FloridaMD JulyAugust 2024

JULY/AUGUST 2024 • COVERING THE I-4 CORRIDOR

Leadership, Resources and Opportunity: What Attracts and Keeps Physicians at HCA Florida Healthcare

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JULY/AUGUST 2024 COVERING THE I-4 CORRIDOR

 COVER STORY

PHOTO: PROVIDED BY HCA HEALTHCARE

As one of the state’s largest healthcare systems, HCA Florida Healthcare focuses on recruiting and retaining top physicians to ensure the highest quality of care for the growing communities it serves. But what attracts and keeps in-demand talent in a competitive market?

HCA Healthcare was founded by physicians who believed the best patient care begins with giving physicians what they need. That means providing physicians a strong voice in decisions and delivery of care; more time to care for patients; the clinical capabilities including equipment, staff and support to promote the best patient outcomes; and ongoing capital investments to increase patient access and improve clinical care. Leadership, resources and opportunity – it’s what attracts and keeps the best and brightest at HCA Florida Healthcare.

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SELECTING A REAL ESTATE BROKER FOR YOUR MEDICAL PRACTICE

21

HELPING VETERANS TREAT OBSTRUCTIVE SLEEP APNEA

PHOTO: PROVIDED BY HCA HEALTHCARE

ON THE COVER:

DEPARTMENTS 2

FROM THE PUBLISHER

8

DERMATOLOGY

9

MARKETING YOUR PRACTICE

10

PULMONARY AND SLEEP DISORDERS

13

HEALTHCARE LAW

14

ORTHOPEDICS

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PEDIATRICS FLORIDA MD - JULY/AUGUST 2024

1

FROM THE PUBLISHER

I

am pleased to bring you another issue of Florida MD. If any of your patients are immunocompromised please share the following important information about Think of me Please and the important work they do to help these individuals.

For immunocompromised individuals, reducing exposure to common infectious bacteria, viruses, molds, and other particles is a daily concern. Think of me Please® is a Florida-based 501(c)3 organization serving individuals with compromised immune systems through education, awareness, and community connections since 2019. It was founded after multiple community members became seriously ill over the holidays when family members came into their homes while sick and contagious.

Too often, immunocompromised patients must choose between staying healthy or participating in everyday activities others may take for granted.

Approximately 6.6% of Americans are immunosuppressed because of health conditions, treatments, or prescriptions. At Think of me Please®, the missing link in healthcare is protecting vulnerable patients from potentially life-threatening illness through precautions anyone can take. It encourages everyone, especially healthcare providers, to take simple steps to keep the immunocompromised individuals they interact with safe. This may include actions like wearing a mask while interacting with the patient or moving the patient to a private room instead of having the patient wait in a general public area. Think of me Please® also launched its Door Hanger Initiative to provide simple signage as a reminder to pause, think, and take any necessary precautions before entering an area where there is an immunocompromised person inside.

The organization also provides community connections through events for immunocompromised individuals, communication with healthcare providers, and its virtual peer support space for caregivers. Think of me Please® shares videos and stories from patients, loved ones, caregivers, and healthcare providers. It asks all people, immunocompromised or not, to think of immunocompromised patients they may interact with, please.

Think of me Please® is always grateful to connect with healthcare providers, share their stories, and accept donations to continue providing education, awareness, and support. Visit ThinkofmePlease.org for additional information or email info@thinkofmeplease. org to request your Think of me Please® Door Hanger today.

Sources:https://thinkofmeplease.org/

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Donald B. Rauhofer Publisher

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Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: John “Lucky” Meisenheimer, MD,Tara M. Griffin, DMD,George Eldayrie, M.D, Julie Tyk, JD, Sonda Eunus, MHA, John Meisenheimer, VII, MD; BS, Sonda Eunus, MHA, Brian Kellogg, MD,Vanessa Fadul, APRN, Anais Andara, PA-C 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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COVER STORY

Leadership, Resources and Opportunity: What Attracts and Keeps Physicians at HCA Florida Healthcare

By Staff Writer

“Our medical staff is very engaged in the operations of the hospital and have been instrumental in our planning for needed hospital services and expansion from day one,” said KC Donahey, Oviedo Medical Center’s chief executive officer. “We rely on our physicians’ expertise to help us identify key elements we need to address that make a difference in the way we care for their patients.”

A HISTORY OF GROWTH AND INNOVATION HCA Healthcare first brought its physician-led hospital approach to Central Florida in 1982, building Central Florida Regional Hospital in Sanford (now HCA Florida Lake Monroe Hospital). Four decades later, in 2022, HCA Healthcare hospitals HCA Florida Poinciana Hospital, Poinciana

PHOTO: PROVIDED BY HCA HEALTHCARE

Healthcare systems that prioritize physician input will thrive. That was the philosophy upon which HCA Healthcare was founded in 1968, and it continues to guide the enterprise today. Now among the nation’s leading healthcare networks, HCA Healthcare has 186 hospitals across the U.S. and the United Kingdom – including 48 hospitals in Florida. This scale provides its physicians access to the latest technology, resources and a network of highly qualified, experienced professionals, creating an environment where providers succeed in their pursuit of medical excellence.

Oviedo Medical Center, part of HCA Florida Healthcare, Oviedo

and physicians in Greater Orlando joined other HCA Healthcare facilities across the state to form HCA Florida Healthcare, the state’s largest healthcare network.

Over the last decade, HCA Florida Healthcare has grown exponentially in Central Florida to meet the healthcare needs of its growing population. The combination of an increasingly high volume of tourists, college students and winter residents in addition to the increasing numbers of local residents, creates a dynamic environment of high demand for healthcare services. Now, in addition to the five HCA Florida Healthcare hospitals in the region – including two Level 2 trauma centers – our physicians can see patients at 12 freestanding emergency rooms, two acute inpatient rehabilitation centers, two ambulatory surgery centers and 13 urgent care centers.

PHOTO: PROVIDED BY HCA HEALTHCARE

“Our population growth is almost four times that of the national average, so it is incumbent upon us to invest in our community and grow along with it,” said Cullen Brown, chief executive officer, HCA Florida Poinciana Hospital, a hospital on the border of Osceola and Polk counties that has undergone several expansions over the past couple of years.

HCA Florida Healthcare physicians serve in leadership roles throughout the organization, ensuring service line expansions and other business decisions support patientcentered care. Our physicians can tap into the clinical experience of more than 45,000 active and affiliated physicians across the HCA Healthcare enterprise to advance their clini4 FLORIDA MD - JULY/AUGUST 2024

COVER STORY

PHOTO: PROVIDED BY HCA HEALTHCARE

cal toolbox. They have access to clinical data, research protocols and quality initiatives from hospitals nationwide to draw from with proven results. The opportunity to share experiences, ask questions and find support from such a vast network consistently leads to best outcomes, as exemplified by the multiyear recognitions of HCA Florida Healthcare hospitals in greater Orlando by Healthgrades for patient safety excellence and clinical quality.

“Our mission at HCA Healthcare is above all else, we are committed to the care and improvement of human life,” Brown said. “What I consistently see is our physicians take our mission to heart, and they demonstrate it through compassion, innovation and positive outcomes.

Our physicians want to be part of a healthcare system in which our standard of care is excellence.”

Access to leading technologies and support from hospital leadership is paving the way for physicians at HCA Florida Healthcare facilities to provide new treatment options to patients in multiple specialty areas. HCA Florida Lake Monroe Hospital recently completed its first dual chamber leadless pacemaker procedure, the newest option for patients with irregular heart rhythms. The procedure includes placing an atrial leadless pacemaker and a ventricular leadless pacemaker that have an implant-to-implant communication technology, allowing the devices to work together to provide synchrony. The procedure was performed by HCA Florida Lake Monroe Hospital’s electrophysiology medical director, Dr. Jorge Diaz, a longtime physician practicing with HCA Florida Healthcare in the Central Florida region.

“As a cardiac electrophysiologist, I value HCA Florida Healthcare’s efforts to provide our patients with the highest level of care,” said Dr. Diaz. “It is important to our hospital and to me personally that I can provide my patients with the latest in treatment and technologies for cardiac care right here in our community.”

Another example of the impact of physician engagement is their involvement in innovation through HCA Healthcare’s Department of Care Transformation and Innovation (CT&I). More

PHOTO: PROVIDED BY HCA HEALTHCARE

UCF Lake Nona Hospital, part of HCA Florida Healthcare, Lake Nona

HCA Florida Lake Monroe Hospital, Sanford

than three years ago, shortly after opening, UCF Lake Nona Hospital was named HCA Healthcare’s first CT&I Hub – one of only two in the country. HCA Healthcare’s CT&I team began its transformative work with innovative research and healthcare design in UCF Lake Nona Hospital’s Family Birthing Unit.

“Being one of the newest hospitals in Central Florida, UCF Lake Nona Hospital has state-of-the-art facilities with a wonderful healing atmosphere,” said Dr. Mark Palazzolo, board certified OB/GYN who practices at Orlando area HCA Florida Healthcare hospitals. “HCA Florida Healthcare has an excellent working relationship with doctors and is supportive of physicians in private practice.”

Dr. Alex Stinard is an emergency room physician at UCF Lake Nona Hospital and HCA Florida Lake Monroe Hospital. Along with about 75 other emergency physicians across several HCA Healthcare hospitals, he is piloting generative artificial intelligence technology that captures conversations between providers and patients, extracting key medical information.

“It is exciting to work with a healthcare company that allows me to combine my passions for quality patient care and technology to contribute to the development of solutions that will improve the patient-provider relationship and lead to better outcomes,” Dr. Stinard said.

Championing CT&I at UCF Lake Nona Hospital alongside its physicians is CEO Wendy Brandon.

“Our physicians bring a perspective that no one else can match, always starting from what is best for the patient,” Brandon said. “As a leader in innovation, HCA Healthcare is able to leverage the expertise of our physicians who bring an entrepreneurial spirit to their work, including them in the development of exciting new technology to improve quality and patient safety.”

FLORIDA MD - JULY/AUGUST 2024

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COVER STORY

Another example of HCA Healthcare’s physician leadership, within our hospitals and the medical community at large, is the important role it plays in mentoring the next generation of physicians. HCA Healthcare’s Graduate Medical Education program, in partnership with the University of Central Florida College of Medicine, was launched 10 years ago in response to the state’s physician shortage. While more college graduates were choosing careers in medicine, new medical school graduates faced a shortage of residency opportunities to continue their training. HCA Healthcare stepped up to be part of the solution.

“Our partnership with HCA Healthcare reinforces our commitment to providing outstand- HCA Florida Lake Monroe Hospital graduate medical education leaders and new residents ing training and mentorship that will prepare the next generation of physicians to deliver Lake Monroe Hospital’s team approach to patient care and the the highest quality of patient care,” said Dr. Deborah German, opportunity to have so much one-on-one training with attendUCF vice president for health affairs and dean of the College of ing physicians. As one of the new residents, he is excited to help Medicine. “Our residents and fellows have the opportunity to build an innovative GME program from the ground up. He said train with some of the best and brightest clinicians in the country. he felt the inaugural program’s excitement from his first interview They have access to clinical data from millions of patient interacat the hospital. tions across the country to reinforce their learning. Best of all, “I felt that energy from those young leaders, our faculty memthey are mentored by proven leaders in the medical field who can bers,” Dr. Madanieh said. “At the end of the interview day, I just help them develop the skills they need to excel in every aspect of felt like, ‘I want to be there!’ I ranked HCA Florida Lake Monroe their careers.”

Hospital first out of 19 on my list.”

Today, there are more than 5,000 residents and fellows in 72 While HCA Florida Healthcare residents are benefiting from HCA Healthcare hospitals across the country, including in Centhe clinical experience of some of the nation’s brightest medical tral Florida at HCA Florida Osceola Hospital in Kissimmee and experts, HCA Florida Healthcare hospitals and the communities HCA Florida Lake Monroe Hospital in Sanford. they serve benefit, too. More than 30 percent of HCA HealthDr. Sameh Madanieh said he was inspired by HCA Florida care residents remain with the system, providing a talented, welltrained supply of physicians with a full understanding of HCA Florida Osceola Hospital, Kissimmee HCA Healthcare clinical systems and protocols.

According to Ross Taylor, MD, chief medical officer at HCA Florida Osceola Hospital, Graduate Medical Education is one of the most important responsibilities of his hospitals’ physician leaders, helping to ensure our community has a sufficient pipeline of well-trained providers for the future.

PHOTO: PROVIDED BY HCA HEALTHCARE

“HCA Florida Healthcare is honored to partner with UCF College of Medicine in providing graduate medical education programs in several specialties, and it is rewarding to have our residents return to begin their practice as physicians with us,” Dr. Taylor said. “At HCA Florida Healthcare, we are dedicated to ensuring our resident physicians are mentored, supported and respected during their time with us. Our goal is to keep these new doctors in Central Florida, and we are as excited as they are when they are matched to one of our hospitals.”

6 FLORIDA MD - JULY/AUGUST 2024

PHOTO: PROVIDED BY HCA HEALTHCARE

A FOCUS ON THE FUTURE OF PATIENT CARE THROUGH GRADUATE MEDICAL EDUCATION

COVER STORY Today, HCA Healthcare’s legacy of physician input continues to inform how every decision is made and guides how the organization works with and for its physicians, from operations to clinical settings to the future delivery of healthcare.

“What’s unique to HCA Healthcare hospitals is easy access to hospital administration,” said John Gerhold, CEO at HCA Florida Lake Monroe Hospital. “Our commitment is to the continuous enhancement of our hospitals by prioritizing the recruitment and retention of our invaluable physicians. We prioritize their professional growth, foster a culture of excellence, and focus on service line development. We have state of the art surgical and critical care services, a collegial family-like work environment where providers and colleagues genuinely care about our patients, and excellent quality of care.”

The importance of a strong and supportive workplace culture for their physicians and other care team members is of particular importance to the leaders of HCA Florida Healthcare’s hospitals across greater Orlando. Several can point to multiple generations of family members and combinations of relatives who care for their patients. HCA Florida Osceola Hospital, a Level 2 trauma center known for providing high-quality care to the community for decades, has numerous examples, including a wife-husband registered nurse team and their licensed practical nurse son working toward his RN. “We know a strong, supportive workplace culture is vital to our partnership with our exceptional physicians,” said David Shimp, CEO of HCA Florida Osceola Hospital. “We continually seek our physicians’ input and feedback in both operational and strategic decision making, and we ensure their voices are heard as opportunities for continuous improvement are identified. We truly shape the way we are leading our healthcare system based on this collaborative culture with our physicians.”

With more than 11,100 physicians throughout the state practicing at nearly 50 hospitals, 54 freestanding emergency rooms, 29 ambulatory surgery centers and 91 urgent care centers, HCA Florida Healthcare is committed to being the healthcare system of choice for its medical team as well as its patients. Dedicated doctors and administrators are committed to ensuring the legacy of physician leadership established by HCA Healthcare’s founders continues to have a profound impact on patient care in Central Florida, now and into the future. 

IN ADDITION TO FIVE PRIMARY HOSPITALS, HCA FLORIDA HEALTHCARE OFFERS EMERGENCY HEALTH SERVICES AT SEVERAL FREESTANDING EMERGENCY ROOMS IN CENTRAL FLORIDA: 1. HCA FLORIDA LAKE MONROE HOSPITAL • HCA FLORIDA HEATHROW EMERGENCY • HCA FLORIDA MOUNT DORA EMERGENCY • HCA FLORIDA CASSELBERRY EMERGENCY

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5. UCF LAKE NONA HOSPITAL

FLORIDA MD - JULY/AUGUST 2024

7

DERMATOLOGY

Melanoma Makes Me a Real Doctor

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

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 an MD practicing in Orlando.  8 FLORIDA MD - JULY/AUGUST 2024

PHOTO: JOHN MEISENHEIMER, VII, MD

Lentigo maligna melanoma.

PHOTO: JOHN MEISENHEIMER, VII, MD

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, MD

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, MD

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.

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.



FLORIDA MD - JULY/AUGUST 2024

9

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 10 FLORIDA MD - JULY/AUGUST 2024

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 - JULY/AUGUST 2024 11

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.

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.

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 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 12 FLORIDA MD - JULY/AUGUST 2024

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.

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 407841-1100 or by visiting www.cfpulmonary.com. 

HEALTHCARE LAW

Understanding Exculpatory Clauses

By Julie A. Tyk, JD. An exculpatory clause purports to deny an injured party the right to recover damages from a person negligently causing his injury. Cain v. Banka, 932 So. 2d 575 (Fla. 5th DCA 2006).

They are disfavored in the law because they relieve one party of the obligation to use due care and shift the risk of injury to the party who is probably least equipped to take the necessary precautions to avoid injury and bear the risk of loss. Applegate v.

Cable Water Ski, L.C., 974 So. 2d 1112, 1114 (Fla. 5th DCA 2008). Such clauses are strictly construed against the party seeking to be relieved of liability. Sunny Isles Marina, Inc. v. Adulami, 706 So. 2d 920 (Fla. 3d DCA 1998). Thus, exculpatory clauses are enforceable, only where, and to the extent, that the intention to be relieved from liability is made clear and unequivocal. Tatman v. Space Coast Kennel Club, Inc., 27 So. 3d 108, 110 (Fla. 5th DCA 2009). The wording must be so clear and understandable that “an ordinary and knowledgeable person will know what he is contracting away.” Id. (quoting Gayon v. Bally’s Total Fitness Corp., 802 So. 2d 420 (Fla. 3d DCA 2001)).

The seminal Florida case on exculpatory clauses is the Florida Supreme Court case of Sanislo v. Give Kids The World, Inc., 157 So. 3d 256 (Fla. 2015). Give Kids the World, Inc. (“GKTW”) provided free vacations to seriously ill children and their families.

When applying for the vacation, the Sanislos executed a “wish request” form that contained a waiver of liability, also known as an exculpatory clause. When the parents arrived at the resort village they again signed a liability release form, also an exculpatory clause. The language of the exculpatory clause is reprinted below for reference: I/we hereby release Give Kids the World, Inc. and all of its agents, officers, directors, servants, and employees from any liability whatsoever in connection with the preparation, execution, and fulfillment of said wish, on behalf of ourselves, the above named wish child and all other participants.

The scope of this release shall include, but not be limited to, damages or losses or injuries encountered in connection with transportation, food, lodging, medical concerns (physical and emotional), entertainment, photographs and physical injury of any kind....

I/we further agree to hold harmless and to release Give Kids the World, Inc. from and against any and all claims and causes of action of every kind arising from any and all physical or emotional injuries and/or damages which may happen to me/us....

Sanislo at 258-259.

While participating in a horse-drawn wagon ride, a rear pneumatic lift designed to allow those in wheelchairs to participate failed, and Ms. Sanislo was injured. The Sanislos brought suit and GKTW filed a motion for summary judgment arguing that the signed releases precluded an action for negligence. The Sanislos filed a motion for partial summary judgment against GKTW’s affirmative defense of release. The trial court granted the Sanislo’s

motion and denied GKTW’s motion.

The jury found for the Sanislos and GKTW appealed. Id. The Fifth District reversed, finding the lower court erred in denying GKTW’s motion for summary judgment because the release signed by the Sanislos was unambiguous and did not contravene public policy. It ruled the exculpatory clause barred the negligence action despite the lack of a specific reference to “negligence” or “negligent acts” in the exculpatory clause.

The Fifth District reasoned that exculpatory clauses are effective if the wording of the exculpatory clause is clear and understandable so that an ordinary and knowledgeable person would know what he or she is contracting away, and that the court had previously rejected “‘the need for express language referring to release of the defendant for “negligence” or “negligent acts” in order to render a release effective to bar a negligence action.’ ” On the public policy argument, the Court said the relative bargaining power of the parties should not be considered because it was outside of the public utility or public function context and the Sanislos were not required to request a vacation with GKTW or go on the vacation. Id. In affirming the Fifth District’s decision, the Supreme Court wrote that the conflict for the Court’s resolution was “whether an exculpatory clause is ambiguous and thus ineffective to bar a negligence action due to the absence of express language releasing a party from its own negligence or negligent acts.” Id. at 260.

The Florida Supreme Court wrote: .... we are reluctant to hold that all exculpatory clauses that are devoid of the terms “negligence” or “negligent acts” are ineffective to bar a negligence action despite otherwise clear and unambiguous language indicating an intent to be relieved from liability in such circumstances. Application of such a bright-line and rigid rule would tend to not effectuate the intent of the parties and render such contracts otherwise meaningless.

Id. at 270.

The Court found that the GKTW liability release form released GKTW and all of its agents, officers, directors, servants and employees from “any liability whatsoever in connection with the preparation, execution and fulfillment of said wish…” The release then provided that the scope of the agreement included “damages or losses or injuries encountered in connection with transportation, food, lodging, medical concerns (physical and emotional), entertainment, photographs and physical injury of any kind . . . .” The Court found that the release clearly conveyed that GKTW would be released from any liability, including negligence, for damages, losses, or injuries due to transportation, food, lodging, entertainment and photographs. Id. The determination of whether an exculpatory clause is enContinued on page 20 FLORIDA MD - JULY/AUGUST 2024 13

ORTHOPEDICS

A New Way to Avoid Surgical Pain Without Drugs

By Firas Abdul, MD Ask any patient and they can tell you that regardless of the benefits they expect to receive from a planned surgical procedure, they are dreading post-operative pain during their recovery. They may accept this as an inevitable part of their treatment, but that doesn’t lessen their stress and anxiety.

The potential habit-forming aspects of some opiates are a big concern. So, the development of a new procedure to block pain receptors with minimal medication is a major step forward. This approach can lead to less stress and anxiety before surgery and faster recoveries afterwards.

Cryoneurolysis is the technical term for the process. The word is a mouthful for a fairly straightforward procedure.

Before getting too deep into the procedure, let’s first think about how your central nervous system works. At the risk of oversimplifying an extremely complex system, you have nerves that control muscles and nerves that transmit sensations to the brain. The network of nerves that transmit sensations to the brain are composed of the individual nerve endings or receptors and the system of fibers that connect those nerves to the brain. These fibers act as a sort of network of pipes carrying information from the receptors.

What we do in cryoneurolysis is to freeze specific nerves without affecting that system of pipes. This technique allows us to, in effect, switch off those nerves. The nerves stop sending signals to the brain, and the patient stops feeling pain from those specific nerves.

In practice, it works like this. Let’s suppose a patient has a severely arthritic knee, and joint replacement surgery is scheduled.

The patient can go to the anesthesiologist several weeks before the surgery for pre-operative cryoneurolysis treatment. There, the doctor uses an ultrasound device to view and identify the specific nerves that are involved. Then, after administering a local anesthesia, the doctor uses a thin probe – basically a needle with a sealed tip – into which a pulse of nitrous oxide creates a tiny iceball at the tip of the probe. Using the ultrasound device, we can see the nerves and precisely guide the probe so this tiny ice-ball forms around each specific nerve, freezing it without damaging the surrounding tissue or the network of nerve pipes. Without the nerve receptors sending sensations to the brain, the patient immediately stops feeling pain from those nerves. This decreases the patient’s pre-operative and post-operative discomfort, reducing the burden of medication. Typically, the nerve receptors regenerate within several months, and by that time the patient will have healed from the surgery.

they are able to be more mobile following surgery. Using this technique, we’re able to add another tool to help patients after a total knee replacement surgery. Many of our patients, already scheduled for an outpatient procedure in which they can go home on the same day as the surgery, now have an option that will further reduce their pain. It’s a game-changer.

We have even had patients for whom cryoneurolysis has been the treatment, not just a component of the treatment. We recently treated an 80-year-old patient who was mentally sharp, but in our judgement was too frail to undergo surgery. However, the pain she was experiencing due to arthritis had severely limited her quality of life. She was unable to walk unassisted, and every step was painful.

After cryoneurolysis treatment, her pain was substantially relieved, and her mobility was restored. In fact, she is even able to now walk without her walker.

It’s important to note that cryoneurolysis only addresses the patient’s pain and not the underlying problems caused by the arthritis. But since surgery was not an option, the elimination of the patient’s pain, and doing it without any of the side effects that might come with other pain treatments, was a terrific outcome.

I had first learned about this technique a couple of years ago, but it wasn’t until we established our new practice within Orlando Health Jewett Orthopedic Institute that we have been able to focus on this. It’s one of the advantages of being in a practice with a singular focus. Everyone who works in the Institute is working one-hundred-percent on our coordinated approach to patient health, patient experience and patient outcomes. It’s a very exciting and rewarding time to not only be practicing anesthesiology, but to be helping patients receive the most up to date care in Central Florida.

Dr. Abdul is the Director of Anesthesiology for the Orlando Health Jewett Orthopedic Institute. 

At Orlando Health Jewett Orthopedic Institute, we have already begun using this technique on some knee-replacement patients, and the results have been very reassuring. Patients have less pain going into surgery and their recovery times are faster because 14 FLORIDA MD - JULY/AUGUST 2024

FloridaMDMagazine.com Your Medical Business Resource

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.

Well Beyond Medicine © 2021. The Nemours Foundation. ® Nemours is a registered trademark of The Nemours Foundation. J7676 (08/21)

FLORIDA MD - JULY/AUGUST 2024 15

PEDIATRICS

DIVISION OF PEDIATRIC PLASTIC SURGERY • NEMOURS CHILDREN’S HOSPITAL, FLORIDA

Adolescent Breast Asymmetry By: Brian Kellogg, MD, Vanessa Fadul, APRN, and Anais Andara, PA-C

WHAT IS ADOLESCENT BREAST ASYMMETRY? Adolescent breast asymmetry can be defined as any difference in size or shape of the breasts in a developing adolescent. Slight asymmetries are common at the onset of puberty. While the majority of these differences resolve with time and reassurance, a subset of patients experience a greater degree of asymmetry that persists throughout puberty and into adulthood.

WHAT ARE SOME CAUSES OF ADOLESCENT BREAST ASYMMETRY? Some adolescent breast asymmetries are manifestations of named conditions or abnormalities. Poland syndrome is a classic example, where affected adolescent females may present with unilateral breast hypoplasia and the hallmark finding of absent sternal head of the pectoralis major muscle. Another example of a named pathologic condition is tuberous breast deformity, in which the inframammary fold on the affected side is constricted and breast parenchyma herniates into the nipple-areola complex.

On the other hand, many young women suffer from significant differences in size or shape in absence of named pathology. Other young women may experience progressive breast deformity and asymmetric development as they grow due to injury to the breast bud earlier in life. Burns, surgeries, or chest tubes, and the scar tissue they leave behind, are common culprits in cases of posttraumatic developmental breast asymmetries.

HOW DOES ADOLESCENT BREAST ASYMMETRY AFFECT PATIENTS? Using validated quality of life measures, prospective studies have demonstrated poorer emotional wellbeing and lower selfesteem among adolescent females with breast asymmetries compared to age-matched peers. Unlike patients with symptomatic macromastia, physical pain or functional impairment is uncommon. However, the negative psychosocial impact of breast asymmetries on adolescents can be profound. Affected young women often report trouble finding clothes that fit, requiring significant padding or prosthetic bra inserts, inability to change in front of their peers in locker rooms, avoidance of beaches or pools, or problems with teasing and bullying. Negative body image and obesity have also been reported in higher frequency in this patient population compared to controls.

HOW ARE ADOLESCENT BREASTS ASYMMETRIES MANAGED? Consultation with a multidisciplinary team of providers can be helpful when developmental breast asymmetries become a concern to the patient. Pediatric plastic surgeons can help reassure patients and families early in pubertal development and discuss future treatment options and timing based on patients’ individual 16 FLORIDA MD - JULY/AUGUST 2024

needs. Early counseling regarding weight management should be offered if indicated, as the majority of reconstructive breast surgeries require weight stability. Patients should be screened for mental health concerns and offered support, if necessary. While it is ideal for the majority of breast development to have ceased before proceeding with surgical intervention, some patients may be candidates for earlier interventions, such as placement of a tissue expander or adjustable saline implant to be filled over time and keep pace with contralateral breast development.

Patients may benefit from any combination of breast augmentation (autologous or alloplastic), breast reduction or mastopexy, based on individual needs and preferences.

CASE STUDY A 15-year-old female presented to a pediatric plastic surgeon with a chief complaint of breast asymmetry due to lack of breast development on the right. She reported no significant changes in weight or breast size over the previous year. On exam, the patient was noted to be at a healthy weight. Her affect was shy and withdrawn. Posture was slouched and bilateral shoulders were held in adduction, presumably to conceal her breast asymmetries. Breast examination demonstrated a non-pathologic, Tanner stage [IV] left breast with grade 1 ptosis. The right breast was severely hypoplastic. The nipple-areola complex was small, superiorly and laterally displaced. The patient was missing the sternal head of her pectoralis major muscle, clinically confirming the diagnosis of Poland syndrome. No other chest wall or upper extremity anomalies were identified.

After several discussions with the patient and family, consideration of the patient’s needs and goals, and verification over time of stable weight and negligible ongoing breast development, the patient elected to undergo staged right breast reconstruction. The first stage of reconstruction entailed placing a tissue expander in the left chest and covering it with the ipsilateral latissimus dorsi muscle. This muscle is commonly utilized in oncologic breast reconstruction to provide additional healthy soft tissue coverage of

PEDIATRICS implants, and to help define the new inframammary fold. Donor site morbidity is minimal. The patient then underwent gradual tissue expansion until the overall skin envelope on the right was similar to that on the left. The tissue expander was then exchanged for a permanent implant.

Lastly, the patient underwent relocation of the displaced, hypoplastic right nippleareola complex by free nipple grafting in conjunction with fat transfer to smooth the transition between implant and chest wall at the superior pole of the breast. Her entire course of right breast reconstruction lasted approximately 1.5 years.

15-year-old female with significant breast asymmetry secondary to right-sided Poland syndrome.

The same patient 1 year after completion of staged right breast reconstruction for Poland syndrome.

The final result demonstrated reasonable appearance of reconstructed right breast, as well as volume symmetry in clothes. (Preop photo A | Post op photo B) The patient was subjectively noted by her treatment team to have significantly improved confidence and a more upright posture, with shoulders carried in a neutral position. Most importantly, the patient expressed extreme satisfaction with her results and described her reconstructive journey as life changing.

To refer a patient or to learn more about our adolescent breast program, visit Nemours.org/plasticsurgery or call 407.650.7715.

We have locations in Orlando, Lakeland and Winter Garden. 

FLORIDA MD - JULY/AUGUST 2024 17

Selecting a Real Estate Broker for Your Medical Practice

By Frank Ricci, Medical/Dental Real Estate Specialist, Licensed Broker & Building Contractor This is the fourth in a series on medical real estate, design and construction with “Selecting Medical Space” [here], Negotiating Medical Leases” [here] and “Central Florida Hotspots.”

There are many sectors in the real estate industry and each sector has its very own unique needs. Even though a real estate license allows a licensed professional to operate within all of these sectors, most professionals concentrate on one in order to become proficient in the unique characteristics of their chosen sector. Residential is vastly different than commercial, industrial vastly different than office and even within the office sector, medical office is very different than general office space. This article will guide you through the essential qualities you should look for when choosing a real estate broker to represent you, whether you are looking to acquire, lease, sell or manage medical property.

THE IMPORTANCE OF EXPERIENCE 1. Working with Medical Practitioners: A broker with extensive experience working with physicians understands the unique needs and challenges of medical professionals. This includes knowledge of the daily operations of a medical practice, patient flow, and the specific requirements for various medical specialties. An experienced broker can provide insights into the best locations, layouts, and features that enhance the efficiency and effectiveness of a medical practice.

2. Healthcare Design Principles: Understanding healthcare design principles, including Evidence-Based Design (EBD) and Therapeutic Environments, is essential. EBD involves using data and research to inform design decisions that improve patient outcomes and staff efficiency. Therapeutic environments focus on creating spaces that promote healing and well-being.

A broker knowledgeable in these principles can help physicians choose or design spaces that enhance patient care and satisfaction.

3. Navigating Complex Transactions: Medical real estate transactions can be complex, involving specific zoning laws, regulatory requirements, and specialized build-outs. An experienced broker has the expertise to navigate these complexities, ensuring compliance with all regulations and facilitating a smooth transaction process.

ADVANCED REAL ESTATE KNOWLEDGE 1. Due Diligence: Conducting thorough due diligence is a critical aspect of any real estate transaction. This involves researching and verifying all aspects of a property, including its legal status, physical condition, and compliance with zoning and environmental regulations. A diligent broker will conduct comprehensive due diligence to ensure that there are no hidden issues that could impact the property’s suitability or value.

18 FLORIDA MD - JULY/AUGUST 2024

2. Utilizing the Latest Tools: The use of advanced tools and technologies is essential in modern real estate practice. This includes geographic information systems (GIS), demographic analysis software, and property search platforms. A broker who leverages these tools can provide detailed insights into market conditions, demographic trends, and property availability, helping physicians make informed decisions.

3. Market Analysis and Demographics: Understanding the demographics of a location is crucial for selecting the right property for a medical practice. This involves analyzing population density, age distribution, income levels, and other relevant factors. A broker with expertise in demographic analysis can help physicians identify locations with the highest potential for patient growth and practice success.

4.`Competitor Analysis: When negotiating a lease or purchase, it is crucial to consider the presence of competitors in the same complex. A broker with a thorough understanding of the local medical market can provide valuable insights into the competitive landscape, helping physicians choose locations that maximize patient access and minimize competition.

5. Financial Analysis: A comprehensive financial analysis of potential properties is essential. This includes evaluating the total cost of ownership, potential return on investment, and the financial implications of different lease or purchase options. An experienced broker can provide detailed financial analyses to help physicians choose properties that align with their financial goals.

6. Understands the Importance of Key Contract Terms: A thorough knowledge of important contract terms and strategies, such as Rights of First Refusal, is vital. These terms can provide significant advantages in securing and expanding practice locations. An experienced broker will know how to negotiate these critical terms effectively, ensuring that physicians have the flexibility to grow their practice as needed.

7. Unique Marketing Strategies: A proficient broker will employ unique marketing strategies to attract potential prospects. This includes utilizing digital marketing, networking within the medical community, and leveraging professional associations to reach the right audience. Innovative marketing ensures that available spaces are presented to the widest and most relevant audience possible.

Continued on page 20

It’s not about

counting the days.

It’s about making the days count.

Hospice • Palliative Care • Grief Support

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 FLORIDA MD - JULY/AUGUST 2024 19

EXPERTISE IN HEALTHCARE DESIGN AND CONSTRUCTION 1. Evidence-Based Design (EBD): EBD principles are crucial in creating spaces that improve patient outcomes and staff efficiency. A broker familiar with EBD can guide physicians in selecting properties that incorporate these principles, resulting in better-designed facilities that support high-quality care.

2. Therapeutic Environments: Creating a therapeutic environment involves designing spaces that promote healing and well-being. This includes considerations such as natural light, noise reduction, and comfortable waiting areas.

A knowledgeable broker can identify properties that offer these features or have the potential for such modifications.

3. Understanding the Construction Process: A thorough understanding of the construction process is essential for any broker working in the medical real estate sector. This includes knowledge of medical build-outs, compliance with healthcare regulations, and the ability to manage construction timelines effectively. An experienced broker can oversee the construction process, ensuring that the final space meets all requirements and is delivered on time.

4. Cost Segregation: Cost segregation is a valuable tax strategy that involves identifying and reclassifying personal property assets to shorten the depreciation time for taxation purposes. This can result in significant tax savings for medical practices. A broker who understands the value of cost segregation can provide invaluable advice during the property selection and purchase process.

SUPPORTING THE MEDICAL COMMUNITY A broker who is deeply embedded in the medical community not only understands the technical aspects of real estate but also the broader context in which medical professionals operate. Going beyond traditional brokerage services to actively support the medical community through various initiatives demonstrates a commitment to the field:

1. Technical Articles and Presentations: Contributing to the knowledge base of the medical real estate sector by writing technical articles and delivering presentations on relevant topics helps keep clients and the broader medical community informed about the latest trends, challenges, and opportunities in medical real estate.

2. Board Memberships: Involvement in local professional organizations that support the medical community ensures staying connected and contributing to the industry’s development. Serving on boards allows brokers to influence decisions that shape the future of medical real estate and advocate for the needs of medical professionals.

3. Community Engagement: Actively participating in community events and professional organizations not only strengthens networks but also reinforces commitment to the medical community. This engagement helps brokers better understand the unique challenges faced by healthcare providers and tailor their services to meet specific needs.

CONCLUSION In summary, selecting a broker with the right experience and expertise can provide you with a strategic advantage, helping you find the ideal space for your medical practice and ensuring a smooth and successful transaction. The right broker will not only secure the best property for your needs but also offer valuable insights and support throughout the process, contributing to the long-term success and growth of your medical practice.

Frank Ricci is president of Healthcare Realty & Development LLC and H R & D Construction Inc. and has over 30 years of medical real estate brokerage, construction and development experience. He can be reached at (407) 947-5074, or FrankR@HealthcareRealtyOnline. com. • https://www.healthcarerealtyonline.com/contact • www.linkedin.com/in/frank-ricci-b0832a9 • https:// www.facebook.com/HealthcareRealty/ .

HEALTHCARE LAW Continued from page 13 forceable will be determined by the Judge as the enforceability of a pre-injury release is a question of law. The enforceability therefore, will depend on the Judge assigned to the matter. Physicians should not assume that because a patient signed a liability release form the patient does not have a viable cause of action. Physicians should consult with an experienced attorney who can examine the facts of the case and help you determine the best path forward. 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. 20 FLORIDA MD - JULY/AUGUST 2024

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.. 

Helping Veterans Treat Obstructive Sleep Apnea

By Tara M. Griffin, DMD, DBDSM, DASBA As we celebrate Independence Day, it is crucial to remember the brave men and women who have fought for our freedom.

Veterans have made countless sacrifices to protect our nation, and it is our duty to ensure they receive the care and support they deserve. One prevalent issue among veterans is obstructive sleep apnea (OSA), a condition that can have serious consequences if left untreated.

A 2019 report estimates that over 1.5 million veterans have been diagnosed with OSA and up to 80% of those diagnosed are not being successfully treated. Continuous Positive Airway Pressure (CPAP) has been the gold standard for treatment for the past 40 years, however, in 2020 after a world-wide recall of CPAP machines, more than 600,000 veterans have been affected and another 600,000 are not compliant with the machines they have been prescribed.

Obstructive sleep apnea is a common sleep disorder characterized by pauses in breathing during sleep, often leading to fragmented sleep and low oxygen levels in the blood. This condition not only affects the quality of sleep but can also have detrimental effects on overall health and well-being. When you experience low oxygen levels in the blood on a regular basis, this creates inflammation in every organ system which leads to chronic debilitating health issues. For veterans, the impact of OSA can be particularly challenging, given the physical and mental toll of their service.

Fortunately, there are effective treatment options available for “managing” and now “resolving” obstructive sleep apnea. While CPAP therapy and surgery are commonly used, most veterans may find these options unavailable and potentially dangerous after recent recalls, uncomfortable and invasive. In such cases, alternative treatments like FDA-approved oral medical devices for sleep apnea can offer a more comfortable and convenient solution.

These custom oral devices are designed to help keep the airway open during sleep, reducing the risk of breathing pauses and improving overall sleep quality. By using these devices, our veterans are experiencing fewer awakenings during sleep, reduced daytime fatigue, improved cognitive function, better overall health and improved quality of life.

Compared to CPAP therapy, studies show that oral medical devices have a compliance rate of over 80% after 5 years of use which is much better than CPAP compliance and just as effective at lowering high blood pressure and reducing cardiovascular risks for patients. Based on recent FDA approved technology, up to 34% of patients may no longer need an oral medical device after 12 months of treatment.

One of the significant benefits of using oral medical devices for sleep apnea is their ability to address not only the physical symptoms and root causes of OSA but also the associated mental health challenges. Many veterans with OSA also suffer from

conditions like post-traumatic stress disorder (PTSD), which can be exacerbated by poor sleep quality and trauma experienced while serving.

Over 1.3 million veterans have been diagnosed with PTSD through service-connection with the VA. By improving sleep quality with custom oral medical devices and adjunctive therapies, most veterans we have treated, experience a reduction in PTSD symptoms, fewer headaches, and a decrease in night terrors! Better sleep can have a profound impact on mental health and overall well-being, allowing veterans to lead more fulfilling and productive lives.

For healthcare providers working with veterans, it is essential to consider alternative treatment options for sleep apnea. By offering veterans a comfortable and effective solution for managing or resolving OSA, healthcare providers can help improve the quality of life for those who have served our country.

At Sleep Solution Centers, we are a Community Care Provider for veterans and make it our priority to see our new patients within a week of receiving a referral from the VA. Our motto is, “Our freedom isn’t free but a good night’s sleep can be!”

As we honor our veterans this Independence Day, let us not forget the importance of supporting their health and well-being.

By raising awareness about alternative treatments for obstructive sleep apnea and advocating for the use of FDA-approved oral medical devices, we can make a meaningful difference in the lives of those who have sacrificed so much for our freedom. Let us stand together in providing the care and support our veterans deserve!

Tara M. Griffin, DMD, DBDSM, DASBA, graduated from Nova Southeastern University in 2006, with a doctorate in Dental Medicine. She became passionate about helping her patients breathe and sleep better and completed her Diplomate with the American Academy of Dental Sleep Medicine in 2011. In 2015, she completed her Diplomate with American Sleep and Breathing Academy. In 2016, she became a Clinical Advisor with Vivos Therapeutics to help educate and mentor doctors interested in the treatment of OSA with oral medical devices.

She owned a private practice focused on sleep, TMD and general dentistry in the panhandle of Florida for 17 years before becoming the co-founder of Sleep Solution Centers in Medical City, Orlando in 2024. She may be contacted at 407-502-0110 or by visiting www.sleepsolutioncenters.com 

FLORIDA MD - JULY/AUGUST 2024 21

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2024

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