j u ly / a u g u s t 2 0 1 6
GastroIntestinal Healthcare
Exceeding the Standards for High-Quality Colonoscopy and Care
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 Vitamin D Physician Leadership
We’ve Taken Screening To Another Dimension!
3-D
MAMMOGRAPHY
“With 3-D mammography, we are able to see
tissue better than ever before - detecting small cancers at an earlier stage and also decreasing stressful false positives. We are excited about what offering this, close to home in Smithfield & Clayton, means for women, families and physicians.” Dr. Cary Bizzell Radiologist Johnston Health
Screening Saves
! s e v Li
To schedule your 3-D Mammogram in Smithfield or Clayton Call:
919-938-7749
www.johnstonhealth.org
From the Editor
Afordable Quality
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
Colonoscopies save lives, so long as they are affordable and performed by well-trained endoscopy staff. In this month’s cover story featuring Gastrointestinal Healthcare, practice founder Boris Cvetkovski, M.D., discusses the importance of colonoscopies at appropriate intervals, based on adherence to quality indices and proper documentation.
Also in this issue of The Triangle Physician, endocrinologist Carly
Editor Heidi Ketler, APR heidi@trianglephysician.com Contributing Editors Boris Cvetkovski, M.D. Marni Jameson Carly E. Kelley, M.D., M.P.H. Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G. Margie Satinsky, M.B.A.
Kelley explores the far-reaching benefits of Vitamin D and the impact
Creative Director Joseph Dally jdally@newdallydesign.com
of Vitamin D deficiency. Practice consultant Margie Satinsky begins a
Advertising Sales
series on physician leadership in private practice. Physician advocate Marni Jameson updates on hospital mergers and the need for greater
info@trianglephysiciancom News and Columns Please send to info@trianglephysician.com
antitrust enforcement. Gynecologist Andrea Lukes discusses women’s sexuality.
The Triangle Physician is published by: New Dally Design
The Triangle Physician is a cost-efficient vehicle for communicating
Subscription Rates: $48.00 per year $6.95 per issue
your news to the medical community at-large, a circulation of more
Advertising rates on request Bulk rate postage paid Greensboro, NC 27401
than 9,000 professionals. Spotlight your practice in a cover story and/or advertise at competitive rates. Inquire to info@trianglephysician.com. With gratitude and respect,
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.
2
The Triangle Physician
Table of Contents
4
COVER STORY
GastroIntestinal Healthcare
Exceeding the Standards for High-Quality Colonoscopy and Care j u ly / a u g u s t 2 0 1 6
FEATURES
8
Vol. 7, Issue 7
DEPARTMENTS 7 Practice Management
Endocrinology
Day-to-Day Operations
Vitamin D Gastroenterologist Carly Kelley talks about the importance of maintaining proper Vitamin D levels in adults and children.
12
Common Leadership Problems Undermine Successful
10 Women’s Health Sex and Females
14 Duke Research News Physician Advocacy
Are Hospital Mergers Really Better for the Patient and the Community? Physician advocate Marni Jameson Carey likens hospital-hospital
Study Examines Mental Illness in Adults, Gun Violence and Suicide
16 NEWS
Welcome to the Area
mergers with physician-hospital consolidation.
On the Cover: Boris Cvetkovski, M.D., is committed to providing quality care.
july/august 2016
3
Cover Story
GastroIntestinal Healthcare
Exceeding the Standards for High-Quality Colonoscopy and Care By Boris Cvetkovski, M.D.
Over recent years, there has been a major
duced risk of colon cancer and prevention
Not surprisingly, reducing or limiting this
initiative from both private and government-
in many cases.
cost has been a point of emphasis for insurers and patients. The Affordable Care
based insurers to provide the public with cost-efficient, high-quality and appropriate
It is recommended that all average-risk men
Act mandates that insurers pay for screening
medical care. This initiative has affected
and women age 50 years or older should
colonoscopy. So cost is not necessarily an
all corners of the health care industry,
undergo colorectal cancer screening.
issue in these circumstances. However,
including the field of gastroenterology.
High-risk patients, due to family history of
there are occasionally components of the
colorectal cancer or precancerous polyps,
procedure that have historically not been
A significant portion of a practicing gas-
may need to begin screening at a younger
covered by insurance. These include the
troenterologist’s day is spent performing
age.
cost of the laxative preparation, anesthesia services and/or pathology.
medical endoscopy, most notably, colonoscopies. The colonoscopy has been a
As a result of this screening initiative, we
breakthrough medical procedure. It allows
have witnessed a significant reduction
Also, surveillance colonoscopy (a colo-
access and direct visualization of the colon
in the incidence and mortality of colon
noscopy performed to follow up a pre-
and the ability to locate and remove colon
cancer in the United States over the past
vious finding, such as colon polyps or
polyps.
decade. There is little debate that screening
colon cancer) is not necessarily a 100
colonoscopy saves lives by preventing
percent-covered service, as copays and
Colon polyps are the established precur-
colon cancer. However, the benefits of
deductibles are often applied. With the
sors to colon cancer. Simply, removal of
a colonoscopy come with a significant
rapid growth of high-deductible insurance
colon polyps results in a significantly re-
financial cost.
plans, patients are finding themselves in
The staff of GIH is committed to improving your health from the inside out.
4
The Triangle Physician
a position where they have to pay for a significant portion or all of the cost of a surveillance colonoscopy. These realities have resulted in both insurers and patients demanding and expecting high-quality and cost-effective medical care, including colonoscopy. Throughout recent years, the gastroenterology community – gastrointestinal (GI) societies in concert with GI practitioners – has responded with a distinct and concerted effort to provide high-quality colonoscopies at appropriate intervals. Today, the time between colonoscopies is determined by well-established guidelines. Factors that determine an appropriate interval before the next colonoscopy
Treatment is coordinated to provide excellent patient care.
include the number, size and types of polyps removed as well as family history of
models will be based, to some degree,
polyps need to be seen and removed
colorectal cancer and polyps. If the interval
on attaining and maintaining adequacy in
during a colonoscopy. The ability to find
between procedures is too short, then the
these measures. There will be financial
polyps is significantly affected by the
patient is exposed to the risk and cost of
penalties for those providers who fail to
quality of the preparation prior to the
a potentially unnecessary colonoscopy.
maintain these standards.
procedure. Perhaps the biggest downside
If the interval is too long, then they are
to colonoscopy is requirement to drink a
exposed to an increased risk of developing
At
an interval colorectal cancer.
electronic medical record system, gMed,
GastroIntestinal
Healthcare,
our
purging laxative prior to the procedure.
works in concert with a colonoscopy
Historically, this required consuming a clear-
Importance of Documentation
database,
Improvement
liquid diet the day before the procedure
There is little doubt that providing high-
Consortium (GIQuIC), to collect and
and drinking a laxative the evening before.
quality
send quality data on every colonoscopy
However, it became clear that there was
performed to the database.
significant accumulation of bile and mucus
colonoscopies
at
appropriate
intervals benefits patients as well as
GI
Quality
insurers. However, how to achieve this goal
material between drinking the laxative
and document it has evolved and continues
For example, appropriate colonoscopy
and having the colonoscopy the following
to evolve.
interval time is tracked via GIQuIC. At
day. As a result, most gastroenterologists
GastroIntestinal Healthcare, we employ
have employed a “split-dose prep,” which
There are certain quality indices that have
accepted
determine
requires drinking half of the prep the
been established as significant indicators
colonoscopy interval. We also exceed the
evening before and the other half early in
of a high-quality colonoscopy. Monitoring,
standards for all other quality indicators.
the morning of the colonoscopy.
indicators has become an integral part
Quality Indicators
This practice has resulted in some patient
of most endoscopy units. Databases of
The quality indicators for colonoscopy
dissatisfaction due to having to set an alarm
this information have been established.
that are presently being tracked include:
for 3 a.m. to wake up and drink laxative.
Electronic health records that document
preparation quality, cecal intubation rate,
However, it has clearly resulted in superior
colonoscopies are evolving to automate
colonoscope withdrawal time, adenoma
preparations, translating to more effective
documentation of these quality indicators.
detection rate, complication rate and
visualization and removal of colorectal
Insurers, including Centers for Medicare
appropriate colonoscopy intervals.
polyps, especially small, flat polyps.
To perform a quality colonoscopy and
The
prevent colorectal cancer, precancerous
each procedure is documented by the
guidelines
to
documenting and keeping track of these
Services, are collecting these data. It is anticipated that future reimbursement
quality
of
the
preparation
july/august 2016
for
5
perforation
or
drug
reactions.
High
performance based on all the other quality indicators would be negated in the setting of an elevated complication rate. Data on complications is gathered via GIQuIC as well as by insurers. Minimizing
complications
requires
a
dedicated and concerted effort by not only the endoscopist but also the entire endoscopy
staff.
The
GastroIntestinal
Healthcare staff members and I are proud of our extremely low complication rate. A quality colonoscopy is not something Gastrointestinal Healthcare’s inviting lobby provides drive-up drop off and easily accessible complimentary parking.
that happens without effort. It requires careful planning and attention to detail carried out by a dedicated and well-trained
endoscopist and results are tracked. At
examining the colon, the more likely they
GastroIntestinal Healthcare, we employ a
are to find colon polyps.
split-dose prep.
endoscopy staff. Documenting colonoscopy quality indi-
At
GastroIntestinal
Healthcare,
every
cators has facilitated objective evaluation
Cecal intubation rate is another benchmark
colonoscopy withdrawal is timed to ensure
of practitioners and established a bench-
that is monitored and tracked. It indicates
that sufficient time is spent examining the
mark standard. Achieving and maintaining
the percentage of time that the cecum
colon and thus maximizing polyp detection.
these standards is of benefit to insurers,
(beginning of the colon) is reached and
endoscopists and, most of all, patients.
visualized during a colonoscopy. In order
Perhaps the single-most-important quality
to perform a high-quality colonoscopy, the
indicator is adenoma detection rate (ADR).
After practicing in Maine for seven years,
entire colon must be examined.
The ADR is calculated based on the
gastroenterologist Boris Cvetkovski, or “Dr.
percentage of times that an adenomatous
C,” founded GastroIntestinal Healthcare, at
Photo documentation of the cecum indi-
(precancerous) polyp is detected during
2011 Falls Valley Drive, Suite 106, in Raleigh.
cates that the colonoscope traversed the
a screening colonoscopy. I like to think
Dr. Cvetkovski earned his undergraduate
entire colon. Images of landmarks of the
of it as the endoscopist’s batting average.
degree from Cornell University and his med-
cecum, the appendiceal orifice and ileo-
It is the best gauge of how effectively the
ical degree from the New York University
cecal valve, should be obtained for each
endoscopist is performing his or her prime
School of Medicine. Following his residency
colonoscopy.
objective, finding precancerous colon
at New York University Medical Center, he
polyps. Prep quality, cecal intubation rate
completed fellowships in gastroenterology
The standard for cecal intubation rate is
and colonoscope withdrawal time all
and hepatolbiliary medicine at Memorial
90 percent. The cecal intubation rate at
directly affect the ADR.
Sloan-Kettering Cancer Center/Cornell Uni-
GastroIntestinal Healthcare approaches 100
versity Medical Center. Dr. Cvetkovski is cerInformation used to calculate ADR is
tified in gastroenterology by the American
gathered by GIQuIC on each screening
Board of Internal Medicine-Gastroenterolo-
the
colonoscopy performed. The ADR at
gy. He is a member of the American College
colonoscope is then withdrawn and the
GastroIntestinal Healthcare has consistently
of Gastroenterology, the American Society
colon walls are examined, looking for
been well above the standard.
for Gastrointestinal Endoscopy, the Ameri-
percent. Once
the
cecum
is
reached,
precancerous polyps. Numerous studies
can Gastroenterological Association and the
have demonstrated that if the endoscopist
A colonoscopy is a very safe procedure,
North Carolina Medical Society. For more in-
spends less than six minutes withdrawing
particularly when performed by a well-
formation or to make an appointment, call
the scope and examining the colon, then
trained and experienced endoscopist,
(919) 870-1311 or visit www.giraleigh.com.
the ability to detect polyps is diminished.
however it is not without potential risks.
The
These risks include bleeding, infection,
6
longer
the
endoscopist
The Triangle Physician
spends
Practice Management
Common Leadership Problems Undermine Successful Day-to-Day Operations By Margie Satinsky, M.B.A.
This article is the first of two on leadership coaching for health care providers. It focuses on common leadership problems. The second article, focusing on ways to enhance leadership skills, will appear in the issue of The Triangle Physician. During the past 14 years we’ve helped
High Drama: When practices are start-
many physicians in all specialties start new
ing from scratch or undergoing a major
practices or improve their existing ones.
change (e.g. new software system), lack
We focus on the nuts and bolts of running
of knowledge and/or fear of the unknown
a practice: developing the right team
may result in high drama. Angry temper
of professionals; financial management
tantrums, finger pointing and name-calling
including but not limited to revenue cycle
and impatience with internal workforce
management; selecting and implementing
members and/or external vendors erupt.
software; compliance; marketing (including
High drama doesn’t solve problems; it cre-
Website content); practice operations; and
ates them. More often than not, it discour-
human resources.
ages people from working collaboratively to focus on the problems at hand and find
If there’s one lesson we’ve learned, it’s
practical solutions.
Margie Satinsky is president of Satinsky Consulting L.L.C., a Durham consulting firm that specializes in medical practice management. She has helped many physicians start new practices, assess the wisdom of affiliating with a larger health care system and improve their current practices. Ms. Satinsky is the author of numerous books and articles, including Medical Practice Management in the 21st Century. For more information, visit www. satinskyconsulting.com.
that no aspect of running a medical practice flourishes or thrives without
Lack of Flexibility: In a business environ-
professionals who leave one position
strong physician leadership. A physician’s
ment, there’s rarely one way to address
and accept a job offer each have unique
ability to articulate his/her vision for the
and resolve a problem. Unwillingness to
processes. Delays are common and not
future, to make good decisions and to
objectively explore multiple options often
necessarily deliberate. Impatience, anger
build and maintain respectful professional
rules out the approach that makes the most
and disrespect don’t expedite progress and
relationships carry a great deal of weight in
sense from both substantive and financial
are likely to cause even more delays.
determining the outcome of any business
perspectives.
project. A good physician leader creates a
Inattention to Good Communications:
healthy working environment and culture
Rigid Adherence to Timelines: Many phy-
Two communications issues we repeatedly
that stimulates personal and professional
sicians who want to open a new practice or
experience are: (1) failure to clarify
growth for everyone in the practice.
make a major change insist on a deadline
expectations and provide helpful feedback;
of yesterday. Just because you can’t wait to
and (2) failure to check email/phone/text
Many of the leadership problems we’ve
leave your current situation and open your
messages on a timely basis in order to
observed are common regardless of
own shop or just because you need to make
keep a complicated process moving. Most
specialty. We’ll identify some of them and
a major and often costly change in practice
business projects are team efforts that
then examine ways in which physicians
operations doesn’t guarantee the world will
require timely input from multiple people.
in leadership positions can avoid such
adhere to your timetable.
If one person drops the ball, the project
problems and/or acknowledge/address them when they arise.
stalls, deadlines are missed and work runs Architects, builders, landlords, managed-
over budget.
care companies, software vendors and
july/august 2016
7
Endocrinology
By Carly E. Kelley, M.D., M.P.H.
During the past 10-to-20 years there has
calcium absorption and causes parathyroid
been a renewed interest in vitamin D for
hormone (PTH) secretion.
its potential benefits with regards to a wide variety of diseases.
Vitamin D levels that are 30 nanograms per milliliter or greater are optimal for bone
The significance of vitamin D was first
health, since this is when maximal calcium
recognized in 1650 with a formal medical
absorption occurs. Additionally, multiple
treatise on rickets, a disease then more
studies have shown that PTH rises (i.e.
frequent in the rich than the poor. During
secondary hyperparathyroidism) as the
the Industrial Revolution of the 1800s, the
vitamin D levels fall below 30 nanograms per
prevalence of rickets increased from 40
milliliter. Levels between 10-29 nanograms
percent to 60 percent among children in
per milliliter are consistent with vitamin D
urban areas due to a lack of sunlight.
“insufficiency.” Vitamin D levels below 10 nanograms per milliliter are consistent with
In the early 1900s vitamin D was discovered
vitamin D “deficiency.” It has been estimated
as the agent in cod liver oil that cured rickets.
that one billion people worldwide and at
This discovery led to the fortification of milk
least one-third of the United States population
and other foods with vitamin D in the 1930s
have vitamin D deficiency or insufficiency.
and a resultant decrease in the prevalence
Factors known to influence vitamin D levels
of rickets.
include race, vitamin D intake, sun exposure, adiposity (due to sequestration of vitamin D in
Vitamin D comes in two forms: D2 and
body fat), age, physical activity and genetics.
D3. Vitamin D3 is produced in the skin
Carly Kelley was born in Livingston, N.J. She graduated magna cum laude from the College of William and Mary in Virginia. She earned her medical degree and master in public health from the University of Medicine and Dentistry of New Jersey, where she was inducted into the Alpha Omega Alpha Honor Medical Society. She then completed her postgraduate medical training at Duke University, which included internship, residency and an endocrinology fellowship. During her fellowship training, she presented or published in the areas of thyroid, parathyroid, pituitary, lipids and polycystic ovary syndrome. Dr. Kelley is board certified in both internal medicine and endocrinology and is working on her Endocrine Certification in Neck Ultrasound (ECNU). She is a member of both the American Association of Clinical Endocrinology and the Endocrine Society. When not practicing medicine, Dr. Kelley dedicates her time to her husband and two children and enjoys running, cycling and photography.
and from the diet (deep-sea fatty fish, egg
Vitamin D deficiency in children may
yolks, liver). Vitamin D2, found in some
result in rickets, a disease of inadequate
plants and produced commercially by
mineralization of growing bone, which
irradiation of yeast, is used for fortification
manifests with leg deformities, enlargement
of the pelvis, femurs, metatarsals or lateral
and prescription supplements. The total 25
of growth plates, rib cage deformities,
margins of the scapulae.
hydroxyvitamin D (25(OH)D) measured
bone pains and delayed growth. In adults,
by liquid chromatography-tandem mass
inadequate mineralization from vitamin D
Data suggest there are additional skeletal
spectrometry identifies both D2 and D3.
deficiency results in osteomalacia. Patients
benefits associated with vitamin D, such
Both forms are metabolized in the liver
with osteomalacia may present with bone
as an increase in bone mineral density,
and kidneys to 1,25 dihydroxyvitamin D
pain, increased serum alkaline phosphatase,
a decreased risk of fractures (both non-
(“calcitriol”), the active form that mobilizes
increased PTH, low serum calcium, low
vertebral and hip) and falls and an
calcium from the bone, increases intestinal
serum phosphorus and pseudofractures
improvement in lower-extremity function.
8
The Triangle Physician
Endocrinology units of vitamin D3.
Mounting evidence also has shown effects
The Endocrine Society, on the other hand,
on cardiovascular disease, diabetes, cancer,
recommends higher doses to achieve
multiple sclerosis and other autoimmune
levels of 30 nanograms per milliliter and
An effective strategy to treat vitamin D
disorders, allergies and asthma, infection,
avoid the other possible skeletal and non-
deficiency and insufficiency in children
mental illness and pregnancy outcomes.
skeletal risks connected to inadequate
and
Vitamin D receptors are present in multiple
vitamin D status; 600-1,000 international
international units of vitamin D2 weekly for
tissues, including cells of the pancreas,
units per dose for children aged one to 18
six weeks and eight weeks, respectively.
immune system, macrophages, vascular
and 1,500-2,000 international units per dose
Administration of 600 to 1,000 international
endothelium, stomach, epidermis, colon
for adults older than age 18.
units per dose is effective at maintaining
adults
is
to
prescribe
50,000
vitamin D levels in children; administration
and placenta. In these tissues the 25(OH)D is converted to calcitriol, which influences
While screening for vitamin D deficiency
of 50,000 international units of Vitamin D2
local-tissue gene expression among over
is indicated for vulnerable populations,
every two weeks or 1,000-2,000 international
200 genes.
there is currently insufficient evidence to
units per dose of Vitamin D3 is effective at
recommend screening in the asymptomatic
maintaining levels in adults.
After reviewing more than 1,000 studies,
population. Vitamin D deficiency or
the Institute of Medicine (IOM) instead
insufficiency may be prevented with
Vitamin D intoxication is extremely rare, but
decided that the current research shows
sensible
of
may occur with inadvertent or intentional
inconclusive non-skeletal benefits. Thus,
foods containing vitamin D and vitamin
ingestion of excessively high doses. Doses
the IOM recommended dietary allowance
D supplementation. Sunlight is the most
of more than 50,000 international units per
of 600 internal units for children and adults
important source of vitamin D. A single
dose may raise levels of 25(OH)D to more
age one to 70 years aims only to achieve
exposure to the summer sun in a bathing
than 150 nanograms per milliliter and result
sufficient bone health at the population
suit for 20 minutes may produce the
in hypercalcemia and hyperphosphatemia.
level.
equivalent of 15,000 to 20,000 international
sun
exposure,
ingestion
State-of-the-art, expert, cost effective, timely endocrinology care is what Carolina Endocrine has to offer your patients. • Consultation & Treatment • 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. Carly Kelley, M.D., M.P.H. Erin Wetherill, PA-C
july/august 2016
9
Women’s Health
Sex and Females By Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G.
Each woman is different: her level of inter-
general questions about sexual satisfac-
is to consider psychiatric illnesses and gen-
est in sex, her response to sex, how it im-
tion are recommended before becoming
eral health factors that may impact sexual
pacts her relationship. As healthcare pro-
more specific. For instance, you can ask
function:
viders, the fact that each woman is unique
a woman to rate her sexual activity on a
is something to be valued. A healthy sexual
scale from 1 (bad) to 10 (great). Then,
relationship can and hopefully does have
follow-up questions could include a direct
•A nxiety Disorders
a positive impact on a woman’s life. Unfor-
question, “Do you have any problems or
•H ypertension (greater tendency for
tunately, approximately 43% of US women
concerns relating to sex?” Some providers
women with HTN to have low libido
report a ‘sexual problem’.1 The National
prefer a less direct manner, “Many women
compared to age matched controls)
Health and Social Life Survey (NHSLS) has
your age not some problems with sexual
•E ndocrine disorders (diabetes, thyroid
shown that sexual problems/complaints
activity”, and see if your patient is comfort-
disorders, estrogen deficiency)
were associated with low physical and
able talking about it. If the healthcare pro-
•G ynecologic issues (pelvic floor
emotional satisfaction with sexual partners
vider is comfortable bringing up the topic,
and low general happiness. This supports
then the patient will be more comfortable
that health care providers need to address
discussing it.
2
•M ood Disorders (depression or bipolar disorder)
disorders, postpartum) •O ther Chronic Illness (cancer, skin conditions)
this important topic. Review of potential medications that may contribute to a sexual disorder or problem is important as well. Laboratory test for the evaluation of a sexual problem includes testing of thyroid function, SHBG (sexual hormone binding globulin), testosterone, estrogen, progesterone, and albumin levels. Another element in evaluating a woman’s sexual problem is in understanding her expectations. Some women enjoy sex, but others may want to simply satisfy their partner and be done. Many women are someWithin the population of women who re-
There are validated diagnostic tools that
where between enjoying and not enjoying.
ported a ‘sexual problem’1, 63.9% were pre-
physicians can use. For the broader diagno-
Our providers review some of the sexual
menopausal and 37.4% reported extreme
sis of female sexual disorders, one can use
‘myths’. 1) First, there is a ‘perfect’ orgasm.
dissatisfaction with their sex lives. Further,
the Female Sexual Function Index (FSFI) or
This is not true. The intensity will vary and
1 in 10 women reported low sexual desire
the Brief Profile of Female Sexual Function
that is to be expected. Scenes from the
and associated stress which may be hypo-
(B-PFSF). A different questionnaire is the
movies are often not realistic. Often, just the
sexual desire disorder or HSDD. The good
Golombok Rust Inventory of Sexual Satis-
intimacy through intercourse can improve
news for women with HSDD is that there is
faction (GRISS). All are available through
a relationship. 2) Second, masturbation is
now a medication, addyi (flibanserin) that
the Internet. Such questionnaires should be
bad. This is not true. If a woman can mastur-
is available to them (see below).
thoroughly understood by the providers be-
bate and give herself an orgasm, then she
fore giving to patients. The review of these
is more likely to be able to have an orgasm
How can a healthcare provider help or
questionnaires is beyond the scope of this
with a partner. Many women are uncomfort-
what should a provider ask? In addition
article.
able with this. 3) Third, it is all physical. This is not true. Your thoughts can have a big
to a good history and physical, just bringing up the question about sexuality is im-
Once a provider determines that there is a
impact on sexuality. If a woman is thinking
portant. Research has shown that more
sexual problem for a woman, the next step
‘what if I get pregnant’, ‘I want this to end’, or
10
The Triangle Physician
Dermatology ‘I need to do laundry’ – then this can inhibit her sexual response. Talking during sex about what feels good, giving feedback to your partner, complimenting your partner, just allowing yourself to enjoy it – are all excitatory and enhance a woman’s experience (and her partner’s experience).
BOTOX® COSMETIC • COOLSCULPTING® • FACIAL FILLERS • MICRODERMABRASION
“She wanted to spend less time worrying and more time living” I REFERRED HER TO SOUTHERN DERMATOLOGY
As mentioned earlier, addyi is a new medication for women. It is used in premenopausal women who have low sexual desire. The side effects include dizziness, nausea, tiredness, and dry mouth. The majority of women have no side effects and feel improved sexual desire. The providers at the Women’s Wellness Clinic are all certified to prescribe this medication. You can learn more about it at www.addyi.com. If a woman experiences discomfort or pain with intercourse, then we offer a new procedure done within our office for vaginal rejuvenation, the FemiLift procedure through Alma laser. This newest minimally
THE SKIN RENEWAL CENTER AT S O U T H E R N D E R M AT O L O G Y
southernderm.com
FOR THE MOST ADVANCED SKIN CARE TREATMENTS, REFER YOUR PATIENTS TODAY!
919-863-0073
LASER HAIR REMOVAL • CLEAR + BRILLIANT® • THERMAGE®
• FRAXEL® DUAL
invasive treatment causes small microlesions within the vaginal mucosa that triggers production of new collagen and tissue regeneration over several weeks. You can learn more about this through www.vcon-
DER131_AD_Triangle Physican WANT Conc.indd 4
DBT Group for Adolescents
3/15/16 2:49 PM
with Meredith Hailey, MSW, LCSW, CH
fidence.com. Dr. Lukes is one of the first to be trained within North Carolina. Providers at the Women’s Wellness Clinic
DBT is noted to be very successful for clients with difficulty managing their emotions. Ms. Hailey was trained by Marsha Linnehan's (the creator of DBT) original students and trained and has supervised other therapists in DBT since 1995.
are devoted to helping women improve their sexual relationships. We work diligently with each woman to devise an effective and individualized treatment for her. All healthcare providers should take an interest in a woman’s sexual experience – even
Some of the issues our clients experience are: Mood Swings | Depression | Substance Abuse | Poor Impulse Control Borderline Personality Disorder | Eating Disorders | Anxiety/OCD Self-Injurious Behavior | Suicidal Thoughts | Anger Problems
if it is to refer her to one of our providers. This can make a positive impact for your female patient.
1. Shifren JL, Monz BU, Russo PA, Segreti
26 week program (4 modules) 6:00pm - 7:30pm | Every Thursday Ages 15-18
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
Call Meredith Hailey at 919-761-5023 to find out more about the group, or to schedule a consultation to determine if this group is a good fit.
and predictors. JAMA. 1999;28(6):537-544.
july/august 2016
11
Physician Advocacy
Are Hospital Mergers Really Better for the Patient and the Community? By Marni Jameson
A
ll across the country hospitals are
grew by 18 percent over the prior year and
merging at a feverish pace, and that’s
by 70 percent when compared to 2010. The
not necessarily healthy.
Affordable Care Act is driving much of this consolidation by reinforcing the notion that
In 2015, the number of hospital transactions
there is safety in size.
Marni Jameson is the executive director of the Association of Independent Doctors. You may reach her at (407) 571-9316 or marni@aid-us.org. Visit www.aid-us.org for more information.
While that may or may not be true, studies have demonstrated that consolidation drives prices only one way – up. That’s why AID is involved. This impact on cost is also why we at the Association of Independent Doctors are working with the Federal Trade Commission to block two hospital mergers – one in central Pennsylvania and one in northern Illinois – that would harm communities by forming monopolies. A national nonprofit, AID began in Winter Park, Fla., three years ago to help
“The Affordable Care Act has unleashed a merger frenzy, with hospitals scrambling to shore up their market positions, improve operational efficiency and create organizations capable of managing population health. … This activity could have lasting repercussions for consumers; the last hospital-merger wave (in the 1990s) led to substantial price increases with little or no countervailing benefit. “Since the primary driver of growth in private spending in recent years has been price increases for health care services, a compelling argument can be made for putting the brakes on consolidation. But, unless new public and private initiatives are developed to discourage consolidation and to support enforcement of antitrust law, most of these deals will proceed unchallenged.”
independent doctors resist another kind of consolidation, the vertical kind, in which hospitals buy independent medical practices. This trend also drives up health care costs. These days the association also is working to slow horizontal consolidation, the hospital-to-hospital kind, which is a related trend. Here are the two cases in play, both are making headlines and challenging our legal system. • I n May a federal judge in Pennsylvania
– Leemore S. Dafny, Ph.D., Harvard economist, New England Journal of Medicine, January 2014. 12
The Triangle Physician
gave the green light to Penn State Medical Center and PinnacleHealth
Physician Advocacy System to merge, a decision the FTC
companies, the authors concluded. Of
A Hershey/Pinnacle’s conglomerate would
is trying to reverse on appeal to the
course, they do.
create a 1,213-bed system, resulting in the nation’s 16th largest hospital.
United States Appeals Court for the Third District.
The Illinois hospitals have countered this accusation by pledging to create their
Our best hope is that the U.S. Court of
in Illinois sided with two large hospital
own insurance plan, which would cost
Appeals for the Third and Seventh Circuits
systems, Advocate Health Care and
consumers less – as if that’s such a great
will take a clear-eyed view, and see the
NorthShore University HealthSystems,
idea. When the hospital that provides your
merger attempts for what they are – another
seeking to merge, ignoring the FTC’s
health care also sells you your insurance,
way for hospitals to profit at consumers’
argument that the merger would cause
you need to be very worried.
considerable expense.
The FTC is appealing that decision as
Put into context, if the Illinois hospitals are
The FTC’s job is to prevent monopolies from
well.
allowed to merge, the combo would create
forming that could harm Americans, but
the largest hospital system in the nation,
judges like those who ruled in the Hershey/
a 16-hospital system with more than 4,000
Pinnacle and Advocate/Northshore cases
• In June another federal district judge
prices to go up and quality to go down.
FTC attorneys in both cases asked AID to
write amicus briefs requesting the appellate RADAR: BAY15001 hospital beds in a concentrated area. If that
make the job difficult.
courts to side with theAd: FTC,Version because1that
isn’t a monopoly, what is?
these two appeals will have a large impact
Currently the nation’s largest health system
important for America that we keep health
on the future of health care in America.
is New York-Presbyterian Hospital/Weill
care competitive. But, frankly, I wish more
Cornell Medical Center with 2,259 beds. In
American judges would enforce anti-trust
Antitrust Enforcement Is Needed
second place is Florida Hospital Orlando
laws, so we didn’t have to.
But these events beg a bigger question: Why
with 2,242 beds, according to Becker’s
do we have a government agency, namely
Hospital Review.
is what is best for patients. The6/15 outcome of Date:
We are happy to help, because it’s
the FTC, whose job it is to enforce anti-trust laws when our country’s own judges don’t uphold them? Consolidation may be the way health care is going in this country, but that doesn’t make it a good idea, and it certainly isn’t a good reason for judges to rubberstamp every merger hospitals ask for. Like all hospitals seeking to merge, these entities promise their mergers will lower prices by creating greater efficiencies. The only problem is not one study has shown that hospital consolidation lowers prices. In fact, the opposite is true. In June a study from the University of Southern California found that patients who go to large multi-hospital systems rather than independent hospitals pay $4,000 more per patient, ($19,600 compared to $15,600). The larger systems “used their market power
Do you have lower abdominal pain due to
Endometriosis? Women’s is currently conducting a clinical research study and (CompanyWellness Name) Clinic is currently conducting a clinical research study and is isininneed needofofqualified qualifiedvolunteers. volunteers.To Toqualify, qualify,you youmust mustbe beaawoman woman between between the ages ages of 18-65 18-65 who has lower abdominal abdominal pain pain due due to toEndometriosis. Endometriosis. Compensation forfor study-related time andand travel. Compensationupuptoto$840 $XXXis isavailable available study-related time travel.
Interested? Call
919-251-9223 0-000-00-00000
249 NC Highway 54, Suite 330ST 0000EStreet Name, Suite 000, City, Durham, NC 27713 www.companywebsite.com
www.cwrwc.com Find Us On Facebook
The Women’s Wellness Clinic offers Radiant Research or Clinical Research many opportunities for you to Advantage or Comprehensive Clinical participate in clinical trials. In addition Development Logo and Tagline Here. to the endometriosis study, there Radiant Tagline: We Can’t Do It Without are trials on birth control, migraines, YOU! CRA Tagline: Enhancing bacterial Patient Care urinary tract infections, Through Clinical CCD Tagline: vaginosis, andResearch. heavy periods. Call The Proof is in more the Performance. 919–251–92234 information.
to demand higher prices” from insurance
july/august 2016
13
WI
Duke Research News
Study Examines Mental Illness in Adults, Gun Violence and Suicide People with serious men-
prevention, and that’s both wrong and right,”
the study, two-thirds involved adults who
tal illnesses who use guns
said lead author Jeffrey W. Swanson, Ph.D.,
were already prohibited from accessing a
to commit suicide are
professor in the Department of Psychiatry
gun, pointing to problems with background
often legally eligible to
and Behavioral Sciences at Duke.
checks and enforcement, according to a Duke Medicine press advisory.
purchase guns, despite Jeffrey W. Swanson, Ph.D.
having a past record of an
“Our federal gun regulations pertaining to
involuntary mental health
mental illness prohibit lots of people from
The study’s findings suggest some suicides
examination and brief hospitalization, ac-
accessing firearms who are not violent and
and violent crimes with guns could be
cording to a new Duke Health analysis.
never will be,” Dr. Swanson said. “At the
prevented by a law many states have already
same time, they fail to identify some people
enacted. The law blocks the sale of new
The study, released in the June issue of
who will be violent or suicidal. With these
guns by federally licensed dealers to people
Health Affairs, looked at gun use, violent
data, we can improve criteria for restrictions
who have been involuntarily held during a
crime and suicide among 81,704 people
that might actually reduce gun violence but
mental health crisis but were not committed
diagnosed with schizophrenia, bipolar
also carefully balance risk and rights.”
against their will.
Miami-Dade and Pinellas counties during a
The data showed slightly higher-than-
About 26 percent of people in the study
10-year period starting in 2002.
average violent crime arrest rates among
had previously been through an involuntary
disorder or major depression in Florida’s
adults in the study, but found their use of
mental health evaluation during a crisis or
During that time, 254 study subjects com-
guns in those crimes (13 percent) was lower
similar incident but still could own or buy
mitted suicide nearly four times the average
than in a comparable population from the
guns under Florida laws at the time.
suicide rate of the general adult population
same community (24 percent). Of the arrests
in Florida during the same period.
for violent gun-related crimes observed in
Of the 50 people who used a gun to kill themselves, 72 percent were legally eligible to buy guns at the time of their deaths. The other 28 percent were not supposed to have or buy a gun but used one to take their own lives. Although this study is limited to a specific population – adults involved in the public behavioral health system – the findings can guide federal and state efforts to more precisely tailor mental health-related legal restrictions to reduce gun violence, the authors said. The study relied on a large volume of court and health records to examine the gun rights of people with serious mental health conditions and whether limits on their gun access could reduce violent crime and suicide involving guns. “There is a lot of focus on people with mental illness in the discussion of gun violence
14
The Triangle Physician
“These individuals have already been
Duke Research News identified during a previous mental health crisis, Dr. Swanson said. “They haven’t been committed, but we know they’re at increased risk of harming themselves or others. This is a lost public health opportunity in many states. States could say, ‘let’s use these mental health records that already exist to separate that individual from guns, at least temporarily.’” After the study period, Florida enacted a law to prevent the sale of guns to some people who had a mental health crisis but were not involuntarily committed. But that law doesn’t address the problem of guns already in their
However much you value wildlife conservation in North Carolina,
DEC NC
11
1234
quadruple it.
That’s right! Your conservation effort is increased by a 3-to-1 matching gift. So, when you are one of the first to display the new North Carolina Wildlife Habitat Foundation NCDMV license tag, your $10 tag contribution to the organization becomes $40 in lands preserved. The all-volunteer North Carolina Wildlife fe Habitat Foundation assists in acquisition, on, management, and protection of land in North Carolina for the conservation of habitats needed to preserve wildlife
right here in the Old North State. Conservation education efforts are preparing future generations to sustain your concern for the lands we protect today. At www.ncwhf.org, download the license tag application and see the good works in process. pp Your new tag shows your support and your n contribution is put to work…times four. co
www.ncwhf.org w
reach, Dr. Swanson said. Other states, such as California, do address weapons already in the home. Gun violence restraining orders can block new gun purchases and allow law enforcement to remove existing weapons from people deemed by a judge to be at high risk of harming themselves or others. “The study in Florida is one piece of the puzzle, and we want to continue to build evidence from different states to draw a better picture of how these laws work under different conditions,” Dr. Swanson said. “We live in a country where private gun ownership is cherished, constitutionally
Sporting Clay Course
protected and very prevalent. Gun violence is a challenging problem in the U.S., and
• Open Tuesday–Saturday 8a.m. till 6p.m. • Sunday 1p.m. till 6p.m. •Monday by appointment only • Over a mile course • 14 Stations
one that requires a lot of careful thinking and research to bring evidence to bear for these policies.” In addition to Dr. Swanson, study authors include Michele M. Easter; Allison G. Robertson; Marvin S. Swartz; Kelly AlanisHirsch; Daniel Moseley; Charles Dion; and John Petrila. The research received funding from the National Science Foundation, the Robert Wood Johnson Foundation program in Public Health Law Research, the Brain and Behavior Research Foundation and the
• Covered 5 Stand • Wing Shooting- Quail/ Pheasant/ Chukar Hunts • Driven Pheasant Hunts • European Tower Hunts • Shooting Instructions • Gun Rental • Ammo Available • Dog Training
• Fishing • Corporate Events/ Retreats/Team Building • Birthday Parties, Bachelor/ Bachelorette Parties • Church Groups , Individual Outings • Complete Packages Available
Elizabeth K. Dollard Charitable Trust. The authors cited no conflicts of interest.
july/august 2016
15
News Welcome to the Area
Physicians
Keyaria Denise Gray, DO Neonatal-Perinatal Medicine; Pediatrics
Duke University Medical Center Durham
Jeremy Thomas Jubach, DO Cardiovascular Surgery
Duke University Medical Center Cardiovascular and Thoracic Surgery Durham
Katie Kwaschyn, DO Geriatrics; Internal Medicine
UNC Hospitals Chapel Hill
Dominick Paul Trapani, DO Family Practice
Chelsea Marley Clinton, MD
Jordan Alexander Holmes, MD
Tracey Harrop Liljestrom, MD
Abdominal Surgery; Obstetrics; Gynecologic Surgery; Gynecology Critical Care Medicine
Radiation Oncology
Internal Medicine; Pediatrics
UNC Hospitals Chapel Hill
Duke University Hospitals Durham
Peace Nnenna Ibekwe, MD
Joshua Gray Long, MD
Pediatric - Emergency Medicine
Emergency Medicine
UNC Hospitals Chapel Hill
UNC Hospitals Chapel Hill
Kimberly Rae Ward Jackson, MD
Zak Loring, MD
Pediatric Cardiology
Duke University Hospitals Durham
Duke University Hospitals Durham
Elizabeth Koch Cole, MD Internal Medicine
University of North Carolina Hospitals Chapel Hill
Catherine Callaghan Coombs, MD Hematology and Oncology, Internal Medicine
UNC Lineberger Comprehensive Cancer Ctr Chapel Hill
Falls Pointe Medical Group Raleigh
Brittany Marie Dixon, MD
Jordan Price Allem, MD
Duke University Hospitals Durham
Cardiology; Internal Medicine
Wakemed Raleigh Campus-Heart Center Raleigh
Kathleen Elizabeth Batley, MD Hospitalist; Internal Medicine
Duke University Hospital Medicine Durham
Adam Rod Bensimhon, MD Pediatrics
University of North Carolina Hospitals Chapel Hill
Meaghan Rolland Bowling, MD Obstetrics; Gynecology Endocrinology/Infertility
Raleigh
Margaret Kelly Burkhead, MD Family Medicine
Raleigh
Paul Richard Carney, MD Child Neurology
University of North Carolina Chapel Hill
Tracy Cassagnol, MD Family Medicine
2777 Brentwood Rd Raleigh
Daniel Lee Cavanaugh, MD Orthopedic Surgery; Orthopedic Surgery of the Spine
University of North Carolina Hospitals Chapel Hill
Austin Wei-Hong Chan, MD Infectious Diseases, Internal Medicine
Duke University Hospitals Durham
Peter Leonard Charvat, MD Emergency Medicine
Johnston Health Smithfield
16
The Triangle Physician
Hospitalist; Internal Medicine
Matthew Evan Ehrlich, MD Neurology; Vascular Neurology
Duke Medical Durham
Amine El-Amraoui, MD Anesthesiology
University of North Carolina Hospitals Chapel Hill
Patrick Shane Ellsworth, MD Internal Medicine; Pediatrics
UNC Hospitals Chapel Hill
Bradley David Figler, MD Urology
UNC-Chapel Hill Urology Chapel Hill
Cory Shamar Henderson, MD Cardiology; Cardiovascular Disease, Internal Medicine; Hospitalist
UNC Hospitals Chapel Hill
Mark Edward Henry, MD Anesthesiology - Critical Care Medicine
UNC Hospitals Chapel Hill
Sara Marie Higginson, MD Abdominal Surgery; Colon and Rectal Surgery; Critical Care Pediatrics; Critical Care Surgery; General Surgery; Reconstructive Surgery; Plastic Surgery/Hand Surgery;
Duke University Health System, Dept of Pediatrics Durham
Cardiology; Internal Medicine
David Manly, MD
Pooja Dipak Jani, MD
Cardiology; Cardiovascular Disease, Internal Medicine
Preventive Medicine/Occupational; Public Health
Duke University Hospitals Durham
UNC-Chapel Hill Chapel Hill
Jolene Rose Jewell, MD Dermatology
Triangle Dermatology Durham
David Yutaka Johnson, MD
Andrew Julian Mincey, MD Ophthalmology
Carolina Eye Associates Pinehurst
Jill Caroline Moore, MD Gastroenterology, Internal Medicine
Radiology
Duke Gastroenterology Durham
Duke University Hospitals Durham
Berjees Mukhtar, MD
Tyler Bridgeland Jones, MD Emergency Medicine
University of North Carolina Hospitals Chapel Hill
David Franklin Kappa, MD
Psychiatry
Cary
Antoinette Truc Nguyen, MD Obstetrics and Gynecology
UNC Family Planning Chapel Hill
Obstetrics and Gynecology
Adam Carl Ottley, MD
Duke University Hospitals Durham
Pediatrics
Katherine Pandelidis Kaufman, MD
Erica Sopah Peethumnongsin, MD
Internal Medicine; Pediatrics
Morrisille
Emergency Medicine
University of North Carolina Hospitals Chapel Hill
Duke University Medical Center Durham
Edward Robert Kessler, MD
Anatomic and Clinical Pathology; Pathology
Pulmonary Disease and Critical Care, Internal Medicine
Duke University Hospitals Durham
Adnan Imdad Khan, MD Neurology
Duke University Hospitals Durham
Irina Perjar, MD UNC Hospitals Chapel Hill
Jennifer Kay Plichta, MD Surgery
Duke Surgery Durham
Karla Michelle Pou, MD
Snehankita Gurunath Kulkarni, MD
Diabetes; Endocrinology, Internal Medicine
Laura Ann Previll, MD
WakeMed Physician Practices Raleigh
Abdominal Surgery; Colon and Rectal Surgery; Critical Care Surgery; Emergency Medicine; Facial Plastic Surgery; General Surgery; Head and Neck Surgery; Maxillofacial Surgery; Neurological Surgery; Neurological Surgery, Pediatric
Rachel Elizabeth Hines, MD
Duke University Hospitals Durham
UNC Dept of Surgery Chapel Hill
Samareh Ghorbani Hill, MD Pediatrics
Family Medicine; Family Practice
University of North Carolina Hospitals Chapel Hill
UNC Endocrinology Chapel Hill Geriatrics; Internal Medicine
Duke Clinic 1J Durham
Andrew Martin Price, MD
Emergency Medicine
Critical Care-Internal Medicine; Hospitalist; Neurology; Vascular Neurology
Duke Emergency Department Durham
Duke University Hospitals Durham
Brenda Jean Lanan, MD
News Welcome to the Area Michael Charles Raisch, MD
Gita Suneja, MD
Dermatology
Radiation Oncology
Duke Dermatology Durham
Duke University Medical Center Durham
Daniel Hampton Reed, MD
Hung-Jui Tan, MD
Emergency Medicine; Urgent Care
Aberdeen
Nicholas Thomas Rudnick, MD
Urological Surgery; Urology
Steven Michael Salisbury II, MD
Raymond Joseph Toher Jr., MD
Emergency Medicine
Internal Medicine
WEPPA Cary
Samaritan Health Center Durham
Carolyn Mariko Sawyer, MD
Reid Christopher Vegeler, MD
Duke University Hospitals Durham
Abdominal Surgery; Colon and Rectal Surgery; General Surgery; Proctology; Surgery
William David Scheidler, MD Psychiatry
Pinehurst Surgical Pinehurst
UNC Hospitals Chapel Hill
Carolina Veronese, MD
Benjamin Houghton Schmidt, MD
UNC Hospitals Chapel Hill
Neurology; Vascular Neurology
Duke University Medical Center Durham
Stephen Patrick Shaheen, MD Emergency Medicine; Sports Medicine
Duke Family Medicine Residency Program Durham
Neema Kapadia Sharda, MD Internal Medicine, Geriatric
Duke University Hospitals Durham
Lauren Elizabeth Siewny, MD Emergency Medicine
Duke University Medical Center Durham
Jeremy Matthew Silver, MD Emergency Medicine
Emergency Medicine
Joseph Sam Wehby Jr, MD Family Medicine; Family Practice
University of North Carolina Hospitals Chapel Hill
Blair Nicole Wendlandt, MD Pulmonary Disease and Critical Care, Internal Medicine
General Surgery
University of North Carolina Hospitals Chapel Hill
Duke Regional Hospital Durham
Steven David Owens, PA Emergency Medicine; General Practice
FirstHealth Pinehurst
Allison Brooke Brantley, PA Neurology/Psychiatry
LaQuetta Monet Planter, PA Internal Medicine
NC Neuropsychiatry Chapel Hill
Select Specialty Hospital-Durham Durham
Caroline Elizabeth Cordell, PA Pinehurst
Trina Darlene Powell, PA Psychiatry
Triangle Neuropsychiatry Durham
Autumn Kari Konz Fingerson, PA Internal Medicine; Neurology
Linda Chang Schelle, PA
Duke Neurological Disorders Clinic Durham
Critical Care Surgery
828 Aaron Circle Durham
Paige Lauren Hunter Fricke, PA
Kristina Marielle Stanson, PA
Family Medicine - Adolescent Medicine; Family Medicine - Geriatric Medicine; Hospitalist; Internal Medicine; Student Health
Vanessa Marie Taylor, PA
Chapel Hill
Hey Clinic Raleigh Abdominal Surgery; Internal Medicine
Jordan L Hausladen, PA
Duke University Hospital Durham
Cardiology; Critical Care-Internal Medicine; Emergency Medicine
Mary Kathryn Tucker, PA
Sharon Bain Henderson, PA
Family Medicine; General Surgery; Geriatrics; Internal Medicine
Raleigh
Hillary Hays Weissinger, PA Family Practice (and OMT); Student Urgent Care Health NEWSOURCE-JUN10:Heidi 8/5/10 12:57 Rheumatology, PM Page 1 Cary
Raleigh
Moritz Caspar Wyler Von Ballmoos, MD
Do They Like What They See?
Thoracic Cardiovascular Surgery; Thoracic Surgery
Duke Health Div of Cardiothoracic Surgery Durham
Make sure you connect with your key audiences using strategic, cost-effective advertising, marketing and public relations.
Muhammad Shahzad Zafar, MD Duke University Hospitals Durham
Hospitalist; Internal Medicine
501 Willard St Durham
Julie Ann Wesp, MD
Diana Marie Spahlinger, MD
Tara Breanne Spector, MD
Critical Care-Internal Medicine
Hilary Ann Boydston, PA
UNC Hospitals Chapel Hill
Child Neurology; Clinical Neurophysiology; Neurology; Pediatrics
WakeMed Physician Practices Obstetrics & Gynecology Morrisville
Michelle Marcella McMoon, PA
Duke University Medical Center Durham
Durham Gynecology; Obstetrics; Gynecologic Surgery
FirstHealth Moore Regional Hospital Pinehurst
Family Medicine; Gynecology - Reproductive; Obstetrics and Gynecology; Pediatrics
Dermatology - Pediatric - Dermatology; Emergency Medicine; Family Practice; Reconstructive Surgery; Plastic Surgery; Surgery; Urgent Care; Urology
UNC Hospitals Chapel Hill
Shreyansh Dineshbhai Shah, MD
Afua Boatemaa, PA
William Arthur Teeter, MD Emergency Medicine
UNC Division of Surgical Oncology Chapel Hill
Emergency Medicine; Hospitalist; Neurology
Raleigh
Duke University Medical Center Durham
General Surgery; Surgical Oncology
Catherine Marie Landgraf, PA
UNC Hospitals Chapel Hill
Radiology
Pediatrics
Physician Assistants
Our services range from consultation, to design, to creation and implementation of strategic plans.
Kajal Gordhan Zalavadia, MD Internal Medicine
Bariatric Specialists of North Carolina Cary
newsource & Associates
Duke University Hospital Durham Call (540) 650-3686 or send inquiries to hketler@verizon.net.
Our network of smart, creative, award-winning specialists serves the health care industry throughout the Mid-Atlantic.
Maybe it’s happiness in a child’s eyes. Whatever the desired outcomes, count on us to ensure your key messages have the 20/20 clarity to deliver.
july/august 2016
17
NO ONE SEES YOU LIKE WE DO. The way we see it, image is everything. So we specialize in everything imaging. From prevention and detection to diagnosis and intervention. All provided in 20 Triangle locations by more than 150 certiďŹ ed technologists and subspecialty radiologists. Every one of them with the unique ability to see beyond the patient to the person inside.
G
BO I
G MA
IN
DY
RO
I
MA G
NEU
IN G
VA
VE
IN
T
TH
-C
ERA
PET
PY
MRI
P E D I AT
ST IMAGING
RIC I M AGIN G
BREA
SC
R
PH
Y
U
LA
IM
AG
IN
G
ORT
HO PEDIC I M AGING
M
M AM
OG
RA
Be seen by people who specialize in you at WakeRad.com.