Florida MD August 2021

AUGUST 2021 • COVERING THE I-4 CORRIDOR

AdventHealth Cancer Institute’s Blood and Marrow Transplant (BMT) Program:

Treating Aggressive Cancers with Cutting-Edge Therapies in Central Florida

Blood Cancer Expertise You Can Trust

AdventHealth’s Blood and Marrow Transplant Center is the only comprehensive stem cell transplant program in Central Florida, offering services locally so patients don’t have to travel far for care.

As the most established program of its kind in the area, we perform more than 120 transplants annually and continually exceed the national benchmarks for survival rates. We’re here when you need us most — providing safe, award-winning cancer care.

We provide: • The only FACT-accredited and longest-standing comprehensive hematopoietic stem cell transplant center in Central Florida

Our Cancer Experts

• Expertise in stem cell transplantation to treat complex conditions such as leukemia, lymphoma and multiple myeloma • Access to innovative immunotherapies, including CAR T-cell therapy • Acute leukemia expertise and dedicated resources for expedited patient treatment • Exceptional patient-centered care throughout the transplant experience, with comprehensive support programs and resources for patients and their families

21-AHMG-00232

• Second-opinion consultations to help patients make informed decisions on their cancer diagnoses

AdventHealth Orlando is recognized by U.S. News & World Report as one of America’s best hospitals for cancer treatment.

Juan Carlos Varela, MD, PhD Medical Director

Rushang Patel, MD, PhD

Now offering virtual visits for your convenience.

Call us at 407-863-9129 or visit AdventHealthCancerInstitute.com/BMT.

Blood and Marrow Transplant at Orlando 2415 North Orange Avenue, Suite 601 Orlando, FL 32804

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AUGUST 2021 COVERING THE I-4 CORRIDOR

 COVER STORY

There are many reasons that AdventHealth Cancer Institute’s Blood and Marrow Transplant (BMT) Program is Central Florida’s program of choice for the treatment of acute leukemia and other complex blood cancers.

PHOTO: DONALD RAUHOFER

The hospital is known for its use of leading-edge techniques like stem cell transplants and immunotherapy. But it’s the support and guidance patients and their families receive at what can be a confusing time that makes the program a standout. A dedicated navigator makes referrals easy for both referring physicians and patients, and care is expedited when patients receive a critical diagnosis like acute leukemia. This is part of the program’s “patient first” philosophy incorporated by the entire team to put patients on a pathway to success.

The award-winning program treats all aggressive cancers, such as acute leukemias, including acute lymphocytic leukemia (ALL) and acute myeloid leukemia (AML), as well as aggressive Hodgkin and Non-Hodgkin lymphomas. Located in Orlando, it is the longest standing and oldest stem cell transplant and acute leukemia program in the Central Florida region, serving patients from across the Southeastern U.S. and beyond, according to its director, Juan Carlos Varela, MD, PhD. ON THE COVER: Rushang D. Patel, MD, PhD, FACP and Juan Carlos Varela, MD, PhD

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CANNABIS JOB GROWTH CONTINUES TO INCREASE

PHOTO: DONALD RAUHOFER

16 YOUR PATIENT IS NOT HAPPY WITH THEIR KNEE OR HIP REPLACEMENT. WHAT’S NEXT?

DEPARTMENTS 2

FROM THE PUBLISHER

8 PULMONARY 11 DERMATOLOGY 12 MARKETING YOUR PRACTICE 13 13 PEDIATRICS 14 HEALTHCARE LAW

FLORIDA MD - AUGUST 2021

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FROM THE PUBLISHER

I

am pleased to bring you another issue of Florida MD. Human trafficking is one of the horrors in today’s society. It’s modern day slavery and Central Florida is one of the worst places in the country. I have asked Paving the Way, an organization headquartered here in Central Florida

that helps physicians spot signs that one of their patients could be a victim. Please check out their website and help put a stop to human trafficking.

Best regards,

Donald B. Rauhofer Publisher

Check out our newly redesigned website at www.floridamd.com!

According to Homeland Security, there are over 300,000 children a year trafficked in the United States. In fact, Florida ranks 3rd in the county for calls to the National Trafficking Hotline and right here in Central Florida, Orange county ranks 2nd in the state for child trafficking case. Sadly, the average age of entry is 11-14.

Those facts can be frightening, leaving most people asking, who am I to do anything about this? More importantly, what can I do?

Paving The Way Foundation was created to provide answers to those questions. We’ve educated over 13,000 youth, parents, teachers, and community leaders about human trafficking, the impact it has on families and the actions to take to prevent it.

A surprising statistic is 88% of trafficking victims reported being in a medical setting for various concerns but did not feel safe enough to ask for help. We can prevent that from happening by training our frontline teams to learn the signs of trafficking, understand grooming and recruitment tactics and how to engage with patients about this silent crime to get them to safety.

Here is one action you can take right now: put the National Trafficking Hotline number in your phone, 888-3737888, you can call 24 hours a day, 7 days a week.

To learn more about what you can do or ways to get involved in ending human trafficking we invite you to join in the fight, please go to our website, www.pavingthewayfoundation.org click on programs for information on what’s available to educate you and your staff or download one of our tool kits. Together we can disrupt the cycle of human trafficking.

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Email press releases and all other related information to: info@floridamd.com

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Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: John “Lucky” Meisenheimer, MD, Daniel T. Layish, MD, Foley Davelaar, DO, George J. Haidukewych, MD,Julie A. Tyk, JD, Sonda Eunus, MHA, Michael Patterson NHA, OTR/L, CEAS, Juan Lopez, Pharm D, John Meisenheimer, VII Art Director/Designer: Ana Espinosa Florida MD is published by Sea Notes Media,LLC, P.O. Box 621856, Oviedo, FL 32762. Call (407) 417-7400 for more information.

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Although every precaution is taken to ensure accuracy of published materials, Florida MD cannot be held responsible for opinions expressed or facts expressed by its authors. Copyright 2021, Sea Notes Media. All rights reserved. Reproduction in whole or in part without written permission is prohibited. Annual subscription rate $45.

Cannabis Job Growth Continues to Increase

By Michael Patterson, NHA, OTR/L, CEAS Job growth in the cannabis industry will be fueled by sustained sales growth and the launch of new state markets, especially on the recreational side of the business. According to analysis from the 2021 MJ Biz Factbook, the marijuana industry will employ 340,000-415,000 full-time equivalent workers across the United States in 2021 and grow to 545,000-600,000 by 2025. A link to the factbook is below: https://mjbizdaily.com/factbook/?utm_medium=email&utm_ source=newsletter&utm_campaign=MJD_20210629_NEWS_ Daily These figures account for workers directly employed by cannabis businesses, including budtenders and extraction technicians, as well as employees of ancillary companies that support the marijuana industry such as consultants and lawyers. The retail sector constitutes most of the jobs in the cannabis industry, driven by requirements in nearly all states to sell marijuana in distinct physical locations.

Unlike alcohol, marijuana cannot be sold alongside other goods in traditional retail outlets such as a grocery or drugstore. The use of full-time equivalent workers is a method for standardizing employment estimates and equating the hours worked by several part-time employees to the hours worked by full-time employees.

Cannabis job gains in 2021 will be largely driven by the implementation of new markets across the United States, such as recently added states of Connecticut, New York, and soon to be added Rhode Island. Cannabis employment in 2020 exceeded that of mainstream industries such as web developers. Cannabis jobs were more than the number of U.S. nurse practitioners, a high-demand employment sector across the country, particularly during the COVID-19 pandemic.

The 2020 pandemic didn’t lead to wide-scale contraction in the marijuana labor market. Though sales in select markets suffered, such as Nevada where much of the industry is reliant on tourism, many recreational and medical cannabis markets experienced higher than average sales volume.

ANALYSIS If your business operates in the health care field, the growth of cannabis related jobs will make it harder to find talent. The cannabis industry (medical and adult use) is rapidly evolving into more accepted careers in which to work. Therefore, you will see more medical professionals (MDs, Physician Assts, NPs, Nurses, Therapists, Pharmacists, Laboratory Technicians, Pharmacy Technicians) start to leave traditional medical jobs and begin working in the cannabis industry.

As a medical professional who is a licensed Occupational Therapist and Nursing Home Administrator, I can tell you I was drawn to the cannabis industry because it was just getting started. I feel I can shape the way this industry grows and bring in regulation that is important for public safety, commerce, and patient access.

Also, people who come work in the cannabis industry are willing to learn and take direction. This makes employees feel more connected to the company, rather than having to adapt to a medical system that has been in existence for 100 years and is extremely reluctant to new ideas. Furthermore, this trend will lead to less and less companies performing drug screening for cannabis.

Cannabis jobs will become more and more common, especially when federal legalization is enacted (sooner rather than later). As a medical healthcare employer, it is smart to be aware of this trend and find ways in which you can compete for talent with this new and exciting industry.

Michael Patterson NHA, OTR/L, CEAS is CEO of US Cannabis Pharmaceutical Research and Development LLC. (uscprd.com). He is a healthcare executive with 25+ years experience in: Cannabis-Hemp investment, Law, Regulation, Compliance, Operations, & Management, Skilled Nursing, Pharmacy, Laboratory, Assisted Living, Home Healthcare, & Healthcare Analytics. He is a subject matter expert in the Global Cannabis and Hemp Industry with Gerson Lehrman Group (glg.it) & Guidepoint. He is an editorial board member of the American Journal of Medical Cannabis, licensed Nursing Home Administrator, & licensed Occupational Therapist in 4 states. 

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It’s not about

counting the days.

It’s about making the days count.

Hospice • Palliative Care • Grief Support

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COVER STORY

AdventHealth Cancer Institute’s Blood and Marrow Transplant (BMT) Program: Treating Aggressive Cancers with Cutting-Edge Therapies in Central Florida

By Staff Writer

The hospital is known for its use of leadingedge techniques like stem cell transplants and immunotherapy. But it’s the support and guidance patients and their families receive at what can be a confusing time that makes the program a standout. A dedicated navigator makes referrals easy for both referring physicians and patients, and care is expedited when patients receive a critical diagnosis like acute leukemia.

This is part of the program’s “patient first” philosophy incorporated by the entire team to put patients on a pathway to success.

The award-winning program treats all aggressive cancers, such as acute leukemias, including A highly specialized scientist preparing to test life-saving stem cells from a transplant acute lymphocytic leukemia (ALL) and acute product. myeloid leukemia (AML), as well as aggressive • Chemotherapy forms the backbone of treatment for most leuHodgkin and Non-Hodgkin lymphomas. Lokemias. The BMT team focuses on timely testing for DNA cated in Orlando, it is the longest standing and oldest stem cell changes in the leukemia cells, which allows them to use the transplant and acute leukemia program in the Central Florida most focused treatments available and avoid the use of less efregion, serving patients from across the Southeastern U.S. and fective drugs. beyond, according to its director, Juan Carlos Varela, MD, PhD.

PHOTO: DONALD RAUHOFER

A FOCUS ON THE CUTTING-EDGE Throughout its venerable history, innovation has been the hallmark of the AdventHealth BMT Program. “Right from the moment the patient is diagnosed, we use the latest tools available,” explains Rushang D. Juan Carlos Varela, MD, PhD and Patel, MD, PhD, FACP, Rushang D. Patel, MD, PhD, FACP clinical leader of the Acute Leukemia Program.

“These modern therapies are more effective and much less toxic than previous treatments.”

Here are a few of the treatments available to patients at AdventHealth Cancer Institute:

• Stem cell transplants may be used for patients who are at high risk of relapse or for treating relapse when it occurs. Only about 200 programs in the country perform the sophisticated stem cell transplants offered at AdventHealth Cancer Institute, and the BMT team does about 150 per year—around 1,700 since the program’s inception. The most established acute leukemia and stem cell transplant program in Central Florida, the program has been FACT-accredited for 12 years, meaning it has performed at or above expectation throughout its history.

• New immunotherapy treatments, in which the body’s own immune system is used to prevent, control and eliminate cancer, continue to be added to the program. One such treatment is CAR T-cell therapy, an FDA-approved standard of care for some forms of aggressive, refractory Non-Hodgkin lymphoma and certain other blood cancers. This cancer treatment, which also is part of many ongoing trials for additional forms of blood cancer, uses a patient’s own T-cells (a type of FLORIDA MD - AUGUST 2021

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PHOTO: DONALD RAUHOFER

There are many reasons that AdventHealth Cancer Institute’s Blood and Marrow Transplant (BMT) Program is Central Florida’s program of choice for the treatment of acute leukemia and other complex blood cancers.

COVER STORY immune system cell) to fight the disease. CAR T-cells are made by removing white blood cells from a patient, genetically modifying them using a deactivated virus, and then infusing the modified cells back into the patient’s bloodstream. The modification of the CAR T-cells causes them to attack the cancer cells.

KEY RESEARCH Moreover, AdventHealth Cancer Institute participates in more than 100 clinical trials each year, several of which are available at only a few centers around the country. In fact, in 2020, as part of a clinical trial of a novel cellular therapy treatment for AML, the AdventHealth BMT program performed the first-ever infusion in the world of this therapy into a patient.

The program’s physicians, most of whom hold both medical and doctoral degrees (MD/PhDs), and staff are constantly working to stay ahead of the curve searching for breakthroughs in hematologic cancer treatment. This dedication to discovery gives AdventHealth’s patients unique access to innovative treatment methods. “We are delivering world-class expertise and care,” Dr. Varela says. “And these programs are constantly expanding.

There’s a lot being done around the world with research and therapies, and we are able to deliver that here.”

MAKING IT EASY ON PHYSICIANS AND PATIENTS At the AdventHealth BMT Program, the latest advancements aren’t just found in the clinical arena. First, the physician referral process is simple, involving just one phone call—even on a holiday or during the weekend. “That one call can lead to a patient transfer, often within a few hours,” says Dr. Patel. “We have made communication easy for referring physicians, who can reach the physicians here at any hour through our cell phones.

They don’t go through multiple lines to reach us.”

Once admitted, patients are cared for by an entire team that

can include the program’s four physicians, specially trained nurse practitioners and physician assistants, clinical pharmacists, transplant coordinators, a dedicated infection specialist, and social workers. Through weekly conferences that also involve multiple pathologists, radiologists, and other specialists, the team develops personalized treatment plans for each patient.

Members of the BMT Program team could choose to work in less demanding surroundings, Dr. Varela says. “They choose to stay with the group, even though these patients’ needs are very complex. Everyone here is dedicated to the cause. Everyone here loves taking care of these patients.”

ACUTE LEUKEMIA PROGRAM: WHEN TIME IS OF THE ESSENCE At the hospital, the clock never stops ticking. With an acute leukemia diagnosis, cancer cells can multiply in as little as a few hours and are quick to spread to other parts of the body. At AdventHealth, these time-sensitive cases are fast tracked, which can be life-saving.

“These are very complicated diseases and very sick patients,” Dr. Varela says. “The first few hours are really important. To get the patients in as quickly as possible, to get them situated, to get them started with the right treatments—all those things are vital in the patients’ successful treatment.”

Responding to a referral is a top priority, no matter the day or time of year. “We don’t stop just because it’s a holiday or a weekend,” Dr. Patel says. “Our excellent team of pathologists will even get reports to us on the weekend. So as soon as the patient gets here, we get the workup and get started. This is a life-threatening situation, and we don’t waste time beginning treatment.”

THE PATIENTS AS PART OF THE TEAM

Dr. Varela and Dr. Patel review a patient’s scans to determine best next step for treatment.

The BMT team places an emphasis on including the patients in their treatment process. “We don’t impose any positions or values on our patients,” says Dr. Patel.

“It’s their health. We try to educate them in a way that they can understand and try to give them as much information as we can. These are tough diseases to treat, so you want to engage them as much as possible in the decision process.”

PHOTO: DONALD RAUHOFER

The program also makes plenty of support services available—from music and art therapists to a pulmonologist, nutritionist, dietitian, and physical therapists.

Dedicated hematopathologists provide immediate, state-of-the-art testing on site. And then there’s the Leukemia Navigator, a licensed clinical social worker who coordinates total patient care by guiding the patients through the admittance process and then helping them through all stages of treatment scheduling. The Leukemia Navigator even helps access resources, including counseling and social work.

“Everything revolves around the patient,” Dr. Varela says. “We treat the patient, rather than the cancer. That sounds like a clichéd phrase, but it is very true. Every 6 FLORIDA MD - AUGUST 2021

COVER STORY patient’s needs are very different, and our program does a fantastic job of recognizing that, adjusting and giving every patient personalized treatment and care.”

Within the BMT Program, a dedicated suite of 32 private rooms come complete with their own bathrooms and refrigerators, as well as a sitting area for families. “The patients who come here are very sick,” says Dr. Patel. “These sound like small things, but some of these patients are here for a month … These things make a big difference.”

Patients also have access to five conveniently A lab scientist preparing stem cells for cryopreservation (freezing of stem cells for future transplant). located infusion centers at AdventHealth hospitals across the region. It’s just one more way AdventHealth Cancer Institute’s Blood and Marrow Transplant (BMT) Program meets the needs of its patients in the Central Florida region.

PHOTO: DONALD RAUHOFER

When needed, world-class surgeons, lung doctors and an intensive care unit are available at the hospital, he says. “It’s all right here, in Orlando.

Such a massive, coordinated effort is not easy unless the program has been running for a long time with a patient-centered approach.”

To learn more about the Blood and Marrow Transplant Program at AdventHealth Cancer Institute, visit AdventHealthCancerInstitute.com/BMT.

Rushang D. Patel, MD, PhD, FACP, is a boardcertified, fellowship-trained medical oncologist and hematologist, and the clinical leader of the acute leukemia program. He has special interest in managing patients with acute leukemias and high-risk lymphoma and performing haploidentical transplants. Dr. Patel has conducted extensive research on cancer-causing toxic chemicals such as dioxin (Agent Orange), cigarette smoke and others, and he holds a PhD from Penn State in Integrated Biosciences — Molecular Medicine. 

PHOTO: DONALD RAUHOFER:

Juan Carlos Varela, MD, PhD, is the Medical Director of the BMT Program and an MD/PhD graduate of the Medical University of South Carolina. He undertook his residency at Johns Hopkins Hospital, followed by fellowship training in hematology at the Johns Hopkins Hospital and the Sidney Kimmel Comprehensive Cancer Center. Dr. Varela’s clinical interests include novel immune therapies for hematological malignancies as well as bone marrow transplantation and treatments for leukemia, lymphoma and multiple myeloma.

A lab scientist performing separation of stem cells from peripheral blood for transplant.

FLORIDA MD - AUGUST 2021

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PULMONARY AND SLEEP DISORDERS

Shift Work Sleep Disorder

By Daniel T. Layish, MD, FACP, FCCP, FAASM

Optimal sleep and wakefulness requires proper alignment between an individual’s intrinsic circadian rhythm and their desired sleep wake schedule. The word circadian comes from the Latin “circa” meaning “about” and “dian” meaning “day”. Our intrinsic circadian rhythm is controlled by an internal clock in the hypothalamus (suprachiasmatic nucleus). The hypothalamus receives signals from the retina that entrain the circadian rhythm to the light dark cycle. The circadian rhythm affects the timing of sleep.

There is also a homeostatic sleep drive, which controls sleep intensity, and it is determined by how long an individual has been awake.

Shift work sleep disorder is a recurrent or persistent mismatch between a person’s habitual sleep wake schedule and their endogenous circadian rhythm. Shift work sleep disorder can be associated with insomnia or excessive sleepiness (or both). The conventional time cues (zeitgeber = “time giver” in German) of sunlight and social activities are frequently out of phase with the altered sleep schedule in an individual with shift work sleep disorder. Many shift workers revert back to their traditional daytime schedule during non-work days. By definition, the course of shift work sleep disorder parallels the period of the shift work and remits with termination of shift work. An individual SLEEP FACTORS with shift work sleep disorder may use a large portion of their free time for recovery of sleep, which may have negative social consequences such as marital discord and impaired social relationships. Shift work sleep disorder tends to be more common after age 50. Between 5 and 8% of the population is exposed to night work on a regular or periodic basis.

Shift work sleep disorder is usually a clinical diagnosis. A formal sleep study (polysomnogram) may be helpful to exclude other etiologies of a patient’s symptoms. The sleep study should ideally be performed during the regular hours of sleep of the individual having the study. To diagnose shift work sleep disorder one must exclude any other medical or psychiatric conditions which could account for the symptoms. In addition, the symptoms should not meet criteria for any other sleep disorder which can produce insomnia or excessive daytime sleepiness (such as Jet-lag syndrome). Women appear to be slightly more prone to developing shift work sleep disorder. Interestingly, women tend to quit their shift work less often than men. The occurrence of shift work sleep disorder may vary depending upon the speed and direction 8 FLORIDA MD - AUGUST 2021

of shift rotation. It may also vary depending upon a patient’s diurnal preference. It appears to be less common in individuals who identify themselves as “night owls”. Individuals with shift work sleep disorder have been found to have higher rates of peptic ulcer disease as well as more sleepiness related motor vehicle accidents. Other consequences of this disorder include absenteeism from work, higher rates of depression and missed family and social activities as well as chronic fatigue and poor work performance. There have also been studies which link shift work sleep disorder to glucose intolerance as well as higher risk for alcohol and substance use. Sleep CIRCADIAN FACTORS

SHIFT WORK COPING ABILITY

ENVIRONMENTAL FACTORS

diaries can be helpful in assessing patients with shift work sleep disorder. Actigraphy can be useful as an adjunct to history, physical exam and sleep diary. Actigraphy recording should consist of at least three consecutive 24-hour periods. Circadian rhythm markers (such as core body temperature monitoring or timing of melatonin secretion) are more difficult and typically are not used in routine clinical settings.

Treatment for shift work sleep disorder can include exposure to bright light in the work place as well as administration of wake promoting agents during evening work hours. Other treatments include scheduled napping as well as hypnotic agents to improve daytime sleep. Maintaining a regular sleep wake schedule during both work and non-work days is also recommended (as well as minimizing light or noise in the bedroom and allowing sufficient time in bed for sleep during the daytime). Other recommendations include limiting light exposure by using dark sunglasses during the morning trip home from work. The timing of

PULMONARY AND SLEEP DISORDERS

FLORIDA MD - AUGUST 2021

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PULMONARY AND SLEEP DISORDERS light therapy is critical. The American Academy of Sleep Medicine recommends light exposure before the core temperature is reached in an individual with a morning/evening/night schedule (versus administrating light therapy after core temperature in an individual with a night/evening/morning schedule). Studies have utilized various light intensities from 2350 to 12,000 lux. Some but not all studies of bright light therapy have also restricted daytime light exposure. Different schedules of light exposure have also been used. Melatonin has both sleep promoting (hypnotic) and phase shifting properties. Melatonin (when given to night workers before their daytime sleep) may enhance daytime sleep and appears to have no effect on subsequent nighttime alertness.

In a study published by Czeisler in The New England Journal of Medicine in 2005, modafinil resulted in decreased accidents/ near accidents during the commute home (versus placebo). Treatments for shift work sleep disorder can include modafinil (Provigil) as well as armodafinil (Nuvigil). These medications are nonamphetamine stimulants believed to act on the hypothalamus, although their exact mechanism of action is unknown.

more difficulty coping with shift work than men).

In general, the circadian clock adjusts better to clockwise rotation because it is naturally easier to delay sleep to a later hour.

Typically, longer shifts (such as 10-12 hours) cause more sleepiness than eight hour shifts. Women doing shift work tend to get less sleep than men when they are not working because of their persistent family and social obligations. Overall, night and rotating shift workers comprise approximately 6% of all workers. About 1% of the working population in the United States is believed to suffer from shift work disorder. Increased awareness of this disorder should allow more individuals to receive proper diagnosis and therapy.

Shifts can be permanent, fixed or rotating. Shift can rotate forward (clockwise) (from morning to evening to nighttime) or backward (from night to afternoon to early morning shift). Rotating shifts seem to cause more sleep difficulties than permanent shifts and counter clockwise rotation affects sleep wake activities more than clockwise rotation. The speed of rotation and the length of the shift may also impact an individual’s symptoms.

University in Durham, North Carolina. Since 1997, he has

It appears that workers on permanent night shifts sleep one to four hours less than day workers and individuals on rotating shifts sleep about two hours less than day workers. There are several factors involved in this. Shift workers must try to sleep at a time when their circadian/ wakefulness drive is exerting pressure on them to remain awake. The desire to spend time with family or take care of household or social obligations is also a factor. Environmental factors such as noise and light may also be obstacles to sleep quality for shift workers.

TABLE 1: FACTORS INFLUENCING THE EFFECT OF SHIFT WORK ON SLEEP AND WAKEFULNESS • Type of shifts (permanent, rotating).

• Duration of shifts.

• Speed of rotation (slow or fast).

• Direction of rotation (clockwise or counter clockwise).

• Social and family disruption.

• Exposure to natural or artificial light.

• Existing health problems.

• Age (over 50 is more adversely affected than younger individuals) • Gender (female shift workers seem to have 10 FLORIDA MD - AUGUST 2021

Daniel Layish, MD, graduated magna cum laude from Boston University Medical School in 1990. He then completed an Internal Medicine Residency at Barnes Hospital (Washington University) in St.Louis, Missouri and a Pulmonary/Critical Care/Sleep Medicine Fellowship at Duke been a member of the Central Florida Pulmonary Group in Orlando. He serves as Co-director of the Adult Cystic Fibrosis Program in Orlando. He may be contacted at 407841-1100 or by visiting www.cfpulmonary.com.



DERMATOLOGY

Melanoma Makes Me a Real Doctor

By John “Lucky” Meisenheimer, MD and John Meisenheimer, VII

Melanomas come in all different shapes and sizes. They are rarely the archetypal jet black, nodular mole-like growth, in which even a first-year medical student could make the diagnosis.

Melanomas may appear elevated, they can be flat, they can be multicolored, and they do not have to have pigment. Some melanomas can persist for very long periods before being discovered, such as lentigo maligna melanoma. Others can grow rapidly and deadly in a few weeks. Melanomas can develop beneath the nails, and even in non-skin areas such as the eye, oral cavity, nasal sinuses, even rectally.

The best guidance for identifying melanomas for non-dermatologists is using the mnemonic ABCDEs of melanoma evaluation, Asymmetry of the lesion, Border irregularity, Color variation, Diameter greater than 6mm and Evolution. However, dermatologists rarely use the ABCDE guide, as most of us know by looking because of intuitive expertise. When a dermatologist observes a suspicious lesion, in our mind, it pops up, “that looks suspicious.” Intuitive expertise is ubiquitous throughout all specialties and comes with experience. The ER doc that walks into a patient room and immediately diagnoses congestive heart failure with only a glance is demonstrating intuitive expertise. Intuitive expertise can be confounding to medical students who need to look up everything online. Still, it is this intuitive expertise we all gain through training and experience that makes us “real” doctors.

Lucky Meisenheimer, M.D. is a board-certified dermatologist specializing in Mohs Surgery. He is the director of the Meisenheimer Clinic – Dermatology and Mohs Surgery. John Meisenheimer, VII is a medical student at USF. 

PHOTO: JOHN MEISENHEIMER, VII

Lentigo maligna melanoma.

PHOTO: JOHN MEISENHEIMER, VII

As a Mohs surgeon, I rarely “pop” pimples anymore, not that there is anything disgraceful about helping a patient with a disfiguring skin disease that can leave them permanently scarred.

As the Seinfield episode would suggest, laypeople might seem to think unless you are saving lives, you are not a “real” doctor. So, I guess in a sense, melanomas make dermatologists “real” doctors (and let’s not forget squamous cell carcinomas and basal cell carcinomas can also kill you).

I know in my practice over the last 30 years, I have found hundreds of melanomas. Even to this day, when I see a melanoma, I quietly give myself a high five. When you catch melanoma in time, you have changed a person’s life for the better, even if they may not realize it. At the same time, I am also grateful that I did not miss that melanoma. There is always a degree of stress when doing a “routine skin exam” there is nothing routine about melanoma or the potential for missing a melanoma.

A superficial spreading melanoma.

Nodular melanoma.

PHOTO: JOHN MEISENHEIMER, VII

Jerry was having dinner at a restaurant with his dermatologist girlfriend.

Seinfield - “How’s the life-saving business?

Dermatologist girlfriend - “It’s fine.”

Seinfield - “It must take a really, really big zit to kill a man.”

Dermatologist girlfriend - “What is with you?”

Seinfield - “You called yourself lifesaver. I call you pimple popper M.D.” A restaurant patron walks up to their table and says, “Dr. Sitarides?”

Dermatologist girlfriend - “Mr. Perry, how are you?”

Mr. Perry - “I just want to thank you again for saving my life.”

Seinfield - “She saved your life?” Jerry has a shocked look on his face.

Mr. Perry - “I had skin cancer.”

Seinfield - “Skin cancer, damn.” Jerry’s face twists in the agony of defeat.

PHOTO: JOHN MEISENHEIMER, VII

When I was in medical school and revealed to my classmates that I wanted to be a dermatologist, they usually gave me a flabbergasted look and said, “You want to pop zits for a living?” Immediately followed by, “You don’t want to be a real doctor?” I wish the Seinfeld episode, when Jerry was dating a dermatologist, had been released so that I could refer them to it. The Seinfeld episode went something like this:

Pathology of a melanoma.

FLORIDA MD - AUGUST 2021 11

MARKETING YOUR PRACTICE

Is Your Online Reputation Costing You Patients?

By Sonda Eunus, MHA, CMPE What does your online reputation say about your practice? If you have a negative online reputation, you are missing out on new patients every day. Most medical practices now get the majority of their new patients through Google and other search engine queries, such as “Pediatrician in Orlando”. If your practice appears in these searches, the most common next step for a potential new patient would be to check out your reviews – what are other patients saying about your practice? It has been reported that 90% of consumers read online reviews before visiting a business and that online reviews influence 67% of purchasing decisions (Bright Local). For this reason, it is incredibly important to pay attention to the rating and reviews that your practice has on search engines, social media platforms, and local online business directories.

However, despite the importance of cultivating a positive online reputation, only 33% of businesses report actively collecting and asking for reviews (1). One great process to set in place at your practice is asking for patient reviews after each patient visit. It can be as simple as training your front office staff to ask each patient how their visit went while checking them out, and if they receive favorable feedback then they can ask the patient to please leave a review on Google or Facebook about their experience. If they receive negative feedback, this feedback should be taken very seriously, and management should be notified as soon as possible so that the issue can be mitigated before the patient decides to post a

negative review.

Setting up an automated text or email campaign that asks each patient for their feedback after their appointment is also a great way to improve your online reputation as well as to correct any issues that may be occurring at your practice.

When you receive feedback from patients, you are then able to prompt them to leave a public review on Facebook, Google, Yelp, Healthgrades, or other applicable review platforms. However, you must be aware that legally, you are not allowed to only direct people with favorable feedback to leave reviews, which is known as review-gating – so if you are implementing an automated system like this, just make sure that you are aware of this limitation. There are online reputation management platforms which allow you to customize the messages that people see when they leave negative feedback as opposed to positive feedback, but both of those messages must still offer the option to leave a public review. However, if you create your message in such a way as to communicate to the patient who may leave negative feedback that you are working hard on resolving the issue and that someone will be in touch shortly, that may prevent them from leaving a public negative review.

When you receive a public review on Google, Facebook, or other review sites, make sure that you respond to it – either by thanking them for a good review or by asking them to contact you to discuss how you can improve their experience. Do not argue or try to defend yourself online – try to speak about it with them privately, fix the issue, and ask them to remove the review if possible.

When you receive great reviews, make sure to cross-share them on your various social media platforms. You should also create a “Reviews” page on your website and add all great reviews to this page. This instantly adds credibility to your website.

Finally, make sure that when you look over the feedback and reviews that you receive, you are paying attention to what the negative reviews are saying – this is a great opportunity to identify current process challenges and improve your patients’ experience at your practice. Need help managing your practice’s online reputation? Visit www.lms-plus.com to see how Leading Marketing Solutions can help.

Sonda Eunus is the CEO of Leading Marketing Solutions, a Marketing Agency working with Medical Practices and other Businesses to help them identify the best marketing strategies for their business, create a strong online presence, and automate their marketing processes for a better return on their Marketing budget. Learn more about Leading Marketing Solutions at www.lms-plus.com.

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PEDIATRICS

Body Image and It’s Role in Physical Activity: A Systematic Review

By Cassidy Foley Davelaar, DO, FAAP, CAQSM

INTRODUCTION The benefits of youth sports participation are numerous and uncontested. Motor competence in children is positively associated with cardiorespiratory fitness, muscular strength, muscular endurance and a healthy weight status. Research has proven that children who play sports are more likely to incorporate health and fitness into their adolescent lives. In addition to their physical benefits, sports should be fun, and the exercises involved in participation should assist in the development of movement skills. Despite the benefits of developing motor competence at a young age, 70% of children will drop out of sports by age 13 years. By age 14 years, girls drop out of sports at a rate two times greater than that of boys “Not fun” followed by “not good enough” are often cited as top reasons for sports attrition.

However, diving deeper into the literature, “fun” and “not good enough” are very subjective and are packed with deeper meaning.

A better understanding of the motivation involved in youth sports attrition may assist in keeping our youth in sports and more physically fit.

My unique perspective as a double-board certified pediatric sports medicine doctor and a Division I college athlete allows me to see children who fall behind in their gross motor skill from both a pediatrician’s and an athlete’s perspective. I am passionate about getting kids active – especially female athletes – and preventing sports attrition. I have made fundamental movement skills and physical literacy the focus of my research. I have also treated the youngest athletes in my clinic and on the tennis courts as a medical provider for the United States Tennis Association.

This topic is of utmost importance now, especially in the wake of Covid-19 and childhood inactivity and obesity. I believe by fostering early activity, exposure to fundamental movement skills and free play, we can improve not only the development of elite athletes but improve the health of our adolescent communities.

WHAT ARE FUNDAMENTAL MOVEMENT SKILLS? Fundamental movement skills are movements that are the building blocks for more complex physical activities like sports.

Examples of these skills include object control skills (throwing, kicking, striking, catching, underhand rolling, and dribbling) and locomotor skills (running, hopping, jumping, sliding, leaping, and galloping). The acquisition and gradual mastery of these skills lead to the development of physical literacy.

WHAT IS PHYSICAL LITERACY? Physical literacy is the ability to put movements together into more complex activities, like participation in sports. Somewhat similar to academic literacy, physical literacy is important to the motor development and the physical, cognitive and social growth of children.

WHEN IS THE BEST TIME TO INTRODUCE SPORTS? Before the age of 6 or 7, children have an inflated perception of their physical abilities. This is the best time to introduce them to a variety of activities and to invest time in the participation of physical activities.

IS IT BEST TO PLAY ONE SPORT OR MULTIPLE? A variety of movements are beneficial. Fundamental movement skills include locomotor skills like running and object control skills like throwing or catching. The more skills children are exposed to the more likely they are to be comfortable with those skills in the future. As children age, they become more aware of their skill level and are more likely to participate in what they feel they are competent in doing.

WHAT CAN WE DO TO ENCOURAGE PARTICIPATION? In addition to encouraging participation at a young age, speaking to children in a positive way regarding their abilities and their appearance is influential in their perception of their skills. Lastly, reintegration of adolescents into physical activity is possible through education of the benefits of exercise. The pressure “look like an athlete” or have the stereotypical physique is a large deterrent from participation. Avoiding mirrors, posters, comparisons and pressure to appear a certain way will benefit these adolescents. Weight training programs also appear to be more successful.

Call (407) 650-7715 to refer a patient to Dr. Foley Davelaar.

Reference articles information available upon request

Cassidy Foley Davelaar, DO, FAAP, CAQSM is a Harvard Medical School and Boston Children’s Hospital trained sports medicine and pediatric orthopedic physician and a member of the orthopedics and sports medicine team at Nemours Children’s Health. She is an assistant professor at the University of Central Florida College of Medicine and has authored several articles in peer-reviewed journals on topics including young athletes, overuse injuries, injury prevention and concussion management. Prior to Nemours, Dr. Foley Davelaar served as a physician for the Atlanta Ballet, the Boston Ballet, the U.S. Figure Skating Association, the Boston Marathon and several high schools. She has worked closely with the Boston Conservatory of the Arts, Trinity College and Northeastern University and was a varsity athlete at Columbia University, where she earned her bachelor’s degree. 

FLORIDA MD - AUGUST 2021 13

HEALTHCARE LAW

Social Media – Five Things Physicians Should Never Post

By Julie A. Tyk, JD Last year, Alaska dentist, Seth Lookhart, made national headlines for filming a video of himself riding a hoverboard while extracting a patient’s tooth. Dr. Lookhart filmed the procedure on a sedated patient without authorization and forwarded the video to several people. A lawsuit was filed by the State of Alaska in 2017 charging Dr. Lookhart with “unlawful dental acts”, saying his patient care did not meet professional standards. The lawsuit goes on to further allege Dr. Lookhart joked that performing oral surgery on a hoverboard was a “new standard of care,” citing phone records that were obtained. Dr. Lookhart has also been charged with medical assistance fraud for billing Medicaid for procedures that were not justified, unnecessary, and theft of $25,000 or more by diverting funds from Alaska Dental Arts.

On Friday, January 17, 2020, Dr. Lookhart was convicted on 46 counts of felony medical assistance fraud, scheming to defraud, misdemeanor counts of illegally practicing dentistry and reckless endangerment. Dr. Lookhart is expected to be sentenced on April 30, 2020. He faces the possibility of up to 10 years in prison.

A doctor in Rhode Island was fired from a hospital and reprimanded by the state medical board. The hospital took away her privileges to work in the emergency room for posting information online about a trauma patient. The doctor’s post did not include the patient’s name, but she wrote enough that others in the community could identify the patient, according to a board filing.

The popularity of social media has exploded in recent years.

According to a recent PEW report, 70% of Americans use social media. Before jumping on the bandwagon, healthcare professionals are advised to be mindful of the possible ramifications of posting information on social media sites. There are numerous legal issues that can arise when healthcare providers use social media, including issues related to patient privacy, fraud and abuse, tax-exempt status, and physician licensing. The Federation of State Medical Boards has issued the Model Guidelines for the Appropriate Use of Social Media and Social Networking in Medical Practice, which contains the “industry standards” for cyber security, online behavior, and patient privacy. Physicians should familiarize themselves with these guidelines.

Here are five things which physicians should never post to social media.

1. Inaccurate Medical Information: Medical professionals should avoid republishing, sharing, “liking,” or “retweeting” news stories about medical treatments unless they have completely read the story and have verified its accuracy. If a user finds inaccurate medical information through your social media channel, it can reflect very poorly upon you and your practice.

Healthcare professionals also need to be careful about providing medical advice to patients using social media. If a patient

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receiving the medical advice from a doctor through social media is located in a state in which the doctor is not licensed, the doctor giving the advice risks liability under state licensing laws.

2. Do Not Post Anything that Violates Patient Confidentiality: Friending patients on social media sites may pose risks under Health Insurance Portability and Accountability Act (HIPAA) and state privacy laws. The fact that an individual is a patient of a healthcare provider falls within the types of health information that these laws are designed to protect.

As a rule, healthcare providers should not use social media to share any health information that could be linked to an individual patient, such as names, pictures, and physical descriptions, without the patient’s consent. The American College of Physicians recommends that doctors be especially aware of the implications for patient confidentiality when using social media. There have been cases of physicians losing their medical license after posting an image on social media that violated patient confidentiality. Always obtain permission from the patient in writing if you intend to use an image featuring any body part. Avoid talking about specific patients at all on social media unless you have permission to do so. Even if there is no chance that a patient could be identified by what you write on social media, it is considered unprofessional to discuss the specifics of their condition.

Also be careful when taking photographs of yourself while in your practice. There have been cases where medical professionals have accidentally included the image of the patient behind them while taking a ‘selfie’. Make sure there are no patient health records on display when taking photos in the medical practice and no patients are included in photographs unless they want to be.

3. Your Personal Information: The American College of Physicians (ACP) and the Federation of State Medical Boards (FSMB) recommend that doctors create separate social media accounts for their professional and personal lives. They also suggest that the professional profile be more visible than any personal one.

4. Opinions on Controversial Issues: Any controversial topic or “hot button” topic should be avoided as much as possible, including anything to do with religion, politics, racism, abortion, and gun control.

Moreover, healthcare providers that are exempt from taxation under Section 501(c)(3) of the Internal Revenue Code are prohibited from intervening in political campaigns and from seeking to influence legislation as a substantial part of their activities. This restriction may extend to advertising on

HEALTHCARE LAW or sponsoring social media sites that support a political candidate or particular pieces of legislation.

5. Complaints or Rants: It is unprofessional to use social media platforms to complain or rant about your professional situation. Everything you write on social media may one day come back to haunt you. A patient might realize that you were complaining about them on social media.

A medical malpractice claim can have far reaching implications. The Health Care Practice Group at Pearson Doyle Mohre and Pastis, LLP, is committed to assisting Clients in navigating and defending medical malpractice claims. For more information and assistance, please contact David Doyle and Julie Tyk at Pearson Doyle Mohre & Pastis, LLP. Julie A. Tyk, JD, is a Partner with Pearson Doyle Mohre & Pastis, LLP. Julie concentrates her practice in medical practice defense litigation, insurance defense litigation and health care law. She has represented physicians, hospitals, ambulatory surgical centers, nurses and other health care providers across the state of Florida. She may be contacted by calling (407) 951-8523; jtyk@pdmplaw.com. 

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FLORIDA MD - AUGUST 2021 15

Your Patient Is Not Happy with Their Knee or Hip Replacement. What’s Next?

By George J. Haidukewych, MD According to the Agency for Healthcare Research and Quality, more than 790,000 knee and 450,000 hip replacements are performed in the United States each year. While these numbers declined somewhat over the past year due to obvious reasons and events related to the pandemic, experts project a significant upward trend in medically indicated joint replacement surgeries over the next 10 years.

More than 85-90 percent of patients who undergo total knee or hip arthroplasty (TKA/THA) surgery experience a favorable outcome, with a decrease in pain, an increase in mobility and an overall improved quality of life. And with advances in technology, patients can expect their replacement joint to function well for 20 years or longer. But not all joint replacement surgeries are successful. Complications and failures can occur, and patients who expected dramatic pain relief and function after a knee or hip replacement may present with persistent pain, as well as considerable frustration and unhappiness.

About a third of patients will still have some aches and pains following knee or hip replacement. Early problems can be due to technical factors involving the surgery, inadequate rehab, or more serious problems such as infection or loosening. Problems can also occur years after surgery as the ceramics and plastics start to wear through. A joint replacement that had previously been functioning well for several years can suddenly start hurting or swelling.

The most common complaints following TKA include swelling, activity-related pain and mechanical symptoms, like a crunching behind the kneecap and even clicking when the patient walks.

With THA, common painful symptoms include persistent pain around the tendon or bursa on the side of the hip.

WHAT DO YOU DO IF YOUR PATIENT EXPERIENCES PERSISTENT PAIN AFTER JOINT REPLACEMENT SURGERY? Sorting out what is a normal discomfort for a prosthetic joint and what is a more serious problem is not always straightforward.

What may seem like a minor ache or pain could be a sign of a more serious underlying problem. Problems such as instability or loosening of the knee or hip, or even more unusual problems like corrosion or metal sensitivity, can be easily misdiagnosed; ruling out infection and instability is critical.

The optimal plan of care for those patients who continue to experience ongoing joint pain after TKA or THA is an evaluation referral with an orthopedic specialist. Specialized tertiary referral centers like Orlando Health Jewett Orthopedic Institute offer expert specialist care and advanced technology, including leadingedge imaging, such as MRI scanning with metal artifacts suppression, to diagnose reasons for persistent symptoms after a knee or hip replacement.

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Sometimes patients have unrealistic expectations of their replacement, because of what they’ve been told or seen on TV or social media.

Expecting the joint to be normal versus artificial is a common source of dissatisfaction. They may not follow proper rehab or activity levels. These patients require a comprehensive evaluation of their overall fitness level, including other joints like the shoulders and ankles. Patients need to focus on total body fitness and understand what a replacement joint can and cannot do.

An overall aging population, a rise in the prevalence of risk factors such as obesity, and the popularity of maintaining active lifestyles not only contribute to the increasing number of joint replacement surgeries, but also the inevitable consequential increase in complications or failed joint replacements. We also have seen an increasing number of joint replacements in a younger patient population whose active lifestyles place added stress and wear on their original and replacement joints. With normal use and activity, every joint replacement implant begins to wear over time, and excessive activity or weight may increase the rate of this normal wear, causing the replacement joint to loosen and become painful.

Evaluation by an orthopedic specialist may determine that a painful knee or hip replacement does need any further surgical intervention. It may simply be something that indicates additional physical therapy, weight loss or activity modification. But there is an increasing number of patients who will require a joint replacement revision (redo).

WHEN IS REVISION SURGERY NECESSARY? Revision, or redo, surgery is a complex procedure that involves removing and replacing the original joint implant, usually due to a complication from the initial replacement.

Overall, complication rates following TKA or THA surgery are low. Serious complications, such as a joint infection, occur in fewer than 1-2 percent of patients. Instability can occur in 2-3 percent of knee replacements, and 2-3 percent of hip replacements can have a dislocation or similar problem. These percentages are small, but given the large number of surgeries performed, it adds up to a significant number of people experiencing undue discomfort and pain.

Typically, more women than men undergo knee replacement, with hip replacements being about even between men and women. Overall, men place more wear on replacement joints than women, due both to more body weight and slightly more activity, resulting in a slightly higher need for revision surgery.

Data from Medicare shows that the average rate of revision surgery within 90 days is 0.2 percent but increases to 3.7 percent

within 18 months. These are usually due to infection or mechanical complications of the implant. While surgical techniques and implant designs and materials continue to advance, implant surfaces can wear down and the components can loosen over time. Research suggests that long-term wear and loosening affects 6 percent of people after 5 years and 12-15 percent after 10 years.

Only a handful of centers in Florida specialize in diagnosing and treating conditions associated with problematic joint replacements.

Specialists with the Orlando Health Jewett Orthopedic Institute perform hundreds of successful revisions of knee and hip replacements every year for patients throughout Florida and the Southeast.

These complex, long procedures can be challenging and require multidisciplinary and subspecialty care, including infectious disease experts and plastic surgeons, as well as advanced surgical, intensive care, recovery and rehabilitation facilities that provide a higher level of care. Backed by all the resources of the Orlando Health system, Orlando Health Jewett Orthopedic Institute offers this advanced level of care. And, expected to be completed in 2023, a new, state-of-the-art orthopedic complex on Orlando Health’s downtown Orlando campus will usher in the next generation of orthopedic care.

Ultimately, the basic message for your patients is “Don’t give up hope!” An orthopedic surgeon who specializes in complex knee and hip revision work can provide a comprehensive evaluation to determine how to best correct a persistent joint replacement problem.

Internationally recognized for joint replacement surgery and trauma, George J. Haidukewych,

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MD, serves as Orlando Health’s director of orthopedic trauma and chief of complex joint replacement, practicing at the Orlando Health Jewett Orthopedic Institute. Dr. Haidukewych specializes in total hip and total knee replacements as well as orthopedic trauma. He brings extensive experience in the management of failed and infected total hip and total knee replacements and in reconstruction of the joints after trauma. Up to half of his practice is dedicated to solving these challenging problems from around the Southeast. Dr. Haidukewych completed his residency training at the Mayo Clinic in Rochester, Minnesota, as well as a fellowship at Florida Orthopaedic Institute in the Tampa Bay area..

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