Shoulder and Elbow Pathology and Surgery - and worked with colleagues from around the country to edit and produce the content for the 2018 program. The Journal of Bone & Joint Surgery ( JBJS) has been the most valued source of information for orthopaedic surgeons and researchers worldwide for over 125 years and is the gold standard in peer-reviewed scientific information in the field.

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Women’s Hospital at Saint Joseph East Welcomes First Baby of 2019 Lexington, Ky. ( January 2, 2019) – The Women’s Hospital at Saint Joseph East welcomed its first baby of 2019 at 11:52 p.m. on January 1. The parents from Lexington, who preferred not to be named, welcomed Noah Musgrove. He weighed 7 lbs. and 4oz. and was 19 ¼ inches long. Each year, hospital staff work with local businesses to create a welcome wagon for the first baby born in the new year, including gift certificates, diapers, wipes and assorted gifts. “We always look forward to the arrival of the first baby of the year and enjoy making this experience so special for families,” said Joan Morrin, RN, Nurse Manager, Women’s Hospital at Saint Joseph East. The Women’s Hospital at Saint Joseph East delivered 2,300 babies in 2018.

KentuckyOne Health Teams up With God’s Pantry Food Bank to Provide Food to Patients in Need Patients in emergent need in Berea and London to receive baskets Berea, Ky. ( January 2, 2019) — KentuckyOne Health has teamed up with God’s Pantry Food Bank to fund a pilot program that will provide immediate food assistance for patients in emergent need at Saint Joseph London and Saint Joseph Berea. As part of the partnership, KentuckyOne Health will have food baskets on hand at the two facilities, as well two health clinics in London and one health clinic in Berea. “We are very excited about this and humbled that we will be able to assist our

patients to meet a basic human need,” said Neva Francis, Vice President, Healthy Communities, KentuckyOne Health. KentuckyOne Health identified Berea and London through screenings for social determinants of health – basic human needs – as two locations where incremental hungerrelief services would provide more timely aid to residents who are seeking access to food. The screenings are part of the work KentuckyOne is doing through a Robert Wood Johnson Foundation grant. “Nutritious food helps improve health. Patients experiencing hunger or food insecurity may experience issues like prolonged recovery times that potentially increase medical costs,” said Michael Halligan, CEO, God’s Pantry in Lexington. “Working with Saint Joseph London and Saint Joseph Berea to identify those who are hungry will allow intervention and access to nutritious food.” The emergency food baskets contain cans of vegetables and fruit, pasta sauce, boxes of pasta, milk, cereal, soup and crackers. God’s Pantry Food Bank also recently initiated an emergency food box program in Lexington at the Veterans Affairs Medical Center.

Lexington Clinic Welcomes New Family Medicine Physician Lexington Clinic is excited to introduce our newest primary care provider! Dr. Jordan Prendergast, a family medicine physician, is now accepting patients of all ages at Lexington Clinic Veterans Park. She joins Dr. Marisa Belcastro and Dr. Craig Irwin at this location, and her arrival would be of interest for any of your readers needing to establish primary care in the new year.

Baptist Health Lexington repeats its top 'A' grade for hospital safety Baptist Health Lexington has once again earned the top grade of “A” for hospital safety from The Leapfrog Group, a national nonprofit healthcare ratings organization. Of the 51 hospitals rated in Kentucky by The Leapfrog Group, only 12 received an A grade. Leapfrog Hospital Safety Grades are assigned to more than 2,600 general acutecare hospitals across the nation twice annually. Baptist Health Lexington also received an A grade in Leapfrog’s April 2018 reporting. The Safety Grade assigns letter grades of A, B, C, D and F to hospitals nationwide based on their performance in preventing medical errors, infections and other harms. Baptist Health Lexington was one of 855 hospitals across the United States awarded an A in the November update of grades. “To receive an A again this year reaffirms all of our efforts to provide the safest compassionate care available,” said William G. Sisson, president of Baptist Health Lexington. “We continue to be recognized on a national level for keeping quality and safety as our No. 1 priority.” The Leapfrog Hospital Safety Grade uses national performance measures from the Centers for Medicare & Medicaid Services (CMS), the Leapfrog Hospital Survey, the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), and the American Hospital Association’s Annual Survey and Health Information Technology Supplement. The Hospital Safety Grade’s methodology is peer-reviewed and fully transparent, and the results are free to the public. To see Baptist Health Lexington’s full grade, and to access patient tips for staying safe in the hospital, visit www.hospitalsafetygrade.org .

“Baptist Health Lexington is dedicated to improving the quality of care for our patients who suffer a heart attack, and the American Heart Association’s Mission: Lifeline program continues to help us accomplish that goal through internationally respected clinical guidelines” – Susan Mobley, RN, BSN, MBA, NE-BC, VP of Cardiovascular Services

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PROSTHETICS

Team Hi-Tech The journey a new amputee takes can be long and difficult to navigate. The staff at Hi-Tech Artificial Limbs, Inc., understands that process. Our philosophy is a simple one: we strive to be an ongoing partner in our patient’s life as an amputee and work with the entirety of their healthcare team, from beginning to end, to produce the best possible outcomes. Many times, an amputation is performed as a result of an underlying health problem. In those cases, an orthopedic or vascular surgeon determines amputation is necessary. Although most patient’s focus at this point is on the surgery itself, a consultation with a prosthetist at this time can be extremely beneficial. Hi- Tech offers free pre-amputation consultations to discuss the steps that will be taking place. Also, physical and occupational therapists get involved sometimes before, and definitely after surgery, working with the patient to develop core strength, balance, and all of the motor skills necessary to get back to a functional, normal life. Here at Hi-Tech, we often tell our new amputees: “We’ll begin when you’re ready. We’ll meet and simply talk as many times as you need to, and that’s fine.” Pressing amputees to be ready when they’re not is counterproductive. We are careful to not casually overlook the body and social issues that undeniably change with amputation. It’s healthiest when the amputee can find peace and encouragement through interaction and information from their rehab team. It is at this point when the patient may be able to look forward… not backward. Hi-Tech will conduct a post amputation consultation and thorough evaluation of each amputee. A patient should expect that evaluation to involve many aspects their overall health, including level of amputation, strength, activity levels and goals. For example, if a person just lost their leg, then the health and strength of the remaining leg has now become that much more important. In most cases, we will provide compression garments “shrinkers” to begin to shape the limb, reduce edema and increase circulation well before the prosthetic fabrication begins to insure the limb is healed, healthy and ready

Taking it one step at a time, increasing the goals as they go, is imperative.

to be molded and measured. We provide the proper information and answer any and all questions the amputee and their family members may have to ease any apprehension about the somewhat unfamiliar process. The amputee’s family and friends become a vital part of the rehab team as well. Many times, they provide the transportation for all initial visits. They are often in the room helping absorb information, and for most people this is not casual knowledge. When people have strong family support, their outcomes are typically better for these reasons. When the surgeon finally releases the amputee to begin their rehabilitation, it’s advisable to get the family doctor informed and involved in this process. It is not always necessary for the family physician to know all of the intricate parts of the prosthetic technology, but it certainly helps for them to know the reason for use and the potential benefits. Many of the subsequent prescriptions are coming from the family doctor, so having them involved as soon as possible is of great benefit. Outcomes and goals play a big role in this process. Having clear-cut and objective goals to work toward can have great benefits. It may that be the patient wants to one day run a 5K race, or it could be that they simply want to walk out to their mailbox or stand to fix dinner for their family. Taking it one step at a time, increasing the goals as they go, is imperative. At times, there will be some form of case manager through insurance and/or workers’ comp. Hi-Tech’s staff connects with them so we can align our goals for the patient. Working and communicating with the case managers, we can be more effective with care. When patients become more comfortable communicating their own thoughts and needs with their case manager, this proactive approach can also lead to greater opportunity for success. There is also a psychological component to life after amputation. Can I go out on a date again? How do I overcome any possible body image issues I may have? Will I be able to return to my job and provide for my family? Many successful outcomes occur when the amputee realizes they are not “on an

island.” It can seem like they may be the only one in the world going through this, when in fact they are part of a group numbering in the millions. Much of the necessary support and encouragement for the new amputee is found through mentorship. Groups like The Amputee Coalition of America (ACA) serve as a fantastic resource, being such a large and influential organization. One of the most important factors in acceptance and progress is finding the commonality among amputees. Sometimes clinical psychology and counseling outside the family is necessary, but typically mentorship and community provides the most positive outcomes. Hi-Tech can connect patients with peer visits and mentoring from experienced and successful amputees. Being proactive and well informed allows the amputee patient to better claim ownership of their new life circumstances. It’s up to all of us to advocate for each amputee. Hi-Tech’s role in this process reaches far beyond designing, fabricating and fitting the best possible prosthesis for each patient. Having a supportive group of professionals, family and friends surrounding the amputee will always be vital. We at Hi-Tech Artificial Limbs, Inc., will always be very proud to be a part of this team.

859.278.2389 1641 Nicholasville Road, Lexington, KY 40503 M-Th 8am–4:30pm, F 8am–3pm

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Travel

Things to See and Do in

CHIANG MAI, THAILAND By Satu Susanna Rommi

Chiang Mai is Thailandâ&#x20AC;&#x2122;s second largest city and a peaceful alternative to Bangkok. The capital of Northern Thailand is known for its temples and its markets, and it is one of the main centres for learning traditional Thai massage. Chiang Mai is surrounded by mountains, forests and national parks that are perfect for daytrips and for trekking.

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Lifestyle Section • Winter 2019 • Kentucky

The Chiang Mai Old Town

The old town is protected by a moat and stone walls. Its narrow lanes are lined with guesthouses, restaurants, coffee shops and stores that serve the crowds of foreigners who travel to Chiang Mai every year. The old town is a good place to find budget accommodation and its restaurants serve both Thai cuisine and Western food.

300 Buddhist Temples

Chiang Mai was once the centre of the Lanna Kingdom that ruled Northern Thailand for hundreds of years. Today Chiang Mai has more than 300 Buddhist temples (wat) and many are built in the Lanna style. It is difficult to walk anywhere in Chiang Mai without passing the gilded rooftops of a temple. Wat Chedi Luang in the old town is one of the most impressive temples in Chiang Mai and one of the most popular tourist attractions in the city. The old brick chedi (a tower that contains relics) that is now partly ruined dates back to the 15th century. Wat Chedi Luang was once briefly the home of the famous Emerald Buddha that is now located in Wat Phra Kaew in Bangkok. Next to the old chedi is a viharn (an assembly hall where the main Buddha images are kept) that was built in the early 20th century and houses a large standing Buddha statue. A beautiful wooden temple, Wat Phan Tao, stands next to Wat Chedi Luang and is also

open for visitors. Most Buddhist temples in Chiang Mai are free to enter and welcome foreign tourists, but visitors should dress appropriately and behave respectfully.

Thai food, cheap but delicious street food and foods from all parts of the world. The many local markets are great places to sample local food and fresh tropical fruit.

The Doi Suthep Temple

Traditional Thai Massage

It would take a long time to visit each of Chiang Mai’s more than 300 wats, but one temple that is definitely worth exploring is Wat Phra That Doi Suthep. This 14th century wat stands on the Doi Suthep mountain just outside Chiang Mai and is one of the holiest Buddhist shrines in North Thailand. Daytrips to Doi Suthep are easy to arrange and the drive up the mountain is very scenic.

Street Market Shopping

Chiang Mai is known for its street markets and many visitors end up doing a lot of shopping here. There are few things you cannot find at the daily Night Bazaar or the weekly Sunday market in the old town. The Night Bazaar covers a large area around Chang Klan Road. Prices can be slightly higher than at the Sunday market that takes over Ratchadamnoen Road every Sunday evening. Both markets are packed with vendors who sell clothes, souvenirs, textiles, handbags, hill tribe arts and crafts from the villages in the mountains, fake designer goods, DVDs, jewellery and delicious food. Food is another good reason to visit Chiang Mai. You can find excellent

Chiang Mai is a centre for learning traditional Thai massage and the perfect place to get a massage. There are dozens of Thai massage schools in Chiang Mai and even more places that offer massage treatments, but the quality of the massages can vary. Reputable traditional Thai massage schools include the Old Medicine Hospital and the Loi Kroh. The latter also offers massage treatments. Respected and well known Thai massage masters who teach and give treatments in Chiang Mai include Pichest Boonthumme and Sinchai.

Travel to Chiang Mai

Chiang Mai is easy to get to. There are daily flights from Bangkok and there are comfortable and affordable overnight trains from Bangkok to Chiang Mai. Buses connect Chiang Mai to many destinations in Central and Northern Thailand. Most guesthouses and hotels arrange trips to destinations around Chiang Mai. Day trips and longer excursions include treks to the mountains, visits to elephant camps and tours of handicraft villages. It is also easy to arrange onward travel to other cities in North Thailand or trips across the border to Laos.

Inthakhin traditional offerings of flowers.Buddhist Thai offering flowers attended a ceremony to worship the city pillar at Wat Chedi Luang temple annually before the rainy season.

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