MD Update Issue 149

THE BUSINESS MAGAZINE OF KENTUCKIANA PHYSICIANS AND HEALTHCARE PROFESSIONALS ISSUE #149 WWW.MD-UPDATE.COM

No Pain Points Here VOLUME 13 • #6 • December 2023/January 2024

By taking an innovative approach to treatment and a progressive position on staffing, Commonwealth Pain & Spine is changing the face of pain management ALSO IN THIS ISSUE NEURO-ONCOLOGY AT UOFL HEALTH – BROWN CANCER CENTER MYOPIA, THE SILENT OPHTHALMIC EPIDEMIC EXPANSION AT THE PAIN TREATMENT CENTER OF THE BLUEGRASS MIGRAINE TREATMENT AT NORTON NEUROSCIENCE INSTITUTE TRANSCRANIAL MAGNETIC STIMULATION FOR DEPRESSION AT WELLWARD MEDICAL PHYSICIAN SUICIDE PREVENTION

Experience Matters.

The board-certified physicians at CHI Saint Joseph Medical Group — Orthopedics are proud to offer comprehensive orthopedic care.

When your quality of life has been affected by a bone or joint disorder, the orthopedic team at CHI Saint Joseph Medical Group is ready to get you back on your feet. With over 50 years of combined experience, our board-certified and fellowship-trained surgeons are passionate about their high standards of care.

Berea 305 Estill Street Berea, KY 40403

London 148 London Mountain View Drive, Suite 4 London, KY 40741

P 606.864.0770

P 606.864.0770

Bardstown 875 Pennsylvania Avenue Bardstown, KY 40004

160 London Mountain View Drive London, KY 40741

P 502.348.5685 Corbin 1 Trillium Way, Suite 306 Corbin, KY 40701

P 606.864.0770 Flemingsburg 101 JB Shannon Drive, Suites A & B Flemingsburg, KY 41041

P 606.209.0010 Lebanon 325 W. Walnut Street, Suite 300 Lebanon, KY 40033

P 502.348.5685 Lexington 211 Fountain Court, Suite 320 Lexington, KY 40509

Orthopedics Team

Collin Ball, DPM

Patrice Beliveau, MD

Anup Chattha, MD

Vincent DePalma, DO

Adam Franson, DO

Kevin Magone, MD

James Rollins Jr., MD

Frank Taddeo, MD

P 606.864.0770 Mount Sterling 624 N. Maysville Road, Suite A Mount Sterling, KY 40353

P 859.497.4144 Somerset 118 Tradepark Drive, Suite B Somerset, KY 42503

P 606.416.5225 Winchester 1850 Bypass Road Winchester, KY 40391

P 859.737.5188

P 859.264.9820

Jan Veloso, DPM

CHISaintJosephHealth.org

THE BUSINESS MAGAZINE OF KENTUCKIANA PHYSICIANS AND HEALTHCARE PROFESSIONALS

THE BUSINESS MAGAZINE OF KENTU

Editorial Calendar

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2024

ISSUE #146 WWW.MD-UPDATE.COM

ISSUE #150 (February) HEART & LUNG HEALTH

Above and Beyond

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

Endocrinologist Kupper Wintergerst, MD, and his team go the extra mile for their patients with diabetes

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ESSIONALS

ISSUE #151 (April) INTERNAL SYSTEMS

Dermatology, Endocrinology, Gastroenterology, Geriatric Medicine, Internal Medicine, Integrative Medicine, Infectious Disease Medicine, Lifestyle Medicine, Nephrology, Urology

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

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

ATRIST CHI SAINT JOSEPH HEALTH PSYCHI SEES DISTURBING TRENDS IN ADOLESCENET MENTAL HEALTH

VOLUME

VOLUME 13 • #3 • JULY 2023

Lexington Clinic Orthoped ic Surgeon Tharun Karthikeyan, MD , Embraces the Advantages of the ROSA Robot

UofL HEALTH - CENTER FOR WOMEN’S HEALTH EXPANDS CARE INTO COMMUNITIES

AGAZI INESS M

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ISSUE #147 WWW.MD-UPDATE.COM

ALSO IN THIS ISSUE

THE BUS

OF KENTUCKIANA PHYSICIAN

ISSUE #153 (September) MUSCULOSKELETAL HEALTH

Orthopedics, Physical Medicine & Rehabilitation, Sports Medicine, PT/OT

ISSUE #154 (October) CANCER CARE

Hematology, Oncology, Plastic Surgery, Radiology, Radiation

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

ENT, Mental Health, Neurology, Neuroscience, Ophthalmology, Pain Medicine, Psychiatry Editorial topics and dates are subject to change

To participate, please contact Gil Dunn, Publisher GDUNN@MD-UPDATE.COM 859.309.0720 (direct) • 859.608.8454 (cell) Send press releases to gdunn@md-update.com

LETTER FROM THE EDITOR/PUBLISHER MD-UPDATE MD-Update.com

Welcome to the “It’s All in Your Head” issue of MD-Update!

Mental health is the newest challenge facing the world’s healthcare providers. Post COVID-19, the World Health Organization has added mental health to its list of Sustainable Development Goals, saying that depression is one of the leading causes of disability and that “people with severe mental health conditions die as much as two decades earlier due to preventable physical conditions.”

The October 10, 2023, issue of Time focused on the stressful and debilitating changes that American teenagers are living with: anxiety, depression, suicide, gun violence, social isolation, sexual violence, and cyber-bullying. Multiple studies show that young adults are manifesting more mental health problems than their peers did decades ago, brought on by a combination of COVID19 isolation, social media, political division in the world, and the ominous fear of climate change.

With bad news just a “swipe” away, it’s no wonder teens are troubled.

Pain, Depression, Brain Tumors, Myopia, and Migraine We have a wide selection of physician stories in this issue. Our cover story has a slightly different approach as we not only introduce you to two new interventional pain medicine specialists, but we also go behind the scenes to meet the leadership team of the five female top executives at Commonwealth Pain & Spine.

In our Special Section stories, neuro-oncologist Guneet Sarai, MD, reveals where her motivation comes from when she treats patients with brain tumors. Our friend Bruce Koffler, MD, shares his concerns and personal history dealing with myopia. The long-standing Pain Treatment Center of the Bluegrass is expanding. Dr. Brian Plato, Norton Neuroscience Institute neurologist and migraine specialist, addresses widely held misconceptions and new treatment options for migraine.

Danesh Mazloomdoost, MD, and Wellward Medical continue to innovate with new uses of technology in his ongoing quest for integrated wellness.

Physician Wellness You’ll find a discussion on physician suicide and physician wellness on page 24, written by psychiatrist Courtney Markham-Abedi, MD. I’m grateful to Dr. Markham for her contribution to MD-Update on a difficult topic and invite you to read what she has to say.

Errors and Omissions We had some errors and typos in the Women First of Louisville story in MD-Update #148 that we need to correct. Women First started their mammography screening in 2006. The practice now has at least 20 all-female practitioners. Delaying a first pregnancy until after the age of 25 may be a risk factor. Dr. Rebecca Booth was honored as one of Today’s Women Most Admired in 2009.

We regret the errors and apologize for any misunderstanding regarding the exemplary practices at Women First of Louisville.

Next year is already here and so is the 2024 MD-Update editorial calendar on the preceeding page. When you see your specialty, give me a call. I’m sure you have a good story to share.

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

Volume 13, Number 6

ISSUE #149

EDITOR/PUBLISHER

Gil Dunn gdunn@md-update.com GRAPHIC DESIGN

Laura Doolittle, Provations Group COPY EDITOR

Amanda DeBord

CONTRIBUTORS:

Jan Anderson, PSYD, LPCC Courtney Markham-Abedi, MD Bruce Koffler, MD Philip Massey Scott Neal, CPA, CFP Douglas Stephan, Esq.

CONTACT US: ADVERTISING AND INTEGRATED PHYSICIAN MARKETING:

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o Pain 10 N

Points Here

By taking an innovative approach to treatment and a progressive position on staffing, Commonwealth Pain & Spine is changing the face of pain management

CONTENTS 4 6 7 8 10

HEADLINES ACCOUNTING FINANCE LEGAL COVER STORY

SPECIAL SECTION: 14 NEURO-ONCOLOGY 16 PAIN MEDICINE 18 OPHTHALMOLOGY 20 REGENERATIVE MEDICINE 22 NEUROLOGY 24 PSYCHIATRY 26 MENTAL WELLNESS 28 NEWS 32 EVENTS

COVER PHOTOGRAPHY BY ALEXANDRA ROGERS

ISSUE #149

14 NEURO-ONCOLOGY

16 PAIN MEDICINE

18 OPHTHALMOLOGY

20 PAIN/REGENERATIVE MEDICINE

22 NEUROLOGY

24 PSYCHIATRY ISSUE #149 3

Headlines

UofL Health Depression Center Conference

Advances in biological and psychosocial treatments for mood disorders

BY JAN ANDERSON PSYD, LPCC LOUISVILLE Kentucky

healthcare professionals are fortunate to have one of the nation’s top depression centers right here at the University of Louisville. The UofL Health Depression Center Conference, November 16–17, 2023, drew nationally recognized researchers focused on advanced methods for challenging clinical problems.

Michael Thase, MD Jennifer Wood, MD What are some of the most promising developments in mental health treatment? tive behaviors. For the process to work, new behaviors need to feel better in the moment, Evaluate and Manage Difficultnot just like delayed gratification. to-Treat Depression.

The acronym “TRAP” (trigger, response, It starts with removing any connotation avoidance pattern) is a clever way to identify of blame attached to the diagnosis, suggest- the depression loop behavior, which is then ed Michael Thase, MD. That’s why it’s no replaced with a “TRAC” (trigger, response, longer called treatment resistant depression. alternate coping) response.

Difficult-to-treat depression (DTD) is not The general program is described with the a diagnosis; it’s more of a description of the acronym “ACTION” (assess behavior/mood, patient’s prognosis and course of treatment. choose alternate responses, try out those alternate responses, integrate these alternatives, Behavioral Activation for observe results, and (now) evaluate).

Treating Depression and Anxiety.

Here’s how BA can help reduce rumination, Behavioral activation (BA) is a third-gener- a particularly common avoidance behavior ation behavior therapy for treating depression that worsens mood: and anxiety. The emphasis is on engaging in • Trigger: What gets the rumination started? positive and enjoyable activities to enhance • Response: Describe the rumination menone’s mood. tal behavior. What does the patient tell This does not just mean encouraging your themself? patients to “get out there” and schedule enjoy• Avoidance Pattern: What does the patient able activities, get more exercise, and socialize get from rumination? How does it tempomore, says Thase. BA focuses on connecting rarily help them? the dots between actions and emotional con• Evaluate the effectiveness of rumination as sequences. The goal is to identify “depression a coping strategy: Did it improve the sitloops,” coping behaviors that provide temporary uation they were ruminating about? How relief but come with high-cost consequences. they feel after ruminating?

Whether it’s avoidance, escape, rumination, • Identify and experiment with alternate copalcohol, or other drugs, the idea is to replace ing responses that might work better and less effective coping patterns with more adapmake the patient feel better. For example, 4 MD-UPDATE

PHOTOS PROVIDED BY UofL HEALTH DEPRESSION CENTER

ask them to substitute a different behavior (e.g. watching a comedy).

Try reducing the amount of rumination by giving themself a time limit to their rumination. If it’s too late and they’re already in the TRAP, advise them to not fight or resist the rumination. Instead, simply notice (without judgment) the felt experience of ruminating. Ask, What’s it like to ruminate?

Does it feel expansive or contracted?

Are there any specific sensations or areas of the body that activate when they are ruminating? How do they feel after ruminating?

• Finally, tap into the part of their brain that is designed to compare relative rewards.

Evaluate all the results of any alternative behaviors compared to rumination behavior. Compare results from each behavior (positive, negative, or neutral) in the moment, versus later.

Is Estrogen to Blame?

The hormonal fluctuations in women during the teenage and perimenopausal years are a major, but not the only, influence in mood disorders. While estrogen has been the main focus of research and is strongly associated with mood, it’s more complicated than that, according to Jennifer Wood, MD. Here’s what we do know: About one-third of gynecologists do not ask their patients about depression.

Here’s why that needs to change: Until puberty, there’s no difference in depression rates between boys and girls. Starting at puberty, female rates of depression increase to twice that of males.

Make a Safety Plan Patients who contemplate or attempt suicide say that implementing a safety plan was

SPECIAL SECTION the thing that made the most difference in their treatment outcome and recovery.

Stephen O’Connor, PhD, shared recent research on suicide risk and key findings that can improve how we evaluate and treat patients with risk for suicide, including action steps for helping someone in emotional pain.

How Can You Help Someone in Emotional Pain?

• Ask: Are you thinking of killing yourself?

• Keep them safe: Reduce access to lethal items, means, and places.

• Be there: Listen carefully and acknowledge feelings.

• Help them connect: Call 988 (Suicide and Crisis lifeline. A person doesn’t have to be suicidal to call, and there is a substance abuse option.

• Stay connected: Follow up.

The Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) 1. Identify risk factors: Note those that can be modified to reduce risk.

2. Identify protective factors: Note those that can be enhanced.

3. Conduct suicide inquiry: Ask them about their suicidal thoughts, plans, behavior, and intent.

4. Determine risk level/intervention: Determine risk. Choose the appropriate intervention to address and reduce risk.

5. Document your assessment of the risk, rationale, intervention, and follow-up.

More information is at https://store.samhsa. gov/sites/default/files/sma09-4432.pdf Other breakout sessions covered the most promising developments in these areas of mental health treatment: • Core methods for assessing and treating cognitive impairment in mood disorders and mood disturbances in dementia.

• Evidence-based treatment strategies for depression related to trauma.

• Mood symptoms and evidenced-based interventions for improving coping and promoting well-being in patients with life-limiting illnesses.

• Core principals of interpersonal psychotherapy, evidence for its effectiveness, and examples of the diverse and widespread applications of this treatment method.

Headlines

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• 24/7 Medical Call Center • Legislative advocacy in partnership with the Kentucky Medical Association • Events and programing throughout the year • Installation of officers, January 16, 2024 ISSUE #149 5

Accounting

HIPAA-Compliant Accounting Software (Part 2)

BY PHILIP MASSEY, SOFTWARE SERVICES DIRECTOR

Editor’s intro: This is part 2 of a description of HIPAA Compliant Accounting Software. Part 1 is available in MD-Update Issue #148.

How Does HIPAA Compliance Work?

For an organization to become HIPAA-compliant, they must create policies, examine current practices, and implement necessary changes.

The Department of HHS’ Office for Civil Rights, the governing body that oversees HIPAA rule enforcement, does not offer any formal designation for an organization that complies with the rules. Rather, compliance is tested through audits and reporting. Only when an organization is found to be out of compliance through an audit or evaluation is formal action taken.

To understand this process in-depth, we need to review the full text of the HIPAA rules.

Here is a high-level overview of steps an organization must take to achieve and maintain HIPAA compliance.

1. Designate HIPAA Privacy and Security Officers These roles can be held by one or more individuals. The persons with these positions should receive formal security officer training and be granted authority within the organization to act on behalf of the company in the interest of maintaining compliance. They are also tasked with creating and implementing the organization’s HIPAA compliance program.

2. Establish Security Safeguards To ensure the security and privacy of PHI handled by your company, your designated HIPAA officers must establish organization-specific privacy and security protocols. These policies should be well-documented, updated, and shared with staff and contractors as part of a regular training program. In fact, HIPAA mandates that staff be trained on HIPAA policies at the time of orientation and at minimum once yearly after that. At the conclusion of their training, they must 6 MD-UPDATE

sign a document asserting they understand the HIPAA policy.

There are three types of safeguards that are mandated by HIPAA rules: Administrative Safeguards: These are the security measures that govern how HIPAA policy is administered within the organization. It covers the adoption of security systems, training of personnel, and regular assessment of security measures.

Physical Safeguards: These policies dictate how PHI is kept secure within the physical confines of the office or data center. While ePHI is at the greatest risk from hackers, there are still many instances of theft from employees or contractors who can physically access data on-site.

Technical Safeguards: These security measures protect ePHI from cyberattacks.

Both hardware and software must be audited and controlled to ensure they meet HIPAA network requirements. There must also be procedures established for the proper editing of digital records.

3. Draft a Breach Notification Protocol This protocol ensures that an organization is in a state of readiness to report should a breach occur. HIPAA mandates that the following groups must be notified: Individuals: All individuals whose PHI was compromised must receive notification within 60 days of the incident.

Media: When a breach affects more than 500 residents of a state or jurisdiction, organizations are required to notify major media outlets in that region within 60 days of the incident, sharing the same information that was sent to the affected individuals.

Secretary of Health and Human Services: The Secretary must be notified of any breaches, regardless of the number of individuals affected. Like media notification, if the breach impacts 500 or more

individuals, the Secretary must be notified no later than 60 days following the breach.

For breaches affecting fewer than 500 individuals, incidents may be reported annually.

4. Maintain Business Associate Agreements All covered entities must receive satisfactory assurances that business associates are HIPAA-compliant. Business Associate Agreements should be reviewed on an annual basis. When entering into a contract with a business associate, covered entities should outline the details of when and how the business associate is permitted to use protected health information.

5. Keep Complete Records and Conduct Regular Self-audits HIPAA compliance is an ongoing process that is subject to self-reporting and outside audits. Maintaining records is critical to an organization to avoid fines and penalties for falling out of compliance. This applies not only to your internal documents and files but also any systems or software used by employees and associates.

In assessing whether accounting software meets HIPAA standards, you’ll want to determine where the data is stored (servers versus local computers and devices), who has access, and which practices are being used by business associates. Note that organizations are still responsible for PHI that might be vulnerable due to lax passwords or access controls, even if the software itself is encrypted end-to-end.

Keep Your Business in Compliance Partnering with HIPAA-compliant accounting software like Sage Intacct is an important step to safeguarding your patient’s vital information as well as avoiding penalties, which can be costly both to your bottom line as well as your reputation.

To learn more about the benefits of working with HIPAA-complaint accounting software, contact pmassey@ddaftech.com

Finance

A Year in Review and the Road Ahead

BY SCOTT NEAL, CPA, CFP®

Bidding farewell to 2023 and stepping toward the exciting and unpredictable world of 2024, let’s reflect on the economy and investment markets, and their impact on our wellbeing.

The Economic Landscape of 2023 The global economy was characterized by both optimism and uncertainty. Some key trends and events that had an impact over the past year: • Pandemic recovery: Being in healthcare, you may disagree that significant progress was made on multiple fronts. From where I sit, vaccination campaigns gained momentum, leading to a gradual return to a sense of normalcy in many regions. In response, governments and central banks implemented fiscal and monetary policies to support businesses and individuals • Inflation concerns became a central focus early in 2023. The year began with rising prices, some of which are beginning to come down, fueled by supply chain disruptions, increased demand brought on, in part, by the fiscal policies of more money in circulation, and increased wage pressures that led to worries about sustained inflation. Sadly, it is often the worry about inflation that drives policy, even more than the actual shift in supply and demand curves, the ultimate driver of inflation.

• A technology boom is clearly underway. The tech sector continued to thrive with rapid advancements in areas like artificial intelligence, renewable energy, and blockchain technology. The rapid change of technology, especially at big companies that are now branded as the “Big 7,” is causing many seniors to rethink staying in the workforce. I got very excited when 60 Minutes recently aired its piece on IBM’s Quantum Computing. If you didn’t see it, you should check it out.

• Of course, 2023 will go down in history for the geopolitical tensions we have seen played

out on the evening news. This is especially true between the major powers: the U.S., China, and Russia. Trade disruptions, cybersecurity issues, and territorial disputes added uncertainty to global markets.

• Climate change and sustainability have become central themes in both economic and investment discussions. Companies have increasingly embraced ESG (environmental, social, and governance) principles and policies, and many investment companies report that more investors seek green and sustainable opportunities.

Looking Ahead to 2024 From this vantage point, let’s turn our attention to what the future might hold for 2024 in the world of economics and investments.

• Physicians are in a better position than I am to assess, but I believe that the pandemic recovery will continue. It appears to me that the journey to full recovery is ongoing, and we may, in our lifetime, never be without COVID somewhere in the world. If I am right, vaccination campaigns will continue, and countries will strive to strike a balance between economic reopening and public health.

• Inflation outlook: Central banks will undoubtedly remain vigilant in their efforts to manage inflation, although they are usually a bit behind the curve. The challenge will be to normalize monetary policies (i.e., short-term interest rates) without causing a sharp economic downturn. Remember that our Fed has a target of 2% inflation. The economist Dr. Woody Brock has painted very good reasons why it is more likely to settle in around 3.0 – 3.5%. At this writing, it is 3.24%. That compares to 3.7% last month and 7.75% last year.

• Tech advancements: The tech sector is expected to continue its rapid growth with innovations in artificial intelligence, quan-

tum computing, and biotechnology. (If any of you have insights on biotech or pharma research, drop me a line.)

• Geopolitical tensions are unlikely to go away anytime soon. Investors should remain attuned to potential risks and opportunities associated with these tensions. Trade policies, sanctions by one country or coalition against another, as well as cybersecurity are likely to remain key issues.

• Sustainable investing (ESG) is likely to gain even more prominence in 2024, with a focus on green infrastructure projects, renewable energy, and companies committed to sustainable practices. Be on the lookout for governments around the globe to potentially enact stricter ESG regulations.

• It seems more important than ever to pay attention to the world economy and particularly emerging markets (i.e., those less well developed). That’s one reason that I read The Economist for its perspective.

Already mentioned is the impact that pandemic recovery is likely to have on global growth. Caution should be exercised to remain aware of potential volatility and political hotspots. Speaking of which, 2024 is an election year in the U.S. Any forecasts could rapidly be undone, depending on who gets elected and who doesn’t.

Conclusion As we navigate the economic and investment landscape of 2024, it’s clear that we are living in a world of both challenges and opportunities.

The lessons of the past year have taught us the importance of adaptability and foresight in making investment decisions. We look forward to helping you make well-informed choices toward achieving your goals and objectives in the coming year.

Scott Neal, CPA, CFP is the president of D. Scott Neal, Inc. a fee-only, fiduciary financial planning and investment advisory firm with offices in Lexington and Louisville. You may write to him at scott@dsneal.com.

ISSUE #149 7

Legal

Duty to Respond to a Subpoena Duces Tecum

BY DOUGLAS STEPHAN, ESQ

Medical practitioners and health care record custodians may be served a subpoena duces tecum (subpoena) to compel attendance at the taking of a deposition or at a judicial hearing or trial, and to bring relevant documents. A subpoena can deal with hard copy and electronically stored information (ESI). So what do you need to do in order to comply with your duty to respond when you receive a subpoena duces tecum?

(This article only addresses subpoenas issued in lawsuits in which you or your practice is not a party; if you or your office is involved in a lawsuit and receive a subpoena in connection with that suit, please contact your attorney immediately.)

Subpoena Basics A subpoena is generally delivered as a state Administrative Office of the Courts (AOC) form but must state the name of the court and the title or style of the action. It must be directed to the witness or record custodian.

It shall command the person to whom it is directed to attend and give testimony at a specified time and place for a particular party.

It must be signed by the officer, otherwise it would not be properly issued.

The subpoena should describe the records sought but routinely may be as broad as “a complete, certified copy of any and all medical/billing records pertaining to a specified patient.” The subpoena will direct a records custodian to appear for a deposition and to produce the requested records. It may also state that the records custodian can produce the records before the specified time in lieu of attending the deposition. A subpoena can be served by certified mail or by personal delivery.

What To Do When You Receive a Subpoena?

Upon receipt of a subpoena: • Immediately forward it to your risk management personnel, as a subpoena for med8 MD-UPDATE

ical, employment, or other records may indicate that a lawsuit is about to be filed.

• Always refer to your office’s written policies regarding the use and disclosure of patient records to determine if the subpoena needs to be directed to a Health Insurance Portability and Accountability Act (HIPAA) compliance officer.

• Finally, the subpoena should be forwarded to your office’s records custodian.

When medical providers receive a subpoena for patient information, HIPAA permits the disclosure of protected health information (PHI) provided certain procedural requirements are satisfied. PHI can be disclosed in response to a subpoena under the HIPAA “litigation exception” following confirmation that the requesting party made “reasonable efforts” to (1) notify the patient or (2) secure a “qualified protective order.” “Reasonable efforts” requires that a notice of the subpoena or intent was sent to the patient or his attorney, the patient had enough time to object, and no objection was made, or all objections were resolved. A “qualified protective order” limits the use of the records and directs that all the records be returned or destroyed at the conclusion of the litigation. If the subpoena does not meet these requirements, the records should not be produced until appropriate documentation is provided.

Certain “privileged” records receive special protection under state and federal law: HIV records, mental health records, psychotherapist notes, communications between your practice and any attorney representing that practice, evaluations prepared at the request of an attorney that would not have been prepared in the ordinary course of business, and (for skilled nursing facilities) material generated by the quality assurance committee. The witness may be required to produce such writings and tangible things as he or she controls even though the witness does not have actual possession of them. If a subpoena requests any

of these documents, please consult the appropriate personnel. It may be necessary to ask your attorney for specifics on how to respond.

Producing the Records… or Objecting If the record keeper receives no objection from the patient or other parties to the lawsuit and if she chooses to produce the records, she may ask for the reasonable expenses of producing what the subpoena commands from the requesting party. Once that payment is received, the custodian may certify the accuracy of the records and then forward them to the requesting attorney. If the records custodian opts to produce the records before the deposition date, then confirm if the requesting attorney will cancel that deposition appearance.

Alternatively, the custodian may decide that the records should not be produced and forward to the requesting attorney a written “objection” within ten days after the service of the subpoena, or on or before the scheduled deposition, whichever comes first. A timely written objection requires the requesting party to obtain a court order to set aside the objection in order to receive the records. If the practice does not produce the records but fails to send a timely written objection, the custodian may need to appear at the deposition.

Additionally, the practice may be subject to contempt of court and other penalties.

It is important to issue a prompt, timely, and proper response to any subpoena.

Therefore, it is critical that you, your records custodian, and your office staff be familiar with the pertinent duties, rules, policies, and procedures for responding to subpoenas.

This article is intended as a summary of how to respond to a subpoena duces tecum and does not constitute legal advice.

E. Douglas Stephan is a partner with Sturgill, Turner, Barker & Moloney, PLLC, working in healthcare law and medical malpractice defense. He can be reached at (859) 255-8581.

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Cover Story

Jenna Dismore, MD, and Katherine Williams, DO, Pain Medicine Specialists at Commonwealth Pain & Spine

10 MD-UPDATE

Cover Story

No Pain Points Here

By taking an innovative approach to treatment and a progressive position on staffing, Commonwealth Pain & Spine is changing the face of pain management.

BY DONNA ISON LOUISVILLE In the last fifty years, the gender

gap among medical practitioners has narrowed tremendously, with female medical students now making up more than 50% of the incoming class. Currently, more than one-third of those in the physician workforce are women. However, in some specialties there is still a significant amount of gender disparity. Pain management is one example, with only 18% of doctors within this specialty being female.1 This also holds true in upper-level management across the field.

At Commonwealth Pain & Spine (CP&S), however, women make up a majority of key positions…and the organization is thriving.

Narrowing the Gender Gap in Pain Management According to Executive Director of Clinical Operations Monica Hurley, “The administrative leadership team at CP&S is largely female. If you look at healthcare as a whole, it is a female dominated occupation. In leadership roles, however, men primarily advance above women. Commonwealth Pain & Spine has removed the barrier for female leaders and identified an exceptional group of women to lead.”

In staffing, the company’s goal is to hire the most qualified people for each leadership role to achieve the mission of providing the most comprehensive and compassionate care to pain patients. Executive Director of Human Resources Helen Schrock, PHR, SHRM-CP, states, “My goal is to have the best talent sitting in the right chair, at the right time.”

This has resulted in there being, from the 1 Doshi, Tina and Mark Bicket. “Why Aren’t There More Female Pain Medicine Physicians?” Regional Anesthesia & Pain Medicine, vol 43, no. 5, 2019, pp. 516-520. doi.org/10.1097/ AAP.0000000000000774.

“My goal is to have the best talent sitting in the right chair, at the right time.”

— Executive Director of Human Resources, Helen Schrock, PHR, SHRM-CP, Executive Director of Human Resources top down, a staff composed of a majority of women in a multitude of roles—from clinicians to chief administrators.

For Chief Financial Officer Michelle Blandford, this experience is new. “From my experience, it is highly unusual. I am new to Commonwealth, but prior to joining the team, I was accustomed to being the only female in meetings or on business trips. Some of my greatest mentors have been male. However, as a female in the world of finance and business, there is something very comforting and supportive about being surrounded by so many like-minded females,” says Blandford.

Jenna Dismore, MD, joined CP&S in 2015 because she believed in its vision and way of practicing medicine. Prior, she completed her medical degree as well as her residency in anesthesia and fellowship in pain medicine at the University of Louisville School of Medicine. She says, “Historically speaking, medicine has been male driven. If you look at statistics now for admissions to medical school, females have taken the lead. In the past, when picking specialties and medicine, males usually tended to predominate interventional fields such as surgical specialties.”

Dismore believes that changes in the precon-

PHOTO BY ALEXANDRA ROGERS

ceived notions of what family roles entail has led more females to pursue interventional types of specialties. Originally, she was focused on pediatrics, but realized through her surgical rotation that she liked being in the operating room as well as being an interventionalist.

Mindset and Model Also Sets CP&S Apart Commonwealth Pain & Spine also differs from many other pain clinics in its approach to pain. Instead of adhering to the antiquated surgery-first delivery model, CP&S opts for a less invasive, more cost-efficient model to treat the gamut of pain, including migraines, sciatica, arthritis, back and neck pain, phantom limb, spinal stenosis, myofascial pain, and degenerative disc disease. Their 21 offices located throughout Kentucky, southern Indiana, and Illinois strive to consistently deliver innovative, clinically proven pain relief that is safe, responsible, and effective.

This philosophy is also reflected in the way their physicians approach patient care.

Dismore acknowledges the unique nature of pain—two patients may have the exact same pathology but experience this pain in very different manners. Therefore, during her first meeting with a patient, she focuses on listening, gaining a comprehensive understanding of their particular situation, and getting on the same page with treatment and goals. She explains, “A patient’s quality of life is extremely important. Promising a 100% pain-free life is an impossible task, but working towards enjoyment and being able to do the things that bring a person joy should be the focus. At a patient’s first visit, a treatment plan should be established and appropriate goals and expectations should be set. Treating chronic pain is usually a work in progress but,

ISSUE #149 11

Cover Story

Monica Hurley Executive Director of Clinical Operations Commonwealth Pain & Spine

Helen Schrock, PHR, SHRM-CP Executive Director of Human Resources Commonwealth Pain & Spine

Michelle Blandford Chief Financial Officer Commonwealth Pain & Spine

thankfully, several treatment modalities are usually available.”

Among these modalities are selective nerve root block, nerve ablation, neurostimulation, visco-supplementation, and a variety of injections, including epidural steroid. Of these, Katherine Williams, DO, finds neuromodulation to be an area of particular interest as well as utilizing basivertebral nerve ablation in the treatment of vertebrogenic back pain. Williams—who earned her Doctor of Osteopathic Medicine from the Touro College of Osteopathic Medicine in New York City and then went on to serve as chief resident and complete a pain medicine fellowship at Vanderbilt University Medical Center in Nashville, Tennessee—was motivated by the developing strategies to address pain while minimizing opioid exposure.

Since joining CP&S in 2021, she has served their primarily adult patient population who present with a variety of chronic and acute pain issues, ranging from everyday low back pain to more complex pathologies such as complex regional pain syndrome (CRPS), cancer-related pain, and compression fractures. She states, “Our focus is developing a comprehensive pain management plan that considers not just medications or interventional therapy options, but also the functional limitation that pain can lead to for some patients. I am committed to an individualized patient-centered approach with the goal of individualized, patient-centered outcomes.”

Executive Director of Ambulatory Surgery Centers Janet L. Carlson, MSN, BSN, RN, CRN, NE-BC, echoes Taylor’s sentiment: “As many have stated before me, there is no ‘I’ in the word team. I love how we each support one another and encourage each other to deliver on our mission, vision, and values for CP&S. I rarely hear anyone using the word ‘I’—I hear ‘we’ on a daily basis with our interactions. We foster an environment of inclusion and collaboration.”

Collaboration within the company is not limited to the usual interactions between the direct healthcare providers but extends throughout the entire organization. Hurley explains, “Our team meets weekly to discuss updates within each department and evaluate how any changes will affect other departments, ultimately affecting the patients. It is crucial that we all collaborate and provide the patient with a pleasant experience from the first moment they speak with a new patient scheduler to receiving a consult with a physician or discussing a billing question with a team member.”

“Commonwealth Pain & Spine has removed the barrier for female leaders and identified an exceptional group of women to lead.”

— Monica Hurley, Executive Director of Clinical Operations 12 MD-UPDATE

A Company Culture of Collaboration In addition to their commitment to optimal patient outcomes, CP&S is dedicated to fostering an environment that sets both their patients and staff up for long-term success. According to January T. Taylor, Executive Director of Operations, “The culture at Commonwealth Pain & Spine is unique and unlike any other organization that I have worked with. We truly value our team members and are dedicated to their success both in and out of the workplace.

There is a mutual respect and appreciation throughout the entire organization, and it starts from the top. It is not uncommon for Jeff Ellison, our CEO, to interact with the administrative and clinical support teams.”

PHOTOS BY ALEXANDRA ROGERS AND HAELI SPEARS

The Future of Pain Management and CP&S Perhaps no field has come further or changed more significantly in the past three decades as that of pain management. The devastating results of the opioid epidemic demanded that the medical profession engage in research to find alternative pharmacologic and inter-

Cover Story

“Being in pain management is extremely rewarding especially when you are able to see so many great outcomes. When a patient’s quality of life is improved or they can participate in things that are important to them, it really makes what I do all worth it.”

— Jenna Dismore, MD ventional treatments.2 This has led to major breakthroughs in the way pain is viewed and dealt with both within the field and by society at large. Williams points out, “I think that the specialty of chronic pain is in an era of innovation, especially from an interventional standpoint, as we hope to offer longer-lasting, effective treatment options for pain.”

Dismore expounds, “Pain management continues to see advancements every year.

Interventional treatment continues to be the focus with more types of beneficial procedures. More and more data continue to be gathered every year on the risks associated with chronic opiate medication management.

It is no secret that there is an opiate problem in our society. With the advancements and legalization of medical marijuana, I foresee that the way opiates are used in the future will change. There will still be a definite need for opiate medication management, however how it is utilized will continue to change.”

As for the future of Commonwealth Pain & Spine, the strategic direction can be described in one word: Growth. CP&S recently merged with Interventional Pain Specialists of Bowling Green, adding Daniel Reynolds, MD, Christian Unick, MD, Eric Vessels, 2 “The Evolution of Pain Management: Experts Weigh In.” Practical Pain Management, vol. 20, no. 4, 2020.

January T. Taylor Executive Director of Operations Commonwealth Pain & Spine

Janet L. Carlson, MSN, BSN, RN, CRN, NE-BC Executive Director of Ambulatory Surgery Centers Commonwealth Pain & Spine

MD, John Gardner, MD, and Rodney Miller, MD, to its team of 15 physicians.

Carlson, whose role is to lead the ambulatory surgical center (ASC) initiative, states, “We have been granted two certificates of need in the state of Kentucky for me to develop.

Additionally, we have selected busy markets in Indiana where we plan to develop ASCs for our client population. The majority of surgical and interventional procedures we offer chronic pain patients can safely be performed in ASCs with easier access to healthcare while also offering affordability. Combined with our excellent reproducible patient quality outcomes, ASCs offer our patients a triple win.”

Hurley adds, “Immediately, the plan is to incorporate ambulatory surgery centers within the company and a Complete Care Program, both allowing patients to remain in one ecosystem for all their chronic pain needs.

As we continue to grow these new programs, I will be intimately involved in creating new workflows and verifying compliance.”

To facilitate these improvements, every department is taking steps to guarantee a smooth and successful expansion. For Blandford, this means providing the data and analytics needed to keep the team focused on strategic goals and to support data-driven decision-making. “With the rapid pace of change and growth that Commonwealth has and continues to experience, I am focused on building sustainable infrastructure in the business that

can support the growth and allow us to appropriately scale with that growth,” says Blandford.

In Closing Both Dismore and Williams regularly see first-hand the life-changing effect successful pain management can have on a patient, which reaffirms their decision to go into this male-dominated specialty.

Dismore related a case in which a woman had the once in a lifetime opportunity to travel to Europe with her daughter to meet the Pope. However, she feared her worsening back pain would make the pilgrimage impossible; she could neither walk long distances nor stand for extended periods of time. After being prescribed an interventional treatment plan along with conservative medication, the patient was able to complete the trip and make her dream come true. “Being in pain management is extremely rewarding, especially when you are able to see so many great outcomes. When a patient’s quality of life is improved or they can participate in things that are important to them, it really makes what I do all worth it,” Dismore states.

As for why the staff finds working at Commonwealth Pain & Spine equally rewarding, Schrock, perhaps, summed it up best, “I look forward to Monday, coming back to work. I know that I’m in the right place and fulfilling my purpose. I want everyone at Commonwealth to feel that way.”

ISSUE #149 13

Fighting the Good Fight

Guneet Sarai, MD, finds inspiration in her brain cancer patients

BY JIM KELSEY

Originally from India, Dr. Guneet Sarai joined UofL Health – Brown Cancer Center in August of 2023 as the Director of Neuro-Oncology.

LOUISVILLE Growing up in Chandigarh, India,

Guneet Sarai, MD, would often go with her father to his work at the local hospital. Now deceased, he was an anesthesiologist who took great pride in his work and the role he played in patient care. His job mattered to him, and it was a lesson he wanted his daughter to learn.

“He would take me with him to the hospital to see what he was doing,” says Sarai. “Just looking at how satisfied he was from his job, very early in childhood I decided that I wanted to become a physician.”

Sarai stayed on that path, attending the Government Medical College and Hospital in Chandigarh before coming to the United States. In 2011, she completed an internal medicine internship at Johns Hopkins Good Samaritan Hospital in Baltimore, where she also did her residency in internal medicine in 2013. She finished a neuro-oncology fellowship at the University of Virginia in 2023, then joined UofL Health – Brown Cancer Center as the director of neuro-oncology in August 2023.

Sarai specializes in the treatment of brain and spinal cord tumors. It is an area of focus she was drawn to during her time at Johns Hopkins.

“When I was rotating, I would go to the 14 MD-UPDATE

neuro-oncology clinic and work with my attendings,” she says. “I would see patients with brain tumors in the clinic. I started doing research on neuro-oncology and I found how challenging it was — the diagnosis, the treatment of brain tumors, talking to the patients, trying to help them with the symptoms they had. I also found out how we established a relationship with the patients and helped them through this journey with treatment. It gave me a sense of satisfaction to help them through their journey. That’s when I decided this was the fellowship I wanted to do.”

Yes, just like her father, Sarai found a profession that brought her satisfaction. She understood the value of that and continues to do so, on a daily basis, at the UofL Health – Brown Cancer Center, where she already feels right at home.

“When I interviewed here, I found this to be a really good group,” says Sarai, whose husband, Bikram Saini, MD, recently joined the University of Louisville School of Medicine Department of Family and Geriatric Medicine. “We have excellent neurosurgeons and radiation oncology doctors. I found the team not only to be excellent PHOTO BY JOHN LAIR

in what they do, but also very personable. I knew they would be excellent coworkers.”

Collaboration and Multidisciplinary Care These team members meet mid-day as part of what they call the “tumor board,” a multi-disciplinary board that discusses all the patients that have been or will be seen that day. In addition to Sarai, the tumor board includes neurosurgeons, a neuro-radiologist, a radiation oncologist, and a neuropathologist.

Prior to the meeting, Sarai sees brain tumor patients at her clinic in the UofL Health – Brown Cancer Center. After tumor board, she is part of a multidisciplinary afternoon clinic in which the patient stays in one room and is seen individually by the various specialists involved in that patient’s care. Sarai also sees patients in the hospital if her opinion is needed. Patients with brain tumors often present with seizures or stroke-like symptoms and are diagnosed via MRI. “Most brain tumors end up needing surgery, and that’s where the neurosurgeons come in play,” says Sarai. “When surgery is not possible, we take a small tissue sample to test called biopsy. Once we have this diagnosis,

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the next step, though not all patients need it, would be radiation. We then send the patient to the radiation oncologist here at UofL Health. Once the radiation is over, they come back to me to get chemotherapy if needed.”

New Treatment Options.

More Hope.

Many times, Sarai’s first meeting with the patient is a difficult one.

“Sometimes when the patient comes to me, they are not even aware that they have a brain tumor or they are not sure and awaiting the final results,” she says. “Unfortunately, that’s when we have to break the news that there is a brain tumor. After I introduce myself, then we talk about the diagnosis and why it is a higher or lower grade diagnosis, whether it is a primary brain tumor, or brain tumor that comes from cancer elsewhere in the body. Then we talk about the treatment options. The outcomes really depend on what kind of tumor it is. Some lower grade tumors have really good outcomes. For higher grade tumors, we are in

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the process of developing better chemotherapy and better treatments.”

While there is hope due to significant advancements in treatment, as well the new information gained via ongoing clinical trials, Sarai knows all too well how difficult it is for a patient to hear that they have a brain tumor.

“The next question is the most difficult question that a neuro-oncologist has to deal with — ‘What is the prognosis?’” says Sarai. “It’s always very difficult. Not sometimes. Always.”

Patient Empathy Is Key Sarai shares the good news with her patients that brain tumor patients are living longer and that new techniques and treatments are showing promise. There is hope, but she understands how crippling the diagnosis can be. How does she get through the process of sharing this news on a regular basis?

“By having empathy and understanding how difficult it is for the patient to even know that they have a brain tumor,” she says. “This is the most difficult situation in their life, and

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Neuro-Oncology

this is a human being who is depending on me to help them through their journey. It’s my responsibility to do that. The patients themselves are so resilient. Despite the difficult diagnosis, their attitude toward life — I mean, there’s so much to learn from my patients.

Even if it’s a poor prognosis, they want to make the best of their life, they want to spend their time with their family. This is what gives me the courage. That’s what keeps me going.”

It also helps that Sarai can often offer genuine signs of hope. New therapies and treatments are producing better outcomes.

She is involved in three clinical trials, actively seeking more information and examining new treatment plans.

“Diagnosis of brain tumor is not the end; it’s the beginning of the journey, actually,” says Sarai. “We can offer more clinical trials here; even if the tumor comes back, we do have more chemotherapies available as a second line. We can do genetic testing of the tumor and try newer treatments available.”

Sarai cites immunotherapy and the use of tumor treating fields — mild electrical fields that are sent through the patient’s scalp to disrupt the cancer’s spread — as promising treatments developed and enhanced in recent years.

“We also have advances in knowing the gene mutations involved in tumors with meningioma and treat them accordingly,” Sarai says. “We have better chemotherapies for central nervous system lymphoma, another difficult to treat brain tumor. All of these are advances in treatment.”

Despite the encouragement of improved treatments and clinical trials, Sarai knows that the diagnosis of a brain tumor can be devastating and the course of treatment daunting. It’s a long journey, but one she is committed to taking with her patients.

“Helping my patients through this difficult diagnosis and the treatment gives me a sense of gratitude,” says Sarai. “It gives meaning to my life, that I have done something meaningful and have helped these patients through the most difficult diagnosis — and actually the most difficult treatment — that you can ever imagine. This is the right place for me. This is what I wanted to do from day one when I became a physician.”

ISSUE #149 15

Generations of Care

Celebrating its 35th year in business, The Pain Treatment Center of the Bluegrass expands its services LEXINGTON/RICHMOND The Pain Treatment

Center of the Bluegrass is celebrating its 35th year of caring for Kentuckians. Since 1988, when Ballard Wright, MD, a certified anesthesiologist and pain physician, opened his practice, Ballard Wright, MD, PSC, also known as The Pain Treatment Center of the Bluegrass (PTC), his practice has specialized in pain management. “PTC has provided pain patients all over Central and Eastern Kentucky with compassionate, quality care over the past three decades,” says Heather Wright, administrator and daughter of Ballard Wright. “We have pain physicians from different specialties. Those specialties are anesthesia, neurology, physical medicine and rehabilitation, family medicine, and palliative care. All these different specialists work together to evaluate patients to alleviate their pain,” says Wright. Moreover, over the past year, PTC has brought in addiction medicine specialists, fostered a relationship with CHI Saint Joseph Hospital, and opened a new location in Richmond, Kentucky.

Expansion of Services to All of Madison County As part of the Center’s desire to help pain patients across the Commonwealth, it has grown its outreach by connecting with referring

Rebecca Freeland, MD

Dr. Karim Rasheed, MD

providers and healthcare institutions throughout the state. One such connection occurred at the beginning of 2021 when the Center became affiliated with CHI Saint Joseph Health’s network of hospitals and outpatient clinics.

As the preferred provider for all CHI Saint Joseph Health’s pain management centers, PTC supplies physician services to multiple CHI Saint Joseph Health locations, including Berea. Having expanded its services to Berea, PTC was the natural choice to take over the care of Hammid Malik, MD’s patients when

he decided to close his practice, Richmond Pain Management, in Richmond, Kentucky, this past July. In his letter to his patients, Malik highlighted the following: “PTC has been taking care of Kentuckians for over 30 years, and they are committed to providing you with compassion, respect, and quality care. I know that you will be in good hands with the transition of your treatment to The Pain Treatment Center of the Bluegrass.”

Obtaining the Richmond office allowed PTC to consolidate its pain care services to

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

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 16 MD-UPDATE

PHOTOS PROVIDED BY THE PAIN TREATMENT CENTER OF THE BLUEGRASS

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the patients in Madison County. Along with Michael Hamilton, PA-C, Malik’s longtime physician assistant, Rebecca Freeland, MD, and Karim Rasheed, MD, physicians with The Pain Treatment Center of the Bluegrass will see new patients at the 2187 Lexington Road location, as well as continue to see the established patients as usual. Ms. Wright highlighted that the Center’s goal was to minimize any disruption in care for Malik’s pain patients who depend on medical treatment to keep them functioning.

As well as continuing to service current patients, PTC is bringing two new services to the Clinic’s patients—first, counseling services via the Center’s Behavioral Medicine department—something not previously offered.

Working with a behavioral medicine specialist, patients learn coping skills to handle the psychological components of pain. These techniques help patients feel more in control of their situation. “Most patients find they can better manage their pain with just a few

sessions,” emphasizes Kellie Dryden, LCSW. Second, the Center is providing addiction medicine services. As part of the Center’s mission to help provide Kentuckians with a better quality of life, the Center recognized almost two years ago that it needed to open a new department to treat opioid use disorder in its high-risk patients. “While we had all these different specialists work together to evaluate patients with the end goal of alleviating their pain,” says Wright, “we realized one component was missing—helping patients who have pain but also have been abusing their opioid medications.”

With a combined clinical experience of over 25 years in pain and addiction, Richard Lingreen, MD, and psychiatric nurse practitioners Joannie Cook, PMHNP-BC, and Kay Wilson, DNP APRN, seek to help those patients who want to live a life free of opioid abuse or misuse.

“For years, our physicians have used a multi-specialty, multi-modality approach to

Pain Medicine

alleviating pain, but we realized there was a gap in our treatment. Now, by bringing these services to not only our Lexington location but also our satellite clinics, including the Richmond clinic, the Center will hopefully be able to help alleviate the number of Eastern Kentuckians suffering from the abuse of opioids,” stated Peter Wright, MD, the medical director.

Part of Their Mission Since Ballard Wright started his one-office practice 35 years ago, his goal has been to employ experienced, multi-specialty pain providers, skilled behavioral medicine specialists, and compassionate staff to offer exemplary treatment and care to the pain patients of Kentucky. “By partnering with CHI and taking over Richmond Pain Management, in addition to the Center’s expansion of services, PTC is fulfilling its mission to help provide Kentuckians with a better quality of life,” sums up Ms. Wright.

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Pain/Regenerative Medicine

A Pathway to Wellness

Transcranial magnetic stimulation at Wellward Medical offers hope to patients with treatment-resistant depression

BY GIL DUNN LEXINGTON As a teenager, Jane felt like she was

different than her friends. Up until high school, she was energetic, optimistic, and the one her friends sought for support. What started as a period of darkness evolved to a chronic history of recurrent and deep depression. By the time she was in her forties, she carried with her the heavy burden of failed treatments including medication, psychological counseling, and even electroconvulsive therapy (ECT).

“I felt like I was fading away, not just from my life but from the lives of those I love,” she shared, recounting the litany of medications and the disorienting rounds of ECT that had left her feeling more like a “foggy ghost,” as she described, than a person. Her story is not unlike those of many of the patients who struggle with treatment resistant depression.

This affects up to half of all patients treated for depression, many of whom have tried and failed to find relief with conventional treatments of medications and talk therapy.

When she was referred to Wellward Medical, she had resigned herself to the realization that this was who she was, until transcranial magnetic stimulation (TMS) rekindled a flicker of hope. “When my doctor suggested TMS, I discovered it wasn’t about changing my medication routine; it was about changing my brain’s routine,” she said. This scientifically grounded optimism is at the core of TMS therapy—a noninvasive procedure that uses repetitive magnetic pulses to stimulate specific regions of the brain, encouraging a return to normal function.

TMS is a novel modality in psychiatry. In treating mood disorders, the mainstay of psychiatry has been to augment a deficit of certain neurotransmitters. Whereas medications either enhance production or inhibit degradation of certain neurotransmitters, TMS accomplishes the same goal by stimulating and reinforcing the circuits that build the 18 MD-UPDATE

Danesh Mazloomdoost, MD, known to his patients as Dr. Danesh, is founder and medical director of Wellward Medical.

same neurotransmitters endogenously.

The principle is straightforward. Complex cognitive processes like mood and executive function take place in multiple foci of the brain linked together within networks. In recurrent affective disorders, these networks fall into a cycle of disarray.

“By focusing on the dorsolateral prefrontal cortex, TMS uses induction currents, similar to the mechanism that charges your phone wirelessly, to exercise specific circuits in the brain,” says Danesh Mazloomdoost, MD, known to his patients as Dr. Danesh, medical director of Wellward Medical. This engages the part of the brain where diminished activity is often linked to depression.

“Each session felt like a step toward myself,” Jane reflected. “It was as if someone was gently knocking on the door of my mind, reminding it to wake up.”

Jane’s treatments were brief, daily engagements with the TMS machine, lasting just minutes but building a foundation for lasting change over several weeks. Unlike the systemic effects of antidepressants or the cognitive risks of ECT, TMS offered Jane a targeted PHOTOS PROVIDED BY WELLWARD MEDICAL

approach without the side effects that had long overshadowed her treatment history. “I walked out feeling clearer, not cloudier,” she noted, a sentiment that resonates with many who undergo TMS. The growing recognition of TMS in treating conditions like treatment-resistant depression and obsessive-compulsive disorder has positioned it as a beacon of innovation in psychiatric care, gaining broad-spectrum insurance coverage. As neural mapping and understanding about physiology evolves, more indications are being studied. At Wellward, the team is considering using TMS for chronic pain by regulating and desensitizing the pain processing centers of the brain. There is also research in using it to stimulate the punitive and reward centers of the brain in treating addiction, facilitating recovery from stroke, reducing the impact of movement disorders, helping patients with attention and hyperactivity, and much more.

“We’re not just seeing symptoms ease,” says Dr. Danesh. “We’re seeing lives reclaimed with focused attention to particular regions of the brain.”

Within their treatment framework, Wellward incorporates other novel psychiatric innovations, enhancing and complementing the effects of TMS. One such treatment is the use of ketamine, known for its rapid-acting antidepressant properties and its ability to foster neuroplasticity. “Ketamine is a catalyst,” Dr. Danesh notes. “In conjunction with TMS, it not only accelerates treatment but allows patients to engage in therapy from a whole new perspective, one that shows a greater degree of compassion for self that many struggle with in their depressed state.”

For patients struggling with anxiety or PTSD as the aftermath of trauma, another innovative treatment used by Wellward is the stellate ganglion block (SGB). Following physical or emotional trauma, the autonomic system can undergo neuroplastic changes

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Pain/Regenerative Medicine

“By focusing on the dorsolateral prefrontal cortex, TMS uses induction currents, similar to the mechanism that charges your phone wirelessly, to exercise specific circuits in the brain.” — Danesh Mazloomdoost, MD

that increase the activity of the sympathetic system. This leaves people in chronic state of “fight or flight,” perpetuating the reaction from trauma. Studied most among veterans with PTSD, SGB helps reset the setpoint of the autonomic system.

“It’s not just about treating an illness, it’s about fostering a holistic sense of health,” Dr. Danesh describes.

These treatments, while innovative, are not standalone solutions at Wellward. They are integrated within Wellward’s HEAL framework of Health, Energy, Activity, and Lifestyle.

This is a comprehensive care model for treating both physical and emotional pain through the dimensions represented by HEAL: Health represents the pursuit of medical well-being; Energy focuses on balancing mood and the autonomic nervous system, crucial for transitioning between states of stress and relaxation; Activity emphasizes movement as medicine; and Lifestyle encompasses the routines of selfcare that sustain long-term health.

“We see TMS, ketamine, and stellate ganglion blocks not just as treatments, but as

tools,” Dr. Danesh clarifies. “Tools that, when used within our HEAL framework, empower our patients to take charge of their health and reclaim their lives.” Health coaching and group sessions, pillars of the HEAL framework, complement the TMS therapy, providing patients with a community and a curriculum designed to sustain and nurture their journey to wellness.

“There is solidarity here,” Jane observed.

“You feel part of a collective stride toward better health.”

Dr. Danesh, speaking to the collaborative nature of Wellward’s approach, underscored the value of this support system. “Our aim is to arm our patients with the tools they need to navigate their health long term,” he said. “When we talk about recovery, we’re talking about an enduring return to wellness, and that’s a path we walk together with our patients.”

Wellward’s model is reflective of a larger shift in mental health treatment—a shift towards recognizing the patient as a whole person. “It’s about seeing beyond the diagno-

sis,” Jane expressed. “At Wellward, I’m not just a case of depression; I’m a person with a story, with goals, with a life to return to.”

For physicians considering a referral to Wellward, the clinic represents a partnership in patient care, one that honors the complexity of mental health and the individuality of each patient. “Referring to Wellward means you’re not passing off a problem; you’re opening up a pathway,” Dr. Danesh assures his colleagues.

In the journey of Jane’s resilience and transformation, we witness the profound impact of comprehensive, innovative psychiatric care.

Her story, a reflection of the many individuals who confront the relentless grasp of treatment-resistant depression, highlights the pivotal role of transcranial magnetic stimulation (TMS) as a beacon of hope in the evolving landscape of mental health treatment. As Wellward continues to champion the cause of patient-centered care, we are reminded that true healing extends beyond the realm of diagnoses and prescriptions, offering patients not just a return to wellness but a renewed lease on life.

ISSUE #149 19

Myopia: Our Ongoing Silent Ophthalmic Epidemic Loss of global productivity is in the billions of dollars

BY BRUCE H. KOFFLER, MD LEXINGTON Over the summer of 2024, major

global news outlets including the Wall Street Journal and EuroNews shed light on the growing epidemic of nearsightedness, known also as myopia, in children. Children around the world are being diagnosed with myopia at alarming rates, including nearly 80 percent of young adults in some Asian countries. Here in the US, over the past 40 years, the myopia rate in the population has gone from 25 percent to almost 45 percent. Studies predict that one in every two people will develop myopia by the year 2050, a projected five billion people!

Awareness of myopia among practitioners and parents needs to expand so that early identification and treatment can prevent much larger vision problems later in life.

While the exact reason for the increase of myopia cases is unclear, lifestyle changes brought on by the COVID-19 pandemic could share the blame. Increases in the

amount of entertainment screen time, confinement to an indoor home environment, and the switch to online learning have placed children in front of screens for a longer part of the day. An NIH-sponsored study published by EducationWeek indicates that children spend over an additional hour more on screens now than they did pre-pandemic.

Looking at screens such as a computer, tablet, or phone for long periods causes the eyeballs to elongate and become nearsighted (myopic), causing distant objects to be blurry. In the US, myopia affects half of young adults, twice as many as 50 years ago, and can contribute to poor school performance, shortened attention spans, headaches, and eye strain.

If myopia in children is left untreated, serious life-debilitating and permanent vision problems such as retinal detachment, glaucoma, cataracts, macular degeneration, blindness, and more can develop. Untreated myopia conditions can result in severe economic losses for both the individual and the world

in general. Lost productivity from untreated myopia and myopic macular degeneration around the globe was valued at an estimated $244 billion in 2015.

You might ask why, as an ophthalmologist, I am so interested in myopia progression.

Myopia has affected me most of my life! By the third grade, at age eight, I had to wear thick eyeglasses in order to see at school and to play sports. I was very self-conscious of the glasses and hated to wear them on a basketball court or baseball field. It was impossible to see at the swimming pool. As a teenager, contact lenses were available for me, but because they were made of hard plastic materials I was never able to adapt to them. Thankfully now, more comfortable treatments are available, increasing patient compliance and resulting in a more positive corrective outcome.

When evaluating quality of life indicators utilizing validated questionnaires, studies show that the ability to see without contact lenses or glasses leads to improved self image

Source: The Australia and New Zealand Child Myopia Report 2022/23 20 MD-UPDATE

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and self-confidence, fewer activity restrictions, less worry, and higher overall satisfaction with vision.

This is probably no surprise to those of us who have had to be dependent on optical Source: A Parent’s Guide to Raising Children with Healthy Vision correction since childhood.

Evidence-based myopia control treatments to grow around the world, treatments and include a wide variety of options in addition best practices to slow the progression need to to glasses. Daytime multifocal soft contact be more widely utilized. If projections of 50% lenses, low-dose atropine drops, and a special of the population having myopia by 2050 are molding technique using gas permeable con- correct, with 10% having severe myopia, we tact lenses called orthokeratology (OrthoK) will be dealing with large numbers of older have all been shown to reduce axial length patients suffering from loss of vision from up to 50-60 percent in most studies. OrthoK retinal detachment, macular degeneration, can allow patients to reshape their cornea increasing and earlier cataract formation, and by wearing specially designed gas-permeable more severe glaucoma. The economic impact contact lenses, worn while sleeping, to tem- of lost productivity and dollars spent in carporarily and reversibly reduce refractive errors ing for these seniors will be staggering! Two following lens removal in the morning. In my organizations that help coordinate this care experience, I prefer OrthoK in young children in our area are the Bluegrass Council for the starting at seven to eight years of age, as they Blind and the Kentucky Department for the adapt well to the nighttime wear. The gentle Blind. Early interventions that not only corshaping of the cornea occurs overnight, and rect myopia, but also slow the excessive axial the child can then remove the contacts in the elongation and scleral stretching, are critical morning and be contact lens and glasses free in minimizing the risks of complications that throughout the rest of the day. The majority may lead to irreversible vision loss. of the children that I treat adapt to this system Myopia control options need to be preand seem to tolerate it well. scribed with a custom-tailored approach by I started fitting OrthoK lenses first in adult the eyecare practitioners working together patients, who do extremely well with this con- with primary care offices, including pediatritact lens modality. Patients in their 40s and cians, family practitioners, and internists. All 50s with developing dry eye disease or increas- primary care offices should be doing vision ing allergy symptoms, like itchy or scratchy checks on patients as early as possible. It is eyes, and who are failing with traditional imperative for the long-term health of the daytime contact lens wear, do very well with eye that interventions are initiated in a timeOrthoK. I also fit teenagers beginning their ly manner. Throughout China, Japan, and contact lens journey with OrthoK lenses. Due Korea, programs are being started to identify to the nighttime wear, they love the freedom and treat this growing myopia problem, but that these lenses offer them to participate in more still needs to be done, especially here in all sport activities and to prevent the sensation the Commonwealth, to save the vision of our of a foreign body in their eyes during the day. next great generation.

In summary, myopia is a combined disease of genetic predisposition and environmental Bruce Koffler, MD, can be reached at bkoffler@aol.com influences. As the myopia epidemic continues and at gdunn@md-update.com.

Ophthalmology

BRUCE H. KOFFLER, MD grew up in Brooklyn, New York, and graduated from Brooklyn College. He attended Georgetown University School of Medicine in Washington, DC, and completed his internship, residency, and his fellowship in corneal transplants and infectious eye disease at the Georgetown Center for Sight. He began his academic career in 1979 and became an associate professor at the University of Kentucky where he taught for four years. During that time, he established the University of Kentucky Lions Eye Bank. In 1983, Koffler opened his private practice, the Koffler Vision Group.

He specialized in corneal diseases, corneal transplants, cataract surgery, LASIK, glaucoma, orthokeratology, myopia control, contact lenses, and infectious diseases of the eye.

Koffler Vision Group operated a dry eye center and clinical research institute. Koffler serves as a past president of the International Medical Contact Lens Council (IMCLC) and helps to organize symposia for the World Ophthalmology Congress (WOC). He also serves as the international director for the Eye and Contact Lens Association (ECLA) and is a board member for the American Association of Orthokeratology and Myopia Control and the International Academy of Orthokeratology and Myopia Control.

He travels nationally and internationally for various speaking engagements for the organizations he represents. Koffler was honored by his peers with the Best Doctor in America designation and was most recently awarded the Senior Leadership Award from the American Academy of Ophthalmology and the Fick-Kalt-Müller Research and Teaching Award for the ECLSO society. He was the first non-European to be presented this honor.

ISSUE #149 21

Dr. Brian Plato uses an ophthalmoscope to conduct a patient's fundoscopic eye exam.

Tackling Migraine … Oh What A Pain!

A battle Norton Neuroscience Institute is helping patients win

BY MENISA MARSHALL LOUISVILLE Some people believe severe head-

ache and migraine are the same thing. “Not so!” says Brian Plato, DO, neurologist and headache specialist with Norton Neuroscience Institute.

“Migraine is not a headache. It’s a complex neurological condition with headache as one of its symptoms,” says Plato. “I often treat patients who have migraine but not headaches.”

Migraine symptoms can mimic various conditions. For example, Plato has seen migraine patients convinced they are having a stroke.

“We don’t have the benefit of a scan, a blood test or anything I can show patients to explain or confirm what’s causing their pain,” says Plato. “Migraine is a clinical diagnosis essentially made by sitting down and talking with patients for a relatively long time.”

Plato earned his medical degree from the Chicago College of Osteopathic Medicine. He completed his internship and residency in neu22 MD-UPDATE

rology at the UofL School of Medicine where he served as chief resident of neurology and completed a mini-fellowship in headache medicine.

He is board-certified in neurology and headache medicine. He is an investigator on several headache disorder clinical trials. He works through the Alliance for Headache Disorders to raise awareness and advocate for various issues.

A Team Approach to Care According to Plato, ten board-certified headache specialists practice in Kentucky.

Half of them currently work at Norton Neuroscience Institute, along with nurse practitioners who have certificates of qualification in headache care. The program is adding a neurologist who specializes in pediatrics and young adults, and expects soon to have seven physicians board-certified in headache medicine on its team.

Plato stresses Norton Neuroscience Institute is committed to providing every PHOTO BY JAMIE RHODES

patient with accurate information, plus specialized effective and compassionate care. This commitment applies across the board, beyond headache and migraine care.

“Regardless of a patient’s diagnosis – whether it’s migraine, epilepsy, Parkinson’s disease or any other condition – the level of collaboration at Norton Neuroscience Institute is exceptional when it comes to meeting our patients’ care needs,” says Plato. “This is because our work is driven largely by an environment that is not competitive but collaborative.”

Migraine, and Phases, and Impacts … Oh My The Centers for Disease Control estimate 12% of the U.S. population suffers from migraine. In Kentucky alone nearly a half-million people live with the condition that tends to impact more women than men.

While every case may not warrant specialized care, many produce disabling impacts.

Various health organizations that assess levels

SPECIAL SECTION of disabling conditions rate acute and persistent migraine attacks as essentially equal to quadriplegia.

Migraine’s symptoms generally fall into four phases. In Phase I (Prodrome) patients often report experiencing various symptoms in the days—or sometimes hours—leading up to the attack. For example, they may have yawned more, suffered neck pain, urinated frequently, felt generally moody or been sensitive to light.

Phase 2, Aura, typically involves transient neurological symptoms caused by the brain’s electrical pulses. Patients may see light flashes, have distorted perception, or temporarily lose vision. Such events are not generally dangerous, but can interfere with daily activity and work.

Not all patients progress to stage three, the headache or “attack” phase commonly associated with migraine. This phase often involves severe pain, light sensitivity, nausea, and vomiting. It may produce language difficulties, loss of balance, numbness or weakness and is sometimes mistaken for a stroke.

Postdrome, migraine’s last phase, can last hours or days after the headache phase resolves.

Patients often describe it as “a migraine hangover” because it can produce fatigue, difficulty concentrating, dizziness, and mood swings.

The phases’ collective impact is powerful, says Plato. If you had a Prodrome phase for a day or two, a headache phase for a day, and a postdrome phase for another day more than half your week would be lost to just one migraine episode. Many patients have three or more episodes a week.

Successfully Navigating “Uncharted Waters” Diagnosing and treating migraine is sometimes like navigating uncharted waters. It can get complicated, and like many aspects of modern medicine it changes rapidly.

Diagnosis generally starts with determining if patients have at least two headache-related symptoms (pain lasting 4 to 72 hours, one-sided, moderate-to-severe in intensity, throbbing quality of pain or avoidance of physical activity). Non-headache symptoms typically include sensitivity to light and sound, nausea, or vomiting.

Plato clarifies that while patients with

intense pain sometimes fear a brain tumor or aneurysm, these conditions do not typically present with recurring headaches. American Headache Society guidelines do not indicate brain scans for recurring migraine-compatible headaches because the probability of a normal scan is 99.8%.

Norton Neuroscience Institute’s experts are encouraged to see major shifts in awareness, diagnostics, and treatment that recognize migraine’s impact as a serious medical condition. One key development came in 2010 when the FDA approved Botox for treating chronic migraine. These are episodes that occur 15 or more days per month with at least 8 incidents that meet migraine’s diagnostic criteria.

Botox injections are administered every 12 weeks into 31 designated sites. They work by blocking nerve signals that trigger the release of neurotransmitters during a migraine. Plato finds patients often have “fantastic outcomes” with repeated use of Botox, yet he offers some caveats.

For one thing, Botox is not a “one and done treatment.” Patients must commit to several rounds of injections. It can also be difficult to “pinpoint” the treatment’s efficacy rate. A typical efficacy standard for clinical trials is a 50% reduction in headache days per month. Based on this marker, Plato usually tells patients, “You have about a 50% chance of having a 50% or more reduction in the number of pain days per month.”

The problem, he notes, is this isn’t necessarily an effective outcome measure for every patient. He explains using a sample scenario: Imagine a patient who has headaches 30 days a month that gets two Botox treatments.

At follow-up the patient reports the headaches still happen every day, but the pain is “ninety percent better.” What used to be an “8 to 10” headache is now a “1 or 2.” This is a statistical failure because the patient did not get 50 percent better, yet the improved pain levels are substantial “success markers.”

Patients typically want to know Botox’s likelihood to help them. Plato explains a key effectiveness marker is the percent of patients willing to come back every three months for injections into their heads.

“Our experience is, if it gives them meaningful relief, patients will continue treatment,” Plato says.

Neurology

He notes that while Botox does not have the option of dose reduction, its injection intervals can be spread out to 3 or 4 months.

They can be even further apart if patients continue to do well.

Beyond Botox therapy, another major “migraine breakthrough” came in 2018 when Calcified Gene Related Peptide (CGRP) received FDA approval. This changed the perception of migraine dramatically and gave providers powerful new treatment options.

“With CGRP, our team is able to say, ‘Here’s a molecule in your body causing your migraines’. This lets us target specific molecules with targeted medicines,” says Plato.

Leading From Expertise Norton Neuroscience Institute is committed to meeting patients’ ever-changing needs. That commitment plays out in two major ways: • Telemedicine Care: Published studies confirm telemedicine’s use as a safe, effective resource for headache care. Plato estimates 30 percent of Norton Neuroscience Institute’s care visits are currently done via telemedicine. Given its effectiveness and convenience, plans are underway to expand its use.

Telemedicine eliminates geographic barriers and provides ready access to specialists for those who live near or far away.

It also cuts down on “canceled appointments.” Patients whose conditions may worsen after scheduling a visit can complete their visits online.

• Research and Education: Research is a critical element of Norton’s work. One issue generating significant interest is the role stress plays in migraine attacks. Other studies are looking at why women tend to have more migraines than men.

Beyond clinical research, patient and community education are key parts of the institute’s work. Team members have developed a valuable program titled, “The Headache School.” This patient-level collection of video lectures is available online and free to anyone who would find it useful.

Brian Plato, DO can be reached at brian.plato@ nortonhealthcare.org. The Headache School is at nortonhealthcare.com/headacheschool.

ISSUE #149 23

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Psychiatry

“Don’t Let This Darkness Fool You. All Lights Turned Off Can Be Turned On”

BY COURTNEY MARKHAM-ABEDI, MD LEXINGTON Singer-songwriter Noah Kahan

penned the above line about his struggle with mental illness. The line encapsulates what mental health practitioners and fellow physicians would like to impart to our colleagues struggling with what has been called a silent pandemic—the loss of physicians to suicide.

It is important that this is not forwarded as a platitude or a false reassurance that all will be well, but rather as a call to action and improvement in awareness. As a health care system, we have been faced with barriers over the last four years that were largely unprecedented in our current workforce.

The strain on an already struggling system has shed light on failures that have been present for far longer than the strain of COVID19. The impact of the increased burden and stress is still being felt and will be felt for decades to come. The answers to the rebuilding of the medical systems are far too vast to touch on here, but one very important issue that needs to be discussed is physician suicide.

Dr. Lorna Breen was an emergency physician who toiled on the front lines of the pandemic. She died by suicide in 2020. Her family has worked to advocate and bring awareness to suicide in physicians, and in March 2022, the Dr. Lorna Breen Health Care Provider Protection Act was signed into federal law. This piece of legislation provides a framework and funding for implementing measures aimed at addressing and educating about mental health care and suicide in healthcare professionals.

The higher risk of suicide faced by physicians was first described in 1858, so this is not a novel situation. It is widely reported that there are about 300-400 deaths of physicians by suicide each year, and that physicians are about two times more likely to die by suicide than the general population. It has been hypothesized that these numbers may surge 24 MD-UPDATE

in the post-COVID era, but that data is not fully available.

There are many risk factors that are known contributors to suicide in physicians, including depression, anxiety, and substance use disorders. A study published in 2020 by JAMA Surgery highlighted some other factors, including a slightly older age at the time of suicide than the general population — though there also appears to be a bimodal distribution with the second increase being during the time of training and early career, being of Asian or Pacific Islander ancestry, or having health problems, job stressors, and civil legal problems.

These additional factors, some of which appear to be specific to physician cohorts, can be areas in which further research could help elucidate ways to intervene.

Ending the Stigma Other information that highlights physicians’ personality types, as high achieving or Type A personalities are potentially at higher risk of suicide. Often physicians are held to superhuman standards by their colleagues, patients, and society. Physicians are human, and we suffer from mental illness, including depression, anxiety, and substance use disorder, all of which predispose individuals to death by suicide.

An additional burden cast upon our profession is the fear of getting treatment — licensing boards, which vary state to state, ask us about psychiatric treatment every year when we renew our licenses. The Kentucky licensure asks broadly if you have an illness that would keep you from practicing medicine — which is in line with the Federation of State Medical Boards, the governing body that makes recommendations about state licensing boards. As part of an immediate action by the Dr. Lorna Breen Act, the licensing boards were required to uphold the recommendations of the FSMB, which included attempts to decrease stigma and encourage

Courtney Markham-Abedi, MD, is an inpatient psychiatrist at the VA in Lexington, Kentucky. She was born and raised in Point Pleasant, West Virginia, attended Denison University and matriculated to West Virginia University School of Medicine after her junior year. She met her husband Nick Abedi, MD, at West Virginia School of medicine, and they came to Lexington, Kentucky, for training in psychiatry and general surgery, respectively. Nick later completed vascular surgery fellowship and is president of United Surgical Associates.

Markham has been named by feedspot. com as one of the 1,000 best healthcare journalists and editors. Her writing about various topics in psychiatry has been featured in many online publications, and she has appeared on a number of podcasts. She has an interest in inpatient psychiatry, health care inequities, reducing stigma associated with mental illnesses, and narrative medical writing as an outlet for capturing the experiences of healthcare professionals.

physicians to seek help by removing barriers, one of which is fear of disclosure to licensing boards. Kentucky was already following the guidelines, but there are many states that were not. In Kentucky, Senate Bill 12 was passed in 2022 as well. It also encourages physicians to seek care, while ensuring confidentiality.

Like so many of the readers of this publication, I have been there for my patients the day

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after I received a cancer diagnosis, and when I realized I had to have radiation treatment, my first concern was, “Can I work?” This left me to ponder, what if my diagnosis was not physical?

What if I or any of my colleagues had to miss work to receive treatment for depression or another mental illness? Should our licensing boards handle mental illnesses differently than physical ailments, or should this decision be left between the physician and their care providers?

In my career, I have grown to understand the resilience and humanity that is inspired by suffering in one’s own life, whether that be of a physical, psychiatric, or spiritual nature. I do not support the different treatment of psychiatric illnesses when it comes to decisions of licensure. Luckily, our licensing board is attempting to remove barriers to care of mental illnesses in physicians by attempting to remove stigmatizing language in board renewal processes.

Advocating for Each Other Nearly every month, I hear of the loss of another physician by suicide. Each one of these individuals bears testimony to the struggle that is being a physician in the current times.

Each deserves the quiet contemplation of how to make things better and then the advocacy that should follow. The last moments of our colleagues’ lives are harrowing, no doubt, as we physicians die with guns to our heads, pills in our mouths, or a myriad of different ways, all aimed at ending pain. We indeed are human.

With these lives pass knowledge built over years and thousands of hours of study as well as the essence of the person who acquired all that knowledge and accomplished all of what a career in medicine entails — even one that has been cut short.

At the end of the day, we are not defined by our accomplishments, but speaking for myself and likely a lot of readers, it absolutely can feel that way. Our training contributes to our belief that we are only as good as our last success, and we all know the flip side of that coin.

We need to advocate for the ability to take

Psychiatry

time to go to medical appointments, to be able to seek help without fear of losing licensure or our jobs. We are making strides, but so much more needs to be done. Collectively, we need to be a part of this change — part of that is working on our own stigma about receiving mental health care, and part of that is working with health care agencies to make sure that when we need support, that support is in place and easily accessible. We need to speak the names of our colleagues that have died by suicide and advocate for current and future physicians for improved access to care unfettered by fear to utilize the very same lifesaving treatments we recommend to our patients.

I hope this piece will serve to increase awareness and to encourage us all to work on decreasing stigma. Please keep on hand these numbers, which are some important resources to individuals struggling.

SOME CURRENT RESOURCES Physician Support Line: 1.888.409.0141

The free and confidential hotline connects physicians to psychiatrists from 8:00 a.m. to 1:00 a.m. Eastern, seven days a week.

National Suicide Prevention Hotline: Dial 988 ISSUE #149 25

Mental Wellness

Are You Stuck?

Think smarter to move forward

BY JAN ANDERSON, PSYD, LPCC

When you force yourself to choose between two lose/lose options, no wonder your brain shuts down and you get seriously stuck.

In MD-Update #146 I introduced readers to a way out of life’s Catch-22 dilemmas, those double-bind hell holes I call Bad Ass Dilemmas (BAD).

I’m a big fan of both/and thinking (BAT) as a way to free yourself up and move forward.

Instead of being forced to choose between two binary opposites, BAT is mind-blowing way to level up your thinking and come up with a better third option. I call this Door #3.

As a brief recap, here’s how both/and thinking works: Rather than asking, Do I pick A or B? reframe the problem as How can I accommodate both A and B? By accommodate, I don’t mean trade-offs, compromise or any proposition that leaves you with a soul-sucking lose/lose feeling. I’m talking about a way to level-up your thinking so you have a chance for a win/win.

Both/and thinking is not just mind-blowing. It can be life-changing. That’s why I want to continue this conversation with my readers and clients.

Now is the perfect time to do some both/ and thinking, as you reflect on the past year and focus on your vision of the new year.

Being Stuck Sucks Is there anything worse than being stuck?

Bad Ass Dilemmas (BAD) are like one of those bad dreams where you’re trying to run, but somehow you can’t move.

• Should I give up or keep trying in this relationship?

• Should I leave this job or stay because of the money?

• Should I try to have kids or not?

When your personal values are challenged, it’s easy to get stuck in a BAD. Do I put myself first or should I be there for the team?

Do I tell my partner about my (fill in the 26 MD-UPDATE

blank) or do I keep it a secret?

When the stakes are high, it’s easy to get stuck in a BAD. If I break up with my romantic partner, how do I know I’ll find someone better? What if I can’t repeat my success in this new job or business venture?

I can say yes and be taken advantage of.

EITHER I can let myself be happier OR I can give up my drive to do better.

Either/or thinking can shut down your brain and leave you trapped in a catch-22 hell hole.

Either/Or Thinking Can Keep You Seriously Stuck

Either/Or Thinking Can Make You Overreact or Underreact

Limiting yourself to either/or options can It’s like your nervous system is designed keep you seriously stuck. It’s hard to get with an accelerator and a brake function. moving when, no matter which direction you And your accelerator gets stuck. Or you don’t take, it feels wrong. Here’s the brain science realize you have the parking brake on. Your behind why: either/or responses are either “too much” or 1. You’re trying to decide without all the “too little.” information. (Your brain doesn’t like that.)

So why don’t we stop this craziness and get 2. The outcome is uncertain. (Your brain centered in clear thinking? really doesn’t like that.)

Well, there’s this crazy thing we humans do: Our brains love the elegant simplicity and The insanity trap of doing the same thing over the feeling of certainty that comes with a and over, but somehow expecting a different black-or-white answer. And that binary mind- result. set works great for math problems and techniActually, it’s not that crazy. It’s just an ordical issues. Heck, either/or thinking is the basis nary human thinking error: If I try harder, of Western science and all the advancements maybe it will work this time. If I keep doing it has brought us as a society. it, maybe it will finally work.

Problem is, either/or thinking usually sucks when applied to complex human interactions. Catch-22: There’s a Way Out A black-or-white forced choice is woefully So how do you get out of a soul-sucking inadequate for personal values dilemmas like BAD? these: truth vs. loyalty, TOO MUCH: BALANCED: TOO LITTLE: individual vs. commuOver-correct Centered Under-correct UNDER-THINKING: nity, short-term vs. longOVER-THINKING: CLEAR THINKING: Impulsive decisions term, or justice vs. mercy.

Obsessing Rational problem-solving Compartmentalize Ruminating Creative problem-solving Neither answer feels Denial • Distraction right. Both answers feel EMOTIONAL REGULATION: OVER-EMOTING: UNDER-EMOTING: Distress tolerance wrong.

Volatile Numb Aware of your feelings EITHER I can Drama Stonewalling Aware of feelings of Sensitized Insensitive express my true others feelings OR say REACTIVITY: RESPONSIVENESS: PARALYSIS: Impulsive behavior Grounded Freeze, choke nothing and avoid Knee-jerk reactions Think before act Give up too quickly hurt feelings.

Trying too hard Freedom to choose Don’t even start EITHER I can be OVER-RELATING: BALANCED RELATING: UNDER-RELATING: selfish and say no Over-dependence, needy Emotionally available with Under-dependence (anxious attachment) good boundaries (avoidant attachment) OR

Mental Wellness

One of the masters of either/or thinking, Albert Einstein, was smart enough to know when to drop it and shift paradigms: “We cannot solve our problems with the same level of thinking that created them.”

Einstein knew that our brains don’t crave just certainty. Your brain likes creative problem-solving, too. And it has a remarkable ability to hold two completely contradictory thoughts at once, wrestle and play with them, and eventually come up with an even better third option incorporating elements of each.

That’s what Einstein did when he shifted out of either/or thinking and stopped asking if an object was either in motion or at rest. He shifted into both/and thinking and wondered if an object could be both in motion and at rest simultaneously.

You don’t have to be a genius to get the hang of both/and thinking. It doesn’t even have to be hard. Take the simple phrase: Less is more. It sounds contradictory or even illogical, but a less-is-more approach can simply be ingenious. It’s a great example of how both/ and thinking juxtaposes two opposite ideas, accommodates them both, and finds a creative way to get something done.

Here’s another example. Can you see how just rewording the earlier either/or questions can automatically engage the creative problem-solving part of your brain?

• How can I let myself be happier — without losing my drive to do better?

• How can I set better boundaries and say no — without being selfish or mean?

• How can I be honest and express myself — in a way that also considers the other person’s feelings?

Tap Into Your Capacity for Both/And Thinking: Tapping into both/and thinking starts the same way any good movie does. It draws you in with something unexpected, conflicting, or puzzling that piques your interest: Step 1: Tap into your natural curiosity.

Examine each opposite thought or idea, asking, What is important about this? What points are missing from this perspective? Is my understanding or interpretation of what was said accurate? What else is important?

Step 2: Now hold both these two opposite perspectives in your mind simultaneously and ask, How can I accommodate both? What would it be like if both perspectives could be integrated into something even better?

The slightly unsettling process of jumping back and forth between two contradictory, competing thoughts has a sneaky way of getting you unstuck and moving forward.

This happened recently when distraught parents reached out to me with a “Sophie’s Choice” dilemma: Our daughter is forcing us to choose between her and our son.

The parents’ dilemma could be described as two either/or demands from their daughter.

1. EITHER you force my brother to apologize to me OR I will cut all contact with you.

2. Tell my brother that EITHER he must apologize to me OR you will throw him out or cut him off financially.

Daughter was justifiably upset with Brother’s serious behavioral issues and Mom and Dad’s conflict-avoidant response.

However, her either/or demands created a catch-22 for her parents. Predictably, their initial responses backfired: Mom: It’s unreasonable for Daughter to expect us to choose her over our son. Maybe I can reason with her.

Dad: If Daughter could see how this situation is tearing me up, maybe she wouldn’t do this.

By the time Parents reached out for professional help, poor Mom had boxed herself into an either/or mindset: Mom: I can’t support them both at the same time.

Me: Actually, you support BOTH Daughter AND Son at the same time.

1. Start by not fixating on specific demands.

Instead, focus on finding out what’s most important to each person.

2. Support Daughter by addressing her underlying need to feel heard and supported. I’m guessing it’s more about your helping her feel safe from his impulsivity and aggressive behavior.

3. Support Son by not demanding that he apologize. I suspect there are a number of ways Son can make amends that will work for Daughter.

I remember two incredibly simple interactions that marked a turning point for the whole family. One was Dad’s ability to focus on feelings first instead of going into fix-it mode: Dad: I didn’t realize the toll this was taking on you.

Daughter: Thank you for saying that.

Then Son managed a beautiful repair attempt with Daughter. It was remarkable that he didn’t apologize or even say it directly to Daughter. Daughter merely overhead it.

Son to Mother: I want to have a good relationship with my sister.

Both/and thinking is an effective way to express conflicting emotions, reconcile seemingly opposing ideas and find a counterintuitive way to achieve difficult goals. When you start cultivating your capacity for both/ and thinking, it can feel like your head will explode. When this happens, remind yourself that you’re learning to think like Einstein. It’s a sign that your brain is getting smarter and your thinking is becoming more expansive.

Coming up: How to Translate Both/And Thinking Into Emotional Regulation on the Inside and Behavior Change on the Outside.

Please stay tuned. (Or if you can’t wait, please get in touch with me for a complimentary consultation.)

ISSUE #149 27

News News News

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

Baptist Health Medical Group Welcomes New Physicians and Announces Retirement ELIZABETHTOWN Fedwa

Lutfi, MD, has joined Baptist Health Medical Group Family Medicine.

Lutfi provides well visits and disease prevention, health maintenance, and care for urgent conditions. Her special interests include heart disease, diabetes, preventive and urgent care medicine, medication compliance and safety, and wellness across the lifespan.

An Elizabethtown native, Lutfi earned her medical degree from Ross University School of Medicine in Dominica, West Indies. She then completed a family medicine residency at Lake Cumberland Regional Hospital in Somerset. She is certified by the American Board of Family Medicine and is a member of the American College of Physicians. She is fluent in Arabic and intermediate in Spanish.

internal medicine, preventive medicine, medication compliance and safety, advance directives, and wellness across the lifespan.

A native of Cartagena, Columbia, Manotas Gomez earned his medical degree from Libre University in Barranquilla, Columbia. He completed an internal medicine residency at NYC Health + Hospitals, South Brooklyn Health, in Brooklyn, New York. Manotas Gomez has completed courses in arterial line placement, central venous catheter, and paracentesis. He is a member of the American College of Physicians and is fluent in Spanish and Portuguese.

Manotas Gomez will be practicing at Baptist Health Medical Group Family Medicine at 100 Helmwood Plaza Drive in Elizabethtown.

ELIZABETHTOWN Karlee Grace, DO, has joined

ELIZABETHTOWN Jeffrey Austin, MD, has

joined Baptist Health Medical Group General Surgery. He specializes in da Vinci® robotic surgery and minimally invasive laparoscopic and endoscopic surgical procedures involving the thyroid, parathyroid, gallbladder and colon, as well as abdominal hernia repair and more.

A native of Bowling Green, Austin earned his MD from the UofL School of Medicine and completed his general surgery residency at Charleston Area Medical Center in Charleston, West Virginia.

Austin has earned certification in da Vinci Xi™ robotic surgery as well as endoscopic and laparoscopic surgeries. In addition, he has completed the Advanced Surgical Skills for Exposure in Trauma course. He is a member of the American College of Surgeons and the American Medical Association.

Baptist Health Medical Group OB/GYN. Grace provides care for all women’s health needs, including annual wellness visits; complete preconception, pregnancy, and postpartum care; contraceptive counseling; gynecological conditions, and menopause management.

A native of Lafayette, Tennessee, Grace earned her BS at Western Kentucky University.

She earned her Doctor of Osteopathic Medicine and completed a residence in obstetrics and gynecology as Ascension MacombOakland Hospital in Warren, Michigan.

Grace has earned national board certification from the American Osteopathic Board of Obstetrics & Gynecology. She has also earned certification in American Heart Association Basic Life Support, Advanced Cardiovascular Life Support, and Neonatal Resuscitation.

She holds certification for da Vinci® RoboticAssisted Surgery and has completed the Nexplanon® clinical training program.

ELIZABETHTOWN Jonatan Manotas Gomez,

MD, has joined Baptist Health Medical Group Family Medicine. Manotas Gomez provides well visits and disease prevention, health maintenance and care for urgent conditions. His special interests include cardiovascular disease, 28 MD-UPDATE

ELIZABETHTOWN Kyle Romines, MD, has

joined Baptist Health Medical Group Family Medicine, offering from well visits and disease prevention, health maintenance and care for urgent conditions. His special interests

include heart disease, high blood pressure, preventive medicine, medication compliance and safety, and wellness across the lifespan.

A native of Campbellsville, Romines earned his MD from UofL School of Medicine and completed a family medicine residency at Baptist Health Deaconess Madisonville.

ELIZABETHTOWN Logan Garthe, MD, has

joined Baptist Health Medical Group Family Medicine. He offers well visits and disease prevention, health maintenance and care for urgent conditions. His special interests include heart disease, high blood pressure, preventive medicine, medication safety, and wellness across the lifespan.

A native of Highland, Illinois, Garthe earned his MD from Southern Illinois University School of Medicine, where he also completed his family medicine residency.

Garthe is board certified by the American Board of Family Medicine and is a member of the American Academy of Family Physicians. He will be practicing at Baptist Health Medical Group Family Medicine at 534 Hillcrest Drive, Brandenburg, Kentucky.

LEXINGTON Sean Stokes, MD, has joined the

Baptist Health Network as a surgical oncologist with Lexington Surgical Specialists, formerly Lexington Surgeons.

The Lexington native received a bachelor’s degree in engineering at Pennsylvania State University. He is a graduate of the UK College of Medicine and completed the general surgery residency program at the University of Utah. He completed a complex general surgical oncology fellowship at the Moffitt Cancer Center in Tampa, Fla. Stokes will maintain a broad practice in surgical oncology with a focus on hepatobiliary, pancreatic, and gastrointestinal surgery.

LOUISVILLE Mahrokh

Nokhbehzaeim has joined the Baptist Health Medical Group. She treats adrenal, bone, calcium, pituitary, neuro-

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Fedwa Lufti, MD

Jeffrey Austin, MD

Jonatan Manotas Gomez, MD

Karlee Grace, DO

endocrine and thyroid disorders and manages diabetes, lipids, and obesity conditions for patients.

Nokhbehzaeim trained at Tehran University of Medical Sciences School of Medicine, completed an Internal Medicine residency at West Suburban Medical Center in Oak Park, Illinois, and an Endocrinology fellowship at Marshall University.

Logan Garthe, MD Sean Stokes, MD Marokh Nokhbehzaeim, MD Her associations include the Endocrine Society, American Gerard its 2022 Association of Clinical Endocrinology, Citizen of the Year Educational Commission for Foreign Medical for exhibiting high Graduates, American College of Physicians, ethical standards in and the Iranian Medical Council. meeting the needs of his patients and their ELIZABETHTOWN Paul Gerard III, MD, with families. He has Baptist Health Medical Group Family served as chief of Medicine (Freeman Creek), retired on staff, chaired the October 1. He has more than 40 years of Ethics Committee, commitment and service to the fields of fami- and delivered more Kyle Romines, MD Paul Gerrard III, MD ly medicine and geriatric medicine. than 1,000 babies at Throughout his medical career, Gerard has Baptist Health been a well-respected patient advocate with a Hardin. particular interest in end-of-life care. He startGerard earned his MD from the UofL palliative medicine and has taught medicine at ed the hospice care program in Hardin School of Medicine, completed his residency both UofL and UK. County, now Hosparus of Central Kentucky, in family medicine at the Uof L-affiliated hosStaff members who have worked alongside serving as medical director for 35 years, pitals and a fellowship in geriatric medicine Gerard describe him as an “amazing, profesand was instrumental in developing Baptist at University College Hospital in London, sional and caring” physician who has dedicatHealth Hardin’s Palliative Care program.

England. He is board certified in family ed himself to providing the highest quality of The Kentucky Nurses Association named medicine, geriatric medicine, and hospice and care.

PHOTOS PROVIDED BY BAPTIST HEALTH

ISSUE #149 29

News

CHI Saint Joseph Medical Group Welcomes General Surgeon, OB-GYN, Pulmonologist, and Family Care Physicians LONDON CHI Saint Joseph Medical Group –

Surgery welcomes general surgeon Nicholas Capal, DO, MS, to Laurel County. Capal’s journey into medicine began with a desire to make a meaningful impact, and today, he specializes in providing surgical solutions that improve the health and well-being of his patients.

Originally from Cincinnati, Capal spent nine years in Youngstown, Ohio, pursuing his medical education and training. He received his DO degree at the Lake Erie College of Osteopathic Medicine in Erie, Pennsylvania, in 2018. Following medical school, he embarked on a general surgery residency at Mercy Health – St. Elizabeth Youngstown Hospital, a community-based hospital and Level 1 Trauma Center in Ohio.

During his residency, Capal gained extensive experience in trauma, critical care and acute care surgery and developed proficiency in minimally invasive, laparoscopic, and robotic surgical techniques. As a general surgeon, Capal embraces the diversity of cases that come his way, from trauma and gall bladder surgeries to cancer operations. His patient-centric philosophy underscores the importance of forging a partnership between physician and patient. He believes patient education is paramount.

Nicholas Capal, DO, MS 30 MD-UPDATE

Capal’s decision to join Saint Joseph London was influenced by both professional and personal reasons. He was already familiar with the area, as he had family members living in the region for 15 years.

BARDSTOWN CHI Saint Joseph Medical Care

– Obstetrics and Gynecology in Bardstown welcomes its newest addition, Hanna Peterson, MD, MS, to its team of local providers. Peterson brings a wealth of dedication, experience, and a heartfelt commitment to women’s health and reproductive care. Dr. Peterson’s journey into medicine was deeply personal.

“I had health issues as a child and was inspired by my physicians and the nurses who cared for me,” Peterson says. That personal connection is the foundation of her patient-centered approach. “They come first.

Their needs will always come first.”

From the Gainesville, Florida, area, Peterson earned her MD in 2019 from the University of Florida and completed her residency training in Louisville, Kentucky in 2023. Her decision to join CHI Saint Joseph

Hannah Peterson, MD, MS PHOTOS PROVIDED BY CHI SAINT JOSEPH HEALTH

Medical Group was influenced by her positive experience during her residency.

“When I came to Kentucky for my residency training, I rotated to Bardstown during my residency. Rural health care seemed like a good fit to be a first-line provider to connect patients with subspecialists.”

In her role at CHI Saint Joseph Medical Group, Peterson will provide annual care visits for women and offer gynecology care for those in their post-menopausal years. She has a passion for preventive health care, urging women to prioritize regular visits, even in post-reproductive years.

LEXINGTON CHI Saint Joseph Medical Group

welcomes Ibrahim Shahoub, MD, specializing in pulmonology and critical care medicine.

Shahoub hopes to help more Kentuckians suffering from COPD and lung cancer. Shahoub’s journey in medicine started early with a determination to make profound improvements in people’s lives.

Born in Zliten, Libya, Shahoub embarked on his medical career at the University of Tripoli School of Medicine, where he earned his MBBCh degree, the equivalent of an MD. His dedication to furthering his medical knowledge led him to the United States, where he completed the United States Medical

Ibrahim Shahoub, MD

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Licensing Examination and became certified by the Educational Commission for Foreign Medical Graduates.

Shahoub then entered the Internal Medicine Residency Program at the Joan C. Edwards School of Medicine at Marshall University, where he honed his skills in diagnosing and treating a wide range of medical conditions.

Following his residency, he completed fellowships in both pulmonary medicine at Marshall University and critical care medicine at the University of Kentucky. He is board certified in internal medicine, pulmonary medicine, and critical care medicine. Additionally, he holds certifications in basic life support, advanced cardiovascular life support, and advanced trauma life support.

“Nothing is as meaningful as when a patient who was on the brink of death walks out of the hospital,” said Shahoub. “When treating patients, I think compassion comes as the top priority. People get sick, and they feel weak.

Put your hand in their hand, they feel it, and it gives you a rewarding feeling.”

MD from the UK college of Medicine. He completed his residency at Mercy Health – St. Rita’s Medical Center in Lima, Ohio. Jones’s background includes a role as a certified nursing assistant, providing direct patient care to disabled patients and building strong relationships with nursing staff. His research experience and publications demonstrate his commitment to patient well-being, delving into patient-provider interactions regarding chronic pain management.

With a background in neuroscience and a deep commitment to a holistic approach to health care, Jones aims to provide comprehensive, holistic, and preventive care. He is dedicated to discussing options for his patients beyond just medication. Jones’s commitment to improving health care goes beyond the office. He actively engages with the community to understand their health care needs and fosters an atmosphere of trust.

LONDON CHI Saint Joseph Medical Group –

Family Practice in London welcomes Jarred Jones, MD, back to the Bluegrass State and into its family practice team. Jones, a native of London, brings a deep commitment to improving the health and well-being of the community he grew up in. Jones has a unique perspective on health care, which is deeply rooted in his family’s own experiences and his desire to prevent avoidable health problems.

Jones is a graduate of Brown University in Providence, Rhode Island, and received his

Jarred Jones, MD

Dermatology Associates of Kentucky Joins Lexington Clinic LEXINGTON Dermatology Associates of

Kentucky (DAK) and Lexington Clinic announced a partnership to become a leading dermatology group practice organization in Central Kentucky.

“We’re very excited to welcome Dermatology Associates of Kentucky (DAK) as a part of Lexington Clinic.

In addition to expanding our care to patients in the communities we serve, we’ll also increase our collective capabilities with some of the foremost thought leaders in dermatology,” said Stephen J. Behnke, MD, CEO of Lexington Clinic.

The newly combined DAK and Lexington Clinic Dermatology group now includes 10 board-certified dermatologists and 10 providers who practice in five locations across the Bluegrass, mainly Lexington, Frankfort, Mount Sterling, and Somerset.

“We are excited to join Lexington Clinic as both the organizations are aligned in their commitment and focus on providing high quality patient care.

Our physicians and providers will also be able to share knowledge and actively learn from one another, which will improve clinical outcomes,” said Ryan Fischer, MD, at DAK.

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ISSUE #149 31

Events

KPMA 2023 Fall Virtual Conference LOUISVILLE The

Kentucky Psychiatric Medical Association (KPMA) held its first-ever virtual conference on October 27, 2023. Dr. Laurie Ballew addressed the challenge of medication management during

Ashley Butler, Esq

pharmaceutical shortages, particularly the need for stimulants. Dr. Rachele Yadon shared her experiences and resources for treating mood and anxiety disorders during the perinatal period. Attorneys Ashley

Karen Keith, Esq

Butler and Karen Keith from the law firm Stoll Keenon Ogden, PLLC discussed the legal pros and cons of telehealth and also provided an update of Kentucky law pertaining to telehealth inpatient care.

Dr. Rachele Yadon

Dr. Laurie Ballew

PHOTOS PROVIDED BY KPMA

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32 MD-UPDATE

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