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The Business Magazine of Kentucky Physicians and HealthCare Administrators may 2011

Issue Spotlight:

Women’s Health

Meet the MISses Local women doctors are the new champions of minimally invasive surgery, which has been slow to gain acceptance in GYN practices nationwide.

Volume 2, Number 5

Also inside

Other Perspectives on MIS and Women’s Health from Interventional Radiology, Vascular Surgery, and Cardiology Practitioners Internal and Functional Medicine Specialist Authors Book on Stress-Related Illness Women Volunteer Insights into the Factors Shaping Women’s Health


Discover the Experience that New Moms are Buzzing About. The Women’s Hospital at Saint Joseph East celebrated its first anniversary March 29, 2011. In our first year alone, we helped deliver more than 2500 bundles of joy to new moms across central and eastern Kentucky. The Women’s Hospital at Saint Joseph East offers moms-to-be a comfortable, family centered environment and spacious rooms. To learn more about what new moms are buzzing about, call 859.967.2229 or for a virtual tour, visit us online at www.SaintJosephEastKY.org.

Unique Care for Women Also Available at The Women’s Hospital at Saint Joseph East Michelle Morton, M.d. Saint Joseph cardiology Associates 170 n. eagle creek, Suite 104 859.629.7100 credentiAlS American Board of cardiology SPeciAltY echocardiography, nuclear cardiology & diagnostic cardiac catheterization PrActice FocUS AreA Women’s cardiac disease, hyperlipidemia, cAd, chF & Preventive cardiac disease

kriSti h. Mckenzie, M.d. Saint Joseph obstetrics and Gynecology Associates 170 n. eagle creek, Suite 104 859.967.5848 credentiAlS American Board of obstetrics & Gynecology and Fellow of AcoG SPeciAltY laparoscopic Surgery and Minimally invasive Procedures PrActice FocUS AreA Abnormal Periods, Fibroids, hormone replacement and obstetrics


Getting back to life sooner after surgery Comprehensive Services: • • • • • • • • • • • •

Digital Mammography Osteoporosis Screening OB/GYN Ultrasounds (3D/4D) High Risk Obstetrics Genetic/Preconception Counseling Urinary Incontinence Testing/Surgery Menopause Management Minimally Invasive GYN Surgery da Vinci® Robotic Surgery Hormonal Therapy Management

Bleeding Disorders • Lactation Counseling *

Find out more about us online: www.wfoflou.com Or call to set up a new patient referral : (502) 891-8700 Baptist East Medical Pavilion, 3900 Kresge Way, Suite 30, Lousiville

The National Women’s Health Information Center and HealthNewsDigest.com

** Based on total number of patient surgeries from 2007-2010 at Women First of Louisville. PLLC

Pictured from left to right: Dr. Lori Warren, Dr. Mollie Cartwright, Dr. Rebecca Terry, Dr. Rebecca Booth, Dr. Holly Brown, Dr. Leigh Price, Dr. Kelli Miller, Dr. Stephanie Dutton, Dr. Ann Grider, Dr. Michele Johnson, Dr. Ann Clark, Dr. Margarita Terrassa


Letters

FROM THE DESK OF

Megan Campbell Smith, Editor-in-Chief

When I had a daughter, I realized in the first moments after her birth that everything I would do from that moment on was to provide for her future wellbeing. I realized that my choices for her infant care would be prescriptive not only of her chances for survival today but more so for her prosperity far into the future. I realized that I was writing into her body a script for her adult self and its wellness to come. I pondered this over the next few month when I would take breaks from developing this healthcare magazine to nurture my daughter through her infancy. I thought about breastfeeding and mirror neurons and other physiological phenomena. I thought often about the way humans are linked, not just in families but in the societal networks as well, by corporeal directives to provide for the future well being of others. As a mother caring for a daughter, I wondered how our doctors and researchers are preparing for her health future, and I wondered if our social infrastructure in the years leading up to her adult life would assure her that she could retain access to quality care once she crossed that threshold into womanhood. To be honest, I have doubts. The cross-section of society that can reasonably expect access to basic health services is narrowing by the day. Political meddling being mostly to blame, there is still no assurance against a laissez-faire approach spreading even greater health disparities across the state and the nation. Superficially, I’m not keen on the idea that my hospital bill covers part of the expense of indigent care; but the premise that healthcare is no human right would mean firstly that hospitals do not have to provide care, and then that no one has to provide. In my deeper self, I believe this is tragic negation of our accomplishments heretofore and of the selfless contributions our physicians and researchers have made to our universal benefit. There is one thing on this point for which I am certain: we as a society care more for the infirmed than we care for the poor. And a second thing: measured by incidence, we are getting poorer. I worry about the future of our daughters’ wellbeing because there is much doubt whether they will attain levels of personal wealth that will assure their access to care, by which I mean that the old dream is over. We’ll have to find a new vision and a new reason to move forward.

Submit your Letter to the Editor to Megan Campbell Smith at mcsmith@md-update.com 2 M.D. Update

Kentucky Issue Volume 2, Number 5 May 2011 Publisher

Gil Dunn gdunn@md-update.com Editor in Chief

Megan Campbell Smith mcsmith@md-update.com Associate Editor

Greg Backus gbackus@md-update.com Photographer

Kirk Schlea kirk@ md-update.com Writers

Jennifer S. Newton Melissa B. Zoeller Graphic Designer

James Shambhu art@md-update.com

Contributors: Lisa English-Hinkle Scott Neal

Send your Letters to the Editor to: mcsmith@md-update.com

Mentelle Media, LLC

921 Beasley Street, Suite 210 Lexington, KY 40509 (859) 309-9939 phone and fax Mentelle Media, LLC is locally owned and operated. Mentelle Media strives to produce top quality referral and marketing resources for Kentucky’s professionals by welcoming the participation of our readers. For more information about how your business or medical practice can get involved, contact Gil Dunn at (859) 309-0720. Standard class mail paid in Denver Co. Postmaster: Please send notices on Form 3579 to 921 Beasley Street, Suite 210 Lexington, KY 40509 M.D. Update is peer reviewed for accuracy. However, we cannot warrant the facts supplied nor be held responsible for the opinions expressed in our published materials. Copyright 2010 Mentelle Media, LLC. Contact Mentelle Media for information on obtaining reprints. Individual copies of M.D. Update are available for $7.95.


Contents

may 2011 Volume 2, Number 5

2 FROM THE DESK OF 6 AREA HOSPITALS 8 Health Care Reform 10 HEALTH MEDIA 13 FINANCE 14 LAW 16 COVER STORY 23 SPECIAL SECTION

cover story

WOMEN’S HEALTH

Meet the MISses

Local women doctors are the new champions of minimally invasive surgery, which has been slow to gain acceptance in GYN practices nationwide.

24 RESEARCH 26 MATERNAL-FETAL MEDICINE 28 OB/GYN 29 NURSING 31 CARDIOLOGY 32 INTERVENTIONAL RADIOLOGY 34 VASCULAR SURGERY 36 GRAND ROUNDS 45 EVENTS 47 ARTS 48 INDICES

On the Cover:

Ann Grider, MD, OB/GYN with Women First of Louis ville, performs minimally invasive surgeries at Baptist Hospital utilizing the da Vinci surgical system.

special section

Investigating Women’s Health from a multi-specialty perspective.

24 Research

26 Maternal-Fetal 31 Cardiology Medicine

32 Interventional 34 Vascular Radiology Surgery may 2011 3


2011 EDITORIAL CALENDAR 2011 EDITORIAL CALENDAR APRIL

Or thopedics & Spor ts Medicin e

MAY

Women’s Health

JUNE

Derm atology, Plastic Surger y & Allergies

JULY *

Intern al Medicin e & Prim ar y Care

AUGUST *

Pediatrics & ENT

SEPTEMBER

Urology & Nephrology

OCTOBER

Oncology

NOVEMBER

Neuroscience

DECEMBER

Psychiatr y & Ment al Health

Submission Deadline: Second Friday of the month before issue

4 M.D. Update

JOIN TH E CLUB! Cont act u s t o d a y.

Gil Dunn, Publisher (859) 309-0720 phone gdunn@md-update.com Megan Campbell Smith, Editor-in-Chief (859) 309-9939 phone mcsmith@md-update.com mcsmith@md-updat


????????

Intelligence Quotient

In a ceremony on May 15, 2011, celebrating a major milestone for UK HealthCare and the University of Kentucky, the new 12-story patient care pavilion at UK Albert B. Chandler Hospital was dedicated and unveiled to the public. US Rep. Ben Chandler, Gov. Steve Beshear, state Senate President David L. LEXINGTON

Williams, state Rep. Bob Damron, and Lexington Mayor Jim Gray joined UK President Lee T. Todd Jr., UK Executive Vice President for Health Affairs Dr. Michael Karpf, and UK Chandler Hospital Chief Administrative Officer Ann Smith in a ribbon-cutting ceremony attended by several hundred faculty, staff and community members. “Today marks a

significant achievement for the University of Kentucky in our mission to improve people’s lives through excellence in education, research, service, and health care,” Todd said. “This magnificent, state-of-theart medical facility provides an environment and the momentum to continue to raise the bar in providing high-quality patient care.” may 2011 5


Area Hospitals

Introducing the New Chandler Medical Center Intuitive wayfinding and evidence-based design make it a first rate facility today; flexibility makes it viable far into the future. By Megan C. Smith On May 22, UK HealthCare began admitting patients into the new 12-story patient care pavilion at UK Albert B. Chandler Hospital. Now open are many public spaces – an atrium, chapel, surgical waiting, and auditorium – and two patient care floors – neuroscience and surgical services – providing128 intensive care and acute care beds. At the public unveiling and dedication ceremony and on May 15, while a hundreds of guests toured the new facility, I spoke with design architect Michael Kennedy with Ellerbe Becket of Minneapolis, Minnesota. Kennedy’s firm Ellerbe Becket is a national healthcare design specialty firm whose has built a reputation upon their outpatient facility projects for the Mayo Clinic. The new Chandler Hospital represents the latest advancements in evidence-based healthcare design, but it also incorporates local and regional character which is essential to the core func-

tion of providing for the health of Kentuckians. Kennedy points out the dispersion of smaller, intimate seating alcoves throughout the hospital, “Not only in the waiting rooms, but also off of the concourse for families to gather and relax before going up to the patient floors.” Since Kentuckians tend to come to the hospital as family, “there are also special spaces and features in the patient rooms to help families stay together comfortably.” The integration of Kentucky-themes arts into the interior architecture is successful as a diversion and as a touch point for the identity of this place. Sympathetic with regional architecture, the interior is warm in color and material, open to vast swaths of natural light, and appropriately scaled to promote comfort and familiarity. Buildings don’t heal people, as Karpf observed in his dedication remarks,” but, if we are going to be an academic medical center comparable to the best in the country, we have to have the

facilities to support the people we recruit.” The concourse, designed as the organizing spine between new elevator lobby and the Gill Heart Institute and old hospital, is busy with researchers and physicians, techs and patients, even on this opening day. In the future, says Kennedy, it will be the bridge between the patient and the research institutions of the university. The wayfinding of the new hospital is intuitive and simple. The entrance sequence is clearly indicated from the semi-circular porte-cochere and transitions seamlessly through the twostory lobby, where visitors easily orient to the concourse above and its linked facilities beyond. “The atrium space,” says Kennedy, “acts like the glue between the hospital structures” and provides food and retail services for the convenience of visitors and staff. One of the design’s successes is the intuitive sequence of dropping off patients, parking, and finding the surgical waiting room at the point where the bridge lands on the new pavilion floor.

E. Britt Brockman, MD

The pedestrian bridge provides visual and physical linkages for intuitive wayfinding. The reason why this $800 million building project matters, says Britt Brockman, MD, ophthalmologist and chair of the UK Board of Trustees, is that “UK desires to be perceived as a regional subspecialty care provider.” The new 6 M.D. Update

Chandler Medical Center is positioned to become a leader in tertiary care. What’s important next, says Brockman, “is expanding facilities for research. We need to invest in the medical center while working with regional and

community hospitals – not competing with them over basic services. This will allow the region to develop with more partners and fewer competitors while UK becomes a strong central axis for tertiary care.”


To last, the facility has to be adaptable. Not all institutions have the foresight to build this way. The surgical waiting room itself is immense – capable of holding 200 or visitors – but organized into conversational clusters accented with fine art from Kentucky-based artisans. These are examples of the way Kennedy designed the facility for visitor’s peace of mind. The new patient rooms utilize evidencebased healthcare design trends: single occupancy reduces nosocomial infections, and large views with ample daylight promote healing. The room size is universal, meaning that the rectangular patient room bay is of identical size throughout the structure regardless of whether its use is “acute” or “intensive.” The use of nested toilets between two patient rooms provides for a flexible plan on every floor. Many physicians are familiar with the outmoded “in board” toilet rooms that were carved out the hospital room in the past, says Kennedy, but those left inflexible and irregular spaces that are expensive to adapt. The nested toilet motif, while requiring a larger footprint, is more economical in the long run.

Kennedy believes that the new Chandler Hospital has already set a new standard of inpatient healthcare design . “When we initially came here, the Mayo Clinic, one of our long-term clients, came here to see the hospital and get some ideas,” he says. “They realized that this center equals if not surpasses what the Mayo Clinic has for inpatient facilities.” The most enduring elements of the design, Kennedy posits, will be the flexibility of the plan and the design features in the patient, diagnostic, and treatment spaces. “It’s a larger plan, but it is less expensive in the long run,” says Kennedy. “Hospitals change, technology changes. To last, the facility has to be adaptable. Not all institutions have the foresight to build this way.” ◆

The patient rooms promote healing through their evidence-based healthcare design features. The surgical waiting room is organized into conversational clusters and accented with fine art by Kentucky-based artisans.

may 2011 7


Health Care Reform

Governance Reform, Not Health Reform

The Health Care Compact Alliance wants states to decide; has plan to nullify large, centralized Health Care Reform. M.D. Update editor-in-chief Megan C. Smith spoke by phone with Leo Linbeck, III, vice president of the Health Care Compact Alliance, out of Houston, Texas. The Health Care Compact (HCC) is a 501(c)(4) organization that is advocating that states bypass the federal health reform law by entering an interstate compact, which is, according to the HCC website, “an agreement between two or more states that is consented to by Congress... that restores authority and responsibility for healthcare regulation to the member states (except for military healthcare, which will remain federal), and provides the funds to the states to fulfill that responsibility.”

by the way the incentive programs were structured. It was not on purpose, not a conspiracy. It is just the nature of large scale systems. So we are going after the fundamental issue of who will be in a position to make decisions.

What is the Health Care Compact’s position on how healthcare should be administered?

Megan C. Smith: We in Kentucky recently elected a physician-Senator with some creative ideas about how governance should work. Why is governance important in the discussion on healthcare?

Leo Linbeck III: That is a very fair question. Most people dive into healthcare and want to immediately talk about policy. The most fundamental question really is who should be making the implementation decisions. Historically we have had a system where patients in consultation with their physicians made the decisions. That is not a perfect system by any stretch, with issues arising around accessibility and payment among other things. How we are going to deal with decision making is critical in any large scale enterprise like this. Who will have decision making authority and the responsibilities attendant upon that? We generally begin the analysis of healthcare with the assumption that the system should be self-governing. Much of the debate on policy has presupposed an answer to that question, which is that the decisions should be made in Washington, DC. We have had a system where prices, procedures, and coverage decisions have been made explicitly or indirectly in Washington, DC already. We came to the 8 M.D. Update

Leo Linbeck III is vice president of the Health Care Compact Alliance.

view that that was something that needed to be fixed.

What experience led you to your current interest in governance?

Some of my personal views have been influenced strongly by my work with charter schools and education. I saw school districts that increasingly centralized control and emphasized their non-teaching, nonstudent administrative functions. I found that the more centralized it got, the worse the decision making became. It is just that the nature of the problems become too big and complex. It also disempowers the people on the front-lines, in education, the teachers and principals. Solutions they could see and knew would work were penalized

There are differences in regional population that make different systems necessary. There are about 500,000 people in the state of Wyoming. I can look out of my office window at downtown Houston and see 500,000 people. Ideally you want to give patients and physicians the ability to solve the commons problem through direct support instead of governmental administration. The commons problem is about the fact that there are those of us who pay for people who cannot pay, like parents paying to cover their children. It is important also for research and development. It refers to objectives that cannot be accomplished by individuals, families, even small communities, and requires more organization. The question is how do we decide which issues fall into the commons and which do not belong there. The Compact says that states decide what is common and what is not, which is likely a very workable condition for states with smaller populations. It may be the case in states with more people that the organization will have to go to the county level to address these problems. There really may be a variety of solutions. States with smaller, stable, generally


The question is how do we decide which issues fall into the commons and which do not belong there. The Compact says that states decide what is common and what is not. homogenous populations may find singlepayer systems work well for them, and that is great. They should do that if that is what the people of their state want. Other states may need to take a different approach, and I think we will see a lot of diversity in solutions to providing healthcare across the country. What we are trying to do is to push authority over decision making as far down the chain-of-command as it needs to go to work. The step from federal to state is an important step. Whether that is the only step necessary will be determined by individual states. That first step is important because it preempts the healthcare regulations that are already in place.

are indexed for inflation and population changes, so it is not a static amount. If they determine that there are federal regulations that interfere with what they want to do then they have the right in the compact to suspend that federal law.

Is this a radical idea? How much of a change are we talking out?

The day that the compact is adopted, nothing changes. Each individual state has to look at the federal regulations that apply and decide whether they want to change them or leave them as they are. The states

can suspend federal laws in the compact when they want to solve the issues those laws address themselves. Whichever way they go they are responsible for funding it, so the power and the responsibility are transferred to the state, but so are the resources. It is a matter for the states to act in the best interest of their citizens. For things like NIH or FDA grant research, I think that everyone will stay in the existing system. The states will become customers of those institutions, instead of being customers of Congress. Continues on page 15

The HCC proposes to use block-grant funding to give states the financial resources to pay for healthcare. How is that going to work?

The amount of money involved in the block grant is essentially the same as the amount spent on healthcare in 2010 in each state. 95% of federal funding for healthcare falls into five programs: Medicaid, Medicare A, B, and D, and S-CHIP. That money gets drawn down in the same way that most mandatory spending block grants do. As the state spends money, funds are transferred from the federal treasury into the state’s treasury. The state is responsible for the decision of what to spend that money on.

Kentucky healthcare systems are making big investments in the formation of ACOs. If the state chooses to continue to deliver public healthcare through ACOs, then the block grant is the capitation?

LL: Yes. Basically it gives them the money and if they can use less of it, it goes to the benefit of the state. The block grants may 2011 9


Health Media

Outsmarting Stress

Dr. Lena Edwards’ new book Adrenalogic sheds misconceptions on stress-related diseases. LEXINGTON Healthcare providers are not immune to the stressrelated diseases that they treat. Exhaustion, weight gain, and depression are common among most of modern society today. In some ways, stress is integral to who we are: incorporated deep within our bodies are stress responses adapted from harsh environments we outsmarted eons ago. Even still, we tend to dismiss or underestimate the impact that stress has on our lives. In writing her new book Adrenalogic, Lena Edwards, MD, FAARM, internal and functional medicine specialist at Balance Health and Wellness Center, provides new insights into the role of stress on health and breaks down the medical and physiological misconceptions of stress. “Stress is a pervasive problem that everyone can relate to,” says Edwards. It causes problematic symptoms that are difficult to treat, and conventional medical doctors are not well trained on how to guide patients to be more proactive and prevent stress related diseases. Edwards emphasizes the importance of taking the time to really sit and talk with patients in order to get a good idea of what is causing the stress, and then to give them good ideas on how to deal with it. Stress and stress-related hormone elevations can cause many of the diseases that are seen on a daily basis and treated with prescription drugs. One of Edwards goals in writing

eliminates misconceptions of the body’s response to it. She explains that the term “adrenal fatigue” has become widely used but needs some clarification. “Many people think that they have a malfunction of the adrenal glands that is making them feel terrible. That whole concept is a misnomer,” she says. “It can be very dangerous for people to assume something and not know what is actually going on.” Tiredness does not necessarily mean that one’s adrenal glands are not working. “Many people will go to their doctor with vague symptoms, and when their test results come back normal, the doctor has no solution or treatment to provide,” observes Edwards. “My book is all evidencebased, so when the patient has an issue, they can use my book as a resource and share it with their physician.” While the primary purLena Edwards, MD, FAARM, pose of Adrenalogic is to internal and functional educate lay people, Edwards medicine specialist at Balance hopes it will help physicians, Health and Wellness Center. too. “Physicians do not have the time to sit and read all of Adrenalogic is to draw integrative and the literature,” she says, “so I have done conventional medicines closer together. it for them.” “There is a big gap between them now, Edwards believes physicians will benefit she explains. “There is a lot that the tra- from research on allostasis and the hypothaditional medicine doctors are not taught lamic-pituitary-adrenal (HPA) axis, which that I think we need to learn. There are a makes clear that the hormonal release under lot of things that I never used to be able stressful conditions involves more than just to help patients with that I now can since adrenal glands. “Clearly the stress response I have the tools to do so.” is very individual and it is mediated by a Edwards’ book clearly define stress and lot of different things like gender and age, and subjective things like perception and personality. Basically the HPA axis in all of us, once it is activated, is designed to help us survive. This axis helped the survival of our species, it helps us adapt. We can function at a sub-optimal level with high blood pres-

Many of us do not understand the clinical consequences of stress. 10 M.D. Update

Kirk Schlea 2008

By Greg Backus


sure, heart disease, insomnia, or depression and survive.” Surviving with chronic diseases is attributable to the concept of allostasis, or the process of the body stabilizing through change. Edwards explains, “Our bodies adapt to chronic conditions, but the adaptation can become abnormal if too prolonged. That is why many people today develop illnesses and diseases that were not present a hundred years ago.” Edwards examines the roles of hormones in the stress reaction and the treatment of stress conditions. She focused the book primarily on the hormone cortisol because that it is widely identified as a contributor to stress-related diseases, if clearly not the only influence. Cortisol can be associated with disease when there is either too much or too little in the system. An example is the effect of elevated cortisol on the hippocampus, which is responsible for memory and the context in which memories are accessed. Elevated cortisol damages that part of the brain and can affect memory functions. Most studies have shown that the effect is reversible, but in chronic conditions the problem can be irreversible. Edwards understands that many physicians regard stress conditions as difficult to diagnose and treat because of the subjectivity of the symptoms. “There are actually over 4,000 papers on the subject of cortisol as the cause of many mood disorders, particularly major depression. People who have chronically elevated cortisol levels generally have major depression,” she says.“Studies are showing that many antidepressant medications work by lowering cortisol and that the effect has nothing to do with serotonin. Drug companies are now actually trying to make a drug that will indirectly lower cortisol for the treatment of major depression. People that have chronically low cortisol, which is commonly mislabeled as adrenal fatigue, tend to have more apathy and seasonal affective disorder.” Patient awareness and education is a crucially important part the treatment of stress conditions, and. Edwards wants to give people a good starting point on a very complicated topic. “I really wanted people to understand that it is a universal pervasive problem and the kinds of affects it has on all of us. I discuss ways that people can be properly tested and there is a chapter which talks about how stress can affect all of your

other hormones and through that affect everything from fertility to sleep patterns to blood sugar control. It includes paragraphs on cortisol’s relation to insulin, thyroid hormone, estrogen and many others.” One common denominator when people talk about sources of stress in their lives is a feeling of lack of control. People who perceive themselves to be in a position of helplessness find it to be one of the most stressful scenarios there is. “I bring that up

because as a physician that is often how I feel,” she explains. “I do not have control over how I practice to the extent that I would like because insurance companies tell us what we will get paid, pharmaceutical companies get into the mix, the federal government with health care reform. There are so many external factors that potentially influence us away from doing what we want to do. Unfortunately, stress can change who you are as a human being.” ◆

JENIFER DUNCAN

TAMARA McCAIN

Vice President, Treasury Management Officer

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Finance

Inflation! What inflation? Nearly every financial article today contains some reference to the headwinds that our economy faces as we look into the remainder of 2011 and beyond. These are: 1) the ending of QE2 at the end of June and 2) the return of inflation, presumably due to money printing. The Fed chairman took to the airwaves last month and ended speculation that QE2 would be stopped before reaching its target. It will go until June 30 and hit $600 billion, as planned. With that announcement, stocks have continued to rise. So let’s consider inflation. Most financial advisors’ concern about inflation focuses solely on the loss of purchasing power of future dollars. In these articles I have introduced other, hopefully more valid, ways to think about inflation.

on supply disruptions, a la Middle East unrest. Globally, growth in business expansion, particularly in developing countries, would seem to be adding to this fear. To be certain, BY Scott Neal higher commodity costs or higher labor costs can result in a form of inflation that is troublesome. Remember the late 70’s. As companies struggle with trying to meet rising costs, they must raise prices. This is what economists call “cost-push” inflation and should

This change represents nothing short of a revolution in monetary theory and practice. It is hard to believe that nobody in the financial press is reporting this. Last month, I introduced you to the writings of Ed Easterling, author of two books and the brain behind www.crestmontresearch.com, a free website. Ed updates the website at least quarterly with the kind of data that one needs in order to make sense of the long term cycles of the stock market—particularly as they are affected by inflation and GDP. Sorry, dear reader, anecdotal evidence and opinions reported by popular media pundits just won’t cut it. To refresh, Easterling has posited that stock market performance (price changes) should be modeled with consideration given to an outlook for both inflation and GDP. The stock market favors price stability and mild inflation. Inflation higher than the long run average of 3% will likely hurt stock performance. Likewise, deflation could be worse and, while a small probability, is not completely off the table. The recent run up in commodity prices, particularly gas and food, has led many to conclude that high inflation is the obvious and only conclusion to our current situation. Some articles focus solely on demand, particularly China as the cause; others focus

be very familiar to a healthcare provider. Another form of inflation is created when demand increases faster than supply and shortages result. Many pundits have said that an increase in spending by the consumer is essential to economic recovery. Increased demand that outstrips supply could result in what economists refer to as “demand-pull” inflation. Recall the late 60’s. As you watch the debate in Congress about taxes and spending, keep this in mind. But these are wholly different kinds of inflation from the money printing variety which many people seem to fear the most. Economists call this “monetary inflation” and it can be the most pernicious of the forms of inflation. It would certainly seem to be the most preventable since it is predominately policy driven. Monetary inflation would be a new state for most of us alive and working today. The U.S. has not experienced monetary inflation in a very long time. Previously, it was thought that that the Fed would have to sell all those Treasury securities purchased in QE1 and 2 in order to keep monetary

inflation from becoming an inevitable conclusion to the current state. Much ink has been devoted to the devastating impact that such a move will take. That is no longer true. Recall that the Fed has not printed new currency (as many believe) to make the purchases of Treasury securities on the open market. It has simply increased the reserves of the banks. The intended result was that companies and consumers would borrow those reserves (creating deposits) and that is the step where “money” gets created. That has not happened. We, the consumer, seem to lack the animal spirit to borrow and spend and banks lack the will or ability to risk capital, particularly having lived through 2008. Thus, a lot of those reserves are still just that—reserves at banks, not money. Up until recently, the Fed was prohibited from paying banks for their reserves. Now they are able to do so and to change the rate at will, as a matter of policy. As of this writing the rate is 0.25%. If big banks start creating too much money via lending, then the Fed can simply raise the remuneration rate to the point that the bankers would rather have a risk free rate of x% vs. a risky loan to John Q. Public at x + y%. This change represents nothing short of a revolution in monetary theory and practice. It is hard to believe that nobody in the financial press is reporting this. It will not be a panacea to prevent any future money inflation, but it adds a new variable that will enable the Fed to do its job with much greater finesse. Of course, it still necessitates that Ben and friends at the Fed act appropriately and timely. If they do, we should be able to enjoy greater price stability (or at least less instability) than would have otherwise been the case. I am sure that this is not the end of this story but it gives hope. Scott Neal is a CPA and Certified Financial Planner and President of D. Scott Neal, Inc. a fee-only financial planning and investment advisory firm. Questions and comments are welcome at scott@dsneal.com or 1-800-344-9098. ◆ may 2011 13


law

Room for Improvement On March 31, 2011, the long awaited proposed rule on accountable care organizations (ACOs) was released. While ACOs were only addressed in seven pages of the Patient Protection and Affordable Care Act (ACA), the proposed rule about them is 429 pages. Simultaneously, the Department of Justice and the Federal Trade Commission also released for public comment a joint “Proposed Statement of Antitrust Policy Regarding Accountable Care Organizations Participating in the Medicare Shared Savings Program” offering limited protections for CMS-approved ACOs. These Proposed Rules and Guidance are exceedingly complex—so complex that many providers and their associations have labeled the Proposed Rules as unworkable. As Donald Berwick, Administrator for CMS wrote, “the creation of ACOs is one of the first delivery-reform initiatives that will be implemented…with the purpose to foster change in patient care so as to accelerate progress toward a three–part aim: better care for individuals, better health for populations and slower growth in costs through improvements in care.”1 The Proposed Rule defines how physicians, hospitals, and other key constituents can adopt this new organizational form and share in the savings generated by coordination and de-fragmentation of care. Under the Proposed Rule, however, the complex requirements for qualification coupled with a new risk sharing mechanism where losses can be attributed to ACOs will make establishing these organizations expensive and risky.

How is an ACO formed?

Under the Proposed Rule, an ACO must be a legal entity that is recognized under state law and holds its own Taxpayer Identification Number. The ACO must be comprised of eligible participants which include (1) physicians and mid-level practitioners in group practices; (2) networks of individual practices of ACO professionals; (3) arrangements between hospitals and ACO participants; (4) hospitals that employ physicians; and (5) other groups of providers that the Secretary of Health and Human Services (Secretary) designates. Despite having the ability to do so, the Secretary did not expand the types of providers eligible to establish ACOs other than to include certain critical access hospitals. 14 M.D. Update

ACOs, however, do have the ability to establish broad collaborations that may include other Medicare enrolled providers and suppliers like nursing facilities, rural health clinics, etc. ACOs must, howBY Lisa English Hikle ever, have a sufficient number of primary care physicians to provide services to at least 5,000 beneficiaries. To participate in the Shared Savings Program, an ACO must submit a lengthy application with supporting documentation to CMS. The Proposed Rule spells out detailed requirements that include requirements for each provider member to participate in governance along with Medicare beneficiaries and community stakeholders such that “appropriate proportional control” exists to ensure that the ACO is provider-driven and patient-controlled. In other words, CMS does not want administrative and financial entities to control ACOs. If accepted into the Shared Savings Program, the ACO must agree to participate for three years and the ACO’s executive must certify that its participants are willing to become accountable for and report on the quality, cost and overall care of the Medicare fee-for-service beneficiaries assigned to the ACO. In addition, the Proposed Rule requires that the ACO share in the risk that the cost of care will exceed established benchmarks by paying back a share of losses sustained by the Medicare program on a beneficiary’s course of care in addition to sharing in the savings generated. Moreover, ACOs must reach a certain threshold of savings before they can participate in the upside of shared savings. In addition, 25% of an ACO’s savings are not distributed until the end of the third year of participation. Under the Proposed Rule, an ACO has the ability to choose to participate in one of two programs or “tracks.” Under Track 1, a participating ACO will share in the savings for all three years, but will be required to assume risk for losses only in the third year. Under Track 2, a participating ACO will share in the savings and the losses for all

three years. ACOs that choose Track 2 will be paid a higher percentage of savings than the Track 1 participants.

How are beneficiaries assigned?

Under the Proposed Rule, an ACO will be required to assume responsibility for meeting all the healthcare needs of a minimum of 5000 beneficiaries for at least three years. Each patient will be assigned to the ACO where the patient receives most of his/her primary care. A patient could be assigned either retrospectively or prospectively to an ACO, based on the patient’s use of primary care services. Patients will be notified if their primary care physician is participating in the ACO, but a beneficiary will not be able to choose his or her ACO. The ACO will be responsible for patient care management and quality of care. In addition, each beneficiary will have the ability to seek care from providers outside the ACO. An ACO may not limit a beneficiary to certain providers, implement utilization management, or require prior authorization for services. The Proposed Rule is part of an overall effort by CMS to link reimbursement to quality of care and outcomes rather than volume. According to the Proposed Rules, CMS will define specific quality and continuous improvement goals that ACOs must meet to qualify for shared savings that include: (1) patient/caregiver experience; (2) care coordination, transitions, and information systems; (3) patient safety; (4) preventive health; and (5) at-risk population/frail elderly health. In the Guidance released with the Proposed Rule, CMS has proposed using 65 nationally recognized measures that range from general processoriented items such as getting timely care and appointments to specific clinical areas, including immunization, cancer screenings and heart failure prevention. Initially, ACOs will engage in complete and accurate reporting, but in subsequent periods, CMS will actually assign quality scores for each measure. In addition to comprehensive quality reporting, CMS intends to actively engage in monitoring ACOs by looking at financial and quality data, site visits, beneficiary/ provider complaints, and audits.

Conclusion

The Proposed Rule is exceedingly compli-


cated and creates significant drawbacks for providers seeking to form ACOs, particularly smaller providers. Compliance with the requirements for an ACO’s governance is very complicated and may make governing boards too large to function efficiently. Assessing the financial impact of forming an ACO is very difficult, particularly given the fact that ACOs have no ability to direct beneficiaries to participating providers or any real mechanism to project what cost-savings can be generated. Of CMS’ Physician Group Practice Demonstration Project’s ten large physician group practice members, only two were able to attain better than a two percent saving threshold the first year and only half were able to surpass this savings threshold after three years. It is noteworthy, however, that all ten were able to meet the quality standards imposed. Based upon the start-up costs for the demonstration project, the GAO estimates that start-up costs and first year operating costs for an ACO to be $1.7 million. For Kentucky providers, the initial costs of implementing an ACO may be insurmountable, particularly for smaller hospitals and rural providers. Hospitals that employ large numbers of physicians seem to be in the best financial position to establish ACOs. However, physicians, particularly primary care specialties, appear to be the financial key to ACO success. Fortunately, the Proposed Rule is just that a proposed rule. Hopefully, these points will be communicated to CMS so that these exceedingly complicated requirements do not become a barrier to implementing ACOs. Comments may be filed with Centers for Medicare & Medicaid Services by June 6, 2011 no later than 5:00 pm. This article is intended as a summary of newly enacted federal law and does not constitute legal advice. Lisa English Hinkle is a Partner of McBrayer, McGinnis, Leslie & Kirkland, PLLC. Ms. Hinkle concentrates her practice area in healthcare law and is located in the firm’s Lexington office. She can be reached at lhinkle@mmlk. com or at (859) 231-8780. ◆

1

(Endnote) Berwick, Donald, “Launching Accountable Care Organizations” NEJM, March 31, 2011.

Governance Reform, Not Health Reform Interview with Leo Linbeck III continued from page 9

What is the status of the HCC model legislation?

The compact is really just a contract between the states. So to join each state needs to file a bill that contains the same language as the compact. Different states format bills differently and may use different language before and after, but the bill itself is a static text. It has been introduced as legislation in thirteen states, with two more imminent. It has gone through both houses in four states. The governor of Georgia signed and the governor of Arizona vetoed it. The governor of Georgia thought that the state should make healthcare decisions for the people of the state, not be reliant on the federal government to make those decisions. The governor of Arizona felt that she could make her own deal with the Secretary of Health and Human Services, but we think we will get it through in Arizona next January.

And how are discussions of the compact shaping up on both sides of the aisle?

When we started the campaign we got immediate support and traction within the Tea Party movement. They were enthusiastic about it because they saw it as state empowering. The way things are shaping up these days if the Tea Party gets behind something then the Republicans get behind it and the Democrats will be more dubious of it. It has taken us some time to build support within the Democratic caucuses

of the states. There are a significant number of Democrats who oppose it because they view it as an attack on PPACA. But the healthcare system was broken before we passed Health Care Reform! President Obama deserves tremendous credit for focusing peoples’ attention on the healthcare policy crisis. We do not agree with the direction he took it, continuing the emphasis on centralization that all prior administrations have endorsed. The largest recent healthcare entitlement recently passed was signed by President Bush, Medicare D. It is sort of a bipartisan mess in Washington, DC. The political process is not designed to do fundamental analysis. We do have some opposition on the Republican side because some of them are big fans of the health insurance industry, and frankly the big health insurers love having concentrated decision making in Washington, DC. Same with the big pharmaceutical and healthcare provider corporations. It is not as clear as Right versus Left or Democrat versus Republican on this initiative.

What is your perspective on the case of Kentucky?

The people who know the most about Kentucky’s needs are the people who live there. State leadership is aware of the problems in the system and may feel hamstrung by federal regulations or lack of resources and we are trying to cut out the middle man. We want the money to be controlled by those who only have the interests of their state as their agenda. As more states come along we will see more variety in ways to make this work. If the people of a state are unhappy with the decision making, they will call their state legislator. This is an order of magnitude closer to the people than having them handled on the basis of Congressional districts. If the model favors ACOs or traditional models, then how the citizens spend their money may have a big impact. ◆

may 2011 15


Cover Story

Minimally invasive surgical options for gynecological procedures like hysterectomy or myomectomy include laparoscopy (pictured here), vaginal surgery, and robot-assisted surgery. Still, minimally invasive surgery is poorly received in GYN practices nationwide. Ann Grider, MD, OB/GYN, is co-managing partner of Women First of Louisville, PLLC. She is a da Vinci trained MIS specialist.

Meet the MISses

Local women doctors are the new champions of minimally invasive surgery, which has been slow to gain acceptance in GYN practices nationwide. By Megan C. Smith Photography by Kirk Schlea 16 M.D. Update


The only way we are going to change those statistics all over the country is to educate women to seek out doctors who will perform minimally invasive procedures. – Ann Grider, MD

LOUISVILLE In medicine’s quest for ever better surgeries via ever smaller incisions, it’s hard to believe that minimally invasive surgery has been slow to gain acceptance in one very common procedure. Hysterectomies, of which 600,000 are performed in the US each year, have a paltry MIS rate of only 30-40%. Minimally invasive surgical options for gynecological procedures like hysterectomy include laparoscopy, vaginal, and robot-assisted surgery. Still, the abdominal approach prevails at GYN practices nationwide. There is at least one group of women physicians who are challenging conventions and paving the way for greater access to MIS procedures for women in Kentucky and beyond. Overseeing this changing of the guard is Women First of Louisville, an all-female OB/GYN group practice formed decades before all-female OB/GYN was popular. Here, no fewer than 94% of hysterectomies are performed with a minimally invasive approach. So how does Women First’s co-managing partner and MIS specialist Ann Grider, MD, account for this outperfor-

Lori Warren, MD, gynecologist (far right) performing a laparoscopic hysterectomy at Baptist hospital East in Louisville. Warren is a nationally renowned advocate for increasing women’s access to minimally invasive gynecological procedures.

mance? “We provide the care we would want for ourselves,” she says. Being able to relate to patients from the gender-basis of shared life experiences is certainly a powerful factor contributing to Women First’s attainment of high MIS rates – there is an empathy there that encourages more proactive health choices and encourages healthcare decision made in the best interest of the patient. A focus on wellness helps women avoid surgery in the long run, and when faced with surgery, patients are encouraged to make the choice that is right for them. Grider points out that for a woman to be in control of her healthcare decision making, she must have access to all of the care options appropriate to her case. Like other surgeries, the open

approach to gynecological procedures can result in scarring or increased infection and trauma. A lengthy recovery time can have significant economic and emotional impact on a woman as she spends extended time away from family or work activities. These concerns must be weighed against costs and risks, among other factors, before a woman can be certain that her choice, fully informed, is the right one. This is why patient education is key. “The only way we are going to change those statistics all over the country is to educate women to seek out doctors who will perform minimally invasive procedures,” says Grider. It’s not a question of whether or not doctors have women’s best interests in mind, but rather the simple question of whether or not a may 2011 17


cover story

doctor offers minimally invasive techniques that should be raised. For Grider, being da Vinci trained reflects a professional dedication to the patient’s benefit, but for most providers motivation to change will likely come from another source. Nationally-based patient education efforts will very likely result in increased demand for MIS-trained gynecologists. Until then, she observes, “doctors are not motivated to learn MIS techniques because they get paid less, it takes a lot of time and energy to learn it, and the old way works fine. But it is just not in the best interest of patients.” Grider’s colleague and MIS-specialist Lori Warren, MD, is one of the nation’s leading advocates for increased access to minimally invasive hysterectomies. Having successfully conveyed the cause to mass media, including a feature segment on CBS Evening News with Katie Couric, Warren also focuses on professional education for doctors nationwide. Warren says she is proud of her work preparing doctors

companies are not incentivizing doctors to do it. WSLI, whose constituency is comprised of established and emerging women surgeons, is engaging the new generation of women providers with mentoring, marketing, and negotiation resources that will enable them to break down these barriers and provide more minimally invasive procedures. “Another thing I am trying to promote

I am trying to promote the idea of us doctors helping each other out because we all have the same goal of taking better care of women. – Lori Warren, MD to meet the increased demand for minimally invasive gynecologic procedures, especially through her chairmanship of the Women’s Leadership Surgical Initiative (WSLI), a collaborative professional development component of the American Institute of Minimally Invasive Surgery (AIMIS). Warren observes three reasons for the lag in MIS for gynecological care: providers are not getting the training, patients do not know to ask for it, and hospitals and insurance 18 M.D. Update

through WSLI is the idea of us doctors helping each other out because we all have the same goal of taking better care of women,” says Warren. “AIMIS founders realized very quickly that most doctors going into minimally invasive gynecological surgery were women, so they asked me to come on board and be in charge of the WSLI. They felt that we needed to have more women leaders in this male dominated specialty.” “For years, I felt like the burden of this

was on my shoulders. But I realized that there have to be others who feel the same that I do,” she says. In the 1990’s when Warren was training, only 13% of her medical school colleagues were women, but by 2008 the discipline had flipped to 75% female. Identifying established women providers to provide networking and education on practice management and best practices is an important aspect of Warren’s advocacy today. Women First colleague Holly W. Brown, MD, is one of those experienced providers that Warren is talking about. Brown’s personal history is, like many women’s, tailored to the needs of profession and family. Brown, who trained with the busy gynecologic services department at St. John’s Mercy Medical Center in St. Louis, Mo., has had a career-long interest in vaginal surgery. “As newer techniques have developed, like laparoscopic approaches, I have learned those and kept up,” says Brown. “One of the main reasons to use laparoscopic approaches is because it is less invasive for the patient, but vaginal surgery is already one of the least invasive surgeries.” Vaginal surgery, which typically does not require any incisions in the abdomen, makes


recovery from surgery much easier. Also, incisions in the vagina heal much more quickly than those in the skin, and they are less painful. Brown performs many procedures with a transvaginal approach including hysterectomy, anterior and posterior colporrhaphy, and repairs for urinary incontinence. Today Brown splits her time between obstetrics and gynecologic care, but she admits that she may be the only OB/GYN to return to obstetrics after having already enjoyed a period of practicing GYN exclusively. For Brown, the decision to drop OB came when her son was in high school, when she felt she should spend more time at home. On going back to OB, she says, “I have always loved the mixture, the continuum from teenager to elderly. I missed that, so I have been happy to go back.” Brown credits her colleagues for supporting her interests, and points out that this is really the way that business works at Women First. “This practice is very concerned about being up to date and current across the board: new surgical techniques, comprehensive care within the office, as well as keeping up to date with EMR and that sort of thing.” Brown had practiced in another Louisville group for 16 years before joining Women First, and she says that this cutting-edge approach in the allfemale practice has been very positive. “One of the nice things about this practice is that there are enough of us with varied interests and talents that we have someone looking out for what is coming out and what is new in each area,” she adds. “We have one person that really concentrates on mammography. We have another that concentrates on bone densitometry. A couple of us have done quite a bit dealing with urinary incontinence and pelvic floor surgery. We have a couple who are interested in the newer da Vinci techniques, ultrasound, high-risk obstetrics, all of these different fields.” Brown explains the benefit to this diversity of professional interests is that “you do not feel like you have to keep on the cutting edge of everything. Each of us can cover our own area, and then we can all bring it together.”

Dr. Lori Warren observes three reasons for the lag in MIS for gynecological care: providers are not getting the training, patients do not know to ask for it, and hospitals and insurance companies are not incentivizing doctors to do it.

may 2011 19


cover story

Women Taking Care of Women Practice co-founder and co-managing partner Rebecca Terry, MD, has based the entire practice philosophy on five small words: Women taking care of women. Not only does Women First provide patients with complete gynecological and obstetrical services with an emphasis on preventative care, the Women First ethos also embraces the professional development of its practitioners, allowing each to develop her niche. “When I first came to Louisville,” she recalls, “I was the first woman on the east end doing obstetrics and gynecology, so that was my niche.” Terry helped to develop the practice from two to four providers in its first year, and she boasts that Women First now employs 12 physicians who provide the entire spectrum of women’s health needs. She emphasizes that service, putting patient needs first, is responsible for the group’s success. Preventative care and wellness have been integral parts of the Women First mission since its first year when Rebecca Booth, MD, joined the practice. Booth has an interest in menopause and in hormones, which she believes are “a huge part of wellbeing” for women of all ages. She has devoted the last few years to educating, teaching, and writing about hormones and has gained national recognition as the author of the self-health book The Venus Week. “There are very few specialties that have such an opportunity to devote themselves to wellness in young people,” observes Booth. “Most youths are reluctant to do preventative medicine, to make preventive care visits with their physician; they typically make doctor visits that are illness oriented. “But a woman has to go for her reproductive needs and screenings, such as Pap smear screening and family planning needs, and this gives us a unique opportunity to take care of her during a time of wellness which can inspire family wellness and also lifelong wellness.” She says. “It is part of our mission, and I think that we 20 M.D. Update

are uniquely focused on that compared to other practices.” In writing The Venus Week, Booth explored the need to communicate with women who feel puzzled about their health. Booth developed the metaphorical language of the Venus Week to convey both understanding of health and to deliver the responsibility to the individual to take care of herself. “I was working hard to try to develop understanding in my patients about what their hormones are for and how they work,” she recalls, “when I decided I needed to do a broader project with metaphorical communication. That was the impetus for the book, as well as a deep concern about hor-

have are simply not enough to ensure wellness unless we can empower her to see that she is in charge of her own overall health. The annual wellness exam is not enough. That empowerment can only happen if there is understanding. When a woman is victimized by the mystery of her body, particularly her hormonal makeup, she really feels that she cannot take charge. If we cannot deliver the understanding, then we will fail at delivering overall wellness.” Women First practitioner

monal wellness for women who are more vulnerable than men to difficulties with hormonal aging.” This difficulty, she says, is due to women’s cyclic gonad and what she calls “programmed gonadal retirement”. The affects go beyond health to encompass relationships, aesthetics, weight control, and metabolism, among many things. Booth attests that her primary motivation is to empower the patient to take care of herself. “The brief visits that we

Ann Clark, MD, the group’s only high-risk pregnancy specialist, agrees that empowering women to take charge of their health is an essential component of their profession. As a perinatologist, Clark counsels pregnant women about their health options at a time when they are facing difficult medical decisions. Clark provides ultrasound and perinatal consults for patients with chronic hypertension, diabetes, neurological disorders, or


Image provided by Women First of Louisville, PLLC

who are on multiple medications. Many of these conditions can be managed by a qualified OB, so Clark’s role in the practice is usually as the consulting specialist. “The most important thing,” she says, “is for women with high-risk conditions to see me for a pre-conception consult.” Regrettably, even for known high-risk conditions, most women have unplanned pregnancies. The reasons are varied, “such as they cannot take oral contraceptives or they didn’t believe they could become pregnant. Also, some women are in denial about their risks, that it will all be okay,” explains Clark. “Things usually do work out,” but Clark cites the example of a long-standing insulin-dependent woman who has very elevated blood sugar during the first trimester. An unplanned pregnancy delays adjustment of the women’s insulin, resulting in serious birth defects of the heart valve or spinal cord. Clark also encourages pre-conception counseling for women over 35. One of the biggest misconceptions she faces is that

once women turn 35, they become a “ticking time-bomb” and their risks for pregnancy complications skyrocket. “That is not true at all,” she says. “That misconception comes from risk for Down syndrome, but at the age of 35 the risk for Down’s is 1:200.” Improved ultrasound and fetal blood diagnostics give women much more information about their condition, so the great fear compared to the low risk is unwarranted. “Other women fear complications from amniocentesis,” she adds, “but those risks of complications are even less at 1:1000.” The Women First philosophy for obstetrics - healthy baby and healthy mom – is focused on allowing women to have the pregnancy experience of their choosing, whether that’s no elective amnio, an unmedicated birth, or elective C-section. The practitioners like Clark try to educate women about their options while providing access to the highest level of appropriate care. That’s the way women take care of women. ◆

Physicians of Women First of Louisville, PLLC Pictured from left to right in the back row: Dr. Margarita Terrassa, Dr. Leigh Price, Dr. Stephanie Dutton, Dr. Kelli Miller, Dr. Ann Clark, Dr. Michele Johnson, Dr. Holly Brown. Seated in the front row: Dr. Lori Warren, Dr. Mollie Cartwright, Dr. Rebecca Terry, Dr. Ann Grider, Dr. Rebecca Booth

may 2011 21


Women’s Health From a social-political perspective, providing quality women’s health today relieves healthcare burdens in the future. Advancements in middle age women’s health have significantly reduced the incidence of disability among baby boomers and pushed back into the 70s and 80s the chronological age at which a person is considered old. Reductions in chronic disease, like osteoporosis and cognitive impairment, help to alleviate the expense of healthcare and the burden of disability.

Pictured: Female patient visited by Dr. David Blake (Lexington Neurology). Photo by Kirk Schlea, 2008

may 2011 23


research

Discovering the Future of Kentucky Women’s Health UK’s Center for the Advancement of Women’s Health seeks to define the factors – economic, social, and environmental –shaping Kentucky women’s health. By Greg Backus

LEXINGTON University of Kentucky rheumatologist and director of the Center for the Advancement of Women’s Health (CAWH), Leslie J. Crofford, MD, is looking forward to the future of comprehensive women’s healthcare, but she’s no mere optimist. Crofford is helping to define that future through the discoveries from the Kentucky Women’s Health Registry, a longitudinal cohort study of the environmental factors shaping women’s health decisions and, ultimately, health outcomes. Crofford founded the Kentucky Women’s Health Registry (KWHR) in 2006 with the goal of following 20,000 Kentucky women for 10 years. On track with 14369 volunteer participants and counting, KWHR serves two essential research purposes. First is the longitudinal cohort study, and second is its use as a participant pool for variety of studies. Crofford based KWHR on a similar program at the University of Michigan. “Theirs is focused more on diagnoses, and it functions as a participant pool much more than this one; but that is where the idea of a web-based registry came from,” she says. The KWHR infrastructure is available to investigators across UK’s campus, the University of Louisville, and public health departments across the state. It can be used by anyone approved by the scientific advisory committee. Since the cohort study follows the same participants year after year, it can be used to perform epidemiologic studies looking at large cross-sections of women or to compare different counties or regions in the state. As a participant pool, KWHR is a resource to identify people who might qualify and be interested in participating in a variety of other studies. ”We review the studies submitted,” says Crofford, “and if we find that it is an important study and clearly applicable to women, we will send out requests to people who meet the inclusion criteria to ask if they are interested. So we kind of serve as an honest broker for studies, which increases the number of women who participate in research studies.” 24 M.D. Update

Dr. Leslie Crofford hopes that the Kentucky Women’s Health Registry program will provide patients with tools to increase their understanding of health.

We are looking for all of the factors that play into a healthrelated quality of life. We collect information about diagnoses, but a larger part of the survey has to do with simple questions: Do you go to the doctor? Do you get vaccines? If not, what are the barriers? Do you drive yourself? The registry’s data on participants’ health histories and medical diagnoses are all self-reported. What really interests Crofford are the relationships between

socio-demographic factors like education, who the participant lives with, their familial and societal roles, health behaviors, and lifestyle choices. “We are looking for all of the factors that play into a health-related quality of life. We collect information about diagnoses, but a larger part of the survey has to do with simple questions: Do you go to the doctor? Do you get vaccines? If not, what are the barriers? Do you drive yourself? Do you have problems with transportation? “All those kinds of questions that have impact on health related quality of life which may not be directly related to any particular diagnosis,” explains Crofford. “If you have more information about the person, what their current level of stress is, whether or not they work four jobs or have caregiving responsibilities for elderly parents, whether they are depressed or anxious, then you can understand much more deeply why a person is healthy or not.”


One of the study’s key indicators is how participants perceive their own health. It is not a biological measure. It is a simple question integrating biology, psychology, psychiatry and behavior, and other kinds of generic social factors that contribute to whether someone feels healthy or not, and it turns out to be the gold standard that many other researchers use. “I am particularly interested in the case of women with symptoms that are not associated with diagnoses,” says Crofford, “like fatigue, unrefreshing sleep, and non-specific pain. There are a lot of symptoms that defy diagnosis.” Indeed, KWHR asks many questions that focus on those kinds of symptoms that are often outside of the realm of diagnosis. “If you really look at why people go to the doctor, most of the time the presenting complaint is pain or fatigue,” explains Crofford, “and many times in cases like this, no specific diagnosis is found.” Crofford points to a recent CAWH

study using KWHR data that looked at connections between smoking and pain, and she and her colleagues were able to demonstrate that there is a very strong association between the dose of cigarettes that a person takes in and the risk for having multiple chronic pain conditions. “We can quantitate the risk, and we can quantitate regarding former smokers. So, people who quit will have their risks go back down to something much closer to those who were never smokers. That is one kind of crosssectional study that we can do,” she says. “It is hypothesis generating in some ways. Do people smoke because they are in pain? Does smoking itself actually change the way pain is perceived in individuals? There are a lot of different ways you can generate hypotheses using cross-sectional data sets. Then you can use longitudinal data sets, go back and do the same kind of study looking at people, for example, who smoked the first time and look at their pain conditions, and

then look at those who have since quit to see how many have less pain.” The registry, Crofford notes, is designed in part to demonstrate to women all of the things that go into their health. “The strongest predictor of good health is education,” she says and points to the keynote address of UK’s April 2011 Appalachian Health Summit: Focus on Obesity. William Dietz, MD, PhD, director of the Division of Nutrition, Physical Activity and Obesity for the Center for Chronic Disease Prevention and Health Promotion, CDC, reported that everything that one does associated with medical care only has 10-20 percent to do with how healthy one feels. “The most important aspect of how healthy people feel has much more to do with whether they have a job that they like,” Crofford exclaims. “The reason that the registry is so comprehensive is because those factors cannot be ignored if your primary interest is health related quality of life.” ◆

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may 2011 25


Maternal-Fetal Medicine

Two at Time

Medical management of high-risk pregnancies means balancing risks and benefits to mother and child. By Greg Backus Maternal-fetal doctors are in the unique situation of providing care for two patients simultaneously. Medical management in the case of high-risk pregnancies involves balancing the risks and benefits, as well as assessing alternatives, in the approach to both mother and child. “Our job is to optimize the outcome for both of them,” says Jeffrey King, MD, division director at UofL Maternal-Fetal Medicine, “and we are very cognizant of the dual responsibility.” King is proud of the staff, the facilities, and the work philosophy at UofL, where as director can stay involved with patient care and the clinical aspects of the practice. He believes that a large part of the quality of care provided comes from the depth of experience that the four doctors bring to the management of pregnancy and its complications. “We have seen patients from all over the state and from all over the country with various issues,” he says. “We bring the wealth of our experience to the care and management of our patients today.” King and his colleagues Vernon Cook, MD, Jonathan Weeks, MD, and Stanley Gall, MD boast 90 years of experience in maternal-fetal medicine. Formerly called perinatology, explains King, the title of what these doctors do has changed to reflect more clearly the domain of their services. “We deal with the health of mothers and their children, managing the medical and surgical complications associated with pregnancy,” says King. “It is a clearer explanation as to what we do, what services we offer, and what patients we take care of.” To adapt to changing times, King says, is an important part of their philosophy. “Everything that we do is from the standpoint of trying to be non-directional. In the old days a patient would be told what they ought to do, and generally they did that. That is too paternalistic,” King acknowl26 M.D. Update

Jeffrey King, MD, division director at UofL Maternal-Fetal Medicine.

The choice you make now is the best choice you can make if you have all of the information available to you. edges. “Women have recognized that they have the ability to direct their own futures and make their own decisions. So we strive to provide accurate information. The decision that I would make is not as important as the decision that they have to make when there are complications, because I am not the one that has to live with the results,” he says. “I have to make sure that the patient knows what choices they have and what the impacts and expected outcomes of those choices are.” The Maternal-Fetal Division includes a prenatal clinic run by the University Foundation, which is a residential clinic with supervision by the attending faculty. It

is an active clinic, with around 50 patients coming in twice a week. Referrals also come in from the region and beyond, including Frankfort, Campbellsville, Owensboro, and into Southern Indiana. There is also a private practice location in the new faculty practice building, UofL Healthcare Outpatient Center (HCOC). The types of patients seen in both locations are similar, but the patients in the HCOC building are considered private patients, and they are seen independently of the residents. The facility has 9 LDR rooms and 4 rooms within the labor and delivery area for patients with stable antepartum complications during pregnancy. There are 32 postpartum beds for women who have delivered. Some antepartum patients are kept in the postpartum unit if they are not proximate to delivery or have other issues with their pregnancy . Some require observation or the establishment of medical control of underlying medical issues. Most of the women who come to the clinic, says King, do so because they have a


problem as a result of a prior pregnancy that did not go as planned. “They may have had premature labor or delivery, hypertension, or long-standing diabetes. In cases where there are known underlying medical issues that increase risks associated with pregnancy the clinic is often sought out, or the patient is referred in by their general OB/ GYN.” Patients who have lost pregnancies in the past, those who have lupus or thyroid dysfunction, or cancer patients who require coordinated care and treatment are often referred to us. Many conditions may require coordination with a patient’s primary care physician who is managing some aspect of their medical care. “For instance,” King explains, “patients that have renal failure and are on dialysis require detailed coordination. You cannot do dialysis the same way as you did when they were not pregnant. You have to pace it differently so that they do not develop problems with blood pressure. Patients who are diabetic may have a diabetologist following them, and coordination is again very important so that the goals of bloodsugar control are maintained during pregnancy. Coordination is often very important, but there are many conditions we can manage independently during pregnancy.” “Surprisingly,” says King, “the treatment of cancer and the management of pregnancies go together well.” Most chemotherapies administered for the treatment of breast cancer do not have an impact on fetal growth and development. In cases where a patient is close to delivery it may be better to delay treatment for a month to concentrate on the delivery, but at 16 or 18 weeks King will begin their treatment and carry them through the pregnancy. There are some specific agents like methotrexate that cannot be used, but most of them are safe. Cases with complex, long-standing diabetics with complicating vascular or renal disease are more likely candidates for coordination. Patients that tend to need high degree of coordinated care are often cardiac patients, seizure disorder patients, HIV and renal patients. Pregnancies complicated by substance

abuse and addiction are an increasing problem nationwide. King has seen a number of pregnant women who are at least using, if not addicted. “We work closely with the two methadone centers in the region, the Moore Center here in Louisville and another across the river in southern Indiana.” King is interested in the potential for acute detoxification efforts for some of the obstetric patients. There are concerns about the appropriateness of acute detoxification programs during pregnancy, as they may lead to acute withdrawal of both the mother and the baby and potentially adverse outcomes associated with that. “It is a significant need,” he says, “but we do not have the infrastructure in place to deal with it on a regular basis. We work closely with JDAC and see the women going through rehabilitation very frequently and take care of them

in our antepartum prenatal clinic, manage their pregnancies and deliveries.” The program involves prenatal education and a prenatal nutritionist, diabetic and genetic counselors. King considers the program fortunate to have a group of extremely well trained and competent sonographers who help with imaging. “Our medical assistants are essential in bridging between the patients and the doctors,” he adds. “Patients sometimes find it easier to talk with them than to talk to their doctors. It really is a team approach. We refer to the practice of medicine today and into the future as a ‘team sport’. So many people are involved now. Case managers, social workers, all kinds of ancillary personnel are crucially important. The problems are so much more extensive than they were in the past.” ◆

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may 2011 27


OB/gyn

Bringing Deliveries Back to Georgetown

UK -Georgetown partnership stems from UK’s mission to help community hospitals provide basic services close to home. By Megan C. Smith Across Kentucky, the University of Kentucky is collaborating with community hospitals to ensure that residents have access to basic health services. The new UK HealthCareGeorgetown obstetrics partnership, including complete OB/GYN services provided by Joseph R. Haynes, MD, is one of the latest formed under this mission. It also enjoys one compelling competitive advantage : Haynes is the only obstetrician delivering at Georgetown Community Hospital. He joined the practice full-time in September 2010 to meet community needs for obstetrical care. “We have lots of women who have delivered at Georgetown before who had good experiences and really wanted to deliver here again,” says Haynes. “The patients are glad to have someone here locally to take care of them.” Here, providing more personalized care is an important service goals. “Because we are a smaller community, I get to know my patients very well. When it’s time to deliver, everyone is very familiar,” says Haynes. Since many of the nurses are from the Georgetown area, they already know many of the women who are delivering. “Like Georgetown itself,” says Haynes, “we’re like a small community.” The practice has plans for a second OB/ GYN to join in August 2011 and a third in 2012. Haynes reports their plans are to grow beyond the 600 annual births that Georgetown experienced in the past.

28 M.D. Update

ily practice are joined in the same Bevins Lane facility. Consolidating the practices provides efficiencies for the staff, “and we’ve got nice new offices specifically designed for our needs,” Haynes enthused. Haynes participated in weekly design meetings to make sure the plan modifications included the needs of the ultrasound machine and wall-mounted flat screen monitor. The non-stress test room also received special considerations. Haynes is able to provide a full spectrum of women’s care including annual exams, Pap smear screens, in-office procedures like colposcopy and LEEP, and referrals for mammography and bone density scanning. Haynes is an assistant professor of Obstetrics and Gynecology at UK, and in addition to obstetrical care, his clinical interests are hysterectomies, laparoscopy, and minimally invasive surgery. He received his medical degree at the University of Missouri, Columbia, School of Medicine; completed his residency at the University of Kansas; and was fellowship trained at UK Chandler Hospital. ◆

Joseph R. Haynes, MD, OB/GYN

The practice has plans for a second OB/GYN to join in August 2011 and a third in 2012. He believes that women who want to stay in Georgetown will appreciate the service they provide. “We have an attractive location for women to go to receive their OB care, and we are excited about what we are doing,” he says. “There is a lot of enthusiasm both from Georgetown Hospital and from a UK perspective.” For ease of use, the OB/GYN and fam-


Nursing

From Colombia, with Love

Innovative neonatal nursing protocol Kangaroo Care contributes to increased breastfeeding rates and improved mother-infant bonding. By Greg Backus LOUISVILLE In 1978, very high infant mortality rates at the Instituto Materno Infantil NICU in Bogotá, Colombia inspired Dr. Edgar Rey Sanabria, professor of neonatology at the Universidad Nacional de Colombia, to recommend that mothers of low birth weight babies should warm their infants against their chests in skin-to-skin contact, allowing breastfeeding when needed and freeing up limited incubator space in the NICU. According to Chris Summerfield, BSN, RNC, coordinator of Women’s Health Community Education at Baptist Hospital East (BHE), Kangaroo Care, as this innovative program came to be known, has become a widely popular neonatal nursing protocol for full term babies in the US. Baptist is one of several Kentucky health systems to introduce the program in recent years. “Our patients were telling us that they wanted Kangaroo Care,” says Summerfield, “and our nurses agreed that they thought the babies and mommies did better when they stayed together.” When the nursing staff presented their proposal to the BHE director of nursing, Summerfield recalls how “the body of information available at that time was making it clear that Kangaroo Care was becoming known as a best practice.” Breastfeeding rates at BHE are typically very good, Summerfield reports, but since Kentucky as a state ranks low on breastfeeding scores, “we are trying to find ways to promote breastfeeding with all of our moms.” Women can get a lot of contradictory information about delivery, so Summerfield and other educators at BHE make an effort to show mothers how easy caring for a newborn can be. They often correct misconceptions such as breastfeeding will hurt or that few mothers produce enough milk on their own. “I was recently exposed to a survey,” she says, “in which the participants were middle income, educated women. The survey showed that a majority of them did not know that a term pregnancy was 40 weeks or that if a baby is delivered at 34 weeks the mother’s milk will be different than if she had gone to term.” Proponents of Kangaroo care emphasize the skin-to-skin contact between the mother

and newborn. One of the positive benefits of this contact is that it mitigates the stress the baby experiences from the birth and the many adjustments it makes to its new environment. “Physiologic changes have to happen,” says Summerfield, “for example the heart has to change how the blood flows. The baby has to start breathing air and clear out all the fluid out of the lungs. This is a stressful time for a newborn.” She continues, “We want to put the baby skin-to-skin on the mom’s chest as soon as possible after delivery.” Towels are placed on the mother’s belly, where the baby will be laid after delivery. Nurses check for three important indicators to determine the appropriateness of Kangaroo Care: term length, crying, and muscle tone. If the baby meets the minimum criteria, then the newborn is placed on the mother’s chest. Nurses continue to care for the infant there. The cord is clamped, the baby is dried and dressed in a diaper and hat. The baby’s condition, such as heart rate and response to stimulus are assessed there on the mother’s chest.

Designed for premature babies in Bogotá, Columbia, Kangaroo Care has become a widely popular neonatal nursing protocol for full term babies in

the US, too.

Chris Summerfield, BSN, RNC, coordinator of Women’s Health Community Education at Baptist Hospital East.

“There have been scientific studies showing that the mother’s breasts warm up to warm the baby - when the baby is placed there. Sometime within the first 45 minutes to an hour, the baby will seek out the breast because we are mammals; mothers produce milk for babies. You have to be patient and not interfere,” says Summerfield. Through this process, babies stay warmer and are better adjusted to their new environment. Even some mothers come out better adjusted, Summerfield reports, as KC inspires a mother to have confidence in herself. “We have had many converts, as we affectionately call them, from mothers who are not sure about it or did not want to breastfeed at first. After they see how their baby will seek it out for themselves, they are usually converted. The first milk is so high in antibodies, it helps the gut to start working correctly, and as the baby nurses at the breast, it decreases the chance of bleeding for the mother. There are really wonderful things that happen for both baby and mom from the first feeding. I think it is intrinsic that you need to hold your baby, and it is exciting to see evidence of why. “Mother and baby do not want to be separated,” says Summerfield. ◆ may 2011 29


30 M.D. Update


cardiology

Gender Differences in Cardiovascular Disease UofL women’s heart specialist Dr. Rita Coram speaks out on missing the signs of cardiac disease. By Gil Dunn

LOUISVILLE The Women’s Health Program at University of Louisville is “still in its infancy, but growing daily with great promise,” says Rita Coram, MD, FACC, interventional cardiologist, faculty member, and director of UofL’s Women’s Cardiovascular Health Program (WCHP). WCHP is both a clinical and a research program. “The clinical arm addresses comprehensively all aspects of our patients’ cardiovascular health, anything from preventative risk factor identification and modification to actual interventional treatments of arterial disease, atherosclerosis, in any arterial bed of the body,” explains Coram. “Then, we have the research arm which really delves into the issues of gender differences, the variance of treatment effects on female hearts, the differential progression of heart disease as well as mortality outcomes.” WCHP is integrated into the general cardiology comprehensive fellowship at UofL without the need of an extra year of training. Through that fellowship, Coram teaches the gender differences in cardiovascular disease, most specifically linked to interventional cardiology. “It is central to the understanding of basic pathophysiology, progression, and treatment of coronary atherosclerosis,” she says. According to Coram, the mission of the WCHP is twofold: to spread awareness of heart disease at all levels starting with the patient herself and then her surrounding support system up to the medical practitioner, hospital systems, and EMS; and, just as importantly, to engage in focused research further elucidating the gender differences in atherosclerosis at the “plaque level” and to secure more female representation in clinical trials for more gender specific interpretation. There are many issues with women’s cardiovascular health that Coram believes need drastic improvement. “It is a field,” she says, “that has been relatively neglected and poorly understood.” Women are underrepresented in clinical trials, the results of which are extrapolated and applied potentially inappropriately on that gender. Women’s cardiac symptoms are more likely

Rita Coram, MD, FACC, is an interventional cardiologist, faculty member, and director of UofL’s Women’s Cardiovascular Health Program.

Unfortunately, younger patients are the ones at highest risk of death and lifelong heart failure in case of a heart attack. The majority of “young and healthy women” have no primary care physician other than their OB/GYN, and their basic cardiac risk factors are not screened until it is too late. to be atypical causing diagnostic dilemmas and delay in therapy with subsequent higher mortality and morbidity, especially in the setting of a heart attack. Women’s coronary arteries are more likely to appear

deceivingly normal, which diverts the focus away from pertinent cardiac treatments and preventative measures. Many women still do not recognize that their number one killer is heart disease or believe that they are immune from that until after menopause. Unfortunately, younger patients are the ones at highest risk of death and lifelong heart failure in case of a heart attack. The majority of “young and healthy women” have no primary care physician other than their OB/GYN, and their basic cardiac risk factors are not screened until it is too late. In women, a massive myocardial infarction, or heart attack, is most frequently the result of plaque rupture or erosion leading to clot formation and jeopardizing or stopping the flow of blood down that artery. “As a result,” says Coram, “death begins instantly in the heart muscle subtended by that vessel and deprived of blood and oxygen”. The earlier the symptoms are recognized by the patient, presented to the hospital, and reversed by the interventional cardiologist by opening the artery, the less the mortality and resulting congestive heart failure. Continues on page 35 may 2011 31


interventional Radiology

Challenging Conventions

Interventional radiologist Douglas Coldwell, MD, PhD, applies scientific imagination to image-guided surgeries that provide improved outcomes for women facing a variety of difficult health conditions. By Greg Backus and Megan C. Smith Over the past fifteen years, medical leaders have debated the impact upon medical subspecialties of the rapid development of less-invasive technologies for the treatment of vascular problems. As devices came to market, so too did the subspecialization of vascular surgery. Initially, these devices relied on approaches firmly in the purview of cardiologists and interventional radiologists: balloons, stents, guide wires, and fluoroscopy. Vascular surgeons as a whole had little experience in these approaches before the device market emerged, but with the help of the market forces, they have enjoyed an improved reputation since. Interventional radiology, in the meantime, has taken a bum rap. “You think this is a dying specialty?” asks Douglas M. Coldwell, MD, PhD, director of vascular and interventional radiology at UofL, incredulous when challenged with the standing of interventional radiology today. “As I see it, this is an interesting, dynamic, and growing specialty,” asserts Coldwell. Interventional radiology (IR) entails the diagnosis and treatment of pathologies using the least invasive techniques possible. These image-guided interventions are made peripherally, often by vascular catheterization, and result in reduced trauma, infection, and cost of recovery. Coldwell observes that IR specialists are highly-skilled physicians who “get to solve problems on the fly, adapting techniques we have used from other procedures to the case at hand.” Coldwell explains that IR’s long history with vascular approaches to image-guided surgery began over 40 years ago with Dr. Charles Dotter of Oregon, whose character legacy of innovative spirit and technical skill still imbue IR providers with an understanding that “our methods can be applied to a lot of disease processes,” says Coldwell, “more and more on a daily basis.” Coldwell, himself an unconventional physician possessing limitless energy and imagination, is board certified in inter32 M.D. Update

Douglas M. Coldwell, MD, PhD, director of vascular and interventional radiology at UofL

Much of Coldwell’s work resides at the horizons of medicine. In 2002, he was the first doctor in the US to perform Yttrium-90 (Y-90) radioembolization for the treatment of metastatic liver cancer

radiologists who are fellows of both. Coldwell received his undergraduate and doctorate degrees in Physics from Rice University, and he enjoyed a successful early career in material science before receiving his medical training at the University of Texas Medical Branch in Galveston. After a residency in diagnostic radiology and a fellowship in cancer interventional radiology, Coldwell served on several university faculties - six times as director of interventional radiology - and is an  internationally recognized author and lecturer.

Y-90 Radioembolization

ventional radiology with over 25 years of clinical experience. He is an MD, a PhD, a FSIR (fellow of the Society of Interventional Radiology), and FACR (fellow of the American College of Radiology). Since about 8% of the ACR are fellows, and 8% of the SIR are fellows, Coldwell is a member of an elite group of 1% of all

Much of Coldwell’s work resides at the horizons of medicine. In 2002, he was the first doctor in the US to perform Yttrium-90 (Y-90) radioembolization for the treatment of metastatic liver cancer. He has since treated over 500 patients with Y-90 and supervised the treatment of a thousand more as he has travelled around the world lecturing on its efficacy. For inoperable hepatic cancer, Y-90 radioembolization is remarkable effective


because “Anything that is put into the hepatic artery goes only to tumors,” explains Coldwell. “I have been doing this stuff for over 20 years and I’ve put all kinds of things into the hepatic artery to treat tumors, but this is the most effective stuff I have ever put in there.” Liver tumors, being hypervascular, create a preferential flow. The microspheres containing the Y-90 particles are 32 microns in diameter – sized just right so that they become lodged in the tumor bed. There, they deliver a dose of 1000 gray. “External beam treatment for lung cancer delivers 60 gray at the maximum dose. Head and neck tumors receive 100 gray. This treatment is delivering ten times more than external beam because it is delivered directly to the tumor,” says Coldwell. “This is intra-arterial brachytherapy. It directly irradiates the tumor with beta particles, then decays off in about 30 days. It is an enormous dose of radiation with incredibly precise targeting. These tumors do not stand a chance.” Coldwell observed 95% tumor response rate in colon cancer metastases in the first two hundred patients treated. It’s not a cure, says Coldwell, “but there is no other therapy in cancer treatment that comes close.” The therapy is also cost effective. One dose of the Y-90 powder is about the same as one and a half months of treatment with Avastin, and it usually only requires one or two outpatient treatment sessions with no OR recovery time. Recently, Coldwell has focused on the effectiveness of Y-90 radioembolization in metastatic breast cancer, which shows similar response. “The mean survival rate of women with breast cancer that metastasizes to the liver is 14 months,” says Coldwell. “We analyzed the data at 14 months after diagnosis, and if we had not done the treatment we would expect to see half of our patients still living at the time of data analysis. With this treatment we had 87% of our patients alive.” Looking into his crystal ball, Coldwell believes Y-90 radioembolization is a possible treatment option for any tumor that can

be vascularly isolated from normal tissue. Good candidates, he posits, include kidney cancers and some bone cancers. In the right situation, “it is really only limited by our ability to put our catheters where they need to go,” he says.

Uterine Fibroid Embolization

Another application of the IR approach that Coldwell performs regularly is uterine fibroid embolization (UFE ), which is an alternative to open surgery and has been shown in OB/GYN literature to produce results equivalent to myomectomy. In UFE, a small tube is placed in the arteries leading to the uterine fibroid, which is then closed off with resin particles. When the blood flow is blocked, the fibroid involutes. “You have to be really careful about which ones you decide to do,” Coldwell explains. Subserous myomas if treated by UFE would fall off into the abdomen and could develop into other problems, and intracavitary myomas, while they could feasibly be treated with UFE, are easily removed through hysteroscopic resection. “The ones that you want,” says Coldwell, “are the intramural ones. Unfortunately that is the minority of them.” There are risks common to both myomectomy and uterine fibroid embolization. Loss of fertility is a possibility, and so it early menopause that may result from ovarian injury. UFE has been in use for ten years, and Coldwell believes there is not enough data to say whether patients will retain the capacity to have children after uterine fibroid embolization. However, in his experience, a significant number of patients have. “While I cannot promise it, I cannot say that it will be impossible either.” All this considered, Coldwell believes that perimenopausal patients who do not want to have a myomectomy are as close to perfect a candidate for uterine fibroid embolization as it gets. “We are still talking about a huge part of the population here,” he notes, pointing out that there may be as many as 22 million African-American women with uterine fibroids, a population

group particularly affected by the condition. UFE requires a one or two night stay in the hospital, and patients are usually back on their feet in a week. Compared to the three to six week recovery time for abdominal or laparoscopic myomectomy, Coldwell believes that this one of many good reasons to choose this procedure, along with a 30% decrease in procedural cost.

Vertebral Augmentation

Coldwell often provides vertebral augmentation for treatment of osteoporotic vertebral compression fractures – a condition causing extreme pain and often affecting senior women. In vertebral augmentation, a needle is placed into the vertebral body from the back, and through that needle another cutting needle creates a channel into the vertebral body. Then, a cement is pumped in that intercalates between the trabeculae of the vertebral body, ensuring that the whole vertebral body is infused. “We end up fusing the fractured fragments together,” he says. “I have had patients arrive in a wheelchair and walk out two hours later, pain-free, after receiving this treatment. It is just astounding.” It is important to note that time is of the essence for the successful treatment of vertebral compression fractures. Four to six weeks after the fracture occurs, the fragments might heal in places, but most will not heal in the correct locations. An accurate diagnosis is also necessary. “We have to prove that there is vertebral compression fracture in cases of patients presenting with extreme back pain,” says Coldwell. An MRI is showing edema can ruling out a chronic cause for the back pain, like arthritis. Vertebral augmentation, says Coldwell, “has a high success rate of achieving enduring pain relief.” Ever displaying a fervor for creative problem solving, Coldwell observes that vertebral augmentation is not only excellent for treating the effects of osteoporosis, it is also good for people who have tumors that have spread to their back. Recent studies show that it can be used to treat tumors in the spine, stopping the pain and killing the tumor. ◆ may 2011 33


Vascular Surgery

Hired Gun

Ephraim McDowell’s first employed specialist, Dr. Neil S. Weintraub, gives boost to minimally invasive surgery program. By Gil Dunn From the suburbs of New York City to the rural Danville, Kentucky, Neil S. Weintraub, MD, became Ephraim McDowell’s first employed specialist when, in August 2009, he became chief of Vascular Surgery at Ephraim McDowell Regional Medical Center (EMRMC). He is the only board certified vascular surgeon at EMRMC. Weintraub completed medical school at the University Of Chicago Pritzker School Of Medicine with internship, residency and fellowship at New York University. His specialties are carotid disease, hemodialysis access, lower extremity vascular disease, abdominal aortic aneurysm and venous disease. Weintraub’s goal for EMRMC is “to provide any surgical procedure that can be done safely in this hospital to the Central Kentucky community.” Under his leadership, surgical specialties at EMRMC are energized. “We have vascular and an excellent spine program that is growing,” says Weintraub. “We have an active ENT service and orthopedics. We are starting to get plastic surgery back as well. We have a full spectrum of surgical options that do not require referral to a tertiary care center. We are not doing intra cranial neurosurgery or cardio thoracic, but we are doing a lot of back surgery.” As an example of Weintraub’s focus on minimally invasive surgery (MIS), the VNUS Closure procedure is now performed at EMRMC on patients with venous disease which “is very common, about ten times as common as arterial disease across the country,” remarks Weintraub. Most venous disease stems from faulty valves in the veins, either spontaneously or after a blood clot. At some point the valves get destroyed. The blood flows backwards down the leg. “Normally,” says Weintraub, “there are valves that break it up. Patients with venous reflux get increased pressure in the veins of the lower body because of this backward flow. This can lead to varicose veins, skin damage, and venous ulceration. Treatment

DANVILLE

34 M.D. Update

Neil S. Weintraub, MD, chief of Vascular Surgery at Ephraim McDowell Regional Medical Center.

Weintraub’s goal for EMRMC is “to provide any surgical procedure that can be done safely in this hospital to the Central Kentucky community.”

for this is to get rid of the segment of the vein that is diseased. In superficial reflux, which is the most common cause, we treat the greater saphenous and lesser saphenous veins.” In the past, the corrective procedure was removal of the vein, aka “vein stripping,” an open surgery, painful for patients, requiring general anesthesia and extended recovery. The VNUS Closure procedure allows Weintraub to use radio frequency energy. “We puncture the vein without any incisions and insert a special catheter up the vein, under ultrasound guidance. The catheter uses radio frequency energy to seal the vein so that there is no longer blood flowing through the vein. It is done under local anesthesia and patients go home the same day and resume their normal activities the next day. The post operative pain is far less than it was with the surgical procedure,


Gender Differences in Cardiovascular Disease continued from page 31

there is less bruising and no bleeding,” says Weintraub. Patient volume for the VNUS Closure has increased dramatically in recent months. Weintraub projects a patient volume of five to ten cases per month. The majority of Weintraub’s venous patients are female due to hormonal factors and pregnancies, however Weintraub points to genetics as the overriding cause. “People will attribute it to lifestyle. They will say they got varicose veins from standing up all the time. Invariably, when I see a patient with significant varicose veins or venous disease, their mothers and grandmothers had it. With the exception of a spontaneous occurrence from a blood clot, it’s frequently a familial condition.” According to Weintraub, the patient population ranges from mid-twenties to seniors with more varicose veins in the younger patients and more venous ulceration in the older ones, who are not as concerned about cosmetics and aren’t working on their feet all day and having symptoms from varicose veins. The move to EMRMC has given Weintraub the opportunity to pursue dual goals of serving the community and enjoying personal pastimes of bicycling and travel with his wife, Elita. “I hope to help people in this community. We are reducing the travel time in half for our patient population in Danville and the surrounding counties in our service area. Many vascular conditions demand an on-going relationship with a physician. Arterial and venous diseases are chronic conditions that are never really cured. It is managed with treatment and you have to keep seeing these patients on a regular basis, often for the rest of their life.” “We should not be limited by manpower, only by medical concerns. If there is anything we cannot offer to the community, it should only be because it should not be done in a regional center, but in a tertiary care center, not because we do not have the doctor,” says Weintraub. ◆

Door to balloon (DTB) is the measure of the time it takes for the health system to move the patient from the minute of arrival in the emergency room to the time the interventional cardiologist successfully opens the artery in the catheterization laboratory. The national recommendation for DTB is 90 minutes. Under Coram’s leadership and the critical help of a multidisciplinary team, UofL attained an average DTB of 62 minutes in 2010. The obvious symptoms of a heart attack are well known, but the atypical, more frequently deceiving ones in women are jaw/teeth pain, upper

back pain, shortness of breath, nausea and cold sweats, chest pressure, heaviness or squeeze, upper stomach pressure, and indigestion. Factors that contribute to higher cardiac risks are diabetes, hypertension, dyslipidemia (abnormal cholesterol), abdominal obesity, smoking, sedentary lifestyles and family history of premature cardiac disease. “The best way to avoid heart disease is not to treat it, but to prevent it,” concludes Coram. “Women need to visit their primary care physician as early as in their 20’s so that their risk factors are identified as early as possible and acted upon before it is too late.” ◆

may 2011 35


grand rounds NEWS ◆ ARTS ◆ EVENTS news@md-update.com

Four Kentucky Hospitals among 100 Top Hospitals

Central Baptist Hospital Expansion

STATEWIDE Three Kentucky hospitals that have been named top hospitals on the Thomson Reuters annual 100 Top Hospitals list: St. Elizabeth Healthcare in Edgewood was recognized in the Teaching Hospital category. Flaget Memorial Hospital in Bardstown and Harlan ARH Hospital in Harlan were recognized in the Small Community Hospitals category; and Saint Joseph East in Lexington was recognized in the Medium Community Hospitals category. The data for the 2011 study were collected from a number of public sources, including federal Medicare statistics. Hospitals do not apply, and winners do not pay, to receive this honor. Thomson Reuters, an independent firm that performs the annual study, compared each hospital to peer hospitals in five categories: major teaching hospital, teaching hospital, large community hospital, medium community hospital, and small community hospital.

Baptist Healthcare System Retains “AA-” and “Aa3” Bond Ratings

LEXINGTON Baptist Healthcare System, Inc. has received “AA-” and “Aa3” bond ratings from Fitch Ratings and Moody’s Investor Service respectively. Baptist Healthcare System owns five acute-care hospitals throughout Kentucky, including Central Baptist Hospital in Lexington. Fitch Ratings affirmed BHSI’s bond rating at “AA-” with a stable outlook May 10, and Moody’s Investor Service affirmed BHSI’s bond rating at “Aa3” with a stable outlook on March 25. Both agencies noted its strong ratings were due to Baptist’s statewide market presence and its strong balance sheet. 36 M.D. Update

Bond ratings serve to allow existing and potential bonds holders to assess the ability of a company or corporation to pay back the funds it borrows. The higher the rating, the lower the risk is to the bondholder. “During this time of uncertainty in the healthcare industry and in the face of numerous downgrades of health care organizations, it’s nice to have independent affirmation of the confidence in the management team throughout our statewide organization as well as the confidence in our strategies and our vision moving into the future” said Carl Herde, CFO of Baptist Healthcare System, Inc. “We understand that our facilities are community assets and we have a fiduciary responsibility to provide the best care possi-

ble for each community,” Herde continued. “Our focus on providing the highest quality of patient care while constantly challenging ourselves to be as cost efficient as possible has allowed us to maintain our ratings.”

UofL physician named Emergency Department Director of the Year

LOUISVILLE Royce D. Coleman, MD, FACEP, has been named Emergency Department Director of the Year by the Emergency Medicine Foundation (EMF) of the American College of Emergency Physicians (ACEP) and Blue Jay Consulting. Coleman is the Emergency Department medical director at University of Louisville Hospital and an associate professor of


NEWS

emergency medicine at the University of Louisville. He is a Fellow of ACEP and was honored at the ACEP Emergency Department Directors Academy in Dallas. A panel composed of appointees from EMF and Blue Jay Consulting chose the Emergency Department Director of the Year from over 70 national candidates. “This has been a very humbling experience,” Coleman said. “The nomination was (made) without my knowledge, initiated by colleagues that I have been privileged to work with for many years.”

UK OB/GYN Chosen for Leadership Program

LEXINGTON Dr. Wendy Hansen, chair of the Department of Obstetrics and Gynecology at UK, has been chosen to participate in the Hedwig van Ameringen Executive

Wendy Hansen, MD

Leadership in Academic Medicine (ELAM) Program for Women at Drexel University College of Medicine. Hansen is one of only 54 senior faculty across the country named to ELAM’s 2011-12 class of fellows. ELAM is the only national program

dedicated to preparing senior women faculty for positions of leadership at academic health centers. While the number of women graduating from health professional schools across the country continues to climb, the number of women holding positions of leadership in academic health centers lags severely behind. ELAM’s mission is to increase the number of women in senior academic leadership positions, where they can ultimately help change the culture of academic health organizations to become more accepting of different perspectives and responsive to societal needs and expectations. In order to be accepted into the program, each fellow must be nominated and supported by the dean or other senior official of her institution, and ELAM continues to cultivate strong partnerships with partici-

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may 2011 37


THErE’s oNLy oNE. And this year it’s Norton Healthcare. Each year the National Quality Forum (NQF) honors one health care organization with its top award – the National Quality Healthcare Award. NQF presents this award to an organization that serves as a role model for achieving meaningful, sustainable improvements in patient care. We’re honored to be recognized for what we do every day – providing outstanding, quality-driven care. Learn more at NortonQuality.com.

38 M.D. Update


NEWS

pating institutions throughout the yearlong fellowship. One aspect of this relationship is the curricular requirement to conduct an Institutional Action Project, developed in collaboration with the fellows’ dean or other senior official. These action projects are designed to address an institutional or departmental need or priority.

Another Walmart Clinic for Central Baptist

WINCHESTER Walmart and Central Baptist Hospital have opened “The Clinic at Walmart” at the Winchester Walmart on Bypass Road. This is the second time that Central Baptist Hospital has opened a convenient care clinic within the retailer’s Central Kentucky stores. The clinic provides convenient, affordable access to basic healthcare services for individuals 24 months and older, seven days a week, with no appointment necessary. “By joining with Walmart to operate The Clinic at Walmart, Central Baptist Hospital is one step closer to ensuring the health and wellness of our community,” said William G. Sisson, president & CEO of Central Baptist Hospital. “Our clinic is staffed with licensed healthcare providers, even on nights and weekends, so families can walk in and know they will receive quality care without a long wait. It also helps ease the burden on our emergency rooms, which aren’t designed to treat everyday illnesses like sore throats.” Baptist Healthcare System has embarked on a statewide initiative to offer clinics in Walmart stores throughout Kentucky. The first Walmart clinic in the state opened in November 2009 in the Hamburg Walmart in Lexington. There are more than 100 instore clinics in Walmart stores throughout the country.

Eight Institutions Join Appalachian Translational Research Network

LEXINGTON Researchers from the University of Kentucky have joined forces with seven regional academic centers and community organizations to work toward changing

health disparities in Appalachia through the creation of the Appalachian Translational Research Network (ATRN). The Appalachian region is a 205,000-square-mile area that spans from southern New York to northern Mississippi. It includes 54 Kentucky counties, all of West Virginia and parts of 11 other states, with an estimated population of 24.8 million. States that include significant portions of Appalachia consistently demonstrate high rankings for many chronic illnesses and diseases, with Kentucky and West Virginia having some of the worst rankings in the country in cancer, smoking, obesity, and diabetes. Recently, health experts and representatives from federal, state, and local organizations met at the first annual  Appalachian Health Summit  to discuss the obesity epidemic, promising research and possible ways to tackle the region’s many health issues. The new network will be looking at these issues through a translational science lens, a perspective that uses collaborations to help accelerate the process that lab research goes through to become real-world health solutions. The ATRN is dedicated to enhancing research collaborations and seeking new avenues to address the significant health challenges and disparities in Appalachia. Members of the collaborative include the University of Kentucky, The Ohio State University, the University of Cincinnati, Marshall University, Morehead State University, Pikeville College, and the Appalachian Regional Commission.

site survey on April 12 and 13. A team of Joint Commission expert surveyors evaluated EMFLH for compliance with standards of care specific to the needs of patients, including infection prevention and control, leadership and medication management. According to Mark Pelletier, RN, MS, executive director, Hospital Programs, Accreditation and Certification Services, The Joint Commission, “Accreditation is a voluntary process and I commend Ephraim McDowell Fort Logan Hospital for successfully undertaking this challenge to elevate its standard of care and instill confidence in the community it serves.”

UK Nursing Chair inducted into Nurse Researcher Hall of Fame

Debra K. Moser, DNSc, RN, FAAN, professor and Linda C. Gill Chair in Nursing in the UK College of Nursing is one of 15 nurse researchers who will be inducted in July 2011 into the Sigma Theta Tau International Nurse Researcher Hall of Fame. This unique recognition honors nurse

LEXINGTON

Joint Commission Accreditation for Ephraim McDowell Fort Logan

Ephraim McDowell Fort Logan Hospital (EMFLH) has earned The Joint Commission’s Gold Seal of Approval for accreditation by demonstrating compliance with The Joint Commission’s national standards for health care quality and safety in hospitals. Ephraim McDowell Fort Logan Hospital underwent an unannounced on-

STANFORD

Debra K. Moser, DNSc, RN, FAAN

may 2011 39


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researchers who are Honor Society of Nursing, Sigma Theta Tau International (STTI) members who have achieved longterm, broad national and/or international recognition for their work; and whose research has impacted the profession and the people it serves. STTI selected inductees who are leaders, mentors, scholars, and role models. Moser is noted for her work with the RICH (Research and Interventions for Cardiovascular Health) Heart program, which seeks to improve heart failure patient outcomes and promote cardiovascular risk reduction in special populations. The RICH Heart Program is an interdisciplinary research collaborative that includes faculty, students, staff, post-doctoral fellows, and visiting scholars from both the United States and international sites. Scholars working with the RICH Program have received

40 M.D. Update

more than $20 million in federal and other extramural funding, have published more than 300 peer-reviewed papers, and received many awards. Moser has received continual funding for her research since 1989 from the National Institutes of Health, the Health Resources and Services Administration, the American Heart Association, and the American Association of Critical Care Nurses. Moser is a prolific author with more than 200 journal articles, three books and more than 20 book chapters.

Best Practice Partner Award to EMRMC

Ephraim McDowell Regional Medical Center (EMRMC) is pleased to announce that the Medical Center has been awarded a “Best Practice Partner Award” by Courtemanche & Associates (C&A), a

DANVILLE

national healthcare consulting firm based in Charlotte, NC. Ephraim McDowell Regional Medical Center will be recognized at C&A’s annual conference to be held in St. Louis, MO, in May. “We are honored to have received this award from C&A,” says Sally Davenport, chief nursing officer, Ephraim McDowell Regional Medical Center. “Our goal is to provide the best medical care and customer service possible to our patients and visitors. We are particularly proud when those efforts to improve our patients’ safety are recognized by organizations like Courtemanche & Associates.” The winning initiative was selected based on the theme of this year’s conference, “Empowering Performance: Unlocking Regulatory Success.” Award winners demonstrated a direct impact on regulatory compliance and considered the many facets


NEWS

of an empowered organization including, the strength of the leadership team, collective and collaborative decision-making, financial stewardship, patient safety and staff and physician satisfaction. The Medical Center was chosen for this award based on the utilization of lean tools and Change Management Theories to successfully improve the Emergency Department patient’s length of stay, patient flow and their experience as well as improving the supporting department’s performance. The improvements from this multifaceted approach are evidenced by the Emergency Department’s September 2010 performance measurements. The average door to discharge time was 95 minutes, an average reduction of 55 minutes per visit. The average door to admission time was 137 minutes, an average reduction of 89 minutes per visit. The average door to triage or room time was 1.1 minutes, an average reduction of 11 minutes. The average door to physician screening exam time was 12.5 minutes, an average reduction of 16.1 minutes.

UK Neuroscientist Elected to Dana Foundation

LEXINGTON Linda J. Van Eldik, director of the UK Sanders-Brown Center on Aging, is among seventeen leading researchers newly elected to the Dana Alliance for Brain Initiatives. Supported entirely by the Dana Foundation, the Dana Alliance is a nonprofit organization of more than 300 lead-

Linda J. Van Eldik, PhD

ing neuroscientists committed to advancing

public awareness about the progress and promise of brain research. Van Eldik specializes in research related to the causes, effects, and treatment of Alzheimer’s disease. The Dana Foundation is a private philanthropic organization that supports brain research through grants and educates the public about the successes and potential of brain research.

HOSPICE CARE CENTER OPENS

Hospice of the Bluegrass-Mountain Community opened the Hospice Care Center near Hazard ARH Regional Medical Center with a public ribbon cutting ceremony on May 3, 2011. The Hospice Care Center will serve southeastern Kentucky  and will add approximately 60 new jobs to the area. Hospice of the Bluegrass – Mountain Community will continue to provide excellent service to patients at home. The new Center will offer a setting for terminally ill patients who need more complex care, when death is approaching and care in the home is not preferred, or when a family needs respite from daily intensive care of their loved one. Patient stays are usually brief - five to seven days. Monica Couch, director of Hospice of the Bluegrass-Mountain Community, says that having the Hospice Care Center provides a valuable option. It offers family and friends 24-hour visitation and encourages them to remain involved in the patient’s care. The 20,000 square foot Hospice Care Center has a lodge-inspired design and features twelve patient suites in a wheelchairaccessible, one-story building. Each patient suite includes a sunroom, private garden patio and private bathroom (with wheel-in shower), and the facility offers common areas such as family lounges with fireplaces, family rooms with dining and snack areas, chapel, and children’s playroom.

HAZARD

Patient Navigator Program at Markey Cancer Center LEXINGTON

The UK Markey Cancer Center

is helping cancer patients and their families with the launch of the state’s first American Cancer Society Patient Navigator Program, made possible with support from AstraZeneca. The navigator program helps patients with concerns beyond the clinical side of their disease. The overall goal, says American Cancer Society patient navigator Melanie Wilson, is to improve the quality of life for cancer patients, survivors and their caregivers. As Markey’s patient navigator, Wilson will be available to help patients find resources for a variety of needs. After a diagnosis, patients may want to seek information on the following: Transportation, coping strategies, appearance-related needs, financial assistance, and information on cancer types and treatment options. 

JHSMH President/CEO Receives ACHE Regent’s Award

Marty Bonick, president and CEO of Jewish Hospital Medical Campus in Louisville, Kentucky has received the American College of Healthcare Executives Early Career Healthcare Executive Regent’s Award. The award was bestowed on Bonick by the Kentucky ACHE Chapter at the Kentucky Hospital Association meeting in May. The Early Career Healthcare Executive Regent’s Award recognizes ACHE affiliates who have made significant contributions to the advancement of healthcare management excellence and the achievement of ACHE’s goals. Affiliates are evaluated on leadership ability, innovative and creative management, executive capability in developing their own organization and promoting its growth and stature in the community, participation in local, state, or provincial hospital and health association activities, participation in civic/ community activities and projects, participation in ACHE activities, and interest in assisting ACHE with its objectives. Bonick has served as president and CEO of the Jewish Hospital Medical Campus since February 2008. Prior to joining Jewish Hospital, he served as CEO of

LOUISVILLE

may 2011 41


NEWS

Send News Announcements to news@md-update.com

Marty Bonick

Oklahoma State University Medical Center in Tulsa Oklahoma. He is board certified in healthcare management as a Fellow of the American College of Healthcare Executives, demonstrating a commitment to professional excellence. He was recognized nationally as one of Modern Healthcare magazine’s “Up and Comers” for 2008 and by Business First newspaper as one of Louisville’s “40 Under Forty” dynamic young leaders. The American College of Healthcare Executives is an international professional society of more than 35,000 healthcare executives who lead hospitals healthcare systems and other healthcare organizations. ACHE is known for its prestigious FACHE credential, signifying board certification in healthcare management, and its educational programs including the annual Congress on Healthcare Leadership, which draws more than 4,500 participants each year.

As the affiliate network’s medical director, Jones will provide leadership to the network of hospitals in Central and Eastern Kentucky that collaborate to provide stateof-the-art oncology care and associated programs in close partnership with the Markey Cancer Center. Priorities include increasing the availability of clinical trials and novel treatments in smaller communities and improving patient education on cancer prevention, treatments, and resources. Jones says he was thrilled when offered the chance help the affiliate network further grow and prosper. In addition to his executive duties for the cancer center and affiliate network, Jones will continue his own research into cancers of the lung and gut, as well in the development of novel drugs and treatment strategies. He will also see lung and gastrointestinal cancer patients in the clinic on a regular basis.

New Associate Medical Director for Markey Cancer Center

Her clinical goals include the early detection of breast cancer using new technologies including elastography and tomosynthesis. Szabunio also serves as the division chief of women’s radiology for UK HealthCare. Szabunio comes to UK from the Moffitt Cancer Center in Tampa, Fla. She earned her medical degree from Drexel University College of Medicine (formerly Hahnemann University Medical School) in Philadelphia and completed a radiology residency and fellowship at Long Island Jewish Medical Center in New York.

New Executive Director for Ephraim McDowell Foundation

DANVILLE Randy Greene of Danville has been appointed to the position of Executive Director of the Ephraim McDowell Health Care Foundation (EMHCF). Greene has been the Interim Executive Director since January 2011. Randy served as the Grant Research and Development Analyst for EMHCF from

The UK Markey Cancer Center has appointed Dr. Margaret M. Szabunio associate medical director for its Comprehensive Breast Care Center. In this role, Szabunio is a key member of a multidisciplinary team of specialists dedicated to providing patients with the attention they need through all phases of breast health, including prevention, screening, diagnosis, and treatment.

LEXINGTON

New Deputy Director for Markey Cancer Center

LEXINGTON The UK Markey Cancer Center has appointed medical oncologist Dr. Dennie V. Jones Jr. as its deputy director, responsible for the center’s clinical outreach, research, and education programs. Jones will also serve as the medical director of the Markey Cancer Center Affiliate Network and professor of internal medicine in the UK College of Medicine. Previously, Jones held cancer center leadership positions at the University of New Mexico and the University of Texas Medical Branch in Galveston. 42 M.D. Update

Randy Greene

Margaret M. Szabunio, MD

2009 until his appointment as Interim Executive Director. During that time, he secured over $300,000 in new grant awards and helped to manage nearly twice that amount of grants. Prior to joining EMHCF, he was the Marketing Manager for Jackson MSC in Barbourville, KY, and he served as


NEWS

Marketing Director for J.D. Legends/Strike Zone Lanes in Nicholasville, KY. Randy has a long history as an editor, working for companies including The Lexington Herald Leader, The Cynthiana Democrat, McGraw-Hill, and Doubleday & Co.

Joint Venture for Surgical Care Affiliates and JHSMH

Jewish Hospital & St. Mary’s HealthCare (JHSMH) has begun a joint venture partnership with Surgical Care Affiliates (SCA) to expand its outpatient surgery capabilities, and build a surgical network in partnership with physicians in the Louisville area. Included in the new joint venture partnership are Premier Surgery Center, currently located in downtown Louisville and SurgeCenter of Louisville located in the Dupont area of St. Matthews. Both of these centers are currently managed by SCA.

LOUISVILLE

As a multi-specialty surgery center, SurgeCenter of Louisville provides a variety of surgical specialties for patients including ophthalmology, ENT/otolaryngology, orthopedics, gynecology, urology, podiatry, and plastics procedures. The Premier Surgery Center of Louisville is also a multispecialty surgery center that currently does a high volume of pain, gastroenterology, and general surgery procedures. That downtown center will be replaced by a new freestanding facility on the Jewish Hospital Medical Center Northeast campus. The new center is scheduled to open in 2012.

Results Are In on Avastin v. Lucentis

LEXINGTON Researchers are reporting results from the first year of a two-year clinical trial that Avastin, a drug approved to treat some cancers and that is commonly used off-label

to treat age-related macular degeneration (AMD), is as effective as the Food and Drug Administration-approved drug Lucentis for the treatment of AMD. The report, from the Comparison of AMD Treatments Trials (CATT), was published online April 29 in the New England Journal of Medicine. CATT is funded by the National Eye Institute (NEI), a part of the National Institutes of Health. Avastin is widely used off-label in the treatment of AMD because it is significantly less expensive than Lucentis. “Over 250,000 patients are treated each year for AMD, and a substantial number of them receive Avastin. Given the lack of efficacy data regarding Avastin for AMD treatment, the NEI had an obligation to patients and clinicians to conduct this study,” said Paul A. Sieving, MD, PhD, director of the NEI. Retina Associates of Kentucky has been

may 2011 43


NEWS

Send News Announcements to news@md-update.com

working with the National Institutes of Health for more than four years participating in this important study. “We are elated with the results which demonstrate that both of these medicines offer patients a new opportunity to regain vision in this previously blinding disease. These encouraging results seem to hold true for many patients, and offer hope to those who suffer from macular degeneration,� said Thomas Stone, MD, principal investigator and partner of Retina Associates of Kentucky. Stone is a nationally recognized authority on diseases and surgery of the retina, macula, and vitreous. Genentech, the maker of both drugs, originally developed Avastin to prevent blood vessel growth that enables cancerous tumors to develop and spread. In 2004, the FDA approved Avastin for the systemic treatment of metastatic colon cancer. Genentech later developed Lucentis, derived from a protein similar to Avastin, specifically for injection in the eye to block blood vessel growth in AMD. NEI launched CATT in 2008 to com-

44 M.D. Update

received Lucentis monthly or PRN, or Avastin monthly or PRN. Enrollment criteria required that study participants had active disease. Investigators in the CATT study will continue to follow patients through a second year of treatment. These additional data will provide information on longerterm effects of the drugs on vision and safety. The FDA has not evaluated data from the CATT trial.

Central Baptist Opens Diagnostic Center in Georgetown

Thomas Stone, MD

pare Lucentis and Avastin for treatment of wet AMD. The study has now reported results for 1,185 patients treated at 43 clinical centers in the United States. Patients were randomly assigned and treated with one of four regimens for a year. They

GEORGETOWN Scott County residents now have more convenient access to the quality medical services of Central Baptist Hospital through a new facility, Central Baptist Outpatient Diagnostic Center in Georgetown, which opened April 13. The 9,000-square-foot center located at 206 Bevins Lane offers the following: Diagnostic services (CT scan, ultrasound, and X-ray); digital screening mammography; and laboratory services.


events Cardinal Hill Rehabilitation Hospital raises $423,883 during 40th annual telethon

Cardinal Hill Rehabilitation Hospital’s Annual Telethon raised $423,883 on Sunday, April 17th. Lexington Philanthropists Marylou Whitney and John Hendrickson, faithful friends and supporters of the hospital, generously gifted the hospital with a $100,000 donation. John Hendrickson personally presented the donation live on Sunday’s broadcast. The Telethon, produced and supported by WKYT-TV 27, is broadcast live from the hospital on Versailles Road, shown on WKYTTV 27 (Lexington viewing area) and WYMTTV 57 (Hazard viewing area). Cardinal Hill Telethon proceeds will be used to provide programs and direct patient care to children and adults. “These donations do change lives,” said Jimmy Nash, president of the Cardinal Hill Board of Trustees, “As we celebrate 60 years of service, we continue to serve patients and their families thanks to the generous support that we receive.  I encourage people wanting to see their Telethon dollars at work to visit us at the hospital, where we treated over 8,000 children and adults last year.” Cardinal Hill Rehabilitation Hospital is Kentucky’s leader in providing physical rehabilitation services to people of all ages. Our goal is to achieve maximum independence for each patient. ◆

LEXINGTON

Receiving 2011 HAVE Award Geri Wells, president of Ephraim McDowell Regional Medical Center Auxiliary (center) receives the 2011 Hospital Awards for Volunteer Excellence from AHA Board of Trustees chair-elect Teri Fontenot (left) and AHA Committee on Volunteers chair Barbara Bergin (right).

Community Service HAVE Award goes to Ephraim McDowell Auxillary The Ephraim McDowell Regional Medical Center (EMRMC) Auxiliary was a recipient of a Hospital Awards for Volunteer Excellence (HAVE) Award presented April 11 during the American Hospital Association (AHA) Annual Membership Meeting in Washington, D.C. The EMRMC Auxiliary was recognized in the Community Service Programs category.  The prestigious award recognized the Auxiliary’s involvement with the Hope Clinic and Pharmacy. The AHA honored four hospital volunteer programs with the HAVE Award.  The Awards Program is in its 28th year and highlights the extraordinary efforts of volunteer programs and the positive impact their contributions have on the patients, hospitals, health systems and communities they serve. Recipients of this year’s prestigious award hail from Kentucky, Maryland, California and Illinois. The Hope Clinic and Pharmacy is a partnership of Ephraim McDowell Regional Medical Center, Heart of Kentucky United Way, the Salvation Army, The Presbyterian Church of Danville and the Boyle County Health Department.  The clinic and pharDANVILLE

macy provides free medical care and prescription drugs to residents of Boyle, Casey, Garrard, Lincoln, Mercer and Washington counties who suffer from chronic illness and are unable to afford the medical services to help with their illness. The clinic is located at 105 Daniel Drive in Danville. “I am honored that our Auxiliary received this national award,” says Linda Tillman, director of Volunteer Services and Senior Programming for Ephraim McDowell Health. “Receiving this award shows the high level of dedication and commitment of our volunteers.”

M.D. Update publisher Gil Dunn was one of several volunteers helping to raise funds during Cardinal Hill Rehabilitation Hospital’s Annual Telethon on April 17, 2011.

may 2011 45


AT PRESS TIME

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Make That 2 ACHE Regents Honorees Art J. McLaughlin, MD Atefeh Gupta, MD Lori L. Atkins, MD Christine E. Huxol, MD We welcome new patients.

Services Provided Digital Mammography Consultation Film Review / Breast Exam Breast Ultrasounds Cyst Aspiration U/S Guided Biopsies Stereotactic Biopsies Bone Density Studies

DuPont Medical Center 4004 DuPont Circle, Suite 230 Louisville, Kentucky 40207 (502) 893-1333 FAX (502) 899-9576

www.wdcntr.com 46 M.D. Update

Norton Healthcare’s president and CEO, Stephen A. Williams, receives ACHE Regent’s Award From Norton Healthcare LOUISVILLE Stephen A. Williams,

president and chief executive officer, Norton Healthcare, received the American College of Healthcare Executives Senior-Level Healthcare Executive Regent’s Award at the ACHE breakfast during the Kentucky Hospital Association’s May 11 meeting. The award was presented by Brian C. Doheny, FACHE, chief operating officer, Jewish Hospital Medical Center, and ACHE’s Regent for Kentucky. The Senior-Level Healthcare Executive Regent’s Award recognizes ACHE affiliates who are experienced in the field and have made significant contributions to the advancement of health care management excellence and the achievement of ACHE’s goals. Affiliates are evaluated on leadership ability; innovative and creative management; executive capability in developing their own organization and promoting its growth and stature in the community; contributions to the development of others in the health care profession; leadership in local, state or provincial hospital and health association activities; participation in civic/community activities and projects; participation in ACHE activities; and interest in assisting ACHE in achieving its objectives. Williams is board certified in health care management as a fellow of the American College of Healthcare Executives, demonstrating a commitment to professional excellence. He has been with Norton Healthcare since 1977 and has served as president and CEO since 1993. Before that, he served as executive vice president and chief operating officer (1988-93); vice president, quality management (1986-88); vice president, managed hospitals (19841986); administrator, Caldwell County Hospital (1980-84); and assistant to the executive vice president (1977-79). A native of Lola, in Western Kentucky, Williams earned a bachelor’s degree in business administration from Murray State University and a master’s in health care administration from the University of Minnesota. Williams has the unique distinction of having served as CEO of Kentucky’s smallest

hospital at the time (Livingston County, 26 beds, 1972-77, at age 22) and now serving as CEO of Kentucky’s largest health care system. He led Norton Healthcare’s pioneering development of total quality management in the health care industry in the mid-1980s, which led to Norton Healthcare being recognized as the first in the nation to receive Healthcare Forum’s Commitment to Quality Award in l988. He has authored several articles and spoken nationally on strategies in health care quality management. He also was recognized as one of four emerging leaders nationally in 1990. Norton Healthcare has been designated as one of the top 100 integrated health care organizations in the nation. Under Williams’ leadership, this year, Norton Healthcare won the prestigious National Quality Forum National Quality Healthcare Award. The organization has been recognized consistently as one of the best places to work in Metro Louisville, the state of Kentucky and nationally. In addition, Norton Healthcare and Humana are one of only four national pilot sites, and the only one in Kentucky, to study the Accountable Care Organization (ACO) model through the prestigious Brookings – Dartmouth ACO Pilot Project. With more than 11,200 employees and some 2,300 total physicians on its medical staff, Norton Healthcare is Louisville’s third largest private employer. Williams is active in health care and civic organizations on the national, regional and local levels. He has served as a member of the board of trustees of the American Hospital Association and chaired its Regional Policy Board 3 (seven southeastern states and the District of Columbia). He has chaired the board of trustees of the Kentucky Hospital Association and has received its Award of Excellence. He has served as co-chair of Greater Louisville Inc. (the city’s chamber of commerce and economic development organization); chair of Louisville’s Metro United Way (raising more than $28 million for charity); chair of KentuckianaWorks (the region’s workforce investment board); and has served on the boards of Leadership Louisville, Fund for the Arts, University Medical Center, University Health Care Corporation and many others. He also has been recognized by Murray State University with its Distinguished Alumni Award and received the first Jerome T. Bieter Award for Outstanding Leadership from the University of Minnesota. ◆


arts

Love and Things Like Love

LEXINGTON Think of love as a yellow stitched line, running across an old black and white photograph, like a roadmap through memory. Or, imagine love as two wrinkled elephants bound together by a chain of flowers. Or, even, love as a huggable heart sculpture, made entirely of pink lingerie. Love, as expressed in LAL’s upcoming exhibition Love and Things Like Love opening May 27 and running through July 10, is as varying as the people experiencing the emotion. From the poignant to the profane, the heartfelt to the humorous- love takes the form of loss, compassion, intimacy and even disconnect. The work, created by 49 artists, shows an array of definitions applicable to everyone at one point in their life or another. Artist Jane Waggoner Deschner stitches simple messages of love atop found photographs from the early- to mid-Twentieth Century. The combination of stitchery and found snapshots gives her, according to her artist statement, “a chance to moralize, in sampler-esque form, on some of the thoughts and lessons my maternal self needed to share—accountability, acceptance, love, honesty, compassion, integrity, gratitude and generosity.” Artist Jillian Ludwig delicately draws love as two animals intertwined with strands of flowers. She states in her artist statement, “To further imply the natural unwavering acceptance of the others true self, the series was drawn in a quiet monochromatic pallet, an intimate size format, and infused with richly tantalizing details in hopes to celebrate the revealing and acceptance of our lovers and our own personal imperfections.”

“Embrace Me, So Big You Can’t Get Around It” by Tyler Mackie, from Love and Things Like Love. Hand-dyed women’s slips, polyfil, crochet, crystal, bed sheets, afghan, mussell shell, doll hair, pom poms, and beading; 6’ x 5.5’ x 1.5’.

Events for Love and Things Like Love include: Palette: June 4, 6p – 11p, LAL @ Loudoun House

A special VIP date night when guests will view the varying interpretations of love as well as sample heavy hors d’oeuvre created by Lexington’s premiere chefs. The night will also feature fine wine pairings, live music and dancing, and a cash bar with featured wines and other spirits.Tickets are limited and are $40 per person and $75 per couple. Reservations at 859.254.7024.

Fifth Third Bank 4th Friday: May 27, 6p – 9p| June 24, 6p – 9p| LAL @ Loudoun House

A networking event with light appetizers and cash bar. $7, LAL Members are free and LexArts card holders are 2 for 1. may 2011 47


Featured Professionals Marty Bonick . ............................................... 41-42

Kelli Miller...................................................... 16-21

Rebecca Booth............................................... 16-21

Debra K. Moser . .................................................39

E. Britt Brockman............................................... 5-7

Scott Neal . .........................................................13

Holly Brown................................................... 16-21

Leigh Price..................................................... 16-21

Mollie Cartwright . ........................................ 16-21

Thomas Stone......................................................44

Ann Clark....................................................... 16-21

Chris Summerfield . ............................................29

Douglas Coldwell........................................... 32-33

Margaret M. Szabunio ........................................42

Royce D. Coleman ........................................ 36-37

Margarita Terrassa......................................... 16-21

Rita Coram .................................................. 31, 35

Rebecca Terry ............................................... 16-21

Leslie J. Crofford .......................................... 24-25

Linda J. Van Eldik . ..............................................41

Stephanie Dutton........................................... 16-21

Lori Warren.................................................... 16-21

Lena Edwards ............................................... 10-11

Geri Wells............................................................45

Lisa English-Hinkle ....................................... 14-15

Stephen A. Williams.............................................46

Wendy Hansen . ............................................ 37-38

Neil S. Winetraub.......................................... 34-35

Joseph R. Haynes ...............................................28 Randy Greene .............................................. 42-43 Ann Grider .................................................... 16-21 Jeffrey King .................................................. 26-27 Michele Johnson............................................ 16-21 Dennie V. Jones . ............................................... 42

Leo Linbeck III . ......................................... 8-9, 15

In last month’s M.D. Update, we incorrectly identified Dr. Stephen C. Umansky. Inquiries regarding Dr. Umansky should be directed to his office at the Lexington Clinic: (859) 258-8566.

Cane Manor.........................................................28

Jewish Hospital.................................................. C3

Republic Bank......................................................11

www.kyvacationrental.com............ (859) 309-9939

www.jewishheartcare.org.............. (502) 560-8514

www.republicbank.com..................1-888-584-3600

Central Kentucky Audiology.................................43

Kirk Schlea Photography......................................30

Women’s Hospital at Saint Joseph East............. C2

www.heartodayheartomorrow.com.(859) 277-5090

www.schleavisualarts.com............. (859) 332-7562

www.sjhlex.org.............................. (859) 967-2229

Commonwealth Cancer Center............................44

Lexington Clinic Orthopedics - Sports Medicine.37

Soterion Medical Services.....................................9

www.commonwealthcancercenter.com....1-800-295-7269

LCSportsMed.com.......................... (859) 258-8575

www.soterionmedical.com............. (859) 233-3900

D. Scott Neal........................................................27

Logan Financial....................................................40

Unified Trust........................................................ C4

www.dsneal.com............................1-800-344-9098

phil-loganfn@triad.rr.com............. (336) 945-3966

www.unifiedtrust.com...........(859) 296-4407 x 202

DCx: the Design Commission..............................22

MAG Mutual.........................................................25

Women First of Louisville......................................1

collaborate@thedesigncommission.com.....(859) 797-1261

www.magmutual.com....................1-888-642-3074

www.wfoflou.com.......................... (502) 891-8700

Ephraim McDowell...............................................12

Norton Healthcare...............................................38

Women’s Diagnostic Center................................46

www.emhealth.org......................... (859) 239-1000

www.NortonQuality.com..........................................

www.wdcntr.com........................... (502) 893-1333

Michael Karpf..................................................... 5-7 Michael Kennedy .............................................. 5-7

advertisers index

Physicians Financial Services...............................35 physiciansfinancialservice.com...... (502) 893-7001

For advertising information contact Gil Dunn, Publisher (859) 309-0720 or gdunn@md-update.com 48 M.D. Update


A service of Jewish Hospital & St. Mary’s HealthCare

The biggest innovation in heart surgery is also the smallest. And it’s only available at Jewish Hospital.

Introducing da Vinci® robotic-assisted heart surgery at Jewish Hospital. Dime-sized incisions. Reduced pain. Shorter recovery time. These are just some of the benefits of Jewish Hospital’s da Vinci® robotic-assisted heart surgery and other minimally invasive techniques. These procedures represent the future of heart care. And in this area, they’re only available here. To learn more, call 502-560-8514 or visit jewishheartcare.org.

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5/10/11 2:45 PM


Who undeRstands the financial needs of a Medical pRactice MoRe than a doctoR?

Dr. Gregory Kasten, Founder/CEO Unified Trust

In the early 1980’s Dr. Gregory Kasten was a successful, practicing anesthesiologist. He began exploring ways to achieve successful financial outcomes for both himself and his fellow physicians and his innovative ideas lead to the creation of Unfied Trust. Today, Unified Trust is a national trust company. We’re located in Lexington, Kentucky and are one of a handful of companies in the country that offer true fiduciary responsibility. We also have more experience and expertise in dealing with the unique issues facing physicians, medical practices and groups than anyone in the area. To learn more about our innovative and systematic approach to helping doctors and medical practices reach their financial goals, call Gregory Kasten at 859-296-4407 x 202 or visit unifiedtrust.com.

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M.D. Update May 2011 - Women's Health  

Meet the MISses. Local women doctors are the new champions of minimally invasive surgery, which has been slow to gain acceptance in GYN prac...