Page 1

s e p t e m b e r 2 014

Duke Center for Metabolic and Weight Loss Surgery Global Leaders in Minimally Invasive Bariatric Surgery


Also in This Issue

Language Barrier Update: Cervical Cancer Screening

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Duke Center for Metabolic and Weight Loss Surgery

Global Leaders in Minimally Invasive Bariatric Surgery

s e p t e m b e r 2 0 14



Womenâ&#x20AC;&#x2122;s Health

Update: Cervical Cancer Screening Lindsay Wojciechowski provides the latest recommendations on when to start and stop screening, as well as frequency.


Vol. 5, Issue 6

DEPARTMENTS 9 Gastroenterology

18 UNC Research News

Understanding of IBD-IBS from a Biopsychosocial Perspective

Largest Genetic Analysis Reveals New Way of Classifying Cancer

12 Practice Management

19 UNC Research News

More Older Patients in Emergency Department Are Malnourished

15 Duke Research News Cancer-Fighting Drugs Might Also Stop Malaria Early

20 WakeMed News

16 Duke Research News


Challenging Cases: Overcome Language Barriers

Revenue Cycle Management

- Age Does Not Increase Surgical Risks of Deep Brain Stimulation - Gut Flora Finding May Advance Development of HIV Vaccine

17 UNC Research News

-G  arner Healthplex Exceeds Projections -F  amily-Togetherness and Privacy Are Goals of Major BirthPlace Renovations

21 News

Welcome to the Area

New Approach Uncovers Cancer Genes

Dr. Margaret Boyse has found that accurate diagnosis is more likely with techniques for improved patient communication.


The Triangle Physician

COVER PHOTO: L-R: Back Row: Surgeons, Alfonso Torquati, M.D., MSci, Dana Portenier, M.D.; Front Row: Surgeons, Chan Park, M.D., Philip Omotosho, M.D., Jin Yoo, M.D.

If You Have Patients Who Could Benefit From A Rheumatologist, Dr.Anshul Rao of Johnston Health WelcomesYour Referrals! If you have patients who are suffering from arthritis, or related diseases, you have a rheumatology specialist nearby who welcomes your referrals. Anshul M. Rao, MD, a rheumatologist, is seeing adult patients ages 18 and older at offices in the Medical Arts Pavilion on the Smithfield campus of Johnston Health and at the Johnston Professional Plaza on the Clayton campus of Johnston Health. Dr. Rao finds it gratifying to offer a myriad of treatments that allow patients to maintain and continue their quality of life. He is treating patients suffering with the following conditions:

Gout Lupus Vasculitis Psoriatic Arthritis Myositis Pseudogout Scleroderma Osteoporosis Sarcoidosis Ankylosing Spondylitis Rheumatoid Arthritis Spondyloa Spondyloarthritis


Mon. - Wed. - Fri. 507 N. Bright Leaf Blvd. Suite 100

Call For Appointments: 919-934-3022

CLAYTON Tues. & Thur. 2076 Hwy 42W. Suite 330

From the Editor

Beyond Obesity T H E M A G A Z I N E F O R H E A LT H C A R E P R O F E S S I O N A L S

This month’s cover story highlights the expertise and experience of the Duke Center for Metabolic and Weight Loss Surgery, internationally known for its multidisciplinary approach to weight management and co-morbidity mitigation.

In consultation with their surgeon, patients select from a range of procedures that can result in weight loss and dramatic improvement in associated metabolic, hormonal and physiological conditions, such as diabetes, hypertension and sleep apnea. Duke’s weight-loss program encourages primary care physicians to take an active role in the ongoing surveillance and guidance of patients.

Also in this issue, gastroenterologist Douglas Drossman takes special care in understanding the correlation between disease and patient symptoms, particularly as it relates to irritable bowel syndrome. Nurse practitioner Lindsay Wojciechowski

Editor Heidi Ketler, APR Contributing Editors Margaret B. Boyse, M.D. Douglas Drossman, M.D. Margie Satinsky, M.B.A. Lindsay Wojciechowski Creative Director Joseph Dally

Advertising Sales info@trianglephysiciancom News and Columns Please send to

helps make sense of recent recommendations for cervical cancer screening. Dermatologist Margaret Boyse shares her own best practices in overcoming language barriers to improve diagnoses. Practice management consultant Margie Satinsky offers a medical practice checklist for maintaining good financial health.

Fall is fast approaching. It’s a great time to set goals for next year and to remind

The Triangle Physician is published by: New Dally Design Subscription Rates: $48.00 per year $6.95 per issue Advertising rates on request Bulk rate postage paid Greensboro, NC 27401

you of the select audience of The Triangle Physician – the more than 9,000 professionals within the Raleigh-Durham medical community. For details on how you can make the most of your marketing dollars with coverage in this magazine – whether contributing news and medical insight at no cost or a cover feature or advertising at competitive rates – please contact me for details at heidi@

With great appreciation for all you do,

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The Triangle Physician

Every precaution is taken to insure the accuracy of the articles published. The Triangle Physician can not be held responsible for the opinions expressed or facts supplied by its authors. Opinions expressed or facts supplied by its authors are not the responsibility of The Triangle Physician. The Triangle Physician makes no warrant to the accuracy or reliability of this information. All advertiser and manufacturer supplied photography will receive no compensation for the use of submitted photography. Any copyrights are waived by the advertiser. No part of this publication can be reproduced or transmitted in any form or by any means without the written permission from The Triangle Physician. Maternity




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Cover Story

Duke Center for Metabolic and Weight Loss Surgery Global Leaders in Minimally Invasive Bariatric Surgery By Jennifer Cash

is genetic or has other medical origins.

Recognition of obesity as a disease –

Greater understanding of obesity through-

chronic, progressive and disabling – repre-

out the medical profession is leading to im-

sents a significant advance. Last year, the

proved and safer outcomes for many who

The Duke Center for Metabolic and Weight

American Medical Association approved

struggle to fight the battle of the bulge. Di-

Loss Surgery is a center of excellence that

the disease status, which offered further

ets and exercise have not always been the

specializes in weight-loss surgery options


answer, especially for those whose obesity

to fit people in all stages of obesity. Patients eligible for the surgery are diagnosed with a body mass index (BMI) greater than 35. “We know obesity greatly impacts people’s lives. When we do surgery, we can help patients achieve their full potential,” says bariatric surgeon Alfonso Torquati, M.D., M.Sci., director of the Duke Center for Metabolic and Weight Loss Surgery. “Weight-loss surgery is for people that have been dealing with the medical problem of obesity,” says fellow bariatric surgeon Chan Park, M.D. The Road to Surgery Duke’s in-house bariatric team is comprised of six fellowship-trained surgeons, a physician assistant, a clinical psychologist, registered dieticians, an endocrinologist and nurses, along with other dedicated support staff. “Our multidisciplinary team has been around the longest in the Triangle area and has the most experience doing bariatric surgery,” says bariatric surgeon Dana Portenier, M.D. As a result, patients experi-

Ranjan Sudan, M.D., surgeon, reviews a case with Kimberly Ashley, R.N., clinical team leader.


The Triangle Physician

ence tremendous success.

Duke offers an individually tailored ap-

Duke’s comprehensive bariatric care in-

proach to bariatric surgery. After an initial

cludes monthly support groups. An evalu-

consultation with each patient, surgeons

ation process throughout the treatment –

help the individuals determine the right

from the pre-surgical education program

surgery for their unique medical condition.

to post-surgical support – ensures patients

Patients then meet with each member of

achieve their weight-loss goals.

the team. “Weight-loss surgery often has an incredIn addition to preparing patients mentally

ibly positive impact on individuals that is

for surgery, the psychologist educates

rarely seen with other surgical, medical

them on how surgery will impact their

or psychological treatments, which likely

lives afterward. “Helping patients prepare

gives patients a sense of hope for an alter-

for surgery, psychosocially, can help with

native future,” says Dr. Friedman.

potential challenges ahead and bolster a successful adjustment,” says clinical psy-

Weight-Loss Procedures

chologist Kelli Friedman, Ph.D.

Duke Center for Metabolic and Weight Loss Surgery specializes in advanced surgical

A dietician works with the patient to estab-

weight-loss techniques, including mini-

lish strategies for improved nutrition, be-

mally invasive endoscopic, single-incision

havior modification and exercise, and the

laparoscopic and robotic surgeries.

Endocrinologist Leonor Corsino, M.D., M.H.S., F.A.C.E.

endocrinologist addresses such existing conditions as diabetes. “Our close collabo-

“Our very experienced team leads in in-

ration with the surgical team as part of our

novation and is very well known nation-

typically lose 55 to 65 percent of excess

comprehensive bariatric surgical care in-

ally and internationally for its expertise.

weight, mostly in the first year.

cludes the management of their endocrine

At the same time, we are compassionate

conditions,” says endocrinologist Leonor

and, therefore, able to offer the latest treat-

Sleeve gastrectomy removes a large por-

Corsino, M.D.

ments in a holistic manner,” says bariatric

tion of the stomach to restrict food intake.

surgeon Ranjan Sudan, M.D.

Patients lose 40 to 55 percent of excess

Duke is the only multidisciplinary center

weight, most within one to two years.

in the Triangle. “In one single morning,

Roux-en-Y gastric bypass is the gold stan-

our patients can have an evaluation with

dard for weight-loss surgery and is chosen

Adjustable gastric banding places a

a weight-loss surgeon, endocrinologist,

by nearly two-thirds of patients. This pro-

band around the stomach to limit food in-

psychologist and nutritionist. This is very

cedure creates a small gastric pouch to

take. The band can be adjusted – loosened

unique and very valuable for our patients

limit food intake. Food passage is rerouted

or tightened – after surgery and in the clin-

wishing to take less time off from work,”

through the intestines to limit the number

ic. Patients lose 30 to 40 percent of excess

says Dr. Torquati.

of calories absorbed into the body. Patients

weight gradually, up to five years.

Sleeve Gastrectomy

Adjustable Gastric Banding

Duodenal Switch

September 2014


Duodenal switch involves removing a

pertension, sleep apnea, hyperlipidemia,

surgeons. “We have trained a lot of the

portion of the stomach and “switching”

heart disease, asthma, osteoarthritis and

people that are out there. This is where

around the small intestine to alter the


they learned to do what they do,” says Dr. Park, a former fellow of the Duke program.

digestion process and limit food intake. Patients lose 60 to 80 percent of excess

“Bariatric surgery is an extraordinary phe-

weight, mostly in the first year. Dr. Sudan

nomenon; it is uncommon for a surgical

Not only do Duke’s bariatric surgeons im-

was the world’s first surgeon to perform

procedure to be responsible for the long-

pact patient lives through surgical care,

the duodenal switch procedure robotically.

term remission or mitigation of so many

they also work to influence legislators and

comorbid conditions,” says bariatric sur-

regulators across the state on health care

geon Philip Omotosho, M.D.

matters. Dr. Sudan, who is president of the

Revisional procedures are personalized

Bariatric Society of the Carolinas, has been

based on patients’ specific needs and conditions.

“After gastric bypass and sleeve gastrec-

working to improve access to bariatric care

tomy, the intestine starts producing larger

in North Carolina.

amounts of hormones that improve insulin action. In many patients with diabetes, abetes,” says Dr. Torquati, who is involved

Primary care and specialty physicians are invited!

with clinical research and studies the

What: “Selection and Medical

mechanisms involved in the resolution of

Management of Weight Loss Surgery

diabetes and cardiovascular diseases after

Patients” continuing education course,

bariatric surgery.

presented by Duke

these changes result in remission of the di-

When: Saturday, Oct. 11 The cost of treating obesity-related medi-

Where: The Umstead Hotel in Cary

cal conditions far outweighs the cost of

Register: (919) 470-7034

weight-loss surgery, according to Dr. Omotosho. “Alongside durable weight loss, this is the unparalleled benefit of bariatric sur-

Referring Providers

gery to our patients.”

Because pre-operative and follow-up care is essential for a successful surgical out-

Clinical psychologist Kelli Friedman, Ph.D.

Minimally Invasive General Surgery

come, the Duke Weight Loss Surgery team

The bariatric surgeons at Duke are highly

strives to build a working relationship with

trained in minimally invasive general sur-

referring providers.

gery. Advanced laparoscopic technologies result in less scarring, reduced pain and

Post-surgery patients are seen annually by

quicker recovery.

their bariatric surgeon. However, it is important for primary care providers to un-

Life-Changing Results Patients who undergo bariatric surgery at

“Our group offers the latest surgical ap-

derstand the support they should provide

Duke have tremendous success following

proaches to ‘general surgery’ problems,

to help keep their patients on the weight-


such as single-incision laparoscopic pro-

management track.

cedures for hernias and gallbladders; ab“You can see in a few months after surgery

dominal wall reconstruction for complex

Duke Minimally Invasive General and

a major change and how it will affect the

hernias; and endoluminal procedures for

Weight Loss Surgery has locations in Dur-

patient’s quality of life,” says Dr. Torquati.

reflux disease and Barrett’s esophagus, to

ham and Raleigh in close proximity to

name a few. Furthermore, we also see lipo-

Duke Regional Hospital, James E. Davis

Weight-loss surgery is not all about losing

mas, cysts and inguinal/umbilical hernias,”

Ambulatory Surgical Center and Duke Ra-

weight. “There are metabolic, hormonal

says bariatric surgeon Jin Yoo, M.D.

leigh Hospital. For more information on the weight-loss surgery program at Duke,

and physiological changes that occur after Since 1993, the Duke Minimally Invasive


and Bariatric Surgery Fellowship has of-

more information regarding referrals to the

Usually there is dramatic improvement in

fered world-class training to surgeons who

Durham or Raleigh clinic, call the physi-

such co-morbidities as Type 2 diabetes, hy-

are now among the nation’s best bariatric

cian liaison number: (919) 907-9077.

surgery,” says Dr. Park.


The Triangle Physician



Understanding of IBD-IBS from a Biopsychosocial Perspective By Douglas A. Drossman, M.D.

As providers we often struggle to understand

visceral sensitization may occur from prior

the patient’s illness experience in relationship

inflammation leading to abdominal pain and

to their disease, i.e. the observable data from

diarrhea in up to 20 percent of patients treated

X-ray, endoscopy or histopathology. With

with these potent agents.

structural disorders, such as inflammatory bowel disease or peptic ulcer disease, we

The chronic pain of illnesses like IBD-IBS is a

often assume that the patient’s symptoms

biopsychosocial, multidimensional process,

correlate highly with the evident disease

with sensory, emotional and cognitive

activity. However, a patient’s illness or their

contributions to the experience that relates to:

perception of ill health may vary considerably

1) Ascending visceral pain transmission

from their disease or the externally verifiable

2) Peripheral amplification of visceral signals

evidence of a pathological state.

3) Reduced inhibition by the central nervous system (CNS) of ascending pain signals at

An important example of this possible incongruity can be noted in inflammatory bowel disease (IBD), ulcerative colitis or

the level of the dorsal horn 4) Central amplification via psychological distress

Crohn’s disease. Some patients with active and ulcerating IBD may have few symptoms

Thus, chronic pain involves dysregulation of

and may not even present for treatment until

neurophysiological processes at spinal and

a complication, such as bleeding, obstruction

supraspinal levels. Furthermore, with chronic

or abscess, arises. That is because mucosal

pain, increased afferent visceral stimuli do not

inflammation alone is not sufficient in many

contribute as much as CNS upregulation of

cases to cause pain or other gastrointestinal

incoming visceral afferent signals, which can

symptoms. The pain of IBD relates to

bring even regulatory (normally subliminal)

penetrating ulcers that reach neural plexi,

signals to a point of conscious awareness and

fistulas, obstruction or severe inflammation.


In contrast, it is not uncommon for us to see

Dr. Douglas Drossman graduated from Albert Einstein College of Medicine and was a medical resident and gastroenterology fellow at the University of North Carolina. He was trained in psychosomatic (biopsychosocial) medicine at the University of Rochester and recently retired after 35 years as professor of medicine and psychiatry at UNC, where he currently holds an adjunct appointment. Dr. Drossman is president of the Rome Foundation (www.theromefoundation. org) and of the Drossman Center for the Education and Practice of Biopsychosocial Care ( His areas of research and teaching involve the functional GI disorders, psychosocial aspects of GI illness and enhancing communication skills to improve the patientprovider relationship. Drossman Gastroenterology P.L.L.C. ( specializes in patients with difficult-to-diagnose gastrointestinal disorders and in the management GI disorders, in particular severe functional GI disorders. The office is located at Chapel Hill Doctors, 55 Vilcom Center Drive, Suite 110 in Chapel Hill. Appointments can be made by calling (919) 929-7990.

patients with IBD who report marked pain and

Our understanding of IBD-IBS pain in terms of

diarrhea, but with endoscopic or radiological

both peripheral (gut) and central (brain and

mild or microscopic disease, a similar

spinal cord) acting factors leads to important

phenotype to that of post-infectious irritable

therapeutic implications for the treating

bowel syndrome (PI-IBS). We now call this

physician. The management of centrally

entity IBD-IBS.

driven chronic pain may evoke more centrally

syndrome, in which opioids paradoxically

targeted treatments in addition to or instead

increase pain.

Both IBD-IBS and PI-IBS share similar

of anti-inflammatory agents, for example.

pathophysiological origins with evidence for

Antidepressants, including selective serotonin


mucosal inflammation (more so in IBD), often

reuptake inhibitors to tricyclic antidepressants,

Grover, M.; Herfarth, H.; Drossman, D.A. The

in response to infection, which then leads to

and psychological treatments, including

functional-organic dichotomy: Post-infectious

loss of mucosal membrane integrity, cytokine

cognitive behavioral therapy and hypnosis,

irritable bowel syndrome and inflammatory

activation and upregulation of myenteric

are examples of centrally targeted therapies

bowel disease-irritable bowel syndrome. Clinical

nerves, causing pain. The dissociation

for chronic pain as might occur in IBD-IBS.

Gastroenterology and Hepatology 2009;7:48-53

between illness and disease in IBD is most

Narcotic use should be avoided as continued

evident since the use of potent biological

use can escalate gastrointestinal symptoms,

Grover, M.; Drossman, D.A. Pain management

anti-TNF (tumor necrosis factor) agents that

leading to opioid induced constipation or

in inflammatory bowel disease; IBD Monitor

can literally wipe out observable disease, yet

the infrequently recognized narcotic bowel


September 2014


Weight Management


Cervical Cancer Screening By Lindsay Wojciechowski

Cervical screening has saved women’s

As a result, guidelines for cervical cancer

lives. It can detect potentially pre-

screening have changed in the last few

cancerous changes caused by sexually

years, often creating confusion for primary

transmitted human papillomavirus. If left

care providers. The recommendations

untreated, abnormal cells may progress to

overall suggest less frequent testing.

invasive cervical disease. In the United States, cervical cancer screenWhile the Papanicolaou test (or Pap

ing guidelines are issued by several organiza-

smear) is considered reliable, it’s not

tions. The remainder of this article summa-

perfect. As a result, many colposcopies

rizes the recent updates from: 1) The United

and other follow-up procedures occur that

States Preventative Services Task Force (USP-

likely are unnecessary.

STF) in 2012; 2) the American Cancer Society, the American Society for Colposcopy

According to Mahdavi & Monk (2005), it

and Cervical Pathology and the American

is estimated that 50-60 million Pap smears

Society for Clinical Pathology (ACS/ASCCP/

are done every year in the United States

ASCP) in 2012; and 3) the American College

and that approximately 3.5 million of these

for Obstetricians and Gynecologists (ACOG)

are read as abnormal. Approximately

in 2012.

Lindsay A. Wojciechowski is a nurse practitioner and consultant to the Women’s Wellness Clinic and the Carolina Women’s Research and Wellness Center (CWRWC). She has worked as a clinical nurse practitioner for Triangle Family Practice at Duke University Medical Center since 2006. She also has taught courses at the Duke University School of Nursing. Ms. Wojciechowski’s focus is on women’s health and family medicine, and she also is the lead medical writer for the Women’s Wellness Clinic.

How frequently to screen: All guidelines

2.5 million women therefore undergo colposcopy despite the fact that most

When to start cervical cancer screen-

recommend testing women aged 21-29

human papillomavirus (HPV) infections

ing: All organizations recommend onset of

every three years with cytology only. HPV

clear without treatment.

screening at age 21, regardless of the age of

testing in women under the age of 30

first sexual activity. All women older than

has been shown to detect transient HPV

The good news for adolescent girls is that

21 who have never been screened should

infections, often leading to unnecessary

even with HPV infection, the changes in

undergo evaluation.

colposcopies. Testing for HPV is not recommended in women under the age of

cervical cytology usually resolve or go

30 years.

away on their own. In fact, up to 90-95

When to stop screening: All recommend

percent of low-grade lesions (and some

screening to stop at age 65, assuming that

high-grade lesions) in adolescents will

the woman has had adequate screening

For women older than 30, frequency of

spontaneously resolve (Moscicki et al.,

in the past (three consecutive negative

screening depends on the type of testing


cytology results or at least two consecutive


negative cytology/HPV co-tests in the last

• ACOG and ACS/ASCCP/ASCP recom-


10 years). The clinician may determine

mend testing every five years with both

follow-up evaluation should not be done

that there are women older than 65 with

cytology and HPV testing. Co-testing

unnecessarily. There are disadvantages

concerning symptoms, high risk of new

with both cytology and HPV testing can

to frequent and potentially unnecessary

exposure or poor screening history that

lead to earlier diagnosis of high-grade le-

colposcopies, as well as treatments with

warrants continued screening.







sions. • USPSTF recommends testing either every


(LEEPs) or ablative treatments. They

Women who have had a hysterectomy

five years with both cytology and HPV or



(that was unrelated to cervical cancer) are

every three years with cytology only.

consequences, discomfort and potential

not advised to undergo cervical cancer

adverse health outcomes.





The Triangle Physician

• Older women who have not been screened adequately over the years

should receive testing (cytology every


three years or co-testing every five

Your Skin needs

years) until 70-75 years of age.


No guidelines recommend HPV testing only, unless in clinical settings with limited cytology resources.

Your skin needs the protection and strength of a defensive line. We offer that defense in great medical grade skin care products and skin rejuvenation procedures from Southern Dermatology including:

Management of abnormal Pap smears is beyond the scope of this article. Certainly


providers are encouraged to consult with experts and to consider each woman individually.

We’re part of the team to provide you with the most advanced therapies for prevention and early detection of skin cancer!

In conclusion, it is necessary to emphasize that although the factors addressed above (age of first screen, type of test, frequency of screening) are very important, they have

We keep you safe. Make an appointment today!

less impact on the effectiveness of cervical


cancer screening than does thorough follow up after abnormal screening results.


According to Saslow et al. (2007), half of

women who are diagnosed with invasive cervical carcinoma have never had a pap smear. In addition, another 10 percent had not had a pap smear in the last five years.


55 Vilcom Center Drive Boyd Hall, Suite 110 Chapel Hill, NC 27514

Drossman Gastroenterology PLLC a patient-centered gastroenterology practice focusing on patients with difficult to diagnose and manage functional GI and motility disorders. The office is located within the multidisciplinary health care center, Chapel Hill Doctors. Dr. Douglas Drossman is joined by physician’s assistant, Kellie Bunn, PA-C. Appointments are scheduled on Tuesday and Wednesday and most laboratory studies are available.


Unfortunately, early cervical cancer is usually asymptomatic, emphasizing the importance of screening and follow up. Close and careful follow up with all patients with abnormal results is crucial to the wellbeing of the patient.

Drossman Gastroenterology

References Mahdavi, A. & Monk, B.J. (2005). Vaccines against




cervical cancer: promises and challenges. Oncologist, 10:528.

8/19/14 11:00 AM

Moscicki, A.B., Shiboski, S., Hills, N.K. (2004). Regression of low-grade squamous intra-epithelial lesions in young women. Lancet, 364:1678. Saslow, D., Castle, P.E., Cox, J.T. (2007). American Cancer Society Guideline for human papillomavirus (HPV) vaccine use to prevent cervical cancer and its precursors. CA Cancer J Clin, 57:7.

September 2014


Practice Management

Financial Management:

Revenue Cycle Management By Margie Satinsky

Financial stability is an important goal for all medical practices. Assuming that you’ve created and use both operating and capital budgets, what can you do to keep your practice in good financial health? We recommend focusing on the big picture of revenue cycle management, as well as on the individual components that comprise it. Here’s the big picture and specific suggestions.



Fees charged to payers and patients


Reimbursement by managed care plans and government payers Participation in value added incentive programs Appointment scheduling Financial Information provided to all patients

Margie Satinsky is president of Satinsky Consulting L.L.C., a Durham consulting firm that specializes in medical practice management. She’s the author of numerous books and articles, including Medical Practice Management in the 21st Century. For more information, visit

Communications with patients prior to visit or procedure


Issue identification of issues and problem resolution:

Billing and collections


Benchmarking financial performance


Corrective action Documenting revised processes Staff training

Accounts Receivable (AR) by specific payer Erroneous payer reimbursement that does not correspond to contract

• Analyze your payer mix for both

not, the problems lie not with the

management is clear, look at the list

managed care and government payers.

programs but with your own negative

of recommendations. Resolve to make

• Stay current on payer specific methods

attitude and with your staff’s inability

changes to enhance your practice’s

of reimbursement and negotiate often.

to use information that already resides

financial performance.

Plans rarely come to you with offers of

in your practice management and/or

Now that the scope of revenue cycle

higher reimbursement. Both public and

electronic health record systems.

• Regularly review the list of services

private payers are shifting to pay for

• Enhance your chances of receiving

that you provide and make sure the

value payment methods. An example

payment for all care that you provide

mix is appropriate. For example, if you

is Blue Cross Blue Shield of North

by obtaining accurate demographic

offer services that are reimbursable

Carolina, which has both a Blue Quality

information and verifying insurance

by insurers as well as other services

Physicians Program (BQPP) and a

coverage before every visit or proce-

for which patients pay out of pocket, does the mix produce your targeted net

tiered product.


• Look closely at the many ways in which

• Provide patients with written financial

you can receive financial incentives

policies for your practice before the

• Review the fees that you charge at least

for providing and documenting quality

visit/procedure. Request payment at

annually. Use the Medicare Resource-

and cost-efficient care. Don’t be so

the time of the visit. After the second

Based Relative Value Scale for your

quick to dismiss these programs as

no-show, charge for the visit. Encourage

state as a benchmark.

“not worth my time.” More often than

prompt payment but be willing to



The Triangle Physician

develop payment plans to help patients

about rates of payment and actual

system. Ask your vendor for guidance

meet their financial obligations.

vs. expected reimbursement by CPT

if you need it.

• Code each visit appropriately and

code. If problems arise, notify the payer

• Get the right help from the right

make sure you are up-to-date on coding

immediately and resolve the issues

professionals. CPAs report on the

before they escalate.

activity that has occurred and make

changes. External coding auditors can

• Know where to get all the information you

sure you have proper controls in

• Make sure that your billing staff or out-

need to review financial performance.

your practice. Practice management

side billing and collections company

CPAs provide general information but

consultants who understand workflow

scrubs claims before sending them to

don’t give you the patient- and payer-

help you assess workflow and identify

different payers. Sloppy claims submis-

specific details that you can find in your

sion leads to an unnecessary buildup of

practice management system.

provide good guidance.

• Take advantage of the reporting capa-

rejected claims. • Submit




and resolve problems. • Take the financial pulse of your practice

bilities of your practice management

after you complete all of the suggestions above. You can expect good results!

receive electronic deposits into your bank account. • Manage claims denials carefully. You’re leaving money on the table if you don’t review denials, take corrective action, and train your staff not to make the same error over and over again. • Work your accounts receivable (AR) methodically, focusing on the largest and most recent claims. • Separate unpaid claims that are 90 days or older and send them to an external collections agency. • Implement a clear policy for write-offs. Take claims that you are unlikely to collect off your books. • Develop and implement clear policies and procedures for revenue cycle management. Put them in writing. • Clarify responsibilities for your revenue cycle management program. Most practices let the practice manager take charge and work with both an internal team and external professionals. • Train staff on the entire revenue cycle




just the component for which an individual is responsible. Successful revenue management depends on the interrelationship of the parts. • Abandon the habit of judging financial performance




month’s net profit (loss) with that of the previous month. Instead, use standard ratios and by comparing the actual to the expected performance. • Review

payer specific

information Womens Wellness half vertical.indd 1

12/21/2009 4:29:23 PM

September 2014


Patient Care

Challenging Cases:

Overcoming Language Barriers By Margaret B. Boyse, M.D.

According to the United States Census Bu-

for his skin condition.

reau, approximately 60.6 million people, nearly one in five people age five or older,

He had a horrible case of dermatitis, with

speak a language other than English; a

inflamed skin on his neck, arms and legs.

number that has grown by 158 percent

All I had to go by was the appearance of

over three decades. Additionally, those

it, so we had to try different treatments to

speaking a language other than English

get him better. I initially treated the patient

at home (7 percent), said they spoke Eng-

for eczema and psoriasis, but later came

lish “not at all,” while another 15.4 percent

to the conclusion that Mr. X was afflicted

said they spoke English “not well.”

with dermatitis from an infestation.

Clearly, good communication between

A guiding principle in our work is that

caregivers and patients is essential to

treatment of skin conditions must be

safe, high-quality health care services. Re-

based on a correct diagnosis. If I’m hav-

Approximately 60.6 million people, nearly one in five people age five or older, speak a language other than English search shows that communication failures

ing problems with a case and ask, “Why

between patients and physicians contrib-

isn’t my treatment working?” I’m asking

ute to adverse events and medical errors.

the wrong question. The more important question is: “Is my diagnosis correct?”

Yet many physicians are likely to confront the reality of patients who cannot understand them at some point in their medical careers. At Southern Dermatology & Skin Cancer & Skin Renewal Center, we are not strangers to cross-cultural medical encounters. We have people from all over the world in Raleigh. Sometimes in dermatology you don’t need a medical history, but when you do need the history and you’re unable get it, it can be very challenging. I can recall “Mr. X” a patient from a small island off the coast of Vietnam who did not speak any English; it proved to be extremely challenging to communicate with this patient, who desperately needed help


The Triangle Physician

Despite our communication problems, I

Dr. Margaret Boyse practices at Southern Dermatology & Skin Cancer & Skin Renewal Center. After earning her medical degree from the University of Texas, she completed her internship at Walter Reed Army Medical Center and residency at the University of Michigan. Special interests include: general adult and pediatric dermatology, dermatologic surgery, cosmetic dermatology and skin cancer. She is a member of the American Academy of Dermatology and North Carolina Medical Society. Visit for more information. feel sure Mr. X understood that we were desperately trying to help him, and that he had to make a leap of faith to take the medicines we prescribed, knowing that without treatment, his condition almost certainly would get worse. So I offer the following advice on overcoming language barriers that is based on years of experience: • Use simple words; avoid jargon and acronyms. • Limit/avoid technical language. • Speak slowly (don’t shout). • Articulate words completely. • Repeat important information. • Provide educational material in the languages your patients read. • Use pictures, demonstrations, video or audiotapes to increase understanding. • Give information in small chunks and verify comprehension before going on. • Always confirm patient’s understanding of the information – patient’s logic may be different from yours.

Duke Research News

Cancer-Fighting Drugs Might Also Stop Malaria Early Scientists searching for new drugs to fight

One of the advantages of her team’s ap-

stage of malaria that lurks in the liver also

malaria have identified a number of com-

proach is that focusing on the liver stage

worked against the stage that lives in the

pounds – some of which are currently in

of the malaria lifecycle – before it has a


clinical trials to treat cancer – that could

chance to multiply – means there are fewer

add to the anti-malarial arsenal.

parasites to kill.

Malaria-free mice that received a single dose before being bitten by infected

Duke University assistant pro-

mosquitos were able to avoid

fessor Emily Derbyshire and

developing the disease alto-





than 30 enzyme-blocking molecules called protein kinase

Medicines for malaria have

inhibitors that curb malaria

been around for hundreds of

before symptoms start.

years, yet the disease still afflicts more than 200 million

By focusing on treatments that

people and claims hundreds

act early, before a person is

of thousands of lives each

infected and feels sick, the

year, particularly in Asia and

researchers hope to give malaria – especially drug-resistant strains – less time to spread.

Bites from mosquitoes like this one are responsible for transmitting malaria, a disease that claims hundreds of thousands of lives each year. Photo credit: Wikimedia Commons.

Africa. Part of the reason is malaria’s ability to evade attack. One of the most deadly forms

Using a strain of malaria that primarily

of the parasite, Plasmodium falciparum,

The findings appear online and are sched-

infects rodents, Ms. Derbyshire and Jon

has already started to outsmart the world’s

uled to appear in a forthcoming issue of

Clardy of Harvard Medical School tested

most effective antimalarial drug, artemis-

the journal ChemBioChem.

1,358 compounds for their ability to keep

inin, in much of southeast Asia. Infections

parasites in the liver in check, both in test

that used to clear up in a single day of treat-

tubes and in mice.

ment now take several days.

person to person through mosquito bites.

“It used to be that researchers were lucky

Diversifying the antimalarial arsenal could

When an infected mosquito bites, para-

if they could identify one or two promising

also extend the lifespan of existing drugs,

sites in the mosquito’s saliva first make

compounds at a time; now with advances

since relying less heavily on our most com-

their way to the victim’s liver, where they

in high-throughput screening technology

monly used weapons gives the parasite

silently grow and multiply into thousands

we can explore thousands at once and

fewer opportunities to develop resistance,

of new parasites before invading red blood

identify many more,” said Ms. Derbyshire,

Ms. Derbyshire said.

cells – the stage of the disease that triggers

an assistant professor in the Departments

malaria’s characteristic fevers, headaches,

of Chemistry and Molecular Genetics and

Another advantage is that the compounds

chills and sweats.

Microbiology at Duke.

they tested suppress multiple malaria pro-

Most efforts to find safe, effective, low-cost

Focusing on a particular group of enzyme-

drugs for malaria have focused on the later

blocking compounds called protein kinase

stage of the infection when symptoms are

inhibitors, they identified 31 compounds

“That makes them like a magic bullet,” she

the worst. But Ms. Derbyshire and her team

that inhibit malaria growth without harm-


are testing chemical compounds in the lab

ing the host. Several of the compounds are

to see if they can identify ones that inhibit

currently in clinical trials to treat cancers

The research was supported by Duke Uni-

malaria during the short window when the

like leukemia and myeloma.

versity, Harvard Medical School and the

Malaria is caused by a single-celled parasite called Plasmodium that spreads from

teins at once, which makes it harder for the

National Institutes of Health (Grant Num-

parasite is still restricted to the liver, before symptoms start.

parasites to develop ways around them.

The same compounds that stopped the

ber: GM099796) September 2014


Duke Research News

Age Does Not Increase Surgical Risks of Deep Brain Stimulation Implanting deep brain stimulation devices

medications. But as the disease progresses –

poses no greater risk of complications to older

and as people age – tremors and side effects

“Our study should help patients and families

patients than it does to younger patients with

of medication, including involuntary muscle

considering DBS as a potential treatment

Parkinson’s disease,

movements, are less controllable. So it’s this

option for managing the symptoms of

researchers at Duke

older population for whom DBS could be

Parkinson’s disease,” Dr. Lad said. “It also

Medicine report.

quite beneficial.”

provides guidance to surgeons about the risks of common complications among older patients.”

The findings, pub-

In the study, Dr. Lad and colleagues

lished Aug. 25, in

analyzed data from more than 1,750 patients

the journal JAMA

who underwent DBS from 2000-2009. Of

Dr. Lad said the findings could work to



those, 132 patients, or about 7.5 percent,

remove age as a potential criterion to

concerns that pa-

experienced at least one complication within

exclude patients from getting DBS, which

tients older than

90 days of having the DBS device implanted.

is currently under-utilized overall and

age 75 are poorer candidates for deep brain

Complications included wound infections,

even more so among older people with

stimulation (DBS), because they may be

pneumonia, hemorrhage or pulmonary

Parkinson’s disease.

prone to bleeding, infections or other com-


Nandan Lad, M.D., Ph.D.

In addition to Dr. Lad, study authors include

plications that can arise after surgeries. In the Duke-led analysis, the researchers

Michael R. DeLong; Kevin T. Huang; John

“Parkinson’s disease is one of the most

determined that increasing age did not

Gallis; Yuliya Lokhnygina; Beth Parente;

common movement disorders, and it

significantly affect the overall complication

Patrick Hickey; and Dennis A. Turner.

primarily afflicts older people,” said senior

rates, although the 90-day risk of older

author Nandan Lad, M.D., Ph.D., director of

patients acquiring pneumonia was elevated.

The National Institutes of Health funded the

the Duke Neuro-Outcomes Lab. “For many,

Dr. Lad said this complication is typical

study (CA 156687).

movement disorders can be managed with

among older people undergoing surgeries.

Gut Flora Finding May Advance Development of HIV Vaccine nally arise to fight the virus are ineffective.

also cross-react to the HIV envelope.”

testines appear to

These initial, ineffective antibodies target

Dr. Haynes said the body fights most new

play a pivotal role

regions of the virus’s outer envelope called

infections by deploying what are known as

in how the HIV vi-

gp41 that quickly mutates, and the virus

naïve B cells, which then imprint a memory

rus foils a success-

escapes being neutralized. It turns out that

of the pathogen so the next time it encoun-

ful attack from the

the virus has an accomplice in this feat –

ters the bug, it knows how to fight it.


the natural microbiome in the gut.



ganisms in the in-

Barton F. Haynes, M.D.


But when the HIV virus invades and be-

system, according “Gut flora keeps us all healthy by helping

gins replicating in the gastrointestinal

the immune system develop and by stimu-

tract, no such naïve B cells are dispatched.

The study, published Aug. 13 in the journal

lating a group of immune cells that keep

Instead, a large, pre-existing pool of mem-

Cell Host & Microbe, builds on previous

bacteria in check,” said senior author Bar-

ory B cells respond – the same memory

work from researchers at the Duke Human

ton F. Haynes, M.D., director of the Duke

B cells in the gut that fight bacterial infec-

Vaccine Institute that outlined a perplexing

Human Vaccine Institute. “But this research

tions such as E. coli.

quality about HIV: The antibodies that origi-

shows that antibodies that react to bacteria

to new research from Duke Medicine.


The Triangle Physician

Duke Research News This occurs because the region of the HIV

pool triggered by gut bacteria that cross-

Lockwood, Robert Parks, Krissey E. Lloyd,

virus that the immune system targets, the

reacts with the HIV envelope,” said lead

Christina Stolarchuk, Richard Scearce, An-

gp41 region on the virus’s outer envelope,

author Ashley M. Trama. “This supports

drew Foulger, Dawn J. Marshall, John F.

appears to be a molecular mimic of bac-

the notion that the dominant HIV antibody

Whitesides, Thomas L. Jeffries Jr., Kevin

terial antigens that B cells are primed to

response is influenced by previously acti-

Wiehe, Lynn Morris, Bronwen Lambson,


vated memory B cells that are present be-

Kelly Soderberg, Kwan-Ki Hwang, Georgia

fore HIV infection and are cross-reactive

D. Tomaras, Nathan Vandergrift, Katherine

with intestinal bacteria.”

J. L. Jackson, Krishna M. Roskin, Scott D.

“The B cells see the virus and take off –

Boyd, Thomas B. Kepler and Hua-Xin Liao.

they make all these antibodies, but they aren’t protective, because they are target-

Dr. Haynes said the finding provides com-

ed to non-protective regions of the virus

pelling new information for HIV vaccine

This study was supported by funds from


development, which is the next phase of

the National Institute of Allergy and In-


fectious Diseases, part of the National Institutes of Health, through the Center

Dr. Haynes and colleagues said the findings were confirmed in tests of people

“Not only can gut flora influence the devel-

of HIV/AIDS Vaccine Immunology (U19-

who were not infected with HIV. Among

opment and function of the immune sys-

AI067854) and the Center for HIV/AIDS

non-infected people, the researchers iso-

tem, but perhaps also pre-deter mine our

Vaccine Immunology-Immunogen Discov-

lated mutated gp41-gut flora antibodies

reaction to certain infections such as HIV,”

ery (UM1-AI100645-01); as well as from the

that cross-react with intestinal bacteria.

Dr. Haynes said.

National Cancer Institute, also part of NIH, through a Viral Oncology Training Grant

“The hypothesis now is that the gp41 anti-

In addition to Dr. Haynes and Ms. Trama,

body response in HIV infection can be de-

study authors include M. Anthony Moody,

rived from a pre-infection memory B cell

S. Munir Alam, Frederick H. Jaeger, Bradley


UNC Research News

New Approach Uncovers Cancer Genes UNC Lineberger Comprehensive Cancer

growth rates. A high growth rate of

In fact, one of the genes identified –

Center researchers have developed a

cells, also known as cell proliferation, is

CPT1A – is already a target for drug

new integrated approach to pinpoint the

recognized to be associated with poor

development in lymphoma and could

genetic “drivers” of cancer, uncovering

prognosis for breast cancer patients.

potentially be tested for breast cancer patients as well. Drugs targeting CPT1A

eight genes that could be viable for Analyzing multiple types of genomic

have been shown to inhibit human

data, UNC Lineberger researchers were

cancer cell line growth in vitro and in

The study, published online August 24 in

able to identify eight genes that were

mouse models of lymphoma.

Nature Genetics, was authored by Michael

amplified on the genomic DNA level,

Gatza, Ph.D., lead author and post-doctoral

and necessary for cell proliferation in

This analytical approach used to better

research associate; Grace Silva, graduate

luminal breast cancer, which is the most


student; Joel Parker, Ph.D., director of

common sub-type of breast cancer.

includes a comprehensive and integrated

targeted breast cancer therapy.





analysis of multiple data types including

bioinformatics, UNC Lineberger; Cheng and senior

“Using this new computational approach,

gene expression data, somatic mutations,

author Chuck Perou, Ph.D., professor of

we were able to take advantage of the

DNA copy number and a functional

genetics and pathology.

rich data resources that exist and identify

genomics data set.

Fan, research associate;

a number of new potential drug targets These researchers studied a variety of

for a specific subset of breast cancer

“While we were able to pinpoint drivers

cancer-causing pathways, the step-by-step

patients. This is an important step down

for breast cancer, this approach can and

genetic alterations in which normal cells

the road towards more personalized

will be applied to other tumor types in

transition into cancerous cells, including

medicine,” said Dr. Perou.

the future,” said lead author Mike Gatza.

the pathway that governs cancer cell

September 2014


UNC Research News

Largest Cancer Genetic Analysis Reveals New Way of Classifying Cancer Researchers with The Cancer Genome Atlas Research Network have completed the largest, most diverse tumor genetic analysis ever conducted, revealing a new approach to classifying cancers. The work, led by researchers at the UNC Lineberger Comprehensive Cancer Center at the University of North Carolina at Chapel Hill and other The Cancer Genome Atlas (TCGA) sites, not only revamps traditional ideas of how cancers are diagnosed and treated, but could also have a profound impact on the future landscape of drug development.

Charles M. Perou, Ph.D.

“We found that one in 10 cancers analyzed in this study would be classified differently using this new approach,” said Charles M. “Chuck” Perou, Ph.D., professor of genetics and pathology at UNC Lineberger and senior author of the paper, which appeared online Aug. 7 in Cell. “That means that 10 percent of the patients might be better off getting a different therapy – that’s huge.” Since 2006, much of the research has identified cancer as not a single disease, but many types and subtypes and has defined these disease types based on the tissue – breast, lung, colon, etc. – in which it originated. In this scenario, treatments were tailored to the affected tissue, but questions have always existed, because some treatments work and fail for others, even when a single tissue type is tested.


The Triangle Physician

In their work, TCGA researchers analyzed more than 3,500 tumors across 12 different tissue types to see how they compared to one another – the largest data set of tumor genomics ever assembled, according to Katherine Hoadley, Ph.D., research assistant professor in genetics and lead author. They found that cancers are more likely to be genetically similar based on the type of cell in which the cancer originated, compared to the type of tissue in which it originated. “In some cases, the cells in the tissue from which the tumor originates are the same,” said Dr. Hoadley. “But in other cases, the tissue in which the cancer originates is made up of multiple types of cells that can each give rise to tumors. Understanding the cell in which the cancer originates appears to be very important in determining the subtype of a tumor and, in turn, how that tumor behaves and how it should be treated.” Drs. Perou and Hoadley explain that the new approach may also shift how cancer drugs are developed, focusing more on the development of drugs targeting larger groups of cancers with genomic similarities, as opposed to a single tumor type as they are currently developed. One striking example of the genetic differences within a single tissue type is breast cancer. The breast, a highly complex organ with multiple types of cells, gives rise to multiple types of breast cancer – luminal A, luminal B, HER2-enriched and basal-like – all of which were previously known. In this analysis, the basal-like

breast cancers looked more like ovarian cancer and cancers of a squamous-cell type origin, a type of cell that composes the lower-layer of a tissue, rather than other cancers that arise in the breast. “This latest research further solidifies that basal-like breast cancer is an entirely unique disease and is completely distinct from other types of breast cancer,” said Dr. Perou. In addition, bladder cancers were also quite diverse and might represent at least three different disease types that also showed differences in patient survival. As part of the Alliance for Clinical Trials in Oncology, a national network of researchers conducting clinical trials, UNC researchers are already testing the effectiveness of carboplatin – a common treatment for ovarian cancer – on top of standard of care chemotherapy for triple-negative breast cancer (TNBC) patients, of which 80 percent are the basal-like subtype. The results of this study (called CALGB40603), which were published in the Aug. 6 issue of Journal of Clinical Oncology, showed a benefit of carboplatin in TNBC patients, according to a UNC press advisory. This new clinical trial result suggests that there may be great value in comparing clinical results across tumor types for which this study highlights as having common genomic similarities. As participants in TCGA, UNC Lineberger scientists have been involved in multiple individual tissue-type studies, including most recently an analysis of a comprehensive genomic profile of lung adenocarcinoma. Dr. Perou’s seminal work in 2000 led to the first discovery of breast cancer as not one, but in fact, four distinct subtypes of disease. These most recent findings should continue to lay the groundwork for what could be the next generation of cancer diagnostics.

UNC Research News

More Older Patients in Emergency Department Are Malnourished More than half of emergency department patients age 65 and older who were seen at UNC Hospitals during an eight-week period were either malnourished or at risk for malnutrition. In addition, more than half of the malnourished patients had not previously been diagnosed, according to a new study by researchers at the University of Timothy F. Platts-Mills, M.D., M.Sc. North Carolina at Chapel Hill. The study was published online August 13 by the journal Annals of Emergency Medicine. “Malnutrition is known to be a common problem among older adults. What is surprising in our study is that most of the malnourished patients had never been told that they were malnourished,” said Timothy F. Platts-Mills, M.D., M.Sc., assistant professor of emergency medicine in the UNC School of Medicine and senior author of the study.

“Our findings suggest that identifying malnutrition among older emergency department patients and connecting these patients with a food program or other services may be an inexpensive way to help these patients,” Dr. Platts-Mills said. “Older adults make more than 20 million visits to United States emergency departments each year. Our results add to a growing body of evidence that more needs to be done to develop the capacity of emergency departments to address the underlying conditions that impact health for older adults, particularly for those with limited resources.” The study included 138 adults age 65 and older who sought treatment in the emergency department at UNC Hospitals during an eight-week period. All were patients with no cognitive impairments, were not critically ill and did not live in a nursing home or skilled nursing facility. The nutritional status of each was assessed using the Mini Nutritional Assessment Short-Form (MNA-SF), a six-item tool that combines body mass index and the patient’s answers to questions about weight loss, decline in food intake, recent stress or disease, mobility and neuropsychological disorders. The results produce a score from 0 to 14. Malnutrition is de-

fined as a score of 7 or lower, while at risk for malnutrition is defined as a score from 8 to 11. Sixteen percent were found to be malnourished and most of these (77 percent) said they had not previously been diagnosed as malnourished. Sixty percent were found to be either malnourished or at risk for malnutrition. There were no significant differences in the prevalence of malnutrition between men and women, across levels of education or between those living in urban versus rural areas. However, the prevalence of malnutrition was higher among patients who reported having depressive symptoms, difficulty eating (due to dental pain, ill-fitting dentures, etc.) or difficulty buying groceries (due to lack of transportation, lack of money, etc.). First author of the study is Greg F. Pereira, B.S.P.H., a recent graduate of the UNC Department of Nutrition. Co-authors are Wesley C. Holland; Mark A. Weaver, Ph.D., research assistant professor in the UNC Gillings School of Global Public Health; and Cynthia M. Bulik, Ph.D., distinguished professor of psychiatry in UNC School of Medicine and nutrition in the UNC Gillings School of Global Public Health.

September 2014


WakeMed News

Garner Healthplex Exceeds Projections The numbers show that WakeMed Garner Healthplex was needed in the community when it opened its doors Aug. 19, 2013. Since then, more than 22,600 patients have been seen in the facility’s emergency department – far surpassing the projected first-year numbers of 14,642. On opening day, the Garner Healthplex emergency department (ED) treated 29 patients, according to a WakeMed press ad-

visory. Within the first month, the medical and nursing staffs were treating 52 patients per day. Now, care is provided to an average of 64 patients daily. The highest patient volume to date is 102 patients in one day, which occurred this past June 9. In addition to the 10-bed, 24-7 ED, WakeMed Garner Healthplex offers lab and imaging services, including diagnostic X-rays, ultrasounds, computed tomography scans and

magnetic resonance imaging, as well as primary and specialty care physician practices for adults and children.

WakeMed Garner Healthplex: Year in Review (8/19/13 – 8/10/14) ED patients: 22,653 Adult patients: 18,172 Pediatric patients: 4,481 Highest-volume day: 102 (June 9, 2014)

Family-Togetherness and Privacy Are Goals of Major BirthPlace Renovations WakeMed Health & Hospitals is investing $10.6 million in a 2,400-square-foot expansion and renovation of the Women’s Pavilion & Birthplace in Raleigh. It is slated to debut next summer. According to a press advisory, the expansion supports WakeMed’s patient/ family-centered approach that encourages rooming-in, allowing families to stay together throughout the celebration of new life and making it easier for mothers to have privacy.

The family-centered expansion will heighten maternal and infant care by including: • Fifteen spacious labor-and-delivery suites that ensure privacy and comfort. • Three state-of-the-art surgical suites for C-section and special needs deliveries. • A new antepartum high-risk unit for the complex needs of high-risk pregnancies, with eight private rooms with advanced technology. • A comprehensive program of services

and staff to protect both mother and child during pregnancy and immediately after birth “This expansion is significant for women with high-risk pregnancies. The new antepartum unit will provide expectant mothers experiencing a high-risk pregnancy or delivery with the safest environment and the most specialized care available,” said Thad McDonald, M.D., medical director of WakeMed Physician Practices-Obstetrics/ Gynecology. The improvements are reportedly designed to complement WakeMed’s LevelIV Neonatal Intensive Care Unit (NICU), the only one in Wake County. The new birthplace will be in close proximity. Each year, more than 7,500 babies are born at WakeMed’s hospitals in Raleigh and Cary – more than any other hospital system in Wake County. The WakeMed Foundation is working to raise $2.5 million through its Labor of Love campaign. To learn more or to donate, visit and select charitable giving.

$10.6 million renovation is planned for the Women’s Pavilion & Birthplace at the Raleigh Campus.


The Triangle Physician

News Welcome to the Area


Melissa Maria Erickson, MD

Sachin Shrikar Kunde, MD

Orthopedic Surgery of the Spine

Pediatric Gastroenterology; Pediatrics

Family Practice

Duke University Hospitals Durham

WakeMed Health & Hospitals Raleigh

Kate Scott Ettefagh, MD

Thomas Joseph Lawton II, MD


Anatomic Pathology

Mary Kenney Cirigliano, DO Pittsboro Family Medicine Pittsboro Danya Julina Josserand, DO Orthopedic Surgery

Triangle Orthopaedic Associates, PA Durham Sameer Mohammad Maroof, DO Adolescent & Young Adult Medicine; Diabetes; Family Medicine; Family Practice; General Practice; General Preventive Medicine


UNC Hospitals Chapel Hill Ammon Milton Fager, MD Hematology and Oncology, Internal Medicine

Duke University Hospitals Durham Andrew Clarke Flandry, MD Family Medicine

Hakim Azfar Ali, MD

UNC Hospitals Chapel Hill

Pulmonary Disease and Critical Care, Internal Medicine

Lauren Franz, MD

Duke Pulmonary Transplant Clinic Durham Melody Anita Russell Baldwin, MD Abdominal Surgery; Gynecology; Obstetrics

Child Psychiatry; Psychiatry

Center for Developmental Epidemiology Durham

Harris and Smith OB/GYN Durham

Marc Gregory Granata, MD

Maya Said Bitar, MD

6228 Seven Lakes West West End


University of North Carolina Chapell Hill Christian Blake Cameron, MD Internal Medicine; Nephrology

Duke University Hospitals Durham David Christopher Caretto, MD Occupational & Environmental Medicine

Duke University Hospitals Durham Neil Caye Chungfat, MD Ophthalmology

UNC Dept of Ophthalmology Chapel Hill Michael Stuart Coleman, MD Internal Medicine

North Hills Internal Medicine Raleigh Jeffrey Ward Cooney, MD Neurology

Internal Medicine

Kevin Otey Herman, MD Diagnostic Roentgenology Radiology; Musculoskeletal Radiology; Neuroradiology; Nuclear Radiology; Pediatric Radiology; Neuradiology; Vascular and Interventional Radiology

UNC Hospitals Chapel Hill David Kemp Hower, MD Internal Medicine

Eagle Hospital Physicians c/o Alamance Regional Medical Center Burlington Lisa Brooks Hutchison, MD

Family Medicine

Department of Family Medicine Aycock Building Chapel Hill George S. Edwards III, M.D. Operative and Nonoperative Care of Hand, Wrist, Elbow and Shoulder

Raleigh Hand Center Raleigh James Merritt Edwards, MD Gynecologic Oncology; Gynecology; Maternal and Fetal Medicine; Obstetrics; Gynecologic Surgery; Critical Care Medicine; Obstetrics and Gynecology; Urogynecology

Duke University Hospitals Durham

Abdominal Surgery; Colon and Rectal Surgery; Critical Care Surgery; General Surgery; Head and Neck Surgery; Medical Oncology; Neoplastic Disease; Oncology, Internal Medicine; Radiation Therapy; Surgery; Surgery - Surgical Critical Care; Surgical Oncology

Duke University Medical Center Durham Lauren Simel Lewis, MD Obstetrics and Gynecology

Duke Womenâ&#x20AC;&#x2122;s Health Associates Durham James Robert Lovrich, MD Critical Care Pediatrics

UNC Hospitals Chapel Hill Tracy Ann Manuck, MD Maternal and Fetal Medicine; Obstetrics; Obstetrics and Gynecology

University of North Carolina Chapel Hill Chapel Hill Niharika Bansal Mettu, MD Hematology and Oncology, Internal Medicine

Duke University Hospitals Durham Mimi Chandler Miles, MD Family Medicine

UNC Hospitals Chapel Hill

UNC Hospitals Chapel Hill Thorsten Markus Seyler, MD Orthopaedic Sports Medicine; Orthopedic Surgery; Orthopedic Surgery, Adult Reconstructive; Orthopedic Surgery, Trauma

Duke University Durham Roozbeh Sharif, MD Critical Care-Internal Medicine; Hospitalist; Internal Medicine; Internal Medicine Critical Care Medicine; Internal Medicine - Sleep Medicine; Pulmonary Disease and Critical Care, Internal Medicine; Pulmonary Disease, Internal Medicine

Duke University Hospitals Durham Afreen Idris Shariff, MD Internal Medicine

Rex UNC Healthcare Raleigh Mayank Singhal, MD Internal Medicine

Novant Health Franklin Medical Center Louisburg Mark Quentin Smith, MD Diagnostic Radiology

Durham Neil Kenton Stafford, MD Hospitalist; Internal Medicine

Hospital Medicine Durham Jennifer Danielle Stromberg, MD Family Medicine; Family Medicine - Sports Medicine; Student Health

Richard Joseph Oâ&#x20AC;&#x2122;Brien, MD Clinical Neurophysiology; Neurology

Duke University Student Health Services Durham

Koyal Jain, MD

Duke University Neurology Durham

Khoon Ghee Queenie Tan, MD

Frunze Petrosyan, MD

Duke University Hospitals Durham

Internal Medicine - Nephrology

UNC Hospitals Chapel Hill Infectious Diseases, Internal Medicine

Christina Marie Drostin, MD

Kenneth Leung, MD

Diagnostic Radiology; Musculoskeletal Radiology; Neuroradiology; Pediatric Radiology; Radiology; Vascular and Interventional Radiology

Duke Medical Center Durham

Child Psychiatry; Pediatrics; Psychiatry

Matthew Girard Johnson, MD

UNC Hospitals Chapel Hill

UNC Department of Pathology and Laboratory Medicine Chapel Hill

Cody James Alexander Schwartz, MD

Duke University Hospitals Durham

Cardiac Electro physiology, Internal Medicine; Cardiovascular Disease, Internal Medicine; Critical Care-Internal Medicine; Diabetes; Gastroenterology, Internal Medicine; Hematology and Oncology, Internal Medicine; Hospitalist; Internal Medicine; Internal

Nephrology, Internal Medicine

Johnston Health Smithfield

UNC Hospitals Chapel Hill

Ann Marie Reed, MD

Chad Samuel Kessler, MD

2712 Alderman Durham

Suzanne Leigh Katsanos, MD

Administrative Medicine; Emergency Medicine; Internal Medicine

Pediatric Rheumatology; Pediatrics

Durham VAMC Durham

Alexie Danielle Riofrio, MD

Sonita Khan, MD

Duke University Hospitals Durham

Family Medicine

Wayne Memorial Hospital - EMA Group Goldsboro Bharati Kochar, MD

Diagnostic Radiology; Musculoskeletal Radiology; Radiology

Catherine Koontz Rogers, MD Psychiatry

UNC Hospitals Chapel Hill

Gastroenterology, Internal Medicine

UNC Hospitals Chapel Hill


Szymon Lukasz Wiernek, MD Cardiology; Cardiovascular Disease, Internal Medicine

UNC Hospitals Chapel Hill


Editorial Calendar October Cancer in women Wound management November Urology ADHD December Otorhinolaryngology Pain management September 2014



THE BEST PROTECTION IS EARLY DETECTION. For 25 years, we served Smithfield from Johnston Memorial Hospital. Now we’re back. In a new location. And we bring with us more than 60 years as the region’s premier provider of outpatient imaging. We also bring screening mammography to your community. And, because early detection is what it’s all about, access and scheduling couldn’t be easier. What’s more, the appointment itself is just 30 minutes from check-in to exam completion. So there’s never been a better time (or place) for a checkup.

At your request, Wake Radiology can easily obtain your most recent mammogram from other practices.


Wake Radiology | 218 Venture Dr. Smithfield, NC Behind the Carolina Premium Outlets Hours: Monday-Friday 8:00am-4:30pm Appointments: 919-232-4700 |

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Trianglephy sept14 final  

The Triangle Physician September 2014

Trianglephy sept14 final  

The Triangle Physician September 2014