Kentucky Doc Summer 2016 by Rockpoint Publishing

summer 2016 • volume 8 • issue 2

EXERCISE FOR PHYSICIANS

Farhad Karim, MD A Return to Running After CABG

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Contents | Summer 2016

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

Physician Exercise: What does exercise do for your wellness and work-life balance? by Andrew R. Hoellein, MD The Greatest Treatment for Pain: Exercise by Danesh Mazloomdoost, MD Family, Faith & Family Medicine Caresse Wesley, DO by John A Patterson MD, MSPH, FAAFP Enhancements To Brain Funciton By Exercise by Robert P. Granacher Jr., MD, MBA

05 06

08 10

PROFILE IN COMPASSION

Rice Leach MD, MPH Public Health Servant by John A. Patterson MD, MSPH, FAAFP

Healthy Body – Healthy Mind Profile of Baptist HealthwoRx by Lowell Quenemoen MD

COMMUNITY NEWS

Why do I Exercise? by Paula D. Bailey, MD

FROM THE COVER

A Return to Running After CABG by Farhad Karim, MD

Exercise: The science behind the why by Tuyen T. Tran, MD

BUSINESS

Welcome to this summer edition of KentuckyDoc Magazine. Please take a moment to scan the cover, wherein we have portrayed our former LMS President, Farhad Karim, MD. Please see his story, as it is a remarkable one rarely heard by physicians. This edition of the KentuckyDoc focuses on exercise and its benefits for all, including physicians. Dr. Hoellein starts off the serious topic with Physician Exercise: What Does Exercise Do for Your Wellness and Work Life Balance? Andrew is an avid cyclist and runner. Not only does he give us insight into a physician using exercise to maintain life-balance, but he also provides interesting statistics on sudden death while running. Danesh Mazloomdoost, MD is a new edition to our LMS Editorial Board. Being a pain physician, he gives significant insight into using an exercise regimen as a treatment modality for chronic pain. His article is followed by a profile of Caresse Wesley, DO. John Patterson of our Editorial Board reviews how Caresse integrates family and faith with her practice of family medicine. John portrays a physician who integrates wellness into her medical practice, and then practices what she preaches to her patients by setting reasonable boundaries for herself so that she might avoid becoming a victim of physician stress. Dr. Granacher provides a brief scientific review of the beneficial aspects of exercise and its ability to enhance brain function. His article is followed by Dr. Patterson’s wonderful portrayal of our LMS Past President, Rice Leach, MD, MPH. As most know, we recently lost Rice from our medical community, but his legacy as a public health servant remains instilled in many of us, and certainly into the fabric of public health in Fayette County and the nation. Lowell Quenemoen, MD profiles Baptist HealthwoRx and its fitness and wellness center. This program is administrated through the Baptist Health system in Lexington and is situated at their off-campus site at Lexington Green Mall. Following this, much like the personal article by Dr. Karim, Dr. Paula Bailey also profiles herself and answers the question, “Why do I exercise?” This dietician-turned-physician provides a simple menu for beginning exercise and maintaining a personal regimen within one’s life. Please take time to see the announcement for the LMS, “Burnout Proof Live Workshop.” This will be presented October 15, 2016 from 8:30 a.m. until noon at a Lexington venue and will feature Dr. Dike Drummond, a Mayo Clinic trained family physician. Dr. Drummond is renowned for

his advice on how physicians may make their practices and personal lives burnout proof while lowering stress levels, enhancing relationships, and improving work-life balance. The program is designed so that spouses may attend and participate as well.. Also, please notice in this volume of KentuckyDoc, the announcement for our second annual essay contest for active physicians, residents, and medical students. Last year’s contest was a runaway success, and we are hoping to enlarge upon that this year. Prizes will be awarded for first, second, and third place in each of the three categories. This year’s theme is: “Healthy and Happy Doctors Provide Better Care, Define Barriers and Solutions to Physician Wellness.” Be aware that your essay is due no later than August 15, 2016. Visit our website at www.lexingtondoctors.org for further details. Dr. Tran provides us an overview of the science behind exercise and its positive impact upon reducing mortality. He provides a particular focus on the unexpected negative outcomes from physical inactivity. His article is followed by our business section, which is written by Jim Ray. Jim provides a marketing approach to answer the question: “How healthy is your practice?” His article is followed by the poignant look at elder abuse provided by Dr. Dani Vandiviere. She provides training programs for workers in the Eldercare industry and for their families. Please take time to provide us feedback on how we are doing with KentuckyDoc Magazine. Remember, this magazine is designed by physicians and provided to physicians with unique physician perspectives on healthcare and medical practice issues. Lastly, the fall issue of KentuckyDoc will publish all of the essays provided by our active physicians, residents Robert P. Granacher Jr., MD, MBA and medical editor of Kentucky Doc Magazine students so that Tuyen Tran, MD our readership may enjoy the products Lowell Quenemoen, MD of our winners. Until then… Amanda Faulkner, MD

Editorial Board Members

Bob

Learning the Signs of Elder Abuse by Dr. Dani Vandiviere

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John Patterson, MD Thomas Waid, MD Dav Goodnauth, MD Brent Morris, MD Danesh Mazloomdoost, MD

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Physician Exercise: What does exercise do for your wellness and work-life balance? By Andrew R. Hoellein, MD It is 5:00 am on a Wednesday morning in February when I feel a kick in the back. Oh yeah, one of the twins climbed in bed last night, something about an upset tummy. Which one? Probably Zac. It’s almost time to get up anyway, Brent and Elizabeth will be meeting me at the corner at 5:30. I shouldn’t have stayed up watching that game last night, especially for an overtime loss. It is so warm under the covers…and the kicks aren’t that bad, he’s still small. Of course my wife vacated last night at the mention of a possible GI issue. She is a very talented physician, fast runner, and wonderful mother, but she doesn’t do vomit. I wonder if her group is still going at 6:15. Get up! I don’t want to keep my little running group waiting - although sometimes they don’t show! I’ll feel a little guilty tonight if I don’t get this run in. Also, I won’t have another chance to exercise today; the twins have basketball practice tonight. There are many times when I don’t want to get up. And sometimes, I don’t. However, after having made early morning runs or cycling a near daily routine, I actually miss it on those days. I feel better during the day, with more energy, and more focus. When patients tell me they don’t have time to exercise, I can mock them in a superior tone. Just kidding, I don’t do that. In the evening, I feel better on the days I exercised. I sleep better. I’m more patient with the children. And I hope I’m a better husband. But why so early? Initially this was just to get exercise in before the children woke up. Then it became earlier when my wife started running in the mornings with her group. We would love to run together but can’t leave them at home alone yet. Occasionally, it’s even earlier if training for a race, a friend wants to go earlier, or work duty scheduled early. Sunday morning group bike rides at sunrise are one of my favorite things. The comradery, the scenery of central Kentucky, and the lack of much traffic at the time are a very rewarding combination. The running group helps. One feels an obligation to a group, especially a small group. You don’t want to make them wait and I always enjoy the conversation. Ear buds help. While running, I have “read” innumerable audiobooks, classics, best sellers, non-fiction, it doesn’t matter (as long as the volume is low). Podcasts help, especially

those short ones that span the time of the planned run. An exercise tracking program helps. Most programs can compare your run with previous runs and with friends and even residents and students. Signing up for a race really helps. Feeling committed to training for certain distances and certain times is motivating for competitive people, physicians especially. Sign up for the Bluegrass 10,000, Run the Bluegrass, the Bourbon Chase, or any local event will help you get out of that bed. You may not win but can at least push for personal records. Injuries hurt, pun intended. It is necessary to take days off to recover from them and to cross-train to avoid them. Stretching is recommended, something I write feeling a bit hypocritical. As healthy as my family and work life are while running, I’ve discovered how cranky I can be when taking time off for an injury. This year, I’ve discovered a new sympathy for those with overuse injuries, I’m sorry to those I’ve been less than empathic in the past. Doctors like to weigh the risks and benefits in an evidence-based manner. So, ponder this data when trying to make you get out of bed on a cold morning: First, risks. Is exercise dangerous? Bicycle fatalities seem common recently, but relatively, bicycling is far safer than walking. In 2013, there were 743 cycling deaths compared to 4,735 pedestrian deaths.1 Besides the usual running injuries such as plantar fasciitis, iliotibial band syndrome, and my recent affliction, a tensor fascia lata injury, fatalities have been reported in long distance runners. However, the Race Associated Cardiac Arrest Event Registry (RACER, great name!) found a rate of cardiac events and sudden death in marathoners and halfmarathoners of 1/184,000 and 1/259,000, respectively, which is lower than the rates for collegiate athletes, triathlon, and middleaged joggers. The 59 events in 10.9 million participants were more likely to be male and most causes attributed to hypertrophic cardiomyopathy.2 The benefits are abundant, however. A PubMed search yields only a couple hundred thousand hits even when limited to human and English language studies. Exercise is associated with metabolic,3 functional,4, 5 mental,6 and may be as good if not better than medications to prevent certain cardiovascular outcomes7 and cancers8 just to name a few. The evidence favoring exercise is overwhelming. OK, so I get up. Elizabeth is indeed waiting in front of her house and we see Brent

jogging down the street. I’ll try to not talk about my children so much this time. Also, Brent and I probably talked too much football the other day for Elizabeth’s taste. Where to? How far? When do you have to be back? Arboretum it is! We’re off. Hey guys, Zac said the funniest thing about football yesterday... About the Author Andrew R. Hoellein, M.D., is a native of western Pennsylvania and went to medical school at MCP-Hahnemann (now known as Drexel) in Philadelphia. He came to the University of Kentucky for residency in Internal Medicine where he met his wife, Deidra Beshear, MD. After residency, he completed a Master Educator Fellowship earning a Master’s degree in Education. He currently serves as the Clerkship Director of Internal Medicine at the University of Kentucky College of Medicine. Andrew and Deidra have three very active sons. He enjoys spending time with his family and of course, running and bicycling through central Kentucky. Sources and Resources 1. Pedestrian and Bicycle Information Center. Pedbikeinfo.org. Accessed May 12, 2016. 2. Kim JH, Malhotra R, Chiampas G, et al. Cardiac Arrest during LongDistance running Races. N Engl J Med. 2012;366:130-140. 3. Yoshino M, Klein S. Endurance Exercise: More Pain, More Metabolic Gain. Ann Intern Med. 2015;162(5):385-386. 4. Bronfort G, Evans R, Anderson AV, Svendsen KH, Bracha Y, Grimm RH. Spinal Manipulation, Medication, or Home Exercise With Advice for Acute and Subacute Neck Pain: A Randomized Trial. Ann Intern Med. 2012;156:1-10. 5. Villareal DT, Chode S, Parimia N, et al. Weight Loss, Exercise, or Both and Physical Function in Obese Older Adults. N Engl J Med. 2011;364:1218-1229. 6. De Moore MH, Beem AL, Stubbe JH, Boomsa DI, De Geus EJ. Regular Exercise, Anxiety, Depression, and Personality: A Population-based Study. Prev Med. 2006 Apr;42(4):273-9. 7. Naci H, Ionnidis JPA. Comparative Effectiveness of Exercise and Drug Interventions on Mortality Outcomes: A Metaepidemiological Study. BMJ. 2013;347:f5577 8. Lee IM. Physical Activity and Cancer Prevention: Data from Epedemiology Studies. Med Sci Sports Exerc. 2003;35(11):1823-1827.

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The Greatest Treatment for Pain:

Exercise By Danesh Mazloomdoost, MD

Mrs. Smith is a 68 year overweight female with a 40 pack-year smoker and diabetic neuropathy. She recently underwent knee arthroplasty on the left but postponed contralateral surgery because of her difficult post-operative pain. She continues to have pain “all over” her body including the operative knee. Considering all available treatments for Mrs. Smith’s various pains – weight loss, smoking cessation, diabetic management, medications or surgery of any kind – the most cost-effective, but often neglected, is a lifestyle that incorporates exercise. Beyond the commonly lauded cardiovascular effects, there is a growing body of evidence that explains why exercise is so potent at pain relief and prevention. On a molecular and cellular level, exercise promotes a concert of beneficial effects, far more numerous than the scope of this article. Just a few highlights, however, can help Mrs. Smith understand the impact on her sense of well-being and pain. Regular aerobic activity boosts production of “happy” neurotransmitters like dopamine, serotonin, and norepinephrine in the midbrain. These are the same compounds that downregulate perception of noxious signals and limit transmission beyond the thalamus and dorsal horn of the spine. Chronic pain pathways are often established and perpetuated as a result of declining neuroplasticity (the ability to generate or remodel synapses). Functional MRI studies demonstrate that exercise directly increases brain

plasticity as corroborated by animal studies showing improvements in circulation and upregulation of neural growth factors such as IGF-1 and BDNF1. Brain plasticity is needed to mitigate the central sensitization and upregulation of noxious signaling that takes place when a patient is in chronic pain. Simply explained to Mrs. Smith, pain begets more pain and exercise reverses that feedforward cycling. Through neurologic mechanisms, Mrs. Smith’s diabetes and circulatory problems contribute to her pain more than she realizes. Nerves do not need insulin to absorb glucose, therefore elevated levels accumulate in nerves and are converted to sorbitol and fructose2. As a downstream effect, this causes oxidative stress and nerve damage which increases noxious action potentials and neural misfiring. Thus, aside from the diabetic neuropathy, all pain is amplified through this process. Additionally, the circulatory changes resulting from the nerve damage, and the vascular impact of hypertension, smoking and dyslipidemia can all inhibit tissue healing and amplify pain. All of these mechanisms are reversed by exercise. Meta-studies show that exercise reduces A1C by 0.8%, HDL increases 2.5%, blood pressure decreases 3.4/2.4 mmHg, mean weight loss of 15 lbs sustained after 1 year, and higher levels of abstinence from smoking at 3 and 12 months3. Mrs. Smith, however, may argue that it hurts more when she moves and that tells her that she’s incurring more damage when she exercises. While it is true that movement of a damaged joint will evoke inflammation, not all inflammation is bad. A controlled level of inflammation promotes healing and

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regeneration. It releases growth factors and chemokines that promote tissue healing. It mobilizes mesenchymal stem cells found on blood vessels and in adipose tissue to migrate to the damaged region and regenerate the damaged tissue (P Wahl, Minim Invasive Ther Allied Technol., 2008). As we age, the number of regenerative cells and mechanisms decline. The sheer volume of damage we accumulate as we age overwhelms the body and the only way a region is prioritized is through movement and exercise. Once a structure starts to degenerate and become painful, a chain reaction can evolve. Guarding and compensation around the original injury cause atrophy in ancillary structures. For example, an arthritic knee is a disincentive to walking or climbing stairs. As a result, the quadratus group weakens. In stride, this muscle group diminishes the impact to the knees with every step by acting as a shock absorber and controlling the decent of the planted foot. Weaker quadriceps equals greater impulses to the knee, which cause more pain and more guarding. Progressively, the diminishing movement accelerates bone resorption and reduces mechanisms that repair soft tissue support like ligaments. It is counterintuitive to most, since most of what we are used to – cars, washing machines, clothes, chairs, etc – accelerate their disrepair with use but biology regenerates when used properly. Put in laymen’s terms, Mrs. Smith, “move it or lose it” works better for your joints than it does your car. As a group, physicians commonly underemphasize the role of an active lifestyle often because of skepticism about the

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impact of counselling, the time it takes to do so, and lack of patient motivation. Behavioral change, however, requires a 2-front approach appealing to both reason and emotion. Engaging with Mrs. Smith on the emotional element of her pain -- the limitations she experiences interacting with grandchildren, functional barriers to activities of daily living, and her disengagement from social outings – gives Mrs. Smith the emotional context upon which the above reasoning can have an impact. Then reason can give Mrs. Smith the tools to understand your prescription to exercise. Physical activity is not a one-size-fits-all prescription, however. Advising activity without direction or monitoring can actually be counterproductive. Discouragement and skepticism of exercise benefits can rap-

idly set in during the initial stages of transition from sedentary lifestyles to mobility. Just like starting a new anti-depressant or diabetic medication, Mrs. Smith needs close follow-up and encouragement. Pain has been labeled as a “vital sign,” however, there are no guidelines to measure this objectively. Perhaps we should replace it with a more objective sign of health, such as exercise. About the Author Danesh Mazloomdoost MD, a born and raised Kentuckian, pursued his medical degree and anesthesiology training from Johns Hopkins and subsequently a fellowship in pain management at MD Anderson Cancer Institute. He is the Medical Director of Pain Management Medicine, a multi-disciplinary practice begun by his family of physicians in the 1990s. Dr.

Danesh advocates for a paradigm shift in healthcare to reduce its reliance on opiates. He guides patients through rehabilitative and regenerative techniques in healing the underlying causes of pain using translational science and the latest innovations in the field. Sources and Resources 1. Davis J, Blair S “Sports and exercise medicine” In: Brukner P, Khan K, Clinical Sports Medicine 4th Edition Australia: McGraw Hill Education 2013; 51-54. 2. Kelkar P “Diabetic Neuropathy” Seminars in Neurology, 2005; 25(2): 168-173 3. Metkus TS, Baughman KL, Thompson PD “Exercise Prescription and Primary Prevention of Cardiovascular Disease” Circulation 2010;121:2601-2604.

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Physician Health and Well Being

Family, Faith & Family Medicine Caresse Wesley, DO By John A. Patterson MD, MSPH, FAAFP Family practice physician Caresse Wesley, DO loves family medicine because it focuses on the whole person rather than a single organ system. She says, ”I love being the doctor who will not give up on her patients. Many times I hear of patients who still suffer with their symptoms because their doctor gave up looking for the cause. I want my patients to know I really do care about them and their suffering. That is why I chose medicine as a career.” However, like many of her physician colleagues, she knows first-hand the experience of job stress and burnout. This increasingly common, distressing experience has been very real for her even though she is an early career physician, having completed her family practice residency at the University of Louisville only 6 years ago. When she began practice, she was shocked by the demands of juggling patient care, paperwork, the electronic medical record, self-care and family life. She just wanted to practice what she loved. Instead, the combination of personal stressors and practice stressors began taking a heavy toll. She has had to contend with three major personal losses in the span of a few yearsonce during residency and twice since beginning practice. The grief associated with

these losses was difficult to manage without professional help. It was very hard to carry the weight of that grief into the office and compassionately support her patients as they dealt with their own life stressors. Family stress, financial stress, work stress and the stress of elder caregiving contributed to many of her patients’ clinical symptoms. Her great challenge was to take good care of herself as she took good care of others- managing her own stress as she helped her patients manage theirs. While she was functioning professionally on the outside she was feeling burned out on the inside. She felt some of her compassion and empathy slipping away. She was losing the joy of doing what she loved. Being inspired by a preventive medical model of self care, prevention and lifestyle medicine, she followed some of her own advice by utilizing professional counseling, just as she recommends for her patients who are experiencing major life stressors. It helped her gain perspective. Having worked alongside her as a family practice colleague in 20102011, I can attest to her successfully and professionally navigating this rough terrain. She is now once again approaching her patients from a place of love and respect, even though many of them want a magic bullet to cure what ails them rather than consider lifestyle changes, counseling or meditation- whole person approaches she believes in and practices herself. She says,

Caresse Wesley, DO

“I practice with a functional medicine approach, always trying to find root causes and get the patient healthy physically and emotionally. I have found the most success personally and professionally when I use nutrition as a foundation and use medicine as a last resort. Personally, I follow a moderate paleo diet which I also recommend to my patients, individualized for them.” Her self-care has always been deeply anchored in her religious faith. She explains, “I have a personal relationship with Jesus and read the Bible every morning. I have someone else to share my burdens. It helps sustain the love and compassion I want to bring to my family and my patients.” She is

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Summer 2016 • Kentucky

I want my patients to know I really do care about them and their suffering. That is why I chose medicine as a career. – Caresse Wesley, DO

clear about what is most important in her life- her faith, her husband and their children ages six and eight. “Our family practices prevention using diet, supplements and an active lifestyle.” She confesses that work and family obligations prevent her from devoting the time she would like to physical activity. She also admits to feeling torn and being pulled in two directions as a working mom. Although she works 4 days a week, she would like to be home more with the kids doing simple everyday things like grocery shopping. But she knows she is setting a worthwhile example for her children- seeing their mom devoted to her faith, devoted to her family and devoted to her patients. She also thinks her children benefit from seeing her strong work ethic and ability to endure in the face of life’s unavoidable suffering.

She advises medical students and residents to set reasonable boundaries for themselves in order to avoid becoming victims of the epidemic of physician stress, job dissatisfaction, burnout and suicide. She urges them to have a life outside of medicine. “They need to have a preventive lifestyle plan in place. They need to keep things in perspective and remember why they chose medicine as a career path. They need to find ways to keep compassion alive in their personal life as well as their professional life.” Caresse Wesley finds time each year to volunteer for her alma mater, Asbury University- another deep love in her life. Her faith and self-care commitment are the foundation from which she cares for her family and her patients with joy, empathy, love and compassion.

About the Author Dr. Patterson Chairs the Lexington Medical Society’s Physician Wellness Commission, is past president of the Kentucky Academy of Family Physicians and is board certified in family medicine and integrative holistic medicine. He is on the family practice faculty University of Kentucky College of Medicine and University of Louisville School of Medicine and teaches nationally for Saybrook School of Integrative Medicine and Health Sciences (San Francisco) and the Center for Mind Body Medicine (Washington, DC). After 30 years in private family practice in Irvine KY, he now operates the Mind Body Studio in Lexington, where he offers integrative medicine consultations specializing in mindfulness-based approaches to stress-related chronic conditions and burnout prevention for helping professionals. He can be reached through his website at www.mindbodystudio.org

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Kentucky

Enhancements To Brain Funciton By Exercise By Robert P. Granacher Jr., MD, MBA There is substantial evidence that lifestyle factors such as exercise can improve learning and memory, delay age-related cognitive decline, reduce risk of neurodegneration of the brain, and play a substantial part in alleviating depression.1 Exercise of almost any kind provides substantial physiological enhancement of brain functions. These include: 1. Exercise enhances learning and plasticity. 2. Exercise is neuroprotective to brain tissue. 3. Exercise is therapeutic and protective in depression. Significant research has shown that in humans, robust effects following exercise have been most clearly demonstrated in aging populations where sustained exercise participation enhances learning and memory, improves executive function, counteracts age-related and disease-related mental decline, and protects against age-related atrophy in brain areas crucial for cognitive processing, such as the hippocampus.2 Extensive medical research demonstrates that exercise has neuroprotective effects. These effects have been defined with respect to reducing brain injury, and to delaying onset of and decline within several neurodegenerative diseases. For example, engaging individuals affected by stroke in post-stroke therapeutic exercise programs accelerates functional rehabilitation.3 Retrospective and cross-sectional stud-

ies suggest that participation in physical activity delays onset of and reduces risk for Alzheimer disease, Huntington’s disease, and Parkinson’s disease, and can even slow functional decline after neurodegeneration has begun.4 Therapeutic effects of exercise on depression have been most clearly established in human studies. Randomized and crossover clinical trials demonstrate the efficacy of aerobic or resistance training exercise (for two to four months) as a treatment for depression in both young and older individuals. The benefits reported in these studies are similar to those achieved with antidepressants and are exercise dosedependent.5 Furthermore, therapeutic effects of exercise on depressive symptoms have been demonstrated in conditions of neurodegeneration in humans. A randomized clinical trial, providing three months of exercise intervention, improved depressive symptoms in individuals with Alzheimer disease, whereas non-exercising subjects showed worsening of depressive symptoms.6 Numerous research studies have confirmed that enhanced hippocampal neurogenesis is one of the most reproducible effects of exercise in mammals, including humans. It is thought to be a key mechanism mediating exercise-related improvements in learning and memory, and resistance to depression. Moreover, exercise leads to widespread growth of blood vessels in the hippocampus, cortex, and cerebellum. These blood vessels, in turn provide increased nutrient and energy supply. This ensures that the enhanced brain function stimulated by exercise can be supported and maintained. In addition, there is substantial evidence of exercise-induced increase in microglia and astrocytes in several brain regions.1 Lastly, there is abundant evidence from animal and human research that growth factors from exercise-induced benefits augment learning and plasticity of neural tissue. Brain-derived neurotrophic factor (BDNF) is essential for hippocampal function, synaptic plasticity, learning, and modulation of depression. Exercise increases BDNF in several brain regions, and the most robust and enduring response occurs in the hippocampus.7

As can be observed, exercise is the least expensive modulator of CNS microanatomy and neural function available to our patients. Its benefits cam be achieved with as little as 15 minutes of walking or resistance training three times weekly. About the Author Robert P. Granacher, Jr., MD, MBA practices clinical and forensic neuropsychiaty in Lexington and Mt. Vernon, KY. He is a noted scientific author and past president of the Kentucky Psychiatric Medical Association. He is currently president-elect of the Lexington Medical Society and Clinical Professor of Psychiatry at the University of Kentucky College of Medicine. Sources and Resources 1. Cotman CW, Berchtold NC, Christe L-A. Exercise builds brain health: key roles of growth factor cascades in inflammation. Trends Neurosci. 2007; 30: 464-472. 2. Huyn P, Abreu BC, Ottenbacher KJ. The effects of exercise training on elderly persons with cognitive impairment and dementia: a meta-analysis. Arch Phys Med Rehabil. 2004; 85: 1694-1704. 3. Rabadi MH. Randomized clinical stroke rehabilitation trials in 2005. Neurochem Rem. 2007; 32: 807-821. 4. Podewils LJ, Guallar E, Kuller LH, Fried LP, Lopez OL, Carlson M, et al. Physical activity, APO-E genotype, and dementia risk: findings from the Cardiovascular Health Cognition Study. Am J Epidemiol. 2005; 161: 639-651. 5. Blumenthal JA, Babyak MA, Moore KA, Craighead WE, Herman S, Khatri P, et al. Effects of exercise training on older patients with major depression. Arch Intern Med. 1999; 159: 2349-2356. 6. Teri L, Gibbons LE, McCurry SM, Logsdon RG, Buchner DM, Barlow WE, et al. Exercise plus behavioral management in patients with Alzheimer disease: a randomized control trial. JAMA. 2003; 290: 2015-2022. 7. Kuipers SD, Bramham CR. Brain-derived neurotrophic factor mechanisms and function in adult synaptic plasticity: new insights and implications for therapy. Curr Opin Drug Discov Devel. 2006; 9:580-586.

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Kentucky

Profile in Compassion

Rice Leach Proud to MD, MPH Public Health Servant Partner with You By John A. Patterson MD, MSPH, FAAFP

In 1992, the Estill County health department nurse told me that Kentucky’s new Commissioner of Public Health had just paid us a visit. She described Rice Leach as a former patient himself, with clearly visible head and neck residuals from prior surgical treatment for cancer. She also described him as warm, down-to-earth and funny. He had come to Irvine to understand the operational needs of Kentucky’s county health departments. As a member of the Estill County board of health, I was impressed and appreciative of this hands-on approach from our state’s highest public health official.

I was also appreciative of the approachable personality she described- a personality that sounded like a breath of fresh air and sharp contrast to an often remote bureaucracy. As part of my own interest in public health advocacy during Kentucky’s “tobacco wars”, I met with Rice Leach in his Frankfort office later that same year to discuss national and state initiatives to reduce youth access to tobacco products. My face-to-face visit with Rice was also prompted by having just met a former colleague of his from his years in the Indian Health Service. I was told I simply had to meet Rice Leach and would enjoy the experience. I had worked briefly in the Indian Health Service myself and expected to share stories of our respective service. I was surprised to also share our mutual special experiences participating in traditional Native

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American sweat lodge ceremonies. For years afterward, our common love and respect for this sacred indigenous community health ritual was a warm and meaningful touchstone as we crossed paths in public health advocacy. Neuro-psychiatrist Robert Granacher MD first met Rice Leach in medical school in 1963. He recalls, “Rice was inspired and influenced by Kurt Deuschle MD, who created at UK the first Department of Community Medicine in the US. It had a nationally recognized powerhouse faculty and Rice gravitated to them. Deuschle had previously developed a pioneering program of health care for the Navaho reservations and was recognized nationally for his compassionate caring. I think this rubbed off on Rice, who later administrated US Indian Health Service facilities for many years and became a Deputy

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Summer 2016 • Kentucky US Surgeon General. As a medical student, Rice was always witty, went out of his way to pursue community health issues for the medically underserved… he was always a highly compassionate person and public health was his mission.” John Poundstone, MD, MPH, preceded Leach as Lexington’s public health commissioner. They also were in medical school together and attended Harvard School of Public Health. He says, “Rice always had a quip or homespun, good old Kentucky story to share.” Internist and immediate past president of KMA, David Bensema MD says “Rice Leach spoke to everyone, and I mean everyone. Regardless of who stopped him to ask a question or seek advice, he gave them the time they needed. Rice would stop, turn in his en bloc style, tilt his head to the right, listen intently to the question, extend his left hand slightly palm down, and with his long fingers fluttering in cadence with his words, respond to the question, leaning in slightly toward the individual he was responding to. His responses almost invariably included a homey analogy that was usually tailored to the individual’s likely life experiences. Rice was so innately compassionate that he could uncannily deduce someone’s capacity to grasp information and provide it in terms that they could ingest and use. I cherish those memories.” Emery Wilson, former Dean of the UK College of Medicine, describes Rice Leach as “knowledgeable and compassionate about the health of the public. He played major public health roles in the U.S. Public Health Service, Kentucky Department of Health and Family Services, and Fayette County Health Department. Above all, Rice had the passion to promote the health of the people at every level and the effervescent personality to accomplish its goals.” Psychiatrist Nat Sandler served on the Board of Health with Dr. Leach for many years and says “Rice was never trying to be something he was not. What you saw was what you got. He was genuine, caring, downto-earth and devoted to the population he served, his family and the staff that served with him. No false airs.” Jeanette Hart worked in the commissioner’s office alongside Rice in the LexingtonFayette County Health Department. She recalls, “It takes a certain kind of person to be enthusiastic about the work we do. He had a passion for public health and liked to say he had over 300,000 patients to care for- meaning the entire city of Lexington. I broke the news of my pregnancy to my co-workers on the first day of spring last year, but he was offsite. I happened to be chairing a meeting when he returned to the office but that didn’t stop him. He busted through the double doors and congratulated me, hugging me and kissing the top of my head, saying ‘the world needs more Jeanettes.’ It was a very sweet moment I will always remember.” Dermatologist John Roth MD is a past board chair of the Lexington-Fayette County Health Department and officially hired Rice

for his second stint as Commissioner. He at a Lexington Medical Society meeting.” says, “Rice was a compassionate man totally Pediatrician Don Neel saw Rice Leach committed to his profession. He spent many in action for many years through their long hours at the health department making mutual involvement in the Kentucky Medical sure deadlines were complete and stretching Association. He describes Rice as “a servant dollars when both state and federal fundof the people his entire career who had an ing were being cut. Mayor Gray, Rice and I uncanny way of explaining the facts with sat down before Rice took the position of witty remarks meant to drive home a point Commissioner. The discussion was how about health care or its delivery. He always to maintain a federal grant to build a new had a command of the statistics relating to primary care clinic and guide the health the poor health of Kentucky’s citizens and department through upcoming budget cuts. worked tirelessly to improve them. Often, he He told me when I hired him that he did not was able to rise above the political fray in his need overtime or comp time, just a straight testimony relating to the health department salary. He knew he would work many long and it’s needs- which was a gift few poshours and did not want to overstress the sess. As Kentucky Commissioner of Health, health department budget. He spent way I found him always available and open to more than 40 hours a week at the health suggestions to improve health care in spite of department and only took time off when he a limited budget and personnel. At medical needed treatment for his lymphoma. He was meetings over the past few years, he often truly devoted to his work. He would attend rose to make a brief point that was always Board of Health meetings even on the days he spot on and left no doubt that his passion was received chemo. Even with his health issues still there. He had such a way with words and and huge job as Commissioner of Health his wisdom ran deep. He had so many favorhe found the time to act as President of the ite sayings like ‘the canoe doesn’t just leak on Lexington Medical Society and an active my side’. Even if you disagreed with him, you member of the Lexington Rotary Club. He respected his view. Rice was a special soul and and his wife even participated in the Rotary one of a kind. All of us will miss his voice.” Club’s Dancing with the Stars. Rice was In a tribute to Leach shortly before his extremely devoted to his wife and often tells death, Lexington Mayor Jim Gray saidof the time they met in Guatemala. I don’t “Simply put, we are a healthier community think we will ever find another physician so because of Dr. Leach.” totally committed to public health. Thank you, Rice. Patrick Padgett, CEO of the KMA Job well done, public servant! describes Rice as “the quintessential public health voice for Kentucky over the past quarter century. He not only thought about global public health issues, he took every opportunity to talk about them as well. Whether it was the flu, smoking, public drinking water or public safety, Rice talked about these issues in public forums and challenged You’ve thought about it for years. You know you need to do others to act when action was needed. it. And there’s no time like the present. But you aren’t quite He was also a passure how to quit smoking. Your doctor is here to help. sionate advocate for other physicians Visit us online to learn what questions to ask your doctor, to get involved in access all available resources, and stick to the plan so you public health issues, can hit pause on smoking. often calling on physicians to serve on local public health boards and clinics. He obviouswww.committoquitky.org ly wanted others to take up the torch of public health in his absence, which is why I believe he spoke about it the last time I heard him speak publicly

Commit to

Quit

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Healthy Body – Healthy Mind Profile of Baptist HealthwoRx By Lowell Quenemoen MD Physical activity has greater importance in our increasingly sedentary and technological work environment and family lifestyle. In medicine more of our day is spent on “paperwork”i.e. electronic records and e-mail communications, our leisure time may be spent binge watching television series and our kids are occupied with electronic video games. Recognizing this, many physicians are pursuing a variety of workout regimens (see other articles this issue), some to maintain overall health and optimum weight, some to improve competitive athletic skills and endurance, others to promote weight loss and many just to have fun in sports and team play. Lexington offers many venues ranging from athletic complexes for multiple sports to specialized centers for yoga, gymnastics and aquatic sports. We have beautiful tree lined rural roads for biking and jogging.

For many, fitness centers provide the site with services ranging from equipment for individually directed regimens, to personal trainers, and some with a whole range of activities aimed at health and wellness for families, for both sexes and for all ages. Baptist HealthwoRx Fitness and Wellness Center falls into the last category. It is a division of Baptist Health Lexington and is situated off-campus at Lexington Green Mall. It is a workout facility open to the public and is staffed by exercise physiologists, certified trainers, dietitians and health educators. An onsite health library includes publications on diet, exercise programs, specific health issues, smoking etc. Further educational opportunities include lectures on general health and specific medical issues and these are given by medical professionals. Although clients may employ a personal trainer, Grant Gensheimer, manager and exercise physiologist, states that there is always someone on the gym floor to provide advice regarding specific equipment along with duration and frequency of exercises. He points out that the range of ages runs

from teens to seniors and primary concern is safety of the client. Most of the workouts include aerobic (“with oxygen”) exercises. These are steadystate cardio performed at a steady moderate pace and are important to improvement of endurance and cardiovascular health. This tends to use glycogen stores first followed by fat burning. Activities include biking, jogging, walking and low intensity circuit training. Over time there may be a down-regulating of muscle building hormones (Leptin, testosterone and thyroid hormones) and a leaner, more slender physique. Elements of anaerobic (“without oxygen”) exercise are also used in varied amounts more so by elite athletes attempting to build more muscle but are associated with increased lactic acid production and fatigue. Anaerobic activities include weight training, sprints, circuit training and HIIT (High Intensity Interval Training). Mr. Gensheimer stresses that even for the person starting a regimen that strength training and flexibility as well as cardiovascular exercises are all parts of the initial program.

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Baptist HealthwoRx Fitness and Wellness Center is a division of Baptist Health Lexington and is situated off-campus at Lexington Green Mall. It is a workout facility open to the public and is staffed by exercise physiologists, certified trainers, dietitians and health educators. Over 110 group classes are offered weekly including multiple spinning sessions, kick Boxing, Zumba, Tai Chi, PiYo, and multiple levels of yoga. “Silver Sneakers” is a group class for seniors stressing range of motion, strengthening and activities of daily living and “Brains and Balance” is a class involving activities to maintain and improve memory and language. Core exercises are used to improve balance and lessen fall risk. Another targeted group is the pregnant woman with stretching, breathing exercises and relaxation achieved through yoga and a second class using aerobic exercises and stretching. Off-site aquatic classes are offered at the Hampton Inn twice a week. A combined program with Orthopedics “Joints in Motion” is held there as is “Aqua Fit”, an aquatic aerobic exercise class. Water aerobic exercises provide toning and cardiovascular conditioning with less strain on muscles, joints and bones and is often a safer exercise program for pregnant women, seniors and people with arthritis and joint disease. Activities may include walking and jogging

in waist deep water, lower body exercises with alternating leg swings, kicking, and resistance training. High intensity anaerobic activity can be accomplished with rapid interval alternating jogging and sprinting. Back on-site is a Barre rom with a full wall of mirrors and mounted ballet barre. The “Barre Fit” program uses exercises dependent on body weight or small hand weights and rather than using large compound muscle movements, uses small incremental (“one inch down, one inch up”) movements that are held or isometric movements. Sessions include warm-up with mat exercises and push-ups followed by arm exercises with light weights. These are then followed by barre activities for the lower half of the body as well as core focused moves at the barre. The program improves strength and promotes weight loss but does not have a large cardio component. Teresa Smith, Director of HealthwoRx and Community Education Services, points out that this is not a primary hospital physical therapy program or cardio rehab pro-

gram but would be the next step after these specific programs have been completed and the patient cleared to participate in a more generalized exercise and wellness program. For the patients diagnosed with cancer there is a group class on “Yoga for Cancer Healing”. The Center is open from 5:30 to 9:00 on week days with shorter weekend hours. Parking is plentiful and for parents working out at the center child care services for children from 6 months to 10 years are available. About the Author Lowell Quenemoen MD is a retired clinical neurologist having practiced in Columbus, Ohio for 20 years before moving to Billings, Montana for a further 15 years of practice. At the time of his retirement he was a Clinical Associate Professor at the University of Washington Medical School Department of Neurology. He is a graduate of the University of Minnesota Medical.

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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

In Memoriam James C. Ridenour, Jr., M.D. passed away May 26, 2016 at the age of 72. Dr. Ridenour at-tended the University of Tennessee (Memphis) Medical School, did his internship in anesthesiology in Roanoke, VA in the US Air Force, and residency at the University of Kentucky Medical Center. He worked at St. Joseph Hospital until 1981, and he played an important role in the opening of the Lexington Surgery Center where he worked until retirement. Dr. Ridenour was a member of the Lexington Medical Society since 1974. He is survived by his wife, Susan, two sons, and five grandchildren. Donations can be made to the Myeloma Institute, UAMS, 4301 W. Markham Street, Slot 816, Little Rock, AR 72205.

Dates to Remember AUGUST 15: LMS ESSAY CONTEST ESSAYS DUE

AUGUST 19: HERALD-LEADER MEDICAL SUPPLEMENT ARTICLES DUE

Prizes awarded for 1st, 2nd, and 3rd place in each of three categories: Active physician, resident, medical student Submit essays to lms@lexingtondoctors. org. For more information go to lexingtondoctors.org.

The Lexington Medical Society will publish its 20th annual health care supplement, “Your Partners in Good Health,” with the HeraldLeader on a Sunday issue at the end of October. Contact Karen Arvin (859) 278-0569, karvin@lexingtondoctors.org. For more information go to lexingtondoctors.org

AUGUST 24: LEXINGTON MEDICAL SOCIETY FOUNDATION 27TH ANNUAL GOLF TOURNAMENT, PRESENTED BY BB&T Proceeds benefit Lexington area, medicalrelated, non-profits like Surgery On Sunday, the Ronald McDonald House, Camp Horsin’ Around, and the Baby Health Service. Contact Cindy Madison (859) 705-0003, cmadison@lexingtondoctors.org. For more information go to lexingtondoctors.org

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Summer 2016 • Kentucky

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Why

do I exercise? By Paula D. Bailey, MD I like to think it is because I know it is good for me. Cardiorespiratory exercise, or aerobic exercise, may decrease risk of heart disease, decrease blood pressure, improve mood, improve focus and attention, improve sleep, decrease obesity, improve lipid profile, and improve the action of insulin.1,2,3,4 Along with other healthy lifestyle modifications, seventy-five minutes of vigorous cardiorespiratory exercise weekly may decrease cancer risk.5 Which medication does all that? To my knowledge there is not one pill that will accomplish these things. Exercise is free and has very few negative side effects. So how much exercise is enough? The World Health Organization and the Centers for Disease Control and Prevention recommend 150 minutes of moderate or 75 minutes of vigorous aerobic exercise per week. We are not sure what the optimal amount of aerobic exercise is, and likely it is different from person to person, but we do know that even a small amount is better than none. My exercise of choice is to run now but if someone had tried to convince me when I was 25 years old that I would someday call myself a runner, I would have argued to the contrary vehemently. Growing up I participated in softball and gymnastics, then in col-

lege took up racquetball. So athletic – yes. A runner? No. I thought it was boring and hard on your joints. After my second year out of residency, I was tired and heavier than I had ever been. I was also 36 years old – no longer playing softball (for that you need a team) and not playing racquetball (for that you need a court). I did not belong to a gym because I did not have time to go in the morning prior to work. So now I run. It is my “me” time. While running, there are no pagers, cell phones, tablets, computers, or any other plea for my attention. While running I have solved many problems and made life decisions because that is when I do my best thinking. I never have an excuse not to exercise because I do not need expensive equipment or a class. All that is needed is a pair of shoes and space (or a treadmill). Even when I travel these two things are available. So how do you become a runner? My first advice is start slow. I chose to start with a program called “Couch to 5K”. It is a program designed for people who have not done aerobic exercise in a long time (or ever). It slowly introduces jogging to reduce risk of injury and allows a pace that suits your fitness level. There are now many online forums discussing this program and “apps” for your smartphone that will help you achieve your goals. The original program is nine weeks but you can repeat weeks if you are not feeling up to the next

time goal or if you miss a week, you can just pick up where you left off. It can work for anyone. The next struggle is keeping it up. Exercise to be beneficial must be a habit. There are things you can do to increase the likelihood that you will be successful in keeping it up. First start small. For example instead of trying to exercise and hour per day, decide to exercise at 30 minutes three times in the next week. That is doable. It is finite and achievable. Next, make a plan. It makes it concrete and manageable. On Monday, Wednesday, and Friday I am going to run for 30 minutes. Ensure that all variables are controlled – have your shorts and shoes prepared the day before and a specific time allotted. Do it at the same time every day. First thing in the morning works for me. I know that as soon as I get up, my first activity is putting on my running clothes. Then once I am dressed it becomes much easier to step out the door and less likely I will be distracted by other things. Find the time that works for you – time when there are fewer demands on your time. Make it an appointment. Put your exercise on your calendar like every other important meeting. This helps ensure the time will not be monopolized by other activities. Next, don’t skip. Make sure you have thought of the excuses you will have and plan to avoid those. Remember why you are trying to make it a habit and ensure those reasons are

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“While running I have solved many problems and made life decisions because that is when I do my best thinking... all that is needed is a pair of shoes and space (or a treadmill).” – Paula D. Bailey, MD at the front of your mind. If you do need to miss a day, don’t give up. Reschedule the next session and make sure it is the priority. And last, give it time. Habits are formed over time. It will not become your routine in a week. Stay focused on why it is important and make sure it remains a priority. When it becomes habit, you will miss it when other things must take priority. 1. Start small 2. Have a plan 3. Do it at the same time every day 4. Make it an appointment 5. Don’t skip 6. Give it time I now feel good. I have been at the same weight, which is a healthy weight for me, for almost 8 years and I eat healthy but don’t starve. My HDL, good cholesterol, is >90, my blood pressure is in the normal range, and I never have insomnia. I feel good, have energy to make my busy schedule tolerable, and hope to keep this up for many more years. I attribute many of these things primarily to running. It is worth it!

About the Author Paula D. Bailey, MD is a Kentucky native and completed a BS in Dietetics at Eastern Kentucky University in 1990. After working as a dietitian for six years, Dr. Bailey started at the University of Kentucky College of Medicine in 1996, graduating in 2000. She then completed a Medicine Pediatrics residency, followed by a general Internal Medicine fellowship along with a Master’s degree in Healthcare Administration. Dr. Bailey will start her thirteenth year as an attending hospitalist at the University of Kentucky Hospital in July and her work interests are resident education and health systems research. Sources and Resources 1. Garber, CE, Blissmer, B, Deschenes, MR, et al. Quantity and quality of exercise for developing and maintaining cardiorespiratory musculoskeletal and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sport Exerc. 2011; 43(7): 1334-59.

2. Kodama S, Saito K, Tanaka S, et al. Cardiorespiratory fitness as a quantitative predictor of all-cause mortality and cardiovascular events in healthy men and women: a meta-analysis. JAMA. 2001; 301(19): 2024-35. 3. Hogan CL, Mata J, Carskusen LL. Exercise holds immediate benefits for affect and cognition in younger and older adults. Psych Aging. 2015; 28(2): 587-94. 4. Ross R. Effects of exercise amount and intensity on abdominal obesity and glucose tolerance in obese adults: a randomized trial. Ann Intern Med. 2015; 162(): 325-34. 5. Song M, Giovannucci E. JAMA Onc. Published online May 19, 2016. doi: 10.1001/jamaoncol. 2016.0843. 6. WHO website accessed May 5, 2016. http:// www.who.int/dietphysicalactivity/factsheet_ adults/en/ 7. CDC website accessed May 5, 2016. http:// cdc.gov/physicalactivity/basics/adults/index. htm

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From the Cover

A Return to Running After CABG Farhad Karim, MD

The longer I continued running, the easier it was not to start smoking again for the simple reason that I did not want to let the effort go to waste. Running made me feel better and helped me quit smoking. â&#x20AC;&#x201C; Farhad Karim, MD

Before I started running, I was a smoker, with a horrible family history of heart disease. My father had an M.I. at age 42 and died at age 52. Premature death from heart disease was a common occurrence in my family. I knew of my risk of heart disease and I tried to quit smoking once and failed. A low point occurred during my Allergy fellowship in 1980. While attending the American Thoracic Society meeting, I found myself sneaking out of the meeting of Pulmonologists and Allergists to a corner to smoke. At that point, I made a decision to quit smoking to set a good example for my children and my patients. I quit cold turkey, but found myself needing something to curb the craving. Perhaps, I thought, exercise might help take my mind off smoking. Believing that exercise and smoking were not compatible, I started running, initially around the block and gradually longer. It worked, and the longer I continued running, the easier it was not to start smoking again for the simple reason that I did not want to let the effort go to waste. Running made me feel better and helped me quit smoking. Soon running became part of my daily routine. I discovered that running in the morning was better because it did not interfere with my schedule, allowing me to run routinely a consistent 6 miles daily. I soon discovered additional benefits to running. While running, my mind drifted into a meditative state, and this clarity has helped me to come effortlessly to better approaches to problem solving that I had not previously considered. 5 years after I started running, I was intrigued by the road races, which began gaining popularity. I ran my first 10 K race in 1985, and as I became more motivated I observed my time dropping as I progressed. My family history of heart disease was always in the back of my mind, and I wondered if running could overcome it. I believed I was in perfect health, but still wanted to be better. After reading a medical journal article that marathon runners have the highest median HDL, I immediately wanted to become a marathoner. I trained for and ran my first marathon (26.2 Miles) in March, 1986. That was the first of my 13 marathons, including the Boston Marathon for which I qualified with a time of 3 Hrs. 23 Min. My marathon training consisted of running 63 miles a week, including a run of 21 miles on Saturdays. I later stopped running marathons due to the time commitment, but I continue

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The feeling of wellbeing is hard to explain, and I hope others will be motivated to consider regular exercise. – Farhad Karim, MD

running 6 miles daily, with occasional added 5 and 10 K races. Since my father had an M.I. at age 42, I concluded that if I passed his attained age without a cardiac event, this would prove that running had altered my risk. And if I lived past age 52 (his age of death), it would prove that one can overcome the expected unfavorable outcome of bad genes with regular exercise. Once I surpassed age 52, I believed that I had beaten the odds. However, at age 61, I experienced some vague symptoms of shoulder tightness after a regular 6 miles run which felt like I had run a marathon. Prompt evaluation, including cardiac stress testing, revealed normal myocardial perfusion and functions. Over the next 2 years, I noticed that my breathing felt “out of sync” when I ran, requiring me to stop frequently. I knew that my heart was normal, based on recent evaluation, so it was getting frustrating not knowing the cause. I finally had a cardiopulmonary stress test, and towards the end of the test, an ST segment change was noted. Subsequent coronary angiogram testing revealed multi-vessel disease with 10 blockages ranging from 70 – 100%, but with good collateral circulation. I urgently underwent a 6 vessel CABG and recovered quickly. The news of my CABG came as a shock to everyone who knew me as a runner and raised questions about the benefits of exercise. I assured them that it indeed helped by delaying the onset of disease by 20 years, based on my family history. Also the development of collateral circulation as a result of running prevented any heart

muscle damage. Cardiac rehabilitation and careful monitoring allowed me to resume running and within months I was able to build back my mileage to 6 miles daily, which I am currently maintaining. Before starting to resume races, I was evaluated at the Cardiovascular Performance Program at Massachusetts General Hospital, a specialty program in cardiovascular disease in athletes. An extensive evaluation revealed excellent cardiac function, and normal exercise physiology, and I was cleared to run without limitation provided that I paid attention to the following 5 key factors regarding exercise safety:

ing. That fear keeps me motivated. Further motivation comes daily after I finish my run, shower and enjoy my breakfast and then I am energized for the rest of the day. That feeling of wellbeing is hard to explain, and I hope others will be motivated to consider regular exercise. Running may not be for everyone, but it is possible for almost everyone to be engaged in some form of exercise on a daily consistent basis by carving 30 to 60 minutes out of the day by reducing watching TV or surfing on the phone. Other benefits of exercise are well known and described further in this edition of Kentucky Doc.

1. Prepare adequately for an event 2. Proper warm up and cool down 3. Respect respiratory viral illness by skipping exercise 4. Annual periodicity by cutting back on running for 3 months out of the year 5. Vigilance to warning signs suggestive of recurrent obstructive coronary disease

About the Author Dr. Karim completed residency in pediatrics at the Pontiac Affiliated Hospitals in Pontiac, MI and his fellowship in Allergy and Immunology at The University of Chicago before starting practice. He is an active member of several national and local professional organizations including the American Academy of Allergy, Asthma and Immunology, Lexington Medical Society where he served as President in 2011, and Kentucky Medical Association where he has served as a delegate from Lexington. Dr. Karim has been the Chief, section of Allergy at Central Baptist Hospital, Lexington since 1998. He is also active in the local community and has served on several boards. Dr. Karim is certified by The American Board of Pediatrics. He is a fellow of the American Academy of Allergy, Asthma, and Immunology. His interests include running and motorcycling.

At the MGH I learned that symptoms of heart disease in runners are different from non-running persons, and usually present with either burning in the chest or “breathing out of sync,” as was my case. I am frequently asked why I run every day. I am afraid that if I start cutting back or skipping occasionally, I will find excuses not to run regularly, and lose my motivation to remain a regular, competitive runner. Once that happens, I fear I may stop running altogether. And if I stop running, I fear I might be tempted to resume smok-

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2016 Lexington Medical Society

2nd Annual

Essay Contest PRIZES AWARDED

THREE CATEGORIES

1st place prize $600 2nd place prize $300 3rd place prize $100

Active Physician Resident Medical Student

Theme:

“Healthy and happy doctors provide better care, define barriers and solutions to physician wellness.”

Prizes awarded for first, second and third place in each of the three categories

Details:

Due no later than August 15, 2016.

visit lexingtondoctors.org for details

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Kentucky

Exercise:

The science behind the why By Tuyen T. Tran, MD

How often have we witnessed people patiently waiting for a “closer” parking spot when ample spaces are available just a few steps farther? One of the most substantial Western social changes is the gradual transition from daily lives that require high levels of physical exertion to lives which are increasingly sedentary. As technology advances, especially in communications and transportation, people’s daily routines are less physically demanding. While enhancement of productivity and yielding more leisure time are welcomed, the unexpected negative outcome is health risk from inactivity.

Fig. 1: Relative risks of death from any cause among participants with various risk factors (e.g., history of hypertension, chronic obstructive pulmonary disease [COPD], diabetes, smoking, elevated body mass index [BMI ≥ 30] and high total cholesterol level [TC ≥ 5.70 mmol/L) who achieved an exercise capacity of less than 5 METs (metabolic equivalents) or 5–8 METs, as compared with participants whose exercise capacity was more than 8 METs. Error bars represent 95% confidence intervals. Adapted, with permission, from Myers et al (N Engl J Med 2002;346:793-801). Copyright © 2002 Massachusetts Medical Society. All rights reserved.2

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Summer 2016 • Kentucky

As technology advances, especially in communications and transportation, people’s daily routines are less physically demanding. While enhancement of productivity and yielding more leisure time are welcomed, the unexpected negative outcome is health risk from inactivity.

Inactivity is a health risk! Physical inactivity is one of the modifiable risk factors for both primary and secondary prevention of premature death from any cause (cardiovascular disease, diabetes, some cancers, and osteoporosis).1 There is also evidence supporting a linear relationship between physical activity and health status, especially longevity of life (see Figure 1). And not surprisingly, it appears that physical activity (musculoskeletal fitness) correlates with disability or independence with activities of daily living (see Figure 2). So what about Kentucky? Based upon CDC data (see Figure 3), Kentuckians were not last (score of 16.6%) in regards to physical activity; but, we were clearly not exemplary! According to United Health Foundation’s 2013 report, Kentucky ranked 45th among all US states in overall health. Is there a correlation? I propose that there is; but, the confirmatory evidence is lagging. As you read the articles depicting exemplary colleagues who are promoting the incorporation of exercise into their already busy lives, I encourage you think about the tremendous impact each of you, as physicians, as inspirational leaders for your patients, will have upon the community at large. Patients look to their physicians as role models. It is no longer sufficient to “…do as I say;” we need patients to see what it is we do to effect positive change. About the Author Tuyen Tran, MD emigrated from South Vietnam after the war. He completed his undergraduate in biology/chemistry and medical school at the University of Missouri – Kansas City in a six year program. His is currently boarded in internal medicine and addiction medicine. Sources and Resources 1. Warburton Darren E.R., Nicol Crystal Whitney, Bredin Shannon S.D. Health benefits of physical activity: the evidence. CMAJ. March 14, 2006; 174(6). Doi:10.1503/ cmaj.051351. 2. Myers J, Prakash M, Froelicher V, et al. Exercise capacity and mortality among men referred for exercise testing. N Engl J Med 2002;346:793-801. 3. Warburton DE, Gledhill N, Quinney A. Musculoskeletal fitness and health. Can J Appl Physiol 2001;26:217-37. 4. Nutrition, Physical Activity and Obesity Data, Trends and Maps web site. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity and Obesity, Atlanta, GA, 2015. Available at http://www.cdc. gov/nccdphp/DNPAO/index.html.

Fig. 2: Theoretical relation between musculoskeletal fitness and independent living across a person’s lifespan. As a person ages, his or her musculoskeletal fitness (i.e., muscular strength, muscular endurance, muscular power or flexibility) declines, such that a small impairment may result in disability. Many elderly people currently live near or below the functional threshold for dependence. High levels of (or improvements in) musculoskeletal fitness will enhance the capacity to meet the demands of everyday life and allow a person to maintain functional independence for a greater period.3

Fig. 3: Percent of adults who achieve at least 150 minutes a week of moderateintensity aerobic physical activity or 75 minutes a week of vigorous-intensity aerobic physical activity and engage in muscle-strengthening activities on 2 or more days a week4 †

doc • Summer 2016

Kentucky

Marketing

How Healthy is Your Practice?

A medical practice is a unique business, but it is still a business. Therefore, certain fundamentals apply. New patient acquisition must play a role in your planning and practice management.” – Jim Ray, Jim Ray Consulting Services

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Business Section • Summer 2016 • Kentucky

By Jim Ray Do you know your New Patient Acquisition ratio? Do you track it on a monthly, quarterly and annual basis? Normal businesses lose a certain percentage of clients due to attrition. To grow, they depend on an influx of new clients. For your medical practice to grow, it also depends upon new patients. Are your efforts driving the right types of patients and related procedures to your office? If there’s a Variable Compensation Component (VCC) associated with your practice, what are you doing to actively develop it? Is your staff participating in these activities on a consistent basis? This requires going beyond simple exam room signs (e.g. Have You Had Your Flu Shot?). It means pursuing a specific set of activities with each qualified patient.

Nothing Happens Until Something Happens

I wrote about online, physician directories in my previous article (Spring 2016). They’ll provide additional exposure for your practice. Many provide an opportunity for someone to rate your services. I included information about the 5-Star reviews often found on Google and other platforms. Many of my clients have asked me to record a brief, but customized, video explaining how to leave a review. These can be easily sent to people, as a follow up. With any advice, the question is: Did you take action? Have you or your staff done a search to see if any reviews already existed? Did your staff actively promote online ratings for your practice? A few days ago, I was looking for a new podcast. I stumbled upon an episode by Scott Smith. He made an interesting statement: “Nothing Happens Until Something Happens.” That’s great advice. Regardless of how badly you hope or wish for different results, it’s still up to you to do something to cause a different outcome. Action must be taken. A medical practice is a unique business, but it is still a business. Therefore, certain fundamentals apply. New patient acquisition must play a role in your planning and practice management. Your practice model may dictate the variables over which you can exert influence/control. The key is to define them.

Once defined, a plan can be developed and implemented to positively impact your VCC. It’s not all that different from treating a patient. It’s about focusing on the desired outcome. To maintain a healthy body, you need to make good choices about diet and exercise. To maintain a healthy practice, you need to make good choices when it comes to marketing to your next generation of patients.

As my internist advises me, “Your numbers matter.” The same advice applies to any business (your practice included). Take time to review your numbers: • Are you treating more new patients this year verses last year? • Are you performing more of the right types of procedures to impact your VCC (within ethical guidelines, of course)? • Are there changes in the demographics of your market which may present opportunities for you? • How effective have your individual actions been at moving the needle toward your personal goals for the practice?

Controllable Variables

One way to grow your practice is to expand your market visibility. This is much more than simply some online reviews, or even a website. There are other variables you can control, if your goal is to grow. I’m a proponent of writing articles. There are many publications looking for your valuable insights. Our society trusts our physicians. You have a natural authority. Exercise it. Look for small magazines, online publications and other resources visible to your primary market. There’s also the option of participating in forums, discussions and even seminars. There is a myriad of topics, not all of them are strictly medical. Find an area of interest and see if you can cultivate an outlet for your opinions and/or perspectives. You might refer to these events on your blog. Yes, you should have a blog. It’s one of the most important and effective ways to increase your online visibility. Another group of variables includes activities you and/or your staff should perform after a patient leaves your office. For new patients, consider sending a thank you card. They’ve just decided to become a source of income for you and your practice. A quick thank you is a nice touch and helps you to stand out from the crowd. For new and existing patients, if you’re not doing “Experience Audits,” now’s the time to start. By following up with patients, you’ll have an opportunity to identify issues in your processes. This may help you to identify areas of frustration, confusion and/or inconsistency. It may also provide insights into issues with your office staff. By allowing them to discuss problems directly, you reduce the chance they’ll voice negative opinions in online reviews. Better yet, if they had a terrific experience, now would be an excellent time to encourage them to leave a 5-star review or other rating. Your patients have charts. Your practice should as well. Look at them regularly. If you aren’t progressing, it may be time to change the treatment protocol for your particular situation. As you spend time reading this edition of Kentucky Doc, and its advice on keeping you healthy, don’t neglect the health of your practice. Know your numbers. If warranted, don’t hesitate to call in a specialist.

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Kentucky

Learning the Signs of

Elder Abuse

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Summer 2016 • Kentucky

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 (1-877-2287384). 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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Take Care of Your Patients by Taking Care of Yourself

The Lexington Medical Society

Physician Wellness Program

TAKE CARE OF YOUR PATIENTS BY TAKING CARE OF YOURSELF The Physician Wellness Program (PWP) was designed as a safe harbor for physicians to address normal life difficulties in a confidential and professional environment.

WHY WAS THIS PROGRAM CREATED? Being a physician isn’t easy. Difficulties with the current health care delivery system, maintaining a healthy work/ life/family balance, and dealing with the normal stresses of everyday life can take their toll on physicians. We serve not only as treating physicians, but many times as counselors to our patients who turn to us for guidance. Who do we turn to when we need to talk through an issue or get some coaching for how to handle stress in our life? Too often the answer is “no one,” and that is regrettable because it is imperative that we be as healthy as possible in our role as health care providers. We deserve to function at our best in all areas of our life. By addressing areas of difficulty, we can decrease our stress levels and increase our levels of resilience.

Some examples of those difficulties include: •

Family issues

•

Depression & anxiety

•

Relationship problems

•

Difficulty managing

•

Work-related

•

stress

difficulties

•

Mood swings

Alcohol/drug abuse

•

Suicidal thoughts

How PWP Works We have contracted our program with The Woodland Group. The Woodland Group will provide counseling to active physician members of the Lexington Medical Society and UK Graduate Medical Education residents and fellows. Non-emergency sessions will be scheduled during regular business hours. Emergency sessions can be scheduled on a 24-hour, 7 days-a-week basis. Seven licensed psychologists make up the Woodland Group and have been vetted by LMS. Steven Smith, Ph.D. and Sandra Hough, Ph.D. are our program coordinators and will serve as points of contact to access PWP. The Woodland Group will maintain a confidential file for each physician, but no insurance will be billed and LMS will not be given any information about those who utilize the program. As such, this program is completely confidential which is crucial to its success. LMS will pay The Woodland Group a monthly bill based on the number of sessions provided. The Woodland Group will verify LMS membership from the physician finder on the LMS webpage.

TO MAKE YOUR APPOINTMENT 1) Call the confidential hotline at 1-800-350-6438 and leave a message in either Dr. Smith’s or Dr. Hough’s voice mailbox. 2) They will call you back to schedule an appointment. It’s that simple!

PWP Benefits 6 free sessions each calendar year Complete confidentiality Easy access Convenient location (535 W. 2nd Street, Suite 207) 24/7 availability

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

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

Our providers make the difference. *Passport’s growing network of providers now includes 3,720 primary care physicians, 14,014 specialists, 131 hospitals, and 5,619 other health care providers. Ratings are compared to NCQA (National Committee for Quality Assurance) national averages and from information submitted by the health plans.

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