Orlando Medical News March 2015

PROUDLY SERVING CENTRAL FLORIDA

March 2015 December 2009 >> $5

PHYSICIAN SPOTLIGHT PAGE 3

Kavita M. Pattani, MD ON ROUNDS

Providing a Helping Hand

Florida’s free and charitable clinics receive $4.5 million in state funding ... 4

Blessing this House Grace Medical Home achieves national significance as PCMH with spiritual care

By JULIE PARKER

Susie Richetti, a mother of four who’s also a full-time student, was dismayed when her husband’s business took a financial hit.

Faced with an already shoestring budget, she didn’t know where to turn until she learned about Grace Medical Home, a low-cost clinic for uninsured patients in Orlando.

“Depression kinda sneaks up on you,” admitted Richetti. It’s great to have “an outside perspective that says, ‘Hey, you have a lot going on. It’s OK that you feel overwhelmed.’”

Grace Medical Home, which opened to patients in May 2010, is unique with its offering of spiritual care as a medical home component.

“We weren’t able to address all we wanted with our patients … it broke our hearts,” said Orlando pediatrician Marvin Hardy, MD, founder of Grace. “Spiritual care is about tending to the heart of the patient. It sums up why we’re here. If we didn’t have that aspect, we’d feel pretty empty about our accomplishments.”

A $135,000 grant from Dr. Phillips’ Charities allowed the free clinic to launch a spiritual care program.

“We’ve talked a lot about what we offer medically, but we’re also here because we feel strongly that God loves all people and calls us to love all his children, no matter what’s going on in their lives,” said Hardy, noting that 70 percent of Grace’s nearly

2,000 patients report feeling closer to God since becoming a patient. “Who follows up with the patient in the exam room whose husband just lost his job, or may need to leave their home, or received a bad diagnosis, or might be thinking dark thoughts or (CONTINUED ON PAGE 4)

Dr. Jeffrey Hartog

Facilitating the Practice of Telemedicine

Breast Reconstruction Options Winter Park plastic surgeon facilitates oncologic management of breast cancer ... 9

Legislature, FMA support legislative action to reimburse telemedicine for same rate as in-clinic visit and other benefits

By JULIE PARKER

By the time state lawmakers meet March 3 for the 2015 opening legislative session, legislation bringing Florida to the forefront of telemedicine may very well need only the polishing of a few details. Or will it? Both bills lack one important element: parity for telemedicine reimbursement.

State Sen. Aaron Bean (R-Jackson-

ONLINE: ORLANDO MEDICAL NEWS.COM

ville), a staunch supporter of telemedicine, indicated earlier this year that a proposed telemedicine bill will likely pass this session. Bean, chairman of the Senate Health Policy committee, said last year’s 26-page bill was too complex for bipartisan support.

The much shorter 2015 draft of Senate Bill 478 should facilitate the practice of remote medicine, Bean said.

The Florida TeleHealth Workgroup, (CONTINUED ON PAGE 7)

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PhysicianSpotlight

Kavita M. Pattani, MD Chair, Thoracic/Head and Neck Cancers Section, UF Health Cancer Center - Orlando Health

By JEFF WEBB

ORLANDO - When Kavita Pattani gave birth to her first child, she was a chief surgical resident whose focus on her career was laser-sharp. “I had him at 7:30 in the morning and by 10 a.m. I was making phone calls to check on my patients,” said Pattani, who only took off one week before returning fully to her duties at Louisiana State University’s Department of Otolaryngology, Head and Neck Surgery in Shreveport.

For her second and third children, Pattani “relaxed” and took off two weeks before returning to work. Now, as she plans the birth of her fourth son in May, Pattani laughs at the suggestion it might be time to consider a slightly longer postpartum break from work. “We’ll see,” she said.

That resolve is a clear reflection of the passion – and enduring intense focus – the 39-year-old has for her profession and her patients, then and now, as a head and neck surgical oncologist in the Thoracic/Head and Neck Cancers Specialty Section at UF Health Cancer Center – Orlando Health.

That clinic is “the busiest at the cancer center in terms of patient flow,” said Pattani, who came here in 2010 after finishing a fellowship at John Hopkins in Baltimore. The center is staffed by three surgeons who consult about 120 patients a week. Pattani will see about 60 of those on her two days in the clinic, and the rest of the time she can be found in the operating room, where some surgeries can take 9-10 hours as she works with surgeons who specialize in plastics and dental reconstruction.

Still, Pattani hopes to grow the practice.

“I would like to see (that department) continue to expand and gain the recognition it deserves. Through our multidisciplinary care and our excellent and dedicated staff, we are able to offer and uphold the standard of care with a state-of-the-art and evidencebased practice,” she said.

How did Pattani gravitate toward such a specialized surgical discipline? “I always wanted to be a physician,” said Pattani, the oldest of four children born and raised in Detroit and the daughter of a businessman and a registered nurse. “My parents were very influential in guiding my decision in becoming a physician and building a strong work ethic,” she said. “My parents … worked hard their entire lives in order to better their children’s futures. I saw them work opposing shifts my entire childhood in order to care for us and save for our future. I had the desire to make their dreams a reality.”

After graduating from the University of Michigan (dual majors in biology and economics), Pattani secured a Masters of Basic Medical Sciences at Wayne State University. Then she went to St. George’s orlandomedicalnews

.com

University School of Medicine in Grenada, earning her MD in 2003. That is where she embraced the loves of her life: otolaryngology and Sanjay Pattani, a medical student who would become her husband and father of their children, now aged 7, 4 and 2.

Pattani knew long ago she wanted to be a surgeon. “I had done electives in many surgical subspecialties trying to find the right fit. My husband suggested I do an elective in otolaryngology. At first, I was hesitant since medical school training and your core rotations in the clinical portion do not really focus on this super-specialized field. But I gave it a chance. I loved it! I loved the anatomy, the broad scope, and the complexities of the field. I also loved that it was a competitive and challenging field, something I also have a drive for,” said Pattani. “My mentors in residency at LSU in Shreveport played a big part in propagating my interests. They … helped me develop the skills so I could pursue my fellowship at Johns Hopkins. From my first year as an intern to my last as a chief resident, I never faltered.”

Pattani left her mark on the faculty at LSU, as well. Cherie-Ann Nathan, MD is professor and chairman of the Department of Otolaryngology, Head and Neck Surgery, at LSU Health Sciences Center

in Shreveport. She also is director of head and neck surgical oncology at the Feist-Weiller Cancer Center.

Nathan remembers Pattani as “one of those physicians who has an infectious, dynamic personality. Her smile alone makes you notice her, even before you start talking to her. She is very succinct. She always said the appropriate things and she never beats around the bush. She has a surgeon’s personality and always paid attention to details. That is what distinguishes between being good and being the best – attention to detail,” Nathan said recently.

Like Pattani, Nathan is married to a physician and has raised children while excelling in a complex, competitive field. Nathan “was a huge influence,” said Pattani.

“I could always see myself succeeding in a demanding field (as Nathan has.)”

Nathan remembers Pattani as “one of my best students ever, one of the most dynamic and technically gifted surgeons par excellence I have had the pleasure of training. … My greatest regret is that she did

stay in academics because she would have been a great role model for aspiring physicians and women surgeons.”

Pattani credits her husband Sanjay, an emergency room physician who also is chairman of the Emergency Department at Florida Hospital Waterman, as being integral to both her professional and personal success.

“I owe a lot to him for pushing me to explore out of the box. We have always been a major support for each other. We have pushed each other to reach our maximum potentials. We guide each other and partake in each other’s successes. It is crucial to me, as a successful female surgeon, to have a supportive husband,” she said.

Balancing a healthy family and social life with a demanding career is not easy, she said, but “through the continued and unfailing support of my family, I have been able to overcome this challenge.”

Pattani’s passion outside the OR and her home is nurturing her Indian culture.

In addition to English, she speaks Hindi

Orlando Office 80 W. Michigan Street Orlando, FL 32806

(CONTINUED ON PAGE 9)

Dr. Phillips Office 7460 Doc’s Grove Circle Orlando, FL 32819

Ocoee Office 10000 W. Colonial Drive, Suite 483 Ocoee, FL 34761 407-648-4323 Clermont Office 2080 Oakley Seaver Drive Suite 100 • Clermont, FL 34711 352-241-7585

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Providing a Helping Hand Florida’s free and charitable clinics receive $4.5 million in state funding

By JULIE PARKER

For the first time in Florida’s history, state lawmakers have allocated $4.5 million to free and charitable clinics across the state that provide primary and specialty care services to uninsured and lowincome, underserved residents.

The grants, administered by the Florida Association of Free and Charitable Clinics (FAFCC) by contract with the Florida Department of Health, will allow 69 free and charitable clinics and networks to fund a variety of needs -- the acquisition of medical and dental equipment, electronic health records systems, expansion of volunteer recruitment and retention, and strategic planning for income diversification.

“Free and charitable clinics provide a much needed safety net for uninsured residents who otherwise might not be able to afford expensive medical and dental treatment and who are ineligible for subsidized coverage through the health insurance marketplace,” said Mark Cruise, a 20year industry veteran who joined the St. Petersburg-based FAFCC as executive director last July. “Our new grant program makes it possible for these organizations to build capacity (and) reach even more

people who need services.”

One hundred percent of the grant money passes through the organization to FAFCC member clinics and networks. We use none of it for administration.

The five largest grant recipients statewide are Grace Medical Home in Orlando ($177,037), Florida International University Mobile Health Center in Miami ($158,040), Shepherd’s Hope in Orlando ($157,000), Caridad Center in Boynton Beach ($150,000), and Lakeland Volunteers in Medicine in Lakeland ($145,930).

The Tampa metro area’s three largest free and charitable clinics garnered a total of $286,949 in grants. The St. Petersburg Free Clinic in St. Petersburg, Florida’s oldest free clinic established in 1970, received $98,349; Clearwater Free Clinic in Clearwater received $98,200; and the Judeo Christian Health Clinic in Tampa received $90,400.

“The grants provide funds for organizational capacity building types of initiatives,” said Cruise. “We’re very excited about the impact they’re making in enabling clinics to build a strong foundation for the long term.”

Senate President Andy Gardner, a (CONTINUED ON PAGE 6)

FAFCC MEMBER/FISCAL AGENT

CITY

GRANT

Barnabas Health Services Barnabas Center, Inc.

Fernandina Beach

Brandon Outreach Clinic Brandon Outreach Clinic, Inc.

Brandon

Caridad Center Caridad Center, Inc

Boynton Beach

Caring for Miami Mobile Health Unit Caring for Miami, Inc.

Palmetto Bay

$40,812

Catholic Charities Free Clinics Catholic Charities of Central Florida, Inc.

Orlando

$58,000

Center for Family Health Eldermed, Inc.

Tampa

$30,735

$83,675 $45,600 $150,000

Clearwater Free Clinic Clearwater Free Clinic, Inc.

Clearwater

$98,200

Community Dental Clinic Community Dental Clinic, Inc.

Clearwater

$37,400

Community Health Center of West Palm Beach Community Health Center of West Palm Beach, Inc.

West Palm Beach

$59,450

Community Health Outreach Westjax Outreach, Inc.

Jacksonville

$58,000

Community Medical Care Center Community Medical Care Center of Leesburg, Inc.

Leesburg

Community Smiles Dade County Dental Research Clinic, Inc.

Miami

$28,333 $134,782

Crescent Community Clinic Crescent of Hernando, Inc.

Spring Hill

$44,000

Englewood Community Care Clinic Englewood Community Care Clinic, Inc.

Englewood

$43,100

Epilepsy Association of Central Florida Epilepsy Association of Central Florida, Inc.

Orlando

$82,800

FIU Mobile Health Center Florida International University Foundation, Inc.

Miami

$158,040

Flagler County Free Clinic Flagler County Free Clinic, Inc.

Bunnell

$66,145

Florida Baptist Mobile Dental Unit Florida Baptist State Convention, Inc.

Jacksonville

$48,440

Florida Waterman Community Primary Health Clinic Florida Hospital Waterman Foundation, Inc.

Eustis

$40,920

Good Health Clinic Good Health Clinic, Inc.

Tavernier

$52,915

Good News Care Center Miami Baptist Association, Inc.

Miami

$38,835

Good Samaritan Free Clinic Talbot House Ministries of Lakeland, Inc.

Lakeland

$92,180

Good Samaritan Free Clinic The Good Samaritan Free Clinic, Inc.

Fort Pierce

$39,350

Good Samaritan Health Centers Good Samaritan Health Centers, Inc.

St. Augustine

$62,731

Good Samaritan Health Clinic of Pasco Good Samaritan Health Clinic of Pasco, Inc.

New Port Richey

Grace Medical Home Grace Medical Home, Inc.

Orlando

$57,110 $177,037

Health and Hope Clinic Health and Hope Clinic, Inc.

Pensacola

$48,035

Helping Hands Clinic Helping Hands Clinic, Inc.

Gainesville

$38,500

HEP Free Dental Clinic Homeless Emergency Project, Inc.

Clearwater

$42,850

Hope Medical Clinic Hope Medical Clinic, Inc.

Destin

$50,598

Jesus Clinic The Jesus Clinic, Inc.

Daytona Beach

$46,060

Judeo Christian Health Clinic Judeo Christian Health Clinic, Inc.

Tampa

$90,400

Lake Wales Free Clinic Lake Wales Care Center, Inc.

Lake Wales

Lakeland Volunteers in Medicine Lakeland Volunteers in Medicine, Inc.

Lakeland

$39,226 $145,930

(CONTINUED ON PAGE 6)

Blessing this House, continued from page 1 considering drugs?”

Grace set the bar high before it opened. Stephanie Garris, JD, executive director, joined the free clinic in November 2009, with the idea of pursuing the highest national designation possible for its patients.

“If we were going to call ourselves a medical home, which we considered an ideal model, we needed to become a nationally certified PCMH,” said Garris.

“Our board thought, wouldn’t it be cool that the low-income, uninsured would have a place like that? We set the standard to pursue that goal.”

In 2011, Grace teamed up with the University of Central Florida (UCF) College of Medicine’s Regional Extension Center (REC) to demonstrate evidencebased, patient-centered care that combines teams of healthcare providers and health information technology to help patients become more actively engaged in their own care. The National Committee for Quality Assurance (NCQA) tasked RECs nationwide with helping clinics achieve recognition as a Patient-Centered Medical Home (PCMH).

“Most free clinics have limited hours, or are open certain nights, but we’re very 4

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MARCH 2015

fortunate to be open every weekday, from 8 am to 5 pm,” said Garris.

When Grace received a three-year, Level 2 accreditation in October 2014, it became one of only 10 free clinics nationwide PCMH-designated. It may be the only free clinic in the nation to have PCMH certification and offer spiritual care.

“Many people go for the PCMH designation because they get a higher level of reimbursement from insurance companies, but we don’t get any incentive more than a plaque on the wall,” said Garris. “We knew it was the right thing to do.”

At the heart of a medical home are relationships, added Hardy.

“In particular, medical relationships,” he said. “A doctor’s office gets to know its patients. That’s exactly what the uninsured struggle to find. Nationwide, about 84 percent of uninsured aren’t part of a medical home. Grace is a place where their name is known, their chart is kept, and they return over and over.”

The average patient with chronic medical problems visits Grace 10 times a year for primary care, and three times for specialty care.

SAVE-THE-DATE On Saturday, Nov. 7, Grace Medical Home will host its singular annual fundraising event. Let’s Say Grace, a creative dinner benefitting the free clinic, will open at 5 pm for participants to set up tables. “It’s entirely up to the table host and guests to plan the theme, menu, decorations and attire for the table,” explained Stephanie Garris, executive director of Grace. Fellowship begins at 6 pm and includes a tour of the facility. After blessing the meal, dinner will be served around 7 pm, followed by a program and the result of table awards. In 2013, “Peter Pan” won the People’s Choice Award; “Roller Derby” was named Most Humorous; “The Sound of Music” Most Beautiful; “Instagram” Most Original; and “Despicable Me” Best Costume. For more information on the 2015 event, visit GraceMedicalHome.org.

“This is care they couldn’t afford to receive before becoming a patient,” said Hardy.

Garris, the only Floridian on the 12-member board of the National Association of Free & Charitable Clinics (NAFC), said Grace has had a waiting list since it opened.

“Once you become a patient, you’re able to get in same day sick visits,” she explained. “The longest time to wait is to become a patient. We add to the waiting list every single month, from 20 to 50 patients.”

Last year, Grace reported 8,500 patient visits. ER visits by Grace patients dropped 51 percent after becoming a patient, and non-urgent visits dropped 65 percent.

Grace board members, with representation from Florida Hospital and Orlando Health, initially came together while mulling ways to help the one in four Orange County residents who are uninsured.

“Everyone on the board grew up in Orlando, and several of us have been on international mission trips together,” said Hardy. “We began to assess needs in our backyard, meet with community leaders, (CONTINUED ON PAGE 9)

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MARCH 2015

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5

Providing a Helping Hand, continued from page 4 Republican from Orlando, championed the FAFCC appropriation, said Cruise.

“President Gardner has been a staunch supporter of the free and charitable clinics,” he said. “We’re very grateful for his support and that of so many other legislators – Republicans and Democrats alike in both chambers – who came together and recognized the need to support our sector in this challenging healthcare environment. It’s the kind of partnership between the state and our sector that makes sense fiscally and for the health of our vulnerable neighbors in need. We’re hopeful the appropriation continues next year. We’re working hard to inform legislators about how the money is being used this year, the difference it’s making, and why it should be continued.”

Concerning the controversy over whether to expand healthcare coverage for Floridians, Cruise firmly believes all citizens should have access to coverage and care.

“The best way to achieve that goal is through a broad, bipartisan solution that everyone can salute and get behind,” he

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said. “For our part, we’ll continue to work very hard to care for the people left behind by the Affordable Care Act. In Florida, that’s a lot of people! We’re not under any illusion that the ACA or the expansion of Medicaid will result in everyone having coverage, especially in Florida.”

Cruise has been in constant contact with state association colleagues across the country concerning trends in the free and charitable clinic sector.

“Some folks outside our industry have concluded that free and charitable clinics are closing their doors in rapid numbers due to the ACA,” he said. “That simply isn’t true. When I’ve asked about closures, none of my colleagues has noticed a trend in that direction. The few clinics across the country that have closed have simply garnered a lot of attention. (None in Florida have closed.) In contrast, most clinics report an increase in patient volume. The demand for free and charitable clinics isn’t going away. In fact, we have six new clinics across the state that are planning to open this year. That tells you a little bit about the need.”

FAFCC MEMBER/FISCAL AGENT

CITY

Lee County Volunteers in Medicine Lee County Volunteers in Medicine, Inc.

Lehigh Acres

GRANT $38,900

Light of the World Charities Light of the World Charities, Inc.

Palm City

$56,210

Light of the World Clinic Luz Del Mundo Light of the World, Inc.

Oakland Park

$45,000

Lotus Wellness Center Sundari Foundation, Inc.

Miami

$53,969

Miami Rescue Mission Clinic Miami Rescue Mission Clinic, Inc.

Miami

$50,580

Mission House Mission House, Inc.

Jacksonville Beach

$46,700

Mission Smiles Mission Tampa, Inc.

Tampa

$30,450

Muslim American Social Services Muslim American Social Services, Inc.

Jacksonville

$35,300

My Clinic Jupiter Jupiter Community Health Services, Inc.

Jupiter

$42,500

Open Door Health Center Open Door Health Center, Inc.

Homestead

$70,425

Palm Beach County Project Access Specialty Network Palm Beach County Medical Society Services, Inc.

Palm Springs

$58,500

Palm Springs Baptist Church Medical Mission Clinic Palm Springs Baptist Church, Inc. West

Palm Beach

$34,150

Samaritan’s Touch Care Center Samaritan’s Touch Care Center, Inc.

Sebring

$55,650

Senior Friendship Centers Senior Friendship Centers, Inc.

Venice

$95,225

Shepherd’s Hope Shepherd’s Hope, Inc.

Orlando

$157,000

Space Coast Volunteers in Medicine Indian River Volunteers in Medicine, Inc.

Viera

$45,000

St. Andrew Community Medical Center St. Andrew Community Medical Center, Inc.

Panama City

$70,315

St. John Bosco Clinic SSJ Health Foundation, Inc.

Miami

$68,130

St. Lucie County Health Access Network St. Lucie County Health Access Network, Inc.

Fort Pierce

$72,225

St. Petersburg Free Clinic St. Petersburg Free Clinic, Inc.

St. Petersburg

$98,349

SW Florida Free Pain Clinic Fort Myers First Church of the Nazarene, Inc.

Fort Myers

$49,300

The Haley Center First Baptist Church of Winter Haven, Inc.

Winter Haven

$44,408

The Heights Center Clinic The Heights Center, Inc.

Fort Myers

$38,955

The Way Free Medical Clinic The Way Free Medical Clinic, Inc.

Green Cove Springs

$51,400

Turning Points Community Coalition on Homelessness, Inc.

Bradenton

$61,100

University of Florida Mobile Outreach Clinic University of Florida Foundation, Inc.

Gainesville

University of Miami Pediatric Mobile Clinic University of Miami, Inc.

MIami

Virginia B. Andes Volunteer Community Clinic St. Vincent de Paul Community Health Care, Inc.

Port Charlotte

$84,500

Vision is Priceless Vision is Priceless Council, Inc.

Jacksonville

$71,221

Volunteers in Medicine Jacksonville VIM JAX, Inc.

Jacksonville

$105,860

We Care Jacksonville We Care Jacksonville, Inc.

Jacksonville

$77,600

We Care of Lake County We Care of Lake County, Inc.

Tavares

$51,800

We Care Physician Referral Network Alachua County Medical Society Foundation, Inc.

Gainesville

$73,800

Westside Samaritan’s Clinic Westside Samaritans Clinic, Inc.

Gainesville

$42,283

Willa Carson Health & Wellness Center Willa Carson Health & Wellness Center, Inc.

Clearwater

$42,406

$45,600 $105,000

$4,500,000 6

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MARCH 2015

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Facilitating the Practice of Telemedicine, continued from page 1 initiated by the Southeastern TeleHealth Resource Center (SETRC), held a summit in Orlando last December, with improved telemedicine policy at the top of the agenda. Last month, the workgroups met throughout Florida to provide insight and direction regarding the advancement of telehealth and to encourage collaboration among existing telehealth networks and programs.

“Once improved telemedicine legislation is approved and implemented, we’ll have elements in place to help facilitate its growth,” said SETRC director Rena Brewer, RN, MA. “The medical community is committed to the advancement of telehealth because of its great potential to reach more patients.”

Michael P. Smith, MA, MPA, development director of the Telemedicine Program for the Florida State University College of Medicine, and Ken Peach, executive director of the Health Council of East Central Florida, participated in a telemedicine press conference at the Florida Capitol that included Bean, Sen. Arthenia Joyner (D-Tampa), Rep. Travis Cummings (R-Clay County), and Rep. Mia Jones (D-Duval County), and garnered quite a bit of publicity.

“As Rep. Jones mentioned, after four years of effort, this may just be the year to get this legislation passed,” said Smith, noting that Miami Children’s Hospital, an early pioneer of telemedicine since 1973, Lee Memorial Health System, Florida Chamber of Commerce and Baptist Health South, among others, provided compelling demonstrations of telemedicine’s potential for Florida.

The Florida Medical Association released a position statement on telemedicine in its legislative agenda, “The FMA’s Prescription for a Healthy Florida,” supporting the use of new technologies to expand access to areas where too few physicians or a second opinion by a specialist is quickly needed.

“Our goal is to expand the use of telemedicine while ensuring high standards and providing appropriate safeguards to protect patient safety and privacy,” said Jeff Scott, FMA director of legal and governmental affairs, noting four components the statewide association believes must be accomplished: Definition of Telemedicine: Florida must clearly define the practices of telehealth, telemonitoring and telemedicine.

The definition of telemedicine must include language that requires an established patient-physician relationship and also the requirement for patient-informed consent.

Physician Accountability: Physicians using telemedicine must be licensed in Florida. To ensure the safety of Florida’s patients, these physicians should meet uniform standards of care. The Florida Board of Medicine must have jurisdiction to credential and discipline these physicians practicing medicine on Florida patients via telemedicine.

Continuing Medical Education orlandomedicalnews

.com

(CME): All physicians practicing telemedicine must comply with state laws and rules.

The best way to maintain this knowledge in an ever-changing technological landscape is for physicians to complete CME provided by their professional association.

Reimbursement: Lack of payment for telemedicine services is a significant barrier to widespread adoption of this innovative technology. Parity for face-toface consults and telemedicine consults must apply in the private insurance market and Medicaid. The physician expends the same amount of time, skill and diagnostic expertise when conducting a consult, whether face-to-face or via telemedicine.

“As with any new technology, there’s always potential for abuse,” Scott pointed out. “It’s important that insurance companies are prevented from using telemedicine physicians as ‘gatekeepers’ to deny care. In addition, health plans should by prohibited from using telemedicine to get around network adequacy requirements.”

Scott emphasized there are no reimbursement issues in either bill.

Smith suggested the lack of reimbursement “is a strategic move ... that will be addressed in subsequent years.”

The House counterpart (HB 545), introduced by Cummings and Jones, defines telehealth and telehealth provider, provides for practice standards for telehealth providers; authorizes telehealth providers to prescribe controlled substances via telehealth with exception; and provides for the maintenance and confidentiality of medical records.

Senate Bill 478 has an addition: “prohibits the use of telehealth or specified computer-controlled devices to prescribe optical devices.”

The Florida Senate Health Policy Committee unanimously voted in favor of Senate bill 478, which was amended and now more closely conforms to the House version.

“We supported the bill in the Senate Health Policy committee,” said Scott. “We’d like to do some fine tuning, and are working with the sponsors to accomplish this.”

FromthePublisher Highly targeted and intensely personal.

Those words apply to so much of this month’s edition of Medical News. The focus is on maximizing outcomes … from the push to narrow down cancer types to better understand how to target an individual’s treatment … to the realization that healthcare marketing requires a different approach from ‘one size fits all’ when it comes to allocating tight budgets to the greatest effect.

They also aptly describe Medical News. With publications in 11 markets, primarily in the Southeast, Medical News has grown to be an invaluable source of clinical and business information impacting the healthcare industry. Our readership is pretty evenly split in each market between clinicians and the executives leading health systems, practices, entrepreneurial business ventures, industry associations, and allied consulting firms covering legal, financial, technology and other industry concerns.

Someone recently asked me about our model of covering both business and clinical news. The reason, as all of you know, is simple. In today’s healthcare landscape, the two are inextricably connected. Physicians and researchers must work with an eye toward achieving the best outcomes in the most efficient, cost effective manner. Similarly, administrators recognize reimbursement is increasingly tied to patient outcomes, quality and safety. And, of course, it’s all wrapped in a maze of regulatory compliance issues that impact all sides of the equation.

In total, our readership delivers the key decision-makers that address quality, improve patient outcomes, educate the next generation of clinicians, advance the science, create disruptive technologies, provide solutions, and otherwise transform the healthcare industry. If these are the people you wish to reach, I’d love to discuss sales and partnership opportunities to help you deliver your message in a highly effective, targeted manner.

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Breast Reconstruction Options Winter Park plastic surgeon facilitates oncologic management of breast cancer

By JULIE PARKER

Winter Park plastic surgeon Jeffrey Hartog, MD, has become a “goto” specialist for breast reconstruction, using novel tissue engineering procedures incorporating fat that can even Dr. Jeffrey restore sensation in the Hartog skin over the breasts.

“Fat grafting has revolutionized the breast reconstruction landscape and made it more accessible to women,” said Hartog, noting that unfortunately, only one in three women who have mastectomies have breast reconstruction. “Many don’t even know about breast reconstruction options beyond the traditional approach, particularly those who have undergone complex therapy, because many reconstruction procedures are complex and expensive, with fairly high complication rates, especially in the face of radiation.

• This is where fat grafting for breast reconstruction really shines.”

Oncologic management of breast cancer often includes adjuvant radiation therapy, Hartog noted. “From a reconstructive plastic surgery perspective, adjuvant radiation therapy presents a number of challenges,” he said. “Problems encountered include increased capsular contracture around implants placed under radiated tissue and distortion of the breast in lumpectomy patients that significantly compromises the concept of breast-sparing surgery in the first place. The incidence of reconstruction compromise and complications in the face of adjuvant radiation therapy is as high as 50 percent in some studies.”

Recent advances in autologous fat transfer techniques provide a relatively simple method of salvaging implant reconstruction complications, while also restoring lumpectomy defects and simultaneously reversing radiation-related tissue compromise. Autologous fat transfer is a low-risk, no-incision technique that can be performed as an outpatient procedure in most cases, Hartog pointed out.

“The discovery that fat is rich in stem and regenerative cells has contributed

greatly to our understanding of the mechanism by which autologous fat transfer restores the vitality of tissue compromised by radiation therapy,” he explained. “We now understand that fat transfer provides both volume to the tissues through the adipocyte component and a true healing and regenerative component due to the action of the stem and regenerative cells associated with the microvasculature of the grafted fat.”

Staged fat transfer procedures may serve as an alternative for the full range of reconstructive procedures, from limited lumpectomy defects to full mastectomy reconstruction.

“We can also initiate fat transfer as an immediate reconstructive procedure at the time of a mastectomy,” he emphasized.

“The procedure involves a standard liposuction harvest procedure, filtration and washing of the fat and microdroplet fat injection into the recipient tissues,” he said. “Depending on the size of the defect, the number of fat transfer procedures may range from a single low-volume procedure for small lumpectomy defects to five or six procedures to reconstruct a radiated mas-

tectomy defect. Fat transfer is useful in combination with breast implants to enhance the tissue thickness and quality over the implants. Consider this procedure, known as the lipoflap technique, an alternative to other tissue flap procedures.”

Very few limitations exist for candidates of fat grafting for breast reconstruction, as even very slim women will usually have some fat to add to the breast area, even if it is to just improve the tissue coverage over an implant.

The best time to reconstruct a breast is when weight is relatively stable, Hartog noted. “When fat takes, for the most part, it’ll respond to weight changes like it would where we took it from,” he explained.

Because fat is very rich in regenerative cells, substantial evidence shows a tremendous improvement in the quality of radiated tissue beds, said Hartog.

“It’s really something that needs to be brought out not only for reconstruction,” he said, “but also for women with lumpectomies and radiation that could benefit from the relatively simple procedure of fat removed by liposuction.”

Blessing this House, continued from page 4 and dreamt about opening a medical home for uninsured, low-income patients.”

Nearly a dozen primary care physicians volunteer at the clinic weekly, along with 20 specialists once a month, accounting for 12,035 annual volunteer hours. In 2012, the value of prescription medications secured was $1.11 million.

“If a female patient has an abnormal pap smear, a colposcopy can be done here,” said Hardy. “Diabetics who are difficult to manage can see an endocrinologist here. Patients can get primary and specialty care, mental health counseling, labs, spiritual care … all under one roof. If we need to refer patients for a colonoscopy or MRI, we call on our community partners and we are so grateful for their willingness to join us in serving our neighbors in need.”

For now, Grace is located in two adjacent buildings. Rather than open a second clinic, the board would perhaps consider a larger facility. “We’re almost at capacity

now,” said Garris.

Concurrently, Grace is collaborating with UCF College of Medicine and University of Florida College of Pharmacy to run a night clinic funded by the Diebel Legacy Fund, ironically called KNIGHTS (Keeping Neighbors in Good Health through Service). Medical students, from first- to fourth-year, operate the clinic under the supervision of attending and volunteer physicians.

“It teaches medical students how to care for the underserved in the community,” said Hardy.

To augment Grace’s $1.7 million annual budget, privately funded, the clinic an annual fundraising event – Let’s Say Grace – a few weeks before Thanksgiving.

“We’re so fortunate to have such incredible community support,” said Garris.

“We could never envision Grace Medical Home would grow to the total holistic care for uninsured, low-income patients.”

www.orlandomedicalnews.com

PhysicianSpotlight

Kavita M. Pattani, MD, continued from page 3 and Punjabi, all of which were used in her home as a child. For the past two years, she has taught Hindi in Sunday school.

Pattani also is an accomplished Bollywood dancer and choreographer, a talent she demonstrated when she won the Miss India Michigan crown in 1996 and 1997, and later competed in the Miss India USA and Miss India Worldwide pageants. She also was the lead female vocalist in a 2001 Hindi film. “If I were able to live a dual orlandomedicalnews

.com

life, (singing and dancing) would be what I would pursue,” she said.

“I feel fortunate I am able to balance and embrace the Indian culture. I have the advantage of (actively) promoting the Indian culture and also loving every moment of being ALL American. Having the ability to take what I feel is good and right from both cultures has made me the person I am (and) helps me with my professional and personal interactions.”

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Professional Healthcare News For advertising opportunities, please contact John Kelly 407.701.7424 • JohnKelly@OrlandoMedicalNews.com

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Addressing the Need for Clear and Honest Communication with Seriously Ill Patients

By JAMES WRIGHT, DO

Despite the fact that chemotherapy delivered to cancer patients with a poor prognosis is intended only to provide palliation, not a cure, a national survey has found that a majority of patients with metastatic lung or colorectal cancer have false expectations regarding the curative potential of the treatment.

The survey results raise the question as to whether the needed patient-physician c onversations about palliative and end-of-life care are taking place, according to two articles published recently in The New England Journal of Medicine (NEJM).

In one article, entitled “Patients’ Expectations about the Effects of Chemotherapy for Advanced Cancer,” the authors’ findings, in summarizing the survey’s results, suggest that patients who do not know whether a treatment offers any possibility of cure may be compromised in their ability to make informed treatment decisions that are consonant with their preferences. And what is perhaps most worrisome is that this misunderstanding could represent an obstacle to optimal end-of-life planning and care.

Researchers analyzed interview responses of 1,193 patients who were diagnosed with metastatic lung or colorectal cancer between 2003 and 2005, who had discussed chemotherapy with at least one physician and who had opted to receive palliative chemotherapy. All patients were participants in the national Cancer Care

Outcomes Research and Surveillance (CanCORS) study.

Key findings Following are the key findings of the survey: • Overall, 69 percent of patients with lung cancer and 81 percent of those with colorectal cancer gave responses suggesting they did not understand that chemotherapy was very unlikely to cure their disease.

• The risk of reporting inaccurate beliefs about chemotherapy was higher among patients with colorectal cancer compared with those with lung cancer (odds ratio [OR], 1.75; 955 confidence interval [CI], 1.29 to 2.37).

• The risk of misunderstanding the intent of chemotherapy was also found to be higher among African-American patients (OR, 2.93; 95% CI, 1.80 to 4.78) and Hispanic patients (OR, 2.82; 955 CI, 1.51 to 5.27) compared with non-Hispanic white patients.

Factors such as educational level, functional status and the patient’s role in decision making were not associated with the likelihood of inaccurate expectations about the curative potential of chemotherapy.

‘A serious problem of miscommunication’ In an editorial that accompanied the NEJM article about the national survey, Tomas J. Smith, MD, and Dan L. Longo, MD, of the Sidney Kimmel Cancer Center

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at Johns Hopkins University School of Medicine, Baltimore, stated that if patients actually have unrealistic expectations of a cure from a therapy that is administered with palliative intent, the medical establishment has a serious problem with miscommunication, and this problem needs to be addressed.

Doctors Smith and Longo go on to state that studies have shown that twothirds of doctors tell patients at the initial visit that they have an incurable disease, but only about a third actually state the prognosis—at any time. The doctors wonder what conversations took place between the CanCORS study patients and their physicians. For instance, if patients were told their disease was incurable, did they not understand or did they choose not to believe what they were told? These are important questions to ask. Doctors Smith and Longo add that it is not easy to tell patients that they are going to die, so most doctors choose not to do so. This might explain their joint observation that, two months before death, half of all patients with lung cancer had not heard any of their doctors use the word ‘hospice.”

Most patients want to know whether or not they can be cured, and physicians can provide them with the information they need in order to plan for their remaining life, note Smith and Longo. They suggest the “ask, tell, ask” conversation.

• Ask patients what they want to know about their prognosis.

• Tell them what they want to know.

• Ask, “What do you now understand

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Physicians require assistance in holding conversations that acknowledge death and that help patients with life-limiting illness to understand their curability, observe Smith and Longo. And, they add, this is not one hard conversation for which doctors can muster the courage; rather, it is a series of conversations that must take place over time from the first existential threat to life” Recommendations for physicians include: • State the prognosis at the first visit.

• Appoint someone in the office to ensure that a discussion of advance directive options occurs.

• Help to schedule an informational visit from a local hospice within the first three visits.

• Offer to discuss prognosis and patient/family coping at each illness transition.

If patients are offered truthful information—repeatedly—on what is going to happen to them, they can make more informed decisions and choices regarding their plan of care, assert Smith and Longo. Doctors have the tools to help patients make these difficult decisions; they just need the gumption and incentive to use them.

Joint Commission launches educational campaign Helping seriously ill patients and their families to become proactive in understanding and seeking the services of palliative medicine and hospice is the focus of a new educational campaign from The Joint Commission. Entitled “Speak Up: What You Need to Know about Your Serious Illness and Palliative Care,” the program offers free downloadable brochures, videos and posters.

Topics addressed in the brochure include how and when to get palliative care, questions palliative care specialists might ask patients, questions for patients to ask their palliative care providers and where to get more information.

The campaign, which was launched in October 2012, was developed in collaboration with the American Academy of Hospice and Palliative Medicine, the Center to Advance Palliative Care, the Hospice and Palliative Nurses Association and the National Hospice and Palliative Care Organization.

James Wright, D.O., is a regional medical director at VITAS Healthcare, the nation’s leading provider of end-of-life care. To learn more about VITAS, please visit www.VITAS.com

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Best Practice: Evidence-Based Standards of Care

Venous Disease/Pearls and Pitfalls in Recognition and Treatment Venous disease is estimated to affect 25 million people in the United States. Venous ulcers, the most significant complication, affect approximately 500 thousand people.

More than 2 million working days are lost each year and approximately 3 billion dollars is spent treating venous disease.

In addition, venous disease is estimated to account for 1 to 3 percent of the total healthcare budget. Although venous disease cannot be avoided, greater awareness in the general population and especially among physicians can diminish the impact.

Risk factors include heredity, age, gender (females > males), hormonal (estrogen and progesterone), pregnancy, obesity, jobs Corona Phlebetatica with prolonged standing, trauma, and previous superficial or deep vein thrombosis.

Graduated compression stockings are the first line of therapy for spider telangiectasias, ankle edema and skin changes, pregnant women, or those who have jobs that entail standing for prolonged periods of time. Patients sometimes complain they are hot or hard to get on, but we must be firm and tell them about the problems that can follow. Insurance companies often insist on 3 to 6 months of conservative therapy with compression stockings prior to approving any treatment.

The majority of patients with advanced skin changes have superficial venous valvular insufficiency. Many will also have perforator or deep vein involvement.

Patients with peripheral arterial disease and/or significant type 1 diabetes must be treated cautiously. If pulses can’t be detected, or the patient has ankle/arm index less than 0.5, compression is contraindicated. In patients with chronic swelling or pain in an extremity, obvious varicosities, or florid patterns of telangiectasia (spider vein), the vascular lab is the first step in the treatment algorithm. But, a word of warning, when a venous evaluation is ordered, most hospitals and diagnostic labs perform a test for venous thrombosis. One must specifically ask for an evaluation for venous insufficiency, and even then, most exams are inadequate. A study should be performed with the patient standing using valsalva and compression maneuvers to check for valvular reflux. The deep, superficial and perforator systems should be studied and reflux times should be noted along with the vein diameters. This exam reveals whether a patient has evidence of old deep vein thrombosis with scarring or obstruction. Therapy for superficial veins should not be undertaken if there is a significant obstructive component in the deep system. I see a large number of patients who have had a venous evaluation at an outside lab and 99% of these exams are inadequate for evaluation of venous insufficiency. Patients with severe type 1 diabetes or known arterial disease should have an arterial evaluation to rule out significant disease, which might contraindicate compression or venous therapy.

Early skin changes consist of pink to red discoloration which may be blotchy and dry (stasis dermatitis). The underlying tissue may be firm. These areas should be lubricated and massaged at least two times a day. With time, a darker brown discoloration develops and the tissue becomes firmer. This is referred to as a lipodermatosclerosis.

The cause is inflammation, secondary to metalloproteinases, lymphocytes, macrophages, and red cells that traverse the capillary membrane because of the hydrostatic pressure of gravity. The brown discoloration is the result of red cell destruction with deposition of Lipodermatosclerosis feratin. This tissue is very vulnerable to ulceration. Some patients will go on to develop lymphedema with swelling of the foot because the lymphatics in the lower legs are fibrosed by the inflammation. Flare ups of this tissue frequently occur with long periods of standing, and the tissue can become erythematous and even exude fluid. Sometimes this fluid has a scaly appearance or can even appear as a white exudare. It is important to recognize this as an exacerbation of stasis dermatitis, an inflammation, not cellulitis, an infection. In these times of concern about nosocomial and opportunistic infections, we must avoid using antibiotics for this condition. The erythema will often persist for weeks, and if left on antibiotics for that period of time, patients are vulnerable to fungal infections, MRSA, and clostridia difficil colitis. The best treatment is to focus on the underlying veins, but this takes time. Use of hydrocortisone cream, elastic compression, and elevation are bridge maneuvers. Biopsy of the skin should never be an option. The only place for a biopsy is at a site of long standing ulceration, or an ulcer, which is refractory to optimal therapy to rule out cancer.

We must be aware of patient’s complaints of aching, heaviness in the leg, and swelling as the day progresses.

Varicose veins can lead to significant problems and should not treated as merely a cosmetic concern. Early attention can avoid later problems.

Venous Ulcer

Presented in Partnership by Orlando Medical News and Vascular Vein Centers Dr. Hugo V. Hart Dr. Hugo V. Hart is a board certified general surgeon with over 29 years of experience. He has been practicing in the Central Florida area for over 23 years and is currently on staff at Orlando Regional Medical Center and Florida Hospital. Dr. Hart is an active member of the American College of Phlebology, the society for vein professionals. Dr. Hart is an active member of the Hispaniola Medical Charity, the medical mission organization that has been established to provide medical care to the impoverished people in the Dominican Republic.

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In Honor of National Doctor’s Day We extend our deep appreciation to our VOLUNTEER PHYSICIANS for the thousands of hours of service donated to the men, women and children of Central Florida.

Adler, Lee, DO Achong, Ronald, DDS Acosta, Luis, DDS Aebli, Craig, DDS Agarwal, Rohitas, MD Ahmed, Fawad, MD Ahmed, Nadeem, DDS Ahmed , Khurshid , MD Ahmed, Imtiaz, MD Aina, Olubisi Olutosin, DDS Aldea, Ximena P., DDS Ali, Raza, MD Ali, Sohail, MD Alicia, Luis, DDS Aliev, Ulan, DDS Allen, John M., DDS Allen, Luis, MD Amaro, David, DDS Amilineni, Ram, MD Anderson, Kathleen E, DDS Anderson, Michael, MD Andrade, Antonio, MD Andrews, Douglas T, DDS Angulo, Jorge, DDS Anjum, Sunaya, DDS Ansari, Najm-Us-Sehr, MD Araujo, Gerson P, MD Arlonetti, Pablo, MD Armotrading, Joseph McDonald ll, MD Arnold, Daniel L, MD Arthur, Allison K., MD Ata, Joseph A., DDS Ata Edwards, Jill, DDS Atkins, James, MD Attermann , Steven, DO Aufseeser, Glenn, DPM Aujla, Narinder, MD Awan, Muhammad, MD Azbel, Alexander, MD Azizi, Abdul, DMD Azmi, Farrukh, MD Badger, Michael, DDS Bagby, Richard, MD BaiRossi, Nicole, MD Baker, Norton M., MD Baker, Robert, MD Baker, Kristy, MD Ballagas, Frances, DDS Bancroft, Laura, MD Bannout, Larry N., DDS Barinas, Froilan, DDS Barinas, Norma, DDS Barnard, Thomas, MD Barnard, Denise, MD Baron, Neil, MD Barr, Louis H., MD Barreto, Rohit, MD Barrett, Robert L., MD Barry, Brenda, MD Bates, Thomas R., MD Baylor, Jeffrey E., MD Beattie, Jeffery L., DDS Bedney, Daniel, MD Behzadi, Ali, DDS Beltran, David A, DDS Benjamin-Arias, Cavelle, MD Bermudez, Juliana P., DDS Bernal, Lissette R, DDS Berry, Stephen E., DDS Bertot, Carlos A., DDS Bhanji, Rahm, DDS Bifsha, Enea, DDS Bigsby, Glenn, DO Bigsby, Glenn E. IV, OS Bird, Eugenio F., MD Bishop, John W., DDS Blatnoy, Vitaly, MD Blue, David, DDS Boger, Gregory N., MD Bonn, Kevin T, DDS Borrero, Margarita, MD Brady, Jeffrey D., MD Bravo, Stephen, MD Breit, Bruce, MD Brint, Steven, MD Briscoe, Joshua, MD Brooks, Sherry, MD Brooks, Steven K., MD Bruno, Patricio, DO Buelvas, Christopher, MD Bullard, Timothy, MD Burchfield, Tommie, DDS Burks, Robert R., DDS Burns, Pearl K, DDS Butler, Stephen A, MD Cacho, Joaquin O.R, MD Cameron, Doris, MD Campbell, John, MD Cangiano, Thomas G., MD

Cao, Trang M, DDS Cardenas, Heydi P., DDS Carducci, Theresa, MD Carlyle-Clark, Kimberly, DDS Carmody, Erin J., DDS Carson, Thomas, MD Carter, Ben F., DDS Carter, Kirsten, MD Cassidy, David, MD Castiglioni, Analia, MD Chada, Aditya, MD Chan, Alan, MD Chapman, Enrique, MD Chard, Chris, DDS Chase, John R., MD Chau, Son, MD Chaun Yeung, Victor Luen, DDS Cheatham, Michael, MD Cheatham, Susan, MD Chen, Edem, MD Chen, Peter S., DDS Chin, Wei-Shen, MD Chiu, Jeffrey C, MD Chivukula, Krishna, MD Christain, David C, DDS Clark, Ann, MD Clark, Darwin, MD Claussen, Eric, DDS Clay, Elizabeth, DO Clayman, Allen, MD Cohen, Jeffrey M., MD Cohen, Michael J., MD Cohen, Philip L., MD Cohil, Kirk, DDS Cohn, Richard A., MD Coleman, Brian O., DDS Colimon, Liza, MD Colon-Arvelo, Agdha Merlee, DDS Colon-Bengoa, Carlos Rafael, DDS Colvin, Joseph, MD Condron, Colin, MD Conner, Michael, DDS Contestable, Clement J, DDS Cook, Gary G., DDS Cooper, Sharrel, MD Cooperman, Elliot W, MD Cornett, Benjamin, MD Cowan, David, MD Cox, William, Jr., MD Crofton, Daniel J., DMD Crossman, Bruce, MD Crotty, Christopher P., MD Cruz, Belisa, DDS Cunningham, Matthew, MD Curley, Charles Edward, DDS Curry, Susan, MD Czarniecki-Burzynski, Yolanda, MD Dandashi, Moutaz, DDS Daniel, Kathryn, DDS Daouk, Ayman, MD Davenport, William, MD Davis, David, MD Davis, Wilber, DDS Dayal, Nimesh, MD De La Fuente, Sebastin G., MD De La Roza, Melissa, MD DeForrest, Brenda, OD DeJesus, Samuel, MD Delgado, Lazaro, MD Demas, Maria, DDS Desai, Uday, MD DeWild, Chuck N., DMD Diaz, Nelson, DDS Diebel, Donald, MD Doherty, Nicole, DDS Dreifus, Leonard S., MD Dubbin, Clifford B., MD Dumios, Richard A, MD Dunn, William B, DDS Dunn, Ingrid, MD Elenberger, Charlotte, MD Ellis, George F., MD Enfinger, Ross, DDS Essary, Lydia R, MD Eubanks, William Stephen JR, MD Everett, George, MD Faas, Megan M., DDS Fakih, Faisal, MD Falco, Mark A., DDS Fatima, Rasha, DDS Feldman, Moises, MD Feuer, Kenneth R., MD Fidy, Ramez, DDS Figueroa, Ruben, DDS First, Victor R., DDS Fishberg, Alexander, MD Flatley, James P., DDS Florin, Jorge L., MD Fontaine, Pierre, MD Foss, Joseph, MD

Franceschi, Alejandro C., MD Franco, Cynthia E., OD Franklin, Joe, MD Freed, Mitchell, MD Freilich, Ira, MD Frisch, Mark, MD Fussell, Tara, DPM Gallagher, Joseph, MD Gallas, Steven, DO Gammichia, John, DMD Ganne, Sravanthi, DDS Garber, Mitchell, DO Garcia, Maria, MD Garrett, Kathryn, MD Gavino, Belinda, MD Gay, Madison, MD Gelikman, Grigory, MD George, Richard, MD George, Philip, MD Georges, Cletus, MD Gerkovich, Jack, MD Gerstenblitt, Dan, MD Gill, Charles, DDS Gindle, Jessica, DDS Glickman, Penny, MD Glosson, Charles R., DDS Gody-Rapport, Emilia M., DDS Goldberg, Avery, DDS Goldberg, Avery, DMD Golomb, Alyson, DDS Gomez, Nadia, MD Gomez, Rebecca, MD Gomez-Amador, Jorge, MD Gonzalez, Alfredo E., MD Goodman, Ira J., MD Gordy, Bruce, DDS Gordy, Caroline S, DDS Gousse, Ralph, MD Graham, Anthony T., DDS Gray, Daniel, DDS Green, Anne E,, DDS Greenbaum, Lennard, MD Greenberg, Andrew, DDS Greenberg, Martin P., DDS Greenwood, Scott D., MD Gros, Bernard, MD Gross, Howard E., MD Gross, Terrance, MD Guarneri, John, MD Guerra, Luz M., DDS Gummadapu, Ramkishan, MD Gundian, Julio, MD Gurian, Michael, MD Guthrie, George, MD Hall, Steven, DDS Hameed, Rumaisa, MD Hammoudeh, Basil, DDS Hannah, James Edward, MD Hansen, Barbara, MD Hardeman, John H., DDS Harden, David, DMD Harden, Kelly, DMD Harding, David, MD Hardy, Marvin, MD Hari, Aashiv, MD Harmon, Rhonda Leish, MD Hart, Hugo, MD Helmers, James, MD Hernandez, Caridad, MD Hernandez, Danilo R., DDS Hertz, Amy, DDS Hilal, Raouf E., MD Hinton, David, DDS Ho, Henry, MD Holehouse, Thomas G., DDS Hoover, Frederick, MD Hopkins, Lynne, MD Howell, Michael L., MD Hu, Yan Fei, DDS Hudak, Robert, MD Huether, William, MD Hughes, Laura, MD Huhn, John F., MD Hunter, Thomas, DDS Hurbanis, Matthew, MD Iheme, Chiamaka, MD Ilagan, Maria, MD Ilagan, Marlon, MD Isaacs, Karl, MD Isler, Aaron E., DDS Ismail, Salma, MD Jaber, Reem M., DDS Jablonski, David H., MD Jacobo, Elias, MD Jacobs, Daniel H., MD Jaime, Diana, MD Janmeja, Milan, MD John, Jooby, MD Johnson, Lucien Samuel, DDS Johnson, Jeremy, MD

Johnson, Jerri, MD Johnson, Seth, DO Jones, Daniel, MD Jones, Kenya N., DDS Juhasz, Jason, MD Kahn, Bernard Albert, DDS Kalidas, Kirti, MD Kallepalli, Vamsi, DDS Kalser, Gary A., MD Kalser, Gary, MD Kamat, Amit S., DDS Kang, Barry S., MD Kansol, Harvey Lee, DDS Kapil, Sanjiv, MD Kaplan, Albert A., DPM Kar, Pran, MD Katsur, Justin J., DDS Katzman, Robin, DDS Katzman, Ross, DMD Kaviani, Kia, DDS Keehbauch, Jennifer, MD Keown, Marcy L., DDS Kevin, Sherin, MD Khadka, Saraj, MD Khan, Adnan, MD Khan, Jaseem, MD Khan-Assad, Bibi, MD Kielmovitch, Izak H., MD Kilgus, William J., MD Kim, Thomas Y., MD Kim, Victor , DO King, Troy, DDS Kitson, Joanne, MD Klaiman, Allan, MD Kleckner, Kimberly, MD Knipe, Ronald C., MD Kohli, Simi, MD Koren, Daniel L., DDS Kossow, Alan, DO Kramer, Lawrence, DO Krupitsky, Andrew, DO Kuhlman, Jeffrey, MD Kumar, Mukesh, MD Kwong, Raymund, DDS Laddu, Prashanta A., MD Laliberte, Michel, DPM Landa, Jennifer, MD Lane, Timothy, DDS Larach, Sergio, MD Lavasani, Leela S., MD Lawson, Scott D., DDS Layish, Daniel, MD Lazar, Adam M., DDS Lee, Jason David, DDS Lee, Raymond, DDS Lee, Wha-Joon, MD Lee, Young S., DDS Lehman, Jeffrey J., MD Lemieux, Peter, DDS Lemoine, Jason E., MD Lipkin, Brad A., DDS Liu, Dan, MD Lizama, Anna, MD Logsdon, James B, DDS Lombana-Cano, Edward Henry, DDS Londono, Jorge, MD Lopez, Michael, DDS Lopez Torres, Minta Wood, DDS Lopez, Ricardo, MD Lopez-Cintron, Jose , MD Losada, Nelsa C., OD Lovett, Rodney, MD Lowe (Bennett), Ericka S., DDS Lu, William, MD Luzan-Magruga, Maria Emilia, DDS Madhany, Nasirdin, MD Madison, Gay, MD Madison, III, James, MD Magruder, G., Jr, MD Mahan, Mark, MD Mailler-Savage, Erica Ann, MD Maniar, Gigi, MD Manon, Aisha, DDS Mansour, Kelly C., DDS Marcos-Arenal, Joselus D., DDS Martin, Brigette, DDS Martinez, Javier, DDS Martinez, Pablo, DDS Mason, Christopher , MD Massey, Johnson P., MD Matar, Ramzi, DDS Mathias, Patrick F., MD Matos, Ruth, MD Mavrofrides, Elias, MD McCann, Sean, DO McDonald, Douglas, MD McCarus, Tamberly, MD McIntire, Amanda M, DDS McIntosh, David L., DDS McNamara, Charles, DMD

Mehta, Krishnakamal, DDS Mehta, Rahul, MD Mejia, Luis, MD Mengel, Marvin, MD Merzenich, Angela, ME Michael, Anderson, MD Miller, Kathryn E., DDS Miller, Javier, MD Miller, Mandel, MD Mina, Sherwin, MD Miner, Jean, MD Mir, Hamza M., DDS Mivrofrides, Elia, MD Mohan, Sirisha, MD Mokris, Michael S., MD Mokris, Patrick, DDS Moosa, Mohammed, MD Morales, Ofilio, DMD Morgan, Thad, DDS Morris, Len, MD Moses, Edmond Boxley lll, MD Moskowitz, Jeffrey G., MD Mund, Lawrence D., DDS Muriel, Michelle, MD Murphy, John, MD Myers, Nicole, DO Myrie-Richards, Velma, MD Nair, Rajesh, MD Nair, Santosh, MD Nasir, Shazia, MD Nathanson, Richard, MD Naughtin, Ryan, MD Needham, John, MD Nelson, John, DDS Nelson, Jeffrey, DO Nevarez, Leslie, DDS Newman, Charles E., MD Nguyen, Carolyn, DDS Nguyen, Christine Bich Hoang, DDS Nguyen, Duy T., DDS Nguyen, Hoang Long, DDS Nguyen, Maria L., DDS Nguyen, Michelle, MD Nguyn, Jennifer, DDS Nhu, Nguyen Hoang, DDS Nicola, Rania S, DDS Nieves-Quinones, Daniel A., MD Norestant, William, DDS Nowell, John, OD Nunez, Erick J., DDS Oberoi, Ravi C., DDS O’Brien, Patrick S., DDS O’Brien, John, MD O’Donnell, Arlene, DO Olmos, Rololfo, DDS Olson, John, MD Ordona, Natividad, DDS Ortiz-Castillo, Evelyn C, DDS Oshinowo, Adeoti E., MD Oshner, Richard, DDS Outlaw, James, DDS Pacheco, Carlos, MD Packing-Ebuen, Jennifer, MD Pal, Parul, MD Palmer, Sheallah, MD Panuccio, Denise, MD Panzer, David, MD Pappas, Harry R., MD Parekit, Kevin, DDS Park, Linda K, DDS Parker, Claude J. , MD Parks, Ross A., MD Parpia, Ashifa Hirani, DDS Partain, Jonathan, MD Pascarella, Eugene, DPM Pascarica, Magdalena, MD Patange, Vijay, MD Patel, Ashwinkumar, MD Patel, Chirag, MD Patel, Nishita, MD Patel, Pinkal, MD Patel, Rakesh, MD Patel, Ripak A., DDS Patel, Sushil, DDS Patel, Neel, MD Patni, Aftab, MD Paulk, Laura, MD Pederson-Buck, Lauren, MD Pedrosa, Evelyn, MD Pellarin, Robert D, DDS Perceval, Paul, MD Petrilli, Richard, DDS Petrosova, Elina, MD Phamnguyen, Bryan, DDS Philip, Philip T., DDS Phillips, Jeffrey, MD Pillai, Aravind, MD Pimental, Paul A, DDS Pinango, Kyra, MD Pinillos, Kathleen M., DDS

Steppie, Michael, MD Stieg, Frank, MD Stieg III, Frank H., MD Stine, Sandra, MD Stone, Harry C., MD Straker, Richard, MD Stricker, Jeffrey, DO Strickland, Carolyn, DDS Styne, Phillip A., MD Sutton, David Fredrick, DDS Sutton, Robert, MD Swana, Hubert, MD Taggart, John P., MD Tak, Ravi, MD Tamayo, Raul, MD Temple, Timothy John, DDS Terezides, Andonis, DDS Tesar, James, MD Thakur, Murad K, DDS Thill, Jeffrey, MD Thomas, Damita, MD Thomas, Donald, DDS Thompson, Eddie M., DDS Tibio, Abigail, DDS Tillery, Don E. Jr, DMD Timmel, Michael, MD Tipirneni, Kiran, MD Torres, Adalberto, Jr Torres, Annabell, MD Toth, George, MD Tran, Deanna, DO Tran, Diane, DDS Tran, Faye, DDS Tran, Hao Nhu, MD Tran, Truc, MD Trillo, Carlos, MD Tringas, Andrew J., DDS Trivedi, Aileen, DDS Vahidi, Navid, MD Van, Jennifer T., DDS Vandervoort, Robert, PharmD Van Dijk, Frans, MD Varela, Moncia, DDS Vargas, Lillian, MD Vaughan, David, MD Vaught, Jessica, MD Verma, Bishnu, MD Vu, Nga T., DDS Vuyyuru, Sujatha, MD Vyas, Veda, MD Wadina, Paul, MD Wagner, Curtis B., DPM Walcott, Sean A., DDS Walczak, Steven, MD Waldheim, Eddie, Jr., MD Waldman, Adam, MD Wallace, Kevin B., DDS Ward, Michael A., DDS Wardlaw, Wendi K, DDS Warner, Scott, MD Wasif, Sandra S., DDS Wasliw, Christopher, MD Watkins, Michael D., DDS Watters, Jacob, DO Weatherly, Mark, MD Weaver, Robert P., MD Weber, Rebecca, MD Webster, John Christopher, MD Weeks, Reya C., DDS Weeks, Travis A., DDS Weinstock, Rebecca Ann, DDS Westmoreland, Pamela M., DDS Wierzbicki, Joanna, MD Williams, Chris, DDS Williams, Lantana M., DDS Williams, Marcus, DDS Williams, Natalie, MD Williamson, Paul, MD Windham, Wayne, MD Wong, Carol, DDS Wozniak, Christopher, DO Wright, Chad , DDS Wright, David J. lll, OS Wu, Jiann-Jang (Eric), DDS Yao, Effie Chem, DDS Yoon, Sydney, MD Yudenfreund-Sujka, Shari, MD Yurkiewicz, Lisa A., DDS Zainib, Hameer, DDS Zak, Bret, DDS Zakari, Ahmed, MD Zang, Yingtao, DDS Zargari, John, DDS Zettlemoyer, Terry, DDS Ziajka, Paul, MD Zilioli, Armand, MD Zittel, Colleen, MD Zittel, Gregory, MD Zoch, Robert, DDS

Plumley, Donald, MD Poiley, Jeffrey E., MD Polo Cueto, Jose, MD Poppell, Magaly G., DDS Porterfield, James, MD Porth, Eli, MD Portnoy, Barry, MD Portoghese, Joseph, MD Posgai, Scott, MD Posniak, Robert, MD Poulos, Margaret, MD Powers, Bethany, DO Prince, Timothy, MD Pryor, Norman, MD Puig, Heidy, MD Qureshi, Imtiaz, MD Rahmatullah, Mehr, MD Ramesh, Seela, MD Ranjan, Rachna, DDS Rasool, Abid, MD Reddish, Gregory, DDS Reddy, Tadur, MD Reese, Bradley R., MD Reid, Anne, DDS Reid, Robert, DDS Reimer, Faith, MD Rensberry, Matthew, MD Richbourg, Samual, MD Richman, Laurence, DPM Rivera-Ramirez, Inoel, MD Rivero, Carlos A., DDS Robbins, Matthew, MD Roberts, Victor, MD Robertson, John, MD Rodriguez, Wilfredo, DDS Rodriguez, Arsenio, MD Rodriguez, Richard, MD Rogers, William, Jr, MD Romain, Josette, MD Rosenthal, Bennett, MD Ross, David Jeffery, DDS Ross, Richard M., OD Rothschild, Dennis, DDS Ruderman, William, MD Rujing, Han, MD Russow, Linda K., DDS Sadhu, Sanghamitra, MD Sadler, Larry, MD Sadowsky, Jeffrey, MD Sagar, Meenor, MD Salatich, Dale, MD Salazar, Michael, DDS Salazar, Sergio, MD Salonek, Carol M, DDS Sandifer, Johnny B., DDS Sandoval, Javier, DO Sanglang, Gabriel J., DDS Santos, Viviana S., DDS Sarvotham, Grace, MD Saunders, Holly, MD Savage, Christopher R., MD Schahdev, Manu M, DDS Schmitt, Charles Scott, DDS Schmitt, Karen, DDS Schoedler, Scott, MD Schwartz, Kerry, MD Scott, Araron J., DDS Seche, Sergio R, MD Sedaros, Steve A., DDS Seela, Srinivas, MD Serrano, Yaharia M., DDS Shaik, Naushad Abdul Salam, MD Shami, Halla F., MD Shanta, Singh, DDS Sheela, Harinath, MD Sheikh, Asad, MD Sherin, Kevin, MD Shirley-Williams, Lisa F., MD Siddiqui, Muqeet, MD Siddiqui, Sarah, MD Sidhu, Harmanjit, MD Sieger, Barry, MD Silberbusch, Marc, MD Simmonds, Arlic V. Jr., MD Simmonds, Sonia E, DDS Simms, David, DDS Simms-Cendan, Judith, MD Simpkins, Jennifer, MD Sladek, Gary, MD Smith, Craig A, DDS Smith, Susan, MD Smith, Jeffrey, MD Smith, Richard, MD Snow, Stephen, MD Solberg, Kirk H., DDS Spector, Brian C., MD St Matthew-Daniel, Tejumade, DDS Stanford, Thomas, MD Steele, William A., MD Stefan, Manuel, DMD

“Making Healthcare Available For Everyone In Our Community” Shepherd’s Hope, SpecialCare, Dental Care Access Foundation, Grace Medical Home, Florida Department of Health-Orange, and Florida Hospital Community After Hours Clinic are all members of the Primary Care Access Network (PCAN).

FOR VOLUNTEER OPPORTUNITIES, CONTACT: Maureen Kersmarki, Chairwoman, PCAN www.pcanorangecounty.com Phone: 407-836-PCAN

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Dental Care Access Foundation 407-898-1525 | Grace Medical Home 407-936-2785 | Shepherd’s Hope, Inc 407-876-6699 SpecialCare, Inc. - 407-836-2519 | Orange County Health Department 407-858-1400 x1123 We regret if a Physician’s name has been overlooked.

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More Than a Legal Look: The Business Implications of Recruitment Agreements

By JACQUELINE BAIN

Many lawyers have written extensively on the legal issues surrounding recruitment agreements, but there is an information gap out there between the discourse over the legal issues and how those issues make an impact on the actual business, the practice. When a practice decides to employ a new physician with the help of a hospital, the practice is essentially a business making a business decision. With that in mind, the practice must fully inform itself of the implications that a recruitment agreement will have on their bottom line.

In many ways, recruitment agreements are designed to foster positive interactions between recruited physicians, physician practices and hospitals. They are a useful tool for a practice to bring on a new physician without having to expend large amounts of money before the practice gains a return on its investment.

Recruitment agreements general involve a hospital “loaning” money to a physician to entice the physician to treat patients

in the hospital’s community. In the alternative, the hospital “loans” money to a practice employing a physician to affray the costs associated with the physician joining. These “loans” are forgiven over a specified time period, provided that the recruited physician continues to serve patients within the hospital’s community during that time period.

It is important to remember, however, that a recruitment agreement is first a loan. As a result, the physician and the practice may each have to agree to obligations in order to satisfy the hospital.

As such, a practice must fully inform itself of the agreement it proposes to enter into. Important questions for a practice to when employing a physician under a recruitment agreement include, but are not limited to: • Can your practice afford to repay the loan to the hospital on the terms contained in the recruitment agreement?

Hospital will often look first to the practice to repay the loan if the physician does not remain in the community during the forgiveness period.

Practices should attempt to offload this responsibility onto the physician as much as possible.

• How will the hospital filing a UCC-1 against your practice’s AR (or the recruited physician’s AR) affect your ability to obtain a practice loan in the future? Along with the actual recruitment agreement, sometimes, hospitals will file a lien against the practice until the loan is completely forgiven.

These liens may prevent the practice from obtaining any additional loans during that period.

• Is your practice prepared to repay to the hospital any money earned in excess of the physician’s loan? In the recruitment agreement and corresponding note, hospitals will sometimes require a practice to use money earned in excess of the loaned amount to pay down the loan.

• What exactly is the hospital’s guarantee designed to supplement? A hospital may require that the money it is providing will be used only toward a physician’s salary and/or employ-

ment benefits. If your practice intended to use a portion of the money to account for the increased overhead associated with employing a new physician, this is something that must be addressed with the hospital prior to receiving the loan.

• Does the practice intend to employ the physician with a non-compete?

The laws place restrictions on how restrictive a practice’s non-compete may be. Moreover, even if your noncompete is compliant with the law, many times hospitals are required to approve the non-compete as a condition of providing the loan.

As with many contracts, terms contained in recruitment agreements are often negotiable. Working closely with a hospital to create an agreement that addresses both legal and business concerns that are important to both parties is paramount.

Ms. Bain of the Florida Healthcare Law Firm is a healthcare attorney licensed exclusively in New York and has specific experience with compliance and negotiating and analyzing healthcare contracts. She can be reached via email at Jackie@ FloridaHealthcareLawFirm.com.

Medical Office Resources of Florida MOROF is a professional team of service and supplycompanies, practice administrators and healthcareprofessionals providing valuable knowledge for the Floridamedical industry through one unified source

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The Untold Story of Sleep Apnea Part 2

By BRIAN D. FUSELIER, DDS AND BARRy A. LOUGHNER, DDS, PHD

Part one of this three-part article published previously in Medical News described the double jeopardy of glucocorticoidinduced sleep debt. Here, Part 2 describes the action of adenosine on the homeostatic regulation of slow-wave, non-REM activity, and the perturbations of the highly structured architecture of normal sleep caused by adenosine modulation leading to sleep debt.

The neuroscience of sleep describes the role of adenosine as it relates to the depth of sleep. According to the homeostatic model of sleep, delta power is a measure of the depth of sleep.

Delta power is expressed by the dominance of slow waves in the EEG (1-4 Hz), and linked to sleep need and prior wakefulness. The action of adenosine on delta power is twofold: First, extracellular adenosine inhibits wake-promoting neurons in an area of the basal forebrain (BF) called the ascending reticular activating system (ARAS). Second, the release of intracellular adenosine from glial cells, and the binding of adenosine to its neuronal receptor begins a chain of events that leads to the generation of slow wave nonREM activity.

One function of sleep is considered to be the restoration of energy reserves in the brain. The brain is responsible for 25 percent of total energy consumption of the body. Interestingly, CNS neurons are incapable of storing more than 30 seconds of energy. Thus, glial cells play a restorative role in providing energy to cortical neurons. The following paragraph is dedicated to briefly unpacking the neuroglial process of energy restoration. This process begins with the principal intracellular metabolic pathway of adenosine in glial cells followed by complex interactions between 4 different membrane-bound neuronal receptors: When glial cells become energy challenged and glycogen reserves are diminished, glial cells scavenge two ADP molecules to make one high energy ATP molecule and one residual AMP molecule. AMP is degraded to adenosine which is released from glial cells and immediately has a direct effect on cortical neurons. The effect of adenosine on cortical neurons promotes very high delta power that aids in characterizing the depth of stage N3 slow-wave synchronized

Analytical data confirms, that “Illness” accounts for 39% of employee callouts.

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...Are you prepared?

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non-REM sleep. Adenosine binds with high affinity to its A1 neuronal receptor and activates it. Next, activated adenosine receptors intracellularly phosphorylate what are called slow-leak potassium (K) channels, causing an outflow of positively charged K ions, making the inside of the neuron more negative, thus hyperpolarizing the inside of the neuron. As a consequence of intracellular hyperpolarization, what follows is de-inactivation of T-type voltage-gated calcium (Ca) channels that have special properties. One property is that these special Ca channels have a lower threshold of activation than voltage-gated sodium (Na) channels at the normal resting membrane potential. De-inactivation of these Ca

channels allow any small rise in resting membrane potential to open these Ca channels.

Positively charged Ca ions rush into the cell making the inside of the neuron more positive, thus depolarizing it, thereby reaching the higher activation threshold for Na channels that open and generate a burst of low-voltage, high-amplitude Na action potentials (see Figure 1). In slow-wave non-REM sleep, these action potentials are recognized as the complex, synchronized, EEG wave forms. Multitudes of these wave forms, through time, have slower frequency and higher amplitude causing greater depth of delta power density in stage N3 slow-wave sleep. Thus, the binding of adenosine to its neuronal receptor begins a chain of events that promotes quiet sleep with high delta power in non-REM deep stage. The end result is restoration of energy reserves in the brain.

Restoration of energy reserves will

not occur completely in the setting of fragmented sleep. Examples of fragmented sleep include obstructive sleep apnea/hypopnea syndrome (OSA) or upper airway resistance syndrome (UARS). Both cause frequent fracturing of delta power density in non-REM sleep resulting in multiple micro-arousal intrusions occurring in alpha sleep stage, or awakenings showing beta EEG wave forms.

In addition, in the setting of fragmented sleep, ATP levels decrease in wake-active regions of the BF due to increased energy consumption. As a result, extracellular adenosine accumulates selectively in the ARAS. As a homeostatic sleep regulatory agent, adenosine promotes the transition from wakefulness to sleep by inhibition wake-promoting BF neurons. Administration of A1 receptor agonists promote sleep and enhance deep delta power density necessary for restorative sleep. Thus, at accumulated levels, adenosine is available in the ARAS to, at least temporarily, compensate for micro-arousals and awakenings by the inhibition of wake-generating neurons.

Moreover, what antagonizes sleep with high delta power in non-REM activity, and antagonizes the inhibition of wakepromoting ARAS neurons is caffeine. Caffeine is used by 85 percent of Americans, many to ward off daytime somnia. Caffeine is a nonspecific adenosine receptor antagonist for both A1 and A2a receptors. Thus, caffeine acts to promote wakefulness by binding to adenosine receptors on cortical neurons and shutting down the cascade of molecular events reducing slow wave sleep described above. Finally, caffeine will compete with adenosine for receptor sites in the ARAS and increase the activity of wakepromoting neurons in the BF and decrease total sleep time.

Brian D. Fuselier, DDS, is a member of the International Association for the Study of Pain, and the American Pain Society.

Barry A. Loughner, DDS, MS, PhD is a member of the International Association for the Study of Pain, the American Pain Society, the American Dental Association, and the Ethics Committee of the American Association for the Study of Headache.

Dr. Fuselier and Dr. Loughner are actively practicing at Central Florida Oral and Maxillofacial Surgery, a unique service with both oral surgeons and facial pain specialists practicing together. For more information visit www.cforalsurgery.com

DAWN RIVERA CELL: 407-280-0892 Arbor Phone: 1-800-634-1958 Dawn @Arborstaff.com www.arborstaff.com

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GrandRounds We Care of Lake County Celebrates 20 Years We Care of Lake County, a physician access network supported and led by the Lake-Sumter Medical Society, celebrated their 20th anniversary with a Moonlight Gala on the Lake. The festivities were held on January 30 at the newly completed Tavares Pavilion on the Lake, honoring their founding fathers and recognizing volunteer physicians. The black-tie event featured the Chris Charles Jazz Quartet with dancing and dining following a brief ceremony. Founder, Tully Patrowicz, MD, was overwhelmed by the accolades directed to him for his vision and efforts in forming this non-profit designed to help the underserved and uninsured adults in Lake County. Senator Alan Hays was quick to praise Dr. Patrowicz and other doctors for their perseverance and generosity, and Lake County Commissioner, Leslie Campione, presented a Proclamation, naming January 30, 2015 as We Care of Lake County Day.

Avi Bhandary, M.D. Downtown

Michael Creamer, D.O. Downtown

TTeddrick Dunson, M.D. Altamonte Springs

Peter Morrow, MD, Selected as New President of Catholic Medical Association On February 4, 2015, Dr. Peter Morrow, Internal Medicine physician and employed physician at St. Cloud Regional Medical Center, was sworn in as the President of the Catholic Medical Association (CMA).

Dr. Morrow is now the 2015 President of the largest association of Catholic health care professionals in the United States.

Dr. Morrow is a Board Certified Internist with added qualifications in Geriatric Medicine. He has been practicing in St. Cloud and Osceola County for over 20 years.

As a community-oriented and faith-driven physician, Dr. Morrow has placed a lot of emphasis on serving those around him. Dr. Morrow is highly involved in his church, including leading as the Medical Director at the church’s free clinic, St. Thomas Aquinas Medical Clinic.

Dr. Morrow has also been very involved in the Osceola County Council on Aging, which assists the elderly, disadvantaged, and disabled in Osceola County. The Council on Aging runs a free medical clinic where Dr. Morrow sees patients and serves as Medical Director.

Carlos J. Placer, M.D. SandLake

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Board Certified in Orthopaedic Surgery Specializing in Sports Medicine, Knee & Shoulder Surgery

Alicia Reiss, PA-C

Travis B. Van Dyke, MD

Board Certified in Orthopedic Surgery Specializing in Sports Medicine, Trauma and Joint Replacement of Shoulder, Knee, and Hip

Lynn Coetzee, PA-C

ORTHOPAEDIC SUBSPECIALTIES: Spine • Elbow • Foot & Ankle Hand & Wrist • Hip • Knee • Shoulder Pediatrics • Oncology • Sports Medicine Pain Management • Physical Therapy

Oviedo Saturday Walk-In Clinic No Appointment Necessary | 9am -1pm

Samuel S. Blick, MD

Board Certified in Orthopaedic Surgery Board Certified in Orthopaedic Surgery Specializing in Sports Medicine, Specializing in Cervical & Lumbar Spine Knee and Shoulder Surgery Surgery, Minimally Invasive Spinal Surgery Adult Spinal Reconstructive Surgery

Bryan L. Reuss, MD

Board Certified in Orthopaedic Surgery Board Certified in Sports Medicine Specializing in Sports Medicine, Knee, Shoulder & Hip Surgery

Michael D. Riggenbach, MD

Board Certified in Orthopaedic Surgery Specializing in Hand and Upper Extremity Surgery, Peripheral Nerve Surgery, Microsurgery, and Pediatric Hand Surgery

Stevie Jackson, PA-C

Alan W. Christensen, MD

Board Certified in Orthopaedic Surgery Specializing in Hand Surgery and Upper Extremity Surgery

Michael D. McCleary, MD Specializing in Primary Care Sports Medicine

Matthew R. Willey, M.D

Board Certified in Physical Medicine and Rehabilitation and Sports Medicine Specializing in Interventional Pain Medicine, Sports Medicine, and Electrodiagnostics

Victoria Henriquez, PA-C

Colin Penn, PA-C

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407.254.2500 OrlandoOrtho.com 407.254.2500

6 CONVENIENT LOCATIONS TO SERVE YOU: Downtown Orlando | Winter Park | Sand Lake | Lake Mary | Oviedo | Lake Nona