january 2016
MacPhee Plastic & Reconstructive Surgery Transgender Patients Find Expertise, Compassion in N.C. Plastic Surgeon
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 “Little Pink Pill” AID Makes Strides in 2015
Johnston Health Has The Places & People To Make Every Delivery Special!
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Our hospitals in Smithfield & Clayton feature spacious birthing suites and experienced, caring staff who are devoted to making your delivery special.
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From the Editor
Brave New Directions 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
In this issue’s cover story, we learn about plastic and reconstructive surgeon Keelee MacPhee’s mission to provide gender-confirming reconstruction in addition to her more conventional practice. Dr. MacPhee’s groundbreaking work serves to transform transgender patients emotionally and improve their quality of life as well. Her determined quest to advance surgery in this emerging field has led to national recognition. This month The Triangle Physician also features physician advocate Marni Jameson, who talks about the successes of Association of Independent Doctors in just one year. Obstetric gynecologist Andrea Lukes is dedicated to increasing awareness of the many facets of women’s health, and this month she discusses the benefits of flibanserin to treat low sexual desire.
Editor Heidi Ketler, APR heidi@trianglephysician.com Contributing Editors Wendy Coulter Marni Jameson Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G. Margie Satinsky, M.B.A. Creative Director Joseph Dally jdally@newdallydesign.com
Advertising Sales info@trianglephysiciancom News and Columns Please send to info@trianglephysician.com
Practice management consultant Margie Satinsky provides a comprehensive overview of the considerations needed to determine if hiring a professional administrator makes sesne. Practice marketing consultant Wendy Coulter continues her four-part series with five more benefits of branding.
The Triangle Physician is published by: New Dally Design Subscription Rates: $48.00 per year $6.95 per issue Advertising rates on request Bulk rate postage paid Greensboro, NC 27401
These are exciting times in health care and medical research, and we look forward to sharing your discoveries, breakthroughs and insights in 2016. Our readers represent the more than 9,000 within the Raleigh-Durham medical community. There is no cost to run your medical news and professional commentary. Advertising rates are competitive. Please send inquiries to: info@trianglephysician.com. Here’s wishing you and yours a happy, healthy and prosperous New Year!
Heidi Ketler Editor
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
Table of Contents Category
4
COVER STORY
Keelee MacPhee, M.D., Plastic Surgery Transgender Patients Find Expertise, Compassion in N.C. Plastic Surgeon january 2016
V o l . 7 , I ss u e 1
FEATURES
9
Endocrinology
20 Powerful Reasons to Brand Your Practice: Part 3 of 4 Wendy Coulter provides professional perspective on branding and gives five more reasons why practices need to do it.
12
10 Physician Advocacy
AID: What a Difference a Year Makes
14 Practice Management
Is a Professional Practice Administrator Right for You?
16 Duke Research News
Women Cardiologists Do Different Work, Make Less Money than Men
17 Duke Research News
Finding Solves Circadian “Mystery”
18 UNC Research News Women’s Health
“Little Pink Pill” Can Improve Women’s Sexual Experiences Dr. Andrea Lukes addresses the importance of sexual health and the benefit to some of new medication to improve desire.
DEPARTMENTS
- New SARS-like Virus Can Jump Directly from Bats to Humans - Technique to Jumpstart Bone Cell Formation Discovered Unexpectedly
19 UNC Research News
UNC and NCCU Awarded $7.5 Million for Alcohol Health Disparities Study
20 News
Bullies at Risk of Eating Disorders
21 Welcome to the Area
january 2016
3
Cover Story
Transgender Patients Find Expertise, Compassion in N.C. Plastic Surgeon Plastic and reconstructive
surgeon
Keelee
J. MacPhee, M.D., of Renaissance Plastic & Reconstructive Surgery, met her first transgenKeelee J. MacPhee, M.D.
der patient in 2005. He was a transman who
she never would have guessed was trans-
“While surgery doesn’t address every problem, it can go a long way in helping people feel more like themselves and live happy, productive lives.” – Keelee MacPhee, M.D.
gender. He was masculine, sounded like a man and worked on a farm. “He looked like
researched together to decide on the de-
that were not consistent with who he felt
any other farm guy, with huge muscles and
tails of shape and nipple positioning.
like on the inside were finally gone.”
The surgery was a success, and the man
With the gender-confirming surgery, the
But this man had been born female. In his
was ecstatic with the results. He was so
patient also was able to have the gender
early 30s at the time, he had been living as
much more comfortable without the bind-
marker changed on his legal identification.
male since adolescence.
ing and was better able to perform his job.
He went on to legally marry his girlfriend,
a full beard,” Dr. MacPhee remembers.
and Dr. MacPhee was invited to the wedding.
The man arrived at Dr. MacPhee’s office
“It was a dramatic change for my patient
with his very pretty, petite girlfriend and
physically, but also emotionally and psy-
their infant daughter. Dr. MacPhee would
chologically,” said Dr. MacPhee. “The anxi-
“The courage of this man to be true to him-
later learn that a friend had donated
ety and depression of having body parts
self in such a conservative environment, where he was risking his safety every day,
sperm, so they could start a family.
was profound for me to witness,” said Dr. The physical examination revealed that the
MacPhee. “It was through this experience
man had massive breasts – G cup size – and
that I realized just how great an impact my
he had tried all sorts of uncomfortable and
work could have on people’s lives. Plastic
even painful ways to bind and hide them.
surgery isn’t just about a physical change; it
He had struggled to find physicians who
often affects people on a deeper emotional
were willing to help him, and at some point
level. In my experience, that’s always the
along the way, he had resorted to buying
case for transgender patients.”
testosterone off the street and the Internet. The Numbers Tell the Story Studies and statistics support this premise.
Dr. MacPhee performed a bilateral mastectomy with free nipple grafting based on her best judgment of how his chest should
Social norms encourage transgender indi-
look. There was not a great deal of infor-
viduals to suppress their gender identity (the gender one feels oneself to be). Yet
mation available about transgender chest surgery at the time, so doctor and patient
4
The Triangle Physician
Female-to-male chest surgery after results.
many transgender people feel a fundamen-
tal unease and dissatisfaction with their biological sex. Being forced into traditional stereotypes often results in anxiety and depression. Furthermore, transgender people experience discrimination at a significantly higher rate than the general population. According to the National Transgender Discrimination Survey, 26 percent of trans people lost a job due to bias, 50 percent were harassed on the job, 20 percent were evicted or denied housing and 78 percent of trans students were harassed or assaulted. For a trans person of color, discrimination is exacerbated. It is not surprising then that the suicide rate is higher for the transgender population. But the extent of the disparity is staggering: In a survey conducted by the National Center for Transgender Equality, 41 percent of transgender and gender non-conforming respondents reported attempting suicide, compared to 1.6 percent of the general population.
Male-to-female facial feminization involving multiple procedures: Brow lift with frontal bone reduction, upper blepharoplasty (eyelid lift), and chin implant.
Pioneering a Field of Medicine
“I’ve had patients tell me their families re-
With this realization as her driver, Dr.
Many trans individuals want to make their
ject them, and it’s hard for them to find a
MacPhee conducted a bit of her own re-
bodies as congruent as possible with their
welcoming community,” said Dr. MacPhee.
search. She learned there were a very
gender identity, and in this way, sex reas-
“Many are loners, and they don’t feel safe.
limited number of skilled transgender sur-
signment improves their quality of life. To
While surgery doesn’t address every prob-
geons in the United States, making sex re-
live and be accepted as the man or woman
lem, it can go a long way in helping people
assignment surgery difficult for patients to
one sees oneself to be can bring enormous
feel more like themselves and live happy,
obtain. She decided this was the direction
relief and contentment.
productive lives.”
she wanted to take her practice. With a degree in plastic and reconstructive surgery from the University of North Carolina School of Medicine, residencies at UNC and the University of Florida, and private practice experience, Dr. MacPhee had the conventional training to perform many procedures that a trans patient might need. But she wanted to augment her traditional plastic surgery capabilities with specialized training in transgender reconstruction. This turned out to be more difficult than one might think. Since transgender surgery is not a surgical specialization offered
january 2016
5
at any medical school in the United States, Dr. MacPhee had to be a pioneer in the field. She researched and self trained, and she sought out several renowned transgender surgeons from around the country with whom she could exchange techniques and best practices. Her perseverance gave her new skills to take back to her practice in North Carolina. Nationally Recognized Transgender Surgeon Today Dr. MacPhee offers procedures for both trans women (MTF) and trans men (FTM) – including FTM top surgery, as well as MTF breast augmentation, vaginoplasty, tracheal shave, forehead bossing reduction
exam and, of course, for the surgery, but
dominoplasty and rhinoplasty, as well as
and other facial feminization treatments.
initial consultations, family meetings and
other facial plastic surgeries.
Following the standards of care set forth
some post-surgery follow-up appointments
by the World Professional Association for
can often be handled remotely.
She admits that she had some hesitation early on in opening up about the transgen-
Transgender Health (WPATH), she continues to train and develop her transgender
“Having patients go home and still be able
der side of her practice, not knowing what
practice, staying abreast of new proce-
to communicate with me directly saves
her traditional plastic surgery patients
dures and surgical advancements as they
the patients extensive travel time and ex-
would think.
unfold.
pense,” said Dr. MacPhee.
Her focus and dedication to this area of
A smart-phone application uses telemedi-
read on our patients’ feeling about trans-
practice are what draw transgender pa-
cine to communicate with other providers
gender surgery,” Dr. MacPhee said. “I was
tients from across the country to the Trian-
who have a role in the patient’s care, such
pleased to learn that a large majority of our
gle. She performs surgeries at North Caro-
as therapists, primary care providers and
cisgender patients support this area of our
lina Specialty Hospital and Duke Regional
endocrinologists. Patients can feel confi-
practice.”
Hospital. Board certified in plastic surgery,
dent that their personal information is safe,
Dr. MacPhee has built a reputation for her
since it uses three levels of encryption.
“We actually did phone interviews to get a
Changing Lives for the Better Whether she is performing traditional plas-
skill, compassion and understanding. “These tools are also helpful for patients
tic surgery or transgender reconstruction,
Technology Brings Patients Closer
who want to have an out-of-town family
Dr. MacPhee is focused on helping people
The need to travel to North Carolina from
member involved in their care without hav-
make positive changes.
far and wide creates certain challenges for
ing them physically travel to North Carolina
patients in their recovery and follow-up.
for appointments,” she said. “This is a real
“I’m so honored and feel so lucky to be
Therefore, Dr. MacPhee’s practice deploys
advantage in the level of care and personal
able to do this work,” she said. “If I can
several technologies to bridge the distance
connection we can provide our patients.”
help make people’s lives happier, safer, healthier and authentic, then that is what
once patients return home. Reactions from
I want to do.”
Telemedicine and HIPPA (Health Insur-
“Mainstream” Patients
ance Portability and Accountability Act)-
While transgender procedures tend to get
For more information about Dr. Keelee
compliant online chatting are enabling
the most attention, Dr. MacPhee also has a
MacPhee and her plastic and reconstruc-
communication without the need for trav-
large cisgender (non-transgender) patient
tive surgery practice, visit her website at
el, helping patients manage costs. Patients
population. She routinely performs breast
www.keeleemacpheemd.com.
must be seen in person for the physical
augmentations and breast reductions, ab-
6
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The Triangle Physician
Practice Marketing
20 Powerful Reasons to Brand Your Practice Part 3 of 4 As we explored earlier in this series, your
By Wendy Coulter
recognize and remember it!
practice must differentiate its product or service from others and help build a col-
Be Recognized
lection of perceptions that will resonate
Recognition and memory of a brand is
with your patients in order to thrive and
key. Even with many dollars spent in ad-
grow. I continue with five more reasons to
vertising, sales conversion is not nearly as
brand your practice.
high without brand recall. A unique and creative brand story helps increase brand
Motivate Employees
recognition!
A brand strategy can help employees better understand their responsibility in rep-
Probably some of the most recognizable
resenting the practice and contributing to
branding in history has been done by Mc-
its success. It helps them know how to act
Donald’s through the golden arches and
and how to meet goals.
Ronald McDonald, not to mention this memorable jingle: “two all-beef patties,
Apple’s brand strategy includes a state-
special sauce, lettuce, cheese…”
ment that, “People don’t come here to play it safe. They come here to swim in the
Communicate What Your Practice
deep end. They want their work to add up
Stands for
to something. Something big. Something
An effective brand story goes beyond
that couldn’t happen anywhere else.” This
features and benefits and communicates
brand statement helps the company at-
style and character, including values and
tract people who are motivated and who
business principles. Many take this a step
will, in turn, be loyal to the company.
further by committing to local charities or even global causes.
Create Consistency Practices with clear and consistent brand-
For example, TOM’s was founded with a
ing help patients know what to expect
mission to donate a pair of shoes to a per-
when they visit, which puts them at ease.
son in need for every pair it sells.
Wendy Coulter is president of Hummingbird Creative Group Inc. She is a graduate of the School of Design at North Carolina State University with degrees in architecture and industrial design and a minor in communications. She founded Hummingbird Creative Group in 1995, with a desire to put her ideas to work, creatively solving problems for small businesses. Hummingbird Creative Group is an award-winning, full-service branding agency that helps companies define brand strategy, develop sustainable brand messaging and implement marketing tactics through advertising, graphic design, sales enablement, public relations and online marketing services. Awards include “Pinnacle Business Award” from the Raleigh Chamber of Commerce, as well as “Business of the Year,” “Employer of the Year” and “Successful Achievement” awards from the Cary Chamber of Commerce. Ms. Coulter was named a “Top 50 Entrepreneur,” “Woman Extraordinaire,” “Mover and Shaker” and “40 Under 40,” to name a few. She is active in a variety of community and civic endeavors and frequently presents on such topics as branding, marketing, advertising and design.
Ask patients why they first visited, why
Your brand story should be consistent across all media from your corporate
Establish a Strong Reputation
they come back and why they chose you
identity and advertising, to your website
Reputation really is what branding is.
over competitors. The answers to these
and phone etiquette. And, you need to be
Looking for the right brand message for
questions can help you form a brand
committed to consistency for a long time…
your practice? Look straight to your repu-
promise, and as you continue to live up to
Turns out, just when you are tiring of your
tation and build on that.
that promise, your brand will establish a strong reputation.
brand story, patients are just beginning to
january 2016
9
Physician Advocacy
AID
What a Difference a Year Makes By Marni Jameson
T
he start of a new year is a great time to take stock and ask whether you’re on the
right course. For me, that includes reflecting on what has happened at the Association of Independent Doctors, since I joined as executive director a little more than a year ago. What a difference a year makes. The reason behind AID’s exponential
Marni Jameson is the executive director for the Association of Independent Doctors. You may reach her at (407) 865-4110 or marni@aid-us.org.
Frankly, worthy though I thought the cause,
growth is simple. It’s the result of commu-
I wasn’t sure the saving of America’s inde-
nicating a timely message tied to a solution.
pendent doctors was a fight we could win.
When doctors ask me, “Why should I join?”
Fortunately, I relied on the opinions of two
– and lately they ask every day – all I have to
smart, forward-thinking certified public ac-
do is look back at the past year’s highlights
countants.
and share them.
Tom Thomas and Carol Zurcher, partners
Here are 10 reasons:
AID-SAVE
at Thomas, Zurcher & White, an accounting
Fast Growth
Thanks to a partnership we have estab-
firm in Winter Park, Fla., saw a need for a
AID is the only national association dedi-
lished with medical supplier McKesson and
trade association dedicated to helping in-
cated to supporting independent doctors,
a national group purchasing organization,
dependent doctors survive. The worrisome
and we are growing fast. In the past year,
AID members save between 15 percent and
trend of hospitals buying up medical prac-
we have tripled our membership to nearly
35 percent on medical office supplies. The
tices was hurting the practice of medicine,
1,000 doctor members in 14 states, coast to
AID-SAVE program typically allows mem-
driving up costs astronomically and impact-
coast.
bers to recoup the cost of membership – $500 a year – in fewer than three months.
ing communities financially. State Chapters But no one was speaking up for the doctors.
We have three chapters in the United States,
Online Directory
So Thomas and Zurcher formed AID, and
and we are looking to form chapters in
If they choose, members may be part of
at the association’s charter meeting in April
every state. The existing chapters – Maine
AID’s online directory of independent doc-
2013, 100 doctors joined. Eighteen months
(260 members), California (61 members),
tors, which we promote to media. It is part
later, when I came on board, AID had just
and South Carolina (36 members) – were
of a campaign telling consumers why it’s
shy of 300 members and already a voice on
all groups of independent doctors that rec-
important to go to an independent doctor
the national stage.
ognized they were simply running in place
and providing a tool for them to find one.
and would be better off joining a national Today, we are nearing 1,000 doctor mem-
association and being part of a larger col-
United Front
bers in 14 states.
lective voice.
We give doctors the resources to champion their issues and answers to their questions,
10
The Triangle Physician
Practice Management such as what to consider when asked to
Focus
Chicago. The speaking calendar is filling for
join a clinically integrated network (CIN),
We stick to our goals: Stop hospital-doctor
2016.
and whom to call for help with insurance
consolidation, promote transparency in
contracting issues. We provide templates
health care pricing, push for parity in pro-
We are also a go-to source for national me-
for letters to send to lawmakers, and materi-
vider reimbursement by promoting site-neu-
dia and have been cited in media dozens of
als for media outreach. This is only a sam-
tral payments; help enforce anti-trust laws;
times in the past year. We give independent
pling of the support membership provides.
and stop nonprofit hospitals’ abuse of their
doctors a collective voice that’s long been
tax-exempt status.
missing from the discussion.
The fight for independence takes time,
Infrastructure
We are stronger together. We will do an
money and know-how. We have all three.
We were founded by business people, two
even better job as we grow. But to stop the
In December we hired our second full-time
CPAs and a health care attorney. We are a
trend of hospital consolidation, we need
person, a publicist with 18 years of public
501c6 nonprofit, have all the proper insur-
significant numbers, resources and you.
affairs and media experience. Together,
ances, dedicated office space and support
along with the occasional intern, we work
staff and are well capitalized.
Time and Expertise
Yes, we still have days where we feel like David up against 10 Goliaths, the personifi-
full-time getting the message out to consumers, media, businesses and lawmakers
Presence
cation of our nation’s giant hospital systems
about the importance of keeping doctors
In the past three months alone, AID has
and their lobby on steroids. But mostly days
independent. Although doctors harbor
presented at the national Medical Group
are marked by small steps toward progress
strong opinions, they are not inclined to
Management Association (MGMA) confer-
and the years marked by great strides.
organize, communicate strategically and ef-
ence in Nashville, at the National Physicians
fect change. We are.
Council on Healthcare Policy, on Capitol
For more information or to join AID, go to
Hill, and at Becker’s Healthcare Forum in
www.aid-us.org or call (407) 865-4110.
Spend Time c Your Patients, Not Battling IT. Get HIPAA Compliant Solutions
Let’s Talk Tech! Call (919) 296-1089 SAMIT-Medical.com
january 2016
11
Women’s Health
“Little Pink Pill” Can Improve Women’s Sexual Experiences By Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G.
There is a new “little pink pill” for women
chosocial approach. This emphasizes “the
called Addyi. Made by Sprout Pharmaceu-
importance of understanding human health
ticals, the medication is indicated for the
and illness in their fullest contexts by sys-
treatment of premenopausal women who
tematically considering biological, psycho-
have hypoactive sexual desire disorder.
logical and social factors and their complex
This is a problem characterized by low
interactions on health and illness.”
sexual desire that causes marked distress or interpersonal difficulty.
There can be unresolved physical or sexual trauma, abuse, medications and more that
Approximately 43 percent of women in the
may contribute to low sexual desire. It takes
1
United States report a “sexual problem.”
time to consider the causes of low sexual
The National Health and Social Life Survey
desire, but it is important to consider for
(NHSLS) has shown that sexual problems/
both the health care provider and the wom-
complaints were associated with low physi-
an experiencing low sexual desire.
cal and emotional satisfaction with sexual partners and low general happiness.2 Given
Given that only about one-third of women
the impact sexual problems can have for
with distressing sexual problems seek help,
women and their partners, this is a problem
health care providers must improve their
that health care providers should consider.
own screening of sexual concerns. This
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.
dress sexual health. Is this a medication that will work for your patient? This medication (flibanserin) is a 5-HT1A receptor agonist and a 5-HT2 receptor antagonist that has been studied in 11,000 women.3 The approved dose is 100 milligrams once at night. This has been shown to improve sexual desire, decrease distress and increase the number of satisfying sexual events. The contraindications include alcohol, moderate or strong cytochrome P450 3A4 inhibitors and hepatic impairment (addyi.com). The most common side The cause of low sexual desire is com-
isn’t easy to discuss for many women – and
effects of Addyi include dizziness, somno-
plex. Recently there has been an increase
unfortunately it isn’t easy to discuss for
lence, nausea, fatigue, insomnia and dry
in our understanding of low sexual desire.
many health care providers.
mouth.
and Woodard3, the pathophysiology should
The recent approval of Addyi gives women
In addition to considering treatment for low
be considered in the context of the biopsy-
and their providers an opportunity to ad-
sexual desire, it is important to provide sex
According to a recent review by Kingsberg
12
The Triangle Physician
Women’s Health education to women (and men). Do patients understand the normal sexual func-
Family Physician Needed
tion and models of the sexual response? The theories explaining this for women are many, but one of the most recent is by Rosemary Basson, M.B., F.R.C.P., of the University of British Columbia, who introduced an intimacy-based circular model to help explain the multifactorial nature of women’s sexual response.4 It emphasizes that women may not be motivated by spontaneous desire but that desire can result from arousal in the context of a loving relationship, illustrating that there is an intricate interplay of emotional intimacy, sexual stimulation, psychological factors and satisfaction within a relationship. This is something the providers at the Women’s Wellness Clinic review with each woman. Could a little pink pill help? “Yes!” Treatments for a problem help create the opportunity for patients and providers to learn. Sexual health is a complex issue, but when a woman has a healthy one –
Family Physician Needed at Avance Primary Care, Raleigh, NC Avance Care, P.A. is seeking a Board Certified Family Physician at our new Oberlin Rd practice opening in late 2015. Avance Care’s model was created to benefit our patients AND our physicians. • Work/life balance – our providers work 40 hours per week or less • Average patient load of less than 3 patients per hour • Proprietary operating and provider support systems – paperless facilities • Highly trained support staff • State of the art facility with onsite Pharmacy, X-Ray, Nutritionist, Behavioral Health Services, Allergy Testing and Immunotherapy • Operation that has consistently met or exceeded NCQA PCMH level 3, BQPP level 3, United Bridges to Excellence, Meaningful Use, NCQA DRP • Market leading private practice compensation package
Learn more about us at avancecare.com/about/about-us Apply online at avancecare.com/about/careers-providers
it is life enriching and helps relationships overcome many challenges. MOHS MICROGRAPHIC SURGERY • EXCISIONAL SURGERY • CRYOSURGERY
The providers at the Women’s Wellness
this includes sexual health. We have dedi-
“She wanted to move on with her life.”
cated time to understanding this complex
I REFERRED HER TO SOUTHERN DERMATOLOGY
Clinic are focused on providing the most comprehensive care to our patients, and
issue and the treatment options that may work for individual women. References 1. Shifren JL, Monz BU, Russo PA, Segreti A, Johannes CB. Sexual problems and distress in United States women. Obstet Gynecol. 2008;112(5):970-978. 2. Laumann E, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA. 1999;28(6):537-544. 3. Kingsberg and Woodward. Female
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Sexual Dysfunction, Focus on Low Desire, Obstetrics & Gynecology, Vol 125, No 2, Feb 2015.
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PHOTODYNAMIC THERAPY • LASER SURGERY • TOPICAL MEDICATION
1 DER131_AD_Triangle Physican I Want 4.indd
january 20163:49 PM 13 8/27/15
Practice Management
Is a Professional Practice Administrator Right for You? By Margie Satinsky, M.B.A.
Is a Professional Practice Administrator Right for You?
update regularly? • Do we know the demographic trends,
Managing a medical practice requires
community dynamics, new laws and
both vision and operational skills. In some
regulations and competition, so we
practices where the physician(s) owner(s)
can respond appropriately to ongoing
has both managerial skill and an interest in administration, the physician runs the practice, providing direction to an office
changes in the environment? • Do we have a marketing plan that supports our strategic business plan?
manager and other staff. An alternative
• Have we identified the external
is for the physician(s) owner(s) to hire
individuals, organizations and
an experienced professional practice
agencies, with whom we need to
administrator.
develop relationships?
How do you know if a professional practice administrator (PPA) is right for
Financial Management • Do we have a revenue-cycle
you, and if it is, how do you find the right
management system that enables us
person? The best way to approach this
to meet our financial goals?
question is to start with your needs. Ask
• Are we satisfied with the way we
yourself the following questions about the
prepare and monitor our operating
current management of your practice.
and capital budgets?
Margie Satinsky, MBA, is President of Satinsky Consulting, LLC, a Durham, NC consulting firm that specializes in medical practice management. She’s provided strategic planning and operational guidance to more than 100 practices in North Carolina. 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. Facilities •D oes our current facility meet our current and projected needs?
• Do we have a managed care strategy Daily Practice Operations • Do our current methods for overseeing daily practice operations
that helps us maximize the revenue we receive and monitor actual vs. expected payments?
• Do we work well as a team to identify operational problems, determine potential solutions and implement changes on a timely basis? • Do we develop and clearly communicate practice plans and policies to physicians, staff and patients on a timely basis?
Human Resources
• Do we have a strategic business plan that guides our thinking and that we
14
The Triangle Physician
to support the administration of our patient care?
• Are all responsibilities and accountabilities clear? • Do we have standardized job descriptions and a job classification system? • Do we have and use a formal performance review system? • Do we have systems for physician recruitment, hiring, orientation and
Planning and Marketing
•D o we use information technology practice and the direct provision of
meet the needs of physicians, managers, staff and patients?
Information Technology
performance?
Quality and Quality Improvement • Do we systematically respond on a timely basis to patient complaints and questions about claims? • Do we use satisfaction surveys for patients and for referring physicians? • Can we document the care that we provide to individuals and to groups of patients? • Do we benchmark our practice against acceptable standards and take
Practice Management measures to improve the care that we
appropriate issues?
Medical
• Are we comfortable having a PPA
provide? Legal and Regulatory Compliance • Do we have and use a compliance plan?
Managers
(NCMM)
and/or
Triangle Medical Managers. Some of our
work with us to develop a vision for
clients have had good luck with Craig’s
the practice and assume responsibility
List or indeed.com.
for assuring that our operations
support that vision?
If you already have a practice manager who has some but not all of the skills that
Finding the Right PPA
you want in a PPA, invite him or her to ap-
• Do we use consultants to help us with
If your responses to this second list of
ply for the position. Use your structured
Obtaining Outside Help When We Need It tasks we cannot perform internally?
questions indicate that your practice is
job description to objectively match skills
• Do we manage the consultants that
receptive to hiring a PPA, make sure you
against requirements and minimize any
we have identified as appropriate
find the right person for you. Begin with
discomfort that arises if your current per-
resources for our practice?
a job description and an employment
son isn’t qualified for the job. You may find
agreement that covers salary, benefits,
that with education and coaching, your
profit
current employee can actually do the job.
Will a Professional Practice Administrator WorkRADAR: for Us?
BAY15001
sharing,
bonus,
leadership
development and professional education.
If the responses to theAd: questions Versionabove 1
Conclusion
identify aspects of your current Date: 6/15practice
With
job
By doing an honest assessment of your
that need improvement, keep going.
opportunity, decide if your recruitment
practice, determining your practice’s
respect
to
posting
the
efforts will be national, regional or local
readiness for a PPA, and using an objective
Honestly assess your potential for accepting
and contact the professional organization
process for recruitment and hiring, you
a new management arrangement. Here are
to which most practice administrators
can make sure that the management of
belong – i.e. Medical Group Management
your practice meets the highest standards
Association (MGMA), North Carolina
of excellence.
good questions to ask: • Are we satisfied with the role that physicians now play in managing our practice? • Does the current office manager have the vision and skill to make the practice flourish? • Are our physician leaders intellectually receptive to sharing power with a PPA? • Given our personalities, what’s the likelihood that we can adjust to hiring a PPA? • Are we willing to support an appropriate compensation package? • If necessary, are we willing to revisit our governance structure and distribution of responsibilities? • Would a PPA give physicians more time for patient care, practice planning and professional education? • If we have multiple locations, can a PPA help us centralize functions that are not decentralized? • Are physicians receptive to working in partnership with a qualified and experienced non-physician PPA
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january 2016
15
WI
Duke Research News
Women Cardiologists Do Different Work, Make Less Money than Men Despite efforts to in-
types of work performed and pay rates.
totals more than $1 million.
crease gender diversity in cardiology, major
The researchers found that:
differences
job
•W omen constitute about 12 percent of
“This is the first study to show that although
and
cardiology ranks, which is dispropor-
men and women cardiologists share the
pay persist between
tionately low, given that half of medical
same specialty, they have markedly dif-
men and women who
school graduates are female.
ferent job descriptions,” Dr. Douglas said.
in
characteristics Pamela S. Douglas, M.D., M.A.C.C., F.A.S.E.
counterparts. Over a lifetime of work this
patients,
•W omen are more likely to specialize in
“Thirty-nine percent of men are interven-
according to a Duke Medicine-led study
general/noninvasive cardiology, with 53
tionalists vs. 11 percent of women, and this
presented at the annual American Heart
percent pursuing this subspecialty com-
sets the stage for higher compensation.”
treat
heart
Association meeting.
pared to 28 percent of men. •A lmost 91 percent of male cardiologists
The researchers found that the ranks of
stated they work full time, while about
women cardiologists remain disproportion-
80 percent of women said they work full
ally small compared to those in medicine
time.
overall; women who choose the field are
•M en dominate in interventional sub-
much less likely to specialize in higher-pay-
specialties that perform higher-paying
ing interventional procedures; and women
catheter-based procedures. More than 39
earn less, even when adjusting for the dif-
percent of male cardiologists reported an
ferent types of work they do.
interventional subspecialty, compared to 11 percent of women.
“These results recapitulate the salary differ-
•M en earn more money, even after ac-
ences that have been found among male
counting for all measured differences
and female physicians, lawyers, business
in job description, practice setting and
executives and others,” said cardiologist
productivity. Inherent in the measure of
Pamela S. Douglas, M.D., M.A.C.C., F.A.S.E.,
productivity are the known biases in the
Geller professor of research in cardiovascu-
billing system referred to as the relative
lar diseases at the Duke Clinical Research
value unit (RVU), in which procedures
Institute. Dr. Douglas is senior author of the
are reimbursed by the federal Centers for
research, which is also being published in
Medicare & Medicaid Services based on
the Journal of the American College of Car-
a score that accounts for the complexity,
diology.
time and value of a service. Interven-
Credit Mark Dubowski for Duke Medicine.
tional procedures generally have higher
“The differences in subspecialization and
“Cardiology needs to be welcoming to
RVU scores than cognitive services. As
practice were striking and merit note,” said
women,” Dr. Douglas said. ”One way to do
a result, male cardiologists generated a
radiation oncologists Reshma Jagsi, M.D.,
this is to acknowledge these differences
median 9,301 RVUs, while women gener-
associate professor at the University of
and work toward correcting them.”
ated 7,430.
Michigan and the study’s first author. “But
•T he different procedures, working hours
it’s also important to note that the differ-
Dr. Douglas and colleagues analyzed data
and billing rates translate into higher
ence in compensation between men and
from 161 cardiology practices in United
earnings for men – a median of about
women couldn’t fully be explained by dif-
States communities surveyed in a 2013 re-
$100,000 a year more for men than for
ferences in subspecialty, procedures or the
women.
many other personal, job and practice char-
port from MedAxiom, a firm that gathers
acteristics that we evaluated.”
and distributes data and business informa-
•E ven adjusting for differences in the
tion specifically for cardiologists. The sur-
amount and type of work performed,
vey is considered a non-biased look at busi-
women in cardiology make about
Dr. Douglas said the study did not address
ness practices, including hours worked,
$32,000 less per year than their male
the reasons why women steered to gen-
16
The Triangle Physician
Duke Research News optimizing patient care.”
eral cardiology rather than the interven-
“It’s important to be looking at this, be-
tional subspecialty nor did it explain the
cause we as a profession are not having
differences in the workload. But the study
full access to our ‘talent pool’ of qualified
In addition to Drs. Douglas and Jagsi, study
authors suggest that the differences could
internal medicine residents,” Dr. Douglas
authors include: Cathie Biga; Athena Pop-
stem from enduring gender inequities pro-
said. “That becomes a business and health
pas; George P. Rodgers; Mary N. Walsh;
fessionally and differences in choices in
care issue, as we increasingly recognize the
Patrick J. White; Colleen McKendry; Joseph
work/life balance.
importance of diversity among providers to
Sasson; and Phillip J. Schulte.
Finding Solves Circadian “Mystery” A team of scientists
adapts to diverse conditions, such as tem-
The findings have several implications. The
from Duke-NUS Gradu-
perature and metabolic changes.
phosphoswitch gives researchers and scientists a potential drug target to influence
ate Medical School Singapore (Duke-NUS) and
The research team found that the stability
the behavior of the circadian clock. This
the University of Michi-
of PER2 is dependent on a process called
new target may make it possible to counter
gan at Ann Arbor have
phosphorylation, in which phosphates are
the effects of jet lag, shift work and perhaps
discovered a molecular
added at key sites to influence the function
seasonal affective disorder.
switch that regulates the body’s circadian
of PER2. Dr. Virshup and the team discov-
clock and allows it to keep time. This switch
ered that phosphorylation acts as a switch.
The study also provides a mathematical
could be a potential drug target to treat cir-
This “phosphoswitch” leads to two alterna-
model that accurately predicts the behavior
cadian rhythm disorders caused by jet lag,
tive fates for PER2: increased stability or in-
of the clock under different circumstances.
shift work or metabolic disorders.
creased degradation.
This model will be useful in determining
David Virshup, M.D.
when drugs should be administered to Normally, the circadian body clock (24-
The researchers report that this phospho-
modify circadian rhythms, so they are most
hour cycle) is synchronized with the ris-
switch is sensitive to changes in tempera-
effective.
ing and setting of the sun, ensuring that
ture and metabolic signals, and so it fine-
we sleep at night. One of the reasons this
tunes clock speed as needed. Usually, the
The next step for the team is to test their
is possible is because the body clock is
rate of a biochemical reaction increases as
predictions in an animal model. They plan
relatively insensitive to small changes in
the temperature rises, so in this case the
to explore more about how phosphatases,
temperature. This is important, because
speed of the body clock should increase
an enzyme found in the body, and other
otherwise the body clock could run too
if the temperature rises. However, the team
kinases may be important in regulating the
fast when it is hot or too slow when it is
showed that at higher temperatures, the
circadian clock. Their current hypothesis is
cold. A long-standing scientific mystery is
phosphoswitch ensures that degradation
that the interplay of these systems will regu-
how the human body clock compensates
of PER2 is slower, therefore maintaining the
late the sleep and wake cycle.
for changes in temperature and maintains
speed of the body clock. In addition to Dr. Virshup and Dr. Forger,
its speed. “This study sheds light on one of the biggest
study authors include first author Duke-
Over the past few decades, research has
mysteries of the circadian clock in the last
NUS research fellow Min Zhou and KAIST
advanced the understanding of the circa-
60 years and has helped to explain some
(Korean Advanced Institute of Science
dian clock. One of the proteins critical for
of the basic mechanisms that govern the
and Technology) mathematician assistant
determining the timing of the clock, as well
timing of the clock,” explained Dr. Virshup,
professor Jae Kyoung Kim. This research
as the timing of sleep, is Period2 (PER2).
director of the Cancer and Stem Cell Biol-
is supported by the Singapore Ministry of
ogy Programme at Duke-NUS and professor
Health’s National Medical Research Coun-
In the current study, published Oct. 1 in
of pediatrics at the Duke University School
cil under its Investigator Research Grant.
the journal Molecular Cell and led by David
of Medicine. “By using both biochemical
Virshup, M.D., from Duke-NUS and Daniel
analysis and mathematical modeling we
For more information, please visit www.
Forger, Ph.D., from Michigan, the findings
demonstrated how the core circadian clock
duke-nus.edu.sg.
shed light on how PER2 regulates our cir-
keeps to a 24-hour cycle despite tempera-
cadian clock. It also clarifies how the clock
ture changes and metabolic changes.”
january 2016
17
UNC Research News
New SARS-like Virus Can Jump Directly from Bats to Humans
Ralph Baric, Ph.D.
Researchers from the
“Studies have predicted the existence of
was thought to have been extinct since
University of North Car-
nearly 5,000 coronaviruses in bat popula-
2004.
olina at Chapel Hill have
tions, and some of these have the potential
discovered a new SARS-
to emerge as human pathogens,” said se-
Dr. Baric and his team demonstrated that
like virus that can jump
nior author Ralph Baric, Ph.D., a professor
the newly-identified SARS-like virus, la-
directly from its bat
of epidemiology at the UNC Gillings School
beled SHC014-CoV and found in the Chi-
hosts to humans with-
of Global Public Health and professor of
nese horseshoe bats, can jump between
out mutation. However, researchers point
microbiology and immunology the UNC
bats and humans. They showed that the
out that if the SARS-like virus did jump, it
School of Medicine and world-renowned
virus can latch onto and use the same hu-
is unclear whether it could spread from hu-
expert in coronaviruses. “So this is not a
man and bat cellular receptor for entry. The
man to human.
situation of ‘if’ there will be an outbreak of
virus also replicates in primary human lung
one of these coronaviruses but rather when
cells, the preferred target for infection.
The discovery, reported in the Nov. 9 is-
and how prepared we’ll be to address it.” “This virus is highly pathogenic, and treat-
sue of Nature Medicine, is notable not only because there is no treatment for this
SARS first jumped from animals to humans
ments developed against the original SARS
newly discovered virus, but also because
in 2002-2003 and caused a worldwide out-
virus in 2002 and the ZMapp drugs used to
it highlights an ongoing debate over the
break, resulting in 8,000 cases, including
fight Ebola fail to neutralize and control this
government’s decision to suspend all gain
one case in Chapel Hill. With nearly 800
particular virus,” Dr. Baric said. “So build-
of function experiments on a variety of se-
deaths during that outbreak, SARS-CoV
ing resources, rather than limiting them, to
lect agents earlier this year. The move has
presents much like flu symptoms but then
both examine animal populations for new
substantially limited the development of
can accelerate, compromise breathing and
threats and develop therapeutics are key
vaccines or treatments for these pathogens
bring on a deadly form of pneumonia. The
for limiting future outbreaks.”
should there be an outbreak, according to
outbreak was controlled through public
a UNC press advisory.
health interventions and the original virus
Technique to Jumpstart Bone Cell Formation Discovered Unexpectedly Photo Credit: Max Englund, UNC Health Care
Janet Rubin, M.D.
Researchers at the Uni-
By treating stem cells – which can be-
versity of North Caro-
come fat or bone cells - with cytochalasin
Dr. Rubin added, “This was not what we ex-
lina School of Medicine
D – the result was clear: The stem cells
pected. This was not what we were trying to
may have found a way
became bone cells. Further, injecting a
do in the lab. But what we’ve found could
to tip the scale in favor
small amount of cytochalasin D into the
become an amazing way to jump-start lo-
of bone formation that
bone marrow space of mice caused bone
cal bone formation. However, this will not
could help those who
to form.
address osteoporosis, which involves bone loss throughout the skeleton.”
heal slowly, particularly the elderly. “And the bone forms quickly,” said Janet They used cytochalasin D, a naturally oc-
Rubin, MD, senior author of the paper and
The research published in the journal Stem
curring substance found in mold, as a
professor of medicine at the UNC School
Cells details how the scientists altered the
proxy to alter gene expression in the nuclei
of Medicine. “The data and images are so
stem cells and triggered bone growth.
of mesenchymal stem cells to force them to
clear; you don’t have to be a bone biolo-
become osteoblasts (bone cells).
gist to see what cytochalasin D does in one
At the center of the discovery is a protein
week in a mouse.”
called actin, which forms fibers that span
18
The Triangle Physician
UNC Research News cytoskeleton but do not allow the actin to enter the nucleus, the little bits of actin just sit in the cytoplasm, and the stem cells do not become bone cells.” Dr. Rubin’s team then turned to a mouse model. Using live mice, they showed that cytochalasin D induced bone formation in mice. At left, green actin fibers create architecture of the cell. (Right) With cytochalasin D added, actin fibers disband and reform in the nuclei.
Bone formation in mice isn’t very different from that in humans, so this research might
the cytoplasm of cells to create the cell’s
“My first reaction was, ‘No way, Buer,’” Dr.
be translatable, according to a UNC press
cytoskeleton. Osteoblasts have more cyto-
Rubin said. “‘This must be wrong. It goes
advisory. And while cytochalasin D might
skeleton than do adipocytes (fat cells).
against everything in the literature.’ But he
not be the actual agent scientists use to trig-
said, ‘I’ve rerun the experiments. This is
ger bone formation in the clinic, Dr. Rubin’s
what happens.’”
study shows that triggering actin transport
Buer Sen, M.D., first author of the stem cells paper and research associate in Dr. Ru-
into the nuclei of cells may be a good way
bin’s lab, used cytochalasin D to break up
Dr. Rubin’s team expanded the experi-
to force mesenchymal stem cells to be-
the actin cytoskeleton. In theory – and ac-
ments while exploring the role of actin.
come bone cells.
cording to the literature – this should have
They found that when actin enters and
destroyed the cell’s ability to become bone
stays in the nucleus, it enhances gene ex-
Dr. Rubin, the vice chair for research at the
cells. The cells, in turn, should have been
pression in a way that causes the cell to
UNC School of Medicine, holds joint ap-
more likely to turn into adipocytes. Instead,
become an osteoblast.
pointments in pediatrics and pharmacol-
Dr. Sen found that actin was trafficked into
ogy, and is an adjunct professor of bioen-
the nuclei of the stem cells, where it had
“Amazingly, we found that the actin forms
the surprising effect of inducing the cells to
an architecture inside the nucleus and
become osteoblasts.
turns on the bone-making genetic pro-
This work was funded by the National Insti-
gram,” Dr. Rubin said. “If we destroy the
tutes of Health.
gineering.
UNC and NCCU Awarded $7.5 Million for Alcohol Health Disparities Study Researchers at University of North Carolina
pathology, alcoholic liver disease, alcohol-
thology creating an ac-
School of Medicine and North Carolina
related cancers, including breast cancer,
tive NCCU program that
Central University have been awarded $7.5
and the effects of alcohol and marijuana on
will involve students
million to continue an ongoing collabora-
brain stem cells and neurotoxicity.
and prepare them to become leading scientists
tion aimed at understanding and reducing alcohol-related pathologies among African-
Gregory Cole, Ph.D., chair of biological and
Americans.
biomedical sciences at NCCU, and Fulton
Fulton Crews, Ph.D.
in the future,” Crews said.
Crews, Ph.D., director of UNC Bowles CenThe award from the National Institute on
ter for Alcohol Studies,
This partnership opens UNC research
Alcohol Abuse and Alcoholism (NIAAA) of
are lead investigators of
laboratories, core facilities and libraries to
the National Institutes of Health (NIH) is for
the project.
NCCU faculty, improving opportunities for
$6 million to NCCU and $1.5 million to UNC
“The UNC-NCCU part-
developing productive research laborato-
over a five-year period. This funding will
nership will promote,
ries at NCCU and providing NCCU students
continue a research program investigating
support, and mentor
with opportunities to work with some of the
research on alcohol pa-
world’s leading alcohol researchers.
the molecular mechanisms of fetal alcohol
Gregory Cole, Ph.D.
january 2016
19
News
Bullies at Risk of Eating Disorders Being bullied in childhood has been associated with increased risk for anxiety, depression and even eating disorders. But according to new research, it’s not only the victims who could be at risk psychologically, but also the bullies themselves. Researchers at Duke Medicine and the University of North Carolina at Chapel Hill were surprised to find that in a study of 1,420 children, those who bullied others were twice as likely to display symptoms of bulimia, such as bingeing and purging, when compared to children who are not involved in bullying. The findings are published in the December issue of International Journal of Eating Disorders. “For a long time, there’s been this story
Illustration by Mark Dubowski for Duke Medicine.
could be affected.
about bullies that they’re a little more hale
Children who were both bullies and victims had the highest prevalence of anorexia
and hearty,” said lead author William Cope-
Participants were divided into four catego-
symptoms (22.8 percent compared to 5.6
land, Ph.D., associate professor of psychia-
ries – children who were not at all involved
percent of the children not involved in
try and behavioral sciences at Duke Uni-
in bullying; victims of bullying; children
bullying) and also the highest prevalence
versity School of Medicine. “Maybe they’re
who sometimes were victims and some-
of binge eating (4.8 percent of children as
good at manipulating social situations or
times were instigators; and children who
compared to less than 1 percent of uninvolved children) and vomiting as a way to
All of these behaviors can have devastating effects on the long-term health of children
maintain their weight. But the impact of bullying behavior on those who were bullies was also significant, with 30.8 percent of bullies having symp-
getting out of trouble, but in this one area
were solely bullies, repeatedly abusing oth-
toms of bulimia compared to 17.6 percent of
it seems that’s not the case at all. Maybe
er children verbally and physically, socially
children not involved in bullying.
teasing others may sensitize them to their
excluding others and rumor mongering
own body image issues, or afterward they
without ever becoming a victim themselves.
have regret for their actions that results in
All of these behaviors can have devastating effects on the long-term health of children,
these symptoms like binge eating followed
The researchers were not surprised to find
said Cynthia M. Bulik, Ph.D., a distinguished
by purging or excess exercise.”
that victims of peer abuse were generally at
professor of eating disorders at UNC-Chapel
increased risk for eating disorders.
Hill and a co-author on the findings.
terviews from the Great Smoky Mountains
Children who were victims of bullying were
“Sadly, humans do tend to be most criti-
Study, a database with more than two de-
at nearly twice the risk of displaying symp-
cal about features in other people that
cades of health information on participants
toms of anorexia (11.2 percent prevalence
they dislike most in themselves,” Dr. Bulik
who enrolled at age nine. The data is con-
compared to 5.6 percent of children who
said. “The bullies’ own body dissatisfaction
sidered a community sample and not repre-
were not involved in bullying) and bulimia
could fuel their taunting of others. Our find-
sentative of the United States population but
(27.9 percent prevalence compared to 17.6
ings tell us to raise our vigilance for eating
offers clues to how children ages nine to 16
percent of children not involved in bullying).
disorders in anyone involved in bullying
The findings come from an analysis of in-
20
The Triangle Physician
News exchanges – regardless of whether they are
“We want to do a better job of understand-
In addition to Drs. Copeland and Bulik,
the aggressor, the victim, or both.”
ing why some people are able to experi-
study authors include Nancy Zucker, Dieter
ence the same things as others and be able
Wolke, Suzet Tanya Lereya and Elizabeth
Although many children experience life-
to get through them without the same con-
Jane Costello.
long effects, many appear to cope and suc-
sequences,” Dr. Copeland said. “We really
ceed after such experiences, Dr. Copeland
need to understand the resilience in those
The study was sponsored by the National
said. He and colleagues are examining
who have been bullied. That can help us
Institute of Mental Health (MH63970,
myriad factors, including looking at finan-
determine the children who are going to
MH63671, MH48085, MH080230); the Nation-
cial and educational outcomes and genetic
need the most attention and how we can
al Institute on Drug Abuse (DA/MH11301);
biomarkers associated with bullying or be-
promote those traits in others to increase
the William T. Grant Foundation; and the
ing victimized.
their resilience.”
Economic and Social Research Council in the United Kingdom (ES/K003593/1)
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Abdominal Surgery; Young Adult Medicine; Adolescent Medicine; Critical Care Pediatrics; Critical Care Surgery; Critical Care-Internal Medicine; General Surgery; Hospitalist; Internal Medicine - Nephrology
Duke University Medical Center Durham
204 Sandhurst Rd Raleigh
january 2016
21
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