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PHYSICIAN SPOTLIGHT

Fresh Images

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Sarasota Memorial has a new partner for radiology services

Brian E. Angsten, MD ON ROUNDS

By JEFF WEBB

SARASOTA - When Radiology Associates of Florida became the new provider for Sarasota Memorial Hospital Health Care System, not only did its staff expand, so did the breadth of services, depth of talent and resources available at SMH. That’s the consensus of all entities involved in this new partnership, which has been months in the making and took effect in June. A selection committee at SMH chose Radiology Associates of Florida and based its decision on the group’s ability to expand services, enhance the patient experience, control costs and further SMH’s reputation for quality care, said spokeswoman Kim Savage. “The collaboration with Radiology Associates of Florida combines the strengths of both organizations ...” said David

Sports Medicine Community Weighs In Zurich 2012 Concussion Consensus Statement clarifies issues, muddles others, exemplifies mystery of TBI ... 6

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Novaerus ‘Kryptonite’ New technology called ‘the most significant development in HAI prevention in decades’ By LyNNE JETER

When West Gables Health Care Center Administrator Marco Carrasco learned about a new technology to reduce healthcare-acquired infections (HAI) at the 120-bed skilled nursing facility in Miami, where the median age is 86 and the average short-term stay is 32 days, he immediately contacted the Tampa-based company that developed it.

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Soon after, Carrasco implemented Novaerus, the first scientifically-proven system for airborne infection control, HAI and disease prevention. Encased in small, inconspicuous units, Novaerus provides continuous airborne infection control by passing air through its patented disruptive plasma field. The process emits billions of harmless electrons that destroy the protein bio-films of viruses. It also breaks down the cell walls

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PhysicianSpotlight

Brian E. Angsten, MD Angsten Center for Pulmonary & Sleep Disorders By JEFF WEBB

SARASOTA - The title of Brian Angsten’s blog tells a full story in just a few words:

LUNGMAN45 An Obese Physician Tries to Heal Himself Break it down: Angsten is a pulmonologist. He’ll soon be 45 years old. He is obese, tipping the scales at more than 300 pounds. And the goal is about personal healing. But as one reads more closely, Angsten’s thoughtful and refreshingly candid musings emerge as motivational, educational and inspirational. More on the blog later. First, some background. Angsten is in solo practice in Sarasota, where his patients avail themselves of any one of his four board-certified specialties: Pulmonary disease, internal medicine, critical care medicine and sleep medicine. During the season he sees upward of 20 patients per day. He’s up at 4:30 and doing rounds at two hospitals, Sarasota Memorial and Doctors Hospital of Sarasota. “I start at the hospitals because pulmonary care is critical care and you really have to be there to come up with a plan for the day (for the patients),” Angsten said. He’s in the office by about 10 a.m. Angsten’s work at Doctors Hospital was recognized recently when he was named 2013 Physician of the Year. The award is bestowed by employees of the hospital through an anonymous nomination and voting process. “The staff – nurses, therapists, and other employees who are not physicians – decided,” Angsten said. “That’s why it meant so much to me.” “I’ve loved working at Doctors. The things I love most are the people, the nursing staff, even the administrators. People have been very nice to me and are goodhearted. They do a good job by the patients. (The hospital) is smaller, so it’s easier to get to know people there,” he said. It also may be a bit easier for Angsten to get to know people because of his roots and relations in Florida. He grew up in Inverness and Clearwater. He completed his undergraduate studies at St. Petersburg Junior College and the University of Florida in Gainesville. He attended medical school at the University of Miami, where he met Joelle, a Sarasota native. The physicians married in their fourth year of school and matched for residency programs at the Kalamazoo Center for Medical Studies in Michigan. “We actually enjoyed living there, but we are Floridians and we had a baby so we wanted to be nearer family and the sunshine,” Angsten said. Joelle’s family is in Sarasota and his mom lives in medicalnews

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Bradenton. He and Joelle now have three children, a 17-year-old daughter and boys ages 13 and 9. And they are the private motivation for tackling his obesity problem in a very public way, Angsten said, who has struggled with his weight his whole life. “I hope more than anything that I am an inspiration to my kids with this.” “As a practicing physician, it is an especially difficult burden. It gives me empathy with patients and colleagues who struggle with similar demons,” he said. “As you might imagine, it’s a little harder as a physician (who is obese) to talk to people about the complications of their obesity,” he said, acknowledging the do-as-I-say, not-as-I-do scenario. “I’ve neglected (my obesity) for a good while because I really haven’t had many complications from it. But I’m getting older and the complications are going to come.” Angsten said he wanted to lose weight without having to have surgery, and he hoped to find a way to help himself and also set an example for his patients. “I hope that by making a public proclamation that I’m going to do this, it inspires others,” he said. The blog (www.lungman45.wordpress.com), which he began to write in May, is a good way to hold himself accountable, he said. “By putting myself out there it

puts me on the hook. I just felt that if I was ever going to get motivated I was going to have to start laying it out there publicly and make myself vulnerable,” he said. And it appears that Angsten has real talent for “laying it out there” in a format that combines learning and laughter. When he started the blog he weighed 335 pounds and had a body mass index (BMI) of 46.7. His weight-loss strategy is to consume only 1,000 calories a day Monday-Friday, and only 2,000 on Saturdays

and Sundays. Exercise complements the diet. Each entry updates readers about his weight, while also offering details about what is working – and often isn’t – as he counts calories. The wit is martini-dry under entries headlined Every bite is sacred, My mother-inlaw is a great cook, Black beans are my friend, and Is there any redeeming quality to exercise? And, in a post titled The holiday hunger scale, he speculates that one may be in trouble if “You have never eaten domesticated animals before, but your pets seem a little more interesting to you” while dieting. Angsten also waxes philosophical. In one entry he draws comparisons between his journey toward weight loss and the original Star Wars movie. In another he uses late musician Bob Marley and the Rastafari religion to make a point about sacrifice and commitment. And, as one might expect, Angsten also uses his soapbox to explain the intricacies of metabolism, macronutrients and the importance of modified behavior. But regardless of the tone he uses in his cathartic endeavor, Angsten is clearly focused on his family. “I hope that if my children can learn anything from me, it’s that you don’t give up, and that the way you accomplish things is persistence,” he said.

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Novaerus ‘Kryptonite’, continued from page 1 of bacteria, and denature mold, allergens and odors. Cost effective, each unit requires less energy than a 40-watt light bulb. Environmentally, Novaerus eradicates nearly 100 percent of all airborne pathogens and reduces microbial surface counts by up to 90 percent. “We’re on the cusp of the next significant advancement in medical technology, and once healthcare facilities across the country are able to follow our lead, I expect we’ll finally see a reversal in the ever-growing numbers of HAI cases,” said Carrasco. For a before-and-after comparison, West Gables Health Care Center had 485 admissions, of which eight patients were rehospitalized for pneumonia during the sec-

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ond half of last year. During the first two months of this year with Novaerus technology, Carrasco noticed enhanced quality outcomes and a significant reduction in readmissions. Of 115 total admissions during that time frame, only three patients were re-hospitalized for pneumonia. But the real eye-opener, Carrasco said, occurred in the room of a tracheotomy patient who was highly susceptible to infection as the opening in her neck healed. “Every case is unique, but these patients are at a high risk of infection because of the openings and tubes in their necks,” he said. “The fact … this patient recovered and went home sooner than what we consider to be the standard length is remarkable.” Odor control is a bonus, said Carrasco. “When you first enter our building, you notice the air feels fresh and is completely absent of any odor,” he explained. “The Novaerus units eliminated odors in the common room and hallways, allowing us to forgo the use of harsh chemicals that simply masked smells.”

U.S. Rollout

Launched just before Christmas in Florida, the response to Novaerus has been incredible, said company CEO Kevin Maughan, who met Carrasco during the Florida Health Care Association’s (FHCA) annual convention last year. By late spring, 15 percent of Florida’s skilled nursing facilities (SNF) had implemented Novaerus. “Ninety-five percent of those who’ve tried the Novaerus system are customers,” said Maughan, who stumbled across the technology being used in the aerospace industry in 2008. “I’d eyed it for the infection control industry, of which some $15 billion is spent on surface cleanliness and hand hygiene. Yet the negative outcomes based on HAIs cost about $40 billion. It seemed the market had a problem with that. As I did more research, I learned that almost no one was treating the air.” Maughan rolled out Novaerus in the U.K. and Ireland in 2009. After a clinical trial showed a 68 percent reduction in environmental MRSAs (Methicillin-resistant Staphylococcus aureus) at a London hospital with Novaerus, the U.K. National Health Service selected it as last year’s leading air Smart Solution for HAIs. “We see ourselves as a complementary and cost-effective component of good nursing care,” said Maughan, noting that HAIs kill more people annually than breast cancer, prostate cancer, and automobile accidents combined. Maughan expedited the introduction of Novaerus to the market at an affordable price after a family member of a scientist working on the technology required a leg amputation from an HAI. The company’s medical model involves leasing the equipment to healthcare facilities for three to five years. The typical cost to a SNF is roughly $2,500 a month, Maughan said. “There are no startup fees or hidden costs or expenses,” he added. “It’s Medicare cost reportable, and we also have a money back guarantee.”

TARGET: TAMPA When Novaerus CEO Kevin Maughan was seeking a corporate home in the United States, Tampa was an easy pick. “We knew Florida well,” he said. “We wanted it to be our launch market in the U.S. Logistically, Tampa was the right place from a cost perspective. We also found rich talent in the Tampa market, which will help us dramatically increase our operations over the next few years. We were eager to be in an area with four universities and wonderful resources.” Novaerus plans to add 175 employees to its existing workforce of 25 in Tampa by mid-2014, with 35 to 45 new hires by the end of this year. “It would be helpful for us to find people with infection control backgrounds that have also worked on the commercial side of healthcare,” said Maughn. “It’s a difficult mix to find, but they’re out there.”

Kevin Maughan

Standard HAI Prevention Practices • Isolating infected patients; • Requiring staff to wash their hands after each patient examination and ensure hand hygiene stations are numerous and easily accessible; • Minimizing the use of invasive devices, such as catheters; • Wearing protective gowns, masks, gloves and other equipment; and • Cleaning surfaces with harsh chemicals. SOURCE: Novaerus.

A Brief History of Infection Control Advances In 1867, British surgeon Joseph Lister  began using carbolic acid as an antiseptic in surgical procedures, significantly reducing mortality rates from infection by 30 percent within a decade. Before, a patient could undergo a procedure successfully only to die from a postoperative infection, ward fever. In the mid-to-late 19th century, various infection control protocols were developed and adopted, which remain vigorously enforced today: hand-washing, using heat to sterilize surgical instruments, and surgical masks. Medicine won significant battles against infectious diseases, including the eradication of tuberculosis. But in the mid-20th century, bacteria started fighting back. In 1947, only a few years after the advance of mass production penicillin, Staphylococcus aureus was discovered, one of the earlier bacteria indicating penicillin resistance. In 1961, Methicillin-resistant Staphylococcus aureus (MRSA) was first detected in Britain. Now, half of all MRSA infections in the U.S. are resistant to penicillin, methicillin, tetracycline and erythromycin. More recently, worldwide outbreaks of infectious diseases such as H5N1, severe acute respiratory syndrome (SARS), and H1N1 have emerged. Earlier this year, the Centers for Disease Control and Prevention (CDC) issued a warning around the growing threat of “nightmare superbugs” that are untreatable because they’re resistant to even the most powerful antibiotics. The CDC reports this class of superbug – Carbapenem-resistant Enterobacteriaceae (CRE) – has been found only in nursing homes and hospitals. About 4 percent of acute-care hospitals, and 18 percent of long-term acute care hospitals in America, reported at least one case of dangerous CRE bacteria – germs that are resistant to most ‘last-resort’ antibiotics. SOURCE: Novaerus.

Without thinking about it consciously during his formative years, Maughan’s foray into searching for a better way to fight HAIs began in childhood, after hearing tales of frustration about it from his medical family– his father, an MD; his grandfather, a pediatric surgeon; and his great grandfather, a general surgeon. “There hasn’t been one significant development in infection control since the late 19th century,” he said, knowing early on that “as bacteria become more resistant to traditional medicines and procedures, technology must play a role in their eradication.” Infection control companies have developed technologies that create hydrogen peroxide-based fogs or vapors to reduce the risk of cross-contamination of infec-

tious diseases associated with using a rag, wipe or sponge. Because they’re labor-intensive, Novaerus doesn’t consider those solutions competition. “Time is money, more than ever,” said Maughan. “Labor is so expensive, and time spent on HAI control by the nursing staff could be spent on other patient care needs. This technological solution requires no labor costs. By comparison, our solution is very inexpensive. It works 365/24/7.” To prevent aerial dissemination, technology can accomplish what medicine and standard HAI prevention practice cannot, such as eradicating airborne and surface pathogens and significantly reducing microbial surface counts, said Maughan.

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Fresh Images, continued from page 1 Verinder, chief operating officer of Sarasota Memorial Health Care System. It is an unprecedented expansion for Radiology Associates of Florida, which has added 16 physicians to its existing 32-member staff. The practice has been based in Tampa since 1970 and the group’s “... well-seasoned team of radiologists embraces the opportunity to serve such a great community” as Sarasota, said Larry T. Smith, CEO. All the physicians who will work at SMH and its satellite imaging centers will live in the area, according to Gregg Baran, MD, a neuroradiologist who was appointed medical director of SMH’s Radiology Department. As a matter of fact, some were already here, having worked with the group that had the contract before, Radiology Associates of Sarasota. “We were one of eight groups that were invited to submit a proposal for the contract at SMH. It was a long, very straightforward process, said Baran, noting that the new agreement is for three years. Baran characterized the arrangement with SMH “as a natural fit for our group. It’s a large hospital, one of the top 50 hospitals in the U.S., and it’s a teaching hospital.” That all resonates with Radiology Associates of Florida, he said, because “we have provided high-quality radiology services at Tampa General Hospital for over 40 years.” In addition, all the physicians in the group are fellowship-trained, boardcertified subspecialists who are the primary teaching faculty for the University of South Florida’s Department of Radiology. At SMH, Radiology Associates of Florida will be working with 4th-year medical students from Florida State University, said Baran. The academic and research component was key in the decision of Justin Lee, MD, to accept the group’s offer to come to Sarasota. Lee, a vascular and interventional radiologist, said he was working just a few months ago in an academic setting at Georgetown University Hospital. “I thought the opportunity here seemed really unique because it is a large hospital and it does have a medical school associated with it. I actually specified when I interviewed that I did not want to lose some of the things I was doing in my academic career,” he said. “SMH has the facility to do research, it has an IRD (Interventional Radiology Department) and it has med students who want to participate in research,” he said. “A few of the protocols I wrote at Georgetown I am looking to bring here, and I have been warmly greeted about those plans,” said Lee. “It will add another dynamic that I am not certain was here before, making it a really multi-dimensional practice.” Sam Shube, MD, also a vascular and interventional radiologist, described Radiology Associates of Florida as a “hybrid practice. We are both a private practice and academic. We all have faculty appointments at USF and we train residents in radiology subspecialties. In addition, we cover Tampa General’s 1,000-plus beds and now Sarasota Memorial’s 806 beds.

We also cover Town and Country Hospital in Tampa,” he said. Shube and Baran pointed out the significance of the Sarasota practice to draw on physicians in the Tampa practice to provide back-up or additional coverage in certain specialties. “We will bring state-of-the-art services, with coverage in all specialties,” said Baran, including full-time coverage from a neurointerventional radiologist and a pediatric radiologist. That should translate to more comprehensive care for patients, as well as increased volume. “We perform over 280,000 imaging tests a year at the hospital’s main campus and seven neighborhood care centers,” said SMH spokeswoman Savage. “We expect our volumes the first year with the new group to remain the same as last year. But with all of the added capabilities and full time coverage of neurointerventional and pediatric radiologists, we anticipate an increase in subsequent years,” she said. The hospital also will purchase more than $1 million in new equipment specifically for the radiology department, said Savage, including: A new interventional angiography machine for low-dose radiation, high-resolution 3D imaging. An EkoSonic endovascular system used to dissolve blood clots in the arms and legs, as well as treatment of pulmonary embolisms. A Radiofrequency Ablation (RFA) system (minimally invasive procedure for treating certain internal pain sources and various malignant and benign tumors). The bulk of the work they will do in Sarasota is diagnostic radiology, “probably about 90 percent,” said Baran. That means reducing turnaround times for patients going through the emergency room, for example. “We measure that every day. Our turnaround times are expected to be 30 minutes or less for every STAT case,” he said. But Baran said he anticipates that in a few years the volume of interventional radiology services will increase significantly. “We expect it to be two to three times larger in a couple of years.” Shube added that the group is setting up a clinic for interventional radiology patients in the hospital, and that with the addition of a neurointerventional radiologist, the hospital, which is already a comprehensive stroke center, will be able to “provide 24/7 stroke service for brain tumors, brain hemorrhages and brain aneurysms.” Lee said that interventional radiology also will play a more prominent role in oncology at SMH. “When (residents) here talk about what they would do for advanced oncology care, they said they would go north to Tampa or Moffitt (Cancer Center),” he said. So, one of his goals is to establish an “advanced interventional oncology practice that would provide that level of care without (patients) having to commute. “I’d like to change that so people will feel that they are getting up-to-date, first-class medicine at SMH,” said Lee.

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Sports Medicine Community Weighs In Zurich 2012 Concussion Consensus Statement clarifies issues, muddles others, exemplifies mystery of TBI By LYNNE JETER

No RTP (return to play) on the same day, regardless of circumstances. An earlier return to light exercise, recommended. And the differential between pediatric and adult patients, clarified. Those are among the highlights of the 2012 Concussion Consensus Statement derived from the 4th International Consensus Conference on Concussion in Sport, held last November in Zurich. Every four years, the International Ice Hockey Federation, International Olympic Committee, International Rugby Board, International Federation for Equestrian Sports, and FIFA (International Federation of Association Football) host the conference, which results in an updated concussion consensus statement. “The new statement shows that we basically still don’t understand concussions, and there are many opinions on how to diagnose and treat them,” said William FeldWilliam ner, DO, a sports medi- Dr.Feldner cine specialist at South County Family & Sports Medicine and St. Anthony’s Medical Center in St. Louis,

Mo., and team physician for Lindenwood University and USA Volleyball. He’s also a board member of the Joint Commission for Sports Medicine and Science, an editorial board member of the Clinical Journal of Sports Medicine, and past president of the American Osteopathic Academy of Sports Medicine. “And, while it’s not in the (consensus) statement, there’s some interesting genetic research going on. We may eventually be able to predetermine if someone is more susceptible to concussion based on their genetic makeup.” Marc Hilgers, MD, PhD, director for sports medicine fellowship, sports medicine research, and a sports medicine physician at Level One Orthopedics Dr. Marc with Orlando Health in Hilgers Central Florida, said he didn’t expect major changes in the 2012 consensus statement. “I’ve been keeping my finger on the pulse of knowledge and I knew what was coming down the pike,” said Hilgers, also the team physician for Orlando City Soccer and the Minor League Umpire Association, medical advisor for the Florida Orthopaedic Institute, and assistant pro-

fessor of family medicine at the University of South Florida. “That’s why I wasn’t surprised, especially with the broad spectrum of specialists from all over the world who met to write the updated statement, that it

was kept general and not too progressive.” Bill Hefley, MD, an orthopedic surgeon and partner at OrthoSurgeons based in Little Rock, Ark., said the latest consensus statement Dr. Bill Hefley showed “great development in the CRT (concussion recognition tool) for lay use.” The 2008 conference resulted in the development of the Sport Concussion Assessment Tool (SCAT2), a standardized method of evaluating athletes ages 10 years and older for concussions. “This tool takes out the ‘guesswork’ and interpretation for laymen,” said Hefley. “The SCAT3 has a background section, which is a great addition to the SCAT2. Also, the SCAT3 is much more streamlined with clinician instructions on its own page, rather than after each section. The Child-SCAT3 is a great new tool for younger athletes who may sustain concussions.” Todd Ross, MS, ATC, an athletic trainer for Pulaski Academy with OrthoSurgeons, highlighted the 2012 consensus statement’s importance “because it continues the worldwide awareness of (CONTINUED ON PAGE 8)

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Noncompetes are Once Again Relevant for Recruited Doctors By JEFFREY L. COHEN

When the Stark II (Phase III) regulations were released in August, 2007, they clarified that when a hospital recruits a physician to a medical practice, the employment agreement between the medical practice and the newly recruited physician may contain practice restrictions as long as they do not “unreasonably restrict the recruited physician’s ability to practice medicine within the recruiting hospital’s service area. This stymied many medical practices which were reluctant to hire a new physician without a noncompete and nonsolicitation provision. A 2011 CMS Advisory Opinion (No. CMSAO-2011-01) changed this. The Advisory Opinion involved a pediatric orthopedist who was recruited by a hospital to a medical practice. The medical practice wanted to hire the new doctor, but was not willing to do so without a noncompetition provision and other restrictive covenants. The practice asked CMS for guidance because the Stark regs suggested that perhaps a noncompete could not be contained in the employment agreement of a physician recruited by a hospital to join a local medical practice. In fact, a prior version of the Stark regs

was clear that noncompetes were not permitted in the employment agreements of physicians recruited by hospitals. Hospital recruitment transactions involve bringing a physician into a new area and funding the start up period (usually a year). The nice thing for a medical practice is that the dollars given by the hospital to the practice (the difference between salary and benefits and collections) can run into the hundreds of thousands of dollars! The down side was that the medical practice could not tie the recruited physician’s hands with a noncompete or other similar restriction. The Advisory Opinion is, however, a game changer because it allowed the medical practice to impose a noncompete on the recruited physician. As mentioned, the practice would not hire the recruited physician without the noncompete. The noncompete had a 25 mile radius, and the Opinion cited the following relevant facts: • The recruited doctor would remain on one of five hospitals within the 25 mile zone; • The recruiting hospital’s service area extended beyond the 25 mile zone, in which there were at least three other hospitals within a one hour driving range;

• The noncompete complied with applicable state law. Based on these facts, the OIG permitted a one year noncompete because it did not “unreasonably restrict the doctor’s ability to practice in the recruiting hospital’s service area. Certainly, many other medical practices can be sure to follow suit. Physicians interested in nocompetes must be familiar with state law. Getting to the bone of the issue, noncompetes are enforceable in Florida if: • The geographic zone in the noncompete is reasonable. This depends on where the practice draws its patients. If patients come to the practice from just down the street, a ten mile radius is probably overbroad; • The duration is two years or less (though it can be longer in some limited circumstances); • The employer has complied with all of the terms of the employment agreement. If the employer has breached the contract that contains the noncompete, most courts will reject a claim to enforce it; • The employer does the type of thing that the departing employee does. If the employee is the only person

performing toe surgery for instance, and the practice will not provide toe surgery services once the employee leaves, the practice probably does not have a legitimate business interest to protect by enforcing the noncompete; and • Stopping the ex employee from practicing in the geographic zone does not create a healthcare crisis or shortage. This is tough. Very few practice areas are in such dire straits that the departure of one doctor will adversely affect the provision of such services in the area. Physicians should also be familiar with the practical aspects involved in noncompetes. Mistake 1 - Racing to litigation Going to court is a crap shoot. Once litigation begins, it takes on a life of its own and costs can be nuts, sometimes in the hundreds of thousands of dollars. You may think it’s a simple noncompete case. There rarely is such a thing. And if you sue someone on a noncompete breach, they may turn around and sue you in the same lawsuit for something. And...insurance does not cover any such claims. (CONTINUED ON PAGE 9)

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Sports Medicine, continued from page 6 concussions (and) shows the dedication the medical society has for learning more about concussions, how to recognize concussions, how to properly manage athletes with concussions, and how to properly and safely return an athlete to play after a concussion has subsided.” The only major blip noted repeatedly: the altered position on CTE (chronic traumatic encephalopathy). Hilgers called it “an interesting update … on an issue that had ‘percolated up’ since 2008.” • The 2008 section on chronic traumatic brain injury (TBI) notes: “Epidemiological studies have suggested an association between repeated sports concussions during a career and late life cognitive impairment. Similarly, case reports have noted anecdotal cases where neuropathological evidence of CTE was observed in retired football players. Panel discussion was held, and no consensus was reached on the significance of such observations at this stage. Clinicians need to be mindful of the potential for long-term problems in the management of all athletes.” • The 2012 TBI section notes that “clinicians need to be mindful of the potential for long-term problems in the management of all athletes. However, it was agreed that CTE represents a distinct tauopathy with an unknown incidence in athletic populations. It was further agreed that a cause and effect relationship has not as yet been demonstrated between CTE and concussions or exposure to contact sports. At pres-

ent, the interpretation of causation in the modern CTE case studies should proceed cautiously. It was also recognized that it’s important to address the fears of parents and athletes from media pressure related to the possibility of CTE.” “It seems unclear what their true position is between the two consensus statements and needs to be better explained,” said Ross, particularly given the unfortunate trend of former and current professional athletes taking their own lives for their families “to donate their brain … to prove CTE is in fact an issue.”

NOTABLE HIGHLIGHTS

Todd Ross

Todd Ross, MS, ATC, an athletic trainer for Pulaski Academy with OrthoSurgeons in Little Rock, Ark., emphasized other notable 2012 Concussion Consensus Statement highlights:

• In the preamble, “ … therapists, certified athletic trainers … coaches and other people” were replaced with “primarily for use by physicians and healthcare professionals,” which better addresses who should be diagnosing concussions and handling RTP decisions concerning concussions. • “Brain injury” was added to the first sentence to read: “Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain induced

Among high-profile, self-inflicted deaths in recent years are professional athletes Junior Seau, Derek Boogard, Dave Duerson, who may have been the only one to commit suicide and leave instructions donating his brain for the study of CTE. Former NFL Chicago Bears quarterback Jim McMahon has agreed to donate his brain to science after his death. Another point of controversy: concussion determination. A neuropsychologist in the field of treating concussions pointed out the 2004 consensus statement was driven largely on a grading scale (1-3) for concus-

by biomechanical forces.” “One could argue the point of, by definition, a concussion isn’t an injury but a process,” he said. “Adding the language of brain injury nullifies this objection.” • A timeline for concussion status was identified as “in some cases, symptoms and signs may evolve over a number of minutes to hours,” which could broaden the clinician’s interpretation of signs and symptoms. • The “Classification of Concussion” subtitle was changed to “Recovery of Concussion.” • In the neuropsychological assessment subtitle, the second and third paragraphs were rewritten and show less of an emphasis on the patient seeing a neuropsychologist. However, the emphasis changes to neuropsychological (NP) testing and a multidisciplinary approach to concussion management.

sion with loss of consciousness serving as a means of grading the severity of concussion, from which the 2008 consensus statement began to deviate. “My take is that a concussion is more black and white,” he said. “Either you have a concussion or you don’t. When you get into grading scales and severity ratings, you oftentimes relay misinformation to patients and the other providers involved in the case. Calling it a yes-or-no decision takes that away. Oftentimes, athletes get caught up in whether their concussion was mild or severe, which leads to poorly-based expectations about recovery. A concussion is a concussion and everybody recovers differently.” In the clinical treatment and management of concussion, the clinician is the key, said the neuropsychologist. “The consensus statements, the most recent one included, spend a lot of effort discussing sideline assessment tools, baseline testing, cognitive assessment tests, balance testing, RTP decisions, and preferred means of assessment or treatment,” he said. “All these components are tools that, when used correctly by a well-trained clinician, can be extremely valuable. But the clinician remains the most important piece in terms of concussion treatment and management. The consensus statements do very little in terms of providing practical guidelines for the clinical care of concussion with respect to the individual clinician.”

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Noncompetes are Relevant, continued from page 7

That means you are paying out of pocket for a lawsuit, the certainty of which can never be guaranteed and which will seem endless once you run out of patience or money for the process. Often, the reality is that noncompete litigation involves the strategy or seeing which party can outspend the other one. If you are an employer, ask yourself the following two questions before commencing litigation: • Does it make good economic sense to enforce the noncompete? Is the former employee a business threat? • Is there a way to work out a deal with the employee, short of litigation? In some situations, it makes no business sense to pursue a noncompete. For instance, if the employee has been employed for several months and if the patients are all referred by the employer, then the employee may not be a competitive threat to the employer. The employer will find a replacement doctor at some point and refer the business to the new doctor. Case closed. It is also possible to work out settlements before going to court. For instance, you might avoid litigation by lowering the geographic zone or the duration. You might also negotiate a buy out of the noncompete. If you are an employee who wants out of the noncompete, sit down with the employer and see if you can agree on a way out, so that both of you can have peace and move on. Mistake 2 - Doing it Yourself Noncompetes are governed by state law. There are both statutes and cases that inform lawyers about what types of noncompetes are enforceable and which are not. Do not work off of an old contract to create a new noncompete, since the laws (and the cases that construe them) change often. Do not use a friend’s noncompete, since you will not be able to tell if it will be enforceable at this time or under the circumstances that apply to you. The enforceability of noncompetes is extremely fact specific. Since noncompetes are strictly construed by courts, drafting them requires a trained eye. The Advisory Opinion marks a significant development in the area of noncompetes for physicians recruited to medical practices by hospitals. Though some states do not allow noncompetes to be applied to physicians, many states do, including Florida. Finding a way to satisfy both the federal and state authorities will be essential for ensuring an effective and enforceable noncompete. With over 24 years of healthcare law experience following his experience as legal counsel for the Florida Medical Association, Mr. Cohen is board certified by The Florida Bar as a specialist in healthcare law. With a strong background and expertise in transactional healthcare and corporate matters, particularly as they relate to physicians. Mr. Cohen can be reached at www.floridahealthcarelawfirm.com

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Skin Cancer Treatment Advancement Non-surgical alternative for treatment of NMSC eliminates scarring, better choice for older patients By LYNNE JETER

Terri Hayes Henson, MD, was aware of the underutilization of superficial radiation therapy (SRT), a non-invasive alternative treatment for non-melanoma skin cancer (NMSC) approved by the FDA in 2007. After thoroughly discussing the new modality with Mohs surgeons across the country, the dermatologist from Southaven, Miss., invested roughly $230,000 for the mobile device and room preparation expenses and began offering the modality on June 7. “Lack of awareness is the only reason why it hasn’t been widely introduced,” said Henson, the first dermatologist to offer SRT in a tri-state area. “Dermatologists in general have a knee-jerk reaction to surgery. But SRT is making a resurgence because there’s a need for this optional treatment.” Nationwide, targeted photon therapy is a favorable NMSC treatment option, thanks to improved technology and treatment protocols that allow treatment to be done on an outpatient basis for patients who are considered suboptimal candiDr. Terri Henson standing by the Sensus SRT-100 dates for surgical procedures. “The improved therapeutic moinstructor in the Department of Internal dality gives us a lot of flexibility and verMedicine at Mercer University School of satility in the treatment and management Medicine in Macon, Ga. of non-melanoma skin cancers,” dermaHenson, founder of The Dermatoltologist David Kent, MD, told members ogy Clinic of North Mississippi PLLC, of the American Academy of Dermatolsaid the investment represents “a good ogy (AAD) at its recent annual meeting. ROI” because “if I brought a Mohs sur“Until recently, all the radiation therapy geon into my practice, it would cost a lot treatment was 30 to 40 years old, withmore.” She refers patients requiring Mohs out the production of newer machines or surgery to Mohs surgeons in Memphis. any new research and development perThe SRT process, a less expensive alformed. The quality of the older machines ternative to Mohs micrographic surgery, became somewhat dated and devices betakes about two minutes per treatment in came temperamental, requiring effort to a series of 5-12 sessions on an outpatient perform radiation treatments.” basis in Henson’s office. It’s adaptable to Older SRT systems once used for non-ambulatory patients in wheelchairs; treating various types of cancer conditions their head may be immobilized with foam require long set-up procedures and larger blocks. It’s also a good option for patients space, and are challenged with costly taking blood-thinning medication. maintenance and lack of parts availability. Henson was quick to caution that With the development of newer, safer SRT, made by a Boca Raton, Fla.-based and more efficient radiation machines company that sold 60 units in 24 months that undergo rigorous annual inspections worldwide, “isn’t for everybody.” by state departments of health, along with “The ideal patient is 65 or older,” she dosimetry of the doses made much simpler explained. “There’s a risk down the line – with total fraction tables, targeted photon a delayed reaction 25 to 30 years later – of therapy is much easier to administer. An dyschromia, a disorder of pigmentation in important note: The equipment emits less the irradiated field.” radiation than a dental x-ray. Every case must be individualized, “One of the benefits of radiation thersaid Henson. apy is that we can concurrently treat mul“In certain situations, for example tiple lesions in one sitting,” said Kent, an

a 60-year-old who doesn’t want to face surgery, as long as they’re aware of the risks, I’d do it,” she said. Most insurance providers – and Medicare – approve the procedure. “Some insurers might require prior authorization,” she said. “But it’ll be less costly than the alternative, which is Mohs micrographic surgery. It’s simply another modality to treat these common malignancies.” In cases where patients have tumors with aggressive histologic growth features, such as often seen in morpheaform basal cell carcinoma, Mohs surgery may be a better treatment option. “For select patients and tumors, targeted photon therapy is an excellent option to consider,” said Kent. “In my experience, the new and improved radiation therapy technology offers us a viable, cost effective and cosmetically attractive treatment option for nonmelanoma skin cancers, and is a wonderful addition in our armamentarium.” Henson’s interest in dermatology was sparked after 1995 AAD president Rex Amonette, MD, FAAD, founder of the Memphis Dermatology Clinic and the tri-state area’s inaugural Mohs surgeon, talked to pre-med honors students at the University of Memphis. By the time she completed a rotation in dermatology during her elective fourth year at the University of Tennessee Health Science Center (UTHSC) College of Medicine in 1993, Henson was hooked. However, to get into the very competitive field, Henson worked hard to graduate third in her class. She completed her dermatology residency at UTHSC. “I liked the lifestyle opportunity that comes with dermatology, though I’m on call often since we’re the only dermatology clinic to do hospital consults with Baptist (Memorial Hospital) DeSoto,” said Henson, who has a nurse practitioner and physician assistant on staff. With research showing one in five people will develop skin cancer, and the massive baby boomer generation morphing into senior status, Henson runs a very busy practice. “I’m thrilled to offer SRT,” she said. “It won’t replace surgery by any means, but it’s a good non-invasive option for my patients who don’t want surgery. It’s a painless, wonderful treatment with excellent cure rates (98 percent effective) and cosmetic outcomes.” JULY 2013

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GrandRounds Palm Beach Cancer Institute Joins Florida’s Largest Community-Based Oncology Network Florida Cancer Specialists & Research Institute (FCS), announced that Palm Beach Cancer Institute (PBCI) joined the practice, effective June 1, 2013. According to William Harwin, M.D, President of Florida Cancer Specialists, the new merger will increase the number of locations of the state’s largest independent oncology/hematology practice and provide expanded services to cancer patients on the east coast. The merger with PBCI will add four clinical sites to the Florida Cancer Specialists’ network, extending service areas to the communities of West Palm Beach, Palm Beach Gardens, Wellington and Atlantis in Palm Beach County. Patients will now benefit from additional financial assistance programs, fully-integrated electronic medical records with a user-friendly patient portal, and increased access to the latest cuttingedge treatments. Florida Cancer Specialists & Research Institute offers a full range of oncology and hematology services, including clinical research and the use of evidencebased medicine and proactive patient support services.

Comprehensive Care Can Help ALS Patients Live Longer, Easier In medicine, there is perhaps no harder diagnosis to accept than amyotrophic lateral sclerosis (ALS). A progressive and ultimately fatal neuromuscular disease, it attacks the nerve cells in your brain and spine, immobilizing the body inch by inch, and eventually making it impossible to stand, walk, talk and breathe. Commonly referred to as Lou Gehrig’s disease — named for the famous Yankee slugger who received his diagnosis in 1939 – many die within two to five years of the onset of symptoms from respiratory illness. About 10 percent survive for 10 or more years. Although there is only one FDA approved drug, riluzole, that modestly slows the progression of ALS, several other drugs, including stem cell therapy, in clinical trials hold promise. Gregory Hanes, MD, a Sarasota neurologist who specializes in ALS and neuromuscular disorders and who heads Sarasota Memorial’s Center for Neuromuscular Disorders, a MDA/ALS Comprehensive Care Clinic, said there are other significant therapies and new treatment guidelines to manage the symptoms of ALS and help people maintain as much independence as possible and prolong survival. Among other interventions, the guidelines state that life expectancy and quality of life may increase for people with ALS who enroll early in a specialized multidisciplinary clinic to optimize

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care. The clinics combine the expertise of multiple specialties, including a neurologist, pulmonologist, respiratory therapist, physical and occupational therapists, nutritionist and mental/behavioral health specialist. Doctors do not know what causes ALS, though studies have suggested that in some cases, poisonous substances (toxins) in the environment or viruses may play a role. Researchers also are studying genetic and hormonal factors. Sarasota Memorial’s Center for Neuromuscular Disorders has been designated by the Muscular Dystrophy Association as a MDA/ALS Comprehensive Care Clinic. The multidisciplinary clinic offers: • Diagnostic and genetic testing • Coordinated care and treatment by multiple specialists • Access to clinical trials The clinic is located in Sarasota Memorial’s Institute for Advanced Medicine.

Fawcett Memorial Hospital Awarded an “A” for Patient Safety Fawcett Memorial Hospital was again, honored with an “A” Hospital Safety ScoreSM by The Leapfrog Group, an independent national nonprofit run by employers and other large purchasers of health benefits. The Hospital Safety ScoreSM was calculated under the guidance of The Leapfrog Group’s Blue Ribbon Expert Panel using publicly available data on patient injuries, medical and medication errors, and infections. U.S. hospitals were assigned an A, B, C, D, or F for their safety. To see Fawcett Memorial Hospital’s scores as they compare nationally and locally, visitwww.hospitalsafetyscore. org, the Hospital Safety ScoreSM website, which also provides information on how the public can protect themselves and loved ones during a hospital stay. Calculated under the guidance of The Leapfrog Group’s nine-member Blue Ribbon Expert Panel, the Hospital Safety Score uses 26 measures of publicly available hospital safety data to produce a single score representing a hospital’s overall capacity to keep patients safe from infections, injuries, and medical and medication errors.

Study Finds Improved Surgical Outcomes With Robotic Arm Assisted Surgeries Initial results of an ongoing, 10-year study on partial knee replacement surgery provide clinical evidence that robotic arm assisted MAKOplasty Partial Knee Resurfacing procedures result in improved accuracy and less pain when compared to manual procedures using Oxford® implants. The study, which was conducted at the University of Strathclyde and Glasgow Royal Infirmary in Scotland, compares the outcomes of 100 partial knee replacement procedures that

involve only one compartment of the knee. Of these, 50 were robotic arm assisted MAKOplasty procedures, and 50 were performed manually without robotic arm assistance. The researchers found that: · MAKOplasty patients experienced significantly lower post-operative pain from day one up to 8 weeks after surgery 1 · Using robotic arm assistance, implants were placed with higher accuracy in all six component measures evaluated in the study, with four of the six showing statistical significance 1 · A significantly higher percentage of MAKOplasty patients (57 percent vs. 26 percent) had excellent American Knee Society Scores -- a widely used functional outcome measure for knee surgery -- compared with those who had manual procedures 1 These findings were presented at the American Academy of Orthopaedic Surgeons 2013 Annual Meeting in Chicago. Lakewood Ranch Medical Center has been offering MAKOplasty Partial Knee Resurfacing since November, 2012. Partial knee surgery is known to be challenging when done manually, and accurate placement and alignment of implants are important determinants of patient outcomes said David Cashen, MD, Medical Director of the Orthopedic Spine and Joint Center at LWRMC. The visual, auditory and tactical feedback this procedure offers enables both greater accuracy and more consistency in results he said. During MAKOplasty, the RIO system provides the surgeon with real-time visual, tactile and auditory, feedback to facilitate optimal joint resurfacing and implant positioning, which can result in a more natural feeling knee.

Peace River Heart Institute and Florida Advanced Cardiothoracic Surgery Align Peace River Regional Medical Center is opening its doors once again. This time they are inviting the community to meet Dr. Christiano Caldeira, their new cardiothoracic surgeon and founder of Florida Cardiothoracic (FACT) Surgery of Tampa. FACT Surgery is Tampa’s leading cardiothoracic group and Dr. Caldeira is an expert in cardiac surgical procedures. PRRMC has partnered with FACT Surgery to enhance its current comprehensive cardiovascular services and they have named Dr. Caldeira their new Medical Director of Cardiovascular Surgery. This alignment was created to enhance Peace River’s comprehensive cardiovascular services according to Richard Satcher, Peace River Regional Medical Center’s CEO. Medical News is pleased to provide space for press releases by providers in our Grand Rounds section. Content and accuracy of the releases is the sole responsibility of the issuer.

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Manatee-Sarasota-Charlotte Medical News July 2013  

Sarasota Memorial has a new partner for radiology services

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