Au g u s t 2 015
Wake Internal Medicine Consultants, Inc. Largest Independent Multi-specialty Group in the Triangle
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6
COVER STORY
Wake Internal Medicine Consultants The Triangle’s Largest Independent Multi-Specialty Group
a u g u s t 2 0 15
FEATURES
12
Vol. 6, Issue 7
DEPARTMENTS 9 Gastroenterology
Patient Care
10 Practice Management
Put Yourself in Your Patient’s Shoes
Eric Challgren understands that pain is per-
sonal and uses his own experience with it to help his patients.
13
Understanding Functional Dyspepsia
Suggestions for Internal Measures Can Boost Marketing Initiatives
14 Women’s Health Understanding Migraine Fundamentals
16 Duke Research News
Brains of Smokers Who Quit May Be Hard Wired for Success
16 Duke Research News
Endocrinology
Hashimoto’s (Autoimmune) Thyroiditis Michael Thomas gives a diagnostic overview
Thin Colorectal Cancer Patients Have Shorter Survival Than Obese Patients
18 UNC Research News
Scientists Find New Evidence of Key Ingredient During Dawn Of Life
20 NEWS WakeMed Physician Practices-Pediatrics to Launch Positive Parenting Program
of a common cause of declining thyroid
20 NEWS
function.
2
The Triangle Physician
Welcome to the Area
From the Editor
Orchestration 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
Bravo to Wake Internal Medicine Consultants, this month’s cover story, a fast-growing group of “fiercely independent” physicians. The multispecialty practice is described as a “premier medical group” that is patient and wellness focused. At its foundation are principles of fiscal responsibility and a spirit of philanthropy. It’s a model of how diverse attributes can work in harmony.
This issue of The Triangle Physician is robust, with a host of contributing editors, who write about subjects they are passionate about. Dermatologist Eric Challgren notes how his own experience with a painful condition makes him a better physician. Gastroenterologist Douglas Drossman describes the distinctive symptoms of functional dyspepsia. Endocrinologist Michael Thomas provides an overview of Hashimoto’s thyroiditis. Gynecologist Andrea Lukes reviews migraine fundamentals. Practice management consultant Margie Satinsky looks at
Editor Heidi Ketler, APR heidi@trianglephysician.com Contributing Editors Eric D. Challgren, M.D. Douglas A. Drossman, M.D. Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G. Margie Satinsky, M.B.A. Michael J. Thomas, M.D., Ph.D. Creative Director Joseph Dally jdally@newdallydesign.com
Advertising Sales info@trianglephysiciancom News and Columns Please send to info@trianglephysician.com
The Triangle Physician is published by: New Dally Design
ways a practice can boost customer satisfaction from within.
Subscription Rates: $48.00 per year $6.95 per issue
The Triangle Physician is a great instrument for communicating practice
Advertising rates on request Bulk rate postage paid Greensboro, NC 27401
news and sharing professional expertise. All can join in. There is no charge to run medical news and commentary. Advertising rates are competitive, making the magazine a cost-effective way to orchestrate your marketing message to the more than 9,000 professionals in the Triangle medical community. So chime in! We welcome your inquires and comments: info@trianglephysician.com.
With great appreciation for all you do,
Heidi Ketler Editor
4
The Triangle Physician
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.
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The Triangle Physician
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Cover Story
Wake Internal Medicine Consultants, Inc. The Triangle’s Largest Independent Multi-Specialty Group With 27 physicians and six physician assis-
better care and customer service to their
WIMC’s philosophy is the patient is the cen-
tants across 10 different specialties, Wake
patients. So when someone asks, “tell me
ter of all that is done. “If we make this our
Internal Medicine Consultants (WIMC) has
about the culture of WIMC,” the answer of
focus and mission, we cannot go wrong in
solidified itself as the area’s largest inde-
“it’s the way we do things around here”
an ever-changing health care world. We are
pendent medical group – and it doesn’t
can be spoken with pride, knowing the
determined to be good citizens, recogniz-
show signs of slowing.
practice is committed to its mission of
ing the influence health care workers and
being the premier medical group in the
physicians can have on a community. In
The practice continues to expand with the
region. WIMC achieves this through the
addition to delivering state-of-the-art medi-
addition of a gynecologist and an internist
delivery of consistent, high-quality medical
cine, we believe that the philanthropic,
joining Sept. 1, 2015, as well as a gastroen-
care and customer service to patients, ven-
volunteering and educational activities we
terologist joining Oct. 1, 2015. The practice
dors and each other, as well as providing
are engaged in support this community
has independently thrived for more than
service founded on the principles of fiscal
stewardship mentality,” says Matt Johnson,
75 years as “a big practice with a small-
responsibility and respect for privacy and
Chief Administrative Officer of Wake Inter-
town feel, providing a lifetime of quality
the dignity of every individual.
nal Medicine Consultants.
care,” said Christopher N. McDaniels, M.D. “I partner with patients from age 17 until
A 75-Year Local History
The physicians pride themselves on be-
the end of life. I not only evaluate, diagnose
The Wake Internal Medicine Consultants
ing fiercely independent. As owners of the
and manage acute and chronic conditions,
multi-specialty clinic began as a one-physi-
practice, they play an integral role in the
but work very hard to engage patients on
cian internal medicine practice opened by
decision-making processes of the clinic.
their own path of wellness,” says Daniel J.
Dr. Thomas Umphlet in 1938. Dr. Umphlet
The physician partners at WIMC are ex-
Mollin, M.D.
ran his practice at the Cameron Apartments
pected to lead and serve on committees that range from an Information Technology Committee to a Compliance and Peer Review Committee. This hands-on approach has been instrumental in the group’s ongoing success. A Culture Centered Around Care With the addition of a new chief administrative officer in 2014, the group identified patient satisfaction as its top objective, and a close second was employee satisfaction. The charge to the new administrator was to focus on these objectives, believing that happy, engaged employees deliver
6
The Triangle Physician
In-house CLIA (Clinical Laboratory Improvement Amendments) certified laboratory
building in Raleigh with a medical office and onsite lab. His lab was the only approved serology lab in North Carolina that was not state owned. Almost a decade later, the office relocated as partners were added. The practice became a corporation in 1981 and relocated to the Rex Hospital medical office. Four years later, the office was moved to its current location, 3100 Blue Ridge Road. After much growth and planning, an expansion was made to a North Raleigh satellite office at the Durant Medical Center in March 2008, and it became the home of Wake Internal Medicine Consultants’ internal medicine and pediatrics program. Wide Array of Specialties
WIMC focuses on making sure patients are as comfortable as possible during in-office procedures, such as a computed tomography scan.
As a multi-specialty clinic, WIMC offers preventive and specialty care to serve people
• Urgent care
Meet Wake Internal Medicine Physicians
with a wide variety of needs. Many of the physicians are certified in subspecialties,
Wake Internal Medicine provides an exten-
Wake Internal Medicine’s team is commit-
such as sleep medicine or pulmonology.
sive number of onsite services, making it
ted to becoming the premier multi-spe-
easy for patients to receive most of their
cialty medical group in the Raleigh area
Specialties and subspecialties offered at
care in-house. These services include:
through delivery of consistent, high-quality
WIMC include:
• CLIA (Clinical Laboratory Improvement
medical care.
• Internal medicine
Amendments)-certified laboratory
• Pediatrics
• Nuclear cardiology
Internal Medicine
• Gastroenterology
• Ultrasound
Bhavna Bhat, M.D.
• Gynecology
• Echocardiography
Donald B. Campbell, M.D.
• Nonsurgical orthopedics/sports
• Computed tomography scanning
C. Brad Carlson, M.D.
• Radiology
Kevin E. Dougherty, M.D.
• Bone density/DEXA (dual-energy X-ray
Jonathan Flescher, M.D., F.C.C.P.
medicine • Sleep medicine • Pulmonary medicine
absorptiometry)
• Geriatrics
• Endoscopy procedures
• Cardiology
• Gynecology procedures
- Specializing in pulmonary medicine Wayne L. Harper, M.D. Jessica C. Heestand, M.D. Rodger D. Israel, M.D. - Specializing in geriatrics Arvind N. Jariwala, M.D. Stuart J. Levin, M.D. - S pecializing in pulmonary and sleep medicine Bushra Mastoor, M.D. Daniel J. Mollin, M.D. Anthony Rico, M.D. Treva W. Tyson, M.D. Med-Peds Sarah Hughes, M.D. Christopher N. McDaniels, M.D. John J. Meier IV, M.D.
Gastroenterologist Dr. Bulent Ender interviews a patient to assess problems and symptoms.
august 2015
7
- www.wakewomenshealth.com
Gastroenterology Charles F. Barish, M.D., F.A.C.P., F.A.C.G.,
Main location:
(919) 719-2600
Wake Internal Medicine
A.G.A.F. Bulent Ender, M.D.
3100 Blue Ridge Road, Suite 100 & 300
Marc A. Herschelman, D.O.
Raleigh, NC 27612
Angela Hira, D.O.
North Raleigh location:
Seth A. Kaplan, M.D.
- www.wakesportsmedicine.com (919) 719-2270 - www.rxuc.com
Wake Internal Medicine & Pediatrics
Gynecology
10880 Durant Road, Suite 100
Prashanti Aryal, M.D, F.A.C.O.G.
Raleigh, NC 27614
Main: (919) 719-2250 North Raleigh: (919) 719-2260
Richard W. Kurzmann, M.D. Marianna G. Law, M.D., F.A.C.O.G. Rosemarie Newman, M.D.
- www.wakeinternalmedicine.com (919) 781-7500 - www.wakepediatrics.com
Nonsurgical Orthopedics/
(919) 781-7500 - www.wakegastro.com
Sports Medicine Matthew G. Kanaan, D.O.
(919) 781-7515 Bushra Mastoor, M.D.
C. Brad Carlson, M.D.
Anthony Rico, M.D.
Arvind N. Jariwala, M.D.
Bhavna Bhat, M.D.
Bulent Ender, M.D.
Jessica Hedrick, P.A.
John J. Meier IV, M.D.
Charles F. Barish, M.D.
Christopher N. McDaniels, M.D.
Daniel J. Mollin, M.D.
Donald B. Campbell, M.D.
Matthew G. Kanaan, D.O.
Richard W. Kurzmann, M.D.
Jonathan Flescher, M.D.
Kevin E. Dougherty, M.D.
Lori C. Bridges, P.A.
Marc A. Herschelman, D.O.
Stuart J. Levin, M.D.
Treva W. Tyson, M.D.
Rodger D. Israel, M.D.
Rosemarie Newman, M.D.
Sarah Hughes, M.D.
Seth A. Kaplan, M.D.
Wayne L. Harper, M.D.
Marianna G. Law, M.D.
8
The Triangle Physician
Gastroenterology
Understanding
Functional Dyspepsia
By Douglas Drossman, M.D.
Dyspepsia is a common clinical condition associated with a complex of upper abdominal symptoms including: discomfort or pain centered in the upper abdomen,
1. A decrease in distal stomach motility (antral hypomotility) and delay in gastric emptying; 2. Impaired reduction in gastric tone
feeling of abdominal fullness, early satiety,
(impaired gastric accommodation) in
abdominal distention and bloating, belch-
response to meals, which may lead to
ing and nausea.
a decrease in the ability of the stomach to expand and allow the consumption
The exact prevalence of functional dyspepsia (FD) in the general population is not
of large meals; and 3. Disordered gastric electrical activity as
known, but it is estimated that as many as 25
recorded by electrodes placed over the
percent to 40 percent of adults experience
upper abdomen (electrogastrography).
symptoms of dyspepsia in a given year.
These findings suggest that some patients with FD may have gastric motor
The differential diagnosis of dyspepsia
or electrical abnormalities.
includes: acid-related disorders, such as gastroesophageal reflux disease (GERD)
Several studies also have shown that
and peptic ulcer disease (PUD); gastric
patients with FD are significantly more
inflammatory conditions, such as helico-
sensitive to stomach distention (by an in-
bacter pylorigastritis, nonsteroidal anti-in-
tragastric balloon) compared to healthy in-
flammatory drug (NSAID)-related erosions
dividuals. Moreover, patients with FD have
or gastropathy; functional dyspepsia; and
reduced duodenal motor response and
less common but still possible upper ab-
are more sensitive to intraduodenal acid
dominal cancer (e.g., gastric, esophageal,
infusion. Interestingly, hypersensitivity to
pancreatic tumors).
mechanical distention was found to be correlated with symptoms of pain, belch-
Consistent with the Rome III classification
ing and weight loss, while intraduodenal
system, FD is diagnosed by one or more
acid correlated more with nausea.
of the following symptoms occurring for at least three months:
Functional dyspepsia also may be subclas-
1. Bothersome postprandial fullness,
sified by Rome III criteria into one or both
2. Early satiation,
of two symptomatic groups:
3. Epigastric pain or
1. Postprandial distress syndrome â&#x20AC;&#x201C; Both-
4. Epigastric burning.
ersome postprandial fullness and/or early satiety.
In addition, there is no evidence of struc-
2. Epigastric pain syndrome â&#x20AC;&#x201C; Epigastric
tural disease identified by upper endos-
pain and/or burning, and the pain is not
copy or other diagnostic studies.
intermittent, it is not generalized or localized to other abdominal or chest regions,
The cause of FD has been difficult to define.
it is not relieved by defecation or flatus
Several specific motility abnormalities have
and it does not fulfill criteria for gallblad-
been described in subgroups of patients
der or sphincter of Oddi disorders.
with FD. These abnormalities include:
Dr. Douglas Drossman graduated from Albert Einstein College of Medicine and was a medical resident and gastroenterology fellow at the University of North Carolina. He was trained in psychosomatic (biopsychosocial) medicine at the University of Rochester and recently retired after 35 years as professor of medicine and psychiatry at UNC, where he currently holds an adjunct appointment. Dr. Drossman is president of the Rome Foundation (www.theromefoundation. org) and of the Drossman Center for the Education and Practice of Biopsychosocial Care (www.drossmancenter. com). His areas of research and teaching involve the functional GI disorders, psychosocial aspects of GI illness and enhancing communication skills to improve the patient-provider relationship. Drossman Gastroenterology P.L.L.C. (www.drossmancenter.com) specializes in patients with difficult-to-diagnose gastrointestinal disorders and in the management GI disorders, in particular severe functional GI disorders. The office is located at Chapel Hill Doctors, 55 Vilcom Center Drive, Suite 110 in Chapel Hill. Appointments can be made by calling (919) 929-7990.
Newer understanding in functional dyspepsia shows that these two subgroups may have different physiological features and thus may be amenable to more specific medication treatments. Postprandial distress syndrome reflects impaired relaxation of the gastric fundus and could respond to buspirone (a fundic muscle relaxant), and more recent evidence shows a response to mirtazapine. On the other hand, epigastric pain syndrome reflects nerve sensitization and treatments, such as proton pump inhibitors initially, and then tricyclic antidepressants, or serotonin norepineperhine re-uptake inhibitors may be helpful for this as well. august 2015
9
Practice Management
Suggestions for Internal Measures Can
Boost Marketing Initiatives By Margie Satinsky, M.B.A.
Marketing your practice makes a difference!
We’ve helped more than 100 practices over
patients who are waiting to listen to confi-
In an article that appeared in the October
the years, and the response that feels most
dential discussions at the check-in window?
2014 issue of The Triangle Physician, we rec-
welcoming to us is the voice of the practice
Is worn furniture uncomfortable for sitting?
ommended steps you can take to promote
owner herself, welcoming the call and pro-
the services you provide and traps to avoid.
viding further instructions depending on
Do you take advantage of opportunities for
Those suggestions and cautions had an ex-
the purpose of the call. We also like mes-
patient education about your providers and
ternal focus.
sages that spare us from the experience of
the services that you provide? Do you use
waiting on hold and that offer a call back
background music or educational TV pro-
option.
grams to enhance the atmosphere?
impressions; treating patients as individu-
Our back bristles when employees sound
Treat Patients as Individuals
als; ensuring that established patients un-
as if they’d rather be anywhere other than
One way you can enhance loyalty to your
derstand the complete scope of services
the practice. If we need to cheer them up,
practice is to recognize each patient as an
offered; turning negatives into positives;
we take our business somewhere else.
individual.
ing the entire workforce on the marketing
With respect to patient communication
If you’ve performed a procedure in your
team; following up after patients leave the
through a secure patient portal, the interac-
office or at another location, follow up af-
office; and regularly taking the pulse of the
tion can be positive or negative. It depends
terwards to ask how the patient is feeling.
practice.
on the effort you put into vendor selection
Remember birthdays, anniversaries and
and into customization and testing the fea-
other special occasions.
The seven suggestions in this article focus on internal marketing. They deal with first
focusing on workforce satisfaction, includ-
Let’s return to basics and reiterate the
tures of your portal prior to going live with
meaning of marketing, be it internally or ex-
patients.
If one of your patients receives notice in the local newspaper or appears on TV, ac-
ternally focused. Marketing consultant Peter
knowledge the occasion. Go the extra mile!
Drucker calls marketing your “whole firm,
Many vendors that specialize in electronic
taken from the customer’s point of view.”
health record (EHR ) software now offer
Taken one step further, marketing means
their own portals but don’t provide the
Ensure Existing Patients Under-
“coordinated efforts to communicate with
same levels of support and expertise as
stand the Full Scope of Services
and persuade customers to purchase, use
vendors that specialize in portal design and
Many patients seek care or treatment for a
and repurchase the services that you pro-
operationalization. That portal is your sec-
specific reason and are unaware that the
vide through multiple points of influence.
ond voice, so make sure it’s robust, not an
practice offers other services.
afterthought to other software. Amanda Kanaan, president and founder of
The American Medical Association describes marketing as the process of plan-
First impressions in the waiting room count
WhiteCoat Designs in Raleigh, reminds her
ning and executing the conception, pricing,
too. Given the physical space and layout
clients to keep patients informed about the
promotion and distribution of ideas, goods
of your practice, is check-in and check out
full scope of services offered. Two effective
and services to create exchanges that satis-
easy and private? Do long patient waiting
ways to spread the word are by making in-
fy individual and organizational objectives.
lines snake out the door or do you add
formation available in the waiting area and
more staff at those times of the day and
by having staff describe all the services of-
Concentrate on First Impressions
days of the week when volume is highest?
fered.
Remember the importance of first impres-
Do workforce members greet patients with
sions. When potential new patients contact
a smile or a scowl?
quire about services and appointments,
Pay attention to your waiting areas. Do
what reception do they get?
chairs face the check-in area, encouraging
10
The Triangle Physician
Be sure to identify and highlight services on your website, too, so patients can learn
your practice by phone or by email to in-
more when they access the patient portal.
Practice Management Margie Satinsky, MBA, is President of Satinsky Consulting, LLC, a Durham, NC consulting firm that specializes in medical practice management. She’s provided HIPAA compliance consultation to more than 100 Covered Entities and Business Associates. Margie is the author of numerous books and articles, including Medical Practice Management in the 21st Century. For additional information, go to www.satinskyconsulting.com.
Make Workforce Members Part of
Check the Practice Pulse Regularly
The Marketing Team
How do you know your internal marketing
Consider every workforce member a part
efforts are working? Take the pulse of your
of the marketing team. Encourage everyone
practice. Seek patient input through satis-
to deliver a consistent message about “your
faction surveys and focus groups. Use the
story” or brand. The more frequently a pa-
same approach with referring physicians
tient hears the same message repeated, the
and their office staff.
more likely he or she will be to remember it and share it with family and friends.
Solicit input from your own workforce and encourage your staff to come forward with sug-
Follow Up After Patients Leave
gestions for improvement. Here’s an example.
the Office
One of our clients devotes time during each
Most office visits are short, allowing little
weekly meeting to group discussion of an as-
time to share all the messaging that the
pect of operations that needs improvement.
practice would like to provide to patients.
Once the problems are out on the table, ev-
Furthermore, patients may not remember
erybody takes ownership and the group de-
all they hear.
velops its own remedial suggestions.
Try turning negatives into positives, such as
Amanda Kanaan suggests continuing con-
Finally, try the mystery shopper approach
when a patient is kept waiting for an unex-
versations with patients even after they’ve
and learn the fine points about your prac-
pectedly long period of time. An immediate
left the office. Newsletters and social media,
tice. You may be surprised – both positively
“I’m sorry” to acknowledge the problem
used appropriately, are good communica-
and negatively!
and show respect for the patient’s time can
tion tools.
Turn Negatives into Positives
help lift his or her mood. Focus on Workforce Satisfaction The workforce, not expensive equipment, is
practice mission, goals and priorities. Re-
55 Vilcom Center Drive Boyd Hall, Suite 110 Chapel Hill, NC 27514
Drossman Gastroenterology PLLC a patient-centered gastroenterology practice focusing on patients with difficult to diagnose and manage functional GI and motility disorders. The office is located within the multidisciplinary health care center, Chapel Hill Doctors. Dr. Douglas Drossman is joined by physician’s assistant, Kellie Bunn, PA-C. Appointments are scheduled on Tuesday and Wednesday and most laboratory studies are available.
move the ambiguity from reporting rela-
919.929.7990
www.drossmangastroenterology.com
every practice’s most valuable asset. Workforce members who enjoy the work that they do and receive appropriate recognition for their efforts work well as a team and convey their satisfaction to patients. Keep everybody on the same playing field by developing and communicating a clear
Drossman Gastroenterology
tionships. Make sure that job descriptions accurately spell out job expectations and responsibilities. Set an example for collaboration and teamwork and reward it when you see it. Thank employees for a job well done – before they remind you that a review or bonus is overdue! Take time out to say thanks with a special social event.
august 2015
11
Patient Care
Put Yourself in Your Patient’s Shoes By Eric D. Challgren, M.D.
As a dermatologist, I try to always keep
the pain scale.
in mind a patient’s perspective, because I, too, am a patient. Between chasing my
If my pain is a 5, on a 1-to-10 scale, that
three active children and my own hobbies
very same pain may register as a 3 or a
of biking, skiing, playing golf, softball and
10 for someone else in terms of their own
swimming, some people would assume I
internal sensor. The range can be excep-
am perfectly healthy when seeing how ac-
tional on all levels: physical, mental and
tive I am. But that is not the case.
emotional, ranging from mild to major.
I have ankylosing spondylitis (AS), a form
Of course, patients in pain seek out dif-
of arthritis that primarily affects the spine.
ferent providers, depending on their
It causes inflammation of the spinal joints
perceived source of the pain. Yet, there
that can lead to severe, chronic pain and
are no general rules that apply to all the
other complications. Because of this,
variations of, or even all the treatments for,
when patients come to me in pain, they
pain. Some who are dealing with chronic
can be sure they will have my full sympa-
pain even have mental tricks that help di-
thetic support and attention.
rect their focus off of the pain and onto where it should be at any given time.
Yet, each of us is different in our sensa-
Dr. Eric Challgren graduated from North Carolina State University with a bachelor of science degree in chemical engineering. He earned his medical degree from the Medical College of Ohio and completed his dermatology internship at Medical College of Ohio and residency at the Medical College of Wisconsin. Dr. Challgren is a fellow of the American Society for Mohs Surgery and a member of the American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, American Academy of Dermatology, American Medical Association, North Carolina Medical Association. Areas of special interest include Mohs surgery, pediatric dermatology, dermatologic surgery, cosmetic dermatology and skin cancer.
tion of, and response to, pain, so it can
Phil Mickelson, the great golfer, has gotten
be a complicated, difficult symptom to
a lot of attention in recent years, because
plifies my belief that we either become a
treat. As physicians, we simply need to
he continues to play his sport at the high-
prisoner of our pain, or we learn to func-
serve the patients in pain as best we can,
est level while dealing with the pain and
tion with our pain – as he continues to do,
wherever they may place themselves on
limitations of psoriatic arthritis. He exem-
week after week. We all need an effective way to manage pain so that it does not diminish quality of life. That source frequently involves physician-patient interaction. This is when walking in a patient’s shoes can be beneficial. Instead of simply going into a patient visit prepared to do an examination or to give results, try taking a second to run through the visit as if you are this patient. Combining your knowledge as a physician with your own experiences as a patient can drastically improve your patient care. If you have never approached a patient from this perspective, I recommend giving it a try.
12
The Triangle Physician
Endocrinology
Hashimoto’s (Autoimmune) Thyroiditis
By Michael J. Thomas, M.D., Ph.D.
In 1912, Dr. Hakaru Hashimoto first de-
tibodies (e.g., thyroid peroxidase and/or
scribed four Japanese female patients
thyroglobulin antibody) titers are usually
who presented with diffusely enlarged
markedly elevated (compared to minimal-
thyroid glands (goiter) and associated
mild elevations in these antibodies, which
with hypothyroidism. This condition was
are seen in up to 10 percent of the normal
subsequently recognized to occur world-
adult population). It is unclear whether
wide and came to be known as Hashimo-
these thyroid antibodies play a destruc-
to’s thyroiditis, an autoimmune disease of
tive role in disrupting thyroid function or
the thyroid, characterized by lymphocytic
whether they arise as a consequence of
infiltration, followed by a slow decline in
the lymphocytic infiltration. These thyroid
thyroid function.
antibodies are not specific to Hashimoto’s thyroiditis (in other words, they can be
It affects about 20 million Americans and
measurable in Graves’ disease and other
is the most common cause of acquired hy-
forms of autoimmune thyroid dysfunc-
pothyroidism. Hashimoto’s thyroiditis usu-
tion), but the huge majority of patients
ally occurs after puberty, becoming more
with Hashimoto’s thyroiditis will have
common with advancing age and occurs
these thyroid antibodies present.
5-10 times more often in women than men. Thyroid ultrasound reveals a hypoechoic On exam, the thyroid is usually of normal
gland with a heterogeneous echotexture
size or slightly enlarged and is slightly
and occasionally a nodular appearance.
Dr. Michael Thomas graduated from the School of Medicine at West Virginia University in Morgantown, with medical and doctorate degrees in pharmacology and toxicology. He completed post-graduate medical training at Barnes Hospital at Washington University in St. Louis, including his internship, residency and fellowship in endocrinology. Dr. Thomas established Carolina Endocrine, P.A., in the summer of 2005. He was previously a faculty member in endocrinology/medicine at Washington University, the University of Iowa and the University of North Carolina at Chapel Hill. Dr. Thomas is board certified in internal medicine and endocrinology and is licensed to perform endocrine nuclear medicine procedures and therapies at Carolina Endocrine. He is a fellow of the American College of Endocrinology and has completed Endocrine Certification in Neck Ultrasound.
firm/rubbery to palpation. Infrequently, a
Fine-needle aspiration biopsy is indicated
thyroid bruit may be present. Occasion-
for nodular structures greater than 1 centi-
ally, a nodular texture or shotty lymph-
meter. Most patients will develop primary
adenopathy may be present around the
hypothyroidism, which is characterized by
thyroid hormone supplementation. Cur-
thyroid gland. Other signs and symptoms
an elevated thyrotropin stimulating hor-
rently, there is no effective way to reverse
of hypothyroidism may be manifest, al-
mone (TSH) or low free thyroxine (T4).
thyroid autoimmunity that will prevent the
though some people may be diagnosed
Hypothyroidism, if/when it develops, is
progression of hypothyroidism. Patients
when they are euthyroid (prior to the de-
usually treated with thyroid hormone sup-
who have Hashimoto’s thyroiditis are
velopment of hypothyroidism). Infrequent-
plementation (e.g. levothyroxine). Recent
at slightly higher risk of acquiring other
ly, Hashimoto’s thyroiditis may present
studies show that treating euthyroid wom-
autoimmune diseases in the future. Simi-
with transient hyperthyroidism (“Hashi-
en with autoimmune thyroiditis may lower
larly, the first-degree relatives of patients
toxicosis”), which usually quickly evolves
the incidence of miscarriage, particularly
with Hashimoto’s thyroiditis are at slightly
towards hypothyroidism in a matter of
in the first trimester.
higher risk of developing Hashimoto’s thyroiditis and other autoimmune diseases in
weeks to months. Hashimoto’s thyroiditis usually causes perOn laboratory evaluation, thyroid autoan-
general.
manent hypothyroidism, requiring lifelong
august 2015
13
Women’s Health
Understanding
Migraine Fundamentals By Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G.
Headaches are common, and this article
common in women than men. The pain
the role of serotonin and calcitonin gene-
reviews the fundamentals on migraine
may intensify over minutes to one or more
related peptide (CGRP). The likelihood of
headaches.
hours. It is dull, deep and steady when
a genetic basis to migraines has been rec-
mild to moderate in intensity. It can then
ognized for some time as well.
The Top 2 most common types are 1)
become throbbing or pulsatile when se-
tension headaches and 2) migraine head-
vere.
There is better understanding of how the
aches. Tension headaches can cause
various factors connect. The relationship
pressure or tightness on both sides of the
Pathophysiology of Migraines
between gender and the many different
head. Migraine headaches are episodic
There is growing evidence on the patho-
triggers of migraines is an emerging sci-
in nature. They may start off mild and be-
physiology of a migraine.
ence.
of the head. They can cause nausea or
It clearly involves the activation of the tri-
Triggers include stress, worry, menstrua-
vomiting and make one sensitive to light
geminovascular system – the trigeminal
tion, use of birthbirth control pills, physi-
or sound.
ganglion and the upper cervical dorsal
cal exertion, fatigue, lack of sleep, hunger
come worse and may affect just one side
nerve roots. These sensory nerve roots
and certain foods or drinks. Certain medi-
Between 12 percent and 16 percent of
project and then innervate large cerebral
cations and chemicals also can trigger
people in the United States experience
vessels, pial vessels, dura mater and large
migraine.
migraine headaches. Migraines are more
venous sinuses. There also is evidence of Diverse Symptoms
ACNE • MOHS SURGERY • SKIN CANCER • PSORIASIS • ECZEMA • DERMATITIS
The impact of migraine on a patient’s life can be significant. The following illustrates.
“He wanted his confidence back.”
1) One woman explains that “I have to stop whatever I am doing when I know a migraine is beginning. I go home and
I REFERRED HIM TO SOUTHERN DERMATOLOGY
turn the lights off and go to sleep.” 2) A different woman describes that she “feels nauseated and tired. My vision can be blurred and pain begins over one eye.” She avoids perfumes, chocolate, alcohol, nitrates, loud noises, heat, sun, overhead lights, lack of sleep, eye strain and caffeine. She also recognizes a relationship between barometric pressure and her headaches. Her headaches, she said, always start as neck pain.
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“cloudy, dull ache, starting from my forehead and radiating toward the back
919-782-2152
of my head. My eyelids are heavy. There
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14DER131_AD_Triangle The Triangle Physician Physican I Want 4.indd
3) One patient notes that she has a
3/18/15 3:56 PM
is such a sensitivity to light and sound.
Women’s Health Lying down helps, but it does not elimi-
relievers, perhaps anti-nausea medica-
nate the headache, which usually lasts
tions and other medications more specific
all day.”
to the cause of migraines. Beta blockers, antidepressants, anticonvulsants and oth-
Diagnosing Headaches
er agents also can have a positive impact
There are different migraine subtypes. The
on migraines.
most widely accepted diagnostic criteria for migraines are through the International
Lifestyle habits can help minimize the fre-
Classification of Headache Disorders,
quency and intensity of migraines, so pa-
third edition (ICHD-3).
tients are encouraged to practice healthy eating and sleeping habits and get regular
Recognizing that a headache may not be a
exercise. At the Women’s Wellness Clinic,
typical tension headache but a migraine is
Karen Saylor, F.N.P., is a specialist in the
important in management.
treatment of migraines. She works with women on their diet and triggers. Man-
The providers at the Women’s Wellness
agement techniques include biofeedback,
Clinic work with neurologists within the
relaxation training, cognitive-behavioral
Triangle to make the proper diagnosis of
therapies and acupuncture.
migraine. We also help patients understand what type of headache they may be
Prevention
experiencing and how to get relief.
We currently are enrolling for a clinical research study on the prevention of acute
Symptom Relief
migraines in women between the ages of
Treatment depends on the frequency, se-
18 and 65 years of age. For more informa-
verity and symptoms. Commonly, the treat-
tion about the study, call the Women’s
ment of acute migraines focuses on pain
Wellness Clinic at (919) 251-9223.
After earning her bachelor’s degree in religion from Duke University (1988), Dr. Andrea Lukes pursued a combined medical degree and master’s degree in statistics from Duke (1994). Then, she completed her ob/gyn residency at the University of North Carolina (1998). During her 10 years on faculty at Duke University, she cofounded and served as the director of gynecology for the Women’s Hemostasis and Thrombosis Clinic. She left her academic position (2007) to begin Carolina Women’s Research and Wellness Center. She and partner Amy Stanfield, M.D., F.A.C.O.G., head the Women’s Wellness Clinic, the private practice associated with Carolina Women’s Research and Wellness Clinic. Women’s Wellness Clinic welcomes referrals. Call (919) 251-9223 or visit www.cwrwc.com.
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august 2015
15
Duke Research News
Brains of Smokers Who Quit May Be Hard Wired for Success Smokers who are able to quit might actually
“Simply put, the insula is sending messages
be hard-wired for success, according to a
to other parts of the brain that then make the
study from Duke Medicine.
decision to pick up a cigarette or not,” said Merideth A. Addicott, Ph.D., assistant profes-
The study, published
sor at Duke and lead author of the study.
in Neuropsychopharshowed
The insula, a large region in the cerebral
connectivity
cortex, has been the subject of many smok-
among certain brain
ing cessation studies that show this area of
regions
people
the brain is active when smokers are craving
who successfully quit
cigarettes, said Francis Joseph McClernon,
smoking compared to
Ph.D., associate professor at Duke and the
those who tried and
study’s senior author. Other studies have
failed.
found that smokers who suffer damage to
macology, greater
Merideth A. Addicott, Ph.D.
in
the insula appear to spontaneously lose inThe researchers ana-
terest in smoking.
lyzed magnetic reso-
This image represents the average connectivity among 44 study participants who successfully quit smoking versus the average functional connectivity for 41 participants who relapsed. The colored regions represent the average functional connectivity with the posterior portion of the insula, an area of the brain linked to cigarette cravings in smokers. A Duke Medicine study shows there is more connectivity between the insula and the somatosensory cortex among the smokers who quit compared to those who relapsed. Image credit: Duke Medicine.
“We have provided a blueprint. If we can increase connectivity in smokers to look more
nance imaging scans
“There’s a general agreement in the field that
like those who quit successfully, that would
of 85 people taken one
the insula is a key structure with respect to
be a place to start. We also need more re-
month before they
smoking and that we need to develop cessa-
search to understand what it is exactly about
attempted to quit. All participants stopped
tion interventions that specifically modulate
greater connectivity between these regions
smoking, and the researchers tracked their
insula function,” Dr. McClernon said. “But in
that increases the odds of success,” Dr. Mc-
progress for 10 weeks. Forty-one partici-
what ways do we modulate it and in whom?
Clernon said.
pants relapsed.
Our data provides some evidence on both of
Francis Joseph McClernon, Ph.D.
those fronts and suggests that targeting con-
In addition to Drs. Addicott and McClernon,
Looking back at the brain scans of the 44
nectivity between insula and somatosensory
study authors include Maggie Sweitzer, Brett
smokers who quit successfully, the research-
cortex could be a good strategy.”
Froeliger and Jed Rose.
before they stopped smoking – better syn-
Neurofeedback and transcranial magnetic
The researchers received funding from
chrony (coordinated activity) between the
stimulation, used to improve depression, are
the National Institute on Drug Abuse (R01
insula, home to urges and cravings, and the
two treatments that modulate brain activity.
DA025876; K01 DA033347). Dr. McClernon
somatosensory cortex, a part of the brain
With the findings in this study, researchers
is also a site principal investigator on an
that is central to our sense of touch and mo-
now have more information on where to fur-
investigator-initiated grant (GRAND) from
tor control.
ther investigate, Dr. McClernon said.
Pfizer Inc.
ers found they had something in common
Thin Colorectal Cancer Patients Have Shorter Survival Than Obese Patients Although being overweight with a high
to a new study from Duke Medicine.
Cancer, found that patients with a low or healthy body weight lived an average
body-mass index has long been associated with a higher risk for colorectal cancer,
The study, which was presented July 1 at
of two-and-a-half months less than over-
thinner patients might not fare as well after
the European Society for Medical Oncol-
weight and obese patients.
treatment for advanced cancer, according
ogy World Congress on Gastrointestinal
16
The Triangle Physician
Duke Research News The results surprised researchers, who
Patients with the lowest BMI, from 20
expected obese patients to respond more
to 24.9, which would be considered a
The study does not indicate that being
poorly to treatments for Stage 4 colorectal
healthy weight by BMI guidelines, sur-
overweight is in any way protective for
cancer due to their increased risk of de-
vived an average of 21.1 months after start-
patients undergoing cancer treatment, Dr.
veloping the disease and having it come
ing treatment.
Zafar said. Instead, the results suggest that there could be an aspect of biology that
back. There is some evidence that many obese patients also receive less-than-
Patients with a BMI of 25 to 29, considered
could put thinner patients at a higher risk
optimal dosages of cancer drugs or have
overweight, survived an average of 23.5
for poor outcomes, he said.
other health problems that complicate
months, the study found. By compari-
recovery.
son, patients with BMIs of 30 to 35, obese
“There may be a relationship between
by the standards, survived an average
having a lower BMI and how much treat-
“Contrary to our
of 24 months. Patients with BMIs of 35.1
ment patients can tolerate,” Dr. Zafar
hypothesis,
and higher survived an average of 23.7
said “I would hypothesize that the lowest
months.
weight patients in our analysis received
pa-
tients who had the
or tolerated less treatment or received ad-
lowest BMI (body-
Syed Yousuf Zafar, M.D.
mass index) were
Although the study found significant dif-
equate treatment at first, but became too
at risk for having
ferences in how long a patient lived based
sick to receive additional therapy. That
the shortest sur-
on their BMI ranges, patients of all weights
may be where we can focus more atten-
vival,”
tion on improving their outcomes.”
lead
saw similar rates of progression-free sur-
author Syed Yousuf Zafar, M.D., associate
vival or a halt in their tumor growth. Pa-
professor of medicine at Duke. “In this
tients whose tumors stopped growing
In addition to Dr. Zafar, study authors in-
case, patients with the lowest body weight
went an average of 10 months without
clude M. Kozloff, J. Hubbard, E. Van Cut-
– people who had metastatic colon can-
progression, but the stoppage in tumor
sem, F. Hermann, A.J. Storm, E. Gomez, C.
cer and a BMI of less than 25 – were at the
growth does not necessarily improve
Revil and A. Grothey.
highest risk.”
chances of survival.
said
According to guidelines, a healthy adult’s BMI ranges from 18.5 to 24, while a BMI below 18.5 is considered underweight. The study authors examined data pooled from
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august 2015
17
UNC Research News
Scientists Find New Evidence of Key Ingredient During Dawn Of Life Before there were
biology evolved from opposite strands of
Scientists know that inside modern living
cells on Earth, sim-
the same remarkable ancestral gene.
cells there are enzymes called aminoacyl-
ple,
Charles Carter, Ph.D.
tiny
tRNA synthetases that dramatically speed
catalysts
most likely evolved
“We found, quite surprisingly, that two op-
up this reaction. Like all enzymes, synthe-
the ability to speed
posite strands of DNA from a single ancient
tases are remarkably sophisticated ma-
up and synchronize
gene probably provided the code for dif-
chines. They belong to two different fami-
the chemical reac-
ferent catalysts that both activated amino
lies: Class I synthetases activate half of the
tions necessary for
acids,” said Dr. Carter. “The peptide made
20 amino acids that link together to form
life to rise from the primordial soup. But
from one strand activated those amino ac-
proteins, and Class II synthetases activate
what those catalysts were, how they ap-
ids needed for the insides of proteins, and
the other half.
peared at the same time and how they
the peptide made from the other strand ac-
evolved into the two modern superfamilies
tivated those amino acids needed for the
Dr. Carter’s team devised experiments to
of enzymes that translate our genetic code
outsides of proteins.”
physically take apart the synthetases to show that the necessary catalytic activity
have not been understood.
comes from parts of the enzymes that all members of each synthetase
In the Journal of Biological
family share: the parts that
Chemistry, scientists from the University of North
bind to ATP. These parts –
Carolina School of Med-
chains of 46 amino acids –
icine provide the first
compose about 5 percent
direct experimental evi-
to 10 percent of the total
dence for how primor-
size of modern enzymes but exhibit more than 40
dial proteins developed
percent of their total activity.
the ability to accelerate the central chemical reaction neces-
Dr. Carter calls these enzyme fragments
sary to synthesize proteins and thus
protozymes – from the Greek root “pro-
allow life to arise not long after Earth was created.
Comprehending catalysis
tos” meaning first. His team found that the
A key obstacle in creating living things is
enzymatic activity of these protozymes fo-
This finding provides another insight into
speeding up chemical reactions that nor-
cuses on the activation reaction with ATP.
the dramatic inventions nature made as
mally proceed at very slow and different
prebiotic chemistry evolved into life bil-
speeds so that all reactions proceed at
This catalytic activity means that the
lions of years ago. Earlier this month,
about the same rate inside cells.
protozymes were able to form very tight complexes with the least stable, slowest-
Charles Carter, Ph.D., professor of biochemistry and biophysics and senior
From this standpoint, one reaction in mod-
to-form structures during the transitions
author of the JBC paper, and his UNC
ern biochemistry towers above the others
that occur during the chemical reactions
colleague Richard Wolfenden, Ph.D., re-
as an obstacle to the formation of life: the
that form proteins. These tight complexes
ported in the Proceedings of the National
reaction that combines amino acids with
of enzymes within these “transition states,”
Academy of Sciences more evidence for
adenosine triphosphate, or ATP, a mole-
Dr. Carter said, would be very necessary
how amino acids were selected to match
cule that transfers chemical energy within
during catalysis and thus for the creation
with a genetic blueprint to form proteins,
cells. This combination allows proteins to
of the first life on Earth.
the machines of living cells.
assemble spontaneously. Without a catalyst, this reaction would be slower than any
Designer evidence
This latest paper provides evidence that
of the other steps in protein synthesis by
Dr. Carter then got help from colleague Bri-
the two major superfamilies of enzymes
about a thousand-fold.
an Kuhlman, Ph.D., professor of biochem-
that translate the genetic code in modern
18
The Triangle Physician
istry and biophysics, to create “designer”
UNC Research News protozymes from a single gene in which
blueprints for life actually contained more
times and places before there were cells to
one strand codes for a protozymic ances-
information than anyone had realized, be-
package life’s machinery.
tor of class I synthetases and the other
cause both strands of the ancestral gene
strand codes for a protozymic ancestor of
were responsible for encoding the two
class II synthetases.
classes of synthetases needed for the creation of proteins.”
Surprisingly, their experiments revealed that both designer protozymes exhibited
This result unifies what scientists previ-
the same catalytic activity as did the proto-
ously considered to be two distinct super-
zymes Dr. Carter’s team had isolated from
families of modern enzymes and greatly
the modern synthetases.
simplifies the complex process of forming the diversity of catalysts necessary for life:
“We discovered that nature solved the
both catalysts were available at the same
problem of activating amino acids des-
This research was sponsored by the National Institutes of Health. JBC paper first author, Luis Martinez, an undergraduate, conducted many experiments as part of the UNC Summer Undergraduate Research Experience (SURE). Other undergraduates contributed to this work, thanks to the American Biophysical Society summer course in biophysics at UNC and the UNC Post-baccalaureate Research Experience Program (PREP). Each program is offered by the UNC School of Medicine Office of Graduate Education.
tined to be inside (class I) folded proteins and outside (class II) folded proteins by evolving a single gene to do both jobs,” Dr. Carter said. “Moreover, the protozymes managed to do this in a most unusual way: by relying on two entirely different interpretations of the same genetic information.” Dr. Carter’s previous work on Earth’s earliest enzymes had pointed strongly in this direction. But his team’s current research marks the first direct, experimental “proof of principle” of a hypothesis originally proposed in 1994 by two theoretical evolutionary biologists – Sergei Rodin, Ph.D., D.Sc., and Susumu Ohno, Ph.D., D.V.M. – who said that one gene could encode different proteins from each of its two strands. “We now have more information about how amino acids eventually evolved into complex molecules necessary to create life as we know it,” Dr. Carter said. “But perhaps more importantly, we’ve been able to provide a new set of tools that will enable others to approach questions about the origin of life in ways that are scientifically sound and productive.” And there are still questions about how all this happened. “This doesn’t yet solve the central chicken and the egg problem,” Dr. Carter said. “Even the designed protozyme requires a ribosome to synthesize it and lead to protein creation. But what we’ve shown is that
Womens Wellness half vertical.indd 1
12/21/2009 4:29:23 PM
august 2015
19
News
WakeMed Physician Practices-Pediatrics to Launch Positive Parenting Program The John Rex Endowment announced a
a childhood mental health specialist and a
“Parents are an essential part of their child’s
four-year $769,271 Project LAUNCH grant to
family-centered health navigator to its team,
care at WakeMed, and Triple P is an exten-
support implementation of a family-centered,
providing more developmental screening
sion of our commitment to parent education,
collaborative care program within WakeMed
and behavioral health assessment tools – like
positive parenting practices and community
Physician Practices-Pediatrics.
Triple P – for young children and families.
collaboration to help ensure the safety and well-being of local children and families,” said
Project LAUNCH (Linking Actions for Un-
Physicians will receive Triple P training, and
Rasheeda Monroe, M.D., medical director of
met Needs in Children’s Health) is a nation-
together with the childhood mental health
WakeMed Physician Practices - Pediatrics.
ally recognized, family-centered initiative that
specialist and family-centered health naviga-
aims to improve child wellness systems.
tor will work with a patient’s parents or care-
The team will also help families evaluate if ad-
givers to help them incorporate practical,
ditional resources may be needed and con-
With the grant award, WakeMed Physician
easy-to-implement parenting strategies from
nect families with other community partners.
Practices (WPP)-Pediatrics will implement a
the evidence-based program into everyday
family-Centered Medical Home model and
life – from doctor visits to bedtime routines.
WakeMed
Physician
Practices-Pediatrics,
based at WakeMed Raleigh Campus, pro-
the Triple P - Positive Parenting Program. Triple P is designed to provide parents and
Improved parenting skills, confidence and fam-
vides primary medical care to children ages
caregivers with the knowledge and resources
ily relationships help prepare children, and pro-
newborn to 18 years. The John Rex Endow-
they need to manage childhood behavior
vide them with the tools needed, for success
ment works with the community to support
and raise confident, healthy children.
in school, at home and beyond. Positive parent-
the physical, mental and emotional well-be-
ing also reduces the prevalence of behavioral,
ing of children.
Additionally, WPP-Pediatrics will welcome
emotional and developmental problems.
State-of-the-art, expert, cost effective, timely endocrinolgoy care is what Carolina Endocrine has to offer your patients. • Neck Ultrasounds (ECNU certified) • Fine needle aspiration biopsies • Nuclear medicine studies
All in one convenient location behind Rex Hospital at 3840 Ed Drive, Suite 111.
919-571-3661
www.CarolinaEndocrine.com Michael Thomas, M.D., Ph.D. George Stamataros, D.O. Carly Kelley, M.D., M.P.H. Eileen Andres, PA-C Erin Wetherill, PA-C
20
The Triangle Physician
News Welcome to the Area
Physicians
Philip CoganCasey, DO Hospitalist; Internal Medicine
Annie Jayanth, MD
Promish Shrestha, MD
Duke University School of Medicine Durham
Hospitalist
Eagle Hospital Physicians Rocky Mount
Sound Physicians Elizabeth City
Bo Jiang, MD Cardiology; Cardiovascular Disease, Internal Medicine
Evan Sutton, MD
Daniel LewisMyers, DO
UNC Hospitals Chapel Hill
Anesthesiology
Family Medicine; Family Practice; Urgent Care
Duke University Hospitals Durham
Novant Health Wallburg Family Medicine Winston-Salem
Sameer ShantaramKamath, MD Critical Care Pediatrics
John Paul Velasco, MD
Shaun Robert Wagner, DO
Duke University Medical Center Durham
Family Medicine; Family Practice
Diagnostic Radiology; Neuroradiology; Nuclear Radiology; Radiology
UNC Hospitals Chapel Hill
Yasmin Ali, MD Neurology; Neuroradiology; Vascular Neurology
Duke University Hospitals Durham
Rebecca FrancesAshton, MD General Surgery
University of North Carolina Hospitals Chapel Hill
Robert Bala, MD Family Medicine
Rocky Mount Family Medical Center Rocky Mount
Bethany EvangelineBeasley, MD Gynecologic Surgery; Obstetrics and Gynecology
Kernodle Clinic Burlington
J Bradford HampshireBertumen, MD Infectious Diseases, Internal Medicine
Duke University Hospitals Durham
Peter Jonathan McAleaCeponis, MD Administrative Medicine; Emergency Medicine; Family Practice
Duke University Hospitals Durham
Wilkes Family Health Center North Wilkesboro
Silpa Kamisetti, MD Addiction Psychiatry; Child and Adolescent Psychiatry; Child Psychiatry; Forensic Psychiatry; Geriatric Psychiatry
Duke University Hospitals Durham
Mariam Wasim, MD Neurology
Duke University Hospitals Durham
Huiwen Bill Xie, MD
Mildred Kwan, MD
Cytopathology; Pathology
Allergy and Immunology; Rheumatology
3400 Wake Forest Rd Raleigh
UNC Allergy & Immunology Clinic Chapel Hill
Yi Xie, MD
Olivia ReidLinthavong, MD Neonatal-Perinatal Medicine; Pediatrics
University of North Carolina Hospitals Chapel Hill
Amy Eleanor Marietta, MD
Anatomic and Clinical Pathology; Hematology Pathology; Pathology
301 E. Winmore Avenue Chapel Hill
Manaf Mohamed Zawahreh, MD
Family Medicine
Blue Ridge Community Health Services Hendersonville
John C.Mavropoulos, MD Dermatology; MOHS-Micrographic Surgery
30 Forest Green Drive Durham
Neurology; Sleep Medicine
Duke University Hospitals Durham
Physician Assistants
Mitchell Travis Adams, PA Emergency Medicine
Seema Lynn Mishra, MD Administrative Medicine; Family Medicine; Legal
Medicine Aetna Morrisville
Wilkesboro Regional Medical Center North Wilkesboro
Jalal Alghabra, PA Laboratory; Dermatology - Pediatric - Dermatology
Joel GarryMorash, MD
Polley Clinic Smithfield
Family Medicine; Integrative Medicine; Psychiatry
2530 Erwin Rd Durham
Elaine Mejia, PA
Duke Family Medicine Center Durham
Heather HopeNorth, MD
Cerrone AkilCohen, MD
Alexander AryaEksir, MD Psychiatry
Duke University Hospitals Durham
Tatyana ElizabethFontenot, MD Otorhinolaryngology
UNC Hospitals Chapel Hill
Rachana Bharatkumar Gandhi, MD Neurology; Neuromuscular Medicine
Duke University Hospitals Durham
Jonathan LuisGarcia Esqueda, MD Abdominal Surgery; General Surgery; Surgery
UNC Hospitals Chapel Hill
Stuart DavidGinn, MD Otorhinolaryngology
WakeMed Raleigh Campus Raleigh
Cardiology; Cardiovascular Disease, Internal Medicine; Family Medicine; Family Practice; General Practice; Clinical Cardiac Electrophysiology
Rheumatology, Internal Medicine
Margeret R. Pardee Memorial HospitalRheumatology Hendersonville
210 Glenview Lane Durham
Nahla Abdelmonem MostafaOsman, MD
Urgent Care
Internal Medicine
11010 Presidio Drive Raleigh
Jeremy Bryant Moses, PA Pardee Urgent Care Hendersonville Alex Perez, PA Emergency Medicine; Family Medicine; Urgent Care
Mihai Puia Dumitrescu, MD
Novant Health Lexington Primary Care Lexington
Neonatal-Perinatal Medicine; Pediatrics
Duke University Medical Center Durham
Returi Sarada Rao Schossow, PA Adolescent Medicine; Allergy; Cardiology; Cardiovascular Disease, Internal Medicine; Dermatology; Diabetes; Endocrinology
Shruti Mukund Raja, MD Neurology
Duke University Hospitals Durham
400 W Rosemary St Chapel Hill
Luna Taina Sanchez, MD
Kathryn Abbigail Whittington, PA
General Practice; Psychiatry
Emergency Medicine; Family Medicine; Family Practice; Internal Medicine; Surgery; Urgent Care
Duke University Hospitals Durham
5110 Copper Ridge Dr Durham
august 2015
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