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THE BUSINESS MAGAZINE OF KENTUCKIANA PHYSICIANS AND HEALTHCARE PROFESSIONALS ISSUE #148 WWW.MD-UPDATE.COM

VOLUME 13 • #5 • November 2023

Not Your Mother’s Breast Care Focusing on early detection and targeted care, the surgeons at Baptist Health Breast Surgery are ensuring patients receive the most innovative and individualized care available ALSO IN THIS ISSUE (CAR) T CLINICAL TRIALS AT UofL HEALTH - BROWN CARE CENTER 3D MAMMOGRAPHY IS WELL CARE AT WOMEN FIRST OF LOUISVILLE CHI SAINT JOSEPH HEALTH ONCOLOGY IN RURAL COUNTIES GLIOBLASTOMA RESEARCH & TRIALS AT NORTON CANCER INSTITUTE

THE BUSINESS MAGAZINE OF KENTUCKIANA PHYSICIANS AND HEALTHCARE PROFESSIONALS World Class Hand Care

VOLUME 12 • #4 • SEPTEMbEr 2022

Legendary practice Kleinert Kutz continues the training and legacy of its founders

ALSO IN THIS ISSUE SPORTS MEDICINE AT UofL HEALTH & ATHLETICS TAKING THE PAIN OUT OF JOINT PAIN AT WELLWARD REGENERATIVE SPORTS MEDICINE AT CHI SAINT JOSEPH HEALTH NEW ORTHOPEDIC CENTER AT BAPTIST HEALTH LOUISVILLE

2023-24

Editorial Calendar

World Class Hand Care Legendary practice Kleinert Kutz continues the training and legacy of its founders

2023 ISSUE #149 (December) – IT’S ALL IN YOUR HEAD

ALSO IN THIS ISSUE SPORTS MEDICINE AT UofL HEALTH & ATHLETICS

Pain Medicine, ENT, Mental Health, Neurology, Neuroscience, Ophthalmology, Psychiatry

2024 ISSUE #150 (February) – HEART & LUNG HEALTH World Class Hand Care

Cardiology, Cardiothoracic Medicine, Cardiovascular Medicine, Pulmonology, Sleep Medicine, Vascular Medicine, Bariatric Surgery

Legendary practice Kleinert Kutz continues the training and legacy of its founders

ISSUE #151 (April) – INTERNAL SYSTEMS Endocrinology, Gastroenterology, Geriatric Medicine, Internal Medicine, Integrative Medicine, Infectious Disease Medicine, Lifestyle Medicine, Nephrology, Urology ALSO IN THIS ISSUE

SPORTS MEDICINE AT UofL HEALTH & ATHLETICS

TAKING THE PAIN OUT OF JOINT PAIN AT WELLWARD REGENERATIVE SPORTS MEDICINE AT CHI SAINT JOSEPH HEALTH

ISSUE #152 (June) – WOMEN & CHILDREN’S HEALTH

NEW ORTHOPEDIC CENTER AT BAPTIST HEALTH LOUISVILLE

OB/GYN, Women’s Cardiology, Oncology, Urology, Pediatrics, Radiology

ISSUE #153 (September) – MUSCULOSKELETAL HEALTH World Class Orthopedics, Physical Medicine & Rehabilitation, Sports Medicine, PT/OT Hand Care Legendary practice Kleinert Kutz continues the training and legacy of its founders

ISSUE #154 (October) – CANCER CARE Hematology, Oncology, Plastic Surgery, Radiology, Radiation

ISSUE #155 (December) – IT’S ALL IN YOUR HEAD ALSO IN THIS ISSUE

SPORTS MEDICINE AT UofL HEALTH & ATHLETICS

ENT, Mental Health, Neurology, Neuroscience, Ophthalmology, Pain Medicine, Psychiatry TAKING THE PAIN OUT OF JOINT PAIN AT WELLWARD REGENERATIVE SPORTS MEDICINE AT CHI SAINT JOSEPH HEALTH

NEW ORTHOPEDIC CENTER AT BAPTIST HEALTH LOUISVILLE

Editorial topics and dates are subject to change

World Class Hand Care

To participate, please contact Legendary practice Kleinert Kutz continues the training and legacy of its founders

Gil Dunn, Publisher • GDUNN@MD-UPDATE.COM • 859.309.0720 (direct) • 859.608.8454 (cell) Send press releases to gdunn@md-update.com VOLUME 12 • #4 • SEPTEMbEr 2022

NEW ORTHOPEDIC CENTER AT BAPTIST HEALTH LOUISVILLE

VOLUME 12 • #4 • SEPTEMbEr 2022

SPORTS MEDICINE AT CHI SAINT JOSEPH HEALTH

VOLUME 12 • #4 • SEPTEMbEr 2022

TAKING THE PAIN OUT OF JOINT PAIN AT WELLWARD REGENERATIVE

ALSO IN THIS ISSUE SPORTS MEDICINE AT UofL HEALTH & ATHLETICS TAKING THE PAIN OUT OF JOINT PAIN AT WELLWARD REGENERATIVE SPORTS MEDICINE AT CHI SAINT JOSEPH HEALTH NEW ORTHOPEDIC CENTER AT

LETTER FROM THE EDITOR/PUBLISHER

Welcome to the Cancer Care Issue of MD-Update Two things can be true at the same time, right? Kentucky is at the top of the CDC’s list for mortality due to cancer, particularly lung cancer; and cancer care is improving in Kentucky with research, treatment, and clinical trials at multiple major healthcare systems throughout the state. Review of the National Cancer Institute online data shows decreases in ovarian, thyroid, lung, and colon cancer in Kentucky among both males and females of all ages. That’s the good news. The bad news was an increase in both prostate cancer and esophageal cancer, particularly among Kentucky males. And Kentucky continues to have rates of lung cancer that are higher than most of the rest of the country. September was national Prostate Cancer Awareness month. If you were at the Kentucky State Fair, perhaps you saw Dr. Stephen Henry promoting prostate screening, which has become a mission for him. At the same time, Dr. Mark Evers and the UK Markey Cancer Institute announced their achievement of the National Cancer Institute “Comprehensive” Cancer Center designation, the highest level of recognition awarded by the NCI. November is Lung Cancer Screening month, and the Kentucky Department for Public Health is urging providers to encourage at-risk patients to get screened. More information on the department’s lung screening is on page 22 and at www.nlcrt.org.

In This Issue Having just finished October, Breast Cancer Awareness month, our cover story on breast surgery at Baptist Health Louisville feels timely. Mortality from breast cancer in Kentucky is dropping due to early detection, screening, and more targeted treatments. When surgery is needed, breast surgeons step up. Read more about four breast surgeons in Louisville who embrace that vitally important moment on page 10. Research, clinical trials, and long-term physician-patient relationships are the bread and butter of our Special Section physicians, Rebecca Booth, MD, Mohamed Hegazi, MD, Dana Johnson, MD, and Kaylyn Sinicrope, MD. I think you’ll enjoy the stories on how each of them is advancing cancer care in Kentuckiana. Our friend James Borders, MD, has a new home, a place to continue his “calling and ministry.” Dr. Borders recently joined Bluegrass Care Navigators to direct the Program of All-inclusive Care of the Elderly, PACE, a program designed for the dually-eligible Medicare/Medicaid insured patients with the goal of providing at-home care for “aging in place.” He writes extensively about the PACE program on page 24 with contact information. Learn more about Dr. Borders’ new mission and the PACE program. The MD-Update editorial calendar for December and all of 2024 is on the preceding page. I invite you to look for your specialty and give me a call. If your specialty is not included, call me on that as well. Until next time, all the best,

Gil Dunn Editor/Publisher MD-Update

2 MD-UPDATE

SEND YOUR LETTERS TO THE EDITOR TO: Gil Dunn, Publisher gdunn@md-update.com, or 859.309.0720 phone and fax

MD-UPDATE MD-Update.com Volume 13, Number 5

ISSUE #148

EDITOR/PUBLISHER

Gil Dunn gdunn@md-update.com GRAPHIC DESIGN

Laura Doolittle, Provations Group COPY EDITOR

Amanda DeBord

CONTRIBUTORS:

Jan Anderson, PSYD, LPCC James Borders, MD Philip Massey Scott Neal, CPA, CFP Tuyen T. Tran, MD, MBA, FACP, FASAM

Gil Dunn gdunn@md-update.com

Mentelle Media, LLC

38 Mentelle Park Lexington KY 40502 (859) 309-0720 phone and fax Standard class mail paid in Lebanon Junction, Ky. Postmaster: Please send notices on Form 3579 to 38 Mentelle Park Lexington KY 40502 MD-Update is peer reviewed for accuracy. However, we cannot warrant the facts supplied nor be held responsible for the opinions expressed in our published materials. Copyright 2023 Mentelle Media, LLC. All rights reserved. No part of this publication may be reproduced, stored, or transmitted in any form or by any means-electronic, photocopying, recording or otherwise-without the prior written permission of the publisher. Please contact Mentelle Media for rates to: purchase hardcopies of our articles to distribute to your colleagues or customers: to purchase digital reprints of our articles to host on your company or team websites and/or newsletter. Thank you. Individual copies of MD-Update are available for $9.95.

CONTENTS 4 5 6 7

ISSUE #148

HEADLINES ACCOUNTING FINANCE OP/ED

10 Not Your

Mother’s Breast Care

Focusing on early detection and targeted care, the surgeons at Baptist Health Breast Surgery are ensuring patients receive the most innovative and individualized care available SPECIAL SECTION: 13 SS: OB-GYN/RADIOLOGY 16 SS: HEMATOLOGY 18 SS: ONCOLOGY/ PALLIATIVE CARE 20 SS: NEURO-ONCOLOGY 22 26 28 31

PUBLIC HEALTH SCREENINGS MENTAL WELLNESS NEWS EVENTS

COVER PHOTOGRAPHY BY PAUL MARTIN

FEATURED

7 OP/ED

13 MAMMOGRAPHY

16 HEMATOLOGY

18 ONCOLOGY/ PALLIATIVE CARE

20 NEURO-ONCOLOGY

ISSUE #148 3

Headlines

Markey Cancer Center Attains NCI’s Highest Status as a Comprehensive Cancer Center LEXINGTON The UK Markey Cancer Center

has earned a National Cancer Institute “Comprehensive” Cancer Center designation, the highest level of recognition awarded by the NCI. Markey is the first and only center in Kentucky to achieve this designation. There are currently 72 NCI-Designated Cancer Centers in the country, and 56 of those are Comprehensive Cancer Centers. Markey received an initial NCI Designation in 2013. In addition to achieving the Comprehensive designation, the UK Markey Cancer Center was awarded $13.5 million through a five-year renewal of its NCI Cancer Center Support Grant to support research programs, shared equipment, and resources. “The elevation to Comprehensive Cancer Center is an achievement that underscores our commitment to addressing the health care needs of the people of Kentucky, a state burdened by the highest cancer inci-

B. Mark Evers, MD, UK Markey Cancer Center director

dence and death rates in the nation,” said B. Mark Evers, MD, UK Markey Cancer Center director. “Together, we will turn the tide against this disease to conquer cancer in the Commonwealth.”

Free Prostate Cancer Screening at the KY State Fair LOUISVILLE September

is national Prostate Cancer Awareness month. To bring awareness to prostate cancer and screenings, the Kentucky Prostate Cancer Coalition (KPCC), provided annual screenings at the Kentucky State Fair. This annual event has counseled and screened Stephen Henry, MD, founder of the Kentucky Prostate Cancer Coalition, over 17,000 men since its discusses prostate cancer screening options with a husband and wife at inception in 2004 and is the 2023 Kentucky State Fair. only possible through the More information on the KPCC is available online generous donations by the Lexington Cancer at kentuckyprostatecancer.org or by emailing Foundation, Pfizer and the Kentucky Cancer stephenhenrymd@icloud.com. Program (KCP.) 4 MD-UPDATE

PHOTOS PROVIDED BY UK HEALTHCARE & KPCC

Accounting

HIPAA-Compliant Accounting Software BY PHILIP MASSEY, SOFTWARE SERVICES DIRECTOR

Healthcare providers and their business associates who handle identifiable protected health information (PHI) have both an ethical imperative as well as a legal mandate to ensure the privacy and security of this data. The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that establishes requirements for the protection of patient health information from unauthorized use and disclosure without patient consent. Do you know if your accounting software is HIPAA compliant? Did you even know that it’s supposed to be?

md-update.com YOUR RESOURCE FOR THE BEST IN KENTUCKY HEALTHCARE

Let’s look at what HIPAA rules mean for healthcare accounting software, which entities need to meet compliance requirements, and how organizations become HIPAA compliant.

How Does HIPAA Apply to Accounting Software? Passed in 1996, HIPAA has grown from its beginnings as a way to make health insurance more portable for people changing jobs to a set of regulations that govern the privacy and protection of sensitive patient information. HIPAA applies to both covered entities (for example, healthcare providers and insurers) and their business associates (any organization that must access PHI in the course of their business operations, such as vendors who provide billing, accounting, or legal services to covered entities). If an accounting software system used by a covered entity contains identifiable protected health information, such as patients’ names and contact information within detailed Accounts Receivable data, then it is subject to HIPAA rules.). The following HIPAA rules apply to accounting software compliance.

Empowering physicians to focus solely on the demands of their clinical practice

HIPAA Privacy Rule This rule mandates the protection of individually identifiable health information. Identifying data includes name, phone number, address, social security number, or any other personally identifiable details. Medical information covered by this rule includes mental or physical diagnosis, medical treatments, or payment history. The HIPAA Privacy Rule dictates the use of patient data by healthcare providers and to whom they can disclose this information without explicit patient permission.

HIPAA Security Rule This rule sets standards for how organizations secure electronic protected health information (ePHI). The safeguards required include administrative (policies and procedures for maintaining security), physical (controlled access), and technical (cybersecurity) safeguards. We’ll examine these safeguard designations more closely in a subsequent section. All security measures must be documented. To learn more about the benefits of working with HIPAA-complaint accounting software, contact pmassey@ddaftech.com.

Health system solutions and advisory services

Outsourced accounting, audit, and tax

Medical billing and credentialing

Risk management and compliance

Finance and revenue cycle

Technology and data analytics

management

deandorton.com/healthcare

ISSUE #148 5

Op/Ed

New Outpatient E&M Coding Guidelines May Mitigate Physician Burnout Does the AMA and CMS collaboration go far enough?

test. Other concepts clarified include “independent historian,” “stable, chronic illness,” “acute, uncomplicated illness or injury,” and “combination of data elements.” For details of the new guidelines, visit: Code and Guideline Changes/ AMA (ama-assn.org) to download the PDF.

BY TUYEN T. TRAN, MD, MBA, FACP, FASAM LEXINGTON Physician burnout has reached

epidemic levels in the United States. Typical symptoms of physician burnout include loss of enthusiasm for taking care of patients and decreased satisfaction. There is also increased detachment, emotional exhaustion, and cynicism. Some of the signs of physician burnout include disproportionately higher rates of depression, substance abuse, and suicide. National statistics report that 400 physicians commit suicide annually. This threatens the health of both physicians and our patients! The causes for physician burnout are complex and multifactorial, but the most significant contributor is the documentation burden for billing. The 2022 Medscape Physician Burnout & Depression Report (Kane, 2022) surveyed 13,000 physicians in 29 different specialties in 2021 and found that the burnout rate was about 42%, the depression rate was 21%, and 54% stated that the burnout had a “strong to severe impact on their lives.” Over 60% of the participants reported “too many bureaucratic tasks, such as charting and paperwork.” Fortunately, there are new CMS office-visit coding guidelines which are simpler and more flexible. The hope is that physicians will have more time to spend with patients instead of doing clinically irrelevant administrative burdens. And hopefully, we can mitigate some of the stressors which contribute to our physician burnout epidemic.

Coding Updated It has been over 25 years since the coding guidelines for outpatient evaluation and management (E/M) services have been updated. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) collaborated to extensively revise the E&M coding guidelines for office 6 MD-UPDATE

Onerous Documentation

Tuyen T. Tran, MD

and/or outpatient services. As of January 1, 2021, the new guidelines for E&M CPT office visits (99202-99215) became effective. The major changes include: 1) eliminating the need to document required “elements” for history and physical exams (e.g., no more irrelevant Review of Systems documentation), 2) allowing the physician to determine whether to document using Medical Decision-Making (MDM) or total time, and 3) modifying the MDM to focus on tasks that affect the management of the patient’s condition rather than simply adding up tasks. The new guidelines model the SOAP format (Subjective, Objective, Assessment, and Plan), which many physicians are familiar with. Additionally, the new coding guidelines have clarified several gray terms from the past 1995 and 1997 E&M Coding guidelines. (Believe it or not, these have not been updated until now!) For example, the term “tests” includes imaging, laboratory, psychometric, or physiologic data. A clinical laboratory panel such as a basic metabolic panel is a single test. A unique test is defined by the CPT code set. For example, multiple results of blood glucose values are considered one unique

Let’s examine a sample case of a patient with known COPD who presented for a cough. For the history and physical, the physician should only document medically appropriate details for that patient at the time of the visit. In this particular case, the physician is expected to document any relevant history of the current illness to include PMH, SH, and ROS. However, the number of “elements” in each category is not mandated. Next, the physician may choose to implement either the MDM or Total Time Spent. For the “Medical Decision Making” portion, there are three (3) elements: 1) number and complexity of the problem or problems the physician addresses during the E&M encounter, 2) amount and/or complexity of the data reviewed and analyzed, and 3) risk of complications, morbidity, and/or mortality of patient management decisions made during the E&M visit to include complications related to the patient’s problems, the diagnostic procedures, or the treatment. The physician is required to document the assessment of the condition and/or problems, how the diagnosis was achieved, and the thought process for selecting the management option. The documentation of each distinct test, document, order, or independent historians adds to a counter which will determine which E&M level was achieved. Thus, to achieve an E&M level 3 (99203 or 99213), the physician needs to document and satisfy two of the three MDM elements. For Element: number and complexity of problem

Op/Ed

addressed, any one of these will satisfy the element: 1) two or more self-limited or minor problems, or 2) stable chronic illness, or 3) acute, uncomplicated illness or injury. For the Element: amount and complexity of data reviewed and analyzed, the documentation must satisfy at least one of the two categories: 1) category 1: tests and documents (meet any combination of two bullets: reviewed prior external note from a unique source, reviewed result of a unique test, or ordered a unique test, 2) category 2: assessment requiring an independent historian. Finally, for Element: low risk of morbidity from additional diagnostic testing or treatment, documentation of the shared decision making and commenting on the fact that the risk for morbidity is low. For E&M levels 4 and 5, the MDM requirements are more demanding; but the documentation is clinically relevant. The other option is to utilize the Total Time Spent with patient. As expected, it’s

the sum total of time the physician spent to provide the care to the patient. However, note that documentation of time for each activity is necessary to account for the care. Please refer to AMA’s guidelines for additional details.

Slightly Optimistic Although I am excited about these new outpatient guidelines, I recognize that many colleagues will push back, arguing that the documentation requirement has simply shifted. While that is true, I would much rather document clinically relevant details about my patient than frivolous details to simply check a required box. I also recognize and stated in the introduction that physician burnout has many contributing factors. As an optimist, I just wanted to share that the major contributing factor to physician burnout has been addressed, perhaps not as strongly as many may want. However, I am willing to take any stride, large or small, toward reducing phy-

sician stress and burnout. One final note: it would be nice to have official education and training on how to implement this! Tuyen T. Tran, MD, MBA, FACP, FASAM is CEO and co-founder of 2nd Chance Center for Addiction Treatment in Lexington. He is past-president and executive board chair of the Lexington Medical Society and KMA 10th District Trustee.

859.278.0569

www.lexingtondoctors.org REFERENCE Kane L. Physician Burnout & Depression Report 2022: Stress, Anxiety, and Anger. Medscape. January 21, 2022.

AT T O R N E Y S KENTUCKY | T E NNE SSE E

YOU CARE FOR EVERYONE♦ WE TAKE CARE OF YOU♦ From the business of health care to compliance to litigation defense, Sturgill Turner’s experienced health care attorneys provide comprehensive legal services to health care providers, hospitals and managed care organizations across the Commonwealth.

Put our experience to work for you. Sturgill, Turner, Barker & Moloney, PLLC ♦ Lexington, Ky. ♦ 859.255.8581 ♦ STURGILLTURNER.COM ISSUE #148 7

Finance

Year End Is the Time for Re-evaluation BY SCOTT NEAL, CPA, CFP®

The economy appears to be in a whirlwind of uncertainty. Interest rates are up. Even with more rate increases, we believe that it is not likely that the Fed will be successful in getting inflation back to 2%. After a dismal 2022, stocks have rebounded nicely this year despite the moves the Fed has made. According to some estimates, as we go to press the stock market is overvalued by 30+ percent or more. Here is a checklist of year-end items to consider for tuning up your portfolio.

Consider tax-loss and/or capital gain harvesting. If you invest in a diversified portfolio, you may have specific investments that have fallen from your purchase price, i.e. you have an unrealized capital loss. Look at individual investments and consider that the red ink spells “opportunity” to harvest those losses and offset capital gains that you might have booked earlier this year. Do it with care. You may not want to offset a short-term loss (i.e., assets held less than a year) with longterm gains. One can only deduct $3,000 of net capital losses, but you can carryover any unused losses to next year, but $3,000 of net loss can be used to offset ordinary income. Just remember the wash-sale rule says that in order to deduct the loss, you must wait at least 30 days before investing in that same company or buying a substantially identical investment.

Maximize retirement contributions. Now is the time to make sure that you have taken full advantage of retirement plan contributions for this year. Look at your year-to-date contributions to your retirement accounts i.e. 401(k), 403(b) and IRA. For 2023, an individual may contribute up to $22,500 in their 401(k) and $6,500 into an IRA. If you are over 50, you may add an addi8 MD-UPDATE

tional $7,500 for retirement plans, $1,000 for IRA accounts, or $3,500 for Simple IRAs. Hopefully, you have also taken advantage of the mega-Roth contribution if your employer’s plan permits. Please discuss this maneuver with our tax advisor if you are eligible.

Double-check RMDs. If you are 72 or over, take care to ensure that you have taken your required minimum distribution for this year. Also, even if you aren’t 72, but have an inherited IRA, you may need to take the RMD on that account. The penalty for failure to distribute required minimum distributions is onerous. If you are interested in taking a charitable distribution (known as a QCD) and avoid taxes on the distribution, that must be done before you take your RMD. As you consider your RMD, it is also a good time to look at your tax projection for this year. Consider if the withholding on the RMD can help you avoid an underpayment penalty if you have not had enough withheld or paid in estimates throughout the year.

Update tax projections for 2023 and 2024. We suggest that you always maintain a rolling 2-year projection of both state and federal income taxes. You may need your advisor to do this for you. Let me explain. Since you have filed your 2022 tax return, and you know most of your year-to-date amounts for 2023, you should use that data to prepare a projection for 2023 and 2024, looking for tax saving opportunities by shifting income and deductions from one year to the other.

Consider the impact of rising interest rates on investments. While you should always be mindful of your portfolio, the year-end is a great time

to reassess where you want to be for the next year. This year it is even more important because we simply don’t know which way the economy is headed and whether the Fed will raise rates, leave them where they are, or even possibly lower them. Should you consider commodities, adding fixed income or daily liquid alternatives to your portfolio? There are some very good opportunities to invest in short-term money-market-type investments that enable you to remain highly liquid while earning a decent return. This is the good news from the Fed’s action. Laddering out 3 month T-bills has also become quite popular. Every investor should re-evaluate his or her investment goals, risk tolerance, risk capacity, and asset allocation on an ongoing basis. At a minimum, do it once a year to determine whether the portfolio has deviated this year from its target allocation and whether the target set some time ago needs to be altered due to changes in the economy or in each individual circumstance. The great temptation is to let winners continue to grow to the point that they become a concentrated risk. Taking gains for the purpose of risk reduction is usually a good idea. Now is also the time to look at the liability side of your balance sheet, especially if you have variable rate or high interest rate debt. Remember, it’s okay to carry debt with an interest rate that is less than your portfolio return, but it might make sense to use some of the portfolio to pay off credit cards, home equity, or automobile loans. Getting in gear now to prepare for what lies ahead creates an environment for growth and stability of your finances. Don’t put this off. Plot your course for 2024! Scott Neal is president of D. Scott Neal, Inc., a fee-only financial planning and investment advisory firm with offices in Lexington and Louisville. Correspond with him at scott@dsneal.com or by calling 1-800-344-9098.

Kim is

Living Proof

Treated for cancer at Baptist Health Louisville and Baptist Health Floyd in 2017.

Celebrated her wedding anniversary on a Caribbean cruise.

BaptistHealth.com

Cover Story

(l-r) Allison Hatmaker, MD, Stephanie Warren, MD, Sarah Couch, MD, Lindsay Arnold, MD

BY DONNA ISON LOUISVILLE Breast cancer is a common form

of cancer in Kentucky with 30,270 new cases and 10,090 associated deaths being projected for 2023.1 Mortality rates, however, have sharply decreased in recent years from 31.5 to 21.6 per 100,000.1 These promising statistics from the National Cancer Institute are due in large part to early detection and more targeted treatments.2 The surgeons at Baptist Health Louisville Breast Surgery are improving out1 Gibson, K. Healthcare: Beating Breast Cancer. The Lane Report. May 23, 2023.https://www.lanereport.com/165153/2023/05/ healthcare-beating-breast-cancer/#:~:text=In%20Kentucky%2C%20the%20American%20Cancer,behind%20lung%20 and%20bronchus%20cancer 2 https://statecancerprofiles.cancer.gov/ 10 MD-UPDATE

comes by bringing the latest techniques and technologies in screening, diagnosis, biopsy, surgical intervention, treatment, and post-operative care to Kentuckiana.

The Scope of Care Breast surgery is a discipline that involves the treatment of malignant disorders of the breast as well as diagnosing and managing benign diseases of the breast and nipple. According to breast surgeon Allison Hatmaker, MD, “Most people think of breast surgery as a field for the removal of breast cancer. Although that is a large part of what we do, breast surgeons are often the first point of clinical contact for a woman with a breast mass that could be a

cancer. We are imagers who perform biopsies to obtain a tissue diagnosis, counselors for the women in grief over a new diagnosis, coordinators of care within the multidisciplinary approach to the treatment of breast cancer.” Colleague and breast surgeon Stephanie Warren, MD, echoes this sentiment, stating, “Unlike some other surgical subspecialties, we often see nonsurgical problems and follow our patients for many years. Our practice is unique in that we have several ultrasound-certified surgeons. We can perform aspirations or biopsies during patient visits.” Hatmaker reiterated that imaging is a major component for fellowship-trained breast surgeons of this era, pointing out that they

Cover Story

“I cannot imagine feeling more reward in any other job…the patients are incredibly courageous, graceful, and grateful.” - Allison Hatmaker, MD

“Unlike some surgical subspecialties, we often see nonsurgical problems and follow our patients for many years.” - Stephanie Warren, MD

“Funding for breast cancer research is an area we can point to and say, ‘The dollars have paid off.’” - Sarah Couch, MD

received extensive training in breast imaging with ultrasound specifically being used as an extension of physical exam, a tool to guide diagnostic biopsies, and a localization tool in the operating room. Hatmaker attended the University of Louisville School of Medicine and completed both a general surgery residency and a breast surgery fellowship at Vanderbilt University in Nashville, Tennessee. She joined Baptist Health in 2009. Warren is a more recent addition to the team, arriving at Baptist Health in 2018 after completing a breast surgery fellowship at Vanderbilt University. Prior, she graduated from the Medical College of Georgia and then completed a residency at the University of Louisville.

She adds, “Immunologic therapies have been a game changer, especially in triple negative breast cancer. The advent of HER2 directed therapies in the 90s continues to be a force for research and additional therapies for HER2+ tumors.” Upon completing her medical degree at the University of Louisville School of Medicine, Couch continued her training as a general surgery intern at the University of Massachusetts Medical Center and then continued her residency at the University of Louisville. She completed a breast surgery fellowship at Emory University in Atlanta, Georgia. The focus of modern breast surgery is on precise tumor removal, performed in the most minimally invasive yet comprehensive means possible; targeted therapy; and optimum quality of life after breast surgery, the goal being that the patient is not only cancer-free, but also has post-operative functionality with full range of motion, feels cosmetically whole, and suffers low rates of lymphedema. One way that physicians are reducing the prevalence of lymphedema is through preservation of the axillary nodes. In the past, these nodes were routinely removed from the armpit, which was linked to increased rates of lymphedema. Warren states, “Over the past twenty years, we have seen a de-escalation of axillary surgery, sometimes in exchange for axillary radiation. We continue to have ongoing trials helping us understand axillary

management, especially in the setting of neoadjuvant chemotherapy.” She also notes improvements in breast reconstruction: “In recent years we have also had advances in oncoplastic techniques, usually with the assistance of our plastic surgery colleagues. This has allowed many women, who otherwise may not have been a candidate, to undergo breast conservation.”

Advancements in Diagnosis and Treatment The field of breast cancer treatment has seen major advancements over the years. Breast surgeon Sarah Couch, MD, states, “Funding for breast cancer research is an area we can point to and say, ‘The dollars have paid off.’ Because of the advances in treatments—both in targeted chemotherapies as well as appropriate surgical and radiation therapies—patients have more individualized treatment plans that give them the best odds of survival while trying to reduce the impact of our therapies.”

PHOTOS BY PAUL MARTIN

Surprisingly Broad Patient Population In addition to breast cancer patients, the surgeons at Baptist Health Louisville care for patients with benign breast disease and for patients at high risk of developing breast cancer. Warren explains that the surgeons regularly address a broad scope of breast problems, such as benign/nonsurgical issues (e.g., breast pain) benign surgical issues (e.g., radial scars, papilloma, atypia), abnormal imaging, and even lactational issues. Couch elaborates, “Breast surgeons have the scope of care and follow-up to manage not only diagnosed breast cancers, but also highrisk lesions like LCIS (lobular carcinoma in situ) and atypical hyperplasia. We help manage high-risk screening and discuss the role of risk-reducing surgery with patients.” General surgeon Lindsay Arnold, MD, came to Baptist Health in August of 2020. She shares a story about a patient. “I recently was able to care for a patient diagnosed with ISSUE #148 11

Cover Story

breast cancer at a young age—the same age as me. There was so much overlap in where we were at in our lives…our family life, our place in our careers, things that are important to us. I saw and understood her fears and uncertainties on a more personal level. I remember tearing up with her in our conference room at her initial visit. Breast cancer can affect people in all walks of life, which is why it is so important we continue to offer early detection and effective multidisciplinary care.” Arnold attended medical school at the University of Tennessee College of Medicine and completed both a general surgery residency and a trauma/critical care fellowship at the University of Louisville School of Medicine.

Collaboration Is Crucial In addition to the surgeons, the Baptist Health Breast team relies on oncologists, radiologists, plastic surgeons, and specialized staff, all working closely together with the goal of providing each patient with customized, coordinated breast care. The breast surgeons share an office with nurse practitioners and with Bill Hoagland, MD, who together care for patients in the High-Risk Breast Clinic. According to Hatmaker, “We are proud to have a robust multidisciplinary team, including the largest group of breast fellowship-trained surgeons and the largest group of breast specific radiologists in Louisville. We are blessed to have a dedicated, skilled group of medical oncologists, radiation oncol-

“Breast care, in general, is no longer one size fits all.”- Lindsay Arnold, MD 12 MD-UPDATE

“We are proud to have a robust multidisciplinary team, including the largest group of breast fellowship-trained surgeons and the largest group of breast specific radiologists in Louisville.” — Allison Hatmaker, MD ogists, and plastic surgeons who support our patients as well. Other important members of the team include the genetic counselors, the nurse navigators, the research nurses, the physical therapists, the survivorship nurses, the nutritionists.” Members of the team frequently discuss cases, pathology results, and care plans. There is also a weekly breast cancer multidisciplinary conference, in which oncologists, radiation oncologists, breast surgeons, genetic counselors, nurse navigators, research coordinators, and behavioral health providers all come together for an in-depth look into particular patients, plus developments within the field, and best practices. Couch points out, “We continue to push the needle forward in treatment options in all fronts—surgery, medical oncology, radiation therapy—but the collaborative nature of breast cancer treatment is, in my opinion, what propels the field forward.”

In Closing All four surgeons agree that breast cancer care is continually advancing. According to Arnold, “Breast care, in general, is no longer one size fits all. We have so many therapies and options for patients with all types of breast disease, including abnormal breast biopsies, breast cancer, and those at increased risk for developing breast cancer. A heavy emphasis has been placed on finding ways to tailor care to improve the long-term quality of life of each patient.” In the words of Couch, “Breast surgery is the best of both worlds; we get to think critically about complex medical problems and counsel patients about their options several days a week, but we also are able to spend time in the operating room, working hands on to attempt to cure the patient.”

The doctors all agree that the field is incredibly rewarding. “I find purpose in meeting patients at a very stressful time in their lives and being able to explain things in a way that they see these excellent outcomes. I enjoy getting to know these patients, their families and friends, and their life milestones through long-term visits,” says Arnold. In closing, Hatmaker states, “I cannot imagine feeling more reward in any other job. The disease is fascinating, there is great reward in surgically solving or fixing things, and the patients are incredibly courageous, graceful, and grateful.”

For referrals to: Allison Hatmaker, MD, Stephanie Warren, MD, Sarah Couch, MD 3950 Kresge Way, Suite 303 Louisville, KY 40207

502.896.7660 For referrals to: Lindsay Arnold, MD 4001 Kresge Way, Suite 200 Louisville, KY 40207

502.895.1995

Rebecca Booth, MD, OB-GYN, is co-managing partner of Women First of Louisville. She has been the physician director for the Women First Breast Imaging Department since its inception.

Women’s Well Care in 3D

Mammography is part of wellness care at Women First of Louisville BY GIL DUNN LOUISVILLE Women

First of Louisville, a full-service OB-GYN practice founded, owned, operated, and staffed exclusively by women, started offering mammography services to their patients in 1991. The goal was to provide mammography as “a wellness model, not a sickness model,” says Rebecca Booth, MD, OB-GYN, one of the early partners in Women First. Women First sees between 300-400 OB-GYN patients per day, over 15,000 per

year. Eventually, the vast majority of these women need a mammogram. Why not offer that service in-office as part of their integrative well care for women model, asks Booth. The interest in mammography screening was so strong that in 2006, Women First hired Debra Hensley as its first “breast imaging navigator” to communicate with patients on the results of their mammogram. Lynette Wood, LPN, is also a breast imaging navigator, and Hillary Meyer is breast imaging supervisor. Women First is an OB-GYN medical practice, so the mammogram images are sent to PHOTO BY GIL DUNN

the Louisville radiology practice, Women’s Diagnostic Center, for reading. Turnaround is typically 4-7 hours, says Booth. Ninety-six percent of the mammograms are BI-RADS (breast imaging reporting and data system) zero or 1, says Booth, meaning no additional screenings are needed except for the annual exam. Only 4% need follow-up. “Our breast imaging navigators are highly trained to communicate with our patients on the results of their mammograms, whatever the BI-RADS score is,” says Booth. “Our well care model is based on wellness and moving ISSUE #148 13

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OB-GYN

Rebecca Booth, MD, OB-GYN has been practicing medicine for over 34 years. She is a co-managing partner of Women First of Louisville, one of the largest OB-GYN practices in the southern/central United States. She sees about 90 patients per week. Booth completed undergraduate studies at the University of Kentucky and received her medical degree from the University of Louisville School of Medicine, where she was inducted into the Alpha Honorary Society. She completed her internship and residency at the UofL Department of Obstetrics & Gynecology and received board certification in 1991. Booth is an internationally recognized expert in hormonal wellness and author of The Venus Week: Discover the Powerful Secret of Your Cycle...At Any Age. She has appeared on The Today Show and has been extensively featured in women’s magazines and medical journals. She has been named in Louisville Magazine as one of Louisville’s “Top Docs.” She was honored as one of Today’s Woman’s Most Admired Women in 2009. She has been published as an expert in topics that include preventative healthcare for women and menopause and hormonal management. 14 MD-UPDATE

our patients through one or more procedures. The flow cannot ‘stop, drop and direct’ towards just one problem. The flow has the assumption of wellness and integrative care.” Recall of patients for another mammogram or biopsy have decreased with the advancement of 3D mammography, because they are easier to read and interpret, says Booth. Additionally, the in-office setting and one-day turnaround benefits patients because “there’s less cost to the patient and less exposure to radiation, also less time, anxiety, and less breast cancer worry,” she states. “We were one of the first in the region to bring mammography in-office, and we do it as part of our annual well care exam. Our goal was to increase compliance with screening recommendations. And we see that compliance has markedly increased,” says Booth. “Our appointment staff facilitate scheduling. Most of our patients are very interested in being proactive with their breast cancer screening.” “It’s been a real gift to me that we are able to offer this service to our patients,” says Booth.

Women First of Louisville Established in 1988 by Rebecca Terry, MD, OB-GYN, Women First of Louisville has been a pioneering force in creating one of the initial all-female practices in the field of obstetrics and gynecology. What began as a modest two-physician group has flourished into a robust team of 20 all-female practitioners. This diverse group includes both physicians and advanced practice clinicians who are experts in various aspects of women’s health, offering a comprehensive range of services that span the gamut of women’s health care needs. Their services include preventative care, obstetrical and preconceptual counseling, contraceptive management, sexual and menopausal health, surgical services both in-hospital and in-office, urinary incontinence and bladder care, and other services to meet their patients’ gynecologic needs. In addition, Women First is equipped with several in-house diagnostic facilities, featuring a full laboratory, ultrasound department for both gynecologic and obstetrical assessments, bone density testing, and a breast imaging suite. Women First’s breast imaging department has continually evolved to incorporate technological advancements in the field. Initially offering film-based mammography, they transitioned to digital imaging and have since upgraded to state-of-the-art 3D digital mammography with computer-assisted interpretation. The full transition to 3D imaging was made once it became clear that both patients and clinicians recognized its superior diagnostic capabilities and insurance coverage became more consistent. To further enhance the patient experience, they have recently completed an extensive renovation of their imaging suite to featuring private changing rooms to ensure comfort and privacy, streamlining the patient flow throughout the suite. The mammography suite is equipped with three cutting-edge 3D digital mammogram machines operated by highly trained staff.

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OB-GYN

Benefits of 3D Mammography Even for patients considered low-risk, 3D mammography offers superior tissue visualization. Most radiologists agree that this advanced technology not only boosts the likelihood of early detection but also minimizes false-positive results. Booth says that it is essential to note that very few women fall into the ‘truly low-risk’ category. Many women have one or more risk factors for breast cancer, often unbeknownst to them. For instance, delaying a first pregnancy until after the age of 25 is a risk factor, as is never becoming pregnant at all. “Given that breast cancer is the most prevalent form of cancer among women, it’s prudent to consider anyone with breast tissue as having some level of risk,” she says. Although many patients are aware that mammography screening should begin at age 40, some may require earlier screening based on family history or genetic predispositions, like BRCA1 and BRCA mutation carriers. Typically, women rely on both public awareness and professional advice for these services. “Because we see women throughout their life span, we clearly communicate preventive measures and even discuss what is recommended for the next annual visit to help our patients prepare,” says Booth. Women have the option to schedule their own 3D mammograms at various free-standing breast imaging centers, especially in urban areas where this technology is readily available, but Women First feels that the opportunity to have a physical clinical breast exam along with other preventative health services is the best integrated way to deliver screening services. Mammography is considered extremely low risk; however, a tiny amount of radiation is delivered to the tissue as would be true of a chest X-ray, but much less radiation than a more involved imaging procedure such as a CT scan. 3D imaging does not add significantly to the risks of radiation exposure and does increase the detection rate as well as lowering the need for compressed or additional images. Most radiologists would agree that 3D mammography is now the standard for breast tissue imaging for all women eligible for screening. Booth addresses a continuing misconception among women that mammography is painful. Many Women First patients share that the experience was easy compared to what they had imagined or had heard from others. “While false positives are a concern, most women would rather be proactive and are aware that early detection saves lives and reduces the need for aggressive surgery,” says Booth. On a personal note, Booth says that she keeps a list of her patients that have had breast cancers detected by the Women First team. She shares that “My mother-in-law is on that list twice, and she lived to be almost 90 free of cancer. There are many women I love and care about on the list, including some of my closest friends. It is a quiet reminder in my desk drawer of our mission to help our patients live longer and healthier lives.”

3D TOMO for all our patients We recommend it for yours. 3D Tomosynthesis Mammography is now the standard for breast tissue imaging, and it’s all we use for our patients. Offering superior tissue visualization while minimizing false-positive results, 3D TOMO gives our patients the best chance possible at early breast cancer detection.

And in the fight against breast cancer, earlier detection is still the key.

Women First’s mammography department is accredited by the American College of Radiology.

502.891.8700

womenfirstlouisville.com ISSUE #148 15

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Hematology

It’s in His Blood

Hematology and Oncology physician Mohamed Hegazi, MD, fights side by side with his patients and their families BY JIM KELSEY

Mohamed Hegazi, MD, chief of Bone Marrow Transplants and director of Blood Cancer, Cellular Therapy and Transplant programs at the UofL Health–Brown Cancer Center and associate professor at UofL School of Medicine

LOUISVILLE As the saying goes, perception is

reality. For patients with blood cancers such as leukemia, lymphoma, and myeloma, the reality is that they are facing a dreaded disease and the perception can be understandably gloomy. But for Mohamed Hegazi, MD, chief of Bone Marrow Transplants and director of Blood Cancer, Cellular Therapy and Transplant programs at UofL Health – Brown Cancer Center, there is light amidst the darkness. “Some say, you’re dealing with cancer, that must be really depressing. It is the contrary to me. It’s very rewarding to be part of that journey and that battle,” says Hegazi. “It all depends on how you look at it. Being able to 16 MD-UPDATE

alleviate suffering and make the patient feel good, get them to enjoy precious moments and see their family in a good quality of life is an extremely rewarding thing. I get the honor and privilege to be part of this with the patients and their families.” Connection and family are very important to Hegazi; he has two brothers who are pharmacists and another who is currently in medical school. Hegazi was born in Egypt and grew up in the United Arab Emirates where his father worked. He attended medical school at the University of Mansoura Faculty of Medicine in Egypt and did his residency at Jersey Shore Medical Center in New Jersey. PHOTO BY JOHN LAIR

He completed a fellowship at the UofL School of Medicine, where in 2018, he joined the faculty and now serves as an associate professor. “When I came to the United States and did rotations at the UofL Health – Brown Cancer Center, the relationships I saw between the physicians and their patients always reminded me of when I was young and my father would be very connected with his physician. He would explain to us why he appreciated that person’s opinion,” says Hegazi, explaining that those memories are why he chose hematology and oncology over his other interest, cardiology. “The relationship between the doctor and the patients is much stronger in the

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Hematology

Mohamed Hegazi, MD, sees a brighter future ahead with academic medical centers such as UofL Health manufacturing their own cells.

I believe healthcare systems—especially academic healthcare systems like UofL Health that have the ability to manufacture their own product—will bring down the cost and make manufacturing much more streamlined by making what we need on site.”

A Patient’s Advocate

hematology and oncology world compared to cardiology. That’s what sealed the deal.”

Collaboration, Clinical Trials, and Cell Therapy Today, Hegazi is part of a team of four physicians; each has three weeks in clinic and one week of inpatient rounds at the hospital. In addition to meeting with patients, Hegazi also has standard meetings with administration, finance, and the other members of his team. Additionally, he meets with the research office to review patients who are enrolled in clinical trials. On top of that, he gives lectures and teaches the fellows. All of Hegazi’s patients are 18 or older and have developed blood cancers. His role varies from being their primary oncologist to providing a second opinion, informing about clinical trial options, or overseeing bone marrow transplants. Among the procedures and courses of treatments he oversees are allogenic stem cell transplants, which are from a donor to the patient, typically to treat leukemia or myelodysplastic syndrome. Hegazi and his team also provide cell therapy for melanoma, lung cancer, cervical cancer, and head and neck cancers via tumor-infiltrating lymphocytes (TIL) therapy. TIL therapy uses the patient’s own immune cells from the solid tumor to kill tumor cells. “There are those people who love to think outside the box, who love to come up with ideas that haven’t been touched before,” Hegazi says of the scientists behind the array of new therapies being developed. “I don’t come up with the ideas, but I bring the clini-

cal trials to be available for my patients here.” Hegazi gives the example of chimeric antigen receptor (CAR) T-cell therapy, which involves using immune T cells, a type of white blood cell, to fight and destroy cancer cells. The available CAR-T therapy targets one marker for leukemia and lymphoma. “We are looking at adding more targets to make it an even more successful therapy,” says Hegazi. “We are trying to attack the cell from more angles to increase our chances to eradicate the disease.” Increasingly, the approach is to find ways to help the body destroy the cancer itself. “You can help the body’s own cells detect the cancer and kill it on its own and have a better outcome than giving more chemo,” says Hegazi. “We take the patient’s own lymphocytes out. In the lab, we introduce genetic material in the DNA of those lymphocytes that makes them capable of detecting the cancer. Those cells are able to kill the cancer cells on their own, but they don’t have the cancer marked. So when you put the genetic material in them, you put a marker on top of them that marks the cancer. They engage with the cancer cell and kill it.” This technology and approach is all very new and still being developed. Additionally, costs for these treatments are unmanageably high. But Hegazi sees a brighter future ahead with academic medical centers such as UofL Health manufacturing their own cells. “The therapies that we have to send to be manufactured and come back to us are very expensive,” says Hegazi. “In the future, PHOTO BY TOM FOUGEROUSSE

Hegazi understands that patients and their families dealing with these diseases have more than enough to handle beyond having to worry about unmanageable healthcare costs. He is in the fight with them for better treatments, less cost, and, most importantly, better outcomes. “When you go into this field, you find yourself being the best advocate for patients when they develop what they have, because you’ve seen it and you know what it’s like,” he says. “You want someone who has been through this many times to tell you, ‘What do I expect, how am I going to feel, where am I going to be?’ I might not be able to put out fires, but when we have to face it and the patient has to go through, I will hold his hand and we will do our best together to get through. My goal is that they understand what we are doing and what are we promising them. You have to be as real as possible, as supportive as possible, as caring as possible with compassion and sympathy.” Hegazi stresses that transparency and honesty are crucial in communicating with the patients and helping them understand what they are facing and what their expectations can be. The expected outcomes aren’t always favorable, but Hegazi and his team pledge to be with the patient and their families every step of the way. “Even when we lose the battle, that doesn’t mean my relationship ends with the patient’s family, says Hegazi. “I do my best to attend the funeral or visitation. My team does the same thing. We connect with the families on a very human level. Their loss is huge to us. We share that with them because their families become members of our team in caring for the patient.” Though the reality might be that they aren’t actually family, Hegazi’s perception says otherwise. ISSUE #148 17

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Oncology

Cancer Care in Rural Kentucky Dana Johnson, MD, stays close to his roots and sees a bright future for cancer patients

BY GIL DUNN

Palliative Care for a Chronic Condition

MT. STERLING/LEXINGTON After World War

Advancements in cancer treatment, such as new medical therapies, DNA specific drugs that are less toxic, improvements in radiation, and early detection mean that patients with cancer are living longer. Like other oncologists, Johnson concurs that “cancer is becoming a chronic disease more than a terminal one. People are living longer; therefore, the need for palliative care is growing as the two specialties continue to intersect.” Palliative care offers treatments that care for the patient as a whole person, not just as a cancer patient. Emotional, social, and lifestyle pressures often take a toll on oncology patients and their caregivers, and effective palliative care addresses some of those needs. “This kind of support is best achieved by talking to patients and seeing what their individualized goals are. We focus on simple modalities, matching the invasiveness of treatments to the patient’s unique goals, and helping them keep doing those activities that matter most to them,” says Johnson. He cannot deny the holistic quality of palliative care: “Holistic care has to be part of the approach,” says Johnson. “People who come to our clinic are talking about very emotional topics. Life, death, and possibly how they want to spend their last days. When you’re in our place, you can’t just look at pain and ignore the rest ... there’s much more emotional care in our field than in most others.” For these reasons, Johnson states that the clinic also has a chaplain available to patients and families. The opioid epidemic in Kentucky presents a challenge for palliative care providers. Johnson says that he and fellow providers are well aware of potential drug diversion behaviors, so they work closely with local pharmacists and use the KASPER registry to monitor activities such as physician shopping and drug misuse. “We’re very mindful of the potential

I, Mount Sterling, along with Lexington, Shelbyville, and Maysville, was one of the four major loose leaf tobacco markets in Central, Northern, and Eastern Kentucky. The roots of tobacco use run deep in the central/eastern counties of Montgomery, Bath, Menifee, Powell, Rowan, Clark, and Morgan counties. Even today, nationwide smoking rates remain higher in rural counties than in urban counties, according to the American Lung Association’s 2023 report, “Top 10 Populations Disproportionately Affected by Cigarette Smoking and Tobacco Use” with 19% in rural versus 11.4% in urban areas. Dana Johnson, MD, hematologist, medical oncologist, and palliative care specialist at CHI Saint Joseph Health – Cancer Care, regularly sees this disparity in his clinical practice. Johnson estimates that over 33% of his patients are treated for lung cancer, with smoking rates up to four packs of cigarettes per day. Many of his patients are in later stages of the disease. Lack of access to care and transportation challenges contribute to this unfortunate occurrence, says Johnson. “There’s no bus service or public transportation in the poor rural counties that people can use to get here, so they need family or friends to bring them. The good news is that with CT screening initiatives in rural counties, we are seeing a shift in patients coming in with earlier stages of the disease.”

Finding a Niche Johnson grew up in Ashland, Kentucky, and received his undergraduate and medical degrees at the University of Kentucky. After his internship at the University of Tennessee, he returned to Lexington for an internal medicine residency and medical oncology fellowship at UK. A perpetual student, Johnson recently earned his PhD in history from UK. His subject was 18 MD-UPDATE

Dana Johnson, MD

medical history and women’s health. Johnson joined CHI Saint Joseph Health in 2011. He sees his cancer patients in Mt. Sterling and has a palliative care clinic every other Friday in Lexington. Johnson chose to study cancer and palliative care because of the advancements he observed in the fields as he was working toward his medical degree. Oncology and palliative care merged seamlessly and palliative care had surfaced as a viable option for medical oncology patients with the emergence of Medicare coverage and reimbursement. Johnson’s patient population is of advanced age and presents with cancers common to the region, most notably lung, breast, colon, and prostate malignancies. Palliative care provides advanced care for patients who have been treated repeatedly and still experience symptoms of pain, including emotional symptoms that are both persistent and very difficult to control. Hospice and palliative care are not necessarily synonymous. Johnson states, “I enjoy palliative care. It’s less high-tech treatment procedures and more about making people comfortable, giving them a quality of life.” Fellow oncologists usually serve as referring physicians for palliative care and hospice services alike. PHOTO BY GIL DUNN

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for misuse, but I continue to treat the sick patient because that’s my job,” says Johnson. Like many practices, palliative care comes with its own share of misconceptions. Johnson names two. “The first is that everyone who comes here ends up in hospice. And the second is that our patients have given up. The opposite is true. We work diligently to help them feel as good as they can for as long as they can.” An ardent student of history, Johnson gives a prediction about the future of palliative care. As people live longer lives and thus become vulnerable to more diseases, he sees a continuing merger between palliative care and oncology in coming years. “The interface between medical oncology and palliative care will necessitate growth in this area,” says Johnson.

The Cleveland Clinic Connection In May 2021, CHI Saint Joseph Health announced an expansion of its affiliation with the Cleveland Clinic Cancer Center to

include patients and physicians in Bardstown, Mount Sterling and London, Kentucky. In the announcement then-Saint Joseph Mount Sterling president Jennifer Nolan said that physicians and patients in rural counties would now have “access to second opinions and input to treatment plans from one of the nation’s most respected cancer programs.” Johnson says that he is in regular contact with the Cleveland Clinic Cancer Center, averaging at least one contact a week, usually more. The benefits are multiple, he says. “We have standardized protocols in our system for administering chemotherapy. We have quick access to a second opinion in real time. And we have a real-time consult on a complicated case.” Johnson recalls that when he first started practicing oncology over 25 years ago, he and his colleagues believed that they were on the cutting edge of treatment, which he ruefully acknowledges was true, but naïve. “Patients that 20 years ago would not have survived are

Oncology

now living with cancer as a chronic condition with a quality of life,” he says. “The rapid development of new cancer fighting drugs is driving the evolution of drug therapy, giving us much more hope for a future with more effective treatment.”

Cancer Care Center 3470 Blazer Parkway Suite 350 Lexington, KY 40509

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Neuro-Oncology

Neuro-Oncology Program Taps “Power of Three”

Collaboration + Advanced Technologies + Research = First-rate Brain Tumor Care as a form of “implantable radiation” put into a patient’s surgical cavity after removal of a tumor.

BY MENISA MARSHALL LOUISVILLE A familiar adage tells us good

Research and Clinical Trials: There is Hope

things come in threes. Neuro-oncologist Kaylyn Sinicrope, MD, sees the truth of this in action through Norton Cancer Institute’s Neuro-Oncology program. Fueled by multidisciplinary collaboration, advanced technologies, and research, this program provides first-rate care for patients and families dealing with brain tumors.

Collaborative Multidisciplinary Care Regularly scheduled meetings are a key element of multidisciplinary care. Various departments gather weekly to plan how they can best fit the needs of patients and their families. “We have a tumor board every Monday morning before we start our clinic, where we discuss cases and agree upon a treatment plan for each patient,” says Sinicrope. Depending on the type of brain tumor involved, care plans may include combinations of neurosurgery, radiation, and chemotherapy. Chemotherapy — typically low-dose temozolomide (Temador) — is generally delivered orally in conjunction with radiation. It is often a final treatment step for many patients. After completing six to twelve months of radiation, patients usually have a treatment break. As they resume, chemotherapy dosages are adjusted as needed. Sinicrope follows up with patients after treatment. Should a tumor reoccur, their next care steps may include referrals to additional specialists as needed. Because patients and families face multiple challenges, neuro-oncology team care includes social workers and behavioral health specialists. Additional specialists assist with insurance and disability issues. 20 MD-UPDATE

Kaylyn Sinicrope, MD, neuro-oncologist at Norton Cancer Institute’s Neuro-Oncology program

Advanced New Technologies Aggressive forms of cancer often call for aggressive treatment. For instance, potentially high-risk surgeries that may affect key brain functions are sometimes necessary. David Sun, MD, PhD, neuro-surgeon and executive director of the Norton Neuroscience Institute, is skilled with minimally invasive neurosurgical techniques. When conditions call for resection, Sun utilizes various leading-edge technologies and procedures that help minimize patients’ potential risks. Sun routinely performs laser interstitial thermal therapy (LITT), a minimally invasive procedure that uses a small laser to destroy unhealthy brain tissue. He is proficient with this innovative technique that several prominent cancer centers are currently using to treat deep or recurrent brain tumors and radiation necrosis. GammaTile is another advanced technology Norton’s experts have brought to Kentucky to treat newly diagnosed or recurrent malignant intracranial neoplasms. Sinicrope describes it PHOTOS BY JAMIE RHODES

High-profile patients such as Senators John McCain and Ted Kennedy and President Biden’s son Beau Biden have raised awareness about glioblastoma, yet much remains unknown about this typically fatal brain tumor. National cancer guidelines, which many experts use as a framework for optimal cancer care, recommend all patients with glioblastoma should consider clinical trials. “In my opinion, it’s our responsibility to offer patients clinical trials,” says Sinicrope. “We currently have trials here, both in the initial diagnosis and recurrent stages, should tumors come back.” SurVaxM is one promising clinical trial locally underway. It assesses a treatment that mimics the power of the surviving peptide to increase immune response to glioblastoma. Patients who enter this trial continue to receive standard care, including radiation and chemotherapy. More research is needed to confirm this Phase 2 trial’s results, but early outcomes are promising. One recently published study reported the signal peptide used produced “fairly significantly prolonged overall survival.” Another current clinical trial involves wearing a medical device that transmits alternating electrical currents to kill tumor cells and interrupt tumor growth. Early results show promise in disrupting tumor-treating fields in later stage cases. Ongoing work is assessing the device’s earlier treatment impact. Both these multi-site trials for newly diagnosed patients are actively recruiting. Any patients whose tests confirm a glioblastoma diagnosis can benefit from information on these available trials.

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Neuro-Oncology

Clinical trials normally include placebocontrolled arms, which mean not all patients who enroll receive active intervention. Sinicrope is surprised — and encouraged — that most patients who enter a study are altruistic about their chances of getting a placebo. “They say even if they don’t get the intervention, they’re still helping others,” she says. Sinicrope credits research and advanced treatments for changing the “nothing can be done” mindset about glioblastoma. While some patients experience an aggressive course with significant disability, advanced treatments are now helping many patients enjoy years of good-quality life. “There is hope,” says Sinicrope. “Our treatments are effective, and we’re working hard to advance what we’re doing.”

A “Why Statement” That Speaks Volumes Sinicrope cannot recall a time when she did not want to be a doctor. As a young girl, she used toothpicks and hydrogen peroxide to fix her dad’s scrapes or small injuries. She attended UC Davis College in California, then worked at a women’s health clinic before applying to medical school at Boston University. A combined residency program at Harvard led her to Brigham and Women Mass General Hospital, the inpatient facility for the Dana-Farber Cancer Institute, where she fell in love with oncology. She and her husband, Brent Sinicrope, MD, share a commitment to quality patient-centered medical care. He is an orthopedic surgeon with Ellis & Badenhauser Orthopedics. Unlike many specialized practices, oncology promotes close patient relationships. “It’s almost a family medicine approach within a particular specialty,” says Sinicrope, whose office at Norton Cancer Institute’s Brownsboro site is directly across from the inpatient hospital. Her days typically start with hospital rounds. She likes to meet new patients in the hospital before they’ve had any type of surgery. If patients under her ongoing care are hospitalized, she makes sure to see them so their inpatient care team includes someone they know well. Between seeing patients, she fits in administrative and clinical trial work.

Oncology promotes close patient relationships. “It’s almost a family medicine approach within a particular specialty.” - Kaylyn Sinicrope, MD

Sinicrope’s patients are generally in their fifties or sixties, but ages can vary. She sees more males than females, but the difference is not substantial. Brain tumors typically impact the healthy and unhealthy alike. Sadly, the most common tumor Sinicrope treats is terminal. Life expectancy can vary, but many glioblastoma patients live less than 20 years. This sets the stage for frequent visits that lead to a close doctor-patient relationship. “I know all about all their vacations and families. We see pictures and postcards and that kind of thing,” says Sinicrope. “I think we’re a part of their lives as much as they’re a part of ours.” When Sinicrope sees new patients, she generally has a fairly accurate diagnosis in mind based on their imaging test results. If she’s confident they’re facing an aggressive primary brain tumor, she shares her concerns but holds off on unpacking their prognosis in detail. “Before we begin to consider surgery, biopsy, or any sort of intervention for definitive diagnosis, I try to get to know the person a bit,” she says. “It’s good to find out what is important to patients, who is part of

their support network and what defines them in terms of occupation or hobbies.” Over time, brain tumors often impact cognition and functionality. She feels it’s important to understand people before they embark on such a life-changing process. It helps in tailoring treatment plans that respect patients’ priorities and quality of life. This care approach, Sinicrope notes, typifies Norton Cancer Institute’s commitment to quality care for every patient. Because neurooncology is so specialized, she encourages anyone diagnosed with a brain tumor to consider a consult with the Institute if they live within a two-hour drive of Louisville. She wants all patients to understand their available treatment opportunities, including clinical trials. To minimize in-person trips, patients can access many advanced therapy resources using virtual technology. Ultimately, Sinicrope believes her “why” boils down to a desire to help patients live as long a life and as good a life as they can. Beyond this, she considers it vital to understand the widespread impact cancer makes on patients, families and even their broader communities. ISSUE #148 21

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Public Health

Lung Cancer Screening Day Can Be Every Day BY ELIZABETH ANDERSON-HOAGLAND HEALTH PROMOTION SUPERVISOR KENTUCKY DEPARTMENT FOR PUBLIC HEALTH FRANKFORT Lung cancer is the leading cause

of cancer death in Kentucky despite being the third most common type of cancer. Over 4,500 mothers, fathers, sisters, brothers, sons, and daughters are diagnosed with lung cancer each year. While this number is still too high, the rate of lung cancer incidence has fallen dramatically over the past thirty years in the state, mirroring the reductions in cigarette smoking and the increase in indoor smokefree spaces.1 Cigarette smoking remains the top cause of lung cancer, with eight in ten cases tied directly to the patient’s own cigarette use.2 However, it is important to note that radon exposure (a colorless, odorless gas that is naturally found in some types of rock), occupational exposure and exposure to secondhand smoke are risk factors to lung cancer as well, all of which can multiply one’s risk of cancer. In the past, lung cancer was a death sentence, but with modern medical technology and medications, lung cancer can be treated if caught at an early enough stage. Six in ten adults will be alive five years after diagnosis if lung cancer is caught at a localized stage.3 If cancer is caught early patients will not only live longer but also have a higher quality of life. Unfortunately, only 24 percent of cancers are caught at a localized stage. This is why screening is so important. Current recommendations for an annual low-dose CT scan are for those: • 50 to 80 years old • Have a 20-pack-year smoking history • Currently smoke or have quit within the past 15 years.4

Low-dose CT scans are quick and painless and involve no needles or dyes. For those who meet the screening criteria, an annual lowdose CT scan is covered by insurance with no co-pay to the patient. Before sending a patient to be screened, it is important to have a conversation with them about the risks and benefits of screening.5 For example, a low-dose CT scan does have minimal radiation exposure, but it is still radiation exposure. A patient who is in otherwise poor health may decide they would decline to pursue treatment if diagnosed with lung cancer and may prefer to enjoy their current time without additional worries. It is important to respect the wishes of each person. It is also important to counter any shame, stigma, or fatalism that patients may experience. Cigarettes are designed and manufactured to be addictive and have been heavily marketed to appeal to consumers. Historically, cigarettes were even marketed toward teenagers. There is no shame in being human and having a human brain hijacked by a drug. Free help is available for Kentuckians who want to quit smoking, or using other tobacco products, at www.quitnowkentucky.org or by calling 1-800-QUIT NOW. Patients should know that cancer treatment is evolving all the time. In the early stages, laparoscopic surgery and newer medications have good success rates. The key really is early detection.

Lung Cancer Screening Day Lung Cancer Screening Day is an opportunity to emphasize the importance of lung cancer screening as well as open screening centers during non-traditional hours to reach patients who may not be able

to access an appointment during the week. This year Lung Cancer Screening Day was Saturday, November 11. Unfortunately, Kentucky is often near the bottom of national health rankings. However, when it comes to lung cancer screening, Kentucky is leading the pack. Kentucky consistently ranks second or third in the nation for the percentage of eligible patients receiving screening. In 2002, 14.7% of eligible patients were screened, compared to a national average of 5.7%.6 But we can do better than that, and Lung Cancer Screening Day is one way to do it. Lung Cancer Screening Day is an opportunity for health care systems to open screening centers during non-traditional hours to meet the needs of patients who can’t make appointments during the week. We know that patients who are lower income, live far away from screening centers, have low literacy levels, or are underinsured are less likely to access cancer screenings. Holding hours on the weekend or evening hours is one way to provide the flexibility that can make it easier for at-risk patients to get necessary screening. If this is something that is of interest to you or your health care system, the National Lung Cancer Roundtable has a toolkit for screening centers and health care systems that includes marketing, materials for patients and financial planning tools. This kit can be accessed at https://nlcrt.org. Even once Lung Cancer Screening Day has passed, health care providers can continue to refer to lung cancer screening year-round. And many screening facilities have evening and weekend hours year-round to better serve their patients.

1 Age-Adjusted Invasive Cancer Incidence Rates by County in Kentucky, 2020 - 2020. Based on data released Nov 2022. Kentucky Cancer Registry. Cancer-Rates.info. 2 What Are the Risk Factors for Lung Cancer. U.S. Centers for Disease Control and Prevention. 3 American Lung Association. State of Lung Cancer Report 2022: Kentucky. 4 U.S. Preventive Services Task Force. Lung Cancer: Screening. Rockville, MD: U.S. Dept. of Health and Human Services, Agency for Healthcare Research and Quality. 5 Lowenstein, L. M., Deyter, G. M. R., Nishi, S., Wang, T., & Volk, R. J. (2018). Shared decision-making conversations and smoking cessation interventions: critical components of low-dose CT lung cancer screening programs. Translational Lung Cancer Research, 7(3), 254–271. 6 American Lung Association. State of Lung Cancer Report 2022. 22 MD-UPDATE

Together we can defeat cancer. When it comes to the groundbreaking research it takes to defeat cancer, we’re more than just dedicated at Norton Cancer Institute. As the cancer leader in the region offering innovative clinical trials of novel therapies, such as advanced cellular therapies (CAR-T cell therapy), our subspecialty cancer physicians are active investigators on numerous research efforts. Currently, we offer over 170 active clinical trials and pivotal studies in every phase of cancer treatment. If you have patients who may be eligible for a clinical trial, our research team will screen them within two days and work alongside their established providers. Call (502) 629-2500, ext. 19469.

Complementary Care

A Well Kept Secret in Senior Health Care

Program of all-inclusive care for the elderly is designed to help age in place an inpatient facility. PACE staff members work to anticipate problems before they grow more complex and difficult to manage. Although concierge Medicare care has become a luxury offering to some people in the community, the holistic care provided by PACE serves an historically medically underserved and marginalized population.

BY JAMES BORDERS, MD LEXINGTON PACE, which stands for Program of

All-Inclusive Care of the Elderly, is perhaps the most well-kept secret in healthcare. Although PACE has been in existence in the United States since the 1970s, Kentucky’s first PACE program started operating in 2022. PACE is a program primarily designed for patients with Medicare/Medicaid (the “dually eligible”), whose needs traditionally require skilled nursing home care. The ultimate goal of PACE is to allow participants to “age in place,” avoiding nursing home or other long-term care. Federal and state governments recognize that placing such patients into skilled nursing facilities is the most expensive option for care provision and often not the best plan for maintaining an acceptable quality of life for these patients. Services are 100 percent covered for participants with both Medicare and Medicaid who transition completely to PACE program care. The physician at PACE becomes the participant’s primary care physician. All non-emergency care, including primary care and specialist services, must be provided by the program or an authorized entity to be covered by PACE. Other costs and restrictions apply to individuals who only have Medicare or are paying privately.

Better Care Is the Outcome

James Borders, MD

PACE programs must have a facility capable of providing health evaluations, adult daycare, meals, transportation to and from the center or other healthcare providers and facilities, and any other services to provide optimal healthcare. It is typical for PACE patients to be seen in the Center 2-3 days per week. This allows PACE staff to become familiar with all aspects of each patient’s healthcare needs. Participants are also visited in their homes when needed by PACE staff who are equipped and empowered to determine appropriate interventions in order to maintain their health and quality of life in their homes and thus avoid moving them to

Evidence shows that, compared with age and morbidity-matched cohorts treated in traditional care models, PACE participants fare better by several important measures. Cited in Leavitt’s 2009 interim report to Congress, a U.S. Department of Health and Human Services study found that PACE participants reported better self-rated health statuses, better preventive care involving vision and hearing screenings, higher rates of seasonal vaccine administration, and fewer cases of depression. A 2010 study in The Journals of Gerontology by Wieland et al. reported the five-year survival in a PACE population compared with alternative institutional and home- and community-based care. Despite PACE participants being older and more cognitively and functionally impaired than those in an otherwise matched cohort, PACE participants had a substantial long-term survival advantage after five years of

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Complementary Care

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follow-up. The benefit was especially apparent in moderate- to high-risk participants. PACE centers serve as adult daycare centers where medical personnel get to know each participant on a personal level to provide any needed medical evaluations, including both wellness and acute care visits, physical and occupational therapy, nutritional assessments, meals, and the socialization that is so essential to the person’s sense of well-being. Transportation to and from the PACE Center and other medically related visits is provided by PACE if transportation is a barrier.

Relief for All Parties Involved To be most effective, the PACE team assumes primary care for the patient and oversees all aspects of their healthcare, including that provided by specialists. Although specialty care remains available, contracted specialists understand that the PACE physician and PACE Center teams will give as much specialty care as they are qualified to provide.

DSNEAL.COM

When fully understood and implemented, PACE offers relief to all parties involved: the patient, the patient’s family, and the patient’s primary care physician struggling to manage the care of someone with inadequate healthcare infrastructure to prevent the frequent pleas for help represented by a chaotic healthcare experience. These patients are often characterized by frequent emergency room visits, hospitalizations, missed appointments due to lack of transportation, or inadequate social support. To qualify for the program, a patient must be at least 55 years old, live within counties assigned to active PACE programs, be able to live safely in the community with PACE services at the time of enrollment, and meet state-defined criteria for skilled-nursing home care. It is critical to share with prospective PACE participants the restrictions and fees, particularly for those who are not dually eligible with both Medicaid and Medicare coverage. Individuals who have only Medicare are eligible for PACE but must pay a fee. Other par-

ticipants may pay privately for PACE services and have different payment structures. For all PACE participants, all healthcare must be received at or coordinated by the PACE Center. Participants may be fully or personally liable for the cost of services not authorized by PACE. PACE participants may voluntarily disenroll from the program without cause at any time. The disenrollment date will be coordinated between Medicare and Medicaid for a participant who is dually eligible. As of July 2023, there are three approved PACE programs in Kentucky. If you have dually eligible or Medicare-only patients whose healthcare needs you are struggling to meet, PACE may be an option. PACE personnel can evaluate the patient to see if they meet the required criteria for acceptance. In Central Kentucky, PACE is administered by Bluegrass Care Navigators for patients residing in Anderson, Fayette, Franklin, Jessamine, Woodford, Barron, Clinton, Estill, Jackson, Laurel, Madison, McCreary, Pulaski, Rockcastle, Warren, and Wayne counties. In Jefferson County it is administered by Senior CommUnity Care of Kentucky. For Central KY, contact Bluegrass Care Navigators at 855.492.0812 for more information. For the counties of Barren, Clinton, Estill, Jackson, Laurel, Madison, McCreary, Pulaski, Rockcastle, Warren, and Wayne, contact Horizon PACE at 877.589.3053. James Borders, MD, is a 1979 graduate of the UK College of Medicine and received his internship and residency in internal medicine at Baylor University Medical Center in Dallas, Texas, followed by six more years in private practice in Dallas. In 1988, he returned to Lexington to join his twin brother John in internal medicine practice, continuing in that role until accepting the role of chief medical officer of Baptist Health Lexington in 2015. Dr. Borders retired from that position in July 2022. Borders recently joined Bluegrass Care Navigators to direct their new PACE program. While chief medical officer at Baptist, Borders co-led the ethics committee and was heavily involved in case management, often confronted by challenging cases for whom programs like PACE could provide helpful solutions. Leading PACE seemed to be a natural evolution in his career path to provide care for marginalized and disadvantaged patients. He considers PACE to be a calling and ministry to this population and greatly looks forward to this new career chapter. ISSUE #148 25

Mental Wellness

What I’ve Learned About Parent Adult-Child Estrangement BY JAN ANDERSON, PSYD, LPCC

Parents call it estrangement. Adult children are more likely to call it no contact. Regardless of what you call it, the near epidemic of adult children cutting off their parents is a thing. It used to happen primarily to parents who severely abused their children. Or your ex turned your kid against you or made them choose sides, and they didn’t pick you. Today’s young adults seem to have more reasons than ever to break up with their parents. Nowadays, it’s just as likely to be your daughter-in-law or son-in-law driving the estrangement. Or your adult child may decide to dump you based on differences in politics, personality, or lifestyle. The cut-off may be accompanied by demands that you apologize, observe their boundaries, get your own therapy, or just go away. I wouldn’t wish parent adult-child estrangement on my worst enemy.

How Estrangement Really Works Estrangement counseling is one of my specialties. I write about this incredibly painful topic often for MD-Update and on social media. As my knowledge keeps evolving and unfolding, I keep sharing what I’ve seen and learned from this FGO (freakin’ growth opportunity) we call estrangement. Here’s the good news: Most of the traps parents fall into are due to people just being human. Even so, one of the great things about humans is that we’re intelligent and adaptive. Our human nature may predispose us to fall into traps, but we’re also pretty good at figuring out how to get out of them—and updating our mindset so we don’t fall into the same trap again. Let’s start with some hardball about how estrangement really works. Then, we’ll focus on two primary skills that can help you reduce the sheer suffering of estrangement and increase your chances of reconnection with your adult child.

Mindset Update 1: Recognize that your adult child may be unwilling or unable to work on the relationship with you. It’s not unusual for you as a parent to want more closeness and connection with your adult child than they want with you. Even so, realizing you’re no longer that big a priority in your adult child’s now-overcrowded life can sting. When it comes to estrangement, your adult child may not feel anywhere near the sense of urgency you do about healing the rift. With lots of life ahead of them, it’s easier for your adult child to take the position I don’t want to. And you can’t make me. It’s also possible that your adult child may not have the capacity to do the psychological work required for reconciliation and recon26 MD-UPDATE

nection. They may not (yet) have the emotional intelligence and social skills necessary to handle conflict, especially with a former authority figure like you. Heck, do you know anyone who’s naturally good at conflict resolution? If your adult child is conflict-avoidant (aren’t most of us?), they may see the only way to handle the hot potato of conflict with an extreme form of avoidance—no contact. It may be extreme, but you have to admit it’s a simple, black-andwhite solution. If confronted, your adult child may display the annoyingly human tendency to get defensive and counterattack. They may find it easier to make you wrong or bad to justify their decision to cut you off. Let’s face it: It’s simpler and requires much less strategic thinking and negotiating skills.

Mindset Update 2: Recognize that the balance of power has shifted. In the beginning, when your adult child starts saying and doing things you don’t like, it’s easy to forget that the balance of power has shifted. From a negotiating standpoint, you are now in a one-down position. Here’s an example. Your adult child may have a very different recollection of their childhood and perception of your parenting. The way your adult child remembers it or sees it now may not seem fair—or even accurate— to you. It’s natural to feel a need to object or question your child’s perception. It’s natural to expect that you deserve a chance to defend or at least explain yourself and put things into perspective. It’s also a trap. As a conflict resolution strategy, it’s a trap to lead with trying to talk your child out of their feelings and convince them that they’re wrong. But it’s not a good move for you to do

Mental Wellness

this at this stage of negotiations. It’s a matter of timing. That doesn’t mean your feelings don’t count and don’t need to be processed. For now, process your feelings with someone else.

Mindset Update 3: Rethink what you’re getting from your current strategies. What do you get when you go Rambo? When you’re feeling helpless rage or righteous indignation, resorting to threats, coercion, or retaliation is easy. These power plays are tempting because they may bring you a few moments of brief relief. Here’s what a power play costs you: Relationship repair. So you won the battle. Yay for you. You just lost the war.

What do you get when you go covert and clandestine? When you’re feeling powerless, it’s easy to fall prey to guilt trips, subtle pressure, and other forms of manipulation. Here’s why these covert power plays are so tempting: They may work! You may succeed at making your adult child feel guilty or pressured. Just don’t expect that to make them then want to be with you. Here’s what covert power plays cost you: Relationship connection. Why would your adult child want to be around someone who makes them feel bad?

What do you get when you go desperate? You’d think that acts of sheer desperation would trigger some empathy from your adult child. One distraught father told me, “If my daughter could only see how much this estrangement is tearing me up, I think

she’d stop doing this to me.” My response? Don’t count on it. Your daughter is more likely to accuse you of being a narcissist and making it all about you.

The Bigger, Better Offer: Get more resilient. Get more strategic. The balance of power in your relationship may have shifted, but that doesn’t mean you have to become a victim. There are ways you can reclaim some of your sanity and learn to strategize better so you increase your chances of getting what you really want: reconnection with your adult child. It’s a two-pronged approach that focuses on building emotional resilience and strategic thinking skills. The magic of these two skills is that they play off and reinforce each other, so you can start with either one.

Get More Resilient Focusing on resilience will give you two practical skills to face inner conflict. 1. Distress Tolerance: Learning to cope in the moment without making it worse. Distress tolerance is about replacing habitual freak-out behaviors with more effective short-term coping strategies. These simple techniques help you slow things down so you can get grounded physically, regulate your emotions, and get through stressful situations. One of my favorite tools is an app based on research by Dr. Judson Brewer. You can practice in as little as 20-30 seconds and his small moments, many times approach has been shown to be highly effective. 2. Emotional Regulation: Emotional regulation focuses on long-term lifestyle behaviors that make it easier to stay

emotionally balanced over time. What keeps you in balance? Is it getting enough rest or exercise? Staying in touch with friends? How do you know you’re getting out of balance and making yourself susceptible to getting frayed emotionally? I know I’m in trouble when I find myself eating ice cream for breakfast, explained one of my clients.

Get More Strategic I suggested earlier that you recognize that the balance of power has shifted. It’s an invitation for you to start thinking strategically about how to renegotiate the terms of relationship with your adult child. For example, your ability to recognize that you are now in a one-down position is not fun, but it can help shift from a deadlock mindset into a negotiating frame of mind. In a negotiation, you have to be able to consider more than one perspective. Holding alternative perspectives not only frees up your problem-solving capacity. It also gives you a little relief from the negative emotions attached to one particular view. What if your adult child isn’t doing this because they don’t care? What if they’re not doing it because they enjoy hurting you? What if they’re in pain, too? What if it’s more about them? What if they’re doing what they think is in their best interest? Developing your ability to think like this is the estranged parent’s superpower. It enables you to accept what is while simultaneously working for change. It can enable you to let go without giving up. It can allow you to go on with your life without abandoning hope. It can help you to love your child from a distance. It can even empower you to learn from the experience without being destroyed by it.

YOUR RESOURCE FOR THE BEST IN KENTUCKY HEALTHCARE ISSUE #148 27

News News News

SEND SEND YOUR YOUR NEWS NEWS ITEMS ITEMS TOTO MD-UPDATE MD-UPDATE > news@md-update.com > news@md-update.com

Baptist Health Louisville Adds New Physicians LOUISVILLE Lindsay Snow, MD, has joined

Baptist Health Medical Group. Snow is board certified in family medicine as well as medical acupuncture and has special interests in women’s health and LGTBQ+ medicine. She is also a certified lactation counselor. Snow comes to the Baptist Health Medical Group after training at the UofL School of Medicine and completing a family medicine residency in St. Louis. B. Arayo Sokan, MD, has joined Baptist Health Medical Group. Sokan specializes in primary care and is a member of the American College of Physicians. He trained at the UK College of Medicine and was an internal medicine resident at the University of Cincinnati College of Medicine. Conor O’Neill, MD, has joined Baptist Health Medical Group. He is a primary care specialist with certifications from the American Heart Association in Basic Life Support and Advanced Cardiovascular Life Support. O’Neill trained and completed an Internal Medicine residency at the UK College of Medicine. Samuel Walling, MD, has joined Baptist Health as a colorectal and general surgeon, offering compassionate, patient centered care. He specializes in minimally invasive colorectal and general surgery procedures, including surgery to treat colon and rectal cancer, diverticulitis, Crohn’s disease, ulcerative colitis, fecal incontinence, hemorrhoids, and anal fistula, as well as gallbladder surgery and hernia repair. Walling trained at the UofL School of Medicine and completed a general surgery residency at the UK Albert B. Chandler Medical Center and the UK Good Samaritan

28 MD-UPDATE

Lindsay Snow, MD

B. Arayo Sokan, MD

Conor O’Neill, MD

Samuel Walling, MD

Madeline Baker, MD

Calvin Ward, MD

Hospital. He also completed a colon and rectal surgery fellowship at both UK hospitals. Madeline Baker, MD, has joined the Baptist Health Medical Group and is accepting new patients in Louisville and Shelbyville. Baker specializes in OB-GYN and provides all women’s health needs, including annual wellness visits, preconception care, complete pregnancy/ postpartum care, and menopause management. Baker trained at the UofL School of Medicine, where she was the Ryan Residency Family Planning Resident of the Year and Golden Apple award winner for teaching excellence.

PHOTOS PROVIDED BY BAPTIST HEALTH

LEXINGTON Calvin Ward, MD, has joined the

Baptist Health Medical Group Maternal-Fetal Medicine team. Ward is available to provide maternal-fetal medicine care, from the assessment of fetal growth and well-being to the diagnosis and management of nonroutine pregnancies. He is a graduate of the UK College of Medicine, where he completed the maternal-fetal medicine fellowship program. He completed his OB-GYN residency at Ohio State University College of Medicine/Mount Carmel Hospital, where he served as administrative chief resident.

SEND YOUR NEWS ITEMS TO MD-UPDATE > news@md-update.com

CHI Saint Joseph Medical Care – OB/GYN Welcomes New Physician and APRNs LEXINGTON Katherine Foster, MD, has joined

CHI Saint Joseph Medical Group – OB/GYN in Lexington. Foster hails from Cincinnati, Ohio, and is dedicated to a patient-centered approach and is focused on making a lasting impact on the field of gynecology and women’s health. Foster received her BA in microbiology, graduating magna cum laude from Miami University in Oxford, Ohio. She received her medical degree from the Ohio State University College of Medicine and Public Health. She completed a two-year research fellowship at the University of Texas MD Anderson Cancer Center, where she investigated new therapies for treatment-resistant ovarian cancer. Colleen Honey, MSN, APRN, FNP-BC, has joined the CHI Saint Joseph Medical Group – OB/GYN. Honey earned an associate degree in nursing from Bluegrass Community

Katherine Foster, MD

Colleen Honey, APRN

and Technical College and her nursing degree from Western Governors University. She earned her Master of Science in nursing from Indiana Wesleyan University in 2021. BARDSTOWN CHI Saint Joseph Medical Group

– OB/GYN in Bardstown has added Katy Marcum, APRN, to its team of caregivers.

Katy Marcum, APRN

Marcum began her career as a registered nurse in labor and delivery at Flaget Memorial Hospital and brings labor and delivery, lactation, and women’s health expertise to the team. In addition to working in labor and delivery, Marcum is also a certified lactation counselor, helping new mothers with breastfeeding. Marcum received her BS in nursing from Midway University and her MS from Frontier Nursing University. She has had more than 12 years of experience in obstetrics, nursing and gynecology, and pain management.

Lexington Clinic Welcomes 3 New Physicians LEXINGTON Carlos Ramirez-Icaza, MD, is

board-certified in sleep medicine, critical care medicine, pulmonary medicine and internal medicine. He received his medical degree from Indiana University School of Medicine and has been in practice for more than 20 years. He performs bronchoscopy, thoracentesis, and indwelling pleural catheter placements in addition to providing services in complete pulmonary function evaluation including spirometry, lung volumes, diffusing capacity, arterial blood gases, and pulse oximetry. His professional interests include COPD, asthma, and intestinal lung disease. Icaza is fluent in English and Spanish. Kory N. Brinker, DO, attended the University of Kentucky for both his undergraduate and graduate education, where he received his BS in agricultural biotechnologies and his MS in public health. He then attended the University of Pikeville, Kentucky College of Osteopathic Medicine for his

Carlos Ramirez-Icaza, MD

Kory N. Brinker, MD

medical training. Brinker is board certified in family medicine and provides services in general family medicine, geriatric medicine, women’s, pediatrics, urgent care, and preventive medicine. Robert Christopher Spears, MD, received his medical degree from UofL School of Medicine. He completed a residency in neurosurgery at UK. Spears provides consultation services in cranial, spinal, and peripheral nerve surgery, including brain tumors, vas-

Robert Christopher Spears, MD

cular lesions, spinal tumors, degenerative spinal disease, epilepsy, pituitary tumors, and compressive neuropathies. Spears’ professional interests include primary and metastatic tumors of the brain and spinal cord. Lexington Clinic was founded in 1920 and is Central Kentucky’s oldest and largest group practice with 300+ providers in 30 different specialties and serves more than 600,000 patients every year in its 25+ locations throughout Central Kentucky.

PHOTOS PROVIDED BY CHI SAINT JOSEPH HEALTH AND LEXINGTON CLINIC

ISSUE #148 29

News

Interventional Pain Specialists Merges with Louisville-based Commonwealth Pain & Spine GREEN Interventional Pain Specialists (IPS), South Central Kentucky’s premier chronic pain practice, merged with Louisville-based Commonwealth Pain & Spine. The merger, effective August, 2023, brings together two organizations utilizing a multi-modal approach to pain management. Founded in 2012, Commonwealth Pain & Spine serves the region with over 400 employees, including 15 physicians in 17 clinics across Kentucky, Indiana, and Illinois. IPS has four offices in Bowling Green, Glasgow, and Franklin and is a complementary geographic fit with Commonwealth. “We are excited to announce our partnership with Interventional Pain Specialists. This merger is a big step forward in our commitment to providing high quality pain care to the people of Kentucky,” said Kyle Young, MD, one of Commonwealth’s founding partners. “The BOWLING

Heart Care Expands in Madison, Indiana, surrounding counties Norton Heart & Vascular Institute welcomes Keith A. McLean, MD, cardiologist MADISON, IN Norton Heart & Vascular

Institute welcomed Keith A. McLean, MD, cardiologist, to Norton King’s Daughters’ Health in Madison, Indiana, in the Norton King’s Daughters’ Health Downtown Medical Building. McLean is board certified in cardiology and provides specialized heart care for his patients, including education and treatment of key factors to prevent heart disease. Having a practice in Madison allows Dr. McLean to provide care close to home for patients in Jefferson, Scott, Ripley, Switzerland, and surrounding counties in Indiana. “I am looking forward to working in the Madison community and I’m excited to connect with patients from the area,” said McLean who brings 25 years of experience in cardiology to the Norton Heart & Vascular Institute team. He joins cardiologists Anil K. Sharma, MD, and Gerasimos S. Stavens, MD, in the Madison office. Before joining Norton Heart & Vascular Institute, McLean was a cardiologist with JenCare Senior Medical Center in Louisville, Kentucky, and was director of echocardiography at Edward Hines, Jr. VA Hospital in Hines, Illinois. McLean is an associate member of the American College of Cardiology. 30 MD-UPDATE

Christian Unick, MD

Kyle Young, MD

providers and administrators at IPS will be a great addition to our growing team.” IPS has been a cornerstone of pain management in the region for over 30 years. Daniel Reynolds, MD, Christian Unick, MD, and Eric Vessels, MD, lead the team’s five fellowship-trained and board-certified physicians, and will continue to provide patient care post-merger. “Our merger marks an exciting new chapter for Interventional Pain Specialists,” said Unick.

LEXINGTON MEDICAL SOCIETY Physicians taking care of the community since 1799

The Lexington Medical Society is the principal voice & resource for Central Kentucky physicians to enhance their professional lives & improve the health of the community • Physician Wellness Program – Take care of your patients by taking care of yourself. » 8 free counseling sessions per calendar year » Completely confidential and easy access » Call (800) 350-6438

For more information visit

lexingtondoctors.org or call

(859) 278-0569

• Credentialing • 24/7 Medical Call Center • Legislative advocacy in partnership with the Kentucky Medical Association • Events and programing throughout the year

PHOTOS PROVIDED BY NORTON HEART & VASCULAR INSTITUTE AND COMMONWEALTH PAIN & SPINE

Events

GLMS Foundation Doctor’s Cup scholarship recipients with their checks. This year the GLMS Foundation awarded 11 scholarships at $10,000 each. PHOTO PROVIDED BY GREATER LOUISVILLE MEDICAL SOCIETY

LOUISVILLE The GLMS Foundation hosted

The GLMS Doctor’s Cup Greater Louisville Medical Society Foundation Gives Record Amount for Scholarships

their 13th annual Doctor’s Cup golf scramble on September 18th where they awarded 11 scholarships for $10,000 each — a new record amount! With 28 teams playing for the title and to support the future of medicine, it was a beautiful day. Save the date for next year’s Doctor’s Cup on September 30th at Hurstbourne Country Club.

Poor documentation during intake resulted in a

wrong-site surgery

causing permanent damage to a good knee.

The Joint Commission data reveals that wrong-site incidents are the fourth most frequently reported sentinel event. To minimize surgical errors, practices insured by ProAssurance can access annual risk assessments to learn how well their surgical teams and protocols are working. Risk consultants gather and review the data, note potential weak spots, and deliver recommendations based on former claims. Helping our insureds assess their patient safety procedures and sharing strategies learned from our closed claims history helps them mitigate risk and be prepared if they ever need to face a malpractice claim.

* The Joint Commission, Sentinel Event data released for 2022. Visit: bit.ly/43TXUGi.

ProAssurance.com • 800-282-6242 ISSUE #148 31

Events

Sixteen past presidents of the Lexington Medical Society: Front row (l-r): Lisle Dalton, MD, Michael Lally, MD, Robert Granacher, MD, Emery Wilson, MD, Allen Grimes, II, MD, Bruce Brody, MD. Back row; John Collins, MD, Terry Clark, MD, David Bensema, MD, Dale Toney, MD, Khalil Rahman, MD, Terrence Grimm, MD, Tuyen Tran, MD, Thomas Waid, MD, Farhad Karim, MD, Robert Belin, MD. Attended but not pictured John Stewart, MD.

Past Presidents Gather at Lexington Medical Society Meeting LEXINGTON The annual LMS/KMA 10th

District Trustee/Past Presidents Dinner meeting of the Lexington Medical Society brought together 16 former presidents of the Society on October 10 at the Signature Club in Lexington. The featured speaker of the evening was Michael Kudak, MD, current president of the Kentucky Medical Association, who spoke on multiple topics, including the KMA Physician Leadership Institute; the KMA annual meeting; “Voices for Vaccination,” a KMA public health initiative encouraging compliance and supported by the KY Hospital Association and the KY Nursing Association; the KMA

CME guarantee; and the KMA Physician Care program. Kudak also spoke about KMA initiatives in the KY legislature including its emphasis on prior authorization reform. The next meeting of the Lexington Medical Society is scheduled for January 16, 2024, with the installation of new leadership team of officers: Angela Dearinger, MD, president, Hope Cottrill, MD, president-elect, Christine Ko, vice president, Tina Fawns, MD, vice-president elect, and Marisa Belcastro, MD, sec/treasurer. Information on the Lexington Medical Society is available at 859.278.0569 and www.lexingtondoctors.org.

Michael Kudak, MD, Winchester pediatrician and current president of the Kentucky Medical Association, spoke on multiple topics concerning KY doctors.

Lee Dossett, MD, LMS president, addresses the audience.

1Y UK medical students with KMA president: Anna Mae Flannery, Jonathan Hauke, Gabriella Beharry, Michael Kudak, MD, Emily Izgarjan, and Kate Whitman. 32 MD-UPDATE

PHOTOS BY JOE OMIELAN

Miller DeWeese of Professional Purchasing Group, an LMS meeting sponsor, speaks with a new Lexington physician.

Melanie Townsend, MD Otolaryngologist/Head & Neck Surgical Oncologist

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