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Vol. 8 No. 5


After Breast Surgery


Among Medical Professionals

ASD New Early Intervention Options at LifeScape




Interventional Neurology


Interventional Neurology

That’s why

the Sanford Neuroendovascular Team is here. With a stroke, time lost is brain lost, which makes it crucial to get the right care. Sanford Health is proud to be a Primary Stroke Center and has a dedicated neuro-critical care unit, which means we provide advanced life-saving stroke care 24 hours a day, seven days a week. We have the region’s only interventional neurology team providing the latest minimally invasive surgical options for blood clot retrieval.

For more information, call our Sanford Neuroendovasular Team at (605) 312-8500. 019046-00280 5/17

IMMEDIATELY CONNECT with our HIGHLY TRAINED stroke specialists through tele-stroke technology.





VOLUME 8, NO. 5 ■ J U LY / AUGUS T 2017


REGULAR FEATURES 4 | From Us to You 5 | MED on the Web Interpreting the Data Story, Avoiding heat-related illness, Advances in gynecologic surgery

12 |  News & Notes Here’s what’s happening around the region


LifeScape Offers New Options for the Youngest Patients

By Peter Carrels JULY / AUGUST

IN THIS ISSUE 19 | Managing Lymphedema in the Summer

■ By Carrie Langston How to help make warm weather easier for patients with lymphedema

20 | Eustachian Tube Balloon Dilation System

Now Available in the Black Hills ■ By Virginia Olson

■ By Alex Strauss Think it can't happen to your practice? Here is why a local expert says you're wrong.

21 | Local Physician Inventor to Develop


New Catheter System

23 | Avera Plans System-Wide Implementation of Cognitive Computing Platform

23 | New Orthopedic Residency Program to Start Next Summer

24 | Bariatric Surgery as a Last Resort for Extreme Childhood Obesity

The Quest for Better Cosmetic Results After Breast Surgery

A conversation with Sioux Falls oncoplastic surgeon Julie Reiland, MD


25 | H  elmsley Charitable Trust pases $300 milion milesone for rural healthcare

28 | How to Deal with Negative Comments Online

■ By Dean McConnell Your response to a negative review can affect its impact on your reputation.

30 | Four Simple Steps to Speak Confidently with a Foreign Accent ■ By Treva Graves

Make sure your patients — and everyone else — can get your meaning

Health Professionals and Opioid Addiction

■ By Anne Geske Reframing the problem with a compassionate and therapeutic approach

Two-year-old Vivienne with LifeScape Aquatics Instructor Marrina Kaun. Adaptive Aquatics helps with sensory challenges, water safety, exercising, and other therapeutic goals. Photo courtesy LifeScape



Protecting Your Office From Cyber Attack

Vol. 8 No. 5


After Breast Surgery


Among Medical Professionals


ASD page

New Early Intervention Options at LifeScape


By Virginia Olson and Alex Strauss

One in 68 children is diagnosed with Autism Spectrum Disorder. But with new options for therapeutic intervention in children as young as 12 months, South Dakota area ASD patients now have a better chance than ever to reach their full potential.



From Us to You Staying in Touch with MED


ELCOME TO THE SUMMER ISSUE of MED Magazine, the area’s only publication exclusively for healthcare professionals in South Dakota, Southwest Minnesota, Northwest Iowa and the surrounding region. Whether you are picking up our publication for the first time or are a long-time reader, we hope that we will find something in these pages to enhance and support both your life and your practice. This month’s cover feature centers on some newly available approaches at Lifescape designed to help very young children with autism. We spoke with the therapists who are offering these interventions for a better understanding of how they work and who can benefit. Also this month, some sage advice from a regional leader in cybersecurity protection. If you think it can’t happen to you, Earthbend urges you to think again. We talked with VP Wade Hoffman for some simple strategies that may help you and your practice avoid a cyber-nightmare. We also have exclusive interviews with an oncoplastic surgeon on her quest to help women feel better about their bodies after cancer, an ENT utilizing a new tool to treat Eustachian tube dysfunction, and a surgeon treating GERD with magnets. You will find all of that plus expert advice for minimizing a foreign accent, managing negative comments online, addressing the problem of opioid dependence among healthcare professionals, and more. As always, we welcome your comments, suggestions, and submissions. Reach us any time at info@MidwestMecialEdition. com. Here’s to (at least a few) lazy summer days, —Alex and Steff


Sioux Falls, South Dakota


SALES & MARKETING Steffanie Steffanie Liston-Holtrop




PHOTOGRAPHER studiofotografie Alex Strauss



Treva Graves Carrie Langston Dean McConnell STAFF WRITERS Virginia Olson Liz Boyd Caroline Chenault John Knies

COPY EDITOR Andrea Conover

Reproduction or use of the contents of this magazine is prohibited.

©2017 Midwest Medical Edition, LLC

SDAHMPR will have a track at the SDAHO fall conference in Rapid City. All healthcare marketing professionals are invited to attend.

The executives of the South Dakota Association of Healthcare Marketing and Public Relations (SDAHMPR) at this year’s Summer Conference in Chamberlain. From L to R: Paige Baskerville (Secretary), Kim Rieger (Treasure), Steffanie Liston Holtrop (President), Julia Yoder (Past-President), Jennifer Bender (Vice President).

August 1 Next Advertising deadline August 5 Next Contribution deadline


Midwest Medical Edition (MED Magazine) is committed to bringing our readership of 5,000 South Dakota area physicians and healthcare professionals the very latest in regional medical news and information to enhance their lives and practices. MED is published 8 times a year by MED Magazine, LLC and strives to publish only accurate information, however Midwest Medical Edition, LLC cannot be held responsible for consequences resulting from errors or omissions. All material in this magazine is the property of MED Magazine, LLC and cannot be reproduced without permission of the publisher. We welcome article proposals, story suggestions and unsolicited articles and will consider all submissions for publication. Please send your thoughts, ideas and submissions to Magazine feedback and advertising and marketing inquiries, subscription requests and address changes can be sent to MED is produced eight times a year by MED Magazine, LLC which owns the rights to all content.

CAN’T GET ENOUGH CONTACT INFORMATION Steffanie Liston-Holtrop VP Sales & Marketing 605-366-1479 Alex Strauss Editor in Chief 605-759-3295 Fax 605-231-0432 MAILING ADDRESS PO Box 90646 Sioux Falls, SD 57109 WEBSITE

MED welcomes reader submissions! 2017 Advertising EDITORIAL DEADLINES Jan/Feb Issue December 1 March Issue February 1 April/May Issue March 1 June Issue May 1


November Issue October 1 December Issue November 1


Let MED Help You Plan Your Fall Schedule! Our popular online calendar includes a list of upcoming events, conferences, and CME opportunities. You’ll also find links and numbers that make it easy to register or get more information. Don’t miss the events you want to attend. (Did we mention that you can add your own event for free?)

This month only on the Web

Exclusive Interview

SD’s only member of the Society of Gynecologic Surgeons

Reading the Numbers

Revealing quality data is on its way

July/August Issue June 1 Sep/Oct Issue August 1


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Protecting Your Office from a

CYBER ATTACK By Alex Strauss



to terrify most business owners: When trying to access a computer file, the user suddenly receives a notification that the file has been encrypted and the only way to unlock it is to pay. It is called a ransomware attack and, when it happens in healthcare, the ramifications can reach far beyond expense and inconvenience. According to the Department of Health and Human Service’s Office of Civil Rights, which oversees the enforcement of patient privacy laws such as HIPAA, the personal health data of 30 million Americans has been compromised by this and other kinds of cyberattacks since 2009. Cyber attackers can sell that data to criminals who may falsify insurance claims or create bogus prescriptions before anyone even notices. Sensitive data could even be released publically, creating a means of extortion and a privacy nightmare. It is not surprising, then, that healthcare records can be worth 5 to 10 times as much as financial records like credit card or bank account numbers.

The Weakest Link “The malicious people out there who are trying to attack medical targets through cyber means continue to take advantage of the weakest link–people,” says Wade Hoffman, a Certified Information Systems Security Professional and CTO/VP of Earthbend. “It is not as though these companies don’t have anti-virus software and firewalls. But the reality is that if someone in the office clicks on a link in an email or inadvertently opens a malicious attachment, it can spread to the entire system and lock it down very quickly.”


Hoffman says the fact that difficult for someone in pospeople are often working session of the data to release quickly and sorting through it publically. “This allows you many emails can make them to just say, ‘I have a backup less suspicious or careful than and I’m not going to pay you’,” they should be in evaluating says Hoffman. “Of course, it the legitimacy of every email still costs time and money to and attachment. Add to that restore your data.” the fact that the “bad guys” are In addition, Hoffman says continually changing the new technology can be used source of their emails and it is on top of antivirus software to Wade Hoffman a recipe for cyber disaster. recognize and stop the telltale According to Hoffman, in the span of progression of an attack before it spreads to just a year-and-a-half, the number of cyberatthe entire office. But no technology is fooltacks on facilities in our region has risen proof, which is why Hoffman and his dramatically, from about one a quarter to colleagues at Earthbend have implemented one or two every month. During particularly new staff training for their clients. Staff who bad waves of attack, there have been multiple are trained to recognize the signs of malicases in a single week. cious activity are much less likely to fall “It used to be common to come across victim to it. clients who seemed to think that this might “These things will still happen, but if be all smoke and mirrors,” says Hoffman. everyone is working with a certain level of “Now it is rare to see those people. Pretty skepticism and you have done these other much everyone is concerned about it.” steps, including backing up your data and encrypting your data, you will be in a great position to protect your and your clients’ assets,” says Hoffman. ■

Tips for Protecting Your Data

In addition to anti-virus software and firewalls, Hoffman recommends a 3-2-1 approach to cybersecurity. “We recommend a robust and regularly-tested backup system that includes three total copies of important files–two that are kept on site and one that is stored in the cloud,” he says. Regardless of where it is being stored, Hoffman says all data should also be encrypted. That would make it much more

Midwest Medical Edition

Beckenhauer Construccon has been providing high quality construccon service to its clients for 139 years and counnng. Safety of the staff, paaents, visitors, and crews is always at the top of our list to control. We do so by connnual training, monitoring, providing the best of equipment to assist us, and constant communicaaon with the client so they are aware of our every move. We go above and beyond the industry standard requirements when it comes to proteccng employees, client staff, paaents, and visitors. If you are not already one of Beckenhauer Construccon’s clients, we urge you to visit with any of our past or current clients to see what they have to say about doing business “The Beckenhauer Way”.

July / August 2017


Breast cancer treatment with genomic medicine provides a response rate

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imaging with more angles of the breast for better views and earlier diagnosis.

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Consult with your insurance plan for coverage. *Value of sequencing-guided treatment for patients with advanced malignancies. 2016 ASCO Annual Meeting, (suppl; abstr TPS6632)


The Quest for Better Cosmetic Results After Breast Surgery For a woman diagnosed with breast cancer, fighting that cancer is usually her primary focus. It may not be until much later that she may come to consider and even regret her disfigurement from radical surgery. But Sioux Falls breast surgeon Julie Reiland, MD, says it doesn’t have to be this way. Reiland is helping to lead the national charge to offer women a chance to come out of surgery feeling not just healthy but also whole thanks to breast-conserving oncoplastic surgery. MED: What led you to begin looking for ways to repair breasts after surgery? Dr. Reiland: Ever since I got out of residency, I thought, I don’t like these ugly incisions in the middle of the breast. It hurts me to look at the breast and think that I have disfigured them. Every woman with breast cancer should be able to have an operation that still helps her look their best. Ninetyeight percent of women with early stage breast cancer are surviving. Why wouldn’t we want them to thrive, too? MED: Where did you learn to do this kind of repair work? Dr. Reiland: In 2009, I took a course that really helped me say ‘OK, I can do more advanced repairs of my cancer defects.’ So I started taking out the cancer, reshaping the breast, and going to the other side and making it look even. There are some cases where I know I am going to need a plastic surgeon. But in a woman of average size who doesn’t need a reduction, that is something I am capable of doing. It is all about conserving breast tissue.

MED: Doesn’t leaving some breast tissue behind increase the risk that the cancer will come back? Dr. Reiland: We know that whether a woman removes the breast or has a lumpectomy and radiation, survival is the same. Removing your breast does not ensure that you are going to live longer. It is true that we can do beautiful things with mastectomies, but it if doesn’t make you better, why do it? And if I am going to save the breast, I want it to be the best looking breast ever. MED: What impact do you think this can have on a patient psychologically? Dr. Reiland: A woman doesn’t want to have to get out of the shower every day and see a disfiguring reminder that she had breast cancer if she doesn’t have to. Even equalizing the other breast helps them to forget that they had the surgery. Her breasts look like they belong together and the scars heal. MED: What are you doing to help bring other breast surgeons on board with this idea?

Dr. Reiland: First, the American Society of Breast Surgeons has asked me to chair a working group of surgeons to see how we can help our patients have better cosmetic results. I will also be putting on courses for them around the country, teaching the two techniques that I use 90 percent of the time. One big key is for women to starting asking their doctor what their results are going to look like. That will help drive it. MED: There has been some pushback from some in the plastic surgery community. How do you respond? Dr. Reiland: People are often afraid of new things. But everybody should want a breast surgeon to do a good job. And there are many places in the country where patients do not even have access to a plastic surgeon. My local colleagues in plastic surgery know that if I have a patient who really needs a plastic surgeon, I’m going to use them. Most have been very supportive and the truth is, we need them more than ever. ■ Dr. Reiland taught her first oncoplastic breast surgery course at Avera in June.


Medicine, the only profession that labors incessantly to destroy the reason for its existence. — James Bryce

July / August 2017

” 9

Rapid City Surgeon Offers Minimally Invasive Option for GERD

LINX® System


By Alex Strauss


AGNETS are playing an

increasingly important role in several different areas of medicine, from the use of remote magnetic navigation and spatially targeted therapeutics in cardiology to magnetic induction hyperthermia in oncology and MRI in radiology. Now, general surgeons like Andrew Van Osdol, MD, at Rapid City Regional Hospital are using magnets to provide relief to patients with gastroesophageal ref lux disease or GERD. Since late last year, Dr. Van Osdol has been offering an alternative to the standard Nissen fundoplication surgery for these patients–a tiny bracelet of magnetic beads designed to provide minimally invasive augmentation of the weak lower esophageal sphincter. “It’s more or less become an automatic choice for me, especially for younger patients with smaller hiatal hernias,” says Dr. Van Osdol.


The force of attraction between the titanium beads of the FDA-approved LINX system keep the valve to the stomach closed. The force of a swallow, belch or vomiting opens the beads. “The cool thing about the magnets is that the further apart they get, the less attraction they have, unlike a band around that sphincter,” says Dr. Van Osdol. “Once the device is scarred in mobile, the esophagus can distend to its normal limitation.” GERD is extremely common, affecting an estimated one in five people in the US and driving thousands to seek relief from antacids. But, as Dr. Van Osdol points out, most antacids are designed for short-term use of two to three months at a time. Emerging research suggests that people on these drugs for years could potentially raise their risk for diseases such as osteoporosis, Alzheimer’s, renal failure,

heart failure, heart attack, and bacterial infections. “Most of the time, by the time someone comes to see me, they have progressed through stronger and stronger antacid medications,” says Van Osdol. “They have gotten to the point where they either just don’t want to take antacids anymore or the antacids are no longer working for them.” With LINX, 85 percent of patients can get off all antacids immediately and another 7 to 8 percent may only need them occasionally. The most recent data shows those figures don’t change in most patients, even after five years, while 30 to 50 of Nissen patients are back on antacids after ten years. In contrast to Nissen fundoplication, wherein the top part of the stomach is wrapped around the lower esophagus to improve the reflux barrier, LINX is less invasive, requiring only five tiny incisions. Most patients can go home the same day and are able to eat a normal diet right away. Another big advantage to LINX, says Van Osdol, is that it can be removed if it ever becomes necessary.

Midwest Medical Edition

A clinical study of 100 patients showed that difficulty swallowing, pain, and stomach bloating were the most common risks associated with the LINX System. About 9 percent require dilation of the esophagus after the surgery. Dr. Van Osdol says dysphagia has disappeared in most of his patients by about six weeks. Nationally, only 3 percent of LINX patients still have swallowing issues after a year. While LINX is not for all patients (so far, it is only approved for those with hernias of 3 cm or less), and is not yet covered by all insurance providers, Van Osdol says it can be a life-changing option for some. The first step is to determine what is really going on. “I encourage a referral for upper endoscopy for any patient who has had reflux for two or three years,” says Dr. Van Osdol. “Screening endoscopy will tell us if there are any pre-cancerous changes or Barrett’s esophagus. Once we have a diagnosis, we can decide which patients are good candidates for surgery and which would rather stay on their antacids.” ■

Andrew Van Osdol, MD


Happenings around the region

South Dakota Southwest Minnesota Northwest Iowa Northeast Nebraska

News & Notes AVERA



Dr. Dave Kapaska, Regional President and CEO of Avera McKennan Hospital & University Health Center, retired from his position on June 30th. David Flicek, Chief Administrative Officer of Avera Medical Group will replace Kapaska as President and CEO. Dr. Kapaska has

Regional Health broke ground on its new Advanced Orthopedic and Sports Medicine Institute in early June. This $55 million project is

The Sanford Sports Science Institute has collaborated with the National Scholastic Athletic Foundation to become the nonprofit organization’s exclusive national sports medicine research partner.

served as Regional President and CEO of Avera McKennan since October 2010 and was the 16th administrator in the 100-year history of Avera McKennan.

Avera Heart Hospital is one of only 19 hospitals nationwide to receive a double five-star rating from CMS for its quality care and service. The HCAHPS

(Hospital Consumer Assessment of Healthcare Providers and Systems) rating is based entirely on patient survey scores on 27 questions. The second rating is called the Overall Hospital Quality Star Rating and includes 57 measures on outcomes and patient experience. Currently, 188 hospitals have a five-star rating based on HCAHPS and 83 have a five-star rating for overall hospital quality.


designed to treat athletes and the general public, with the goal of restoring optimum performance for both. The 114,850-square-foot institute will anchor a complex focused on pain control, musculoskeletal health, rehabilitation, and physical enhancement. The Regional Health Foundation presented the thirteenth annual wine tasting event, “Grape Time”, on June 9. The event benefitted Women

and Children’s services at Rapid City General Hospital. Participants of Grape Time enjoyed wine tasting, local entertainment and cuisine, and a silent auction.

The Society of Thoracic Surgeons has awarded Regional Health Heart and Vascular Institute with their distinguished three-star rating for its patient care and outcomes in coronary artery bypass grafting (CABG) procedures. The STS three-star

rating, the highest possible, places Regional Health among the elite for heart bypass surgery in the United States and Canada. Historically, approximately 10-15 percent of participants receive the three-star rating.

NSAF promotes and develops America’s top youth track and field athletes with the goal of identifying and developing future Olympians. This five-year collaboration will enable Sanford Health to conduct research in conjunction with NSAF. The Sanford Sports Science Institute staff attended their first major NSAF event–the New Balance National Outdoors–in North Carolina in June. Sanford nurse Cindy Groen, RN, received the Daisy Award for Extraordinary Nurses this spring. Groen works in the

Radiology Interventional Clinic at Sanford USD Medical Center.

SIOUXLAND The Sioux City Explorers collaborated with Mercy Medical Center to present two events in June. The first was the

second annual Blue Out Night to benefit Mercy’s Child Advocacy Center for the prevention and awareness of child abuse on June 3. The second event, Strike Out Stroke, was held on June 6 and was presented for awareness of stroke as an emergency as well as signs, symptoms and risk factors.

Lea Greathouse, Executive Director of Mercy Medical Center, has been named a Certified Fund Raising Executive by CFRE International. Individuals

granted the CFRE credential met a series of standards set by CFRE International which include tenure in the profession, education, demonstrated fundraising achievement and a commitment to service to not-for-profit organizations. They have also passed a rigorous written examination. UnityPoint Health – St. Luke’s

Cardiology Services has received the Mission: Lifeline Gold Receiving Quality Achievement Award and Mission: Lifeline NSTEMI Silver Quality Achievement Award for

implementing specific quality measures outlined by the American Heart Association for the treatment of patients who suffer severe heart attacks.

OTHER Michael Brozik, MD, has joined Surgical Institute of South Dakota.

Dr. Brozik is a Madison, South Dakota native who graduated from the USD Sanford School of Medicine and completed his general surgery residency and his surgical critical care fellowship at St. Joseph Mercy Hospital in Ann Arbor, Michigan. Dr. Brozik will begin seeing patients on August 1.

Midwest Medical Edition

91st Annual Convention

Sept. 20-22, 2017 • Rapid City, S.D. •

Early Intervention for


Spectrum Disorder

LifeScape Offers New Options for the Youngest Patients


By Virginia Olson and Alex Strauss CCORDING TO the most

recent data from the Centers for Disease Control and Prevention, one in 68 children is diagnosed with Autism Spectrum Disorder (ASD) – up from one in 150 in 2002. ASD is now the diagnostic category listed in the DSM-V to describe a group of developmental disorders encompassing a range of symptoms and levels of disability. Characteristics of ASD include delays in the development of communication skills and vocabulary, problems in building relationships, and being socially withdrawn. Symptoms often appear at an early age. Babies and toddlers with autism spend less time looking at people, are less responsive when their names are called, and often fail to develop gestures such as pointing, which are important to set the stage for language. By the time they enter school, these tendencies can cause serious problems in learning and social interaction. Experts now say that Vicki Isler therapeutic intervention


as early as possible may be the key to mitigating the effects of ASD and maximizing these children’s potential. LifeScape, a long–time regional leader in providing services to people with disabilities and their families, is offering innovative and evidence-based new options for earlier ASD intervention. Depending on their unique situation, a child who has been diagnosed with ASD as early as 12 months of age can now receive multidisciplinary therapy through Early and Intensive Behavioral Intervention (EIBI) or through a new approach called the Early Start Denver Model (ESDM). Both models utilize principles of Applied Behavior Analysis (ABA).

Early and Intensive Behavioral Intervention In their 2014 book, Comprehensive Guide to Autism, authors Lars Klintwall and Svein Eikeseth describe Early and Intensive Behavioral Intervention (EIBI) as “an evidence-based intervention which uses principles and procedures from Applied Behavior Analysis to teach adaptive behaviors to young children with ASD.” Vicki Isler, Ed.D, BCBA-D, Director of Residential and Education Services at LifeScape, has decades of experience with ABA

therapy. She says the tenets on which it is based are relatively simple and universally applicable. “Behavior that is reinforced will happen again. This goes for all of us, whether or not a person has autism.” Although ABA can be used with any age group, as Klintwall and Eikeseth observe, the approach appears to be especially effective when applied early (ideally before age 5) and intensely (30 to 40 hours of therapy per week). A 2014 analysis of EIBI published in Research in Developmental Disabilities found that, among toddlers with autism who entered the therapy program before their second birthday, 90 percent made significant gains. While all children in the study gained from the therapy, the percentages gradually dropped the older a child was when they entered therapy. “From the time the pediatrician can say there is a developmental delay, we can begin to work with them,” says Isler. Although the therapy has not been covered by insurance in South Dakota (which will be changing soon - see below), Isler has seen the impact of EIBI in her former state of Florida. “Many of these children, if you can get them into therapy early enough, can go into school without even showing symptoms of autism.” Delivered under the direction of Board

Midwest Medical Edition

Amanda Barton, BCBA, works with Hudson to demonstrate some of the in-home ABA therapy techniques used in EIBI.

it, the therapy has not been covered by insurance, making it inaccessible for many South Dakota families who might benefit from it. Unlike physical therapy that may be effectively delivered in weekly one-hour visits, EIBI can require up to 40 hours a week and cost as much as $40,000 a year. As a result, at LifeScape, ABA therapy has been largely restricted to the inpatient population where the school district helps foot the bill. But thanks to the efforts of parents, therapists, and other advocates, South Dakota became the 39th state to mandate insurance coverage for therapy for ASD in 2015, with the provision that BCBAs must be licensed by the state, just as occupational therapists or physical therapists currently are. Isler worked on a committee to write the new rules for licensing BCBAs, who will be licensed under the state Board of Social Work. She anticipates that all of the state’s BCBAs will have the opportunity to become licensed by the end of the year and begin billing insurance companies for their services. “For years, we have known that early, intensive intervention is what many of these children needed,” says speech language pathologist Megan Wiessner, MA, CCC-SLP, part of LifeScape’s Autism Evaluation Team. “But without having the coverage from insurance, although we have recommended this to parents for years, most just couldn’t pay out of pocket for it.” Under the new law, children with autism will be eligible to receive ABA services through the age of 18. It allows for up to $36,000 a year to cover ABA therapy for children ages zero to six, $25,000 for children Megan Wiessner seven to 13, and $12,500 for those 14 to 18.

EIBI Soon to Be More Accessible

The Early Start Denver Model

Despite significant research supporting the benefits of EIBI, and although South Dakota has long had BCBAs capable of providing

Another option for young children with ASD in our region is The Early Start Denver Model (ESDM), a comprehensive behavioral early intervention approach for children with autism from 12 to 48 months. An adaptation of the Denver Model preschool originally developed in the 1980s, ESDM utilizes a curriculum that includes ABA principles and addresses skills across all domains of development — fine and gross motor, communication, joint attention, activities of daily living, etc. — to provide a multidisciplinary approach for very young children and their families. The ESDM can be used in various delivery settings and utilizes a “naturalistic approach” to increase a child’s interest in activities and other people. “ESDM is a naturalistic developmental behavioral intervention model that takes principles of ABA therapy as well as knowledge of children’s typical development and fuses them together into a curriculum and an approach that any discipline can use,” says Wiessner. “Instead of working one-to-one at a table with an adult, we work on goals within natural activities. It might be a game or an art project or a snack. We embed things like requesting, eye contact, imitation, or vocalization. It is a nice comprehensive option for these little kiddos.” With ASD diagnosis now possible in younger patients, Wiessner says the goal is to teach these small children what they need to know

Jason Dybsetter, BCBA, with Wade. ABA techniques can be used with older children or even adults with ASD.


Midwest Medical Edition

Photos courtesy LifeScape

Certified Behavior Analysts (BCBAs), the EIBI approach consists of identifying which skills the young child lacks, breaking these skills into component parts, and then working on each of these components separately, repeating and rewarding as needed Megan Wiessner, MA, CCC-SLP, works with Silas, age 4, until the child has to develop social interaction and communication within fun and engaging play routines. mastered each step in a sequence and can perform the task independently. “For some reason, children with autism don’t learn by observation and imitation the way other children do. They have to be taught every little thing,” says Isler. “So we use these ABA principles to teach them to follow simple directions, including things they need to do to get ready for preschool such as sitting still, paying attention, and imitating. Then we work on numbers and colors. We teach this all in a very structured way.” In the EIBI approach, the environment is carefully structured so that the child is most likely to be successful at acquiring and maintaining new skills. Repeatedly practicing (and receiving reinforcement for) novel skills in a structured setting prior to using them in a natural setting, is one of the key pieces of an EIBI package. EIBI uses one-on-one discrete training for basic skills and may include less structured teaching for skills like self-care.

to succeed by the time they start school. “It is now possible to help children as young as a year old and we have the tools to diagnose most children by the age of two,” says Wiessner. “Even a handful of years ago children often weren’t diagnosed until eight, nine or ten.” By that time, many were already experiencing problems in school. Although the ESDM approach is new to the area, the research on this emerging therapy looks promising says Megan Johnke, OTD, OTR/L, Director of Therapy at LifeScape. A randomized controlled trial of ESDM published in the journal Pediatrics in 2010 suggested that children who received ESDM therapy for 20 hours a week over two years showed more improvement in their cognitive and language skills, more adaptive behaviors, and fewer autism symptoms than a control group of children who received a variety of other community-based services. The research prompted Time Magazine to name ESDM to its list of top ten medical breakthroughs in 2012 and the approach is sanctioned by the American Academy of Pediatrics. “LifeScape has been providing speech, occupational therapy and psychological services for a long time,” says Johnke. “ESDM is just more collaborative for a well-rounded approach.” LifeScape has taken a lead role in helping its personnel become certified in this new approach to early ASD intervention. Wiessner, who will attend her advanced ESDM training in November, may be the first to receive this certification in South Dakota. Several other LifeScape therapists are currently training in the ESDM curriculum.

Keeping the game fair... you’re not fair game.

Intervention Starts with Evaluation Regardless of which therapeutic path a child ultimately takes, Sioux Falls child and adolescent psychiatrist David Ermer, MD, part of LifeScape’s Autism Evaluation Team, says the first step is professional evaluation. Erner recommends that any child exhibiting early signs of ASD be referred to the autism team for testing, especially if parents have concerns. “There is no harm in making the referral,” says Dr. Ermer. “The harmful thing could be waiting too long because early intervention is so important. The earlier you intervene and start getting help for the child, the better things are likely to go in the school setting, at home, in social settings, and later on.” Dr. Ermer says he has seen for himself the positive impact that early behavioral intervention can make. “I have seen some tremendous differences in children who have gotten help from someone who is highly trained and follows the established guidelines,” he says. “In some cases, I have been able to either stop prescribed medicines or not have to prescribe them at all because things have improved so much. When in doubt, refer on.” “The thing I love about this is that severe behavior is fixable,” adds Isler. “If a child comes in on a ventilator, I can’t do anything about that. But if they come in hitting, kicking, biting and throwing things, I can fix that. You can make a real impact with early intervention.” ■

July / August 2017

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Midwest Medical Edition

Managing Lymphedema in the Summer By Carrie Langston


S SUMMER APPROACHES, patients with lymphedema need to take

Tips for Traveling

extra precautions to prevent a “flair-up”. Those at risk should also be on the the alert for the signs and symptoms of impending lymphedema.

When traveling, especially by air, it becomes very important to wear compression garments. The air pressure decreases in the cabin as the aircraft ascends. Here are a few things that can make a flight more comfortable.

Why does summer heat effect lymphedema? Heat causes our blood vessels to expand or vasodilate. The expansion increases the amount of fluid that moves out of the blood vessels and into the tissues. When the lymphatic system does not work correctly or works inefficiently, the excess fluid does not return to the lymphatic system as it should and lymphedema results. Staying out of the heat isn’t always an option or desired. Patients still want to enjoy summer. In this case, compression garments become a necessary summer accessory to keep the lymphatic system in check. However, limited exposure to the heat will give the lymphatic system the best chance to work optimally. Fortunately, swimming is a great activity to stimulate the lymphatic system, but patients need to be cautioned to have a garment ready to don once they exit the pool. If swimming in a chlorinated pool, patients should shower immediately after swimming and maintain a healthy skin moisturizing regimen. It can also be helpful to wear footwear when swimming in pools or open bodies of water to avoid any scrapes or cuts from rough cement or rocks. Hot tubs are not recommended for lymphedema.

How is skin care important to lymphedema treatment and maintenance? In the summer, it becomes even more important to be vigilant about proper skin care. Lymphedema patients should be sure to use sunscreen to protect from burns, as they can damage the very superficial lymphatic system and cause inflammation to quickly get out of control. Bug repellant also becomes essential as a single bug bite can also quickly escalate the inflammation process and an affected limb can possibly double in size in a very short amount of time.

1. Whether a person has lymphedema or is at risk, a properly fitted compression garment is essential. Garments should be replaced every six months to maintain adequate compression and containment.

2. Reserve an aisle seat. This makes it easier to get in and out of the seat easily to walk the aisles to keep lymph from pooling.

3. Perform seated exercises as often as needed to keep the lymphatic system stimulated.

4. Drink Water. Staying hydrated will also help keep they lymphatic system functioning properly.

5. Remain consistent with a lymphatic supportive diet. Avoid salty food and minimize caffeine and alcohol intake. 6. Avoid carrying heavy luggage with the affected limb.

7. Break up travel into several segments, ensuring layovers with time to exercise and return to normal air pressure, giving the compromised lymphatic system time to recover before going back into the air again. ■

Carrie Langston is a lymphedema specialist at Lymphedema Therapy Specialists in Sioux Falls.


Eustachian Tube Balloon Dilation System Now Available in the Black Hills By Virginia Olson



body part that tends to get much attention – until or unless it fails to work properly. In patients whose Eustachian tubes are unable to drain fluid and equalize pressure, known as Eustachian tube dysfunction, that can mean chronic popping, pressure, or pain in the ears and even muffled hearing. Sufferers might describe their condition as ‘bad ears.’ Loren Jones, MD, ENT, of Spearfish Regional Medical Clinic, recently began using the Acclarent Aera Eustachian Tube Balloon Dilation System for sufferers of Eustachian tube dysfunction. This pioneering new device designed to dilate the Eustachian tubes was approved by the FDA last fall and is already bringing much-needed relief to ear pain sufferers across the region. It is also helpful for people with barotrauma who experience discomfort when flying or other changes in pressure. Dr. Jones attended training on the new procedure in a cadaver lab in California last year. He describes it as revolutionary. “There is nothing else approved for these Eustachian tube sufferers,” he says. “Prior to the balloon procedure, ear tube placement was

the only answer. Often Balloon Dilation System is times the tubes have to be contraindicated in cases of replaced. This creates the persistent Eustachian tube risk for infection and posdysfunction and for anyone sible structural damage to under 22. Also, it is not recthe ear drum after multiple ommended for people with tube placements.” abnormal anatomy such as With the patient under a craniofacial abnormality general anesthesia, the or for people with a condidevice is inflated to 6 tion called patulous millimeters inside the Eustachian tube. Eustachian tube and is held Potential candidates for in place for two minutes. the balloon dilation proceLoren Jones During those two minutes, dure can be evaluated using the pressure causes injury to the mucus the ETDQ7, a scoring system that assesses membranes in the lining of the tube. “The symptoms and outcomes. The tool can be hope is that, when these membranes regenerfound online or Dr. Jones’ office can supply ate, they will do so in a more organized and it to any physician interested in using it to functional manner,” says Dr. Jones. evaluate patients. Most patients require bilateral treatment. Dr. Jones says not only is the procedure The procedure takes about ten to 15 minutes brand new, but his clinic’s offering of it is to do both sides. Early clinical investigations unique in the West River area. with follow-up up to two years after the pro“Until now, patients with persistent cedure have indicated that most patients Eustachian tube dysfunction have had no experience an improvement in symptoms and options and have had to live with bad ears,” that the response is durable. Dr. Jones now Dr. Jones says. “It is pretty exciting to be performs about two procedures each month. offering this special procedure here in The Acclarent Aera Eustachian Tube Spearfish.” ■

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Midwest Medical Edition

Patrick Kelly, MD.

Photo courtesy Sanford Health.

Local Physician Inventor to Develop New Catheter System PATRICK KELLY, MD, with Sanford Vascular Innovations, a division of Sanford Health, will collaborate with Boston Scientific to develop a less invasive catheter system that could transform treatment of pulmonary embolisms. Pulmonary embolisms are most common after surgery, trauma, or periods of prolonged immobility. They also are common in pregnant women and older patients.

July / August 2017

Large or multiple clots can be fatal. Sanford Health and Boston Scientific are working to develop and optimize the design of the newly-invented catheter. The process of bringing a device like this to market can take many years – from engineering and design to clinical trials and finally FDA approval. It is a process that Dr. Kelly has gone through many times before with other inventions.

Boston Scientific regularly partners with physicians and healthcare systems to develop technologies that could improve care or reduce costs. “Engaging in collaborative partnerships with physicians like Dr. Kelly allows Boston Scientific to accelerate the pace of innovation in solving unmet clinical needs,” says Jeff Mirviss, president of peripheral interventions at Boston Scientific. ■


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Avera Plans System-Wide Implementation of Cognitive Computing Platform AVERA HEALTH has announced its plans

to implement a new cognitive computing platform system wide. The platform, called PrecisionPlan, was developed in collaboration with Denver-based Viviphi Ltd. PrecisionPlan is designed to generate patient-specific treatment plans in seconds. The artificial intelligence solution utilizes diagnostic, surgical, demographic and other patient-specific information from the electronic medical record system (EMR) and from next-generation tumor sequencing reference laboratories to generate personalized treatment plans and offer clinical guidance in precision medicine. The strategic collaboration between Avera and Viviphi was established in 2016 to combine Avera’s clinical rules in genomicbased precision medicine with Viviphi’s state-of-the-art cognitive computing platform in oncology. Precision oncology offers personalized cancer therapies to patients, based on their

individual genomic profile. It has been demonstrated that oncology practices that embrace both the best of genomic science and existing nationally-accepted standards of care achieve better outcomes. However, the absence of codified clinical rules in precision medicine in oncology has left many clinicians without practical support and access to the latest knowledge and experts in this dynamic and rapidly evolving field of practice. “The Viviphi solution quite literally puts a virtual peer-to-peer consult in the hands of busy oncologists,” says Gerry Hogue, President and CEO of Viviphi Ltd. “These professionals want to make the right decisions for patients, not organize and collate data. Oncologists are able to accelerate decision-making, improve clinical through-put and efficiency, make better and more appropriate decisions at the individual patient level, and generate considerable savings... while increasing revenue for

their clinic or healthcare institution.” The Viviphi PrecisionPlan platform can be used separately or can be completely embedded within an institution’s electronic medical record system. The platform was validated in clinic and through the Avera Molecular Tumor Board in February through April. Implementation and training to start using it system-wide at Avera will happen later this year. Avera will be the first healthcare system in the world to run patient data through the Viviphi PrecisionPlan platform. Some other leading NCI Cancer Centers in the US have also signed contracts with Viviphi and are preparing to implement the platform in their oncology networks. ■ See the website for more on the PrecisionPlan platform at Avera.

New Orthopedic Residency Program to Start Next Summer FIRST-OF-ITS-KIND PROGRAM IN NORTH AND SOUTH DAKOTA BEGINS SUMMER 2018 SANFORD HEALTH and the University of

North Dakota School of Medicine and Health Sciences have collaborated to launch an Orthopedic Residency Program set to begin next summer. The program is funded by Sanford Health and sponsored by the UND SMHS. This first-of-its-kind program in North and South Dakota creates three residency positions per year that will study in both Fargo and Sioux Falls, eventually resulting in 15 residents training at a time during the fiveyear program.

July / August 2017

Residents will see a wide range of orthopedic disorders for adults and pediatric patients that include adult reconstruction, orthopedic trauma, spine, hand, foot, ankle, amputations, athletic injuries and orthopedic oncology. They will also focus on research. “Given the exceedingly high demand for physicians nationwide, it’s imperative that Sanford get involved with educating the next generation of orthopedic surgeons,” says Bruce Piatt, MD, Sanford orthopedic physician and UND SMHS

Orthopedic Residency Program director. “As a teaching hospital, Sanford is drawn to the importance of education and teaching tomorrow’s physicians to prepare for the future needs of our community. We know that a majority of physicians stay and practice where they are trained.” Residents will spend time in Fargo and Sioux Falls working with surgeons and providers in each region. Sanford Fargo and Sioux Falls currently have residency education for internal medicine, family medicine, general surgery and psychiatry. ■



at Children’s Hospital & Medical Center weighed 362 pounds, had a body mass index greater than 52, and suffered from a host of health issues related to her weight. Her family tried diet, exercise plans, and medication over the years, but the girl continued to gain weight. As fast as she was growing, she could have soon had a heart attack or stroke, so pediatric surgeon Robert A. Cusick, MD, of Children’s Specialty Physicians, an associate professor of Pediatric Surgery at UNMC College of Medicine, performed a gastric sleeve resection on the girl at Children’s alongside the bariatric surgery team from Nebraska Medicine. The laparoscopic procedure employs a stapling device to remove about 85 percent of a patient’s stomach, leaving it in the shape of a sleeve or tube, decreasing food consumption by triggering an earlier satiety. Children’s launched its bariatric surgery program in 2013. As of June 2017, 12 children had undergone either a gastric sleeve resection or a gastric bypass. It is not a first-line response to treating adolescent obesity at Children’s – but it is a viable last resort. “If these kids can achieve great success without surgery, we’d love that. But when they don’t achieve that success, we want to

be able to offer bariatric surgery,” Dr. Cusick says. Candidates for bariatric surgery at Children’s must have a BMI of at least 40 or a BMI of 35 with another significant comorbidity, such as diabetes, obstructive sleep apnea, lipid disorders, pulmonary hypertension or fatty liver disease. To ensure that all other avenues to better health have been exhausted, the pathway to bariatric surgery begins in HEROES (Healthy Eating with Resources, Options and Everyday Strategies), Children’s bariatric weight management program for children and adolescents. The multidisciplinary program combines medical management; required nutrition, behavior and fitness classes; behavioral health therapy and consultations with medical specialists. Prior to surgery, patients must undergo a minimum of six months of medicallymanaged weight loss supervised by the HEROES team, exercise and nutrition classes, psychological testing and clinic follow-up to manage any comorbidities. “It’s a lot of behavioral modification we’re teaching and reinforcing,” says nurse practitioner Carly Frost, MSN, FNP-BC. Dr. Cusick acknowledges the concept of performing the procedure on adolescents is

not without controversy. “There are people who say you shouldn’t be doing this on children – ‘Can’t they just change their lifestyles?’ The problem is that once you get to these very high BMIs, surgery may be the only durable solution.” “The reality is these kids are in our community; they’re getting bullied; and we need to figure out a way to make their lives better,” he says. “We’re trying to get them to lose a significant amount of weight so, with the help of the HEROES program, they can resume a healthier lifestyle.” That has been the case for the then 14-year-old on whom Dr. Cusick performed bariatric surgery. She is now in high school, down 120 pounds, plays sports, and was able to stop taking many of the medications that used to help keep her alive. Doctors have since traced her weight gain to a genetic anomaly that triggered a rare overgrowth syndrome. Dr. Cusick calls his work with young bariatric surgery patients “one of the most rewarding things I’ve done as a pediatric surgeon because you see these significant transformations in these kids. We’ve tried all the medical things and seen them fail. To finally have that success – it changes their whole outlook on life. Their whole persona is changed.” ■

South Dakota Medical Group Management Association

Fall Conference

August 23-25, 2017 Featuring:

@ Cedar Shore Resort – Oacoma, SD

Jim Mathis

Author & Motivational Speaker

Robert S. Thompson, JD, MBA

Business Development Consultant, MMIC

Mollie Gelburd, JD

Associate Director, MGMA Government Affairs

For the full schedule or to register, visit our website at

Betty VanWoert, RN, BSN

Patient Safety/Risk Management Consultant, MMIC

Collections Panel Discussion

Like us on Facebook at Follow us on Twitter @SDMGMA


Midwest Medical Edition

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HELMSLEY CHARITABLE TRUST passes $300 million milestone for rural healthcare EIGHT YEARS AFTER its beginning, the

Leona M. and Harry B. Helmsley Charitable Trust’s Rural Healthcare Program has surpassed a $300 million milestone in grants to improve rural healthcare across a seven-state region that stretches from Montana to Minnesota. Based in Sioux Falls, SD, Helmsley’s Rural Healthcare Program made its first grant in 2010. Helmsley supports innovative technology such as ePharmacy and eEmergency telemedicine, CT scanners, CPR devices, and treatment simulators. Helmsley also funds programs for medically underserved areas in Montana, Wyoming, Iowa, Nebraska, North Dakota, South Dakota, and Minnesota. “As a region, we face a serious challenge in meeting the healthcare needs of our people,” said Walter Panzirer, Helmsley trustee and rural South Dakota resident. “Much of the seven-state area we fund in is sparsely populated. It’s hard to have the same access to medical services that people


July / August 2017

in populated areas take for granted. The Helmsley Charitable Trust seeks to bridge that gap.” For instance, Helmsley’s Rural Healthcare Program is committed to ensuring that every woman in the region lives within 60 miles of a facility that provides digital mammography. After 68 grants to equip 79 sites, that goal is close to being achieved. Another initiative seeks to increase the number of doctors who practice in rural America. Noting that 70 percent of medical professionals settle where they train, Helmsley supported the Billings Clinic Internal Medicine Residency program in Montana in 2015. This month, the first group of doctors graduates from the program. A majority of these doctors have chosen to practice in rural states. The Rural Healthcare Program is one of Helmsley’s worldwide initiatives that focuses on improving lives by supporting exceptional efforts in health and select place-based initiatives. ■

Deep summer is when laziness finds respectability.

Walter Panzirer

HELMSLEY CHARITABLE TRUST GRANTS BY STATE Montana $47,278,047 Wyoming $25,544,634 Iowa


Nebraska $54,090,179 North Dakota


South Dakota


Minnesota $24,204,515 Other


Total Grants $320,675,704

— Sam Keen


Health Professionals and Opioid Addiction Reframing the problem with a compassionate and therapeutic approach



ability of health professionals to place public safety first, doing their job well and unimpaired, is essential. Health professionals are keenly aware of their ethical and moral responsibilities. But through the lens of addicted thinking, an individual may rationalize that their use of opioids won’t lead to impaired judgement. That their diversion—appropriating patients’ prescription medication—won’t affect patient safety or lead to malpractice claims.

Unique factors and risks Generally speaking, health professionals experience chemical dependency at the same rate as the rest of the population. But when the substance is opioids, unique factors and risks come into play for people in the health professions. First, there can be extreme stress on the job. Physicians have a much higher risk of depression and burnout (emotional exhaustion, depersonalization, and a low sense of personal accomplishment) compared to the general population.1 Second, there’s access. When stress leads health professionals to reach for a substance as a coping mechanism, access to opioids is there, especially for those who administer anesthesia and medications. Third, physicians’ and nurses’ very knowledge about disease and medication can lead them to intellectualize their substance use behavior, thinking I know how they work, so I’ll be able to control their use.2 Stressful work environments, burnout, access, intellectualization, and isolation may create a unique set of risks for health

professionals, but the results of opioid use disorder (OUD) are every bit as deadly. “The scary thing for me is that those folks out there who are deep in the throes of addiction feel alone, like they can’t reach out.” says Marc Myer, MD, who works for Hazelden Betty Ford as medical director for Adult Services Minnesota, as well as the Health Care Professionals Program. “Many will die of their addiction before they get to treatment.”

Compassion, not Punishment Employers of healthcare professionals know they have a responsibility to the public. How much do they also have a stake in the success, well-being and careers of their employees? Laurie Drill-Mellum, MD, chief medical officer of Constellation, says, “We have to make sure that people are treated fairly, with dignity and respect. We see the effects of addiction and how it can land on patient care and safety, which we all care about—including the people who struggle with this issue.” A compassionate, not punitive, model of chemical dependency treatment is known to be most effective. To that end, most states have a confidential program for medical professionals that operates outside of the state licensing board. Once enrolled, their adherence is monitored. If they’re noncompliant, they could lose their license. One such successful program is South Dakota’s Health Professionals Assistance Program (SDHPAP). Craig Uthe, MD, a family medicine physician and medical adviser to SDHPAP, says the two cornerstones of the program are accountability and consequences. “We have a personal plan of action that’s

individualized for every participant, using guidelines and policies that are generally followed by the Federation of State Physician Health Programs,” says Uthe. “Addiction is a disease. It was recognized that physicians wouldn’t acknowledge [admit or seek treatment for] their disease if the result was going to be punishment. So many states, including South Dakota, have created trusted, confidential and protected programs away from board disclosure if the individual is willing to get treatment for their disease and not be a risk to the public’s health.” The good news is that after completing treatment and obtaining ongoing support, the five-year success rate for physicians is greater than 80 percent—much higher than the general population.3 ■ Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600-13. Myer M. Trends, treatment and transformation: changing the course of addiction in the health care professional Webinar. Published June 3, 2015. Available at https:// DuPont RL, McLellan AT, Carr G, Gendel M, & Skipper GE. How are addicted physicians treated? A national survey of physician health programs. 2009. J Subst Abuse, 37(1).

There’s more online, including: • An extended version of this article • An addiction self-assessment • What administrators and practice owners can do • Helpful resources

Reprinted from the summer issue of Brink, a risk and patient safety magazine published for MMIC on behalf of Constellation, Inc.


Midwest Medical Edition

Starting the conversation “We want organizations to have safe, competent physicians who are not impaired taking care of our patients,” says Walt Flynn, HR consultant. Here are three basic steps that Flynn uses to broach the subject of potential impairment.

1. Explain why you’re having this conversation. “Here’s what we’ve seen, can you help explain what’s going on?” Talk about observed behavior or verbalizations that have been out of the norm.

2. Help them understand why there’s a concern. “HThere’s ere’s why we’reonline, concerned.” Discuss more including: potential patient safety concerns, • An extended version of this how article coworkers are affected, and risks to the • An addiction self-assessment • What administrators and practice organization. owners can do • Helpful resources

Because your great care comes in all sizes.

© 2017 MMIC Insurance, Inc.

Confronting impairment:

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3. Talk about steps toward remediation.

“Where do we go from here?” Come prepared with what next steps might look like depending upon the direction the conversation takes.


How to Deal with Negative Comments Online By Dean McConnell


ATIENT COMPLAINTS often share one common

denominator—a breakdown in the physician-patient relationship. The best options, therefore, for protecting your online reputation should be directed at repairing and preserving relationships with your patients. Ignoring a negative comment looks like you do not care or that you agree that the comment is valid. Hiding or removing negative reviews may result in a re-post of the comment on multiple sites, pointing out your efforts to “hide the truth.” Attacking the commenter is dangerous and often results in more malicious or derisive comments. What should a doctor do, then? Recognize that you have an unhappy patient. Respond to the complaint in a positive manner. React based on a full and objective assessment of the situation.

Recognize Recognizing that the patient is unhappy is difficult when you are feeling attacked. Negative comments invoke defensive reactions and fears that the physician’s reputation and practice may be seriously harmed. Despite these normal reactions, the patient’s concerns must

be addressed in a professional and appropriate manner. Whether the patient’s complaints are justified or not, the patient is unhappy enough to make his or her complaints known to the world at large. Remember that this is only one of many patients in the practice, most of whom are very happy. While action is often prudent, it needs to be measured and appropriate to the context.

Respond positively Acknowledge that the patient is not satisfied, that patient satisfaction is important, and ask to take the conversation offline to address the issue. A response should be tailored to the specific complaint. If a patient is unhappy about waiting too long, an appropriate response might be: “Thank you for taking the time to comment. While we try to respect each patient’s time, sometimes the number of people who need our help causes unexpected delays, especially when emergencies arise. If there is anything we can do, please give us a call at the office. Your satisfaction is important to us.” If the patient does not call, contact him or her. People will often say things online that they would never say face-to-face. A phone call provides a better chance of connecting with the patient and

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• Just What the Doctor Ordered •

Midwest Medical Edition

solving the problem. Before responding, cool off. Let it sit overnight and ask a trusted colleague to review it before posting. Also, be careful about HIPAA. Do not include treatment or payment information or provide patient names or identifying information in your response.

React appropriately Sometimes patients are right. Maybe the physician was just having a bad day. An explanation and an apology are usually all that it takes to resolve this situation. Maybe the payment policy for “no showsâ€? should not be absolute and it can be waived for the mom who missed her appointment because she had to pick up her sick kid from school. Maybe the problem really is a rude front desk person and corrective action should be taken. Take this opportunity to evaluate the practice and improve it. Sometimes patients are wrong. Nevertheless, they are still patients. Maybe they were having a bad day. Maybe this patient is just not the right fit for your practice and you can provide them with a referral to a colleague that might be a better fit. Try to understand the situation from their perspective and consider whether there is some concession you can live with. A good, long-term patient might be saved for the price of an office visit. Patients who have been heard will sometimes remove their own negative comment or, better yet, post a positive one extolling how the doctor cares about patients and was willing to listen and address the problem. â–

Ask ur tO Abou dge Lo e! g Packa

Dean McConnell, JD, is Senior Legal Counsel at COPIC, a provider of medical professional liability insurance.

July / August 2017


Four Simple Steps

to Speaking Confidently and Clearly if you have a Foreign Accent


By Treva Graves FOREIGN ACCENT is when

a person applies the patterns of their first language to their second language. This is especially problematic when the second language is English. English has a multitude of characteristics that are very different from most other languages. A foreign accent may be strongly influenced by using too much effort and over-pronunciation during speech.

Is an Accent a Bad Thing?


How to ‘Sound American’ in 4 Steps

1. Staccato Intonation

It’s not as hard as it seems. Use fewer words and break your speech into breath groups. Most people speak in run-on sentences with lots of filler words. Break your speech into “units of meaning.” You should use groups of words that can’t be separated. Try using varied intonation, contractions, back resonance and letting the air come out of your mouth on all sounds except, /m/, /n/, and /ng/. It seems overwhelming, but by working on improving your speech and voice patterns with a certified speech pathologist, you will be on your way to speaking with an American accent. Knowing what you’re doing right and wrong is an important mile-marker on your quest to communicate clearly and effectively. ■

People with accents invariably use a consistent intonation pattern, which means that each syllable is the same length and volume. Staccato intonation doesn’t work for Standard American English.

2. Over-Pronunciation When foreign speakers see a “t” they want to pop it. For example: “butter vs. budder.”

An accent is not a terrible thing, but it may not be representative of your personality. An accent is simply a superficial part of your identity. However, people may not always understand everything that you are saying. If patients struggle to follow your treatment recommendations, or they are working too hard trying to understand what you are saying, you may have a problem.

3. Front Resonance

What’s a call to action?

4. Nasality

We have calls-to-action in every communicative situation we find ourselves in. If you are trying to succeed in your professional and personal life, an accent can stand in the way.

Are your lips and face moving when you speak? They should be moving very little-if at all. Most languages are characterized by a front resonance which means that there is a focus of energy in the front of the mouth (lips and teeth.) Standard American English is unique in that the resonance is focused on the back of the tongue.

Treva Graves is a speech language pathologist and a communication coach based in Sioux Falls.

Very often, English speakers are different from other languages in that it is the most oral common language. When people speak ESL, they bring the characteristics of their “mother” tongue into their communication pattern, which often includes nasality.

Learning Opportunities Check out MED’s online calendar for upcoming events and CME opportunities


Midwest Medical Edition

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