Florida MD November 2021

NOVEMBER 2021 • COVERING THE I-4 CORRIDOR

AdventHealth Medical Group: Providing Top Comprehensive Head and Neck Surgery Care to 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

contents 5

NOVEMBER 2021 COVERING THE I-4 CORRIDOR

 COVER STORY

PHOTO: PROVEDED BY ADVENTHEALTH

AdventHealth Medical Group Otolaryngology-Head and Neck Surgery has been specializing in the treatment of benign and malignant tumors of the head and neck area for the past nine years. The program has been so successful in treating patients across central Florida that it has expanded with a second location. J. Scott Magnuson, MD, FACS is the medical director of the program. He explains, “Our first location was opened in 2012 on the campus of AdventHealth Celebration. With the program growth, and many patients seen from Seminole, Flagler, Volusia and Brevard counties, a decision was made to expand the program to the AdventHealth Altamonte Springs campus. This location will better geographically serve the head and neck cancer patients who live in those counties.”

Dr. J. Scott Magnuson demonstrates robotic surgery at the Nicholson Center, AdventHeath’s state-of-the-art surgical training facility.

ON THE COVER: LEFT TO RIGHT: Fawaz Makki, MD; James Bekeny, MD; J. Scott Magnuson, MD, FACS; Gregory Neel, MD; Bruce Haughey, MBChB, MS, FRACS, FACS

3 MEDICAL CANNABIS DOES NOT CREATE COGNITIVE DECLINE IN SENIORS PHOTO: PROVEDED BY ADVENTHEALTH

13 A PATH FOR BETTER BONE HEALTH

DEPARTMENTS 2

FROM THE PUBLISHER

8 PULMONARY

9

MARKETING YOUR PRACTICE

10 DERMATOLOGY 12 PEDIATRICS 13 HEALTHCARE LAW

FLORIDA MD - NOVEMBER 2021

1

FROM THE PUBLISHER

I

am pleased to bring you another issue of Florida MD. I can only imagine the emotional and physical trauma that a woman goes through when she has a mastectomy. The procedure affects not only her body, but her mind and her self-esteem. Now add in the inability to not be able to reconstruct her breasts and give that part of her life back, because she’s uninsured or under insured, and it becomes an unthinkable crushing blow. Fortunately there is My Hope Chest to help women who are unable to afford reconstructive surgery. I asked them to tell us about their organization and how you, as physicians, can help. Please join me in supporting this truly wonderful organization.

Best regards,

Donald B. Rauhofer Publisher

MY HOPE CHEST — Making Women Whole Again In 2010, more than 22,000 uninsured women lost their breasts to cancer and were left disfigured, deformed and feeling “less than whole.” How many years has this figure been growing?

Many organizations raise funds for research, education and “awareness” of breast cancer. Most have no idea there lies a huge gap in assistance for delayed reconstruction and co-pays for survivors wanting this surgery.

My Hope Chest is the ONLY national 501c3 non-profit organization focused on funding breast reconstruction for the uninsured and under insured survivors. Our services “pick up” where other breast cancer organizations leave off… providing the “final step in breast cancer treatment. ” My Hope Chest is about addressing the needs of survivors now. Through wonderful surgeon partnerships we are able to transform the lives of breast cancer survivors who otherwise have no hope of reconstruction.

We hope to hear from you to learn how we can work together to eliminate our wait list and take action to help every woman who desires reconstruction after mastectomy and feel restored in body, mind and spirit.

Wish List • Surgeons to create awareness for My Hope Chest and to identify new clients • Doctors of Distinction- Surgeon partners nationwide to join our program.

• Corporate partners, interested in Win-Win, Commercial- coventure marketing campaigns promoting their product or service by sharing our vision to make sure there is always coverage for reconstruction surgery.

For additional information on how you can help or refer a patient please go to www.MyHopeChest.org.

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Reprints of cover articles or feature stories in Florida MD are ideal for promoting your company, practice, services and medical products. Increase your brand exposure with high quality, 4-color reprints to use as brochure inserts, promotional flyers, direct mail pieces, and trade show handouts. Call Florida MD for printing estimates.

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, Ramamoorthy Nagasubramanian, MD, Scott Bradfield, MD, MBA, Andy Kolb, MD, Naina Mehta, MD, Sonda Eunus, MHA, Michael Patterson NHA, OTR/L, CEAS, Juan Lopez, Pharm D, Pragati Gusmano, ND, 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.

Advertising rates upon request. Postmaster: Please send notices on Form 3579 to P.O. Box 621856, Oviedo, FL 32762.

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.

Medical Cannabis Does Not Create Cognitive Decline in Seniors

By Michael Patterson, NHA, OTR/L, CEAS A recent study published in the September 2020 edition of the Drug and Alcohol Review, determined that the use of medical cannabis does not create a cognitive decline in Senior Citizens. The link to the study is below: https://onlinelibrary.wiley.com/doi/10.1111/dar.13171 The study was performed by Sharon R. Sznitman PhD, Senior Lecturer, Simon Vulfsons MD, Director, David Meiri PhD, Lecturer, Galit Weinstein PhD, Senior Lecturer at Israel’s Haifa University School of Pubic Health. The study included 125 cannabis users who were 50 years and older. Out of the 125 study participants, 63 had Israeli government permission to used cannabis and 62 did not have permission to use cannabis from the Israeli government.

Each participant was put through a multitude of tests consisting of CogState computerized brief battery used to assess cognitive performance of psychomotor reaction, attention, working memory and new learning. Regression models and Bayesian t‐tests examined differences in cognitive performance in the two groups. Furthermore, the associations between Medical Cannabis use patterns (dosage, cannabinoid concentrations, length and frequency of use and hours since last use) with cognition were assessed among Medical Cannabis licensed patients.

Patients were tested before use of Medical Cannabis and after use of Medical Cannabis. The result of the study showed no detectable difference in cognitive ability before or after use of medical cannabis.

Dr. Sharon Sznitman and Dr. Galit Weinstein noted that the results of the study do not show any widespread change on cognition in older chronic pain patients. Considering use of medical cannabis is increasing in older populations, this study could be a first step towards a better risk-benefit assessment of the use of medical cannabis with Seniors. The researchers also noted that “previous studies have shown that medical cannabis can have long-term effects on the brain when consumed at a young age. Those affects are not necessarily the same when consumed in old age.”

ANALYSIS Senior Citizens are the fastest growing demographic of users of Medical Cannabis in the United States. With over 435,000 medical cannabis patients in Florida and the average age of a medical cannabis patient over 50 years old, many Seniors are currently using medical cannabis. However, these numbers could be considered the “tip of the iceberg”. As more senior citizens become comfortable using medical cannabis for their diagnoses with less side effects and more relief than traditional pharmaceutical medications, we will see many more seniors

starting to use medical cannabis into 2021 and beyond.

Physicians and health care organizations need to educate seniors on the benefits of medical cannabis and begin to track the data related to outcomes of seniors who take cannabis as a medicine. Not only is medical cannabis safer than traditional pharmaceuticals (for most patients), but it is also more cost effective for health care organizations (ACOs) for cost of care per patient. The evidence is in the data. As more ACOs and health care entities start to track the data around use of medical cannabis and see better outcomes and decreased cost of healthcare within their system, you will see more acceptance of medical cannabis as a medicine within the current healthcare community.

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

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It’s not about

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It’s about making the days count.

Hospice • Palliative Care • Grief Support

4 FLORIDA MD - NOVEMBER 2021

Featuring specialized programs and services for children to seniors, and a proud Level 5 We Honor Veterans program provider. (866) 269-4240 I reflectionslsc.org

COVER STORY

AdventHealth Medical Group:

Providing Top Comprehensive Head and Neck Surgery Care to Central Florida By: Staff Writer AdventHealth Medical Group Otolaryngology-Head and Neck Surgery has been specializing in the treatment of benign and malignant tumors of the head and neck area for the past nine years. The program has been so successful in treating patients across central Florida that it has expanded with a second location. J. Scott Magnuson, MD, FACS is the medical director of the program. He explains, “Our first location was opened in 2012 on the campus of AdventHealth Celebration. With the program growth, and many patients seen from Seminole, Flagler, Volusia and Brevard counties, a decision was made to expand the program to the AdventHealth Altamonte Springs campus. This location will better geographically serve the head and neck cancer patients who live in those counties.”

multidisciplinary team meets weekly to discuss patient cases and make recommendations for the most advanced, state-of-the-art, personalized care.

COMPREHENSIVE CARE

The goal for recruiting Dr. Magnuson was to build a comprehensive head and neck oncology program that was at the level of an academic, tertiary care center. Prior to his arrival, many patients with head and neck cancers were referred to other centers many miles outside of the Orlando area. Quickly the program was established, so that today, all head and neck cancer patients may be treated here, close to home, and not travel long distances.

The AdventHealth Head and Neck Oncology program includes a multidisciplinary approach to the care of the head and neck cancer patient. The team includes doctors from medical and radiation oncology, head and neck surgeons, a speech and swallowing therapist, a cancer dietician, physician assistants, social workers, and specialized head and neck oncology nurses. While treatment for these patients happens daily, the

Dr. Magnuson was recruited by AdventHealth from the University of Alabama-Birmingham in 2012. During his 18 years at UAB, Dr. Magnuson led the residency training program in Otolaryngology-Head and Neck Surgery (ENT) as well as formed part of the team that cared for patients with head and neck cancer. He is best known for his work in pioneering minimally invasive surgery for patients with tumors of the pharynx. He was part of the team that developed the roboticassisted surgery procedure to remove tumors from the tonsils and deep portions of the tongue and larynx.

PHOTO: PROVEDED BY ADVENTHEALTH

Dr. J. Scott Magnuson demonstrates robotic surgery at the Nicholson Center, AdventHeath’s state-of-the-art surgical training facility.

“The resources that AdventHealth has allowed us to develop and build for our patients has been unbelievable,” says Dr. Magnuson. “The commitment this organization has for the best care for the patients in Central Florida is truly remarkable.”

With those resources, Dr. Magnuson has been successful in recruiting head and neck surgeons to AdventHealth. One of the recruited surgeons is Bruce Haughey, MBChB, MS, FRACS, FACS, a renowned surgeon and researcher who is a leading expert on cancers related to human papilloma virus (HPV) infections. Both Drs. Magnuson and Haughey publish on this area of head and neck cancer and present the data at local, national and international conferences. Dr. Haughey was a member of the American Joint Committee on Cancer (AJCC) where a new staging system was made specifically FLORIDA MD - NOVEMBER 2021

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COVER STORY for HPV-mediated cancers of the tonsils and base of tongue.

Another area of need in the surgical treatment of head and neck cancer patients was with reconstructive plastic surgery.

Many times, large tumors involve important structures of the mouth and throat area. Reconstruction of these areas is necessary to allow the patients to continue to eat and speak after surgery.

“Unfortunately, we see many patients that require removal of the mandible, or even the entire tongue,” says Dr. Magnuson.

“Thankfully we can offer the complex reconstruction of those body parts by using bone from the leg, or tissue from the arm or thigh, and rebuild their mouths so they may still speak and eat.”

PHOTO: PROVEDED BY ADVENTHEALTH

The surgeries that the team performs do not stop at large invasive tumors or tumors of the pharynx. Dr. Magnuson and his colleagues also perform thyroid and parathyroid surgeries, skin cancer surgery, surgery of the salivary glands, and removal of tumors from the skull base. “We are able to perform surgery of the entire head and neck area with the exception of the brain and spine” explains Dr. Magnuson.

QUALITY AT THE CORE “We believe patients are best taken care of in a high-volume facility where they can stay within the organization and not have to go to other places to search for care,” Dr. Magnuson Dr. Magnuson and his PA review a patient’s scans post-surgery.

Dr. James Bekeny, Head and Neck Surgeon, examines a patient during a consultation.

said. “This comprehensive approach streamlines the care for the patient, allows for timely treatment, and gives the patient a sense of safety because there is an entire connected team looking after their needs.”

Always on the cutting edge, the AdventHealth team leads clinical trials aimed at offering the latest treatment plans for head and neck cancer patients. These trials include the newest immunotherapy treatments as well as novel surgical procedures intended to reduce the side effects of treatment. An example is a surgical clinical trial for patients with HPV-mediated cancer of the tonsils. “We believe the treatment for these patients may include less radiation and chemotherapy and still provide the excellent cure rates” states Dr. Magnuson. “AdventHealth is the only center in the state of Florida that can offer this surgical clinical trial to those patients.”

A STREAMLINED REFERRAL PROCESS PHOTO: PROVEDED BY ADVENTHEALTH

From the outset, Dr. Magnuson wanted to assure that referrals to the head and neck oncology program were easy. He recognized that it may be difficult for referring providers to get a timely appointment for a patient. “For best patient care, we must see the patient as soon as possible in the office and then begin the care journey for the patient right away” Dr. Magnuson says. To accomplish this priority, a single phone number has been made available for patient referrals. Provider offices and patients may call 407-303-4120. This number serves the offices at both Celebration and Altamonte Springs. Staff are trained to get the patient in quickly to the best location for the patient. The 6 FLORIDA MD - NOVEMBER 2021

PHOTO: PROVEDED BY ADVENTHEALTH

PHOTO: PROVEDED BY ADVENTHEALTH

COVER STORY

The Head and Neck Surgery team collaborates to perform a procedure on an oncology patient.

doctors in the head and neck surgery group are committed to seeing a new patient within a week, if needed.

During a procedure, the surgeon uses a microscope to hyper-focus on the surgical site, sparing surrounding healthy tissue.

SERVICES PROVIDED

BETTER ACCESS

• Surgical treatment of head and neck tumors

With the addition of its Altamonte Springs location, the AdventHealth Medical Group Otolaryngology-Head and Neck Surgery team can provide even better service to cancer patients in Central Florida. And, with the ability to provide care that matches that of a tertiary academic medical center, AdventHealth is the premiere comprehensive head and neck surgery program in Central Florida. For more information, call 407-303-4120.

• Endocrine surgery (thyroid and parathyroid)

J. Scott Magnuson, MD, is a board-certified otolaryngologist - head and neck surgeon at Otolaryngology and Head and Neck Surgery in Celebration. He possesses advanced training in robotic-assisted surgery, is a leading authority on transoral robotic surgery (TORS), and specializes in helping patients with cancers of the head and neck. His areas of expertise include advanced head and neck surgery, tumor removal, skin cancer surgery, airway surgery, thyroid and parathyroid surgery, reconstructive surgery and voice and swallowing disorders. Dr. Magnuson is an award-winning surgeon whose credentials include his medical degree earned at the University of Texas Medical School in Houston as well as his internship in general surgery and otolaryngology residency at the University of Alabama at Birmingham. 

• Endoscopic/open repair of esophageal diverticula • Surgical management of sleep apnea • Advanced reconstruction including flaps and free flaps • Clinical trials • Minimally invasive surgery including transoral robotic surgery (TORS) and transoral laser microsurgery (TLM) • Skull-base surgery including temporal bone

FLORIDA MD - NOVEMBER 2021

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PULMONARY AND SLEEP DISORDERS

Idiopathic Pulmonary Fibrosis – Current Approach to Therapy By Daniel T. Layish, MD Idiopathic pulmonary fibrosis (IPF) is also known as usual interstitial pneumonitis (UIP). There are estimated to be 48,000 new diagnoses of IPF per year in the United States, with 40,000 deaths per year.

About two thirds of patients with IPF pass away within five years of diagnosis. For many years, combination therapy with prednisone and azathioprine had been used. However, the PANTHER trial revealed convincingly that combination therapy with prednisone and Imuran actually resulted in greater mortality, more hospitalizations, and more serious adverse events than placebo. Therefore, combination therapy with azathioprine and prednisone is no longer recommended. For a while, treatment of IPF had been essentially supportive including supplemental oxygen, pulmonary rehabilitation and vaccination against Streptococcus pneumoniae and influenza. Lung transplant can also be considered when appropriate.

Pirfenidone (Esbriet) is an antifibrotic agent, which has now been shown in several clinical trials to reduce disease progression and improve progression free survival in patients with IPF. Pirfenidone inhibits the synthesis of transforming growth factor Beta, which plays a role in cell proliferation and differentiation.

There have been two previous phase III trials of Pirfenidone that seem to have conflicting results. One study (published in 2010) showed that Pirfenidone slows disease progression while another study (published in 2011) did not meet its end point.

However, this last study did have some trends that were in a positive direction; this resulted in the FDA requesting the “ Assessment of Pirfenidone to Confirm Efficacy and Safety in Idiopathic Pulmonary Fibrosis Study” (ASCEND). The result of this study was published in the New England Journal of Medicine. In the ASCEND study, 278 patients with IPF were randomized to receive Pirfenidone 2403 mg per day for 52 weeks.

277 patients were randomized to receive Placebo. The primary endpoint was forced vital capacity and secondary end points included 6-minute walk test distance, progression free survival, dyspnea, overall mortality and disease specific mortality.The proportion of patients who had an absolute reduction of at least 10% in predicted forced vital capacity (FVC) or who died was 47.9% less in the Pirfenidone group as compared to the Placebo group. In addition, the average decrease in FVC from baseline was lower in the Pirfenidone group versus the Placebo group (235 versus 428 mL). Furthermore, the proportion of patients who had no decline in FVC was 132% higher in the Pirfenidone group than in the Placebo group and there was also less decline in the 6-minute walk distance in the Pirfenidone group compared to the Placebo group as well as better progression free survival.

However, there was no significant difference in dyspnea score and all cause mortality or disease specific mortality between the two groups.

There has been a pooled analysis of data from all three Pirfenidone trials, which revealed that the overall risk for death at 8 FLORIDA MD - NOVEMBER 2021

52 weeks was lower in the Pirfenidone group versus the placebo group with a hazard ratio of 0.52. In this pooled analysis Pirfenidone improved both all cause mortality and disease specific mortality. The most common side effects included gastrointestinal and skin related adverse effects, but these rarely led to treatment discontinuation.

Unfortunately, patients on Pirfenidone do not necessarily perceive improvement and Pirfenidone is certainly not a cure for this serious illness. Nevertheless, it appears to be a good option for slowing down the progression of this serious condition.

Another new option for treating UIP/IPF is Nintedanib (OFEV®) This is a tyrosine kinase inhibitor that targets growth factors including the vascular endothelial growth factor receptor, fibroblast growth factor receptor and platelet derived growth factor receptor. In May 2014, Luca Richeldi et al published the results of two 52 week randomized, double blind phase 3 studies of nintedanib (150 mg twice/day) versus placebo in the New England Journal of Medicine. 1066 patients were enrolled in a 3:2 randomization. The adjusted annual rate of change in FVC was negative 115 ml with Nintedanib versus negative 240 ml with placebo. Diarrhea occurred in over 60 percent of patients on Nintedanib but led to discontinuation in less than five percent.

The most frequent serious adverse reactions reported in patients treated with OFEV® (more than placebo), were bronchitis (1.2% vs. 0.8%) and myocardial infarction (1.5% vs. 0.4%). However, in the predefined category of major adverse cardiovascular events (MACE) including myocardial infarction, fatal events were reported in 0.6% of OFEV® treated patients and 1.8% of placebo-treated patients. Therefore, the clinician must weigh the risk/benefit ratio of using this medication in a patient with known coronary artery disease (or cardiovascular risk factors) carefully.

In conclusion, IPF/UIP is a relatively common and progressive pulmonary disorder. Pirfenidone and Nintedanib are two new agents that appear to slow down the progression of this disease.

Further research needs to be done to identify agents that can reverse pulmonary fibrosis. Since Nintedanib and Pirfenidone seem to have similar efficacy, most clinicians choose one over the other based on side effect profile and dosing considerations.

References available upon request

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 University in Durham, North Carolina. Since 1997, he has 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 407-841-1100 or by visiting www.cfpulmonary.com. 

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.

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.



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 FLORIDA MD - NOVEMBER 2021

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DERMATOLOGY

Not All Basal Cell Carcinomas Are Created Equal

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.  10 FLORIDA MD - NOVEMBER 2021

Nodular basal cell carcinoma.

PHOTO: JOHN MEISENHEIMER, VII PHOTO: JOHN MEISENHEIMER, VII PHOTO: JOHN MEISENHEIMER, VII PHOTO: JOHN MEISENHEIMER, VII

Occasionally a patient will tell me their “doctor friend” recommended that they don’t need treatment for a basal cell carcinoma because it will never hurt you. “Doc, he said it’s only a basal cell carcinoma.”

Dermatologists fully recognize this as a genuinely cringe-worthy statement. You don’t need to see too many people missing various parts of their facial anatomy to know this advice is blatantly wrong. Even in this modern time of medical miracles, people still die from neglected basal cell carcinomas. When pressed for the name of their “doctor friend,” it usually comes up as I don’t remember their name, or it ends up being “Doctor Google.”

It is true a superficial basal cell carcinoma on the torso probably would take years and years for it to cause any sort of significant morbidity to a patient. But, on the other hand, even a small basal cell on the torso will continue to grow if left untreated slowly. What might have been a simple, inexpensive procedure now, a decade later, has turned into a monster of aggravation, discomfort, and cost.

Although metastatic disease risk is low with basal cell carcinomas, it is certainly not zero. Several people die each year from basal cell carcinoma. Even more, patients can have disfiguring bouts with cancer losing various parts of anatomy such as nose, ears, eyes, etc. What a lot of patients and even some physicians are not aware of is that not all basal cell carcinomas are created equal. There are several different histologic growth patterns. These varying histologic types can each behave Infiltrative Basal Cell carcinoma of differently and require different treatment plans. the forehead.

As mentioned before, a superficial basal cell carcinoma is probably not going to cause a great deal of physical damage unless neglected for long periods. There are other types of basal cell carcinomas; morpheaform and sclerosing basal cell carcinomas with infiltrating growth patterns. These cancers left untreated can cause a significant amount of morbidity in shorter periods measured in months, not years. Aggressive basal cell cancers can also become neurotropic, meaning that they “wrap” around a nerve and can track down its length. Neurotropism can be particularly dangerous, especially if this is on the face and affecting a nerve that happens to pass through a foramen into the brain. Clearly, not a good scenario.

Basal cell carcinomas, limited to the skin, tend to be very Pathology of an infiltrative Superficial Multifocal BCC. basal cell carcinoma. amenable to treatment in a variety of different ways. Even as a Mohs surgeon I can think of at least half a dozen different ways that I have treated basal cell carcinomas. Not all basal cell carcinomas need Mohs surgery. Each case of basal cell carcinoma should be evaluated individually and in consideration as to the best method of treatment based on its histologic growth pattern, location, and physical condition of the patient.

The great news about basal cell carcinoma, even though it is the most common type of skin cancer and millions are treated each year, only a tiny percentage of these end up causing death in patients. When someone says I would much rather have a basal cell Neurotropic basal cell carcinoma. carcinoma than a melanoma, there is a caveat; if you die from a basal cell carcinoma, you are just as dead as if you were to die from Sclerosing basal cell melanoma. Happily, most of the time, with early diagnosis and carcinoma. treatment, you don’t have to die from either. Basal cell carcinoma is called cancer for a reason. Give it its respect that it is due, or otherwise, you may regret saying, “oh, you don’t have to worry about it, it’s only a basal cell carcinoma.”

PHOTO: JOHN MEISENHEIMER, VII

PHOTO: JOHN MEISENHEIMER, VII

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

FLORIDA MD - NOVEMBER 2021 11

PEDIATRICS

Increasing Awareness Broadens Access for Childhood Cancer and Sickle Cell Patients

By Ramamoorthy Nagasubramanian, MD Treatment of childhood cancer is one of the great success stories of modern medicine. Often touted as an example of medical advances made possible through research, a pediatric cancer diagnosis that once meant a fatal prognosis is now survivable for 80 percent of patients.

Despite these advancements, cancer remains the leading cause of death by disease among children. What’s more, all pediatric cancers combined receive only 4 percent of U.S. federal cancer research funding.

This past September was Childhood Cancer Awareness Month and Sickle Cell Awareness Month, reminding us to take stock of our current situation and to raise awareness of these conditions.

IMPROVING ACCESS TO ADVANCE HEALTH Having access to care for any medical need is important. But for patients who need the pediatric-focused, specialized treatment that childhood cancer requires, it can take on even deeper significance.

When one considers that society’s most underserved children — from racial and ethnic minority groups — remain more likely to die of childhood cancer than their non-minority peers due to lack of access to care, this is unacceptable.

At Nemours Children’s Health, our Hematology-Oncology team has found that by working together we can better impact two common goals: To find a cure and to reduce the side effects of childhood cancers and sickle cell disease to help all children not just live, but live longer and with a better quality of life — today and for many tomorrows.

HELPING TO HEAL THOUSANDS EACH YEAR Helping all children live longer and with a better quality of life requires that we deliver equitable care.

Our program treats 6,000 pediatric cancer patients in Florida and Delaware each year, and many enroll in the latest clinical trials sponsored by the National Cancer Institute to help children with conditions like: • solid tumors • sarcomas • neuroblastomas • blood disease and blood cancers The volume of patients, coupled with decades of experience, means that more kids are receiving life-saving care and having better outcomes.

Today, our program boasts the nation’s second largest pediatric clinical trial program of its kind and is one of only two pediatric programs nationwide to be recognized as a National Cancer 12 FLORIDA MD - NOVEMBER 2021

Institute Community Oncology Research Program (NCORP).

REDUCING DISPARITIES IN CLINICAL TRIAL ACCESS AND RESEARCH PARTICIPATION To create a more equitable care environment for patients, we have worked intentionally to identify and minimize all barriers to research and clinical trial participation. To measure the impact of these efforts, our program tracks and reports weekly on three essential data elements: 1. Total clinical trial enrollments 2. Clinical trial enrollments across racial and ethnic groups and compared to population estimates 3. Screen failures (eligible but not enrolled) across racial and ethnic groups, as well as primary language spoken Our objective is to enroll all eligible patients on available clinical trials, inclusive of Therapeutic and Non-Therapeutic trials (e.g., symptom management and cancer prevention trials). We measure our program against national benchmarks published each year in the Children’s Oncology Group Report Card.

What we’ve learned along the way is that by understanding the factors that contribute to underrepresentation in research and clinical trials, clinicians can create targeted strategies to increase engagement.

For example, by translating our research consent forms into different languages common in our catchment areas, we have been able to eliminate patient screening failures due to language barriers. This is especially relevant considering that half of our clinical trial enrollments identify as Hispanic or non-white, a significant proportion of whom required consent in a language other than English.

SPECIAL FOCUS ON SICKLE CELL TREATMENT Another area related to the delivery of equitable pediatric care pertains to sickle cell disease, a genetic condition affecting the red blood cells that disproportionately impacts Black children and families. Roughly 3,000 children are born with sickle cell disease in the U.S. each year.

Since sickle trait usually doesn’t cause illness, many parents are unaware that they have sickle cell trait. If two parents both have sickle cell trait, then there is a 25 percent chance that their children can be born with sickle cell disease.

Our Hematology-Oncology program is poised to lead the field of sickle cell care and research. For our work, we’ve been awarded a $10.6-million, 5-year grant from the Center of Biomedical Research Excellence (COBRE).

CONTINUED ON PAGE 16

A Path for Better Bone Health

By Judith A. Moss, DO Osteoporosis, a disease that causes the bones to lose density or thickness, poses a serious health threat to more than 50 million American adults aged 50 and older. Included in that figure are more than 10 million who have osteoporosis, of which more than 80 percent are women, and over 40 million with low bone mass, which increases the risk of developing osteoporosis.

Even though a bone fracture is the most common first symptom, osteoporosis does have a few other subtle signs. Loss of height after age 50 (over an inch) could be due to vertebral fracture.

In women, osteoporosis is often seen about eight years after menopause, when a decrease in estrogen leads to bone loss. But bone thinning — a natural, irreversible process — begins years earlier, in the mid-twenties. Other risk factors that can accelerate bone loss include:

While these breaks can be painless, they may cause back pain and can eventually lead to curvature of the spine in addition to height loss. In severe cases, broken bones in the spine can result in a dowager’s hump, or a condition known as kyphosis.

• Gender: Osteoporosis is more likely to occur in women than in men.

• Age: Although the disease usually presents after age 50, it can start at age 30 or younger.

• Race: Caucasians and Asians are more likely to develop osteoporosis.

• Body frame: Those with a petite frame are at greater risk, due to smaller, thinner bones.

• Family history: Risk increases if there are any close family members with osteoporosis.

• Previous fracture: Someone who suffered a broken bone in a minor incident (low level trauma), especially after age 50, has a higher risk of osteoporosis.

• Sex hormone deficiency: Low levels of a sex hormone (i.e., estrogen) can increase risk.

• Eating disorders: These conditions, especially anorexia nervosa, can affect bone strength.

• Lifestyle behaviors: Smoking, alcohol use and low levels of physical activity increase the risk of osteoporosis.

• Nutrition: Low dietary intake of calcium and vitamin D, necessary for bone strength, increases risk.

• Medications: Certain medicines, like steroids or those for the thyroid, can affect bone strength.

SYMPTOMS OF OSTEOPOROSIS Characterized by weakening of bone tissue and structure and a resulting loss of strength, osteoporosis can lead to an increased risk of fractures. Bones become fragile and can break easily, even when doing normal activities like stepping off a curb. Most people don’t realize they have osteoporosis until they break a bone.

TREATMENT FOR OSTEOPOROSIS Once osteoporosis has developed, the best course of treatment is to try to prevent further bone loss through medication and lifestyle modifications. In most cases, it is not possible to regain bone mass. It also is important to provide education and resources that can help patients avoid falls and fractures. With severe osteoporosis, the likelihood of fractures can make it difficult to live independently. Severe spinal curvature can make it challenging to breathe or complete daily living tasks.

3 HABITS TO COMBAT OSTEOPOROSIS Even though osteoporosis cannot be reversed, it can be prevented. While there are some risk factors that patients have no control over, others offer opportunity to change. Here are three ways to reduce the risk of developing osteoporosis: • Start preventive measures early. Peak bone mass is the maximum amount of bone a person has during their life. Peak bone mass typically occurs in the early 20s for women and late 20s for men, so it’s important to build and maintain bone mass from a young age. Even in children, developing a 10 percent increase in peak bone mass reduces the risk of a fracture as an adult by 50 percent.

• Ensure adequate intake of calcium and vitamin D. Calcium is a mineral that keeps bones and teeth healthy. Since we don’t produce it on our own, it must come from foods we eat.

Dairy foods like milk, yogurt and cheese, as well as dark, leafy vegetables are high in calcium. Vitamin D is necessary because it helps the body absorb calcium. Vitamin D is found in foods like fish, egg yolk and cheese, and in fortified milk, orange juice and ready-to-eat cereal. Those who do not get enough calcium and vitamin D through diet should consider a multivitamin or nutrient-specific supplement.

• Incorporate daily exercise. Physical activity, particularly weight-bearing exercise, puts stress on the bones in a good way, encouraging them to grow and become denser. Examples of FLORIDA MD - NOVEMBER 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 GIFT CERTIFICATES ARE AVAILABLE 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 ANTI-BACTERIAL | SIDE EFFECT FREE | ANTI-INFLAMMATORY the possibility of up to 10 years in prison.

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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.

HEALTHCARE LAW 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.

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.

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

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.

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.

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 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. 

FLORIDA MD - NOVEMBER 2021 15

Increasing Awareness Broadens Access for Childhood Cancer and Sickle Cell Patients

By Ramamoorthy Nagasubramanian, MD

CONTINUED FROM PAGE 12

Through the grant, our program joined Christiana Cares to form the Delaware Comprehensive Sickle Cell Research Center. This center studies the laboratory, clinical and psychosocial sequelae of sickle cell disease and trains future researchers and doctors to improve the care and outcomes for children with sickle cell disease worldwide.

For pediatric cancer and sickle cell patients, increasing awareness of the unique challenges they face in treatment and beyond is an important step to garner more advocacy and support for programs and research.

To learn more about our efforts, please visit Nemours.org/CancerResearch.

Ramamoorthy “Dr. Naga” Nagasubramanian, MD, serves as the Division Chief for Pediatric HematologyOncology at Nemours Children’s Hospital, Florida, where he also serves as a principal investigator for clinical trials in pediatric cancer, sickle cell anemia and hemophilia. Dr. Nagasubramanian is board-certified in pediatrics and pediatric hematology/oncology by the American Board of Pediatrics. He holds associate professor of pediatrics positions at the University of Central Florida College of Medicine and at the Florida State University College of Medicine.

A Path for Better Bone Health

By Judith Moss, DO

CONTINUED FROM PAGE 13

weight-bearing exercises include walking, dancing, tennis and hiking. Doctor can advise patients, particularly those with osteoporosis, on the most effective and safest exercises for them.

While osteoporosis is sometimes considered a natural part of aging, it doesn’t have to be. There are active and preventive measures people can follow, at any age, to help bones stay as strong as possible for a lifetime.

For more health and wellness tips visit OrlandoHealth.com/contenthub Judith Moss, DO, is a board-certified family medicine physician with Orlando Health Physician Associates, specializing in comprehensive, holistic care for patients of all ages and life stages. Dr. Moss earned her medical degree from the University of North Texas Health Science Center at Fort Worth Texas College of Osteopathic Medicine. She completed her family medicine residency at the Texas Tech Health Science Center in Odessa, where she served as chief resident. Dr. Moss is a diplomat of the American Board of Family Practice and the National Board of Osteopathic Medical Examiners.

16 FLORIDA MD - NOVEMBER 2021

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2021

EDITORIAL CALENDAR

Florida MD is a monthly medical/business digital magazine for physicians..

Florida MD is emailed directly to healthcare providers in Orange, Seminole, Flagler, Volusia, Osceola, Polk, Brevard, Lake and Indian River counties. Cover stories spotlight extraordinary physicians affiliated with local clinics and hospitals. Special feature stories focus on new hospital programs or facilities, and other professional and healthcare related business topics. Local physician specialists and other professionals, affiliated with local businesses and organizations, write all other columns or articles about their respective specialty or profession. This local informative and interesting format is the main reason physicians take the time to read Florida MD. It is hard to be aware of everything happening in the rapidly changing medical profession and doctors want to know more about new medical developments and technology, procedures, techniques, case studies, research, etc. in the different specialties. Especially when the information comes from a local physician specialist who they can call and discuss the column with or refer a patient. They also want to read about wealth management, financial issues, healthcare law, insurance issues and real estate opportunities. Again, they prefer it when that information comes from a local professional they can call and do business with. All advertisers have the opportunity to have a column or article related to their specialty or profession.

JANUARY –

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FLORIDA MD - NOVEMBER 2021 17

ORTHOPEDICS CARE

Just for kids.

Kids and teens need prompt and innovative care specifically designed for their growing bodies.

We offer family-centered, kid-friendly care right here in Central Florida. Our expert team, including board-certified and fellowship-trained physicians, uses advanced technologies to diagnose and treat an extensive range of conditions through our highly specialized pediatric orthopedics programs.

From common to rare, we treat disorders and injuries involving bones, joints, muscles and nerves at Nemours Children’s Hospital, as well as our other specialty locations in: • Downtown Orlando • Lakeland

• Lake Mary • Melbourne

• Narcoosee Road • Winter Garden

Call 407.650.7715 to refer a patient.

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