Issue 126 by topdoctormagazine

ISSUE 126

BRINGING HOPE FOR A BRIGHTER COVID-19-FREE WORLD PG 01

IVX HEALTH: YOUR PRIVATE SUITE FOR INFUSION THERAPIES AWAITS PG 11

BRIDGING THE GAP BETWEEN MEDICINE AND BUSINESS FOR BETTER PATIENT OUTCOMES PG 20

TABLE OF CONTENTS

Bringing Hope for a Brighter COVID-19-Free World

The Complicated Relationship Between COVID-19 and Sports Medicine

Embracing Telemedicine: How COVID-19 Is Forcefully Transforming An Industry Resistant To Change

IVX Health: Your Private Suite for Infusion Therapies Awaits

Which path will you choose? The Benefits and Drawbacks of Private and Public Practices

Bridging the Gap between Medicine and Business for Better Patient Outcomes

Could a Once-a-Week Insulin Injection Alter the Treatment of Diabetes?

Pain Management - A Comprehensive Care Guide

Cancer: The "Equal Opportunity" Destroyer with Dr. Julien Fahed

T H A N K F R O N T L I N E

Y O U H E R O E S

TOP DOCTOR MAGAZINE

AUGUST 2021 • ISSUE 125

Bringing Hope for a Brighter COVID-19-Free World

AN INTERVIEW WITH DR. DAVID RAMIN The COVID-19 virus shows encouraging signs of falling behind in the U.S. With the advent of the first FDA-approved vaccines at the end of last year and an efficiently coordinated vaccination campaign, the U.S. has experienced a steep drop in new daily COVID-19 cases (11,500 cases on May 29th), coupled with an even steeper growth in daily (41% of the population fully vaccinated).

Understanding Prevention Is More Important Than Treatment The prospects could not be merrier for the battle-hardened general population, who is ready to reclaim, once again, its freedom of movement and live in an environment devoid of fear. For Dr. David Ramin, a Wayne State University School of Medicine alumnus and head of his private practice in Beverly Hills, this environment of fear exacerbated the global pandemic. It caused numerous people to experience something similar to the entrapment feeling felt by a claustrophobic person. He even shared with Top Doctor Magazine a patient story that speaks for itself on this

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matter: “I had one patient who had twice a week COVID-19 testing done. He did so much that he ended up having trouble with his nostrils and getting perforation.”

Hurting oneself is an unexpected yet ordinary outcome of exaggerated self-care. In Dr. Ramin's view, the physician bears responsibility for educating the patient on the significance of prevention to restrict this environment of fear to a minimum: "The most important thing as physicians is to make sure they (i.e., the patients) are not living in fear. You have to educate them not to live in fear."

An Epidemic of Misinformation This educational work can put the brakes on today's tendency towards self-education from unverified sources, giving rise to our contemporary misinformation epidemic. "Up to 30% of patients who seek assistance for a doctor are worried about certain things that might not be true; they read on Google, and they think they have cancer or some sort of illness, they have very few months left to live, or they're going to die." In a world where the concept of authority is constantly put to the test, Dr. Ramin reminds us that the scientific world's bedrock resides on continuous learning and data analysis. "Anybody can put things on the internet. […] As patients, it's very hard, anybody can come and comment, and those comments might be taken as data." The formidable task of separating presuppositions from actual research is not for anyone to undertake, although this reality might hurt a few egos; however, for Dr. Ramin, the consequences of this unwarranted research are real and troublesome: "People are able to search things and start worrying by things that they shouldn't be."

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Constantly Improving Oneself The second component of a robust and trustworthy scientific world is continuous learning. Dr. Ramin utilizes his teaching experience from the USC Keck School of Medicine to diversify and improve his practice. As an educator, he firmly believes that preparing the next generation of physicians can only be achieved through constant learning. "When you teach medical students, you have to keep updated. I like teaching because that keeps me more up to date." He communicates with Top Doctor Magazine.

diet and lack of activity, to an already diabetes-friendly recipe. However, Dr. Ramin believes that he found an excellent way to treat diabetes in the shape of, you've guessed it, prevention. "It's the simplest way of treating diabetes," he conveys to Top Doctor Magazine. Through constant prevention tactics and weight loss, the blood sugar in diabetes patients will gradually decrease, leading to a decrease in insulin resistance. Less insulin resistance calls for a shorter necessary drug list and facilitates disease amelioration.

Finding Superior Ways to Treat Diabetes Owing to his General Internal Medicine training, Dr. Ramin works with patients whose morbidities cover an extensive range. Out of all, treating patients with endocrine disorders such as diabetes is paramount to his work. "Diabetes is the number one cause of blindness, kidney failure and causes a lot of morbidity and mortality associated with heart disease and stroke." Taking on this prevalent medical issue (which affects over 400 million people worldwide) truly is a daunting task, never mind the COVID-19 pandemic, which added the proper ingredients, such as poor

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Dr. Ramin improves his diabetes prevention tactics through specific medicine that facilitates weight loss. Diabetes patients can achieve weight loss either by disposing of blood sugar through the urine or by causing a feeling of satiety, leading to reduced food intake. Patients will not return to their original eating habits with an already shrunk stomach regardless of how much weight they lost. To conclude, both approaches center on the same issue, namely insulin resistance. "I've changed our practice of medicine, too, to the point that we are going back and getting rid of what's the hallmark, which is insulin resistance."

"If Your Passion Is Medicine, Go for It!" Dr. David Ramin successfully illustrates the physician's sworn quest towards an unquenchable thirst for knowledge and an unbreakable will to help and educate patients daily. While not always a walk in the park, medicine will always reward those who practice it with passion, with love, and with selflessness. "I've spent past 20 years going to hospitals, emergency rooms, being in my office, having my phone ring in the middle of the night, during the day, during weekends, taking care of patients; it's the most rewarding career anybody could have; you deal with the patients, you deal with people's lives." However, for those who are not passionate about medicine, happiness and fulfillment lay somewhere else: "If your passion is medicine, go for it. If your passion is not medicine, you aren't going to be a happy person doing medicine; people who are passionate about medicine become pretty good doctors. People who are not passionate about medicine shouldn't go into medicine." As a parting reminder, Dr. Ramin reiterates the urgent need for a continuous dialogue between physicians and patients in an effort to remove the latter's insecurities and help them recover after this besieged-by-fear pandemic. "It's very important to have an understanding of them (i.e., the patients) and have a way of communicating with them to make sure they can come back and leave their lives because the lack of social interaction will devastate a generation of us." For more information on Dr. David Ramin and his practice, check out the following website.

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T H E C O M P L I C A T E D R E L A T I O N S H I P B E T W E E N C O V I D - 1 9 A N D S P O R T S M E D I C I N E

BY ESTHER OLADAPO

Dr. Zac Maass, a sports medicine specialist at UConn Health and head team physician for Woodstock Academy in Woodstock, CT, shares his story of how his practice was affected by the COVID-19 pandemic, his views on the ever-evolving topic COVID-19 and its effect on sports medicine, and his take on general public health topics in an interview with Top Doctor Magazine. After completing medical school at Michigan State University College of Osteopathic Medicine, Dr. Maass completed his family medicine residency at the University of Minnesota in partnership with Mayo Clinic. Once board certified in family medicine, he then specialized in sports medicine by completing his primary care sports medicine fellowship at the University of Connecticut (UConn) in conjunction with UConn Health. While training at UConn he benefited from the fellowship’s commitment to hands-on learning. As a fellow, he cared for several high-level athletes across a wide variety of sports. He found traveling with the teams, providing extensive sideline medical coverage, and honing his ultrasound-guided procedure skills profoundly fulfilling. While Dr. Maass found his fellowship training enjoyable, he goes on to describe how his journey to sports medicine was not always pleasant. PAGE

Dr. Maass credits his time in medical school as being his defining moment in his personal and professional life. He describes needing to become resilient as he was confronted with immense personal and professional challenges during his 4 years at Michigan State.

"That was a huge adjustment for me, especially given that being sideline for different sporting events and caring for athletes was the reason I was here. To have that all come to a halt was painful."

"I struggled in medical school. The academics were of course very challenging. On top of that my wife and I lost everything in a complex-wide apartment fire. I had to have a sit-down and realize that getting through medical school was probably going to be the hardest thing I will ever do. I felt like I was supposed to be a doctor. Becoming a physician is just down in my soul. I knew that was what I was supposed to do, so I recommitted to pushing through." With the support of his wife and family, he was able to persevere and excel in the remainder of his medical training. The Effects of the COVID-19 Pandemic on His Practice When the full weight of the COVID-19 pandemic hit in March of 2020, Dr. Maass was 9 months into his 12 months of training. It was at that 9 month mark that all sports came to a screeching halt.

Like many of his colleagues at the time, he volunteered to help with frontline COVID-19 testing at UConn Health. The frontline testing experience, along with his passion for athlete healthcare, further motivated Dr. Maass when it came time to care for and eventually begin clearing COVID-positive athletes for return to sport-related activities. Whether it was providing the frontline COVID-19 tests or caring for athletes and their COVID-19 illness, Dr. Maass summarized his experience by stating, "with COVID-19, learning never stops."

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In addition to the medical strain felt by athletes and the general population that had been infected with COVID-19, the pandemic also placed a strain on the ability of medical providers to communicate with their patients given the social distancing guidelines that were in place, especially during the early stages of the pandemic. Navigating the Issues Surrounding Communication and Telehealth During the Global Pandemic Dr. Maass and his team at the UConn Health Center suffered some setbacks during the pandemic as they tried to transition to more telehealth-drive healthcare. "The pandemic ravaged everyone— physically, psychologically, and financially. We had a lot of work to do." According to Dr. Maass, telehealth is a two-way street. Even if a medical facility has the technology and capability to connect with patients via the internet and individual patient portals, the patient must also have access to the technology necessary to facilitate an effective patient-physician interaction. It is clear that the COVID-19 virus is deadly. What has also becoming clear is the massive health equity disparities present within our current health care system. Continued innovation and advancement is necessary to ensure that every individual has the healthcare access necessary to allow for improved quality of life across all of our communities. Vaccination: The Progress, Closeness of the United States to Immunity, and Challenges of Convincing People to Get Vaccinated Dr. Maass believes that, even though it is great that the vaccines are out in circulation, everyone still needs to be disciplined and responsible. "While the vaccine is a crucial part of getting past the virus, we still have to abide by some social distancing guidelines. We still have to mask up; we still have to wash our hands; we still have to look out for the people around us that aren’t yet vaccinated." Again, with the vaccines, there is a lot of apathy and/or hesitancy resulting largely from misinformation. Herd immunity can only be achieved when the vast majority of the population of the United States gets vaccinated. Encouraging hesitant adults (especially parents) to get vaccinated will continue to be a complicated endeavor. However, Dr. Maass believes that honest communication along with properly informed opinions are paramount to getting more individuals vaccinated. Conclusion It will likely take years for the full impact of the COVID-19 virus to be understood. However, Dr. Maass, along with his colleagues at UConn Health Orthopedics and Sports Medicine ,remain committed to providing the highest quality care to their patients, regardless of the obstacles the pandemic may put in their path.

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Embracing Telemedicine: How COVID-19 Is Forcefully Transforming An Industry Resistant To Change By Lateef M. Oyalola

Technology has brought incredible developments in every sector of the economy to facilitate improvements in all aspects of human lifestyle and business. Technological innovation influenced overall performance, job efficiency, effectiveness, and improvement in the quality of service delivery. Yet, implementing telemedicine and all other aspects of digital health has been slow over the years, and multiple great technologies have failed to penetrate the healthcare system. Some professionals who enjoy their routine for several decades tend to become resistant to any disruptions threatening the status quo. Technology is a notorious disruptor that can trigger a sweeping change capable of transforming an industry. Some of these professionals are often reluctant to adopt new technological change out of disinterest and skepticism that it will improve efficiency. The healthcare industry is a notable example of an industry that has been resistant to change. As a result, the adoption of technological innovation in the healthcare system has been challenging. PAGE

However, the recent pandemic triggered a pervasive healthcare emergency globally, and its overwhelming effect necessitated an immediate change to health care delivery. Healthcare providers have resorted to telemedicine to maintain social and physical distancing while meeting people's demand for healthcare service and many have realized its value and ability to provide greater access to quality care. Dr. Cynthia Horner, a licensed, BoardCertified Family Physician and medical director at Amwell Medical Group, a physician owned and operated medical practice that provides telehealth care exclusively on Amwell, has been practicing virtually many years - long before the pandemic - and experienced first hand the impact that telehealth can have on patient care as well as the provider experience.

In an interview with Top Doctor Magazine, Dr. Horner told us, "I started practicing virtually as I was looking for a lasting change in my career because I found that many of the administrative burdens in how we deliver care didn't have to be there. Even though there are technological devices around, we failed to leverage these digital tools. We could not get access to people's health information and access their data. There should be a faster, more efficient, and effective way to do this." Speaking further on the need for telemedicine, Dr. Horner said that the ability to meet people in their home and to provide evidence-based, high-quality care when they need it, where they need it, where she does not have to keep them waiting in a waiting room for 30 to 45 minutes with a bunch of other sick people is an invaluable upgrade to healthcare delivery. For example, Dr. Horner alluded to a recent experience with a mom who was reluctant to take her daughter to the local emergency room, where many COVID-19 patients would surround her.

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"We had a video visit, and I was able to help them. I took a look at the child's breathing and counted her respiratory rate. Basically, I was able to help her know that there are some things that we can do." Dr. Horner further explained that she reconnected with the mom the next day and told her that she didn't need to go to the ER. "Call me back if something comes up. That really helped her. And she did call back the next day, and the child was doing a thousand times better." Dr. Horner said. Dr. Horner pinpointed regulatory restrictions as a major obstacle inhibiting the previous adoption of digital health. Healthcare providers are required to apply for medical licensure across each state before COVID-19, however, some of those restrictions were peeled back during the public health emergencies enacted during the pandemic. "I think during COVID, we saw that some States relaxed their restrictions or included reciprocity agreements with other States that allowed cross-state line medical care. Reducing some of the regulatory barriers to a national care provision is one important factor, and financing is another. Above all, there is a need to create guidelines for digital health in a way that will eliminate fear, provide lower-cost, more efficient care, but not at the expense of quality of care." Aside from the overarching benefit of digital health, Dr. Horner believes that telehealth has an opportunity to decrease the cost of care while improving its efficiency. "I think that's why some health plans, in particular, are very interested in the ability of telehealth to close gaps in care which can not only improve care outcomes but also reduce costs." "As we go forward, what the future of healthcare looks like is an interesting question. I think we're going to find a lot more video care, but virtual will never fully replace inperson - there are still some care interactions that will need to be conducted in-person like labs, surgeries, etc. Still, there is so much we can do virtually today and through digital technologies, we have an ability to make healthcare a much more efficient and better experience for all, " Dr. Horner concluded. PAGE | 10

IVX Health: Your Private Suite for Infusion Therapies Awaits By Esther Oladapo

Over the years, IVX Health has grown tremendously in the medical sector. IVX Health is a nationwide supplier of infusion and injection treatment for people with rheumatoid arthritis, Crohn’s disease, multiple sclerosis, and other serious illnesses. It plays a unique role in the medical line by reimagining the treatment experience for these patients. Tate McDaniel is one of the leading executives at IVX Health, and he was gracious enough to grant Top Doctor Magazine an interview. Tate McDaniel is a graduate of the University of Georgia with a Bachelor’s degree in finance. He earned an MBA in finance from Vanderbilt University and worked with various organizations before becoming a senior vice president at IVX Health. Before joining IVX, Tate worked with a consumer healthcare technology company, Change Healthcare, from 20102018. “It was what drew me to IVX Health, having worked in consumer healthcare already. I had the experience.” Change Healthcare was a startup that he joined, and the team at Change played a pivotal role in molding his views on improving the patient experience. “I was very passionate

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about driving a better experience in healthcare,” said Tate. “One of the things that attracted me to IVX was moving from being a vendor of consumer-facing software to being with an organization as an actual provider and providing care for patients.” Our solution leads to lower costs and a dramatically improved patient experience.

IVX Health’s 46 centers are strategically located in patients’ communities and provide various scheduling options, especially on evenings and weekends. Patients can always unwind in their private suites. The centers are fully staffed with clinical professionals led by a nurse practitioner. Patients tend to develop close relationships with their nurses since most of their diseases are long-term, which helps with the recovery process.

How COVID-19 has impacted IVX Health COVID-19 has raised patient’s concerns about the quality and safety of treatment, particularly among patients with autoimmune disorders, who are on the rise. New infusion and injection therapy provider options are changing how and where advanced treatment is given. As the country grappled with COVID-19, both in terms of its imminent effect on public safety and planning for potential national health emergencies, a rare opportunity presented itself.

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Many patients visit and wait within a shared hospital center for, sometimes, hours-long infusion treatments, depending on the seriousness of their illness and recommended medication schedule. Any hospital experience puts patients at risk for a host of illnesses associated with healthcare. “We recognized COVID-19 as an important opportunity. Because our patients are at serious high risk if they contract the virus, early measures were taken to protect both our workforce and our patients.” Strict procedures were put in place and followed to help curtail the risk to our patients. The pandemic caused an increase in patients wanting to come to IVX who didn’t want to be anywhere close to a hospital. “Our centers are equipped with private rooms for each patient that provides social distancing. Our model had social distancing built into it, so at a time when many in healthcare had to close their practices and move to telehealth visits only, we were able to remain open, making sure our chronically ill patients stayed current on therapy and healthy,” Tate told Top Doctor Magazine.

Telemedicine Boosting IVX Health Telemedicine is the practice of connecting a physician and the patient electronically. Doctors can consult with patients or other doctors using HIPAA-compliant video-conferencing software, thanks to modern technologies. Physicians and patients can transfer information from one computer screen to another in real-time. They can also view and record data from medical devices in different locations. PAGE

With telemedicine apps, patients will visit a doctor for care and recovery without waiting for an appointment. Patients may visit a doctor from the convenience of their own homes. “Telemedicine helped us at the right time when we needed it. With new virtual supervision requirements and virtual visits between patients and their specialists – whether from home or utilizing our HIPAA compliant private suites – we were able to continue providing care throughout the pandemic,” says Tate, emphasizing the vital role telemedicine played —and still plays today. Tate’s parting thoughts with the magazine were linked with continuing to expand IVX’s footprint of infusion centers. “I see a continuation of what we are doing,” he said. “We have the intention of growing faster and expanding our footprint across the country.” And with IVX Health’s recent growth, including the improved demand for the services they—and similar specialist centers, offer, immense expansion of the company and the industry feels entirely possible and imminent.

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T H E

W H I C H P A T H W I L L Y O U C H O O S E ? B E N E F I T S A N D D R A W B A C K S O F P R I V A T E A N D P U B L I C P R A C T I C E S WRITTEN BY IONUȚ RAICEA

In the ever-challenging field of medicine, the image of physicians putting their knowledge and resources to the patient’s use often summarizes the way we understand the medical industry mechanics. Under this picturesque description lay thousands of ever-turning wheels in a complex mechanism whose leadership is constantly responsible for the life and death of millions of patients. However, are physicians responsible for the medical industry mechanism, and, if not, who bears the responsibility? Quite surprisingly, recent data disclosed a number of 14,8% physicians who manage their own practice.

Less than a quarter of the nation’s physicians reign their medical destinies. What about the other physicians? Most frequently, they find employment in hospitals under the leadership of healthcare administrators, whose sole goal is to bring a „business” touch to the medical field. As such, actual physicians, who were the backbone of the medical administrative side last century, are currently outnumbered (3200% growth between 1975 and 2010) by healthcare administrators, whose understanding or willingness to understand how physicians save our lives is frequently deficient.

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Putting Physicians and Healthcare Administrators at Loggerheads Such an arrangement, in which physicians work around the clock to save lives while hospital administrators focus on policy, administration, finance, and organizational behavior, is not meant to last. The two sides are at loggerheads, and the resulting enmity is already claiming casualties. In 2014, 54% of physicians reported a loss of enthusiasm, cynicism, and a reduced sense of accomplishment due to this tense relationship. Instead of pursuing ways to improve health and patient care, physicians are gradually abandoning this “culture of engagement.”

Taking One’s Destiny into Their Own Hands With this in mind, we are entitled to ask, “Where does the fault lie?” ”It’s the other party’s fault,” one might respond. Since hospital administrators have a poor understanding of the physician’s life-saving capabilities, and physicians have the same poor understanding of business and management, distrust was sure to spring in a place where it is least needed – where we save lives. As such, physicians are entitled to take their destinies into their own hands and found private practices. However, what does a private practice entail, especially during pandemic times?

The Perks of a Private Practice The decision to start a private practice employs multiple variables, from choosing the perfect site to finding the appropriate moment to begin in the first place. A physician must treat this path with extensive care and for serious reasons – the road is extremely arduous, especially for young physicians, whose business administration knowledge might not suffice. However, the following perks draw physicians who choose the private practice path: #1: Being your own boss – in a private practice universe, being your own boss translate into free choice concerning employment and a healthier working environment. The physician can build their team while choosing staff members whose personalities do not clash with their own (a common issue within public hospitals). PAGE

#2: Private practices are more lucrative – this advantage does not strictly refer to revenue but to how physicians can distribute the revenue at will. Physicians with a knack for business development can aim for opportunities that elude hospital administrators and, therefore, could cause friction between the two parties. As such, physicians can enjoy complete control of their finances, negotiate salaries, etc., while acknowledging the business world’s ever-present risks. Frequently physicians go through an MBA (Masters of Business Administration) to sediment their business skills before embarking on this endeavor. #3: Providing superior patient care – the physicians’ “culture of engagement” requires constant nurturing to improve patient care at a holistic level. For numerous physicians, the drive towards progress through uncharted medical territories prompts them to abandon administrator-run hospitals and pursue their own ways.

What Could Deter Physicians from Private Practices? Chasing one’s dreams without constraints sure sounds appealing for all, not just physicians. However fulfilling it might sound, starting and running a private practice is a consuming endeavor, for which not all are adequately prepared. For starters, physicians must face the following deterrents: #1: Busier schedule – unless they hire a locum tenens physician to cover, physicians will always be on call, day or night. They can expect some jam-packed days ahead, which translates into less time amongst family and friends. #2: Private practices are not one-size-fits-all – while some medical fields enjoy a certain level of autonomy that prompts them towards private practices, others depend upon hospitals, such as Pediatric Infectious Diseases and some surgical specialties. #3: It could be exhausting – together with private practices come great responsibilities; financial decisions, employment, marketing, and management are but a drop of a private practice’s daily requirements, on top of the physician’s actual medical activity! Such a mountainous workload could translate into an intimidating task for some physicians.

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Reconciling Physicians and Hospital Administrators Instead of increasing the divide between physicians and hospital administrators even further, the two parties would immensely benefit from a joint effort towards bridging this divide and understanding each other’s role in the medical community accordingly. The time has come to dispel the “culture of mistrust between those who deliver care and those who administrate it” and build a sturdier, well-founded bridge between the two worlds. While the first step is always the most difficult, the following propositions are sure to bring the two sides closer together: #1: Restarting the culture of physician engagement – assessing and valuing every physician’s insight on patient care is critical towards healthier patients, happier physicians, and a brighter future for the medical field. #2: Learning about each other – such a requisite goes both ways – hospital administrators will benefit from learning about disease diagnosis and treatment while physicians can reap the fruit from healthcare policy, administration, finance, or organizational behavior training. Essentially, hospital administrators will learn how their colleagues save lives while physicians will ascertain how healthcare is paid for. #3: Remembering to put the patient first – what both physicians and hospital administrators must remember is that they share a common vision, a vision that renders their work fruitful and meaningful, and that is saving patients. For that reason, physicians and hospital administrators need to rekindle their trust in one another and act together towards a solid patient-centered culture.

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Conclusion When guilt is shared, the guilty parties have but one course of action – to forgive each other’s mistakes, rekindle their mutual trust, and strive towards a more hopeful future. Such is the hope that physicians and hospital administrators will put aside their differences and abandon the “Who bosses whom in the medical industry?” question in favor of “How can we better serve our patients?”

Bibliography: 1) https://www.sgu.edu/blog/medical/private-practice-doctors-discuss-self-employment/ 2) https://www.kevinmd.com/blog/2015/08/so-doctor-whos-your-boss.html 3) https://www.healthcare-administration-degree.net/top-healthcare-administrator-the-hospital-ceo/ 4) https://www.forbes.com/sites/sachinjain/2016/06/29/physicians-and-health-care-administrators-friendor-foe/?sh=602238751a95 5) https://scholar.harvard.edu/files/poojachandrashekar/files/mar_apr_2019_264-268.pdf

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Bridging the Gap between Medicine and Business for Better Patient Outcomes

In these hectic days, where predicting the unpredictable is our utmost preoccupation, starting a new business venture with no drop of security for the future might sound unsafe, if not wholly deplorable. However, for some physicians, the COVID-19 pandemic represented as much of a seasonable moment to start their practice as any. Our Top Doctor Magazine team had the pleasure of interviewing Dr. Calvin Williams, MD, a Board-Certified Dermatologist with his degree from Harvard Medical School and extensive training at both the University of Chicago and the University of Texas Southwestern. It might sound crazy, but Dr. Williams had started his private practice, the Essential Dermatology Group, in Bedford, TX, this spring, a couple of days before the interview took place! Therefore, as if the Gods of Fate had decided beforehand, we were ecstatic to learn more about running a practice still in its infancy. With his infinite grace, Dr. Williams was quick to give us insights on his decision to start a practice during a global pandemic while sparing no detail. As he told our Top Doctor Magazine interviewer, "I can talk for a living, and it's absolutely fun for me!"

"Playing Out My Own Dream" After working for the past few years as a physician in different joint partnerships, Dr. Williams decided it was time to transition from being an employee to running his practice, believing that he could exact more positive change from the latter's position than the former's. "I wanted to have my own team, to be in charge of things, and be able to do more than what I was able to do as an employee."

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As a practice owner, Dr. Williams envisions more opportunities for helping the community. "There are different things I want to do in the community when it comes to mentoring students and youth, bringing people in, maybe doing internships, even donating to the basketball teams or local chess clubs that may need different supplies or team uniforms."

"Still Sorting Out the Kinks and the Bugs" Two days after the practice inauguration, Dr. Williams is more enthusiastic about his prospects than ever. What remains is the need to "sort out the kinks and the bugs and, learning the scope of the land outside of dermatology." However, the spirits have not always been so high in Dr. Williams' camp. Ever since he began the practice foundation process a year ago, Dr. Williams frequently found himself second-guessing his plan, mainly due to a climate of global insecurity. "I would honestly say that it was a little bit scary at first because I really had to think about it and make sure that it was the best decision to try to open up during this kind of season we're in, and no one can tell you exactly what was going to happen." He admits that his plan could have fallen prey to the time's vicissitudes at any moment, although he always kept his faith in a more auspicious future. "I'm not going to sit here and act like I was in a crystal ball or whatever. But I have faith that the human spirit would pick up and we would get through it, and then people would still need their care."

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Enjoying a steady flow of patients, Dr. Williams is thrilled that his infant practice is gradually shaping up. However, at the Essential Dermatology Group, the mission transcends the borders of patient care, aiming at creating a solid local community of patients and practitioners. "It will come down to going to the community and making those relationships with the community members themselves and the community physicians around here."

Handling the Business Side of Dermatology Once they fulfill their residency programs and embark upon starting their practice, physicians are immediately hit by a harsh reality – the lack of business education and knowledge. We've interviewed dozens of physicians who advocate for adding business management classes to the medical school curriculum for a simple reason – providing patient care and running a business are two completely different stories. And Dr. Williams is no stranger to this issue. Thankfully, he was blessed with helpful resources and mentorship from some of the most qualified actors in the business. "I've had some great resources, a lot of mentors. And honestly, I learned a lot from my previous office manager who understands business dermatology extremely well, better than a lot of dermatologists now."

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"The Best Time to Start a Practice is Yesterday!" To all the dermatologists or physicians who are ready to take their first steps towards starting a practice but cannot figure out the right time, Dr. Williams has the easiest, most straightforward answer: "The best time to start a practice is yesterday!" If you're a dermatologist in a similar situation, always remember that help is always at hand, in the shape of other fellow dermatologists. "I don't think there's any, any other way to say it but to do it. Use your valuable resources, and that's the other dermatologists that are near you. There is a ton of resources that we use and, I would say, feel free to make the best of them." As a parting reminder, Dr. Calvin Williams reminds us that two sets of hands are stronger than one, which is why it takes a dedicated team to achieve something resilient in life. "I still think it takes a team to create something big and hopefully. I'm no different from that. Yeah, I would have to give a lot of credit to my team, my support staff, my family at home, and my relentless drive to take care of people."

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C O U L D A O N C E - A - W E E K I N S U L I N I N J E C T I O N A L T E R T H E T R E A T M E N T O F D I A B E T E S ?

In a new turn of events, research trials showed that weekly insulin can work as a treatment to treat and manage diabetes. Some medical professionals concur that it is the right move in the right direction. The research involved hundreds of patients with type 2 diabetes. Research analysts managed to evaluate the efficacy and safety concerns of long-form insulin called “insulin Icodec.” The extensive research also involved participants from various countries. The second trial of the research proved that people with diabetes could move from daily insulin injections to weekly Icodec-based injections. The research shows the transition from daily to weekly to be effective and safe for people with diabetes.

Once-a-Week Insulin Injection: What Will be the “Next” Move? The research still requires more affirmation and reaffirmation of findings. Still, it is excellent news for Individuals who have no choice but to inject insulin on a day-to-day basis. Besides, more than 10% of the U.S. population suffers from diabetes. It means over 7 million Americans have to use standard insulin to manage blood sugar levels.

However, the tide is changing, and the new research brings a new ray of light for people with diabetes across the U.S. You have to understand that essentially, an insulin compound is a hormone produced by the pancreas that moves sugar from the bloodstream into the cells. However, a diabetic’s body can no longer produce the required insulin or no insulin at all.

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Insulin Treatment and Insulin Administration Sure, no one can deny the fact that insulin is an excellent treatment, but the added burden to administer insulin is another story. And that’s why the timing of this new research couldn’t be more perfect. It is no longer a fantasy for people with diabetes to take their insulin injections once a week. In fact, more findings will help realize this convenience for people with diabetes and bring down traditional administration barriers for people.

You may not be aware of it, but medical professionals and scientific researchers worldwide have been on the lookout to find a more efficient and effective way to inject insulin. Besides, people with diabetes don’t deserve the exhaustion (and embarrassment) of injecting insulin every single day.

Research Phase 2 and How Insulin “Icodec” Works It is crucial to remember that the new extensive research involves a combination of sequential studies. Phase 2 of these studies showed promising results of weekly insulin injections for type 2 diabetes. Scientifically, insulin Icodec reversibly binds the insulin to the binding albumin. As a result, the binding agent, albumin, slows down the release of an insulin analog and extends the life of the insulin for one week.

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Limitations of Contemporary Insulin Therapies Contrary to misguided perceptions, there is no mindless practice to inject insulin without any cause of concern. Before a person with diabetes injects insulin, they have to figure out the proper dose of medication that would support “their” levels of blood sugar. This variation can differ from one person to another and depends on stress level, exercise, and total carbohydrates in a diet.

Insulin Injections are More Complicated than You Think It would be an understatement to call insulin injections complicated. When it comes to injecting insulin daily, people with diabetes often make injection site or dosage errors. Over time, these types of mistakes create more complications like diabetic ketoacidosis and low or high blood sugar for diabetic patients.

Icodec injections: New Standard for Insulin Therapy? Over the years, there have been several scientific advancements in current insulin therapy. But there are still new opportunities for researchers to explore to make insulin administration more effective and safe for people with diabetes across the globe. And icodec injections have the power to alleviate the suffering and burden of millions of diabetic patients.

More Focus on Convenience When it comes to managing and controlling type 2 diabetes, individuals want more convenience than ever. And the new research findings are optimistic and offer a more convenient approach to people with diabetes to take insulin injections. Some people with diabetes require more than one injection per day. But the results of this research come across as game-changing that would favor people with diabetes. Dr. Ildiko Lingvay, the lead author of the published research, affirms that weekly insulin is far more convenient and practical for diabetic patients.

Final Thoughts If further examination of the findings proves correct, this scientific study will become a savior to patients who take seven insulin injections per day. In hindsight, there are some strings attached to the new research, but it doesn’t change the fact that the weekly insulin injection option is much better for people with diabetes to manage their blood sugar levels and live healthy and normal lives. PAGE

Pain Management - A Comprehensive Care Guide AN INTERVIEW WITH JAMES BOESIGER, PA-C By Yuko Tabasa James Boesiger, DMSc, PA-C, has been at the forefront of pain medicine's evolution for over three decades. However, he still can't forget the profound effect of his childhood experience when he came home to his mother wearing sunglasses in bed and vomiting from chronic pain brought on by severe migraines. And so, it is no coincidence that along with his specialty in chronic pain medicine, Boesiger has a sub-specialty in headache medicine. In his interview with Top Doctor Magazine, Boesiger describes some of the recent advances in chronic pain treatment, the unique challenges of practicing pain management during the pandemic, and where he sees the field moving towards the future. From Emergency Medicine to Pain Medicine Boesiger started his career practicing emergency medicine in 1986, but in the fall of 2005, a life-changing continuingeducation conference sponsored by the American Society of Pain Educators (ASPE) inspired him to change fields, follow his passion for pain management, and become one of Nevada’s first Certified Pain Educators (CPE) by the American Society of Pain Educators. PAGE

The field of pain management has grown considerably since the first 50 people at that Las Vegas conference. Now, Boesiger has seen that small group grow into PAINWeek, a massive annual pain management conference taking up three floors at the Cosmopolitan conference center in Las Vegas with thousands of attendees. Boesiger was also a Credentialed Pain Practitioner from the Academy of Integrative Pain Management. In 2019 he earned his Doctorate of Medical Science (DMSc), from the University of Lynchburg, the first of its kind and an innovative program designed specifically for PAs.

Advances in Headache Medicine This path into chronic pain management would lead Boesiger to one of his passions, headache medicine. The field has experienced evolution since the 1960s when Boesiger's mother suffered from migraines -"we are light-years ahead of where we were." He first learned of the subspecialty through the Diamond Headache Foundation, promoting headache education in the medical field. Boesiger has a Certificate of Added Qualification (CAQ) through the American Headache Society. He tells Top Doctor Magazine that one of the first breakthroughs during his career was moving from the opioid treatment of migraines to using a class of drugs called “triptans”, the first one, sumatriptan approved for use in 1991 as a subcutaneous injection. More recently, Calcitonin Gene-Related Peptides (CGRP) has been lauded as a profound paradigm shift in the treatment of migraines, "Right now, we are in the middle of another revolution in migraine medicine. It's definitely an exciting time for a headache medicine."

Multimodal Pain Management Today, Boesiger practices at the Nevada Comprehensive Pain Center in Las Vegas. The company has six clinics spread across the Las Vegas valley and incorporates a multi-disciplinary approach to chronic pain. "There are a variety of pain conditions we treat, but the majority of patients at the pain center are treated for cervical, thoracic or lumbar spine pain." Osteoarthritis of the knees and other joints, post-surgical pains, diabetic peripheral neuropathy are seen frequently as other neuropathic conditions including fibromyalgia. The clinic uses various interventional procedures such as epidural injections and nerve blocks for pain relief. On the more technical PAGE

end neuromodulation is implanted for spinal stimulation for severe neuropathies and radiculopathies. Nevada Comprehensive Pain Center also firmly pushes for conservative therapy, weight loss, stop smoking, physical therapy, yoga, and chiropractic care. "With pain patients, there's no such thing as one size fits all," Boesiger says.

A Challenging Regulatory Environment Strict government regulations of medications are necessary but complicated for pain management, especially for the prescription of opioids. For Boesiger, Nevada's AB 474 statute brought on several confusing mandates for medical professionals, "It really changed the face of pain management in this state, and I'm sure other states that adopted similar restrictive mandates." Boesiger recalls that these laws' language was so confusing that several primary care physicians, dentists, and pain management specialists just stopped prescribing pain medication altogether. Likewise, patients had to jump through several expensive hoops just to receive the same pain medication they have been reliant on for years.

COVID-19 and Pain Management In April 2020, Boesiger's practice went full telemedicine, which is not an easy choice for a field that traditionally relied on face-to-face interaction. Fortunately, for Boesiger, his clinic had already transitioned to some essential systems to be fully electronic, such as the electronic prescription software system for medications, "I can only imagine the complications we would have endured just to deliver paper prescriptions. It would have been quite complex." At one point in late 2020, so much of the staff was either quarantined from being sick or for being in direct contact with a family member that was sick, that it was just Boesiger and his medical assistant seeing the patients for a few days. We were “Last Man (and Woman) Standing!” Although so much of the practice during the pandemic was improvisationally problem solving on a daily basis, the Nevada Comprehensive Pain Center's six clinic locations allowed for some staffing flexibility during the peak of staff infection or quarantine. Boesiger gives credit to the management team who was able to shuffle staff around from different clinics just to continue patient care. What's in the Future for Pain Management? Boesiger believes in telemedicine expansion, but it remains a complicated issue for pain management due to several drawbacks. If you have a good audio and visual interface, you can assess breathing and respiratory rates. Moreover, you can also assess specific muscles and teach patients particular body movements and therapeutic maneuvers online. Protocol for documentation of the visit has serious potential and could be an invaluable data set down the road for a patient's treatment. "Some ailments, like headaches and migraines, are all in the patient's history, so much of that can easily be done with a telemedicine visit." PAGE

Traditional Ways Beyond the Limits of Telemedicine With over three decades of experience, Boesiger is wary of his field drifting too far into the telemedicine world. One of the first concerns is a practical one, insurance reimbursement. Some payers will pay 40% less for a telemedicine visit versus an in-person one, which is untenable for most businesses showing thinning margins due to recent complicated regulatory laws and already diminished payouts from insurance companies. Deeper concerns for Boesiger are losing the traditional hands-on approach and relationship-defining moments with patients, "The hand holding, the touch, the compassion, the empathy, the 'paton-the-back' if you will." COVID-19 reminds us that we take simple treatments like listening to the lungs and palpitating the abdomen as a given during a hospital visit. Still, these crucial interactions are lost during a telemedicine assessment. Patients are overall reporting to Boesiger that most prefer in-person visits, aside from a few specific cases.

Stigmatization of People in Chronic Pain Boesiger's doctoral thesis focused on the stigma that pain patients experience sometimes on a daily basis. He looked at the impact of glances from strangers, the rolling of eyes from a pharmacist or a co-worker, the challenge of even picking up medication. It can sometimes be attributed to severe depression or adverse developments in mental health observed during the pandemic. For Boesiger, the key to pain management is the earned trust and relationship during the healing process, "The subtle moments of looking into a patient's eyes as they tell their story, means so much to them, perhaps more so than getting a prescription or a shot."

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Cancer: The "Equal Opportunity" Destroyer with Dr. Julien Fahed By Yuko Tabasa

Dr. Julien Fahed's decision to help people through medicine seems to have been a family trait, as all four of his siblings also went to medical school. He attended medical school at the St. Joseph University in Lebanon, then completed his residency in Internal Medicine at the University of Massachusetts Medical School. Not long after that, he completed his fellowship in Gastroenterology in the Midwest. Dr. Fahed has several publishing credits and is a principal author in several medical books, including Irwin and Rippe's Intensive Care Medicine (8th Edition, 2018), where he discusses the management of diarrhea in the Intensive Care Unit.

What's in the Future for Pain Management? It was the process of healing people with technology and innovation that attracted Dr. Fahed to specialize in gastroenterology. "Things that were impossible in the past are now possible, in minimally invasive ways. And the technology keeps getting better and better." Gastroenterology changed radically in the '70s and '80s with the breakthrough of the endoscopy camera. Thanks to the new technology, doctors can quickly identify what the camera sees, take samples, perform biopsies, and even remove objects without surgery.

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Early Screening for Colon Cancer Dr. Fahed says most people are not aware that almost one in 20 people are at risk of developing colorectal cancer, where both men and women are equally at risk. His work is now focused on early cancer detection, as well as preventative measures to make sure that colon cancer doesn't form. He presented his research at Digestive Disease Week (DDW) and the American College of Gastroenterology (ACG). In 2019, Dr. Fahed was invited to present his groundbreaking research on colon cancer screening in 20,000 patients in San Diego at Digestive Disease Week 2019. Unfortunately, patients' screening for colon cancer is often delayed for virtually no sensible reason, according to Dr. Fahed. He describes a patient coming in with stomach pain, and after performing an endoscopic biopsy, found out that it was indeed colon cancer.

After reviewing the patient's file, it was shown that the patient had been directed to have a colon cancer screening every year for the past three years but still chose not to visit a GI. She only saw the gastroenterologist when cancer had already formed. Luckily, her emergency surgery was successful, but the situation is widespread and usually not as fortunate. Still, Dr. Fahed is happy to take these victories when he can, "Telling somebody very bad news one day and two weeks later telling them they are cancer-free. It's an amazing feeling."

Making Choices for Your Health Dr. Fahed has several thoughts on managing the COVID-19 pandemic. To people considering skipping the vaccines, "You have a choice, the virus or the vaccine." He mentions that the long-term damage from COVID-19 to a patient's general health issues is not often widely reported. Another issue from the current COVID-19 pandemic is how it overwhelmed the nation's healthcare system during the initial and second waves. Dr. Fahed tells Top Doctor Magazine that hospital beds in his area were in short supply, and hospitals themselves were struggling to equip workers with PPE properly. PAGE

As a gastroenterologist, he noticed a highly alarming trend of patients delaying care out of fear of the virus. "You've got to make hard choices sometimes," he said, referring to the dilemma that patients had to make: should they avoid hospitals out of fear of COVID-19 or go have regular health check-ups such as early screening for cancer? He noticed he was diagnosing a high rate of colon cancer in late 2020, which he attributes partly to the drop of in-patient screening visits out of concern about medical safety. Ultimately, he decided that he and his staff must adapt to the pandemic, and the greater risk was not identifying cancer at preventable or manageable stages in his patients.

From Guitar Picks to Scalpels Dr. Fahed tells Top Doctor Magazine he remembers graduating from medical school and the feeling of picking up the guitar after years of not playing. At that moment, he was overcome with a mix of bittersweet emotions, knowing that he sacrificed his love of music to give his full attention to his other dream of helping people through medicine. These days, with an accomplished career and thousands of patients saved, he takes some time to play guitar and piano when work allows. On his Twitter account, you can see thrilling endoscopic documentation of Dr. Fahed treating patients with Blakemore tubes, gastric outlet obstruction, or scope clip control of an actively bleeding duodenal ulcer. You can also occasionally see fantastic musical performances on piano or guitar - like his moving cover of Careless Whisper performed in scrubs after a difficult day of saving lives during the early days of the pandemic in March 2020.

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A Word from the Editors Top Doctor Magazine is a magazine from doctors for doctors and patients. We cover everything from cuttingedge medical techniques and procedures to enterprising doctors, dentists, surgeons, naturopaths, chiropaths, orthodontists, and more who are thought leaders within their own medical practice and changing the way we all experience medicine for the better. We wish to be your one-stop digest for inspiration by other professionals in your field who are making waves and setting trends. If you, too, are a trendsetter, reach out to us so we can interview you for your own spotlight within an upcoming Top Doctor Magazine issue!

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Brianna Connors

Justin Miller

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