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Tolnitch Surgical Associates Region’s Premier Breast Specialist

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

Also in This Issue

Weight control measures Sight-saving medication

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Contents

COVER STORY

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PHOTO BY Mitch Danforth

Wake Radiology Pediatric Imaging Children’s Imaging for the Triangle

FEATURES

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Women’s Health

Physician Assisted Weight Loss Dr. Andrea S. Lukes believes physicians have an important role in helping to increase patient awareness of weight-loss basics and the options.

J a n ua r y 2 011 V o l . 2 , I s s u e 1

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DEPARTMENTS 12 Radiology

Finance

The 11 Most Important Financial Questions The 11 most important financial questions that everyone must answer to have a crystalclear plan for success.

Early Diagnosis of Harlequin Eye and Other Carniosynostoses Is Key

14 Practice Management Patient Satisfaction Surveys Offer Feedback and Track Progress

16 Orthopedics Year-round Conditioning Can Prevent Stress Fractures

20 Opthalmology New Medications May Be Effective Treatement for Neovascular Glaucoma

22 Cardiology Farewell to Warfarin?

23 Practice News Wake Radiology Garner Earns Breast Imaging Center of Excellence

23 Physician News Barkers Gains International Recognition for ACL Research

24 News Welcome to the Area and Cover Image: From left, Dr. Gayle DiLalla, Dr. Lisa Tolnitch and Dr. Nancy Crowley.

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The Triangle Physician

Upcoming Events


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From the Editor

Breast Specialists with Heart 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

The debate surrounding early breast cancer detection magnifies the limitations of medical science on this front. Understanding breast cancer’s manifestations in the earliest stages and how it will progress once identified is not altogether clear. We know there is the risk of radiation exposure with mammography, and the reliability of radiological reports can come into question. Self breast exams may be responsible for raising more needless alarm than saving lives, but society as a whole believes the value of just one life saved is worth all the risks. As research races to unravel the promise of genetics, the surest approach to breast cancer detection and treatment is to include the careful scrutiny of a breast specialist, such as those with Tolnitch Surgical Associates, our cover story this month. Dr. Lisa Tolnitch is considered a pioneer in the region. She and her partners, Drs. Gayle DiLalla and Nancy Crowley, have the years of experience, advanced training and state-of-the-art technology needed to make accurate determinations of the smallest suspicions and provide the appropriate treatment. They also have a lot of heart when comes to helping uninsured or underinsured women with breast cancer through the Pretty in Pink Foundation.

Editor Heidi Ketler, APR

heidi@trianglephysician.com

Contributing Editors William K. Andersen, M.D.; Timothy P. Donahue, M.D.; Nitin Gupta, M.D., M.P.H.; Catherine B. Lerner, M.D.; Andrea S. Lukes, M.D., M.H.Sc., F.A.C.O.G; Paul J. Pittman, C.F.P.; and John J. Reidelbach Photography Jim Shaw Photography jimshawphoto@earthlink.net Creative Director Joseph Dally

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Advertising Sales Carolyn Walters carolyn@trianglephysician.com News and Columns Please send to info@trianglephysician.com

Also in this issue, Dr. Andrea Lukes gives weight-loss tips that can be complemented by other weight-loss options. Orthopedic surgeon William Andersen explains the need for year-round conditioning to prevent stress fractures. Ophthalmologist Nitin Gupta discusses the latest medications to treat neovascular glaucoma, and cardiologist Timothy Donahue

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reviews efforts to develop Warfarin substitutes. On the practice management front, John Reidelbach touts the virtues of patient satisfaction surveys for valuable feedback and tracking progress. New this issue, Paul Pittman asks 11 financial questions that may stump you and point to the need for a certified financial

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planner. The Triangle Physician team is excited about what 2011 has in store in the form of new livesaving and life-enhancing advances happening right here in the Raleigh-Durham region. We also look forward to covering your practice news. So please keep us posted and consider the marketing value of advertising in this magazine, delivered to more than 8,000 medical professionals within our region. As always, our gratitude for all you do and best wishes in the new year!

Heidi Ketler Editor

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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. Opinion expressed or facts supplied by its authors are not the responsibility of The Triangle Physician. However, 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.


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On the Cover

Tolnitch Surgical Associates Region’s Premier Breast Specialist

By Heidi Ketler

“Women should be familiar with their own breasts, so when something changes they can bring it to their physician’s attention. If the primary care physician is unsure, then the physician needs to refer the patient to a breast specialist.” – Gayle A. DiLalla, M.D., F.A.C.S., a breast surgeon with Tolnitch Surgical Associates

“Today, we find patients that are a little more advanced in their disease, and they still have a good prognosis with appropriate treatment,” says Gayle A. DiLalla, M.D., F.A.C.S., a breast surgeon with Tolnitch Surgical Associates. She credits a conceptual shift over the past 10 to 15 years. “We know now that not every breast cancer is the same, and we’re able to do more to determine the biology of a tumor.”

“I just discharged a patient in her early 40s, who felt an abnormality that was not a distinct mass. She even had a normal mammogram and ultrasound. I’m just really grateful that her primary care physician, ‘A,’ listened to her, because I think it was something that many would have missed,” says Dr. DiLalla. “Since our practice is so focused on breast disease, we pursued it further.” Lisa A. Tolnitch, M.D., F.A.C.S., founder of Tolnitch Surgical Associates, is regarded as a pioneer in breast health in North Carolina. Hers was the first breast-dedicated practice

Using genetic testing on a tumor, physicians can better determine an individualized approach, instead of the same approach for everyone. For instance, Dr. DiLalla says, many patients may not need radiation. “We can delve a lot more into the patient as an individual, rather than as a big statistic.” Leading the way in breast care The physicians at Tolnitch Surgical Associates specialize in diagnosing and treating breast disease. Their heightened focus and awareness give them a greater ability to identify what is and is not breast cancer.

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The Triangle Physician

In 2009, Tolnitch Surgical became one of the first in the country to receive the Master’s of Breast Surgery certification. Studies show that patients being cared for by surgeons specializing only in breast cancer have a high survival rate, according to Tolnitch. The practice was structured from the start to allow for more prompt diagnosis, in consideration for the patient. “Having the answers as soon as possible reduces the anxiety level for the patient. “The faster the problem can be diagnosed and the patient has a plan for treatment, the more determined they are and the sooner they are off and running,” says Dr. DiLalla. “We try to eliminate the wait.” Tolnitch Surgical offers a full range of in-office breast services, from annual breast exams to minimally invasive procedures. They include digital mammography and ultrasound, and ultrasound-directed core biopsy. According to Dr. DiLalla, almost all biopsies can be performed in their office as core needle biopsies, rather than a surgical PHOTOs BY Mitch Danforth

Early detection is still the frontline defense against breast cancer, yet more women are surviving at later stages thanks, in large part, to progress in genetics.

serving the eastern half of North Carolina when it opened in 1991, with the goal of providing the highest quality of breast care in a compassionate setting.

Diana Seward, R.T., prepares for a stereotactic biopsy.


They continue to endorse the previous recommendations that women should perform monthly self breast exams and those of average breast cancer risk should have annual mammograms beginning at age 40. The consensus is the USPSTF recommendation was flawed by inappropriate representation and outdated data, among other things. Strategy for Patients at High Risk A high-risk clinic within Tolnitch Surgical Associates provides a formalized approach to good breast health. Vernita Harvey, R.N., (left) and Alice Pappas, R.N., set up for an ultrasound-guided biopsy.

procedure. Their stereotactic biopsy services are accredited by the American College of Radiology. Additionally, Drs. Tolnitch and DiLalla, along with breast surgeon Nancy J. Crowley, M.D., F.A.C.S., have extensive training and experience in all advanced breast cancer treatment modalities, including breast conservation procedures and sentinel node biopsy. They also are the most experienced practice in MammoSite five-day targeted radiation therapy (also known as accelerated partial breast irradiation), having taken the lead in piloting the MammoSite balloon approach to accelerated partial breast irradiation in the Triangle. “We have well over 200 patients to date who have completed treatment with excellent results,” says Dr. Tolnitch. Physician collaboration enhances patient care Strengthening its commitment to excellence in patient care, Tolnitch Surgical collaborates regularly with pathology, radiology and oncology colleagues for case review. “This approach allows patients to often have imaging and office visits in a coordinated and seamless fashion, with the goal of a quicker road to diagnosis and treatment,” says Dr. Crowley. Since November 2004, Wake Radiology Diagnostic Imaging physicians and staff have provided screening, and diagnostic mammography and ultrasound in an attached wing of Tolnitch Surgical Associates. Tolnitch Surgical also maintains a collaborative relationship with the Rex

Healthcare pathology group. “We feel collaboration has helped increase the understanding among, and quality of, all our specialties,” says Dr. Tolnitch. Advocates for early detection “Early detection is key to successful treatment,” says Dr. Tolnitch. “When a woman who receives regular screenings and mammograms is diagnosed with breast cancer, she has a 95 to 96 percent chance of surviving. In contrast, cancer in those who are not routinely screened is generally more advanced, dropping the survival rate to 50 to 60 percent.” “Women should be familiar with their own breasts, so when something changes they can bring it to their physician’s attention. If the primary care physician is unsure, then the physician needs to refer the patient to a breast specialist,” says Dr. DiLalla. She adds that “there are still far too many biopsies, but not in our practice. We have the experience and technology to make the best determination to reduce the risk of false positives and needless biopsies.” The physicians of Tolnitch Surgical Associates are among all those who challenge last year’s breast screening recommendations by the United States Preventive Services Task Force. They are allied with “every major organization associated with breast cancer,” says Dr. DiLalla – the American Cancer Society, the National Breast Cancer Foundation, the Association of Breast Surgeons and the American Society of Breast Disease, to name a few.

It emphasizes lifestyle modification and may include recommendations for increased screening, such as starting annual mammograms earlier than 40 or more intensive surveillance. “We try to determine the right amount of surveillance, so we can find problems earlier,” says Dr. DiLalla. “These visits take more time, because we try to cover it all,” she says. Among the risk factors discussed during the patient visit are: • Delayed childbearing or no childbearing; • Family history; • Race and age, to some degree; • Early start of menstruation for certain types of cancer; • Weight, especially around the abdomen, due to higher circulating estrogen levels; • In-vitro fertilization or hormone injections, to some degree; • Proliferative breast disease identified in previous biopsies; and • Lifestyle factors, such as smoking, diet and exercise. Some indications may be approved for the use of tamoxifen. “Traditionally, tamoxifen was used for those diagnosed with breast cancer, and now it is approved for postmenopausal women at increased risk to prevent breast cancer,” says Dr. DiLalla. If prophylactic therapy becomes an option, the physician will help the patient weigh the risks and benefits. “Hopefully, at the very least the patient will make lifestyle modifications,” says Dr. DiLalla. She calls the recent popularity of prophylactic mastectomy, particularly for women with a mutation of the BRAC1 and BRAC2 genes, “interesting,” since the trend JANUARY 2011

7


Meet the Breast Specialists at Tolnitch Surgical Associates

Lorna Ethier (left) and Mary Ann Denton welcome a new patient.

has long been for breast conservation. While she believes that’s still the case, the main message is patients are more “empowered to choose, not like 30 years ago, when they were told this is your only option.” The Increasing Cost of Health Care With almost 20 percent of women in North Carolina uninsured and more than 14 percent living below the federal poverty level, there are many with breast cancer who don’t get treatment because they can’t afford it. Realizing this, Dr. Tolnitch founded the Pretty in Pink Foundation in 2004 to ensure quality care regardless of ability to pay. Her annual goal was to provide financial support for 10 uninsured or underinsured breast cancer patients in Wake County. Since its inception, however, the foundation has helped more than 700 patients throughout North Carolina pay for the surgery, chemotherapy and radiation treatment they could not otherwise afford. Pretty in Pink, which is funded through donations, serves as a client advocate. the staff of Pretty in Pink ensures the efficient use of funds by negotiating reduced fees through a network of physicians and community medical facilities, and helping to manage the care. It also serves as a clearinghouse for breast cancer resources and services for economically disadvantaged individuals and families. In April, Dr. Tolnitch won the 2010 Soroptimist Ruby Award for Women Helping Women, presented by the Raleigh Club of Soroptimist International, recognizing her work through Pretty in Pink. The Pretty in Pink Foundation is now positioned for expansion to every state to ensure no breast cancer patient is denied access to quality care and treatment, says Dr. Tolnitch. Ironically, Dr. DiLalla is concerned that health care reform is actually driving up costs, creating a larger population of underinsured. She says she has observed that “it’s actually more difficult to get things covered.” And she expects it to continue in that direction, as insurance companies restructure and Medicare cuts deepen. This will only increase the need for programs like Pretty in Pink and for physicians to serve as patient advocates. “We (Tolnitch Surgical) spend a lot of time being advocates for patients in working with insurance companies,” says Dr. DiLalla. “I anticipate that whatever the changes are, we need to do the very best for the patient based on the reality of what’s out there,” including educating them about existing patient protections. For more information on Tolnitch Surgical Associates or to schedule an appointment, call (919) 782-8200, or visit www.carolinabreastcare.com.

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The Triangle Physician

Lisa A. Tolnitch M.D., F.A.C.S., first started in practice in 1988 and founded Tolnitch Surgical Associates in 1991. It was the first practice in the area focused exclusively on the treatment of breast disease. She is a key sponsor of, and contributor to, a multidisciplinary conference to keep the specialists involved in breast care current on advances in the treatment of breast disease. Dr. Tolnitch graduated Phi Beta Kappa from the University of Kentucky and earned her medical degree from the College of Medicine at the University of Louisville. She completed her internship and residency at the University of North Carolina-Chapel Hill. Additionally, she was chief resident in 1988. Dr. Tolnitch is affiliated with the American Society of Breast Surgeons and the American Society of Breast Disease, and she is a fellow of the American College of Surgeons. She was a past board member of the American Cancer Society and was also on the steering committee for multidisciplinary breast cancer at Rex Healthcare. Dr. Tolnitch was featured on the Today show in 2009 and is regularly interviewed by regional news programs on advances and issues in the treatment of breast cancer. Nancy J. Crowley M.D., F.A.C.S., has been in the practice of surgery since 1993 and has specialized in breast surgery since 2001. She has published more than 18 peer-reviewed articles on cancer and lymph node dissection. Dr. Crowley graduated Phi Beta Kappa from the University of Wisconsin at Madison and earned her medical degree from Duke University Medical School. She completed her residency at Vanderbilt University. At Duke University, she was a research fellow, senior resident and chief resident in the Department of General Surgery. Dr. Crowley is a fellow of the American College of Surgeons, and affiliated with the American Society of Breast Surgeons, American Society of Breast Disease, Association of Women Surgeons, American Medical Association, North Carolina Medical Society and Wake County Medical Society. She was certified by the American Board of Surgery in 1994. She currently serves on the Breast Care Committee at Rex Hospital. Gayle Ackerman DiLalla, M.D., F.A.C.S, has been in practice 18 years and joined Tolnitch Surgical Associates in 2008. She earned her bachelor’s degree and medical degree from the University of Missouri in Kansas City. She completed her surgery internship and residency at the University of Florida in Jacksonville, and was chief resident in 1992. She began her career in Roanoke, Va., and served as assistant professor of surgery at the University of Virginia. Dr. DiLalla is board certified in general surgery and a fellow of the American College of Surgeons. She is a member of the American Society of Breast Surgeons, Association of Women Surgeons and the North Carolina Medical Society, and serves on the American Society of Breast Disease Advisor Editorial Board. She is a past board member of the American Cancer Society of Charlotte County, and past member of the Board of Trustees at Fawcett Memorial Hospital in Port Charlotte, Fla., and the board of directors of the Virginia Organ Procurement Association teaching hospital.


JANUARY 2011

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Women’s Health

Physician Assisted Weight Loss By Andrea S. Lukes, M.D., M.H.Sc., F.A.C.O.G

Approximately two-thirds of Americans are overweight or obese. Given the prevalence of weight issues in the United States, we encourage health care providers to offer options for assistance in weight loss. The terms “obese” and “obesity” have strict medical definitions based on body mass index (BMI), which takes into consideration height and weight. BMI can be calculated on the Centers for Disease Control and Prevention website at htpp://www.cdc.gov/ nccdphp/dnpa/healthyweight/assessing/ bmi/index.htm The term “overweight” refers to a BMI greater or equal to 25, but less than 30. “Obesity” refers to a BMI of greater or equal to 30. Approximately two-thirds of Americans are overweight or obese. The impact of obesity

on health is considerable and includes the following: hypertension, glucose intolerance, dyslipidemia and obstructive sleep apnea. Physician guidance Health care providers can play an important role in helping these patients take the right steps toward a healthy lifestyle and weight loss. Basic information we should emphasize includes the following: • In order to lose one pound in a week – You must have a deficit of 3,500 calories in that week (500 calories per day for seven days).

• Do not consume less than 1,200 calories per day to avoid slowing down your metabolism. • Eat less, but more often to boost metabolism. Try to consume five to six small meals during the day, beginning with breakfast within 45 minutes of walking. • Keep a food journal – Preferably an online version that will keep calorie count for you, such as: www.thedailyplate. com, www.calorieking.com, www. sparkspeople.com, www.nutrihand.com and www.mypyramid.com. • Exercise – This is so important for weight loss and weight control. • Be mindful of the food you are eating, both in terms of quality and quantity. • Do not multitask when you are eating, and chew your foods well. • Give yourself a pantry, and refrigerator and freezer makeover – Get rid of the foods that tempt you. • Do not eat late at night. Dedicated women’s weight-loss program Additionally, Women’s Wellness Clinic began offering the “Healthy Lifestyle Changes” weight-loss program two years ago. Since then, our patients have been successful in losing an average of 10-15 pounds, although the weight-loss range is from 5-43 pounds. Healthy Lifestyle Changes reinforces the basics above, and provides guidance in the appropriate and safe use of phentermine, approved for weight loss by the FDA (United States Food and Drug Administration), for 10-16 weeks. Phentermine has a sympathomimetic mechanism. The most common side effects are dry mouth, insomnia, dizziness, and mild increase in blood pressure (rarely more severe) and heart rate. Monitoring blood pressure is important.

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The Triangle Physician


After earning her bachelor’s degree in religion from Duke University (1988), Dr. Andrea Lukes pursued a combined medical degree and master’s degree in statistics from Duke (1994). Then, she completed her ob/gyn residency at the University of North Carolina (1998). During her 10 years on faculty at Duke University, she co-founded and served as the director of gynecology for the Women’s Hemostasis and Thombosis Clinic. She left her academic position in 2007 to begin Carolina Women’s Research and Wellness Center, and to become founder and chair of the Ob/Gyn Alliance. She and partner Amy Stanfield, M.D., F.A.C.O.G., head Women’s Wellness Clinic, the private practice associated with Carolina Women’s Research and Wellness Clinic. Women’s Wellness Clinic welcomes referrals for management of heavy menstrual bleeding. Call (919) 251-9223 or visit www.cwrwc.com.

Weight-loss options Given the prevalence of weight issues in the United States, we encourage health care providers to offer options for assistance in weight loss. There are other FDA-approved medications, including diethylpropion, orlistat and sibutramine – each with different mechanisms, doses and side effects. (See N Engl J Med 2008; 358:1941-1950, for more information.)

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Additionally, there are surgical options for individuals. The most common procedures include laparoscopic surgical approaches, such as gastric banding and vertical gastrectomy. The gold standard surgery for weight loss is a Roux-en-Y gastric bypass surgery. The criteria for such procedures includes a BMI of 40 or higher, or a BMI of 35 if there is a high-risk co-morbidity, such as severe sleep apnea, obesity-related cardiomyopathy or severe diabetes mellitus.

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Radiology

Early Diagnosis of

Harlequin Eye and Other Craniosynostoses Is Key By Catherine B. Lerner, M.D.

Working as a team with referring clinicians, pediatric radiologists can facilitate the early detection of this important pediatric diagnosis. Clinicians who care for children are often faced with the task of evaluating an infant for abnormal skull shape. Most cases of localized skull flattening are caused by deformational or positional plagiocephaly, particularly given the successful implementation of the “backto-sleep” campaign. Although abnormal skull shape is due to positioning in the majority of infants, it is sometimes due to craniosynostosis, or premature fusion of a cranial suture or sutures. Craniosynostosis is a serious clinical problem that can require surgical treatment, so differentiation between craniosynostosis and positional plagiocephaly is important. In general, true craniosynostosis is ten-fold less common than positional plagiocephaly. Of the craniosynostoses, most involve just one suture and are isolated events, rather than being part of a genetic syndrome. The suture most frequently involved by craniosynostosis is the sagittal suture (40 to 60 percent of cases), followed by the coronal suture (20 to 30 percent of cases). When coronal suture synostosis is unilateral, the result is one of the

Figure 1. The Harlequin Eye. Skull radiograph in a 2 month-old girl demonstrates findings of unilateral, right-sided coronal synostosis. These include elevation and posterior displacement of the superior and lateral orbital rim.

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The Triangle Physician

more recognizable clinical and radiographic presentations of craniosynostosis, that of the “harlequin eye” deformity of the orbit. The “harlequin eye” is meant to describe elevation of the ipsilateral lesser wing of the sphenoid, with posterior displacement or retraction of the superior and lateral rims of that orbit. A more common, and perhaps more challenging, clinical scenario is that of distinguishing between positional plagiocephaly and the unusual but clinically important lambdoid craniosynostosis. The evaluation begins with the physical examination findings, and there are features here that can help differentiate the two. Both can cause occipitoparietal flattening, but in positional plagiocephaly, when examining the infant from above, one sees frontal bossing and anterior displacement of the ear on the same side as the posterior (occipitoparietal) skull flattening. To the contrary, in the rare cases of lambdoid synostosis, one may see frontal and parietal bossing on the opposite side of the posterior (occipitoparietal) flattening, and the ear on the side of the occipitoparietal flattening may be displaced posteriorly, toward the fusing suture. With lambdoid synostosis, one may also see a “mastoid bump” on the same side as the posterior flattening, as growth can still occur at the patent posterolateral fontanel. When a clinician encounters an infant with abnormal skull shape or facial features that cannot be attributed to positional plagiocephaly, referral to a pediatric radiologist is an important next step. A radiographic skull series serves as the appropriate screening study in evaluation of such infants. The pediatric radiologist evaluates the radiographs for any signs of craniosynostosis such as increased sclerosis at the sutures, narrowing of a suture or

Dr. Catherine Lerner is a pediatric radiologist at Wake Radiology Pediatric Imaging Center. A native of Tallahassee, Fla., she received her medical training at Columbia University College of Physicians and Surgeons in New York and served her internship at St. Vincent’s Catholic Medical Center there. She completed a fellowship in pediatric radiology at Duke University Medical Center, where she was chief resident in diagnostic radiology. She is a cum laude graduate of Yale University, where she earned a bachelor of science degree in biology and a bachelor of arts degree in art history. She has authored articles appearing in Pediatric Radiology and the journal Cancer. Dr. Lerner is board certified in diagnostic radiology by the American Board of Radiology, and is a member of the Radiological Society of North America and the Society for Pediatric Radiology. She can be reached at (919) 782-4830.

loss of suture clarity, or frank bony bridging across a suture. In addition, if performed at a dedicated pediatric imaging center, the pediatric radiologist has the opportunity to examine the patient when indicated. If an abnormality is detected, a low-dose head CT that is tailored to the evaluation of craniosynostosis can be performed. With this head CT, the infant is assessed for additional abnormalities that could not be appreciated on skull radiographs, recognizing that more than one suture may be affected in a minority of patients. In addition, using the pediatric craniosynostosis protocol, three-dimensional reconstructed images can be rendered to aid the surgeon in his or her treatment planning. Working as a team with referring clinicians, pediatric radiologists can facilitate the early detection of this important pediatric diagnosis. A pediatric radiologist is available for consultation weekdays from 8am to 5pm at the Wake Radiology Pediatric Imaging Center, 4301 Lake Boone Trail in Raleigh, (919) 7824830. References - Blaser SI Abnormal skull shape. Pediatr Radiol (2008) 38 (Suppl 3):S488-S496. - Kabbani H and Raghuveer TS. Craniosynostosis. Amer Fam Phys (2004) 69 (12): 2863-2870.


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Practice Management

Patient Satisfaction Feedback and Surveys OfferTrack Progress By John J. Reidelbach

With so much uncertainty in the health care marketplace and the difficult economic times in which physicians find themselves practicing today, many physician groups are looking for ways to improve profitability. It is interesting, however, that when economic conditions look up, efforts to improve the profitability of the practice seem to become less of a priority. It is incumbent upon physician leaders and management to strive for better profitability consistently. If a practice is well run during the good times, it will be better positioned to weather fluctuations in bad times.

Patient satisfaction is considered by most to be a fundamental component of the successful practice. Without high patient satisfaction, a practice can fail. With it, the practice stands a better change of flourishing. There are a number of indicators of well-run practices, not the least of which is how well they are doing financially. Quality of life for the shareholder(s) is another key element; patient satisfaction is arguably the most basic factor underlying practice performance. While patient opinion is purely subjective and, like any human opinion, difficult to measure precisely, its potential value as a

guide in practice management, and most particularly as an indicator of potential problems within a practice, makes an attempt to objectively measure patient satisfaction a worthwhile exercise for any practice. First and foremost, patients want superb clinical care and physicians provide that care. Both physicians and management alike question whether patients really know how to judge that care. Does a well-trained physician with significant expertise in his field lead to patient satisfaction? Can a particularly welleducated, well-trained doctor overcome a practice that is poorly managed? Patients are satisfied or not in ways that are very similar to any individual seeking service, whether it be from a restaurant, a hotel, a store. Patients want their needs met, they want to be treated respectfully and they want to be charged a reasonable fee for the service provided. They expect their time to be considered. They come to physician practices with pre-conceived notions about what that experience will be like. In the case of patients who continue to obtain their care from you, you can probably deduce that their expectations have been met. In the case of patients who do not return, expectations were likely not met. Practitioners should make a conscious decision to be proactive in building patient/ brand loyalty, increasing revenues-perpatient and attracting more new patients through increased referrals by exceeding patient expectations in your base. To do that, physicians will first need to determine exactly what their patients expect. The best place to start is to conduct a baseline patient satisfaction survey to determine if the practice is already doing really well in meeting expectations or just barely getting by. Such surveys provide important information

14

The Triangle Physician


John Reidelbach’s career in health care spans more than 20 years and all facets of administration within physician practices, hospitals and large health care insurers. He founded Physician Advocates Inc. in 1996. Today, he assists health care entities in all aspects of practice management, operation, strategic development and implementation, education, contract negotiations, data analysis and capital funding. His credentials include degrees in engineering and education, and a master’s in business administration. Mr. Reidelbach has designed several health care management entities, including independent physician associations, physician practice management companies, management service organizations and group practices. His experience includes developing equity ownership structures, financial incentives, network administration, and information systems selection and implementation. He also has developed detailed analysis tools for health care providers and product vendors. Mr. Reidelbach can be reached in North Carolina at (919) 321-1656 or in Atlanta at (404) 664-9060; and by e-mail to info@mdpracticeadvice.com.

Leasing Opportunity with Ownership Potential

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from a point of view that physicians and staff simply cannot have and they can also offer an even more valuable secondary benefit – improved patient relations. Patients appreciate being included in your processimprovement efforts and they like being heard. Take the time to carefully format your questionnaire. Keep it simple. Limit the survey to a single page, if at all possible. Include a cover letter from the managing physician outlining your efforts and why you are conducting the survey. Ask for feedback about the amenities and your staff, wait times, availability of appointments, the billing process and the like. Repeat the survey within six months after you begin the process improvement so you can chart your progress. Make the results known to your staff and include them in your efforts to keep and win back dissatisfied patients. Never rest on your laurels, continue conducting surveys on a regular basis even when you think you have all the deficiencies identified and addressed.

JANUARY 2011

15


Orthopedics

Can Prevent Year-round Stress Conditioning Fractures By William K. Andersen, M.D.

We know that bone responds to increased stress by increasing its density, but it takes time for the bone to strengthen. For athletes or anyone involved in specific sports activities, they should be involved in year-round training to stay well-conditioned, and try to increase activities gradually. Like a paper clip that will finally break if bent back and forth multiple times, bone that is stressed during activity can fatigue (weaken) and fracture. Fractures that occur as a result of repetitive small injuries to the bone are called stress fractures. If the bone has been stressed enough times to weaken it but not actually break it in two, it is called a stress reaction. Stress reactions and stress fractures are common over-use injuries and can lead to pain and disability. Females have a higher incidence of stress fractures than males,

16

The Triangle Physician

and amenorrheic female athletes are at even higher risk. Typically, stress fractures occur in people who have had sudden increases in the amount or intensity of an activity or training. Initially, there are complaints of localized pain that occurs at the end of the activity and worsens with increasing activity. The pain improves with rest. As the stress fracture develops, the pain occurs earlier and earlier in the activity. There is local (point) tenderness at the stress fracture site and sometimes swelling. X-rays early on may

show nothing unusual, and a sophisticated test, such as a bone scan, computed tomography scan or magnetic resonance imaging may be needed to identify the fracture. Treatment depends on the location of the stress fracture. To get the fracture to heal, limited activity, a period of non-weight bearing in a cast or even surgery may be needed. During healing, symptomatic treatment with ice and anti-inflammatory medications can help make the patient comfortable.


Dr. William K. Andersen, a fellow of the American Academy of Orthopaedic Surgeons, has been affiliated with Cary Orthopaedic & Sports Medicine Specialists, P.A. for the past 14 years. He earned his medical degree from New York University School of Medicine in New York City. He completed his residency at George Washington University Medical Center in Washington, D.C., and a sports medicine fellowship at Methodist Sports Medicine Center in Indianapolis, Ind. Dr. Andersen can be reached at (919) 467-4992 or www.caryortho.com.

fractures only heal with prolonged time (months) in a non-weight bearing cast and can require surgery. Metatarsal stress fractures occurring in the second-throughfourth metatarsals (the mid-foot) heal well with about four weeks of rest. On the other hand, fifth metatarsal base (Jones) fractures (outside edge of the foot) can require significant time in a non-weight bearing cast and sometimes surgery. Prevention of stress fractures is possible by avoiding sudden increases in activity or training intensity. We know that bone responds to increased stress by increasing

its density, but it takes time for the bone to strengthen. For athletes or anyone involved in specific sports activities, they should be involved in year-round training to stay wellconditioned, and try to increase activities gradually. Appropriate shoe wear that cushions the foot well and absorbs shock also may help avoid stress fractures. Suspect a stress fracture if a patient complains of a prolonged period of increasing pain at a specific point on the leg or foot. Of particular concern are the midtibia, the arch of the foot (navicular) and the outside border of the foot (5th metatarsal).

Tibial stress fractures account for half of all stress fractures. They can occur anywhere along the bone, but usually in the upper or middle third. The fracture is tender to the touch at one specific point. This differs from the tender area in shin splints which radiates along the inner edges of the bone, usually in the lower third. Proximal tibial stress fractures usually heal well with restricted activity. A more ominous (and

fortunately rare) fracture occurs in the tibia anteriorly (in the front) in the middle third of the bone. Unlike the proximal tibial stress fractures, mid-tibia fractures heal slowly and sometimes require surgery. Fibular stress fractures occur 1-3 inches above the ankle, do not usually require casting and heal well with a period of rest. Stress fractures in the foot usually occur in the navicular, calcaneus and metatarsals. Navicular stress fractures cause pain and tenderness on the proximal edge of the navicular (at the crease in the front of the ankle) and in the arch. Unfortunately, these Womens Wellness half vertical.indd 1

12/21/2009 4:29:23 PM

JANUARY 2011

17


Finance

Your Financial Rx The 11 Most Important Financial Questions By Paul J. Pittman, C.F.P.

By shifting your experience of money to an abundance mode, you are able to experience your wealth as “more than enough.”

I

t never changes. Whether I am speaking to a group of 500 or sitting one-on-one with a client, my message is always the same: Get serious, get control and take action! I come across people everyday who may make a lot of money, spend a lot of money, have a fabulous lifestyle, but have no direction whatsoever when it comes to managing their finances. It is never too late. Do not be afraid of change. For many, it is easier to make a bad decision even worse by continuing the destructive process than to face it head-on. This is why I have developed the 11 most important financial questions that everyone must answer to have a crystal-clear plan for success.

18

The Triangle Physician

Chances are, you can answer a few of the questions below, but you need to be able to fully answer all of them to truly take control. Do not fret. This is a work in progress. Complete financial planning is a fluid and on-going process. 1) Have you discovered your true purpose for money, that which is more important than money itself? This is the very heart of your most sacred values. What is it you value more than money? Your true purpose for money is the compass and foundation with which all spending and investing decisions are formed. Every investor has one, but often it takes some focus and development to clarify it into a

laser-focused tool for personal and portfolio growth. This is the first step in developing true peace of mind. 2) Do you know how markets work? Many people have money invested, but very few can honestly say they truly understand how the dynamics of how free markets price securities. They are, in effect, ignorant of the forces that ultimately determine their investing results. Never put money into anything you do not fully understand. A financial coach’s job is to help you focus on the right things, so you don’t have to focus on everything. 3) Have you defined your investment philosophy? Most people do not even know it is possible to have a philosophy when it comes to investing. Not only is it possible, but it is critical to your success. You must first develop and institute a philosophy before you develop a strategy.


Paul J. Pittman, a certified financial planner, is the president and managing director of The Preferred Client Group, a financial advisory and coaching firm for physicians, located in Cary, N.C. Mr. Pittman has more than 25 years of experience in the financial industry and is passionate about investor education. He is also a nationally sought-after speaker, humorist and writer. He can be reached at (919) 459-4171 and or by e-mail at paul.pittman@pcgnc.com. Mr. Pittman personally answers all of his own e-mail.

4) Have you identified your personalrisk tolerance? This is an academic and scientific number that helps you compare various investment scenarios. Remember, you cannot successfully control something you cannot measure. 5) Do you know how to measure diversification in your portfolio? Everyone has heard that you should diversify, but how do you measure it? Correlation is the tool to determine if the portfolio is properly constructed. In a typical portfolio, assets tend to move in a step-rate fashion, so when one goes down, they all go down. To build it right, you must measure it.

and spending decisions? This strategy integrates your life goals, visions, dreams, values and investment risk/return preferences into a total plan for success. Money serves no purpose at all, unless it helps you to live a more powerful and dynamic life. By creating this life-long game plan, your money will take on more purpose and direction, 9) Do you have an investment policy statement? This lays out your game plan. Vince Lombardi left nothing to chance in football, and neither should you with your money. You have to have a plan to guide you to your own victory. 10) Have you devised a clear-cut method for measuring the success or failure of your portfolio? How do you know if your portfolio is doing what it is supposed to do? If you make 15 percent, is that good? If you lose 10 percent, is that bad? What do you compare your performance to? How do you know if it is working?

8) Do you have a customized lifelong game plan to guide all of your investing

Are you ready to shift your personal experience of money and investing from a scarcity mode to an abundance mode? Scarcity means “not enough.” When you experience money in this mode, the outcome is doubt, regret and fear. In this mode, no matter how much money you have, it is never quite enough. Money is experienced as a painful event.

By shifting your experience of money to an abundance mode, you are able to experience your wealth as “more than enough.” Work with a coach to transfer your experience from scarcity to abundance. Don’t put it off; it is too important. You owe it to yourself and your loved ones to find out the answers to NEWSOURCE-JUN10:Heidi 8/5/10 12:57 PM Page 1 these questions. 11) Do you know the three warning

Do They Like What They See?

6) When it comes to building your investment portfolio, do you know exactly what you are doing and why? Much of the average investors’ results are left to chance, or worse yet, to the commissiondriven financial plans of brokers. Many investors simply throw up their hands in disgust and frustration from trying to grasp it all. It doesn’t have to be that way. 7) Do you know where you fall on the Markowitz Efficient Frontier? The most sophisticated investors have been using this tool to build better portfolios for many years. Harry Markowitz is the economist that developed this Nobel-winning investment tool.

signs that you are gambling and speculating with your money versus prudently investing it? They are all components of preparing to fail –otherwise known as “chasing performance.” With the help of a coach, you can discern if you have accidentally fallen into these destructive investor behaviors and traps.

Make sure you connect with your key audiences using strategic, cost-effective advertising, marketing and public relations. Our services range from consultation, to design, to creation and implementation of strategic plans.

newsource & Associates Call (540) 650-3686 or send inquiries to hketler@verizon.net.

Our network of smart, creative, award-winning specialists serves the health care industry throughout the Mid-Atlantic.

Maybe it’s happiness in a child’s eyes. Whatever the desired outcomes, count on us to ensure your key messages have the 20/20 clarity to deliver.

JANUARY 2011

19


Ophthalmology

New Medications May Be Effective Treatment

for

Neovascular Glaucoma

By Nitin Gupta, M.D., M.P.H.

Within a few days, the intraocular pressure is more manageable with eye drops and the iris neovascularization is significantly reduced, and in some cases resolved! Once the visualization to the posterior segment of the eye is improved, laser photocoagulation can be performed as a more definitive treatment. Neovascular glaucoma is a form of secondary glaucoma that often carries a very poor prognosis for visual recovery and can result in loss of the eye itself. It has been referred to as hemorrhagic glaucoma, rubeotic glaucoma or even the “one-hundred day” glaucoma. Neovascular glaucoma results from abnormal blood vessel growth into the iris and trabecular meshwork of the eye. This leads to closure of angle structures and an increase in intraocular pressure. The subsequent glaucoma can be difficult to manage with conventional treatments such as topical eye drops or anterior segment laser. The stimulus for neovascular glaucoma results from retinal ischemia and/or hypoxia and the unregulated release of vascular endothelial growth factor (VEGF). VEGF promotes

20

The Triangle Physician

angiogenesis, and these new blood vessels grow along the pupillary border and iris surface. Over time a fibrovascular membrane can develop that occludes the trabecular meshwork. Obstruction of the aqueous outflow through the meshwork

leads to elevated intraocular pressure. Increased eye pressure may result in eye pain, headache and blurred vision. Clinical signs may include a hazy cornea, rubeosis or a poorly reactive pupil. Retinal ischemia is often related to systemic disease, such as diabetes and hypertension. The most common causes of retinal ischemia and subsequent neovascular glaucoma are as follows: • Retinal Vein Occlusion • Proliferative Diabetic Retinopathy • Ocular Ischemic Syndrome (carotid artery occlusive disease) Timely detection and treatment is indicated in the management of neovascular glaucoma. Traditional therapy aims to target the retinal hypoxia. Thermal laser photocoagulation is utilized to decrease the oxygen demands


In summary, neovascular glaucoma is a devastating disease; fortunately, recent advances in retinal disease management have provided us with additional treatment options that can significantly improve our patient’s chances for visual recovery.

Dr. Nitin Gupta of Taylor Vitreoretinal Center completed his medical education at the Brody School of Medicine at East Carolina University and his ophthalmology residency at the Medical College of Georgia. His vitreoretinal fellowship was served at the University of Kentucky. He is currently in practice with the Taylor Vitreoretinal Center and specializes in diseases and surgery of the retina and vitreous.

of the retina and hopefully decrease the relative hypoxia that is the driving force for the neovascular glaucoma. Retinal laser can be difficult to apply if there is a hazy cornea due to high intraocular pressure or retinal/vitreous hemorrhage obscuring a clear view of the retina. In recent years, there has been increased evidence for the use of offlabel intravitreal bevacizumab (Avastin) to be injected intraocularly to treat neovascular glaucoma. Avastin is a United States Food and Drug Administration-approved intravenous therapy for colon cancer. Over the past several years, off-label intraocular Avastin has been successfully utilized to treat many conditions, such as macular degeneration and macular edema secondary to diabetes or retinal vein occlusion. Avastin is a very potent inhibitor of VEGF and can significantly limit the development of new blood vessels in the retina, iris and trabecular meshwork. I have marveled at how quickly the neovascular response and glaucoma are brought under control with a single treatment of Avastin. Within a few days, the intraocular pressure is more manageable with eye drops and the iris neovascularization is significantly reduced, and in some cases resolved! Once the visualization to the posterior segment of the eye is improved, laser photocoagulation can be performed as a more definitive treatment.

CARY ORTHOPAEDIC Spine Specialists • Epidural Steroid Injections • Acupuncture • Discograms • Spinal Cord Stimulator Trials • Microdiskectomy • Lumbar fusion • X-Stop (spine stenosis) • Kyphoplasty (compression fractures) Our Spine Specialists center employs highly experienced and skilled physiatrists as well as an accomplished Spine Surgeon. This combination of services allows a “total approach” to the health and well being of our patient population.

1110 SE Cary Pkwy, Cary, NC 27518

919-297-0000 Fax 919-232-5328

1005 Vandora Springs Rd., Garner, NC 27529

919-779-3861

www.caryortho.com

Fax 919-779-3234

JANUARY 2011

21


Cardiology

Farewell to Warfarin? By Timothy P. Donahue, M.D.

In recent years pharmaceutical companies have raced to find a suitable replacement for warfarin. Investment banks have estimated that Coumadinreplacement drugs would generate an annual revenue of more than $10 billion.

Dr. Timothy Donahue is a cardiologist with Triangle Heart Associates. He earned his medical degree from Louisiana State University School of Medicine in 1996. He completed a residency in internal medicine at Emory University Hospital in 1999, and fellowships in cardiovascular medicine in 2002 and in cardiac electrophysiology in 2003 at the University of Florida. Dr. Donahue holds board certifications with the American Board of Internal Medicine Specialties in cardiac electrophysiology, cardiovascular disease and internal medicine.

In the early 1920s, reports surfaced detailing a

After a series of failed submissions to the

percent of patients taking dabigatran versus

disease in cattle that caused them to die at an

United States Food and Drug Administration

only 24 percent taking warfarin.

alarming rate after minor medical procedures,

(FDA), the first of the new anticoagulants,

such as dehorning. Further investigation

dabigatran (Pradaxa), was recently approved.

Dabigatran’s

revealed the animals had bled to death after

Dabigatran is part of a novel class of drugs

anticoagulation world will likely be short-lived.

eating a diet high in mold-covered sweet

that directly inhibits thrombin. Thrombin

Rivaroxaban (Xarelto) is an oral, once-daily

clover. Investigators at the Wisconsin Alumni

inhibition slows the conversion of fibrinogen

inhibitor of factor Xa. The recently released

Research Foundation (WARF) eventually

to fibrin, thereby impairing the body’s ability

ROCKET-AF trial randomized more than

found that a benign compound found in the

to form thrombus. Taken twice daily, the drug

14,000 moderate to high-risk atrial fibrillation

clover (coumarin) had been converted by

requires no dietary modification, dosing

patients to rivaroxaban versus warfarin.

the fungus to dicoumarol, which has potent

adjustment or monitoring of coagulation

Rivaroxaban was shown to be noninferior to

anticoagulant properties. Initially used as a

parameters. In the RE-LY Trial (Randomized

warfarin in the prevention of embolism with

poison for rodents, a derivative of dicoumarol

Evaluation

Anticoagulant

no increased risk of bleeding. FDA approval is

was patented as a pharmaceutical (warfarin)

Therapy), more than 18,000 high-risk patients

pending, but is expected in 2011. Meanwhile,

in 1955.

with non-valvular atrial fibrillation were

apixaban, a direct thrombin inhibitor, is

randomized to dabigatran versus warfarin.

making its way through clinical trials.

of

Long-term

lone

perch

atop

of

the

Since then, warfarin has had a great run. During

Dabigatran was superior to warfarin in the

that time, it has been the only available oral

prevention of stroke without increasing the

Not surprisingly, warfarin’s departure will be

anticoagulant medication. Its dominance has

risk of major bleeding. The drug was well

a long goodbye. Cost appears to be a major

persisted in spite of the drug’s glaring flaws,

tolerated, although dyspepsia was seen in 34

barrier to widespread use of this new class

including a slow onset and

of pharmaceuticals. Insured

offset of action, unpredictable

and Medicare patients alike

dosing, need for persistent

generally incur a significant

monitoring and necessary

copay when switching from

dietary modification in treated

warfarin

patients.

In

recent

to

dabigatran,

years

although the manufacturer

companies

offers a card to lower the

have raced to find a suitable

cost to about $30 a month

replacement

for

for insured patients. With

Investment

banks

pharmaceutical

estimated

that

replacement

warfarin. have

Coumadin-

drugs

would

generate an annual revenue of more than $10 billion.

22

The Triangle Physician

no

assistance,

Medicare

and self-pay patients should expect to spend about $225 per month.


Practice News

Wake Radiology Garner Earns Breast Imaging Center of Excellence Wake Radiology Garner has achieved status as a Breast Imaging Center of Excellence, the highest designation by the American College of Radiology (ACR). Breast Imaging Center of Excellence (BICOE) is awarded to centers that have achieved high practice standards in image quality, personnel qualifications, facility equipment, quality control procedures and quality assurance programs. This is the fourth Wake Radiology breast imaging office to be named a BICOE. Other offices previously recognized at this level include Wake Radiology North Hills, Wake Radiology Chapel Hill and Wake Radiology Comprehensive Breast Services in Cary.

The ACR recognizes centers that have earned accreditation in all of its voluntary breast-imaging accreditation programs and modules, in addition to its mandatory Mammography Accreditation Program. “This designation gives women the assurance that they are receiving the best possible exam,” said Kerry Chandler, M.D., director of Wake Radiology Women’s Imaging Services. “Our breast imaging offices are staffed with specialty-trained radiologists and technologists who are dedicated to the highest standards on each exam. It’s our focus on communications with referring physicians and precise attention to detail on each study that has helped us earn this distinguished status.”

American College of Radiology Center of Excellence breast imaging programs are fully accredited in mammography, stereotactic breast biopsy, breast ultrasound and ultrasound-guided biopsy. Peerreview evaluations are conducted in each breast imaging modality by board-certified physicians and medical physicists who are experts in the field. Wake Radiology offers digital screening and diagnostic mammography with computer-aided detection software and breast ultrasound at the Garner location. Radiologists who interpret all of these exams are board certified and have expertise in women’s imaging.

Barker Gains International Recognition for ACL Research Joseph U. Barker, M.D., of Raleigh Orthopaedic Clinic recently had his research on anterior cruciate ligament treatment accepted for presentation at the International Society for Arthroscopy, Knee Surgery and Sports Medicine (ISAKOS). The May 2011 meeting in Brazil will bring together leading sports medicine physicians from throughout the world. Dr. Barker’s research with Eric J. Strauss, M.D., Bernard R. Bach, M.D., and Nikhil N. Verma, M.D., titled “Can You Achieve Anatomic Femoral Tunnel Placement with Transtibial Anterior Cruciate Ligament Reconstruction Using Smaller Tunnel Sizes?” examines the importance of tunnel size when performing anterior cruciate ligament (ACL) surgery. This research also has been recently accepted for publication in The American Journal of

Sports Medicine, the official journal of the American Orthopaedic Society for Sports Medicine. This is Dr. Barker’s second article accepted for publication in this prestigious journal this year. His previous work on ACL injuries examining the use of cadaver ACL tissue, titled “Effect of Donor Age on Bone Mineral Density in Irradiated Bone – Patellar Tendon – Bone Allografts of the Anterior Cruciate Ligament,” was published in November with co-authors Drs. Strauss and Bach, and Richard W. Kang, M.D. Dr. Barker is a fellowship-trained orthopedic surgeon in sports medicine. His areas of expertise include sports medicine, shoulder, hip and knee arthroscopy, and cartilage restoration. Prior to joining Raleigh Orthopaedic Clinic in August 2010, he earned his medical degree from Duke University School of Medicine, where he

was awarded a Howard Hughes Fellowship for his orthopedic research. He completed his internship and residency at Cornell University/Hospital for Special Surgery in New York, and then was selected for a sports medicine fellowship at Rush University Medical Center in Chicago. Dr. Barker has had numerous articles and book chapters on ACL injuries published or presented. He continues to perform clinical and basic science research on ACL injuries, and remains committed to advancing science in this field. Having experienced multiple ACL surgeries himself, he remains passionate about this injury and its treatment. For details, visit www.josephbarkermd.com. To schedule an appointment, call (919) 863-6808.

JANUARY 2011

23


News Welcome to the Area

Physicians Durham Timothy James Amrhein, MD Diagnostic Radiology Duke University Hospitals, Durham

Amritpal Singh Anand, MD Wayne Heart and Internal Medicine, Goldsboro

Melissa Schweikhart Bauserman, MD Pediatrics, Neonatal-Perinatal Medicine University of North Carolina Hospitals Chapel Hill

Lourdes Teresa Benitez Concepcion, MD North Carolina Inpatient Medicine Associates Nash Healthcare System Rocky Mount

Nicholas Hagen Bird, MD Divers Alert Network, Durham

Rael Caspari, MD Pediatrics, Pediatric Hematology-Oncology Duke University Hospitals, Durham

Yvonne Christine Dalton-Etheridge, MD Mary Leigh Anne Daniels, MD Pulmonary Disease and Critical Care, Internal Medicine, Pediatrics University of North Carolina Hospitals Chapel Hill

Leigh Rachele Fylstra, MD Psychiatry, Child Psychiatry Duke University Medical Center, Durham

24

The Triangle Physician

Physician Assistants

Brent Allen Golden, MD

Carolyn Elizabeth Pizoli, MD

Maxillofacial Surgery UNC Oral & Maxillofacial Surgery, Chapel Hill

DUMC T0913 Children’s Health Center Durham

Allison Haberstroh Hall, MD

Aaron James Sandler, MD

Pathology Duke University Hospitals, Durham

Anesthesiology Duke University Medical Center, Durham

Jeremy Don Harrison, MD

Rodney Kevin Sessoms, MD

Internal Medicine, Psychiatry Duke University Hospitals, Durham

Internal Medicine 500 Beaman Street, Clinton

Fan Dong, PA

Sayeed Hossain, MD

Maitriyi Jokhu Shah, MD

Elizabeth Sarah Lewis, PA

Jerry Bauloong Hung, MD

Anesthesiology University of North Carolina Hospitals

Raleigh Pulmonary & Allergy Consultant Raleigh

Maggie Marie Stoecker, MD

Nadiya Leonidivna Kaesemeyer, MD

Pathology Duke University Hospitals, Durham

Psychiatry University of North Carolina Hospitals Chapel Hill

Joshua Neal Tennant, MD Orthopedic Surgery University of North Carolina Hospitals

Nicole Maria Kuderer, MD Oncology, Internal Medicine

Phyllis TestDrews, MD

Jennifer Ann Boos, PA Carrboro

William Scott Boyd, PA Chatham Hospital, Siler City

Chapel Hill

Durham

Jeffrey Michael Rosowski, PA Brier Creek Integrated Pain & Spine, Raleigh

Joseph Jonathan Suarez, PA Raleigh

Upcoming Events March 18-19

Raleigh

Autism Society of North Carolina Annual Conference

To be announced

Rebecca Jane Varley, MD

Hilton University Place Hotel, Charlotte.

Scott Vandervort McCulloch, MD

Pathology Duke University Hospitals, Durham

Anesthesiology Durham

Melissa De Leon Veneracion, MD

Jonathan Sol Kulbersh, MD

UNC Hospitals Dept of Medicine, Chapel Hill

Anesthesiology University of North Carolina Hospitals Chapel Hill

Tania Rae Therese Peters, MD

Garth Stephen Watkins, MD

Dermatology Duke University Hospitals, Durham

Psychiatry University of North Carolina Hospitals

Adebowale Ayoola Odulana, MD

The two-day event features dynamic and informative presentations from internationally recognized autism experts Brenda Smith Myles and Stephen Shore, M.D. Ms. Smith will conduct a day-long workshop on Friday and Dr. Shore will be the keynote presenter on Saturday. Both experts have published numerous books and articles, and spoken at hundreds of conferences. The conference is open to individuals and families interested in autism. For more information about the speakers, schedule and discount hotel rates, and to make reservations, visit www.autismsociety-nc.org.


Benjamin G. Atkeson, MD, FACC YOUR LOCAL CARDIOLOGY PROFESSIONALS Cardiology, Echocardiography, IN JOHNSTON COUNTY Nuclear Cardiology DEDICATED TO QUALITY, SERVICE, AND INTEGRITY

Mateen Mateen Akhtar,MD, MD,FACC FACC Akhtar,

Benjamin Matthew S. G. Atkeson, MD, FACC Forcina, MD

Eric M. Diane E. Janis, MD, FACC Morris, ACNP A. Christian N. Matthew Gring, MD, FACC Hook, MD, FACC 2 LOCATIONS TO SERVE OUR PATIENTS Smithfield Heart & Vascular Associates 910 Berkshire Road Smithfield, NC 27577 Phone: 919-989-7907 Fax: 919-989-3147

ChristianKevin N. R. Gring, MD, FACC Campbell, MD, FACC

Randy Matthew A. MD, FACC Hook, Cooper, MD, FACC

Nyla Ravish Thompson, PA-C Sachar, MD, FACC Eric M. Diane E. Janis, MD, FACC Morris, ACNP CARDIOLOGY SERVICES

Wake Heart & Vascular Associates 2076 NC Hwy 42 West, Suite 100 Clayton, NC 27520 Phone: 919-359-0322 Fax: 919-359-0326

Coronary and Peripheral Vascular Interventions, Pacemakers/Defibrillators, Atrial Fibrillation ARDIOLOGY SERVICES Ablations,CEchocardiography, Nuclear Cardiology, Vascular Ultrasound, Clinical Cardiology, CT Coronary and Peripheral Vascular Coronary Angiography, Stress Tests, Holter Interventions Pacemakers/Defi brillators Monitoring, Cardiovascular Medicine, Atrial Fibrillation Ablations Cardiac Echocardiography, Nuclear Cardiology, Echocardiography Catheterization

Nuclear Cardiology Vascular Ultrasound HE IGHEST UALITY ARDIOVASCULAR ARE LOSE TO OME Clinical Cardiology Nyla Ravish CT Coronary Angiography Thompson, PA-C Sachar, MD, FACC Stress Tests Holter Monitoring mithfield spotlight atkeson.indd 1 1/16/2010 4:57:17 PM Cardiovascular Medicine 2 LOCATIONS TO SERVE OUR PATIENTS Echocardiography Smithfield Heart & Vascular Associates Wake Heart & Vascular Associates Nuclear Cardiology 910 Berkshire Road Cardiac Catheterization 2076 NC Hwy 42 West, Suite 100

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Smithfield, NC 27577 Phone: 919-989-7907 Fax: 919-989-3147

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Clayton, NC 27520 Phone: 919-359-0322 Fax: 919-359-0326

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THE HIGHEST QUALITY CARDIOVASCULAR CARE, CLOSE TO HOME.


Pressing This Button Could Save Your Patients’ Life. Now available at wakerad.com Breast MRI (BMRI) has become a popular topic in both the lay press and in peer-reviewed journals recently and has generated unprecedented interest from our referring clinicians and the patients they serve. The American Cancer Society’s latest guidelines supports a BMRI and mammogram once a year starting at age 30 for high-risk patients.* Since 2005, Wake Radiology has been the regional leader in Breast MRI services having performed over 3,158 BMRI examinations to date. Our subspecialty expertise and quality of imaging and interpretation are well known throughout the area. Our experienced Breast MRI radiologists are available seven days per week to address questions and concerns about your high-risk patients or the procedure itself at BreastRisk@wakeradiology.com or call our BMRI Physician Hotline at 919-788-7978.

G. GLENN COATES, MS, MD Body Imaging Radiologist Director, Body MRI Services Co-director, Breast MRI Services

DUNCAN ROUGIER-CHAPMAN, MD Body Imaging Radiologist Co-director, Breast MRI Services

CARMELO GULLOTTO, MD Body Imaging Radiologist Breast MRI Specialist

DANIELLE L. WELLMAN, MD Women’s Imaging Radiologist Breast MRI Specialist

WAKE RADIOLOGY RALEIGH MRI CENTER | 3811 Merton Drive | Raleigh, NC 27609 | 919-232-4700 WAKE RADIOLOGY CHAPEL HILL MRI | 110 S. Estes Drive | Chapel Hill, NC 27514 | 919-942-3196

SOS Shoe Drive

JOIN WAKE RADIOLOGY HELPING THOSE IN NEED!

shareourshoes.org

Start the new year off by cleaning out your closet and bringing shoes you no longer wear to any Wake Radiology office in January and February and we’ll donate them to SOS for those in need in the Triangle and beyond. Shoes are desperately needed for men, women, and children.

Visit our website to find out how you can help us reach our goal of 2011 pairs of shoes at wakerad.com.

©2011 Wake Radiology. All rights reserved. Radiology saves lives.

*The ACS’s risk factors are available on their website at www.cancer.org.


The Triangle Physician January 2011