FOCUS TOPICS PUBLIC HEALTH RADIOLOGY
January/February December 2014 2009 >> $5
PHYSICIAN SPOTLIGHT PAGE 3
Samuel Thomas “Tommy” Rayburn III, MD
HPV Vaccine Remarkably Effective but Use to Prevent Cervical Cancer is Low in Arkansas By BECKy GILLETTE
UAMS Assistant Professor Probes Innovative Way to Treat Pancreatic Cancer Pancreatic cancer is the fourth leading cause of cancer deaths in the country, and one of the most difficult of the solid tumors to treat ... 5
The U.S. is doing a dismal job of getting young women vaccinated for human papilloma virus (HPV), a strain of viruses that can cause cervical cancer. This is a particularly serious issue in Arkansas, said Kristin Zorn, MD, associate professor in the Department of Obstetrics and Gynecology and division director for Gynecological Oncology, University of Arkansas for Medical Sciences (UAMS). Zorn was in Pennsylvania for eight years before moving to Arkansas in May. She has seen more cases of cervical cancer since moving to Arkansas in a few months than in a couple of years in Pittsburgh, Pa. “We have a lower rate of HPV vaccination than many other parts of the country, and a high rate of cervical cancer in Arkansas,” Zorn said. “It is particularly important to improve the healthcare of Arkansas women and to prevent the next generation from having to suffer from cervical cancer the same way the current generation of Arkansas women have.” (CONTINUED ON PAGE 6)
Vaneerat Ratanatharathon, MD, MBA Professor, Founding Chair, UAMS Department of Radiation Oncology
St. Vincent Visiting Nurse Association Celebrates 75 Years
By LyNNE JETER
Providing skilled nursing care so patients can recover in the comfort of their homes has been shown to improve outcomes and reduce the incidence of the patient having to go back into the hospital ... 7
(CONTINUED ON PAGE 9) COURTESY OF UAMS/TIM TAYLOR
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When Vaneerat (pronounced Wan-er-a) Ratanatharathon, MD, was one of six children growing up in Bangkok, Thailand, in the 1960s, she didn’t question her entrepreneurial father’s orders to attend medical school. “I grew up very happy with not much thought about what I wanted to be when I grew up,” she recalled, with a laugh. “My fa-
ther wanted me to go, so I did. I found it to be very interesting and challenging. It wasn’t my choice, but it’s a very good one. I couldn’t think of anything else but being a physician.” Fortunately, two older brothers paved the way for Ratanatharathon to emigrate to the United States – once she got past the initial hurdle. “The difficulty was getting into medical
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Samuel Thomas “Tommy” Rayburn III, MD Cardiac/Thoracic Surgeon, St. Vincent Hospital, Arkansas Heart Hospital By LYNNE JETER
When Tommy Rayburn, MD, was growing up in the Mississippi Delta during the turbulent 1960s, the son of an engineer and social worker wasn’t affected by the cultural uprising that impacted much of the state and drew unfavorable national attention. “It was much more racially harmonious than other parts of the state,” said Rayburn, recalling his childhood days in Greenville, Miss. “It was an idyllic and fun place to grow up – and much more diversified than many people thought for that region of the world.” Rayburn pointed to the cultural structure, which power players – plantation owners and considerable farmers – set in motion preceding the Mississippi flood of 1927. “I recently read (in Rising Tide: The Great Mississippi Flood of 1927 and How it Changed America, Simon & Schuster, 1998) about the influence of the races working together, which also included Italians and Chinese. By the 1960s, everyone had been working together for decades, so we were somewhat insulated.” Because no family members preceded him in the healthcare profession, Rayburn didn’t initially consider a medical career. Instead, he graduated from Ole Miss with an English degree. “I picked medicine by luck,” he said. “I fell into it, probably because of my dad’s meticulous nature. The human body, especially the anatomy of the heart,
intrigued me. It’s somewhat of a technology business.” For a couple of years while studying at the University of Mississippi Medical Center (UMMC), Rayburn assisted a Baptist Medical Center heart surgeon, where he quickly learned “the ropes of how things worked,” he said. Rayburn initially considered specializing in pediatric heart surgery, but working with children who were very sick “was a difficult thing to constantly deal with,” he said. Following internship and residency training in general surgery at UMMC, Rayburn headed to the University of Florida-Shands Hospital, where he completed residency training in thoracic and cardiovascular surgery. The high-volume medical center in Gainesville, Fla., focused on minimally invasive surgical techniques.
“Great place, great time, great networking,” said Rayburn, of his days in Florida. “Only about 2,500 of us around the country do what I do, and there are only a few degrees of separation in such a small circle.” Rayburn maintains contact with colleagues in Florida, who are involved in various clinical trials offering alternatives to openheart surgery, such as an experimental mitral clip to correct leaky valves or the iliac branch stent-graft used to treat aortic and iliac aneurysms. “I’ve collaborated with some, and minimally invasive procedures will become a bigger part of what we do,” said Rayburn. “The real selling point to patients is being able to make repairs to the heart without big incisions.” Rayburn has traveled the world, giving presentations in countries like Canada, Mexico, Switzerland and Germany on varying topics, such as “Discrete Membranous Subaortic Stenosis,” “Decreased Transfusion with Microplegia,” and “Synergy between Subtherapeutic Cyclosporine and Fructose-1, 6-Diphosphate in Rat Cardiac Allografts.” “Right now, I’m working with a friend from medical school who’s a fulltime medical missionary in Kenya,” he said. “We’re in the process of setting up heart surgery there … a very exciting venture for 2014. The most important part of heart surgery is having a very strong support staff. Because it’s unlike any other medical procedure, you must have really good people around you, or otherwise it
won’t work.” When Rayburn relocated to Little Rock in 1999, he was initially drawn to the state because his wife’s family resides in Arkansas, and it was a short drive to his parents’ home. “At first, it was foreign to me, but I quickly grew to love it,” he said. “Arkansas is such a beautiful place to call home. It’s a hidden gem. Our children are very happy here, and we are, too.” Rayburn joined a practice at St. Vincent’s last summer, where hospital leaders have ramped up its heart program. “My slant is minimally invasive arrhythmia work, and I do a lot of telescopic surgeries,” he said. “We’re doing interesting and fun things that benefit our patients. We’re kicking off a clinical trial for arrhythmia surgery. We’re participating in mitral valve technology studies. There’s always some interesting new technology evolving.” Rayburn and his wife, Shelly, an RN, stay constantly on the go with three children at demanding ages – Sam, 17, Jackson, 13, and Ann Riales, 12. “Growing up as an only child, I didn’t have any idea how siblings deal with each other,” he said, with a laugh. In his spare time, Rayburn enjoys a unique mix of hobbies – golfing, cycling, hunting and reading. “I enjoy doing a lot of different things, though I’m not really good at any of them,” he joked. Concerning biking, for example, he’s quick to point out that he does “nothing hard-core like mountain biking.” “These days, when I’m not at work, I usually plan activities that involve at least one child,” he said. “This time of year, it’s hunting with the boys. There’s never a dull moment, that’s for sure.”
UAMS Radiology Department Tops with Advanced Imaging Techniques By BECKY GILLETTE
It isn’t unusual for visitors to be caught by surprise by the size and scope of the University of Arkansas for Medical Sciences (UAMS) Radiology Department. The hospital has seven magnetic resonance imaging (MRI) machines, including one with the ability to do whole body imaging. UAMS also has a portable computed tomography (CT) machine that can be used in operating rooms, and with MRI performs very sophisticated brain imaging techniques for tumor planning. “Everybody likes pictures that are in color,” said David Amerson, BSRT, assistant director for radiology, UAMS. “These are like nothing you have ever seen before.” UAMS has 185 people who work in radiology, working around the clock. Amerson said David radiology is a very dyAmerson namic service that provides care support 24/7 for their patients on all levels. “We have a very large department,” Amerson said. “We are very proud of what we do. UAMS is a very large hospital with more than 10,000 employees, which makes us the largest employer in Little Rock and the largest public employer in the state. We are a unique hospital because we have most specialties available.
So you have an EHR…
Two of the seven MRIs are 3-T, which relates to how powerful the magnets are. Most MRIs are 1.5-T. These MRI’s are placed in different areas of the hospital.” Amerson said the whole body imaging is helpful for a population of patients with multiple myeloma. The whole body imaging is used to evaluate how well the patient related treatments are working. “Multiple myeloma is a bone marrow disease that is very complicated, but we are also looking at other health conditions,” he said. “We do a sequence called a whole body diffusion scan. The scan used looks from head to toe, and creates a snapshot of information that is used to
look at patients in terms of their progress in therapy. A comparison would be a positron emission tomography (PET) scan, and we probably do more PET CT scans than anyone in the country. A diffusion scan looks like a PET CT scan with the exception that it doesn’t use any radiation. “The full body MRI represents a large percent of our MRI volume on a daily basis and was developed with Phillips Medical Systems into an important clinical tool. Another use of MRI is for brain tractography, a 3-D modeling technique using data collected by diffusion tensor imaging (DTI). Another advanced neuro imaging technique is Functional MRI where the
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patient moves an arm/leg or may read a statement with the corresponding image reflecting areas of the brain are being highlighted. In combination with DTI, the results are greatly beneficial in pre-op planning for brain tumor management.” White matter tracts are what carry nerve impulses in the brain. Amerson said the brain tractography assists surgeons with brain tumor planning and gives direction for the best approach in performing surgery. There are certain tracts you want to stay away from. Brain tractography gives surgeons a pathway of where to operate, and is a good predictor in planning brain surgeries. In addition to cancer patients, the UAMS Radiology Department has a large work effort with trauma patients. “The Trauma Center here does a tremendous job,” he said. “If you are in a car wreck, an anesthesiologist, neurosurgeon and trauma surgeon are waiting on you when you get here. UAMS has many faces. The trauma side is very dedicated to taking care of various levels of injury and the cancer side performs a very special effort to patients who have various complicated issues. We have a population of patients who come from literally all over the world because of the top medical specialists UAMS has attracted and the latest medical equipment that allows a superior level of care.” Amerson finds it refreshing to work with patients from other countries, many of whom may have known little about Arkansas or Little Rock before coming to UAMS. “They are often surprised at how well we do things,” Amerson said. “So we always welcome the opportunity to show what we can do. We like research. We like the opportunity to learn new things. We never stop as far as developing our skills, science and understanding.” Michelle Buchanan, a radiologic technologist with UAMS, said UAMS attracts a lot of doctors who do procedures not available at most hospitals. For example, neurosurgeon Erika Petersen, MD, (CONTINUED ON PAGE 5)
UAMS Assistant Professor Probes Innovative Way to Treat Pancreatic Cancer By BECKy GILLETTE
Pancreatic cancer is the fourth leading cause of cancer deaths in the country, and one of the most difficult of the solid tumors to treat. Wolf E. Heberlein, MD, assistant professor of radiology, University of Arkansas for Medical Sciences (UAMS), is hopeful that his current research will result in a technique to break the stroma around the tumor so it can be penetrated with anti-cancer drugs combined with short bursts of high voltage electricity. Heberlein has received a two-year, $150,000 Research Scholar Grant from the Radiological Society of North America (RSNA) Research and Education (R&E) Foundation for the research aimed at overcoming the current surgical and drug barriers for treating pancreatic cancer by using a minimally invasive, imageguided approach with electric probes. “Dr. Heberlein’s project will investigate a highly innovative and potentially effective way to treat a disease that, at present, is almost universally fatal,” said Hedvig Hricak, MD, PhD, a member of the R&E Foundation Board of Trustees and past president of the RSNA. “It exemplifies the kind of creative, clinically relevant research that the R&E Foundation was designed to support.” Heberlein picked pancreatic cancer because it is the most challenging of the solid tumors. “If it works with pancreatic cancer, I don’t see why it wouldn’t work with other solid tumor cancers,” he said. Heberlein’s translational research work entails using laboratory studies to
UAMS Radiology, continued from page 4 does deep brain stimulation for Parkinson’s patients. She also does spinal cord stimulations. Buchanan and others in her unit run a mobile CT machine, a C-Arm, that can be used in the operating room. When a surgeon is doing a procedure and needs to see a specific part of the anatomy, it is not easy to take the patient out of the operating room and get a CT scan. It saves time and is safer to do the CT scan in the operating room. Buchannan said they also use a Medtronic O-arm in the operating room. “It does 2-D and 3-D reconstruction images before the patient leaves,” she said. “If any revisions are needed, it can be done before the patient leaves the operating room. It is the only equipment like it in Arkansas.” Buchannan said their department attracts and retains skilled technologists with a lot of experience in the field. “Three of us here have almost 100 years of combined experience,” she said. “It says something about UAMS to be able to retain employees for so long.” medicalnewsofarkansas
Wolf E. Heberlein
optimize and find new ways to improve drug penetration into pancreatic cancer by improving technology already in clinical use, Irreversible Electroporation (IRE). IRE uses very short, high-voltage impulses to selectively facilitate drug penetration. Heiberlein said better drug penetration and high-voltage impulses should kill the tumor cells more reliably while reducing side effects. “The technology is in use to treat certain tumors with a NanoKnife, needles and probes, and to treat disease with electrical impulses,” he said. “We are trying to take that as a platform and build on it to improve that technology by optimizing the electricity impulses to get the drugs where they belong, into the pancreatic cancer.” Heberlein has already had e-mails from pancreatic patients wanting to try the new treatment, but the technique is
not yet ready for clinical trials. “Nothing is ready to roll right now,” he said. “Everyone wants it right now. A couple years down the road it should be ready for clinical trials. It is using an established technology, but putting these modules together in a new way. It puts things together in a foreseeable manner to have success.” If it is successful with pancreatic cancer, there is hope for its use in other cancers, like a subgroup of breast cancers that have a stroma around the tumors. The dense structure protects the cancer from conventional drug delivery like chemotherapy. “That is why most of traditional pharmacology doesn’t work because it doesn’t see the cancer,” Heberlein said. “Stroma is a like a cocoon. So we try to break through that cocoon. The main thing is the use of a special application of
electricity percutaneously. It is minimally invasive. We use image guidance to place the needles where they are needed to deliver a combination of drugs and electrical treatment, and whatever else we come up with.” One advantage of this is that it is a platform, not a one-shot application. Heberlein said with that platform, you could apply a number of different things: conventional drugs, new drugs, and nanoparticles. “We have the Center for Integrative Nanotechnology Sciences at the University of Arkansas Little Rock,” Heberlein said. “These very small particles are the dream right now for everyone. They can go everywhere because they are so small. They can induce a changed environment. They could make radiotherapy efficient. You can also incite more oxygen to make radiotherapy more efficient.” Heberlein’s grant proposal was developed under the mentorship of Michael Borrelli, PhD, professor of radiology and biophysics at the University of Arkansas for Medical Sciences (UAMS) College of Medicine and associate director of the Arkansas Nanomedicine Center. Peter Crooks, PhD, chair of the UAMS College of Pharmacy Department of Pharmaceutical Sciences, also will serve as Heberlein’s mentor.
Read Medical News of Arkansas Online: MEDICAL NEWSOF ARKANSAS.COM
Expanding our team, improving your care The Arkansas Neuroscience Institute is pleased to announce Dr. Tarek Abuelem and Dr. Stephen F. Shafizadeh are joining our team of highly specialized neurosurgery experts. Dr. Abuelem served as a post-doctoral fellow at Harvard Medical School and completed his residency at Baylor College of Medicine and MD Anderson Cancer Center. Dr. Shafizadeh completed his training at Northwestern University with an advanced surgical training-infolded fellowship in cerebrovascular and skull base surgery. Both physician completed a fellowship in microneurosurgery, cerebrovascular and skull base surgery at ANI. Along with ANI director, Dr. Ali F. Krisht, and ANI neurosurgeons Dr. Ali I. Raja and Dr. Stylianos K. Rammos,, these new physicians will add to our comprehensive range of neurosurgical services and continue to make ANI the leading destination for neurosurgical patients. Call 501-552-6400 to make a referral.
Left to right: Tarek Abuelem, M.D., and Stephen F. Shafizadeh, M.D., PhD Arkansas Neuroscience Institute Five St Vincent Circle • Suite 210, The Blanford Building • Little Rock, AR 72205 StVincentHealth.com/ANI
HPV Vaccine, continued from page 1
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The vaccine for the HPV virus, which requires three shots, is remarkably effective, Zorn said. Researchers monitored women vaccinated for abnormal Pap smears and found 98 to 100 percent success rates. That type of extremely high efficacy is so unusual in medicine that researchers watched Kristin and waited to see if there Dr.Zorn were more failures. But there weren’t. “It is really remarkable to me the success that has been achieved,” Zorn said. “The challenge when taking it from the study setting to the practice setting is that conditions are less controlled. Women might not complete all three shots. But too few women are even getting vaccinations to begin with.” Vaccination rates are dramatically lower than in other parts of the world. Most countries have a 70 percent or higher vaccination rate. Rwanda has a 90 percent vaccination rate. “The U.S. has an average rate of 35 percent or lower,” Zorn said. “In the U.S., rates of vaccinations are grouped into four regions. The region with the highest vaccination rate for adolescent girls to receive all three doses is 45-50 percent. The lowest rate is 17.6 to 25 percent. Arkansas is in that group, along with most other Southeastern states. “With boys we are seeing only a one percent vaccination rate. Even with low vaccination rates, however, we already are seeing a dramatic drop in the number of young women who have the highest risk strains of HPV. The prevalence of seeing those strains is lower even with partial vaccination. Already we are seeing in clinical practice a difference with those we are getting vaccinated.” There are a lot of factors in the low vaccination rates in Arkansas. There is a certain very vocal group that opposes vaccinations claiming they aren’t safe and have preservatives that can be harmful. “The anti-vaccine groups have lost sight of the fact we have completely altered the face of human healthcare with vaccination strategies,” Zorn said. “For example, in the past many people suffered from and died of infectious diseases in childhood and adulthood. We have turned the tide with measles, mumps and polio. And we have dramatically reduced suffering and death rates through the use of vaccinations. Because we have been so successful, people have forgotten what it is like to suffer through measles, mumps and polio.” Zorn said another reason is that many people may have not known someone with cervical cancer. And there is a stigma around it because HPV is spread through sexual contact. “Most people who have ever been sexually active have been exposed to HPV,” Zorn said. “The truth is it is part of being human to be exposed to HPV. It is a remarkable revolution in women’s
healthcare that we have the ability to prevent the side effects of HPV.” Some women may have had abnormal Pap smears that ultimately cleared up. Only a small percentage go on to have cervical cancer. The FDA has approved the vaccine for females age nine through 26. The 11and 12-year-old population is targeted because it is better to get the protection in place before sexual activity begins. “People are hesitant about the vaccine because it is associated with sexual activity,” Zorn said. “It is uncomfortable to think of your child becoming sexually active. We want to get vaccines on board before that happens at whatever age. Any skin-to-skin contact can spread HPV. Even a girl who is a virgin on her wedding night can be exposed by skinto-skin contact or can be infected by her husband.” The vaccine doesn’t treat HPV, but even women who have HPV can still benefit from a vaccination because it can protect against other strains of HPV that they don’t have. If a young woman has had an HPV infection as evidenced by genital warts or an abnormal Pap smear, Zorn recommends vaccination. The vaccines cover the two strains (HPV 16 and 18) that cause 70 percent of cervical cancer cases. “We know from previous studies that it is highly unlikely that the woman is already infected with both,” Zorn said. “She would therefore benefit from being vaccinated against a strain that she doesn’t already have. One the vaccines also includes two additional strains (HPV 6 and 11), which are the most common source for genital warts and contribute to abnormal Pap smears as well.” Zorn advocates that the HPV vaccination become a routine part of healthcare offered. It needs to be commonplace rather than treating it as a special case. “Although early stage cervical cancer is treatable and curable, it could affect fertility if it requires a hysterectomy,” Zorn said. “Even if a woman is done having children, it is a major surgery to go through that pulls women away from work and family life. In more advanced stages, even with surgery, chemotherapy and radiation, there is a possibility we won’t be able to cure it.” Commonly women are in their late 30s and 40s when they are diagnosed with advanced cervical cancer. They are in the prime of life and having to deal with a life threatening disease. “This is one of the most difficult cancers to deal with,” Zorn said. “It metastasizes widely, and can go into the bones and cause tremendous pain. It is a terrible cancer from that perspective. From a personal perspective, I want to see fewer and fewer women with cervical cancer. I want it to be a great rarity to see a woman with advanced stages of cervical cancer that we can’t treat effectively. In my ideal world, we would be preventing the vast majority of cervical cancer, and the few that happen would be caught early through Pap smear strategies.” medicalnewsofarkansas
St. Vincent Visiting Nurse Association Celebrates 75 Years of Caring for Patients in Their Homes By BECKY GILLETTE
Providing skilled nursing care so patients can recover in the comfort of their homes has been shown to improve outcomes and reduce the incidence of the patient having to go back into the hospital. Home health nurses are becoming even more important today as an integral part of a healthcare team. But it is not a new idea. The St. Vincent Visiting Nurse Association (VNA) is celebrating its 75th anniversary this year. “We were the first home health agency in the state,” said Denise Looker, LSW, MA, director of operations for the St. Vincent VNA. “We started in 1938. At the time, a need was identified in the community by the Junior League. The United Way joined with the Pulaski County Medical Society and the Junior League to form the VNA. It started out as a free-standing agency until 1996 when we were acquired by St. Vincent.” Looker said the benefits of home health are going to become more prominent as healthcare reform is instituted. Home care is the lowest cost provider. Visiting nurses can help patients make the transition from the hospital setting to the home setting. “The home health service is a bridge between not just the hospital, but the physician, medical clinics, skilled nursing facility and nursing homes,” she said. “Regardless of the setting a patient is in, home health serves as a bridge so patients don’t fall through the cracks. We make sure the patients have follow-up appointments with physicians so they don’t have to go into the hospital again. We see it as a circle, a continuum of care.” Looker, who has been with VNA for 30 years, said the service started out with just nurses and evolved to include social workers, speech therapists, physical therapists, occupational therapists and home health aides for personal care. “It really is a team approach to the patient’s care,” Looker said. “And care is different in the home than in the hospital. The patient is more comfortable and clinicians can really see the impact of the home environment on the patient. Everyone assumes patients have the perfect a layout in the house and food in the kitchen—that they have everything they need to get well. The reality is, that is not true in a lot of cases.” One of the biggest issues is making sure patients are taking their medications correctly. For fifty percent of the patients who end up back in the hospital within 30 days, it is because their medications were not properly managed. Nurses can go on into the home, find out which medications are outdated and those that have medicalnewsofarkansas
Patti Retzloff, patient with Visiting Nurse Association nurse Rosemary Terrice at Retzloff ’s home.
been replaced by other medications, and help make sure medications are organized correctly. “Sometimes we see patients with limited financial resources and medications can be very expensive, so we might have to intervene with their physician to get a different medication, one the patient can afford,” Looker said. “Some companies provide home pharmacy services, and we work with them to make sure they have what they need.” The VNA clinical staff carries laptops and can access each patient’s information no matter where they are. The nurses have access to telehealth equipment that can be put in a patient’s home when needed to remotely monitor vital signs. In addition to providing healthcare providers with the information they need to intervene when necessary, Looker said it also provides security for the patient. “It teaches them how to manage themselves better,” she said. “If they are not taking medicine or eating correctly, they will see changes in weight or blood pressure.” Jane D. Evans, PhD, RN, MHSA, an assistant professor of nursing at University of Arkansas Little Rock, worked for VNA from 1993 to 2003 as director of clinical services. She has also seen how much the VNA has helped her mother, Patricia Goss Retzloff. “I love VNA with all my heart,” Evans said. “The work they do is 100 percent focused on patient care. It is multidisciplinary. Not only are they able to go out into the community and give good nursing care, but through their patient assistance fund they are often able to meet basic needs for food and clothing for folks who are less fortunate. It is a very compre-
hensive, mission-oriented organization.” Evans said when her mother was ill in her late 60s and again in her late 70s, VNA came out and helped restore her to
fully independent function, and connected her with services she could use even after she was discharged from VNA. “Home healthcare is generally short term and extremely structured,” she said. “The patient receiving it has to be physically homebound. The goal is to restore independence so patients at least can physically perform their own care and, at best, be able to go back into the community and participate fully. Mom had a great experience with VNA.” A few months ago her mother, who is 87 now, had a spell of low sodium. VNA kicked in, came on a Friday afternoon and got her all set up so she didn’t have to go to the hospital to get fluids. They got the blood levels back in balance, and also arranged to have a physical therapist come out to help restore her strength and balance after a couple of weeks with little activity. She was also taught good cane techniques to prevent falls. “Mom feels better now than she did six months ago, which is a bit of a miracle,” Evans said. “She is back to her adorable self. Recently she was dancing at my 30th wedding anniversary celebration.”
Coping with Medical Malpractice Depositions By Karl G. Sieg, MD, MRO, FAPA
Most physicians try their best to provide quality care for their patients and do not anticipate being the subject of a medical malpractice lawsuit. However, legal complaints are a reality with which doctors have to contend. Once the patient becomes plaintiff and their attorney proceeds with formal allegations of negligence, the parties to the lawsuit then go about collecting as much pertinent information as possible well before trial occurs. This discovery phase of litigation includes carrying out legal procedures like interrogatories which are written questions to the other party in the suit that must be answered under oath. Requests for documents are also made as well as the taking of oral depositions. A deposition is another discovery procedure by which a witness’s testimony is taken under oath prior to trial. A stenographer or court reporter transcribes all of the questions and answers creating a resultant manuscript. It is the defendant physician’s deposition which is of chief importance. During the deposition, opposing counsel typically has an expansive agenda with the goal to
obtain as much information as possible. Another objective that they have in mind is to “lock-down” testimony so that what was said at deposition can be used for impeachment in the event there is inconsistent testimony at trial. The deposition experience is indeed stressful as a physician suddenly finds their integrity and actions called into question. Nevertheless, the defendant needs to be well prepared. Remember that the strengths and weaknesses of the witness are being assessed so the impression being made could potentially influence the case in a way which would aid the defense. Preparation begins with a review of the entire database so that there is a clear recollection of the case. A pre-deposition conference with the defense attorney is also obligatory and should include clarification of any potentially confusing matters. Do not attempt to conceal any information, even that which you perceive to be unfavorable from your defense team. Honesty and candidness are thus a necessity. The physician’s CV should also be checked for any discrepancies, and counsel should be alerted to any web sites or online profiles that are relevant. It is advisable to con-
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duct a mock deposition to further increase the witness’s preparedness. Despite any practice demands, the physician should plan ahead and accordingly allow sufficient time scheduling for the deposition. It is also important to be clear about the deposition’s location and do not allow it to occur at the defendant’s office. Following these suggestions will reinforce confidence during the deposition which will in turn be reflected in the final written transcript. Once the deposition begins, remember that a sworn witness is required to tell the truth. Opposing counsel will ask questions in an attempt to foster answers which might reveal new facts or open up problematic areas. The physician should make every effort to keep their answers clear and concise. Listen carefully and pause before answering to allow time so that each question asked receives prudent consideration. It is helpful to remember that the written transcript itself does not reflect the length of time it takes to answer a question. Exceptions to being brief may occur when an explanation is necessary as well as when defense counsel provides specific instruction. A particularly deceptive scheme to watch out for is a pattern of questioning by opposing counsel intended to prompt only “yes” answers making it hard to say “no” in response to a subsequent ambiguous question. The witness may ask for clarification of confusing or convoluted questions, but should never speculate, guess, or make inaccurate/unfounded statements. If the question is ultimately not understood, it should not be answered with the response simply being “I don’t know.” Alternatively, an answer may be qualified by saying “approximately” or “to the best of my memory.” Definitely avoid the use of adjectives and superlatives such as “al-
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ways” or “never” as these qualifiers can be later used to distort testimony. If questions are asked about a particular document, ask to see that document and take time to review it to make sure that it has not been quoted out of context or mischaracterized. Any pertinent concerns should be noted by the witness on the record. There are circumstances where both attorneys may wish to have a discussion “off the record.” For the witness however, remember that nothing said is ever “off the record.” Many attorneys reserve especially important questions for later on into the deposition hoping that the defendant will be less guarded, so it is important to be well rested and ask for breaks when needed. Composure and concentration must be maintained while resisting the urge to become overly emotional and hostile as there is vulnerability to behave in ways which could negatively affect the outcome of the case. Opposing counsel will test the defendant and hope for mistakes which are recorded in the transcript. Alternatively, they may wait and later on prompt for such behavior at trial. If a mistake is made, simply state for the record that you were in error and correct your statement. There are times where the physician is approached in a congenial manner as a tactic to attempt to gain additional information. And if the attorney becomes silent after an answer, the witness should resist the compulsion to continue talking. Never volunteer extra information, agree to supply any additional documents or provide other evidence. Some physicians going into a deposition believe that if they are allowed to explain their case, opposing counsel will dismiss the complaint which is in fact unlikely to occur. If the deposition is to be videotaped, realize that the recording will likely be played for the jury. It would therefore be important to dress appropriately, look directly at the camera, speak clearly and avoid long pauses in this circumstance. Fortunately, initiating a medical malpractice lawsuit and winning it are entirely different matters for the plaintiff. Only about 7 percent of medical malpractice lawsuits ultimately go to trial, and most of these, about 80 percent, result in a verdict for the defense. By being educated and thoroughly prepared, the defendant physician will not only be better able to cope with completing their deposition, but they will also enhance their likelihood of a favorable judgment.
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Vaneerat Ratanatharathon, MD, MBA, continued from page 1 school at a time when very few women were in the classroom,” she recalled. “It was extremely competitive, and you had to pass an entrance exam to see where you landed. I was too young to be nervous! Faculty of Medical Sciences was my first choice, and I landed that one.” She followed her oncologist brothers to Wayne State University in Detroit, Mich., where she directed the residency/ fellowship training program. One brother directs stem cell research at Wayne State; the other is a medical oncologist and professor at a Bangkok medical school. A board-certified radiologist, Ratanatharathon enrolled in graduate school in the late 1990s, earning an MBA with a certificate in healthcare administration from the University of Miami. Soon after, she heard that UAMS was looking to establish a Department of Radiation Oncology. “I studied for my master’s because I needed a better understanding of healthcare policy,” she said. “When I learned about the UAMS post, I thought it would be an exciting challenge, and very meaningful to set up something that’s lacking and needed. That was the impetus for applying for the position.” In 2000, UAMS brought Ratanatharathon on board. “I mapped out the department infrastructure and went about recruiting faculty,” said Ratanatharathon, who successfully established three divisions – clinical radiation oncology, medical radiation physics and informatics, and biology – and has grown the Department of Radiation Oncology to a team of more than 50 academic and clinically experienced physicians and physicists. The Department has also founded educational and training programs in medical radiation physics and medical dosimetry, the latter in conjunction with the College of Health Related Profession programs. Also, in collaboration with the College of Health Related Profession and CARTI (Central Arkansas Radiation Therapy Institute), the Department faculty assists in the Radiation Therapy
Technology program. “With two accredited training programs, we needed to recruit to replenish our manpower in the educational and training program pool,” said Ratanatharathon. “I’m still setting up the residency program in radiation oncology, the culmination of the program.” Ratanatharathon has also served nationally on the American Board of Radiology Task Force for the Development of the Written Examination and as oral board examiner for the American Board of Radiology, and instructor for the refresher course at the Radiologic Society of
North America in bone metastases. Since 2001, she has served as a member of the Panel for the Appropriateness Criteria for Bone Metastases for the American College of Radiology. “My favorite part of the job is seeing and caring for patients,” said Ratanatharathon, who has taken a 26-year-old nephew under her wings to help educate him in the U.S. “Administrative work is more challenging.” Despite a hectic schedule, Ratanatharathon has found a unique and colorful way to unwind. In her spare time, she paints with oils – portraits and landscapes.
For 37 years, CARTI has been bringing the ﬁght to cancer. Now oﬀering medical and surgical oncology, diagnostic radiology and radiation oncology, CARTI has locations throughout the state to provide convenient access for you. Mountain Home
Radiation Oncology Dr. Gary Wells
Medical Oncology Dr. Kamal Patel Wednesdays
Medical Oncology Dr. Thomas Sneed Mondays, Tuesdays & Wednesdays Morrilton Medical Oncology Dr. Lawrence Mendelsohn every third Monday
To submit or view local events visit the Medical News of Arkansas website. A user name and password are required to submit an event. Under Member Options, go to “free sign up” to register.
Medical Oncology Dr. Balan Nair Thursdays
Radiation Oncology Dr. Cheryl Payne
North Little Rock Little Rock* Stuttgart Benton
Medical Oncology Dr. Lawrence Mendelsohn Dr. Thomas Sneed Dr. Jamie Burton
Medical Oncology Medical Oncology Brad Baltz Dr. Mariann Harrington Dr. Tuesdays, Thursdays Tuesdays
Radiation Oncology Dr. Bryan Imamura
Medical Oncology Dr. Bijay Nair Thursdays
Medical Oncology Dr. Balan Nair Tuesdays
Radiation Therapy Locations
Online Event Calendar
With permission from the Dean of the College of Medicine to do outside work, the Little Rock School District commissioned her to paint a portrait of the late Dr. Don R. Roberts, which is displayed at the Don Roberts Elementary School in West Little Rock. The International Artist Magazine published her work in an instruction book on how to paint landscapes. She’s also exhibited work in shows at Greenhouse Gallery in San Antonio, Texas, and the Arts Center of the Ozarks in Springdale. “Painting is a wonderful outlet for me,” said. “It’s very therapeutic and fun.”
Medical Oncology Dr. Brad Baltz Dr. Jamie Burton Dr. Rhonda Gentry Dr. Mariann Harrington Dr. Kewen Jauss Dr. Omer Khalil Dr. Lawrence Mendelsohn Dr. Balan Nair Dr. Bijay Nair Dr. Kamal Patel Dr. Thomas Sneed Dr. Diane Wilder
Medical Oncology Locations
Head and Neck Surgery Dr. Scott Stern Radiation Oncology Dr. Xiang Gao Dr. Ann Maners Dr. Christopher Ross Dr. Michael Talbert Diagnostic Radiology Dr. Thomas Koonce Dr. Donald Norwood Dr. John Slayden
North Little Rock
Medical Oncology: Dr. Kewan Jauss Dr. Omer Khalil Dr. Lawrence Mendelsohn Dr. Kamal Patel Dr. Diane Wilder Radiation Oncology Dr. Mark Storey Dr. Christopher Pope
To make an appointment call 1-800-482-8561. For more information visit carti.com
GrandRounds UAMS Researcher Shows Estrogen May Protect Women from Severe Liver Fibrosis New research led by a University of Arkansas for Medical Sciences (UAMS) hepatologist suggests that estrogen protects women with nonalcoholic steatohepatitis (NASH) from severe liver fibrosis. The study, led by Ayako Suzuki, Ph.D., M.D., an associate professor in the UAMS College of Medicine and director of hepatology with the Central Arkansas Veterans Healthcare System, shows that premenopausal women have a reduced risk of having more severe liver fibrosis compared to men, but after menopause fibrosis severity is comparable between men and women. The finding was recently published online in Hepatology, a journal of the American Association for the Study of Liver Diseases, and was done at Duke University before Suzuki joined UAMS and the VA. If the findings of the study are confirmed by further research, then they could personalize preventative care for patients with NASH, especially ones with high risk, such as those with obesity, insulin resistance and diabetes mellitus. Nonalcoholic fatty liver disease (NAFLD) includes a range of liver disorders from simple fatty liver to NASH (fatty liver with inflammation), NASH with fibrosis and cirrhosis. With the rapid rise in obesity, diabetes and metabolic syndrome, the prevalence of NAFLD — the result of insulin resistance — has steadily increased. Studies suggest that 10 to 30 percent of the U.S. population currently have some level of NAFLD, making it the most common liver disease in the United States. Suzuki’s research team analyzed data from 541 adults with NASH who were seen at Duke University Liver Clinics and the university’s bariatric surgery center. The average age of people participating in the study was 48. Twenty-eight percent were premenopausal women, 37 percent were post-menopausal and 35 percent were men. Suzuki’s previous research looked at the relationship between NAFLD and development before and after puberty and theorized that differences in physiological levels of sex hormones related to gender, pubertal development, and menopause may modify disease progression of NAFLD. She said the study published recently was an extension of that research.
St. Bernards Home Health Named Top 500 of 2013 HomeCare Elite St. Bernards Home Health has been named to the Top 500 of the 2013 HomeCare Elite™, a recognition of the top-performing home health agencies in the United States. This marks the fifth consecutive year that St. Bernards has
been recognized for its quality performance in the field of home health. Now in its eighth year, the HomeCare Elite identifies the top 25 percent of agencies and highlights the top 100 and top 500 agencies overall. Winners are ranked by an analysis of publicly available performance measures in quality outcomes, best practice (process measure) implementation, patient experience (Home Health CAHPS®), quality improvement and consistency and financial performance. In order to be considered, an agency must be Medicarecertified and have data for at least one outcome in Home Health Compare. Out of 9,969 agencies considered, 2,496 are elite. The award is sponsored by OCS HomeCare by National Research Corporation, the leading products for home health metrics and analytics, and DecisionHealth, publisher of the most respected independent newsletter in the home care profession, Home Health Line. The St. Bernards Home Health program is designed to maintain or restore health to the highest degree possible, increasing each patient’s level of independence, while reducing the effects of disability or illness. Home health care can help shorten the length of a hospital stay, reduce hospitalization, provide an affordable alternative to nursing home or other institutional care and give a more personal quality of patient care through individual attention in the comfort of the home setting.
Baptist Health Makes Land Purchase to Build New Medical Center in Conway Baptist Health has purchased approximately 37 acres to construct a wholly owned and operated medical center in Conway to serve the growing healthcare needs of Faulkner and surrounding counties. Baptist Health is collaborating with more than 30 Conway-based physicians to develop and open the new medical center in Conway to be operated as a not-for-profit, faith-based community hospital providing comprehensive clinical services. Dr. Benjamin Dodge of Conway is chairman of a steering committee of 9 physicians representing over 30 local physicians who for This new hospital facility will address the health-care needs of Faulkner County and surrounding areas, which have experienced unprecedented population growth over the past 10 years. Baptist Health Medical CenterConway will employ approximately 425 health-care professionals and staff and be led by an experienced leadership team working closely with local physicians committed to improving the health of the community. A local full-service hospital will enhance the potential for the area’s eco-
nomic growth by contributing to an increase in local employment and providing state-of-the-art health-care services that help attract new businesses.
UAMS Offers Online Continuing Education Credits A new University of Arkansas for Medical Sciences (UAMS) website portal, learnondemand.org, allows health care professionals at any time to hear lectures and take classes online to earn continuing education (CE) credits. Anybody who has any type of Internet access from a smartphone or tablet, a laptop or a desktop, can reach the website and video lectures archived there 24 hours a day and take a class for credit, according to Sarah Rhoads Kinder, Ph.D., assistant professor in the UAMS College of Medicine Department of Obstetrics and Gynecology. Learn On Demand (LOD), a product developed under the UAMS Center for Distance Health (CDH), allows users to track all their educational hours and credits earned inside or outside the program. The site also is compliant with the CE requirements for all three national accrediting organizations for physicians, nurses and pharmacists. Among the other health professions to which LOD is approved to offer continuing education are registered dietitians, case managers, lactation consultants, physical therapists, respiratory therapists and emergency medical technicians. Although online service is directed at providing continuing education first to Arkansas health care providers, it will be available for anyone else to use for a fee. An LOD user outside Arkansas can pay on the website for a class and begin taking it right away. The UAMS CDH for several years has been offering continuing education classes through live videoconferencing. The creation of LOD began in June 2012. Kesha James, an instructional development specialist in the Center for Distance Health who has worked on the site and service since then, said one of the major challenges was finding a system that would do everything they wanted it to do. Ultimately, a system and software provided by CE City was chosen. In 2014, the Center for Distance Health plans to add a patient portal to LOD that will allow, for example, a pregnant mother with diabetes to receive video instruction in how to manage both her diabetes and her pregnancy. Funding for LOD was secured through a grant from the Health Resources and Service Administration in the U.S. Department of Health and Human Services and from the UAMS Center for Distance Health.
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E. Scott Ferguson, M.D. Outpatient Radiology Clinic, P.A. West Memphis, AR Diagnostic Radiology
Medical Professional Liability Insurance “Together, we’ve practiced medicine in Arkansas for a lot of years. It’s been a wonderful experience, and along the way, we’ve seen SVMIC serve as a source of strength for the physicians of this great state. In 2001, for example, hundreds of Arkansas physicians faced an emergency crisis when another insurance carrier ceased writing policies. SVMIC was there to save the day, with the financial strength to protect these physicians and their livelihood. That financial stability is still a hallmark of the company. SVMIC has been our choice since they first came to the Razorback state in 1989. And that’s not about to change.”
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