The Triangle Physician May 2010 by TTPLLC

M AY 2 0 1 0

Chapel Hill Tubal Reversal Center Database and Berger Babies Are Proof Tubes Can Be Untied

Also in this Issue

Skin Cancerâ&#x20AC;&#x2122;s Increasing Burden on Health Care Costs Skin Cancer Basics

Beyond Imagination. Working in partnership with physicians for over 50 years to bring the benefits of biomedical technology to patients around the world.

Expertise when it matters most Pediatric General Surgery at Duke Children’s Duke’s Division of Pediatric General Surgery serves children of all ages, providing expert surgical assistance for the diagnosis and treatment of a variety of disorders. We perform approximately 1,300 general and thoracic surgical procedures each year.

Henry e. rice, mD

Jeffrey C. Hoehner, mD, phD

Abigail e. martin, mD

For Appointments

For Appointments officE 919-681-5077 (Pediatric surgery)

For Appointments

officE 919-681-5077

(Pediatric surgery) 919-681-6133 (Transplant surgery)

(Pediatric surgery) 919-668-4000 (Duke children’s Specialty Services)

officE 919-681-5077

(Pediatric surgery)

Chief Henry E. Rice, MD, is pleased to announce the division’s expanded appointment availability and the opening of additional pediatric ICU beds—and is proud to count these skilled pediatric surgeons among our faculty members:

Dr. Hoehner performs general pediatric surgery and has special expertise in performing neonatal surgery and treating infants and children with tumors and pectus defects.

dukehealth.org 888 -ASK- DUKE (888-275-3853) for patients 800 - MED - DUKE (888-633-3853) for providers 7394_Peds_Surgery_TP_02.indd 1

In addition to performing general pediatric surgery and transplant surgery, Dr. Martin has special expertise in intestinal failure and transplantation in pediatric patients.

Heather n. paddock, mD

Dr. Paddock provides general surgical care for children and neonates— and has special expertise in minimally invasive and thoracic surgery, congenital diaphragmatic hernias, chest-wall abnormalities, childhood solid tumors, pediatric trauma, and critical care.

Division of pediatric General surgery 3/24/10 4:45:14 PM

Contents

COVER STORY

Chapel Hill Tubal Reversal Center Database and Berger Babies Are Proof Tubes Can Be Untied

FEATURES

SKIN CANCER

It’s Increasing the Burden on Health Care Costs

M AY

2010

VOLUME

ISSUE

DEPARTMENTS 11 CARDIOLOGY Choosing the Optimal Stress Test

SKIN CANCER

BASICS

for Your Patient

15 PHLEBOLOGY Ankle Spider Veins? The Culprit

Cost and efficacy of skin cancer treatment

More than one million cases of non-mela-

will become an increasingly important

noma skin cancer are diagnosed yearly in

issue over time

the United States. That’s more than all other

as our population

types of cancer combined. Most of these

continues to expand and

non-melanoma skin cancers are sun-related.

Could Be Underlying Veinous Disease

18 WOMEN’S HEALTH Women and Urinary Incontinence.

Treatment Begins with Effective Diagnosis

19 SKIN CANCER

these treatments take up a

larger portion of the health

20 NEWS

care dollar.

PET/CT Highly Useful in Melanoma Staging and Restaging Welcome to the Area Events & Opportunities New and Relocated Practices New or Updated Web Sites

22 PRACTICE MANAGEMENT Is It Time for a Practice Assessment? 24 PEDIATRICS $1 Million Gift to

WakeMed Foundation

25 INSURANCE

COVER PHOTO: Gary S. Berger, M.D., Chapel Hill Tubal Reversal Center

The Triangle Physician | MAY 2010

PHOTO BY JIM SHAW

A Million-Dollar Replacement. New Endorsements Can Protect Your Medical Assets

FEBRUARY 2010 | The Triangle Physician

From the Editor

t’s not often that we can undo something we wish we had not done. Just like it’s impossible to take back something we wish we hadn’t said.

The quandary is amplified for women wishing, more than anything, to reverse tubal ligation— considered a permanent form of contraception chosen at a point in life when childbearing is no longer desired. Sadly, the regret that too often follows is well documented. It’s a product of life’s twists and turns, commonly the result of remarriage or the tragic loss of a child. The greatest beacon of hope for these women is Chapel Hill Tubal Reversal Center, where Dr. Gary S. Berger has perfected tubal ligation reversal. Outcomes after this delicate microsurgery are stunning. Two out of three patients conceive. That’s a higher probability than can be expected from in vitro fertilization. What’s more, the center’s tubal reversal procedure is much less involved and actually affordable. As you continue reading this issue of Triangle Physician, Dr. Robert E. Clark and Dr. Tamara S. Housman give a comprehensive review of skin cancer, the importance of prevention and the second chances possible through treatment. Dr. Andrea S. Lukes clarifies how proper diagnosis of urinary incontinence can lead to successful treatment without surgery or medication. An announcement about a $1 million gift to Just For Kids Kampaign reminds readers of the value of WakeMed Children’s Hospital to the Triangle region and the need for community funding as it expands its neonatal intensive care unit. Also in this issue, insurance agent Mike Riddick gives an update on new endorsements that may eliminate wistful desires for a second chance after misfortune strikes. Dr. Lindy McHutchinson explains how spider veins and other symptoms are often the result of chronic venous insufficiency, a medical problem typically covered by Medicare. Finally, a note about the marketing power of advertising on the pages of Triangle Physician, the source for the latest on medical advances that provide second chances in so many ways. Our deepest respect and gratitude for all you do!

Editor Mark Westphal

mark@trianglephysician.com

Contributing Editors Heidi Ketler heidi@trianglephysician.com Mateen Akhtar, MD; Robert E. Clark, MD, PhD; Tamara S. Housman, MD; Andrea S. Lukes, MD, MHSc, FACOG; Lindy McHutchinson, MD; William G. Way, MD; John Reidelbach; Mike Riddick Photography Jim Shaw Photography jimshawphoto@earthlink.net Creative Director Dan Early Van Early

dan@trianglephysician.com van@trianglephysician.com

Advertising Sales Carolyn Walters carolyn@trianglephysician.com News and Columns Please send to info@trianglephysician.com The Triangle Physician is published by Early Design Group 982 Trinity Road | Raleigh, NC 27607-4940 Subscription rates: $48.00 per year $6.95 per issue Advertising rates on request Bulk rate postage paid Tucson, AZ 85726 Every precaution is taken to insure the accuracy of the articles published, The Triangle Physician can not be held responsible for the opinions expressed or facts supplied by its authors. Opinion expressed or facts supplied by its authors are not the responsibility of The Triangle Physician. However, The Triangle Physician makes no warrant to the accuracy or reliability of this information. All advertiser and manufacturer supplied photography will receive no compensation for the use of submitted photography. Any copyrights are waived by the advertiser.

Mark Westphal Editor

The Triangle Physician | MAY 2010

No part of this publication can be reproduced or transmitted in any form or by any means without the written permission from The Triangle Physician.

From the Cover

Database and

Berger Babies Tubes Can Be Untied Are Proof

“What I’ve taken is a very complex, high-tech, expensive procedure and simplified it to make it accessible. The beauty of the surgery as I developed it, is it’s even more effective doing it this way, requiring a quarter of the time and expense, and the patients do better. It’s also safer when performed in the outpatient setting and with minimal operating time.” — Gary S. Berger, M.D.

The Triangle Physician | MAY 2010

More than 8,000 women the world over have been led by a hopeful heart along an often circuitous route to Chapel Hill Tubal Reversal Center. It is the only medical center of its kind, specializing exclusively in the delicate microsurgery to reverse tubal ligation—a form of contraception meant to be permanent. The cost-effective approach, perfected over the past 30 years by Gary S. Berger, M.D., has restored fertility in 2 out of 3 patients.

PHOTO BY JIM SHAW

hapel Hill Tubal Reversal Center maintains the world’s largest patient database on tubal reversals, with outcomes of 5,000 patients since 2000. The database shows that on average 2 out of 3 women have become pregnant after tubal reversal procedures at Chapel Hill Tubal Reversal Center. It also finds that pregnancy rates vary with age and tubal ligation method.

Sandy and Brian waiting to meet with Dr. Berger.

Photos of the positive outcomes speak volumes. These tiny new lives are called “Berger Babies.” Twelve months ago, the first “Monteith Miracle” was born following a tubal reversal performed by Charles W. Monteith, M.D. Having joined Dr. Berger as a tubal reversal specialist two years ago, Dr. Monteith clearly has a growing legion of appreciative parents as well.

PHOTO BY JIM SHAW

A patient’s initial contact with the Chapel Hill, N.C., facility often is by way of its informationpacked Web site, www.tubal-reversal.net. There, one’s belief in second chances is elevated by the lively message board dialogue among patients sharing their experiences after tubal reversal. Pages of testimonials sing praises of the medical team’s professionalism and compassion, and the efficiency and ease of surgery.

Tammy and Gary waiting to meet with Dr. Monteith.

“ Overall, the experience with Chapel Hill (Tubal Reversal Center) was the most amazing thing I’ve done besides giving birth to my own children. They make you feel like there’s another chance. They give you hope.They give you your dream,” says Tammy Gove, 34, of Randolf,

Wisconsin, whose tubal reversal was performed by Dr. Monteith March 24. That same day, Dr. Berger performed a tubal reversal on Sandy Hirschman, 31, of New York City. Both Hirschman and Gove had their tubes tied after having children in previous marriages. Now remarried to husbands who have never had their own child, the women hope to conceive again. Chapel Hill Tubal Reversal Center is a freestanding facility, with a licensed surgicenter that has been accredited by the Joint Commission on Accreditation of Health Care Organizations. The center’s services are so unique that it has been featured by The Learning Channel in “The Operation” series. MAY 2010 | The Triangle Physician

Reality check Tubal ligation is the second most common birth-control method, chosen by more than 12 million American women. Each year 650,000 female sterilizations are performed in the United States. Yet, studies have shown a significant percentage of women have a change of heart later on. This most commonly happens after remarriage or after the loss of a child. For these women, there are two options: tubal reversal surgery and in vitro fertilization.

patients to notify them as soon as they have a positive pregnancy test. Their early pregnancy testing protocol can prevent the risk of a ruptured ectopic pregnancy. There is an approximate 5 percent likelihood that one or both of a patient’s fallopian tubes may become blocked again after the reversal. When one healthy tube is open, pregnancy can occur. Should both become blocked, repeat surgery is offered at a reduced fee in appropriate cases, such as when there is sufficient fallopian tube length and health. Despite the benefits of tubal reversal, interest within the medical community has turned to assisted-reproductive technology. “What I hear from many patients is that they have been advised to go straight to IVF, which is more expensive and complicated, besides being less effective than tubal reversal for most patients,” says Dr. Berger.

• Tubal ligation cannot be reversed; • The only treatment option is in vitro fertilization (IVF); or, • Tubal sterilization reversal is a high cost in-hospital operation.

For the Hirschmans, IVF was not an option because of the risk of multiple births. In their research of NYC ob/gyns, they found tubal reversal surgery to be expensive, between $18,000 and $20,000, and

PHOTOS BY JIM SHAW

In last month’s Triangle Physician article “Regret Turns to Hope with Tubal Ligation Reversal,” Dr. Berger also reports on the reasons why only a small percentage of women who desire a tubal reversal actually undergo the procedure. One is lack of insurance coverage. Another is lack of accurate information about it, such as women being told (often by their physician) that:

World map shows where international patients come from to Chapel Hill Tubal Reversal Center.

Chapel Hill Tubal Reversal Center sets the record straight. Tubal ligation is reversible, although it is a delicate microsurgical procedure. When performed at this dedicated outpatient facility, tubal reversal is more cost-effective—even with travel expenses included—than inpatient tubal reversal or IVF. The Chapel Hill center’s all-inclusive fee is $5,900, with an average 70 percent pregnancy rate. In contrast, the average cost for IVF exceeds $8,000 per menstrual cycle and results in an approximate 30 percent pregnancy rate. The primary benefit of tubal reversal surgery is its high cumulative pregnancy rate because conception is possible in every subsequent ovulation cycle, says Dr. Berger. Tubal ligation reversal also avoids the increased risk of multiple pregnancies associated with IVF (35 percent) and other risks of gonadotropin stimulation of the ovaries. Tubal reversal has a long-term risk of ectopic pregnancy (10 percent to 15 percent), depending on the type of tubal sterilization method. Because of this increased risk—compared with the baseline rate of 3 percent in the general population—Drs. Berger and Monteith instruct 8

The Triangle Physician | MAY 2010

United States map showing where US patients come from to Chapel Hill Tubal Reversal Center.

involved. It also required scheduling four months in advance, multiple office visits, a hospital stay and longer recovery. Eventually, the Hirschmans were referred to three physicians—one in Chicago and one in Florida, in addition to Chapel Hill Tubal Reversal Center. After an Internet search and phone calls, the couple chose Dr. Berger.

“Most of all, why we were willing to travel the distance, we wanted to find a surgeon who does tubal reversal for a living, rather than once in awhile, so the procedure is basically easy,” says Ms. Hirschman.

Over the years, through constant examination of every step in the procedure, Dr. Berger has reduced operating time, tissue trauma, blood loss (5-10 ml), need for post-operative analgesics and healing time before resuming normal activities (four to six days vs. the usual four to six weeks). Minimizing operating and anesthesia time benefits the patient by reducing cost as well as post-operative complications. Working with the same operating and anesthesia team on a daily basis facilitates efficiency, safety, and patient comfort during and after surgery. PHOTO BY JIM SHAW

“Compared with any other approach, such as using a surgical robot, laparoscopic instruments and other microsurgical techniques, our data prove the point that this is the most effective method,” Dr. Berger says. Tammy during her preoperative nursing consultation with Nurse Administrator, Julia Smith, RN.

According to Dr. Berger, the success of fallopian tube reversal is directly linked to surgical experience, and with the increased interest in IVF, the experience that he and Dr. Monteith have is unmatched. Reversing tubal ligation “What I’ve taken is a very complex, high-tech, expensive procedure and simplified it to make it accessible,” says Dr. Berger. “The beauty of the surgery as I developed it, is it’s even more effective doing it this way, requiring a quarter of the time and expense, and the patients do better. It’s also safer when performed in the outpatient setting and with minimal operating time.”

Evidence-based medicine Chapel Hill Tubal Reversal Center also is remarkable because of its database on outcomes that help guide patient decision making and expectations. It is the world’s largest by virtue of the number of procedures performed at the center and the extensive pregnancy follow up. Today, it contains outcomes of more than 5,000 patients since 2000.

The newly created tubal openings are then drawn next to each other by placing a retention suture in the connective tissue that lies beneath the fallopian tubes. The retention suture avoids the likelihood of the tubal segments subsequently pulling apart. Microsurgical sutures are used to precisely align the muscularis and serosa, while avoiding the mucosa of the fallopian tube. The tubal stent is then gently withdrawn from the fimbrial end of the fallopian tube.

PHOTO BY JIM SHAW

Tubal ligation reversal involves microsurgical techniques to open and reconnect the fallopian tube segments that remain after a tubal ligation. The blocked ends of the segments are opened and a narrow flexible stent is gently threaded through their inner cavities, or lumens, into the uterine cavity. This ensures that the fallopian tube is open from the uterine cavity to its fimbrial end. Dr. Berger reviews Sandy’s record with O.R. Supervisor, Chloe Osbourne, RN.

“By having this specialized facility, the world’s largest patient base, a system to maintain follow up, and accumulating and analyzing the data, we really have established for this kind of procedure what patients can expect,” says Dr. Berger. “It’s a significant accomplishment. No one ever had this type of data before based on a patient population numbering in the thousands.”

PHOTO BY JIM SHAW

The center’s database shows that on average 2 out of 3 women have become pregnant after their reversal procedures at Chapel Hill Tubal Reversal Center. It also finds that pregnancy rates vary with age and tubal ligation method. Women under age 30 with tubal clip procedures had a 90 percent pregnancy rate, which fell to 31 percent for those 40 and older who had tubal coagulations.

Tammy and Gary during their preoperative consultation with Dr. Monteith.

“They give you hope and also give you reality. The reality is there is always the chance that it won’t work out,” says Ms. Gove. “My biggest encouragement was the length of my fallopian tubes.” Dr. Monteith gave her a 70 percent chance of pregnancy, based on her age, medical history and sterilization method. MAY 2010 | The Triangle Physician

PHOTO BY JIM SHAW

Dr. Monteith graduated with honors from Xavier University of Louisiana and the University of California at San Francisco School of Medicine. While at UCSF, he was awarded a prestigious Howard Hughes fellowship to research molecular genetics.

Sandy has her postoperative hotel visit with Jennifer Okun, RN.

Practice makes perfect Dr. Berger points to the lack of frequency with which physicians are trained to perform reproductive surgery and repair fallopian tubes, a situation documented in 2004 by the Journal of Fertility and Sterility. “Since the advent of assisted-reproductive technology, surgical training has markedly declined and there remain few fellowship programs in the United States with meaningful numbers of surgical cases,” he explains.

As an obstetrics and gynecology resident at the University of North Carolina at Chapel Hill, he was inducted into the Alpha Omega Alpha honor society, and was the recipient of many awards for resident and medical student teaching. During a seven-year tenure as a clinical assistant professorship with the UNC Department of Obstetrics and Gynecology, he worked in the Department of Obstetrics and Gynecology at Wake Medical Hospital in Raleigh, N.C., and practiced high-risk obstetrics and advanced surgical gynecology. Tammy talking with Dr. Monteith in the 2nd stage PACU.

After microsurgery training at the Cleveland Clinic and a six-month training fellowship with Dr. Berger, Dr. Monteith joined the staff at Chapel Hill Tubal Reversal in 2008. Distinguished in medicine Dr. Berger decided to specialize in tubal microsurgery in 1970 during his first year of OB/GYN residency at Johns Hopkins Hospital. He received his education at Harvard University, the University of Rochester School of Medicine, Duke University Hospital, The Johns Hopkins Hospital, Centers for Disease Control and the University of North Carolina at Chapel Hill. In 1976, Dr. Berger went to England and Belgium to learn about tubal microsurgery, since there were no such programs in the United States at that time. He became a charter member of the Society of Reproductive Surgeons, and in 1979 he entered private practice wanting to create a center ideally suited for outpatient reproductive surgery. Dr. Berger has contributed to medical literature with more than 150 articles and numerous books on reproductive health, including one written for the public, called The Couple’s Guide to Fertility. He first reported on his tubal reversal surgical technique, effectiveness and safety in 1992 in the Journal of Reproductive Medicine. 10

The Triangle Physician | MAY 2010

PHOTOS BY JIM SHAW

As a consequence, Dr. Berger embraced the opportunity to pass on his techniques and experience to Dr. Monteith, who willingly left a successful ob/gyn practice to become a tubal reversal specialist. “Not many physicians have the opportunity to do 50 to 100 tubal reversals in a lifetime. We’ve already done over 8,000 cases. From a learning point of view, that is what you need to become an expert,” says Dr. Berger.

Sandy, Brian, and Dr. Berger discussing Sandy’s procedure and postoperative instructions in the 2nd stage PACU.

Both Drs. Berger and Monteith are board certified by the American Board of Obstetrics and Gynecology. Dr. Berger’s additional certifications in preventive medicine and epidemiology gave him the background to develop the center’s unique patient database. Getting started According to Nurse Administrator Julia Smith, RN, ALNC, patients may be referred to Chapel Hill Tubal Reversal Center by their doctor, but most are self-referred when they learn about Dr. Berger through the Internet or The Learning Channel broadcasts. “The starting point is having Dr. Berger review the operative report of their tubal ligation to see if tubal reversal surgery will be effective,” she says. Dr. Berger’s interpretation of the operative report is provided within 24 hours of receiving it. Staff members are available seven days a week, 365 days of the year to answer inquiries online, by telephone or e-mail, and to follow up with any patients’ questions, as well as their pregnancy reports that arrive daily.

Cardiology

Choosing

The Optimal Stress Test by

Dr. Mateen Akhtar

Dr. Akhtar is a clinical cardiologist with Wake Heart & Vascular Associates. He has offices in Clayton, Smithfield, and Goldsboro and welcomes new patient referrals. Phone: (919) 989-7909. Email: mateenakhtarmd@gmail.com

Cardiac stress testing is an important method of risk stratification for patients with clinical risk factors and symptoms suggestive of underlying coronary artery disease. In this month’s issue, I would like to address a question I am commonly asked by practitioners: “What kind

Several factors should be considered in order to maximize the diagnostic yield from a stress test, while being practical, cost-effective and evidence-based.

for Your Patient

Which Imaging Modality Should I Choose? Coupling SPECT imaging with stress significantly increases the sensitivity and specificity of the test (see table). The advantages of

of stress test should I order for my patient?”

Sensitivity and Specificity for Detection of CAD

SPECT imaging include high sensitivity and

test, while being practical, cost-effective and

Type of Stress Test Average Average Sensitivity Specificity Stress ECG w/o Imaging 67% 77% Stress Echocardiography 79% 87% Stress-SPECT 88% 81% Stress-MRI 88% 87%

and extent of CAD, along with information

To maximize the diagnostic yield from a stress evidence-based, there are several factors to consider. Is Stress Testing Indicated?

ability to accurately quantify the severity regarding myocardial viability. The disadvantages of SPECT are radiation exposure, cost and longer test duration. Stress echocardiography has a lower sensitivity

Stress testing is contraindicated in patients with acute coronary syndromes, possible aortic

age-predicted, then pharmacologic options

for detection of CAD, compared to SPECT,

dissection, unstable arrhythmia, severe symp-

are used. Adenosine and dipyridamole are

but provides information regarding presence

tomatic aortic stenosis or hypertensive

contraindicated in patients with severe

of structural heart disease. The diagnostic

urgency. In patients who have a high pre-test

reactive airway disease or significant AV nodal

utility of stress echocardiography is reduced

probability of significant CAD based upon

block. Regadenoson is a more selective

in patients with difficult acoustic windows

history, ECG and clinical markers, it is often

adenosine agonist that has fewer side effects

(obesity or COPD), in patients with baseline

prudent to proceed directly with cardiac

and tends to be better tolerated. Dobuta-

wall motion abnormalities and in those with

catheterization, since a normal stress test

mine is relatively more labor intensive and

LBBB or paced rhythms. There is also greater

would not sufficiently exclude significant CAD

should be used with caution in patients with

inter-observer variability in interpretation,

in high-risk patients and can be dangerous.

prior arrhythmias.

compared to SPECT. Newer stress imaging with cardiac MRI is available in academic centers

In patients with a very low pre-test probability of significant CAD, stress testing may

It is important to recognize that the sensitivity

and has high sensitivity, while providing high-

not be cost effective. Stress testing is ideally

of stress ECG testing alone without imaging

quality morphologic data.

suited for patients with intermediate clinical

is low (approximately 67 percent; see table) and

risk based upon history, ECG and traditional

is also reduced in women. There are certain

In summary, to choose the optimal stress test

risk factors.

baseline ECG criteria that are non-diagnostic,

for your patient, you need to individualize

including left bundle branch block, LVH with

the selection of stress and imaging modalities

Which Stress Modality

strain, WPW, paced rhythm, digoxin use or

based upon several factors. These factors

Should I Choose?

other significant baseline ST-T abnormalities.

include clinical presentation, pre-test prob-

Options for stress modality include exercise

Stress ECG testing alone is also unable to

ability of CAD, baseline ECG or wall motion

(typically treadmill) vs. pharmacologic (adenosine,

localize the site of ischemia. Patients with

abnormalities, gender, ability to exercise, body

dipyridamole, regadenoson, dobutamine). Exercise

prior revascularization or those at higher

habitus, history of prior revascularization and

is the preferred stress modality, since it provides

clinical risk should have imaging (i.e. SPECT

other medical comorbidities, such as reactive

information regarding functional capacity, which

or echocardiography) coupled with stress.

airway disease or prior arrhythmias.

has useful prognostic implications. If a patient

References: (1) Lee, T.H.; Boucher, C.A. Clinical practice. Noninvasive tests in patients with stable coronary artery disease. N Engl J Med

is unable to e xercise sufficiently to increase their heart rate to 85 percent of maximum

2001;344:1840. (2) Marwick, T.H.; Nemec, J.J., Pashkow, F.J., et al.: Accuracy and limitations of exercise echocardiography in a routine clinical setting. J Am Coll Cardiol 1992;19:82–83. (3) Iskander, S.; Iskandrian, A.: Risk assessment using single-photon emission computed tomographic technetium-99m sestamibi imaging. J Am Coll Cardiol 1998;32:57–62.

MAY 2010 | The Triangle Physician

Skin Cancer

Skin Cancerâ&#x20AC;&#x2122;s

Costs Increasing Burden on Health Care

by Robert E. Clark, MD, PhD

Cost and efficacy of skin cancer treatment will become an increasingly important issue over time as our population continues to expand and these treatments take up a larger portion of the health care dollar.

According to the American Academy of Dermatology, in 1930 approximately 1 in 5,000 Americans was likely to develop melanoma during his or her lifetime. By 2004, the incidence had increased to 1 in 65, and it is now estimated that melanoma is the second most common cancer in women age 20 to 29. 12

The Triangle Physician | MAY 2010

ÂŠ ISTOCKPHOTO.ANDREWJOHNSON

Skin cancer is the most common malignancy in the United States. An estimated 1.3 million new cases of skin cancer will occur in 2010. Of these, approximately 80 percent will be basal cell carcinoma, 12 percent squamous cell carcinoma, 5 percent malignant melanoma and the remaining unusual forms of skin cancer.

Dr. Clark established the Cary Skin Center in 1998. He and Dr. Timothy Flynn are medical directors for the Cary Skin Center and provide skin cancer surgery services for melanoma and Mohs micrographic surgery for nonmelanoma cutaneous malignancies. Dr. Clark received his medical degree from University of Texas Southwestern Medical School in Dallas. He completed his internship in the Department of Medicine at Indiana University Medical Center in Indianapolis, and his dermatology residency and dermatologic surgery fellowship at Duke University Medical Center. Dr. Clark also holds a Ph.D. in Biochemistry from the School of Chemical Sciences at the University of Illinois. Formerly, Dr. Clark was Director of the Dermatologic Surgery and Cutaneous Oncology Unit and Cosmetic Laser Center from 1990 to 1998 at Duke University Medical Center. His areas of expertise include dermatologic surgery, treatment of skin cancer, and laser surgery. He has lectured and trained physicians nationally and internationally in the fields of laser surgery and cosmetic procedures. His professional credentials include: Board Certified, American Board of Dermatology; Board Certified, American Board of Mohs Micrographic Surgery and Cutaneous Oncology; Fellow, American Academy of Dermatology; Fellow, American Society for Dermatologic Surgery; Fellow, American College of Mohs Surgery; Member, North Carolina Medical Society.

Some individuals and families are predisposed to melanoma due to the presence of atypical (dysplastic) nevi. An estimated 5 percent to 10 percent of melanomas develop in people with a family history of melanoma or dysplastic nevi. Still, sun exposure is the leading cause of skin cancer development. Sunburns and artificial tanning have a significant impact on the development of melanoma, in particular. It is estimated that each blistering sunburn prior to about age 20 doubles the risk of melanoma development over an individual’s lifespan. Early detection Treatment of melanoma is based on early diagnosis and prompt surgical excision. Other treatment options are far less effective. Early detection and prompt surgical removal

Reported rates of incidence of melanoma have been increasing at about 4 percent per year in our nation. Skin cancer can largely be divided into two major groups: malignant melanoma and non-melanoma. Approximately 90,000 new cases of malignant melanoma will be diagnosed this year. Malignant melanoma can be dangerous and is responsible for 75 percent of all skin cancer deaths in the United States. Squamous cell carcinoma is largely responsible for the remaining 25 percent. Melanoma is generally considered to be the most lethal form of skin cancer and has the ability to spread from the skin to draining lymph nodes as well as internal organs, such as the brain, lung, liver and bone. It is estimated that one person dies from melanoma every hour of every day in the U.S. Risk factors Those at greatest risk of developing malignant melanoma have fair complexion, blonde or red hair, and green-, blue- or hazel-colored eyes. Most of these individuals have a history of significant sun exposure.

can result in cure rates of melanoma of about 95 percent. However, once the tumor has spread, prognosis is poor. Surgery, radiation nor chemotherapy is effective once the tumor has spread from the skin. Non-melanoma skin cancer Most cutaneous malignancies occur in the non-melanoma skin cancer group—basal cell and squamous cell. Basal cell carcinoma is the most common cancer in humans and develops in greater than one million people every year in the U.S. alone. These skin cancers develop from basal cells, which are skin cells located in the lowest portion of the epidermis. Most basal cell carcinomas occur on skin that has significant sun exposure, such as the face, ears, scalp and upper trunk. These skin cancers typically appear as opaque, translucent or “pearly” bumps that may ulcerate, bleed and then cycle through

the symptoms of bleeding and healing. These tumors tend to be slow in growth and can take several years to reach a large size. Basal cell carcinoma rarely metastasizes; but when it does occur, it leads inexorably to the death of the patient. Over time, basal cell carcinoma leads to extensive damage of surrounding tissue and hence should be diagnosed early and treated appropriately. More than 200,000 cases of squamous cell carcinoma will develop this year and these skin cancers have a tendency to develop in fair-complected individuals beyond age 50. An extensive history of sun exposure correlates strongly with the development of squamous cell carcinoma and its precancerous skin lesions, known as actinic keratoses. Sun, however, is not the only associated factor with squamous cell carcinoma. Squamous cell carcinoma can be seen following radiation therapy, infection with human papillomaviruses, exposure to such chemicals as aromatic hydrocarbons and non-healing wounds of the skin. Squamous cell carcinoma is seen more frequently in light-skin individuals with blonde or red hair and blue, green or hazel eye color. These skin cancers often appear as a scaly, crusted area, with surrounding inflammation. Also, there may be a rapidly-growing tumor or non-healing ulcer. Squamous cell carcinoma has a relatively high rate of metastatic disease when this malignancy occurs on the ears, lips, oral mucosa or genitalia. Early diagnosis and prompt treatment is important to prevent metastasis. Skin cancer treatment Treatment options for skin cancer are highly dependent upon the diagnosis of the tumor. Malignant melanoma requires early diagnosis and prompt surgical removal with excision margins dictated by the Breslow depth of invasion of the tumor cells. The National Institutes of Health has published guidelines for excision margins for malignant melanoma based on the Breslow measurement. More superficial melanomas can be excised in the physician office whereas those with deeper MAY 2010 | The Triangle Physician

invasion may require surgical removal in an operating room, combined with sentinel lymphoscintigraphy to seek evidence of regional metastatic disease. Non-melanoma cutaneous malignancies have available a number of different treatment modalities. Deciding which treatment option is best for a given patient requires that the physician take into account a number of factors including, but not necessarily limited to, the diagnosis of the skin cancer, its histopathological subtype, tumor location, size of the tumor, expected aesthetic outcome by the patient, risk of recurrence based on tumor type and treatment option used, and the ability of the patient to undergo a given procedure or treatment option. Treatment of superficial and relatively small non-melanoma skin cancers using cryotherapy or electrodesiccation and curettage can usually be completed in a single office visit on an outpatient basis. Individuals who wish to forego procedural therapy can in some cases be treated with topical medications, such as 5-fluorouracil or imiquimod. These topical treatments should be reserved for nonaggressive, superficial, small skin cancers. 14

The Triangle Physician | MAY 2010

The most common treatments for non-melanoma skin cancer include conventional surgical excision in the medical office, ambulatory surgery unit or hospital operating room. Aggressive skin cancers or those in highly cosmetically sensitive areas can be treated with Mohs micrographic surgery in order to preserve uninvolved normal tissue allowing minimization of the surgical wound while maximizing tumor removal and thereby the cure rate. This procedure is performed on an outpatient basis usually in a medical office. Radiation therapy provides another modality of treatment which may require 10 to 30 visits by the patient for treatment of the tumor. Health care costs Cost and efficacy of skin cancer treatment will become an increasingly important issue over time as our population continues to expand and these treatments take up a larger portion of the health care dollar. The most expensive and least efficient method is radiation therapy ($$$$$), requiring multiple visits; however, in some cases, this may be the best option. This is

followed by conventional surgical excision in the hospital operating room or ambulatory surgery unit ($$$$), incurring OR time, anesthesia, a multitude of OR personnel and post-op recovery charges. Conventional surgical excision or Mohs micrographic surgery in the doctorâ&#x20AC;&#x2122;s office ($$$) is intermediate on the cost scale, but very efficient for both the patient and the health care system. Topical therapies ($$-$$$) allow the patient to treat the skin cancer at home, using relatively expensive topical medications, but cure rates are somewhat low and the risk of recurrence requiring future surgery adds significantly to the cost of this treatment option. Cryotherapy and electrodesiccation and curettage ($) are the least costly and are efficient treatment alternatives. as well. It is incumbent upon physicians to educate their patients to avoid ultraviolet radiation damage to their skin from either the sun or artificial tanning. The use of sun-protective measures, including sunscreens and protective clothing, not only can help diminish the development of skin cancer but also help decrease the impact of skin cancer and treatment on our health care system.

Phlebology

Ankle Spider Veins The Culprit Could Be Underlying Venous Disease by Lindy McHutchinson, MD

Venous reflux is one of the primary sources leading to chronic venous insufficiency and its physical findings: peripheral edema, bulging varicose veins, hyperpigmentation, venous stasis skin changes and, eventually, venous ulcers.

Spider veins are unsightly, dilated veins in the skin, usually appearing on the legs.

Although spider veins are usually considered a cosmetic problem, when they appear in the inner ankle, it can be indicative of underlying venous disease, a medical problem covered by most insurance companies.

Venous Disease occurs when venous reflux (retrograde flow) is present most commonly

in the saphenous leg veins. This venous reflux causes blood pooling and congestion leading to venous hypertension.

Because gravity prevails when reflux is present, this increased venous pressure can cause

dilation of smaller vein branches, especially in the ankle where the hydrostatic pressure is greatest. Because of this increased ankle pressure, clusters of spider veins ultimately appear inside the inner ankle, also called corona phlebectasia, a classic physical finding in venous disease.

What is venous reflux? Normal leg veins work against gravity taking blood via

antegrade flow back to the heart, using one-way flow valves in leg veins. If these one-way flow valves malfunction, blood flows retrograde toward the feet. This unhealthy, retrograde flow is called venous reflux.

Diagnosing venous reflux. Venous reflux is diagnosed by performing a duplex

ultrasound by a specially trained venous ultrasonographer in the vein clinic setting. Duplex means “two.” First, the flow in the veins is evaluated using the doppler flow techniques and, second, the veins in the legs are “mapped.”

The problem with venous reflux. When venous reflux is present, venous pooling and

congestion occur, first, distally and, eventually, progresses proximally. Venous reflux is one of the primary sources leading to chronic venous insufficiency (CVI.) Thus, venous reflux is ultimately responsible for many of the physical findings of CVI: peripheral edema, bulging varicose veins, hyperpigmentation, venous stasis skin changes and, eventually, venous ulcers. Common symptoms of CVI include: tired, achy, heavy, swollen, tender, itchy, crampy, restless legs.

Insurance coverage? No insurance company will cover cosmetic treatments of spider

veins. However, if symptomatic venous disease is also present and deemed a medical problem, most insurance companies, including Medicare, will cover the treatment of the venous disease. MAY 2010 | The Triangle Physician

Skin Cancer

Skin Cancer Basics by Tamara S. Housman, MD

More than one million cases of non-melanoma skin cancer are diagnosed yearly in the United States. That’s more than all other types of cancer combined. Most of these non-melanoma skin cancers are sun-related. Non-melanoma skin cancers (NMSC) include basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and other rarer cancers, such as merkel cell carcinoma, dermatofibrosarcoma protuberans and atypical fibroxanthoma, among others. Melanoma is the most serious type of skin cancer, with an incidence of approximately 68,000 cases in 2009, and accounts for most deaths related to all types of skin cancer. Other types of skin cancer include internal malignancies that metastasize to the skin, and skin leukemias and lymphomas. BCC is the most common type of skin cancer, followed by SCC. Within three years of being diagnosed with one basal cell cancer, almost 50 percent of people develop a new skin cancer. The diagnosis of “in-situ” tumors, such as squamous cell carcinoma in-situ (SCCis) or melanoma in-situ (MIS), indicates that these tumors are confined to the top layer of skin, known as the epidermis. The designation of Bowen’s disease is less frequently used and is the same as SCCis. Early Detection Melanoma is the third most common skin cancer, after BCC and SCC. Death secondary to melanoma depends mostly on the depth of tumor, as measured under the microscope, also known as Breslow depth.

Depth of Melanoma (Breslow Depth)

5-year Survival Rate*

10-year Survival Rate*

In-situ <1mm 1-2mm 2-4mm >4mm

100% 91-95% 77-89% 63-79% 45-67%

100% 83-88% 64-79% 51-64% 32-54%

*Nodal micro- or macro- metastases as well as distant metastases will decrease all survival rates.

The Triangle Physician | MAY 2010

Most melanomas arise as new moles and some arise as changing moles. All moles should be examined using the ABCDE criteria: A – asymmetrical shape; B – borders are irregular/scalloped/poorly defined; C – color varies within same mole; D – diameter is greater than 6mm; and E – evolving/changing mole. Any moles meeting any of these criteria should be evaluated by a dermatologist. Amelanotic melanomas are diagnostically challenging because they lack any pigment and, therefore,there’s usually a delay in diagnosis and, thus, treatment.

Early detection and treatment is the key to surviving melanoma. American Joint Committee on Cancer reports 100 percent survival after treatment for melanoma in-situ.

A board-certified dermatologist, Dr. Tamara Housman is a diplomate, of the American Board of Dermatology and medical director for the Raleigh Skin Surgery Center, specializing in Mohs micrographic surgery and skin cancer surgery. She earned her medical degree from the University of Louisville School of Medicine in Kentucky. She completed her dermatology residency at Wake Forest University in Winston-Salem, N.C. She completed her Mohs micrographic surgery/procedural dermatology fellowship, accredited by both the American College of Mohs Surgery and the Accreditation Council for Graduate Medical Education, at the University of Washington in Seattle. Following her fellowship, Dr. Housman became the founder and medical director of Providence Dermatologic Surgery in Portland, Ore. She has published more than 29 peer-reviewed journal articles. She is a member of the American College of Mohs Surgery, American Academy of Dermatology, American Society for Dermatologic Surgery, North Carolina Medical Society and the North Carolina Dermatology Association

Treatment Using Mohs Mohs Micrographic Surgery is now considered one of the best methods for treating certain types of skin cancer, especially BCC and SCC, with a cure rate of nearly 99 percent. Using this highly specialized procedure for skin cancer removal, the cancer is marked clinically using ink. After administration of local anesthetic, the skin is cut using a scalpel, and this piece of tissue is processed using the frozen-section technique. With Mohs, a very small portion of uninvolved skin or “free margin” is removed thus minimizing the removal of surrounding, healthy skin. The amount of free margin removed—usually between 1 mm to 2 mm—is much less than the usual 4 mm to 6 mm required for the standard excision of skin cancers. Mohs allows examination of 100

I stress that everyone should enjoy living but protect yourself Womens Wellness half vertical.indd 1

percent of the margins and allows the surgeon to microscopically follow

2/18/2010 3:35:23 PM

the extent of the cancer to provide the highest cure rate.

Prevention

• Wear appropriate clothing if you do have to go outside

The key is skin cancer prevention. Skin cancer is caused by cumulative

during that time. I recommend a wide-brimmed hat on a daily basis

sun exposure. It’s not one event or sunburn. It’s the daily short trips

and wearing tightly woven, long-sleeved shirts and long pants.

outside and exposures that add up over our life. You can reduce your risk of skin cancer by following a few simple guidelines.

• Wear sunscreen that has a sun protection factor (SPF) of at least 30 for daily use and SPF 50 or greater for outdoor activities. The

• Avoid doing outdoor activities – boating, tennis, yard

work, golf, etc. – between the hours of 10 a.m. and 4 p.m., when the sun is at its brightest.

product should be liberally applied about 30 minutes before going outdoors and every one to two hours thereafter, but more frequently if sweating or exposed to water. MAY 2010 | The Triangle Physician

Women’s Health

Women &Urinary Incontinence Treatment Begins with Effective Diagnosis

After understanding the cause of incontinence, there are ways a woman may improve her symptoms before turning to medications and surgery.

Andrea S. Lukes, MD, MHSc, FACOG Dr. Lukes received her bachelor’s degree in religion from Duke University (1988), followed by a combined medical degree and master’s degree is statistics from Duke (1994). She completed her Ob/Gyn residency at the UNC (1998). During her 10 years on faculty at Duke University, she co-founded and served as the Director of Gynecology for the Women’s Hemostasis and Thrombosis Clinic at Duke. Dr. Lukes left her academic position at Duke in 2007 to begin Carolina Women’s Research and Wellness Center (CWRWC), and to become Founder and Chair of the Ob/Gyn Alliance. Phone: (919) 251-9223. www.cwrwc.com

and measurement of closing pressures. Abnormal bladder function (which includes involuntary loss of urine, inability to retain urine in a full bladder, unexplained urge to void, frequent urination, getting up at night to void, as well as a weak urine stream) and retention and overflow incontinence are usually readily

rinary incontinence is common.

Diagnosing the Cause

The National Association for

before Treatment

Continence (NAFC) estimates on

Approaches to management of urinary

After understanding the cause of incontinence,

the basis of multiple studies and

incontinence by health care providers often

there are ways a woman may improve her

expert opinion that 25 million adult Americans

will depend on the physician’s specialty. Our

symptoms before turning to medications

experience transient or chronic urinary

focus at the Women’s Wellness Clinic is to

and surgery. They include bladder retraining,

incontinence.

understand and identify the cause of urinary

Kegel exercises, biofeedback, low-voltage

diagnosed following these tests.

incontinence prior to treatment. This allows

electrical stimulation and lifestyle changes,

Health care providers and their female patients

the physician or health care provider to

such as avoiding constipation, smoking and

with urinary incontinence should know that all

approach treatment in a more cognizant and

certain foods (such as spicy foods,

types of the condition are treatable at all ages.

measured fashion.

carbonated beverages, citrus juices), and losing weight.

The two most common types of urinary

Our comprehensive approach to understanding

incontinence are stress incontinence and urge

the etiology of urinary incontinence begins

Although the number and different types of

incontinence.

with a detailed medical history and a physical

medications for urinary incontinence have

exam. We also assess a patient’s three- or

grown, there are potential side effects and

Stress incontinence usually results from

four-day “voiding” diary, noting such activities

long-term concerns with many. Recent studies

stretched pelvic floor muscles after either child

as drinking habits, frequency of urination and

have shown that the common treatments for

birth or weight gain. Also as a result, the

leaks, as well as potential patterns involved

urinary incontinence, bladder anticholinergics,

bladder can “drop” (cystocele) and push against

with leakage.

can impact cognitive function, as recently summarized by Karen Shapiro, PharmD, BCPS,

the vagina. This change of bladder position and weakening of the pelvic floor muscles will

Although urodynamic testing was once reserved

in her MedScape response to the question

impact the urethra—keeping it open—during

for surgical management, we recommend and

“Can Bladder Anticholinergics Be Used Long

stress, such as coughing, sneezing or laughing.

perform simple, virtually painless urodynamics

Term?” posted April 23, 2009.

within our office. The testing, which takes Urge incontinence results from involuntary

about one hour, determines how well the

contraction of the bladder muscle, which can

bladder is functioning, and measures the ability

be related to age, stroke, kidney or bladder

to retain and expel urine.

In conclusion, our approach to urinary

incontinence in women is not immediately

surgery or medication, but diagnosis of the cause of this common problem. With basic

stones and other factors. Although less common, a woman may also have a mixed incontinence

Uroflow testing charts the amount (cubic

urodynamics tests within the office, health

(both stress and urge incontinence), or either

centimeters per second) of urine voided.

care providers can better manage a woman’s

overflow or functional incontinence.

Evaluation of the urethra involves inspection

complaint of urinary incontinence.

The Triangle Physician | MAY 2010

Skin Cancer

William G. Way, MD Chief Medical Officer, Wake Radiology

PET/CT Highly Useful in Melanoma Staging &Restaging

While the worldwide incidence of many cancers has been decreasing, the incidence of melanoma of the skin, unfortunately, is on the rise. In the US, according to the World Health Organization, the incidence of malignant melanoma has increased an average of four percent every year since the early 1970s.1 Early detection and accurate staging are vital to determining, without delay, the most effective treatment for the patient. PET/CT is an extremely useful test for the evaluation of patients with malignant melanoma because the tumor tends to be very hypermetabolic, thus allowing for ready detection of clinically occult sites of disease. Melanoma can be a very aggressive disease. In one study of patients diagnosed with a single melanoma, their risk of developing a second primary melanoma was increased roughly 200 times over that of the general population. That study also showed that for patients diagnosed with melanoma, most second melanomas occurred within two years of the first.2 When a malignant melanoma becomes invasive, it has a tendency to spread first to loco-regional lymph nodes and then throughout the entire body. PET/CT’s usefulness comes not from screening for the disease, but rather for detecting more widespread disease once metastatic loco-regional nodal disease is confirmed. The exception might be for a deep and/or aggressive local lesion where positive loco-regional lymph nodes were expected but none were found since it is possible for this disease to skip

these lymph nodes and metastasize directly to the brain, bone, lung, liver, etc. Thus, PET/CT plays a very important role in the initial staging of malignant metastatic melanoma and in helping guide decisions for the most promising treatment. The unique procedure that we perform for malignant melanoma is to scan the patient from the top of his or her head all the way to the toes. This is a more comprehensive scan than our standard PET/CT scan for other malignancies, which generally extends from the lower part of the brain down to the midthighs. Melanoma, on the other hand, occurs not only on the trunk, proximal extremities, and head and neck, but also on the peripheral extremities and in particular, the sun-exposed areas. Not long ago, for instance, I evaluated a patient with a melanoma on the foot. Since the skin, in essence, is one large organ, and melanoma can occur anywhere on the skin, we perform a full body scan on these patients. While PET/CT is capable of detecting metastatic disease in the draining regional lymph nodes, such as those behind the knee, in the groin, or in the axilla, its primary value in the setting of malignant melanoma is in the detection of more widespread metastases in sites such as the lungs, bones, or liver. Because these tumors tend to be very hypermetabolic, they often are very easy to detect. Thus, PET/CT serves to answer the two big questions: Has the tumor already spread beyond the loco-regional lymph nodes, and is there a second primary skin tumor we didn’t know was there? There could be another primary melanoma, for example, in an armpit or hidden by hair on the scalp, that might have escaped detection despite a very thorough

physical examination by the patient’s referring physician. PET/CT also can be used to direct where and what to biopsy for definitive diagnosis in the setting of widespread metastatic disease. In one instance, for example, several unexpected tumors were discovered on PET/CT in addition to the primary tumor that was initially detected in the patient’s eye at the time of an ophthalmology exam. In this particular case, we were able to direct the referring physician to the site that would be safest and most appropriate to biopsy in order to properly diagnose and stage the patient. PET/CT’s unique ability to detect clinically occult tumors is equally important with regard to ongoing surveillance of patients previously diagnosed with locally or regionally advanced disease as it allows for the early detection of recurrent disease at more remote locations. These patients often will undergo periodic PET followup, since they are at increased risk for the subsequent development of widespread metastatic disease. In this circumstance, a whole-body PET scan serves as a single examination to search the entire body for evidence of disease recurrence. In summary, PET/CT is a very sensitive imaging study that facilitates accurate staging of melanoma when it is initially diagnosed and that allows for the early detection of recurrent disease at remote and often clinically unsuspected locations. World Health Organization. WHO - Health Effects of UV radiation. Web. 2010. Accessed at http://www.who.int/uv/health/ uv_health2/en/index1.html. 2 Burden, A D, Vestey, J P, et al. Multiple primary melanoma: risk factors and prognostic implications. Journal article. 1994. BMJ 376-309. http://www.bmj.com. 1

MAY 2010 | The Triangle Physician

News Welcome to the Area Christina Elaine Adams, MD Family Medicine Durham

Natalie Banet, MD

Pathology University of North Carolina Hospitals, Chapel Hill

Joel Michael Bernstien MD Obstetrics and Gynecology Kamm, McKenzie Ob/Gyn, Raleigh

Mitchell Howard Block, MD Pediatrics Durham

Carolyn Celi Brookhart, MD Pediatrics Chapel Hill, NC 27514

Emily Hueywen Chang, MD

Internal Medicine University of North Carolina Hospitals, Chapel Hill

Sendhil Kumar Cheran, MD Internal Medicine Wake Radiology, Raleigh

Howard Kael Christianson, MD Diagnostic Radiology Duke University Hospitals, Durham

Kimball Lael Christianson, MD Radiology Duke University Hospitals, Durham

Collin Franklin Murphy Clarke, MD Anesthesiology Durham

William Daniel Crocker, MD

Anesthesiology University of North Carolina Hospitals, Chapel Hill

Erin Elizabeth Dainty, MD

Obstetrics and Gynecology Hubert Yeargan Center for Global Health, Durham

Ria Drapete Dancel, MD

Internal Medicine University of North Carolina Hospitals, Chapel Hill

Mathew Alan Davey, MD

Dermatology University of North Carolina Hospitals, Chapel Hill

Amelia Davis, MD Psychiatry Durham

Jason Richard DeLuca, MD Physical Medicine and Rehabilitation Durham

Noelle Annette DeSimone, MD Anesthesiology Duke University Hospitals, Durham

Michael McDonald Dunn, MD Emergency Medicine Bahama, NC

Krista Marie Fajman, MD

Internal Medicine University of North Carolina Hospitals, Chapel Hill

Ryan Clark Gardner, DO

Anesthesiology University of North Carolina Hospitals, Chapel Hill

Ahmad Paiman Ghafoori, MD Radiation Oncology Duke University Medical Center, Durham

Julie Heron Harreld, MD Radiology Duke University Hospitals, Durham

The Triangle Physician | MAY 2010

Winnie Claire Hicks, MD

Tracy Lynn Parris, MD

Quoc Bao Ly Hoang, MD

Lakshmi Priya Paruchuri, MD

Juliann Cotter Hobbs, MD

Isaac William Porter, MD

Richard Preston Hobbs III, MD

Jeevan B. Ramakrishnan, MD

Edward Ross Houser II, MD

Candra Elita Rowell, MD

Ari Isaacson, MD

Elizabeth Lynne Saft, DO

Family Practice Flat Rock, NC

Diagnostic Radiology Duke University Hospitals, Durham

Anesthesiology Duke University Hospitals, Durham

Internal Medicine University of North Carolina Hospitals, Chapel Hill

Urological Surgery Triangle Urology Associates, P.A., Durham

Radiology University of North Carolina Hospitals, Chapel Hill

Woody Herman Jackson, MD Family Practice Chapel Hill

Kristel Leigh Jernigan, MD

Internal Medicine University of North Carolina Hospitals, Chapel Hill

Puneet Singh Jolly, MD

Dermatology University of North Carolina Hospitals, Chapel Hill

Mark Joseph, MD

General Surgery University of North Carolina Hospitals, Chapel Hill

Brita Renee Klein, MD

Psychiatry Duke University Hospitals, Durham

Amy Kantipong Manchester, MD Anesthesiology Duke University Hospitals, Durham

Micah Thomas McClain, MD Internal Medicine DUMC, Durham

James William McCorry, DO Emergency Medicine Granville Health System, Oxford, NC

Diana Borton McShane, MD Dermatology Duke University Medical Center, Durham

Emergency Medicine University of North Carolina Hospitals, Chapel Hill

Internal Medicine Parkway Sleep Center, Cary

Ophthalmology Lowry Ophthalmology, Raleigh

Otorhinolaryngology Capitol Ear, Nose, and Throat, P.A., Raleigh

Anesthesiology University of North Carolina Hospitals, Chapel Hill

Family Practice Hendersonville Family Health Center, Hendersonville, NC

Mark James Sakr, DO

Family Medicine Duke University Hospitals, Durham

Ryan Bobbitt Sanford, MD Internal Medicine University of North Carolina Hospitals, Chapel Hill

James Scott Schauberger, MD Diagnostic Radiology Duke University Hospitals, Durham

Jonathan Kevin Seigel, MD

Pediatrics University of North Carolina Hospitals, Chapel Hill

John Brian Seymour, MD

Emergency Medicine University of North Carolina Hospitals, Chapel Hill

Anish Anilkumar Shah, MD Obstetrics and Gynecology Duke Fertility Center, Duke University Hospitals, Durham

Poonam Sharma, MD

Internal Medicine Duke University Hospitals, Durham

Jessica Stewart, MD

Internal Medicine University of North Carolina Hospitals, Chapel Hill

Michael Jeffrey Vinikoor, MD

Magdalena Sunshine Michael, MD MAHEC, Hendersonville, NC

Internal Medicine UNC Dept of Infectious Diseases Fellowship Program, Chapel Hill

Lauren Shenk Miller, MD

Sarah Anne Vogler, MD

Radiology Duke University Hospitals, Durham

Surgery - Surgical Critical Care University of North Carolina Hospitals, Chapel Hill

Blaine Thomas Mischen, MD

John Alexander Watts V, MD

General Surgery Durham

Radiology Duke University Hospitals, Durham

Fasil Ferris Mohomed, MD

Alisha Nicole West, MD

Pediatrics Morrisville, NC

Otorhinolaryngology University of North Carolina Hospitals, Chapel Hill

Andre Motie, MD

Christine Anne Williams, MD

Internal Medicine Duke University Medical Center, Durham

Internal Medicine University of North Carolina Hospitals, Chapel Hill

Rebecca Bachman Munro, MD

Donghua Xie, MD

Obstetrics and Gynecology Raleigh OB/GYN Centre, Raleigh

General Surgery Duke University Medical Center, Durham

Wanda Kay Nicholson, MD

Daniel Eugene Yoder Jr., MD

Obstetrics and Gynecology University of North Carolina School of Medicine, Chapel Hill

Family Medicine Hendersonville Family Practice Residency Program, Hendersonville, NC

Shannon Armstrong Novosad, MD

Brett Madison Young, MD

Internal Medicine Duke University Hospitals, Durham

Paul Youngbok Oh, MD Gastroenterology, Internal Medicine Kernodle Clinic, Burlington, NC

Radiology Durham

Events & Opportunities May 1, 2010

DUKE EYE RETINOBLASTOMA PATIENT/FAMILY GATHERING Duke Children’s Hospital, 1:00pm to 3:00pm Duke Eye Center, in conjunction with Duke Children’s Hospital, presents the First Annual Retinoblastoma Patient/Family Gathering. Join us to learn how to treat and cope with this condition. Learn more at DukeEye.org! Renee Halberg – 684-2477, Erica Burner – 684-9154, Kimberly Horton – 684-3957 May 1, 2010

BOWTIES FOR BANDAIDS benefits the WakeMed Children’s Hospital building fund and is co-sponsored by Kisco Triangle Communities and Wake Med Foundation. The black tie optional event will be held at Magnolia Glen, 5301 Creedmoor Road, Raleigh. Tickets are $60 or $100/couple. Details at http://www.kiscoseniorliving. com/trianglecommunities_bowties_benefit.html May 7, 2010

3RD ANNUAL TRIANGLE GOES RED FOR WOMEN LUNCHEON will be held from 10 am to 1:30 pm at the Crabtree Marriott. http://www.trianglegoesred.org/ May 7, 2010

9TH ANNUAL BENEFIT AUCTION FOR THE CARYING PLACE The evening’s events include a live auction of precious experiences. Details and tickets at 919-462-1800 or visit http://www.thecaryingplace.org/ May 15, 2010

AMERICAN CANCER SOCIETY’S FUURST ANNUAL BARK FOR LIFE West Point on the Eno Amphitheatre. Pre-registration by April 13 is $20 and includes a t-shirt for the owner, a bandana for the dog, and one doggie bag of goodies. Each additional dog is $5. On-site registration is $25 with t-shirts & bandanas while supplies last. For more information contact Sarah Caudle @ 919-334-5218. www.durham.relay.com May 15, 2010

UNDERSTANDING BLADDER CANCER

May 22, 2010

June 17 – 20, 2010

TAKING CONTROL OF YOUR DIABETES CONFERENCE & HEALTH

CAROLINA REFRESHER LECTURES

Raleigh Convention Center, 9:00am to 5:00pm RALEIGH CONVENTION CENTER 500 S Salisbury St Raleigh, NC 27601 TCOYD brings thousands of people with diabetes into contact with national and local medical professionals for a day of highly informative and motivational programs. Cost $25.00. For more information, visit: http://tcoyd.org/national-conferences/raleigh-2010.html or call us Toll Free at (800) 998-2693 May 29, 2010

SUMMER SALUTE North State Bank presents “Summer Salute” a beach party to benefit Hospice of Wake County. The event will start at 7 pm and will be held at North Ridge Country Club, 6612 Falls of the Neuse, Raleigh. Entertainment will be provided by the Legends of Beach and the event will also include a silent and live auctions and a raffle. Info at 919-645-3197 or http://www.hospiceofwake.org/pages/5/Calendar-of-Events/. June 5, 2010

2010 GEORGE HAM SYMPOSIUM FOR PSYCHIATRY The William and Ida Friday Center for Continuing Education Chapel Hill, NC james_hayes@med.unc.edu http://www.med.unc.edu/cme/events/george-ham-symposium/ ?searchterm=None Mental illness is the leading cause of disability in the U.S. and Canada among people aged 15-44. Nearly half (45%) of those with any mental illness meet diagnostic criteria for two or more disorders. NAMI (National Alliance on Mental Illness) estimates that 334,855 North Carolina adults were diagnosed with a serious mental illness. The goal of this meeting is to provide mental health providers with the latest research and clinical findings that will allow them to formulate treatment algorithms for schizophrenic and subspecialty patients.

Kiawah Island, SC http://www.med.unc.edu/cme/events/carolina-refresher-lectures/ Care of the surgical patient now requires a team approach in the perioperative period to ensure good outcomes. The goals of this meeting are to highlight several key areas in caring for surgical patients including preoperative assessment, high-risk obstetrics, patients with cardiac disease, pediatric care, and perioperative complications. A dynamic and expert faculty has been assembled to present this educational program, which has been designed for physicians, anesthetists, physician assistants, and others who care for the surgical patient. June 21, 2010

GOLF CLASSIC benefiting Hospice of Wake County will be held at MacGregor Downs Country Club, 430 St. Andrews Lane, Cary on June 21 starting at 9 am. Contact 919-522-6131 or visit http://www.hospiceofwake.org/pages/5/Calendar-of-Events/. June 25 – 26, 2010

THE 8TH ANNUAL LANDES SYMPOSIUM: ADVANCES IN UROLOGY The William and Ida Friday Center for Continuing Education Chapel Hill, NC. james_hayes@med.unc.edu http://www.med.unc.edu/cme/events/the-8th-annual-landessymposium/?searchterm=None Urologic Surgery is the integration of surgical activities for the pelvis, primarily for the treatment of obstructions, dysfunction, malignancies, and inflammatory diseases. In recent years, Urologic Surgery has been revolutionized by advances in urodynamic diagnostic systems and minimally invasive surgical techniques, such as laparoscopy, endoscopic examination, implantation procedures, and advanced imaging techniques. The UNC Division of Urologic Surgery offers this educational activity to physicians and other health care providers in the Southeast as an opportunity for attendees to update their knowledge and skills to the newest standards and guidelines in the field.

June 12, 2010

THE KOMEN NC TRIANGLE RACE FOR THE CURE® komennctriangle.org for registration info

New & Relocated Practices CAROLINA ALLERGY & ASTHMA Craig F. LaForce, MD Karen D. Dunn, MD Alan L. Aarons, MD Vincent L. Firrincieli, MD 2615 Lake Drive, Raleigh, NC 27607

Friday Center for Continuing Education, 9:30am Join the Bladder Cancer Advocacy Network (BCAN) for “Understanding Bladder Cancer,” a free educational program for bladder cancer survivors and caregivers. This forum is free, but preregistration is required at 888-901-BCAN or www.bcan.org_888-901-BCAN or www.bcan.org Preregistration is required.

WAKE HEART & VASCULAR Goldsboro Office 2609 Medical Office Place Goldsboro, NC 27534 (919) 231-8253 Joel Schneider, MD

May 15, 2010

Randy Cooper, MD

GREAT STRIDES WALK FOR CYSTIC FIBROSIS

Mateen Akhtar, MD

http://www.cff.org The Halifax Mall, downtown Raleigh will be hosting the Annual Great Strides Walk for Cystic Fibrosis. This event is a 5K walk, which will take you through downtown Raleigh. All proceeds from this event will go to the Cystic Fibrosis foundation to help with research to find a cure for those living with this awful disease.

(Interventional Cardiology) (Electrophysiology) (General and Invasive Cardiology)

Crystal Keen, PA

New or Updated Web Sites

May 16, 2010

INSIDE-OUT SPORTS CLASSIC HALF MARATHON 4001 Weston Parkway, Cary, NC, 7:00am This year, proceeds from the Inside-Out Sports Classic Half Marathon will support several local causes, including the Tammy Lynn Center for Developmental Disabilities and The American Red Cross. For additional information, visit http://www.ncroadrunners.org/IOClassic/, or request information from iosclassic@ncroadrunners.org.

prettyinpinkfoundation.org Pretty In Pink Foundation provides financial assistance and support to underinsured and uninsured North Carolinians with breast cancer.

www.capitalurological.com CAPITAL UROLOGICAL ASSOCIATES 3320 Wake Forest Rd, Suite 320 Raleigh, NC 27609 Phone: 919-526-1717 Fax: 919-790-0108 E-Mail: info@capitalurological.com MAY 2010 | The Triangle Physician

Practice Management

Is It Time for a

Practice

Many medical practice managers report that they are frustrated by never having adequate time to do an operational or financial assessment of their practices to identify and correct the problems which are negatively impacting profitability and productivity.

by John Reidelbach John J. Reidelbach, founder of Physician Advocates, Inc. (PAI), has degrees in Engineering, Education, an MBA and more than twenty years experience in healthcare. Mr. Reidelbach has developed several healthcare management entities to include IPAs, PPMCs, MSOs and group practices. He is experienced in providing assistance to healthcare entities in all aspects of practice management, operation and strategic development and implementation, education, contact negotiations, data analysis and capital funding.

This is because managers are constantly attending to the daily needs of the practice, putting out fires, resolving personnel problems, dealing with cash flow issues and physician generated concerns. As necessary as these activities are to operating a successful practice, they are generally not related to improving practice performance and profitability. An operational assessment and continuous process improvement project is designed to provide the practice with a blueprint for achieving greater efficiency and profitability over the short-term and long-term. A comprehensive operational assessment and improvement process project assesses the following twelve areas of medical practice operations in a top to bottom manner: • Profitability and Overhead Expenses, • Productivity, Capacity and Staffing • Scheduling, Patient Access and Patient Satisfaction • Patient Flow, Operational Efficiency and Office Organization • Coding, Reimbursement and Medical Records • Patient Billing, Insurance Processing and Collections • Compliance and Risk Management • CMS Compliance (Medicare Fraud and Abuse) • HIPAA Compliance • CAL/OSHA Compliance • CLIA Compliance • Malpractice Risk Reduction • Human Resources Compliance • Personnel Management • Facility and Equipment Management • Information Technology Systems • Strategic Planning and Marketing

The Triangle Physician | MAY 2010

• Accounts Receivable Management,

Assessment? A comprehensive practice assessment, which evaluates all of the

how the identified problem or deficiency affects practice cash flow

above-listed areas, utilizes a three-page checklist. However, because each

and/or profitability; it also offers recommendations for changes or

medical practice is unique, with its own specific needs, these assessment

improvements that should be implemented to resolve the identified

projects are tailored to focus on those specific areas of concern to your

problems and discusses options on how to implement the recom-

practice. The areas of focus for each assessment project should be

mended action(s).

discussed and agreed upon in advance. Upon completion of the assessment and compilation of the report A practice assessment checklist tailored to the needs of your practice

of findings and recommendations, a meeting should be scheduled to

is the primary tool utilized for assessing the operational areas included

discuss and elaborate on the final report and answer any questions

in the project. Each item on the checklist is reviewed and discussed

relative to the information and recommended change initiatives.

in detail in the report. Where applicable, the assessment checklist also includes a comparison of the group’s financial and productivity

A practice assessment is of tremendous benefit to a practice in expediting

data with industry standard national and/or regional medians and

the process of identifying operational inefficiencies and problems

“best practices” benchmarks for the client’s specialty and practice

inherent in nearly every practice, large or small, which are negatively

size. Using standard measures, benchmarking provides a continuous

impacting practice productivity, cash flow and profitability. The

process for measuring and learning about your practice’s productivity,

assessment also assists the practice in prioritizing those recommended

costs, profitability and quality. Although medical practices, even

actions which will have the greatest immediate impact on improving

those in trouble, often report the use of benchmarks, they are rarely

practice performance and profitability.

integrated into the daily operations of the practice or used to create

Isn’t it time your practice has a check-up?

riddick insurance group ad.pdf 12/28/2009 7:13:50 PM

accountability or drive performance improvement. If practices truly wish to master their business systems, benchmarking must be used to drive performance to achieve “best practices” standards. Typically, it takes about a week to acquire the information that is necessary for solo practitioners to upwards of a month or more for larger groups, wherein interviews must be scheduled with every member of the staff and time is spent observing the processes in the office from check-in and check-out, to billing, to medical records, to the clinical area. Once

the site work is finished, work on the report commences, which takes anywhere from four

to eight weeks, depending on group size.

The Practice Assessment report (report of

CMY

findings and recommendations) focuses

primarily on problems, deficiencies and/or concerns identified as a result of the analysis of the information provided by the practice and through direct observation. All of the identified problems and/or deficiencies listed on the assessment checklist having a direct or indirect negative impact on practice cash flow and/or profitability are further analyzed in the report. This analysis/assessment explains MAY 2010 | The Triangle Physician

Pediatrics

$1 Million Gift to WakeMed Foundation

Honors Area Pediatrician “Wes and Janet (Chesson’s) gift is not only generous, but it pays tribute to a person who has helped literally thousands of families throughout Wake County.” — Jack Radford, Executive Director, WakeMed Foundation.

Guardian of Pediatric Care in Wake County

first chairman of the WakeMed Foundation Board, a position he held for nine years. Now under his leadership as chairman of the

WakeMed Foundation cites Dr. Bernstein’s

Foundation Physicians Council, WakeMed

dramatic and ongoing role in shaping

Foundation staff and physicians have raised

pediatric health care services and delivery at

$700,000 for the Just For Kids Kampaign,

WakeMed and throughout Wake County.

according to the WakeMed Foundation release.

Among Dr. Bernstein’s contributions was $1 million gift to WakeMed Health & Hospitals and the WakeMed Foundation was pledged in

honor of pediatrician Jerry Bernstein, M.D. and his wife Peg for their friendship and contributions to the community by longtime friends Wes and Janet Chesson. The contribution is in support of the Just For Kids Kampaign under way through 2011 to raise $20 million for both the construction of WakeMed Children’s Hospital and the expansion of children’s services. In recognition of the $1 million pledge, the new pediatric intensive care unit will be named the

the development of the WakeMed Children’s

The children’s hospital is the first WakeMed

Emergency Department, which opened as the

project that is entirely dependent on funding

first of its kind in North Carolina in 1997. As

from the foundation and the philanthropic

a result, children of Wake County have direct

support of the community. While the hospital

access to specialized pediatric emergency

build-out is nearly complete, millions of

care, and WakeMed is the No. 1 provider of

dollars are needed to cover the costs of the

children’s emergency services in the state.

second phase of the project—expansion of the neonatal intensive care unit.

Dr. Bernstein’s greatest contribution, according to the WakeMed Foundation, may well have been his help spearheading the proposal to build WakeMed Children’s Hospital—the first dedicated children’s hospital in Wake County.

Gift a Measure of Gratitude and Friendship

“What Jerry has done for our children, let alone all the children in the community, is invaluable,” says Wes Chesson.

Dr. Bernstein points to the strong allegiance he has had with WakeMed administrators

The Chessons have been friends with Dr.

in working to advance the availability of

Bernstein and his wife, Peg, since 1973. “He

pediatric services in Wake County. “There

first introduced us to the foundation and to the

Care Unit.

have always been receptive ears at WakeMed,”

great things that WakeMed does back in the

he says. “It’s a ‘we-can-do-this’ attitude. That

’70s, when he asked my wife to co-chair the

“The Chessons’ gift is truly special,” says Jack

attitude began with now-retired CEO Ray

foundation’s first gala,” says Wes Chesson.

Champ and continues today with WakeMed’s

“We’ve been WakeMed supporters ever since.”

Jerry C. Bernstein, M.D., Pediatric Intensive

Radford, executive director of the WakeMed Foundation. “I have known Dr. Bernstein for almost 30 years and I can personally say he has been a true champion for children. Wes and Janet’s gift is not only generous, but it pays tribute to a person who has helped literally thousands of families throughout Wake County.” 24 The Triangle Physician

| MAY 2010

current CEO Dr. Bill Atkinson.” Janet Chesson echoes her husband’s sentiments In addition to his physician leadership roles

and adds her gratitude to WakeMed,

as president of WakeMed’s medical staff, the

“WakeMed has taken care of my son, my

Department of Pediatrics and the Medical

husband and my mother, and we have had one

Executive Committee, Dr. Bernstein was the

positive experience after another.”

Insurance

A Million-Dollar Replacement

Mike Riddick

Mike Riddick is the president of Riddick Insurance Group Inc, an independent insurance agency in Raleigh, NC. For 10 years, Mike has been helping professionals protect their assets through insurance and financial planning. The motto of Riddick Insurance Group is to help clients protect their standard of living by being better protected today and better prepared for tomorrow. Riddick Insurance Group specializes in helping small business owners with property, casualty, liability, and life insurance planning.

“We all work too hard to have our businesses jeopardized by things we could easily be protected from. That’s why time spent making sure your practice is protected by someone who has a policy designed for medical practices is well spent.” Many of us have the same desire in common: a passion for helping our clients. It drives many of us to open our own businesses so we can focus on helping our customers in our own way. As small business owners, our passion, heart and soul is making the business run in a way that fulfills a need. We view our employees as family. We want to deliver a service that warrants the respect and appreciation of our clients. On the other hand, what many business owners dread is dealing with administrative things like paperwork and insurance. Just as the medical and health industry evolves every year, so does the property insurance industry. As a result, I’d like to make you aware of three new endorsements every medical practice should consider. Each can be critical to your financial protection. ENDORSEMENT 1 As a medical professional, starting a medical practice is in a league of its own. Many medical practices can be complex in the way

New Endorsements Can Protect Your Medical Assets they are run and even more complex in terms of how the technical equipment is paid for. MRI machines cost on average between $1 million and $3 million. CAT scan machines average between $300,000 and $2 million. Lithrotripter and linear accelerator equipment also costs a small fortune. Here’s the important question: If your practice was destroyed by a fire (or any other peril), how would the insurance company pay for the damages to your technology equipment? Historically insurance policies put equipment under an inland marine format, which gives you a depreciated value for your equipment. Today there are riders that allow certain medical equipment (technology) to be added with replacement cost coverage. We all know technology depreciates rapidly. So, it is nice to know that a three-year-old $2 million MRI machine could be fully replaced with a new one in the event of a catastrophe. ENDORSEMENT 2 Review Board Legal Expense Reimbursement can alleviate another area of heartburn for doctors and medical professionals in the event you are summoned to court or to a medical review board due to a customer complaint. These events take valuable hours out of a doctor’s day, not to mention the mental anguish they cause. Today Review Board Legal Expense Reimbursement policies are riders that can pay for the expenses associated with lost time for these sorts of medical and legal reviews. Some will actually allow up to $75,000 for such costs.

ENDORSEMENT 3 Workers’ compensation claims can often reach $1 million if the employee is permanently injured or disabled. Therefore, the third endorsement you should review is your workers’ compensation to see if it’s specifically geared towards helping medical professionals. In my editorial in last month’s Triangle Physician, I talked about nurse’s liability and how to protect them should they make a mistake. But what happens if they get physically hurt? One of the worst things that could happen would be if a nurse taking blood accidentally jabbed himself with a used needle. Most workers’ compensation policies will cover the testing of the employee for illnesses. If an illness is transmitted, the insurance company would pay for the treatment. However, some policies today will now cover the costs and testing of the employee and patient. In addition, many policies will also cover preventive treatment for the employee so any potential issues are circumvented. This is a huge commitment from the insurance company compared to how claims were treated historically. In summary, I know we all avoid paperwork. We want to spend our day doing what we love the most, helping customers. However, we all work too hard to have our businesses jeopardized by things we could easily be protected from. That’s why time spent making sure your practice is protected by someone who has a policy designed for medical practices is well spent. MAY 2010 | The Triangle Physician

MAY 2010 | The Triangle Physician

;^cVcX^Va higZc\i] · '#+ Wâa^dc ^c cZi VYbîiZY VhhZih VcY +,, bâa^dc ^c eda^Xn]daYZg hjgeajh0 V 7Zhi¼h GVi^c\ d[ 6" :mXZaaZci JceVgVaaZaZY ZmeZg^ZcXZ · bdgZ i]Vc i]gZZ YZXVYZh d[ hZgk^XZ id i]Z ]ZVai]XVgZ Xdbbjcîn 6\\gZhh^kZ XaV^b YZ[ZchZ · cZVgan ,( d[ XVhZh XadhZY lî]dji Vc ^cYZbcîn eVnbZci0 l^c gViZ d[ bdgZ i]Vc .( [dg i]dhZ i]Vi lZci id V kZgY^Xi Vi ig^Va >ccdkVi^kZ g^h` bVcV\ZbZci · ZmiZch^kZ g^h` bVcV\ZbZci hZgk^XZh VcY XjhidbôZY! egVXi^XZ"heZX^[^X egd\gVbh

THE TIME IS RIGHT TO EVALUATE PROMUTUAL GROUP To learn more about ProMutual Group, please visit www.promutualgroup.com/NC.html or call us at (888) 776-6888.

YOUR LOCAL CARDIOLOGY PROFESSIONALS IN JOHNSTON COUNTY DEDICATED TO QUALITY, SERVICE, AND INTEGRITY Christian N. Gring, MD, FACC Cardiac CT Scan Angiography

Mateen Akhtar, MD

Benjamin G. Atkeson, MD, FACC

Eric M. Janis, MD, FACC

Diane E. Morris, ACNP

Matthew S. Forcina, MD

Ravish Sachar, MD, FACC

2 LOCATIONS TO SERVE OUR PATIENTS Smithfield Heart & Vascular Associates 910 Berkshire Road Smithfield, NC 27577 Phone: 919-989-7907 Fax: 919-989-3147

Wake Heart & Vascular Associates 2076 NC Hwy 42 West, Suite 100 Clayton, NC 27520 Phone: 919-359-0322 Fax: 919-359-0326

Matthew A. Hook, MD, FACC

Nyla Thompson, PA-C

CARDIOLOGY SERVICES Coronary and Peripheral Vascular Interventions, Pacemakers/Defibrillators, Atrial Fibrillation Ablations, Echocardiography, Nuclear Cardiology, Vascular Ultrasound, Clinical Cardiology, CT Coronary Angiography, Stress Tests, Holter Monitoring, Cardiovascular Medicine, Cardiac Catheterization

THE HIGHEST QUALITY CARDIOVASCULAR CARE, CLOSE TO HOME.

Location courtesy of Rapid Fitness Boxing Center, Raleigh

Penni, survivor since 2006

Darlene, survivor since 2005

Nancy, survivor since 2004

Robin, survivor since 2006

Lee, survivor since 2003

For living proof that early detection can deck this disease, just ask us. We’re some of the breast cancer survivors of Wake Radiology — we know personally what this fight is like. So we’re a little different when it comes to our patients. Highly understanding. Confidently reassuring. Ready with a solid one-two combination of expert medicine

Read our stories online at wakerad.com

and championship care, starting with your annual screening mammogram.

Wake Radiology salutes the grit, the grace, and the undaunted courage of every breast cancer survivor. Wake Radiology. The team you want in your corner.

7gZVhi >bV\^c\ HZgk^XZh 1 number to call, 16 locations serving the Triangle area. 919-232-4700 | wakerad.com

Proud Year-round Partner of the Susan G. Komen for the Cure, NC Triangle Affiliate.