april 2016
Wake Sports Medicine Triangle’s Only Comprehensive Nonsurgical Orthopedic Practice
T H E M A G A Z I N E F O R H E A LT H C A R E P R O F E S S I O N A L S
Also in This Issue EHR Setup Uniting M.D.s
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Healing Neighbors - It’s What We Do. It’s Who We Are.
From the Editor
Primary Approach Increasingly noninvasive diagnostic and treatment advances are delaying, and in most cases eliminating, the need for surgery. Complementing this trend in orthopedics is the role of the primary care sports medicine physician. This issue of The Triangle Physician features Wake Sports Medicine and its progressive, evidence-based approach to treating a range of musculoskeletal conditions using nonsurgical techniques. As a primary care sports medicine physician, practice founder Matthew Kanaan, D.O., wields expertise in diagnostic and interventional ultrasound and orthobiologics, including platelet-rich plasma (PRP) and mesenchymal stem cell therapy, among other advanced, nonsurgical treatments. In addition he expedites appropriate referrals to physical and occupational therapies and orthopedic surgery. Also in this issue, Triangle Physician contributors offer the benefit of their expertise. This month endocrinologist Carly Kelley discusses differentiated thyroid cancer. Practice management consultant Margie Satinsky presents the final installment of her two-part series on successful implementation of an electronic health record. Physician advocate Marni Jameson describes the frustrations of burdensome government regulations and the growing movement to support independent physicians. Each issue of The Triangle Physician is circulated to more than 9,000 within the Triangle medical community, making the magazine a primary source for those who seek referrals and choose to stay informed. Advertising rates are competitive. Medical news and information is welcome and runs at no cost, as space is available. We can be reached at info@trianglephysician.com. With great appreciation for all you do,
Heidi Ketler Editor
2
The Triangle Physician
T H E M A G A Z I N E F O R H E A LT H C A R E P R O F E S S I O N A L S
Editor Heidi Ketler, APR heidi@trianglephysician.com Contributing Editors Marni Jameson Carly E. Kelley, M.D., M.P.H. Margi Satinsky, M.B.A. Creative Director Joseph Dally jdally@newdallydesign.com
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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. Opinions expressed or facts supplied by its authors are not the responsibility of The Triangle Physician. 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. 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.
Table of Contents Category
4
COVER STORY
Wake Sports Medicine
The Triangle’s Only Comprehensive Nonsurgical Orthopedic Practice a p ri l 2 0 1 6
V o l . 7 , I ssue 4
FEATURES
8
Practice Management
Part II: Tips for Successful EHR Implementation Margie Satinsky’s chronological steps for a smooth transition maximize the roles of staff members and vendors.
12
Physician Advocacy
Fed Up With Excessive Oversight, Doctors Get Organized – Part I Marni Jameson discusses the great frustration that is causing independent physicians to join forces across the country.
DEPARTMENTS 10 ENDOCRINOLOGY
Differentiated Thyroid Cancer
13 DUKE RESEARCH NEWS Prostate Cancer Metastasis Site Has Direct Impact on Survival Time
14 DUKE RESEARCH NEWS Thyroidectomy Recommendation: Choose Surgeons With 25-plus Cases a Year
16 WAKEMED RESEARCH NEWS Supersaturated Oxygen Therapy Has Potential to Improve STEMI Outcomes
17 NEWS
Welcome to the Area
On the Cover: Matthew G. Kanaan, D.O., founder of Wake Sports Medicine, specializes in helping patients delay, and in some cases avoid, surgery, using traditional and cutting-edge treatment options.
april 2016
3
Cover Story
Wake Sports Medicine Triangle’s Leader in Cutting-Edge Nonsurgical Orthopedic Treatments Wake Sports Medicine is the only practice
achieve both short-term and long-term
Primary care sports medicine specialists
in the Triangle that is dedicated solely to
relief,� says Dr. Kanaan, Wake Sports
focus on the nonsurgical treatment of
providing
Medicine founder.
musculoskeletal conditions. Given that
comprehensive,
orthopedic
and
nonsurgical
sports
roughly 90 percent of all sports injuries
medicine
care. From fracture care and arthritis
What Is a Primary Care Sports
are estimated to be nonsurgical in nature
injections
Medicine Physician?
(according to the American Medical
injuries, Matthew G. Kanaan, D.O., helps
In the past patients had limited options
Society for Sports Medicine), the goal
patients delay, and in some cases avoid,
when seeking nonsurgical providers
of the primary care sports medicine
surgery using traditional and cutting-
within the orthopedic specialty, but
physician is to maximize non-operative
edge treatment options. That includes
more
sports
treatments, guide appropriate referrals
experimental orthobiologic procedures,
medicine physicians have been filling
to physical and occupational therapies
such as platelet-rich plasma (PRP) therapy
this void. Having a dedicated nonsurgical
and, when necessary, expedite a referral
and mesenchymal stem cell injections.
specialist is nothing new for the back
to an orthopedic surgeon. Most primary
to
managing
sports-related
recently
primary
care
and spine field, since most orthopedic
care sports medicine physicians will
“For patients, the decision to have surgery
practices
medicine
complete a one- to two-year fellowship in
can be scary, not to mention costly, and
and rehabilitation (PM&R) physicians
an orthopedic department, where they
therefore many of them try to seek out
to manage nonsurgical spine patients.
gain experience in nonsurgical orthopedic
nonsurgical alternatives. I may not always
However, for patients with injuries and
treatments. Within the last five years
be able to keep patients out of surgery.
pain in other areas of the body, such as
this fellowship has included specialized
Sometimes surgery is necessary. However,
the shoulder, knee, hip, ankle and foot,
training, and in some cases certification, in
there are many new, alternative treatment
there has not been a similar complement
musculoskeletal ultrasound.
options available today to help patients
to the orthopedic surgeon.
Dr. Kanaan performs an ultrasound examination of a knee.
4
The Triangle Physician
employ
physical
Dr. Kanaan reviews a same-day X-ray.
How Ultrasound has Transformed
Additionally, he says he can save patients
medications and viscosupplementation for
Dr. Kanaan’s Practice
time and money by using ultrasound as
knee arthritis. However, many patients will
Ultrasound is a longstanding and valuable
a diagnostic tool. In a matter of seconds
exhaust these options with minimal effect
technology in the medical field, but with
a patient with a bad fall can see if his/
on pain or quality of life.
significant advancements in portability,
her rotator cuff is torn without expensive
cost and resolution, it is now finding its
magnetic
a
More recently there has been an interest in
way out of the hospital and into the direct
posterior knee swelling that is suspected
“orthobiologics,” or using a patient’s own
hands of physicians, such as Dr. Kanaan.
to be a Baker’s cyst can be confirmed and
cells in an attempt to stimulate healing and
drained in the office.
decrease pain. Platelet-rich plasma (PRP)
resonance
imaging,
or
and mesenchymal stem cell injections
Ultrasound allows direct visualization of needle placement when performing injec-
Orthobiologic Treatments
are among the orthobiologics that hold
tion therapy. It also enables the physician
(PRP and Stem Cells)
promise as upcoming and novel treatment
to perform more difficult procedures that
Steroid injection (cortisone) is perhaps
were once only performed under com-
the
puted tomography or fluoroscopic guid-
treatment for joint pain. It usually works
PRP is thought to provide a boost to the
ance, at a fraction of the time and cost. Dr.
fairly quickly, has minimal side effects and
body’s own healing ability. It involves
Kanaan not only performs common injec-
is inexpensive. However, steroid injections
taking the patient’s blood and spinning
tions of the knee and shoulder, but also
are not without potential problems. They
it in a centrifuge to separate out the
more technical injections of the hip joint,
do not work for every patient, can increase
platelets, which are then injected back
small joints of the hands and feet, nerve
blood glucose levels and tend to have a
into the afflicted area – whether that is a
sheaths, bakers cysts and tendons.
diminishing effect over time.
joint, tendon or ligament. PRP therapy is
“Not only does ultrasound guidance
So, when a patient is not a good candidate
practices in this country, and while it is not
improve injection accuracy, but patients
for steroid injection or when steroid
covered by insurance, the cost is minimal
appreciate the ability to be able to watch
injection is no longer effective, what options
in comparison to surgical intervention.
the ultrasound-guided injection in real
does the patient have? Certainly there are
time on a large screen in our in-office
many proven methods that insurance will
PRP therapy has been performed for many
procedure suite,” says Dr. Kanaan.
cover, such as physical therapy and oral
years in Europe, but more recently it has
most
common
and
modalities.
well-known
widely performed by many orthopedic
april 2016
5
gained increasing attention as professional
orthopedic physician and newer options
athletes in the United States have been us-
for nonsurgical treatments. His office at
ing it to recover more quickly from injuries.
3100 Blue Ridge Road in Raleigh offers
There is very little risk to the patient, since
onsite X-ray and an in-office procedure
the injection is essentially an autograft
suite, where he performs diagnostic and
transplant, and many patients seem to ex-
interventional ultrasound procedures.
perience some benefit. Research on PRP is mixed, but recent studies have proven
Learn more about Dr. Kanaan and his prac-
some benefit for chronic tendinopathies
tice at www.wakesportsmedicine.com. He
and early osteoarthritis (1,2,3).
can be reached at 3100 Blue Ridge Road, #200, Raleigh, NC 27612 or by phone at (919) 719-2270.
Mesenchymal stem cell therapy uses the patient’s own cells in an attempt to stimulate healing. The difference is that PRP uses platelets in the blood to boost healing, whereas stem cell therapy uses the patient’s own stem cells.
After the adipose tissue is harvested from the patient, the concentrated fat layer that contains the stem cells is injected back into the affected area.
References (1) Meheux CJ, McColloch PC et al.
There are several different types of stem
“There does, however, seem to be enough
“Efficacy of Intra-articular Platelet-
cell sources, including amniotic, bone
research evidence supporting both PRP
Rich Plasma Injections in Knee
marrow and adipose (or fat tissue). Dr.
and mesenchymal stem cell injections to
Osteoarthritis: A Systemic Review.”
Kanaan is currently performing injections
make these treatments worth exploring,
Arthroscopy. 2016 Mar:32(3):495-505.
using both adipose and bone marrow,
but it is too early to predict long-term
(2) Arirachakran A, Sukthuayat A et al.
as he feels the evidence supports these
outcomes. Many fields of medicine are
“Platelet-rich Plasma Versus Steroid
sources over the use of amniotic stem
experimenting with the concept of using
Injection in Lateral Epicondylitis:
cell injections. The evidence for stem cell
stem cells, and orthopedics is no different.”
Systematic Review and Network Meta-
injections is promising
analysis.” Journal of Orthopedics and
, with most
(4,5,6,7)
case studies showing decreases in pain
About Dr. Kanaan and
scores and increases in activities.
Wake Sports Medicine
Traumatology. 2015. Sept 11. (3) Halpern B, Chaudhury S et al. “Clinical
Originally raised in Raleigh, N.C., Dr. Mat-
and MRI Outcomes After Platelet-
However, Dr. Kanaan makes it clear to all of
thew Kanaan is a board-certified primary
Rich Plasma Treatment for Knee
his patients that these procedures are pure-
care sports medicine physician, who
Osteoarthritis.” Clin J Sport Med.
ly experimental. There are no large clinical
completed his medical residency and fel-
2013;23(3):238-239. (4) Jaewoo P, Jung Hun Lee, et al.
studies that show regeneration of tissue
lowship training at Duke Medical Center.
with either PRP or the stem cell treatments.
During his fellowship training, Dr. Kanaan
“Cartilage Regeneration in Human with
received special instruction in diagnostic
Adipose Tissue-Derived Stem Cells:
“My job is to provide safe nonsurgical
and interventional musculoskeletal ultra-
Current Status in Clinical Implications.”
options for patients with orthopedic
sound. While completing training in pri-
BioMed Research International.
ailments,” says Dr. Kanaan. “There are
mary care sports medicine, Dr. Kanaan
Volume 2016 (2016), Article ID 4702674,
many clinics that offer these treatments
served as an assistant team physician for
12 pages.
with a promise that they will regenerate
Duke football, basketball and lacrosse and
tissue and the patient will never need a
assisted with Elon University football. He
“Mesenchymal Stem Cells and their
surgery. This is false advertising.
has volunteered with local endurance rac-
Clinical Applications in Osteoarthritis.”
es, such as the Raleigh 70.3 and Rock and
Cell Transplant. 2015 Dec 18.
“Patients want options. In my experience
Roll Marathon, and served as an adjunct in-
many patients do very well clinically with
structor with Campbell University’s School
both PRP and mesenchymal stem cell in-
of Osteopathic Medicine.
(5) Chang YH, Liu HW et al.
(6) “Regeneration of Articular Cartilage Using Adipose Stem Cells.” J Biomed Mater Res A. 2016 Mar 17. (7) Rodríguez-Merchán, EC. “Intra-
jections, but these injections have not been shown to prevent joint replacement long
Dr. Kanaan opened Wake Sports Medicine
Articular Injections of Mesenchymal
term. There is not one study that demon-
in 2013 to serve patients in the Triangle
Stem Cells for Knee Osteoarthritis.” Am
strates regrowth of tissue on MRI imaging.
area who were seeking a nonsurgical
J Orthop. 2014;43(12):E282-E291.
6
The Triangle Physician
2016
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Practice Management
Part 2: Tips for Successful
EHR Implementation Margie Satinsky, M.B.A.
Finally – you’ve made a decision on pur-
will provide a work plan, spelling out both
chasing or replacing electronic health re-
vendor and practice responsibilities and
cords software. Postpone the sigh of relief
timelines. Review it carefully. Make sure
until you’ve tackled the next challenge –
you understand and agree with all terms,
implementation.
especially those described below.
This article is Part II of a two-part series.
Timing: Some practices prefer a phased
Last month we identified six common
implementation of new software, but oth-
challenges and suggested ways to address
ers opt for the “big bang,” changing every-
them. This month we offer chronological
thing at once. Let practice size, number of
tips for successful implementation.
locations and workforce size determine the decision.
Step 1: Set the stage with a positive
Margie Satinsky is president of Satinsky Consulting LLC, a Durham consulting firm that specializes in medical practice management. She has helped many physicians start new practices, assess the wisdom of affiliating with a larger health care system and improve their current practices. Ms. Satinsky is the author of numerous books and articles, including Medical Practice Management in the 21st Century. For more information, visit www. satinskyconsulting.com.
message. Change is hard. Start the imple-
Vendor responsibilities: How will the
mentation process with a clear explana-
vendor help the practice? Expect the
tion of ways in which the new software
vendor to provide content knowledge
can help patients receive better care and
about software features, use, design and
the practice work more efficiently. Explain
configuration. Vendors also manage the
the steps that will occur, the timeframe
target timeframes, always looking toward
health records (EHR) software from one
and the distribution of responsibilities.
a mutually agreed-upon go-live date. Ven-
vendor and uses a practice management
Address the most important question that
dors also can provide content from other
system (PMS) offered by a different ven-
your staff will ask: “How can we work on
practices in the same specialty. Consider
dor, an important practice responsibility
software implementation while continuing
that content as a starting point for practice-
is making sure the interface between the
to focus on day-to-day responsibilities?”
specific customization. With respect to
two systems works smoothly. Even if two
training, vendors start with the point per-
vendors have already established working
Step 2: Engage the appropriate people
son and offer training – both onsite and
relationships, the practice needs to un-
in implementation. The vendor will re-
web-based – to others as well. Finally, and
derstand how information flows back and
quire the practice to designate a point per-
most important, the vendor provides sup-
forth from one application to another.
son, sometimes called a clinical system
port for testing and go-live.
application specialist, as the key contact
Here’s an example. Many dermatologists
during and after the implementation pro-
Practice responsibilities: Read the
purchase dermatology-specific software
cess. The point person organizes the pro-
agreement carefully. Make sure you un-
for their EHR. They choose a different ven-
cess internally. S/he schedules training,
derstand all the terms so you can hold
dor for their practice management system.
testing and actual go-live in a way that suits
the vendor to its legal commitments. For
The practice must be clear on the way
both practice and vendor. Many practices
example, some agreements call for an
in which the systems work together. The
also designate “super users” – individuals
upfront payment prior to implementation
same would be true of a patient portal, if
who quickly obtain a good grasp of the
and go-live, with the expectation that the
the practice purchased that application
software and can help train and coach
practice will pay the balance following
from another vendor. How does every-
their colleagues.
successful go-live that is acceptable to
thing work together?
both parties. Step 3: Finalize the work plan. After the agreement has been signed, the vendor
8
The Triangle Physician
The practice is also responsible for conIf the practice has chosen electronic
version from either paper or from another
EHR system. Although vendors vary in their approaches to customization, each practice will also have the opportunity to help build the system. Step 4: Get off on the right foot with a good “kick-off” meeting. All vendors
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schedule a “kick-off” meeting to initiate the implementation process. Make sure the right people within the practice are part of this call and ask many questions. Step 5: Manage the delivery of hardware and software. Some practices purchase hardware, as well as software, from the EHR vendor. If that’s your plan, make sure you receive the correct number of items. Get vendor help for setup of an onsite server or connectivity to a remote
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9
Endocrinology
Differentiated Thyroid Cancer By Carly E. Kelley, M.D., M.P.H.
Approximately 62,450 Americans were di-
The American Thyroid Association (ATA)
agnosed with thyroid cancer in 2015, with
recently released updated 2015 guidelines
three out of four of those cases occurring
on the management of patients with differ-
in women and two out of three occurring in
entiated thyroid cancer. These guidelines1
people younger than 55 years of age.
incorporate new data and scientific advances since 2009. For most thyroid can-
Although only about 1,950 Americans died
cers total thyroidectomy is recommended,
from thyroid cancer in 2015, it is the most
though lobectomy may be considered for
common endocrine malignancy and the
low-risk patients. A preoperative neck ul-
third fastest rising cancer diagnosis in the
trasound for cervical lymph nodes should
United States. The two most important risk
be done to help guide preoperative staging
factors for the development of thyroid can-
and surgery. Patients with clinically involved
cer are history of radiation exposure during
lymph nodes and/or higher-risk tumors will
childhood and either family history of a thy-
require lymph node dissection.
roid cancer syndrome (e.g. MEN2, Cowden syndrome, familial polyposis) or thyroid
Thyroid cancer is staged either using the
cancer in a first-degree relative. The major-
TNM (tumor, nodal metastasis and distant
ity of thyroid cancers are papillary ( about
metastasis) or the American Joint Commit-
80 percent) or follicular (about 10 percent),
tee on Cancer staging system, summarized
with several various subtypes; medullary
in Table 1. Staging determines prognosis
and anaplastic thyroid cancer account for
and post-operative management and sur-
less than 5 percent of cases and will not be
veillance. The 2009 ATA risk stratification
further discussed in this article.
system estimates the risk of persistent/ recurrent disease and stratifies patients ac-
Carly Kelley was born in Livingston, N.J. She graduated magna cum laude from the College of William and Mary in Virginia. She earned her medical degree and master in public health from the University of Medicine and Dentistry of New Jersey, at which point she was inducted into the Alpha Omega Alpha Honor Medical Society. She then completed her postgraduate medical training at Duke University, including internship, residency and an endocrinology fellowship. During her fellowship training, she presented or published in the areas of thyroid, parathyroid, pituitary, lipids and polycystic ovary syndrome. Dr. Kelley is board certified in both internal medicine and endocrinology and is working on her Endocrine Certification in Neck Ultrasound (ECNU). She is a member of both the American Association of Clinical Endocrinology and the Endocrine Society. When not practicing medicine, Dr. Kelley dedicates her time to her husband and two children and enjoys running, cycling, and photography.
The most common presentation for patients
cording to low, intermediate or high risk.
with thyroid cancer is the incidental discov-
The 2015 guidelines additionally illustrate
ery of a painless thyroid mass noted on self
this risk of recurrence as a continuum of
of I-131 therapy by following a low-iodine
or physical exam or imaging study. Diagno-
risk with percentages based on certain clin-
diet for 10 to 14 days prior to I-131 therapy.
sis is usually made by fine needle aspiration
ico-pathological features.
I-131 is administered when levels of thyroid-
(FNA) biopsy of the thyroid nodule using
stimulating hormone (TSH) are very high,
ultrasound guidance. Papillary thyroid car-
Postoperative staging and risk stratification
which can be accomplished using recom-
cinoma may reveal nuclear inclusions or
help determine whether additional treat-
binant TSH (thyrogen), which obviates the
grooves and nuclear overlap, in addition to
ment with radioiodine (I-131) therapy is
need for thyroid hormone withdrawal and
“psamomma bodies” (small calcifications
needed. I-131 can be used to ablate normal
hypothyroidism. Side effects of I-131 therapy
within thyroid follicular cells). Follicular
thyroid remnant or treat residual or recur-
include nausea (though emesis is uncom-
thyroid carcinoma cannot be definitively di-
rent thyroid cancer. I-131 also can be used
mon) and sialoadenitis (salivary gland pain
agnosed by FNA biopsy alone; cytopathol-
to identify the presence or location of local
and swelling), dry mouth and dysguesia
ogy usually identifies a suspicious aspirate
or distant metastasis on a nuclear medicine
(abnormal taste sensation). There is a slight-
as a “follicular neoplasm,” based on cellu-
whole-body scan. The role for I-131 rem-
ly increased risk of secondary cancers with
larity, scant/absent colloid and absence of
nant ablation/adjuvant therapy in low-risk
repeated high doses of I-131 therapy, includ-
papillary structures. About 25 percent of fol-
patients is questionable, since current data
ing cancers of the salivary gland, stomach,
licular neoplasms are either follicular carci-
suggests it may not improve survival or re-
bladder and bone marrow (leukemias).
noma or papillary thyroid carcinoma, follic-
currence rates (which are already low).
Women must not receive I-131 if pregnant or
ular variant. The remainder of these lesions are usually benign follicular adenomas.
10
The Triangle Physician
lactating and should delay family planning Patients may enhance the effectiveness
for at least six months. Men are counseled
Endocrinology to delay fathering children for at least three months.
response to therapy, age and comorbidities (e.g. osteoporosis, atrial fibrillation). Serial neck ultrasounds can be periodically performed
For the long term, most patients are placed on thyroid hormone sup-
to identify recurrent disease in cervical lymph nodes. Thyroglobulin,
pressive therapy (levothyroxine) to keep their TSH suppressed. The
a protein that is exclusively produced by thyroid tissue, is a useful
degree of TSH suppression depends on the patient’s initial stage,
tumor marker post-operatively. An elevated or rising serum thyroglobulin may indicate recurrent disease. Unfortunately, up to 20 per-
TABLE 1 – STAGING SYSTEM FOR DIFFERENTIATED THYROID CANCER
cent of thyroid cancer patients have antibodies to thyroglobulin in their serum, which renders the measurement of thyroglobulin un-
T1
Tumor ≤2 cm
T2
Tumor >2, ≤4 cm
interpretable. Thyrogen is a useful diagnostic and therapeutic agent
T3
Tumor >4 cm, or minimally invasive
that facilitates radioiodine uptake and also may be used to stimulate serum thyroglobulin levels.
T4
Tumor of any size, invading local tissues/structures
N0
No metastatic cervical lymph nodes
N1
Metastatic cervical lymph nodes (N1a medial/N1b lateral to carotid)
The 2015 ATA guidelines recommend that patients’ risk status be re-
NX
Not assessed at time of surgery
considered at each follow up according to their response to therapy.
M0
No distant metastases
M1
Distant metastases
They should be classified as having an excellent response (no evi-
MX
Distant metastases not assessed
dence of disease), biochemical incomplete response (abnormal thyroglobulin level), structural incomplete response, or indeterminate
Patient Age <45
Patient Age ≥45
Stage I
Any T, any N, M0
T1, N0, M0
Stage II
Any T, any N, M1
T2, N0, M0
namic risk-stratification scheme recognizes that initial risk estimates
T3, N0, M0
may need to change as new data on the patient’s clinical status are
T1-3, N1a, M0
accumulated following their initial treatment.
Stage III
Stage IV
response (nonspecific biochemical or structural findings). This dy-
T1-3, N1b, M0 T4, N1a-b, M0
References
Any T, any N, M1
1) Haugen, B. et al. Thyroid. 2016; 26(1): 1-133.
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april 2016
11
Physician Advocacy
Don’t Call Me a “Provider”
Fed Up With Excessive Oversight, Doctors Get Organized – Part I By Marni Jameson
“I am not a ‘provider,’ whatever that is,” a car-
But more worrisome, doctors tell me,
diologist from Pennsylvania said angrily over
are the regulations plaguing them. They
the phone the other day. “I’m a physician.”
bristle at meaningful-use regulations. They resent spending hours of their day filling
He wasn’t angry with me. I hadn’t demoted
in computer data when they could be
him with that euphemism. He was mad at
delivering patient care.
the system. And he was venting. They didn’t go to medical school to spend
Marni Jameson is the executive director for the Association of Independent Doctors. You may reach her at (407) 571-9316 or marni@aid-us.org. Visit www.aid-us.org for more information.
A lot of doctors are venting. As the executive
20 minutes of every hour jumping through
director of a national association dedicated
payers’ hoops to get prior authorizations for
to blame for letting this happen. They’ve
to giving doctors a voice and championing
patients. They find it insulting when they
been asleep at the switch – busy getting
their causes (which, really, are all of our
have to get permission from an insurance
more training, removing gallbladders and
causes), I get a lot of calls like this.
company representative to do what they
mending bones – while government, payers
know is best for their patient.
and hospitals have been advancing their agendas.
Doctors are fed up. But what’s different now than from even five years ago is that doctors
And they balk at government’s co-opting
are actively banding together. All over the
their office hours in a patient-data-gathering
But they are paying attention now. Proof
country groups of frustrated physicians
exercise that is of no value to the patient or
lies in the number of organizations like AID
are organizing and speaking out against a
the doctor.
that have been forming and growing and melding.
system that is demeaning their profession, undermining their authority and intruding
“Before I can talk to my patient about a
on their patient relationships.
sinus infection, I first have to ask whether
AID, which turns three years old this
he has any firearms in his house, or
month, is a physician advocacy group
Calling doctors “providers” is just the
whether he has ever thought about hurting
that enlightens consumers, businesses
beginning. But it’s emblematic. Physicians,
himself,
government,”
and lawmakers about the importance of
in general the most educated members of
said Elaina F. George, M.D., an Atlanta
supporting independent doctors. It now has
our society, don’t take kindly to bureaucrats,
pediatric otolaryngologist, Association of
more than 1,000 members coast to coast in
insurance
to
please
the
care
Independent Physicians (AID) member and
14 states and has a voice on the national
administrators blurring the lines of health
a leader in the Association of American
stage.
care hierarchy.
Physicians and Surgeons. Like many
executives
or
health
As one doctor asked me lately: “How did
physicians, she finds the questions time
In next month’s column, I will introduce
consuming and intrusive.
other organizations that have joined in the fight to save the practice of medicine.
we go from being at the top to the food chain to being the food?”
12
The Triangle Physician
Doctors also are realizing that they are partly
Together, we are making progress.
Duke Research News
Prostate Cancer Metastasis Site Has Direct Impact on Survival Time In the largest analysis of its kind, research-
Most patients, nearly 73 percent, had bone
include William Kevin Kelly, Hua Ma,
ers at the Duke Cancer Institute and other
metastases, and their overall median sur-
Haojin Zhou, Nicole C. Solomon, Karim
top cancer centers have found that the
vival was just greater than 21 months. Men
Fizazi, Catherine M. Tangen, Mark Rosen-
organ site where prostate cancer spreads
with only lymph involvement were the
thal, Daniel P. Petrylak, Maha Hussain,
has a direct impact on survival.
smallest subset – 6.4 percent – but had
Nicholas J. Vogelzang, Ian M. Thompson,
the longest median survival at about 32
Kim N. Chi, Johann de Bono, Andrew J.
months.
Armstrong, Mario A. Eisenberger, Abder-
Patients with lymph-only metastasis have
rahim Fandi,Shaoyi Li, John C. Araujo,
the longest overall survival, while those with liver involvement fare worst. Lung
Men with liver metastasis represented 8.6
Christopher J. Logothetis, David I. Quinn,
and bone metastasis fall in the middle.
percent of the patients and had a median
Michael J. Morris, Celestia S. Higano, Ian F.
survival of nearly 14 months. Men with
Tannock and Eric J. Small.
“Smaller studies had given doctors and pa-
lung metastases had a median survival
tients indications that the site of metasta-
time of 19 months and represented 9.1 per-
This research received support from the
sis in prostate cancer affects survival, but
cent of the study population.
National Institutes of Health (CA 155296) and the Department of Defense (W81X-
prevalence rates in organ sites were small, so it was difficult to provide good guidance,” said Susan Halabi, Ph.D., professor of biostatistics at Duke and lead author of the study published online March 7 in the Journal of Clinical Oncology. “With the large numbers we analyzed in our study, we were able to compare all of these different sites and provide information that could be helpful in conveying prognosis to patients,” Dr. Halabi said. “This information could also be used to help guide treatment approaches using either hormonal therapy or chemotherapy.” Dr. Halabi and colleagues from leading United States and international cancer research centers pulled data from nine
“These results should help guide clinical
WH-15-1-0467). In addition, the Alliance
large, Phase III clinical trials to analyze
decision making for men with advanced
for Clinical Trials in Oncology, AstraZen-
outcomes of 8,736 men with metastatic
prostate cancer,” Dr. Halabi said. “They
eca, Bristol-Myers Squibb, Celgene, On-
prostate cancer. The patients had all un-
also suggest that prognostic subgroups
cogenex, Regeneron, Sanofi and SWOG
dergone standard treatment with the che-
should be considered for investigational
provided data.
motherapy drug docetaxel.
therapies that are tested in clinical trials.”
Site of metastases was categorized into four
Dr. Halabi said more research is needed to
groups: lung, liver (without lung), lymph
understand how and why prostate cancer
nodes only, bone with or without lymph
spreads to different organs.
nodes and no other organ metastases. In addition to Dr. Halabi, study authors
april 2016
13
Duke Research News
Thyroidectomy Recommendation:
Choose Surgeons With 25-plus Cases a Year A new study from Duke Health suggests that patients who need
Thyroidectomy is one of the most common operations performed
to have their thyroid gland removed should seek surgeons who
in the United States, often due to cancer, over activity or enlarge-
perform 25 or more thyroidectomies a year for the least risk of
ment of the gland located at the base of the throat that produces
complications.
hormones and regulates metabolism.
More Cases Lead to Better Surgical Outcomes Patients of low-volume surgeons (25 or fewer thyroidectomies per year) have an increased risk for complications when compared to patients of high-volume surgeons (26 or more operations a year.)
Most consumers would be surprised to learn that more than half (51 percent) of surgeons who perform thyroidectomy do so just once a year, according to the study published in the Annals
Thyroidectomies Per Year
Risk of Complication
1 case
87 percent increased risk
2-5 cases
68 percent increased risk
“This is a very technical operation, and patients should feel empow-
6-10 cases
42 percent increased risk
ered to ask their surgeons how many procedures they do each year
11-15 cases
22 percent increased risk
on average,” said Julie A. Sosa, M.D., senior author and chief of en-
16-20 cases
10 percent increased risk
docrine surgery at Duke. “Surgeons have an ethical responsibility to
21-25 cases
3 percent increased risk
report their case numbers. While this is not a guarantee of a positive
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The Triangle Physician
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Duke Research News outcome, choosing a more experienced surgeon certainly can improve the odds that the patient will do well.” Although total thyroidectomy is generally safe, it can cause life-altering complications that were seen in some study patients, such as bleeding, problems with the parathyroid glands and damage
BE WELL. Take control of your health. Take control of your life. We can help.
to the laryngeal nerve that can lead to difficulty speaking, breathing and swallowing. Any complication can require more care, driving up patient costs and potentially compromising quality of life. The study evaluated data from 16,954 paRADAR: BAY15001
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surgeons performed each year and rates of complications. Notably, patients of surgeons who performed fewer than 25 thyroidectomies a year were 1.5 times more likely to experience complications. As the average number of cases increased, the risk of complications for patients steadily decreased. Risks leveled out for surgeons who performed an average of 25 or more operations a year.
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15
WakeMed Research News
Supersaturated Oxygen Therapy Has Potential to Improve STEMI Outcomes WakeMed Health & Hospitals is the second
tacks, PCI involves angioplasty and stenting
O. Wood, M.D., F.A.C.C., a board-certified
hospital in the United States to treat a car-
procedures to quickly open blockages and
interventional and structural cardiologist
diac patient with a potentially breakthrough
increase blood flow to the heart. Some pa-
with WakeMed Heart & Vascular Physicians.
treatment that provides supersaturated oxy-
tients suffer long-term effects from the lack
“This important study of SSO2 therapy may
gen (SSO2) therapy to reduce damage to
of oxygen that causes a heart attack, such
provide physicians with an additional inter-
the heart muscle after an ST elevation myo-
as irreversible damage to the heart muscle
vention to repair the heart muscle, further
cardial infarction.
and the potential for future heart failure.
improve outcomes and help restore quality of life for our heart attack patients.”
This trial, called the IC-HOT (Evaluation
“The lack of oxygen and
of Intracoronary Hyperoxemic Oxygen
the extent of heart-mus-
Dr. Wood performed the
Therapy) study, marks the first treatment
cle damage following a
SSO2 therapy on Feb.
option beyond percutaneous coronary in-
severe heart attack can
23 at WakeMed Heart
carry a poorer prognosis
Center, in partnership
tervention (PCI) for heart attack patients. The standard of care in treating heart at-
Frances O. Wood, M.D., F.A.C.C.
for patients,” said Frances
Pratik Desai, M.D., F.A.C.C.
with Pratik Desai, M.D., F.A.C.C., of Cary Cardiol-
ogy. Oxygen therapy was administered to an ST elevation myocardial infarction (STEMI) patient immediately following coronary angioplasty performed by Dr. Desai. A STEMI is a severe heart attack that occurs when a coronary artery is completely blocked, preventing oxygen-rich blood from reaching the entire heart muscle. The primary objective of the IC-HOT study
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is to collect confirmatory data supporting the safety and effectiveness of SSO2 therapy in appropriate patients who have undergone successful angioplasty and stenting within six hours of experiencing heart attack symptoms. A total of 100 subjects will be enrolled at up to 15 United States investigational centers. According to the American Heart Association, every year nearly one million people in the U.S. have heart attacks, typically caused when the blood flow carrying oxygen to the heart is reduced or blocked. The IC-HOT study is being conducted by TherOx Inc. to support a premarket approval submission to the U.S. Food and Drug Administration and is expected to be completed by December 2016.
16
The Triangle Physician
News Welcome to the Area
Physicians
Erin Elizabeth Hayes, MD
Robert Kyle Sackmann, MD
Sarah Fulton Hendrickson, PA
Pediatrics
Emergency Medicine
Pediatric Urology; Urology
Emergency Medicine
Durham
Durham Emergency Physicians Durham
Stephanie Leigh Hill, MD
UNC Hospitals Chapel Hill
Psychiatry, Geriatric
Theodore Asher Schuman, MD
Associated Urologists of North Carolina Raleigh
Richard MatthewAtkins, MD
Vidant Health Ahoskie
Otolaryngic Allergy; Otorhinolaryngology; Rhinology
Jennifer Kaitlyn Hopper, PA
UNC Dept. of Otolaryngology Chapel Hill
Raleigh
Pediatrics
Whitney Hope Sherry, MD
Internal Medicine
Duke University Hospitals Durham
Pediatrics
Lora Alkhawam, MD
Internal Medicine
Durham VA Medical Center Durham
Alex DavidBibbey, MD Radiology
Duke University Hospitals Durham
Erica Christen Bjornstad, MD Pediatrics; Public Health
University of North Carolina Hospitals Chapel Hill
Ben Adam Blomberg, MD Internal Medicine
University of North Carolina Hospitals Chapel Hill
Eric Sharp Burgon, MD Maxillofacial Surgery
UNC Dept of Oral & Maxillofacial Surgery Chapel Hill
Elizabeth Anne Campbell, MD Endocrinology, Internal Medicine
Duke University Hospitals Durham
Benjamin Hanpin Chi, MD Obstetrics and Gynecology
University of North Carolina at Chapel Hill Chapel Hill
Dana Cooley Clifton, MD Internal Medicine; Pediatrics
Duke University Hospital Durham
Lisa Ann Cowan, MD Ophthalmology
Duke University Eye Center Durham
Andrea Teresa Deyrup, MD Anatomic Pathology; Pathology
Siler City
Anand Raj Dugar, MD Anesthesiology
Chapel Hill
Dorothy Lunette Floyd, MD Obstetrics and Gynecology
Northwest Carolina Women’s Center North Wilkesboro
Sophie Wolfe Galson, MD Emergency Medicine
Durham
Robert Thomas Harris, MD Administrative Medicine; Psychosomatic Medicine
CSC, Inc. Raleigh
Sarah Ann Thiessen Holsopple, MD
Alyssa Ann Jenkins, MD Pediatrics
Duke University Hospitals Durham
Steven Michael Koehler, MD Surgery of the Hand; Orthopedic Sports Medicine; Orthopedic Surgery of the Spine; Adult Reconstructive, Musculoskeletal Oncology; Orthopedic Surgery, Pediatric
Duke University Medical Center Durham
Shachar Laks, MD Abdominal Surgery; Colon and Rectal Surgery; Critical Care Surgery; General Surgery; Surgical Oncology
UNC Hospitals Chapel Hill
Diana Miriam Leitner, MD Ophthalmology
Duke Eye Center Durham
Douglas Smoot Lewis, MD Diagnostic Radiology; Diagnostic Roentgenology Radiology; Musculoskeletal Radiology; Neuroradiology; Nuclear Medicine; Nuclear Radiology; Pediatric Radiology; Radiology; Radiology, Neuradiology; Vascular and Interventional Radiology
General Practice
Natalie Claire Jones, PA Doctors Making Housecalls Durham
University of North Carolina Hospitals Chapel Hill
Braxton Thomas Kinsey, PA
Akshay Sebastian Thomas, MD Ophthalmology
Duke Eye Center Durham
Family Practice/Sports Medicine; Gastroenterology, Internal Medicine; Hospitalist; Orthopedic Sports Medicine, Surgery; Urgent Care
Fuquay-Varina
Joanne Sophia Wyrembak, MD Internal Medicine
Anna Mary Klein, PA Family Medicine
Chapel Hill
Duke University Hospitals Durham
Lindsay Michelle Merriman, PA Hospitalist
Physician Assistants
Central Carolina Hospital Sanford
Christine Marie Ciszek, PA
Jennifer Anne Shurney, PA
WakeMed Physician Practices Raleigh
Abdominal Surgery; General Surgery
UNC Healthcare Chapel Hill
Brianna Norris Dillon, PA Family Medicine
Vaishali Nitin Thanawala, PA
Erwin
Family Medicine; Family Practice
Sanford
Brianna Norris Dillon, PA
Krista Michelle Udd, PA
Family Medicine
Erwin
Margaret Ellen Emerson, PA Gastroenterology, Internal Medicine
Raleigh Medical Group Gastroenterology Raleigh NEWSOURCE-JUN10:Heidi
Critical Care-Internal Medicine; Internal Medicine - Critical Care Medicine
Raleigh
Diana Whitney Walker, PA Family Medicine
8/5/10
Raleigh
12:57 PM
Page 1
Duke University Hospitals Durham
Ilya Leyngold, MD Ophthalmology
Do They Like What They See?
Duke Eye Center Durham
Rachel Ann Miller, MD
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