M A RY L A N D
Physician YOUR PRACTICE. YOUR LIFE.
CELEBRATING MARYLAND WOMEN IN MEDICINE: EXCEPTIONAL CHARACTER & COMMITMENT NEW HOPE FOR MENOPAUSAL WOMEN MANAGING CONCUSSIONS TELEHEALTH: BEYOND OFFICE WALLS
www.mdphysicianmag.com
VOLUME 3: ISSUE 3 MAY/JUNE 2013
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Contents 12
VOLUME 3: ISSUE 3 MAY/JUNE 2013
24 F E AT U R E S
12 Exceptional Character and Commitment 18 Menopausal Women: Clearing Up the Controversies
24 Managing Concussions And Choosing Wisely D E PA R T M E N T S
Cases
| 7 | Superficial Venous Thrombophlebitis: New Practice Guidelines
Compliance
| 9 | How HIPAA Rule Changes May Affect EHR Relationships
Healthcare IT
| 29 | Telehealth Expands Care Beyond Office Walls
Policy
| 32 | Coordinated Healthcare Reform in Maryland
Living
| 34 | The Game of Golf: Learn It, Love It
Solutions
| 37 | Reputation Management – To Do or Not To Do?
Good Deeds
| 38 | House of Ruth Creates Safe Haven For Victims of Domestic Violence
On the Cover: Regina Hampton, M.D., FACS, breast surgeon, medical director of Comprehensive Breast Care Center at Doctors Community Hospital
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JACQUIE COHEN ROTH PUBLISHER/EXECUTIVE EDITOR jroth@mdphysicianmag.com LINDA HARDER, MANAGING EDITOR lharder@mdphysicianmag.com MANAGER OF DIGITAL CONTENT AND SOCIAL MEDIA Jackie Kinsella jkinsella@mojomedia.biz CONTRIBUTING WRITER Tracy Fitzgerald PROOFREADER Ellen Kinsella
To ‘lean in’
– the term coined by Facebook COO Sheryl Sandberg that encourages women to not hold themselves back in their professional advancement – is the perfect theme for this issue. In the following pages, we celebrate four Maryland female physicians who most certainly have been trailblazers and ‘leaned in.’ Each of their stories shares the underlying qualities of character, compassion, commitment, mentorship and family. Early this spring, I cherished the gift of celebrating my dad’s 87th birthday with him. As a child, I used to love to pick his handsome face out from his medical school graduating class. Having been raised without boundaries about what I could do and who I could be, I was always surprised that there were only two women in that 60-yearold medical school photo. Now I realize that those two women were most certainly pioneers who were ‘leaning in’ long before that phrase was in the lexicon. This issue also celebrates the second anniversary of the launch of Maryland Physician Magazine. As a young girl, I was always asked if I wanted to grow up and be a nurse to help my dad, the doctor. That was the mindset of the 60s and early 70s. My answer was always the same, “No, I want to be a doctor and his boss,” (an inkling of my rationale in naming my company ‘Mojo’?). Although when I started college I was taking a pre-med curriculum, my professional and personal journey ultimately took me away from a medical career. However, the route I took eventually brought me back to my intellectual passion - medicine and wellness. Over the last two years, the staff of Mojo Media and Maryland Physician has grown and now boasts two mother-daughter teams – one of them being one of my three daughters and myself. I’m proud to have built a team of very smart, creative and driven people, all of whom happen to be women who share the goal of being able to balance family and professional life. We’re actively ‘leaning in’ and, I hope, leading by example. Since the inception of Maryland Physician, our advisory board has helped to guide us in content development and our advertisers have enabled us to get that content out to you. When you’re making the business decisions that support your practice, no matter the size, please consider our advertisers. Without them, our stories of commitment, dedication and inspiration - all with a focus on improving the quality of patient care throughout Maryland - wouldn’t get to you. To life!
Jacquie Cohen Roth Publisher/Executive Editor jroth@mdphysicianmag.com @mdphysicianmag
PHOTOGRAPHY Tracey Brown, Papercamera Photography Melissa Grimes-Guy, Location Photography, Inc. Kevin J. Parks, Mercy Medical Center Randy Sager, Randy Sager Photography, Inc. DIRECTOR OF FINANCE & OPERATIONS Kyle Marisa Roth BUSINESS DEVELOPMENT Eileen Nonemaker enonemaker@mdphysicianmag.com Maryland Physician Magazine – Your Practice. Your Life.™ is published bimonthly by Mojo Media, LLC. a certified Minority Business Enterprise (MBE). Mojo Media, LLC PO Box 949 Annapolis, MD 21404 443-837-6948 www.mojomedia.biz Subscription information: Maryland Physician Magazine is mailed free to Maryland licensed and practicing physicians and a select audience of Maryland healthcare executives and stakeholders. Subscriptions are available for the annual cost of $52.00. To be added to the circulation list, call 443-837-6948. Reprints: Reproduction of any content is strictly prohibited and protected by copyright laws. To order reprints of articles or back issues, please call 443-837-6948 or email jroth@ mdphysicianmag.com. Maryland Physician Magazine Advisory Board: An advisory board comprised of medical practitioners and business leaders in diverse practice, business and geographic scopes provides editorial counsel to Maryland Physician. Advisory board members include: KAREN COUSINS-BROWN, D.O. Maryland General Hospital PATRICIA CZAPP, M.D. Anne Arundel Medical Center HOLLY DAHLMAN, M.D. Greenspring Valley Internal Medicine, LLC PAUL W. DAVIES, M.D., FACS KURE Pain Management MICHAEL EPSTEIN, M.D. Digestive Disorders Associates STACY D. FISHER, M.D. University of Maryland Medical Center REGINA HAMPTON, M.D. FACS Signature Breast Care DANILO ESPINOLA, M.D. Advanced Radiology GENE RANSOM, J.D., CEO MedChi CHRISTOPHER L. RUNZ, D.O. Shore Health Comprehensive Urology JAMES YORK, M.D. Chesapeake Orthopaedic & Sports Medicine Center Although every precaution is taken to ensure accuracy of published materials, Maryland Physician and Mojo Media, LLC cannot be held responsible for opinions expressed or facts supplied by authors and resources. Printed on FSC certified, 100% PCW, chlorine free paper
4 | WWW.MDPHYSICIANMAG.COM
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Cases
Superficial Venous Thrombophlebitis: New Practice Guidelines Sanjiv Lakhanpal M.D., FACS
CASE: LM, a 78-year old female, was seen in the emergency room with leg pain and localized swelling in the calf. The patient had no significant past medical history except for varicose veins, no history of prior leg clots or family history of clotting disorders. On physical exam, a tender, reddened, indurated area over the lower thigh and medial calf was seen. Ultrasound of the left leg, done in the Emergency Department, showed a superficial thrombophlebitis involving the superficial calf veins and the great saphenous vein. The patient presented for further evaluation in the office and her pain and redness had improved with mild residual induration. Repeat ultrasound in the office showed extension of great saphenous venous thrombus into the common femoral vein. She started treatment with Lovenox and continued on Coumadin for 3 months. Followup ultrasound in three months showed reflux in the great saphenous vein and resolution of the deep venous thrombosis. Patient underwent radiofrequency closure of the great saphenous vein as an outpatient procedure without complications. Coumadin was stopped after the follow-up.
DISCUSSION Superficial Thrombophlebitis (SVT) refers to a clot in a superficial vein associated with surrounding inflammation. The usual clinical presentation is pain, tenderness, induration or erythema along a superficial vein. It is usually treated with NSAIDS (Ibuprofen, etc), compression stockings and warm compresses. SVT is associated with varicose veins, malignancy, pregnancy, estrogen therapy, travel and history of prior leg clots. Although SVT is less studied than deep venous thrombosis (DVT), it is seen more commonly in the general population. The incidence of SVT is about 3-11%, compared to DVT, which is about 1%. It may involve the great saphenous vein in 2/3 of the patients. It is generally considered a benign, self-limited disorder, but it may be complicated by extension of thrombus in the deep venous system. The aim of treatment is not only to relieve local symptoms but also to prevent thromboembolic complications. But the role of anticoagulation is controversial. Most studies have been small and have shown benefit over placebo, but the evidence was of low quality. The CALISTO Study (Comparison of Arixtra in Lower Limb Superficial Thrombophlebitis with Placebo) was recently published which showed benefit of Fondaparinux (Arixtra 2.5mg/d for 45 days) over placebo in 3000 patients with lower limb SVT > 5cm, with lowered incidence of venous thromboembolism, recurrent SVT and extension of SVT. Based on these studies, the American College of Chest Physicians issued new guidelines in February 2012, recommending anticoagulation for
patients with SVT who are at increased risk for venous thromboembolism (SVT>5cm, proximity to deep veins <5cm, positive medical risk factors). Positive medical risk factors include prior clots, cancer, surgery, thrombophilia, estrogen therapy or prolonged travel. Fondaparinux 2.5mg daily or enoxaparin 40 mg daily for a period of 4 weeks is recommended. If DVT is present, the patient should be fully anticoagulated. Ligation of the great or small saphenous vein may be considered for patients in whom anticoagulation is contraindicated. Otherwise, surgery for SVT was found to be associated with a higher risk for thromboembolism. Patients with isolated SVT and no associated risk factors may be diagnosed by physical exam and treated with NSAIDS, compression stockings and ambulation. Repeat physical exam should be done in 7-10 days to evaluate for extension or resolution. Duplex ultrasound should be done in patients with SVT >5cm, involvement of GSV or SSV, presence of phlebitis above the knee, or extension of phlebitis on serial exam. Sanjiv Lakhanpal M.D., FACS, is President/CEO of Maryland-based Center for Vein Restoration. www.centerforvein.com REFERENCES: Decousus H, QuĂŠrĂŠ I, Presles E, et al. Superficial venous thrombosis and venous thromboembolism: a large, prospective epidemiologic study. Ann Intern Med 2010; 152:218. Di Nisio M, Wichers IM, Middeldorp S. Treatment for superficial thrombophlebitis of the leg. Cochrane Database Syst Rev 2007; :CD004982. Decousus H, Prandoni P, Mismetti P, et al. Fondaparinux for the treatment of superficial-vein thrombosis in the legs. N Engl J Med 2010; 363:1222. Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e419S.
MAY/JUNE 2013
|7
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Compliance
How HIPAA Rule Changes May Affect EHR Relationships By Tim Faith
T
HE HITECH ACT IN 2009 SET IN motion a series of changes to the HIPAA rules that govern the use, disclosure and protection of protected health information (PHI). The Department of Health and Human Services (HHS) subsequently issued interim regulations in response to these changes in the law, and this year issued a final regulation as of March 26, 2013 that requires compliance by covered entities and business associates within 180 days. These final regulations make a number of important changes that may impact your relationship with the vendors that provide electronic health record (EHR) licensing and support. First, prior to HiTech, business associates of covered entities were not required to comply with the security rules and standards set forth in the HIPAA security regulations. HiTech changed the applicability of the security regulations to include business associates. The final regulation from
HHS subsequently issued interim regulations to implement these notification requirements, and as of March 26, 2013, HHS issued final regulations that alter the assumptions and exceptions to what constitutes a “breach” under HIPAA. In addition, business associates and subcontractors are obligated to report security breaches to covered entities. Providers selecting an EHR vendor should have an attorney review any proposed contract between your organization and the vendor to ensure that the business associate provisions comply with the final regulations. If you already have an existing relationship, work with your attorney to ensure that the contract in place complies with the final regulatory requirements. All business associate agreements must come into compliance with the final regulations by September 2014. In recent years, some EHR vendors have moved to cloud-based data storage
“If you already have an existing relationship, work with your attorney to ensure that the contract in place complies with the final regulatory requirements.” – Tim Faith
HHS implements this provision of the HiTech Act, but with a twist: subcontractors to business associates are also defined as business associates within the final regulation. What this means is that EHR vendors and their subcontractors must fully comply with the HIPAA security rules, not just with “reasonable” security measures. Second, prior to HiTech, there was no federal requirement that a covered entity or business associate report a security breach that resulted in the disclosure of protected health information (PHI).
and access solutions for their clients. These cloud systems store data collected by the EHR at a remote data center, and make it available over an Internet connection with the provider. Some EHR vendors subcontract with a third party to provide the cloud data storage. More likely than not, that subcontractor is now a business associate under the final regulations and takes on the same obligations as the EHR vendor with regards to your data. The final regulations require a covered entity’s contract with their business associate to
include subcontractor compliance with the final security regulations. Beyond compliance issues, providers should evaluate whether an EHR vendor that hosts your data in the cloud has sufficient security provisions. Such an evaluation makes good business sense because of the incredibly negative consequences of any security breach that results in a loss of PHI for a healthcare provider. For example, does the vendor comply with a recognized, national security standard like NIST? Is the EHR vendor, or the data center it uses for storing your data, audited against an SAS standard like SAS-70? What are the security practices and security devices in place at the EHR vendor to protect your data? If the vendor will host your data, what are its disaster recovery and data backup procedures? Are those procedures regularly tested? Providers and their counsel should also evaluate what, if any, additional provisions should be negotiated into any final agreements to require the EHR vendor’s compliance with a security standard, commitment to security procedures, and related obligations (such as maintaining appropriate encryption for data during its transmission). The changes in HIPAA compliance mean that providers cannot simply rely on the EHR vendor’s representations that they know best regarding security. Further, because the scope of HIPAA now covers most subcontractors of business associates that handle PHI, more entities risk substantial fines for failing to comply with the applicable security standards. All providers should work with their counsel to analyze and address compliance with the final regulations. Tim Faith is an attorney with a private practice focused on technology issues that intersect with legal ones. www.faithlaw.com
MAY/JUNE 2013
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Profile
SPONSORED CONTENT
Saint Agnes Hospitalâ&#x20AC;&#x2122;s Comprehensive Thoracic Program
Gavin Henry, M.D., director of thoracic surgical oncology, and his partner, Riny Karras, M.D., thoracic surgeon.
Combining Robotic-Assisted Surgery, Communication and Multidisciplinary Care for Superb Outcomes
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TRACEY BROWN
work closely with referring physicians, updating them “We after our initial consult. We then keep them informed as the patient progresses.”
T
HE THORACIC SURGEONS at Saint Agnes Hospital have completed their 100th thoracic surgery case using the da Vinci Surgical System, a state-of-the-art robotic technology that is the most advanced surgical equipment available. As proud as Gavin Henry, M.D., director of thoracic surgical oncology, and his partner, Riny Karras, M.D., thoracic surgeon, are of that milestone, they are even more proud of the multidisciplinary process they’ve built. With an emphasis on speed and accuracy, patients and referring physicians receive not only a diagnosis but also a comprehensive treatment plan in a matter of days, not weeks. At Saint Agnes Hospital, treatment plans are created through a multidisciplinary team that includes specialists such as medical oncologists, radiation oncologists and thoracic surgeons. The team meets weekly, ensuring a comprehensive plan with input from all appropriate disciplines.
Patient Education and Physician Communication are Emphasized Dr. Henry, Dr. Karras and the rest of the thoracic team go to great lengths to ensure that patients thoroughly understand their diagnosis and treatment options and to communicate with referring physicians to ensure that the continuum of care is never broken. “We work closely with referring physicians, updating them after our initial consult. We then keep them informed as the patient progresses,” Dr. Karras says. “We always have patients return to their physician afterwards for their ongoing care.”
– Riny Karras, M.D.
Dr. Henry adds, “We spend an hour or more with each new patient to make certain they have a clear idea of their diagnosis and appropriate tests. They leave with an understanding of their lung cancer stage, if appropriate. We encourage them to call us with any questions.”
Experienced Robotic-Assisted Surgery Dr. Henry remarks, “We perform more robotic surgeries than any other hospital in Maryland. We use the robot to perform minimally invasive lobectomies as well as other procedures such as thymectomies and mediastinum mass resections. The robotic-assisted procedure is appropriate chiefly for Stage 1 and 2 lung cancers. It allows us to use ¼ to ½ inch incisions, significantly improves our depth perception with a 3D view and provides better angles so we can reach more tumors with greater dexterity. Patients leave the hospital as soon as one to two days post-op.” As early as the evening of their procedure, patients can sit up and eat without pain, and they can even walk. On the second day following surgery, most patients are released from the hospital, an average of two days earlier than patients undergoing an open lobectomy. “It makes a huge difference to our patients that they can return to work or normal life so quickly. And, where appropriate, they can begin adjuvant chemotherapy sooner,” Dr. Henry says. “When tumors approach 3 - 4 cm, there’s a higher likelihood of regional lymph node involvement,” notes Dr. Karras. “The robotic-assisted lobectomy provides us with a greater ability to
dissect out the nodes and helps with staging and post-op treatment. Previous studies have indicated that a lymph node biopsy was sufficient, but more recent data has found that dissection is better. The robotic procedure helps us achieve that.” Dr. Henry comments, “Our roboticassisted mortality and morbidity rates are comparable to, and in some cases better than, our open lobectomy rates. However, not all patients are appropriate for a minimally invasive procedure. Depending on the size and location of the tumor, and whether the patient has had prior chemotherapy or radiation therapy, we may perform an open procedure. The key is giving patients a safe experience and the most appropriate oncologic surgery.” “The robot is a nice tool in our toolbox, but we’re very cautious about what we do,” Dr. Henry adds. “We continue to do chest wall resections as an open procedure, for example.”
New Pulmonary Nodule Clinic Enhances Benign Care In May 2013, Saint Agnes began offering a pulmonary nodule clinic that provides a comprehensive way to diagnose lung nodules. With the opening of this new service, benign nodules benefit from the same rapid, multidisciplinary approach that malignant nodules have received. For more information about Saint Agnes’ new Cancer Institute, roboticassisted thoracic procedures and the other advanced thoracic services at Saint Agnes Hospital, call 410-368-2910 or visit www.stagnes.org.
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Exceptional
CHARACTER AND COMMITMENT LINDA HAR DE R • P HOTOGRAPHY BY TRACEY BROWN
Continuing our yearly tradition, Maryland Physician interviewed female physicians we admire for their exceptional commitment to leadership. They remind us of the importance of mentors, family support and following your passion. Using Epidemiology To Control Cancer
As a child, Kathy Helzlsouer, M.D., MHS, director, The Prevention and Research Center at Mercy Medical Center, had Broadway dreams, but with a mother who was a nurse and a father who was a physician, the odds were probably stacked in favor of a health career. She recalls, “My interest in medicine was a gradual thing. It wasn’t until I was a sophomore in college that I began to get interested in the possibility of medicine as a career. Because I went to a small college, it was harder to get into medical school but I was fortunate to be accepted at the University of Pittsburgh School of Medicine. There I had my first exposure to epidemiology and eventually got a Masters degree while training in oncology.”
Facing and Fighting Discrimination Female physicians of Dr. Helzlsouer’s generation still had to fight to be 12 | WWW.MDPHYSICIANMAG.COM
accepted. Women comprised only 20% of her medical class. “If a woman said something, then a male physician said the same thing, he got the credit,” she recalls. “I even had a male colleague tell me that I had an abstract accepted just because I was a woman. Today, discrimination in the work place is still there, but it’s more subtle and harder to detect. It’s particularly challenging for women who are starting out to achieve any work-life balance. We were expected to work 60 to 80 hours a week even after residency.”
Achieving Balance “I have a wonderful husband – he gave up his career path to support mine. As a consultant, he’s more flexible. My priority is to work hard but family always comes first. Men want that work-life balance now, too. Interestingly, though, it wasn’t until a male doctor came to a meeting with his young son in a backpack carrier that Hopkins finally got onsite childcare.
KEVIN J. PARKS, MERCY MEDICAL CENTER
Kathy Helzlsouer, M.D., MHS, director, The Prevention and Research Center at Mercy Medical Center
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PHOTOGRAPHY, INC. MELISSA GRIMES-GUY, LOCATION
cancer. When she came to Mercy, she started the Mind/Body Program, based on the one at Harvard. “Breast cancer can be very traumatic and lead to persistent fatigue. The Mind/Body approach can reduce fatigue by 40% without medications. Complementary medicine is so important and so undervalued. We need to think about cancer rehab in the same way that we do
“When I completed medical school in Mumbai, India in the late 1990s, half of my classmates were women. While most of the professors were male, I felt women students were treated equally to men.” As did many women physician leaders, Dr. Vaidyanathan enjoyed the support of excellent mentors during her residency in Pittsburgh. “My mentors not only were excellent clinicians but also humane,
“The best advice I ever got was not to choose my career path based on a concern about lifestyle implications.” — Regina Hampton, M.D.
Lakshmi Vaidyanathan, M.D., medical director of the Shore Health System Palliative Care Program and Shore Home Care Hospice
The women wouldn’t dream of showing up at a meeting with their children!” In academia, balancing career goals with caring is another tightrope that many female physicians walk. “It truly is publish or perish. Women have a harder time saying ‘no’ to committees and other service work that can take away from that.”
Cancer Prevention and Survivorship Ironically, Dr. Helzlsouer has experienced the tragic impact of cancer first hand, losing her one-year old daughter to leukemia. This has influenced her research path. She joined Mercy in 2004 to spearhead its clinical research and programs in cancer risk assessment and cancer survivorship. She has chaired or served on numerous cancer committees throughout her career and was an associate editor for the Journal of the National Cancer Institute. As a result of her contributions to the field, she is the recent recipient of the Martin D. Abeloff Award for Excellence in Public Health and Cancer Control. Much of her current work involves prevention and counseling. “We conduct a genetic counseling assessment for women who’ve had cancer or a strong family history of colon, breast or ovarian cancer.” Dr. Helzlsouer has also focused her considerable talents on improving life after 14 | WWW.MDPHYSICIANMAG.COM
cardiac rehab. Improving quality of life really motivates me. I hope to expand the research and programs to help all cancer patients, especially women with ovarian cancer. We’ve researched the underlying causes of aromatase inhibitors, which increase joint pain, and how we can prevent or minimize the problem,” she adds. “Our survivorship program is critical for cancer patients, who otherwise would fall through the cracks. Medical professionals tend to be too focused on the cancer the patient had and not enough on the ones that they’re at risk for in the future.” Dr. Helzlsouer has passed on her commitment to those she has trained. “I enjoy teaching. It’s rewarding to realize that some of the leaders in the field today trained with me. My advice to young physicians is to find a great mentor. I had some wonderful mentors who helped me find research work that makes a difference.”
Quality, Comfort, Dignity At The End
Lakshmi Vaidyanathan, M.D., medical director of the Shore Health System Palliative Care Program and Shore Home Care Hospice, was destined to become a physician. “Even as a child, I play-acted the care taker, never tiring of pretending I was a doctor. I was the first in our family to become a doctor, with my cousin and brother closely following suit. My parents, who truly honor medicine as a ‘noble profession,’ were always there to lend encouragement. They sacrificed generously to help me see my career goals through.” Fortunately, she encountered little gender discrimination in her training.
dynamic physicians who believed in close interaction with their patients. One who was particularly inspiring spearheaded a robust palliative care program that was ahead of its time. His vision was a great example for me.” That experience influenced her pursuit of certification by the American Academy of Hospice and Palliative Medicine. During her tenure as Chief of Staff at Shore Hospital System, she started the palliative care service with the blessings of senior leadership. Initially located at the Memorial Hospital, Easton, the program has expanded to Dorchester General Hospital and has grown threefold. Her efforts to launch this program were recognized when she received the 2012 Arthur B. Cecil, Jr., M.D. Award for Excellence in Healthcare Improvement. “Palliative care is not about death and dying – it’s about living your best life in the time you have left,” observes Dr. Vaidyanathan. “We strive to maximize patient well being, and tailor their care to what serves their needs best under difficult circumstances. We minimize excessive testing and intervention that may do more harm than good, but we don’t give up on them – our multidisciplinary team approach seeks to do the right thing at the right time.” She acknowledges, “Physicians now recognize the value of requesting a palliative care consult. Most palliative care programs start in the inpatient setting, but as they grow, they expand to outpatient and home settings because we want to provide timely interventions instead of waiting until patients need emergency care.” The Cecil Award honor has helped to raise the profile of Shore Health’s palliative care program. She comments, “That’s been
a fantastic boost to our efforts. One of our goals for the coming year is to raise public awareness so that patients and their families know to ask for palliative care.”
A Family Juggling Act Being married to a urologist and coming home every evening to care for two young children is challenging but also a great joy. “My husband is one of my inspirations,” she enthuses. “Maybe because he’s retired Army, he just rolls up his sleeves to pitch in when he comes home to ‘accomplish the mission’ as he puts it. We strive to spend quality time with our children and are very involved in their school. I believe the old cliché, ‘it takes a village.’ This rings especially true in our busy household as we balance raising our children and maintaining a healthy home and career.”
Sports Medicine Picked Me
It’s not surprising that Leigh Ann Curl, M.D., who helped the Baltimore Ravens win their second Super Bowl this year while being a mother to two young children, has always been a high achiever. “I’ve always gotten by with little sleep,” she notes. “I’m up by 5 am most mornings after six hours of sleep. It takes a lot of self discipline and I have always pushed
myself personally and professionally.” The second oldest of six children in a close-knit family, Dr. Curl, who is an orthopaedic surgeon at the Center for Sports Medicine and Shoulder Surgery at MedStar Harbor Hospital and the Head Orthopaedic Surgeon for the Ravens, had an early morning paper route as a child. She was the first in her family to earn a college degree and was class valedictorian at the University of Connecticut. However, she nearly missed a key deadline to declare for medical school. “I made a final decision to apply about four weeks before most of the deadlines. In medical school at Johns Hopkins, I had an immediate positive reaction to orthopaedics. You could say that sports medicine picked me. The positives have to outweigh the negatives of what you choose and it’s easy to work hard when you enjoy what you do.”
Times Have Changed When Dr. Curl interviewed for her orthopaedic residency, she encountered no other females during the interview process. “I was fortunate to have some excellent mentors and faculty at Hopkins who fostered my interest in orthopaedics despite it being a nontraditional career path for women at the time,” she recalls.
“I realized early on that the surgical attendings were most interested in how well you did your job, but I may have had less margin for error than the men.” She never sensed blatant discrimination during her training at Hopkins, but she does recall that she was asked some inappropriate questions in her residency interviews at other institutions, such as whether she was planning to have children or if she could physically handle the job. She laughs, “I was probably physically more capable than some of the interviewers.”
A Long Sports Career Serving the Ravens is the culmination of a long sports career with top-notch teams. Dr. Curl was herself a Division I basketball star at the University of Connecticut. After becoming an orthopaedic surgeon, she served in various capacities as team physician for the University of Maryland Terrapins, New York Mets, Baltimore Orioles, USA Women’s Basketball, USA Women’s Rugby, Johns Hopkins University and St. John’s University in New York teams. “My initial team physician experience was with the Mets and St. Johns during my fellowship training before returning to a faculty position at Hopkins,” she
Leigh Ann Curl, M.D., orthopaedic surgeon, MedStar SportsHealth at Harbor Hospital, and head orthopaedic surgeon for the Baltimore Ravens
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remembers. “Then I was recruited to University of Maryland to help start their sports medicine program and work with the Ravens and College Park. You just chip away at the barriers.” Her initial reluctance to be in the locker room with male athletes vanished in her time with the Mets. “An equipment guy directed me back to the locker room training area after practice, jokingly telling me the guys didn’t have anything I hadn’t seen already. Today, it’s not a big deal. I used to be acutely aware of being a woman, but now there are growing numbers of female sports physicians and trainers.”
Regina Hampton, M.D., FACS, medical director of Comprehensive Breast Care Center at Doctors Community Hospital
Football is a Year-Round Commitment “It’s really a year-round job that consumes what would otherwise be mostly free time,” notes Dr. Curl when describing her job with the Ravens. A new season “starts” with preparation for the draft at the NFL Combine each February. “We do physicals on over 300 potential draft picks and are buried in the bowels of the stadium looking at MRIs and other test results. There’s the draft, free agency, off season workouts and then the true start of the season in July. Football probably occupies 30 weekends a year on average, and the Super Bowl makes it an especially long season. But I love what I do.”
Follow Your Passion And Be Part Of The Solution Regina Hampton, M.D., FACS, breast surgeon, medical director of Comprehensive Breast Care Center at Doctors Community Hospital, didn’t follow a traditional route to becoming a surgeon. After graduating from college, where she wasn’t interested in taking traditional pre-med classes, she worked for two years as a radiation therapist. Fortunately, the Medical College of Pennsylvania took non-traditional students. “I was a little more focused than those who went straight through,” she recalls.” Her love of surgery came as a surprise. “I thought I would like family practice or pediatrics, but I didn’t. I was surprised to find that I loved my surgical rotation. But I worried that I wouldn’t be able to have a family if I was a woman in surgery. After talking with lots of female surgeons, though, including one who took a full day off each week to be with her children, I realized I could do it.” She started her career as a general surgeon, but began receiving a disproportionate share of breast cases. “In the last four years, I’ve focused 16 |
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exclusively on breast surgery,” she says. “It’s very gratifying to focus on this ever-changing field that is moving to customized treatment for each woman. And today, most of my patients will survive their cancer.”
advice I ever got was not to choose my career path based on a concern about its lifestyle implications. You can adapt your career to your lifestyle and find a spouse that understands the demands of your career.”
Nipple Sparing Breast Surgery
Leadership and Legislative Involvement
One of the most significant advances in breast surgery is nipple-sparing surgery. “If the woman has a small tumor, we leave the nipple and the skin fold. We fill in the breast with an implant or abdominal tissue (TRAM) and hide the scar under the breast so it looks normal.” Dr. Hampton is also enthusiastic about having more treatment options. “Every patient can make the choice that’s best for them. We’re learning that breast cancer is different in every person. A small tumor can spread quickly, while some large tumors will not. Young women often don’t want to have to get a mammogram every six months for the rest of their life – they want to go back to the peace of mind they had before they were diagnosed. They may opt for bilateral mastectomies and benefit from our ability to give them great cosmetic results.”
Family Support As with so many other female physician leaders, Dr. Hampton credits her husband and in-laws with allowing her to have a young child while managing a busy practice. “Their support really helps,” she states. “It’s allowed me to run and grow my practice, and even to do speaking engagements or participate in weekend health fairs.” She encourages female physicians in training to follow their passion. “The best
Dr. Hampton is a past president of the Prince George’s Chapter of MedChi where she was involved in supporting relevant legislation. “I always had the attitude that it is better to be part of the process,” she says. Prior to her MedChi work, she had served on several hospital committees, including the Operating Room and Medical Executive committees. “I want to be at the table for things that are relevant. You can’t just sit back and complain – you need to be part of the solution.” Leigh Ann Curl, M.D., orthopaedic surgeon, MedStar SportsHealth at Harbor Hospital, and head orthopaedic surgeon for the Baltimore Ravens Kathy Helzlsouer, M.D., MHS, director, The Prevention and Research Center, Mercy Medical Center and adjunct professor of Epidemiology at the Johns Hopkins University Bloomberg School of Public Health Lakshmi Vaidyanathan, M.D., medical director of the Shore Health System Palliative Care Program and Shore Home Care Hospice Regina Hampton, M.D., FACS, breast surgeon, medical director of Comprehensive Breast Care Center at Doctors Community Hospital
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Menopausal Women Clearing Up the Controversies
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BY LI NDA HARDER P HOTOGRAPHY BY TRACEY BROWN
Maryland Physician spoke with women’s health experts to provide the latest medical information on common issues in middle-aged women – osteoporosis, hormone replacement therapy and pelvic prolapse. Here is their advice. ABDOMINALLY PLACED PELVIC MESH IS SAFE An estimated 3.3 million U.S. women have pelvic prolapse, and that number is expected to grow by about 50% in the next few decades as women live longer. Victoria Handa, M.D., FACOG, professor of Obstetrics/Gynecology and director, Advanced Training Program in Female Pelvic Medicine and Reconstructive Surgery at Johns Hopkins Bayview Medical Center, hopes to clarify several critical misconceptions about pelvic prolapse and how to best treat it. “Sometimes even among OB/GYNs who don’t see many women with prolapse, there’s a misunderstanding about what prolapse is, and a tendency to confuse it with bowel and bladder function issues. Women often have more than one issue and when they call me saying they have a dropped bladder, they mean they have a non-functioning bladder. They may or may not have pelvic prolapse.” In the past, pelvic support defects were labeled by the organ that was prolapsed (e.g., enterocele or cystocele). The current convention is to classify the prolapse based on where it is and how severe it is. Anterior and posterior compartment prolapses herniate toward the front and back of the vagina, respectively, while in apical compartment prolapses, the top of the vagina (and sometimes uterus) fall down. In severe pelvic prolapse, the uterus protrudes outside the vaginal entrance.
Evaluation The primary assessment for pelvic prolapse is a history and physical exam. If bowel and bladder issues coexist, the physician may also evaluate those. “Patients occasionally, but not normally, need imaging. We can usually deduce the type of prolapse from the physical exam,” explains Dr. Handa.
Treatment Options Non-surgical approaches for pelvic prolapse generally consist of pelvic muscle strengthening exercises and/or a pessary. Dr. Handa notes, “I tell patients that the pessary is a supportive device. Like contact lenses, it doesn’t make the problem go away, but it can relieve your symptoms. Some women use the pessary until surgery, while others may use it long term.” Pelvic muscle exercises typically involve weekly physical therapy for about two months. “Usually, if a woman doesn’t have a benefit within three months, we discontinue it.” Surgery can be performed vaginally, with an abdominal incision, laparoscopically or robotically. “In the past few years, our thinking has changed and we focus more on apical prolapse, pulling the top of the vagina up. Surgical repairs that don’t provide support to the vaginal apex are not as successful in the long term. The good news is that, over the past 10 to 15 years, we’ve accumulated good scientific data to guide us. Sacropexy is considered the gold standard.”
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Victoria Handa, M.D., FACOG, director, Advanced Training Program in Female Pelvic Medicine and Reconstructive Surgery at Johns Hopkins Bayview Medical Center
If the patient has bowel and bladder issues for which surgery is appropriate, surgeons can address those in the same procedure.
Misunderstandings About Mesh Dr. Handa is dismayed by inaccurate perceptions about the safety of mesh used in prolapse repair that have resulted from recent FDA advisories concerning a specific class of surgeries that include transvaginal implantation of mesh. In 2009, the FDA issued an advisory that reported increased complications from transvaginal mesh products. In 2012, they issued a second advisory. “However, the advisory only pertains to a very narrow class of mesh that is placed transvaginally to treat prolapse, which I’ve never used. It does not pertain to mesh placed abdominally or to treatment for stress incontinence,” underscores Dr. Handa. “Unfortunately, the FDA advisory keeps many women from coming in and makes them unnecessarily afraid to have any type of surgery for their prolapse. Physicians need to help address this misconception
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with accurate information such as that at the FDA website (www.FDA.gov).”
New FPMRS Subspecialty Board Another positive development in prolapse treatment is that there are a growing number of specialists in Female Pelvic Medicine and Reconstructive Surgery (FPMRS). This year for the first time, urologists and gynecologists who have specialized training can pass a rigorous exam to become boarded in this subspecialty. “Until now, it’s been hard to know what credentials to look for,” Dr. Handa states. “This certification will help referring physicians and patients know who has the expertise. Over time, hospitals will change their credentialing process accordingly.”
OSTEOPOROSIS: WHO SHOULD BE TREATED AND WHEN? Surprisingly, far more women have osteoporotic fractures than new strokes, heart attacks or invasive breast cancer combined. The National Osteoporosis
Foundation (NOF) estimates that more than 10 million Americans have this condition, and nearly half of all Caucasian women and about 20% of men will have an osteoporotic fracture in their lifetime. While fractures have declined in the past few decades, less than one third of osteoporosis cases have been diagnosed and only one seventh of U.S. women with osteoporosis receive treatment.
DXA Recommendations The NOF recommends that all men over 50 and all post-menopausal women be evaluated clinically for their osteoporosis risk; those at higher risk should receive dual-energy X-ray absorptiometry (DXA) prior to age 65; women not at risk should receive DXA at age 65 (men at age 70), and typically every two years thereafter. “Two to three years post menopause is when the greatest bone loss occurs,” says James Mersey, M.D., an endocrinologist at GBMC. “Age, sex, weight, family and personal history of fracture, smoking, drinking, certain diseases such as
rheumatoid arthritis and corticosteroid use are among the key risk factors.” Dr. Mersey says, “The average 70 year old female has osteoporosis, and anyone with osteoporosis is at increased risk of fracture. Anyone who has lost height, is on steroids, has hyperthyroidism,
therapies run the risk of causing sustained low calcium levels, or at least being ineffective,” Dr. Mersey advises. “We typically provide 50kl units per week for six or more weeks, and then take a second level to see if we need to continue it.”
“Currently, there is no indication for Vitamin D supplements other than bone health.” – James Mersey, M.D.
smokes or drinks, or who has a family history, should get a DXA. Diabetes also increases the risk. If on therapy, the DXA should be repeated yearly. After two normal DXA scans, getting scanned every three to five years is reasonable.”
Diagnosis DXA generates a T-score that compares the patient’s bone density to the optimal bone density for others of the same sex and ethnic group. A T-score greater than -1 is considered normal. A score of -1 to -2.5 implies a higher risk of developing osteoporosis, and a score of -2.5 is diagnostic. The 10-year risk of a fracture can be measured using a fracture risk assessment (FRAX) tool developed by the World Health Organization. It uses a computer algorithm that takes into account age, sex, weight and height, and other variables. Patients can calculate their approximate risk online even without having their bone mineral density (BMD) tested.
The use of bisphosphonates (BPs) has been controversial in recent years, but research data supports its use in women with: z Hip or vertebral fracture z BMD <-2.5 at the lumbar spine or femoral neck z Low BMD and 10-year risk of hip fracture >3% The data also demonstrate that serious side effects with BPs are uncommon. Dr. Mersey comments, “I’ve treated 5000 patients with Fosamax and have never seen anyone develop osteonecrosis and have only seen one patient with an atypical femoral fracture. We still don’t know how long it’s ideal to use BPs, however. At five years, we give a break in treatment if
the bone density is improved. If it is still low and at high risk for fracture, we continue treatment. In 2013, the choices for therapy haven’t broadened, but we have better data about what works.” The key issue with oral BPs (e.g., alendronate, risedronate) is low adherence – typically, half of patients are not taking them appropriately. Dr. Mersey often recommends a yearly injection of parenteral therapy (e.g., zoledronic acid) or a semiannual injection of Prolia to ensure that patients get the appropriate dose. Other commonly prescribed medications include Forteo, the only anabolic therapy for bone loss appropriate for many patients for two years. After bone density has increased, physicians switch their patients to other therapies to maintain bone density. Prolia, a monoclonal antibody, is a powerful anti-resorptive agent injected every six months for women who cannot take BPs. Dr. Mersey explains, “We want it to wear off so the bone turnover rate is not zero, creating more flexible bone. There’s a slight risk of dermatitis, but there are no immediate side effects and even dialysis patients can be on this therapy. Patients must have adequate Vitamin D levels, however.” He concludes, “A common misunderstanding about osteoporosis treatment is that older women don’t need it. But it can reduce the risk of another spinal fracture by 70% and a hip fracture by 25% in one year, preventing many women from
James Mersey, M.D., endocrinologist at GBMC
Treatment If the FRAX score indicates osteoporosis, the patient is typically referred to an endocrinologist or rheumatologist for treatment. A metabolic work-up provides information about the underlying cause of the disease, measuring thyroid hormones, serum CTX, urine calcium, Vitamin D levels and more. “Currently, there is no indication for Vitamin D supplements other than bone health,” notes Dr. Mersey. “Before you treat osteoporosis, you should measure 25 hydroxy vitamin D and if necessary, restore vitamin D levels to the normal range. If not most
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hospitalization and a downward health spiral. It’s the quality of life, not how long it prolongs life, that’s important.”
The Women’s Health Initiative study (a 15-year research study launched in 1991) raised significant questions about the safety of hormone replacement therapy (HRT) for older women. Since the study was discontinued in 2002, however, researchers have reassessed the data from that study and determined that HRT can be a safe and even invaluable aid to many women in the peri-menopausal and early menopause years. Several major professional societies now consider HRT to be the most effective available treatment. Darryn Band, M.D., OB/GYN with Capital Women’s Care and an associate clinical professor at George Washington University, says, “The WHI study found a slightly higher risk of stroke, coronary artery disease and breast cancer, but the average patient in their study was heavier, aged 65 or older and many were smokers, so it was not a fair comparison. These effects were limited to those
Darryn Band, M.D., OB/GYN with Capital Women’s Care
symptoms and urogenital health, including urinary urgency, possible decrease in recurrent UTIs and relief of vaginal atrophy. In addition, HRT has been shown to reduce the risk of colon cancer and improve bone health. “Our goal is to improve quality of life and provide therapy for symptom
“The pendulum is definitely swinging back... more GYNs are starting to use estrogen and progesterone to alleviate symptoms of peri-menopause.”
– Darryn Band, M.D.
participants taking combination oral HRT. The estrogen-only group (those who had had hysterectomies) did not have an increased risk of breast cancer.” Women who have an intact uterus must take progesterone along with estrogen to prevent hyperplasia and the risk of uterine cancer. Dr. Band continues, “The study scared women to the extent that the percent of perimenopausal or menopausal women using HRT has declined from about 50% in 2002 to 25 - 30% today. Today, many experts feel there are significant health benefits to women who begin HRT at the onset of menopause. A clear benefit is the relief of vasomotor
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RANDY SAGER PHOTOGRAPHY, INC
HORMONE REPLACEMENT: SAFE AFTER ALL?
relief for as short a time as possible,” he adds. “Many GYNs feel we’ve done a disservice to women. The pendulum is definitely swinging back. In fact, more GYNs are starting to use estrogen and progesterone to alleviate symptoms of peri-menopause, which include irregular vaginal bleeding and mood lability. These symptoms result from rapid fluctuation in hormone production, which settle down following menopause.” The key is the route of administration and using the lowest dose for the shortest possible time. “Some have suggested that transdermal and transvaginal administration may reduce
some of these risk factors by bypassing the liver.” There are other options for those not interested in hormones. New products such as IsoRel, a soy isoflavone supplement, help with mild to moderate hot flashes. However, black cohosh and fish oil have not been proven effective. A group that includes premature ovarian failure prior to the average age of 51, spontaneous or post oopherectomy, may benefit from hormone replacement therapy. It has been shown that these women have higher morbidity and mortality than women with normal hormonal production. Dr. Band concludes, “HRT should be used for those women that are having severe vasomotor symptoms, issues of well-being or urogenital issues. It should not be used for primary prevention of heart disease or osteoporosis.”
Victoria Handa, M.D., FACOG, professor of Obstetrics/Gynecology and director, Advanced Training Program in Female Pelvic Medicine and Reconstructive Surgery at Johns Hopkins Bayview Medical Center James Mersey, M.D., endocrinologist, GBMC Darryn Band, M.D., OB/GYN with Capital Women’s Care and an associate clinical professor at George Washington University
MANAGING CONCUSSIONS And Choosing Wisely
Maryland children are benefiting from national and local initiatives that promote better treatment of concussions and that limit unnecessary tests and procedures. Our Maryland medical experts explain.
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BETTER MANAGEMENT OF CONCUSSIONS IN THE YOUNG As the medical community becomes increasingly aware of the possible effects of even minor trauma to the brain, and as Maryland became the 18th state to pass laws addressing concussion management in 2011, programs to treat concussions are mushrooming. The Kennedy Krieger Institute now offers one such center, the Neurorehabilitation Concussion Clinic, as the newest arm of their Pediatric Brain Injury Program, which now addresses the full spectrum of brain injury severity. Stacy Suskauer, M.D., the center’s medical director, also was appointed by the Centers for Disease Control and Prevention (CDC) to a work group developing national clinical diagnosis and management guidelines for concussions in children and teens. She explains, “Our program at Kennedy Krieger is unique – every child sees both a neuropsychologist and physician at every visit. The physician may be a pediatric neurologist, physiatrist, or pediatric sports medicine physician, depending on the child’s needs. For example, those with co-existing cervical injuries may be directed to the pediatric sports medicine specialist.” The clinic treats patients aged three to 18; not surprisingly, more than half are athletes, and the majority are teens. Perhaps less obvious, however, is that a minority of these children have lost consciousness. Also surprising is that experts now know that helmets may do little to protect against some concussions, as helmets don’t stop the rotational forces that cause most concussions. “We know that pediatricians may not have time in their busy schedules to manage these patients,” Dr. Suskauer says. “That’s why we’re here.”
Stacy Suskauer, M.D., medical director, Neurorehabilitation Concussion Clinic at Kennedy Krieger Institute
Diagnosis
No one diagnostic test can evaluate concussions. Dr. Suskauer states, “MRIs are not typically ordered. Neurocognitive tests are useful if there’s a history of trauma, whether or not symptoms are noted immediately after injury. If parents think the child’s memory is not quite right, or if a straight A student is suddenly performing as an average student, that’s cause for evaluation.” All of those evaluated by the clinic receive neuropsychological testing, and the clinic providers reach out to the child’s school with recommendations for accommodations.
“If parents think the child’s memory is not quite right, or if a straight A student is suddenly performing as an average student, that’s cause for evaluation.” – Stacy Suskauer, M.D.
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bottom line is – when in doubt, sit it out. If there’s any question, that’s why we’re here.”
CHOOSING WISELY: WHEN MORE IS LESS An initiative launched by the American Board of Internal Medicine (ABIM) Foundation in 2012 called Choosing Wisely® encourages conversations between physicians and patients to promote appropriate testing. The foundation states that its goal is to help patients choose care that is: - Supported by evidence - Not duplicative of tests/procedures already received - Free from harm - Truly necessary Neil Siegel, M.D., medical director of UniversityCare
Current Treatment Approaches
Dr. Suskauer notes, “Cognitive rest is a hot topic now. Is rest best? Yes, at least for the first few days. We avoid an approach of strict confinement until the child is 100% better, because that can lead to additional stress and mood concerns. Instead, we take a symptom-based approach and minimize whatever aggravates the child. Texting, television and other activities can be undertaken to the child’s tolerance. Some children like to listen to, rather than watch, television. “We try to keep the child moving ahead without slowing their recovery,” she continues. “Families often don’t realize that, during the first few days, symptoms can evolve rather than improve. In the first two weeks, there is a metabolic mismatch; the brain needs more glucose but glucose delivery is impaired. Data suggests that DHA (docosahexaenoic acid) can be helpful for brain injury recovery. We recommend a moderate dose based on weight.” After about three to four weeks, many children are ready for a second phase of treatment, with increased safe physical activity. Dr. Suskauer recommends, “Start with just five minutes of walking, and stop before or as symptoms emerge. 26 |
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Especially in athletes, safe exercise may be a critical intervention to improve cerebral blood flow.” Children with cognitive deficits may also benefit from amantadine. It increases dopamine, which drops after brain injury, and blocks the NMDA receptor, a memory function. “We don’t know yet which of these mechanisms is helpful,” observes Dr. Suskauer. “We also may prescribe melatonin if the patient’s sleep is disrupted, as sleep is vital for recovery.” Dr. Suskauer concludes, “One problem physicians should be aware of is that teens underreport symptoms because they feel pressured to be on the field. The
The initiative aims to keep the message succinct and simple enough to be useful to patients. To that end, each medical society that participates has been asked to develop a list of “Five Things Physicians and Patients Should Question.” In April 2012, nine medical societies participated in the first release of these lists. In February 2013, another 18 societies added their lists, including The American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP) and the Society of Hospital Medicine – Pediatric Hospital Medicine. The AAFP’s list does not contain any items pertaining to pediatrics, however. Neil Siegel, M.D., clinical assistant professor of Family and Community Medicine at University
Five Things Pediatricians and Patients Should Question 1. 2. 3.
4. 5.
Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis). Cough and cold medicines should not be prescribed or recommended for respiratory illnesses in children under four years of age. CT scans are not necessary in the immediate evaluation of minor head injuries; clinical observation/Pediatric Emergency Care Applied Research Network (PECARN) criteria should be used to determine whether imaging is indicated. Neuroimaging is not necessary in a child with simple febrile seizure. CT scans are not necessary in the routine evaluation of abdominal pain.
Adapted from the American Academy of Pediatrics Choosing Wisely® list.
of Maryland School of Medicine, observes, “I’ve been attuned to this conservative mode of practice since my residency training, but Choosing Wisely is giving me additional tools to use when talking to my patients. It also helps to start conversations with my colleagues or anyone who is suspicious that you have an ulterior motive if you don’t recommend undertaking a procedure or test. It helps make the case that you’re not trying to cut costs or save money.” He adds, “I can use this list to tell my patients that I’m doing this to keep them safer. Doing more is not always better. Sometimes extra tests don’t help, and sometimes they even cause harm. For example, antibiotics can cause an allergic reaction, or unnecessary imaging tests emit radiation that can be harmful when it accumulates.” Dr. Siegel describes the wide variability of pre-op testing practices among hospitals and physicians. “One hospital will send me evidence-based guidelines, where only certain patients need an EKG, for example. Other hospitals will require ordering everything on the pre-op list, regardless of the patient’s age and health. It’s more convenient for the doctor to get everything because they know there won’t be a delay. But it can lead to unnecessary testing.” Another major area of concern in recent years is the overuse of antibiotics. Recent guidelines have been issued to discourage prescribing antibiotics for many ear infections or sinus infections, for example. “My advice to doctors,” says Dr. Siegel “is to become familiar with your own specialty’s list. Make sure you’re implementing those recommendations in your own practice. Also review the lists from any related specialties. Really own your own society’s measures and become familiar with the broader campaign. All of us serve as public health information sources for our neighbors, family and friends. When they ask us, we should tell them that sometimes less is better. Our specialty societies also have an obligation to publicize the
AMERICAN ACADEMY OF NEUROLOGY GUIDELINES > Athletes suspected of sustaining a concussion should immediately be removed from play to minimize further injury. > Before returning to play, athletes should be assessed by a professional trained in diagnosing and managing concussions. > Athletes high school-age and younger who have a concussion should be managed more conservatively.
campaign in their medical meetings. Hopefully, media attention will help to generate awareness among consumers.” We have a TV screen in our waiting room that we can use for educational purposes such as this Choosing Wisely campaign,” he continues. “We prefer to customize our messages, though, so that patients only get messages appropriate to their personal situation.” Consumer Reports also is helping to educate consumers, with a series of reports and eventually a series of videos on Choosing Wisely. The AARP, the Leapfrog Group, the National Partnership for Women & Families, Wikipedia and others, are among a long list of other organizations working to educate the general public about these guidelines. Visit www.choosing wisely.org for more information. The AAP’s list of five things to question is shown in the sidebar on page 26. Other societies’ lists also include various pediatric tests and procedures to question, such as: z DON’T diagnose or manage asthma without spirometry. (American Academy of Asthma, Allergy and Immunology) z DON’T prescribe oral antibiotics for uncomplicated acute external otitis. (American Academy of Otolaryngology) z DON’T do CT for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option. (American College of Radiology) z DON’T perform ultrasound on
z z z
z z
boys with cryptorchidism. (American Urologic Association) DON’T order chest X-rays in children with uncomplicated asthma or bronchiolitis. DON’T routinely use bronchodilators in children with bronchiolitis. DON’T use systemic corticosteroids in children under 2 years of age with an uncomplicated lower respiratory tract infection. DON’T routinely treat gastroesophageal reflux in infants with acid suppression therapy. DON’T use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen. (the last five are from the Society of Hospital Medicine)
Stacy Suskauer, M.D., medical director, Neurorehabilitation Concussion Clinic at Kennedy Krieger Institute and assistant professor of physical medicine and rehabilitation at the Johns Hopkins University School of Medicine. Dr. Suskauer is a member of a CDC work group where she is developing national clinical diagnosis and management guidelines for concussions in children and teens. Neil Siegel, M.D., assistant professor of Family Medicine at University of Maryland School of Medicine, medical director of UniversityCare and physician at UniversityCare at Edmondson Village
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Healthcare IT
TELEHEALTH EXPANDS CARE BEYOND OFFICE WALLS BY LINDA HARDER
A
S TECHNOLOGY improves and reimbursement trends to global or performance-based pay, telehealth is becoming a more important way to deliver care. Maryland Physician spoke with early adopters to learn how legislation is reducing barriers and how this technology is being used in practice.
Legislative Initiatives H. Neal Reynolds, M.D., associate professor at the University of Maryland School of Medicine, and director of Program Development for the Maryland Critical Care Network, was a member of the state telemedicine task force two years ago. This year, in concert with the Maryland State Medical Society (MedChi) and others, he fought for significant legislative reform. Dr. Reynolds says, “There are three main barriers to the expansion of telemedicine: 1) reimbursement, 2) the burden of
duplicative credentialing in multiple hospitals and 3) interstate licensure. Legislation requiring private insurers to reimburse telemedicine passed last year, but Medicaid was given a mandate to justify non-participation. Legislation introduced this year (HB 931/SB 496) aimed to enhance State of Maryland Medicaid reimbursement for telemedicine services. Unfortunately, the bill that passed will dramatically limit Medicaid reimbursement for telehealth to select conditions in the emergency department.” He continues, “Credentialing was another push this year – The Joint Commission and the Centers for Medicare and Medicaid Services (CMS) agreed that the originating hospital (defined as where the patient is located) can accept a consulting physician’s credentials from the hospital providing telemedicine, but Maryland is the only state that has a Code of Maryland Regulations (COMAR) regulation that requires ‘primary source’ credentialing of every telemedicine consultant.” SB 798/HB 1042 (Hospitals – Credentialing and Privileging Process – Telemedicine) reduces the credentialing burden of a telemedicine consultant by permitting “proxy privileging.” MedChi amendments were negotiated with the Maryland Hospital Association and require the telemedicine consultant to be a Maryland licensed physician and the credentialing and privileging decision to be approved by hospital medical staff. “This legislation is a big step,” notes
Dr. Reynolds. “Telehealth will be cheaper and doctors will be more likely to participate in telemedicine programs thanks to this legislation. For physicians, the burden of multiple hospital privileging packets can be totally overwhelming.” Another bill (HB 934, SB 776) that aims to reconvene and fund the telemedicine task force passed both houses easily; it addressed its structure, linking to CRISP (Maryland’s initiative to connect providers electronically), setting up a state registry and other operational issues. A fourth bill (SB 494/HB 937) that sought to enhance the security of Personal Health MAY/JUNE 2013
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Healthcare IT Information (PHI) via a cooperative and knowledge-sharing relationship with the Maryland Cyber Security Commission did not pass. Extending Primary Care While this year’s legislative battles ensued, Seth Eaton, M.D, MPH, medical director of MedPeds in Laurel, took advantage of the new reimbursement for telehealth to offer this service to patients. Launched in March 2013, Dr. Eaton and his four physician partners and three nurse practitioners use telehealth to provide after-hours urgent care to their patients. They also use telehealth to provide some mental health visits and follow-up care after discharge. “There are two issues where primary care telemedicine is needed – first, to expand availability when the office is not open and second, to improve coordination between hospitals and primary care after discharge,” notes Dr. Eaton. “The latter is now possible thanks to new Medicare rules allowing reimbursement and the private carriers will likely follow. Primary care providers can use the new billing code to coordinate care following discharge.” Since MedPeds participates in CRISP, they have access to real-time data about their patients following discharge from the hospital. Their participation in the state’s Patient Centered Medical Home (PCMH) program enables their care coordinator to reach out to the patient at home. Patients need high-speed Internet access plus a computer that includes a camera and microphone. Of course, any telemedicine visit must be HIPAA compliant, which the practice solves by using ExamMed, a special internet-driven software platform that’s a considerable step up from Skype. Patients register for the telemedicine service by clicking on a link on MedPeds’ website, which takes them to the ExamMed site to register securely for an appointment. Dr. Eaton concludes, “Some patients initially may be reluctant to use telehealth, but that’s changing and I’m confident they’ll see the value. It’s an opportunity to increase quality and decrease costs.” Filling Gaps in Behavioral Health Radiology and behavioral health are generally more advanced in the provision of telehealth than primary care. For years, radiologists have used teleradiology to read 30 | WWW.MDPHYSICIANMAG.COM
imaging studies remotely. In behavioral health, however, availability has not always equaled use. “Telepsychiatry has been available for years,” says David Pruitt, M.D., director of the Division of Child and Adolescent Psychiatry at the University of Maryland. “It’s critically important for children and adolescent psychiatry, as nearly half of psychiatric disorders start in childhood and we have a major shortage of pediatric specialists. And the shortfalls will deepen
“The health department has a partnership for pediatric psychiatric telehealth with the University of Maryland,” comments Don Richter, M.D., medical director of the center and family practitioner/geriatrician. “There is only one full-time adult psychiatrist in the county and there’s no pediatric psychiatrist,” notes Dr. Richter. “Our closest referral system to the east is Cumberland and to the west is Morgantown, and it’s hard to cross state lines. While we also need access to
“There are two issues where primary care telemedicine is needed – first, to expand availability when the office is not open and second, to improve coordination between hospitals and primary care after discharge.” – Seth Eaton, M.D.
with the Affordable Care Act, which is expected to bring in 600,000 new Medicaid recipients, 40% of whom will be children.” Dr. Pruitt adds, “We have to extend our reach if we’re to be relevant. We’re trying to develop new collaborative care models with primary care physicians, schools and the Medical Home model. Telehealth provides a partial solution. Technological advances have made it viable and it offers significant benefits for both patients and providers. According to Dr. Pruitt, the DHMH has advocated for telehealth for roughly the past decade. “Hopkins, University of Maryland and the health departments in Garrett and Somerset Counties operate several pilot sites, and the medical centers are linked with school teams in Prince Georges County and Baltimore City.” One of the barriers is the need for providers to be at the other end, either with the patient or receiving consultative input. “It’s an added cost that needs to be built in,” Dr. Pruitt observes. “We’re not there yet, but as we move to outcomesbased reimbursement, this model will be more viable. The COMAR does a good job of regulating equipment and encrypted data to avoid privacy violations.” On the receiving end, Mountain Laurel Medical Center, a small federally qualified health center (FQHC) in the Garrett County town of Oakland, is expanding telehealth beyond the local health department. The center is also starting its third year in the state PCMH program.
consultative services with medical specialists in areas such as rheumatology and endocrinology; mental health, and especially pediatric mental health, is one of the area’s biggest needs. Telehealth will help to fill that gap.” With some funding from the DHMH, the partners provided a consultative role rather than direct care – helping providers handle behavioral issues in children with ADHD, for example, and teaching them how to approach the child’s parents about managing their disorder. The new telehealth program will allow them to provide direct care as well. “The Learning Collaborative has been helpful in getting this program underway,” Dr. Richter adds. Thanks to the telehealth legislation passed this year, Maryland has made it easier for physicians to reach out to patients beyond the walls of their practice.
H. Neal Reynolds, M.D., associate professor at the University of Maryland School of Medicine, and director of Program Development for the Maryland Critical Care Network Seth Eaton, M.D., MPH, medical director of MedPeds in Laurel David Pruitt, M.D., director of the Division of Child and Adolescent Psychiatry at the University of Maryland Don Richter, M.D., medical director of Mountain Laurel Medical Center and family practitioner/geriatrician
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Policy
Coordinated Healthcare Reform in Maryland
Coordinating the components of the state’s healthcare reform initiatives is a big job. Fortunately, Carolyn Quattrocki, executive director of the Governor’s Office of Health Care Reform, is up to the task. Maryland Physician spoke with her near the close of the 2013 General Assembly session to learn what her office has accomplished and what is planned.
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TRACEY BROWN
A Conversation With Carolyn Quattrocki
What is the role of your office and how do you support federal healthcare reform? In May 2011, the Governor created
the Office of Health Care Reform to lead and coordinate Maryland's implementation of the federal Patient Protection and Affordable Care Act (ACA) of 2010. Essentially, my office has a coordinating role/oversight function with respect to healthcare reform efforts in the state. Maryland Lieutenant Governor Anthony G. Brown has taken a hands-on leadership role, so we work closely with his office. It’s a complicated process. In the first year, together with our partners in the General Assembly, we enacted legislation to set up the governance structure and framework of the Maryland Health Benefit Exchange. Maryland has been at the forefront among states in launching the health insurance marketplaces, or exchanges, required by the ACA. This year, in our third and final big legislative push, we are putting in place the last pieces, which include Medicaid expansion, a funding stream for the
Exchange, and policies to ensure continuity of care for Marylanders moving between Medicaid and commercial insurance, or between different insurance policies. We are working closely with a terrific team from the Exchange, the Department of Health and Mental Hygiene, and the Maryland Insurance Administration. We will have the legislation in place by the end of the session. Marylanders can begin enrolling in qualified health plans starting October 1, 2013, with coverage starting January 1, 2014. The goal is to make health insurance affordable and accessible for all Maryland residents, including the approximately 750,000 who are currently uninsured. By the end of the decade, we hope to cut this number in half. How will the Exchange Work? The
Exchange, which will be known as the Maryland Health Connection, will offer insurance to individuals and small businesses. Small businesses purchasing
Interested parties can visit the following websites for information: z Exchange stakeholders – www.marylandhbe.com z Office of Healthcare Reform – www.healthreform.maryland.gov z Individuals and small businesses – www.marylandhealthconnection.gov What are some of the key challenges you face? Ongoing challenges remain,
the most immediate of which is the sprint from here to October when the Exchange must “turn the lights on.” As I said, though, we have a great team that is making every day count. Over the longer term, we need to continue to find ways to decrease the underlying costs of healthcare. A subcommittee of the Health Care Reform Coordinating Council is looking at new and promising models for care delivery such as Patient Centered Medical Homes (PCMH) and Accountable Care Organizations (ACO).
TRACEY BROWN
through the Exchange will qualify for a tax credit of up to 50% of their contribution to their employees’ premium. They also will be able to offer employees greater choice among plans tailored to their individual needs and greater insurance portability if they change jobs. In addition, individuals with incomes below 400% of federal poverty guidelines will receive federal subsidies for coverage. Establishing the Exchange and building the IT system to support it is an enormous and complicated undertaking. We have received $157 million in federal grants to fund this development and to support operations through 2014. A dynamic, nine-person board oversees this effort, and the Exchange now has a terrific staff. We are also developing a robust consumer assistance program that will help enroll and support people in the Exchange. This education and outreach campaign will be a key to the Exchange’s success in reaching the people who can benefit most. The Maryland Health Connection will divide the state into six regions, with one umbrella “Connector” entity responsible for enrollment in each region. The Connector entities will hire staff and partner with other community organizations to get the word out to people in every corner of their region. They will need to make special efforts to target specific populations that historically have had cultural, linguistic, or other barriers to obtaining insurance. All insurance carriers currently doing business in Maryland have expressed their intent to participate in the Exchange, and we are also pleased to have a few new entrants into the market. The ACA also established Consumer Operated and Oriented Plans (CO-OPs), and at least one, the Evergreen Health Cooperative in Howard County, intends to operate in the Exchange.
What are your goals for this year and beyond? My immediate goals are to en-
sure passage of the Maryland Health Progress Act and to help the team at the Exchange be ready to begin operations
together businesses, government, and educational institutions to create training programs that help prepare people for jobs in high-demand fields. While not limited to the healthcare sector, this program will help address health workforce needs. What have been your office’s greatest successes? While some people have said
the ACA is too prescriptive, it actually gives states a lot of tools and discretion to implement reform in a way that works for us. So I’m proud of involving the full panoply of stakeholders – physicians, insurance carriers, hospitals, consumer advocates, unions, insurance brokers and small businesses – in this process. We recognized early on that we needed the input and expertise of every-
“The goal is to make health insurance affordable and accessible for all Maryland residents, including the approximately 750,000 who are currently uninsured.” – Carolyn Quattrocki
on October 1st. Over the longer term, we want to focus on workforce development. As we get more people into coverage, we need to ensure that we have the right professionals in the right place to meet their healthcare needs. In Maryland, we have decent ratios of providers to patients, but we still have problems with access and distribution. Thus, we are exploring ways to increase access to primary care and to address other shortages, like the lack of behavioral health practitioners on the Eastern Shore. The Health Enterprise Zones, through which communities may seek grants and other financial incentives to attract and retain the allied health professionals necessary to address health disparities, is one promising initiative. (see Maryland Physician’s interview with Lt. Governor Brown from Jan/Feb 2012 Volume 2: Issue 1). Another exciting initiative is the Governor’s EARN program (HB 227 Employment Advancement Right Now) legislation passed this year, which provides grant dollars to match Marylanders seeking new or better jobs with the workforce needs of state employers. The program will bring
one who would be affected by reform in order to implement it most effectively. Our efforts have been inclusive and collaborative, and I believe this has been key to our success. This issue celebrates Maryland women in medicine. What unique skills have you brought and what challenges have you faced as a woman in today’s healthcare environment? My legal
background has been helpful in drafting and shepherding bills through the General Assembly, and in negotiating the compromises that are critical to successful legislation. My work in policy development under Joe Curran, Maryland’s former Attorney General, was also important. Most of all, I’ve been lucky to have had wonderful mentors, several of which were ahead of their time in recognizing the challenges women face and helping me succeed while I was raising four children. Beginning with Attorney General Curran and his deputies, and now working for the Governor and Lieutenant Governor, I am extremely grateful for the importance they have placed on making women integral and successful members of their team. MAY/JUNE 2013
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Living
The Game of Golf: Learn It, Love It
By Tracy M. Fitzgerald
S
OME CALL IT A FAVORITE pastime. Others call it a hobby, a passion or perhaps just a good reason to break away from the “every-day grind” to get outside and enjoy the sunshine along with some good company. It’s one of the few activities that can be relaxing, peaceful, challenging and rewarding all at the same time; it’s the game of golf. Today, more people than ever before are taking to the greens across the state of Maryland. “People love the game because it can be so rewarding and is the ultimate test from a mental perspective,” said Chad Craft, PGA head golf professional at the Hyatt Regency Chesapeake Bay Golf Resort on the eastern shore town of Cambridge. “It’s a great way to enjoy ambience, nature and relaxation after a long day at the office.” Craft and his team at the Hyatt’s River Marsh Golf Club see about 21,000 golfers on an annual basis, who are drawn to the 18-hole Keith Foster award-winning facility, complete with a 20-station practice putting green. While more accomplished golfers will appreciate the challenges presented by the course’s Par 3 gold tees, private instruction, afternoon family golf programs and a specialized “Starting New at Golf Course” are also offered, to accommodate golfers of all levels of experience and interest. “Because professional golf is on TV, people think it is much easier to pick up and learn than it truly is,” said Craft. “The truth is that it takes patience, effort and a solid work ethic.” John Anderes, director of Golf and Grounds at Queenstown Harbor Golf, explains how a lot of his customers hit the green for a unique environmental experience. The facility features two 18-hole championship courses as well as a practice facility with a driving range, 34 | WWW.MDPHYSICIANMAG.COM
A Choptank River view from Queenstown Harbor Golf.
two putting greens, practice bunkers and a designated short-game area. The course is distinguished for its surrounding scenery and wildlife, as well as its commitment to environmental conservation. In fact, Queenstown Harbor earned the national 2012 Environmental Leader in Golf Award, recognizing its leadership in water and energy conservation along with wildlife preservation and management. “Golf is a great game that you can play for a lifetime in some of the most beautiful surroundings you can access,” expressed Anderes, who sees roughly 55,000 golfers each year at Queenstown Harbor. “Come play the back nine of our River course one evening as the sun is dropping slowly over the Chesapeake Bay and the deer are emerging from the tree lines, and then let me know if you are breathing any easier. Our courses are unique because they are very casual and serene.” Nestled between Baltimore and Annapolis, Compass Pointe Golf offers yet another premier public golf facility. With 36 championship-caliber holes consuming more than 800 acres in Pasadena, the course’s “four nines” – North, South, East and West, offer diversity and variety for golfers of all levels of experience. In
Rounding back to the clubhouse at Mountain Branch Golf Club.
addition, a wide range of amenities are featured on-site to help those who are hoping to learn or improve their game. The facilities include a putting green, chipping green and driving range with grass and matted tees. Compass Pointe offers a number of golf leagues and clinics with programs for men, women, co-eds, beginners and those in need of some “refresher” tips.
Building Healthy Practices in today’s dynamic healthcare environment
For those who live, work or travel in a more “northbound” direction, Mountain Branch Golf Club offers a uniquely challenging course, along with the breathtaking views of Harford County’s rolling greens – an added bonus for any golfer. Best known as a public course with private club amenities and conditions, Mountain Branch offers men’s and women’s golf leagues, a specialized ladies clinic as well as private instruction for those who crave to improve their game. Carol McCarthy, general manager and director of Sales and Marketing for Mountain Branch, says that the golf industry as a whole is starting to see some major shifts in terms of who is playing these days. “One misperception that people have is that golf is expensive and that it’s an ‘older man’s game.’ Women are the biggest growth area in golf, followed by teenagers,” said McCarthy. “There are great, inexpensive golf courses out there and programs available for every age. Golf can be played any time of day, from one hour on the range to five hours on the course.” Marylanders who golf or plan to start golfing are fortunate, as there is no lack of options in terms of where to play. According to golflink.com, the state boasts a selection of 231 courses. While many offer course options for the most novice to the most advanced golfers, those who have committed to the game and are in search of the state’s more challenging courses may want to explore Wakefield Valley Golf in Westminster, Caves Valley Golf Club in Owings Mills, Woodholme County Club in Pikesville, Maryland Golf and Country Club in Bel Air, or Bulle Rock in Havre de Grace which are recognized as some of the top most challenging golf courses in the Baltimore area. “What I love most about my job is that I have the chance to see people enjoy the great game of golf,” admitted Craft. “It can be a great lifelong experience.” To search for a golf course or driving range by location, visit golflink.com.
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Solutions
Reputation Management – To Do or Not To Do?
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By Brenda Brouillette
HE REPUTATION MANAGEment buzz in the healthcare industry, and more specifically surrounding physicians, is growing at tremendous speed. Physicians must understand what is necessary to portray and maintain a solid image to build their practice. So what is Reputation Management? It is your online image being monitored, managed, and promoted. In the past, physicians were at the center of control of their image and reputation. However, with the explosive emergence of real time communication, social media and an empowered consumer, this control has shifted. At present, consumers can instantly review, reflect, and report their opinions and reactions. In the future, online rating and grading sites are projected to either make or break a physician’s reputation. A major concern is that no internet regulations regarding these sites exist.
improve an internal process or to educate the consumer. As reported in the Journal of General Internal Medicine, “Dr. Lagu and colleagues examined online reviews of 300 physicians on 33 different physician rating sites and found that nearly 90% of the reviews were positive. The negative comments were mostly actionable criticisms that physicians could address immediately without compromising patient confidentiality.” Some 35% of patients leave a physician’s practice due to issues with staff and office processes rather than the physicians themselves. According to the Journal of General Internal Medicine, “Most negative comments are made on the management of the practice itself with wait times (61%) as well as office staff and appointment access being the most common.” Knowing What to Do
The chief contributors to the challenges of reputation management are the lack of: z Physician interest z Knowing what to do z Regulations in internet marketing The key to successfully deal with this paradigm is to strategically plan and execute a reputation management program. Taking a proactive and positive approach will help a practice deal with its online presence and embrace opportunities to engage in social media. Fear and Lack of Interest
Fear has been a major obstacle for physicians to embrace reputation management. Physicians should understand that a small percentage of posts are negative, and if dealt with correctly, they present an opportunity to
The first step is to monitor your online presence. One free, but limited solution is to sign up for www.googlealert.com. A better solution is to invest in a program that will thoroughly monitor, analyze, and assist with positive social media. An optimal choice is to select one company that offers comprehensive services that include monitoring and digital marketing initiatives to include patient and referring physician engagement. Such services can cost from $150 to $1000 per month. The best way to address the online negative review is to first acknowledge it with a simple, professional message without attacking the reviewer. Next, take the discussion off line by inviting them to contact your office. Most importantly, to protect you from a potential HIPPA violation, NEVER acknowledge that the reviewer is a patient or divulge any patient information. Crafting a scripted response can positively portray the practice as
caring and patient-focused, deflecting the negativity. If the reviewer includes a name, the office should follow up with some good old-fashioned service recovery tactics. While it may not be wise for a practice to address certain negative posts, it is usually better not to ignore them, which can make you seen as aloof, thus adding fuel to the fire. The best tactic is to implement a strong, aggressive campaign for posting positive comments and reviews to overshadow the negative ones, in combination with addressing negative posts. This tactic should be followed with lots of online educational information and communication to establish the practice as a thought leader and medical expert. Developing a Program
Implementing a program can be done in increments. A number of tactics can be utilized in each phase to create an overall program that will help to communicate, educate, develop relationships, and ultimately grow a practice. z Listen – Actively monitor and capture conversations to understand the perception z Participate – Proactively post and publish content on social media platforms as a one-way conversation z Engage – Actively interact with conversations Do not hesitate to embrace reputation management, as it has become a necessity for any practicing physician. Brenda Brouillette, RN, BS, is principal of Savvy Marketing Solution, a healthcare consulting firm. Editors Note: For a list of Top Grading Sites and Online Profile Pages go to our website: www.mdphysicianmag.com/solutions MAY/JUNE 2013
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Good Deeds
House of Ruth Creates Safe Haven For Victims of Domestic Violence By Tracy M. Fitzgerald
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team of counselors and therapists, who work with moms and their children who have endured trauma.” While they may not come with any visible scars or bruises, women who suffer verbal and Founded in 1977, Baltimore's House of Ruth provides a "safe haven" for victims of domestic violence. emotional abuse are also able to take advantage of acknowledge her choices and make the full spectrum of services offered by sure she knows we are here for her.” the House of Ruth. According to Ellyn Women who are seeking support are Loy, Director of Clinical Services, this kind of abuse can range from yelling and not the only people the House of Ruth is working hard to educate. Raising screaming, to intentional manipulation community awareness about the and diminishment of someone’s feelings, prevalence of domestic violence, and the with the abuser’s need for control being teaching people how to identify the signs a key factor. that can indicate someone else is in “The abuser will try to control the trouble, is another priority for Timmins victim by attacking their self-esteem, isolating them or threatening them,” said and her staff. Often, what is happening in the workplace can be a key indicator. Loy. “In many cases the abuser will deny “You have to remember that both that he is being verbally or emotionally victims and abusers are often employed,” Timmins explained. “We “Our role is never to tell her what to do, but have a program called ‘When Intimate instead to provide her with information, Partner Violence Comes to Work’ and the goal is to meet with human resources acknowledge her choices and make sure she teams, managers and supervisors, to help knows we are here for her.” them understand what do to, when they are working with someone who may – Sandi Timmins, executive director of the House of Ruth need help.” To learn more about the House of abusive, and this makes it harder for the “We are known for our emergency Ruth’s workplace education program, or victim to find her reality.” shelter services but this is just one piece for a schedule of upcoming fundraising In 2012, Timmins, Loy and their team of what we do,” said Sandi Timmins, events that you can attend, which will Executive Director of the House of Ruth. of 120 staff members and over 300 local support the organization’s mission, volunteers provided support and services “We help women who can’t go home please visit www.hruth.org. to approximately 15,000 women and find transitional housing or apartments, children. “If a woman is on a path to and provide resources and support to leaving, on average she will come and help them become independent over Maryland Physician would like to go seven times before she will make it time. We also manage a legal clinic, hear about your “Good Deeds.” permanent,” Timmins said. “Our role is staffed by 20 local attorneys who Please share your ideas with us at never to tell her what to do, but instead work pro bono to help women obtain news@mdphysicianmag.com. to provide her with information, protective or peace orders, as well as a HE STATISTICS ARE SIMPLY staggering: research consistently shows that one in every four women will be in a physically abusive relationship in her lifetime. Of the 35,000 individuals who took part in the survey conducted by the CDC, 89% of the women interviewed claimed to have been subject to verbal abuse. Recognizing that women in dangerous or even life-threatening situations sometimes have no place or person to turn to, the House of Ruth was founded in 1977 to provide a “safe haven” for victims of domestic violence. What started at that time as a small shelter staffed by one, has evolved and grown ten-fold. Today, the Baltimore-based organization is recognized as one of the nation’s leading domestic violence centers, providing a comprehensive line of services and support to women and children who want and need a place to go, or perhaps a helping hand as they strive for a fresh start.
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Good intentions or bad judgment?
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