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FOCUS TOPICS PRACTICE MANAGEMENT • HEALTHCARE REAL ESTATE

SERVING A 24 COUNTY AREA, INCLUDING BIRMINGHAM, HUNTSVILLE, MONTGOMERY & TUSCALOOSA

HEALTHCARE SPOTLIGHT PAGE 3

Roseanne Cook, MD ON ROUNDS

HEALTHCARE REAL ESTATE

Medical Clinics Lead Retail Growth in Grandview Area cal Center. The Patchwork Farms development on Cahaba River Road behind Growth in the Grandthe hospital is home to a view area of the U.S. 280 Lifetime Fitness center, a corridor in Birmingham con120,000-square-foot Publix, tinues to increase as medical the Cahaba Ridge Senior and retail businesses, resLiving Community, and taurants and multi-family Aspire Skilled Nursing and developments are locating Rehab facility. Also along throughout the area. “HighCahaba River Road, three way 280 is well represented apartment communities with restaurants, retail, and have opened – Vestavia Reother types of businesses, serve, Crowne @ Cahaba but since the Grandview River, and 4700 Colonnade Medical Center project was Grandview Physicians Plaza is close to full capacity. Apartments. announced, we have seen a Across the street from lot of development activity Grandview Medical Center, the former Strayer University building along 280,” says Jim Adams, Senior Vice President of Acquisitions is now at full capacity. “They added 7,000 square feet to that building for Daniel Corporation. and it is full of medical tenants who were attracted to the area by the Two restaurants – Pappadeaux Seafood Kitchen and Perry’s Steakhouse – are located about one half mile from Grandview Medi(CONTINUED ON PAGE 10) By ann B. DeBeLLiS

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New Procedure for Breast Surgeries By Jane ehrharDT

Many surgeons may not yet be aware of a new technique for breast cancer surgery that has recently emerged. The name – Hidden Scar surgery - describes the purpose. “It’s important for woman to not have a constant reminder of their surgery,” says Susan Winchester, MD, a surgeon with Birmingham Breast Care. “Women come to me after lumpectomies or mastectomies feeling like they’ve been mutilated.” than 252,000 women in the U.S. face invasive breast cancer each year, with one in eight women being diagnosed with the disease at some point in their lives. The Hidden Scar approach places the incision in an inconspicuous area of the breast, and an oncoplastic technique allows the surgeon to keep the contour (CONTINUED ON PAGE 12)

Susan Winchester, MD (left) with Princess Thomas, MD (right)

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HEALTHCARE SPOTLIGHT

The Ministry of Rural Medicine By Lori Quiller

The town of Pine Apple lies about 20 minutes off I-65 South tucked in the southeast corner of Wilcox County along Alabama’s Black Belt. Driving through this farming community, you notice the picturesque countryside dotted with the occasional farm house and antebellum home. This is an old community with a population of around 150 residents. However, Pine Apple is nestled into one of the poorest counties in the country with a population of about 12,000 residents and few physicians to make the rounds. Roseanne Cook, MD is one of a handful of physicians serving the county. The Pine Apple Clinic is a community health center with its business center in Selma. The clinic receives some federal funding, and Dr. Cook has taken care of patients there since 1986. The clinic isn’t the average medical clinic, and Cook isn’t the average rural physician. Dr. Cook is a Roman Catholic nun, a sister of St. Joseph out of St. Louis, MO. In 1979 working as a biology professor, Cook said she felt her life had another mission. So, at age 40, she entered medical school, and her life’s work was about to fully take shape with the intent of delving even deeper into her ability to help our country’s poor residents. “I loved teaching, but I knew the Lord

Roseanne Cook, MD

wanted me to do more. When I first went to my major superior about going to medical school, I wasn’t sure what that answer would be.” she said with a laugh. “The answer was if it’s the Lord’s inspiration, you’ll get in, if not, you won’t get in. And, I got in at age 40 - the age of most of my student colleagues’ mothers.” After medical school, Cook had planned to follow her order to Peru, but the nurse practitioner from her order was

already in Pine Apple and convinced her to come to Wilcox County instead to join the practice. Now as a family physician serving several counties, she has her hands full with patients. But she and her staff always make the best of the situation. “I’ve been in this area since 1986, and it’s poverty stricken. Actually it’s beyond poverty stricken,” Cook said. “These residents work hard, and because they work, they don’t qualify for Medicaid or subsidies, so we do everything we can to make their lives a little better.” The median income for a household in Wilcox county is around $16,646, and the median income for a family is about $22,200. According to the last census, about 36 percent of families of the population were below the poverty line, including 32 percent of those age 65 or over. Dr. Cook’s clinic is a small community unto itself and eagerly accepts donations to continue some of the services the surrounding residents have come to depend upon. The medical clinic building is flanked by an adult care building and learning center building. At the end of the square lies a thrift store-style facility. Unfortunately, due to lack of funding, the adult care and learning center has closed. Yet, the medical clinic building almost doubled in size due to a private donation in 1991.

“We do the best we can with what we have,” Cook said. “Sometimes we have more. Sometimes less. But we always make it work.” Working in a rural setting presents unique challenges for any physician. But in 2001, Cook was faced with one of her most challenging moments when she stopped to help a vehicle of stranded motorists just outside of town. She was on her way to the clinic when she spotted the car on the side of the road. It needed a jump, so she pulled up and got out of her vehicle with her jumper cables. Ready to deliver roadside aide, Cook wasn’t prepared for what happened next. She was knocked unconscious and tossed into the trunk of her vehicle. Driven down a desolate road deep into the county and only partially conscious, she wasn’t sure what was happening until shots were fired into the trunk. Five shots rang out. Four missed. One grazed her cheek. “God didn’t want me to die that day,” she said. Today, she can look back on the incident with an ease that she surely didn’t have 15 years ago. It’s part of her character, woven into every fiber of her soul that keeps her soldiering on every day to treat the patients she’s grown to call members of her extended family. And…she still makes the occasional house call.

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PRACTICE MANAGEMENT

Succession and Talent Management By Jerry Callahan

Foundation of a great manager Many of us have a great opportunity each day to serve. We do this by listening, problem solving, and performing our daily responsibilities to the best of our ability. When we do what we love, we inspire the hearts of others. However, there are days and possibly even months where we are doing what we love but may have lost our passion. The roles of a manager are more complex than ever with revenue cycle management, human resource management, recruiting, cash flow management and financial analysis. And don’t forget that patient in your waiting area that is not exactly thrilled with their “patient experience.” As a result, healthcare employee turnover rates are greater than ever – 19.2 percent as compared to a national average of 17.4 percent in 2015. Perception and realities Peter Drucker wrote a book outlining his view that manager’s role is to make people productive – a noble goal. According to Mr. Drucker, a manager has five primary functions: 1. Set objectives and establish the goals that employees need to reach. 2. Organize tasks, coordinate his/

her task allocation and arrange the right roles for the right people. 3. Motivate and communicate in order to mold staffers into cooperative teams and to convey information continually up, down, and around the organization. 4. Establish targets that measure results and clarify outcomes to ensure that the practice is moving in the right direction. 5. Develop people through finding, training and nurturing employees, the primary resource. These are quite reasonable and fairly intuitive responsibilities. However, as you are performing an inventory of your day, how many of these activities are you able to accomplish? Now that we are all feeling great about ourselves, let us review what I call the Eight Myths about management: Myth number one: The best performer on the team is the most qualified to be the manager. Reality: The skills that lead to success as an individual contributor are very different from those needed to manage. It’s true that top performers usually are the first ones to be considered for promotion. High performance should be a prerequisite for promotion to a manager, but it shouldn’t be the only consideration. The

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Reality: It depends. Management doesn’t always mean more money – it’s just a different type of work which requires different skills. Generally, more money usually comes with greater responsibility. Myth number seven: You can prepare to be a good manager by taking a training course or reading books. Reality: While you can learn a lot through training and reading, it’s also important to: • Get as much practical experience as you can. Look for civic leadership opportunities, practice leading meetings and interviewing, practice your influence and relationship building skills, and be seen as a leader before you are promoted • Observe and learn from other managers. Watch what the good ones do and ask them how they do it and why. Learn what not to do from the bad ones. • Apply what you learn in your daily activities. Myth number eight: A manager needs to be the smartest person on the team. Reality: While a reasonable amount of intelligence (IQ) is essential to be a successful manager, an extremely high IQ is not a predictor of leadership success. In fact, it could even be a detriment. Emotional intelligence (EQ) is a much more accurate predictor of leadership success. 

Talent Management So as we evaluate perceptions, myths and our daily lives, where does that leave us? While it is not a new term, I would suggest that we all begin to focus on daily talent management. The need for talent management and succession planning is critical in the healthcare industry, which faces shortages in all types of leaders (administrative, physician, and nursing), high turnover among leaders (driven in part by a large number of impending retirements) and front-line staff, and growing difficulties in attracting management talent from other industries. (CONTINUED ON PAGE 6)

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ability to enable others to improve their performance becomes even more important. High performers often have never struggled in a job, and have no idea why anyone wouldn’t have the same work ethic they have. Many new managers are frustrated to discover that the same skills that made them the best individual contributor don’t work when it comes to managing others. Myth number two: Managers get to order people around. Reality: Managers have more power, authority, status, and access, but these privileges do not guarantee that a manager has influence. High achievers usually do what their managers ask them to do. Then, when they get promoted, they find out that’s not always the case with their former peers or new team. Influencing the actions of direct reports is just one type of influence. A manager also has to rely on their power of persuasion and collaborative skills to influence peers and others as well. Myth number three: Managers are mean, and care about nothing but the bottom line. Reality: Leaders care about the success of others and the success of the business. While it may be true that managers can’t be friends with their employees, they can be and often are respectful, caring, and fair. They realize that’s the only way to ensure long-term, sustainable high performance. Myth number four: Managers have a lot of freedom. Reality: Managers often have far less freedom to act alone than they anticipate. There are a lot more people to look out after, influence, and add to their network. There is a new set of duties, obligations, and relationships. I’m sure many of us, managers and business owners, sometimes long for the days when they were starting out and had more freedom. Myth numbers five and six: Managers make more money than individual contributors,  and managers make less money than individual contributors.

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PRACTICE MANAGEMENT

Practice Building By Laura Freeman

A generation ago, every city had a daily newspaper. Everybody watched network TV. Every home was hard wired with a phone and had a copy of the yellow pages. Now people can find out about anything immediately with a quick Google search on their smart phone. They are more likely to use their screen time streaming video, watching YouTube, playing games or web surfing. How people get information has changed, and their expectations have changed as well. If they can’t get an appointment soon enough or at a convenient time; if they take off work to make their appointment, and then spend an hour waiting to see the doctor; if the parking lot is always full; if an insurance clerk is rude or a lab tech is rough; or if their bill comes with surprises—today’s patients are much faster than their parents to pick up their smart phone and look for a health care solution that’s a better fit for their lifestyle. So, in today’s world, how do you build and expand a practice while retaining patients and protecting your flow of referrals? “Even for specialists who get referrals from other physicians, marketing is something to think about. Many younger patients don’t even have primary physi-

cians. If they need a dermatologist or allergy specialist, they simply do a search on their phone. They may read a couple of quick reviews and take a look at your website, but if you didn’t come up near the top of their search, they may not even see you,” Maddox Casey, CPA, of Warren Averett said. “Practices need a web presence along with someone who understands search engine optimization and how Maddox Casey, CPA to move to the top of the search list. It’s not enough to build a website and leave it untouched for years. Keeping it updated, adding content related to topics in your field gives search engines something to find when patients are looking for information. Social media sites like Facebook can engage both patients and staff and improve communication. Professional sites such as Linked In can help you connect with colleagues.” PR and other forms of unpaid media can be valuable tools in building awareness among potential patients and referring physicians. Send press releases when you have news. Look into adding your name to lists of expert sources that media can turn to for quotes when stories arise related to your field.

If someone in your practice is comfortable speaking to crowds, list a speakers bureau on your website, or offer to speak to community groups, particularly during awareness months related to your specialty. “As an alternative, if you don’t have someone who is naturally adept at public speaking, look into having members of your practice volunteer in health fairs or screenings at community events,” Debi Waldrup, administrator for Pulmonary Associates of the Southeast said. “We do COPD day in November and lung screenings at other events.” Screenings and participation in community events also offer the potential for media coverage as well as bringing representatives of your practice face to face with potential patients you might otherwise not meet. When considering paid advertising, look for online media that can be targeted to match your patients. If your objective is building referrals, look for professional media targeted to physicians and health care professionals. “Our patients are our best advertising. Around half of our new patients are referred by former patients.” Lisa Warren, CEO of Andrews Sports Medicine, said. One of the best investments we make is putting an extra effort into making sure our patients have a good experience. That’s

why they recommend us to people they know who could use our help. “The old saying is true. If people have a good experience, they tell one person. If they have a bad experience, they tell ten. You have to hire good people and train them well. From the front desk on, anyone in contact with patients should understand the need for building positive relationships.” How does your practice look through a patient’s eyes? It may be time to take a tour, starting with the parking lot. If you are in a large building with a number of practices, there may be times when the lot is so busy that it’s frustrating for patients to park. What is it like walking from parking to the last exam room with a cane or a breathing condition? Would benches along the way help? “If your office is located in an area where traffic and parking are difficult, you might want to look into a satellite office in a less congested area, or the possibility of expanding parking,” Casey said. “Uber might become an option. Some practices are considering sharing costs on an Uber ride from a less congested nearby area for patients who need to be dropped off at the door. The cost to the patient for their share of a $10 ride would be near or less than what they would pay for valet parking. For (CONTINUED ON PAGE 6)

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Practice Building, continued from page 5 a patient who needs a major procedure, it makes sense and it’s a consideration patients would appreciate.” It’s also what advertising agencies call a USP, or unique selling point, that sets businesses apart and creates a preference for their services. “Some practices are offering a concierge service, express check-in, an information desk and other amenities,” Sae Evans, CPA of Warren Averett said. “The next big service is telemedicine. Blue Cross offers coverage with a $10 copay for patients to consult with a physician by videophone for simple things like a cold. The physician can Sae Evans, CPA ask questions to confirm a diagnosis, check the patient’s medical records, then call in a prescription, if needed. The patient gets

help without having to take time off work or get out of a sick bed to come to the clinic. They aren’t spreading germs in the waiting room, or picking up another infection from someone in the next chair.” If you were a patient calling your office to ask about possible side effects of a medication, how many rounds of telephone tag would it take to get an answer? For the growing number of practices who offer an online patient portal, the answer is that it wouldn’t take a call at all. “Patients don’t have to wait for someone to call back, or stay by the phone if they need to talk with someone without risking another round of missed calls. They can communicate by email or chat online with a nurse who can check with the physician,” Tammie Lunceford, CPC with Warren Averett said. A record of the query is on file to add to medical records or discuss at the next

office visit. Medications can adjusted or changed without delay, and symptoms that could be significant can be reported so interventions can begin sooner, which could make a difference in outcomes. “To get patients comfortable with using the portal, it helps to introduce them to it when they come into the office,” Lunceford said. “You can set up the patient portal on a computer in the waiting room. When they register at the desk, if they say they haven’t signed on yet, a member of the staff can walk them through the features and show them how to log in while they are waiting to see their physician.” Waldrup said, “Many of our patients are older. One of the big advantages of a patient portal is for family members who are helping to manage the care of an elderly relative. Our portal is HIPPA compliant, but the patient can give access to a care giver who can help them keep up with their

appointments, medications and get answers to their questions online.” In addition to saving phone time and postage, portals can post the results of routine labs immediately. Patients can compare their levels from the most recent visit with several visits back, which helps when they are working to track and improve their blood pressure, A1C, cholesterol and other measures of health. This continuity is a point in favor of staying with the same practice. As one patient put it, “When they moved, I thought about finding another doctor. But through their patient portal, I can access more than five years of my labs, vital signs and medications and check my appointment times. Being able to track my health feels empowering. I can see I’m doing better on blood pressure, blood sugar and weight. That’s a good reason to stay and recommend my doctor to friends.”

Succession, continued from page 4

What are the underlying principles of talent management? • Senior leadership involvement and commitment • Alignment with organizational mission and business objectives • Talent management as every manager’s number-one priority • Transparency – communicate, communicate, communicate • Continuous evaluation of future talent requirements and gaps • Emphasis on work related learning experience • Leveraging of technology

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The “End Game” So why do we do all these activities when we have already determined we have limited time? In a selfish way, it is to continually restore our passion for work and purpose. The by-products will be higher employee satisfaction, greater employee engagement, lower turnover and a higher trained and motivated staff. If you continue to lack the time needed to invest in your staff and yourself, it will be difficult to regain the motivation and love for your career and job – and everyone around you will know.

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Jerry Callahan is the Director of the Healthcare Services Group for Kassouf. He specializes in business consulting, tax, financial planning, healthcare management, human resources, employee fringe benefits and finance.


PRACTICE MANAGEMENT

The Agility to Adapt By Laura Freeman

Predicting what is going to happen next in Washington would put even the shiniest crystal ball into meltdown mode. Even without uncertainties about the ACA and how future changes may affect insurance--or potential shifts in policy related to the FDA and Department of Health--physicians and practice managers have plenty of strategic thinking to do these days

MACRA In a consensus of practice managers and consultants interviewed, the most immediate concern for most practices is preparing for MACRA. “2017 is the first year that physician practices will be reporting data on quality metrics,” said Maddox Casey, CPA, of Warren Averett CPA’s Health Consulting Group. “Medicare will use that data to build benchmarks that will determine how providers are reimbursed in future years based on quality of care and outcomes rather than payment per procedure.” His associate, Sae Evans, CPA, said, “There are more than 300 metrics that practices can choose for monitoring this year, and it’s important to select metrics that fit your specialty and that you can control to some degree. It may require some changes in how your practice is set up. “Avoiding the need for hospital readmission is one area where physicians can be proactive. For example, an oncologist could target dehydration readmissions by making sure the patient has nausea medications and scheduling staff calls to follow up and encourage patients to stay hydrated.” “Outcomes measures have been moving targets and they can be difficult to obtain,” said Lisa Warren, CEO of Andrews Sports Medicine. “It takes sophisticated IT and data analysis to gather the information and know what to do with it. Hospitals have departments Lisa Warren working on this. In physician practices, it will likely fall to administrators to figure out the challenges.” Tammie Lunceford, CPC with Warren Averett, has been leading MACRA conferences across the state to help administrators prepare. “Unlike some of the changes in health care now being discussed, MACRA is a bipartisan act,” Lunceford said. “It isn’t going away. I urge Tammy Lunceford, CPC practices not to delay in gearing up their quality reporting mechanisms. There will be winners and losers. The winners will be paid more and the losers less. You want to be a winner, so

get ready. If you don’t have leadership in your practice who is up to speed on this, get advice or check your membership societies to see if they are offering help.” Quality-based reimbursement has already filtered down to commercial insurance, and the trend is likely to grow. “For years, Blue Cross has had an incentive program, mostly for primary care, ob/gyn and pediatrics,” Lunceford said. “The metrics are similar to some of the metrics for MACRA. Practice groups can earn up to 30 percent above the Blue Cross fee schedule. It emphasizes quality preventive care; for example, making sure patients get an annual flu shot and mammogram, a colonoscopy at 50.” Debi Waldrup, administrator for Pulmonary Associates of the Southeast, has spent a good deal of work readying for MACRA. “As with any program, we have to learn how to get answers to the problems,” Waldrup Debi Waldrup said. “We have to understand how quality standards develop and what quality looks like for us, and we have to communicate it so our physicians and staff understand it. We’ve always collected data. Now we will be depending on our practice management systems, IT and analytics to collect more and put it in an effective form for reporting.” MACRA is likely to continue evolving, but at least a starting point has been defined. Other changes in legislation,

regulations and economics that could affect medical practices in years ahead are still question marks. Rather than worrying about the unknown, a more productive use of energy is focusing on building the agility of your practice so you are in the best position to weather changes when they come. Agility starts with taking a closer look at profitability from both revenue and cost perspectives. It includes an ongoing process of looking for opportunities to improve productivity and building a culture within the practice that encourages innovation.

Revenue Problems “On the revenue side, the challenge for many practices is that rising health care and insurance costs have resulted in a shifting of more of the financial responsibility to patients in the form of higher deductibles and copayments,” Casey said. “If practices don’t have procedures in place to collect the patient’s share of payments at the time of service, they are probably looking at a growing and aging accounts receivable.” Evans said, “The burden has shifted to physician practices to collect the amount due. Patients often aren’t aware of what changes in their coverage mean until they need it. When appointments are scheduled, the welcome letter to patients should courteously explain that amounts owed by the patient are due at the time of service. It also helps to have mechanisms in place to make it simpler for patients to

pay.” Warren said, “The biggest impact we’ve seen on the revenue side is increasing patient financial responsibility. Last week, a lady came in who had a $15,000 deductible and needed surgery. Half of what we do is treating injuries, and that can include young people who thought a high deductible wouldn’t be a problem. Any imaging, labs and surgery have to come out of the deductible first. Many people simply can’t come up with that much cash on short notice. “We have a financial counselor on staff who reviews insurance before a surgery and calls the patient to let them know what their responsibility will be. If the amount is difficult, we have two options to help them have the surgery they need while making it easier for them to pay for it. One is a zero interest credit card they can use for health expenses. We have to pay a fee for them to use it, but on the up side, we get paid and they get their surgery. For patients who don’t qualify for the credit card, we have been looking into a health care loan program.” If a patient’s insurance requires that in-network labs, imaging and specialists be used to secure full payment, it’s also important to have procedures in place to avoid oversights that result in the patient getting a bill they shouldn’t have to pay. “It’s essential to make sure patients understand their benefits and what they owe,” Waldrup said. “Our practice management system batches eligibility and (CONTINUED ON PAGE 8)

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The Agility to Adapt, continued from page 7 benefits the night before appointments so we can tell patients up front what is covered and what they owe. No surprises.”

Managing Overhead On the overhead side of profitability, two big ticket items are insurance and salaries. “Benefits are important for retaining good staff,” Casey said. “In the past, many physician practices have covered 100 percent of insurance premiums. With the increases in premiums in recent years, that adds up to a major increase in overhead. Practices are now doing more shopping around for coverage and some practice managers have come up with some wonderful ideas for containing costs.” Warren was one of these administrators who used creative thinking to hold costs down. “By going to a higher deductible and adding a gap policy that pays all but the first $500 of the deductible, we were able to save enough to hold costs about where they were, and our employees don’t have to worry about having to pay such a high deductible out of pocket,” she said. Since health care is very much a person to person business, salary and other forms of compensation are a major part of overhead. “Across the board raises and automatic annual bonuses don’t make sense anymore,” Evans said. “To encourage people to pull together and be more pro-

ductive, we suggest that our clients go to incentive plans that reward employees when the practice is profitable. This isn’t always popular at first, but after employees see quarterly incentives when the practice is profitable and have an understanding of what they can do to make that happen, they become much more invested in seeing the practice succeed.” “Merit-based raises also reward innovation and encourage employees to take the initiative,” Casey said. “It’s also important to make sure you have the right person doing the right job. For example, an RN shouldn’t be doing a job an LPN can do. That makes the cost of that work higher. An RN should be doing higher value tasks that require an RN.” Warren said, “It’s important to hire good people and train them well. Here, every new employee spends half a day in each department, so they get a clear sense of the big picture. We follow that up with every employee spending half a day at least once a year in another department. Letting them walk in someone else’s shoes helps them understand why people do things the way they do. It also helps to build better working relationships. Some of the stories we hear are hysterical. One person said, ‘we see 30 patients a day, but I have a whole new appreciation for the front desk when I realized they see 300.’ “I’m also working on an innovation committee, and I plan to put some of our new people on it. Those of us who have

Neurology care close to home.

been here for years don’t always see the dust bunnies, but new people have fresh eyes. I always ask them what they see that doesn’t make sense to them, or what they have seen done a better way.” Lunceford said, “Having the right person in the right job is an important aspect in maximizing productivity. We do personality profile testing here, which helps in matching jobs to work styles. People who are timid could be great in IT, but they aren’t likely to be very effective at collections. Waldup said, “I believe there are two sides to every equation—in this case, cost and revenue. Once a year I go through all contracts, look at what could be rebid or renegotiated and whether we’re getting good value. In hiring, I look for a degree of knowledge and someone who can quickly adjust to a quality driven environment. One person trains everyone, so everyone is getting the same information. If there are questions, they ask either their trainer or their supervisor so they don’t get derailed by misinformation. Hiring the right physicians is also important to the revenue side. You need doctors who can manage their time and be productive.” In smaller practices, managers and staff tend to wear multiple hats. Having a full time person to oversee MACRA development, IT or marketing is a luxury many smaller practices can’t afford. The increase in the volume of details that have to be handled has been a driver for merg-

ers, joint ventures and other structural changes where combined resources allow more focused staffing. Joint ventures between physician practices and hospitals can benefit both while improving overall care and reducing costs. “Hospitals and physicians can partner on many things. We’re seeing more comanagement agreements, especially in delivery rooms and in cardiac cath labs,” Lunceford said. “When hospitals look for partners, they want high quality, innovative physicians and practices that are managed with the kind of strategic thought and agility we’ve been discussing.” By the end of 2017, physician practices will have taken their first step toward MACRA. What changes lie ahead are still unknown. However, those who take steps now to be in a better position to respond are the most likely to succeed.

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Employing Value-Added Design to Improve Performance While it isn’t a new concept that those working in healthcare design strive for aesthetically pleasing form to accompany a facility’s critical functions, the rapidly changing care delivery landscape has caused many to re-think their value proposition, bringing an even larger, more robust skill set to the table. James Bearden, Floor-to-ceiling windows, pendant and task lighting, white counters, and light stone tiles all help weave lightness and brightness into a task station at Phoebe Sumter Medical Center in AIA, executive vice presiGeorgia. dent for Healthcare at Backlit ceiling panel art brings an unexpected sense of the outdoors into an interior space. Gresham Smith and Partnostics. “It is literally putting yourself in the ners (GS&P), said it has been interesting you would for mechanical, electrical and and Six Sigma into their basic operations,” position of the patient,” Bearden noted. In to witness the changes in healthcare over plumbing?” he questioned. Considered Bearden observed. Today, due diligence doing so, he continued, designers begin to the last few decades and to discern the trigessential elements, mechanical, electrical includes having departments sit down and think about physical proximity between ger points that prompted those changes. “I and plumbing features are designed into think through their workflow. points of service, walking surfaces, patient anticipate there will be two or three more the building from the beginning. While IT “You actually have to take the probed design, alarm systems, and assistive new things that come at us in the next few needs used to be added in at some point cesses into account first and then think technologies. years,” he said with a wry chuckle as everydown the design road, technology recently about layout,” Bearden stated. He added Integrating technology has become a one waits to see what direction healthcare has made the transition to essential elethat an eye-opening exercise is to ask staff, prominent consideration in facility design. reform takes next. ment. “It’s really exciting to not only get “If the physical environment wasn’t there, Bearden said they have seen a significant Bearden led GS&P for 13 years as it budgeted but to get it designed well,” how might you be more effective in delivincrease in technology budgets over the chief executive officer and now serves as Bearden said. ering patient care?” Really listening to the last several years for many of their clients. chairman emeritus for the company, which Designing with operational efficienanswers, he continued, informs innovative “How do you turn that needed IT infrahas more than 26 offices in three countries cies in mind has also become mission critidesign. structure truly into the building infrastrucincluding an office in Birmingham. The recal. “There’s not any institution that I’m “All these things now have to mesh ture and think about it the same way as (CONTINUED ON PAGE 12) cent move – back to his healthcare roots working with that isn’t employing lean – is part of the firm’s long-term leadership succession plan. While Bearden’s focus has shifted, his daily workload hasn’t lightened. “About one-third of our company is healthcare work and services,” he said. The concept of value-added design began several years ago as GS&P crafted a 2020 strategic plan, Bearden explained. He said the firm began asking clients very specific questions about the challenges they faced. “It started allowing us to see what we might do with our work to help them be HealthSouth Lakeshore more successful,” Bearden noted. When looking for common elements Rehabilitation Hospital makes that would be applicable to improve perreferrals and admissions easy, formance across the healthcare spectrum, accepting patients seven days a Bearden said they came up with six key week—including weekends. Starting rehabilitation indicators – patient safety, operational efThe Joint Commission Disease-Specific ficiency, integration of technology, adaptnow instead of later gives patients a faster start in Care Certification in Stroke Rehabilitation ability and resiliency, sustainability, and regaining independence. enhancing the human experience through evidence-based design. A Higher Level of Care® Conditions treated include: The key, Bearden said, is to weave • Amputation • Neurological conditions these tenets into the fabric of the project on the front end. “It’s taking the processes and • Hemodialysis • Orthopedic injury working with the staff within the physical • Hip fracture • Stroke environment and looking at it holistically,” 3800 Ridgeway Drive • Multiple trauma injury he explained. Birmingham, AL 35209 For example, Bearden continued, to 205 868-2025 address the safety concerns surrounding Get the referral process started patient falls, GS&P’s multidisciplinary dehealthsouthlakeshorerehab.com by calling 205 868-2025. sign team moves through the steps a patient would take – whether that’s from the bed to the bathroom or down the hall to diag©2017:HealthSouth Corporation:1292468

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GS&P Leader Discusses the Benefit of a Holistic Approach


Medical Clinics Lead Retail Growth in Grandview Area, continued from page 1 hospital,” Adams says. “The 40,000-squarefoot MedHelp 280 building has been remodeled, and both floors are fully occupied. The top floor is leased by Grandview Medical Center.” On the Grandview campus, construction of a new cancer center will begin soon, and Adams expects additional activity there in the future. “Given the location and the activity the hospital has generated, I think it is just a matter of time before we will be able to develop something else on the campus,” he says. For leasing information on The Grandview Physicians Plaza and The 3750 Grandview building, contact Jim Adams at (205) 443-4522.

Physician Properties The Grandview Physicians Plaza, a 207,000-square-foot medical office building, opened in October 2015 and is 78 percent leased, all to medical-type businesses. Adams says they would like to lease the remaining space to medical practices as soon as possible. “I believe all medical specialties are represented in the plaza and many of them are under the Grandview umbrella. Some groups we have leased to directly,” Adams says. “The 3750 Grandview building is fully leased. Many of the tenants are physicians who wanted to be close to Grandview Medical Center.” Rich Campbell of Veritas Medical Real Estate says Adams has done a good job of leasing the buildings. “It is a tall order to get physicians to move from old locations into new buildings, because there can be a bit of

A rendering of the proposed medical office building on Cahaba River Road.

sticker shock,” he says. “There’s usually a natural slowdown in leasing after a large group of physicians comes with an initial move like the one at Grandview Medical Center. You also have the issue of moving physicians being tempted by ownership, and that makes it tough for the campus MOB to compete.” Campbell says the relocation of Grandview Medical Center has sparked growth in the area. “Retail businesses are following the medical businesses and new multifamily developments are growing quickly,” he says. “The area went from just a decent location to an energetic real estate market within 18 months. It has had an enormously positive effect on the area.” Lemak Health will take advantage of the growing medical presence in the U.S. 280 area with the relocation of its clinic from Montclair Road to Cahaba River Road. The new 20,000-square-foot facility houses two digital x-ray units and a state-of-the-art MRI and C-Arm. Drayer Physical Therapy Institute will provide on-site services. “We wanted a location near the new Grandview Medical Center but were fo-

cused on patient convenience. With four separate access points, all from 280 and Interstate 459, we think we achieved that,” CEO Matthew Lemak says. Campbell expects this clinic to be as successful as all the other Lemak facilities. “Matthew Lemak has the ability to house his own practice while also offering complementary patient services, such as physical therapy,” he says. “They have clinics throughout the area, and each one is designed efficiently for best use in the current situation but also flexible enough to accommodate future changes.”

Proposed Development Cahaba River Road is the location of another proposed facility being developed by Plott & Company and Evergreen Real Estate. The 30,000-square-foot, two-story building will be built to house medical service companies. “With all the medical services in the area, the need is growing and we feel that we can be competitive with Grandview,” says Bud Ballard of Plott & Company. “It is a hot corridor, and we think

there is room for growth.” Ballard says the building will house physician offices and possibly an urgent care facility. “We are sitting between two urgent care centers now but feel that the neighborhood could support a third,” he says. Located about half a mile from the Grandview parking deck, the property will house from four to eight tenants, according to Wes Hudson of Evergreen Real Estate. “The number of tenants will depend on the land. Our plan is to have common restrooms, elevators and lobby with essentially two sides on two floors with an entry in the middle,” he says. “We definitely expect to have Class A amenities with architecture along the theme of other developments in the neighborhood.” Campbell points out that this property could face the same issues going on at Grandview Physicians Plaza as they try to reach full leasing capacity. “It’s not unique for real estate to reach critical mass where the last bit is the hardest to lease,” he says. “This proposed facility will eventually be successful, but right now the doctors have to decide how important it is to be on campus or down the street. Trying to compete down the street with a similar rent rate will be tough. Evergreen’s competitive advantage may end up being the ability to offer ownership.” Ballard says they are in the planning stages and are seeking tenants. They hope to complete the facility by first quarter 2018. To discuss opportunities related to this property, contact Bud Ballard at (205) 515-1505 or Wes Hudson at (205) 910-0559.

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Birmingham Medical News


Prescriber Beware: Federal Enforcement Focuses on Drug Treatment Clinics by

Tom Wood

Like pain clinics and pharmacies, practitioners treating substance use disorder appear to be a target for federal enforcers. Under President Trump’s administration and Alabama Attorney General Steve Marshall, law enforcement is not expected to let up. Medication assisted treatment for addiction (MAT) is not a new source of regulation or enforcement, but practitioners have noticed a renewed focus there, along with some confusion. As of the deadline for this article, two Mobile physicians remain on trial for alleged misconduct in operating their pain management practice and pharmacy. Additionally, on February 7, a Huntsville physician described by prosecutors as “a licensed drug dealer” was sentenced to 18 years of prison and supervision, $13.4 million in restitution, plus other penalties and abandonment of his license and clinic. Alabama’s new Attorney General, Steve Marshall, has also been fighting the opioid epidemic for years and will make it a priority. MAT clinics or “methadone clinics” have been proven safe and effective for decades, when provided in conjunction with counseling. Since 2002, buprenorphine (e.g., Bunavail, Suboxone, Zubsolv) has been approved for use by prescription outside of a methadone clinic, in an officebased setting. More than 100 Alabama physicians are now credentialed to prescribe buprenorphine. Nurse practitioners and physician assistants may also now train and become qualified. Patients with substance use disorder now have increased access to care; thus, regulators and enforcers have an increased number of providers on radar. Practitioners in these clinics fall into multiple categories where rules can become confusing even to the federal enforcers. Some practitioners only work in a certified opioid treatment program (OTP), where only methadone is dispensed. Some of these also prescribe buprenorphine. Others see patients at outpatient clinics where buprenorphine is only prescribed. Still others prescribe and dispense - but only buprenorphine. Collectively, these prescribers of buprenorphine are called “DATA-waiver practitioners” because the Drug Addiction Treatment Act of 2000 (DATA 2000) allows for the application of a waiver for specialized prescription privileges that comes with receipt of what is called the “X Waiver”, which is a separate number from the Drug Enforcement Administration (DEA) with the prefix “X”. Many of them are either semi-retired or splitting time with a separate medical practice or multiple MAT clinics, even across state lines. All of the varying situations are legal but present complex compliance issues that make it difficult for practitioners and clinics to rely on

word of mouth advice or an internet search, just as the same doesn’t replace a medical degree. OTPs must apply to the Substance Abuse and Mental Health Services Administration (SAMHSA), to become certified and accredited. Practitioners who treat substance use disorder with buprenorphine (whether through an OTP or not) must apply to SAMHSA for an X Waiver. SAMHSA is an agency of the US Department of Health and Human Services for behavior health with a mission “to reduce the impact of substance abuse and mental illness on American communities.” DEA is the federal enforcer. Practitioners in an OTP should ensure it is certified and accredited (at least provisionally as it works to become accredited within a year) and remains current, and that their work there is properly under the clinic’s DEA registration. OTPs have their own unique state and federal registration and updating requirements. Outpatient clinics treating substance use disorder must not only have their practitioners’ credentials on file but should ensure they remain current at DEA and SAMHSA - correct address, clinic name, telephone number, and current state credentials. Updates may be made online. These websites have known glitches, so after making changes online it’s advised to log out or exit, not log back in the same day, and wait a day or two to verify the changes. Clinics not only benefit from helping new and current physicians stay updated, but also by ensuring departed physicians no longer list the clinic as a place of business. A new certificate should be issued upon acceptance of the modifications, and both the original and new certificates must be maintained until expiration. To treat substance use disorder in multiple states, separate state credentials, separate DEA registrations, and special care are required. Practicing at multiple locations within a state requires separate DEA registrations for each location unless operating under the hospital/clinic’s or OTP’s registration or only prescribing and not dispensing at the other locations. DATA-waiver practitioners may prescribe or dispense buprenorphine outside of a methadone clinic, but dispensing at multiple locations requires separate DEA registration. With an X Waiver and a DEA registration for writing prescriptions within a particular state, a practitioner may prescribe buprenorphine at multiple clinics without additional DEA registrations. The X Waiver applies across state lines and across clinics, but SAMHSA expects to have all current clinic locations listed. Patient limits vary by physician. Federal regulations limit the practitioner to a number of patients with active prescriptions

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MARCH 2017 • 11


New Procedure for Breast Surgeries, continued from page 1 of the breast. “It’s also potentially more effective against the cancer because you can take more tissue, assuring the cancer has been completely removed with negative margins,” Winchester says. Depending on the location of the lump, the incision can be made below the hairbearing area of the axilla, or in the crease under the breast, or around the areolar. In the areolar incision, a lighted retractor elevates a flap of skin and dermis over the superior part of the breast where the cancer rests. “So you’re operating in a tunnel,” Winchester says. “You remove the cancer making sure you’ve got a good margin, and then advance tissue into the defect.” The tissue is advanced over the marker needed for radiation. “Now that you’ve restored the contour, you drop the retraction, and the skin falls back down exactly where it was to begin with,” Windchester says. “Then close at the areolar and, with time, that scar is not visible.”

The certification for the Hidden Scar approach, provided by Invuity — the makers of the lighted retractor — requires about four hours of video presentations and proctoring at least five cases. Last year, Winchester performed around 130 oncoplastic breast surgeries using the method. She’s also proctored her partner, Princess Thomas, MD, in the technique, along with four other surgeons from around the country. The oncoplastic element of refilling the void takes additional training. Provided through the American Society of Breast Disease (ASBD), the five-day course includes intensive training using cadavers. “It’s a large Investment of both time and money,” Winchester says. “This method been used since the 1980’s, mostly in Europe, and we’ve been slow to learn these techniques. So most general surgeons do not know this.” To fill in the defect left from removing the cancer, oncoplastic closure mobilizes

surrounding breast tissue and advances that into the cavity. “If the surgeon knows oncoplastic surgery, then the defect can be filled in, so you can take a little more tissue and assure your margins are negative,” Winchester says. For women facing mastectomies, there is a procedure called the Nipple Sparing Mastectomy (NSM) that saves the nipple, allowing reconstruction to be as natural as possible. “The thing that defines the breast is the nipple,” Winchester says. “The Janet Jackson wardrobe malfunction was not significant until the nipple was seen.” NSM uses a similar technique to Hidden Scar by using an inframammary crease incision, but removes all of the breast tissue while maintaining the blood flow to the nipple. “You have to be very careful not to devascularize the nipple or areolar complex. This takes experience, practice and training,” says Winchester, who has performed over 30 of the procedures and

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never lost a nipple. After the removal of the tissue, the plastic surgeon then has the entire breast flap in which to reconstruct the breast with the nipple intact. “This is especially great for all those facing the genetic mutations,” Winchester says. “It’s a prophylactic alternative that removes 95 percent of the breast tissue, but preserves the cosmesis.” Winchester had a young patient who tested positive for the BRCA1 gene and opted for preventive Nipple Sparing Mastectomy. “When she woke up, she saw her nipples, and she still had hopes of having whole breasts,” she says. After reconstruction, “people couldn’t tell she’d had a mastectomy.” Winchester does not recommend the NSM for cases in which the cancer runs within two cm of the areolar complex. Smokers are also poor candidates because of their small vessel disease. In the case of women with large breasts or those where the nipple droops below the fold, Winchester can remove the cancer and have a plastic surgeon perform a reduction. Most women are candidates, and prefer Hidden Scar Surgery. “Patients are thrilled because they have no visible reminders of their breast cancer,” she says. “Hidden Scar surgery paired with oncoplastic closure makes the breast look like it never had an operation.”

Employing, continued from page 9

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Birmingham Medical News

together in order to work,” Bearden said of creating an efficient, effective built environment. “One of the things I love about working at Gresham Smith is having multidisciplinary teams that allow us to address complex problems holistically.” He added the different points of expertise and connectivity of the team brings about better solutions, which is essential in today’s climate of change as care delivery continues to evolve. “Healthcare institutions are looking at their return on investment for their capital expenses in a much shorter and shorter time frame,” Bearden added. “It used to be about 20 years … now it’s five to seven years.” Because of that, he said architects and designers have moved away from creating rooms or departments for a single, specific use and instead are devising multifunctional areas that anticipate future uses through open-ended design. “Change is going to be inevitable,” Bearden pointed out, “so the goal is to reduce future renovation costs by extending a department’s lifecycle through adaptable healthcare design.” Ultimately, he said the goal is to incorporate all or part of the six defined valueadded areas into a project as determined by each client. Equally important is thinking about how each of the areas impact staff, patient experience, and aesthetics. That thought process is woven throughout the project from the research phase to the design stage and three-dimensional modeling to implementation and construction. “That, I think, is the secret sauce … integrating it into the entire process,” Bearden concluded.


Kidneys from Genetically Engineered Pigs Are on the Horizon UAB’s new xenotransplantation program By Jane Ehrhardt

Within four years, pigs could be providing kidneys to humans in need, thanks to the revolutionary Xenotransplantation Program at UAB. Announced last April, the Xenotransplantation program aims to produce genetically modified pigs to meet the high call for a variety of human organ transplants. “We’re starting with kidneys because the demand is so high,� says Joseph Tector, MD, PhD, the director of the program who has deJoseph Tector, cades of xenotransplant MD, PhD research under his belt. At UAB alone, 3,100 patients are waiting for a kidney. Another 99,000 candidates wait throughout the U.S., with an additional 21,000 in need of some other lifesaving organ transplant. Right now, those people with the most common blood type wait an average of six to eight years for a kidney. To begin the new program, UAB secured a five-year, $19.5 million grant

from biotechnology company United Therapeutics Corporation. Five million of that has gone toward renovation and construction of a 15,400 square-foot facility to house the pigs. Located off the campus, the building will initially hold about 30 pigs. “That’s kind of an incubator for us to get the program off the ground and show that we can get kidneys into people. Once we show it works, we’re off,� Tector says. The pigs will all stem from the same cell population. “We put part of that cell into an oocyte and put that into another female that gestates into a baby pig,� Tector says. “But all the genetic makeup is identical.� The genetic engineering eliminated what commonly triggers the human antibodies that cause the rejection of pig cells. “Most antibodies seem to bind to sugars on the cell surface of a pig, so we’ve knocked out those genes that are responsible for making those sugars,� Tector says. He was surprised at how few sugars had to be identified and removed. He credits their speedy progress in finding the three sugars to the release of new technology for cutting DNA called the CRISPRcas9.

His team accomplished that in 2015. “It lifted the antibody barrier for a lot of people on the wait list,� Tector says. Since then, they have performed a number of transplants in primates. “Five have been out for a year, so we’re optimistic,� he says. This program could eliminate the transplant waiting list. “We could be the source of pigs for the rest of the country,� he says. The pigs would also serve as sources for other needed organs and tissue, such as neuronal cell transplants for patients with certain neurodegenerative diseases, such as Parkinson’s, and corneal transplantations. The next step is to prove they can create pigs in the new facility that are devoid of FDA-required viruses. “We have to make medical-grade pigs,� Tector says. No other animals will be allowed in or out, no one can enter who is ill or been around other pigs within a certain time period. “The pigs have to be kept clean, so there are lots of rules.� Human trials are expected to begin by 2021, dependent on the FDA. “That’s going to take some finessing,� Tector says. The genetically engineered pig right

now should match about 70 percent of those on the waiting list. “Ultimately, I think we can make a pig that’s good for every human,� Tector says. “It might be more than one pig. Not positive yet, but I think we’re looking at a smaller number of pigs than you might think.� Physicians, Tector says, should tell people to have confidence in this process. Pigs have already been supplying heart valves and grafts to humans for years. “This process has been done very carefully,� he says. “It has enormous potential to help people. It’s not something that was just dreamed up overnight.� Initially, UAB plans to complete one human transplant. That would constitute a global first. “Then we’ll do one a month for a year, and then increase it to one a week for a year, and then we will offer this to a wider range of patients,� Tector says. Right now, the program is all about paperwork. “The science for an initial entry to the clinic is done. That’s why it’s a particularly challenging time in my life,� Tector says. “I feel like one of those rodeo riders sitting on the bull in the holding chute — you’re ready to go, but can’t until they open the gate.�

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On the Front Lines of Oral Cavity Cancer Prevention, Detection By CINDY SANDERS

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14 • MARCH 2017

Birmingham Medical News

Incredibly painful to treat, potentially disfiguring, and quite likely to severely impact quality of life in the near- or long-term, a patient’s best line of defense against oral cavity cancer is a good offense in the form of primary prevention and early detection. “There has been an increase in the number of oral cancers diagnosed in the United States on an annual basis,” said Dr. Barbara A. Barbara A. Murphy, Murphy MD, director of Head and Neck Oncology and of the Pain and Symptom Management Program at Vanderbilt-Ingram Cancer Center in Nashville. The American Cancer Society estimates more than 32,000 cancers of tongue, mouth or other oral cavity location will be diagnosed this year. Between 6,000 and 7,000 deaths will occur in 2017 due to oral cavity cancers, which have seen a decline in the death rate stagnate over the last decade.

Prevention To reverse the increased incidence trend, Murphy said it is incumbent upon pediatricians, family practitioners, dentists, and other primary care providers to make sure people fully understand the risk factors, particularly when it comes to tobacco usage. The medical oncologist noted many patients “don’t realize smokeless tobacco increases risk for oral cancers.” When a provider taking a patient history asks, ‘Do you smoke?’ and a patient who chews or dips tobacco truthfully replies, ‘No,’ Murphy said it is a missed opportunity for an important conversation. “We need to extend the question to smokeless tobacco … it’s about asking about the use of tobacco in all its forms,” stressed Murphy, who is also a professor of Medicine at Vanderbilt University Medical Center. Benjamin J. Greene, MD, an assistant professor at the University of Alabama School of Medicine at BirmingDr. Benjamin J. ham, added patients Greene should also understand the heightened risk for oral cancer that comes with the combination of drinking and smoking. “The two work together. It’s a synergistic effect,” said the head and neck oncologist. Greene added the whole is greater than the sum its parts … so the

total risk for an individual who both uses tobacco and consumes alcohol is even greater than simply adding together the risk factor for each vice. He also noted there isn’t evidence of e-cigarettes being any safer at this point.

Early Detection “It’s really critical to recognize the role of dentists and dental hygienists in the early identification of oral lesions,” said Murphy. Greene concurred, calling dental professionals a “first line of defense.” He added that many people also go to primary care physicians with a lingering sore on the tongue or jaw and urged all healthcare professionals to refer such patients to head and neck specialists or an oral maxillofacial surgeon for a consult and possible biopsy. “If somebody has an ulcer or lesion in their mouth that hasn’t healed in two weeks, it should be biopsied … especially if they have a history of smoking or drinking,” Greene said. “My thought is it’s better to do the biopsy and then tell the patient it’s nothing. It hurts to have a tongue biopsy but not as much as having half your tongue taken out because we didn’t catch it sooner.” Murphy noted some of the early manifestations of oral cavity cancers include painful lesions, non-healing ulcers, abscessed teeth that don’t respond to treatment, and swollen lymph nodes. Adenopathy, she said, deserves extra attention. Greene agreed. “A swollen, enlarged lymph node in the neck of someone over 40 is cancer until proven otherwise,” he said. “You should be thinking cancer first. It’s not something you should take lightly.” If oral cavity cancer is caught in its early stages, Murphy said, “It’s not only curable … but curable without the aggressive treatments that are associated with significant morbidity.” As pleased as oncologists are to catch the cancer early, Murphy added, “If it can be found in a pre-malignant stage, that makes us even happier.” Red flags for premalignancy, she noted, include white or red plaque in those who might be asymptomatic or leukoplakia – the thickened, white patches that form on the gums, inside of the cheeks or floor of the mouth. Treatment “Most oral cavity cancers are treated with surgery as a first line treatment,” said Greene. “Then we use radiation and chemotherapy postoperatively as indicated by the pathology.” Murphy noted the use of adjuvant therapy is often necessary but increases risks for patients. “Once you (CONTINUED ON PAGE 16)


The Literary Examiner BY TERRI SCHLICHENMEYER

Attending: Medicine, Mindfulness, and Humanity by Ronald Epstein, M.D.; c.2017, Scribner; $26; 287 pages The appointment will probably be brief. That’s okay, though; you’re informed. You know that when it comes to your health these days, it’s important to make every minute with your doctor count and you’re hoping to be thorough, so you don’t waste her time. The new book Attending by Ronald Epstein, MD might help, by revealing how a good practitioner thinks. Years ago, as a young medical student, Ronald Epstein witnessed a nearcatastrophe in an operating room that almost led to a patient’s death. Shaken, he began to think about what makes a good doctor, and he “came to three conclusions – good doctors need to be self-aware… in the moment… and no one had a road map.” And thus the reason for this book: patients and physicians are both frustrated at what has become of the healthcare system today. On the part of the practitioner, “it is possible to do better” by becoming more mindful. With ever-shrinking appointment

times, it’s especially important for a practitioner to pay attention to a patient, but in different ways. Medical school teaches physicians to deal with the “unexpected and complex,” but they’re not trained to slow their thinking and see the obvious.

Even so, in a good doctor, intuition sometimes takes over. Curiosity is inherently present in mindfulness. It’s asking the seemingly-odd questions, a willingness to see things differently, the cultivation of presence and of active listening, and wanting to avoid the mundane. It’s what makes a doctor want to get to know a patient, if nothing but for the sake of knowing. Practitioners, says Epstein, are taught not to get too close to their patients but sometimes, they can’t help it. They dread the “’What would you do it you were me?’” question, and they hope you never become an “interesting” case. They get sick, too, and it makes them just as fearful as it does you. And they know that sometimes, “no” is the absolute right answer. Though I liked reading Attending very much, the main thing I couldn’t ignore was the struggle in determining its intended audience. Absolutely, author Ronald Epstein, MD wrote this book with healthcare practitioners in mind. There seems to be abun-

dant advice and reminders on each page, with stories that they will understand and to which they can relate. This is a thoughtful, quiet book and, for medical personnel, it’s a phenomenal look at being the kind of healer patients want. But is it accessible for lay-people? There’s where I struggled. I can see where a patient might want to read this book; surely, just as doctors can improve, it’s nice to know how to be a better patient. I’m not sure the new-ageyness will hold the average reader’s interest – that’s more physician-based – but I think there are lessons to learn. Even so, while this book is good and does offer an imagined future for healthcare, those in the field will get much more from it. If that’s you, then you’ll appreciate it. If not, then your time with Attending might be brief. Terri Schlichenmeyer is a professional book reviewer who has been reading since she was 3 years old and she never goes anywhere without a book.

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Birmingham Medical News

MARCH 2017 • 15


On the Front Lines of Oral Cavity Cancer Prevention, continued from page 14 add on radiation or radiation with chemotherapy, the toxicities skyrocket,” she said. Mucositis, an inflammation of the mucus membranes within the oral cavity, is a primary … and extremely painful … toxicity associated with radiation. “Even opioids don’t work well on this pain,” said Murphy. Edema is another issue arising from adjuvant treatments where the swollen tissues can create problems with swallowing and speaking. Murphy said thick salivary gland secretions are another complaint for patients that are almost as

problematic as mucositis. Large lesions typical in later stage cancers pose a host of long-term issues for patients. “Can you resect large lesions? Yes you can, but the effect on the patient is going to be profound,” said Murphy. “This is high dollar real estate in the mouth. When you go in and resect many of these tissues, there is going to be function loss.” Speech, taste and swallowing are all potential casualties. Greene concurred, saying, “The surgeries for oral cavity can be pretty debilitating and disfiguring.” In cases where

the jawline is impacted, Greene said some surgeries take eight to 10 hours. “Usually we do two teams. One surgeon takes out the cancer, and another rebuilds it … if the jawbone has to be rebuilt, that’s stage 4.” As with most cancers, treatment is most effective if the cancer is caught early. “Surgery is definitely curative,” Murphy said of completely resecting smaller tumors. As the staging moves up the spectrum, the treatment plan becomes more complex and outcomes less assured. Greene said the five-year survivability

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rate for oral cavity cancer is over 90 percent for stage 1 cancers but as low as 25 percent for some stage 4 cancers.

Oropharyngeal Cancer Although close in proximity and often linked together for the purpose of discussion, oral cavity cancer and oropharyngeal cancer are two different beasts, Murphy and Greene noted. “There’s a big difference in treatment modalities and in etiology,” Murphy said. “Draw a line right along the edge of your mandible – everything in front is oral cavity and everything behind is oropharynx.” These cancers are often discovered later and therefore have a slightly lower five-year survival rate than oral cavity cancers. The American Cancer Society’s 2017 statistics estimate 17,000 new cases of pharynx cancer will be diagnosed, and 9,700 people will die from all oral cancers with about one-third of those total deaths being from pharynx cancer. Greene said some of the signs and symptoms of oropharyngeal cancer include sore throat, persistent cough, ear pain, and a feeling like something is stuck in the throat. As with oral cavity cancers, Greene said smoking and drinking are risk factors for this type of cancer, as well. However, he continued, “We’re seeing a lot of oropharynx cancers in people who have never smoked and who aren’t heavy drinkers. These are mostly HPVassociated … up to 70 percent of oropharynx cancers are associated with HPV.” Murphy agreed, adding, “The number of HPV-associated oropharynx tumors is epidemic.” On a positive note, HPV-associated oropharyngeal cancers respond better to treatment. “In typical head and neck cancer, when someone has stage 3, you’re thinking a 50 percent five-year survival rate. For HPV-associated cancers stage 3, we’re seeing 85 percent five-year survival,” said Greene. He added the American Head & Neck Society strongly recommends the quadrivalent HPV vaccine for both boys and girls. The recommendation was given despite the difficulty in proving prevention of HPV-related oropharyngeal squamous cell carcinoma (OPSCC) due to the inability to reliably screen for pre-malignancy and the extended latent period between HPV infection and clinical cancer development. However, the authors of the AHNS position statement said the vaccines have been shown to be safe and offer a reasonable precaution based on the observed link between HPV and OPSCC.

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CAC Raises Heart Disease Risk for Younger Adults A major report, from a multi-center investigation, including work done at the University of Alabama at Birmingham, found the mere presence of even a small amount of calcified coronary plaque, more commonly referred to as coronary artery calcium (CAC), in people under age 50 was strongly associated with increased risk of developing clinical coronary heart disease over the ensuing decade. The study, which appeared Feb. 8 in JAMA Cardiology, also revealed that those with the highest coronary artery calcium scores, as measured by computed tomography scan, had a greater than 20 percent chance of dying of a heart event over that same time period. CAC has long been associated with coronary heart disease and cardiovascular disease. However, prognostic data on CAC in younger adults — people in their 30s and 40s — has been very limited, especially in African Americans and women. “We always thought you had to have a certain amount of this plaque before you were at risk of having events. What we showed was that, for younger people, any amount of coronary artery calcium dramatically and statistically significantly increased risk of clinical heart disease,” said Jeffrey Carr, MD, MSc, lead author of the study out of Vanderbilt University Medical Center. “Any measurable CAC in early middle age — scores of less than 100, and

even less than 20 — has a 10 percent risk of heart attack or acute myocardial infarction, both fatal and non-fatal, over the next decade beyond standard risk factors,” Carr continued. The study points to CAC as a very specific imaging biomarker for identifying those people who are at risk earlier in life for heart disease and who might benefit from proven interventions such as cholesterol and blood pressure management, working toward a healthy BMI, smoking cessation and more. Researchers found a person may not be at risk for a heart attack in the near future, but they are at very high risk over the next 10 years of their life. For individuals at this elevated risk, there are proven interventions to modify behaviors and lower risk. Data for this study comes from the National Heart, Lung and Blood Institute (NHLBI) Coronary Artery Risk Development in Young Adults (CARDIA) Study, a longitudinal, community-based study that recruited 5,115 black and white adults age 18 to 30 in four cities — Birmingham, Oakland, Minneapolis and Chicago — beginning in 1985 and followed them for 30 years. Institutions participating included UAB, Vanderbilt, the University of Minnesota, Northwestern University Feinberg School of Medicine, the Colorado School of Public Health, the American Heart Association, the NHLBI and Kaiser Perma-

nente. CT scans were performed on 3,330 subjects for the CAC study, and the mean follow-up period was 12.5 years. CAC of any amount was seen in 30 percent of that group. Investigators sought to answer two primary questions: 1) Can the simple presence of CAC on a chest CT inform clinical practice? 2) Is a CAC score greater than 100 associated with premature death? The answer to both was yes. Researchers found the presence of any coronary artery calcification, even the lowest score, was associated with between a 2.6 and tenfold increase in clinical events over the next 12.5 years. When it came to those with high CAC scores (100 or above), the incidence of death was 22 percent, or approximately 1 in 5. The study showed whether the amount of CAC is high or low, it’s presence is a signal that advanced coronary artery disease is present and enhanced prevention could be warranted. A change in clinical practice that could impact care today is that CAC can easily be identified on routine CT scans of the chest obtained for other indications, Carr said. Whether any kind of general screening for CAC is warranted needs additional research, although the study’s authors suggest that a “CT scan everyone” strategy in all individuals age 32 to 46 is not indicated. Instead, they suggested a more targeted approach based on measuring risk

factors in early adult life to predict individuals at high risk for developing CAC in whom the CT scan would have the greatest value and should be considered. Cora E. Lewis, MD, MSPH, FACP, FAHA, a Professor in the Division of Preventive Medicine and Director of the Division’s Preventive Medicine Clinic at UAB, was a contributing author to Cora E. Lewis, MD the report.

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Collaborative Practice Agreements A Step in the Right Direction for Advancing Healthcare in Alabama By auSTin CroCKer, Pharm.D. CanDiDaTe 2017 anD KaTie LomaX, Pharm.D. BCPS

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As the healthcare field continues to grow and adapt, implementing additional methods of patient care are vital to sustaining a high level of healthcare in the United States. As the U.S. population ages, the prevalence of chronic diseases is increasing as well. These circumstances are creating a crossroads in healthcare, raising the question of how to care for the growing number of patients and what profession can effectively take on this task. Pharmacy is in a prime position to help shoulder this responsibility. Moving beyond a dispensing role, pharmacists can work alongside physicians to ensure patients receive exceptional care through Collaborative Drug Therapy Management (CDTM). CDTM establishes Collaborative Practice Agreements (CPA) with physicians, enabling pharmacists to provide a variety of clinical services. With CPAs, pharmacists work under defined protocols to perform a wide range of services customized to the preferences of the collaborating physician and pharmacist. For pharmacists and physicians to take advantage of these opportunities, they must practice in a state with an established CPA. Authority to participate in CDTM is delegated by a state’s pharmacy practice act. Unfortunately, Alabama is the only state without a CPA in the pharmacy practice act. To better illustrate the advantages of CDTM, it’s important to look at the incredibly diverse settings in which pharmacists can practice. CPAs can be implemented in a variety of disciplines such as the management of asthma, hypertension, dyslipidemia, diabetes mellitus, and anticoagulation among many others. Pharmacist responsibilities in these collaborative settings have been diverse. They include medication reviews, and working alongside physicians developing treatment plans unique to each patient’s needs. Additionally, pharmacists communicate the plan to the patient and provide disease state counseling, freeing the physician to treat the next patient. While CPAs open doors for pharmacists providing new opportunities, patients also see benefits from the collaborative teams. Two studies in particular, assessed patients with hypertension and diabetes mellitus. All of the patients in pharmacist integrated teams achieved statistically significant improvements in clinical parameters regarding their degree of control. For example, patients with a baseline blood pressure of 149/84 mm Hg achieved an average blood pressure reduction of 17/9 mm Hg (132/75) after nine months. A

study evaluating chronically uncontrolled diabetic patients with an average baseline A1C of 9.3 percent, obtained an A1C of 8.18 percent after one year and an A1C of 8.06 percent at the study’s conclusion. By comparison, patients in the control group without pharmacist care, achieved an A1C of 8.69 percent after year one, but only reached an A1C of 8.67 percent at the end of the study. One of the main patient benefits of pharmacist integrated care was the increased access to healthcare. All of these patients continued to see their physician and also saw a pharmacist once every one to three months, as they gained better control of their health conditions. The researchers concluded this increased follow-up with a healthcare provider made a difference in patients gaining better control of their disease states. Finally, physicians were able to save time with their workload while working alongside pharmacists through CPAs. Effectively managing patient populations with hypertension, diabetes mellitus and other chronic conditions requires a significant amount of time, which physicians usually lack due to their substantial daily work load. Once an agreement on the care plan is reached, the physician is able to diagnose more patients. During that time, the pharmacist stays with the previous patient to answer any remaining questions, provide disease state education, and give medication counseling. Support for CPAs is growing nationwide. Nicholas Gentile, the American Society of Healthcare Pharmacists (ASHP) director of state and leader of ASHP’s grassroots political action campaigns, has advocated for expanded pharmacist responsibilities through CPAs such as point of care tests, acute illness screenings and managing medication regimens in chronic diseases. To address concerns of pharmacists competing with physicians for patients, Gentile stated “We’re not trying to pull patients out of physician practices. In fact, we’re trying to work alongside these physicians, nurse practitioners, and other providers to help patients have the best care possible.” Improved clinical outcomes, increased access to care and assisting physicians with their daily workload, only scratch the surface of what CPAs can do for the pharmacy profession, and the healthcare system as a whole. Therefore, implementation of CPAs is a step in the right direction to better serve our patients in the ever changing environment of healthcare. Austin Crocker is Pharm.D. Candidate for 2017 in the Samford University McWhorter School of Pharmacy. Katie Lomax, Pharm.D. (pictured) BCPS is an assistant professor in the Samford University McWhorter School of Pharmacy.


UAB Opens State-of-Art Facility for Clinical Trials of Exercise Medicine The Center for Exercise Medicine at UAB opened its state-of-the-art exercise facility in February. The Exercise Clinical Trial Facility provides equipment and staff for research projects looking at the role of exercise as medicine. “We have developed a much greater appreciation of the role of exercise in human health,” said Marcas Bamman, PhD, professor in the Department of Cell, Developmental and Integrative Biology and the director of the Center for Exercise Medicine. “This is not about exercise for weight loss or simply feeling better; rather, we are striving to understand the role of exercise as medicine at the molecular, cellular and clinical levels.” The facility includes an exercise training zone with 24 resistance exercise stations, Olympic barbells, dumbbells and more than 2,000 pounds of free weights. It also features seven stationary cycle ergometers, nine treadmills and two rowing machines. A cardiorespiratory function laboratory offers 12-lead ECG graded exercise stress testing, aerobic and anaerobic power measurement, and cardiorespiratory and metabolic demand tests during submaximal exercise such as walking, running, cycling or stair climbing. A neuromuscular function laboratory

Marcas Bamman, PhD works with an exercise participant.

allows for the study of joint kinematics and kinetics, strength and force measurements, muscle fatigue testing, and muscle activation, as well as balance and gait analysis. “It’s not enough to simply tell someone they should exercise more,” Bamman said. “We need to be able to present

precise exercise prescriptions to patients that include evidence-based dosing — frequency, intensity and type of exercise — that will be most effective in helping that patient improve health. This facility will provide the infrastructure to help us determine the optimal exercise prescription

for a 70-year-old woman with osteoporosis versus a 30-year-old man with a traumatic brain injury.” “The facility has all of the equipment, but also experts with all of the knowledge to help patients reach their exercise goal, whatever their conditions,” said Lou Dell’Italia, MD, professor in the Division of Cardiovascular Disease, Department of Medicine. “Bamman has attracted some of the best young physiologists to UAB, who are driven to provide an exercise prescription based on the patient’s capabilities.” Bamman proposed the creation of the Center for Exercise Medicine within the School of Medicine in 2010. Following approval from the University of Alabama Board of Trustees in 2011, UAB became one of the first major academic medical centers to establish a center devoted to understanding the benefits of exercise. In addition to conducting its own research, the center has rapidly become a national powerhouse in exercise medicine and serves as a resource frequently tapped by other institutions. “We are excited about the tremendous strides the UCEM has made since its founding at UAB seven years ago,” said UAB President Ray Watts. (CONTINUED ON PAGE 20)

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Prescriber, continued from page 11 of buprenorphine, whether 30 or 100 or now up to 275. The limit does not include patients treated in a methadone clinic, but having the X Waiver, alone, does not qualify a physician to treat an unlimited number of patients with buprenorphine across multiple clinics or states. In Alabama and many other states, MAT is governed by a regulatory set of model guidelines for accepted professional practice. Following these guidelines is a good start, and that includes keeping copies of prescription orders in the medical record. DEA may review these records and suggest the patient’s date of birth is required on prescriptions, but it is not required in Alabama - even if it is a common and appropriate practice. DEA may also suggest the practitioner surrender her license without contacting an attorney. MAT is necessary, safe, and effective, but it is highly regulated. As such, consulting a lawyer should not be viewed as suspicious. Practitioners should not be intimidated or discouraged from obtaining sound legal advice to safely navigate a regulatory environment in order to apply their education, training, and experience to faithfully serve a community in need. Routine DEA audits should not cause a panic. Remain calm and respectful. Politely ask at any time to consult with an attorney, and call a health care lawyer. Many issues may be resolved administratively with professional legal guidance. The law is constantly changing in this area, so consider making legal review part of a routine annual check-up. Tom Wood is a partner in the Health Care Practice Group at Burr & Forman LLP and represents health care providers in regulatory and litigation matters.

RESEARCH NOTES

UAB Developing New Peptide to Combat Familial Hypercholesterolemia Researchers at UAB are testing a new peptide that they hope will lead to better treatment options for familial hypercholesterolemia (FH). FH is a genetic condition that results from the body’s inability to clear low-density lipoprotein (LDL), or bad cholesterol, from the blood. This results in startlingly high cholesterol levels. There are two forms of FH: heterozygous FH (HeFH) and homozygous (HoFH) which is the most serious type of FH. If untreated, HoFH often causes heart disease in the early teen years and sometimes even in early childhood. Professors in the UAB Department of Medicine, G.M. Anantharamaiah, PhD and C. Roger White, PhD are working on the second version of a peptide licensed by Lipimetix, Inc., a biopharmaceutical company. The peptide, called AEMG.M. 28-14, has the potential Ananthararmaiah, PhD to treat patients suffering from HoFH in a new way instead of the usual treatment of plasma/LDL apheresis. AEM-28-14 inserts White, into cholesterol-rich li- C. Roger Phd poproteins and directs them to the receptors on the liver. The lipoproteins are then internalized and degraded through existing pathways, dramatically decreasing blood cholesterol levels for a longer period of time

— nearly two months, compared to plasma/ LDL apheresis, which has to be administered every two weeks. “Current treatments rely on increasing the Pankaj Arora, MD excretion of LDL via the LDL receptor pathway,” Anantharamaiah said. “In FH patients, since LDL receptor is defective, LDL cannot be cleared via this pathway.” Anantharamaiah says the newly developed peptide AEM-28-14 bypasses LDL receptor pathways and has been demonstrated to clear large amounts of LDL in relevant animal models. He believes this may be the most powerful lipid reduction agent yet discovered. An ideal LDL cholesterol level is typically 130 mg/dL. Adults with FH generally have LDL cholesterol levels of 190 mg/dL and above, and HoFH patients not using medication can have LDL levels between 500 and 1,000 mg/ dL which leads to a much greater risk of heart attack or stroke. According to The FH Foundation, it is now believed that one in 250 people (or 1.3 million people in the United States) have HeFH and one in 160,000 have HoFH. FH is responsible for 20 percent of all heart attacks in people 45 and younger. If untreated, 50 percent of men with FH will have a heart attack by age 50, and 30 percent of women will have a heart attack by age 60. UAB Assistant Professor in the Division of Cardiovascular Disease Pankaj Arora, MD says it is imperative to get

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tested for FH if there is a prior family history of the disorder. Arora says educating patients about the physical signs of FH can help. “Education about physical signs such as swollen tendons on the back of the heel, yellow deposits in the skin around the eyes and white deposit of cholesterol around the colored part of the eyes can help to increase awareness,” Arora said. There are only 58 plasma/LDL apheresis centers across the United States, significantly limiting patient access. The scientists hope that this new peptide will lead to better treatment options, which will in turn, lead to more treatment centers for patients to gain access.

UAB, continued from page 19 The Center for Exercise Medicine manages two national networks devoted to exercise medicine. One is the National Institutes of Health¬¬-funded Medical Rehabilitation Research Resource Network, the MR3 Network, working to foster advances in medical rehabilitation research. UAB’s REACT Center — Rehabilitation Research Resource to Enhance Clinical Trials, is one of six partner centers making up the MR3 Network, and serves as the network’s coordinating center. The center also founded and maintains NExTNet, the National Exercise Clinical Trials Network. NExTNet is a 70-member consortium of institutions involved in exercise research. Member institutions are looking at exercise in the context of nearly every major disease or condition, from heart disease and diabetes to aging and cancer. Several active clinical trials are underway using the facility, including the MASTERS trial looking at improving muscle mass in seniors and the TWEAK trial for patients facing hip or knee replacement. The PHITE, or Precision High Intensity Training Through Epigenetics study, sponsored by the U.S. Department of Defense, is working to identify biomarkers to determine ideal training regimens for battle readiness. Other ongoing research includes clinical trials on Parkinson’s disease, a pilot study examining exercise in treating epilepsy and an observational study on ALS. In addition, the UCEM research team and facility will serve as a clinical center for the recently announced National Institutes of Health Molecular Transducers of Physical Activity Consortium, or MoTrPAC, to explore molecular changes that occur during and after exercise. UAB and its two partners — the Translational Research Institute for Metabolism and Diabetes in Orlando, Florida, and Ball State University in Muncie, Indiana — will receive a projected $6.6 million over six years, as part of the nearly $170 million MoTrPAC initiative involving researchers across the United States.


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HudsonAlpha Discovers New Gene Signature for Breast Cancer Researchers at the HudsonAlpha Institute for Biotechnology along with collaborators from UAB and the Huntsman Cancer Institute have discovered a new gene signature regulated by a specific transcription factor – proteins that switch genes on and off – that is involved in regulating processes active in triple negative breast cancer. The research was led by then graduate assistant Joy Agee McDaniel, PhD, who recently joined The University of Texas MD Anderson Cancer Center as a postdoctoral fellow. She and her colJoy Agee McDaniel, PhD leagues discovered a new gene signature regulated by the transcription factor STAT3. “We found that therapies that target STAT3 could prevent metastasis in triple negative breast cancer” McDaniel said. In metastasis, cancer cells break away from where they first formed, travel through the blood or lymph system, and form new tumors in other parts of the body. Triple negative is one of the least treatable forms of breast cancer because it does not respond to hormonal therapies and is usually diagnosed at a later stage. McDaniel points out that while African American women have lower incidence of breast cancer diagnosis compared to white women, African American women have disproportionately lower survival rates from breast cancer. “One out of every three breast cancer diagnoses in African American women is triple negative,” McDaniel said. “I want to help more women survive this devastating form of breast cancer.” This research could lead to a new targeted therapy for triple negative breast cancer, which currently has no therapies tailored to treat its specific genetic makeup..

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CVA Honors Moraski CVA was founded in 1946 by Dr. John B. Burrett who was the first cardiologist to practice in the state of Alabama. As a tribute to Dr. Burrett, each year CVA honors an outstanding individual who has contributed to the advancement of cardiovascular healthcare in Alabama with the John Burrett, MD Award. This year at the The Cardiovascular Update event, Dr. Roger Moraski, former CVA partner and retired cardiologist, was awarded the John Burrett, MD Award. Moraski was the operator for the first balloon angioplasty ever performed in the state of Alabama. The Cardiovascular Update is an annual CME event for healthcare professionals presented by the CVA Medical Education Foundation. This meeting (Left to right) Drs. Bradley Cavender, Roger Moraski, is structured to provide a review of the Gary Roubin past year’s developments along with recommendations for the prevention and treatment of cardiovascular disease. There were over 185 healthcare professionals in attendance at this year’s conference.

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Green Named Executive Director of the Alabama Board of Medical Examiners

Children’s Names Blount Director of Pediatric Neurosurgery

Norris Green was recently named executive director of the Alabama Board of Medical Examiners. Green originally joined the ALBME in July 2015 as the associate executive director and was officially named director following the retirement of Larry Norris Green Dixon in December. Prior to coming to the ALBME, Green worked for 39 years with the Alabama Legislative Fiscal Office and served as its director for his last four years with the organization. “Since joining the ALBME, I’ve enjoyed working with our staff and getting to know Alabama’s physicians who serve as members of the board,” Green said. “We are all working together to shape our state’s health care future.” Green has a Bachelor’s degree in Business Administration from Auburn University, a Juris Doctor degree from Jones School of Law, and is a member of the Alabama State Bar. During his career, he received recognition by the National Association for Legislative Fiscal Offices for outstanding contributions to the Alabama Legislature as well as recognition of the fiscal office by the Center on Budget and Policy Priorities as a model legislative agency. “The Medical Association is excited to work with Norris and continue our strong relationship with the ALBME,” said Association Executive Director Mark Jackson.

Children’s of Alabama has named Jeffrey P. Blount, MD as director of pediatric neurosurgery. Blount earned his medical degree from the University of Rochester and completed the neurosurgery residency program at the University of MinneJeffrey P. sota. Following residency Blount, MD training, he served as staff neurosurgeon at the Naval Medical Center San Diego prior to a fellowship in pediatric neurosurgery at the Hospital for Sick Children in Toronto, Canada. Blount has been active on the Accreditation Council of Pediatric Neurosurgery Fellowships and the Professional Advisory Council of the Spina Bifida Association of America. He is also an active member of the American Society of Pediatric Neurosurgeons, the Pediatric Section of the American Association of Neurological Surgeons and the American Epilepsy Society. At Children’s, Blount has been active on the Clinical Outcomes Committee, Quality Improvement Committee, Credentials Committee and the Medical Executive Committee. Blount’s academic interests center on the surgical treatment of epilepsy in children, the management of children and young adults with neural tube defects/spina bifida. He is pursuing a master’s degree in public health from the UAB School of Public Health.

Former White House Strategist to Lead UAB’s Personalized Medicine Institute Matthew Might, PhD, a renowned computer scientist and strategic leader appointed to the White House Precision Medicine Initiative by former President Barack Obama, has been named the inaugural director of the Hugh Kaul Personalized Matthew Might, Medicine Institute at the PhD UAB School of Medicine. Might comes to UAB from the University of Utah, where he is a Presidential Scholar and an associate professor in both computer science and pharmaceutical chemistry, and from Harvard Medical School, where he is a visiting professor of biomedical informatics. Might’s research interests focus on the intersection of computation and medicine to advance precision medicine through personalized therapeutics. Precision medicine is an emerging practice of conducting medicine that uses a comprehensive set of resources and information — from an individual’s family history and genetic profile to lifestyle and environment — in order to guide decisions for the prevention, diagnosis and treatment of disease. It has attracted significant early attention for its promise in treating rare diseases and cancers at their root cause. “Dr. Might is a passionate scientist, and I believe that his drive and strategic vision will make UAB a national leader in precision medicine,” said Selwyn M.

Vickers, M.D., FACS, senior vice president for Medicine and dean of the UAB School of Medicine. Might’s shift into genetics and drug development was inspired by his son Bertrand, who was diagnosed in 2012 as the first case of NGLY1 deficiency, an ultra-rare genetic disorder. Might then pioneered the use of social media and search engine optimization to find other patients with the rare genetic condition in a successful effort to advance scientific research for the disease. Might was recruited in January 2015 by former President Barack Obama to serve as an adviser to the then newly launched Precision Medicine Initiative. He took on a formal role with the Precision Medicine Initiative as a White House official in the Executive Office of the President in March 2016.

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Nurse Practitioners Join Southeast Gastro Two nurse practitioners have joined Southeast Gastro. Micah Morgan, CRNP, AGNP-C has joined the practice at the St. Vincent’s East office. She is in collaborative practice with Rohit Malik, MD. Morgan received her undergraduate as well as graduate degree from UAB. She has been a reg- Micah Morgan, istered nurse since 2011 CRNP and a nurse practitioner since 2016. Prior to joining Southeast Gastro, her expertise was in the medical intensive care unit at UAB hospital. She is board certified by the American Academy of Nurse Practitioners. Johanna McAnally, CRNP, AGPCNP-C has joined the practice at the Brookwood Medical Plaza office. She is in collaborative practice with Timothy Denton, MD. Johanna She received her un- McAnally, CRNP dergraduate as well as graduate degree from UAB. She has been a registered nurse since 2013 and a nurse practitioner since 2016. Prior to joining Southeast Gastro, her expertise was in the Trauma and Burn Intensive Care Unit at UAB hospital. She is board certified by the American Academy of Nurse Practitioners.

DCH Awards Shirley James Shirley recently received the DCH Excellence Award. Shirley, who joined DCH in 1998, was recognized for his work as manager of facilities and environment of care compliance officer for the DCH Health System. In addition to his work at DCH, he is a key James Shirley player in the Tuscaloosa Rotary Honor Flight that transports veterans and their guardians for free to tour war memorials in Washington, D.C.

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