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PHYSICIAN SPOTLIGHT PAGE 3
Erasmo A. Passaro, MD ON ROUNDS
Florida leaders work on ways to increase residency slots, keep COM graduates in state By LyNNE JETER
Connecting Genetic Risk Factors
USF and Aetna partner on $2.8 million NIH grant to study genetic testing and breast cancer treatment ... 6
Physician Workforce Report
Inaugural Physician Workforce Assessment and Development Strategic Plan aims to strengthen capabilities, improve practice environment ... 9
ONLINE: TAMPA BAY MEDICAL NEWS.COM
Two years ago, 282 graduates of Florida medical schools left the state to pursue PGY-1 (first-year) residencies because of a shortage of in-state slots that continues to exacerbate the growing physician shortage in one of the nation’s fastest-growing and fastest-aging states. “Unfortunately, we lack sufficient residency slots for the number of medical students we graduate in the medical schools in the state,” said Tampa General CEO Jim Burkhart. “We have a great exodus every year of very talented
graduates of medical schools who can’t stay … because we don’t have enough slots.” For example, only 10 of 33 graduates of the University of Central Florida (UCF) College of Medicine’s (COM) charter class found in-state residency slots; only two will remain in Orlando. This fall, 100 students will enter the UCF COM; next fall will signal the first full class of the four-year-old (CONTINUED ON PAGE 5)
New Tampa General CEO Jim Burkhart discusses challenges, opportunities By LyNNE JETER
When James Robert “Jim” Burkhart took over as president and CEO of Shands Jacksonville Medical Center in 2003, the private, not-for-profit hospital was technically bankrupt and in default of its bond covenants. Starting as a consultant in 2001 for the 695-bed teaching hospital, affiliated with the University of Florida Health Science Center in Jacksonville, Burkhart led the 3,800-employee organization to profitability, along with having it designated the only Level I
trauma center in northeast Florida and southeast Georgia. “It was a very nice success story, to be part of the hospital around,” said Burkhart, a fellow of the American College of Healthcare Executives (ACHE), who also led Shands Jacksonville to magnet status and earned a pair of Governor’s Sterling Awards. “I was pleased with the financial and quality turnaround in Jacksonville, and it’s certainly a cap-
stone to my career and a great team effort.” Burkhart had a stellar month in December, when he received his doctoral degree in executive healthcare management from the University of AlabamaBirmingham (UAB) and learned that on March 4 he would follow the retiring Ron Hytoff as CEO of the 1,018-bed, 6,400-plus Jim Burkhart
(CONTINUED ON PAGE 4)
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Erasmo A. Passaro, MD Director, Comprehensive Epilepsy Program, Bayfront Medical Center By JEFF WEBB
ST. PETERSBURG - You can find one of Erasamo Passaro’s favorite quotations in the movie It’s a Wonderful Life. The words appear on a plaque beneath a portrait of George Bailey’s father, Peter, founder of the savings and loan in mythical Bedford Falls: “All you can take with you, is that which you’ve given away.” Based on Passaro’s contributions in the diagnosis and treatment of epilepsy, he will have his hands full when that time comes. Passaro is the architect and director of Bayfront Medical Center’s Comprehensive Epilepsy Program, one of only five Level 4 referral centers in Florida, the highest designation by the National Association of Epilepsy Centers. He proposed and established the program in 2001 at Bayfront, where “no one else on the west coast of Florida deals with the complexity of cases that we do, the ones that require the complicated (brain) mapping, particularly in areas of function,” he said. Passaro, an epileptologist, leads a multi-disciplinary epilepsy team, the only one of its kind in Pinellas County, he said, which includes an epilepsy neurosurgeon, a neuropsychologist, neuroradiologist, a social worker, a speech pathologist and specially trained technologists. That team’s expertise is available to every patient, he said. “We all discuss the complicated epilepsy cases and determine if someone is a candidate for epilepsy surgery, or the best procedure for that (patient).” “It’s an incredible team of people who put their egos aside, who are passionate about what they do, and who bring unique (talents) to the table,” said Passaro, 51.”The synergy that comes together as we change people’s lives is inspiring. I’ve worked in multiple places (that specialize in epilepsy) and the team we have here is just great.” Even when he’s not at Bayfront, Passaro is remotely connected to his patients there. He can monitor them from his office practice, Florida Center for Neurology, or even from his home, he said. “I can see their seizures while it’s happening, or I can just see their brain activity at the time.” Passaro said he sees about 80 patients a week, referred by other neurologists and primary care physicians, but “many are self-referred just because of our reputation ... they find us on the web.” Some travel thousands of miles, noting one who recently came from Hawaii. “When you have complicated illness such as epilepsy, and people are at the end of their rope, they are willing to travel to a place that can find answers,” he said. Passaro is determined to raise aware-
ness about epilepsy, which will affect one in 26 people at some point in their lifetime. He said it can take anywhere from 6 months to 38 years to be diagnosed, and it can affect anyone at any age. Given that it is “one of the major neurological illnesses,” and has direct and indirect costs of about $12 billion a year in the U.S., he said, epilepsy research is woefully underfunded. For example, epilepsy receives less funding than Parkinson’s disease, even though it is more common, Passaro said. “There needs to be greater public awareness because this is a disease that has major ramifications for people’s lifestyles.” Emphasis must be placed on educating health professionals, he said, noting that at Bayfront “everyone is trained in how to recognize seizures, know what to do and not be frightened by them.” Cindy Whittaker has had a front-row seat to observe the evolution of the epilepsy program at Bayfront. She has worked at Bayfront for 36 years, and has been manager of the neurodiagnostics program for 25 years. Her oversight also includes the epilepsy, sleep study and non-invasive cardiology centers. Whittaker said she helped Passaro set up the program, the rooms and the diagnostic staff. “Dr. Passaro is a brilliant – and I
don’t often use that word – physician,” said Whittaker. “He is very passionate about epilepsy. He is very focused on the person and how epilepsy affects their everyday lives,” she said. “We try every possible way to help the patients. Sometimes it’s surgery. Sometimes it’s changing medications. We have patients for whom that changes their life because now they can work, now they can drive, now they can interact with their families. But even for the patients we can’t help in that way, (Passaro) is constantly looking for the newest medications, the newest treatment, the newest (clinical) trial,” she said. “Compassion is one of his greatest traits. He gets very emotionally invested in his patients,” said Whittaker. And Passaro is willing to invest time in treatments, she said. “These are patients who require a lot of patience. It’s not like treating someone with a broken finger or the sniffles. These patients, because of their epilepsy, bring a lot of baggage. Many can’t drive, can’t work, they have difficulties having a social
life. It’s a very needy population,” she said. By the time they get to Passaro, they’ve already been through multiple physicians and medications, Whittaker said, but when they become aware there are epileptologists who focus on their problem, they are very grateful.” Passaro said his decision to help others crystalized when he was very young. After he was held back in first grade in Bayonne, N.J., he “became incredibly motivated to succeed because I had been labeled not one of the smart kids.” Then, when he was 11, his mother, an Italian immigrant, was diagnosed with scleroderma. She nearly died, but “the illness was forestalled at Brigham Hospital in Boston,” Passaro said. “This was a moment that changed my life. ... It propelled me to pursue this profession.” Passaro’s education and training are extensive and can be reviewed at www. floridacenterforneurology.com. What you won’t read there is that he lives in Tierra Verde, is the father of two children (ages 10 and 9) and the husband of Velicia, an (CONTINUED ON PAGE 4)
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Turnaround Specialist, continued from page 1 employee Tampa General Hospital. It serves as the region’s only center for Level I trauma care, comprehensive burn care, and adult solid organ transplants, and doubles as the primary teaching hospital for the USF Health Morsani College of Medicine. “I’m extremely excited about being here,” said Burkhart. “You could say the same thing about TGH, but I didn’t participate in the turnaround. This one had 30 days cash on hand and wasn’t doing well, but wasn’t quite in as bad a shape as Jacksonville. Ron (Hytoff) and his senior leadership did the heavy lifting.” David A. Straz Jr., chairman of the Florida Health Sciences Center Inc., the governing board for Tampa General, said Burkhart was chosen from more than 200 qualified applicants nationwide. “Mr. Burkhart has the skill set and experience we want,” said Straz. “He works closely with a medical school and has a sharp focus on quality patient care. He’s managed a safety net hospital that has faced financial challenges due to state cuts to reimbursements. The transition will be very smooth and he will build upon the success Tampa General already has achieved.” Weeks after he took over the new post, Tampa Medical News spoke with Burkhart about challenges facing hospitals and providing care in the Tampa Bay area. A perfect storm of issues is brewing in the healthcare industry. What do you see as the hospital’s top priorities this year? The single biggest issue is helping to craft whatever healthcare expansion is going to look like in Florida. Right now,
families, is something we can work on.
Surprising Facts about Tampa General CEO Jim Burkhart: In addition to rising in healthcare executive ranks, he spent 35 years in the military, beginning in 1972 and including stints in the Air Force National Guard and Army. He retired as a full colonel in 2007. He has a great sense of humor. When asked what advice he would give others considering a career in hospital administration, he said: “Run!” and quickly added “just kidding!” He learned his work ethic from his father in an unorthodox way. “Daddy didn’t let me sleep (late),” joked Burkhart, who grew up on a dairy farm near Knoxville. “He made me get up every morning to get the cows. The one thing I wanted to do was get a job and education so that I didn’t have to go get cows!” He’s a die-hard Volunteer fan. “My family is from Maryville; my wife’s family is from Knoxville,” explained the University of Tennessee (UT) alum, who earned psychology and biology degrees there, before earning master’s and a doctorate in hospital and healthcare management from the University of Alabama-Birmingham (UAB). For a dozen years, he served as president of Fort Sanders Park West and Regional Medical Centers in Knoxville, two medical centers of 900 beds and a staff of 3,000 employees. “We’ve had a few tough years with (former UT football coaches) Lane Kiffen and Derek Dooley. We’ll see how this new coach from Cincinnati does.”
we’re a little up in the air. State lawmakers didn’t vote to become part of the expansion program to increase the number of people covered through the exchanges. Trying to convince legislators to not sit on the sidelines and let the federal money go away seems to be the smart thing to do. Of course, lots of discussion is needed over that issue. The Senate had a plan to take the money and create a private system. We were OK with that because they didn’t want to use Medicaid. They said they’ll continue the debate into the off session and might bring it up for more discussions in the fall. The second challenge is the state has voted to move to Medicaid DRGs in July. They did that rather quickly, even realizing that if they approve an expansion
program, then they’re going to have to change again. But they still decided to do it, and we’re all going to have to get used to a DRG system of payment under Medicaid even though the specifics haven’t yet been clearly outlined. Obviously, we live in the DRG world with Medicare, but it’ll be interesting to see exactly how they craft the Medicaid system for DRGs in this state. Also important: pay-for-performance issues and continuing to work on the quality of outcomes and patient satisfaction. From a day-to-day perspective, that’s probably No. 1 on our list. We can deal with some aspects of the other issues, but much of that is out of our control. The quality of outcomes and patient satisfaction, which includes patients and their
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Florida, along with the rest of the nation, anticipates a shortage of physicians and nurses over the next few years. What are you doing to prepare for that shortage? From an employee standpoint, Tampa General has 3,000 more than Jacksonville. From a physician perspective, it’s probably 1.5 times larger. There’s a different blend at both hospitals. For example, in Jacksonville, 99 percent of doctors were University of Florida physicians. Here, there’s a blend of USF physicians, community doctors, and a few employed doctors. Our recruitment strategy is to attract them to a hospital with an outstanding reputation and keep them by working collaboratively with them to deliver outstanding care to our patients. We have a reputation for working with physicians in the provision of the best care possible for the patient. Doctors tend to gravitate to that environment. How is Tampa General concerning EMR/EHR integration, and ACO (CONTINUED ON PAGE 6)
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Erasmo A. Passaro, MD continued from page 3 ARNP he married 14 years ago and is now his practice administrator. “She she fills in the blanks for my weaknesses and she supports my strengths. It is good to have a wife who has an understanding of my work and the demands on my schedule,” he said. Passaro finds time to jog about 4 miles five days a week, and one of his favorite weekend pastimes is gardening with his children, in whom he also is planting seeds of spirituality. “Faith is central in my life,” he said. “Scripture lets you know who you are and your place. It centers you. First, that you have reverence and that you’re not the center of the universe. Second, to be thankful and forgiving.” That outlook goes hand-in-hand with advice instilled in him by his grandmother, his mother, and now his wife. “Be thankful for your time, your talents and your treasures. You don’t own them; you are a steward of these gifts and you have a responsibility to serve others.” Peter Bailey would approve.
Incentivizing Residencies, continued from page 1 school when 120 students are admitted. “The state and local community are especially hard hit because residency programs haven’t kept pace with population and medical school growth,” said Deborah German, MD, vice president for medical affairs and founding dean of the UCF COM, noting that Florida has fewer than 18 residents and fellows on duty per 100,000 population, ranking it 42 of 50 states nationally. Orlando produces 102 graduate medical education (GME) graduates annually from core nationally-accredited residency programs. By comparison, Tampa produces 145, and Gainesville, 148. Of Florida’s nine medical schools – two private osteopathic schools, one private allopathic school, and six public allopathic schools – an informal statewide chart released in 2011 shows 510 graduates with a surplus of 260 Florida PGY-1 residency slots in 2000, compared to a projected number of 1,317 graduates with a shortage of 490 slots estimated for 2020.
Challenges and Solutions
Robust medical school growth has drawn attention to the minimal growth of residency programs to provide post-graduate training to Florida’s graduating medical students, while also attracting quality medical school graduates from around the country to provide the foundation for Florida physician workforce of the future, and positioning Florida to best work to develop residency programs to provide such training. Florida State University welcomed its first crop of medical students in 2001, Lake Erie College of Osteopathic Medicine (LECOM) in 2008, UCF and Florida International University (FIU) in 2009, and Florida Atlantic University (FAU) in 2011. UCF and FIU represent the tail-end of graduating their first full classes, in 2017. “When graduates stay in the area to complete their medical training, there’s a very high probability they will remain after training, and set up practice or join an established practice. This is the best way to respond to the physician shortage in Florida,” said LECOM associate dean Robert George, DO, in Bradenton. Of 152 LECOM medical students who graduated on June 9, 36 percent (55) will remain Dr. Robert George in-state to complete residencies and internships. Statistics show that residents and fellows retained from Accreditation Council for Graduate Medical Education (ACGME) programs are highly likely – roughly twothirds, according to the Association of American Medical Colleges (AAMC) – to practice medicine in the area in which residencies and fellowships are completed. Various solutions have been put into place via innovative partnerships to address the residency shortage. For example, Tampa General Hospital, a teaching hospital for the University of South Florida (USF) Health Morsani COM, has 200 residency slots, yet hosts 310 residents. “That additional 110 slots, the hospimedicalnews
tal pays for out of pocket,” said Burkhart. “That’s $100,000 plus for every resident. We can’t afford to keep doing that, particularly when reimbursement from Medicare, Medicaid, commercial insurance and everything else continues to take a hit.”
In keeping pace with primary care needs, 51 percent of 2013 PGY-1 slots in Florida fall under PCP status (internal medicine, pediatrics, family medicine and obstetrics and gynecology), according to the Patient Centered Medical Home model. AAMC’s 2011 State Physician Workforce Data Book
lists Florida with 16,060 total active primary care physicians for a population of 18.7 million, resulting in a ratio of 9.2 per 100,000. “We’ll need more primary care doctors, but why would anyone want to go into primary care when they’re not paid as well, yet have the same level of student loan debt as other students? The real debt occurs when you’re going to medical school,” said Burkhart. “When you’re a resident, at least you’re making some money. Radiology, for example, pays significantly more than primary care (for the ROI). We have to do something to maybe help offset or cover or forgive debt for medical students going into
primary care, and not just in rural areas. Not everybody lives in a rural area. A lot of people in urban areas need primary care doctors. It’s a universal problem.” Last month, UCF COM took a fresh step in training more PCPs when the ACGME approved its first university-sponsored residency program in partnership with the Orlando VA Medical Center and Osceola Regional Medical Center. The internal medicine residency will create 20 slots in 2014 and increase to a maximum of 60 MD graduates annually. “Residency programs are part of the (CONTINUED ON PAGE 8)
FLORIDA RESIDENCY MATCH RECAP FOR 2013 According to the National Resident Matching Program for 2013, PGY-1 quotas and matches per major medical centers in Florida: Bayfront Medical Center in St. Petersburg: 12 of 12 matched. Cleveland Clinic in Weston: 18 of 20 matched. Florida Hospital-Orlando: 36 of 36 matched. Florida State University in Tallahassee: 22 of 23 matched. Halifax Medical Center in Daytona Beach: 10 of 10 matched. Jackson Memorial Hospital in Miami: 210 of 211 matched. Larkin Community Hospital in South Miami: 8 of 8 matched. Mayo School of Graduate Medical Education in Jacksonville: 35 of 39 matched. Miami Children’s Hospital in Miami: 24 of 24 matched. Mt. Sinai Medical Center in Miami: 29 of 30 matched. Orlando Health in Orlando: 62 of 66 matched. St. Vincent’s Medical Center in Jacksonville: 7 of 7 matched. Tallahassee Memorial Healthcare in Tallahassee: 11 of 11 matched. University of Florida in Jacksonville: 81 of 81 matched. University of Florida-Shands Hospital in Gainesville: 153 of 163 matched. University of Miami-Palm Beach in Atlantis: 30 of 30 matched. University of South Florida in Tampa: 128 of 128 matched. West Kendall Baptist Hospital in Miami: 4 of 4 matched. TOTAL: 880 OF 903 MATCHED.
Breakdown of Florida PGY-1 match rates by the most popular specialties: Internal medicine: 233 Family Medicine: 79
General Surgery: 84
Emergency Medicine: 53
Obstetrics and Gynecology: 39
Breakdown of 23 unfilled residency slots by specialty: Anesthesiology: 7
Family Medicine: 3
General Surgery: 3 Surgery-Preliminary: 7
SOURCE: Association of American Medical Colleges (AAMC)’s 2011 State Physician Workforce Data Book.
FLORIDA RESIDENTS & FELLOWS Of 3,512 total residents and fellows in Florida (1.4 per 100,000) on duty as of Dec. 31, 2010 in ACGMEaccredited programs, the breakdown is: 2,176 allopathic school graduates 266 osteopathic school graduates 1,064 international medical graduates (IMGs).
Note: Florida has the third most IMGs, accounting for roughly one-third of all active physicians. SOURCE: Association of American Medical Colleges (AAMC)’s 2011 State Physician Workforce Data Book, National Resident Matching Program.
Connecting Genetic Risk Factors USF and Aetna partner on $2.8 million NIH grant to study genetic testing and breast cancer treatment By LYNNE JETER
The University of South Florida (USF) and Aetna have tapped Rebecca Sutphen, MD, to lead the national, collaborative research project anticipated to facilitate personalized Dr. Rebecca Sutphen medicine and improve cancer care. The ground-breaking $2.8 million National Institutes of Health (NIH) joint venture will examine the influence genetic testing may have on clinical treatment decisions among breast cancer patients and their doctors. Understanding the connection between genetic risk factors, treatment options and results may guide policies and services that can help patients and doctors make more informed, personalized decisions that lead to better health. The NIH award is part of the American BRCA Outcomes Among the Recently Diagnosed (ABOARD) study, which will follow 5,000 Aetna members across the country who have been newly diagnosed with breast cancer and are undergoing genetic testing. “Research shows that many women who develop breast cancer have inherited a strong predisposition to cancer,” said Sutphen, professor of genetics at the USF Department of Pediatrics Epidemiology Center. “However, many of these women aren’t aware of their genetic susceptibility.
They also don’t know they’re at high risk to develop another breast cancer or ovarian cancer in the future and that other blood relatives are at increased risk for cancer.” Current research suggests that only a small fraction of breast cancer patients who have an inherited cancer risk actually receive genetic counseling and testing services. Even fewer receive this information at the time of diagnosis, when it might be most useful for making surgical and other treatment decisions. “This unique academic-industry collaboration will create a new level of research into the impact of genetic information on American cancer patients and their families,” said Sutphen. “Few topics have greater potential for positive public health impact. We appreciate Aetna’s leadership and collaboration to make this important research possible.” For the multi-faceted study, Sutphen, an American Board of Medical Geneticscertified clinical and molecular geneticist and expert in inherited cancer risk, will have access to a multidisciplinary team that includes her research team at the USF Health Morsani College of Medicine – coinvestigators Kristian Lynch, PhD, James Andrews, PhD and Claudia Aguado Loi, PhD – and an Aetna team led by Joanne Armstrong, MD, MPH, the national med-
ical director for women’s health and lead for genomic medicine. Also on board: an advocacy team led by Sue Friedman of the national non-profit advocacy and awareness organization Facing Our Risk of Cancer Empowered (FORCE) and Marc Schwartz, PhD, director of cancer control for Georgetown University’s Lombardi Comprehensive Cancer Center. The project will focus on patient-reported outcomes and medical claims data. Using information from a variety of clinical settings rather than only academic centers will provide a more “real-world” view of current care, said Sutphen, adding that USF and Aetna have developed an extensive research and security infrastructure to ensure the privacy and confidentiality of participant data. “The research will provide critical in-
formation that can help ensure the benefits of advanced genetic testing and genomics can be used to guide safe, effective personalized healthcare,” said Armstrong. “As more sophisticated tests are developed, we have a responsibility to help patients and doctors understand how to act on the information to improve patients’ health.” Certified genetic counselors are in demand to help assess specific cancer risks in families, recommend appropriate genetic tests, and interpret genetic test results. They may also recommend appropriate personalized options for cancer screening, early detection and prevention. Patients and their doctors may use this information to optimize care. The new study builds on an existing research partnership between this multidisciplinary team and researchers from the American Cancer Society. The groups have been working together for the past two years with Aetna Foundation support to better understand the experiences of individuals who have had genetic tests to determine their inherited risk of cancer. The study also looked at differences in treatment, information and health outcomes among minority patients. Results should be revealed by year’s end.
Turnaround Specialist, continued from page 4 formation? We’re doing quite well. We’ve implemented the Epic platform and to his (Ron Hytoff) credit, all areas were implemented at once. We’re further down the road than most hospitals. We don’t have every system working with every system, and we still have more integration to go. Doctors are pretty good at using Epic, and it seems to be working well. We’ve qualified for all our meaningful use dollars and will continue to do so. At least we’re getting a little something back for the money we’re investing. Concerning ACOs, we haven’t formed one. If you ask five people what an ACO looks like, you’ll probably get five different answers at this point in time. We’re studying where we need to go in the managed care arena, and where we want to be on the scale of being fully accountable for everything versus just being a vendor or service provider. The greater Tampa area has roughly 4 million people. If you want to be at risk for 1 million of them, you’d better have your 6
act together. You have to know what being at risk means in particular cases. Becoming responsible for hospital care, primary care, and post-acute care to home care is possible. Those are the more complicated ACOs, taking full risk for everything. Overall, I don’t think we want to be a vendor, so we’ll probably tend to go toward the top of the food chain. However, we’ve not yet made those decisions yet. With the climate today making hospital administration one of the toughest jobs in the market, what advice would you give other healthcare leaders? You have to be flexible, willing to partner, affiliate and work with organizations that in the past you might not have considered. You have to stay cutting edge, be willing to break out of the box, and take a calculated chance. It’s going to be very important for us to manage care of the entire patient, from cradle to grave. There’s a lot of territory to cover. We have to be able to help manage the health of the in-
dividual. It’s a busy job when you have responsibility for large populations. Tampa General is a magnet hospital, ranked the leading hospital in the state by U.S. News & World Report, ranked nationally in nine specialties, and Joint Commissioncertified in 16 specialty areas. In April, the hospital’s Level l trauma center for adults and children became the first and only program in Florida to earn recognition from the American College of Surgeons (ACS) for the quality of its trauma care. How do you maintain such high standards? We take those things very seriously. Obviously, you’re only as good as your next ranking. The U.S. News & World Report ranking comes out every year. To stay at the top of the rankings is difficult. We’re very proud of our rankings and status; having others look as us as a benchmark in specialty areas is very important. medicalnews
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Incentivizing Residencies, continued from page 5 promise that was made to this community and an important element in a medical school that will anchor a medical city,” said German. “If we have more residencies, we’ll have more trained doctors in our community because many doctors practice where they complete their residency programs.” Here’s how it works: Participating hospitals pay residents a stipend and cover the salaries of physician instructors; those costs may be reimbursed through federal Medicare and Medicaid funds. The COM will provide administrative support and oversight of the GME program from its existing state budget. UCF’s program will use an innovative scheduling of residents called the 4+1 rotation schedule, which alternates traditional 4-week hospital and specialty rotations with 1-week blocks of ambulatory or out-patient care. Residents support the 4+1 because it allows them to focus on specific clinical facilities and cuts down on time-consuming travel and logistical problems that occur when residents are dashing from facility to facility in the middle of a rotation. By the end of 2013, Osceola Regional, which is undergoing an expansion program, will have 317 beds. In addition to planning its Level II Trauma Center and meeting the needs of Osceola and Orange counties, Osceola Regional offers specialty programs, such as its Central Florida Cardiac and Vascular Institute
and Orthopedic and Spine Center. “As a part of HCA West Florida, we view creating residency programs as an investment in the future of medical care for our community,” said Osceola Regional CMO Aida Sanchez-Jimenez, MD, who will serve as GME site director. Florida Hospital is also strengthening Orlando’s PCP workforce with accreditation for a pediatric residency program. The first residents will begin training at the Florida Hospital for Children next July. “The hospital is educating the doctors of tomorrow while helping fill an area of medicine where we’re seeing a shortage of physicians,” said Stacy McConkey, MD, pediatric residency Dr. Stacy McConkey program director at Florida Hospital for Children. (Of 112 PGY-1 positions available this year, all were matched.) The 3-year pediatric residency program will have six residents per year, with a total of 18 residents when completely full. Residents will complete their inpatient rotations at Florida Hospital for Children, and have a variety of outpatient pediatric subspecialty rotations including dermatology, urology and neurology. The residents’ primary outpatient experience will be at the new Florida Hospital Center for Pediatric and Adolescent Medicine
Clinic in Winter Garden.
State and National Movement
In Florida, the Governor’s Office attempted this year to increase funding for residency programs, which might incentivize development of positions in the state. The increased funding was included in the Appropriations Act that state lawmakers passed several weeks ago; a “conforming bill” addressed funding for Medicaid-supported residencies. In Senate Bill 1520, which Gov. Rick Scott approved May 20, the Statewide Medicaid Residency Program expands primary care specialties beyond the PCMH scope to include preventive medicine, geriatric medicine, osteopathic general practice, and emergency medicine. Because of complicated formulas regarding changing reimbursement methodologies for hospitals, the money represented in the GME budget line item doesn’t represent all new money. For GME expenses from the general revenue fund, $33 million was the tally. Add to that $46.9 million from the Medical Care Trust Fund. SB 1520 calls for a complex allocation formula to particular medical schools or hospitals, up to $50,000 per FTE (full-time equivalent) resident. Nationally, to help fill the gap between first-year residents and residency slots, the American Medical Association (AMA) in mid-January announced a $10 million competitive grant initiative, “Accelerating Change in Medical Education,”
to be distributed over the next five years to fund projects that support a significant redesign of undergraduate medical education. Eighty-two percent of the nation’s 141 accredited medical school submitted proposals by the Feb. 15 deadline, necessitating an additional vetting process. This month at its annual meeting, the AMA will determine the disbursement. “Florida schools will hopefully get some of the money, for which we’re grateful, but it’s not anywhere close to putting a dent in our needs,” said Burkhart. Additionally, to address the gap of medical school graduates who won’t match to a residency program, legislation was reintroduced in March in both houses of Congress to create new residency positions for Medicare-supported training slots via the Resident Physician Shortage Reduction Act of 2013. Senators Bill Nelson (D-Fla.), Chuck Schumer (D-NY) and Harry Reid (D-Nev.), and Representatives Aaron Schock (R-Ill.) and Allyson Schwartz (DPa.) led the reintroduction of the bills (S. 577, H.R. 1180) to create the additional GME positions, according to the AMA. (At press time, GovTrack estimated a 1 percent chance of S. 577 moving from the Senate Finance Committee, and a zero percent chance of H.R. 1180 moving from House committees.) Editor’s note: Next month, Florida Medical News will continue to focus on the needs for residency programs in the state.
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Physician Workforce Report
Inaugural Physician Workforce Assessment and Development Strategic Plan aims to strengthen capabilities, improve practice environment By LyNNE JETER
Only 14 percent of the state’s 44,804 licensed, practicing physicians are younger than age 40, according to the Florida Department of Health’s inaugural Physician Workforce Assessment and Development Strategic Plan. Released late last year, the plan is chock full of expected and surprising trends in a snapshot to strengthen the state’s physician workforce capabilities while also enhancing the practice environment. “The strategies proposed … lay the groundwork required in pursuit of that goal,” explained John H. Armstrong, MD, state surgeon general and council chairman, about physician attraction, retention and retraining. “Florida shapes a stronger physician workforce today by reviving existing incentive programs, targeting specific types of non-practicing physicians for incentives or retraining opportunities, and improving Florida’s practice climate to reduce physician departures.” Creating Graduate Medical Education (GME) opportunities to narrow the gap between medical school graduates and first-year residency slots is a top priority. “Preventing the annual export of
PHYSICIAN WORKFORCE SPECIALTY COUNTS BY COUNTY: (Note: 157 unique specialties have been divided into 16 main specialty groups.)
HILLSBOROUGH COUNTY: 2,762 Medical specialist: 402 Internal medicine: 386 Surgical specialist: 325
PINELLAS COUNTY: 2,219 Family medicine: 328 Internal medicine: 337
Family medicine: 309
Medical specialist: 327
Surgical specialist: 317
Emergency medicine: 140
Emergency medicine: 132
Radiology: 131 General surgery: 92 Pediatric subspecialist: 87 Pathology: 86 Other: 60
Pediatric subspecialist: 86 OB-GYN: 84 Psychiatry: 79 Pathology: 54 Neurology: 43 General surgery: 42
POLK COUNTY: 746 Internal medicine: 128 Surgical specialist: 113 Medical specialist: 110 Family medicine: 99 Pediatrics: 54 Radiology: 38 OB-GYN: 37 Anesthesiology: 33 Psychiatry: 31 Emergency medicine: 30 General surgery: 21 Neurology: 14 Dermatology: 13 Pathology: 11 Other: 8 Pediatric subspecialist: 6
PASCO COUNTY: 696 Family medicine: 142 Internal medicine: 120 Medical specialist: 112 Surgical specialist: 64 Anesthesiology: 45 Pediatrics: 41 Psychiatry: 35 Emergency medicine: 28 OB-GYN: 25 Radiology: 20 General surgery: 19 Dermatology: 14 Neurology: 11 Pathology: 10 Other: 10 Pediatric subspecialist: 0
(CONTINUED ON PAGE 12)
Johnny Gibbs, MD
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The Strong Patient Voice in the POLST Paradigm By RAFAEL J. SCIULLO
As a hospice care provider for more than 30 years, I know the bitterness that erupts when family members find themselves opposing one another because no one, including their physician, knows the treatment wishes of a patient who is no longer able to communicate. That’s one reason why I support Physician Orders for Life Sustaining Treatment (POLST), a model under consideration in Florida and already adopted in many other states. Research and technology have led to countless advances in medical care no one could have dreamed of even a decade ago. But even ground-breaking new treatments, the advent of widespread electronic medical recordkeeping and so forth have not changed the basic need patients have to believe that their physicians see them as individuals. You might say they want their interactions with their physicians to be off the charts. Patients want to be more than the COPD case or new chemotherapy referral. Most prefer their physicians to know who they are – to advocate for them. The POLST model goes a long way toward doing just that. You may be familiar with POLST. If so, you know the POLST paradigm spells out the expressed wishes of patients, and at the same time, ensures that physicians and other healthcare providers will be able honor such choices. In Florida, with our large population of elderly citizens and rapidly aging baby boomer generation accustomed to doing things its way, POLST is an ideal tool for doctors and other healthcare providers. The POLST model calls for thoughtful dialogue between physicians (or other healthcare providers) and patients regarding end-of-life treatment preferences. Coming to terms with such decisions can be challenging but many patients also find comfort in knowing that difficult decisions about their care won’t be left unmade, perhaps dividing their families or leaving choices up to strangers. Such discussions may culminate with completion of a POLST form, which carries the designation of a medical order. POLST directives are intended to supplement, not replace traditional advance directives for patients approaching the end of life. Because it is a medical order, POLST has greater impact in ensuring that a patient’s wishes will be carried out. It is recognized in all healthcare settings – hospital, long-term care and homecare or during transport.
POLST orders can ultimately spare patients’ families from choices they often feel ill-equipped to make. The order does away with the guess work and angst families often encounter when a relative is seriously ill, instead honoring a patient’s known treatment preferences. And physicians may rest-assured that they are providing exactly the kinds of treatment and care their patients have chosen themselves. Considered best practice by many healthcare providers, the POLST model offers these advantages: • It is a medical order signed by a physician. • It is a one-page, easy-to-follow standardized form. • Unlike DNR orders, POLST goes beyond resuscitation to cover an entire range of life-sustaining interventions, such as intravenous fluids, antibiotics, a feeding tube and artificial breathing. • The brightly colored POLST form is easily identified. As part of a patient’s chart, it travels with the patient from hospital, to nursing home, to ambulance, to the patient’s home and is recognized across all such treatment settings. As president and CEO of one of our nation’s leading hospices, I believe wholeheartedly in the value of patient choice. Studies have shown that most hospice patients choose at least one life-sustaining treatment, and with POLST, they also have the option of declining aggressive end-of life treatment. The POLST paradigm represents a significant step toward helping physicians carry out their patients’ end-of-life treatment and care preferences. That is why I’m pleased that our community hospice, Suncoast Hospice, is the first organization of its kind to pilot POLST in Florida. We look forward to helping seriously ill patients and their families achieve the peace of mind that comes from knowing their decisions about end-of-life care will be handled according to their own wishes and firmly supported by a signed medical order. Rafael J. Sciullo, MA, LCSW, MS, is president and CEO of Suncoast Hospice of Clearwater, Florida, a premier hospice provider recognized for its innovation, expertise and compassion in palliative and end-of-life care. A seasoned healthcare leader, Sciullo took over the top position at Suncoast Hospice in February of this year. He has been an administrator of other hospices and hospitals during his more than 30-year healthcare career. He is a nationally known advocate for endof-life care and has held leadership posts with the National Hospice and Palliative Care Organization (NHPCO). Sciullo may be reached at rafaelsciullo@thehospice. org or via the Suncoast Hospice website – suncoasthospice.org.
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qualified GME candidates to other states is the crucial first step toward shaping the physician workforce of the future,” noted Armstrong. A demographic snapshot shows the average Florida physician is mid-career (59 percent between ages 40 and 60), male (75 percent), and white (63 percent). Every week, a majority spend 36 to 40 hours on patient care, seeing an average of 76 to 100 patients in a single specialty group practice. Two-thirds don’t provide on-call emergency room coverage because of hospital by-law exemption (20 percent), lifestyle considerations (16 percent) and undisclosed reasons (45 percent). Of active, licensed physicians reporting an impending move out of state (4 percent), one-fourth don’t yet have a planned destination. Others plan to relocate to Texas (153), California (120), South Carolina (85), Georgia (85), and New York (66), with the balance scattered around the country, mostly on the East Coast and in the South. Notable trends: • Twenty-four percent of OB-GYNs no longer deliver babies because of liability exposure, cost of professional insurance, medical malpractice litigation, declining government reimbursement rates, and other reasons. • With most of the state’s 1,797 radiologists working in a hospital setting, their practice characteristics reflect reading diagnostic mammograms and sonograms (79 percent), reading screening mammograms (77 percent), performing ultrasound and stereotactic-guided core biopsies (55 percent), reading breast MRIs (48 percent), and reading MRI-guided core biopsies (33 percent). The Physician Workforce Advisory Council is a 19-member group established by state lawmakers in 2010 to address physician workforce needs in Florida. “These strategies, objectives, and progress measures make up the Department (of Health’s) inaugural strategic plan, with an objective of strengthening the state’s physician workforce assessment and development capabilities,” Armstrong emphasized.
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GrandRounds Largo Medical Center Internal Medicine Program Residents Rank in Top 5 Nationwide This week Largo Medical Center received national recognition for its Internal Medicine (IM) program residents ranking 4th in the nation on the most recent American College of Osteopathic Internal Medicine in-service exams. This in-service exam is taken annually by IM residents in more than 140 DO and MD residency programs nationwide. Largo Medical Center is a Statutory Teaching Hospital. Patients benefit from teaching hospitals as the academic environment encourages physicians to seek innovative solutions to patients’ problems. Attending physicians must stay on top of the latest medical developments in order to teach medical students, residents, student nurses and allied health professionals. Largo Medical Center is the 3rd largest American Osteopathic Teaching Hospital in the Southern United States.
Largo Medical Center Receives Quality Blue Distinction Center Designation For Spine, Knee & Hip Surgery Florida Blue has named Largo Medical Center as a Blue Distinction Center in the areas of spine surgery and knee and hip replacement. The Blue Distinction Centers for Specialty Care® program is a national designation awarded by Blue Cross and Blue Shield companies to medical facilities that have demonstrated expertise in delivering quality specialty care. Since 2006, consumers, medical providers and employers have relied on the Blue Distinction program to identify hospitals delivering quality care in bariatric surgery, cardiac care, complex and rare cancers, knee and hip replacements, spine surgery and transplants. The selection criteria used to evaluate facilities were developed with input from the medical community and include general quality and safety metrics as well as program specific metrics Research indicates that the newly designated Blue Distinction Centers demonstrate better quality and improved outcomes for patients, with lower rates of complications and readmissions than their peers. The program provides consumers with tools to make better informed healthcare decisions.
St. Joseph’s Hospital is the First in Florida to Offer Non-invasive Test to Predict Stroke Risk St. Joseph’s Hospital in Tampa is the only hospital in the southeast United States using Non-invasive Optimal Vessel Analysis (NOVA) to quantify the volume of blood flow through tiny blood medicalnews
vessels in the brain using three dimensional imaging. The first of its kind, NOVA provides doctors with precise identification of each vessel for blood flow calculation in order to pinpoint specific areas of concerns, giving physicians a quantifiable idea of a patient’s risk for stroke. It’s very difficult to image vessels that small, according to St. Joseph’s Hospital Interventional Neuroradiologist Matthew Berlet. This software provides a numerical evaluation of blood flow in the brain without an invasive test. The software is designed for patients currently diagnosed as being at-risk for stroke who are taking medication to prevent stroke. NOVA takes preventative care one step forward by being able to tell if a patient is improving with their current medical therapy, or if their prescriptions need to be adjusted. Doctors will be able to tailor treatment and better detect what therapy may or may not be working, Dr. Berlet says. This is the best tool to minimize a patient’s chance of a debilitating stroke. NOVA provides a patient a three dimensional view of the vascular system of the neck and head that is 10 times more sensitive than transcranial ultrasound [the current standard of care] and gives patients a numerical value that is extraordinarily important to managing their risk for stroke. The scan measures blood flow in the brain in milliliters per minute, which is a quantitative numerical value that can be compared to normal values. This determines the severity of the patient’s steno-
sis, or blockage. The scan takes about 10 minutes and a report is instantly generated and printed, showing the patient’s stroke risk. There is no direct alternative to the NOVA MRA system, but a cerebral angiogram can give the degree of narrowing. Unfortunately it is an invasive and expensive test that does not give the quantitative blood flow. It can only provide the degree of narrowing of the blood vessel. Not to mention, the patient is exposed to ionizing radiation and there is a chance of stroke during the procedure itself. NOVA MRA can be expanded to use in triage for patients with stroke symptoms. Since it provides a quick, quantitative result, Berlet said he would like this technology used to give clinicians an even better idea of which stroke patients can be helped with intervention [clot retrieval, angioplasty, stent stroke treatment] when they arrive at the ER with stroke symptoms.
USF College of Nursing receives $2.1-million award from Patient-Centered Outcomes Research Institute to study cancer symptom management The Patient-Centered Outcomes Research Institute (PCORI) has approved a $2.1-million award to the University of South Florida College of Nursing to study “Patient Outcomes of a Self-care Management Approach to Cancer Symptoms: A Clinical Trial.” USF Distinguished Profes-
sor and Thompson Professor of Oncology Nursing Susan C. McMillan, PhD, ARNP, FAAN, will lead the research project. The USF College of Nursing project will test a brief intervention, known as COPE, which aims to teach cancer patients management skills for improving symptoms they identify as the highest priority. Improving cancer patients’ ability to self-manage difficult symptoms may diminish patient suffering, improve quality of life, and decrease emergency room visits and associated healthcare costs, according to Dr. McMillan. The USF College of Nursing study is one of 51 new awards by PCORI, totaling $88.6-million over three years, to fund patient-centered comparative clinical research effectiveness projects. It is part of a portfolio of projects that address PCORI’s national research priorities and will provide patients with information to help them make better informed decisions about their care. The only other new PCORI award in Florida went to the college’s clinical collaboration partner Moffitt Cancer Center to study a navigator-guided psychoeducational intervention for prostate cancer patients and caregivers. Richard Roetzheim, MD, professor of family medicine at the USF Health Morsani College of Medicine, is one of the investigators for the Moffitt study. The randomized clinical trial led by Dr. McMillan will evaluate the effectiveness of COPE in alleviating moderate to high-intensity cancer symptoms causing distress, frequency or interference with patients’ lives. To conduct the study, the
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GrandRounds researchers will recruit 300 cancer center outpatients with breast, colorectal, lung and prostate cancers. All the PCORI projects were selected through a highly competitive review process in which scientists, patients, caregivers, and other stakeholders helped to evaluate more than 400 applications for funding. Proposals were evaluated on the basis of scientific merit, how well they engage patients and other stakeholders, their methodological rigor, and how well they fit within PCORI’s national research priorities. Through the Center for Living with Chronic Illness, the USF College of Nursing focuses the research expertise of its nurse scientists, faculty and students as they collaborate on unique solutions to the nation’s leading health care problems, such as heart disease, Alzheimer’s disease and cancer. The latest awards were part of PCORI’s second cycle of primary research funding. All were approved pending completion of a business and programmatic review by PCORI staff and issuance of a formal award contract. This new round of funding follows PCORI’s initial approval of $40.7 million in support for 25 projects under the institute’s national research priorities
Lehigh Valley Health Network Joins the Moffitt Oncology Network Lehigh Valley Health Network is partnering with Moffitt Cancer Center to enhance cancer care by joining the newly
launched Moffitt Oncology Network. Lehigh Valley, based in Allentown, Pa., is the first member of the network outside of Florida. As a member of the Moffitt Oncology Network, Lehigh Valley will have access to Moffitt’s experts and best practices, which include multidisciplinary cancer care, peer review, clinical pathways and quality assurance standards. The Moffitt Oncology Network extends Moffitt’s knowledge and expertise to physicians and providers with the goal of offering the best personalized cancer care. Lehigh Valley’s physicians will collaborate with Moffitt physicians on patient care and novel clinical research. Key elements of the relationship include: • Joint clinical research-driven cancer care • Utilization of Moffitt Clinical Pathways • Quality management strategies including physician education and audits • Development of strategic Centers of Excellence In 2011, Lehigh Valley announced a partnership with Moffitt to bring the most advanced cancer care to Pennsylvania’s Lehigh Valley and surrounding communities. Collaborations include an ovarian cancer trial to test choices of chemotherapy treatment based on the tumor DNA, and a smoking cessation pilot project targeted at pregnant women. More than 50 patients from Lehigh Valley have been involved in the two projects. Research with the Moffitt Oncology Network is expected to include additional tumor DNA study of various advanced-stage cancers and testing of a new drug for advanced
stages of melanoma. As the importance of quality grows in health care reform, this partnership will position both organizations to better provide the best care in a changing environment. Through use of Moffitt’s evidence based clinical pathways and the novel quality measurement and feedback projects, Lehigh Valley and Moffitt will be well positioned for the future.
Moffitt Cancer Center, QURE Partner to Improve Quality of Care, Cancer Outcomes Moffitt Cancer Center and QURE Healthcare have launched a four-year partnership to measure and enhance the quality of care and improve outcomes for cancer patients. The National Cancer Institute Comprehensive Cancer Center and the health care research and business firm are combining clinical, scientific and technological resources to measure and report on quality metrics. The goal is to better understand clinical practice patterns and physician decision-making so that Moffitt physicians and their physician partners in the community can be more aligned and deliver more effective and efficient care. The collaboration will measure, validate and promote adoption of Moffitt’s nationally acclaimed oncology clinical pathways using QURE’s measurement tool, Clinical Performance and Value (CPV™) vignettes. CPV™ vignettes, QURE’s unique simulated case and evidence-based feedback system, will measure and leverage Moffitt’s leadership in
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GrandRounds multidisciplinary clinical care, molecular diagnostics, chemotherapy protocols and diagnostic radiology. This collaboration also is expected to advance the creation of emerging diagnostics and therapeutics. Once a baseline is established against the Moffitt cancer pathways, the initiative intends to broaden its scope to the economic and quality improvement of full CPV™ deployment across a strategic network of oncology partners across Florida and other states.
Northside Hospital Receives American Heart Association Achievement Award Northside Hospital has received the American Heart Association’s Mission: Lifeline® Silver Receiving Quality Achievement Award. The award recognizes Northside Hospital’s commitment and success in implementing an exceptional standard of care for heart attack patients. Each year in the United States, nearly 300,000 people have a STEMI, or ST-segment elevation myocardial infarction, the most severe form of heart attack. A STEMI occurs when a blood clot completely blocks an artery to the heart. To prevent death, it’s critical to immediately restore blood flow, either by surgically opening the blocked vessel or by giving clot-busting medication. Hospitals involved in Mission: Lifeline are part of a system that makes sure STEMI patients get the right care they need, as quickly as possible. Mission: Lifeline focuses on improving the system of care for these patients and at the same time improving care for all heart attack patients. As a “STEMI Receiving Hospital,” Northside Hospital meets high standards of performance in quick and appropriate treatment of STEMI patients to open the blocked artery. Before they are discharged, patients are started on aggressive risk reduction therapies such as cholesterol-lowering drugs, aspirin, ACE inhibitors and beta-blockers and they receive smoking cessation counseling if needed. Hospitals must adhere to these guidelines-based measures at a set level for a designated period of time to be eligible for the achievement awards.
It was the first note I ever got in crayon. “Thank you for making my daddy feel better.” I keep it on my desk, where I pore over patient records and cash flow statements. Because even if the medical field seems to be changing by the day, the reasons I practice never do.
Medical News is pleased to provide space for press releases by providers in our Grand Rounds section. Content and accuracy of the releases is the sole responsibility of the issuer.
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Recognized nationally. tRusted locally. Caring for patients in 16 Greater Tampa Bay Area communities Tampa Bay Area Physicians Jorge Ayub, MD
Sunil Gandhi, MD, FACP
Jeffrey L. Paonessa, MD
Jose Alemar, MD
Larry Gandle, MD
Janelle Park, MD
Rand W. Altemose, MD
Christopher B. George, MD
Y. K. Peter Park, MD
Jennifer L. Ball, DO
Vivian Griffin, MD
Hitesh Patel, MD
Gregoire Bergier, MD
Andrew E. Hano, DO
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Sawsan G. Bishay, MD
Vu Tran Ho, MD
V. Upender Rao, MD, FACP
Rafael W. Blanco, MD
Nuruddin Jooma, MD, MPH
Mark S. Robbins, MD
Kerry E. Chamberlain, DO
Craig S. Kitchens, MD
Joseph Sennabaum, MD
Hafeez T. Chatoor, MD
Richard A. Knipe, MD
Ramesh K. Shah, MD, PA
Marion T. Chirayath, MD
Julio Lautersztain, MD
Shalin R. Shah, DO
Mamta T. Choksi, MD
Don D. Luong, MD
Gerald H. Sokol, MD, MSc, FCP
Julia Cogburn, MD
Joseph R. Mace, MD
R. Waide Weaver, MD
Michael Diaz, MD
Idelfia A. Marte, MD
David Wenk, MD
Robert L. Drapkin, MD
Arthur J. Matzkowitz, MD
David D. Wright, MD
Matthew A. Fink, MD
Edgar G. Miranda, MD
Gail Wright, MD, FACP, FCCP
Gustavo Fonseca, MD
Magda Melchert, MD
Lane D. Ziegler, DO
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