full issue of Doctoring

Transcription

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[ V2N2 2013 ]
A PHYSICIAN PUBLICATION FROM
THE NORTH SHORE-LIJ HEALTH SYSTEM
MODERN-DAY
House Calls
PAGE 7
SERVING PATIENTS
Who Can’t Pay
PAGE 12
CONSIDERING
Cultural
DIFFERENCES
PAGE 16
SETTING THE
Expanding
Smoke-Free
Standard
PAGE 30
Horizons of Care
NSLIJ_DR_v2n2_H32205_15.indd 1
10/23/13 9:18 AM
Charlie Milburn
Brian Mulligan
Victoria Carlson
Maria Conforti
Ed Lammon
Vice President, Public Relations
Assistant Vice President, Public Relations
Director of Editorial Services
Jamie Talan
Science Writer
Senior Account Manager
Senior Designer
PHYSICIAN-IN-CHIEF, NORTH SHORE-LIJ HEALTH SYSTEM
DEAN, HOFSTRA NORTH SHORE-LIJ SCHOOL OF MEDICINE
Doctoring is published
as a service of the North ShoreLIJ Health System.
se Rec
le
yc
Terence Lynam
Lawrence Smith, MD
eI
Re
n se
rts Before
ov
TRUE NORTH CUSTOM MEDIA
My patient was alone when I arrived. She was lying
on a couch. I set my black bag down and examined
her. I offered her artificial hydration to help with her
inability to eat or drink. She declined. We had a good
visit. As I was leaving, she sat up.
“Dr. Smith, I feel so guilty. I lied to you,” she said.
“You asked me about my sexual history,” she
continued. She reached for a photograph. It was a
picture of her and her mother. They were arm in arm,
comfortable, smiling. She opened the back of the frame
and lifted the picture out. Behind this photo was another
one, worn after decades in hiding. In it was a young
woman with a soldier. They were holding hands, happy.
“We were in love,” she said.
She grew up in Greece, and, during World War II,
American soldiers came to liberate her village. It was
love, she told me. Then, the troops pulled out, and she
never saw her soldier again. She remained faithful and
in love for the remainder of her life.
She wanted me to know her truth before she died.
Two weeks later, she was gone.
Over the course of my career, doctors stopped
making home visits. Today, to help people manage
their care outside the hospital, house calls are back.
When you read “Bringing Home the Healing Touch”
on page 7, you may remember times you stepped into
someone’s bedroom to offer medical care.
Enjoy this issue!
Re m
NORTH SHORE-LIJ EDITORIAL BOARD
extent, number, volume or scope of
cyc
ling
I was given a special gift,
a secret. It was something
tucked so deeply in the life
of my patient that I was
the only one she finally
told. It was at the end
of her life. She wanted
someone to know she
had known romance and
love and connection in
this world. And she told her doctor — me — during a
house call.
In medical school, I never stepped beyond the
threshold of a patient’s life into his or her home. Then
I joined a private practice that routinely made home
visits. During these visits, my relationship with patients
took on a bigger meaning. It was personal, seeing how
they lived in their worlds, and the doctoring I did at
their bedsides became a different kind of medicine.
For many, it was about making them feel comfortable
at the end of an illness. It was about listening.
My patient was in her 70s and dying of metastatic
cervical cancer. Even decades ago, we knew that some
forms of cervical cancer were somehow linked to sexual
activity. She had never been married and was living
with her mother, who was in her 90s. In gathering my
patient’s medical history at the beginning of our one
year together, I asked about her sex life.
My patient was very sick. Her bowels were
obstructed. She could not eat. She told me she did not
want to die in a hospital. Her house was nestled on a
strip of land that jutted out to the bay on Long Island.
Expanding: increasing the
Plea
Leadership Message
>
Managing Editor
TO SUBSCRIBE OR UNSUBSCRIBE, call 800-624-7496.
DOCTORING : V2N2
10/23/13 9:18 AM
DR.
V2N2
contents
D O C T O R I N G
5
GADGETS & GEAR
CULTURE
04.... ECG on the Go
........ Trek Tracker
........ Cutting-Edge Consults
........ On the Record
16.... Culture & Compassion
30.... Clearing the Air
TUTORIAL
05.... Tracking Down
Innate Antibodies
19.... ICD-10
Physician Education
26.... Keeping Patient
Information Under Wraps
OUTREACH
WELLNESS
07.... Bringing Home
the Healing Touch
12.... Guiding Patients
Through the
Financial Maze
23.... Hometown
(and National) Hero
20.... Modern Snake Oil
ON CALL
7
HEY DOC,
DO YOU
HAVE AN
iPAD?
Look inside for
tablet edition exclusives.
FIRST PERSON
10.... Q&A: Hippocratic Growth
34.... Taking the Long View
Locate these icons throughout Doctoring
magazine to learn where you can enjoy
supplemental content in the tablet edition:
Tablet-Exclusive Photography
Tablet-Exclusive Video
20
Get your free tablet
subscription to
Doctoring from the
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FOLLOW THESE STEPS:
NEWSSTAND
(1) Download our app
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(2) Open your newsstand app.
(3) Subscribe to Doctoring.
26
34
(4) Download issues and enjoy!
V2N2: DOCTORING
10/23/13 9:19 AM
G
>
gadgets & gear
A roundup of medical office and/or personal equipment and other products of interest to physicians
by Jamie Talan
ECG ON THE GO ///
1
For patients who worry a lot about their hearts, the HeartCheckTM PEN
is a pocket-sized device that provides a safe and easy way to take
and view an electrocardiogram (ECG). The $259 unit tells users
whether their heartbeat is regular, slow or rapid and can store up to
20 heart rhythms. To use it, patients place their thumbs on silver pads
located on both ends of the device, which gives a reading in about 30
seconds. Patients can plug the unit into a computer to upload their ECG
files to their doctor. HeartCheck is not a substitute for regular cardiac
care, but it can help patients know when to call their doctor. It is not
recommended for patients with pacemakers or implantable devices.
ON THE
RECORD ///
2
TREK TRACKER ///
Are you a walker? Hammacher Schlemmer sells a very cool
pedometer walking stick. Activated when the stick touches the
ground, the pedometer is built right into a shaft below the handle
and tracks the user’s steps, distance, time and use of calories.
The walking stick also includes an LED light for night treks. It
comes with a lifetime guarantee from Hammacher Schlemmer
and sells for $49.95.
CUTTING-EDGE CONSULTS ///
3
Advances in technology now let physicians make house calls remotely.
Companies like JEMS Technology offer telehealth services to physicians
who want to connect with their patients or colleagues. Doctors can use the technology through
their smartphones to consult with patients in home care settings or with other healthcare
providers during surgery. The app requires a JEMS video server and provides a HIPAAcompliant secure environment.
Want to Learn More?
Use your smartphone to scan these QR codes for easy access.
1
heartcheckpen.com
2
hammacher.com
3
jemstech.com
4
Ever wonder what happened to the
turntable? It’s still making rounds, and
music lovers continue to spin vinyl on
their two-channel stereos.
Roy Hall got the idea of manufacturing,
importing and distributing high-end
audio components back in 1985, when
compact disc technology began its
ascent. Mr. Hall loves music, and what
better way to stay connected than to
build a phonograph? He started his
company, Music Hall, and traveled
around the world to meet with companies
interested in his design. He chose a
manufacturer in the Czech Republic that
has been making turntables for half a
century. (Remember your history:
Thomas Edison invented the phonograph
in 1877.) Music Hall also distributes
other high-end stereo components.
For more information about the
coolest sounds in music, visit
MusicHallAudio.com.
4
musichallaudio.com
DOCTORING : V2N2
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on call: resident profile
5
TRACKING DOWN
Innate Antibodies
by Jamie Talan
DANIEL GRIFFIN, MD, PhD, FEELS AS COMFORTABLE PERCHED IN FRONT OF A CELL SORTER
IN THE LABORATORY AS HE DOES TAKING A MEDICAL HISTORY ON AN HIV PATIENT.
Straddling the worlds of research and clinical practice,
Daniel Griffin, MD, PhD, right, worked in the lab at the
Center for Oncology and Cell Biology in the Elmezzi
Graduate School of Molecular Medicine. Thomas
Rothstein, MD, PhD, left, is the center’s director.
Griffin began his medical career tending to patients,
and, after a decade of doctoring, decided to go back to
school for a PhD in molecular medicine. Now he has
returned to the bedside, completing a fellowship at North Shore
University Hospital and LIJ Medical Center for board certification
in infectious diseases. Dr. Griffin likes straddling both worlds and
will set his sights on clinical care with a large dose of research.
His clinical work in infectious diseases has opened the door to
a research fellowship in the laboratory of Stephen Goff, PhD, at
Columbia University, where Dr. Griffin will study how HIV and
retro-viruses evolved to incorporate accessory proteins that enable
the viruses to turn off human genes and take up residence in
the body.
Ultimately, he said, he wants to “work on complex and
Dr.
challenging issues.” At LIJ Medical Center and North Shore
University Hospital, Dr. Griffin has encountered many puzzling
infections.
“Figuring out these problems and positively affecting the lives
of these individuals keeps me committed to direct patient care,”
he said.
SOLVING MYSTERIOUS MALADIES
While recently treating a cancer patient who had an aggressive
infection, Dr. Griffin discovered that the patient had been receiving blood transfusions every couple of weeks to increase his blood
cell count, which had been depleted by cancer treatment. Following
his latest transfusion visit, the patient felt awful. His blood cell
count had plummeted. What was the matter? A careful history
V2N2: DOCTORING
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on call: resident profile
6
FIGURING OUT
THESE PROBLEMS AND
POSITIVELY AFFECTING
THE LIVES OF THESE
INDIVIDUALS KEEPS ME
COMMITTED TO DIRECT
PATIENT CARE.
revealed that the transfusion was
from blood donated on eastern
Long Island, providing the critical
how many types there were and
clue. A blood smear gave an almost
where they resided. Because B1
immediate answer: babesiosis, a
cells in animals appear very early
parasitic illness the patient picked
in life, Dr. Griffin turned to umbiliup from the transfusion itself.
cal cord blood samples culled from
Another case involved a young
women giving birth at North Shore
man who had recently returned
University Hospital. (Women can
from a trip to Africa with abdomiopt to donate the cord blood from
— Daniel Griffin, MD, PhD
nal pain. He underwent an endostheir newborns.)
copy that sampled fluid from the
The lab focused on a subgroup
first part of his small intestine.
of immunoglobulin that does not
In the midst of his parasitology rotation, Dr. Griffin examined the cross the placenta and thus does not come in contact with materspecimen and saw small eggs in the sample. A closer look revealed nal antibodies. That’s when the team found many tiny B-cell manthat the young man had an acute infection with pinworm (entero- ufacturing plants churning out antibodies.
bius vermicularis), which is easily treated and cured.
“You don’t need to do anything to provoke a B-cell response,”
In another case, an insurance salesperson had a foot infection that Dr. Griffin said. “These cells are making antibodies all the time.”
wasn’t accurately diagnosed or cured for a number of years. Aware
He went to work sorting through other B cells to come up
of the patient’s Guyanan origins and frequent returns to the South with pure populations of B1 cells. The lab team dropped single
American country, Dr. Griffin considered more exotic causes. It cells onto a microscope slide, allowing team members to amplify
turned out that the patient had a mycobacterial infection similar to antibody DNA and study its genetic sequence. In this way, they
tuberculosis that had invaded the bone. Dr. Griffin’s accurate diagno- could not only analyze the unique features of antibody-producing
sis led to effective treatment and, ultimately, a cure.
B1 cells, but could also study the nature of the antibody itself. The
“I have learned a lot by listening to my patients,” Dr. Griffin hope is that these kinds of tools will someday allow doctors to
said. “If you listen, they actually tell you what is wrong with them. examine the incidence and role of B1 cells in various diseases.
Then, all of the testing is to confirm that and treat them.”
Following publication of this finding, significant controversy
arose over the true frequency of this cell population. (Dr. Griffin
FROM BEDSIDE TO BENCH AND BACK
believes that the percentage of B1 cells in individuals is variable —
Seeing patients also gives Dr. Griffin ideas for research. First anywhere from one to 10 percent of the entire B-cell population.)
exposed to research as a PhD student at the Elmezzi Graduate
Dr. Griffin will now bring the B1 study into his new world of
School of Molecular Medicine, he began working in the Center infectious disease by looking for hints at new HIV and AIDS treatfor Oncology and Cell Biology. The center’s director, Thomas ments derived from targeting B1 cells. Preliminary evidence from
Rothstein, MD, PhD, had been searching for the body’s natu- renal transplant patients shows that those with a higher number of
ral store of antibodies. These specialized antibodies — innate a type of B1 cell actually require less immunosuppressive medicine.
B-lymphocytes (also called B1 cells) — had been discovered in
The lab team has tested blood from a broad sample population to
mice and other vertebrates, and researchers felt virtually certain measure B1 cells.
that humans had them as well. B1 cells work behind the scenes to
“The highest levels were in a marathon runner,” Dr. Griffin said.
respond to invading microorganisms before the body’s adaptive
A year later, the runner returned to the laboratory for a repeat
immune system kicks in to start making antibodies.
test. This time, she’d spent months recovering from a running
No one had ever clearly identified B1 cells in humans, and injury. Her B1 levels had dropped substantially, raising new
Dr. Griffin took up the challenge. He worked with others in potential theories about how these important cells function.
Dr. Rothstein's laboratory to identify them, as well as figure out
“There are so many unanswered questions,” Dr. Griffin said.
DOCTORING : V2N2
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by Valerie Lauer
outreach
Bringing
Home
the Healing
Touch
7
FOR HUNDREDS OF
LONG ISLAND PATIENTS,
THE HOUSE CALL IS
NO LONGER A RELIC
OF A BYGONE ERA
IN MEDICAL PRACTICE.
V2N2: DOCTORING
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outreach
8
“PROVIDING HIGH-QUALITY CARE IN A HOME
SETTING ISN’T ALWAYS EASY. WE FACE UNIQUE
rustrated with the limitations
of the traditional practice environment and seeking to provide better care for patients who
have trouble visiting physicians’ offices,
Kristofer Smith, MD, joined a growing program that focuses on face-to-face interaction with patients in the intimate setting
of their homes.
Dr. Smith now acts as medical director of
the North Shore-LIJ HouseCalls Program.
Since it was founded in 2006, HouseCalls
has grown to care for more than 800 homebound individuals on Long Island in Nassau, Suffolk and Queens.
“In the past, homebound patients often did not receive the care they needed
because it was hard to leave the house, or
they may have ended up in an emergency
department because it was difficult to see
their primary care physicians on short notice,” Dr. Smith said. “Our program focuses
on reducing unnecessary admissions and
improving care and quality of life, but our
real goal is to win back the trust of our patients. They need to know that we will be
there when they need us.”
F
A DIFFERENT KIND OF CARE
The idea of making house calls may conjure images of old-time physicians with
their black bags, but today’s HouseCalls
physicians carry out sophisticated, hospital-level care in the home, managing both
acute needs and chronic conditions. Some
in-home care offerings include the administration of intravenous antibiotics and fluids,
blood work, echocardiograms, electrocardiograms, feeding tube replacement, prescription management, ultrasounds, urinary
catheterization, and X-rays.
Homebound HouseCalls patients receive
care from a dedicated team of primary care
physicians, nurse practitioners, social workers and other healthcare professionals, all
of whom meet twice a week to discuss their
patients in detail. As a team, they decide
how they can best meet the needs of each
person in the program.
CHALLENGES, AND IT CAN BE AN EMOTIONAL
JOB. BUT NO MATTER WHAT HAPPENS, EVERY DAY
I FEEL LIKE I’VE DONE SOMETHING GOOD, LIKE
I’VE HELPED SOMEBODY. THAT’S WHAT KEEPS ME
PASSIONATE ABOUT WHAT I DO.”
—K
aren Abrashkin, MD, internist
with North Shore-LIJ HouseCalls
“One of the biggest advantages we gain
by making house calls is the deep emotional
connection and level of understanding we
build with patients and their families and
caregivers,” said Karen Abrashkin, MD, a
HouseCalls internist. “We get to learn about
their specific healthcare needs and find out
what they expect and want. It allows us to
connect on a personal level that is hard to
achieve in a busy office practice.”
HouseCalls provides a flexible environment for physicians, helping them promptly
see patients in need, often on the same or
next day. If a patient needs hospital admission, the regular HouseCalls primary care
physician follows up as soon as possible
after discharge to continue providing complete care.
RESULTS ARE IN
Since its inception, HouseCalls has decreased hospital admissions for certain
types of patients by 30 percent, Dr. Smith
estimated. This not only improves the bottom line but also enhances lives for homebound patients, who no longer have to go
through the pain and disruption that can
accompany leaving home for healthcare.
“Patient-centered care programs like this
are the future of the healthcare field,” said
Ramiro Jervis, MD, an internist and medical director of quality for HouseCalls. “We
focus on providing better care — instead
of just more care — to the sickest patients,
such as the frail elderly and those with multiple comorbidities. It’s a value-based program, and quality and efficiency are at the
heart of everything we do.”
NOW HIRING
HouseCalls has been so successful
that there’s a six-month waiting list of
approximately 200 patients trying to enter
the program. There’s a need for internists,
family practice physicians, geriatricians and
nurse practitioners to help meet the growing need, but the day-to-day activities vary
greatly from a typical office setting.
“While it’s important to add efficient,
highly trained people to our team, more
than anything we’re looking for physicians
and nurse practitioners whose philosophy
of care matches the program,” Dr. Smith
said. “We want people who respond to patients’ needs and go above and beyond to
meet and exceed them. One of the reasons
we’ve been so successful is that we look for
and hire these kinds of people at every level.”
DOCTORING : V2N2
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9
The Center for Medicare and
Medicaid Innovation chose North
Shore-LIJ’s HouseCalls service for its
Independence at Home Demonstration last year.
“The Independence at Home Demonstration tests the viability of home-care
programs,” said Kristofer Smith, MD,
vice president and medical director
of advanced illness management at
North Shore-LIJ and medical director
of HouseCalls. “Ideally, it will demonstrate whether having physicians and
nurse practitioners provide care in the
home improves the quality of care and
reduces unnecessary hospitalizations for
the frail elderly.”
Approximately one-third of
HouseCalls program patients
qualify to be part of the
Independence at Home
Demonstration, which
will conclude in 2015.
outreach
A PILOT PROGRAM
TO SUPPORT INDEPENDENCE
AT HOME
onethird
OF HOUSECALLS PROGRAM PATIENTS
QUALIFY TO BE PART OF THE
INDEPENDENCE AT HOME DEMONSTRATION
Could Your Patient Benefit From
HouseCalls?
Tablet-Exclusive Photography
DEVELOPING A DEEP PERSONAL
CONNECTION WITH THE PATIENTS
WE SERVE, THEIR FAMILIES AND
CAREGIVERS ALLOWS US TO ADDRESS
IMPORTANT AND CHALLENGING
ISSUES THAT FACE THE
HOMEBOUND POPULATION.
— Colleen Golden-Bock, LCSW,
HouseCalls' palliative care social worker
ADVANCED
CHRONIC
AGE?
ILLNESS?
MOTIONRELATED
CONDITION?
HouseCalls offers comfort and hope to patients of all ages who are
homebound, whether due to advanced age, chronic illness, a motion-related
condition or some other enduring health concern.
“Developing a deep personal connection with the patients we serve, their
families and caregivers allows us to address important and challenging issues
that face the homebound population,” said Colleen Golden-Bock, LCSW, the
HouseCalls program’s palliative care social worker. “I talk with them about goals
of care, end-of-life choices and advance directives, and help develop plans to
better meet their physical and emotional needs in the long term.”
HouseCalls is not an appropriate service for all patients. Those who join
must use their HouseCalls physician as their only primary care provider. They
may maintain relationships with specialists, and the program will coordinate
visits to medical offices as needed.
Transitioning a patient to HouseCalls requires teamwork and clear
communication between the patient’s prior primary care team and new
provider. The service screens all potential patients to ensure HouseCalls
will suit their needs. Once the patient transitions, the HouseCalls team
works with patients, their families and caretakers to develop a clear plan
of continued care.
V2N2: DOCTORING
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first person
10
Q& A
by Thomas Crocker
Hippocratic Growth
FIVE SEASONED NORTH SHORE-LIJ HEALTH SYSTEM
PHYSICIANS RECENTLY REFLECTED ON A PIVOTAL TIME:
“WHEN DID YOU REALIZE YOU WANTED TO
BECOME A PHYSICIAN?”
DOCTORING : V2N2
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11
an interest in first aid, and I enjoyed studying science in school. My real interest, however, was
economics. The end of my secondary school career coincided with years of social instability in
Haiti, and I wanted to help develop the country. A conversation with my father when I was 18
years old altered my path. He told me one had to be appointed to a position to work in economic
development and that appointments could be politically motivated. He said, “Why don’t you
become a physician? Then you can make people feel better.” I took his suggestion to heart, and
my medical career began.
NICHOLAS GARGIULO III, MD: I wanted to be a physician since the earliest days of my childhood
growing up on Long Island. I became interested in vascular medicine and surgery when my
grandmother had a stroke. I was five or six years old, and I felt helpless, but a foot problem she
developed — gangrene or an ulcer, perhaps — piqued my interest in arteries and veins and their
role in the body.
I have always liked performing research, which I started during medical school and continued
through a substantial portion of my career before turning my full focus to clinical medicine.
I like finding the unknown because doing so helps me better care for patients. That’s why I still
conduct a certain amount of clinical research today — to uncover knowledge that could help the
next patient.
DAVID HILTZIK, MD: I grew up in Teaneck, NJ, and knew at age six or seven that I wanted to be
a physician. Science professionals in my family inspired me. My grandfather, a chemist, worked
on the Manhattan Project, and my grandmother taught science in public schools in Manhattan.
Interests in anatomy, working with my hands and connecting with people helped me realize
I wanted to become a surgeon.
Two other individuals influenced my decision to pursue medicine when I was a child:
my pediatrician and the character Dr. Cliff Huxtable on The Cosby Show. My pediatrician was a terrific clinician who could diagnose many illnesses by phone. I found
Dr. Huxtable inspiring because he formed great relationships with his patients and
enjoyed his career.
HARRY STEINBERG, MD: When I entered high school in my native Philadelphia,
I was interested in science and knew I wanted to help people. I attended a forwardthinking high school with lots of intelligent students, and my time there helped me
realize I should channel my academic interest into a career in medicine.
I chose to specialize in pulmonary medicine because of my experience in the
US Army during the Vietnam War era. I spent a year of my residency focusing on pulmonary disease. When I was drafted, the Army assigned me to a pulmonary unit at
Valley Forge for two years. It was an eye-opening experience: I was told to go do
something I didn’t want to do; I was older than the patients for whom I cared,
and I didn’t completely believe in the reasons for the conflict in which they were
involved, yet it was my job to care for them. The experience taught me I had a talent
for pulmonary medicine, so that’s what I pursued after my military service.
JOSEPH ZITO, MD: I was always interested in becoming a physician during my
childhood on Long Island. My interest spiked during my preteen and teenage years,
when my grandfather and father became ill and I had to spend lots of time in
hospitals with them.
I didn’t truly commit to becoming a physician until my late 20s. I took pre-med
courses in college and intended to become a physician later in life. In the meantime,
I served as a volunteer firefighter in Roslyn, a role I’d held since 17. I eventually transitioned from being an emergency medical technician to a paramedic, which deepened
my interest in medicine. My goals changed on 9/11. I lost two firefighter friends that
day, and I spent more than a week at the site of the World Trade Center helping with
the response. Afterward, I realized I would be able to do more to help people as a physician, so I entered medical school the next year.
THE PHYSICIANS
first person
LOUIS-JOSEPH AUGUSTE, MD: As a Boy Scout during my teenage years in Haiti, I developed
Louis-Joseph Auguste, MD,
surgical oncologist at LIJ Medical
Center and North Shore University
Hospital, president of LIJ's Medical
Staff Society
Nicholas Gargiulo III, MD,
vascular surgeon at Plainview
Hospital and Southside Hospital
David Hiltzik, MD, director of
otolaryngology and head and neck
surgery at Staten Island University
Hospital, associate director of the
Center for Cranial Base Surgery
at the New York Head and Neck
Institute at Lenox Hill Hospital
Harry Steinberg, MD, acting chief
of pulmonary, critical care and sleep
medicine at North Shore University
Hospital and LIJ Medical Center
Joseph Zito, MD, emergency medicine
physician and Intensive Care Unit attending
physician at Forest Hills Hospital, Franklin
Hospital, North Shore University Hospital
and LIJ Medical Center
10/23/13 9:19 AM
outreach
12
DOCTORING : V2N2
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outreach
13
GUIDING
PATIENTS
Through
the
Financial
Maze
by Jamie Talan
V2N2: DOCTORING
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outreach
14
FOR PATTIE FROEHLING,
IT IS ALL ABOUT COMPASSION.
waitress in Manhattan needed
foot surgery but had no means to
pay for it. Another patient arrived
at the emergency department
feeling sick all over, and doctors diagnosed
cancer that would require a bone marrow
transplant. Again, the patient could not afford the treatment. In each case, Ms. Froehling spent time at the patient’s bedside to
help work things out.
As director of revenue cycle for the North
Shore-LIJ Health System, Ms. Froehling
is the bridge to care for patients who are
uninsured or unable to afford their treatment. It is a common occurrence across the
health system, and Ms. Froehling and 40
of her colleagues spend their days helping
patients who require financial assistance
get through the red tape of the health insurance world.
In 2012, North Shore-LIJ worked on
85,935 cases that added up to nearly
$204.6 million in healthcare charges.
The patients involved in these cases
ultimately paid a small portion of their
final costs — nearly $11.6 million, according to Mary DiLorenzo, director of the
health system’s Regional Claims Recovery
Service. That means North Shore-LIJ provided $193 million in charity care.
A
THANKFUL PATIENTS,
THANKFUL PROVIDERS
Ms. Froehling’s office is filled with thankyou cards from people who would not have
survived otherwise. Many patients pay off
their share of debt on a monthly basis. Some
checks, or even small amounts of cash, arrive years after patients have received care.
“Patients are so thankful that we are here
to help them,” she said. “And, at the end of
every day, we are thankful that we can help
so many people.”
Nonprofit hospitals are known to open
their checkbooks to people who need services. A network of charity and government-assisted programs weaves through
every North Shore-LIJ hospital and outpatient facility. Everyone who receives
care in the health system gets information on the Financial Assistance Program,
but few really understand how it works.
Nonprofit hospitals must have programs
available for patients who can’t afford medical care. According to federal law, people
can apply for assistance if they make up to
300 percent above the federal poverty level,
which currently stands at $23,550 per year
for a family of four. But the North ShoreLIJ Health System provides assistance to
those earning up to 500 percent more than
the federal poverty level — $117,250 per
year for a family of four.
Ms. DiLorenzo explained how it works.
When patients come to an emergency
department or hospital-run clinic, their
health insurance information is entered
into the system. People without insurance
are flagged for the Financial Assistance
Program. They can fill out a one-page application, talk with a financial assistance
coordinator on the phone or confer with a
financial assistance officer to see what programs they are eligible for. If they do not
qualify for Medicaid or family assistance
programs, North Shore-LIJ has a program
in place that substantially reduces medical
bills to a level the patient can afford. The
health system also works with people who
choose to pay their own healthcare bills.
Patient payments are based on annual
income divided by the number of people
in the home. The initial event that brings a
patient to the hospital must result in care
that is medically necessary. Elective procedures do not qualify, but the financial assistance team can help arrange insurance
so patients can seek care through clinics associated with the health system. Field representatives make bedside and home visits,
Ms. DiLorenzo said.
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outreach
15
$193,000,000
In 2012, North Shore-LIJ worked on 85,935 cases involving
patients requiring financial assistance. The health system
provided $193 million in charity care in these cases.
“I have seen a patient’s $5,000 bill reduced to $150,” she said. “Some people
don’t believe it and ask for written proof.”
She added that about 40 percent of these
patients pay nothing for their care even
after their bills are reduced substantially.
Financial counselors work with patients
to assess their eligibility for Medicaid,
Family Health Plus, Child Health Plus,
other state insurance programs or the
Group Health Insurance Plan of Greater
New York. Then North Shore-LIJ takes additional steps to help people access healthcare. For example, once patients qualify
for financial assistance, they are also eligible for reduced out-of-pocket costs. In
addition, financial counselors help people
qualify for pharmacy assistance and the
federal Supplemental Nutrition Assistance
Program. Translation services in dozens of
languages facilitate clear understanding of
the options.
BREAKING BARRIERS TO CARE
Ms. Froehling’s office receives 10 to 20
calls a day. So does Joemy Soto, manager
for North Shore-LIJ’s Healthcare Access
Center. Several health system facilities
— North Shore University Hospital, LIJ
Medical Center, Glen Cove Hospital, Staten
Island University Hospital and the Dolan
Family Health Center — have financial assistance representatives on site, and many
hospitals also make managed-care reps
available to walk patients through the eligibility process.
“We help the uninsured by removing
roadblocks to healthcare,” said Terence
Smith, executive director of the Dolan
Family Health Center. “Access to healthcare allows people to find their way into the
mainstream of the economy and culture.”
One mother from Colombia who needed
services decades ago made her living catering and selling ethnic food. Now, one of
her children attends medical school, and
the other is an undergraduate at Brown
University. Mr. Smith sees many grown
children whose families have been coming
to the clinic since it opened in 1995.
One undocumented patient who received
care to rule out cancer recently addressed
the Suffolk County Legislature about the
importance of the Dolan Family Health
Center to the community. Located in
Greenlawn, the center is part of Huntington
Hospital. One of the first orders of business for the center’s staff is helping people
get health insurance. They see around
126 patients a day.
“We monitor our patients coming in, take
note of their insurance needs and try to set
them up in the system,” Mr. Smith said.
Not everyone will qualify for insurance,
he said. About five percent of the center’s
clients receive insurance through Child
Health Plus; Medicaid and Medicaid Managed Care cover about 55 percent; Family
Health Plus, around four percent; Medicare
and Medicare HMO, six percent. About
26 percent of the center’s clients do not
qualify for any state or federal insurance
and are considered self-pay.
“We do better than other health clinics
in Suffolk County that have about 50 percent uninsured clients,” he said.
The Dolan Center has been so successful in meeting community needs that area
doctors in private practice assist the center’s salaried clinicians by donating their
services. Its North Shore-LIJ affiliation
also provides access to neonatologists, surgeons and other health system specialists
on a sliding-scale fee, Mr. Smith said.
Ms. Froehling sees every day as an opportunity to help people who can’t afford
healthcare to get better.
“Can we know that a person walked out
of the hospital with the care they needed?”
she asked. “Yes, absolutely.”
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culture
16
Culture &
Compassion
by Jamie Talan
SENSITIVITY TO CULTURAL
AND RELIGIOUS
DIFFERENCES IS CRUCIAL
WHEN LIVES
ARE ON THE LINE
IN A HOSPITAL SETTING.
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culture
17
the end, they brought fruits,
flowers, ginseng and other gifts
of gratitude.
Korean-American couple Manho and
Jin-ah Lee were fighting to keep their
28-year-old daughter, SungEun Grace
Lee, alive on life support, even after she
expressed wishes to be removed from it.
An aggressive brain tumor had left her
completely paralyzed and bedbound. Her
doctors said the tumor — pressing against
brain regions that govern breathing and
respiration — would kill her in a matter of
weeks, maybe months. In Korean culture,
parents traditionally retain great influence
over their children’s lives far into adulthood. While the Lees wanted to take control of their daughter’s care, American law
prevented them from doing so.
During his daughter’s hospitalization at
North Shore University Hospital last fall,
Mr. Lee petitioned the court to allow him
to make medical decisions for his daughter, even though she had the ability to
make such decisions on her own. A state
Supreme Court ruling supported the young
woman’s right to make her own decisions,
which the New York State Court of Appeals
upheld. With these decisions in hand,
Ms. Lee did agree to allow her father to
oversee her medical care. Kept on a respirator, she was transferred home on Thanksgiving and died three months later.
The case sparked a national debate. Behind the scenes, North Shore University
Hospital clinicians, religious leaders and
administrators met to figure out better
ways to incorporate cultural and religious
beliefs into patient care. The North ShoreLIJ Health System had already formalized
a strategy on diversity, inclusion and health
literacy patterned after a national plan to
meet the needs of patients trying to navigate their care in an unfamiliar language.
In
But language is not the only barrier.
Religious and cultural values shape decisions made during times of illness (and
in health), and this would be the challenge
of the health system’s Office of Diversity,
Inclusion and Health Literacy. Negotiating
such cases is especially challenging when
patient values and beliefs may differ from
those of their family members, as was the
case with Grace Lee.
BRIDGING THE GAP
Barbara Felker, vice president of diversity, inclusion and health literacy for the
health system, was called in early during Grace Lee’s case. She reached out to a
Korean chaplain at Lenox Hill Hospital,
the Rev. Stanley Kim, to improve communication between family members and
the hospital staff regarding their religious
background and beliefs concerning
their daughter’s condition.
Following the Grace Lee case,
Ms. Felker and her colleagues
decided to create the Bridges
Program to focus on assembling a working group of experts
to help staff, patients and families struggling to understand different
ethnic groups’ cultural,
medical and religious
values, as well as their
views of suffering.
“The hope is that these
leaders can make recommendations on how to do
things better,” said Ms. Felker.
The program will begin with putting
together a team to focus on the needs of
the local Korean community. It recently
brought together leaders of the Korean
community, a Korean anthropologist and
expert on aging, and health system doctors and chaplains.
10/23/13 9:20 AM
Understanding culture is key to better care,
said Ms. Felker. The Grace Lee case provides a perfect example.
“Once we brought in the Rev. Kim, he
was able to translate the family’s concerns,
and we better understood how to accommodate their needs,” Ms. Felker said.
There was a lot of bedside prayer. The
family covered Grace Lee’s bed with pinecones, pine needles and branches. The
young woman’s mother thought that a special red ginseng from Korea could help stop
the growth of the brain tumor, and her doctors signed off on it. The family added it to
her feeding tube.
The mother offered bits of the dry,
chewy ginseng to the staff, hoping that it
would give them more energy while caring
for her daughter.
“We need to be expert listeners to fully
understand what is important to patients
and their families at the end of life,” said
Dana Lustbader, MD, head of palliative
medicine at North Shore University
Hospital.
HONORING WISHES
Recently, an elderly man on life support
was dying, and Dr. Lustbader and her colleagues were mindful of his Orthodox Jewish religious belief that the body in a state
of active dying should be left to do its job in
peace. That means no unnecessary disturbances, lights, noise or activity during the
dying process. After the patient takes his or
her last breath, the catheters and breathing
tube stay put until a special team of Orthodox Jewish leaders arrives to remove them.
Any skin, hair or other body part that remains is buried with the patient.
Dr. Lustbader teaches healthcare practitioners how to ask questions about the
cultural and religious beliefs of the patient.
An open-ended question — “Do you have
a faith background that has been helpful
to you in the past?” — can open lines of
communication between the practitioner
and the patient. Also, asking patients what
they are most worried about could lead to
information that could enhance their care
experience.
A NEW VISION
The Office of Diversity, Inclusion and
Health Literacy recently implemented a tool
called Culture Vision that provides specific
information about 47 different cultures. It
is available on Healthport, the health system’s intranet, for health practitioners to
learn about the cultural, dietary, religious
and emotional needs of their patients.
Until recently, the program normally had
about 4,000 monthly visitors. That number climbed to 38,000 when an iPad was
offered as a prize during a minority health
challenge. The numbers have been climbing ever since. There is also a health literacy
module and a clinical cultural competency
module that serve to strengthen the relationship between healthcare providers and
patients with diverse ethnic backgrounds.
This summer, the Office of Diversity,
Inclusion and Health Literacy launched an
online learning program through the Center for Learning and Innovation (CLI) to
allow doctors to move through cases that
will help them understand how to handle
cultural factors that surface when delivering medical care.
Often, this is a balancing act. Earlier this
year, another Korean patient’s family wanted to carry out a traditional acupuncture
ceremony thought to draw toxins out of
the blood. The patient, in his mid-40s, had
suffered a stroke, and his family wanted to
add this to the treatment plan. After a discussion with his healthcare team, a limited
cupping treatment was allowed, but the
family was told that the suction cups used
in the procedure had to avoid critical areas
on the patient’s body. Aggravation of these
areas could lead to a breakdown of the skin
and the potential for bedsores. The cupping
went overboard, and the patient’s doctors
stopped it.
Mostly, cases involve very different attitudes regarding patient care.
“We have been formalizing a strategy for
good communication and delivery of competent cultural care,” said Jennifer Mieres, MD,
chief of diversity, inclusion and health literacy for the health system and medical
director of the CLI.
One aspect of that is evident in the
health system’s extensive interpretive
services, which anyone can access to help
communicate with patients in their native
language. The importance of cultural competency in patient care mandates both the
need to learn to speak plainly and to incorporate cultural beliefs.
“If we understand patients’ concerns, we
can address them and deliver quality care,”
Dr. Mieres said. “It is our job to communicate with our patients on many levels. We
need to really listen to their medical history and understand their culture and how
that plays into their decision-making. It is
a true shift.”
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tutorial
19
COMING SOON ///
ICD-10
Physician
Education
68,000
DIAGNOSIS
CODES
72,000
PROCEDURE
CODES
While medical science, research and technology
have progressed during the past 30 years, inpatient
documentation and coding have remained static.
Our process does not reflect our progress.
That will change on Oct. 1, 2014, when the
United States implements ICD-10 (International
Classification of Diseases, 10th edition) for
inpatient care medical documentation. With
approximately 68,000 diagnosis codes and 72,000
procedure codes, ICD-10 will not necessarily
affect the care we provide our patients, but it will
reshape how we document, code and bill — and,
therefore, how we are reimbursed.
More specific documentation is the driving force
behind ICD-10’s success, making this transition
a challenge for physicians and their teams. North
Shore-LIJ is rolling out a comprehensive education
program with support and resources to ensure early
adoption. More information will be available soon.
Stay updated at HealthPort > Physician Portal
> ICD-10 Survival Guide.
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wellness
20
Modern
Snake Oil
by Jamie Talan
DESPERATE FOR A CURE,
SOME PATIENTS WILL GO
TO EXTRAORDINARY LENGTHS
TO FIND THE MEDICAL HELP
THEY SEEK. UNFORTUNATELY,
THOSE SEEKING MIRACLES CAN
FIND SCAMS INSTEAD.
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wellness
21
terminally ill cancer patient
went to Canada to get injections
of a controversial growth hormone. The shots were administered after the injection site was cleaned
with a cotton ball drenched in vodka.
Before the trip, the man sought to clear the
plan with his physicians. Doctors at North
Shore University Hospital nodded at the odd
request and allowed the dying man his wish.
The parents of an infant with spinal muscular atrophy told their son’s doctor they
wanted to take the child to South America
for an infusion of stem cells. The baby’s doctor knew it would be risky and tiring for the
boy, who was dying. The doctor called the
South American clinic and promised to infuse the mixture if it could be transported
to Long Island. The director of the clinic refused, which meant the family had to hire a
private plane to get the intravenous infusion
for their son. At the clinic, cells were infused
into the body of the boy’s mother, too. She
was pregnant, and she was told that the infusion would protect the fetus from developing the same genetic condition.
A
A DESPERATION-DRIVEN MARKET
Snake-oil salesmen are things of the past,
but hucksters still walk among us, spreading
news of their “treatments” — beneficial
or otherwise — online. The Internet can
be quicksand for desperate patients, who,
upon finding a treatment they believe may
be helpful, have been known to put their
doctors in the position of balancing their
patients’ right to choose treatments against
what allopathic medicine has to offer.
It is not always an easy call, said Dana
Lustbader, MD, chief of the Palliative Care
Unit at North Shore University Hospital.
Dr. Lustbader is the
doctor who called the
South American clinic
to request the intravenous fluid be sent to
New York, saying she
would deliver it accordDana Lustbader, MD
ing to the clinic’s protocol. She had no idea what was in the IV fluid
the clinic touted as a cure for neurological
diseases but was willing to administer it —
without questioning the treatment itself —
to spare the family the expense of the
trip. Her decision was easier to make because she knew the child was going to die.
“Of course, we tried to talk the parents
out of doing this,” said Dr. Lustbader. “They
had no insurance and no money. But they believed that this would save their child. Then,
I decided to reach out to the clinic to see if we
could deliver the treatment ourselves.”
The treatment and travel cost the parents $50,000. Their son died five days later.
OPENING A DISCUSSION
“Nothing goes away as long as it is marketable,” said Stephen Barrett, MD, a retired psychiatrist who heads Quackwatch.org and has
spent the better part of his career trying to
identify medical quackery. “The Internet has
made [the problem of bogus treatments] more
apparent and probably more widespread. It is
not simple to lay out a plan for doctors about
how to manage such misinformation. Often,
they can’t judge it directly. I generally recommend they ask their patients what they are
trying to accomplish, read the claims with
them, and discuss the treatment.”
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wellness
22
The popularity of alternative treatments
makes it even more difficult to spot an
untrustworthy claim, he added. What’s
more, some alternative treatments are fast
becoming offerings at hospitals, clinics and
medical schools.
“If yoga is used as a way of stretching,
that is fine,” said Dr. Barrett. “But if it’s
touted as a treatment to rearrange chakras,
that’s not fine. It’s important that people —
healthcare practitioners and patients — develop the right amount of skepticism. You
are almost guaranteed to go wrong without
an informative anchor.”
Bruce Gilbert, MD,
director of reproductive
and sexual medicine at
the Smith Institute for
Urology, is also boardcertified in acupuncture.
Bruce Gilbert, MD
He believes there is some
benefit in many complementary and alternative treatments, and clinicians need to be
well versed in what they are delivering.
Take testosterone, for instance, which is
known to many as the fountain of hormonal
youth. Many clinicians think testosterone supplementation is safe if a man’s levels are lower
than average or if he complains of low libido.
But what physicians might not know is
that testosterone supplements can permanently turn off sperm production in about
20 percent of patients. This leaves young
men with a new set of problems.
Although Dr. Gilbert refrained from calling this “quackery,” he added, “it indicates
a lack of knowledge that can be harmful to
the patient. Testosterone is a great treatment for someone who needs it, but it can
be bad for those who don’t.”
TARGET: CANCER PATIENTS
Questionable “therapies” can be found
for almost any disease, but cancer seems
to be the condition that most often ignites searches for alternative treatments.
James D’Olimpio, MD, director of cancer
pain and supportive
oncology at the North
Shore-LIJ Cancer Institute, has been practicing medicine since
the 1980s. He’s used
to seeing patients or
James D’Olimpio, MD
their loved ones walk
into his office at the Monter Cancer Center
with a clipboard filled with material printed off the Internet.
“There are not enough good treatments
in cancer, and the majority of patients with
poor-prognosis metastatic cancer have
to think outside of the box, as I do,” said
Dr. D’Olimpio. “I had a recent patient diagnosed with pancreatic cancer who had less
than six months to live. In addition to consulting the standard of care, the oncologist
went online and found some positive studies using an extract of turmeric. Preliminary information suggests curcumin has an
anti-cancer effect, especially in test tubes
[in vitro]. And a published study on a small
group of patients also suggested benefit. The
studies were sufficiently positive that the
National Cancer Institute launched a clinical
trial. It is still ongoing.
“Many of my colleagues just wouldn’t have
done that,” he continued. “I say that it would
not hurt and could possibly help, while we
wait for confirmation.”
Dr. D’Olimpio also said that it is critically important to have an open dialogue with patients about what they are
considering in the way of alternative
medicine. He asks them to list the vitamins and herbs they are taking, as well.
He’s prescribed a mushroom extract used
commonly in cancer hospitals in Japan that
has been shown to improve the immune sys-
tem — an example of how alternative treatments can go hand-in-hand with allopathic
medicines available to patients.
A patient came to him recently with a clipboard and a plastic bag filled with Chinese
herbs. The bag’s contents looked like dirt.
“We went through everything he was taking or considering, and a couple were okay
— meaning they would not interfere with
the treatments I was prescribing — but some
were not,” he said. “Once I explained that
the herbs alter the way the medicines work
against his cancer, he agreed not to use them.”
One patient’s story still lingers in
Dr. D’Olimpio’s mind 20 years later. A teenager with sarcoma had a massive infection
around the port in his chest. The doctor’s
main goal was to heal the wound. The boy
always seemed more animated on Fridays, while at the beginning of the week he
seemed utterly drained and listless.
Dr. D’Olimpio asked the patient’s father if
he noticed the difference in his son. At that
moment, the father said that he had mortgaged his home to buy laetrile infusions and
cleansing enemas for his son. The teenager
went through the routine every weekend.
“‘Let’s find out what your son wants,’ I
said to the father. [The son] did not want
to do the weekend treatments. It was not
helping him, and he felt awful. Instead, he
chose to have a July 4th party and invite all
his friends,” said Dr. D’Olimpio.
The patient died shortly after the party.
“Quackery is profit-driven,” Dr. D’Olimpio
added. “This is a very
emotional time for
patients, and we need to
help them understand
the reality of the
situation.”
NOTHING GOES AWAY AS LONG AS IT IS
MARKETABLE. THE INTERNET HAS MADE
[THE PROBLEM OF BOGUS TREATMENTS] MORE
APPARENT AND PROBABLY MORE WIDESPREAD.
—Stephen Barrett, MD, retired psychiatrist who heads Quackwatch.org
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by Thomas Crocker
V2N2: DOCTORING
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outreach
24
surgical oncologist at LIJ
Medical Center and North
Shore University Hospital and
president of LIJ’s Medical Staff
Society, Dr. Auguste earned his medical
degree in Haiti and settled in the United
States in 1975 to embark on his career. He
began returning to Haiti in 1999 with the
Association of Haitian Physicians Abroad
to provide oncology education to physicians
in the country’s capital, Port-au-Prince.
Political upheaval halted his visits in 2004,
but by 2009, the situation had calmed,
and Dr. Auguste truly began going home.
“Some colleagues and I began visiting Justinien University Hospital, the only hospital
in my hometown of Cap-Haitien, on Haiti’s
north coast,” Dr. Auguste
said. “We provided didactic
With each visit to Haiti, Louis-Joseph Auguste, MD,
lectures about cardiology,
surgical oncologist at LIJ Medical Center and North Shore
various cancers, trauma care
University Hospital and president of LIJ's Medical Staff
and perioperative manageSociety, and his colleagues sow the seeds of sustainable
ment. Just two months later,
healthcare. This past spring, they were gratified to learn
a devastating earthquake
several had blossomed.
destroyed most of the healthThe medical mission team hosted a course in Advanced
care facilities in Port-auTrauma Life Support and Advanced Cardiovascular Life
Prince and killed hundreds
Support for Haitian physicians at Justinien University
of thousands of people. I led a
Hospital in Cap-Haitien last fall. Several months later, the
group of more than 100 medical and nonmedical volunHaitian government relied on the newly trained physicians
teers from the United States
to render emergency care during Carnival celebrations.
and Haiti to help keep the
Even more exciting to the US team was the news that
city’s largest hospital open
medical residents at the hospital were able to use a
during the first week after
defibrillator the group had donated to save the life of a
the disaster.”
patient who suffered a heart attack.
For the past four years,
Dr. Auguste has focused his
efforts primarily on Cap-Haitien, and his
passion for partnering with his Haitian counterparts to help solve the country’s healthcare problems has spread to his colleagues in
the North Shore-LIJ Health System.
A
Growing Success
PARTNERS IN CHANGE
Practicing medicine in Haiti is fraught
with challenges related to historically dysfunctional politics, inadequate infrastructure, poverty and insufficient public education. Hope for a brighter future lies in
Haitian healthcare practitioners’ thirst for
knowledge and eagerness to take the lead
in effecting change.
“These medical missions should be seen
as partnerships in which to exchange information, discuss different approaches to
problems and affirm that all of us belong to
the same human family,” Dr. Auguste said.
“They are opportunities to teach individuals how to fish instead of simply handing
fish to a population in need.”
That philosophy attracted more than 20
physicians and nurses from throughout
the United States — including seven from
North Shore-LIJ — to join Dr. Auguste on
his fifth annual, one-week medical mission to Justinien University Hospital last
November. The group faced obstacles from
the outset: Hurricane Sandy delayed the
arrival of donated medical equipment and
caused significant flooding in Cap-Haitien
just before the team departed. Once the
group reached Haiti, demonstrating students temporarily interrupted a course
in Advanced Trauma Life Support (ATLS)
that mission participants offered Haitian
physicians at the State University of Haiti
School of Medicine in Port-au-Prince.
Treating patients at Justinien University
Hospital — a 123-year-old facility that was
last renovated in the 1920s — in CapHaitien presented another set of challenges.
The US-based physicians worked alongside
their Haitian peers in sweltering, dilapidated conditions that permitted little patient
privacy. Animals roamed the wards.
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outreach
25
AN EXPERIENCE WORTH WAITING FOR
Team members used limited
equipment and knowledge
some hadn’t called upon since
their medical school training
to complete cases that included
parotidectomy, mastectomy, hernia
repair, amputation and several biopsies.
SMALL STEPS
ON A LONG JOURNEY
Clinical practice constituted only part of
the mission members’ activities; they also
devoted time to their goal of fostering sustainability. Physicians conducted lectures
and hosted courses for their Haitian colleagues on topics such as traumatic colon
injuries, management of cardiac events, and
interpretation of urinalysis. American physicians held a journal club to encourage critical thinking. The instructors of the ATLS
course in Port-au-Prince presented the same
program in Cap-Haitien.
It will take many more such missions —
and transformation of a range of factors that
are beyond physicians’ control — to bring
21st century medical care to the poorest country in the Western Hemisphere. But enough
small successes — such as the joy of a physician who has just learned something new or
the gratitude of a patient whose life has been
improved through treatment — can add up
to something big.
To support the Association of Haitian
Physicians Abroad, send your tax-deductible donation (indicate on checks that the
donation is for the North Shore-LIJ/Justinien
Project) to AMHE Foundation, Inc., PO Box
211392, Royal Palm Beach, FL 33421 or visit
amhefoundation.org. For more information
about the association and its missions, visit
amhe.org.
Michael Ziegelbaum, MD, attending urologist at the North ShoreLIJ Health System, has always had a heart for serving others through
nonmedical volunteer endeavors. His dream, however, was to use
his professional expertise to improve the lives of those in need —
a dream he had to defer until he finished raising his children.
In 2012, opportunity knocked. Louis-Joseph Auguste, MD,
surgical oncologist at LIJ Medical Center and North Shore
University Hospital and president of LIJ’s Medical Staff Society,
invited Dr. Ziegelbaum to accompany him on a medical mission
to Haiti last November.
“I had heard about Dr. Auguste’s missions and told him I wanted
to participate in one someday,” Dr. Ziegelbaum said. “When I received
an email from him last summer inviting me to go,
I said to myself, ‘It’s time to fish or cut bait,’” Dr. Ziegelbaum said.
“I am so glad I decided to make the trip. Practicing medicine with my head
in the absence of technology we take for granted and seeing people’s
appreciation for our efforts made for a wonderful experience.”
BACK TO BASICS
The dearth of modern equipment at the mission team’s destination —
Justinien University Hospital in Cap-Haitien — forced Dr. Ziegelbaum and
Arvin George, MBBS, the North Shore-LIJ urology fellow who accompanied
him, to recall techniques they learned in residency. Cases performed included
correction of bilateral ureteropelvic junction stenosis in a toddler and
nephrectomy in an elderly woman. The physicians also treated hydroceles
and urethral strictures.
“I was drenched with sweat most of the time, even in the operating room,
because the air conditioning was inadequate. We practiced open-air medicine
in a hot, humid country,” Dr. Ziegelbaum said. “The gratitude shown to us by
our Haitian colleagues and patients — one man gave me an expression of
such thankfulness when he awoke following a hydrocele procedure — put the
discomfort into perspective. Everyone was so welcoming. I felt like a guest in
someone’s home the whole time.”
The mission marked the beginning of a deeper commitment to Haiti by
Dr. Ziegelbaum. Like Dr. Auguste, he knows the key to building a functional
healthcare system in Haiti is helping Haitian providers develop their clinical
skills. He will be part of Dr. Auguste’s next medical mission this fall — after
spearheading a conference of American and Haitian urologists in Port-auPrince to discuss how Haitian physicians can advance urology services in the
country. His long-awaited first medical mission kindled in him a desire to help
the people of Haiti that doesn’t figure to fade anytime soon.
10/23/13 9:20 AM
tutorial
26
Keeping
by Valerie Lauer
MISPLACING A CELL PHONE. WALKING AWAY FROM AN UNLOCKED
COMPUTER. SHARING A PASSWORD WITH A COWORKER. THESE THINGS
MAY SOUND HARMLESS, BUT THEY COULD LEAD TO UNAUTHORIZED
ACCESS TO THE CONFIDENTIAL INFORMATION PATIENTS AND
COLLEAGUES PLACE IN YOUR CARE.
DOCTORING : V2N2
10/23/13 9:20 AM
tutorial
g UNDER
Patient
Information
27
WRAPS
the wrong hands, medical and personal information can cause trouble — resulting in stolen identities and
leading to fines or worse for those responsible for the loss.
“People who utilize the North Shore-LIJ Health System’s services have an expectation that, when we handle their information, we are keeping it secure,” said Scott Strauss, the health system’s director of corporate
security and emergency management. “That isn’t just our patients’ expectation — it’s a federal law. We’re required to do it.
An employee who violates that law may be obligated to make financial restitution for damages or could face suspension,
termination of employment and imprisonment.”
In
KEEP IT CONFIDENTIAL
Besides responsibility for the health and wellness of others, physicians are entrusted with personal information by patients and staff members. Without this trust, administering care would be impossible. At North Shore-LIJ, all clinicians
are expected to protect sensitive patient and employee information, even as electronic health records make it more complex
to keep data safe. The new Keep It Confidential campaign reminds providers of the important role information security
plays in healthcare settings.
“The phrase ‘Keep It Confidential’ is easy to remember, and it sums up every employee’s obligation when it comes to
patient information,” said Greg Radinsky, the health system’s chief compliance officer. “As part of working for North ShoreLIJ, we are all required to protect patients’ information, just as we are obligated to protect their health.”
The campaign urges North Shore-LIJ staff members to keep information secure, even in the era of electronic health
records, by:
• keeping passwords private;
• keeping laptops and mobile phones secured at all times; and
• encrypting all data, including information stored on mobile devices, flash drives and laptops.
“We should think of our passwords as digital DNA,” Mr. Strauss said. “If we go someplace — into a patient record, for
example — the password leaves a trace. If it is used someplace it shouldn’t be, the Information Services Department will
know about it. And there are consequences for those actions. It’s a simple identification process.”
Ongoing education about protecting patient data is integral to the Keep It Confidential campaign.
V2N2: DOCTORING
10/23/13 9:20 AM
tutorial
28
“We demonstrate our respect for our
patients and members by protecting the
confidentiality of all personal details they
share with us. This data, known as ‘protected
health information’ or ‘PHI,’ can include
patients’ names, addresses, phone numbers,
Social Security numbers, medical diagnoses,
family illnesses and more. Federal and state
laws, as well as quality of care standards,
require us to keep this information
confidential. North Shore-LIJ employees or
members who are patients in our facilities
also must be accorded the highest level of
confidentiality with respect to their medical
records and the PHI in them.”
Page 10 of the North Shore-LIJ Code of Ethical Conduct
“Even a minor violation can cause serious damage.
That’s why sharing your password is something to avoid
at all costs,” Mr. Radinsky said. “If the person you trust
with your password does something inappropriate —
even by accident — it happens under your name. That
winds up being bad for both of you. Just as North
Shore-LIJ guards patient information, you should
protect your information as well. Ultimately, it is your
responsibility.”
North Shore-LIJ complies with all Health Insurance
Portability and Accountability Act (HIPAA) guidelines
for patient-information privacy. That includes adhering to
security recommendations found in the US Department
of Health and Human Services’ Standards for Privacy of
Individually Identifiable Health Information, known as
the Privacy Rule.
Employees can find full guidelines for handling patient
information in the North Shore-LIJ Code of Ethical
Conduct, and specifically in policy 800.42, entitled
“Confidentiality of Protected Health Information.” The full
Code of Ethical Conduct can be viewed at bit.ly/14rhFkd.
North Shore-LIJ associates can report patient data privacy
infringements by calling the confidential Compliance Help Line
at 1-800-894-3226 or by visiting northshore-lij.ethicspoint.com.
10/23/13 9:20 AM
tutorial
29
A RISING CONCERN ///
A 2012 PONEMON INSTITUTE
STUDY FOUND THAT:
+9
4 PERCENT OF SURVEYED
HEALTHCARE ORGANIZATIONS
94%
HAD EXPERIENCED A BREACH OF SENSITIVE DATA OVER A TWO-YEAR PERIOD;
+5
2 PERCENT OF THE ORGANIZATIONS SURVEYED HAD SUFFERED
ONE OR MORE CASES OF MEDICAL IDENTITY THEFT; AND
+T
HE ANNUAL COST OF MEDICAL IDENTITY THEFT IN THE
UNITED STATES ROSE FROM AN ESTIMATED $28.6 BILLION
IN 2010 TO AN ESTIMATED $41.3 BILLION IN 2012.
$41.3 billion
V2N2: DOCTORING
10/23/13 9:20 AM
culture
30
WHEN IT CO
MES
TO SMOKING
g
n
i
r
a
e
l
C
Air
the
CESSATION,
THE NORTH
SHORE-LIJ
HEALTH SYS
TEM
HAS ALWAYS
BEEN A LEA
OF THE PAC
DER
K.
by Valerie Lauer
DOCTORING : V2N2
10/23/13 9:20 AM
During the period when smoking was
prohibited within the building but allowed
immediately outside, I came across a
respiratory therapist working vigorously
on a machine giving oxygen to a lungdisease patient at the end stage of life.
About an hour later, I was walking out of
the building after rounds and saw the
same respiratory technician puffing away.
Wanting desperately to finish one more
cigarette, he lit a second cigarette off the
first, puffing rapidly. IT STRUCK ME — HERE
culture
31
IS A MAN WHO IS TAKING CARE OF A PATIENT
WHO IS DYING BECAUSE OF SMOKING, AND HE
HIMSELF IS AN ADDICT. This story stays with
me, 30 years later, and reminds me of how
far we’ve come.
— Kanti Rai, MD, chief of hematology/oncology at LIJ Medical Center
V2N2: DOCTORING
10/23/13 9:20 AM
32
culture
North Shore-LIJ
SMOKING-CESSATION TIMELINE
Early 1990s
The health system bans
smoking inside its facilities.
1999
North Shore-LIJ
establishes its Center
for Tobacco Control.
Nov. 16, 2006
orth Shore-LIJ was the first
health system on Long Island to
implement a smoke-free campus, and the system’s Center for
Tobacco Control not only influences public
policy but also serves as a regional resource
for all those who wish to kick the habit.
But the health system’s history is hazy
with the ghosts of cigarettes past.
Jan. 1, 2010
N
THAT WAS THEN
It was a different time, long before the Clean
Indoor Air Act or Mayor Michael Bloomberg’s
campaign against outdoor smoking and cigarette-butt litter, when tobacco companies ran
advertising campaigns telling smokers that
lighting up was actually good for them.
“Even as recently as the 1970s, there were
cigarette machines in the hospital and ashtrays in waiting rooms,” said Robert Waldbaum, MD, vice president of physician relations for North Shore-LIJ and professor
of urology at the Hofstra North Shore-LIJ
School of Medicine. “It wasn’t unheard of to
find patients smoking in examination rooms.”
During the Great American
Smokeout, North Shore-LIJ
President and CEO Michael Dowling
announces that the health system
will go smoke-free both indoors
and outdoors.
North Shore-LIJ campuses
go entirely smoke-free.
Growing evidence about the health risks
associated with smoking and warnings from
the US surgeon general caused an irreversible shift in public opinion about lighting up.
“The biggest change I saw was that smoking in meetings and conference rooms just
stopped,” said Bernard Rosof, MD, member
of the North Shore-LIJ Board of Trustees
and professor of medicine at the Hofstra
North Shore-LIJ School of Medicine. “Very
quickly, physicians began to better understand the negative impact of smoking on
their personal lives and on their families.
We had to be role models, and there has
been a remarkable change in behavior since
the 1970s, when you may have seen doctors
smoking in the hospital cafeteria or at major
annual conferences.”
DECADES OF CHANGE
With the passage of time and an increase in public awareness of the dangers
of smoking, the smoking habit has largely
been kicked on US hospital campuses.
“There was a period in the 1980s
when smoking was frowned upon inside
the hospital, so patients and employees
would stand directly outside the hospital to light up, inadvertently exposing
everyone who entered to an enormous
dose of secondhand smoke,” said Kanti
Rai, MD, chief of hematology/oncology at LIJ Medical Center. “That’s all
changed. I am personally very pleased
and proud to belong to this generation,
which participated in the fight to eliminate smoking.”
For more information about North Shore-LIJ’s quit-smoking programs and how to refer patients, call the Center for Tobacco Control
at 516-466-1980.
DOCTORING : V2N2
10/23/13 9:20 AM
culture
33
Encouragement, not judgment, powers the free
smoking-cessation support programs offered by
the North Shore-LIJ Center for Tobacco Control.
tandard
S
n
io
t
a
s
s
e
C
g
in
Setting the Smok
“People who use counseling and
medication are two to three times more likely to
quit smoking successfully,” said Patricia Folan, RN,
DNP, director of the Center for Tobacco Control.
“We want to help people lead healthier lives, and
we’re here to support them even if they relapse.”
The real winners are the employees of the health
system, who benefit not only from a smoke-free
environment but also have free access to smokingcessation resources, medications and counseling,
and even receive a paycheck bonus for each pay period they maintain a smoke-free household.
“I smoked a pack a day for 35 years,” said Marcia
Lubell, RN, staff nurse at Syosset Hospital. “At a
smoking-cessation clinic, I realized these people really knew what they were doing. It wasn’t just talk,
and it was time for me to quit. Now I try to help
support people who make the same decision.”
According to Dr. Folan, approximately 70 percent
of smoking-cessation program participants are
referred by a physician.
“Helping a patient quit smoking involves a lot of
work, focus and attention, and the Center for Tobacco Control’s smoking-cessation program gives
people who smoke the tools they need to quit successfully,” said Bruce Hirsch, MD, an infectious
disease specialist with North Shore University
Hospital. “I appreciate the positive, empowering
approach our program takes. It has influenced my
methods with patients.”
V2N2: DOCTORING
10/23/13 9:21 AM
34
first person
THE COMMENTERS
Taking
he
by Jonelle Todd
w
e
i
V
g
n
o
L
t
Thomas Mauri, MD,
vice chair of orthopedic surgery at
North Shore University Hospital
Bernard Rosof, MD,
member of the North Shore-LIJ
Board of Trustees, professor of
medicine at the Hofstra North
Shore-LIJ School of Medicine
Theodore Strange, MD,
vice president of medical operations for
Staten Island University Hospital – South
Site, associate chair of medicine at
Staten Island University Hospital
IF YOU KNEW THEN
WHAT YOU KNOW NOW,
WOULD YOU HAVE TAKEN
A DIFFERENT PATH?
DOCTORING ASKED
EXPERIENCED PHYSICIANS
TO LOOK BACK OVER
THEIR CAREERS AND
SHARE A FEW INSIGHTS.
Gisele Wolf-Klein, MD,
director for the health system’s
Geriatric Medicine Fellowship
Program, professor of medicine
at the Hofstra North Shore-LIJ
School of Medicine
DOCTORING : V2N2
10/23/13 9:21 AM
DR. WOLF-KLEIN
DR. STRANGE
DR. ROSOF
DR. MAURI
35
WHO OR WHAT INFLUENCED
YOUR DECISION TO GO
INTO MEDICINE?
WHAT HAS BEEN THE MOST
MEMORABLE MOMENT
OF YOUR CAREER?
Try to put all the negative discussion
regarding being involved in medicine in
today’s world in the background. Take joy
every day in the ability to make another
human being healthier or happier. That is
the gift of being a physician.
In about fourth or fifth grade, I wanted
to emulate my pediatrician, whom my
mother adored.
Though there have been many on all different
levels, probably the one that stands out is
taking care of the patients we had at North
Shore Hospital from the Avianca plane
crash in 1990, the challenge of dealing with
the dramatic injuries and the opportunity to
make a big difference in those people’s lives
in such a short time frame.
The medical profession remains one of the
best ways to be involved in people’s lives,
influence their health and well-being, and
instill positive feelings about themselves
and the future. The challenges have always
been real, but opportunities abound.
I still remember his name: Morris Goldberg.
When I was a teenager, he was my general
practitioner. His kindness and the way he
took care of people made an impression on
me, and I emulated him in my career.
My career has included so many memorable
moments — both positive and painful —
that it is hard to identify a single event. But
even in a tragic situation that you know is
not going to end well, you go into it knowing
that you have an opportunity to provide
compassion and emotional support to the
family when they need it most. I continue
to get notes from people I have helped over
the years, and that is gratifying.
I wake up every morning not to go to work,
but to do what I love. Medicine is a noble
profession when it is about wanting to make
a difference, not prestige or financial reward.
Early in life, the illnesses of two family
members I was close to gave me a chance
to see what a difference a caring doctor can
make in someone’s life. I was also attracted
to science, but science is easy. Applying that
science in a compassionate manner is the
hard part.
That day you graduate from medical school
is unforgettable. You walk onto the stage as
“Mister” and walk off as “Doctor.” It is the
culmination of all your hard work. But the
most rewarding thing happens to me every
day, when I am able to help someone, and
they say, “thank you.”
Be ready to welcome change. In the next
decade, you will face diseases that did not
exist when you were in medical school,
technologies you have never heard of and
practice models that have not yet been
developed.
Being blessed with two exceptional grandparents whose company I cherished, I knew
I wanted to take care of older adults. In
medical school, I realized I would never be
able to choose between specialties, so the
broad focus of geriatrics appealed to me —
older adults often present with a complexity
of multiple comorbidities affecting all
organs. I am so glad I made that decision.
There have been so many memorable
moments in my medical career — delivering
a baby in the hospital parking lot one night,
when an unknown woman asked for my
help as I was going home; being asked by
the family to speak at a patient’s funeral;
convincing a son to let me send his wheelchair-bound mother for spinal surgery and
seeing him cry when his mother walked
again.
first person
WHAT ADVICE WOULD YOU GIVE TO
YOUR YOUNGER SELF ABOUT THE
PRACTICE OF MEDICINE TODAY?
ANY PARTING WORDS OF ADVICE?
Enjoy medicine. And realize what an extraordinary privilege it is to receive
the faith and trust of an individual who places his or her well-being into your
— Gisele Wolf-Klein, MD
hands. Live up to the challenge. You are very lucky indeed.
V2N2: DOCTORING
10/23/13 9:21 AM
Nonprofit Org.
U.S. Postage
PAID
NSLIJHS
North Shore-Long Island Jewish Health System, Inc.
125 Community Dr., Great Neck, NY 11021-5502
HEY DOC,
DO YOU
HAVE AN
iPAD?
Download the Doctoring app
for tablet-exclusive video
and photos. Visit the App Store
today to subscribe.
OUR NEW APP IS NOW AVAILABLE!
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patients customize health and wellness content and share it via social media or email.
Download the it in the App Store.
10/23/13 9:21 AM

full issue of Doctoring

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