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At 7:40am on February 23, 2009, Michael Sellars’ car slid sideways into a concrete utility pole while he was driving to work.
Rehabilitation Hospital • Home Health Care Outpatient Therapy • Skilled Nursing Research • Community Programs
BrooksRehab.org
He was taken to UF ShandsJacksonville, where his family learned he had suffered a severe traumatic brain injury (shearing and hemorrhaging of the brain and brain stem), a ruptured spleen and a broken pelvis and left collarbone. He spent most of his stay at Shands in a coma. He was described as being in a “vegetative state”, a disorder of consciousness and neurological state marked by spontaneous eye-opening but without response to external stimuli and from which only 5% to 10% of patients emerge. Brooks medical physicians collaborated with Shands trauma specialists and began an aggressive course of neurostimulant medications and physiologic stabilization while tracking Michael’s level of responsiveness to medical interventions. “Working closely with trauma physicians and the neurosurgeons at Shands allowed us to begin Michael’s brain injury rehabilitation in the ICU. This helped Michael and his family begin the road to recovery sooner,” said Kerry Maher, M.D., Medical Director, Admissions for Brooks. On the morning of April 8, 2009, Michael showed clear signs that he was
emerging and he was deemed ready to transfer to Brooks Rehabilitation Hospital in a “minimally conscious” state on April 10. A minimally conscious state is a disorder of consciousness marked by occasional meaningful responses to external stimuli (e.g., reciprocating a wave, reaching for an object, opening the mouth when food is presented). During his 32 day stay at Brooks, Michael met and/ or exceeded the goals of the brain injury program. Michael began to recognize his family members, follow directions and take a few steps while supported. He emerged from his minimally conscious state into a post-traumatic amnesia state. Post-traumatic amnesia is a neurological state marked by impaired mental status and severe to profound cognitive impairments. Patients are able to engage in automatic, well-learned or habitual behaviors (e.g., eating, bathing, dressing), but are unable to self-manage these very basic activities. “Michael’s case exemplifies not only the advantage of trauma-rehab collaboration in setting the stage for recovery, but also the need to receive rehabilitation at a facility that applies cutting edge research to patient care and a facility that has the full continuum of rehabilitation needed to treat catastrophic injuries from unconsciousness to community. Brooks Rehabilitation is that facility,” said Cynthia L. Beaulieu, Ph.D., ABPP-Cn, Program Director, Brain Injury Program. Michael still had a long journey ahead. During the next few months, Michael continued his recovery at a nursing center in conjunction with therapy sessions at Brooks Rehabilitation Hospital. At this stage Michael participated in a pilot project that applied research findings discovered with survivors of spinal cord injuries, applying neuroplasticity principles related to spinal cord injuries to his brainstem injury. He eventually went home and received home health care. He then progressed to Brooks’ outpatient therapy and the
Neuro Rehabilitation Day Treatment Program for four more months of intense physical, occupational, speech and cognitive therapy. Through the continuum of care that Brooks offers and Michael’s determination, he made significant progress. Michael is now a member of the Brooks Clubhouse, a place where survivors of brain injury can prepare to successfully return to an active life. The Brooks Clubhouse is a communitybased day program where members and professional staff work side by side in the daily operations. Members focus on improving functional abilities, developing work skills and enhancing individual strengths and talents. Michael works in the Clubhouse’s Business Office work unit, performing data entry tasks and participating in the preparation of the weekly Clubhouse newsletter. Michael particularly enjoys aquatic therapy, working with the Brooks therapy dogs and helping to train future service dogs. He is also working with experts at the Brooks Neuro Recovery Center, a new program at Brooks that emphasizes neuroplasticity (the brain and spinal cord’s ability to change, adapt and learn). Under the supervision of a physical therapist, Michael and other
“Michael’s case exemplifies not only the advantage of trauma-rehab collaboration in setting the stage for recovery, but also the need to receive rehabilitation at a facility that applies cutting edge research to patient care and a facility that has the full continuum of rehabilitation needed to treat catastrophic injuries from unconsciousness to community.”
— Cynthia L. Beaulieu, Ph.D., ABPP-Cn
members participate in activities ranging from one-on-one therapy to supervised exercise and group classes depending on their level of recovery.Recovery is aimed at the physical, cognitive, social and emotional level. “Michael has always been an extremely self-motivated person. Put a goal in front of him and get out of his way,” said Joe Sellars, Michael’s father. He has been most excited to get back to some of the things he enjoyed most before the accident, like talking about cars, working out at a local gym and attending home Jaguar games. Michael’s story is not only an inspiration to survivors just starting out on their recovery journey, but his story is also an inspiration to the trauma specialists who save lives following catastrophic events and to the rehabilitation professionals who treat survivors along their lengthy return-to-life journey.
publisher’s
note
It’s no secret that doctors have one of the most stressful jobs on the planet.
Publisher A.J. Beson
business development director Michael E. Hicks
You take care of everyone else, you work long hours in a highstress environment and your job is oftentimes literally a matter of life or death. I have the perfect prescription to relieve some of that stress – go to the movies. While the movie experience has changed considerably, it’s still one of my favorite pastimes. I can completely check AJ and Tara Beson enjoying a night out for a good cause at out when I watch a A Night for Heroes. movie. No cell phones, no appointments to hurry off to, no are plenty of great movies out there one asking me for anything; just two and now is the ideal time to take in uninterrupted hours of a great story. a flick. It’s the perfect way to relax Northeast Florida, in particular, is a and unwind. great place to take in a movie. Take Until next month… the kids to World Golf Village, which boasts the largest IMAX digital 3D screen in the Southeast. The perfect date night can be found at the San Marco or 5 Points theaters. Enjoy great food, beer and wine while you watch the big screen. Plenty of A.J. Beson places host free movies nights – one aj@beson4.com of the best is Jacksonville Beach’s Moonlight Movie Series in May and June. Jacksonville, once considered the Hollywood of silent movies, is also home to an incredible film festival held each October. With 10 feature films up for Best Picture at this year’s Oscars, there
Editor Vanessa E. Wells
Art Director Christine Tarantino
operations manager Stacey Cotner
marketing consultants Stephanie Autry Shannon Mayo Lori Robinson
Media Relations Manager Michelle Jacobs
Media Relations Specialist Katie Whiteman
graphic designer Kyzandrha Zarate
Contributing Editor Virginia J. Pillsbury
Contributing Writers Laura Capitano LaNeta Crighton
Photographer Hayes Photography
For questions or comments or to receive reprints, call 904-992-9945 or fax 904-992-9907.
Florida Doctor is published 12 times per year by Beson4 Media Group. Reprints are available — 13500 Sutton Park Drive South, Suite 105, Jacksonville, FL 32224. Content of the contributing advertisers does not reflect the opinions of the publishers. Advertisers have proofed respective articles, and content is assumed true and correct. Florida Doctor is not responsible for the care given by its advertisers. Florida Doctor is for informational purposes only and is not meant as medical advice. ©2011 Florida Doctor. All rights reserved. The contents of this publication, including articles, may not be reproduced in any form without written permission from the publisher.
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Send story ideas to editor@beson4.com or call 904-992-9945. 2011
Coordinated Compassionate Care, leading edge technology and a team of cancer experts ...all under one roof!
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Features I march 2011 issue 83
•••• cover profile Colon Cancer Awareness Month unites Primary Care Physicians and Gastroenterologists in a partnership to increase colon cancer screenings. Cover photo by Hayes Photography
doctor profile:
The Ultimate Resource 18 Marsha Bertholf, M.D., makes sure the community’s blood needs are met.
PLUS: What’s Happening 8 Space Odyssey 32 Top 5 Screenings 34
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Conquering Colorectal Cancer 23
Towing the Line 28
How diagnosis and treatment is changing for the better.
Swapping fish stories with area physicians.
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Jacksonville Orthopaedic Institute (JOI) Joins Baptist Health Jacksonville Orthopaedic Institute’s Board of Directors and the Baptist Health Board of Directors have signed an agreement that officially makes JOI a subsidiary of Baptist Health. The agreement became effective February 1, 2011. All JOI employees’ jobs and benefits are preserved, and JOI’s seven physician practices and nine rehabilitation centers will retain their respected Jacksonville Orthopaedic Institute brand identity. “We have had a long-term, collaborative relationship with Jacksonville Orthopaedic Hugh Greene Institute for many years. With this agreement, patients with muscle, bone and joint disorders can continue to receive the well-recognized expertise of JOI’s premier group of orthopaedic surgeons, coupled with the complete continuum of services we provide at Baptist Health,” said A. Hugh Greene, president and chief executive officer, Baptist Health. “As the future landscape of healthcare changes, we will be well-positioned to continue meeting the challenges and provide accessible, excellent orthopaedic care.” A January collaboration between Baptist Health and JOI culminated with the opening of the Baptist Beaches Surgery Center.
St. Vincent’s HealthCare Hires New Vice President of Finance Operations St. Vincent’s HealthCare (SVHC) has hired Sean Fitzpatrick as Vice President of Finance Operations. He most recently served as the VP of Finance for Thomas Jefferson University Hospitals in Philadelphia, PA. Fitzpatrick will be responsible for finance, financial planning, financial analysis and decision support as well as budget and accounting for all SVHC entities. A Certified Public Accountant, Fitzpatrick earned a BS in Finance and an MBA from St. Joseph’s University in Philadelphia. “I’m thrilled to join St. Vincent’s HealthCare as the Vice President, Finance Sean Fitzpatrick
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Visit Florida Doctor – North on Facebook to learn more about local medical events in the Northeast Florida community. http://www.facebook.com/FLDoctorNorth
Operations. This is a tremendous opportunity to help St. Vincent’s fulfill its mission and vision through the integration of finance and operations, which is an important step in preparing for the many changes and challenges landmark healthcare reform will bring. I’m also looking forward to becoming a member of the Jacksonville community and representing such an outstanding organization in promoting the values of faith-based healthcare,” said Fitzpatrick.
Hollie Hickman, M.D., Joins TruYou Plastic and Reconstructive Surgery Hollie Hickman, M.D., recently joined TruYou Plastic and Reconstructive Surgery. Dr. Hickman began her surgical training at the Mayo Clinic in Jacksonville where she completed a five year residency in general surgery. She went on to further her training at the Vanderbilt University Department of Plastic and Reconstructive Surgery. While at Vanderbilt, Dr. Hickman had the opportunity to work under the tutelage of nationally recognized plastic surgeons, and received expert instruction in advanced breast reconstruction, cleft lip and palate surgery, traumatic injury to the face, hand and lower extremities, as well as cosmetic surgery of the face and body. She is excited to bring her experience and cutting edge training in plastic surgery to the Jacksonville area. Dr. Hickman has presented at national conferences such as the Southeastern Surgical Conference, Southwestern Surgical Conference, SAGES Meeting, 92nd Annual Clinical Congress, Peabody Colorectal Conference and at the Florida Committee on Trauma. She also spent a year in Bethesda, Maryland at the National Institutes of Health working on a national research program to identify proteins within cancer cells that could be used to assist in curing cancer. Dr. Hickman with Erez Sternberg, M.D., founder of TruYou.
Steve Goldwasser,M.D., Opens New Office at Baptist South Campus Steve Goldwasser, M.D., a member of North Florida OB/ GYN, recently opened a new office on the campus of Baptist South Hospital. Dr. Goldwasser earned his bachelor’s degree at The University of California in San Diego and went on to receive his medical degree from Tulane Medical School. Dr. Goldwasser completed his residency in OB/GYN at the University of Tennessee and his fellowship training in Urogynecology and Reconstructive Pelvic Surgery at The Good Samaritan Hospital in Cincinnati, Ohio. He began his career in Jacksonville in 2000 as the Chief of Urogynecology at the University of Florida. He left the Steve Goldwasser, M.D. University in 2006 to begin his private practice in the community. In January 2011, he joined North Florida OB/GYN.
Congenital Heart Disease Endowment According to the American Heart Association, about 35,000 babies are born each year with some type of congenital heart defect. Congenital heart disease is responsible for more deaths in the first year of life than any other birth defects. However, with early diagnosis, many of these heart defects can be repaired and children can go on to lead normal lives, many without further treatment. In order to educate local pediatricians and family practice physicians about congenital heart disease and help them identify these conditions early in life so children can access necessary cardiac care, philanthropists Bill and Sally Green will establish a new $25,000 endowment called the Jose and Hilda Ettedgui Endowment. The fund will help Patrons of the Hearts and the University of Florida Pediatric Cardiovascular Center affiliated with Wolfson Children’s Hospital provide an annual educational event led by pediatric cardiologists for pediatricians and family practice physicians that allows them to examine children with congenital heart disease and learn the latest in diagnosis and treatment of children with these conditions. The Greens were particularly inspired by the work of Patrons of the Hearts, and its co-founders, Dr. Jose Ettedgui,
Bill and Sally Green
medical director of the University of Florida Pediatric Cardiovascular Center, and his wife, architect Hilda Ettedgui; this led to the establishment of the endowment. Patrons of the Hearts brings children with congenital heart disease from underdeveloped countries to Jacksonville and Wolfson Children’s Hospital for life-saving heartcare. This care is made possible through gifts from donors and fundraising from events like Artscapade. This year, Patrons expects to bring 10 children to Jacksonville for heart care, including one child from Ghana who recently received heart surgery for a condition called Tetralogy of Fallot, and a child from Honduras, who had an ablation procedure for a heart rhythm disorder. Each child is sponsored by a donor (an individual, company or foundation) through a $5,000 gift, which pays for medical supplies, lodging and other expenses. Services are provided at no charge by pediatric cardiologists and pediatric cardiovascular surgeons with the University of Florida/Jacksonville, as well as Wolfson Children’s Hospital.
Mayo Clinic named one of FORTUNE’s “100 Best Companies to Work For” for Eighth Consecutive Year FORTUNE recently announced that Mayo Clinic has been ranked 61 on the 14th annual “100 Best Companies to Work For®” list. This is Mayo Clinic’s eighth consecutive year on the list. Mayo’s leadership attributes this honor to all Mayo Clinic employees. To pick the 100 Best Companies, FORTUNE partners with the Great Place to Work Institute to conduct the most extensive employee survey in corporate America. This year, 311 companies participated in the survey. Two-thirds of a company’s score is based on the results of the Institute’s Trust Index survey, which William C. Rupp. M.D., is sent to a random sample of employCEO Mayo Clinic in ees from each company. The survey asks Jacksonville questions related to employees’ attitudes about job satisfaction, camaraderie and management’s credibility. The other one-third of the scoring is based on the company’s responses to the Institute’s culture audit, which includes detailed questions about pay and benefits, and a series of open-ended questions about hiring, communication, training, recognition and diversity. Any company that is at least seven years old with more than 1,000 U.S. employees is eligible.
St. Vincent’s Medical Center Earns Advanced Primary Stroke Center Designation from the Joint Commission St. Vincent’s Medical Center (SVMC) is home to Jacksonville’s newest Advanced Primary Stroke Center. The hospital received the official designation from the Joint Commission after an onsite review in December. The Joint Commission Gold Seal of Approval is given to centers that make exceptional efforts to foster better outcomes for stroke care. “Time is brain when it comes to stroke care. It is crucial for a person having a stroke to seek medical treatment immediately and where they seek that care can make the difference
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between life and death. We are proud to offer patients an advanced level of stroke care at SVMC,” said Ravi Yarlagadda, M.D., neurologist with the SVHC Spine & Brain Institute. “We work closely with our EMS partners and have established stroke protocols. This includes the development of a highly qualified stroke team. That team is Ravi Yarlagadda, M.D. called into action every time EMS alerts us that a stroke patient is coming to SVMC. It ensures we are mobilized to respond to these critical patients quickly, 24 hours a day, 365 days a year,” said Jennifer Crews, Director of Neurosciences and Orthopedics at SVHC. “I am inspired by the dedication of our medical teams across disciplines at both of our hospitals to provide the highest levels of care. This Advanced Primary Stroke Center designation is the result of hard work from many clinicians but ultimately it is a win for our patients and for that I am most proud,” said Moody Chisholm, CEO of St. Vincent’s HealthCare.
Florida Forum Welcomes President George W. Bush The 2010-2011 Florida Forum speaker series concluded March 1, 2011, with a presentation by President George W. Bush, 43rd president of the United States. His biography, Decision Points, has been on the New York Times best-seller list since its initial release. President Bush is presented by Wachovia, a Wells Fargo Company. The Women’s Board of Wolfson Children’s Hospital sponsors the Florida Forum each year to increase awareness of the hospital’s mission of caring for the specialized health needs of children, and to raise much needed funds for Wolfson George W. Bush Children’s Hospital programs. The 2010-2011 Florida Forum has already featured presentations by President Bill Clinton and best-selling author and humanitarian Greg Mortenson. The funds raised by the Florida Forum will benefit the Larry J. Freeman Behavioral Health Center at Wolfson Children’s Hospital.
Jacksonville Area Veterans Receive New Suits at ‘Suits for Soldiers’ Ceremony Fifteen wounded warriors are now dressed for success and ready to enter the civilian workforce, thanks to Haven Hospice and Dignity U Wear’s recent ceremony to present them with new suits. “It is so moving to see these soldiers wearing the new suits,” says Executive Director for Dignity U Wear, Bob Bryan. “They are starting a new chapter in their lives, and these suits, along with the skills and education they have received through the Wounded Warrior Project, will give them the confidence they need to excel in the community and in the workforce.” All of the soldiers successfully completed TRACK, a 12-month program through the Wounded Warrior Project. They learned various educational and job training skills, while also receiving rehabilitative care for various injuries sustained when serving overseas. 10
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“Working alongside Dignity U Wear to provide these veterans with suits has been an honor,” said Haven Hospice President, Tim Bowen. “It’s absolutely wonderful to see.”
Wounded Warriors pose for a photo in their new suits at Suits for Soldiers, held at the Wounded Warrior Project in Jacksonville. Photos courtesy Karen Tyrrell with Piccolina Photography.
Olympian Shannon Miller and Tom Bush Family of Dealerships Launch Fitness Initiative On January 27, 2011, Seven-Time Olympic Medalist Shannon Miller’s company Shannon Miller Lifestyle (SML) launched a free walking program with Jacksonville Mayor John Peyton. Shannon Miller’s Walk-Fit Program presented by The Tom Bush Family of Dealerships is a free, onlinetracking and rewards program that is designed to help people achieve a healthy and balanced lifestyle. Anyone can sign-up free at shannonmillerlifestyle.com/walk-fit and receive an SML pedometer at select community events or through the SML online store. Over the past year, Shannon Miller Lifestyle (SML) talked to thousands of people about their health and fitness needs. The company received the overwhelming response that people need help getting started on a healthy and balanced lifestyle. That’s why SML created the Walk-Fit Program. “I am so excited to announce my online Walk-Fit Program! Walking is a great way to lose weight-and keep it off,” said Miller. “I’m competitive so I love counting steps. I can compete with myself every day to see how many steps I can log.”
Shannon Miller and Mayor John Peyton announce launch of free walking program.
Walkers take steps to better health.
The title sponsor of the program is the Tom Bush Family of Dealerships, along with other community sponsors including World Gym, Heekin Orthopedic, CSX, 1-2-1 Financial Credit Union, Kossak Family Foundation, Beaches Max Muscle Sports Nutrition, St. John the Divine Church, Velona Therapy, Natural Body Spa and Shop, Vertical Fitness Studio, AmeriCare Home Health and 1st Place Sports.
Wolfson Children’s Hospital 55-Mile Ultra Marathon For the second year in a row, the community celebrated Wolfson Children’s Hospital with a 55-mile Ultra Marathon, a Run 5 to Keep Kids Alive 5-mile run and a One-Mile Fun Run, all beginning and ending at the Jacksonville Landing on Saturday, January 29. The events, part of “One to Grow On,” presented by RPM Automotive, were a culmination of a months-long celebration of the patients at Wolfson Children’s Hospital. The “One to Grow On” celebration also included an allday telethon that raised more than $57,000 through gifts from the community, 55 patient stories broadcast on WJXT TV 4 throughout the months of December and January and a colossal birthday cake with 55 candles (and one to grow on) outside of the entrance to Wolfson Children’s Hospital. January 29’s events began with the 55-mile Ultra Marathon, with returning runners Paul Wilson (whose son Luke inspired Paul to found this event), WJXT meteorologist Richard Nunn, Andy Woods and Dr. Michael Marchigiano, and new participants Amy Costa, Sue Briers, Kevin Ellis, Rob Darner and Errol. The Run 5 to Keep Kids Alive was a five-mile run presented by Brower Financial Group.
physician practices easily connect securely from anywhere. “AMP is a robust agile medical platform with intuitive features and seamless integration that makes the transition to the federal government’s healthcare mandates simple for doctors and medical staff,” said Douglas Malie, CEO and Founder. Malie, a healthcare industry veteran Douglas Malie and entrepreneur launched Point of Care Solutions, a Jacksonville-based organization, to help the independent physician offices implement consolidated cloud-based patient systems to comply with Health and Human Services (HHS) guidelines. “AMP is built within a cloud-computing environment and addresses the critical issues that physician practices — particularly small, budget-conscious medical offices — face in the rapid changing healthcare environment and gives physicians the peace of mind knowing that they are completely secure and their software is HHS certified,” added Malie.
Community Hospice of Northeast Florida Hosts Open House On January 8, the New Bailey Family Center for Caring of Community Hospice of Northeast Florida hosted an open house on the Flagler Hospital Campus. The event included a dedication, ribbon cutting ceremony and facility tours. The Bailey Family Center for Caring is a 12-bed, 11,700square-foot facility that will help meet the short-term, acute end-of-life care needs of patients in St. Augustine and the surrounding communities.
From left to right: John, Mark and Gay Bailey, Joe Gordy, president of Flagler Hospital and Susan Ponder-Stansel, president and CEO of Community Hospice, cut the ribbon at the Bailey Family Center for Caring Open House.
Point of Care Solutions Unveils Agile Medical Platform for Physicians Practices Point of Care Solutions introduces its Agile Medical Platform (AMP), the latest integrated practice management and ambulatory Electronic Health Record (EHR) system available in the United States to manage physician medical practices with a ubiquitous interface. The grid-based platform is packed with innovative features such as EHR, document storage with on demand scanning, a cloud-based collaborative productivity suite and medical research library, making it easier than ever to manage a medical practice. Plus, its virtual desktop lets
A patient room at the Bailey Family Center for Caring of Community Hospice
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A Night for Heroes On Saturday, January 22, A Night for Heroes, celebrated the TraumaOne team, honoring the men and women of our community who care for trauma victims and provide support for victims’ families. The annual black-tie gala was held at the University of North Florida University Center and included cocktails and dinner. A traumatic injury can change the lives of victims and their families forever. What happens in the moments after an injury can make the difference between life and death. The TraumaOne team works together with local agencies to ensure there are as many happy endings as possible. One happy ending involves the story of Ashley Davis. Her life changed in 2009 when she was in a life threatening ATV accident. She was riding on the back of the vehicle when the driver lost control and hit a tree in Osceola National Forest. A quick-thinking friend performed CPR while another ran to the nearest house to call 911. Baker County EMS transported her from the site of the accident to U.S. Highway 301 where she was met by the TraumaOne flight crew. 11 minutes later, she arrived at Shands Jacksonville. Because of quick thinking and action by several “heroes,” Ashley, now 23, is alive and well and looking forward to graduating from the University of North Florida with a degree in elementary education. This year’s “heroes” included University of Florida physicians, Shands Jacksonville nurses and technicians, TraumaOne flight crew, fire and rescue, police and many others. Jeannie Blaylock, anchor for First Coast News, emceed the event. Ruby and Harold O’Steen served as honorary chairs and Tammy Kerwin and Denda Shields served as event co-chairs. David S. Guzick, M.D., Ph.D., Senior Vice President for Health Affairs, University of Florida, President, UF&Shands Health System, Chairman, Shands Jacksonville Board of Directors; Robert C. Nuss, M.D., Dean, Jacksonville Regional Campus, University of Florida College of Medicine, Associate Vice President for Health Affairs, University of Florida; and James R. Burkhart, MHA, FACHE, Chief Executive Officer, Shands Jacksonville presented at the event. Andrew J. Kerwin, M.D., FACS, Associate Professor and Division Chief, Acute Care Surgery, University of Florida College of MedicineJacksonville TraumaOne Program Medical Director delivered the Heroes Presentation.
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1) Sharon Davis, Ashley’s mother; Ashley Davis; J. Bracken Burns, Jr., D.O., MS, Assistant Professor; Associate Program Director, General Surgery Residency; Flight Director, Trauma Service; Larry Davis, Ashley’s father; Cathy Dopson, Ashley’s sister (not pictured: Ryan Davis, Ashley’s brother); 2) AJ Beson and James R. Burkhart, MHA, FACHE; 3) Mike McCoy with Renee and Mike Favo; 4) Louis Costanza and Eric Miller
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Primary Care Physicians and The Borland-Groover Clinic are the
Backbone of Prevention By Virginia J. Pillsbury
March is colorectal cancer awareness month. This means an emphasis on the message “get screened for colon cancer” from both primary care physicians and the physicians of Borland Groover Clinic. If a person is 50 years old, or an African-American who is 45 years old or older it is time to schedule the first screening colonoscopy.
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f course, that screening should come sooner if there is a family history of colorectal cancer. The message is clear: primary care physicians are the driving force and leaders in diminishing the number of deaths from colon cancer. “Together we are partners in decreasing the number of deaths from colon cancer,” says Jeffrey Hoffman, M.D., Ph.D., of Borland-Groover Clinic. “The data is on our patients’ side,” says Bharat Misra, M.D., of Borland-Groover Clinic. “Colon cancer can be prevented with screening colonoscopy if polyps are found early,” he explains. The obvious challenge is to successfully reach a healthy patient with no gastrointestinal symptoms about the importance of undergoing a colonoscopy. “We take healthy 50 year olds and recommend a somewhat invasive procedure; it can be an uphill battle,” says Dr. Misra. And that’s where the teamwork between the primary care physicians and Borland-Groover Clinic becomes essential; proactive primary care physicians encourage screenings and refer those with a family history or symptoms for a diagnostic colonoscopy. “The patients who come directly to us, without being directed by their primary care physicians, are a minority. The largest percentage of our patients comes to us because they have been informed by their primary care doctor that they need to be screened,” says Dr. Hoffman. “The primary care physician has built a rapport and trust with their patients,” says Dr. Misra. “When they suggest a colonoscopy to an eligible patient, often the compliance is high,” he says. “This is the time of year that we really drive home the message that we strive to share all year,” says Renard Rawls,
“The primary care physician has built a rapport and trust with their patients. When they suggest a colonoscopy to an eligible patient, often the compliance is high.” — Bharat Misra, M.D.
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M.D., of the Borland-Groover Clinic. “ The facts are attentiongetting and hopefully spur those eligible for a screening colonoscopy into action. This year approximately 150,000 will be diagnosed with colon cancer and about 50,000 people die annually from the disease. It affects six percent of the American population. It can be a silent killer and people can get diagnosed with colon cancer without having a single symptom – another compelling reason to have that baseline screening at age 50, or ten years younger if when a family member was diagnosed. Progress is being made in the numbers. “We used to have about a third of the population who would come in for screening,” says Akin Cabi, M.D., physician at Borland-Groover Clinic. “Now we have about 50 percent of those eligible who are being screened annually.” He also believes that by sharing personal stories about having a screening colonoscopy can be presented in a positive way; such stories go a long way in
Bharat Misra, M.D., Jeffrey Hoffman, M.D., Ph.D., Renard Rawls, M.D., Akin Cabi, M.D.
convincing someone to have a screening colonoscopy. Dr. Cabi’s father passed away from colon cancer while Dr. Cabi was still in medical school. “My dad had received the flexible sigmoidoscopy test, which was a standard test at the time,” recalls Dr. Cabi. “I urged him to have the colonoscopy but by then it was too late,” he says. He shares his story with his patients to illustrate to them that early detection is the key to curing colon cancer. The truth is that even though screening colonoscopy can dramatically reduce the incidence of colon cancer, patients still associate a stigma with having one done, or even talking about it. Actively sharing stories and experiences, especially when cancer has been diagnosed without symptoms, can help break down that stigma and pave the way to timely screenings. Often it is the patients who have been diagnosed with colon cancer or polyps after having their routine screening that aid in the process by sharing their personal stories and encouraging or insisting that their friends and family go for their screenings. “When patients tell their stories they become advocates for screening,” says Dr. Cabi. Celebrities have also helped pave the advocacy way – most notably Katie Couric helped drive the fear of colonoscopy down by having the procedure
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performed in front of a television audience. “Every year we have more people who have heard of a colonoscopy and more people who are getting them,” says Dr. Misra. Women are more likely to go for their initial baseline screening than men, though statistics show that men are more likely than women to have colon cancer. “Gynecologists are very proactive with their patients and often incorporate an annual rectal exam as part of the exam process,” says Dr. Hoffman. Women tend to have a close and trusting relationship with their gynecologist so when the referral for a colonoscopy is suggested it is usually followed up by the patient. The good news for patients with a normal screening colonoscopy is that the procedure doesn’t need to be repeated for ten years. “The growth sequence from polyp to cancer is usually slow – about five to ten years,” says Dr. Misra. “Three out of four men and five out of six women will have a normal examination at their first colonoscopy and can wait for ten years to have their next colonoscopy,” he adds. Because Borland-Groover Clinic is largely a referral practice, it has strong lines of communication with referring physicians. The patient’s diagnosis, treatment, and recommendations for care are shared with the primary
care or referring physician so that all healthcare providers involved are a part of the team of care. “Once the primary care physician refers the patient, Borland-Groover takes the ball and runs with it,” says Dr. Misra. “Today’s healthcare process is often fragmented with much paperwork, but we have one phone number and one fax line to make the referral process easy. We even handle the insurance aspect,” he explains. “The relationship between us and our patients remains crucial for the return surveillance colonoscopies as well,” says Dr. Rawls. Patients receive reminders from both their primary care physicians and BorlandGroover, so it is easy to see which patients are following up and which aren’t. “Few patients would just come in on their own – they need that extra nudge,” he says. “Of course if symptoms are present, patients don’t need the nudging,” says Dr. Misra. Symptoms can appear at any age and regardless of a young age, those symptoms should be taken seriously. “That is also where family history is important to know. But even without a family history sporadic colon cancer cases can occur at any age. That’s why we all need to treat each patient on an individual basis,” says Dr. Rawls. Borland-Groover physicians practice in
But even without a family history sporadic colon cancer cases can occur at any age. That’s why we all need to treat each patient on an individual basis.” — Renard Rawls, M.D.
state-of-the-art facilities and strive to provide a pleasant environment for the patient with a welltrained, knowledgeable, and courteous staff. “We know that our patients are nervous about the procedure,” says Dr. Misra. “We have a competent and caring staff with nurses who maintain the dignity and modesty of the patients,” he adds. The pre-procedure bowel prep is easier than it has been, the patient is under a light anesthesia during the procedure and usually isn’t aware of the colonoscopy, and patients usually go home about 30 minutes after the procedure and resume normal activities the next day.
Additionally, BorlandGroover physicians practice in the best hospital systems locally with highly trained hospital personnel where their patients receive premier care. “Patients who were never offered a screening colonoscopy, but who are diagnosed with colon cancer because they come to us with symptoms, are never happy about that,” says Dr. Misra. We have clearly defined procedures and treatment care, physician to physician care can lead to better outcomes and the combined partnership is leading the way to a healthier Jacksonville community.
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“They need us to constantly be providing blood products. The need never sleeps.” — Marsha Bertholf, M.D.
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the Ultimate Resource By Virginia J. Pillsbury
Marsha Bertholf, M.D., Medical Director of the Blood Alliance ensures community needs are met As medical director of The Blood Alliance (TBA), Marsha Bertholf, M.D., has the unique position of taking care of the blood product needs for more than 20 hospitals and medical facilities in 11 counties serving Northeast Florida, as well as regions of Georgia and South Carolina.
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hat daunting daily task of collecting 360 pints of blood just to meet minimal need is made possible by the tireless work of The Blood Alliance staff. Weekday mornings at 9 a.m., the entire TBA staff gathers for a vital update on the day’s blood product needs. The often critical need for a certain blood type or types means the urgency of TBA’s mission is constantly at the forefront of the minds here. They have lives to save. Fulfilling a Constant Need At the helm of operations, Dr. Bertholf spends her days reviewing patient issues, checking supply adequacy, making decisions about triaging the blood they have, reviewing donor concerns and reviewing difficult compatibility issues and quality control data. The best and most challenging part of her job is the same thing; TBA provides a unique resource. “We are essential to the medical community,” says Dr. Bertholf. The most challenging? “They need us to constantly be providing blood products. The need never sleeps.” While no day is the same for Dr. Bertholf, every day has the same goal – providing those 360 pints of blood. The need for blood products is constant. “Too much blood at any one time can be a problem because blood has a “shelf-life,” explains Dr. Bertholf. The September 11, 2001 tragedy was an event that emphasized to Dr. Bertholf that on-going need for blood. “Tens of thousands of people donated blood that week –
The Blood Alliance needs 360 pints a day to meet the community’s basic needs.
after an appeal from the United States President – but in reality only a few hundred extra units were needed in New York and Washington, DC,” she says. The lesson learned is the reminder that the blood supply has to be constant, consistent and always there waiting – not just something that follows a disaster. “My on-going challenge is to keep donors aware of and responsive to the daily needs of patients.”
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Dr. Bertholf and Rhonda Martin perform quality assurance on platelet products to ensure the labels reflect the content.
A Love of Pathology Proved a Perfect Match When Dr. Bertholf came on board as medical director in 1994, TBA was half the size it is now. The expected blood collection goal has doubled and TBA now serves the community from St. Augustine to Charleston, SC. “I am responsible for the safety qualifications of the donor, counseling of donors who have a positive infectious disease test, policies for collection and qualifying the blood products,” says Dr. Bertholf who came here from the University of Florida where she co-directed three labs as a clinical pathologist, as well as taught physicians in training and conducted research. “One thing that makes us unique is that blood centers
such as TBA are regulated as a pharmaceutical manufacturing plant,” she says. And another unique aspect is that the holiday season, when other businesses might be taking a breather, TBA kicks into high gear. “The holiday season often brings more need for our blood services – there are more travel and leisurerelated accidents, and often people choose to have their elective surgery during their vacation times,” Dr. Bertholf explains. Because the blood lab is a 24/7 operation, its walls are bright to keep employees alert. It also opens out to a parking lot full of blood mobiles and vehicles to quickly deliver desperately needed blood. “We try to keep a 3-5 day supply of blood housed here to supple-
“One of our biggest goals is to never have a child waiting for blood, but to always have the units waiting for them. Finding appropriate blood matches is a big problem nationally, not just a problem in our area” — Marsha Bertholf, M.D.
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ment what is maintained at the hospitals,” explains Dr. Bertholf. TBA also houses a reference lab for patients who might have difficulty with blood matches. “We have a very specialized inventory,” explains Dr. Bertholf. “There is an emphasis on sickle cell patients because they are often the ones who receive blood over and over again and that can make it hard to find matches,” she explains. “TBA’s medical technologists have the specialized skills to detect all the parts of a blood type to find the best match,” she explains. Since each ethnic group has blood type specializations, it is best when transfusing blood to use blood from a person’s own ethnic group. “One of our biggest goals is to never have a child waiting for blood, but to always have the units waiting for them. Finding appropriate blood matches is a big problem nationally, not just a problem in our area,” says Dr. Bertholf. The Blood Alliance also has a team of nurses that provide therapeutic apheresis, a therapy similar to dialysis. Their nurses remove the dis-
eased blood from patients and replace it with appropriately obtained new blood. A native of Wilmington, North Carolina, Dr. Bertholf attended college in her home state. “After college graduation, I worked as a medical technologist and that exposed me to the role of pathologists in medicine,” she says. She was intrigued with what she saw. “I started to listen to those professors and mentors who encouraged me to continue on to medical school. I loved both primary care and pathology during medical school, but could only choose one.” She is more than satisfied with her choice. Family Life Dr. Bertholf met her husband Roger, who is a Ph.D., clinical chemist with UF&Shands, while they were in school at the University of Virginia. They’ve been married for 25 years and have spent most of their marriage in Gainesville and Jacksonville. They have two children: Aaron is 23 and a chemical engineer in Virginia; Abby is 19 and a sophomore at Florida Southern College in Lakeland. She plans to be a nurse. Balancing children with her work at TBA has been possible thanks to cell phones. Early on, when her children were younger, she worked part time. “This job has allowed me to handle problems over the phone when appropriate,” says Dr. Bertholf of how she handled the family and work balance. When their children were younger, family activi-
“If everyone who donated once a year would come back a second time during the year, we would have enough blood. It’s a community donation that’s a gift, a gift of life.” — Marsha Bertholf, M.D.
ties centered on them and their involvement in music and church. Abby attended Douglas Anderson School of the Arts and specialized in the oboe; she was also a member of the Jacksonville Symphony Youth Orchestra. Aaron was a member of the Stanton Prep and Virginia Tech marching bands. The whole family is musical; Dr. Bertholf enjoys playing the handbells at her church and singing in the choir. This is one way to spend time with her husband, who has volunteered as the interim choir director in the past. Now that the Bertholfs are empty nesters, they have rediscovered their love of boating. Their sailboat hobby is one of the ways they spend some of their free time together now. “We share a
In the cross-match reference lab, Dr. Bertholf and Markisha McClenton analyze samples from patients who are difficult to match and select donor samples that might be suitable. TBA assists the hospitals by finding perfect matches for patients who are difficult to match.
sailboat on the St. Johns with some friends, and I’ve discovered that cell phones work in the middle of the river,” jokes Dr. Bertholf. She also enjoys such hobbies as cooking, needlework and crafts. “I find those things very relaxing and I joke that I used to do them in my former life,” says Dr. Bertholf, who looks forward to the day in the future when she returns to those pursuits. How does she handle stress that the constant need for a life saving product must produce? “I’ve learned that calmness comes with maturity,” says Dr. Bertholf. “I purposely practice not letting things get under my skin. I believe that if you focus on the patient and the needs of the patient, you’ll get to the right answer.”
Blood Basics Every two seconds someone in America needs blood, and of the 60 percent of Americans who are eligible to donate blood, only about five percent actually donate. That percentage drops even lower in Northeast Florida. “There is no substitute for human blood. You can’t manufacture it, and that makes each one of us the ultimate human resource,” says The Blood Alliance (TBA) public relations manager Odette Struys. “Giving blood is a safe procedure and requires time for processing. We test for HIV and hepatitis, among other tests, so the blood actually isn’t ready for use until two days after it is donated,” she explains. That means that if there is a disaster that requires immediate blood products, they need for that blood to have been donated two days before. Blood also has a shelf life; it doesn’t stay usable forever. “Red blood cells, that transport oxygen throughout the body, last for about 42 days. Frozen plasma, which is the combination of water, protein and minerals, helps blood to clot and can last up to a year. Platelets, that control bleeding and help blood clot, only last five days,” explains Struys. “Whole blood lasts 21 days.” One pint of blood can potentially save three lives. What can physicians do? Remind your patients of the constant, urgent need to keep blood products flowing. Families can set up an account and donate blood in honor of a loved one who needs it. “We need a diversity of donors inlcuding young donors,” says Marsha Bertholf, M.D., Medical Director, TBA. “When The Blood Alliance was started in 1942 it was part of the war effort. That generation was fully committed to community service and we need to instill that commitment in our young people.” Organizing a blood drive is a great service project for young people. “If everyone who donated once a year would come back a second time during the year, we would have enough blood,” says Dr. Bertholf. “It’s a community donation that’s a gift, a gift of life.” Visit www.youtube.com/beson4media for a one-on-one interview with Dr. Bertholf.
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Doctors’ offices have the same needs as hospitals and are just as concerned about the application of technology as part of their overall business plan. Technology should always be viewed as a tool to create and modify solutions to the challenges of business. Doctors and medical staff alike should be concerned with how to use their skills to create new and better ways to serve their patients, not with troubleshooting time consuming technology issues. How does BrightLink Technology provide this? With a comprehensive list of services that are designed to proactively prevent issues before they arise and, as issues inevitably do arise, provide quick, professional and reliable resolutions 24/7.
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By LaNeta Crighton
Data released last year by the Centers for Disease Control showed the screening rate for colon cancer (CRC) has increased significantly in recent years. 63% of adults between ages 50-75 had colorectal screening in 2006 compared to just 52% in 2002.
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he increase is encouraging, but it’s clear, a large portion of the population is still not participating in colorectal screening. CRC remains the second leading cause of cancer deaths in this country with nearly one-half of all colorectal cancer cases not detected until they reach late stage. “Since the cause of colon cancer is still unknown, secondary prevention is the next best thing,” says Richard Sprague, M.D., a boardcertified colorectal surgeon with the Borland-Groover Clinic in
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“The advantage of virtual colonoscopy is that you aren’t put to sleep. The disadvantage is that there’s discomfort.” — Richard Sprague, M.D.
Jacksonville. “We try to find polyps that lead to cancer, and we try to find them when they’re still small.”
Richard Sprague, M.D.
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Colonoscopy Since polyps are not typically symptomatic, colonoscopy is the best way of identifying them. Average risk individuals should be scheduled for colonoscopy every ten years, starting at age 50. Beginning January of this year, screening colonoscopy is covered 100% by Medicare with no co-pay. Under current federal guidelines, new private insurance plans are now also required to pay for colorectal screenings with no cost-sharing, but existing plans are excluded. Twenty-seven states have legislation requiring full range coverage for colorectal screening, but Florida is not among them. However, Bassam Rizk, M.D., a board-certified colorectal surgeon with First Coast Surgical Associates in Jacksonville, believes colonoscopy is typically covered. “Most insurances now allow for a screening colonoscopy,” he says. Currently, it’s also the only colorectal screening test recommended by the American College of Gastroenterology for average risk individuals. But, the procedure is not without limitations. “Colonoscopy is imperfect,” says Michael Wallace, M.D., Professor of Medicine and Chief of Gastroenterology and Hepatology at Mayo Clinic. “It doesn’t prevent all cancers and over the past 20-30 years, we’ve studied why it’s imperfect. Certain polyps are difficult to see such as flat polyps, those behind folds or when material is still
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in the colon. We’re discovering how to further improve, how to find more polyps and decrease the miss rate.” A study published in 2004 in the Annals of Internal Medicine found that 14 out of 15 neoplasms missed on colonoscopy were located on the backside of a fold. One way the issue has been addressed is by extending the standard withdrawal time at the end of the procedure to seven minutes. Combined with adequate bowel preparation, this has led to better detection rates. The longer exit time has been shown to improve technique by increasing the number of turns, ensuring better cleansing of fecal material and more careful visualization of fold areas. Dr. Wallace describes this withdrawal period as the most important phase of the colonoscopy procedure. Other Screening The American College of Gastroenterology Guidelines for Colorectal Screening released in 2008 recognizes alternate screening methods in cases where colonoscopy is either not affordable or not desired. CRC screening then includes a flexible sigmoidoscopy every five to ten years, or a virtual colonoscopy every five years, or a cancer detection test such as fecal immunochemical test for blood each year. Guaiac fecal occult blood screening tests are helpful for identifying blood in the stool, but don’t recognize polyps, which are often asymptomatic. Immunochemical occult blood testing is available, but Dr. Sprague sees it
used less frequently. “Immunochemical is not done as often because it’s more expensive,” he says. A study published in Journal Watch Gastroenterology in February 2008 found the immunotherapy test to be more specific and more sensitive than guaiac, but also more expensive and resulting in a higher number of colonoscopies. Virtual colonoscopy is a non-invasive procedure that uses CT or MRI to view the colon. “The advantage of virtual colonoscopy is that you aren’t put to sleep,” says Dr. Sprague. “The disadvantage is that there’s discomfort. Air is pumped into the colon with both procedures, but for virtual, you’re awake, and that’s not comfortable.” In addition, the bowel prep, one aspect of colonoscopy patients find unpleasant, is the same as with traditional colonoscopy. According to Dr. Sprague, other drawbacks are that the procedure is not currently covered by Medicare, and if polyps are found on virtual colonoscopy, you need a regular colonoscopy anyway. Flexible sigmoidoscopy provides a view of the lower colon, but is not a thorough exam. “At least 50% of polyps are above the level you view by a sigmoidoscopy,” says Dr. Sprague. “Past studies say you do decrease colon cancer by doing sigmoidoscopy, but you usually have to do a follow-up with a colonoscopy.” One screening method that’s still in the investigational stages is fecal DNA testing. The non-invasive CRC detection method shows promise but still requires more research. Polyp Removal Techniques One-third to one-half of all colon polyps are adenomatous and associated with a higher risk of CRC. The American Cancer Society says that routine screening increases the detection
of early colon cancer when it’s most curable. “We are detecting cancers at an earlier stage before symptoms develop and therefore, are getting better outcomes,” says Dr. Rizk. “Removing polyps before cancer develops will prevent a patient from developing colorectal cancer,” he says. Historically, all polyps found during colonoscopy were removed for histology whether they were cancerous, pre-cancerous or benign. Over one-half of all benign polyps have almost no chance of ever becoming cancer, but the only way to know that is to remove them. While polypectomy is a routine, outpatient procedure, there is a slight risk of complications. Bleeding from the site and perforation can occur, prompting specialists to look for ways to accurately diagnose polyp types prior to removal. “We’ve tried to develop and test methods to look at polyps in the colon so that we can make very accurate predictions,” says Dr. Wallace. Confocal laser endomicroscopy (CLE) is a diagnostic technique currently being evaluated by endoscopists. CLE allows polyps to be evaluated while they’re still in the colon. A tiny microscope attached to the endoscope makes it possible to examine the cellular structure of polyps as small as 1mm in diameter during the colonoscopy procedure. One study published in the Journal of Gastroenterology and Hepatology reported a 95% overall accuracy when using confocal technology with NBI. “We’re getting the percentage up there,” says Dr. Wallace. “The biggest cost of a colonoscopy is pathology. If we can diagnose and leave behind, we can decrease the cost and complications.” Large polyps, 2-3 cm in diameter, that have typically been referred to surgeons for resection can now be removed by skilled endoscopists using endoscopic
Bassam Rizk, M.D.
A medical illustration of a colon polyp.
“We are detecting cancers at an earlier stage before symptoms develop and therefore, are getting better outcomes.” — Bassam Rizk, M.D.
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Michael Wallace, M.D.
Ron Landmann, M.D.
X-ray of a human intestine
mucosal resection (EMR.) “The colon is only about 4mm thick, so there’s a significant risk of perforation,” says Dr. Wallace. “We inject fluid under polyps to create a blister effect. We also use a blue dye with a thickening agent. It splits the layers to make removal safer.” Endoscopic submucosal resection is used on very large, flat polyps and early cancers. It involves a submucosal injection followed by dissection with special scalpel devices for better precision. In the last five years, Mayo in Jacksonville has experienced a 97-98% success rate for removal of large polyps without surgery. What’s New? Advanced optics and better imaging systems are emerging, and the hope is, they will lead to better diagnosis of polyps and changes in the mucosal lining. High definition colonoscopy is a new and improved version of the standard procedure. Using a high definition video camera and monitor that functions in the same manner as a high definition TV, Dr. Wallace reports researchers saw a significant increase in their polyp detection rate. “With the change to high-def, we went from a rate of 24% to 30%,” he says. That compares to a national rate of 20%. Chromoendoscopy uses blue dye sprayed on the colon to identify polyps and abnormal mucosal tissue. The technique is effective for high risk patients and those with a strong family history, but Dr. Wallace describes other results as mixed. In addition, critics argue the procedure is messy and time consuming. Physicians at Mayo are using a new technique in place of chromoendoscopy. Narrow band imaging, or NBI, utilizes an endoscope fitted with a
“Currently, we use high-definition to detect the polyp and then NBI to determine whether it’s benign or pre-cancer.” — Michael Wallace, M.D.
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blue light filter component that makes polyps easier to see. Because of their richer blood supply, polyps appear darker under the blue light. Studies done at both Mayo Clinic and in Japan showed increased detection rates when NBI was used during colonoscopy. According to Dr. Wallace, NBI works best when combined with high definition optics. “Most also use high def at the same time,” he says. “Currently, we use high-definition to detect the polyp and then NBI to determine whether it’s benign or pre-cancer.” Surgical Treatment At the time of diagnosis, 70-80% of colon cancer patients present with resectable disease localized to the bowel and regional lymph nodes. Minimally invasive techniques are now being used for complicated procedures such as bowel and rectal resections. “The availability of better optics, newer ports, flexible tip cameras and advanced electric and ultrasonic instruments to control the blood vessels and bleeding has made the laparoscopic approach much safer,” says Dr. Rizk. Multiple studies have shown that laparoscopic approach offers clear shortterm benefits with reduced hospital stays, smaller incisions, faster recovery times, more rapid return of bowel function and significantly less post-surgical pain. Long-term success is reflected by outcomes equal to or better than those seen in open surgical procedures including recurrence of disease, number of lymph nodes resected and fiveyear mortality rates. In addition, other types of bowel surgery are also being done laparoscopically. “We currently perform all colon and rectal type operations laparoscopically and/or robotically,” says Ron Landmann, M.D., board-certified colorectal surgeon and Assistant Professor of Surgery at Mayo. “This includes patients with diverticulitis, colon or rectal cancer or inflammatory bowel disease such as Ulcerative
“Colorectal cancer is a disease that can be prevented through regular screenings, a healthy diet and regular exercise.” — Ron Landmann, M.D.
Colitis or Crohn’s Disease.” According to Dr. Landmann, the procedures have been successfully performed routinely, leaving patients with almost no scars and a vastly improved quality of life. One example he gives of the procedures being performed is the complete removal of the colon and rectum down to the anus, creating a neo-rectum/ reservoir for patients and leaving only a one inch wound that resembles a bullet-wound. Patients with polyps, lesions and early-stage cancers without evidence of lymph node metastases, may be candidates for a minimally invasive endoscopic procedure. Transanal endoscopic microsurgery is performed through the rectum and anal orifice. “This utilizes specialized equipment, cameras and tools to remove full thickness specimens and later close these defects,” says Dr. Landmann. “By doing so, an appropriate oncologic resection can be performed, and in many cases, obviating the need for a radical resection.” Colorectal cancer is the third most common cancer among both men and women in the U.S. and approximately 140,000 new cases will be diagnosed this year. “But, colorectal cancer is a disease that can be prevented through regular screenings, a healthy diet and regular exercise,” says Dr. Landmann. “Between 80-90% of patients are restored to normal health if the cancer is detected and treated in the earliest stages. However, the cure rate drops to 50% or less when diagnosed in the later stages.”
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North Florida doctors have a few fish stories to tell
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By Laura Capitano
Living in a coastal community means that Florida residents have several choices when it comes to water sports. Sure, there’s the surfing and the sailing, but the one sport that defines the First Coast is fishing, with Jacksonville serving as the annual host of the largest kingfish tournament in the country.
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rom open ocean, to backyard creeks, the range of available fishing experiences is enough to make you want to stir up a batch of tartar sauce. Three area physicians shared their stories about shedding their stethoscopes whenever they can and heading out on the water to see if they can get a little nibble. A Girly Go-Fast Fishing Boat As many men do, William Pujadas, M.D., a physician with the Jacksonville Orthopaedic Institute learned his love of fishing from dear old dad. Dr. Pujadas grew up in Jacksonville and is now the father of one son and two daughters. The doctor has kept the aquatic family tradition going, and fishing has become what he calls, “a family thing.” In fact, fish helped get the ball rolling on the Pujadas family, as Whitey’s Fish Camp in Orange Park, a favorite boat destination to this day, was the site of the doctor’s first date with his wife. On the menu? Why, she taught him how to eat catfish, of course. Along with Whitey’s, Dr. Pujadas and his family also enjoy cruising their 35-foot sea foam green Marlago, a “girly go-fast fishing boat,” as Dr. Pujadas lovingly refers to it, up to Fernandina. The remote Bird Island in Nassau Sound is a particular favorite destination. The bird sanctuary is an ideal place to beach the
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Dr. Pujadas with a red snapper caught off Jacksonville Beach.
boat and have a picnic lunch. His children also enjoy scuba diving offshore, and he said his daughters love the boat because there is lots of space for them to sunbathe. When the boat sails south to St. Augustine, the Conch House is a favorite destination. Dr. Pujadas said that he tries to get out on the water every other week during the summer and once or twice a month during the rest of the year. Some of Dr. Pujadas’ prize catches include an 80-pound tiger shark, and African pompano that weighed in just three pounds shy of the world record, and a 52-pound dolphin fish. The Pujadas family participates in area kingfish tournaments and are proud members of the Southern Kingfish Association. Dr. Pujadas said his family even qualified for and participated in their first national kingfish tournament this past year. Be it a tournament or a casual sail, Dr. Pujadas noted that, “Any time on the boat is a good, relaxing getaway from the stresses of medicine and everyday life.” Salt Love Paul Bednarzyk, M.D., a physician with Diagnostic Cardiology Associates, grew up in northeast Ohio and started lake fishing at age 4 with his father. From there, he moved on to riding his bicycle over to fish at the Tennessee Valley Authority reservoirs. Dr. Bednarzyk moved to Jacksonville in 1994 and found himself facing a new fishing challenge: salt water. “Fishing here is very different. It’s mostly saltwater fishing, so there was a learning curve. I had to start worrying about tides and salinity
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Six years ago, he tried offshore fishlevels,” Dr. Bednarzyk said. ing and has achieved success in kingfish These days, Dr. Bednarzyk heads tournaments. His team qualified to fish in out fishing one or two weekends a a national tournament in Fort Pierce, Fla. month on his 20-foot Action Craft flats last year and his fishing team finished in boat. The vessel is designed to go into third place, with 26-pound and 37-pound skinny, shallow water, not the open catches. ocean, and he fishes mostly in creeks off Dr. Perkins remembers his first tourthe Intracoastal Waterway, particularly nament five years ago. “I entered on a Clapboard Creek. Only occasionally does whim and caught a big enough one to he hitch a ride to the open ocean. The pay for the gas, and I’ve been hooked doctor said that about 90% of his fishever since,” Dr. ing is catch and Perkins said. It’s his release. He keeps hope that when his just enough for a children get older, dinner or two. they’ll join him on Dr. Bednarzyk the tournament said he has fished team. most of the Far from excluIntracoastal from sive to kingfish, Dr. Nassau Sound Perkins said he is down to Matanzas not picky, he’ll fish Inlet, at one point for anything that’s or another. He likes biting. He typically the variety and cruises his beloved seeks to fish new Paul Bednarzyk, M.D., shows off a nice black drum. boat, a 31-foot spots so he doesn’t Cape Horn that he’s named “Longshot” get bored. Dr. Bednarzyk finds the water offshore between St. Simon’s Island and past Marineland to be particularly gorPonte Vedra. geous but warns his fellow fishermen of Dr. Perkins tries to get out fishing the shifting sandbars in Matanzas Inlet — every other weekend during the summer. if you’re not careful where you’re going, He is looking forward to heading back to you’re going to hit bottom. Fort Pierce April 1 for the kickoff of kingFor more far-away fishing, Dr. fish tournament season. Bednarzyk heads to Cedar Key, Canada, Sometimes, his medical training comes the Bahamas or the Florida Keys. in handy when aboard ship. Dr. Perkins Always looking for fishing buddies, Dr. said that he’s even had to operate on the Bednarzyk tries to round up a couple boat one time when a fishing buddy got friends when he heads out with rod and a hook stuck too deep into his hand. reel. The doctor has even gotten his wife Mainly, Dr. Perkins sees fishing as an interested in the hobby. “The first time I outlet for his kids to get outside and be took her out, she hooked and landed an among nature. “That’s how I grew up, 8-pound redfish. I told her not to expect and I hope they will too.” that every time,” he said. “The biggest thing about going fishing is just being out in nature. You see some incredibly neat things: birds, manatees, dolphins, I’ve even seen humpback whales in the British Virgin Islands,” Dr. Bednarzyk explained. “Catching fish is a bonus.” Hooked Ever Since Samuel Perkins, M.D., a general practitioner and surgeon affiliated with Baptist Medical Center also began his fishing hobby as a boy exploring nature with his dad. Originally from Donalsonville, outside of Waycross, Ga., Dr. Perkins learned to love fishing by catching bass and catfish in the local lake.
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Samuel Perkins, M.D., displays an impressive mahi-mahi.
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By Laura Capitano
Relocating your physician’s office or healthcare facility is far more than a matter of finding fresh walls on which to hang the doctors’ diplomas and plaques. Physicians have unique and specialized facility needs that require attention when seeking a new space.
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ommercial real estate experts agree that increased infrastructure requirements, real estate market trends, location considerations, renovation possibilities and patient convenience all come into play in the search for the ideal new practice space. J. Paul Tyler, President of the Commercial Group at the Haskell Company suggested that for commercial real estate, it is currently a buyer’s market with lots of bargains available as far as pure square footage. However, healthcare facilities aren’t exactly primed to take advantage of the savings. “Physicians have unique requirements,” Tyler said. “Too many physicians make their decisions based on cost per square foot alone, but you have to add the total cost of the move: moving the equipment, making sure the infrastructure meets your plumbing and electrical requirements and clearances, those sorts of costs.” Even acoustics are to be considered when securing a new space to ensure patient privacy standards are upheld during
J. Paul Tyler
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office consultations. “The more specialized the space, the more expensive it’s going to be,” Tyler said. Physicians also need to factor in the amount of patients they stand to lose if the office relocates enough miles away to be considered an inconvenience. Kris Pedersen, a Realtor® with Lifestyles Realty offers another consideration for physicians considering relocation: healthcare reform. While Pedersen agrees that it’s a buyer’s market for physicians looking to expand and get
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new office space, he is finding that, “A lot of physicians are kind of holding off to see how healthcare reform rolls out in the next couple years.” Relocation Resources If circumstances suggest you’ve indeed outgrown your current facility, there are resources to help you find a place in which to relocate and expand. Tyler offered that the
listings, plus analytical services to help you gain commercial real estate property value insights and marketing services to help expose a property for sale.
Know Your Needs When planning to relocate a healthcare facility, Riley Didion, a Commercial Advisor with Grubb & Ellis|Phoenix Realty Group suggested that physicians should deter“In most instances, mine whether renovation is better finding an office condo space or than relocation. choosing a freeAlmost anything can standing building is more in line be renovated, and with the pracrenovation projects and tice’s individual labor costs are at an allrequirements. While a freetime historical low.” standing place is — J. Paul Tyler considered to be a cleaner investment, small firms, for instance Florida Hospital Association may align with an office (FHA.org) has links to webcondo scenario because it’s sites and professional organieasier to find a smaller space. zations that work with physiDidion noted that, “There cians in their relocation needs. can be some really good If you seek out the help synergy within condo assoof a commercial real estate ciations. Four or five groups agent, Tyler suggests you find can assemble in a complex one that specializes in medical and refer to one another.” A office space. If not, the agent condo can also allow a pracmay try to convince you of tice to enjoy the benefits or a a more generic office space larger complex, all the parkthat doesn’t meet a doctor’s ing, for instance, while only requirements. having to pay a fraction of Pedersen points to LoopNet. the parking and landscaping com as a resource for relocatupkeep. ing physicians. The site curDidion continued that the rently lists more than 780,000 downside to a condo exiscommercial properties for sale tence is that you don’t get to or lease, and you can search control who your neighbors locally or nationwide, even for are. “If one of your neighbors distressed and auction propergoes bankrupt, you pay more ties. The site also offers real of the association expenses. estate news, access to lenders And, if you need to expand and brokers and a search feawhile in a condo, you will ture for closed sales. probably need to move. CoStar.com is another site There is no guarantee when Pedersen recommends, and it the neighboring condos will offers commercial real estate
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become available. A lot of the decision comes down to the long-term plan,” Didion explained. Tyler additionally noted that a general office Kris Pedersen Riley Didion condo will not likely have the circuit capacity a physician’s office requires, front. That alone is keeping and so it is better to restrict physicians from buying or the search to medical office building stand alone facilities.” condos. Medical office condos Tyler continued, “We just are more equipped to meet aren’t seeing a ton of new the demands of a physician medical office space being practice, including convenient built right now. Most of it is access to outpatient services, filling in existing space, renoparking and office accessibilvating what they have or a ity, energy saving operations, building expansion.” sustainability measures, space A tendency for small for medical equipment, plus practice groups to have a increased plumbing and elecparticularly difficult time trical clearance. with major bank financing While assessing the needs contributes to offices staying of your growing practice, you put. Tyler encouraged physimay even find that renovation cians that there are options of the current space is more beyond the big banks in the feasible than relocation. If form of private equity and you’re happy with the physiboutique lenders. Physicians cal location, Tyler said that, can also seek lease options “In most instances, renovadirectly from developers tion is better than relocation. who specialize in building Almost anything can be renoand leasing doctor-ready vated, and renovation projects facilities. Hospital systems also and labor costs are at an offer space at subsidized or all-time historical low.” While reduced rates. this portion of the market is Pedersen agrees that when ready to be capitalized on, it comes to securing major practices should figure in the bank financing, your size matadded costs associated with ters. “The more patients there interruption of service or need are, the more likely the docfor temporary space during tors are to qualify.” renovation. For Didion, he sees the financing situation for physiFinancing cians to be more favorable Whatever the relocation since a doctor’s office is a fairplans, there’s the question of ly stable business that tends to who’s going to finance them. pay its bills on time. “For phySome market trends suggest sicians, it’s not that tough to a move to more boutique get financed if they’re going financing arrangements. Tyler to buy the building they are agreed. “Major bank financing going to occupy. They’re one sources are not as prevalent of the easiest groups to get and require more equity up financed right now.”
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TOP 5
Screenings Best Runs
that could save your patient’s life By Virginia J. Pillsbury
So, why would a patient spend the time and money on a screening test if they feel just fine, thank you very much? The answer is simple – screenings save lives.
“It is important for patients to take care of their health and to have the best quality of life throughout their lifetime,” says Anne Waldron, M.D., Baptist Primary Care. “Screenings are for people who do not have signs of a disease, but screenings can detect problems at a very early stage, before symptoms,” she says. They are for healthy people at their normal level of health. Patients must invest in themselves and their health. Periodic screenings are essential because the state of health can change. “Evidence shows that there is more benefit than harm to getting screenings, and when you screen for a disease, it is more easily treated in the early stage – before symptoms,” says Dr. Waldron. Along with the screenings we highlight here, Dr. Waldron believes that others are also worth considering and they include obesity, depression and sexually transmitted diseases. Breast Cancer Screenings “All women should have yearly mammograms starting at age 40 and continuing for as long as the woman is in good health,” advises Joanne Dragun, M.D., of 21st Century Oncology. If the patient has a familial history of breast cancer, particularly a mother who was diagnosed with the disease, that patient should begin mammograms ten years younger than the mother’s age at the time of her diagnosis, if that age is below 50 years old. “If there is a strong family history, the patient may also have an MRI in addition to the mammogram,” she says. “A clinical breast exam should be performed by a family physician or gynecologist annually after age 40,” says Dr. Dragun. “A breast exam should be done every three years for a woman in her 20s and 30s,” she adds. Patients should begin self-breast exams at age 20. “It is very good for a woman to note changes herself,” explains
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Dr. Dragun, “because many times it is the patient who notices the lump.” “Because of these evaluations fewer women are dying from breast cancer. That is a success story and we want to continue what we are doing with screenings,” says Dr. Dragun. Prostate Screening “Early diagnosis of prostate cancer can save a patient’s life,” says Scot Ackerman, M.D., Radiation Oncologist with and Medical Director of First Coast Oncology. “In the 1980s, the survival rates for prostate cancer were low. Today, because of better screening the five year survival rate for prostate cancer is 95 percent.” he says. The recommended screening for prostate cancer is a PSA (Prostate-Specific Antigen) blood test and a digital rectal exam. The current, and recently changed, recommendation according to Dr. Ackerman, “is at age
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50 men should have a meaningful conversation about prostate cancer screening with their physician.” Screenings are essential because an early diagnosis of prostate cancer provides more treatment options. “Once prostate cancer spreads to other parts of the body, treatment options are much more limited,” says Dr. Ackerman. Current Screening Standards: • At age 50, the patient should discuss screening options with their physician, and if appropriate have the PSA test and digital rectal exam. • If the patient is African American or has a familial history of prostate cancer, the discussion should happen when the patient is 45. • If the patient is African American and has a familial history of prostate cancer, the discussion should happen when the patient is 40. Colorectal Cancer Screenings Why is this screening important? “There are 50,000 deaths annually directly related to colorectal cancer,” says Renard Rawls, M.D., of the Borland-Groover Clinic. “It is well worth your patient’s time to have the colonoscopy. It can help prevent this horrible disease.” Colorectal cancer screenings can detect cancer, polyps and nonpolypoid lesions. If a problem is revealed, diagnosis and treatment can quickly begin. “The screening gold standard is the colonoscopy,” says Dr. Rawls. “It is both a diagnostic tool and a therapeutic tool; if polyps are found they can be removed during the procedure.” If cancer is detected, it can
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be treated and the earlier the detection, the better the outcomes. If there are polyps, depending on what kind they are, a followup colonoscopy may be required after three or five years. The following tests are also available: • Fecal Occult Blood Test- two types of this test check for hidden blood in fecal matter. - Guaiac is used to detect blood. - Immunochemical uses antibodies to detect blood. It uses antibodies specific for human hemoglobin, albumin or other blood components and is more specific for human blood than the standard guaiac fecal occult-blood tests. • Sigmoidoscopy – a scope is inserted into the rectum to examine the distal colon. “The drawback is that there may be lesions on the proximal colon that are missed,” says Dr. Rawls. • Virtual colonoscopy – computerized x-ray produced pictures of the colon. “This test has a high sensitivity for polyps that are greater than 10 mm.” explains Dr. Rawls. • Barium enema – x-rays are taken of the colon after the patient has used an enema with a barium contrast solution. Unless there are symptoms, or a family history of colorectal cancer, or a personal history of inflammatory bowel disease, colorectal screenings should begin at age 50 and at age 45 for African Americans.
Joanne Dragun, M.D.
Scot Ackerman, M.D.
Artery Plaque Screening Arteriosclerosis and other vascular diseases can be successfully treated if discovered early. “The forming of plaque is the first thing that happens with arteriosclerosis, or hardening of the arteries,” says David Grech, M.D., cardiologist with First Coast Cardiovascular Institute. There are different forms of artery plaque but the process is the same. “Artery plaque screening finds if an artery is affected and what that artery will affect,” he explains. For example, if it is plaque on the carotid artery that could, if left untreated, lead to a stroke, while plaque on a coronary artery, if left untreated, could lead to a heart attack. Artery plaque screening is suggested for patients with a family history of vascular problems, or with risk factors. “Risk factors include diabetes, high blood pressure, high cholesterol, obesity, inactivity and age. Smoking is the number one preventable risk factor for developing arteriosclerosis,” says Dr. Grech. “Most screenings can be performed by listening to
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the arteries, examining the aorta for enlargement and checking blood pressure in the legs. If the blood pressure is lower in the legs than in the arms, that could be a sign of arteriosclerosis,” he explains. Artery ultrasound might also be a good idea. The age for screening depends on family history, though between the ages of 40 and 50 might be a good time to have an assessment done. “The most important thing is for patients to take care of risk factors,” advises Dr. Grech. Take such steps as stop smoking, lose weight and control diabetes. “Fifty percent of the people in our country die of vascular disease, and heart disease is the number one killer.” Pap Smear “Over the last 30 years, since we started doing the pap smear, cervical cancer in the United States has decreased by more than 50 percent,” says Sonnie KimAshchi, M.D., OB/GYN, Women’s Special Care.
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suggest having the first pap smear at 21 years old, regardless of sexual activity. From 21 to 29 years old, pap smear is recommended every two years. And after age thirty, if the patient has had three consecutive negative pap smears, every three years is recommended. “There are some exceptions to those guidelines,” explains Dr. Kim-Ashchi. “If the patient is immunocompromised (like HIV) or immunosuppressed, or if they were exposed to DES in utero, or have a history of abnormal pap smears then they should have a pap smear more often.” Some studies show that smoking can increase the chance of cervical cancer. The pap smear reveals cervical cancer, early cancer cells, atypical cells and infection. If a woman has had a hysterectomy, for benign reasons, she still needs to see her GYN for annual pelvic exams, but no longer needs a pap smear. And women after age 65 to 70 no longer need the pap smear screening as well, unless something in their personal history makes it necessary.
New Guidelines: The current guidelines
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