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THE BUSINESS MAGAZINE OF KENTUCKY PHYSICIANS AND HEALTHCARE PROFESSIONALS ISSUE #94

The Road Less Traveled Cassis Dermatology & Aesthetics Center forges its own path to growing a successful independent practice

SPECIAL SECTIONS

PLASTICS/ORTHOPEDICS GASTROENTEROLOGY HEMATOLOGY VASCULAR ALSO IN THIS ISSUE VOLUME 6•#5•SEPTEMBER 2015

 HAND SURGERY IN THE DIGITAL AGE  THE IMPACT OF PLASTIC SURGERY  MODERN DAY GASTROENTEROLOGY  ENDOSCOPIC GI TECHNIQUES  THE CHALLENGES OF APLASTIC ANEMIA  THE DRAW OF VASCULAR SURGERY


More locations for digital mammography screenings.

At KentuckyOne Health, we are devoted to providing expert, compassionate care and support for breast care. That’s why we make it easier for you to receive a digital mammography screening by providing more convenient locations. Screening mammograms are fast. They’re safe. And early detection is your best protection. For peace of mind, schedule an appointment at one of our convenient locations listed below.

LOUISVILLE AREA Jewish Hospital 200 Abraham Flexner Way Louisville, KY 40202 502.587.4327 Sts. Mary & Elizabeth Hospital 1850 Bluegrass Avenue Louisville, KY 40215 502.587.4327 James Graham Brown Cancer Center 529 S. Jackson Street Louisville, KY 40202 502.587.4327 3D Mammography available Flaget Memorial Hospital 4305 New Shepherdsville Road Bardstown, KY 40004 502.587.4327 Jewish Hospital Shelbyville 727 Hospital Drive Shelbyville, KY 40065 502.587.4327

Medical Center Jewish East 3920 Dutchmans Lane Louisville, KY 40207 · 502.587.4327 3D Mammography available

Partners in Women’s Health 3940 Dupont Circle Louisville, KY 40207 502.587.4327

Medical Center Jewish South 1903 W Hebron Lane Shepherdsville, KY 40165 502.587.4327

Total Woman 4121 Dutchmans Lane, Suite 500 Louisville, KY 40207 502.587.4327

Medical Center Jewish Southwest 9700 Stonestreet Road Louisville, KY 40272 502.587.4327

LEXINGTON AREA

James Graham Brown Cancer Center Mobile Mammography Van 502.587.4327 Louisville OB/GYN 3999 Dutchmans Lane, Suite 4D Louisville, KY 40207 502.587.4327 Louisville Physicians for Women 4121 Dutchmans Lane, Suite 101 Louisville, KY 40207 502.587.4327

KentuckyOne Health Office Park (formerly Saint Joseph Office Park) 1401 Harrodsburg Road, Suite C-45 Lexington · 859.967.5613 KentuckyOne Health Imaging – Tates Creek 1099 Duval Street, Suite 150 Lexington · 859.313.3554 3D Mammography available Saint Joseph Berea Merle M. Davis Digital Mammography Suite 305 Estill Street, Berea 859.986.6587

Saint Joseph East Medical Office Building 160 N. Eagle Creek Drive, Suite 101 Lexington · 859.967.5613 3D Mammography available Saint Joseph Jessamine Sandra J. Adams Digital Mammography Suite 1250 Keene Road, Nicholasville 859.967.5613 Saint Joseph London 1001 Saint Joseph Lane, London 606.330.6060 Saint Joseph Martin 11203 Main Street, Martin 606.285.6480 Saint Joseph Mount Sterling 225 Falcon Drive 859.497.5000


LETTER FROM THE PUBLISHER

Inside and Out We called this issue of MD-Update “Inside and Out.” That theme gave us the opportunity to meet with Kentucky physicians from different specialties, all working on various internal and external systems. Dermatology, plastics, orthopedics, gastroenterology, hematology, and vascular are all represented. It was enjoyable for us to cover so many topics. We hope you enjoy meeting the Kentucky doctors we spoke with. The Lexington Medical Society’s 26th Annual Golf Outing was also fun. It was a brilliantly pleasant day, full of Kentucky sunshine, mild breezes, and good company. MD-Update was pleased to be a sponsor and to help raise money for the many non-profit organizations that receive grants from the Lexington Medical Society’s Foundation.

In Memory

Readers of my letters in the past know that I am a baseball fan, grew up on Kent Island, Maryland in the middle of the Chesapeake Bay, and that I have referred to my father, Gil Dunn, Sr. occasionally. My father was a pharmacist, who owned his drug store, the only one on the Island and was sometimes paid by the local watermen for their medicine in fresh oysters, crabs, clams, or fish. Really, not a bad way to do business in a small community. My father was also a baseball fan, and one day in 1966 his childhood hero, Hall of Famer Jimmie Foxx paid him a surprise visit in his drugstore. It was a very happy moment for my dad that I want to share with sons, fathers, and longtime baseball fans. It’s probably one of the first photographs I took, and I’m so glad I did. Gil Dunn, Sr. June 1918-August 2015. (L-R) Jimmie

Foxx, Gil Dunn, Sr., and Sammy Dell Foxx, Jimmie’s brother.

Until next time, all the best,

????????

Volume 6, Number 5 ISSUE #94 PUBLISHER

Gil Dunn gdunn@md-update.com EDITOR IN CHIEF

Jennifer S. Newton jnewton@md-update.com GRAPHIC DESIGNER

James Shambhu art@md-update.com

CONTRIBUTORS: Jan Anderson, PsyD, LPCC Jamie W. Dittert, Esq. Jenny Miller Jones Scott Neal Mac Stone Sarah Wilder

CONTACT US:

ADVERTISING AND INTEGRATED PHYSICIAN MARKETING:

Gil Dunn gdunn@md-update.com

Mentelle Media, LLC

38 Mentelle Park Lexington KY 40502 (859) 309-0720 phone and fax Standard class mail paid in Lebanon Junction, Ky. Postmaster: Please send notices on Form 3579 to 38 Mentelle Park Lexington KY 40502 M.D. Update is peer reviewed for accuracy. However, we cannot warrant the facts supplied nor be held responsible for the opinions expressed in our published materials. Copyright 2013 Mentelle Media, LLC. All rights reserved. No part of this publication may be reproduced, stored, or transmitted in any form or by any means-electronic, photocopying, recording or otherwise-without the prior written permission of the publisher. Please contact Mentelle Media for rates to: purchase hardcopies of our articles to distribute to your colleagues or customers: to purchase digital reprints of our articles to host on your company or team websites and/or newsletter. Thank you. Individual copies of M.D. Update are available for $9.95.

Gil Dunn Publisher, MD-Update

Send your letters to the editor to: jnewton@md-update.com, or (502) 541-2666 mobile Gil Dunn, Publisher: gdunn@md-update.com or (859) 309-0720 phone and fax ISSUE#94 1


CONTENTS

ISSUE #94

COVER STORY 3 HEADLINES 5 LEGAL 7 FINANCE 8 COVER STORY 10 SPECIAL SECTION: PLASTICS/ORTHOPEDICS 16 SPECIAL SECTION:

The Road Less Traveled Cassis Dermatology & Aesthetics Center Forges Its Own Path To Growing A Successful Independent Practice BY JENNIFER S. NEWTON PHOTOS COURTESY OF CASSIS DERMATOLOGY & AESTHETICS CENTER PAGE 8

GASTROENTEROLOGY 21 SPECIAL SECTION: HEMATOLOGY 23 SPECIAL SECTION: VASCULAR 25 COMPLEMENTARY CARE 29 NEWS 31 EVENTS

SPECIAL SECTIONS PLASTICS/ORTHOPEDICS

11 HAND SURGERY IN THE DIGITAL AGE: LEXINGTON CLINIC

2 MD-UPDATE

13 MORE THAN SKIN DEEP: DAVID KIRN, MD SPECIAL SECTION: GASTROENTEROLOGY

GASTROENTEROLOGY

16 MODERN DAY GASTROENTEROLOGY: LEXINGTON CLINIC

18 SUBSPECIALIZING IN A GENERAL GI PRACTICE: BAPTIST GASTROENTEROLOGY ASSOCIATES

20 MUCH MORE THAN THE STANDARD CARE: BLUEGRASS SURGERY AND GASTROENTEROLOGY


HEADLINES

Expanding Cancer Care

James Graham Brown Cancer Center opens at Medical Center Jewish Northeast BY JENNIFER S. NEWTON

Cancer patients in Louisville’s east end now have a cancer treatment center closer to home. The James Graham Brown Cancer Center, jointly operated by KentuckyOne Health and the University of Louisville (UofL), has opened a new location inside KentuckyOne Health’s Medical Center Jewish Northeast, conveniently located off Old Henry Road and the Gene Snyder Freeway at 2401 Terra Crossing Boulevard. “Extending the reach of the Brown Cancer Center improves access to care for cancer patients in the region and provides added convenience, access to leading physicians, and support during cancer diagnosis, treatment, and recovery,” said Ruth Brinkley, president and CEO, KentuckyOne Health. Like the downtown location, the Brown Cancer Center at Jewish Northeast offers a broad array of cancer care. This includes multidisciplinary cancer care clinics five days a week for the treatment of a variety LOUISVILLE

Attending the opening of the James Graham Brown Cancer Center at Medical Center Jewish Northeast were: (from left to right) Mark Milburn, vice president of oncology services, KentuckyOne Health; Ruth W. Brinkley, president, KentuckyOne Health; Vivek Ravindra Sharma, MD; Shelly Wyman, patient; Governor Steve Beshear; David L. Dunn, MD, PhD, executive vice president for health affairs, University of Louisville; and Donald Miller, MD, PhD, director of the James Graham Brown Cancer Center.

of cancers such as lung, melanoma, breast urinary tract, bladder, kidneys, and prostate. These clinics consist of surgical, medical, and radiation oncologists with UofL Physicians. They are supported by a team of nurses, social workers, medical assistants, pharmacologists, and other health professionals. The multi-disciplinary approach is designed to provide the best course of treat-

ment for individual patients, along with counseling and support throughout the diagnosis, treatment, and recovery process. The facility also provides diagnostic medical imaging including MRI, PET/CT, CT fluoroscopy, full-field digital mammography, nuclear medicine, X-ray, ultrasound, and DEXA/bone density. New appointments, clinical follow-up, and treatment are available. The new location provides an option for care closer to home for many patients in Louisville and surrounding counties. “In 2013 alone, the Brown Cancer Center had more than 1,200 visits from patients who live in Jefferson County and drove past Jewish Northeast to receive care at the downtown center,” said Donald Miller, MD, director of the James Graham Brown Cancer Center. “It is likely that even more patients came from surrounding counties such as Shelby, Oldham, and Henry. Providing patients with the option to receive care at the best and closest location to them will improve their comfort and overall experience.” ◆ The new location expands upon existing cancer care at Jewish Northeast provided by Cancer and Blood Specialists. In all, 14,000 square feet of Jewish Northeast is now focused on cancer care.

PHOTOS COURTESY OF KENTUCKYONE HEALTH

ISSUE#94 3


HEADLINES

Saving More Lives

HHS recognizes KODA and KHA efforts to increase organ donor enrollment BY JENNY MILLER JONES Kentucky Organ Donor Affiliates (KODA) and the Kentucky Hospital Association (KHA) are among a select group of organ procurement organizations and hospital associations nationwide recognized by the U.S. Department of Health and Human Services (HHS) for working with hospitals and transplant centers in their service area to conduct activities that promoted enrollment in state organ donor registries. KODA, KHA, and these facilities are part of the national Workplace Partnership for Life (WPFL) Hospital Campaign, sponsored by HHS’s Health Resources and Services Administration (HRSA). KODA and KHA recruited hospitals MANY THANKS TO ALL WHO PARTICIPATED IN THE HOSPITAL WORKPLACE PARTNERSHIP FOR LIFE CAMPAIGN!

4 MD-UPDATE

and transplant centers to participate in Phase IV of the campaign and worked with them to plan awareness and registry activities focused on increasing the number of organ, eye, and tissue donors. Facilities earned points for each activity implemented between August 1, 2014, and April 30, 2015, and were awarded gold, silver, or bronze recognition by HRSA. Of the 1,658 hospitals and transplant centers enrolled in the national campaign, 736 were awarded recognition during this phase of the campaign. Since launching in 2011, the campaign has added more than 350,000 donor enrollments to state registries around the country, far surpassing the original goal of 300,000. Hospitals in KODA’s service area were among the highest percentage in participation nationally with 38 hospitals and two transplant centers receiving recognition, including 25 Gold, 11 Silver, and four Bronze. “Kentucky hospitals are committed to saving lives and improving the health and wellness of their patients -- it’s what guides the actions and decisions of nurses, physicians, and other caregivers every hour of every day, 365 days a year, inside Kentucky’s 125 hospitals. KHA is proud to collaborate with hospitals and KODA to ensure the ultimate gift of life is realized when tragedy or illness strikes,” said Michael T. Rust, president of the KHA.    This campaign is a special effort of HRSA’s WPFL designed to mobilize the nation’s hospitals to increase the number of those registered as potential organ, eye, and tissue donors. The campaign unites donation advocates at hospitals with representatives from organ procurement organizations, Donate Life America state teams, and state hospital associations. Working together, teams leverage communications, resources, and outreach efforts to proactively promote the critical need for donors. ◆

KENTUCKY HOSPITALS RECOGNIZED FOR OUTREACH EFFORTS GOLD, SILVER OR BRONZE

GOLD

Baptist Health Hospital Lexington Baptist Health Richmond Clark Regional Medical Center Ephraim McDowell Regional Medical Center Fleming County Hospital Georgetown Community Hospital Hardin Memorial Hospital Harlan Appalachian Regional Hospital Harrison Memorial Hospital Hazard Appalachian Regional Hospital Jewish Hospital Kentucky River Medical Center Lake Cumberland Regional Hospital Meadowview Regional Medical Center Medical Center at Bowling Green Middlesboro Appalachian Regional Hospital Owensboro Medical Health Systems Pineville Community Hospital The James B. Haggin Memorial Hospital University of Kentucky Medical Center University of Louisville Hospital Whitesburg Appalachian Regional Hospital Williamson Appalachian Regional Hospital

SILVER

Baptist Health Corbin Baptist Health Louisville Frankfort Regional Medical Center King’s Daughters Medical Center Mary Breckinridge Appalachian Regional Hospital Norton Brownsboro Hospital Pikeville Medical Center St. Joseph East St. Joseph Hospital Lexington St. Joseph Jessamine St. Joseph Mount Sterling Hospital

BRONZE

Flaget Memorial Hospital McDowell Appalachian Regional Hospital Morgan County Appalachian Regional Hospital St. Joseph London


LEGAL

Ex Parte Communications

What Medical Providers Should Know About Caldwell v. Chauvin. Witness interviews are one of the key tools attorneys use to investigate cases. These are performed “ex parte,” which means that the attorney can meet with the witness without providing notification to any other party involved in the matter. Attorneys use these interviews to learn more about a case’s claims and defenses and to evaluate whether or not it is worth the time and expense to depose the witness. With the adoption of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Kentucky attorneys have faced uncertainty regarding whether and how to seek ex parte interviews of medical providers. The Kentucky Supreme Court has finally addressed this issue in the decision of Caldwell v. Chauvin, No. 2014-SC-000390MR (Ky. June 11, 2015) (Caldwell). This article discusses what medical providers need to know about requests for ex parte communications under Caldwell. It is not intended to displace, change, or modify any existing provider procedures for handling requests for ex parte interviews. The Caldwell plaintiff asserted medical negligence allegations against her surgeon following a discectomy. The defendant surgeon asked the trial court to enter an order that would allow him to conduct

authorize ex parte communications with medical providers. Under the Caldwell decision, medical providers are permitted to engage in ex parte communicaBY Jamie W.Dittert, Esq. tions with attorneys but cannot disclose any protected health information (PHI) unless certain procedural requirements are satisfied. The Kentucky Supreme Court held that HIPAA does not prohibit ex parte interviews with treating physicians and was not intended to preclude discovery regarding a plaintiff ’s medical condition when that person’s medical condition is at issue in a lawsuit. But, the Court also held that the HIPAA Privacy Rule imposes certain procedural requirements that must be satisfied before the provider may disclose PHI during those interviews, as HIPAA protects both written and oral PHI, and those requirements are more stringent than the disclosure requirements that apply to subpoenas. When medical providers receive sub-

PROVIDERS ARE NOT REQUIRED TO PARTICIPATE IN EX PARTE COMMUNICATIONS ex parte interviews of the plaintiff ’s other medical providers. The plaintiff objected, arguing that the ex parte communications are prohibited by HIPAA, the physicianpatient privilege, the American Medical Association’s Code of Medical Ethics, and other Kentucky law. The Kentucky Supreme Court accepted the case to clarify when and under what circumstances courts can

poenas for patient information, HIPAA permits the disclosure of PHI if the medical provider receives certain information. PHI can be disclosed in response to a subpoena (or discovery request) under HIPAA’s “litigation exception” following receipt of satisfactory assurances that (1) the party seeking the records made reasonable, good faith efforts to notify the patient about

the request, and the patient did not object within the time given to raise objections, or (2) reasonable efforts were made to secure a protective order that would prohibit PHI from being used or disclosed outside of the litigation and require that the protected health information be returned or destroyed at the conclusion of litigation. 45 C.F.R. § 164.512(e)(1)(ii). Those assurances, however, are not sufficient to permit the disclosure of PHI during an ex parte interview. Instead, a court order authorizing the disclosure is necessary for the discussion of patient PHI during an ex parte interview. The Caldwell court held that providers can only disclose PHI during ex parte communications “in response to an order of a court or administrative tribunal” under 45 C.F.R. § 164.512(e)(1)(i). For example, the order at issue in Caldwell did not compel the provider to speak with the surgeon’s attorney and did not authorize the disclosure of PHI. Instead, the order stated that court could decide to allow the disclosure of PHI. That language is insufficient to permit the disclosure under HIPAA. Accordingly, a provider should not disclose PHI during an ex parte communication with an attorney without a HIPAA-compliant authorization or a court order that expressly authorizes the disclosure of that PHI. Moreover, any ex parte disclosures should conform to all terms of the order and be limited to the PHI authorized by the order to be disclosed. For example, if an order authorizes the disclosure of PHI relating to a treatment provided for a patient in 2014, the medical provider cannot disclose information from 2015. As such, is important that any order authorizing the disclosure of PHI during an ex parte communication be reviewed carefully. It is important to note that providers are not required to participate in ex parte communications; compliance with the Caldwell procedure only permits the disclosure. Even if a provider receives an order authorizing the disclosure of PHI, he or she may decide that other laws or ethical duties prohibit the disclosure of certain information. Indeed, the Caldwell court ISSUE#94 5


LEGAL THE BUSINESS MAGAZINE OF KENTUCKY PHYSICIANS

AND HEALTHCARE PROFESSIONALS

CALL FOR PARTICIPATION 2015 Editorial Opportunities *

Issue #95 October – SURVIVING CANCER, Oncology, Radiology, Imaging / Hospice, Home Health Issue #96 November – IT’S ALL IN YOUR HEAD, Neurology, ENT, Pain Medicine / Mental Health, Smoking Cessation Issue #97 December/January 2016 PREVENTION AND SENIOR HEALTH, Internal Medicine (including Hospitalists and Concierge Medicine), Family Medicine & Geriatrics, Ophthalmology / Physician Extenders, Residential Care *EDITORIAL TOPICS ARE SUBJECT TO CHANGE.

TO PARTICIPATE CONTACT: Gil Dunn, Publisher • gdunn@md-update.com/ (859) 309-0720 Jennifer S. Newton, Editor-in-Chief • jnewton@ md-update.com/(502) 541-2666

held that ex parte communications with providers regarding treatment are not prohibited by HIPAA, any physician-patient privilege or other Kentucky case law. But, it also noted that the Kentucky Board of Medical Licensure has adopted the AMA Code of Medical Ethics, which imposes an ethical duty regarding confidential communications that “may restrain the physician’s willingness to agree to such an interview.” Additionally, there is authority indicating that physicians should not disclose confidential communications from patients during an ex parte interview regarding that patient’s medical records, pursuant to KRS 311.595(16). A full discussion of confidential communications is outside of the scope of this article, but nothing in Caldwell states that providers must participate in ex parte interviews. Finally, most attorneys are willing to compensate providers for their time

TOGETHER, WITH HOPE AN EVENING TO SUPPORT PEOPLE FACING CANCER 6 MD-UPDATE

spent on an ex parte interview. Due to this recent clarification in Kentucky law, medical providers may be faced with more requests for ex parte communication. Those requests need not be rejected out of hand but should be addressed in light of the language of the court order regarding the communication, the provider’s existing HIPAA policies, discussions with risk management and – in some cases – counsel, and the provider’s good judgment. Jamie Wilhite Dittert is an attorney at Sturgill, Turner, Barker & Moloney, PLLC, where she devotes a large portion of her practice to healthcare law and medical malpractice defense. She can be reached at (859) 2558581 and jdittert@sturgillturner.com. This article is intended as a summary of state law and does not constitute legal advice. ◆

Join us for live music, an auction and River Road BBQ, at a beautiful Louisville farm. Proceeds support Hope Scarves and metastatic breast cancer research. Friday, September 25, 2015 FOR MORE INFORMATION & TICKETS, VISIT US ONLINE AT: W W W. H O P E S C A R V E S . O R G


FINANCE

Looking Inward August 2015 was an inauspicious month for equity markets around the world. Although the sell-off decelerated as the month drew to a close, our own S&P 500 dropped a little more than 6%, Japan’s Nikkei was down 8.2%, Germany’s DAX 9.3%, China’s Shanghai and Hong Kong’s Hang Seng posted losses of over 12% each, and Great Britain’s FTSE lost 6.7%. The media, constantly in need of a current story, has ascribed the cause of such decline as 1) China’s issues that have surfaced in both its economy and markets marked by the devaluation of its currency; 2) the probability that the Federal Reserve may finally raise interest rates; 3) the precarious nature of the European Union as evidenced by its interactions with Greece; and 4) the inability of the emerging markets to save the world with their demand for commodities. Add computerized, high-frequency trading to the news-making events and you have a recipe for nerve-wracking volatility. But the real question remains. Is this simply normal market volatility or is it something more? Let’s dig a little deeper. You have heard me extol the primacy of growth many times in previous columns. It is fascinating that so few journalists speak about the stagnant nature of the world’s economies, opting instead to speculate ad nauseum about the Fed’s next move. The recent GDP announcement of 3.9% U.S. growth in Q2 2015 was celebrated briefly. It needs to be, and in fact could be, well over 5% with the right policies in place to incentivize growth and to reduce corruption. As a nation, we have placed too heavy an emphasis on the Federal Reserve interest rate policy and held off on laying commensurate responsibility at the feet of policymakers. We appear to all have become addicted to the short term fix rather than focusing on long term growth solutions. To assess your own financial future, the central question today is whether you believe that all this is likely to change anytime soon. I do not believe it will. If you haven’t already, it’s time to take seriously your family’s financial future. A good place to start is looking inward. This summer I had the good fortune to meet Dr. Thomas Howard, author of

Behavioral P o r t f o l i o Management: How successful investors master their emotions and build superior portfolios. The book explores the role emotions play in every aspect of financial BY Scott Neal markets -- from how huge sophisticated markets price securities, to the conventional wisdom doled out by investment professionals, to the investment decisions made by individuals and professionals. With the aforementioned losses of August, now is a good time to be thinking about your own reactions to the market. Dr. Howard suggests that staying disciplined in an emotionally-charged, 24-hour news cycle world is a challenge. He presents Behavioral Portfolio Management (BPM) as a superior way to make investment decisions. Emotions and heuristics, according to Dr. Howard, act as brakes on our decision process, preventing us from making good decisions. Here are the most important cognitive errors made by investors according to Howard. Myopic loss aversion (MLA) is so prevalent because we humans experience far greater pain from losing than joy from gaining. In fact, there is evidence that the pain of loss is about twice as great as the joy from a comparable sized gain. This leads to short term evaluation of performance, even for long term goals which often results in premature abandonment of an investment strategy. I call this the tyranny of short time periods. Closely related to MLA is the cognitive error known as fallacy of composition. Many investors believe that in order to do well over the long-run, they must do well in each and every period. Any investment, other than cash, is likely to have periods of negative return. Herding or social validation is another cognitive error. None of us want to be part of a herd; however, we are hard-wired to seek social validation where we can find it. The lesson of our past is that sticking out

from the crowd by doing something different is dangerous. It is only natural to carry this into investment decisions. This is demonstrated by buying what our peers are buying or by buying larger, rather than smaller funds. Interestingly, Howard places stories on the list of cognitive errors of investing. Studies show that we would rather hear stories about complex economic facts than sift through economic statistics. Moreover, we tend to judge the story’s validity by the reputation of the storyteller and whether an explanation is logical to us. He also points out that the more detailed the story, the greater the validity attached (when in fact, more detail increases the chances the story will be wrong). Ever hear the words “past performance is no indication of future performance?” Of course you have. They are contained in every prospectus, performance report, and every advertisement of investment products. But what does everyone do to estimate future performance? They use past performance data. Numerous academic studies confirm this and some even go on to suggest that the exact opposite is true, with poor past performance predicting superior future performance. This is an example of representativeness. Surprisingly, Howard contends that chief among the representativeness error is to infer that the good or bad qualities of a company, however we define those, are representative of the investment qualities of the stock. There are other biases that will be addressed in a future article, but for now ponder whether you are applying any of these in the current market situation. We will also discuss how to release your emotional brakes and move on to more rational investment decision making. If you would like to discuss this, or any other matter relating to your personal finances, give us a call or send and email. It is always good to hear from readers. Scott Neal is president of D. Scott Neal, Inc., a fee-only financial planning and investment advisory firm with offices in Lexington and Louisville. Comments and questions are welcome at 800-344-9098 or scott@dsneal.com. ◆ ISSUE#94 7


COVER STORY

The

Road

This fall Cassis Dermatology & Aesthetics Center is expanding by adding a second physician and a nurse practitioner, as well as opening a second location.

Less Traveled

CASSIS DERMATOLOGY & AESTHETICS CENTER FORGES ITS OWN PATH TO GROWING A SUCCESSFUL INDEPENDENT PRACTICE BY JENNIFER S. NEWTON PROSPECT “Two roads diverged in a wood, and I, I took the one less traveled by, And that has made all the difference.” Who among us didn’t memorize these iconic lines from Robert Frost’s poem “The Road Not Taken” at some point in school? Today in healthcare there is no yellow-brick road, no golden ticket, no one path to success, and there are certainly more than two ways to build an effective practice. But, take Frost’s metaphor of the two paths and consider the trend of hospital-employed physicians vs. the increasing rarity of the independent practice. Even rarer, perhaps, is the independent practice that is not only thriving but expanding. That is exactly what Cassis Dermatology & Aesthetics is accomplishing – a successful independent practice that is growing in patient volume, providers, physical space, and services. To that end, Tami B. Cassis, MD, FAAD, dermatologist and owner of Cassis Dermatology & Aesthetics, has had to follow several paths less traveled and at times forge her own. Eight years ago, Cassis opened her solo practice in Prospect, Ky., which at the time had relatively few medical practices. This fall, she is welcoming her fourth and fifth provider to an office that is 100 percent female-owned and operated, and she will be opening a second location in an area of town that has been vacated by many dermatology practices. 8 MD-UPDATE

PHOTOS COURTESY OF CASSIS DERMATOLOGY & AESTHETICS CENTER

Minda Sermersheim, BSN, RN, performs Intense Pulse Light laser treatment on a patient to reduce redness and dark spots.


The Perfect Storm

she says, “I felt like if I couldn’t beat them, I’d have to give them an In 2010, Cassis was appointed to the Kentucky Board of Medical alternative. If people still want a tan, I’d do it the safe natural way.” Licensure Physician Assistants (PA) Board. She had no exposure The addition of two PAs gave Cassis the ability to expand medito PAs and frankly thought she was the wrong person for the job. cal services as well, to include photodynamic therapy (PDT) and But she persevered and gained an understanding of how PAs can patch testing. fit into the practice model. She describes the timing as “the perfect storm,” saying, “I had The Cassis come to the point in my practice where I Practice Model was saturated. I had a year-plus waiting list.” In Cassis’ model, physician extendCassis was seeing 50 to 60 patients a day and ers only care for medical dermatolwas also preparing to implement electronic ogy patients. The PAs have taken medical records (EMR), a process she knew on most of the acute dermatology would slow her down. “I knew something patients, allowing Cassis to focus had to give. I really felt that a PA would be a on her passion for skin cancer pregreat addition,” she says. vention and treatment, as well as Louisville in general has been slow to cosmetic treatments. “I take cosfollow the physician extender trend, particumetics very seriously, and I feel like larly where PAs are concerned. “I didn’t have I did above and beyond training a model to follow,” says Cassis. “I did what to do that. I wasn’t bringing on made sense to me. Whether I was right or extenders just to dump off Botox wrong, I was going to go for it.” to make money. I was bringing on In 2012, Cassis got a fortuitous letextenders to provide patient serter from PA student Heather Hill, who vices, get people in at a much faster was looking to do her elective rotation in rate, and take quality care of them, dermatology. After the five-week rotation, and it worked,” she says. Cassis hired Hill as her first PA. Hill quickly Both Heather Hill, PA-C, and became busy and a year and a half later, Katie Bickel, PA-C, bought into Cassis brought on a second PA, Katie Bickel. her philosophy and bring a wellABOVE Dr. Tami With the three working full-time, they were rounded internal medicine backCassis, FAAD, says soon running out of clinic space. ground to the practice. she didn’t add “I decided at that point to comAfter obtaining her BS in physician extenders to her practice to pletely build out the other side of Chemistry at the University of make money on the building,” says Cassis of her Louisville, Hill spent five years workcosmetic services but office space in the Norton Commons ing as an ophthalmology technician, "to provide patient development off Chamberlain Lane. before deciding to attend PA school. services, get people in The expansion opened in March She received a Master’s of Science at a much faster rate, 2014, doubling the square footage degree in Physician Assistant Studies and take quality care of the practice to 7,500 square feet. from South University in of them." With more space, came more Savannah, Ga. opportunity. “It allowed us to For the first three expand even faster than I thought,” months on the job, Hill says Cassis. The practice provides shadowed Cassis. “So I a full range of medical, surgical, saw how she did her skin and cosmetic services, includchecks, how she did her ing: CoolSculpting® to freeze fat, biopsies, how she’d treat Endermologie for cellulite reduccertain rashes. When I tion, Botox, fillers, facials, laser hair started seeing patients removal, non-ablative laser skin ABOVE Katie Bickel, PA-C, joined on my own, I mimicked resurfacing, and laser treatment of Cassis Dermatology in 2013 and that,” she says. leg veins. The expansion has allowed says her experience in internal Hill also says the the practice to grow to three estheti- medicine helps her understand broad education PA cians and add a dedicated organic the whole patient. training provides is spray tan room. Acknowledging she RIGHT Heather Hill, PA-C, did advantageous in her got strange looks from her male archi- an elective rotation with Cassis daily practice. “You Dermatology before joining tect, contractor, and designer when have to know about the practice in 2012 as its first she insisted on the spray tan room, physician assistant. [patients’] medicines and ISSUE#94 9


COVER STORY

know what puts them at risk for their LEFT Licensed skin,” she says. esthetician Angie Hill’s practice favors acute der- Dickhaut performs a matology, and she estimates her deep cleansing facial patient population is 10 percent on a patient. children, 40 percent teens, and 50 percent adults. Cassis says both her PAs are excellent with children and have allowed her practice to grow that patient population. Bickel was interested in dermatology from a young age. Pre-med at Wake Forest University, Bickel intended to go to medical school but instead decided to follow the advice of mid-levels providers she encountered while shadowing who recommended the PA path because the lifestyle allowed you to be a medical provider and have a family. Coming from school in North Carolina, which Bickel describes as “a very PA-friendly state,” she has seen the contrast in Kentucky. However, she says attitudes and acceptance have already changed for the better in the three years she’s been practicing her. “I have no regrets. I’m thrilled with the Laura Stothard, RN, RN, became the chief has worked her way way the profession is going,” she says. operating officer (COO) Bickel attended PA school at the up in the practice of Cassis Dermatology from the front desk University of Kentucky and worked in March 2015, but she to nurse and COO. as a nursing assistant in a dermatoldidn’t start there. Stothard ogy office through school. She worked a year joined the practice seven years ago at the in internal medicine before joining Cassis front desk. When she decided to attend Dermatology at the end of 2013. “The skin nursing school, Cassis accommodated her reflects everything that’s going on in the entire schedule. Stothard says, “I feel like it helps body. Having the understanding of internal you in this position (COO) when you know medicine and getting to do that for whole how to do the other positions.” Stothard year really helps me understand skin processes still works in the clinic as a nurse but as and the patient as a whole,” says Bickel. COO also handles scheduling, marketing, Bickel sees 30 patients a day and credentialing, the opening of the new office, estimates her practice is about one-third and hiring. full body screenings and the rest acute Sydney Newton, APRN, who will join dermatology. the practice in October, was Cassis’ first A key aspect of Cassis’ formula is nurse out of residency. “Sydney’s been with promoting from within. Laura Stothard, me since I started, so she’s really trained 10 MD-UPDATE

dermatology-wise above and beyond,” says Cassis. Newton will function just like the PAs in Cassis’ office seeing medical dermatology patients. Andrea S. Burch, MD, FAAD, will join Cassis Dermatology in September as its second physician. She and Cassis went to medical school together. Burch also has her own dermatopathology business.

Patient Experience and Access

The practice’s philosophy is simple. “It’s always about patient care. We are focused on making sure patients have a good experience from the time they call in to schedule to the time they walk out the door, and everything in between,” says Stothard. For Cassis Dermatology, the “team” is not just the medical providers but everyone from the front desk on up. “We have excellent providers, a great front office staff, and nurses who go above and beyond,” says Stothard. Cassis says she never sat out to create an all-female practice environment. It just happened organically. “We have a great practice. Our dynamic just works. We have about 25 women and we all get along and we all support each other. It’s an environment of trying to bring everybody else up,” says Bickel. The practice’s second location is set to open in October at Norton Audubon Hospital with Newton there two days a week. The area once plush with providers is now slightly underserved as dermatologists have flocked to Louisville’s east end over the last several years. “We’re going to take it slow, and see how it evolves,” says Cassis. “It’s all about patient access.” Today the practice is seeing 425-450 patients a week with three providers and expects that number to grow with the start of Burch and Newton. “Now we have patient access for anything,” says Cassis. “I love that. I really feel like I’m doing the right thing.” As Frost wrote, the path less traveled has made all the difference. ◆


SPECIAL SECTION  PLASTICS / ORTHOPEDICS

Hand Surgery in the Digital Age

Enhancing the patient experience through technology BY SARAH WILDER The technological advances made throughout the past decade that we now enjoy in our day-to-day lives have been nothing short of amazing. The same can be said for the medical field, especially with regard to orthopedic surgery. Technological advances such as small joint arthroscopy, bone/suture anchors, and low-profile implants allow for more minimally-invasive procedures that in turn result in a quicker and more predictable return of function following surgical procedures. “For example, 30 years ago, patients were admitted to the hospital the night before and after a carpal tunnel release. Today, this same routine has become a short, outpatient procedure. In addition, new developments, such as endoscopic carpal tunnel release, offer the potential advantage of a faster return to normal activity and work,” says Brandon Devers, MD, orthopedic hand surgeon and Lexington Clinic’s newest physician. “Advances in arthroscopic equipment and bone/suture anchors now allow for arthroscopic treatment of several wrist, elbow, and small joint conditions using minimally-invasive techniques. More low-profile plate and screw configurations now enable us to better stabilize hand fractures while minimizing damage to the surrounding soft tissues. This in turn allows us to be more aggressive with patient rehab in order to avoid adhesion formation and subsequent post-operative stiffness, which is a hand surgeon’s worst enemy.” Advancements have not been limited to surgical procedures, but extend to nonoperative medical management as well. For example, collagenase injections now allow surgeons to inject Dupuytren’s cords within the hand and fingers and perform in-office manipulations to break these cords and straighten the previously flexed digits. This offers the potential to avoid a large open surgical procedure that can result in significant scar formation. Devers, who joins Lexington Clinic Orthopedics – Sports Medicine Center and specializes in hand surgery, completed fellowship training in orthopedic surgery of the hand and upper extremity at the LEXINGTON

Dr. Brandon Devers, Lexington Clinic hand surgeon, uses his experience with modern technology to provide the most comprehensive care for his patients utilizing treatments such as endoscopic carpal tunnel release, arthroscopy, and lowprofile fracture fixation.

University of Cincinnati, a residency in orthopedic surgery at Vanderbilt University Medical Center, and received his medical degree from Baylor College of Medicine. He says he is fortunate to have received this training and education during a time period of exponential growth in medical technology and development and plans to use this

training and experience to offer patients the most up-to-date treatment measures for hand and upper extremity conditions. “Not only have I had the good fortune to receive my training during a time period marked by incredible growth and development in medical practice and technology, but I have also had the privilege of training under incredible surgeons and mentors at both Vanderbilt and Cincinnati. I am extremely humbled by the opportunity I had to complete my hand surgery fellowship under the guidance of world renowned orthopedic hand surgeon Dr. Peter Stern. I look forward to integrating all that he and

PHOTO BY STEPHANIE NORTHERN, LEXINGTON CLINIC.

ISSUE#94 11


SPECIAL SECTION  PLASTICS / ORTHOPEDICS many others have taught me over the years and using my experience with modern medical technology to provide the most comprehensive care for my patients as possible,” says Devers. “My goal is to get the patient back to their pre-injury activity level and work, while minimizing post-operative pain and complications. I believe that utilizing treatments such as endoscopic carpal tunnel release, arthroscopy, and low-profile fracture fixation will help me towards this end.” However, it is necessary that physicians be cautious about embracing new technological advancements at the expense of abandoning established practices and procedures that have a proven track record with regard to patient outcome. At Lexington Clinic Hand Surgery the providers, Devers, along with Stephen C. Umansky, MD, and Michelle Derbin, PA-C, work to not only treat patients with the most up-to-date technology available, but also streamline and standardize all procedures, from the most complex of surgeries to daily office routines. “It is imperative to make well-informed

12 MD-UPDATE

decisions based upon the evidence-based medicine available in the literature, and in turn relay that information to the patient. To that end, it is important to involve the patient in their medical decision making. I believe that it is my job to explain the various options available for the care of a specific condition, including the risk and benefits of each potential treatment course, and then to help patients make the decision that is right for them based upon this information,” says Devers. “I am excited to work alongside Dr. Umansky and Michelle and continue to grow the orthopedic hand practice, as well as manage a variety of conditions, regardless of their complexity. I am

PHOTO BY STEPHANIE NORTHERN, LEXINGTON CLINIC.

The hand surgery providers at Lexington Clinic, Dr. Brandon Devers, Michelle Durbin, PA-C, and Dr. Stephen Umansky treat patients with the most up-to-date technology available and work to streamline and standardize all procedures.

proud to be a part of this practice, and in turn, the well-respected Lexington Clinic Orthopedics – Sports Medicine Center, which has established a tradition of excellence within the community it serves.” ◆


SPECIAL SECTION  PLASTICS / ORTHOPEDICS

More Than Skin Deep

Dr. David Kirn explains the deeper impact of plastic surgery BY JIM KELSEY Self image, like chronic pain, is felt, not seen. Poor self image and low self esteem that are debilitating can sometimes be reversed by a skillful and intuitive plastic surgeon. As a plastic surgeon, David S. Kirn, MD, FACS, knows that there is more to cosmetic surgery than meets the eye. At his Lexington-based practice, Kirn sees many patients for whom cosmetic procedures mean so much more. “What people who only see us on the outside don’t understand is that the cosmetic patient experience can be very powerful,” Kirn says. “There are applications that are absolutely life transforming. It may not make patients live any longer, but it certainly can make them live happier.” Kirn grew up in Pikeville, Ky., and the couple next door happened to both be physicians, piquing his interest at an early age. He graduated from the University of Kentucky (UK) with a degree in physics and then attended the UK College of Medicine. He worked as a computer programmer for the division of plastic surgery between his second and third years of medical school. He quickly fell in love with plastic surgery and ultimately accepted a position with the aesthetic surgery practice of William Dowden Jr., MD, FACS, in Lexington. The two practiced together for 13 years before Kirn started his own practice in 2011. The majority of Kirn’s current practice involves surgeries, but he also performs injections and laser treatments and works with the Aesthetic Skin Care Center, in the same building. He estimates that half of his LEXINGTON

"The cosmetic patient experience can be very powerful, absolutely life transforming," says Dr. David S. Kirn, FACS.

that 90 percent of his patients are female but says cosmetic surgery is becoming more common in males. The most common procedures men seek out are for their eyelids or necks. “For career reasons, many individuals want to look youthful,” Kirn says. One of the challenges in meeting patient expectations is determining the best meth-

The thought of Botox in the late 90s was counterintuitive. You’re telling me I’m going to paralyze muscles … on purpose? practice is facial surgery and the other half is a mixture of breast and body contouring. Kirn serves as the medical director of the Lexington Surgery Center, is certified by the American Board of Plastic Surgery, and is a member of the American Society for Aesthetic Plastic Surgery. He estimates

od of treatment. With a large spectrum of options and new treatments emerging almost daily, there is not always a clear choice. Kirn says his patients tend to be well-educated and well-informed about their options before they arrive for a consultation. “Our patients are really smart,” says Kirn.

“A great example is Botox in the late 90s. A patient brought me an article about it and it was counterintuitive. You’re telling me I’m going to paralyze muscles … on purpose? But we got a vial, and it was miraculous. So we were doing Botox years before it started becoming very popular.” Cryolipolysis is a newcomer generating a lot of buzz. The fatfreezing procedure is being marketed as a non-surgical way to get the results you want, but Kirn warns that even if it works, it might not be the best solution. “It probably does work,” he says. “I saw a report that indicated a result of about a 40cc of fat per area reduction in each zone of treatment with the cryolipolysis system. But if you were doing that area with liposuction, you would have probably taken 400 cc’s out. So does it work? Yes. Is it genuinely effective and will it make you a happy patient? Maybe not.” A more impactful, recent addition is Exparel, a long-acting numbing medicine used on breast augments and tummy tucks. The numbing effect lasts about 72 hours, reducing the amount of narcotic pain medication that Kirn’s patients need during their recovery. Also new is Kybella, a fat-dissolving treatment used to eliminate double chins. “I’m intrigued by it, and we will stay on top of it to maintain our position on the cutting edge,” Kirn says.

Doctor, Inventor, and Tinkerer

Kirn also stays on the cutting-edge in his machine shop. There, the self-proclaimed PHOTO BY GIL DUNN

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SPECIAL SECTION  PLASTICS / ORTHOPEDICS

“lifelong tinkerer” has invented a number of medically-related items, including arm rest boards for operating room tables and a skin cooling device for pre-injection cooling. Kirn proudly claims that his most successful product is a bridle system to hold feeding tubes in place. Kirn developed the AMT Bridle™ over a decade ago after being inspired by a patient who came to him after being injured by an improperly taped feeding tube. Kirn’s bridle holds the feeding tube in place with magnets instead of taping it on the nose. He stresses that his inventions are completely separate from his practice. Any testing is done adhering strictly to the highly regulated standards for medical devices. High standards drive Kirn’s practice as well. He strives to reduce appointment wait-time without sacrificing the time it takes to understand a patient’s desired outcomes, explain their options and select the optimal treatment plan.

Board Certified Plastic Surgeon devoted to advanced techniques in cosmetic surgery of the face, breast, and body Dr. David Kirn evaluates a patient’s face. "I absolutely refuse to cut corners in the consult time," he says.

“I absolutely refuse to cut corners in the consult time to increase work flow,” Kirn says. “It’s that relationship with the patient that matters. Each surgery is very customized to the patient.” And just might help them live happier. ◆

DAVID S. KIRN, MD, FACS 2376 Alexandria Drive Lexington KY 40504-3229 859.296.3195 www.kirnplasticsurgery.com

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PHOTO BY LESLIE TRAPP

THIS IS AN ADVERTISEMENT


8 YEARS STRONG & GROWING

SPECIALIZING IN MEDICAL, SURGICAL AND COSMETIC DERMATOLOGY

CASSIS DERMATOLOGY & AESTHETICS CENTER WOULD LIKE TO WELCOME TWO NEW PROVIDERS:

Andrea S. Burch, MD, FAAD

Sydney Newton, APRN

ALL PROVIDERS ACCEPTING NEW PATIENTS

Tami Buss Cassis, MD, FAAD Andrea S. Burch, MD, FAAD Heather Hill, Certified Physician Assistant Katie Bickel, Certified Physician Assistant Sydney Newton, Nurse Practitioner

Norton Commons 9301 Dayflower Street, Suite 100 Prospect, KY 40059 502.326.8588 www.cassisderm.com

ISSUE#94 15


SPECIAL SECTION  GASTOENTEROLOGY

Modern Day Gastroenterology

Treating GI diseases that are on the rise BY SARAH WILDER LEXINGTON Lexington Clinic Gastroenterology

treats a wide variety of gastrointestinal (GI) issues. In recent years, two of the most common conditions treated are celiac disease and hepatitis C. “While we do see patients with varying conditions in our office each day, we are beginning to see a rise in patients we treat with these two modern-day GI issues,” said An-Yu Chen, MD, head of Lexington Clinic Gastroenterology. “Both hepatitis C and celiac disease are highly relevant in today’s society. With hepatitis C, we are seeing a large number of baby-boomers, a generation with a high population of hepatitis C positive patients, come forward for screening or treatment of this disease. With celiac disease, this condition has become four times more common than it was 50 years ago, and we are seeing a reflection of this in our number of patients treated for it in our office.” Both of these rising diseases, while dangerous to a patient, are manageable through proper treatment and consultation with a specialist. In fact, hepatitis C can now even be cured if caught in time. That is why Lexington Clinic gastroenterologists recommend early screening for these diseases among at-risk patients. Hepatitis C is a blood-borne disease that attacks a patient’s liver. With more than 2.7 million people infected in the U.S., it is the leading cause of cirrhosis, liver cancer, and liver transplantation. It is spread through contact with blood from an infected person, meaning you are at risk only if you have come into contact, in some way, with the blood of someone positive for hepatitis C (shared needles, accidents at healthcare facilities, tainted blood transfusions). For this reason, hepatitis C once carried a negative stigma in society. This should not be the case, given how common hepatitis C really is, particularly among the babyboomer generation. Once contracted, it can take years for symptoms to show up, often in the late stages of the disease. However, with recent developments in treatment, new options have arisen; options 16 MD-UPDATE

Dr. An-Yu Chen, head of Lexington Clinic Gastroenterology, says two diseases, hepatitis C and celiac disease, are modernday GI issues treated by Lexington Clinic Gastroenterology.

that offer patients a 93-100 percent chance to be cured and little to no chance of relapse. And with cases of hepatitis C on the rise, this effective treatment is just in time for thousands of patients who are diagnosed with the disease. “Up until last fall, hepatitis C was treated with interferon, which is much like chemotherapy, and this treatment was only about 35 percent effective in actual cases. Even when the treatment did work, the possible side effects were severe, as severe as suicide in some instances. Additionally, there was a high relapse rate among patients who received this treatment. But with new treatment options, all that has changed,” said Chen, who along with other Lexington Clinic gastroenterologists Scott A. Merkley, MD, and Matthew D. Ashmun, MD, are the leading providers of chronic hepatitis C care in Central Kentucky. The new treatments, direct-acting anti-

PHOTOS BY STEPHANIE NORTHERN, LEXINGTON CLINIC

virals taken orally, are extremely safe for patients. They have very few interactions with other medications and effectively cure this disease. This gives hepatitis C patients a chance to continue on with their lives in a way they may have been unable to before. Unlike hepatitis C, a cure for celiac disease does not exist. However, it can still be managed. “Celiac disease, an immune reaction experienced by a patient with sensitivity who has eaten gluten, produces inflammation within the small intestine, which can cause unexpected weight loss, bloating, and sometimes diarrhea,” said Ashmun. “If left untreated, the condition will in effect deprive a patient’s vital organs, including the brain, nervous system, bones, and liver, of vital nourishment.” However, like hepatitis C, the signs and symptoms of celiac disease are sometimes difficult to see. The two most common symptoms, diarrhea and weight loss, are only present in one-third and half of those


diagnosed, respectively. Additionally, only 20 percent of patients exhibit constipation, and only 10 percent are obese. Since it is so difficult to detect through physical symptoms, gastroenterologists recommend testing for the disease, usually through blood tests or endoscopies. “Once a diagnosis is confirmed, we can work with patients to help them manage this disease through a gluten-free and wheat-free diet,” said Merkley. “Additionally, we may recommend vitamin and mineral supplements, and in some cases, medications to control the inflammation of the intestine.” As both of these diseases continue to increase in today’s society, Lexington Clinic Gastroenterology continues to treat them. Chen, Ashmun, and Merkley, along with James B. Hunter, MD, work with each

patient they see who may have either of these diseases to find a treatment that works for them. “Both hepatitis C and celiac disease are conditions that can be managed, and in the case of hepatitis C, cured,” said Chen. “We work with each of these patients to find the treatment plan that works best for them, and help them get back the quality of life they deserve.” ◆

The Lexington Clinic Gastroenterologists, Dr. Scott A. Merkley, Dr. James B. Hunter, Dr. An-Yu Chen, and Dr. Matthew D. Ashmun, work with each patient to find the treatment plan that works best and helps get the patient back to the quality of life they deserve.

ISSUE#94 17


SPECIAL SECTION  GASTOENTEROLOGY

Subspecializing in a General GI Practice

Two physicians at Baptist Health Medical Group Gastroenterology augment general gastroenterology with subspecialty techniques bringing advanced technology to patients BY JENNIFER S. NEWTON In many internal medicinebased specialty practices today, providers seem to follow one of two approaches: either the generalist, who sees anything and everything, or the subspecialist, who finds a niche and perfects treatment in that area. But Baptist Health Medical Group Gastroenterology has managed to straddle the line between generalist and subspecialist. Of its six physicians, all of them treat general gastroenterology and hepatology patients, but its two newest providers, Mitchell Kaplan, MD, and Brian Beauerle, MD, also subspecialize, having pursued additional training in specific techniques. LOUISVILLE

ERCP - An Exponential Increase in Accuracy

Mitchell Kaplan, MD, spent nine years practicing gastroenterology in New York until 9/11/2001, where his commute to work from New Jersey became impossible. He came to Louisville with the help of headhunters and has been practicing in Kentucky for 13 years now, the last two with Baptist Baptist Health Medical Group Gastroenterology. Kaplan’s specialty is endoscopic retrograde cholangiopancreatography (ERCP), a technique that traditionally combines upper gastrointestinal (GI) endoscopy with x-ray to diagnose and treat problems of the bile ducts and pancreas. “When I started training in 1992, most of the scopes we used were fiber-optic, basically glass fiber cables that ran through the scope and allowed you to look through a lens on one end and see an image out the other side,” says Kaplan, who describes the images as dotted, like old Impressionist paintings. “It was very fragile, very thin, and very limited imaging.” However, Baptist Health Louisville is the only hospital in the region that has acquired a limited release of Boston Scientific’s new 18 MD-UPDATE

PHOTOS COURTESY OF BAPTIST HEALTH

SpyGlass™ DS Direct Visualization System. “We are one of 20 centers in the nation that got in on a new therapeutic update that isn’t available for another year. It’s kind of a scope within a scope system. It allows us to see inside the liver ducts with the camera itself instead of using x-ray, which we use

because we can actually see inside the liver while we’re doing it, we can direct the biopsy to the growth. Now it’s closer to 95 percent accurate,” says Kaplan. ERCP is indicated for therapeutic interventions of gallstones in liver ducts, liver duct and pancreatic tumors, inflammatory strictures, and narrowings of the liver duct LEFT Dr. Mitchell Kaplan is a general gastroenterologist who and pancreas. also specializes in hemorrhoids, Another endoscophepatitis C, and ERCP. ic technology Kaplan utilizes is the Barrx™ BELOW Dr. Brian Beauerle joined RF Ablation System Baptist Health Medical Group (formerly known as Gastroenterology in August 2015 to HALO) to remove build the hospital’s EUS program. precancerous tissue in reflux patients with Barrett’s esophagus. “Previous to this technology, we did upper endoscopies every two years in these patients, and any microscopic cancer seen on biopsy would require the removal of the diseased esophagus. Now we destroy the abnormal tissue preventing the cancer from forming,” he says.

for typical ERCP,” says Kaplan. X-ray imaging limits the efficacy of traditional ERCP because it provides two-dimensional images of three-dimensional structures, as evidenced by an accuracy rate of only 20-30 percent. The latest incarnation is digital. “You have a computer chip now on the end of a soft plastic scope that can actually be passed through a regular scope to look up into the liver duct with crystal clear, large imaging. It allows us to remove much bigger stones,” he says. It can also be used to biopsy abnormal tissues and evaluate strictures. Advanced imaging translates to more efficient diagnosis and treatment. “Now,

EUS - Taking GI to New Levels

Brian Beauerle, MD, is the newest addition to Baptist Health Medical Group Gastroenterology. Fresh out of a three-year gastroenterology fellowship at the University of Louisville (UofL), Beauerle joined the practice at the beginning of August 2015. A Louisville native who attended Louisville Male High School, Bellarmine University, and UofL, Beauerle’s path to gastroenterology took a fortuitous detour at the end of his chief residency year at UofL


when his wife took a two-year secondment in the United Kingdom for Yum! Brands. The couple packed up their two children and moved to Richmond, London. At the time, Beauerle was trying to decide between internal medicine and becoming a hospitalist. He worked briefly with the National Health Service (NHS) before accepting a gastroenterology position at the Royal Surrey County Hospital in Guildford, England. “I developed a passion for what I was doing and wanted to come back to the US and do it,” says Beauerle. “It was a great experience working over there and working in the socialized healthcare system, just getting a different perspective for medicine.” Back in Louisville, Beauerle spent the third year of his fellowship training in endoscopic ultrasound (EUS). Part of the draw of practicing with Baptist Health Medical Group Gastroenterology was the opportunity to start an EUS program. Baptist Health Louisville recently acquired the equipment and did its first case in mid-August. EUS is a form of flexible endoscopy combined with ultrasonography. “We’re able to not only look at the surface of the GI tract like we do with flexible endoscopy, but with the ultrasound component, we are able to visualize the deeper wall layers of the GI tract,” says Beauerle. The technique allows for fine needle aspiration (FNA) of structures within or outside the GI tract. Pancreatic masses may be the most common referral for EUS. Cancer staging is another indication. While not good at assessing metastatic disease, it is good at evaluating tumor depth and local and regional lymph nodes. “We are able to see the depth of invasion into the wall layers of the esophagus or the stomach or vascular invasion if we’re looking at a pancreatic mass,” he says. EUS is also used to diagnose chronic pancreatitis in patients with chronic abdominal pain.

A Virus with a Cure

Both physicians agree the hottest topic in GI right now is the revolution in oral medications for hepatitis C over the last year. According to Kaplan, “I finished training in 1994. When I started, the chance of curing hepatitis C was less than 20 percent.” Beauerle adds, “Five years ago we were using a combination of two medications that were

relatively toxic to the patient, required almost a year of therapy, and at the end of that year, there was only upwards of a 60 percent chance at best that it cleared the virus.” Today the course of therapy is as short as eight to 12 weeks in some cases, and efficacy is 90 percent-plus. “A 96-98 percent cure rate is kind of remarkable. It’s one of the only viruses we can actually cure,” concludes Kaplan. ◆

Baptist Health Medical Group Gastroenterology 3950 Kresge Way, Suite 207 Louisville, KY 40207 Phone: 502.893.0220

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The LINX Reflux Management System is indicated for those patients diagnosed with Gastroesophageal Reflux Disease (GERD) as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximum medical therapy for the treatment of reflux. Caution: Federal law (USA) restricts these devices to sale by or on the order of a physician. Contraindications: Do not implant the LINX System in patients with suspected or known allergies to titanium, stainless steel, nickel or ferrous materials. Warnings: The LINX device is considered MR Conditional in a magnetic resonance imaging (MRI) system up to 0.7-Tesla (0.7T). Laparoscopic placement of the LINX device is major surgery. General Precautions: The LINX device is a long-term implant for use in patients 21 years or older. Medical management of adverse reactions may include explantation and/or replacement. Potential Risks Associated with LINX System: dysphagia, stomach bloating, nausea, odynophagia, increased belching, decreased appetite, inability to belch or vomit, flatulence, early satiety, device erosion, device migration, infection, pain, and worsening of preoperative symptoms. For more information on the LINX Reflux Management System, contact your physician or Torax Medical, Inc. For full patient information visit www. linxforlife.com or www.toraxmedical.com.

8/25/15 11:36 AM ISSUE#94 19


SPECIAL SECTION  GASTOENTEROLOGY

Much More Than Just the Standard Care

Jason P. Harris, MD, FACS, helps Bluegrass Surgery and Gastroenterology Associates expand its services BY MELISSA ZOELLER As the only surgeon in Kentucky certified to perform the state-of-the-art LINX® procedure, Jason P. Harris, MD, FACS, knows how important it is to offer his patients cutting-edge treatments and advancements – treatments that lead to a quality of life that once was not available. LINX, a Torax Medical product, is a band of rare earth magnets placed around the base of the esophagus to restore the body’s natural barrier to reflux, bringing much needed long-term relief to GERD (gastroesophageal reflux disease) sufferers for whom conventional medications have not helped. Harris����������������������������������� ’ first ��������������������������������� successful surgery was performed June 2014 at Saint Joseph Hospital in Lexington and established LINX as an option for GERD patients in the region. (See MD-UPDATE #85 (April 2014), pg. 21, for more discussion of LINX.) His second surgery was just successfully completed this past June. “Each patient is doing wonderfully. The first patient is now over a year out from her operation and the second is now about 10 weeks post-op. They were prepared in advance for the expected, early, and transient dysphagia that is customary with the procedure,” says Harris. “They are now off their reflux medication, can sleep lying flat, eat whatever they like, and no longer wake up in the middle of the night with regurgitation.” Although there are a number of exclusions that limit qualified patients, demand is growing and insurance carriers are slowly beginning to cover the procedure. LEXINGTON

Dr. Jason Harris, general surgeon with Bluegrass Surgery and Gastorenterology Associates, enjoys bringing advanced treatments, such as the LINX procedure for intractable GERD, to patients in Kentucky.

Gastroenterology is a completely independent practice that has recently doubled in size, adding three new gastroenterologists to their staff. Currently the practice includes the newly added gastroenterologists Albert

Saint Joseph Hospital’s robotic program will allow us to offer additional robotic techniques that have not been available previously, such as single-site gallbladder and colon surgery. And LINX is just the beginning for Harris. His main goal is to continue to offer his patients at Bluegrass Surgery and Gastroenterology the most advanced procedures to treat their ailments. Previously known as the Bluegrass Surgical Group, Bluegrass Surgery and 20 MD-UPDATE

Castellanos, MD, James Pezzi, MD, and Amy Tiu, MD, as well as surgeons John Harris, MD, and Ross Tekulve, MD. “It’s been a blessing to have three other physicians in the practice that have a common mindset about patient care and quality, and it provides us the opportunity to offer

something we wouldn’t have been able to before. It’s been a very good transition thus far,” added Harris. Along with the LINX procedure, the practice provides the full gambit of general surgery offerings. Procedures as simple as abscess drainage and breast biopsies to complex, advanced laparoscopic and robotic operations on the foregut and hindgut. “I use robotics currently on select general surgery cases, but I’m hopeful that Saint Joseph Hospital’s robotic program and their plans for a hardware upgrade will allow us to offer additional robotic techniques that have not been available previously,” states Harris. “Single-site gallbladder and colon surgery are some of the options that will be available for robotic surgical procedures. We’ll also be adding robotic hernia surgery, which is an up-and-coming technique for more complex hernias.” As an independent practice, Harris and his partners are available to perform surgeries at any hospital at which they hold credentials. “We are happy to be able to accommodate both independent and employed referring physicians when scheduling our procedures. Patient preference is also considered when choosing a hospital. “It takes an additional stress out of an already anxious time.” The practice is proud of their excellent outcomes and continual growth – growth that will keep catapulting them to the forefront of general surgery. Harris concludes, “We are very proud of our experience and the care we’ve been blessed to provide to others over the last thirty years at Bluegrass Surgical. The group is so happy to have added others who share our vision for quality and collectively we’re very excited about the future.” ◆


SPECIAL SECTION  HEMATOLOGY

The Challenges of Aplastic Anemia

Innovative treatments for a rare, complex blood disorder BY JILL DEBOLT Aplastic anemia is a complex, relatively rare disease of the hematopoietic stem cells in the bone marrow, according to Khuda Khan, MD, PhD. Khan came to the United States on a scholarship and received a PhD in immunology from Yale before completing his residency and fellowship at Duke. In his position as a hematology and oncology specialist at KentuckyOne Health in Louisville, he translates his scientific knowledge of the immune system into treatment therapies for complex disorders, such as aplastic anemia. “This is a challenging area in medicine with many new immunotherapies in clinical research and clinical practice,” says Khan, who sees adult patients ages 18 and above.

aplastic anemia, bone marrow activity is less than 25 percent of normal, whereas, leukemia with aplastic presentation shows a high rate of bone marrow activity.”

LOUISVILLE

Supportive Care and Definitive Treatment

Defining Aplastic Anemia

“Aplastic anemia is a misnomer,” says Khan. “It’s really pancytopenia where all three hematopoietic stem cell lines are decreased - red blood cells, white blood cells, and platelets.” According to Khan, it occurs with an incidence of two-to-four cases per million population each year. Severity of aplastic anemia can range from moderate to very severe and can occur throughout the lifespan. He states that moderate aplastic anemia may not require treatment, whereas severe to very severe disease has a mortality rate of 70 percent within one year if not treated. “Patients with a neutrophil count of less than 500 and a platelet count of less than 20,000 require treatment to survive as they are at high risk for overwhelming infections and spontaneous bleeding,” notes Khan. Close to 50 percent of aplastic anemia

Dr. Khuda Khan says hematology "is a challenging area in medicine with many new immunotherapies in clinical research and clinical practice."

to attack the hematopoietic stem cells,” states Khan. He reports that primary care providers are quick to refer to hematology specialists when they see a patient with pancytopenia, but there can be variants that affect only one or two stem cell lines. Khan gives the example of red cell aplasia caused by the par-

Sometimes people think it’s just an anemia, but the prognosis is just as bad as lung cancer. cases are idiopathic, but it can be caused by exposure to certain chemicals, drugs, radiation, infection, and immune disease. “There is a post viral hepatitis aplastic anemia that predominately occurs in young boys. The hepatitis virus triggers the immune system

vovirus, which affects the red cell progenitors in the bone marrow. Those patients present with a decreased red blood cell count, while white blood cell and platelet counts are normal. He emphasizes, “A bone marrow biopsy is necessary for definitive diagnosis. With

Treating this complex syndrome requires a patientspecific approach depending on the severity of the disease and the patient’s age. “When we first see a patient, they often need supportive care, such as blood and platelet transfusions and antibiotics,” Khan states. Patients may present with symptoms of severe anemia, platelet dysfunction, and infections. Supportive care is a shortterm fix as patients develop antibodies to blood transfusions, notes Khan. He adds, “Intravenous access is challenging due to risks of central line placement in patients with decreased platelets and immune function.” Definitive and curative treatment options for the disease are stem cell transplant or immunosuppressive therapy. Says Khan, “Stem cell transplant is used for younger patients with a suitable donor, usually a sibling with the same HLA phenotype. Prognosis is good with a survival rate of 70 percent for patients under age 49 and 60 percent for patients under age 59. Stem cell transplant is not done over age 60 due to the high incidence of graft vs. host disease.” Khan works closely with the bone marrow transplant program at the James Graham Brown Cancer Center, which is jointly operated by KentuckyOne Health and the University of Louisville. “Immunosuppressive therapy is used for older patients and patients with no suitable donor. This is a three-drug combo using horse antithymocyte globulin (ATG), high PHOTO COURTESY OF KENTUCKYONE HEALTH

ISSUE#94 21


SPECIAL SECTION  HEMATOLOGY

dose steroids, and cyclosporine. Horse ATG is developed by injecting human B cells into the horse, which then makes antibodies against the human B cells. These potent drugs, which can have significant side effects, have a response rate of around 60 percent. Survival for elderly patients with aplastic anemia is less than 50 percent usually due to co-morbidities such as hypertension that increase the risk of sequelae such as spontaneous cerebral hemorrhage,” says Khan.

The Psycho-Social Impact

“Aplastic anemia is a chronic disease and treatment can take months. All this takes an emotional toll on patients and families,” notes Khan. Those patients experience fatigue, bruising, and infections and are subjected to frequent medical appointments, blood draws, etc. “Sometimes patients/families think it’s just an anemia, but the progno-

sis is just as bad as lung cancer,” adds Khan. With their permission, Khan will match up patients to provide emotional support for each other. In addition, the Aplastic Anemia and MDS International Foundation or other hematology or oncology support groups can serve as resources for patients and families.

of finding a match for minority patients. Khan says in summary, “Aplastic anemia is a serious condition with effective therapy. There is hope and we continue to make progress.” ◆

New Developments

There are several new developments in the treatment of aplastic anemia. “Improvements in bone marrow transplant include better antifungal medications to treat potentially fatal infections such as Aspergillus,” he states. The new drug Eltrombopag was recently approved by the FDA for nonresponders to immunosuppressive therapy, especially patients with low platelets. Bone marrow donor registries are helping to find donors for patients without a sibling donor, and donor drives are improving the chances

Khuda Khan, MD, PhD Cancer and Blood Specialists 502.361.8496 kentuckyonehealth.org/ cancer care

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2/23/15 8:45 AM


SPECIAL SECTION  VASCULAR

It’s In His Veins

Nick Abedi, MD, never intended to be a surgeon but could not resist its magnetic draw BY JIM KELSEY “Son of surgeon follows in father’s footsteps and becomes a surgeon.” It’s a nice story, but hardly unique. At least not on the surface, but if you go a little deeper, you find that the career path of Nick Abedi, MD, FACS, was anything but predetermined. Abedi grew up Gaithersburg, Md., before moving to West Virginia in sixth grade. At that time, the thought of growing up to be a surgeon could not have been further from his mind. “I remember my dad working awful hours, not being able to see him the majority of the time or on weekends, and I told myself I wasn’t going to do that,” Abedi says. Even when Abedi began studying at the West Virginia University School of Medicine, surgery was still far off his radar. His plan was to be a cardiologist. That’s what his head was telling him, but it turned out that he was a surgeon at heart after all. “Starting medical school, it’s like you turn on a switch and all of a sudden a magnet is drawing you in one direction,” Abedi says. “That’s really what happened to me. I fell in love with anatomy. I fell in love with being able to have instant gratification. To be able to fix problems was a major reward for me.” Abedi was reluctant to embrace his passion for surgery, but Dr. David McFadden, the chair of surgery at WVU School of LEXINGTON

Dr. Nick Abedi, vascular surgeon with KentuckyOne Health Surgery Associates in Lexington, attended medical school with the intent to become anything but a surgeon, but ultimately, he could not avoid the magnetic draw of surgery’s instant gratification.

a couple’s match. Lexington was not a first choice, but they were both invited to interview and decided to give it a try. From the beginning, it was clear that Lexington had

In medical school, it’s like you turn on a switch and all of a sudden a magnet is drawing you in one direction.

Medicine, mentored Abedi and encouraged him to follow his ambitions. Abedi eventually set his reservations about the impact of a surgeon’s lifestyle on family life aside and moved forward toward a career in surgery. Abedi and his wife Courtney MarkhamAbedi, MD, met in medical school and did

something unique to offer. “We stayed at the Hyatt downtown,” Abedi recalls of their first trip to Lexington for his wife’s interview with the Department of Psychiatry at the University of Kentucky College of Medicine. “The first night I was there I got on the elevator and there’s

William Shatner. I said to my wife, ‘Something’s different about this place.’” That carried over to his interview, where Abedi found that most of the existing residents were married with families, a rarity among the places he had interviewed. Lexington became the couple’s first choice, and they came to Lexington in 2002. Abedi intended to specialize in cardiac surgery, but his first rotation was in vascular surgery. “It was before the rules of 80 hours limits,” Abedi recalls. “I was on call every other day. I remember getting up at 4:30 in the morning to start rounds, and I would stay in the hospital every other day. Amazingly, I loved every minute of it.” Abedi, who credits much of his success during his residency to Eric D.  Endean, MD, FACS, went on to perform his vascular fellowship at the University of Kentucky College of Medicine from 2007-09. Later in 2009, he joined KentuckyOne Health Surgery Associates, where he currently practices with seven other physicians. Most of Abedi’s patients have chronic diseases such as COPD, coronary artery disease, hypercholesterolemia, hypertension, and diabetes. Most are over the age of 60, but many are also in their 40s or 50s. “I love these patients because I can drastically improve their lives,” Abedi says. “I can take them from being unable to get out of bed and walk into their kitchen to being able to comfortably walk in a grocery store and take care of themselves.”

Saving Lives and Limbs

One of the emerging changes in endovascular surgery is treatment of ruptured aortic aneurysms. Survival rates of such patients have historically been very low, but Abedi reports that he’s experienced PHOTO BY GIL DUNN ISSUE#94 23


SPECIAL SECTION  VASCULAR

We don’t perform as many amputations now because, with advanced technology, we can open blood vessels that have been blocked for many, many years. – Dr. Nick Abedi great outcomes treating ruptured aneurysms with a stent graft. Abedi also points to progress in the treatment of peripheral vascular diseases as being central to his practice. Frequently, such cases resulted in amputations, but emerging aggressive treatments are changing that outcome for many patients. “We don’t perform as many amputations now because, with advanced technology, we can

open blood vessels that have been blocked for many, many years,” Abedi says, indicating that he performs a quarter of the open bypasses that he did just a few years ago. “That’s been a huge change in how many limbs we are able to save.” Abedi prides himself on taking on the most challenging of cases. “The message I want to share with other physicians is that, if you have a patient that needs another vascular opinion, if they’re at the end of the road, I’d be happy to see them.” Abedi sees KentuckyOne Health Surgery Associates continuing to grow and becoming “a larger, more robust vascular program” in the coming years. His goal is to establish a group of younger physicians who will want to establish roots in the community. Being part of the community and establishing a solid home life is important to Abedi. He never forgot those thoughts he had as a child, wanting to make sure that he would be there for his family. Now, with a wife and three children, Abedi is staying true to his word. “I’m not my father,” he says. “Even though I’m a vascular surgeon and have a very busy practice, I’ve been able to dedicate a lot of my time to my family. I have three very active kids. I spend a lot of time with my kids, and I think I’ve found my calling.” ◆

KentuckyOne Health Surgery Associates KentuckyOne Health Office Park 1401 Harrodsburg Road, Suite C-100 Lexington, KY 40504 P 859.276.1966 KentuckyOneHealth.org 24 MD-UPDATE


COMPLEMENTARY CARE

Focus on Healthy Communities

Interview with David Martorano, President and CEO of the YMCA of Central Kentucky David Martorano, president and CEO of the YMCA of Central Kentucky, has been involved in the YMCA for most of his career, working with the YMCA in major metropolitan areas such as Milwaukee, Detroit, and Cincinnati, before coming to Central Kentucky in January of 2013. He was attracted to Central Kentucky by both the quality of life and the challenge of making an impact on the health of the community. The YMCA of Central Kentucky covers a four-county area including Fayette, Jessamine, Scott, and Franklin counties and serves about 68,000 individuals. Martorano holds a master’s degree in organizational management and leadership from Springfield College. During his spare time he has passion for a healthy lifestyle, Green Bay Packers football, and supporting families who have children with autism. Martorano and his wife Viki have four children.

MD-UPDATE: What is the role of the YMCA in Central Kentucky?

MARTORANO: The YMCA has three areas of

focus, which are: Youth development - youth programs include after-school care, summer camps, and literacy programs. The YMCA follows national standards that include healthy eating and physical activity in youth development programs. Healthy living - focuses on prevention and providing programs and services to help individuals achieve a healthy lifestyle. We try to meet people where they are at, so our staff can help the individual identify goals and achieve them in a supportive environment. Education on physical activity and healthy eating is an important component. Social responsibility - the YMCA is a community in itself. It’s a melting pot where everybody belongs and feels accepted. The YMCA participates in outreach and makes YMCA services available to all, regardless of ability to pay.

What are some of the star

programs offered by YMCA?

The YMCA is so much more than a “gym and swim.” Several of our programs have a major impact on the health of the community, such as : D i a b e t e s Prevention Program - this is modeled on the program developed by the National Institutes of Health (NIH) aimed at preventing onset of type 2 diabetes mellitus (DM). This program was identified as a healthcare need due to the high rate of type 2 DM in Kentucky. Live Strong Program for cancer patients - taught by coaches who have had cancer, this program provides peer support to individuals post-cancer treatment with the goal of reclaiming their health physically, mentally, and spiritually. Silver Sneakers - this program, which provides subsidized membership for seniors through many healthcare plans, offers specialized activities and socialization to maximize the health of our senior population. Several thousand seniors participate. Summer literacy program for youth - aimed at first and second graders who are falling behind in their reading skills, it focuses on narrowing the achievement gap and minimizing summer learning loss. Using certified teachers, it provides literacy skills and enrichment activities with the goal of getting children back on reading level by fourth grade. Education and reading skills tie directly to the health of the individual and the community.

How does the YMCA engage with healthcare providers in the community?

In addition to insurance providers, we partner locally with KentuckyOne Health.

Martorano congratulates a young participant at the annual YMCA Kids Triathlon, at the Carol Martin Gatton Beaumont YMCA in Lexington. LEFT "I encourage healthcare providers to increase their awareness and referral of patients to specialized programs offered by the YMCA," says David Martorano, president and CEO of the YMCA of Central Kentucky. ABOVE

They have space in our Beaumont and North Lexington facilities and have access to our facilities for their clients. There is a trend of more hospitals collaborating with YMCA programs. I encourage healthcare providers to increase their awareness and referral of patients to specialized programs offered by the YMCA. We have the facilities, qualified staff, and a non-intimidating atmosphere. The YMCA also has a role in watching health trends and identifying unfulfilled opportunities in the community. I serve on the Fayette County Board of Health and recognize the need for improvement in health statistics on diabetes, obesity, and heart disease in Kentucky.

What does the future look like for YMCA?

I often ask “What does the future of our services look like?” While I would like for all facilities to be shiny and new, I also recognize a possible role for virtual membership in the YMCA utilizing the latest technology to increase services. Currently, a new YMCA facility is under construction in the Hamburg area of Lexington with an opening in the summer of 2016, and the North Lexington YMCA is under renovation with a completion later this year. I’m excited about the challenges of improving health for central Kentuckians and the role of the YMCA in providing a breadth and depth of programs to meet the needs of our diverse population. ◆ PHOTOS COURTESY OF YMCA OF CENTRAL KY ISSUE#94 25


COMPLEMENTARY CARE

Three Ways to Improve Your Influence with Patients and Caregivers The best way I can describe the emotional tone in the room was “contained and intense,” as I prepared to facilitate a group of caregivers for patients living with aplastic anemia, MDS, PNH, and related bone marrow failure diseases. An hour earlier I had delivered an interactive presentation for patients and caregivers about how to manage their new normal — living with a serious, chronic disease. Now I was preparing to spend two hours dedicated exclusively to caregivers who were seeking emotional support for the extraordinary difficulties and challenges they had faced and would continue to face with their loved ones. Caregivers kept filing into the room, and we had to keep adding chairs. The room got quite warm. I used no audiovisual aids or handouts and focused on just three questions. Two hours later, what struck me most was how nothing had really changed in these people’s situations, and yet somehow, they were changed. I didn’t have to urge anyone to speak.

Some had been waiting years for the opportunity. The questions were simple, but carefully selected:  Do you feel it is best to BY Jan Anderson, PsyD, LPCC hide the scary facts from the patient or do you think it is best to tell the patient everything?  What is the one thing that is most difficult for you right now?  How are you taking care of yourself? There were other questions that would have been just as effective in focusing on caregivers’ emotional and coping issues. More important than the questions and

More important than the questions and how they were phrased was being fully “present” with the people in the room. Since these are rare diseases, this was the first time many of these caregivers had the opportunity to speak to another caregiver.

how they were phrased was being fully “present” with the people in the room. I think of this skill as the ability to simply “be

with” someone as they wrestle with a difficult decision, situation, or emotion, and after all these years, I continue to be in awe of how incredibly helpful it is to another person when we are able to do this for them. In Issue #91 of MD-UPDATE, I shared specific research-based language used by clinicians that has been found to leave patients not just feeling better about visits with their doctors, but actually doing better in managing their type 2 diabetes. What I’m writing about now is how to infuse your questions and information with an appropriate level of emotional connection to maximize your influence with patients and their caregivers. Here are three ways you can start doing this immediately: 1. MAKE EYE CONTACT EASY. Making eye contact is a significant emotional event, so use it as a way to instantly connect with another person. One of the easiest ways to use eye contact to make an appropriate level of emotional connection with another person is to simply notice the color of the person’s eyes. 2. IT’S BETTER TO RECEIVE THAN TO GIVE (AT LEAST AT FIRST). Seek out someone that is good at establishing an appropriate degree of emotional connection with you — Someone that pays attention to what you’re saying with a non-judgmental awareness that is friendly,

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curious, and compassionate. Receiving this kind of connection from another — seeing it modeled and feeling the effect it has on you — is often the first step in getting good at giving it to others. 3. CULTIVATE THE ART OF BEING “FULLY PRESENT.” START WITH YOURSELF. If you want to connect better with patients and more effectively influence them as they encounter life-changing diagnoses involving life-long treatment and uncertain outcomes, the second step is (paradoxically) cultivating the art of being fully present with yourself. I hesitate to mention the most powerful way I learned to do this because it’s … meditation. Here’s how I got my Type-A, OCD self to begin a meditation practice: I started with what I referred to as my “mocha

meditations”: Every morning I wrapped myself in a blanket and sat on my couch for 10 to 20 minutes in silence as I sipped a cup of coffee and watched my breath go in and out. On days that didn’t work out, I did yoga vinyasa (a form of “moving meditation”). Other alternatives to consider are tai chi, therapeutic journaling, or voice dialogue facilitation. Please contact me if you want more information about any of these alternatives. The idea is to just start somewhere and find what works for you. We may not be able to fix or change things for our patients or their caregivers, but when we’re fully present, we somehow help them deal with things that can’t be fixed or changed. When we��������������� ’�������������� re fully present with another human being, we provide them a container that helps them hold their experience without being shattered by it. ◆

Issue #95 October – SURVIVING CANCER, Oncology, Radiology, Imaging / Hospice, Home Health Issue #96 November – IT’S ALL IN YOUR HEAD, Neurology, ENT, Pain Medicine / Mental Health, Smoking Cessation Issue #97 December/January 2016 PREVENTION AND SENIOR HEALTH, Internal Medicine (including Hospitalists and Concierge Medicine), Family Medicine & Geriatrics, Ophthalmology / Physician Extenders, Residential Care *EDITORIAL TOPICS ARE SUBJECT TO CHANGE.

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ISSUE#94 27


COMPLEMENTARY CARE

Knowing More than Just Where Your Food Comes From!

Pesticides are killing honey bees. If they kill bees, what are they doing to humans? BY MAC STONE A family friend and regular customer, who is also a food intellectual, stopped by our farmer’s market booth recently to talk about some funny answers to her question, “Has this been sprayed?” That conversation leads to the low-down on pesticide use on, or in, non-organic produce. According to the UK College of Agriculture, there are 49 insecticides and 40 fungicides approved for use on cucurbits (e.g. cucumbers, squash, melons). Extensive research verifies their effectiveness and specific regimens are recommended for commercial growers to follow. Typically, the fungicides are sprayed weekly, or more often in rainy weather, to provide prophylactic protection from plant diseases. Insecticide use follows the seasonal pattern of each insect species as they multiply and mature during the growing season. Each of these highly toxic chemical compounds comes with numerous label warnings.

facturer can say it is gone. Systemic insecticides are applied directly to the soil, taken up by the roots, and distributed throughout the plant, including the part you eat! BY Mac Stone Really, we are not making this up. One would hope that farmers obey the delay-to-harvest interval, because there is no on-farm monitoring. Technically the grower could use these products, post a “no-spray” sign or answer a question at the market, with “No, we don’t spray,” but you ain’t gonna wash that off! The post-harvest interval on these can be upwards of 21 days.

Wearing a Bio-hazard Suit to Farm

Let’s talk about Genetically Modified Organisms (GMO) versions of insect and weed control. The toxic compound is in the genetic code of the plant, so every cell replication has the toxin ready for an attack of pests. You ain’t gonna wash that off either! GMO crops are raised with a precisely prescribed pesticide spray program, designed to control every aspect of crop health. Be it the mutant genes or the carcinogenic insecticides, fungicides, miticides, etc. A 2014 Harvard School of Public Health study (mhdwyere@hsph.harvard.edu) associates these designer production packages with the decline of honey bees. Because of the resilience of Mother Nature, the “pests” adapt and/or mutate to exist in this new environment, and resistant strains of insects and weeds have begun to survive. It’s pretty short sighted to think science will out-smart nature and evolution. The intellectual property rights to the GMO pesticide programs are proprietary to the developers so much

LEXINGTON

First are the warnings to the applicator. Bio-hazard suits and full face respirators are recommended. Because of the potential for wind drift, applicator safety is a concern, as well as minimizing the impact to non-target areas adjacent to the food crop. There’s also a prescribed re-entry interval, the length of time before a human, pets or wildlife (bees?), should wait before re-entering the field for risk of exposure to excessive amounts of the toxin. There are also instructions advising how long to wait before harvesting the crop for sale, anywhere from zero to seven days. These toxic compounds are presumably broken down by the “environment,” meaning bacteria, fungi, sunlight and dilution by rainfall. What really happens is actually unclear. How well can spray be washed off in tap water, especially a cantaloupe or broccoli? Some toxins are bio-degraded into a different toxic compound, but the manu28 MD-UPDATE

GMO Plants Have Insecticides in Their DNA

of the data and debate is out of the public domain. The “It’s ok, don’t worry about it” attitude reeks of tobacco. In all fairness, certified organic farmers are allowed to use botanically derived sprays. A short list of naturally occurring materials has been approved by the National Organic Standards Board in a transparent and open forum. These materials can only be applied when all other cultural methods of control like site selection, air drainage, fostering beneficial insect habitat, crop rotation, etc., have not been effective in minimizing pest damage. Also organic farmers must notify the certification agency of any sprays considered for use, and the agency inspects and verifies the farm’s compliance. As we have built up the strength of our soils through crop rotation and natural fertility enhancement, we use few, if any natural sprays on our crops these days. We don’t even own a Tyvek suit or respirator. Next time you’re at a farmers market, ask the vendors first if they grew it. Then ask if it has been sprayed, if so, for what and how many times. Then ask if they use systemic insecticides or GMO seeds. At Elmwood Stock Farm we know none of this is necessary, much less a good idea, even though mainstream agriculture recommends it. This is one reason we are so adamant about the value of organic food. Just ask us, and we will gladly let you know how we raise safe, healthy food for you. Mac with wife, Ann Bell Stone, and extended family farm the 550 acre Elmwood Stock Farm in Scott County. The farm produces certified organic beef, vegetables, fruit, eggs, chicken, heritage turkeys, and tobacco. Mac has served as the executive director of marketing for the Kentucky Department of Agriculture and chair of the National Organic Standards Board, appointed by the USDA Secretary. He now focuses on farming and marketing wholesome organic foods and working with non-profit agriculture and food organizations. ◆


NEWS  EVENTS  ARTS

Lexington Clinic Announces New Physicians

Lexington Clinic is pleased to announce the addition of three new physicians, Melissa V. Avery, MD, MMM, CPE, FAAFP, FACPE, Matthew Bailey, MD, and Shuya Wu, MD, PhD. Avery trained in family medicine at the University of Tennessee, Chattanooga Unit of the College of Medicine and Greenville Hospital System’s Center for Family Medicine in Greenville, South Carolina and received her medical degree from the University of Tennessee, College of Medicine, Health Science Center in Memphis, Tennessee. She is dually certified and fellowed in family practice and medical management and brings an extensive background of family medicine practice to Jessamine Medical and Diagnostics Center. Bailey received his medical degree from the University of Alabama at Birmingham School of Medicine, completed a residency in general surgery at the University of Kentucky and a fellowship in colon and rectal surgery at the Ochsner Medical Center. He is board-certified in general surgery and board-eligible in colon and rectal surgery. Bailey will be a colon and rectal surgery specialist, and will be the only surgeon specializing in colorectal surgery at Lexington Clinic. Wu completed fellowship training in allergy and immunology at Baylor College of Medicine and Texas Children’s Hospital, received her medical degree from Peking LEXINGTON

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University Health Science Center and completed a pediatric residency at Driscoll Children’s Hospital. Wu is board-eligible in allergy and immunology and board-certified in pediatrics. Her board-certification in pediatrics allows Lexington Clinic Allergy and Asthma to treat patients of all ages. In the past, patients ages 18 years or younger were only seen for allergy injections.

Kosair Children’s Hospital Names New Medical Director

Mark J. McDonald, MD, FAAP, has been named medical director of Kosair Children’s Hospital. He succeeds Stephen Wright, MD, who retired July 1 after serving as medical director for 19 years. McDonald earned his medical degree from St. Louis University School of Medicine and completed his residency (pediatrics) and fellowship (pediatric critical care) at Kosair Children’s Hospital through the University of Louisville School of Medicine Department of Pediatrics. He then spent nine years in South Carolina practicing pediatric critical care before returning to Louisville. McDonald currently is a pediatric critical care specialist with University of Louisville Physicians and serves as the medical director of the Kosair Children’s Hospital “Just for Kids” Critical Care Center. He also practices pediatric acupuncture and is an associate professor with the University of Louisville Department of Pediatrics. In addition to his clinical work, McDonald is a member of The American Academy of Pediatrics, the Society of Critical Care Medicine, the American Academy of Medical Acupuncture, the 2016 American Academy of Medical Acupuncture Annual Symposium Committee, the Society of Critical Care Medicine Pediatric Online Practice Exam Committee, the Quality Subcommittee for the Executive Council of the American Academy of Pediatrics LOUISVILLE

Section on Critical Care, and is completing research with the PICU FOCUS Group of the Children’s Hospital Association.

Johnson Named President of Southern Orthopaedic Association

Dr. Darren L. Johnson, professor and chair of the Department of Orthopaedic Surgery at the University of Kentucky, was elected the 33rd Southern Orthopaedic Association president. Johnson is the first president from the state of Kentucky. There are more than 1,400 orthopaedic physicians who are members of the SOA.    Johnson earned his medical degree at UCLA and began his UK career in 1993. He currently serves as director of sports medicine and head orthopedic surgeon for the Kentucky Wildcats. LEXINGTON

International Society for Heart Research Recognizes Bolli

The International Society for Heart Research (ISHR) has honored University of Louisville’s Roberto Bolli, MD, for his contributions to cardiovascular science. The Peter Harris Distinguished Scientist Award, which recognizes a senior investigator for lifetime contributions of major discoveries in cardiovascular science, was presented to Bolli, chief of UofL’s Division of Cardiovascular Medicine, director of the Institute of Molecular Cardiology and director of the Cardiovascular Innovation Institute, as well as vice chair for research in the Department of Medicine, at the organization’s European Section meeting in Bordeaux, France in July. LOUISVILLE

ISSUE#94 29


NEWS The Peter Harris Distinguished Scientist Award is the most prestigious award presented by the ISHR, an international organization devoted to the discovery and dissemination of knowledge in the cardiovascular sciences on a world-wide basis. The ISHR’s 3,000 members are affiliated with seven sections based on five continents. As recipient of the 2015 award, Bolli received a $3,000 honorarium and presented a keynote lecture at the meeting on July 2 on the state of cell-based therapies for ischemic cardiomyopathy. His research is focused on the use of stem cells to treat patients with coronary artery disease. Bolli led the Louisville-based SCIPIO trial that pioneered treatment with a patient’s own heart stem cells to regenerate dead heart muscle. Larger studies are underway which could lead to widespread use of this treatment.

Bryant joins HMH Medical Staff

CYNTHIANA The staff of

Harrison Memorial Hospital is pleased to announce the addition of Kevin Bryant, Doctorate of Podiatric Medicine (DPM), to its medical staff. A native of Johnson City, Tennessee, Bryant graduated from East Tennessee State University in Johnson City, Tennessee in 2006. In 2010, he graduated from Barry University School of Podiatric Medicine & Surgery in Miami Shores, Florida. He completed his residency in foot and ankle podiatry at the Kentucky Podiatric Residency Program in Louisville, Kentucky in 2013. He is board certified in National Board of Podiatric Medicine Bryant is with Progressive Podiatry, which has three offices in Kentucky – Fort Mitchell, Williamstown and soon Cynthiana. Bryant began seeing patients at HMH on July 14 and will have a clinic at the HMH Specialty Clinic every second and fourth Tuesday.

Bhatnagar to Chair NIH Study Section

For the next two years, Aruni Bhatnagar, PhD, will have significant influLOUISVILLE

30 MD-UPDATE

ence over the funding of certain types of scientific research as he leads a panel that considers grant applications to the National Institutes of Health (NIH). Bhatnagar, the Smith and Lucille Gibson Chair in Medicine at the University of Louisville, will serve as chair of the 15-member Clinical and Integrative Cardiovascular Science Study Section, a part of the Center for Scientific Review (CSR) that evaluates grant requests for patient-oriented research involving the cardiovascular system and related regulatory organ systems. Bhatnagar is the director of the UofL Diabetes and Obesity Center, where he leads a group of 30 investigators focused on developing a better understanding of the cardiovascular complications of diabetes. His research focuses on the mechanisms by which oxidative stress affects cardiovascular function. Members of the CSR study sections are selected based on their achievements in their scientific disciplines, demonstrated by their research accomplishments, publications and other activities. The study section chair is in place for a two-year term. Bhatnagar’s term began July 1, 2015 and runs through June 2017.

disorders and the target organ damage from hypertension. She has published more than 450 peer-reviewed papers and two books. She currently holds three NIH grants for research on genes that determine a physiological response to a high fat diet and the cholesterol-controlling drug fenofibrate and hypertension-induced left ventricular hypertrophy.

Ephraim McDowell Earns Stroke Care Award

The Norton Healthcare/UK HealthCare - Stroke Care Network recently presented Ephraim McDowell Regional Medical Center (EMRMC) with the 2015 “Constellation Award” for its work in improving stroke prevention and care for its patients. At the Stroke Care Network’s annual summit in Lexington on July 24, Dr. Michael Dobbs, director of the Stroke Care Network, commended EMRMC for their exemplary level of participation in activities that promote stroke systems of care. DANVILLE

Arnett Named Dean of the UK College of Public Health

University of Kentucky Provost Tim Tracy has selected Donna Arnett, associate dean at the University of AlabamaBirmingham (UAB) School of Public Health and former president of the American Heart Association, as the next dean of the UK College of Public Health. A native of Kentucky, Arnett sees her new role as an opportunity to address health disparities relevant to the region, including cancer and drug abuse. She aims to strengthen the college’s relationships with state and regional health agencies and expand the college’s portfolio of NIHfunded research. She will also partner with the faculty, staff, and students to develop a strategic plan for the college through 2020. Arnett believes the future of population health depends on successful interdisciplinary partnerships, and hopes to facilitate such networks to grow research opportunities and educational capacity at UK. An NIH-funded researcher for 20 years, Arnett studies genes related to hypertensive LEXINGTON

LtoR: Dr. Michael Dobbs, MHCM, director of the UK/Norton Stroke Care Network, Dr. Tracy Courtney, neurologist, medical director of the stroke program at EMRMC, Sharon Blair, RN, MSN, stroke coordinator and director of the Cardiovascular Unit at EMRMC, and Lisa Bellamy, RN, CPHQ, director of Education and Quality for the UK/Norton Stroke Care Network.

In January 2014, UK HealthCare was designated a Comprehensive Stroke Center by the Joint Commission and the American Heart Association/American Stroke Association. As an affiliate in the Stroke Care Network, EMRMC has access to Norton Healthcare and UK HealthCare’s expertise and resources to best ensure their hospital offers “the best care for stroke” for their citizens. ◆


Lexington Medical Society Foundation Golf Tournament

EVENTS

PHOTOS BY GIL DUNN

It was a great day for golf as the 88 players would say at the 26th annual Lexington Medical Society Foundation (LMSF) Golf Tournament on August 26, 2015 at the University Club in Lexington. Organizers estimate that over $30,000 was raised. The LMSF distributes grants to over a dozen Central Kentucky non-profit organizations such as Surgery On Sunday, Baby Health Services, Camp Horsin’ Around, God’s Pantry Food Bank, Faith Pharmacy, and the Lexington Ronald McDonald’s House. The first place team from Family Financial Partners was David Smyth, Tyler White, Trey Welch, and Mike Abrams. The second place team was Susan Neil, MD, Brian Hill, Jackie Omohundro, and Paul Haskins. The third place team, also from Family Financial Partners was Billy Lester, Jed Kerkhoff, Scott Downing, and Bo Howell. ◆

Pediatrician Dr. David Hawse looks pretty pleased to be supporting the LMSF.

LEXINGTON

Playing for the UK Transplant team were (l-r) Matt Burlew, John Douglas, W. Lisle Dalton, MD, and G. Derek Weiss, MD.

Pairing up for the day were (l-r) Blake Bradley, MD, Grace Gibbs, DO, Todd Gibbs, and Mathew Morrison.

Women and children were represented by (l-r) Bradley Youkilis, MD, John Voss, MD, Charles Johnson, MD, and David Hawse, MD.

Enjoying the day and supporting the LMSF were (l-r) John Lepley, Tom Watts, Kaveh Sajdi, MD, and David Betram. Insuring that all the golf shots were accounted for without undue pain were (l-r) Beverly Games, SVMIC, Tim Jahn, MD, Anjum Bux, and L. Porter Roberts, CPA.

Playing for the Kentucky Surgery Center were (l-r) Tad Hughes, MD, Michael Kirk, MD, Hameed Koury, MD, and Bert Laureano, MD. Dr. Tad Hughes shows good form and followthrough on his birdie putt.

The Lexington Clinic team kept an eye on any joints that were under stress, and they did it with heart. (L-r) Peter Hester, MD, John McMullen, director of Orthopedics & Sports Medicine, John Collins, MD, and John Sartini, MD. Dr. John Sartini watches Collins’ birdie putt roll to the hole.

With surgical precision, Dr. Derek Weiss lines up his putt.

ISSUE#94 31


Lexington Medical Society Foundation Golf Tournament continued

EVENTS

Dr. Lyle and Anne Myers (l-r) obviously enjoyed a day of golf and each other while supporting the LMSF.

The ultimate tactician, David Bensema, MD, eyes the break in the green before his birdie putt.

The dapper John Stewart, MD, strikes a casually elegant pose before making his birdie putt. Bruce Broudy, MD, showing how his chipping game keeps him in the game.

The 2nd place team included (l-r) Paul Haskins and Susan Neil, MD.

Brown Cancer Center Celebrates Opening at Jewish Northeast KentuckyOne Health and the University of Louisville (UofL) announced the opening of the James Graham Brown Cancer Center at Medical Center Jewish Northeast on July 29, 2015. A reception and tours of the facility followed the announcement. For more information, see HEADLINES on pg. 3

(L-r) Lexington Medical Society Executive VP Chris Hickey with Dr. John Collins, who chairs the Foundation’s golf event now in its 26th year.

Ruth Brinkley, president and CEO, KentuckyOne Health, addressed the audience, saying, “Through our partnership with the Brown Cancer Center and the University of Louisville we are addressing "Kentucky’s high rates of cancer" and advancing our vision of bringing wellness, healing, and hope to all across the Commonwealth."

Governor Steve Beshear gave remarks at the opening. "This collaborative effort among the Brown Cancer Center, KentuckyOne Health, and the University of Louisville is a model for the type of partnership required to combat the devastation that cancer causes in the Commonwealth," he said.

attendance at the opening were Dr. Subhash Prabhudas Sheth, Cancer & Blood Specialists, KentuckyOne Health Cancer Care; Veronica Speed; Tracey Gaslin, KentuckyOne Health; Kathy Koch Anderson, KentuckyOne Health; and Dr. Khuda Dad Khan, Cancer & Blood Specialists, KentuckyOne Health Cancer Care.

(LEFT TO RIGHT) Enjoying

the reception were Dr. Donald Miller, James Graham Brown Cancer Center; Dr. Mohammed Iltaf Khan, Cancer & Blood Specialists, KentuckyOne Cancer Care; and Dr. Vivek Ravindra Sharma, James Graham Brown Cancer Center.

(LEFT TO RIGHT) In

32 MD-UPDATE

A crowd gathered at Medical Center Jewish Northeast for the announcement of the new James Graham Brown Cancer Center location, which will bring cancer services closer to home for Louisville’s east end residents.


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MD-UPDATE Issue # 94  

Inside & Out: Dermatology, Plastics, Gastroenterology, Hematology, & Vascular

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