THE BUSINESS MAGAZINE OF KENTUCKY PHYSICIANS AND HEALTHCARE PROFESSIONALS ISSUE #86
SPECIAL SECTIONS WOMEN’S HEALTH PEDIATRICS
ONCOFERTILITY AND PEDIATRIC ONCOLOGY
UK pediatric specialists Dr. Leslie Appiah and Dr. Lars Wagner honor the resilience of young cancer patients PICTURED: Leslie Appiah, MD
VOLUME 5, NUMBER 4
ALSO IN THIS ISSUE SINGLE-SITE DAVINCI® HYSTERECTOMY COEMIG DESIGNATION IN LOUISVILLE INTEGRATIVE THERAPY FOR CHRONIC PAIN INTERNAL MEDICINE & PEDIATRICS PRACTICE PEDIATRIC GROUP PRACTICE WITHOUT WALLS PEDIATRIC OUTPATIENT THERAPY PELVIC FLOOR PHYSICAL THERAPY
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LETTER FROM THE EDITOR
All Aboard, Women and Children First! The Women’s Health issue of M.D. Update is always an exciting challenge for us because there are so many possible stories. This year we added pediatrics to the mix and the result was an explosion of stories about new and traditional treatments for the women and children of Kentucky. We are particularly gratified to introduce, via our cover story, Dr. Leslie Appiah and Dr. Lars Wagner to our statewide audience. Through the leadership of Dr. Michael Karpf, executive VP for UK Healthcare, and Dr. Mark Evers, director of the Markey Cancer Center, among others, cancer research and treatment continues to advance. We were also present at the ribbon cutting of the Charles and Mimi Osborne Cancer Center at Baptist Health in Louisville, which will bring all of Baptist Health Louisville’s cancer services into one location. “This is a center of hope,” said David Gray, president, Baptist Health Louisville. “Because of advances in the last 10 to 20 years, at times with various types of cancer, we’ve almost been able to turn it into the management of a chronic disease.”
I direct your attention to the Open Letter from M.D. Update Digital Publisher Megan Campbell Smith on page 8 for the latest on how M.D. Update will soon be available to millions of Kentucky health care consumers who want to know more about the providers and the health care options and advancements in Kentucky. I assure you, this will not be a grading system or consumer review platform. We will continue our peer–reviewed editorial format, which delivers honest, authentic content about the health care professionals in Kentucky. I also ask you to review the M.D. Update Editorial Calendar inside. Find your specialty and then contact us to tell us about your practice, your specialty, and your views on health care in Kentucky in 2014. I look forward to hearing from you. All the Best, Gil Dunn Publisher, M.D.Update Send your letters to the editor to: firstname.lastname@example.org, email@example.com, or (502) 541-2666 mobile Gil Dunn, Publisher: firstname.lastname@example.org or (859) 309-0720 phone and fax 2 M.D. UPDATE
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COVER STORY 4 HEADLINES 7 FINANCE 8 OPEN LETTER FROM DIGITAL PUBLISHER 10 COVER STORY 13 SPECIAL SECTION: WOMEN’S HEALTH
ONCOFERTILITY AND PEDIATRIC ONCOLOGY
19 SPECIAL SECTION: PEDIATRICS 23 COMPLEMENTARY CARE Dr. Leslie Appiah at the Markey Cancer Center Healing Garden
UK pediatric specialists honor the resilience of young cancer patients
30 NEWS 31 EVENTS
BY TIM CORKRAN, PHOTOGRAPHY BY JOHN LYNNER PETERSON PAGE 8
SPECIAL SECTION WOMEN’S HEALTH
SPECIAL SECTION PEDIATRICS
11 GUILER PERFORMS SINGLE-SITE HYSTERECTOMY
14 NORTON RECEIVES COEMIG DESIGNATION ￼
17 INTERNAL MEDICINE & PEDIATRICS
13 HUBBARD DISCUSSES INTERSTITIAL CYSTITIS
16 KENTUCKYONE INTEGRATIVE THERAPIES
19 ONE PEDIATRICS
21 BABY HEALTH SERVICE REACHES 100 ￼
TWO KENTUCKY PHYSICIANS COMPETE IN THE BOSTON MARATHON, ONE YEAR AFTER THE TRAGIC BOMBING AT THE FINISH LINE
Taking Back the Boston Marathon
Ronald G. Shashy, MD, is a board-certified otolaryngologist who practices with Ear, Nose & Throat Specialists in Georgetown, Ky. Shashy is an avid runner. He did not run the Boston Marathon last year but returned this year for his fourth Boston Marathon to show his support of the city and the event.
BY RON SHASHY, MD The day started as nearly 35,000 runners loaded hundreds of school buses in Boston Commons to make the one-way trip to Hopkinton, starting point of the Boston Marathon. There would many nervous folks traveling as this was the oldest, most prestigious races in the world. The best runners on the planet would be present. Each of us was coming from a town or a city where we were the top dog. Now, we would be anonymous among a sea of superathletes. Heck, I had just won an Ironman triathlon three weeks before in Florida; but here I would hope to break into the top 10 percent. This would be my fourth Boston Marathon. I may qualify every year, but I pick certain years to go based on friends who would join me. These race plans began almost one year prior when my residency buddy called. Scott McLean was one of those supermen of whom I spoke. He ran cross country at Michigan 20+ years ago and talked me into my first marathon. I was 32 years old at the time and in Otolaryngology residency training at the Mayo Clinic. “Make sure you have a qualifying marathon time,” he said this time. We were both 45 years old and only needed to run a 3-hour 25-minute time to qualify. He called to make sure that I was qualified and signed up in September. This would be the biggest Boston Marathon ever after what happened in the 2013 bombing. This would represent athletes taking back their sport and not letting two zealots 4 M.D. UPDATE
Scott McClean, MD, and Ron Shashy, MD
change how we live. On race day, we rode together out to the start. No bags, no packs, no extra anything. We wore clothes that we intended to throw away. The rules were tight to protect the event, the spectators, and the runners. As we arrived in Hopkinton, we noted tens of thousands of runners getting ready. We were fenced in and quarantined off. Fences marked where we were to stay. There were police, sheriffs, marshals, FBI, ICE agents, and soldiers protecting us. It was an awesome presence. We loaded into corrals based on our qualifying times. I was in Wave 1, Corral 5 based on my seemingly average qualifying time of three hours from the Derby Marathon in Louisville. There were nine corrals per wave with 800 to 1000 runners in each corral. We were packed in, shoulder to shoulder, by volunteers. The Boston Marathon is strict about controlling the corrals so that runners are seeded appropriately (each runner next to another who would run the same pace). I would leave the gate with runners going 6:40/mile pace. There would be no passing for hours. After the gun, I took two minutes to get to the start line. Thousands of marathoners were seeded ahead of me. We were flying downhill at the start. It seems like a good idea to run downhill, but it burns up your
quads as you “hold the brakes on” to control your pace. It’s actually harder. Boston is a tough course because of this. We go downhill for eight miles, then it’s flat to rolling, and finally in the last third of the marathon, trouble comes with multiple hills. By this time, your legs are toast and the hills keep coming. I’ve laid an egg (3:24, 3:28, 3:20 in ‘12, ‘07, ‘02, respectively) on all of my previous Boston trips because of this course setup. My Garmin GPS had me at a 6:55/ mile through mile 14. I treat racing like a formula or a math calculation. I have calculated several factors: 1. My lactate threshold (where my body goes anaerobic), 2. How fast I go at that heart-rate, and of course, 3. How long I can run at that heart-rate. The goal is to park my heart-rate at the point of anticipated leg muscle failure. Boy, does that hurt, though! The race was exhilarating. The fans were lining the course, sometimes 10-people deep. Screaming. Yelling. Cheering. They gave out extra water, oranges, popsicles, etc. The police presence was most noticeable with placement of law enforcement every 25 feet in some fan-filled areas. Remember, this a point-to-point marathon, so fans are spread across 26.2 miles. The crowd support was awesome! We were taking back the Boston Marathon. It would return to be that glorious world-renowned event. As I hit the hills, my speed faltered as expected. I lost a minute on hill number one, then two minutes on hill number 2, and so on. It hurt and there was nothing I could do about it but hold intensity and heart-rate at >163 bpm. My legs already felt like a nail gun had shot my thighs. That feeling would only last a week. Ouch. Holding it together, I tried to hold a 7:15/mile pace to the end. Four miles, three, two, one. Finish line! I did it! I finished at 3 hours 7 minutes and enjoyed those last yards down Boylston Street, where the bomb had gone off last year. The fans’ cheering echoed between buildings as we ran that last half mile and crossed the line. A medal awaited each of us, but the greatest memory was turning that site of tragedy back into a moment of joy for the finishers. ◆
Returning To Boston, One Year Later
(L-R)With friends Monica Murphy, Kelli Mudd Miller, MD, and Bill Snyder
Facing fear and anxiety, Louisville doctor runs her 4th Boston Marathon
BY GIL DUNN Kelli Mudd Miller, MD, OB/GYN with Women First of Louisville, was only minutes away from the finish line in the 2013 Boston Marathon when she heard the first bomb go off. Moments later, the second blast, only 50 yards away, told her something dreadful was happening. Paralyzing fear rooted her in her spot. Her companion grabbed her and escorted her to safety. (See MD Update Issue #79 for more details.) One year later, as Miller returned to run and finish the race, she was overwhelmed with emotion when she turned onto Boylston Street, the famous final stretch of the 26.2 mile race. “I started sobbing when I turned on to Boylston Street,” Miller says. “I wasn’t prepared for the emotions I felt.” Miller was invited to run in this year’s race by the Boston Athletic Association because she did not finish in 2013. Initially she was hesitant to go back, but eventually she accepted the invitation. “Ultimately, I decided it was an honor to be invited back, to be strong, Boston Strong, and to finish what I started last year. And it was to honor the people whose lives were changed last year physically, emotionally, and spiritually.” Although Miller had run the New York
Marathon in fall of 2013 and kept running as part of her fitness routine, she says that she didn’t specifically train very hard for the Boston Marathon. “It was more about participating in the experience,” she says. Compared to previous years, the emotions, energy, and awareness surrounding the 2014 Boston Marathon were supercharged. “Without question, this was the most moving and electric atmosphere I’ve ever encountered,” says Miller. “It was almost deafening how loud the crowds of spectators were as we ran past them.” To steady herself through the waves of
emotions and the physical challenges of running a marathon through the hilly course, Miller says she repeated the mantra that she had written on her running shoes. It was the quote from Martin Richard, the eight-yearold boy who lost his life from the bomb last year. It said, “No more hurting people. Peace.” “Running down Boylston Street, crossing the finish line, was part of my journey, my closure. It was part of the process dealing with my anxiety and having a good feeling about that place again. It was difficult. It was emotional. It was good,” says Miller. ◆
Our pediatric programs treat a variety of medical, congenital and developmental issues. ADD/ADHD• Amputation• Autism• Cerebral Palsy• Degenerative Joint Disease• Developmental Delay• Down Syndrome• Juvenile Arthritis• Learning Impairments• Multiple Trauma• Muscular Dystrophy• Neurological Disorders• Orthopedic Injuries• Scoliosis• Sensory Integration• Spina Bifida• Voice Disorders www.cardinalhill.org
Senate Bill 118 Sets It Sight on Improved Quality of Care BY FRANK BURNS, MD On April 7, 2014, Governor Steve Beshear signed Senate Bill 118, an act related to prescription eye drops. The bill was heavily lobbied for by the Kentucky Academy of Eye Physicians and Surgeons (“the Academy”). The Academy’s mission is to provide convenient and quality eye care to the citizens of Kentucky and this bill accomplishes just that. Senate Bill 118 was introduced into the Senate on February 4, co-sponsored by Senators Julie Denton, Denise Harper Angel, and Reginald Thomas. The measure unanimously passed the Senate Banking and Insurance Committee and subsequently passed in the House with a vote of 98-1. Beginning January 1, 2015, and applying to health benefit plans issued or renewed on or after January 1, 2015, patients who use prescription eye drops can now refill their prescription after 25 days, instead of
is requested by the insured or prescribing practitioner at the time the original prescription is distributed to the insured, and (2) the prescribing practitioner indicates on the original prescription that such an additional bottle is needed by the insured for use in a day care center or school. For individuals with chronic eye problems who use prescription drops, inadvertent waste of the precious drops can be a significant problem. Most health plans fail to provide an adequate volume because they do not account for any misapplication. If a drop misses the eye, it cannot be recovered. The slightest error in application means the drop is gone forever; it cannot be picked up off the floor and used again like a pill. Because of this, users may have to go for days without the medicine necessary to treat their condition. This unavoidable problem especially affects children, who struggle with hand-eye coordination, and the elderly who experience limited range of motion and hand tremors. For glaucoma patients, an inadequate supply of drops is particularly troubling. Glaucoma treatment is directed at lowering eye pressure to prevent optic nerve damage and loss
PATIENTS WHO USE PRESCRIPTION EYE DROPS CAN NOW REFILL THEIR PRESCRIPTION AFTER 25 DAYS, INSTEAD OF THE PREVIOUS 30, IF THE PRACTITIONER NOTES ON THE PRESCRIPTION THAT ADDITIONAL QUANTITIES ARE NEEDED.
the previous 30, if the practitioner notes on the prescription that additional quantities are needed. For a 90 day prescription, early refills are now permitted between 80 and 90 days. In addition, any health benefit plan that provides coverage for prescription eye drops must now provide coverage for one (1) additional bottle of prescription eye drops when: (1) the additional bottle 6 M.D. UPDATE
of vision. Eye drops are routinely glaucoma patients’ first line of defense. Consistent application is crucial; gaps in treatment can lead to vision loss and increase the risk of blindness. Without proper treatment patients may face much more costly and invasive intervention, such as surgery. Now that patients will soon be able to obtain refills at the 25-day mark (and 80-day
mark for a three-month supply), ophthalmologists can rest easier knowing there will not be detrimental lapses in eye drop usage. Though the new law does not become effective until January 2015, ophthalmologists should begin the discussion now with patients and explain the new 25 and 80-day time frames. Together, provider and patient should consider the need for extra drops. For younger patients, ophthalmologists should ask parents or caregivers whether younger patients could benefit from an extra bottle of drops at a day care center or school and so indicate this on the prescription. A bottle kept at a day care center or school may be refilled once every three months. Remember that it must be noted on the prescription that additional quantities are needed in every instance. As more and more Americans gain access to health insurance coverage, it is important for those in the health care industry to take a step back and assess the scope of coverage that is actually being provided. Too often, health plans do not meet the needs of the insured. By taking note of patients’ everyday problems, like the inadvertent waste of drops, providers have a real opportunity to bring about positive change for their patients while improving the quality of care that they deliver. Sometimes, the smallest of modifications can make a big difference. The Academy saw a problem with prescription eye drop amounts and lobbied for a change. Thanks to the support of the legislators and Governor Beshear’s approval, Kentuckians with chronic eye conditions are now eyeing a better future. Dr. Frank Burns is a general ophthalmologist who performs cataract, refractive, and laser eye surgery and cares for glaucoma patients both medially and surgically. Burns received his Doctor of Medicine from the University of Missouri-Columbia in 1986. He subsequently completed his internship in Internal Medicine, Research Fellowship in Ophthalmology, and Residency in Ophthalmology at the University of Louisville. His offices are located in Middletown and Brooks, Kentucky. ◆
Summer Reading This week I heard a 47 year-old physician, who is not our client, say that he believed he would be retiring in about 5 years or less. Normally, when I hear these kinds of comments, they are filled with excitement and anticipation about the freedom of moving on to something else other than the daily grind of medicine. He, on the other hand, was talking about it with a tone of surrender, rather than victory in a goal achieved. He has a very successful practice and appears to have his financial house in order, and obviously derives a great deal of satisfaction from his calling to heal. When asked about why he would give it up, his response revolved around frustration with governmental and insurance company intervention. I am concerned that this feeling is becoming all too common among practicing physicians. This leads me to wonder whether retirement decisions are not as much emotional as intellectual for doctors. If you find yourself in these shoes, I have found three short books that might help you sort it out. I will briefly introduce you to them in no particular order. In The Money Code, Joe Duran, CEO of United Capital, introduces the reader to what he calls the 5 Money Secrets: 1) Your life will be filled with tough choices. 2) Your entire life is determined by how you make decisions. 3) Your biases will affect every decision you make. 4) You will be distracted by things that really don’t matter. 5) You must have a good process to make good decisions. I especially like the last one, for it reminds me of the admonition that better outcomes are usually derived from starting with a better theory. According to Duran, “the goal of this book is to provide the lasting financial solutions you have been looking for.” In looking for those, he asks the question, “Money: what’s it good for?” In short, he answers, “to avoid pain, to feel good, and to take care of the ones you love.” The heart of the book is written in a rather conversational style around a fictional character, Jack, who learns a way to make better financial decisions. Duran draws steadily upon the
illustrations of Carl Richards, the author of The Behavior Gap. We have used Richards’ material for years and find it very worthwhile. The second book was writBY Scott Neal ten by a physician, Dr. James M. Dahle and is titled The White Coat Investor, A Doctor’s Guide to Personal Finance and Investing. Some of you may already be regular readers of his blog of the same title. The last chapter tells of his mission to “help physicians get a ‘fair shake’ on Wall Street.” Since our firm can
and-forget-it portfolio policy. He does a good job of outlining how a good advisor can add value -- and it’s probably not how you think. One of five ways he lists: “An experienced advisor provides the greatest value by protecting your portfolio from your own behavioral mistakes.” Finally, I will introduce you to my friend, Holly P. Thomas’ book, The Mindful Money Mentality, How to Find Balance in Your Financial Future. She begins by saying that her “hope for this book is that you will begin to cultivate ‘mindfulness’ about your relationship with money.” We see so many people in our practice planning retirement who, having heard the commercial about The Number, fear they don’t have “enough.” Ms. Thomas rightfully questions whether
“AN EXPERIENCED ADVISOR PROVIDES THE GREATEST VALUE BY PROTECTING YOUR PORTFOLIO FROM YOUR OWN BEHAVIORAL MISTAKES.” JAMES M. DAHLE, MD
meet all nine of the criteria he recommends looking for in a financial advisor (one of which is gray hair), it’s easy for us to like his book. I do take at least one significant issue with it however: He is a died-in-thewool modern portfolio theorist and appears to only believe in passive investment in a policy portfolio. That is one way, and a reasonably good way to do investments, but it totally ignores the more recent scholarship of endogenous risk, developed by Mordecai Kurz of Stanford University. Knowing and attending to those limitations in connection with investments is crucial in our opinion. Structural changes in the economy do matter, but they are ignored in the construction and maintenance of a set-it-
money can ever be the only benchmark, or if it becomes a tool that enables you to live the life you truly want. All three of these books have a common thread, addressing issues that confront those of us who, comparatively speaking, are well off. A far cry from “Money for Dummies”, these books speak to thoughtful readers with limited time, who recognize that because they are well-off they have more responsibility, not simply more freedom. Scott Neal, President of D. Scott Neal, Inc., a fee-only financial planning and investment advisory firm with offices in Lexington and Louisville can be reached via firstname.lastname@example.org or 1-800-344-9098. ◆ ISSUE#86 7
OPEN LETTER FROM DIGITAL PUBLISHER
How M.D. Update Can Connect You with Patients Online Dear Health Care Providers:
We make magazines. Media and communications - that’s our thing. Even so, what I’ll always remember most about this job is the day that patient called me for medical advice. “Sir, I am not qualified to help you,” I said and tried to direct him toward the qualified resources, but the truth is I was shocked. Something really big had just happened. A member of the public was calling me, a magazine publisher - okay, a medical magazine publisher - but the public was calling me to get the scoop on the doctors in our magazine. A dozen questions bounced around my head. How did he get my number? What did he really hope to get from me? MD-UPDATE is read by doctors in Kentucky’s referral networks - a network not exactly brimming with laypeople. So, how did he find us? “He must have googled one of our doctors and found a story in our archives,” I thought. He must of dialed the number published in the masthead. He certainly wasn’t looking for me, and maybe he wasn’t
even looking for a particular doctor. He probably just wanted help with a condition or symptom he was experiencing - but he asked Google and Google only knows how to BY Megan Campbell Smith find answers from other experts. Media experts in particular. And that’s when I had it. The Big Aha. I realized that local folks were googling their medical conditions, and they were getting served up our back issues as answers. I looked up the data on our web server,
from organic search (people asking Google for answers), and almost no one bounced (meaning they liked what they found). They needed medical care, and we had the doctors. It was exhilarating, like I had discovered tides. On the spot, I turned my attention to making the most of this amazing power and directing it toward the benefit of our readers, our doctors and their patients. What was happening was good, but it could really be something great. It could be a real service to our community getting MD-UPDATE out to the public so they could know what we know about finding great doctors and navigating healthcare. You know good things don’t happen overnight, and for me it has been a two year journey to match the right technology with
DOCTORS ALWAYS ASK US: HOW CAN I GET PATIENTS TO SEE THE STORY MD-UPDATE DID ON MY PRACTICE? where I published back issues for our readers’ convenience, and the confirmation was absolute. Over 80% of our site traffic came
our size and capacity as independent media. There are also the high ethical and aesthetic standards to meet. But it has finally hapTHE BUSINESS
IANS AND HEALTH
Longevity Bre eds
RURAL HEALTH AND GASTROENTEROLO GY/BARIATRICS/ GENERAL SURGERY
ertise, & Loy aLty
owensboro surge ry center prides tradition of puttin itself on 30-ye ar g patients first in western Kentu
AND HEALTHCARE PROFESSIONALS
CALL FOR PARTICIPATION 2014 Editorial Opportunities * Issue #86 - May Women’s Health, Pediatrics Issue #87 - June/July Dermatology, Plastic Surgery, Hand & Foot Surgery / Men’s Health
Issue #88 - August/September Orthopedics, Physical Medicine, Rheumatology / Acupuncture Issue #89 - October Oncology, Radiology, Imaging / Hospice, Home Health
Volume 5, Number
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alSo iN thiS iSSue teLeMedicine expands pHysici an access endoscopic ULtrasoUnd in georgetoWn Bariatric sUrgery preven ts co-MorBidities Long-terM refLUx reLief WitH Linx® diaBetes nUtrition
Issue #90 - November Neurology, Pain & Addiction / Mental Health Issue #91 - December/January 2015 Nephrology, Urology, Pathology / Organ Donation
TO PARTICIPATE, PLEASE CONTACT:Gil Dunn, Publisher / email@example.com / (859) 309-0720 Jennifer S. Newton, Editor-in-Chief / firstname.lastname@example.org / (502) 541-2666 SEND PRESS RELEASES TO: email@example.com 8 M.D. UPDATE
*EDITORIAL TOPICS ARE SUBJECT TO CHANGE.
pened. We have developed a brand new MD-UPDATE.COM to make sure that you are there when patients are looking. Doctors always ask us: How can I get patients to see the story MD-UPDATE
did on my practice? The reprint, the classic in business media, is exceedingly popular with grateful patients. But I think doctors are asking for more. I think the question is “How can MD-UPDATE perform to the standards of inbound marketing that gets doctors discovered on the Internet?” This is a great time for media. Our dreams of just a few years ago - of being there when patients searched - those dreams where shaped by the technologies witnessed in big media, and in just a few short years they have become available to independent publishers like us. Not yet “standard,” it is still an exclusive club to manage the
resourses and reputation required to succeed online. But we’ve never compromised there. Over the next several issues, we will introduce you to MD-UPDATE ONLINE MARKETING, a dedicated inbound marketing service for physicians who want to be there when Google calls. A service to simplify physician-to-consumer marketing. Watch these pages for info on how to get started. Before I sign off, I have an important favor to ask of you. If you want to reach highly-qualified healthcare consumers online and you choose to use our services at MD-UPDATE.COM, then please sign up early! We have an October launch date, and you will want your story there when we promote the new site to the public. Until then! Yours in cyberspace, Megan Campbell Smith, MD-UPDATE Digital Publisher mcsmith@ md-update.com ◆
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THIS IS AN ADVERTISEMENT ISSUE#86 9
ONCOFERTILITY AND PEDIATRIC ONCOLOGY UK pediatric specialists honor the resilience of young cancer patients
BY TIM CORKRAN
PHOTOGRAPHY BY JOHN LYNNER PETERSON LEXINGTON While most of us grimace at the mention of children and cancer, UK HealthCare pediatric specialists Leslie Appiah, MD, director of Oncofertility, and Lars Wagner, MD, director of Pediatric Oncology, spend their days in a hopeful world devoted to brightening the future of young cancer sufferers. Appiah’s work with oncofertility – the preservation of reproductive organs during cancer treatment – and Wagner’s work with Kentucky Children’s Hospital cancer patients put them on the front line of UK’s efforts to enrich its delivery of care to cancer patients. These two doctors clearly love helping children and are inspired to create comprehensive programs that honor the resilience of their young patients. Their patients’ excitement to get on with their daily lives compels both of them. “We try to capture that energy from the kids, and it really helps us a lot,” says Wagner.
From Childhood Goal to Serving Children
A native Texan, Appiah knew her direction in life early. “As a young girl, I wanted to play an instrumental role in bringing healthy children into the world,” she recalls. Years later, as a budding OB/GYN, she was moved by the comprehensive and compassionate care of a mentor whose “ability to put young gynecology patients at ease, not to mention 10 M.D. UPDATE
UK HealthCare Director of Oncofertility Leslie Appiah, MD
her surgical prowess, made a deep impression on me.” Appiah chose to devote her career solely to gynecology, landing a place as a BIRCWH (Building Interdisciplinary Research Centers for Women’s Health) scholar, then a two-year fellowship in pediatric and adolescent gynecology. Appiah is an acolyte for the evolution of pediatric gynecology towards more process. Through Pediatric and Adolescent Gynecology Fellowship programs, “We are able to train residents and fellows how to talk to adolescents, and how doing this well impacts their ability to deliver quality care.” She explains that, “There is a lot of counseling to be done with young girls – and with their caregivers. It takes time, patience, and dedication to build the rapport needed to work with young girls in managing their gynecologic and reproductive care.” She concludes, “The key is to treat them with respect and not minimize their feelings. Once we do that, we have open lines of communication and can get to the real issues.”
A Next Step: Oncofertility
In 2006, Appiah was drawn to Cincinnati Children’s Hospital because of the patientcentered care and opportunities for academic growth. During her time there she built its Oncofertility program and assumed the role of fellowship director of the Pediatric and Adolescent Gynecology program. Advances in cancer treatments mean patients are living longer; subsequently, quality of life is becoming more of a focus and fertility preservation is central to that. While fertility preservation during chemotherapy and radiation can be a concern for all patients, it is particularly crucial for those youngest patients who have their entire lives ahead of them. Appiah’s devotion to communication and process improvement serves her masterfully in this capacity. She explains that, “My job is to counsel patients, and patient families, before they receive treatment and then provide
Markey Cancer Center is a National Cancer Institute, designated by the National Institute of Health. options for fertility preservation. That may include sperm banking, or freezing of eggs, embryo, or ovarian tissue.” Ovarian tissue freezing, while experimental is the only option for prepubescent girls who have not yet begun to ovulate. It also remains the only option for pubescent patients who do not have the luxury of time to undergo ovarian stimulation and IVF due to the severity of their disease. Few families anticipate this conversation as they focus on getting their child through treatment, but Appiah says that, “When they hear about their options, and they know there is something they can do, they feel relieved. To be actively involved in the preservation of fertility is something that gives families a feeling of control. It’s put in the back of their minds so their energy can go to supporting their child through treatment.” UK brought Appiah to Lexington to establish its Oncofertility program. She has set her sights high: “Our goal is to make this a center of excellence in the management of all aspects of oncofertility: research, practice, and education.” She relies on the Oncofertility Consortium at Northwestern University for support. Directed by Dr. Teresa Woodruff, PhD, who coined the term in 2000, this highly evolved program has developed systematic treatment protocols and is very engaged in disseminating information so that all patients receive the same standard of care. Appiah describes Dr. Woodruff as a mentor noting, that hers is a highly collaborative field, “As our programs
develop, we all reach out to other places that want to develop theirs.” This is a practice she has learned from Woodruff and feels is important to the advancement of the field. Having developed one such program, Appiah is well-prepared for what lies ahead. “One of the challenges with an oncofertility program is to try to ensure standardization of care,” she says. Ideally, within UK, a cancer diagnosis will trigger a fertility consult, then access to treatment options will be ensured for all patients, and every patient will be treated equally. However, barriers such as cost and lack of insurance coverage for assisted reproductive technologies (ART) exist and Appiah and Wagner work closely together to identify and address these barriers when possible. This involves considerable coordination across the medical campus. Other program goals are to conduct research and publish findings, increase knowledge about the role of fertility preservation in the management of other chemotherapy-treated diseases such as systemic lupus erythematosus and sickle-cell anemia, and to push for treatment-related policy reform at the state level. Appiah spends one day a week at Norton Hospital in Louisville, seeing oncofertility patients of all ages and genders in collaboration with both pediatric gynecologists and adult oncologists there.
Pediatric Oncology: Appeal and Evolution
Dr. Lars Wagner developed an interest in pediatric oncology early in medical school at UK, so he chose a residency at UT Memphis, which has an association ISSUE#86 11
with St. Jude’s Children’s Hospital. After four years as a general pediatrician, he did fellowship training at St Jude’s. His work in pediatric oncology initially took him to the University of Utah, then Cincinnati Children’s Hospital, where he and Appiah worked together for a number of years. The field satisfies him on several levels. He says, “I love both the science and the complexity of it: I work with all the age groups, every type of special- UK HealthCare ist, and I do acute, ICU, and Director of Pediatric Oncology Lars Wagner, MD primary care.” Childhood cancers makes up only about two percent of all oncology. Wagner explains, “This allows us cancer cases, yet the pediatric oncology to target the treatment to specific genetic community is a highly collaborative group features in an individual patient’s tumor, so driven to serve afflicted children. They it really limits side effects.” Along with this, place almost 50 percent of their patients risk stratification is another way that pediinto clinical trials and pool data from many atric oncologists are mitigating side effects facilities to ensure sufficient data. Wagner for young patients. “Very intensive therapies says that most pediatric oncology programs are appropriate for the highest risk patients, rely on The Children’s Oncology Group as but may not be necessary for standard risk a major source of funding for research that patients,” Wagner explains. provides measureable results. Patient care is evolving thoughtfully. A Comprehensive Approach Wagner notes increased attention to the Serves Children Best affective experience of patients, saying “It’s The arrival of Appiah adds another dimena critical part of supporting kids during this sion to Wagner’s program. Right away she process.” His facility has two social workers began working with patients and families on staff who provide emotional and psy- on oncofertility issues. He says, “I was so chological support for patients and families. thrilled when she got here. Leslie provides His most recent addition is a child-life direct intervention for some of our patients, specialist, Meg Halstead She is dedicated counseling for others.” His nursing staff to putting kids at ease during their clinic is already seeing the difference, from new visits, distracting and entertaining them faces in the clinic putting families at ease to before the doctor arrives, and educating information about medicines that can spare them about their body. “Meg is definitely young ovaries. Soon his entire clinic will the favorite member of our staff,” he notes. move to a more convenient location, adjaA school-intervention specialist comes on cent to the Kentucky Children’s Hospital. UK’s commitment to practicing at the board soon. Both of these positions were funded by the student-run UK fundraising frontiers of pediatric health and oncology are highly valued by both physicians. organization, “DanceBlue.” Targeted therapies, or genetic targeting, Wagner says he “can sense a lot of changes are a new paradigm popular in pediatric that we are trying to make and see growth in 12 M.D. UPDATE
the program. I know what kids can do when they have adults who grasp their needs.” Appiah knows her program has support from the top and the right people are in place to make it go. “Between Dr. Evers, Dr. Wagner, and Dr. Wendy Hansen (chair of OB/GYN) I have the ear of the necessary people,” she notes. Together, they are moving oncology forward for the youngest cancer patients in the Commonwealth. “Wagner and I see things similarly and want the same things for these patients,” says Appiah. Wagner concludes, “It’s a good place to be. Sure there are some very sad days, but lots of victories. This is a fight worth fighting because we are really making a difference.” ◆
For more information or to refer a patient contact
SPECIAL SECTION WOMEN’S HEALTH
SINGLE SITE, MULTIPLE BENEFITS
Dr. Michael Guiler champions the single-site daVinci® hysterectomy BY JIM KELSEY PHOTOGRAPHY BY JOHN LYNNER PETERSON Understandably, much of a patient’s concern with surgery is what happens when it’s over. How long will I be in pain? How much will it hurt? How big will the scar be? So anytime a new surgical procedure or technological advancement reduces even one of these concerns, it’s significant. Hysterectomy performed robotically using the daVinci Surgical System with a singlesite incision is a unique example of a procedure that reduces pain and scarring and even offers benefits to the surgeon. Michael Guiler, MD, sole practitioner at Personal Healthcare for Women in Lexington, says that word is spreading about the positive impact of the daVinci singlesite procedure of hysterectomy patients. “The single site is relatively new but there’s a lot of exposure out there, so we’re getting a lot of questions,” says Guiler, who developed a large referral base over his 34 years of medical practice. “By the time a patient is referred to me, they know how I approach things. They do ask about the robot and if it’s the right thing for them.” More often than not, Guiler’s answer to that question is “yes.” Guiler, who delivered nearly 8,000 babies before ending his obstetrics practice in 2006 to focus solely on gynecology, says most hysterectomies can be accomplished with the single site procedure. He cites incidence of large fibroid tumors or extremely complicated endometriosis as examples of conditions that increase the difficulty and length of the procedure to the point that it might be no longer advantageous. While more than 50 percent of the hysterectomies in the United States are still preformed with open procedures, single site is the norm at Guiler’s practice, which he runs with his wife Sherry Guiler, DNP, APRN. “I prefer the robotic approach because I think it’s better for the patient and it’s easier for me, so we both benefit,” says Guiler who performs the majority of his robotic assisted surgeries at Saint Joseph East Hospital in Lexington.
Dr. Michael Guiler performs the majority of his robotic assisted surgeries at Saint Joseph East Hospital in Lexington.
Guiler credits the opportunity to perform the robotic procedure, while sitting at a console rather than standing in an awkward position for up to two hours at a time, with reducing his fatigue and increasing his mental focus. “The most challenging part of the procedure is getting used to not being at the patient’s side when you do the surgery,” says Guiler, who attended medical school and completed his residency at the University of Kentucky. “You give up contact sensation for visualization. But after you’ve done a few cases, you can see so well your feedback tells you that you can feel even though you’re not there. That’s how good the visualization is. You can see better with the robot than you can if you open the patient. With the human eye, there are limitations in visualization of the surgical field, but with the robotic camera it magnifies using high defi-
nition technology. The single site procedure typically begins with a 2.5 centimeter incision through the navel. That small incision includes four ports. One has a camera, one has an assist, and then there are two arms with which to operate. “For patients, it’s better in terms of pain; it’s shorter recovery; it’s better cosmetically; and it’s less fearful when you wake up and just have only one very small incision,” Guiler says. “From the physician standpoint, it’s technically a little more difficult. There’s another learning curve when doing robotic surgery with multiple ports than with only a single port. You have a smaller range of motion. You have to be focused on one area of the surgical field at a time. “That gives you somewhat of a limitation as far as the type of surgery you do. It wouldn’t be advantageous for the patient in complicated cases because of the time involved. But for the typical indications for hysterectomy or removing an ovary, single site is a very good choice for the patient if ISSUE#86 13
SPECIAL SECTION WOMEN’S HEALTH
they meet the criteria,” says Guiler. While the cosmetic benefit of the small incision are similar in both laparoscopic and robotic procedures, patients report significantly less pain associated with the robot. That is directly correlated to the markedly reduced trauma to the abdominal wall. “When you have a straight stick laparoscopic instrument, you have to grind and move it around, which takes all the tissue with it, “Guiler says. “When you do it with the robotic instrument, it has a fulcrum point so there’s no tension or trauma to the abdominal wall where the instrument goes through.” Having performed a dozen single-site hysterectomies to date, Guiler is quick to champion technology that provides so many benefits to both patients and surgeons. “I just feel like it’s been one of the most rewarding parts of my practice to be able to change to robotic surgery,” he says. ◆
I prefer the robotic approach because I think it’s better for the patient and it’s easier for me, so we both benefit,” says Guiler
Single site instrumentation set-up
PROVIDED BY INTUIT
Personal Healthcare For Women J. Michael Guiler, MD Sherry D. Guiler, DNP, APRN 1720 Nicholasville Road Suite 406 Lexington, KY 40503 PHONE: FAX:
14 M.D. UPDATE
Single site hysterectomy cuff closure PROVIDED BY INTUIT
Single site incision provides minimal scarring and “almost painless surgery,” says Guiler.
SPECIAL SECTION WOMEN’S HEALTH
Yes, It Is A Real Illness BY JOHN HUBBARD, MD LOUISVILLE The Hubbard Clinic has treated over 1500 cases of Interstitial Cystitis (IC) since 2000. Many patients tell us they have had an extensive work-up and been told everything is normal, yet they continue to have symptoms. Our most common complaint is symptoms of a UTI, yet antibiotics don’t really help; and when we get records, their urine cultures (when obtained) were negative. A typical UTI is a bacterial infection involving the mucosal lining of the bladder. A urinalysis is very helpful but never totally accurate, so a urine culture is imperative. If the culture is negative, antibiotics are not indicated. On the other hand, IC is a nonbacterial irritation/inflammation of the inner wall of the bladder because of microscopic leaks in the bladder mucosa. Therefore, urine (which is high in potassium) leaks into the inner bladder wall, causing muscles and nerves to become irritated. This leads to typical IC symptoms of frequency (tight muscles lead to decreased bladder capacity), nighttime voiding, discomfort with a full bladder, urethral pain, feeling of incomplete emptying, pelvic pain/ pressure, and pain with intercourse. Recent large studies reveal three-to-
six percent of females have some symptoms of IC, and it tends to run in families. The female-male ratio is 5:1. The cause of IC is unknown. It is not infrequently associated with migraine headaches, irritable bowel syndrome, fibromyalgia, and endometriosis – yes, other conditions that are difficult to diagnose but nevertheless very symptomatic and painful to the patient. Treatment depends on the severity of the symptoms. The most important step is telling the patient that I believe I know what is causing their symptoms; it is not in their head; it will not take one day off their life; and it is treatable but chronic so they must follow all of our advice to get better. In mild cases this explanation plus diet changes is all that is needed. In more symptomatic cases a cysto/ hydrodistension/biopsy is done under conscious sedation in the office. At different levels of sedation the patient reacts to pain, so a determination is made of the degree of urethral pain, posterior bladder pain, bladder pain as the bladder is distended, and bladder volume. Biopses are then obtained to count mast cells to gauge if environmental pollutants are playing a role. At
the end of the procedure a pain cocktail is instilled into the bladder to alleviate postop discomfort. These findings tell us how aggressive we need to be in our treatment. Rarely is only one treatment needed. There is a lot of trial and error when coming up with the right ingredients for a particular patient, especially when it comes to diet, meds, and allergies. Treatments presently being used in our clinic include: oral medications, dietary advice, bladder instillations, behavioral therapy, physical therapy, Botox bladder instillations, and Allergist consultation. John Hubbard, MD, urologist, is a solo practitioner and medical director of The Hubbard Clinic. ◆
For Patient Referral Contact
The Hubbard Clinic
firstname.lastname@example.org www.hubbardclinic.com Phone: 502-893-3510 Fax: 502-894-9863
2335 Sterlington Road, Suite 100 Lexington, Kentucky 40517 (859) 268-1040 Fax: (859) 268-6165 Email: lprober email@example.com www.barcpa.com
SPECIAL SECTION WOMEN’S HEALTH
A Regional Resource for Female Pelvic Health
Norton Suburban Hospital pursues COEMIG designation to foster public awareness and provide standardized top-notch care BY JENNIFER S. NEWTON LOUISVILLE If you mention “support system” in the company of gynecologists, their first thought may be of pelvic organ prolapse repair rather than a program that unites services for women. At Norton Suburban Hospital, both definitions apply. The organization has made a recent push to reorganize their existing women’s services and standardize clinical care in the hopes of expanding their presence as a regional resource in women’s health. Norton Healthcare is currently in the midst of a significant renovation of Norton Suburban Hospital, transforming it into the future Norton Women’s and Kosair Children’s Hospital, which is scheduled to open fall 2014. Having a solid foundation in women’s health, both at its downtown Louisville campus and at Norton Suburban, the physical renovation gave the health system the opportunity to reevaluate and realign its women’s health services to better serve patients. Female pelvic health is a top priority for Norton Healthcare. In 2013, Norton Suburban Hospital sought and received designation as a Center of Excellence in Minimally Invasive Gynecology (COEMIG™) by the AAGL-Advancing Minimally Invasive Gynecology Worldwide. They are currently the only facility in Kentucky to hold that designation. Jonathan Reinstine, MD, an OB/GYN with Associates in Obstetrics & Gynecology, is the medical director of the Pelvic Health Program and the COEMIG program at Norton. Having been in Louisville for 32 16 M.D. UPDATE
years and having performed laparoscopic hysterectomies for 25 years, he says Norton has always practiced advanced minimally invasive surgery. However, the COEMIG designation lends further credibility to the program, while fostering quality improvement and safety, providing high clinical benchmarks, reducing health care costs, and raising public awareness. Both the facility, including all aspects of surgical care – preoperative, post-operative, nursing, laboratory, emergency, radiology, etc. – and the surgeons are certified. COEMIG certification is a three-year cycle.
Navigation and Teamwork
Reinstine estimates 25 to 30 percent of women suffer from pelvic health issues and says the key to treatment is considering multiple organ systems. While Norton had a variety of specialists and services already in place, “Our goal was bringing them together,” he says. To facilitate assembling the pieces of the puzzle, Norton hired Melissa Ulfe, RN, as nurse navigator. Ulfe managed the COEMIG application process and helped establish clinical pathways to meet COEMIG requirements. Ulfe has 20 years’ experience as an RN and five years as a patient navigator, first with breast cancer patients and now in pelvic health. The pelvic health team includes specialists in gynecology, urogynecology, pediatric and adolescent gynecology, urology, allergy, colorectal surgery, interventional radiology, anesthesiology, physical therapy, and mental health. The team is a mix of Norton Healthcare-employed specialists and inde-
(L TO R) Melissa Ulfe, RN, is nurse navigator for Norton Healthcare’s Pelvic Health Program, and Jonathan Reinstine, MD, is director of the Pelvic Health and COEMIG programs.
COEMIG certification allows us to do the things that get done on a daily basis with a higher level of sophistication and coordination. pendent practitioners. “Our goal was to get the best folks that we could, regardless of affiliation,” says Reinstine. The team holds a monthly pelvic health conference that is open house-wide for the presentation and consultation of difficult cases and updates on new technologies. Physical therapy for pelvic floor disorders is one of the more unique aspects of the program. Commonly, patients do not realize physical therapy is even an option for female pelvic problems. Norton utilizes Dunn Physical Therapy, an independent
details on what each physician’s passion and niche is. “If I get calls, I know what doctors specialize in and can funnel patients in the right direction,” says Ulfe. Nursing and ancillary staff meet quarterly for updates and in-services. Physicians receive a plethora of education during their formal training, but not as much attention is given to “education for physicians of today,” says Reinstine. “Missy’s gotten us certified for category one CMEs. Not only are we educating but we are helping others keep their certification up.” He believes the CME program will be a resource for all OB/GYN-related specialists in the region. For Reinstine, it’s not about competition but about support. “I want [the program] to be a resource. I’m interested in enhancing what other physicians do in their own practices,” he says. ◆ PT practice specializing in these issues. [See related article on Dunn Physical Therapy on page 25.]
A Higher Level of Sophistication
Like most gynecologic surgeons, those with Norton’s pelvic health program treat a high volume of uterine fibroids, endometriosis, pelvic organ prolapse, urinary incontinence, and gynecological malignancies. Reinstine says there is increasing attention on chronic pelvic pain, utilizing the multidisciplinary approach and physical therapy for treatment. The surgeries and treatments surgeons use have not changed with COEMIG certification, but the surgeons must follow specific standards and demonstrate proficiency and volume. The cohesiveness created in pursuit of the designation is providing easy interaction and regular consultation among physicians on difficult cases. “We are doing a lot of the things that get done on a daily basis but at a higher level of sophistication,” says Reinstine. Norton Suburban Hospital does have the da Vinci Surgical System® and the capability to do single-site hysterectomies robot-
ically. Though Reinstine contends, “One of the big things now is to find that proper value position for robotics with increasing cost-consciousness.” Another benefit that has emerged is the standardization of care. “One of the things that’s very helpful is reducing variation. If, as a group of surgeons, we can practice pretty consistently, that helps the nursing staff and the operating room staff be prepared. Patients are getting a very consistent message, and the process runs very smoothly,” says Reinstine.
A critical component of the COEMIG requirements is education, which includes patient education, nursing and ancillary staff education, and physician education. In addition to organizing resources for COEMIG, Ulfe helps educate patients on disease processes and treatments and how to navigate the complex health care system. “What I like to tell the lay person is [nurse navigators] are like the GPS in your car. We are here to get you through the health care system,” says Ulfe. She also has insider information – she has a list, not only of all the specialists, but one that includes
Solutions for pelvic health disorders Call (502) 899-6310 to refer a patient. Learn more at NortonHealthcare.com/ Pelvic-Health-Program. AAGL Center of Excellence in Minimally Invasive Gynecology™, COEMIG™ and the COEMIG seal are trademarks of the AAGL. All rights reserved.
SPECIAL SECTION WOMEN’S HEALTH
KentuckyOne Health Offers Comprehensive Integrative Therapies for Chronic Pain Sufferers BY DEBORAH ANN BALLARD, MD, MPH Chronic pain affects about 100 million Americans. Women experience certain painful conditions more than men. Fibromyalgia, irritable bowel syndrome, migraine headaches, chronic neck and back pain, and pelvic pain are the most common conditions. The causes of these conditions remain largely unknown and treatments have been mostly symptomatic, giving only partial relief. Fortunately, we are beginning to understand why some people develop chronic pain and how to better prevent and treat it. People who experience sexual, physical, or emotional abuse as children are almost three times more likely to develop chronic pain, post-traumatic stress disorder, depression, and general poor health as adults. People with low coping skills, little social support, and high levels of stress respond poorly to treatment for chronic pain. The degree of
disorder of body, mind, and spirit that is best treated by addressing all three components. Integrative Medicine (IM) offers new hope for chronic pain sufferers because it treats the whole person – body, mind, and spirit. It emphasizes lifestyle changes, self-help, and non-drug, non-surgical approaches whenever appropriate. IM incorporates evidence-based therapies from all healing traditions such as acupuncture, yoga, transcendental meditation, and herbs. IM offers a wide variety of personalized treatments that are much less invasive, expensive, and risky than surgery or addictive drugs. At the International Research Congress on Integrative Medicine and Health, May 12-16, 2014, researchers presented growing evidence that IM therapies such as anti-inflammatory diet, exercise, massage, psychotherapy, acupuncture, yoga, tai chi,
RECENT RESEARCH SHOWS THAT PEOPLE WITH CHRONIC PAIN HAVE LOSS OF GRAY MATTER IN THEIR BRAINS AND MAY BE LESS RESPONSIVE TO DOPAMINE. suffering from chronic pain is heavily dependent on the sufferer’s perceptions, beliefs, expectations, and resiliency. People with chronic pain often experience re-victimization as they seek treatment, and undergo many unnecessary, unhelpful, expensive, and even dangerous diagnostic studies, surgeries, and drug treatments. Particularly troubling is the potential for chronic pain suffers to develop addiction to narcotics and other prescription drugs, leading to more disability and suffering. Kentucky is among the states with the highest numbers of deaths from prescription drug overdose. Chronic pain is now understood as a 18 M.D. UPDATE
meditation, and spinal manipulation can help chronic pain sufferers. Recent research shows that people with chronic pain have loss of gray matter in their brains and may be less responsive to dopamine, an important neurotransmitter in depression, addictions, and pain perception. In one study, people with chronic pain who underwent cognitive behavioral therapy for 12 weeks not only felt better but also showed increases in the gray matter in their brains. Other studies show that hopeful people who believe in a treatment experience much more relief from the therapy than nonhopeful people. Physicians used to dismiss
the placebo effect, but IM practitioners seek to enhance the mind’s ability to lower pain perception as part of their treatment. IM practitioners understand that people can unlearn pain behaviors and favorably alter the structure and function of their brains. In the fall of 2013, The American College of Physicians issued new guidelines concerning the treatment of chronic pain and recommended that IM therapies be considered for people with chronic pain. KentuckyOne Health is the first health care system in the region to offer integrative medicine centers where people with chronic illnesses, including pain, can receive comprehensive evaluation and treatment by a team of providers including physicians, physical therapists, nutritionists, exercise physiologists, acupuncturists, yoga, tai chi, and meditation teachers. Dr. Deborah Ann Ballard is a board certified internist whose 22 years in medicine spans primary care, endocrinology, clinical research, and prevention and wellness. Ballard is board certified by the American Board of Integrative Holistic Medicine. She is a certified Tai Chi for arthritis instructor. Ballard joined KentuckyOne Health in June 2013 with a primary care practice affiliated with Flaget Memorial Hospital in Bardstown. In her new role, she is providing integrative medicine consultations and focusing on prevention and wellness initiatives across KentuckyOne Health and its service area. ◆
The Healthy Lifestyle Centers Medical Center Northeast 2401 Terra Crossing Boulevard (502) 210-4520 250 East Liberty, Suite 102 (502) 581-0110. A third center will open at Sts. Mary and Elizabeth Hospital toward the end of July 2014.
SPECIAL SECTION PEDIATRICS
Educating Patients, Advocating for Physicians The independent practitioners of Internal Medicine & Pediatric Associates practice more than just medicine BY JENNIFER S. NEWTON A self-proclaimed “rare breed,” the physicians of Internal Medicine & Pediatric Associates in Crestwood, Ky. are united in their love of both pediatric and adult patients. Also unified in preferring not to practice obstetrics or surgery, the physicians chose their specialty because it offered more comprehensive training in their areas of interest. “We’re somewhat of a rare breed, but I felt like if I exclusively did pediatrics I would miss my adult patients and vice versa,” says Ilana C. Kayrouz, MD, the newest member of the practice, having joined in 2010. “The reason I chose medpeds over family practice is I felt like it was a little more in-depth training in the areas I wanted to focus my practice – we’re really fully internists and pediatricians.” Tracy L. Ragland, MD, agrees that a four-year program, including pediatrics and inpatient care, is what drew her to the joint residency. “Family medicine residencies had a lot of OB focus and surgical training, along with pediatrics, sandwiched into three years. I felt like I couldn’t learn enough about comprehensive pediatrics and internal medicine in this time frame … and I wanted to be able to take care of sick patients in the hospital too,” says Ragland. For Tony G. Karem, MD, the patient mix is important. “I like complexities of internal medicine, but the pediatrics part is enjoyable. The interaction with [kids] has always been one of my favorite things,” he says.
All three of the physicians are from Kentucky, both Karem and Kayrouz are from Louisville and Ragland is from Leitchfield, and all three attended the University of Louisville (UofL) for medical school and residency.
In fact, it is the common thread of residency that brought the physicians together. Karem was one of Ragland’s resident supervisors when she was a medical student. And as part of Kayrouz’s residency, she rotated with the practice.
(L TO R) Dr. Tony G. Karem, Dr. Ilana C. Kayrouz, and Dr. Tracy L. Ragland are partners in Internal Medicine & Pediatric Associates in Crestwood, Ky.
Karem is the most senior member of the practice, having joined in 1995, shortly after it was established by Dr. Carl Paige, who is now is solo practice in Oldham County, Ky. The group is still active with the medpeds residency at UofL, having an average of five residents rotating through the office at any given time.
Cooperation & Collaboration
The practice’s patient volume is somewhere between 4,000 and 6,000 active patients, and each physician dictates their own schedule, one of the perks of private practice. Ragland says she sees about 10 fewer patients a day than she used to in an effort to allow time for increasing non-clinical duties and more complex patients. Karem describes his patient mix as 70 percent internal medicine and 30 percent pediatrics. Kayrouz sees a higher volume of pediatric patients, estimating her ratio to be 55-60 percent internal medicine and 40-45 percent pediatrics. As part of her pediatric population, she sees some children with special needs and developmental delays. In addition to working collaboratively with each other and referring physicians, a critical component of the practice’s treatment approach is working in cooperation with patients. “We try to educate our patients to empower them to do the right things and the healthy things,” says Karem. Another benefit the joint medpeds practice allows is a family-wide picture of overall health. In some cases, the group sees four or five generations of families. “Knowing the parents well gives you a whole different dynamic of taking care of the child,” says Karem. Adds Kayrouz, “If you know the whole family, it’s much easier to take care of each component of the family.”
Independence and the ACO
Ragland echoes her partners’ points on quality care and patient education as keystones of the practice’s philosophy, but offers, “We can’t talk about that without saying physician autonomy is important.”
PHOTO PROVIDED BY INTERNAL MEDICINE & PEDIATRIC ASSOCIATES
SPECIAL SECTION PEDIATRICS
Three years ago was a turning point for the practice, as the Affordable Care Act was passing and primary care doctors were getting monthly knocks on their door from hospital systems. “We started realizing that we probably needed to be more outward looking if we wanted to stay independent,” she says. What they found was an independent practice association (IPA) in Kentucky that had been around for 20 years and was started by Dr. Greg Ciliberti – The Association of Primary Care Physicians (APCP). According to the APCP website, “APCP is helping physicians in nondependent or small group practices to organize, so that they can compete successfully for the growing number of patients in managed care plans while still maintaining an independent practice.” Soon after they became involved with the APCP, CMS began offering independent
practices the opportunity to take part in a Medicare Accountable Care Organization (ACO). For the last 18 months, Internal Medicine & Pediatric Associates has participated in the ACO. Though patient education has always been a priority for the practice, Ragland says, “Our involvement in the ACO has helped elaborate on that, helped us see the importance of developing more of a medical home environment.” The practice is considering having their medical assistants trained for specialized counseling in nutrition, respiratory issues, and smoking cessation, as well as inviting physical therapists and psychotherapists to have a part-time presence in their office. The idea of a medical home is a natural fit for physicians who have always tried to practice to the full extent of their training. “I think that we do a great job in managing
most things here without always referring out,” says Kayrouz. “All of us have the same idea – that’s what we were trained in and we’re managing up to a point where we’re comfortable.”
More than Just Medicine
Practicing medicine is not the end point for these physicians. They feel strongly it is their responsibility to help prepare the physicians of tomorrow for the ever-changing health care environment and to advocate for physicians in leadership roles in on-going health reform. Through their ties to the residency program, they are encouraging more formal training in business and legislative issues. “It’s part of the practice of medicine, knowing something about business and something about political advocacy,” says Ragland. ◆
Tony G. Karem, MD Ilana C. Kayrouz, MD Tracy L. Ragland, MD 7101 W. Highway 22 A Joint Commission accredited private surgery center where our physicians perform diagnostic and surgical procedures for the treatment of pain, to include:
P.O. Box 548 Crestwood, KY 40014 Phone (502) 241-6567 Fax (502) 241-5083 www.oldhamcountydocs.com
20 M.D. UPDATE
SPECIAL SECTION PEDIATRICS
Group Practice Without Walls
Proactive physician groups create solid business model for a changing health care environment BY DR. LAWRENCE JONES, PRESIDENT OF ONE PEDIATRICS LOUISVILLE In the face of a rapidly changing health care climate, physicians are experiencing significant uncertainty due to increased regulations, decreasing reimbursements, rising expenses, and added competition. In effort to diminish some of these industry pressures, my group along with six other independent pediatric practices in the metro region have come together to form ONE Pediatrics. East Louisville Pediatrics, All Star Pediatrics, Kaplan Barron Pediatric Group, Pediatrics of Bullitt County, Prospect Pediatrics, South Louisville Pediatrics, and Springs Pediatrics, created a “group practice without walls” with the goal of providing the highest quality pediatric care in the region. ONE Pediatrics is dedicated to the idea that independent primary care practices, in collaboration with their patients, are best equipped to make appropriate health care decisions. By combining resources, our groups are able to acquire the latest technology at the lowest cost and pool our time and talents for developing innovative health care solutions at the local level. Our seven pediatric practices are spread throughout the Kentuckiana area. We are all fiercely independent and did not want to be owned by larger corporations. We think the model we developed is distinctively innovative and will provide the children in our practices with the finest care possible. Best of all, each of our groups remain 100 percent clinically and financially in control of our own practices. “Our patients will not be able to tell that anything has changed when they come to our office,” according to my colleague, Dr. Pat Hynes of Prospect Pediatrics. “Our signs are the same, our patients still see their same personal physicians and staff. What we hope they WILL see is more advanced technology and more efficient scheduling, which leads to shorter wait times and a better overall patient experience.” By integrating financially and clinically, the unique business model gives each group access to the best qualities a practice can have. “We are already gaining
ONE Pediatrics is part of a layered business model that starts with control at the physician level. The group is made up of seven independent pediatric practices represented by the following physicians: BACK ROW (L TO R): Steven Kamber, MD; Patrick Hynes, MD; Lawrence Jones, MD; Eliot Thompson, MD FRONT ROW (L TO R) Al Allgeier, MD; Casey Lewis, MD; John Roth, MD
economies of scale and realizing greater efficiencies through cooperating on the use of clinical and non-clinical components of our practices. The larger structure of the group has already helped us acquire the premier pediatric EHR (electronic health record) in the market. And, we are on the way to becoming one of the first pediatric practices in the region to be nationally certified as a Patient Centered Medical Home,” stated Dr. Casey Lewis of Pediatrics of Bullitt County, another associate of mine. Additionally, we will be partnering with the specialists and ancillary health providers that give the best and most personal care possible. All of these initiatives will help ONE Pediatrics provide the highest quality and most integrative care available today to our families. ONE Pediatrics is part of a layered business model that starts with control at the physician level. Each office is unique in its operations but as part of the larger structure will be able to pool resources to acquire the latest technology and monitor quality measures. Each of the seven groups are also founding members of a national management corporation, ONE Management Services Corporation (OMSC), based in Louisville
and Dallas. OMSC provides all management services and benefits for our staff, as well as the operational expertise our practices need to provide high quality and cost effective care for our patients. The goal is to empower independent practices so that they can succeed and grow in a volatile health care setting by offering unique partnerships, investment opportunities, and business services. One such investment opportunity is the Pro One Insurance Program, where we are able to convert some of the present expense associated with professional liability insurance into a long-term asset growth strategy. By combining independent local practices with a national management corporation, ONE Pediatrics can provide the highest quality, personal pediatric care in a structure designed to withstand the momentum of increased government and corporate intervention in primary care. Our group plans to continue to expand beyond the metro area and become a regional force in pediatric care. Lawrence Jones, MD, FAAP, has been practicing pediatrics since 1983 and has been with East Louisville Pediatrics since 1986. Dr. Jones is certified by the American Board of Pediatrics as well as a fellow of the American Academy of Pediatrics. ◆ ISSUE#86 21
SPECIAL SECTION PEDIATRICS
Baby Health Service Reaches 100 Year Birthday Service still vital in the aftermath of ACA BY KATHLEEN EASTLAND, BOARD PRESIDENT
LEFT Margaret Lynch, longtime head
22 M.D. UPDATE
nurse at Baby Health Service, poses with two patients and Dr. Alex Steigman, head of pediatrics at the University of Louisville Medical School, at the clinic in 1958. BELOW LEFT “There is still so much unknown on how the ACA will impact the uninsured children we serve,” says Dr. Tom Young, a University of Kentucky pediatrician, who has been involved with the clinic for more than 30 years. BELOW A volunteer physician and nurse at Baby Milk Supply, later renamed Baby Health Service, examine a patient in 1918 at the organization’s free clinic, then in an old house on Mechanic Street near Gratz Park in Lexington. Baby Health Service turns 100 years old this year.
PHOTO BY TOM EBLEN / LEXINGTON HERALD-LEADER
(two nurse practitioners and one registered nurse). We rely on two hand-written fund drives – one focused on individuals in the community and one on businesses – both completed by the board members and grants, applications for which are completed by volunteer board members. A question we hear on a regular basis is, “How will Baby Health continue to be effective or necessary with the Affordable Care Act (ACA)?” Our medical director, Dr. Tom Young, a University of Kentucky pediatrician, who has been involved with the clinic for more than 30 years, offered the following explanation: “There is still so much unknown on how the ACA will impact the uninsured children we serve. We have always had children who were uninsured that were eligible for Medicaid or KCHIP. It is likely some
will gain coverage as more parents receive Medicaid. We also have a growing number of Hispanic children and international families who will not be eligible under ACA expansion. I think we can say that BHS has always provided quality health care for children who fall through the health care cracks and will continue to do so. When and if we are not needed, we will, with a note of great accomplishment, retire knowing we served children well. We will obviously continue to track our service levels, and if they do drop significantly over the years, we can consider next steps. For now, we meet a great need in our community. Too much is not known.” One thing that is known, however, is that Baby Health looks forward to enjoying a second century of serving the children of our community. ◆
PHOTO PROVIDED BY BABY HEALTH SERVICE.
Baby Health Service, Inc. of Lexington, Ky. is celebrating a century of community service with a celebration at Keeneland on May 31, 2014. Begun in 1914 as Baby Milk Service, this non-profit has grown from a group of six local women, who soon added a nurse and physician, to a working board of 59 women, three paid medical staff, and nearly a dozen pediatricians, who volunteer their time each morning in the clinic to see patients. Our patients are children and adolescents who do not have private insurance, Medicaid, KCHIP, or any other form of health insurance. Baby Health Service, Inc. provides free comprehensive healthcare to children from birth until their 18th birthday. In 2013, Baby Health served more than 2,100 children and adolescents in the central Kentucky area. How many non-profits can boast 100 years of existence? We are unique in the Commonwealth and nearly unique across the country. In 1914, deliveries of milk, formula, cod liver oil, and even food were made to low income families. The addition of a nurse in 1915 enabled Baby Milk Service to begin weekly clinics and immunizations by the 1920s. With the inception of welfare after World War II, the policy of specializing in families ineligible for government assistance was put into effect. The 1950s saw the nurses driving trucks around the community to provide polio vaccines for eligible children. The 1966 installation of Sister Michael Leo Mullaney, of the Sisters of Charity of Nazareth, as administrator of Saint Joseph Hospital, ushered in the establishment of Baby Health Service in the waiting room of the emergency room of the hospital in Lexington. Today, more than half a century later, Baby Health Service still enjoys an incredibly generous relationship with Saint Joseph, now part of KentuckyOne Health. The clinic occupies the lower level of a building owned by KentuckyOne Health and pays an annual rent of $1, as well as enjoying greatly reduced rates for diagnostic services provided by the hospital. The clinic operates with no federal or United Way funding. Our budget for 2014 is $191,000, with three paid part-time staff
Child and family health outreach program gets results BY MEGAN C. SMITH Becoming a parent can be a life changing experience. There is no way to know just how challenging, rewarding, and frustrating parenthood will be. Kentucky’s Health Access Nurturing Development Services (HANDS) is a free, voluntary program that pairs parents with skilled and trained professionals. Starting before the baby arrives these trained professionals - nurses and family support workers - visit parents at critical prenatal and early childhood development points, where they provide health information, training in problem solving techniques, and parenting skills development. HANDS visitor’s also help new parents fulfill their basic needs such as food and housing. Visits cover healthy eating habits, baby-proofing the home, bedtime routines, importance of well-child visits and immunizations, and community resources. HANDS, which began in 2000 under Kentucky’s Department for Public Health, remains one of the largest early childhood home visitation programs in the nation, making over 16,000 home visits each month. Close to 11,000 families participate in the program each year. The program is
HANDS Programs by County Bourbon Boyle Clark Fayette Franklin Garrard Harrison Madison Montgomery Nicholas Scott Woodford
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offered at no-cost to parents. The program serves all 120 Kentucky counties for first time parents and is now serving families
and parents, providing assurance that some things are normal and sometimes they need to see the doctor,” says Hacker. “We have the advantage of seeing the baby in its home environment, something that physicians rarely get to see. This lets us give practical, hands on information.” The HANDS program continues to produce excellent maternal and child outcomes. HANDS worker Virginia Hutton meeting with dad Bryan Evaluations conducted by the Moore and eight-week-old son Atticus Moore. University of Kentucky Research Foundation examined HANDS with more than one child in 78 Kentucky with comparable families and noted counties. HANDS services must begin dur- HANDS families are 46 percent less likely ing pregnancy or before the newborn reach- to have a low birth weight baby and 26 es three months old. percent less likely to experience a premature Families at risk for a range of negative birth. Pregnancy-induced hypertension is outcomes, such as low birth weight, pre- 49 percent less likely in an expectant mothterm infants, financial difficulties, poor par- er participating in HANDS and materenting skills, child neglect, substance abuse, nal complications during pregnancy are and domestic violence, begin the family 40 percent less than comparable families. intervention prior to birth and continue Substantiated reports of child maltreatment through the first two years of the child’s life, are 47 percent less. when brain development is occurring most “Decades of neuroscience and behavrapidly. Home visits begin intensely then ioral research indicate that the brain is taper as important milestones are reached, constructed through a process that begins parenting skills improve, and self-suffi- before birth and reaches a rapid pace in the ciency is established. HANDS promotes first few years of life, reaching 80-90 perpositive health-related behavior and infant cent of its adult size by age three.” Hacker care-giving, in addition to providing social added “responsive, caring, and supportive support and access to community resources relationships that start at home are critical and medical care. Quality of parent-child to healthy brain development. We know the interaction and parental sensitivity to the first 1000 days lay the foundation for life. growing infant’s needs, in addition to gen- HANDS is there to help parents build the eral knowledge about child development, best foundation possible.” ◆ are additional features of the program. Karen L. Hacker, MSW, CSW, supervisor and coordinator of the Fayette County HANDS Program, says that “HANDS is a fabulous resource for obstetricians, midwives, pediatricians, and related health care professionals to refer their patients to. “We review with parent’s baby milestones and nutrition, health promotion, the For additional information about importance of immunizations schedules, regular doctor visits, breastfeeding, and even make interactive toys to stimulate brain contact Karen Hacker development.” Family Services Center manager, Some first time parents feel over(859) 288-4099 whelmed with uncertainty. “We have helped firstname.lastname@example.org. www. pediatricians with first time parents who KYHANDS.com call the office frequently with questions. We FACEBOOK-KYHANDS can act as a go-between for the physicians PHOTO PROVIDED BY HANDS
To Overcome, Function, & Thrive
Cardinal Hill Pediatric Outpatient Therapy helps children conquer disabling obstacles and flourish functionally BY GIL DUNN PHOTOGRAPHY BY JOHN LYNNER PETERSON LEXINGTON Comprehensive. Challenging. Compassionate. Rewarding. Pediatric outpatient services at Cardinal Hill Rehabilitation Hospital in Lexington implements therapies and outcomes for the most tender patients, children. It’s a fair question to ask, “Who benefits more from successful outcomes, the patients or the providers?” Cardinal Hill Rehabilitation Hospital (CHRH) started in 1950 as a hospital for children with polio and has evolved to provide various programs that address down syndrome, cerebral palsy, muscular dystrophy and motor limitations, ADD/ ADHD, overweight children, autism, language delays, picky eaters and sensory aversions, congenital disorders like scoliosis and spina bifida and many more, providing Occupational Therapy (OT), Physical Therapy (PT), and Speech Language Pathology (SLP) services for children birth to 18 years old, treating some of the more rare genetic disorders and conditions. Jenna Johnson, MCD, CCC-SLP, Outpatient Therapy Coordinator – Pediatrics, explains “Each child we see has unique circumstances, including their diagnosis, their background, their family dynamics, or their therapeutic needs.” Cardinal Hill has the ability to treat pediatrics in both an inpatient and outpatient setting, which allows for continuity of care using a multidisciplinary approach, says Johnson. Patients are required to have a referral order from a physician.
Leann Kerr DPT, DHS, CBIS, works with neurologically involved pediatric patients, and her primary focus is the restoration or development of functional movement. Creating neuroplasticity, changes in neural pathways, requires high repetition of the set movement pattern over a period of time. A robotic gait trainer, like the Lokomat®, assists in providing the same exact motion 24 M.D. UPDATE
repetitively, resulting in a new functional movement pattern. This improves recovery measures for patients with all types of diagnosis and is vital to a successful recovery. “We are very fortunate that Cardinal Hill is committed to providing advanced technology. It is amazing to see an individual come into the facility in a wheelchair or walking with the assistance of devices and leave walking out on their own, without any restrictions. The level of functional improvement would not take place in the same amount of time with more traditional approaches to intervention,” says Kerr.
Much More than Playing in the Pool
The unique design of the Cardinal Hill Aquatic Center offers not only the opportunity for typical aquatic sessions focusing on motor development and performance, but also the opportunity to satisfy the various sensory needs of specific patients. Pediatric patients who receive therapy in the pool have medical diagnoses including but not limited to, autism, juvenile arthritis and neurological conditions, osteogenesis imperfecta type III and reflex neurovascular dystrophy. The patients benefit from the decreased gravitational impact as well as the unique thermal desensitization provided by the various pools. Addie Burnham MOT, OTR/L, works with autistic children, who benefit from the rich sensory input of the pool that increases eye-contact, reciprocal interaction, and participation in structured activities. Therapeutic activities that might cause meltdowns are easily achievable in the pool and patients display increased play schemes, social interaction, fine motor skills, and tactile processing as a result of the input provided through skilled services in the water. Children who have significant motor limitations have increased active and passive range of motion with aquatic therapy and can develop improved typical movement patterns in a gravity eliminated environment, says Burnham. “I also like to transi-
tion to aquatics with children who have plateaued with traditional therapy approaches. Often a simple transition for a session can facilitate progress once again.”
You Can Say That Again
Kristen Wheeler, MS, CCC-SLP, is a speech language pathologist who sees children diagnosed with a variety of communication delays, genetic syndromes, autism, and developmental delays. When appropriate, Wheeler works with children in co-treat sessions with OT where the child’s occupational therapist addresses their sensory needs, and she targets communication goals in a more structured way. Co-treat sessions may occur in a traditional therapy room, sensory gym, or in the pool. All patients have the potential to progress in speech-language therapy, says Wheeler. Children with caregivers who actively participate in the therapy process and follow-through with home programs typically demonstrate excellent progress and carry-over of skills learned in therapy. Every situation is unique, Wheeler continues, but each child has the potential to be a functional communicator. Some children may become independent verbal communicators, while others may use picture symbols or augmentative communication devices to communicate. “Whatever their mode of communication, my goal for them is to become a functional independent communicator,” says Wheeler.
Activity & Nutrition with a Dash of Self-Esteem
Fit Kidz is geared toward the overweight and obese child population. Typically these children perform well in the program because they participate in physical activity for 60 minutes on two different days of the week. Additionally, children and parents receive nutrition and healthy lifestyle information to incorporate in their everyday lives. The majority of the lifestyle changes come in the home environment. Unfortunately,
Turner uses Kinesio taping to strengthen joints and muscles.
without parental support, the child is usually not successful in the program. Self-esteem plays an important role in Fit Kidz therapy, says Jennifer Robinson, BS, exercise science, Fit Kidz coordinator. “The most challenging aspect of my work is having a child believe in his or her self. Many of these children are bullied in school, so when they come in for Fit Kidz, they are emotional and have a lot of selfdoubt,” says Robinson. Robinson encourages her patients to eat healthy, be physically active, and understand they are not the only ones with a weight problem. In the group setting, each child gets to know others of the same age who are also dealing with weight issues. While this is the most challenging aspect, Robinson says it also becomes the most rewarding aspect as well. “Over the course of 10 weeks, each child begins to see themselves in a new light. It is amazing the transformation a child undergoes. They make new friends, learn healthy lifestyle changes, but more importantly, begin to see the positives in themselves and gain confidence in the things they can do,” says Robinson.
Yuck! - Food Aversions
Heather Roach, OTR/L, has worked in pediatrics for 14 years with children of all ages and abilities with extensive training in feeding using a sensory based approach, as well as behavioral strategies. A sensory based approach works by helping children accept a variety of foods through play and exploration. Children learn best through play, which makes this approach so successful. Parents are also taught strategies to use at home to improve the child’s acceptance of new foods and textures, which is essential for success in the program. “To have a family say that meal times are no longer a battle, and they can go
Pediatric patients respond to the play in aqua therapy, L-R Burnham & Wheeler
“I love seeing children succeed in doing something that was previously challenging,” Roach “Cardinal Hill is committed to advanced technology,” Kerr
“All I ask is for them to have fun and to try,” Robinson
out to eat without worrying that the child won’t be able to eat or sit through the meal is very rewarding,” says Roach. Also seeing children gain height and weight and not rely on their feeding tubes for nutrition is very rewarding. When needing to use a more behavioral approach, it can be challenging to find the best reward for the child, says Roach.
ing increased movement, decreased pain, or decreased swelling, dependent on the technique utilized and the intended goal for the movement, says Turner. As Kinesio® tape is a non-invasive treatment method, it is easy to apply and is flexible to encourage active movement while assisting with normalizing movement patterns. Unanimously, the OT, PT, and SLP providers at Cardinal Hill Pediatric Outpatient Services say the most rewarding aspect of their work is the improvement, large or small, that their patients achieve during therapy. ◆
Flexible Therapy Fuels Movement
Alexandra (Allie) Turner, MS, OTR/L, CBIS, used Kinesio® taping in adult patient to alleviate pain and assist with joint stability for patients with normal movement patterns to increase their independence with occupation based tasks. She now employs Kinseo® taping with pediatric patients to increase their acceptance of weight-bearing positions. Patients respond by show-
For patient referral 2050 Versailles Road Lexington, KY 40504 (859) 246-8801 www.cardinalhill.org ISSUE#86 25
“There’s Physical Therapy for That”
Dunn Physical Therapy specializes in pelvic floor dysfunction and is on a mission to raise awareness of treatment options for women and children BY JENNIFER S. NEWTON You probably won’t overhear women in a coffee shop talking about painful penetration, and you won’t see women posting comments on Facebook or Twitter about urinary incontinence or pelvic pain. These issues are often too hushhush, too intimate, and too uncomfortable for women to discuss with even their closest friends, let alone their doctor. But Susan Dunn, PT, of Dunn Physical Therapy, is on a mission – a mission not only to help women, and children, with pelvic floor issues but also to educate the public and health care providers that evidence-based treatments exist and can provide relief from sometimes embarrassing and emotionally charged pelvic problems. Dunn established Dunn Physical Therapy 14 years ago. The practice now has two Louisville locations, employing six
therapists, and seeing an average of 200 patients a week. Because pelvic floor therapy is outside what is taught in physical therapy school, the specialty is somewhat unique. Says Dunn, “We could easily have multiple locations, but you don’t want watered-down physical therapy. And it takes a while to get the training for this.”
An Organic Path to Pelvic Patients
Susan Dunn, PT
Dunn’s path to specializing in the pelvic floor was more organic than deliberate. “I did not choose this, it chose me,” says Dunn. Her interest in PT school was in sports medicine for the female athlete, but the complexity of the female body necessitates services beyond traditional physical therapy for issues such as pregnancy, post-partum care, and the inability to use tampons. “Athletes were having to go to Indianapolis to see a physical
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therapist because I did not have training in this area,” she says. Dunn subsequently did a fellowship program in pelvic dysfunction (now called a residency). “I did not think it would take over my career. I thought it would just be an adjunct specialty I had in treating athletes. When I finished my training, within one year my entire schedule was full once word got out,” she says. As her awareness grew, so did her passion. Dunn estimates her patient population is 70 to 75 percent female pelvic floor patients, although they do treat general orthopedic physical therapy needs. Each of her therapists that treat the pelvis also specialize in another area of the body, such as pelvis and spine. In addition to adult female patients, the practice also treats male pelvic problems and pediatric bowel and bladder dysfunction and
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pelvic pain. Dunn employs a pediatric specialist for these issues in children ages five to 18.
“There’s Therapy for That?”
“The most common complaint I get is patients will come in and say, ‘I had no idea there is physical therapy for the pelvic region,’” says Dunn. Pelvic floor therapy is applicable for urinary and fecal incontinence, trauma from vaginal delivery, pelvic pain, dyspareunia or painful penetration (whether with intercourse or the use of tampons), and complications from oncology treatments. While aging, giving birth, and menopause can cause pelvic dysfunction, Dunn insists none of these problems is a “normal” part of life that women just have to deal with. “Women don’t have to live with incontinence. It’s not a normal part of aging. That’s like saying getting obese is a normal part of aging,” she says. Dyspareunia is a condition Dunn sees in young women. The first sign is often young girls who cannot insert tampons.
Dunn educates patients that the problem is a tight muscle and not that something is wrong with them. “With pelvic floor, not everybody is born with the flexibility for tampons and intercourse,” she says. “The more we can make this a public conversation, the more women will know that the treatment is out there,” says Dunn. Women who survive uterine or cervical cancer often suffer complications from chemotherapy and radiation. “The aftermath is they can’t have intercourse because the vaginal tissue is practically scarred closed. There’s physical therapy for that,” says Dunn. Therapeutic treatments for pelvic floor issues are akin to any type of physical therapy. “Any research and data we have to treat skeletal muscles applies to the pelvic floor,” says Dunn. The practice’s treatment approach involves looking at the body holistically, including the pelvic floor, bowel, and bladder. Therapists commonly recommend behavioral modifications and dietary changes. Other treatment strategies include identifying irritants to the
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bladder, looking at the patient osteopathically for joint alignment, and of course, examining the soft tissue and rehabbing the muscle for strength, flexibility, and endurance.
Independently Owned, Insanely Life-Changing
The practice is owned solely by Dunn and is independent of the local health systems. “Everything is one-on-one with patients,” Dunn stresses. “The reason I stay independent is I don’t want to lose that.” However the nature of Dunn’s services does require a team approach between physical therapist, referring physician, and consulting specialists. “I always say that treating the pelvic area is like a three-legged stool, and you take one leg away and stool is going to fall over. The three legs of that stool are the MD, the PT, and the third leg can either be a nutritionist or a psychologist, normally a psychologist,” says Dunn. The psychologist is critical to coping with the emotion tied to this area of the body. With an already full schedule, Dunn’s future wish list includes Southern Indiana and Louisville South End locations. However, the challenge is finding qualified clinicians. To that end, the practice is a teaching facility, and Dunn guest lectures at the PT program at Bellarmine University in the hopes of inspiring PT students to pursue the specialty. Dunn’s path to pelvic floor dysfunction has not only changed her life but is reaping positive results among her patients. This therapy can be “insanely life-changing,” she says, allowing patients to participate fully in life. ◆
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28 M.D. UPDATE
What Do Women Want?
Learning to balance femininity and strength BY JAN ANDERSON, PSYD, LPCC In your work with women, what is the #1 issue you encounter?
Whether I’m working with a young woman in her 20s or 30s or a woman over 40, the core issue is usually a vexatious variation of the following dilemma: A woman struggling to integrate her femininity with her strength and capability in a way that really works – so she is able to move forward in her work, her relationships, and the world in general. If we pose her issue as a question, it can focus and energize her process toward the goal. How can I operate with confidence and strength in the world without sacrificing my femininity? How can I be in an intimate relationship without losing myself?
Can you be more specific?
Yes. Let’s say the woman has achieved career success but is unfulfilled in her personal relationship – oftentimes it’s what marriage researcher John Gottman calls the “classic marital impasse” – a wife seeking emotional connection from a withdrawn husband. Another variation is the woman who is unfulfilled in her personal relationship … because she doesn’t have one. Some women avoid getting too involved with a man because of a legitimate concern lurking in the background — on some level, she realizes she doesn’t know how to be in an intimate relationship without losing herself. Interestingly, for both women the journey is the same: The delicate and empowering process of learning to be in touch with her strength and her vulnerability — at the same time. How is this possible? In Partnering: A New Kind of Relationship, Drs. Hal and Sidra Stone give two hints: If you feel that you are at the mercy of the other person, you’ve become too vulner-
able. If you feel totally in charge of the situation, you have probably moved too much to your power side. Your partner’s reaction will tell you whether or not you have struck a good balance. A balanced presentation usually elicits a favorable response. If your partner becomes angry or judgmental, you have probably moved too far to one side or the other.
What is one of the hardest issues for women to deal with?
ing for a husband. The woman has interpreted this age-appropriate, legitimate, and normal human need for connection and relationship as “needy” or “insecure.” I usually ask, “In achieving a goal at work, how can you be anything but passive, but leave it to chance or luck that you might meet someone?” When these same women say, “I don’t want to play games,” I respond with “This isn’t about playing games. It’s about understanding human nature and responding accordingly.” Dr. Jan Anderson is a Licensed Professional Clinical Counselor with a Doctorate in Clinical Psychology. Her private practice includes over 15 years of experience counseling individuals, couples, and families. ◆
When a self-sufficient, independent woman marries, she may be very distressed to see herself transform before her very eyes into someone who now reflexively assumes a traditionally feminine role in the relationship. “How did this happen?” she wonders. The power that she feels at work or in the world dissolves when she comes home and walks through the door. As one woman lamented, “I’m a tiger at work, but more like a hamster in a cage at home.” Particularly if she becomes a mother, an old cultural rule may spring up strongly, unexpectedly, and automatically. “You can do as you wish only after you have cared for everyone else.” This striking change is usually due to the internalized cultural rules about the woman’s role as a wife and mother. It’s actually bigger than the individual woman’s situation and culture – it’s archetypal. So we have to work at all three levels – individual, cultural, and archetypal.
What other situations are common dilemmas for today’s woman?
I encounter a number of women who are embarrassed to let others know that they want to get married and that they are lookISSUE#86 29
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varied spectrum of clinical emergency settings, ranging from military hospitals to Level III trauma centers. He is a graduate of University of Louisville School of Medicine and completed his residency in emergency medicine at University of Louisville Hospital. Dr. Charlotte Ingwersen (LEFT) and Erika Wooldridge, ARNP
KentuckyOne Health Medical Group Adds Mother-Daughter Team
KentuckyOne Health Medical Group added two new professionals. Charlotte Ingwersen, MD, and her daughter Erika Wooldridge, ARNP, will join KentuckyOne Health Primary Care Associates in Shepherdsville. Both Ingwersen and Wooldridge come to KentuckyOne Medical group from Bullitt County Family Care Center. The new practice is scheduled to open June 9, and both Ingwesen and Wooldridge are currently accepting new patients. The office located at 187 Adam Shepherd Parkways in the Kroger shopping center. For more information about the practice, or to book an appointment, call (502) 543-4119.
Sherrard joins KentuckyOne Health Medical Group
KentuckyOne Health Medical Group, part of KentuckyOne Health, is pleased to announce the addition of Charles D. Sherrard Jr., MD. Sherrard is the clinic-attending physician for the Ford Louisville Auto Plant Occupational Medical Clinic. He also serves as attending physician for Medical Center Jewish South, also part of KentuckyOne Health. Additionally, he serves as assistant clinical professor at University of Louisville School of Medicine, in the emergency medicine residency training program. Sherrard is board certified in and specializes in emergency medicine with over two decades of experience in a broad and
30 M.D. UPDATE
UK PA Program and Norton Healthcare Announce Preceptor Partnership
The University of Kentucky College of Health Sciences Physician Assistant Studies program and Norton Healthcare are launching a preceptor partnership program. The first cohort of physician assistant (PA) students will begin their clinical clerkship rotations with preceptors in the Norton Healthcare system in Louisville this June. Norton Healthcare has pledged nearly $715,000 over three years through its James R. Petersdorf Fund to support the preceptor program, which will develop a robust network of qualified PA preceptors within the Norton Healthcare system. The preceptors will teach, supervise, and evaluate PA students during their clinical clerkship rotations with the aim of offering full-time employment with Norton Healthcare to 50 percent of the students upon completion of their clerkships. UK HealthCare and Norton Healthcare have a history of collaboration, including alliances in clinical programs, workforce, education, and research. The organizations believe that there is power in partnership, and the ultimate goal is to improve health care for all Kentuckians. Physician assistants play a vital role in providing access to quality health care. PAs examine, diagnose, and treat patients under the supervision of physicians. According to the U.S. Bureau of Labor Statistics, employment of physician assistants is projected to increase 38 percent from 2012 to 2022. Its growth far outpaces the projected 10.8 percent employment increase across all occupations for the same period. LEXINGTON
Louisville Symposium on Heart Disease in Women June 28
LOUISVILLE The University of Louisville, in conjunction with KentuckyOne Health and University of Louisville Physicians, is hosting a one-day conference in Louisville to help educate patients and health care professionals about the prevention, recognition, and treatment of the disease in women. Heart disease is more deadly for women than all forms of cancer combined, according to the American Heart Association, and 90 percent of women have one or more risk factors, and more than one in three have some form of cardiovascular disease. Yet, women don’t recognize that heart disease is their biggest health threat. To help in this educational effort, Kendra Grubb, MD, assistant professor of cardiovascular and thoracic surgery at UofL, has organized the 2014 Louisville Symposium on Heart Disease in Women, the first of what is planned to be an annual event. The conference will be held Saturday, June 28, at the Jewish Hospital Rudd Heart & Lung Center, 16th Floor Conference Center, 201 Abraham Flexner Way in Louisville. It is designed to provide physicians, nurses, allied health professionals, and the community with upto-date information pertaining to the prevention and treatment of cardiovascular disease in women. Two dozen doctors and health professionals are scheduled to speak including Toni Ganzel, MD, dean of the UofL School of Medicine, and Ruth Brinkley, CEO of KentuckyOne Health. The conference begins at 7 a.m. with registration and a continental breakfast, with the program starting at 8 a.m. The event ends at 5 p.m., with a reception to follow. Continuing medical education (CME) credit is available. For more about the conference, go to http://www.louisvilleheartdiseasewomen.com/home.html or call 502-561-2180. ◆
Cardinal Hill Telethon Total Tops $450,000
Baptist Health Louisville Opens Charles and Mimi Osborn Cancer Center
Charles A. Osborn, Jr., and Carrie Scharf, MD, medical director of Radiation Oncology share ribbon cutting duties with David Gray, president Baptist Health Louisville, looking on. ABOVE (L-R) r. Bob Linker, MD, medical director of Oncology Program, and John Huber, MD,CBC Group medical director, at the opening of the Charles and Mimi Osborn Cancer Center. TOP “Baptist Health touches one in four or five cancer patients in Kentucky and Southern Indiana. This Center is the crown jewel of Baptist Cancer Care,” says Steve Hanson, CEO Baptist Health. LEFT (L-R)
LOUISVILLE- Baptist Health Louisville celebrated the opening of the Charles and Mimi Osborn Cancer Center with a ribbon cutting and open house on Friday, May 16, 2014. The Center brings all of Baptist Health Louisville’s cancer services together in one location. The philanthropic support of Charles A. Osborn, Jr., was made to honor his wife, Mary Taylor “Mimi” Osborn, who passed away at Baptist Health Louisville in 2014 after a 10-year battle with breast cancer. Mimi Osborn was an active supporter of the arts, education, and Louisville’s natural resources and history. The Center has renovated medical offices and exam rooms for medical oncology physicians, including improvements to the outpatient infusion center, where more than 14,000 chemotherapy infusions are administered annually; an expanded radiation therapy facility, including the BrainLab Novalis Shaped Beam, which delivers highly focused radiation therapy, most commonly used for cranial cases plus lung, liver, and spine; on-site relocation of the hospital’s PET/CT scanner; a new Cancer Resource Center that provides educational information and hosts support groups for patients and their family members; and additional space to offer multidisciplinary clinics and genetic counseling, as well as conduct cancer research. “Our focus is the future and the impact we can make on the care of cancer patients. That begins here, today,” said Bob Linker, MD, medical director of Oncology Program. “’Family is spoken here’ is a saying we have at Baptist.” “Patient centered care describes what we do at Baptist, said John Huber, MD, CBC Group medical director. ◆
LEXINGTON-The 43rd annual Cardinal Hill Rehabilitation Hospital telethon on April 27, 2014 raised $450,041, said Jenny Wurzback, director of the hospital’s community relations. That surpassed last year’s total of $359,000 on the strength of several large donations, Wurzback said. The largest donation came from Cathy and Don Jacobs, who gave $100,000. In addition, Marylou Whitney and her husband, John Hendrickson, and the E.O. Robinson Mountain Fund each gave $50,000, with the Robinson gift designated to support people from 30 Eastern Kentucky counties, Wurzback said. Additionally, a pledge of $25,000 came from the Creech Family Foundation in memory of Virginia Creech, who helped start the work at Cardinal Hill. Money raised during the telethon helps cover care Cardinal Hill provides but for which it doesn’t get paid. That uncompensated care usually totals more than $2.5 million a year. ◆
Photo caption; (l-r) William O. Witt, MD, medical director of the Cardinal Hill Pain Institute, and Gil Dunn, M.D. Update, worked the phones for the Cardinal Hill Telethon. Witt made a personal donation of $1,000.
University of Louisville Hospital Honors Organ Donor Families LOUISVILLE In recognition of Donate Life Month, University of Louisville Hospital, part of KentuckyOne Health and one of the country’s largest organ donation facilities, and Kentucky Organ Donor Affiliates (KODA) TOP Mark Pfiffer, MD, chief medical honored organ donor famiofficer for University of Louisville lies in a special ceremony Hospital, spoke of the impact on Tuesday, April 29, 2014, organ donation has on both donor recognizing those who have families and organ recipients. given the gift of life through BELOW University of Louisville Hospital staff, KODA organ and tissue donation. representatives, and donor families Families planted flowers in plant flowers in the Legacy of Life honor of their loved ones Memorial Garden. at the hospital’s Memorial Garden. A new Donate Life flag was raised in front of University of Louisville Hospital by family members of organ donor Sheldon Sharpe.Mark Pfeifer, MD, invited donor families to help raise the new KODA flag in honor of their loved ones. Pfeifer noted, “Our trauma team works to save everyone that comes through our doors. It’s not always possible, but from loss comes hope that other lives may be impacted in very meaningful ways. Your loved one and your family are part of our family forever.” ◆
32 M.D. UPDATE
Kimberly Stigers, MD,
and Marta Kenney, MD, KentuckyOne at KentuckyOne Health Announces radiologists Health Breast Care at Saint Joseph East. $1 Million Renovation and Expansion of Breast Care at Saint Joseph East LEXINGTON Saint Joseph East, part of KentuckyOne Health, shared
construction plans on a $1 million expansion and renovation of the hospital’s breast care center on May 7, 2014. The project is funded in part by the Saint Joseph Hospital Foundation and will include the new imaging technology digital breast tomography, often referred to as 3D mammography. “3D mammography, tomosynthesis, is an exciting new technology in breast imaging for enhanced detection of early breast cancer,” said Kimberly Stigers, MD, radiologist. “We are grateful to KentuckyOne Health and the Saint Joseph Foundation for making this technology available for our patients.”Tomosynthesis is a technique that uses motion to better exhibit relevant anatomy while allowing the superimposed structure to fade. “Mammography is the most cost effective exam proven to reduce mortality from breast cancer,” said Marta Kenney, MD, radiologist. “We stand behind the recommendation that women get a yearly mammogram beginning at age 40. Mammography saves lives.”The expansion will add nearly 2,100 square feet to the existing breast care center. The extra space will allow for an additional mammography suite with private dressing rooms and waiting areas for family members. The availability of additional dressing rooms and diagnostic areas will better accommodate and assist with the transition between patients and procedures.Breast screening and bone densitometry services will move to a space separate from areas where patients receive diagnostic services, including ultrasounds and biopsies.◆
TESTIMONIALS “M.D. Update provides me with the latest trends in medical services, practice management and cutting edge technology in the state. Reading it makes me feel like I am an active part of the regional healthcare community.” --- Darryl Kaelin, MD, Associate Professor, U of L, Medical Director Frazier Rehab Institute, Division of Physical Medicine & Rehab
“We have found that MD Update is the best way to inform our physician colleagues in the state of Kentucky about new and exciting things in our practice. It almost always garners a response from other physicians of: ‘I did not know you were doing that’. We will continue to use MD Update on a regular basis.” -- Richard Lingreen, MD Commonwealth Pain Specialists, Frankfort
“I look forward to receiving M.D. Update. No other publication gives me the same information and keeps me up to date on what other physicians in Kentucky are doing in their medical practice like M. D. Update. I read every issue.” -- William Wood, MD, founder Retina Associates of Kentucky
25 BB&T/Lexington Annual Medical Society Golf Outing th
REGISTER NOW Wednesday, August 27, 2014 University Club of Kentucky 1:00 p.m. shotgun start
All proceeds to benefit the Lexington Medical Society Foundation. Each year the LMS Foundation distributes grants to several local organizations, including Baby Health Service, God’s Pantry Food Bank, Faith Pharmacy, Mission Lexington, Ronald McDonald House and Surgery on Sunday.
Get your team together, sponsor a hole and register to play!
Shamble Tournament (Play best drive then play own ball to the hole)
Patrick Cashman, SIS
Put together own Foursome or Committee will help form teams
Wendy G. Cropper, M.D.
GOLF – INDIVIDUAL PLAYERS: $100.00/person
Kenneth V. “Tad” Hughes, III, M.D.
HOLE SPONSORSHIP: $500.00 (Includes signage and newsletter recognition)
HOLE SPONSORSHIP WITH 4 PLAYERS: $500.00 (Includes signage and newsletter recognition)
WHITE TEE SPONSORSHIP: $2000.00
John W. Collins, M.D., Chairman
W. Lisle Dalton, M.D. Gil Dunn, M.D. Update John Maher, BB&T
(includes banner recognition, newsletter recognition, hole sponsorship and 4 players)
Jon H. Voss, M.D.
GOLD TEE SPONSORSHIP: $6000.00 – BB&T
David Smyth, Family Financial Partners
To Sign Up: Please contact a committee member or Jaime Verba (firstname.lastname@example.org) or at LMS office 859-278-0569 with questions or to sign up.