The Triangle Physician February 2010 by TTPLLC

FEBRUARY 2010

Wake Heart & Vascular Associates On Cardiologyâ&#x20AC;&#x2122;s Leading Edge

Also in this Issue

Heart Disease: Equal Opportunity Killer Treating Painful Spine Fractures

YOUR LOCAL CARDIOLOGY PROFESSIONALS IN JOHNSTON COUNTY DEDICATED TO QUALITY, SERVICE, AND INTEGRITY Benjamin G. Atkeson, MD, FACC Cardiology, Echocardiography, Nuclear Cardiology

Mateen Akhtar, MD

Eric M. Janis, MD, FACC

Matthew S. Forcina, MD

Diane E. Morris, ACNP

Christian N. Gring, MD, FACC

Ravish Sachar, MD, FACC

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

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

Matthew A. Hook, MD, FACC

Nyla Thompson, PA-C

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

THE HIGHEST QUALITY CARDIOVASCULAR CARE, CLOSE TO HOME.

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

Contents

COVER STORY

Wake Heart & Vascular Associates: On Cardiology’s Leading Edge

FEATURES

HEART DISEASE:

Equal Opportunity Killer

Many are not aware that heart disease is the No. 1 killer of women, and they often experience a very different and more subtle set of symptoms than men.

FEBRUARY 2010 VOLUME 1 ISSUE 2

DEPARTMENTS

TREATING

11 ELECTROPHYSIOLOGY

PAINFUL SPINE

FRACTURES

12 WOMEN’S HEALTH Heavy Menstrual Bleeding: A

Patient Selection Is the Key Given the current controversy over vertebroplasty—a minimally invasive treatment performed by interventional radiologists in individuals with painful osteoporotic vertebral compression fractures that fail to respond to conventional medical therapy—what’s a patient to do?

Ablation of Atrial Fibrillation

Comprehensive Strategy

17 CARDIOLOGY Are Small Elevations in Cardiac

Troponin Clinically Significant?

18 Q & A

Uterine Fibroid Embolization

19 NEWS Welcome to the Area

Events & Opportunities to Connect

New and Relocated Practices

20 PRACTICE MANAGEMENT Revenue Cycle Management in Physician Practices: What it Takes to Get Paid!

23 INSURANCE Evaluating the Lease on Your Business Life

24 GOOD BUSINESS

Medical Communication

26 LOCAL INTEREST The Right Stuff:

The North Carolina Museum of Natural Sciences

Cover Photo: Wake Radiology Musculoskeletal specialists left to right: Peter Leuchtmann, MD; Russell Wilson, MD; Lyndon Jordan, MD; William Vanarthos, MD; Joseph Melamed, MD; Charles Pope, MD and Nik Wasudev, MD. Photographed in the mammal research department of the North Carolina Museum of Natural Sciences. Special Thanks to Lisa Gatens and Jon Pishney.

The Triangle Physician | FEBRUARY 2010

27 ROUNDS

Pick Out Flu-Fighting Foods

FEBRUARY 2010 | The Triangle Physician

From the Editor

ooking at this edition reminds me of how much I love my job, and perhaps it will affect you similarly. Since my job is to ensure Triangle Physician stays on the cutting edge with you, my days are awe filled. I am constantly struck by the depth of compassion and courage to push the envelop within the region’s medical community.

Here again, our cover story takes an in-depth look at an international pioneer—Wake Heart & Vascular Associates. Not only is this practice cutting edge and comprehensive, it has a strong community service mission to promote prevention and its underlying culture is based on genuine compassion for its patient. Wake Heart is all heart, and it shows in words and actions. Also in this issue, widely held public misconceptions about heart disease—particularly with regard to gender differences—are brought to light. Prevention is at the crux of this major public health issue. And medical professionals have an important role to play in risk-factor intervention. Keep reading and you’ll gain a greater awareness of phlebology, and treatments for varicose and spider veins. Mike Riddick, Riddick Insurance Group, shares advice on professional liability coverage for nurses. You’ll get the heads up on the best data-backup strategies. You’ll also gain insight into the power of a recognizable brand in building loyalty among patients and referring physicians. While on that topic, consider the value of branding on the pages of Triangle Physician. It has a powerful reach of more than 8,000 physicians, physician assistants and hospital staff in Alamance, Chatham, Durham, Granville, Harnett, Johnston, Lee, Moore, Nash, Orange, Person, Sampson, Vance, Wake, Warren, Wayne and Wilson counties.

Editor Mark Westphal

mark@trianglephysician.com

Contributing Editors Heidi Ketler heidi@trianglephysician.com Mateen Akhtar, MD; Chris Doane; Stephen P. Loehr, MD; Andrea S. Lukes, MD, MHSc, FACOG; Lindy McHutchinson, MD; Thomas L. Presson Jr., MD; John Reidelbach; Mike Riddick; Mark Wiener Photography Jim Shaw Photography jimshawphoto@earthlink.net Creative Director Dan Early Van Early

dan@trianglephysician.com van@trianglephysician.com

Advertising Sales Carolyn Walters carolyn@trianglephysician.com News and Columns Please send to info@trianglephysician.com

The Triangle Physician is published by Early Design Group 982 Trinity Road | Raleigh, NC 27607-4940 Subscription rates: $48.00 per year $6.95 per issue

And please share your practice news—new physicians, relocations, openings, events, etc.

Advertising rates on request Bulk rate postage paid Tucson, AZ 85726

In closing, a heartfelt thank you for all you do.

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.

Until next month,

Mark Westphal Editor

Opinion expressed or facts supplied by its authors are not the responsibility of The Triangle Physician. However, The Triangle Physician makes no warrant to the accuracy or reliability of this information. All advertiser and manufacturer supplied photography will receive no compensation for the use of submitted photography. Any copyrights are waived by the advertiser. 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.

The Triangle Physician | JANUARY 2010

His treatment of heart failure yields success Duke cardiologist Joseph Rogers, MD, and colleagues are defining the best strategies to help heart failure patients. Heart failure is pretty common, isn’t it? Nearly six million Americans are living with heart failure—when the heart can’t adequately do its job of pumping blood through the body. The good news is that we’ve seen dramatic improvements in the treatment of heart failure in the past decade. What’s new in the treatment of advanced heart failure? At the advanced stage—affecting about 150,000 Americans— medications typically become ineffective, and heart transplantation is not an option for most. We have recently learned that these patients can benefit greatly from permanent implantation of a left ventricular assist device (LVAD), which works to pump blood more efficiently through the body.* Duke has been a leading center in this research. What does the future hold? I believe the next step is the use of mechanical blood pumps for heart failure patients earlier in their illness to extend quality and years of life. Also, we could potentially begin testing stem cell therapies that would promote recovery of the heart and removal of the pump. Why would you encourage heart failure patients to come to the Duke Heart Center? At Duke we have a top-tier program: outstanding doctors, a team approach, close collaboration with our colleagues in heart surgery and heart rhythm disorders, a dedication to advancing our knowledge of heart failure through research, and a passion for understanding and treating the unique aspects of each patient’s disease. Also, Duke is one of the vanguard centers of the Heart Failure Research Network, a consortium of institutions providing insights into new treatments for heart failure. Only 69 centers in the United States offer destination LVAD therapy for advanced heart failure.† Duke is one of them.

Learn more about treatment options for heart failure offered by Dr. Rogers and his colleagues, Drs. Michael Blazing, G. Michael Felker, Adrian Hernandez, Andrew Lodge, Carmelo Milano, Christopher O’Connor, and Eric Velazquez, by visiting our Web site.

Duke Heart Center dukehealth.org/heart

888-ASK-DUKE

* Dr. Rogers presented these findings on November 17 at the American †

Heart Association’s Scientific Sessions 2009. Source: cms.hhs.gov

From the Cover

Wake Heart & Vascular Associates:

PHOTO BY BRYAN REGAN

On Cardiologyâ&#x20AC;&#x2122;s Leading Edge

Wake Heart & Vascular Associates, founded in 1985, has grown to become eastern North Carolinaâ&#x20AC;&#x2122;s largest cardiology practice. Its growth is a reflection of founding principles to provide the highest level of cardiac care and cutting-edge technology in the region. Its mission is to serve patients and work with their primary doctors in the prevention and treatment of complex cardiac and vascular disease. 6

The Triangle Physician | FEBRUARY 2010

The practice has broadened beyond cardiac care to include expertise in peripheral vascular and carotid artery disease, including the treatment of stroke. This extension of the practice is a result of the similar nature of the disease processes and treatment strategies for most types of vascular disease. Many of the techniques are transferable to other vascular beds, but all have their own nuances. The basic primary and secondary preventive strategies are similar. In fact, the overlap of patients with atherosclerosis involving more than one vascular territory is over 50 percent.

Today, 24 cardiolovascular specialists at

Dr. Schneider went on to establish the first endovascular program in 1998, when the new WakeMed Heart Center opened. The expansion of angioplasty and stenting in patients with peripheral vascular disease was a natural extension of his interventional cardiology work. The program has since expanded to include carotid artery stenting, acute stroke management and endovascular repair of abdominal and thoracic aneurysms. Nearly 50 patients underwent endovascular repair of abdominal aortic aneurysm last year, allowing minimally invasive care to patients who otherwise would require a complex

Wake Heart & Vascular Associates provide the full complement of cardiology and vascular services: clinical cardiology, echocardiography, nuclear cardiology, cardiac catheterization, interventional cardiology, electrophysiology, cardiac magnetic resonance angiography; treatments for peripheral vascular, carotid artery and cerebrovascular diseases; even pediatric interventional cardiology.

“All 150 staff members at Wake Heart are integral to our excellent patient care and services. Like our doctors, they come from diverse backgrounds, and are dedicated to supporting the physicians in their delivery of the best possible cardiovascular care. We all treat our patients like family, with the utmost care and understanding.”

open operation. This past December, Dr. Schneider performed the first elective endovascular thoracic aneurysm repair, in collaboration with cardiothoracic surgeon Abdul Chaudhry, M.D., of Capital Cardiovascular Surgery. “This Joel Schneider, M.D., F.A.C.C.

Joel Schneider, M.D., F.A.C.C., was recruited by Wake Heart in 1993, after completing an

advanced technology allows patients far easier and safer approaches to managing aneurysmal disease,” says Dr. Schneider.

interventional cardiology fellowship at Emory

Wake Heart founding partner James Tift

University Hospital. Interventional cardiology

Mann III, M.D., is one of the world leaders in

specializes in the prevention and repair of

radial catheterization and interventions, and

atherosclerotic arteries, caring for a range of

helps train physicians in the United States in

issues from acute myocardial infarction to

that technique. Robert Lee Jobe, M.D., F.A.C.C.,

“The strength of Wake Heart lies in the

stable chronic angina. He was instrumental in

F.S.C.A.I; Jimmy Locklear, M.D., F.A.C.C.;

broad range of services we provide, the

starting the coronary stent program at

William N. Newman, M.D.; and Gregory C.

excellent doctors and the commitment to

WakeMed, introducing the new and now widely

Rose, M.D., F.A.A.C., are all actively involved

excellent care,” says Eric M. Janis, M.D.,

accepted technology to the region.

in the Wake Heart cardiac stenting program.

F.A.C.C., a cardiologist at Wake Heart’s

James Tift Mann III, M.D.

Dee Darkes Chief Operating Officer

Smithfield office. “What this group brings is the ability to work together, to collaborate and get input from colleagues who are experts in their fields, and to take care of all patients with any cardiovascular problem under one big umbrella.” MEDICAL LEADERS “Over the years, each new physician who has come to the practice has brought a new set of skills to enhance our comprehensive care and keep us on the leading edge,” says Dr. Janis, whose areas of expertise include echocardiography, nuclear cardiology and cardiac catheterization. In addition to advanced training, most of the medical staff are board certified and many are Fellows of the American College of Cardiology.

FEBRUARY 2010 | The Triangle Physician

Robert Lee Jobe, M.D., F.A.C.C., F.S.C.A.I

Matthew A. Hook, M.D.

Christian N. Gring, M.D., F.A.C.C.

At about the same time that the Food and

The newest member of the Wake Heart

ablation, a non-surgical technique for treating

Drug Administration approved carotid

medical staff is electrophysiologist Matthew

atrial fibrillation and restoring normal rhythm.

stenting in 2004, Ravish Sachar, M.D.,

S. Forcina, M.D., from Duke University

F.A.C.C., was recruited from The Cleveland

Medical Center and the Medical University

Wake Heart electrophysiologist Randolph

Clinic to develop the carotid stenting pro-

of South Carolina. Soon after joining the

Cooper, M.D., F.A.C.C., says his colleagues are

gram at WakeMed. Since then, more than

practice in 2009, Dr. Forcina led the devel-

encouraged by the use of wireless-monitoring

1,000 carotid stenting procedures have been

opment of a specialized lab at WakeMed

capabilities of implantable defibrillators and

performed, with a less than 1 percent stroke

Heart Center that now provides the newest

pacemakers. “We’re expanding our ability to

risk. Dr. Sachar, one of the authors of the

procedures to treat and potentially cure

follow patients with heart failure and not only

Manual of Peripheral Vascular Intervention,

atrial fibrillation.

treat them but diagnose them remotely. That

also has helped develop what has become

way we can manage patient care over the phone

the region’s largest peripheral vascular

Wake Heart’s team of electrophysiologists,

disease treatment program at WakeMed

who specialize in the study and treatment of

Heart Center.

rhythm disorders of the heart, include: Kevin

COMMUNITY-BASED CARE

Ray Campbell, M.D.; Randolph Cooper, M.D.,

As Wake Heart & Vascular Associates’

Matthew A. Hook, M.D., joined Wake

F.A.C.C.; and James R. Foster, M.D., F.A.C.C.

services have expanded, so too has its reach.

Heart from The Cleveland Clinic in 2007 to

Therapeutic modalities include antiarrhythmic

Today, 15 Wake Heart locations serve an

expand the WakeMed coronary artery

drug therapy; surgical implantation of

area from southern Virginia to multiple

stenting program. He also brought with him

pacemakers, cardioverter-defibrillators and

locations in eastern North Carolina. Wake

solid expertise in peripheral vascular

resynchronization devices; and radiofrequency

Heart’s newest office in Oxford, N.C., opens

procedures, carotid stenting and intracranial

Randolph Cooper, M.D., F.A.C.C.

in association with Granville Medical Center

interventions.

instead of in the hospital,” says Dr. Cooper.

this summer. The Goldsboro office is being relocated across from Wayne Memorial

Christian N. Gring, M.D., F.A.C.C., also

Hospital, and will offer expanded services and

trained at The Cleveland Clinic in dedicated

more examination rooms. “The new office

non-invasive heart imaging, including cardiac-

will allow us to see more patients and offer

computed tomography, angiography and

additional noninvasive services, such as

cardiac MRI. He brought his skills to Wake

echocardiology, nuclear cardiology, stress

Heart in 2006.

testing and peripheral vascular studies,” says Dr. Schneider.

The Triangle Physician | FEBRUARY 2010

Mateen Akhtar, M.D.; Benjamin G. Atkeson,

Dr. Zellinger says many of Wake Heart’s

North Carolina, making Wake Heart &

M.D.; Arthur Y. Chow, M.D., F.A.C.C.; Joseph

relationships with referral physicians began

Vascular the busiest cardiology practice.

M. Falsone, M.D.; Andrew C. Kronenberg,

with the practice founders some 25 years

M.D., F.A.C.C.; Robert B. Wesley II, M.D.,

ago. “Wake Heart values and nurtures its

F.A.C.C.; and Michael Jay Zellinger, M.D.,

working relationships in the various com-

F.A.C.C., are all instrumental in providing

munities. That’s what’s helped build the

care to the community in locations like Cary,

practice,” he says. It also assures continu-

Clayton, Knightdale, Lewisburg, North Wake

ity of care. As soon as patients have been

and Smithfield. “We want to bring cardiology

treated for their cardiovascular problems by

care to the community, so the community

Wake Heart, they are returned to the care

doesn’t have to travel long distances to us,” says

of their referring physician, with ongoing

Dr. Zellinger, a founding Wake Heart partner.

communication between all doctors in-

Dr. Schneider points to Wake Heart’s participation in WakeMed’s “STEMI” (St-Segment, E-Elevation, M-Myocardial, I-Infarction) program, designed to achieve the national “door-to-balloon time” standard for opening an infarct artery in under 90 minutes. The Code STEMI program boasts an average door-to-balloon time of 55 minutes. The STEMI team is activated as

volved in their care.

soon as the emergency medical technician

“No. 1, Wake Heart has always been available, reliable and provided great expertise; response for follow up has been excellent. It’s just a great group to work with,” says Dr. Samuel

EKG, which is sent to the WakeMed

ageal echo test and heart catheterization in

with Dr. William J. Stackhouse at Goldsboro

the 90-minute goal, meaning that a patient

Smithfield. The procedures showed both

Medical Specialists. They’re referral relation-

coronary artery disease and a severe heart

ship traces back to Wake Heart’s early years.

receiving the best care possible,” says Dr.

Dr. Janis points to the case of a 77-year-old Clinton woman who suffered from dizziness. She was referred to Dr. Hook in the Wake Heart Smithfield office, saving her a 30-to-40-minute drive to Raleigh. After testing in the office showed she had blockages in both neck arteries and a loud heart murmur due to a heart valve problem, she was set up for a specialized transesoph-

B. McLamb Jr., who practices internal medicine

reaches the patient in the field and takes an Emergency Department to be analyzed. If an acute myocardial infarction is suspected, a special cardiac team prepares for the patient’s arrival and alerts the on-call interventional cardiologist. “This past year, Wake Heart physicians achieved a 100 percent success in reaching experiencing a heart attack can count on

Dr. Gring caption ??????????????

TIME AND EXPERIENCE

Schneider. “What we do is life changing, not

WakeMed, where Dr. Hook first placed a

OF THE ESSENCE

only life saving.”

stent in one of the patient’s neck arteries

By virtue of its expertise, size and proximity,

and then referred the patient for heart valve

Wake Heart physicians have been at the

surgery. “By providing services in multiple

forefront of advances in cardiac and vascular

locations at different hospitals, we were

care at WakeMed Heart Center in Raleigh,

able to give superior service for the patient,

and have been integral to its success. With

with a minimum of difficulty for her and

more than 27,900 total procedures performed

her family,” says Dr. Janis.

each year, it is the busiest heart center in

valve problem. Surgery was scheduled at

Dr. Schneider points to a complicated case recently involving a 51-year-old man who arrived at the hospital having a heart attack. With the Code STEMI team ready, the man was taken directly from the ambulance to the catheterization lab. The patient’s heart FEBRUARY 2010 | The Triangle Physician

standout.” Had intravenous thrombolytic agents been administered, the outcome may not have been so successful. “Everything we do in our practice is done in an evidence-based way or as part of clinical trials,” says Dr. Sachar. “The physicians who are doing these procedures are very welltrained. They are leaders in their field nationally and internationally, and they bring that expertise to the area. They are involved in and lead numerous cutting-edge clinical trials for new devices, drugs and protocols.” COMMUNITY COMMITMENT Wake Heart & Vascular Associates cardiologists are involved in the community, serving on boards and committees, speaking at community forums and promoting good cardiovascular health for all. On Saturday, Feb. 27, the practice will join WakeMed Heart Center in hosting the fifth

Ravish Sachar, M.D., F.A.C.C.

repeatedly stopped and had to be defibrillated

into the feet. “Procedures that result in limb

16 times. The blocked artery was opened within

salvage result in a dramatic improvement in

30 minutes of arrival and afterward the patient

quality of life.”

was transferred to the coronary care unit. Drs. Sachar and Hook also helped lead the When delivering the good news to the family,

development of Wake County’s first acute

Dr. Schneider recalls noting that only the

interventional stroke program at WakeMed

patient’s young daughter and her grandmother

Heart Center, which is the only Joint

were in the waiting room. He came to learn

Commission-certified primary stroke center

the girl’s mother had died of cancer last

in Wake County. Until recently, stroke could

year, and by saving the patient, he also had

only be treated by giving clot-dissolving

prevented the child from becoming an orphan.

agents intravenously, called thrombolysis. With FDA approval, Wake Heart physicians

“The most rewarding part of our work, probably

are now able to remove clots directly from

for all of us, is the impact we make for patients

the brain, often with dramatic clinical

and their families,” says Dr. Schneider.

results. “It’s very cutting edge. No one else in Wake County is doing this and there are

PERIPHERAL VASCULAR AND

only a handful of centers of this kind in the

CEREBROVASCULAR PIONEERS

country,” says Dr. Sachar.

“We are expanding the frontiers at both ends

annual cardiovascular education symposium to share information on advances in cardiology and heart/vascular care, with an emphasis on prevention. This year’s “Health Care in Evolution: Opportunities and Challenges for the Cardiovascular Patient” will shed light on health care reform. The symposium will be from 8:30 a.m. to 3:45 p.m. at WakeMed Heart Center Conference Center. It is open to all medical professionals. Call (919) 350-8547 for details. For their quality of life contributions, the cardiologists at Wake Heart have won numerous accolades and awards. Two have been named Health Care Heroes by The Triangle Business Journal, Dr. Sachar in 2009 and Dr. Janis in 2007. Drs. Mann and Janis were selected by The Triangle Business Journal and Best Doctors Inc. as two of the Best Doctors in America for 2009-2010.

of the body, in the brain and in the feet,”

He recalls the case last March of a 37-year-

says Dr. Sachar.

old woman who had delivered twins by

Janis reflects on all the rewards of his calling:

C-section two weeks prior. She arrived at

“being a part of the medical community and

“Advances in restoring blood flow in the legs

WakeMed completely paralyzed on her left

the community as a whole; helping patients

and feet are saving legs that would have been

side, after suffering a stroke on the right

work on preventing heart disease; helping

amputated five or 10 years ago,” he says. The

side of her brain. During an eight-hour pro-

people focus on staying healthy; keeping a

technology uses a combination of balloons,

cedure, Dr. Sachar removed all the blood

positive attitude even in the face of serious

stents, lasers and atherectomy devices to go

clots and the woman made a complete

illness or a disabling medical condition; and

into the small arteries below the knee and

recovery. Today, he calls the case a “career

allowing people to stay healthy and active.”

The Triangle Physician | FEBRUARY 2010

Radiology

On Balancing the

Benefits and Risks of CT Radiation Exposure by

Thomas L. Presson Jr., MD

Director, Radiation Safety Programs, Wake Radiology

Over the past 25 years, computed tomography (CT) scans

introduce state-of-the-art imaging and provide guidance on appropriate

have become one of the most powerful tools in medicine. Recent

ordering. Our web site carries a link to the American College of

news, however, has highlighted potential health risks from radiation

Radiology’s most current ACR Appropriateness Criteria®.

exposure associated with CT. One study projected a sizeable number

Experience and expertise are vital to minimizing exposure. All

of new cancers that could arise from all CT studies performed in

Wake Radiology outpatient locations have a radiologist on site, and 100

the U.S. in 2007. Another found a wide variation in radiation doses

percent of technologists are CT certified by the American Registry

(1)

for common CT exams.(2) Also in the

for Radiologic Technologists. This caliber

headlines: alarming instances of high

of care provides a multitude of benefits.

(3)

radiation overexposure from CT scans.

One example is the work-up of a patient

Yes, our medical community

found to have an incidental mass on a

should be concerned. While we have

chest x-ray. With a radiologist on site,

recognized the potential risks of CT

the CT technologist can ask him or her

exams for years, the new numbers

to define the area to be scanned. If the

reflect a remarkable increased use of

suspect nodule is in the upper part of

this extremely valuable diagnostic tool.

the lung, a scan of a third or a half of

By some estimates, 72 million CT scans

the lung often will allow a diagnosis.

were performed in 2007 in the US.(1)

In addition to the above, we

Let’s remember two key points.

reduce exposure to breast and thyroid

Statistically, an individual’s presumed

tissue by using bismuth shielding. Our

increased risk of cancer from one CT,

CT scanners utilize dose modulation, a

or even a handful, is very low. And,

feature that dynamically measures body

while overuse and overexposure are

density during the scan and decreases

always concerns, this data must be

the dose depending on the density of

weighed against what may happen to a

bone it must penetrate. We also record

patient if he or she does not have a CT scan. Is the population at large

the dose of each scan in the patient’s permanent chart.

better off or worse off? We don’t yet have an answer.

Behind the scenes, part of my mission is to organize and maintain

Our challenge, then, is to use CT most appropriately while

safety protocols and oversee the rigorous American College of

minimizing the risk it imposes. At Wake Radiology, we approach this

Radiology CT scanner certification program. All scanners in our

on a variety of fronts.

outpatient offices are certified or have certification underway, as is the

case for our two newest scanners. We very closely and continuously

Wake Radiology employs stringent dose reduction guidelines for

adult and pediatric CT exams; our protocols have been well below

monitor settings and output.

recommended levels for some time. It is critical that children not

receive adult doses, and Wake Radiology participates in the Image

patients receive from CT scans does pose a small but real risk, one

Gently® initiative sponsored by the Alliance for Radiation Safety in

that will slightly increase with each additional scan. With care taken

Pediatric Imaging.

at every level, this risk can be minimized. That being said, CT remains

one of our most essential diagnostic tools to evaluate and follow a

We also are proactive in suggesting alternative modalities to

avoid radiation altogether. The number of indications for which

Overall, we believe it’s reasonable to conclude that the radiation

great number of medical conditions.

MRI and ultrasound may be used continues to grow, including most diseases of the abdominal organ systems.

Thus, we put great stock in helping clinicians select the most

appropriate imaging to minimize exposure, and each Wake Radiology subspecialty section maintains a consultation hotline for this purpose. Our annual Radiology Today seminar, open to all physicians,

References: 1) Berrington de González A, Mahesh M, Kim K-P, et al. Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch Intern Med. 2009; 169(22): 2071-2077. 2) Smith-Bindman R, Lipson J, Marcus R, et al. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Arch Intern Med. 2009; 169(22): 2078-2086. 3) “New Focus on Dangers of CT Scans.” Jonathan LaPook. CBS Evening News. 14 Dec 2009. Accessed 17 Jan 2010 at http://www.cbsnews.com/stories/2009/12/14/eveningnews/main5979332.shtml.

FEBRUARY 2010 | The Triangle Physician

Womenâ&#x20AC;&#x2122;s Health

A Clinical Study on

Osteoporosis

Bone health is an important concern for women. The problem of osteoporosis affects approximately 30% of postmenopausal women and 40% of those women will sustain one or more fractures in their lifetime. The worldwide prevalence of osteoporosis makes it a serious public health concern with estimates of over 200 million people worldwide currently suffering from this disease. Within the United States and Europe it affects over 30% of all postmenopausal women 40% of whom will sustain one or more fragility fractures in their lifetime. In the US alone osteoporosis or osteopenia will affect over 40 million Americans and result in more than 1.5 million fragility fractures per year. (1, 2)

(3)

(1, 2)

factors that are dependent on bone mineral density include: untreated hypogonadism, malabsorption, endocrine disease, chronic renal failure, chronic liver disease, COPD, immobility, and certain drugs (including aromatase inhibitors, androgen deprivation therapy). Of these risk factors, most of us recognize that age is one of the leading risk factors, however, it is important to realize that even young women can develop osteopenia and osteoporosis. Our staff is focused on bone health and has been fortunate to begin a FDA clinical trial on osteoporosis. The most common medications for osteoporosis are the bisphosphonates, such as alendronate or clodronate or ibandronate. This class of drug prevents bone resorption; whereas, as evidence has emerged that a new type of drug which is anabolic or helps with

Most women know that osteoporosis is a problem involving bone, yet many do not recognize

bone growth is being studied.

the many risks factors for osteoporosis. These can be divided into 2 different categories: one

The IRB approved information for this clinical

that is independent of bone mineral density and one that is dependent on bone mineral

trial that we provide to subjects for this study

density. The specific risks factors that are independent of bone mineral density include: age,

is shown below â&#x20AC;&#x201D; and the FDA approved

previous fragility fracture, maternal history of hip fracture, glucocorticoid therapy, current

consent form is posted on our website at

smoking, alcohol intake, rheumatoid arthritis, low body mass index, and falls. The specific risks

www.cwrwc.com:

The Triangle Physician | FEBRUARY 2010

by Andrea S. Lukes,

Participating in clinical research is an

What to Expect

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

important decision and should be thought

Study participants will be asked to visit a

through carefully. You should never feel you

research site 9 times over a 2-year period.

have to take part in a clinical research study.

Participants will have bone mineral density

If you do participate, you will be free to

testing, blood drawn at each visit, and will

withdraw from the study at any time, for any

be asked to take the study drug once a day.

MD, MHSc, FACOG

reason. You will keep the right the same routine medical care you received before study participation. Your study doctor will discuss any other treatment that may be

In conclusion, although we offer such clinical trials—our focus is on women’s health. We offer all options including identifying the most

helpful to you.

convenient location for bone density

What is a Clinical Research Study?

How Do I Qualify?

is a health issue that should to be addressed

Clinical research studies try to answer specific

You may qualify for this study if you:

question about investigational study drugs.

• Are female and 45 to 85 years of age

A new investigational drug must go through

• Have not had a period in at least 5 years

several phases of clinical research, the study

• Have taken oral medication to treat your

drug could later be available to the public.

osteoporosis for 3 years or more • Have taken alendronate therapy for the

A clinical research study participant works

past 1 year or more

with a research team that includes doctors, nurses, and sometimes social workers and

If you qualify, you will receive study-related

other health care professionals. The participant’s

care, study medication and bone mineral

and study team’s commitment is important to

density testing (to assess bone health), at no

help meet the objectives of the research study.

charge.

evaluations for the women we see. Osteoporosis by healthcare providers. Better management of the disease will result in improved outcomes for our patients through reductions in both morbidity and mortality. Our staff is devoted to combining our clinical expertise and our interest in high quality research to provide a range of options for our patients. References: (1) 1. Melton III L, Chrischilles EA, Cooper C, Lane AW, Rigs BL: Perspective: How many women have osteoporosis? J Bone Miner Res 1992;7: 1005-º10 (2) Randell A, Sambrook PN, Nruyen TV, Lapsey H, Jones G, Kelly PJ, Eisman JA. Direct clinical welfare costs of osteoporotic fractures in elderly men and women. Osteoporosis Int 1995;5:427-32 (3) Cooper C. Campion G Melton LJ 3rd. Hip fractures in the elderly: a world-wide projection. Osteoporosis Int. 1992 Nov;2(6): 285-9.

FEBRUARY 2010 | The Triangle Physician

Heart Disease

Heart Disease: Equal Opportunity Killer

Most of us are familiar with the classic heart

and in acknowledging gender differences

attack symptoms — the “movie heart attack,”

in the treatment of CVD in women.

where a middle-aged man suddenly clutches

Research shows that prevention of risk

his chest complaining of crushing chest pain and pain radiating down the left arm. What many are not aware

of is that heart disease is the No. 1 killer of

factors for cardiovascular disease is the best practical solution. The challenge is to communicate to your patients

the importance of taking preventive steps on an everyday basis.

women, and they often experience a very

different and more subtle set of symptoms.

Much attention has been directed toward a

In fact many heart attacks in women start

better appreciation of the influence of gender

slowly, with mild pain or discomfort. Wom-

on cardiovascular risk and management,

en may also present with symptoms such

but important gaps in knowledge remain.

as nausea, fatigue, jaw or neck pain that

Recent developments in cardiovascular

are often overlooked by patients and mis-

research undoubtedly will have a significant

diagnosed by physicians as being related to

impact on prevention, clinical care and out-

stress or other illnesses.

comes of women and will provide direction for future work. Epidemiological studies and

Physicians, nurses and other healthcare pro-

randomized clinical trials provide compelling

viders who care for women need to be aware

evidence that coronary heart disease is largely

of some fatal facts. Cardiovascular diseases

preventable. Therefore, prevention of risk

(CVD), especially coronary heart disease

factors for cardiovascular disease is an

and stroke, are the leading causes of death

important practical solution for women.

in women in the United States. They claim more female lives than the next five causes of death combined.

Is it gender difference or gender bias? Probably some of both. Several factors may

Consider the facts:

explain the apparent disparity in treatment

• Nearly 37 percent of all female deaths in

of men and women: • In the past, many of the major cardiovascular research studies were conducted on

• The death rate due to CVD is higher in

men. Results of current clinical studies may

black women than in white women. • One in 2.7 females who die, die of heart disease, stroke and other cardiovascular disease compared with one in 30 who die of breast cancer. • Women who have heart attacks are more likely than men to die from them within a few weeks. • Misperceptions still exist that CVD is not a real problem for women. In 2005, more than 36 million American women were age 55 or older.

help clarify the gender differences that affect pathophysiology, diagnosis and treatment of women with heart disease. • Clinicians and patients often attribute chest pains in women to noncardiac causes, leading to misinterpretation of their condition. • Women may have a greater tendency than men to have atypical chest pain or to complain of abdominal pain, difficulty breathing (dyspnea), nausea and unexplained fatigue.

The risk of cardiovascular disease increases with age, and that’s one

• Women may avoid or delay seeking medical care, perhaps partly

reason it’s important to raise awareness of this major public health

due to denial or their lack of awareness of both typical and atypical

issue, particularly for older women.

heart attack symptoms. • Since women tend to have heart attacks later in life than men do,

Physicians can take an assertive role in risk factor intervention 16

The Triangle Physician | FEBRUARY 2010

they often have other diseases (such as arthritis or osteoporosis)

the United States occur from CVD.

that can mask heart attack symptoms. Age and the more advanced

nutrition, alcohol consumption, physical inactivity and smoking can

stage of coronary heart disease in women can affect the treatment

be controlled.

options available to physicians as well as the greater mortality of women after heart attacks.

Awareness of factors such as increasing age, race and heredity that

• Some diagnostic tests and procedures may not be as accurate

cannot be controlled is critical. About four out of five people who die

in women, so physicians may avoid using them. That means the

of coronary heart disease are age 65 or older. At older ages, women

disease process resulting in a heart attack or stroke may not be

who have heart attacks are more likely than men are to die from them

detected in women until later, with more serious consequences.

within a few weeks.

• The exercise stress test, or stress ECG, may be less accurate in women. For example, in young women with a low likelihood of

Heredity and race are perhaps some of the strongest indicators of risk.

coronary heart disease, an exercise stress test may give a false

Children of parents with heart disease are more likely to develop it

positive result. In contrast, single-vessel heart disease, which

themselves. Women often assume that even though the men in their

is more common in women than in men, may not be picked up on a routine treadmill test. • Noninvasive and less invasive diagnostic tests that are more precise tend to be more expensive. These include thallium, sestamibi, or echocardiographic stress tests. The predictive value and costeffectiveness of newer technologies, such as electron-beam computed tomography (EBCT), are not well defined. Because the number of women who are older and at risk in the population is growing, diagnosing and treating heart disease, stroke and other cardiovascular diseases is vital. Clinicians must act to prevent these diseases before warning signs appear or a heart attack occurs. Prevention and control of risk factors must start when a woman is young and continue throughout her life.

Heart Attack Warning Signs

family have suffered heart disease, they are not at risk. African Americans have a higher percentage of hypertension than whites and their risk of heart disease is greater. How do I enhance

• Chest discomfort. Most heart attacks involve discomfort in the center of the chest that lasts more than a few minutes, or that goes away and comes back. It can feel like uncomfortable pressure, squeezing, fullness or pain. • Discomfort in other areas of the upper body. Symptoms can include pain or discomfort in one or both arms, the back, neck, jaw or stomach. • Shortness of breath with or without chest discomfort. • Other signs may include breaking out in a cold sweat, nausea or lightheadedness

patient compliance? Studies have shown that only about onethird of eligible patients continue risk factor interventions over the long term. However, data also show that this proportion can be significantly increased by a team approach. When healthcare professionals — including physicians, nurses, dietitians, other clinicians and health educators — manage risk reduction therapy with follow-up methods such as office or clinic visits and telephone contact, patient compliance is enhanced. Women are learning more about heart disease now than ever before and have been

Do clinicians provide “equal opportunity” medical care to patients? Though the situation is improving, research suggests that fewer women than men with

As with men, women’s most common heart attack symptom is chest pain or discomfort. But women are somewhat more likely than men to experience some of the other common symptoms, particularly shortness of breath, nausea/vomiting, and back or jaw pain.

told to talk with their healthcare providers about developing an effective heart disease prevention plan. If women know their numbers and assess their risks now, they can work with you to significantly reduce their

suspected acute heart attack symptoms

chances of getting heart disease tomorrow,

are referred for noninvasive tests, and

next year, or 30 years from now.

fewer women than men who test positive for heart disease are recommended for further testing and treatment. Because of the

Join the Movement

high fatality rate associated with first heart attacks in women, it is

Join the Go Red for Women movement to connect with colleagues

important to evaluate women with suspected heart attacks promptly,

and patients nationwide who share your commitment to prevent

carefully and completely.

heart disease. Register now at GoRedForWomen.org/professionals and see how you can help women live longer and stronger.

It is even more important to emphasize prevention through reduction of risks. Discussing a patients risk factors and developing a plan

Healthcare providers can also take advantage of American Heart

together to address them is an important step in helping patients

Association resources such as professional journals, treatment

take control of their heart health. Risk factors such as obesity or

guidelines, patient education tools and the latest in research at

overweight, high cholesterol, high blood pressure, diabetes, poor

http://my.americanheart.org/professional. FEBRUARY 2010 | The Triangle Physician

Radiology

Patient Selection Is Key in

Treating Painful Spine Fractures Society of Interventional Radiology supports additional scientific studies, fights negative backlash from two controversial studies that compared vertebroplasty to placebo that possibly places patients with osteoporosis in jeopardy of losing beneficial treatment. Given the current controversy over vertebroplasty—a

dedicated to improving health care through minimally

minimally invasive treatment performed by interventional

invasive treatments. “Before treatment, many of these

radiologists in individuals with painful osteoporotic

osteoporotic patients are in constant pain and cannot

vertebral compression fractures that fail to respond to conventional medical therapy—what’s a patient to do? Trust your medical team to decide if you are an appropriate candidate for vertebroplasty and trust the

manage everyday activities. Many are confined to bed for up to six weeks. These are the people we help; with vertebroplasty they can go home in one to two days. Candidates for the procedure are those who

experience of hundreds

have failed to respond to

of thousands of other

conventional medical

patients who have under

treatment (such as rest,

gone the spine treat-

analgesics and narcotic

ment successfully and

drugs). Vertebroplasty

received life-improving

can give patients their

effects, says the Society of

lives back,” said Stainken,

Interventional Radiology.

president of the Imaging

“Hundreds of thousands

of patients have greatly benefited from vertebroplasty with almost complete resolution of their pain; tens of thousands dependent

Network of Rhode Island and chair of the diagnostic imaging department at Roger Williams Medical Center in Providence, R.I. “Interventional radiologists have the critical

on intravenous narcotics have been discharged from

skills in imaging and patient care that make them experts

the hospital virtually pain- and drug-free following their

at determining which patients are the most appropriate

treatment,” noted SIR President Brian F. Stainken, M.D.,

candidates to receive the treatment,” he added.

FSIR, who represents the national organization of nearly 4,500 doctors, scientists and allied health professionals 12

The Triangle Physician | FEBRUARY 2010

Image: In vertebroplasty, a needle about the width of a cocktail straw is inserted through the skin into the fractured bone. A bone cement is injected. The cement hardens, stabilizes the bone and prevents further collapse. This stops the pain caused by bone rubbing against bone.

Two studies published in the New England Journal of Medicine in August were the first clinical trials to test vertebroplasty against a placebo, and many experts were stunned by the results that suggested that patients got equal amounts of modest pain relief whether they got vertebroplasty, where medical-grade bone cement is injected into broken vertebrae, or a dummy injection. “SIR supports the use of vertebral augmentation (vertebroplasty and kyphoplasty) for patients with painful compression fractures. In addition, SIR supports the important role of research regarding the role of vertebral augmentation, but we should take note that it is increasingly clear that these studies did not tell the whole story,” said Stainken. “The groups of patients studied and the analysis raised as many questions as were answered,” he said. Based on the NEJM findings, the society recommended that interventional radiologists inform patients of the studies’ controversial results during consultation. “The studies demonstrate the importance of debate and rigorous analysis of all data prior to rushing to conclusions. We must closely monitor trends in vertebroplasty research. There will be additional studies at SIR’s Annual Scientific Meeting in March that will provide new perspective on the aforementioned studies and reaffirm our perspective that vertebroplasty provides long-term and rapid pain relief for appropriately selected patients,” said Stainken. “We are concerned about the possibility that insurance coverage may be withdrawn for vertebroplasty and possibly kyphoplasty because of the controversy generated by the two NEJM studies,” said Stainken. If that occurs, access to these procedures would be limited to patients enrolled in approved trials, leaving many patients in severe pain without a solution. SIR is keeping a watchful eye on this to protect patients’ access to medical treatment. SIR will continue to serve as a leader in future trials of vertebroplasty that may confirm or contradict these studies or may identify subsets of patients more likely to benefit from vertebral augmentation, noted the SIR president. SIR member and vertebroplasty expert J. Kevin McGraw, M.D., FSIR, agrees. “While we welcome the two studies by

researchers David F. Kallmes, M.D., and Rachelle Buchbinder, Ph.D., to the body of literature on this technique, the results of these trials are discordant with personal experience and more than 15 years of accumulated medical literature espousing the benefits of vertebroplasty,” said McGraw, section head, interventional radiology, at Riverside Radiology and Interventional Associates in Columbus, Ohio. “SIR recognizes the value of randomized controlled trials and evidence-based medicine; however, the weakness in the studies and the degree of discordance between the outcomes of these studies, prior studies and experience, suggest that it is premature—and possibly incorrect—to conclude that vertebroplasty is no better than a control sham procedure,” he noted. Criticisms of both studies include the small numbers of patients treated; the small percentage of eligible patients who were actually enrolled in the trial; inclusion of patients with milder degrees of pain and disability than are usually treated in a typical practice; the small amount of cement injected; treatment of patients with chronic compression fractures; the incomplete use of MRI or CT to confirm that the fracture was the likely source of pain; and the high rate of crossover from placebo to vertebroplasty in one of the studies, explained McGraw. Criticism has also come from one of the studies’ investigators. William Clark, M.D., St. George Private Hospital, Sydney, Australia, an investigator with the Kallmes study, said he regarded that study as “meaningless.” In addition, he called the Buchbinder study “a rush to judgment on ‘science-based medicine’ without applying scientific technique in appraising the studies” in comments posted to the Arthritis Today Web site. Clark noted numerous flaws in the studies, indicating they had “inappropriate patient selection, terrible recruitment and selection bias with the majority not followed.” (continued on next page) FEBRUARY 2010 | The Triangle Physician

Osteoporosis, the most common type of bone disease, is characterized by low bone mass and structural deterioration of the bone resulting in an increased susceptibility to fractures. Osteoporosis affects 10 million Americans and is responsible for 700,000 vertebral fractures each year. Multiple vertebral fractures can result in chronic pain and disability, loss of independence, stooped posture and compression of the lungs and stomach. Vertebroplasty, a minimally invasive treatment performed by interventional radiologists under imaging guidance, stabilizes collapsed vertebra with the injection of medical-grade bone cement into the spine. “This reduces pain and can prevent further collapse of the vertebra, thereby preventing the height loss and spine curvature commonly seen as a result of osteoporosis. Vertebroplasty, when used appropriately in accordance with established practice standards by expert providers, dramatically improves back pain within hours of the procedure, provides long-term pain relief and has a low complication rate, as demonstrated

The Triangle Physician | FEBRUARY 2010

in multiple studies. We must not rush to new conclusions, especially based on these recent controversial studies,”said McGraw. More information about the Society of Interventional Radiology, interventional radiologists and vertebroplasty can be found online at www.SIRweb. org. SIR’s Research Reporting Standards for Percutaneous Vertebral Augmentation were published recently in the Journal of Vascular and Interventional Radiology as an additional reference for physicians. SIR’s Commentary on Vertebroplasty and the August Studies in the New England Journal of Medicine is also available on the society’s Web site.

We’ll put a Triangle Physician ad or an EDG one here

Phlebology

Tired, Achy, Heavy Legs? Patients with

Many patients think their leg symptoms are

Diagnostic evaluation includes H&P and

from aging, poor physical condition, or just

duplex ultrasound. Duplex ultrasound is usually

long, hard days. In fact, most patients,

performed in the office by a specialized

physicians and other providers, don’t even

technician and is considered the “gold

know leg symptoms could be caused by

standard” to evaluate venous insufficiency.

venous disease or unhealthy circulation in

Using duplex ultrasound, the technician

their leg veins. Patients don’t tell their

evaluates the flow of blood in the leg veins

physician, because they usually aren’t asked

and “maps” the veins.

Lindy McHutchinson, MD

Lindy McHutchinson began training with notable physicians in the field of Phlebology, first at Duke University as an observational fellow with Dr. Cynthia Shortell, chief of vascular surgery at Duke. Subsequently, Dr. McHutchison completed an extended clinical preceptorship with Dr. John Mauriello, fellow of the American College of Phlebology and nationally known educator in the field. She also trained with Dr. John Kinglsey in Birmingham, Alabama, another nationally known phlebologist. Prior to her interest in varicose veins, Carolina Vein Center – Southpoint.

Treatments are usually short, outpatient office procedures focused on closing

about the symptoms, and most patients don’t realize their leg symptoms could be a medical

Normally, leg veins have functional, one way

problem, easily treatable and covered by most

flow valves to keep blood flowing against

insurance plans, including Medicare. Sadly,

gravity towards the heart. If these flow valves

many patients are suffering unnecessarily.

are defective, absent or other conditions are present, blood flows retrograde or backwards

What is Phlebology?

down the leg causing venous congestion

Phlebology is one of the newest recognized

and increased venous pressure. This venous

fields of medicine and is dedicated to the

congestion and hypertension are ultimately

diagnosis, treatment and study of vein disease,

responsible for most of the symptoms and

which afflicts 80 million Americans or

physical findings of chronic venous

approximately 20% of the adult population.

insufficiency which include: leg discomfort,

Phlebology treats both the medical (venous

cramping, tenderness, burning, throbbing,

insufficiency) and cosmetic (spider veins)

swelling, varicose veins, skin changes

aspects of venous disease. If a medical problem,

and eventual venous ulcers.

unhealthy veins with either endovenous laser ablation and/or sclerotherapy (injections.) Bulging varicose veins are usually extracted via micro phlebectomy. Recovery time is brief, and patients usually return to normal activities the same or following day. Watch a short informational dvd on our website to learn more about these office procedures at www.carolinaveincenter.com If you have any questions about Phlebology, please do not hesitate to contact me at the Carolina Vein Center, Lindy McHutchison, MD, (919) 405-4200, lindy@carolinaveincenter.com We are committed to educating the community, both physicians and patients, and are happy to do a short presentation in your office.

most insurance companies, including Medicare, will cover the evaluations and treatments. Venous disorders diagnosed and treated by Phlebologist include: chronic venous insufficiency, varicose veins, spider veins, venous leg ulcers, congenital venous abnormalities, venous thromboembolism and other disorders of venous origin.

Symptoms of Venous Leg

Ankle swelling leg swelling tired achy heavy

painful purities throbbing cramping burning

stinging numbness restless legs

FEBRUARY 2010 | The Triangle Physician

Q&A

Varicose and Spider Veins

Medical Director, Regional Vascular Associates and Triangle Interventional Services. Medical School | Wake Forest University (Bowman Gray School of Medicine). Residency | Diagnostic Radiology, Mallinkrodt Institute of Radiology and Wake Forest University School of Medicine. Fellowship | Vascular and Interventional Radiology, Alexandria Hospital. Board Certification | American Board of Radiology with Certificate of Added Qualification in Vascular and Interventional Radiology.

Stephen P. Loehr, MD

required to achieve clearance. Larger, deeper

Triangle Physician:

varicose veins and feeder veins (those not

What is required for preauthorization by the

visible on the surface of the skin), may require

patient’s insurance companies?

Triangle Physician:

ultrasound-guided sclerotherapy.

Dr Loehr:

What are the different types of Varicose and

Triangle Physician:

Requirements for vein procedure coverage

Spider Vein treatments? Why would you use

Do health care insurance companies cover

include approved medical necessity, and a

one method over another?

vein procedures?

trial at conservative treatment which may

Dr Loehr:

include: Leg elevation, NSAID medications,

RF Ablation/Laser ELT

Varicose vein treatment is covered by most

and prescription medical grade compression

Varicose Veins can be treated using radio

insurance companies when the patient is

hose used for up to 3-6 months, depending

frequency ablation (RF) or Endovenous Laser

symptomatic (see ‘What are some of the

on insurance provider. All patients are seen

Treatment (ELT, or EVLT ) or a combination

symptoms of true Varicose Veins?’ below).

again after a conservative treatment regimen

of the two. Both are minimally invasive

We will work with your patients to maximize

to assess for change in clinical status.

outpatient procedures performed using

their insurance benefits.

Triangle Physician:

imaging guidance. Once a local anesthetic is

Triangle Physician:

Does vein disease affect women and men

applied, a thin catheter is inserted into the

If patients don’t get covered by their insurance

equally?

vein and guided up the great saphenous vein.

carriers, can you estimate their final cost?

Dr Loehr:

RF or laser energy is then applied to the inside

Dr Loehr:

Women account for 85-90% of varicose vein

of the vein heating the vein and sealing it

Yes. We have price lists for all vein procedures.

cases. Women are particularly afflicted with

closed. Blood that was circulating through

Triangle Physician:

reticular veins, the most harmless looking

the vein is naturally re-routed to healthy

What are some of the symptoms of true

veins, but the most symptomatic. Reticular

veins. This procedure takes about 1 hour start

Varicose Veins?

veins are the cause of Restless Leg Syndrome

to finish, and there is minimal pain.

Dr Loehr:

(RLS) in women. When these veins are

Ambulatory Phlebectomy

Common symptoms of varicose veins

effectively treated, the discomfort and

Ambulatory phlebectomy (microphlebectomy)

include: pain, fatigue, itching, burning,

automatic movements diminish. In men,

is used for vein removal of large, bulging

swelling, cramping, restlessness and

instead of reticular veins, the culprits are

varicose veins. Small incisions are made and

throbbing. Varicose veins often become large

multiple,

the veins directly removed. Phlebectomy is

and ropelike. Overly distended varicose

“high pressured small vein disease” (hpsvd).

done in the office with local anesthesia.

veins, especially near the ankle, can rupture

The varices, unfortunately, are often mistaken

Sclerotherapy

and cause bleeding. In some cases, varicose

for “cosmetic” telangiectasia (spider veins).

veins can cause serious health issues such as

Please call or visit our website at

vein treatment, utilizes a tiny needle to inject

venous leg ulcers.

triangleinterventional.com .

a small amount of sclerosing solution directly

Triangle Physician:

into the vein. This solution causes vein wall

What is the recovery time after radio-

Questions in March and April will be focused

irritation, collapsing and shutting down the

frequency/laser ablation or phlebectomy?

on Pain Management followed by Central

vein, causing the vein to be absorbed by the

Dr Loehr:

Venous Access and Oncology. Please submit

body. Sclerotherapy is completed in minutes,

Most patients resume most activities shortly

your questions to lpritchett@aac-llc.com or

but multiple sclerotherapy sessions may be

after each session.

call 919.677.9729 for referral information.

Sclerotherapy, the gold standard for spider

The Triangle Physician | FEBRUARY 2010

small-branching

varices

and

Cardiology

by Dr. Mateen Akhtar

What You Should Know About

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

Peripheral Arterial Disease

Peripheral arterial disease (PAD) is atherosclerotic disease of the arteries, excluding the coronary and cerebral arteries. Risk factors for development of PAD are similar to those for coronary artery disease and include age, diabetes mellitus, hypertension, dyslipidemia, and tobacco use. There is significant morbidity and mortality caused by PAD and it remains an under-recognized condition. In this article, I will review symptoms, screening, and treatment options for the three most common forms of PAD: abdominal aortic aneurysm, carotid atherosclerosis, and lower extremity arterial atherosclerosis

Lower Extremity

Atherosclerotic Disease Symptoms: Claudication — exertional calf, thigh, or buttock pain (20-30%), Atypical leg pain (30-35%), Asymptomatic (30%), Critical Limb Ischemia (1-2%) At-Risk Patients

(based upon ACC/AHA guidelines):

• Age 40-49 with diabetes mellitus + one Abdominal Aortic Aneurysm (AAA)

Carotid Artery Stenosis

Definition:

Prevalence:

all strokes.

Abdominal aortic diameter exceeding 3 cm. Up to 13% in men and 6% of women over age 65. Rare under age 60. Symptoms:

Carotid artery stenosis causes up to 7% of

other risk factor • Age 50-69 with history of smoking or diabetes mellitus • Age ≥70

Symptoms:

Screening:

of stroke or TIA.

pressure measurements taken in the arms

Carotid duplex ultrasound is highly sensi-

< 0.4 indicates severe PAD. The ABI test is

Often asymptomatic. May have symptoms

Ankle-brachial index (ABI) — ratio of blood

Diagnosis:

and ankles. ABI <0.9 is abnormal. An ABI

ruptures are fatal). May have abdominal

tive and specific. Other modalities include

highly specific. Sensitivity may be reduced

pain or back pain.

MRA and CTA.

in subjects with calcified arteries. If clinical

Age, male gender, tobacco use, family history

Auscultation for carotid bruits. No role for

such as CTA, MRA, or angiography.

Majority are asymptomatic. May present with rupture/sudden death (80-90% of AAA

Risk Factors:

of AAA, connective tissue disorder, diabetes mellitus, dyslipidemia. Diagnosis:

Screening:

suspicion is high, suggest further evaluation

screening asymptomatic individuals.

Treatment:

• Mild-to-moderate carotid stenosis:

aggressive risk factor modification, exercise

Treatment:

Abdominal ultrasound is highly sensitive

Antiplatelet agents, statin therapy, anti-

and specific.

hypertensive therapy, and annual carotid

Screening:

The US Preventive Task Force guidelines recommend AAA screening for: • Males over age 65 with a history of smoking • Males over age 60 with a family history of AAA

Treatment:

Risk of rupture increases with aneurysm size. Recommend treatment once AAA diameter > 5.5 cm or for rapid expansion. Options include open surgical repair vs. endovascular stent grafting.

duplex for monitoring. • Symptomatic, severe carotid stenosis:

For mild-to-moderate PAD, recommend rehabilitation programs, anti-platelet agents, ± cilostazol. For severe PAD, revascularization via vascular surgery or percutaneous angioplasty/stent may be indicated.

Revascularization is indicated with carotid endarterectomy vs. carotid stenting. • Asymptomatic, severe carotid stenosis: Controversial — need to weigh risks vs. benefits of revascularization vs. medical therapy on case-by-case basis.

In conclusion, maintaining a high index of suspicion for PAD and remembering to screen patients is important since early detection of PAD allows for early aggressive medical therapy and improved outcomes. Cardiovascular consultation is recommended for your at-risk or symptomatic patients. FEBRUARY 2010 | The Triangle Physician

Electrophysiology

Lead Extraction by Anil Gehi, MD

Undergraduate | Massachusetts Institute of Technology 1996 Medical School | University of California at San Francisco, 2000 Internal Medicine | University of California at San Francisco, 2003 Fellowships | Mt. Sinai Medical Center, 2006 (Cardiovascular Medicine), Emory University, 2008 (Cardiac Electrophsiology) Certification | Internal Medicine, Cardiology, Electrophysiology Clinical Interests | Pacemaker (including biventricular) & defibrillator implantation, device extraction, catheter ablation for SVT, VT, and atrial fibrillation.

Over the last 20 years, there has been

the vein over lead with the capability of

tremendous growth in the use of implantable

delivering controlled laser energy or mechanical

device for cardiac rhythm management,

disruption to cut through any scar tissue and

including pacemakers, implantable cardiac

free the lead from the heart. In this way, lead

defibrillators, and biventricular pacemakers.

extraction with a >90% success rate and a

Accompanying this growth is an increasing

2-3% overall complication rate can be achieved

incidence of lead dysfunction and device-

with only a 0.5% major complication rate.

related infection. Additionally, as patients are routinely implanted with devices that may need

Any lead extraction program requires a

to be maintained for decades, abandoning

multi-disciplinary team. Besides the primary

dysfunctional leads is becoming more and

operator (often a cardiac electrophysiologist)

more problematic. Abandoned leads can lead

who must be experienced in lead extraction

to vein occlusion or even valvular dysfunction

and also well-versed in device implantion

and these potential complications can be

and management, it is critical to have support

ameliorated or avoided completely if the

from cardiothoracic surgery and anesthesia

problematic leads are extracted.

personnel familiar with all potential complications of lead extraction and re-implantation. This collaboration is critical to

A recent consensus statement from the Heart

Rhythm Society clarified the indications for

transvenous lead extraction. These indica-

maintaining the safety of the procedure. The reason for this is the small but finite risk of

tions include: 1) evidence of device system

greatly reduced the risk of extraction. The

cardiac rupture with tamponade, and this can

stenosis or occlusion preventing access to

basis of all of these techniques is first to

require immediate thoracotomy to control

transmit lead traction to the tip of the lead

hemorrhage.

infection (including pocket infection), 2) venous the venous circulation, and 3) unused leads

that interfere with device function or number in excess of 4 leads on one side.

in the heart rather than to the available proximal end of the lead in the pocket. This

As the benefit and utilization of cardiac

is achieved using a stylet that locks to the tip

implantable devices continues to expand, it is

With the general aging of the device patient

of a lead. This countertraction to the tip of

critical that there is supporting capability for

population, and the increasing complexity

the lead is coupled with some form of sheath

lead extraction. Patient with 2 or 3 unused,

of implantable devices there is an increasing

that is passed over the lead and used to cut

abandoned leads who may be living with

need for leads to be removed or replaced.

away the fibrous adhesions that fix the lead

an implantable device for many years are at

to the heart. In its simplest form this can

unacceptable risk from long-term lead

Over time leads usually are fixed in place

be achieved with a simple sheath, although

related complications. It is far better to extract

by scar tissue and become impossible to

several tools have been developed to assist

unused leads early in the course when it can

extract by simple traction. Due to the risk

in breaking through fibrous adhesions. The

be achieved with minimal complications. The

and technical challenges of lead extraction,

most common sheaths utilize either laser

coming years will likely see lead extraction

many physicians who implant devices are

energy (Spectranetics) or a rotating stainless

expand from a treatment for device related

reluctant to extract implanted leads. Over

steel cutting tip (Cook Medical). With such

infection to an expanding role in removing

the last decade, several developments have

techniques, a sheath is advanced through

dysfunctional or abandoned leads.

The Triangle Physician | FEBRUARY 2010

News Welcome to the Area

Events and Opportunities

ANDREW BABCOCK, MD

GRACE MCCARTHY, MD

Family Medicine University of North Carolina Hospitals Chapel Hill

Anesthesiology Duke University Hospitals, Durham

KATHLEEN BALLAS, MD

HEATHER PADDOCK, MD

Pediatrics Cary

Pediatric Surgery Duke Division of Pediatric Surgery, Durham

BRIAN BRITT, MD

RICHARD RUNKLE III, MD

Internal Medicine Duke Raleigh Hospital, Raleigh

Anesthesiology University of North Carolina Hospitals, Chapel Hill

TODD BROMBERG, MD

STEFANIE SCHUMAN,MD

Anesthesiology Pain Management Chapel Hill

Ophthalmology Duke Eye Center, Durham

KALLOL CHAUDHURI, MD

RAJDEEP SINGH, MD

Anesthesiology Duke University Medical Center, Durham

Neurology Duke University Medical Center, Durham

SWAPNA CHAUDHURI, MD

RYAN STANGER, MD

Anesthesiology Duke University Medical Center, Durham

Anesthesiology University of North Carolina Hospitals, Chapel Hill

CHIH-CHENG CHEN, MD

ERIC STROTHER, MD

Neurology Carrboro

Anesthesiology Raleigh Family Health Care, Raleigh

DAN COTOMAN, MD

MILLIE SURATI, MD

Psychiatry Durham

Otorhinolaryngology Duke University Hospitals, Durham

PHILIP DAVENPORT, MD

PRIYANKA UPPAL, MD

Neurology Duke Neurology of Raleigh, Raleigh

Internal Medicine Cary

MARK FASZHOLZ, MD

CREIGHTON VAUGHT, MD

Anesthesiology Durham

Otorhinolaryngology Alamance ENT & Facial Plastic Surgery, Burlington

ARASH FOROUGHI, MD

CLAUDIA VISSAGE SCRUGGS, MD

Neurology Duke University Hospitals, Durham

Internal Medicine University of North Carolina Hospitals, Chapel Hill

PEARLINE GRANT, MD

JOSEPH WILSON, MD

NATIONAL WEAR RED DAY Show your support for the fight against heart disease in women and the American Heart Association’s Go Red For Women movement by sporting your best red outfit Feb. 5th. For a free downloadable Wear Red Day kit, visit GoRedForWomen. org/WearRedDay or contact the AHA at 919-463-8307. Feb. 13, 2010

25TH ANNIVERSARY TRIANGLE HEART BALL Raleigh Convention Center, Downtown Raleigh 463-8353 www.triangleheartball.org 25th Anniversary event raises funds to support American Heart Association research and education for heart disease and stroke, the #1 and #3 leading causes of death in America. Feb. 13, 2010 from 6 p.m.– 11 p.m. Feb. 13, 2010

BLUE JEAN BALL The third annual Blue Jean Ball, a women’s health benefit , will be held at the Sheraton Imperial, on Page Road, Durham, NC. The event date is Saturday, February 13, 2010. Join the “dress down,sparkle up” event where Blue Jeans are the expected attire. A silent auction, dinner and live band are a part of what you will enjoy during an evening dedicated to raising awareness and funds to provide surgical and medical care to women in East Africa. For ticket or program information, please visit http:// bluejeanball.mc.duke.edu or call (919) 660-2378. Feb. 27, 2010

CARDIOVASCULAR DISEASE 2010, HEALTH CARE IN EVOLUTION: OPPORTUNITIES AND CHALLENGES FOR THE CARDIOVASCULAR PATIENT WakeMed Heart Center, Conference Center WakeMed Raleigh Campus 3000 New Bern Avenue Raleigh, NC 27610 Jointly sponsored by Wake Heart And Vascular Associates and Wake AHEC This program will present comprehensive insights into cardiology and care of the patient with or at risk for cardiovascular conditions. Register online: www.wakeahec.org April 7, 2010

Family Medicine Raleigh

Orthopedic Surgery Triangle Orthopaedics, Durham

ANDREW GREEN, MD

TAYLOR WOFFORD, MD

General Surgery Wilson

Internal Medicine University of North Carolina Hospitals, Chapel Hill

WAYNE KELLEY, JR., MD

JORDAN YOUNG, MD

Orthopedic Surgery Duke University Hospitals, Durham

Internal Medicine Wayne Memorial Hospital, Goldsboro

AARON LENTZ, MD

ROBIN ZENICK, MD

Urological Surgery University of North Carolina Hospitals, Chapel Hill

Feb. 5, 2010

Pediatrics Premier Pediatrics, Southern Pines

New and Relocated Practices

NATIONAL START! WALKING DAY Lace up your sneakers and take a walk to celebrate National Start! Walking Day. Walking has been proven to lower heart disease risk and improve wellness. For free walking resources visit StartWalkingNow.org or contact the AHA at 919-463-8353. Apr. 16 and 17, 2010

CME: 2ND ANNUAL EMILY BEREND ADULT RECONSTRUCTION SYMPOSIUM A comprehensive hip and knee course presented by Adult Reconstruction, Division of Orthopaedic Surgery, Duke University Medical Center • Lectures on hot topics in hip and knee arthroplasty and live video demonstrations on the latest operative techniques • Visiting professor Adolph V. Lombardi, MD, FACS Friday, April 16, 2010 (Knee session) Saturday, April 17, 2010 (Hip session) Duke University Medical Center Register and get more information at cmetracker.net/DUKE/Courses.html This activity has been approved for AMA PRA Category 1 credit.TM Sponsored by Duke University School of Medicine May 7, 2010

DUKE GENERAL SURGERY OF RALEIGH (two locations) Duke Medicine Plaza 3480 Wake Forest Road, Suite 506 Raleigh, NC 27609 office 919-420-5000

American Institute of Healthcare & Fitness Offices 8300 Health Park, Suite 211 Raleigh, NC 27615 office 919-847-8235

TRIANGLE GOES RED FOR WOMEN LUNCHEON Crabtree Marriott, Raleigh 919-463-8307 www.trianglegoesred.org Celebrate the power of women to join together in the fight against their No.1 killer – heart disease. Enjoy heart health seminars, networking, a healthy lunch and powerful keynote address.

FEBRUARY 2010 | The Triangle Physician

Good Business

Averting

Mark Wiener, President of BizCom Web Services has more than twenty years experience working with medical practices, large and small, to aid them in curing their technical, regulatory, management and communication practice ailments. He currently, works with practices to help them manage and minimize their overall IT budgets by providing enterprise-class solutions to small and midsized practices all the while increasing security and improving practice performance, communications and efficiencies.

Data Disasters by Mark Wiener www.bizcomweb.com

Physicians juggle many responsibilities: from having to supervise the care of their patients, fighting with insurance companies over treatment plans, managing staff, and making sure the medical and billing records remain intact and accessible. Today, much of the critical information that runs the medical practice is stored in electronic form. For many physicians, it is a disorganized file cabinet which contains: • Employee records • Tax records • Patient billing records • Patient medical records • Insurance claim follow up letters • Letters of Medical Necessity

“backup”— the process of making copies of data so that these additional copies may be used to restore the original after a data loss event. Electronic Medical Record (EMR) and Practice Management (PM) systems use complex databases and generally have their own backup utility. Some practices use these intrinsic utilities while others rely on the tools within server backup software due to ease of use and automation with the latter. Regardless of method, someone needs to make sure the backups store all of the required data, actually work, and can be restored easily.

• Office forms

When electronic trouble strikes and data loss occurs, the vast majority of medical offices are unprepared to get their office functioning again in quick order. This is the purpose of a

The Triangle Physician | FEBRUARY 2010

Common back up strategies: • No backup – This places your practice at risk for data loss and HIPAA data retention violation. • Tape backup – This is a better option; however, high tape failure rates due to environmental issues (humidity, dust, heat and overuse), regular tape replacement needs and security issues make this a less desirable choice. • Local disk backup – This creates an immediately readable version of the data and allows easy access to get to small amounts

The technology exists to prevent permanent

policies often are inadequate and leave your

and temporary data loss. Especially in the

practice with a huge risk exposure.

medical industry, it is unacceptable to be prepared. According to the SBA, if a business loses its data for more than 10 days, there is an 87% probability that it will file bankruptcy and close. It is imperative that practices review their data handling procedures. It is important to also understand the data recovery components (and its limitations) in their office business insurance policy. Remember, the basic limits included in your

Don’t take unnecessary risk. Review your data back up and retention strategies with your IT professional.

of data without having to restore the entire volume; however, in the case of a building wide disaster like fire, your backup data would be permanently lost. • Online backup – This strategy provides for the security of an offsite backup, but it may take several hours to restore the data when done over the internet. • Multiple strategies – Utilizing multiple strategies, like local disk backup coupled with online backup, yields the best results and does not require regular employee intervention. So, how does one decide? Every practice may have a different answer depending on available resources and their needs. How much data do you have? Where is the data located (server, local computers, email, flash drives, portable hard drive)? What is the sensitivity of the data? How do you ensure that all required data is recoverable in case of a drive failure or disaster? How long will it take to restore the data? How long will the practice not be able to operate if the electronic medical records or the billing system are offline? Many practices are concerned about using off site or online backup services due to HIPAA rules. HIPAA should not be a concern if backups are properly encrypted prior to transmission to the data storage company. A Business Associate Agreement is unnecessary when strong encryption technology is used. The vender has no access to your data because the encryption key is held exclusively by the medical practice. There are greater HIPAA concerns with local tape and disk backup copies being retained that are not properly secured. Womens Wellness half vertical.indd 1

12/21/2009 4:29:23 PM

FEBRUARY 2010 | The Triangle Physician

Local Interest

Discover Historic

Wilmington

Cape Fear Museum of History and Science is the oldest history museum in North Carolina. Since its founding in 1898, the Museum has grown and changed. It began collecting confederate relics, and now collects images and artifacts that help us understand the history, science and cultures of the region.

The Museum began in one room, staffed only by volunteers. It has evolved into a professionally run, American Association of Museums accredited institution, housing more than 50,000 objects. Visitors encounter the skeleton of a giant ground sloth, standing 17 feet tall in the

atrium. The bones were discovered in Wilmington during the 1991 construction of a retention basin. The long-term exhibit, Cape Fear Stories, takes visitors through time, from the age when the Cape Fear Indians inhabited the region through present day. Enjoy the model of Civil War Wilmingtonâ&#x20AC;&#x2122;s waterfront, experience the dramatic Battle of Fort Fisher sound and light show, and walk through a classroom from the era of segregated schools. The Museum is also home to the Michael Jordan Discovery Gallery, an interactive exploration of the ecosystems of southeastern North Carolina. An ever-changing calendar of special exhibits, programs and events offers something fun and educational for everyone throughout the year.

MUSEUM HOURS:

Tuesday-Saturday, 9a-5p and Sunday 1-5p. The museum is open seven days a week between Memorial Day and Labor Day. Admission is $6 for adult and $3 for children with senior, student and military discounts. For more information, call the Museum at 910.798.4350 or visit capefearmuseum.com. SPECIAL EXHIBIT: Going to the Movies runs through November 7, 2010. Experience the history of a century of movie-going in the Lower Cape Fear region. Explore where people went to the movies. Discover how the theater experience has changed over the years. Watch some of the first films local residents may have seen. Conservation Matters runs through September 6, 2010. Explore the art and science of artifact conservation. Discover what it is, who does it, and why it matters to museums. A selection of beautifully conserved furniture and other wooden objects from the Museumâ&#x20AC;&#x2122;s permanent collection will be on display. Special exhibitions are free with Museum admission.

The Triangle Physician | FEBRUARY 2010

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

Insurance

Liability Nurse

The of a

The nurse is a critical team member in any health services business. The nurse is one of the key faces that everyone sees at a medical practice, whether itâ&#x20AC;&#x2122;s the beginning of the visit or the end of a long procedure. Their friendly smile and steady hands help the client feel calm and secure about the procedure they are about to have. And although they play such a friendly role, nursing professional liability claims are at an all time high.

Secondly, know what your coverage limits mean and if legal costs are included. Many policies will pay legal costs (the cost to defend you) in addition to whatever the limits of the policy are. Many policies will use a per claim limit and an aggregate limit. For example if your policy reads $1,000,000/$2,000,000 under the coverage amount, that often means the insurance company will pay out up to $1 million for any one claim and up to $2 million in total for the policy.

Unfortunately any customer, for any given reason, can sue a nurse at any time. The nurse doesnâ&#x20AC;&#x2122;t have to be wrong, it just happens. As with anyone else, being sued makes the nurse feel embarrassed and insecure about his or her job. Immediately emotions of fear, anxiety, and uncertainty take over.

Finally, do some research on the financial stability and claims history of the company offering you the coverage. There are many insurance companies in business today and you always want to do business with a company that has a good reputation and a solid rating with A.M. Best (I recommend A or higher). If you arenâ&#x20AC;&#x2122;t sure about the company offering you coverage, contact your insurance agent and see if they have suggestions.

Where does this put a nurse and what can they do to be prepared? Nurses Professional Liability is a great way to calm these fears. Historically the areas of nursing that have been the most prone to claims are anesthesia, medication administration, midwifery and monitoring roles; however, claims today are expanding to all areas of the field. Higher standards of care, failure to follow procedure and failure to document conditions and treatment are some of the biggest causes of law suits. All medical offices should have professional liability insurance for their doctors and staff. However, today nurses can get coverage for themselves independently of what their employer offers. This coverage is called Nurses Professional Liability.

People are coming from all over the country to receive treatment here in the Triangle. Please make sure you are covering yourself and your career from disaster!

There are two ways a nurse can purchase Professional Liability. First, is a stand-alone Nurses Liability policy, which many carriers offer. Secondly, many home insurance companies offer Nurses Professional Liability coverage as a rider on existing home insurance policies. Having the rider added to the home policy is probably the cheapest and most efficient way to have the coverage added and still give nurses the security they need. There are three key things that I recommend to nurses who are looking at purchasing this coverage: First, is the coverage on a claims made basis or on an occurrence basis? There is a very big and important difference. Claims Made means that the policy will only pay the claim if the claim is made while the policy is in force. Occurrence basis means the policy will pay the claim if the error or omission was done while the policy was in force. With Occurrence basis it does not matter if the policy is in force when the claim is made. As you can see there is a very big difference between the two. FEBRUARY 2010 | The Triangle Physician

Marketing

Have You Been

Branded? Companies constantly bombard us with brands in today’s culture in an effort to establish a loyal customer base. Isn’t that what every practice wants… a loyal customer base from which a practice may sustain itself on a long term basis? The Physician Already Has One Brand

by Chris Doane Chris Doane founded Southern Crescent Solutions in 2006. Southern Crescent Solutions, a marketing firm located in the Atlanta, Georgia area specializes in web development, CRM Systems, and interactive marketing for a broad range of clients. Mr Doane holds a BFA from the University of Georgia, a Project Management certification from Georgia Tech and a Certified Webmaster certification from Oglethorpe University. He has 20 years of experience in marketing, corporate communications, and information technology. His background includes a diverse range of experience with both small business and large corporate operations. Before starting Southern Crescent Solutions, he managed the Internet operations for a publicly traded insurance holding company located in Atlanta, Georgia. During his tenure there, major projects included the development of a patented CRM system for use in the sales and marketing division and the design and implementation of the company’s branding and interactive marketing campaigns.

Brand Management and the Benefits

your market share while building mind

of a Strong Brand

share. Once you have mind share, your customers will automatically think of you

Your name and who you are is, in fact, your personal brand. Ultimately, the issue then is

If you were to ask one of your patients,

first when they think of your area of specialty.

not whether you have a brand, the issue is

“What comes to mind when you think of

• A solid branding strategy communicates

how well your brand is managed. So what

my practice”. Would they say, friendliness,

a strong, consistent message about the

exactly is a brand. Branding today is used

professionalism, state-of-the-art, well-trained,

value of your services. A strong brand

to create an emotional attachment to a

convenient, accessible? Brand image is

helps you sell value and the intangibles

practice. Branding efforts create a sense of

defined as a patients’ perceptions as reflected

that surround your practice.

higher quality. In other words, a brand is the

by the associations they hold in their minds

• A strong brand signals that you want to

promise of value when a patient considers

when they think of your practice. Brand

build customer loyalty. A strong branding

your practice over another. These promises

management recognizes that your market’s

campaign will also signal that you are

can be implied or explicitly stated.

perceptions may be different from what

serious about marketing and that you

you desire while it attempts to shape those

intend to be around for a while.

Over time, your brand should expand into

perceptions and adjust the branding strategy

your marketing collateral including your

to ensure the market’s perceptions are

website, brochures, logo, slogans, etc.

exactly what you intend.

• Branding builds name recognition for your practice. • A brand will help you articulate your practice’s values and explain why you are

Branding can be enhanced by the images you

competing in your market.

use in your advertising, and the by words

Here are just a few benefits you will

you use to describe your practice and area of

enjoy when you create a strong brand:

specialization. After sufficient impressions,

• Branding creates trust and an emotional

If a brand is successful in making a connection

the patient remembers these associations.

attachment to your practice. This attach-

with people and communicating its distinct

When combined with a well-conceived

ment then causes your market to make

advantage, people will want to tell others

brand management strategy, your advertising

decisions based, at least in part, upon

about it and word-of-mouth advertising

has the power to shape your organization’s

emotion-- not necessarily just for logical

will develop naturally. This top-of-mind

or intellectual reasons.

awareness occurs when you ask a person to

brand image in a way that positively affects your organization’s revenue, reputation and patient loyalty over the long-term.

• A strong brand can command a premium

name practices within a particular specialty

price and maximize the number of patients

and your practice comes to mind. Once that

that can be taken.

type of differentiation is established in the

• Branding will help you “fence off ” your patients from the competition and protect 28

The Triangle Physician | FEBRUARY 2010

market’s mind, advertising can help maintain and shape the brand.

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BRENT A. TOWNSEND, MD | Pediatric Radiologist

CATHERINE B. LERNER, MD | Pediatric Radiologist

LAURA T. MEYER, MD | Pediatric Radiologist

Wake Radiology is the first radiology practice in Raleigh to open a dedicated pediatric outpatient imaging center. Four fellowship-trained, pediatric radiologists have created a child-friendly environment for your young patients who range from a few days of age to eighteen years old. Our pediatric radiologists are all subspecialty trained and are keenly aware of the unique challenges that your pediatric patients present. Because children are more sensitive to radiation than adults, we strive to use the smallest doses of radiation possible that will still provide diagnostic images and offer experienced guidance in selecting the most appropriate imaging modalities for your patient. Wake Radiology Pediatric Imaging. Deliverying the finest care for your smallest patients.

Wake Radiology Pediatric Imaging | 4301 Lake Boone Trail, Ste 100 | Raleigh, NC 27607 | Scheduling 919-232-4700 | wakerad.com