LouisviLLe Medicine - Greater Louisville Medical Society

Transcription

Louisville
GREATER LOUISVILLE MEDICAL SOCIETY
Medicine
VOL. 60 NO. 5 OCTOBER 2012
GLMS Board of Governors
David E. Bybee, MD, board chair
Russell A. Williams, MD, president
James Patrick Murphy, MD, president-elect
Bruce A. Scott, MD, vice president and AMA delegate
Heather L. Harmon, MD, treasurer
Robert A. Zaring, MD, MMM, secretary
and AMA alternate delegate
Robert H. Couch, MD, at-large
Rosemary Ouseph, MD, at-large
Tracy L. Ragland, MD, at-large
Jeffrey L. Reynolds, MD, at-large
John L. Roberts, MD, at-large
Wayne B. Tuckson, MD, at-large
Fred A. Williams Jr., MD, KMA president-elect
Randy Schrodt Jr., MD, KMA 5th district trustee
David R. Watkins, MD, KMA 5th district
alternate trustee
K. Thomas Reichard, MD, GLMS Foundation president
Stephen S. Kirzinger, MD, Medical Society Professional Services president
Toni M. Ganzel, MD, MBA, interim dean,
U of L School of Medicine
LaQuandra S. Nesbitt, MD, MPH, director,
Louisville Metro Department of Public
Health & Wellness
Jay P. Davidson, The Healing Place chairman
Adele Murphy, GLMS Alliance president
Louisville Medicine Editorial Board
Editor: Mary G. Barry, MD
Elizabeth A. Amin, MD
Deborah Ann Ballard, MD
R. Caleb Buege, MD
Arun K. Gadre, MD
Stanley A. Gall, MD
Larry P. Griffin, MD
Kenneth C. Henderson, MD
Jonathan E. Hodes, MD, MS
Tom James, MD
Teresita Bacani-Oropilla, MD
Tracy L. Ragland, MD
M. Saleem Seyal, MD
Dave Langdon, Louisville Metro Department
of Public Health & Wellness
David E. Bybee, MD, board chair
Russell A. Williams, MD, president
James Patrick Murphy, MD, president-elect
Lelan K. Woodmansee, CAE, executive director
Bert Guinn, MBA, chief communications officer
Ellen R. Hale, communications associate
Donna Watts, communications designer
Advertising
Cheri K. McGuire, director of marketing
736.6336, [email protected]
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Louisville Medicine is published monthly by the
Greater Louisville Medical Society, 101 W. Chestnut St.
Louisville, Ky. 40202 (502) 589-2001, Fax 581-9022,
www.glms.org.
Articles to be submitted for publication in LM must be
received on electronic file on the first day of the month,
two months preceding publication.
Opinions expressed herein are those of individual
contributors and do not necessarily reflect the position
of the Greater Louisville Medical Society. LM reminds
readers this is not a peer reviewed scientific journal.
LM reserves the right to make the final decision on all
content and advertisements.
Circulation: 4,000
On the cover:
In 1962, the Jefferson County Medical Society sponsored a highly successful polio vaccination campaign.
Story on page 20.
Louisville
Greater Louisville Medical Society
6
Medicine
Vol. 60 No. 5 OCTOBER 2012
f eature articles
Clinical Measurements: Why They Are Important
to Doctors
Tom James, MD
20
When Polio Was Eliminated from Kentucky:
The 50th Anniversary of the Sabin Oral Polio Vaccine
Campaign
Virginia T. Keeney, MD
25
From the Field to the Clinic
Julie Anne Smith
de p artments
5
From the President
Poised to Knock One Out of the Park
Russell A. Williams, MD
11
In Remembrance
Mark L. Jaggers, MD
Todd J. Purkiss, PhD, MD
13
Reflections
The Olympics, Facts or Fancy?
17
Book Review
The Creative Destruction of Medicine by Eric Topol, MD
M. Saleem Seyal, MD, FACC, FACP
28
Alliance News
Adele Murphy
29
30
33
We Welcome You
Physicians in Print
Doctors’ Lounge
Listing Badly
Mary G. Barry, MD
Beware the Subtle Signs of Parkinson’s Disease
Todd S. Shanks, MD
A Fragment of Medical Economic Ephemera Revisited
Charles C. Smith Jr., MD
Letter to the Editor
Jay P. Davidson
Robert F. Sexton Jr., MD
OCTOBER 2012
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From the President
Russell A. Williams, MD
GLMS President
Poised to knock one
out of the park
This year at the KMA Annual Meeting, I noticed a change in the direction the winds were blowing. One
of the themes of the meeting was
how to keep legislators out of exam
rooms, so to speak. Time and again,
physicians spoke with deep emotion
about protecting the physician-patient relationship.
Leading up to the meeting, the
GLMS delegates met through the
summer to develop resolutions. This
group revealed an intensity I hadn’t
seen before. With increased numbers
of GLMS members in attendance
and greater dialogue, our last meeting ended up being a five-hour
session where we fine-tuned our 10
resolutions to send forward. Another
four resolutions were submitted
by individual GLMS members. As it
turned out, the House of Delegates
considered a total of 23 resolutions.
As KMA past president Gordon Tobin
put it, our resolutions had the most
substance.
I think we are at a crossroads
regarding what the practice of
medicine will be in the future. Physicians should take a proactive stance
regarding the health care of our state
and nation. As I’ve said before, we are
the most knowledgeable folks when
it comes to health care.
Right now, GLMS can have a loud
voice when it comes to the direction
of our profession. Our colleague Dr.
Fred Williams is now president-elect
of the KMA and a pair of Lexington
physicians are in key positions at the
AMA (Dr. Ardis Hoven is presidentelect and Dr. Steve Stack is chair of
the Board of Trustees). As we have
demonstrated, GLMS has an increasingly influential role in the KMA.
We can easily be heard, not only
on a state but national level. If you
want to be heard, now is the time
to participate in some way. If you’re
not a member, join the AMA. When
you see emails to call your legislators, take a few minutes of your time
and do that. I’m sure I don’t have to
mention again that we each need to
give to the Kentucky Physicians PAC
(www.kppac.org).
Don’t let the hospitals, insurance
companies and corporations dictate
how you take care of your patients or
how you practice. As our resolution
on corporate influence stated, physicians “should be free to refer patients
to physicians and facilities they
believe will best serve their patients
without enticement or penalty from
any employing or contracting hospital system or other corporation.”
Let’s try to get legislators to work
with us in a collaborative way to
determine how best to prescribe
opioids. A pair of GLMS resolutions
deal with this issue:
• Calling for amendment of House
Bill 1 in the 2013 session of the Kentucky General Assembly and working with the Kentucky Board of Medical Licensure to revise the regulations so
that physicians can apply sound clinical judgment without fear of criminal
prosecution or licensure sanctions
• Informing the public and legisla-
tors that codifying the practice of
medicine with statutes and regulations limits the ability of physicians to
exercise their clinical judgment in the
best interest of each patient
• Advocating for improvements to
KASPER
• Seeking adequate reimbursement
for psychiatric therapies for
addiction.
And physicians need to develop a
model of how to best utilize nurse
practitioners and physician assistants
in the team-based practice of medicine. We want to proactively work
with the professional associations
for nurse practitioners, physician
assistants and other non-physician
providers of medical care to define a
team-based care model that promotes access to high-quality, costeffective care for patients.
I’m proud of our GLMS team. Let’s
not allow other interests to steal the
bases on us. As we move forward in
the months ahead to carry out these
plans and effect change in Kentucky, I hope I can count on all GLMS
members to join us in advocating for
the physician-patient relationship. If
we unite as physicians, I believe we’ll
have the opportunity to knock one
out of the park.
To get more involved at GLMS,
email me at [email protected] or
call the GLMS executive director’s
office at 502-736-6302. LM
Note: Dr. Williams practices General
Surgery with Associates in General
Surgery.
OCTOBER 2012
5
Clinical Measurements:
Why They Are Important to Doctors
Tom James, MD
Like fireworks on July Fourth, the
sets of clinical measures displayed
in public and private venues about
doctors’ clinical practices have
rocketed out of nowhere, creating
colorful descriptions of physician
practice patterns in the lay press.
Many measures, once released, have a short life and are not
again used. Some of these measure sets scintillate and last
longer, like measures of diabetes and heart disease. What many
doctors hope is that, like a fireworks display, the measures of
medical quality are only briefly luminescent before fading. But
here the analogy ends. Measures of clinical quality and accountability are here and will not go away. The measures used by the
Centers for Medicare and Medicaid Services, health plans, and
government and consumer groups have grown out of the medical education tradition of testing as a road map to improvement.
Perhaps it is appropriate to first define clinical measures. These
are designed to take defined elements of care measured for the
individual physician, group practice or integrated system and
compare results achieved against standards. Avedis Donabedian
described the measures of quality as structure, process and outcomes.1 Physicians have inherently understood this taxonomy of
quality. We are past the days of identifying a high-quality physician based on the achievement of board certification. Certification is a structural measure. Obtaining board certification and
recertifying are now considered minimal standards. Studies on
patient outcomes, whether treated by certified or non-certified
physicians, show little difference.2 Structural measures of quality may also include the organization of the clinical practice
such as 24/7 availability or “after-hours” appointments, so that
patients in the practice have access to the doctor at times more
convenient to them. Recently in a private conversation, Dr. Beth
McGlynn, formerly of RAND Corporation, told me that structure
measures should not be discounted, as often the practice environment for a physician can make a huge difference in how well
that doctor can manage her or his patients.
Process measures reflect the steps on the care pathway.
Prescribing controller medications for patients with moderate to severe asthma or following the HbA1c in diabetics are
two examples of process measures. The adherence to these
measures is associated with better clinical results. Outcome
measures are bottom-line measures. Were the goals of treatment achieved? Some outcome measures are more easily
determined in the short run, such as “patient experience of care.”
But outcome measures may be more difficult because often
the best outcomes require significant time to demonstrate a
statistical difference. The outcome measure of reduced rates of
amputation in diabetic patients is such a long-term marker that
it is not practical except at a population level. For that reason,
researchers often use surrogate markers for outcomes such as
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the achievement of an LDL level less than 100 mg/dL in a patient
with coronary artery disease, or an HbA1c less than 7 percent in
patients with diabetes. While these are not final outcomes, they
are so well-correlated with outcomes that such measures are
considered outcome markers.
Outcome measures are considered to be superior over structural and process measures, but only if they can be collected in
an appropriate fashion. Unlike process measures, which should
be performed routinely, outcome measures are very much
dependent on many other medical and social variables. As such,
the calculation of outcomes must involve risk-adjustment and
proper attribution to the treating physician(s).
Measures of structure, process and outcomes all have a proper
role in measuring the overall quality of care. Introduced into CMS
from his past role at the Institute for Healthcare Improvement,
former CMS Administrator Dr. Don Berwick has further described
quality through the lens of the “triple aim.” He says that quality should be measured in terms of: improvement of individual
health and the experience of care, improvement of population
health and reduction in the aggregate cost of care, but by innovations not restrictions. Federal efforts have now shifted toward
finding accountability markers for physicians, hospitals, nursing
facilities and health plans that can measure structure/process/
outcomes in terms of the population, the aggregation of individuals and the resources consumed to achieve those outcomes.
So, How Does This Affect the Doctor in Practice?
The call to measure how physicians practice is coming from
multiple quarters. While the American Medical Association’s
Physician Consortium on Practice Improvement began developing measures more than a decade ago, they were intended as
educational tools to assist physicians who were interested in
practice improvements. Subsequently, the use of measures has
evolved for use in rating doctors on the quality of care they provide. Measurement has been included in federal law, in regulation and in pay-for-performance programs by health plans. This
last use was developed as insurers were, themselves, rated on
how well doctors in their network appeared to be adhering to
national standards. The concept of rating doctors has continued
to grow. Consumer groups such as “Angie’s List” or specialized
websites such as Healthgrades.com and Vitals.com provide
information on physician training, office hours, malpractice suits
and patient survey results. While many doctors believe that it is
primarily disgruntled patients who use such sites to ventilate,
these companies all report that just as in Lake Wobegon, physicians as a whole rate higher than expected. Other rating systems,
such as Castle Connolly, use peers to rate each other. Such rating
systems have been criticized for being “old boys clubs,” since the
ratings are physicians’ subjective views of other doctors. Doctors
have lived with these rating systems without a significant impact
on their practice primarily because their relationships with
their patients have trumped these rating systems. But with the
Continued on page 8
ThE ArT And SCIEnCE oF MAnAgIng
ChronIC ILLnESS
Make plans to attend the annual Internal Medicine Update, a discussion of various
topics on the art and science of managing patients with chronic illnesses.
Continuing education credits for physicians and nurses – 7.25 on Friday,
3.75 on Saturday
For more information or to register, visit NortonHealthcare.com/CME, click on
“CME Live Activities.”
16th annual Internal Medicine Update
Nov. 30 and Dec. 1, 2012
8 a.m. to 5 p.m.
Louisville Marriott Downtown
280 W. Jefferson St.
Continued from page 6
rating systems coming from private and governmental payers,
the game is changing. Insurers are using ratings of adherence to
quality metrics and of cost-efficiency to reward physicians who
score higher on both counts. But the insurers are also using these
rating scores to tier physicians for higher or lower co-payments.
Physicians not scoring well may find that their patients have to
pay more out of pocket in terms of co-payments. According to
the theories of behavioral economics, this means that patients
now have to put a monetary price tag on the value of their relationship with their doctor. Many patients will pay more for continuing a relationship with a high-tiered doctor, but others will
seek out doctors who will cost them less out of pocket. This has
been carried to the next level by several health plans that have
created smaller networks based on quality and efficiency scoring.
A patient seeing a non-participating physician in a smaller network product may have to pay anywhere from 20 percent to 100
percent of the doctor’s charges. This can cost the patient much
more than in a typical PPO plan where the patient may pay up to
20 percent of the negotiated fee. These scores will have some real
impact on the physician’s ability to maintain the same panel of
patients.
Under health care reform, individuals will be able to purchase
insurance through state or federally operated exchanges. Those
below state-specific thresholds will have subsidies to help them
purchase insurance through the exchanges. Further, most
Washington pundits expect that small employers will no longer
provide a defined health insurance benefit, but begin to provide
a defined contribution to their employees so that they may purchase insurance on the exchanges. Why is this important to physicians, aside from their roles as small employers themselves? The
insurers offering health benefit plans in any exchange will have to
provide cost and quality data on their own performance, which
is in reality the collective experience of doctors in their network.
While originally envisioned to provide insurance access for the 30
million Americans currently not covered, the addition of individuals covered by small employers may balloon that number coming
through the exchanges to nearly 20 percent of all Americans. So
doctors whose scores disadvantage the insurers may well be removed from the plans offered on the exchanges. This, of course,
is the intention. The concepts from Washington are to use behavioral economic pressures on physicians, hospitals, nursing home
and other health care providers to change practice patterns.
So, What Is a Physician To Do?
Understanding the rationale and the rules is half the battle.
If doctors are to be valued based on their adherence to quality
standards and to cost-efficiency, then the physician has choices
to make. A doctor could elect to find a niche where he or she is
insulated from Medicare, Medicaid and most private insurers.
Already, we have a number of physicians who practice concierge
medicine or who have a large percentage of their practice coming from cash-paying patients. Doctors who perform Lasik or
cosmetic surgery already have taken that step.
But for other physicians, the choices will involve real practice
changes that include the following.
Adoption of electronic medical records that meet meaningful
use requirements: The ability to communicate information about
patient care has become more difficult. The doctors’ lounge was
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the place for physicians to talk about individual patients. But with
so many doctors becoming office-based, the doctors’ lounge is
no longer a venue for communication. Furthermore, there is a
greater expectation for primary care physicians and specialists to
share information among each other and directly with patients.
That requires a digital connection. Electronic records must be
able to communicate information among physicians. The Office
of the National Coordinator for Health Information Technology
is looking for measures that will demonstrate that physicians do
exchange information with each other, and that care plans are
shared electronically with others. Such measures do not exist currently, but the ONC is looking to develop them and to use them
for federal incentives and penalties.
Use of electronic prescribing that includes information on the
cost of drugs as well as drug interactions: Electronic prescribing has
been touted as a way to reduce medication errors that result from
pharmacists misinterpreting handwritten prescriptions. But many
of the current e-prescribing systems do not have access to cost
information or to health plan formularies. The Epic system at Norton
Healthcare, for example, does not provide information on either
cost or preferred tier drugs. Physicians then may find themselves
toggling between Epocrates as an independent software program
and the e-prescribing software. Having such information available
helps to keep out-of-pocket expenses lower for the patient, and
can become important as health plans look at the cost-efficiency of
physicians. This is especially important for primary care physicians
and doctors who have minimal numbers of procedures and where
the bulk of nonphysician costs come from pharmacy.
Develop a patient coordinator for the office patients: Care
coordination is key for avoiding unnecessary or redundant care.
In past years, the role of the care coordinator was that of the
primary care physician. But in a high-volume practice, that is not
practical. Rather, physicians, especially primary care physicians,
psychiatrists, cardiologists, oncologists and other physicians who
follow patients longitudinally, are expected to coordinate the
care of their patients with chronic conditions. The health care
system is complicated. Even well-educated patients find difficulty
in managing multiple physicians, testing at various sites and
hospitalizations. Already hospitals and long-term care facilities
are being penalized for readmissions within 30 days. Can it be
long before doctors too will have their readmission rates published? That is currently being explored. Further, the Clinician and
Group Consumer Assessment of Healthcare Providers Survey that
is currently in use has survey questions for patients asking if their
doctors explained the care recommended and coordinated their
care. Physician groups will need to invest in care coordinators for
their high-risk patients to improve patient care, enhance patient
experience, achieve preferred status with health plans and be
prepared for Medicare’s measurement in the future.
Find out the costs of hospital care and outpatient services:
Doctors are often surprised at the cost of hospital care when
it is pointed out. But too often the physician finds it is the cost
of care at hospitals, ambulatory surgical centers, laboratories
and imaging centers that puts them as “financial outliers.” This
was addressed in a recent JAMA article discussing the ethical
need for physicians to be aware of the cost impact on others, of
their selection of resources. The first level of pain may be that of
patients whose insurance may have a high deductible, if they
Continued on page 14
OCTOBER 2012
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In Remembrance
mark l. jaggers, MD
(1965-2012)
On July 13, 2012, the day before my
41st birthday, we lost a friend and colleague, Dr. Mark Jaggers. While that date
will stick in my mind for obvious reasons,
my memories of Mark will always remain
vivid, because he was one of the most
inspiring individuals I have ever known.
I remember when I first heard his story.
I was a wet-behind-the-ears first-year medical student at the University of Louisville,
and Mark was a year ahead of me. One
day, it was announced that he would be
giving a talk, which I later learned he had
given many times before and would many
times again. What was so interesting about
this particular student? He had cancer. Not
“had” in the past tense. Mark was actually
living with cancer. Who goes to medical
school when he has cancer? Well, you had
to know Mark.
Born on June 30, 1965, right here in
Jeffersontown, Mark attended Purdue
University on an Air Force scholarship
to study aeronautical and astronautical
engineering. Once in the Air Force, he
was among a privileged few selected to
pilot one of the largest cargo planes in
the world, the C-5 Galaxy. He flew the C-5
during the Gulf War, as well as to support
humanitarian efforts in Somalia.
His Air Force career was cut short,
however, when he was diagnosed with
cancer. An unusual abdominal tumor, it
was eventually brought under control by
physicians at the MD Anderson Cancer
Center, although it could not be completely removed without killing him. What
would you or I do in that position? Mark
was a serviceman, not just in title, but in
spirit. He wanted to continue to make a
difference in the lives of others. Inspired
by the very physicians who had saved his
life, Mark chose to pursue a second career
in medicine and ultimately ophthalmology.
Mark was one of my senior residents at
the University of Louisville. We all knew
he had cancer. A slim man, you could not
miss the unusually protuberant belly that
held the tumor. He also made occasional
runs to the VA Medical Center for bloodwork or various chemotherapy infusions.
Of course, Mark never acted like it affected
his life. He never let his disease define
him. He excelled as a resident and as a
practicing ophthalmologist. He was also a
dedicated family man. His time outside of
work was spent with his wife of 21 years,
Becky, and his amazing children, Meredith
and Colin – often in attendance at their
various sporting events.
Sure, there were setbacks in his treatment, but Mark just always seemed to
bounce right back. You had the feeling
that the cancer would never actually beat
him. In February of this year, his disease
became more aggressive. He was still
fighting; however, that fight appeared to
weigh on him like never before. I texted
with him a few weeks before he finally
succumbed. He said his prognosis did not
look good and that he was praying for a
miracle. I asked if he was open to having visitors, and he replied that he would
contact me when he was feeling up to it.
I knew then I would never see my friend
again. He may not have gotten his miracle,
but for those of us fortunate enough
to know Mark, he was our miracle. He
showed us how life should be lived. Thank
you, my friend, and goodbye. LM
–Todd J. Purkiss, PhD, MD
OCTOBER 2012
11
R e f lections
The olympics,
fact or fancy?
The years 776 B.C. to A.D. 393: The
inhabitants of the city-states of ancient
Greece, suspending their differences
and even their internecine wars, meet
every four years to compete on the
Olympian plains to gain bragging
rights to the prowess and strength of
their athletes. Fact or fancy?
The year A.D. 2012: Her majesty, the queen of England, greets James Bond, then parachutes down from a
helicopter to a mega-stadium, to greet a waiting crowd
representing 204 countries, in the heart of London, and
opens a worldwide competition of athletes of the modern
Olympics. Fact or fancy?
The recently concluded XXX Olympiad shows that
modern man, despite natural disasters, threats of nuclear
proliferation, terrorism, wars and political turmoil, can
come together in peace and orchestrate an extravaganza
of inclusion that people, two millennia hence, will wonder
whether it was fact or fancy. Who will ever guess then that
it was a little bit of both?
We, humans of the here and now, as a whole, have to be
proud that we were able to rise above conflicts of interests
and stage such an epic undertaking. It took tremendous
planning, cooperation and pooling of talents and resources to push through this spectacle – and the world did it
again. The glow of youth, the display of comely sculpted
bodies and the feats of strength, speed and dexterity were
astounding. The artistry, precision and dancelike qualities of the presentations did not happen by chance. They
represented years of sacrifice, unselfishness and the determination of each athlete and their supporters to pursue
excellence. These Olympians came to the competitions
already tried and tested winners in their own right.
Was it not thrilling to see “our” American athletes
succeed and overcome difficulties? Didn’t we feel
pride and exult in their triumphs? When the gymnasts
catapulted without falling, when the young fencers
fenced with dexterity, didn’t we cheer? When the divers broke the water without a splash, and the swimmers
Dr. Oropilla’s granddaughter Lee Kiefer competed in
fencing at the Olympics.
touched the wall first, and the relay runners passed the
batons without dropping them, didn’t our hearts skip a
beat and did we not rise from our chairs? Likewise, when
one broke a leg, or lost a match, or fell from a beam, were
we not dismayed and did we not wish the athlete would
mend and not take it too hard? We had claimed them as
our own from start to finish.
If we felt that way with “ours,” so did the other countries,
big and small, which, like us, also wore their hearts on
their sleeves. Some little island nations had their place in
the sun once the playing field was leveled. Witness the trio
from Jamaica who ran like the blowing wind! Amazing!
Beautiful people all, whether ours or theirs, it really did not
matter. The sentiments were the same – they wanted to
prove to themselves, to the people they represented and
to the world that they gave their best. To everyone, one
thing was clear. Each athlete’s experience, like a pebble
dropped in a quiet pond, sent ripples in ever-widening
circles to all who knew them or had heard of them, parents, family, beloved coaches, colleagues, countrymen,
fans, friends and friends of friends; in fact, the whole wide
world. It was a tangible good that had to be shared.
Can these feelings of unity, kinship and goodwill, the
recognition of the value of hard work and determination
and the showcasing of the heights to which the spirit and
body can rise be the reason why we mortals decided to
revive and continue the Olympic tradition? Will it survive
another millennium or two? Will it continue to be fact, or
will it fade into fancy? LM
Note: Dr. Oropilla is a retired psychiatrist.
OCTOBER 2012
13
The Evolution of Quality
Metrics
in Health Care
Tom James, MD
Health care has moved on from private interactions between
a doctor and patient. Two concepts have disrupted that doctorpatient relationship. The first is that of third-party payment.
Since by design patients pay roughly 20 percent of health care
costs, they are insulated from the true cost of care. As such,
they often do not value it as highly, may generate greater
demand than necessary or may ignore medical advice. Thirdparty payment systems have been shown repeatedly to allow
cost escalation. The second construct is that access to medical
care services is a right. Everyone legally in the United States is
entitled to access to preventive and curative services. This is a
compassionate and humane extension of values in this country,
but it comes with a price. Because of the impact of these two
forces, all elements of the medical care delivery system are now
being audited to ensure that maximum value can be achieved.
While doctors feel this pressure at a personal level, these same
audit demands are being made at institutional levels for insurers, hospitals, home health agencies, pharmaceutical and DME
companies, and nursing facilities.
The distinction in this wave of scrutiny is that measurement
is very personal for the doctor but is the cost of business for
the institutions. For everyone, it is additional work and additional time that is not compensated for in the traditional sense.
Doctors used to complain about the additional work involved
in submitting data for the CMS Physician Quality Reporting
System that provided an additional 1 percent on Medicare
reimbursement, if the data were submitted properly and if CMS
counted it accurately. That was a positive, if minimal, impact on
the bottom line. But now CMS is moving from positive incentives to fee reductions with its requirements for PQRS reporting
as well as for adherence to meaningful use of interoperable
electronic medical records as well as electronic prescribing.
have insurance at all. The next level of impact is on themselves
if they find that their cost profiles put them at a disadvantage
compared to like specialists in the community. And finally, there
is the societal impact, which Dr. Berwick has described as small
incremental costs that, when aggregated, force society to make
painful choices.
Have conversations with other physicians caring for your
patients: When possible, good old-fashioned discussion between
doctors enhances care by getting everyone on the same footing.
Treat your patients individually and as a population: Physicians went into medicine with altruism. We all want to do the
right thing by each patient, and each one is unique with his or
her own value system. Those need to be respected. But at the
same time while individualizing care, the doctor may fail to
perform what would otherwise be an automatic response, such
as checking lipids and HbA1c on all patients with diabetes. By
using practice management software or EHRs, the doctor can
get a sense of how he/she is doing in always performing quality
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Others are also engaged in this process of private reporting. The individual member boards of the American Board of
Medical Specialties have all adopted Part IV of their respective
recertification, which requires physicians to identify areas of
improvement, make practice process adjustments, remeasure
the results and submit that to their board. This is a process
very similar to PQRS. Societies such as the Society of Thoracic
Surgeons, the American College of Surgeons, the American College of Gastroenterology and the American Gastroenterological
Association now have all developed registries where physicians
in those fields can submit clinical data that populate specific
quality metrics. While such registries have been used for physicians to review their own results compared to peers, such data
is, with physician approval, now being shared with insurance
companies and others. STS data has even been published in
Consumer Reports.
In areas of the country with strong business or consumer
advocacy groups, there has been publication of quality metrics
data and even cost information to the public. Most of the
reporting is at group practice levels such as with the statewide
efforts of the Minnesota Community Measurement or the Wisconsin Health Information Organization. Some have reported
at the individual physician level. In the Louisville area, the
Kentuckiana Health Collaborative has merged data from Anthem, Humana and Passport for private reporting to individual
physicians. KHC is now able to report at the group level. But the
pressures nationally are to move from such private feedback
reporting to public reporting. Dr. Kevin Weiss, former CEO of
the ABMS, has stated that studies of private reporting generally show minimal improvement. For that reason, employers,
insurers and the government are moving to public reporting.
Already, many insurers show cost and quality measurement
results to their members. The federal Physician Compare tool
on the CMS website is moving to show quality measures for
physicians by 2014.
At this time, research has shown that patients still rely on
word of mouth and insurance benefits to make their decisions
on where to seek medical care services. Most public websites
metrics, or in how the doctor is doing in meeting quality standards. Good electronic medical record systems allow the doctor
to see how frequently these standards are met. This also helps
the physician with Physician Quality Reporting System reporting
and meeting the Part IV standards of most specialty boards.
Be aware of measures from the National Quality Forum: CMS
and health plans both draw their measures largely from the ones
endorsed by the National Quality Forum. As a public-private
entity, the NQF puts all of its measures on the website. These are
available to anyone free of charge. But if that is what CMS and
health plans use to measure doctors, it makes sense to be ahead
of the game by going there first, seeing the measures and making
sure that the practice can measure them.
OK, So Why Should Physicians Take These Steps?
Now that CMS has announced the amplification of its “Physician Compare” website, there is genuine concern in the medical
community for the ratings of performance that CMS will display.
This will include information on cost and quality from its own
are not user-friendly, and people often lack computer access
at the time of medical need. But there are directional changes
occurring. These tools are now being readied for smartphone
applications, so they will be more immediately accessible to
people having a health care need. The science of consumerism
has joined in. Studies by Judith Hibbard at the University of
Oregon have determined that the public wants websites to be
more proscriptive in pointing out “high-value” doctors and hospitals.3 People would rather have the website advise them than
have to assemble information on cost of care, quality metrics,
patient experience and geographic accessibility.
Is There Any Hope?
As recently as 2005, measures were being created independently by various insurers, consumer groups and government agencies. This left the physician not knowing what measures to follow.
Over the past several years, there has been agreement among
reporting entities to primarily use measures that have been
endorsed by the National Quality Forum. This body is a publicprivate consortium that is well-represented by physician specialty
societies, especially by the American College of Physicians and the
American College of Surgeons. Further, a greater consistency of
measures is being achieved by the agreement between the ABMS
boards, CMS and many insurers to allow registry-based measures
to serve multiple purposes. That can limit the amount of time the
physician needs to spend in data collection.
This year a new concept was introduced, the “family of
measures.”4 Often, measures have been applied to physicians,
hospitals and health plans universally regardless of which
entity could really impact the results. It is often frustrating to
physicians to find that they are being measured on quality
markers that they could not control such as events within the
hospital or health insurance benefits. This new concept has
been described by the CMS chief of the Office of Clinical Quality
and Standards, Dr. Patrick Conway. Dr. Conway was a physician
with the University of Cincinnati prior to going to Washington.
His view is that for any medical condition with which doctors or
hospitals or facilities are involved, each has a separate role and
claims data. The intention of CMS is to move toward “value-based
purchasing” by 2014. That would create more incentives to use
“high-performing” physicians and disincentives for the beneficiary in using low-performing doctors. Again, as this largest of all
payers begins to display its enhanced Physician Compare website
and enter into value-based payment arrangements, there may be
significant disruption in some practices.
Conclusion
The use of measures of quality, efficiency and patient experience of care are here and will be increasingly used to create
networks or for differential payment. Physicians need to be
cognizant of these trends and to be proactive in getting ahead of
the curve. The actions that physicians should take include greater
use of office electronics, awareness of differences in cost of care,
ability to measure patient satisfaction and evaluation of clinical
outcomes across the entire panel of patients. Some of the activities are not expensive, but others will require capital outlays that
may be recouped over several years of practice.
so should have measures of accountability that are unique to
the entity’s contribution to care. In other words, let’s build measures so that we have all oars in the water rowing in the same
direction. Wow, there is a constructive direction. As a result, the
Measurement Application Partnership that under the Affordable Care Act is designed to advise the secretary of health and
human services can now simplify the process. There will be
a limited set of measures, and each set will be more defined
with accountability measures that apply uniquely to doctors,
hospitals, health plans and nursing facilities. These families of
measures (as depicted above) are being constructed in 2012, to
be delivered to the secretary in January 2013 for use in Medicare, Medicaid, value-based purchasing and some 20 other HHS
programs in 2014.
All of these efforts may simplify the reporting of measures
of clinical quality, resource use and patient experience of care.
They will limit the measures for physicians to what doctors can
impact. Incentives and disincentives from CMS are likely to be
mirrored in the private sector. The fireworks display of measures
appears to be headed toward a more organized light show.
References
1. Donabedian A. Evaluating the quality of medical care. Milbank Q.
2005;83(4):691-729.
2. Chen J, Rathore SS, Wang Y, et al. Physician board certification and
the care and outcomes of elderly patients with acute myocardial
infarction. J Gen Intern Med. 2006 Mar;21(3):238-44.
3. Hibbard JH, Greene J, Sofaer S, et al. An experiment shows that
a well-designed report on costs and quality can help consumers
choose high-value health care. Health Aff. 2012 Mar;31(3):560-8.
4. Families of Measures from National Quality Forum: www.qualityforum.org/map (accessed June 30, 2012). LM
Note: Dr. James is co-chair of the GLMS Quality Improvement and
Patient Safety Committee. He is medical director of Humana’s National Network Operations and practices Internal Medicine and Pediatrics with Norton Community Medical Associates-Audubon West.
In addition, he is chair of the National Quality Forum’s Health Plan
Council; co-chair of the AQA’s Public Reporting Work Group; and a
member of the AMA’s Physician Consortium on Practice Improvement Work Group on coronary artery disease and hypertension.
OCTOBER 2012
15
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LOUISVILLE MEDICINE
boo k review
The Creative
Destruction
of Medicine:
How the Digital
Revolution Will Create
Better Health Care
By Eric Topol, MD
Publisher: Basic Books, 2012
Reviewed by M. Saleem Seyal,
MD, FACC, FACP
“One’s mind, once stretched by a
new idea, never regains its
original dimensions.”
–Oliver Wendell Holmes
“We are currently entering an
epoch that will be as transformative to
medicine as were the eras of Flexner and the
feuding Shippen and Morgan, one or two
centuries ago ... With the advent of EHRs,
tele-health, smart medical machines, genomics,
personalized medicine, stem-cell therapies and
nanotechnology, the practice of medicine is
changing irreversibly.”
–William Hanson, MD, in Smart Medicine, page 84, Palgrave Macmillan, 2011
Dr. Eric Topol is very well-known in cardiology circles.
A past chairman of the Cardiology Department at the
Cleveland Clinic, he is currently at the Scripps Clinic in La
Jolla, California, as a practicing cardiologist, professor of
genomics, director of the Scripps Translational Science
Institute and co-founder and vice chairman of the West
Wireless Health Institute. He also wears many other hats,
including prolific author of more than 1,200 manuscripts
and editor of more than 30 medical textbooks such as
the popular Textbook of Cardiovascular Medicine and the
very first Textbook of Interventional Cardiology. He is a
frequent speaker at cardiology meetings, and I have had
the occasion to meet him and have found him to be very
approachable, unpretentious and an affable individual. He
is one of the top 10 most-cited researchers in medicine,
has led many cardiology trials that have had profound
impact on evidence-based practice and is a member of
the prestigious Institute of Medicine.
Dr. Topol is uniquely qualified to write this timely and
transformative book about the “creative destruction” of
medicine, which in fact has already begun. Because of
the ostensibly negative connotation of the title, he immediately defines the term “creative destruction” in the
introductory chapter. The term was popularized by Joseph
Schumpeter, the noted Austrian economist, and denotes
“transformation that accompanies radical innovation.” The
Internet and the digital revolution with iPhones and other
smartphones, social media and the genomic information
explosion, including pharmacogenomics with its rapidly
approaching personalized medicine initiatives, will radically transform the medical landscape for both doctors and
patients. Medicine, which hitherto has been a resistant
nut to crack, with extremely tardy responses to the digital
and genomic revolution thus far, is poised to undergo a
major overhaul and is the last frontier to be “creatively
destroyed.” This fantastically lucid book is chock-full of
important information, along with Dr. Topol’s upbeat and
optimistic perspective about the future of medicine. It’s a
breath of fresh air in these days of unremittingly gloomy
scenarios. The sheer number and caliber of people vouching for and praising the book, who are listed in its first two
pages, are noteworthy and include such names as Drs.
Elias Zerhouni, Dean Ornish, Mehmet Oz and Atul Gawande along with many CEOs and other officers of major
companies.
An unprecedented, consumer-mediated futuristic
super-convergence is in the offing, which Dr. Topol maintains will catapult the “old dumbed-down” medicine of
OCTOBER 2012
17
today into the new individualized medicine of tomorrow,
enabled by the phenomenal maturation of digital capabilities including wireless biosensors, genome sequencing,
powerful health information systems and virtually unlimited computing might from “cloud” servers. There are
wrist-watch-like and Band-Aid-type biosensors available
that capture data about our physiologic and pathologic
processes, track a multitude of metrics and process complicated algorithms. We are very close to nanosensors being
embedded in our circulation that will forecast the emergence of cancer, impending heart attack or autoimmune
catastrophe. If this is not the stuff of sci-fi, I don’t know
what is. But then, apart from some computer wizards, no
one ever envisioned what a smartphone could possibly do
only a few years ago!
We have a broken and yet stupendously expensive
health care system in the United States. Dr. Topol talks
about the gridlock of the medical community, government
and the life science industry, attributed to their unwillingness and resistance to embrace innovation. A real revolution is deemed necessary, but it mostly or solely will be the
consumers demanding the creative destruction or “Schumpetering” of medicine. People trust their virtual peers on
the social networks more than their physicians, and they
have easy and immediate access to the tsunami of information on the Internet. They can now download their lab
reports, have access to their medical records and get their
genome scanned or even wholly sequenced on their own.
Anyone can get their genomic information, including the
effectiveness of certain drugs taken, by simply ordering a
pharmacogenomic panel from such outfits as 23andMe,
Navigenics or Pathway Genomics, just to name a few.
The big convergence of six major digital advances over
the past 40 years (cell phone, personal computer, Internet,
digital devices, genome sequencing and social networking) comprise an epoch-making confluence of technology
in human history. It is estimated that there will be 6 billion
mobile phones available by next year with almost universal
connectivity. Dr. Topol brings up the issue of the recently
described digitally induced attention deficit disorder
(DADD). Our neurotransmitters become ever-vigilant and
perpetually revved-up due to an avalanche or blitzkrieg
of data and information. The downside of instant Internet
connectivity for patients who are thus empowered to look
up any medical condition or available drug is that they
then self-diagnose and attempt to make medical decisions.
This tsunami of information can create both personal and
mass confusion. Therapeutic drug choices become quite
problematic since the average drug has a list of more than
70 potential side effects. Thus there are important limitations on the quality and reliability of Internet information,
and we already see patients who, after reading about
diseases and symptoms, imagine that they are sick, have
something very rare or are having “drug reactions,” hence
becoming e-hypochondriacs or cyberchondriacs.
Savvy patients are currently keeping exhaustive logs of
their weights, blood pressures, heart rates, blood sugars, lipid profiles, other laboratory values and numerous
18
LOUISVILLE MEDICINE
biometric data. This state of affairs apparently is going to
go through an unimaginable transformation – a creative
destruction, as Dr. Topol maintains. In the rapidly changing world and in the not-too-distant future, with wireless
sensor systems becoming highly prevalent, there will be
biosensors and apps for everything that can be measured,
tracked or reported continuously, even during sleep. This
will, in part, include continuous blood glucose measurements (without a finger stick), better or more detailed
and prolonged heart rhythm monitoring, 24-hour blood
pressure measurement and telemonitoring of blood pressure, and Band-Aid adhesive sensors detecting air quality,
besides many others. An “iPill’ is even now being promoted by Phillips Electronics as a way to wirelessly release a
drug at a specific location in the gastrointestinal tract. The
eventual hope is that these sorts of tech aids will increase
patient compliance. But who will review all this data? Will it
be truly useful, or just more digital noise?
Dr. Topol devotes considerable space to the subject of
genomics, with a superb introduction to human genome
sequencing, which celebrated its 10th anniversary in 2010.
Pharmacogenomics related to the use of several drugs is
described in detail, including genotyping in a few conditions such as hepatitis C (for use of PEG-interferon alpha),
coronary stenting (for use of Plavix) and conditions requiring the use of warfarin, to determine suitability and effectiveness. We are not at a stage of routine genotype-guided
use of drugs or their dosages, but an era of personalized
medicine according to our genomic information is not too
far in the future. Gene expression profiling is being used
for select conditions including the prognosis of breast cancer, for monitoring rejection after organ transplantation
and for detecting the presence of coronary artery disease.
Targeted cancer therapy is emerging as a viable and important innovation, including the BRAF-mutation-directed
drug for malignant melanoma, Gleevec for chronic myelogenous leukemia targeting a fusion gene and Herceptin
for breast cancer that targets the HER2 estrogen receptor.
Genomics is truly an ongoing revolution, and there certainly are explosive discoveries waiting to be announced in
the near future.
The rest of the book deals with electronic health records
and their pros and cons, more innovations in imaging
technologies and miniaturization and portability (in the
pocket) of handheld imaging gizmos. Dr. Topol recommends a “rebooting of the life science industry,” a fundamental change in our system and the creative destruction
of old rules, and maintains that “the stage has been set
for catalyzing wireless innovative solutions to transform
the future of medicine.” The book is highly recommended
for medical students, residents, practicing physicians in
private practice, academic physicians, administrators and
other health care professionals, who will all witness the
creative destruction of medicine as we have known it. LM
Note: Dr. Seyal practices Cardiovascular Diseases with River
Cities Cardiology.
OCTOBER 2012
19GLMS
Foundation Nica
When Polio Was
Eliminated
from Kentucky:
The 50th Anniversary
of the Sabin Oral Polio
Vaccine Campaign
Virginia T. Keeney, MD
Fig. 1 At left, polio patients in
iron lungs.
Fig. 2 Below, the physicians
who led the vaccination
campaign. From the Bulletin
of the Jefferson County Medical Society, October 1962.
20
LOUISVILLE MEDICINE
Where were you on October 7, 1962?
That’s 50 years ago, and chances are many of you hadn’t
even been born yet. But if you were an infant, a child, a
teenager, an adult or a senior citizen, I hope you were in
one of the Sabin Oral Polio Vaccine Program’s clinics in
Louisville and Jefferson County enjoying your sugar cube
containing its precisely measured dose of vaccine.
Yes, 2012 is the 50-year anniversary of the most successful immunization program ever accomplished, not just
in Kentucky, but in campaigns in all the United States and
other parts of the world as well.
Polio (or poliomyelitis) was an acute contagious disease
characterized by fever, sore throat, headache and vomiting, frequently with stiffness of the neck. It targeted children, though it occurred in adults as well. In its most virulent form, the central nervous system was involved, with
stiff neck, muscle pain and sometimes ascending paralysis,
with paralysis even of muscles that control breathing.
I still have a vivid memory of six soldiers in iron lungs
at our station hospital in Korea in 1947. We had frequent
power failures and, at the first flicker of the lights, everyone rushed to hand operate the machines until power
returned. Unable to call for help, the patients clicked with
their mouth and teeth as loudly as they could.
The largest polio epidemic in the United States occurred
in 1952, when 58,000 were stricken, 3,000 died and
21,000 were left paralyzed or living in iron lungs (Fig. 1).
It is difficult now to imagine the public frenzy that occurred every summer. Parents, terrified that their children
might be exposed, kept them from going to camps and
even from swimming in local pools. Every community had
reminders of polio’s virulence, with former patients in
wheelchairs or, worse, iron lungs.
As a junior medical student in the summer of 1952, I
was working in the polio ward at the old Louisville General
Hospital. I stood soaking towels and blankets in hot water
(the Sister Kenny treatment) to wrap around the legs of
our patients. As I wrung out a terry cloth towel, I felt the
sweat beading on my forehead. I was five months pregnant, and the late-afternoon heat was taking its toll on me.
My work was interrupted by the sound of footsteps, and
I looked up. Dr. Walter Coe, the attending staff that day,
was crossing the room.
“Mrs. Keeney?” he said in a penetrating voice. “You must
stop immediately and leave the unit.”
“Why?” I asked in an astonished voice.
“I’ve just been advised by public health officials that
pregnant women are especially at risk for polio.”
I did as he said without further questions.
Before the advent of the Salk and Sabin vaccines, no means
of prevention was available. As soon as the board of the Jefferson County Medical Society (now Greater Louisville Medical Society) felt satisfied of the safety of a mass immunization
program, it decided to sponsor a polio vaccine campaign.
Dr. Everett Baker, chairman of the JCMS Board of Governors, appointed four members, Drs. William VonderHaar,
Robert McClendon, Kenneth Crawford and Thomas Wallace, to serve as an executive committee to organize and
carry out a polio vaccination project for Jefferson County.
Dr. VonderHaar chaired our group
the program’s success.
and also became chairman of the
Finally it was Sunday, Octooverall program.
ber 7, 1962, and time for the
Their first move was to meet with
first clinics to open.
representatives of the Junior Cham It was a beautiful day. The
ber of Commerce, which agreed to coclinics ran like clockwork,
sponsor the program. The chairman
manned by thousands of volunof the four JCs was Tevis Bennett. The
teers. There were even volunfour MDs and four JCs constituted
teers at each clinic to take the
the Program Steering Committee,
vaccine out to those who were
with authority and responsibility for
unable to come inside, waitconducting the campaign overall.
ing in their cars for the sugar
Next, the committee recruited me
cubes.
to be the volunteer full-time medical
There were four “polio busdirector. The Steering Committee and
es” to transport people to clinics
I became known as “The Fabulous
in the central and western parts
Five” within JCMS, which more than
of the city. Sugar cubes and vaccompensated for the hours of work
cine were also taken to institu(Fig. 2).
tions where people were unable
Sabin oral polio vaccine was chosen
to come to the clinics.
rather than Salk, partly because Sabin vac- Fig. 3 Dr. Keeney appeared on the cover of The Helicopters provided by the
cine was taken by mouth, unlike the Salk Courier-Journal Magazine on October 7, 1962, Kentucky National Guard hovered
with a 2-year-old girl taking her sugar cube.
vaccine, which was given by needle. There
overhead, carrying emergency supwere three types of the Sabin vaccine that
plies to outlying clinics (Fig. 4). I
were given a month apart. In our case, we scheduled Type I
rode in one and looked down upon the tens of thousands
to be given on the first two Sundays of October 1962, Type
in line for their sugar cubes. “Thank goodness,” I thought.
II on the first two Sundays in November and Type III on the
“The lines are moving fast.”
first two Sundays in December. The dose for each was three
The small instruments used to deliver exactly three
drops of vaccine on a sugar cube (Fig. 3).
drops of vaccine on each sugar cube worked well most of
The second and important advantage of the Sabin
the time, but occasionally one would jam up, stopping a
vaccine was that it killed the polio virus lurking in the inwhole line of people waiting for their vaccine. This was an
testines, making it impossible for a person to be a carrier.
emergency. Dr. VonderHaar and I were on call to repair
This made possible our goal of immunizing the commuthem, and
nity by trying to motivate people of all ages to take the
we were
vaccine, thus eliminating carriers.
kept busy
To emphasize the safety of the polio vaccine, Kenneth
each clinic
Thompson from Citizens Fidelity Bank suggested that my
Sunday.
three children take their first doses on television, which
Mayor
they thoroughly enjoyed.
Bill Cow I was responsible for coordination of the entire proger helped
gram, which quickly became a full-time job. As part of our
in many
preparation, we first studied the handful of cities that had
ways, but
preceded us. The planning at first was general and overall,
personally
such as determining how many locations we would need
I was most
to vaccinate the entire city and county. Louisville’s popugrateful
lation was 350,000 at the time, so we judged that 46 locathat he
Fig. 4 The Courier-Journal, October 8, 1962. Dr.
VonderHaar and Tevis Bennett are on the right.
tions, each active two Sundays a week apart for each type
arranged
of the vaccine, should provide sufficient access for the city
for his
and county, which were separate at that time. Makeup
limousine and driver to be available to transport me – and
clinics and a very early morning clinic were also provided.
my family – on my Sunday round of clinics and emergen We progressed through assignments of groups of voluncy calls. His friendly driver enjoyed turning on the siren to
teers; for example, the pharmacists were assigned to place
the delight of the children, who had helped out all along
the dose on the sugar cubes. Finally, there were detailed
by manning phones and organizing some of the endless
lists of duties for each volunteer job, from the MD clinic
paperwork.
chief to the persons who handed each child a certificate
On the ground, I could see the amazing variety of ages
of polio immunization at the end. There was no charge,
in the line: babes in arms, children with their parents,
but baskets were placed at the end of the lines to receive
of course, and grandparents, too. All ages, even a whitecontributions.
haired gentleman in a wheelchair and an erect little old
Dr. VonderHaar was a superb leader, and his attention
to administrative detail was an important contribution to
OCTOBER 2012
21
lady in tennis shoes pushing
her walker along, came. Inside
the clinic, an elderly couple told
me they were there to be sure
they would never be polio carriers to their grandchildren.
The year of planning had
turned into action. The people
were turning out in droves, and
Louisville would be immunized
against the dreaded polio (Figs.
5-6). Actually, thanks largely to Dr.
Russell Teague, state health commissioner, most counties in Kentucky scheduled programs at the
same time as ours to take advantage of our advertising and public
relations campaigns. Or when the
vaccine ran out, they followed at a
later date.
Everyone helped – television,
radio, creative mailings, advertising
agencies. The list was endless, the
result of Ken Thompson and the
Advertising Club’s outreach. I was
surprised to learn there were 26
newspapers published in Jefferson
County, including many printed
in foreign languages, and they all
pitched in.
The net result was overwhelming success. To celebrate,
Dr. McClendon chaired a banquet where 96 representatives of some 32 organizations which, in turn, represented
the thousands of volunteers, were given certificates of
appreciation by the Steering Committee.
Several individuals received special gifts. Calvin Anderson, on loan from General Electric, who was in charge of
information, and Ken Thompson, on loan from Citizens
Fidelity Bank, who headed the promotional end of public
relations, were given silver mementos and awards of merit.
I was given a Kentucky Colonel commission and a beautiful silver charger, which bore the signatures of the eight
members of the Steering Committee.
Among the others who received special awards were Dr.
John Walker of the Dental Society, Capt. Frank Quick representing the Police Department and Celestria Uftring representing the Red Cross and the Registered Nurses’ Association.
A few statistics illustrate the success of the program.
More than 90 percent of the population 19 years of age
and younger was immunized against all three types of
polio, as were 80 percent of the children of preschool age
(Fig. 7). A large number of adults took the vaccine and
could no longer be carriers.
Polio immunization in the United States is now a routine procedure given to children (babies) along with other
routine vaccines, such as the one for diphtheria, whooping
cough and tetanus. This is essential to continue the community protection against polio. As far as I can ascertain,
there have not been any cases of polio in Kentucky since
22
LOUISVILLE MEDICINE
Fig. 5 Headline in The
Courier-Journal, October 8,
1962, about the first day of
the campaign.
Fig. 6 Above, polio vaccination certificate. Credit: Louisville Metro
Department of Public Health and Wellness.
Fig. 7 Below, the medical society’s record of immunization totals,
published in the JCMS Bulletin, March 1963.
the successful Sabin oral program ended in 1963.
Tragically, however, there are still polio cases in some
parts of the world. Rotary International is among the organizations working to eliminate this dreadful disease from
the planet.
History may record the Sabin Oral Polio Vaccine Program as one of the most dramatic events of the 20th
century, an event based not on war or storm or flood, but
rather based on ending the occurrence of a deadly, crippling disease that was conquered and eradicated, we hope
forever. LM
Note: Dr. Keeney is a retired child psychiatrist. She thanks
Charles C. Smith Jr., MD, for his article, “Caring for the
Polio Patient” (Louisville Medicine, December 2007), and
GLMS Communications Associate Ellen R. Hale for research assistance.
AUGUST 2012
23
The physicians of Kentuckiana Ear, Nose & Throat, P.S.C.
are pleased to announce and welcome a new associate:
Thomas S. Higgins, M.D., M.S.P.H.
ENT and Fellowship-trained Sinus Specialist
Burton J. Cohen, M.D.
Kenneth L. Silk, M.D.
Bruce A. Scott, M.D.
Mark A. Severtson, M.D.
Sameet S. Sohi, M.D.
Marion D. Eyre, M.D.
Kenneth L. Balcombe, M.D.
Dr. Higgins is a board-certified otolaryngologist with
subspecialty fellowship training from The Johns Hopkins
Medical Institutions in the medical and surgical
management of sinus and nasal disease (“Rhinology”).
We Provide:
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502-736-6342 or visit us at
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He obtained his MD and MSPH degrees from the University
of Louisville. Prior to his Fellowship, he completed a
residency in otolaryngology at Eastern Virginia Medical
School. Dr. Higgins sees patients for all adult and pediatric
ear, nose, and throat problems and has a special interest in
complex sinus disease. From his fellowship training, Dr.
Higgins has extensive experience in complex and revision
endoscopic sinus surgery, frontal sinus surgery, endoscopic
tumor resections, and the medical management of sinus
disease.
Dr. Higgins and his family are excited to move back to their
hometown. More information is available at
www.higgins-sinus.com and www.kentuckianaent.com.
Dr. Higgins’ practice locations include:
Springs Medical Center
6420 Dutchmans Pkwy, #380
Louisville, KY 40205
Jewish Outpatient Care Center
225 Abraham Flexner Way, #401
Louisville, KY 40202
Springhill Commons
1405 Spring Street
Jeffersonville, IN 47130
502-894-8441
New Referrals Accepted at all Locations
24
LOUISVILLE MEDICINE
From the Field
to the Clinic
Julie Anne Smith
Medical school is,
shockingly, quite
similar to my
experience playing
collegiate field hockey.
I never thought about comparing the two until I found
myself buried in a book, frustrated with my inability to
master major biochemical pathways. I made a deal with
myself to just survive medical biochemistry. Upon making
that promise, I had to chuckle. The word “survive” brings
back fond memories. I recalled an early morning conditioning session in which our strength coach attempted to
motivate his exhausted athletes with an inspiring speech.
He proceeded to explain the survive-thrive continuum.
With the stadium stairs awaiting us, he warned that even
though our attitude would be focused on just surviving the workout, there should also be some elements of
thrive. Needless to say, there were no casualties that day,
and I may have even experienced a few seconds of thriving. The workouts were unpleasant; however, I needed to
put in the work to accomplish an even bigger goal – a Big
East championship. My days as a student-athlete closely
resemble my days as a medical student.
The pace has not changed. There is only one pace, and
that is fast. Then, I was expected to run fast; now, I am
expected to learn fast. During my first few days of medical
school, I felt like I was drowning in the workload. I had to
adapt quickly in order to just keep my head above water.
I was puzzled because adapting to the medical school
lifestyle was not a problem of work ethic, but rather, there
OCTOBER 2012
25
were simply not enough hours in the day. Preceptorships,
assignments, small groups, problem-based learning, quizzes, exams and labs filled up the calendar in addition to the
many hours of studying that made us burn the midnight
oil. When the days are too hectic, I tell myself to just survive; however, medical school has proved to be a different
challenge. I need more moments of thrive to be the great
physician I aspire to be.
In order to establish myself at the far right end of the
survive-thrive continuum, I had to tweak my game plan.
Time was of the essence, so my challenge as a first-year
medical student was to learn efficiently. To be more efficient, I had to be better prepared day by day, week by
week, leading up to an exam. Preparing for an exam is like
preparing for game day. You study your opponent, review
your strengths and practice your weaknesses – the same
strategy works for medical school.
To say that a day in my medical life is busy is an understatement. My life as a student-athlete was busy, but
medical school introduces a whole different element to the
word busy. To illustrate, my day as a second-year student
would begin at 5:45 a.m. with rushing to get ready for
school with coffee in one hand and breakfast in the other.
I would arrive to school around 7 a.m. to prepare for the
day or peruse through material I didn’t get to the night
before. Classes would start at 8 a.m. and last until noon. My
mission at that point would be to find free lunch supplied
by an interest group hosting a guest speaker. However, so
would the other 150 hungry medical students in my class,
so a lunch talk would quickly turn into an episode of “The
Amazing Race.” My afternoon hours would include completing an independent learning assignment and preparing for a Team Based Learning quiz, commonly known as
TBL, that week. To conclude the day, I would complete
an assigned preceptorship at University Hospital in order
to hone my history taking and physical exam skills before
third-year rotations. Finally, I would get to apply what I was
learning in the classroom to the bedside. The exception
was that I would be now dealing with a real person, not a
standardized patient. One time, I interviewed a gentleman
who was anxiously awaiting the results of his EGD and
biopsy with fears of adenocarcinoma of the esophagus
looming in his mind. I performed a focused physical exam
and thanked him for his time. I discussed my findings with
the chief resident along with my differential diagnoses and
the prognosis of esophageal cancer. At that point, everything came full circle with integrating pathology, physiology and even the art of medicine. Despite the hectic schedule, it was a very fulfilling school day. I made some time for
myself by going for a jog. Then it was dinner, followed by
more studying, and lights were out by midnight. For the
next day, repeat all of the above.
With the overwhelming amount of stress that medical
students endure, it easy to forget the big picture: that you
applied to medical school to become a doctor. Despite the
26
LOUISVILLE MEDICINE
demands of a rigorous curriculum, the patient encounters
remind me of why I chose this career path. This wasn’t new
territory to me since I experienced the same feeling running the never-ending stadium stairs. It is hard to complete
such difficult tasks alone, especially when the ultimate
goal seems far away from the moment. It is easier when
you have support from others. Therefore, whether it’s your
teammates or your classmates, a support system is crucial
for success during those grueling times. Your classmates
are no longer just your colleagues that you study with on
the weekends, but your friends, best friends.
Since my first day, I have learned that my medical life
paralleled my athletic life, embracing the survive-thrive
continuum. Some days you feel unbeatable. Others, you
feel defeated. Regardless, your objective does not change.
I applied to medical school because I wanted to become
a great primary care physician. I played field hockey so I
could win a Big East championship. So whether it’s the
marathon-long days or the stadium stairs, you still have to
remember why you took that path in the first place. LM
Note: Julie Anne Smith is a third-year medical student at
the University of Louisville.
Because
home is where
she wants to be.
If you or a loved one have physical limitations and could benefit from help in the home,
call ResCare today. A ResCare Home Help caregiver can be scheduled for help in the home
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ResCare is help care for seniors.
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alliance news
Adele Murphy
GLMSA President
“The more you read, the
more things you will know.
The more that you learn,
the more places you’ll go.” –Dr. Seuss, I Can Read With My Eyes Shut!
October is my favorite month of the year. I love the
leaves changing, pumpkins, apples, festivals, football,
cooler weather, shorter days, kids back in school and getting together with my friends in the GLMS Alliance. The
fall is a great time to get involved.
On Tuesday, October 16, at 10 a.m. everyone is invited
to GLMS headquarters at The Old Medical School Building, 101 W. Chestnut St. Come and peruse a fantastic collection known as the Wolf Art Gallery. It was named after
Dr. Richard Wolf, the former medical director of Kosair
Children’s Hospital and project manager for the renovation and revitalization of The Old Medical School Building.
The amazing exhibit includes pieces created by former
medical students who attended class in the old building,
their professors and family members. While there, we
will also have the opportunity to learn more about the
wonderful work of the Greater Louisville Medical Society
Foundation and its medical missions and scholarship
initiatives.
Another reason to love the fall is that October is National Book Month. As the weather cools and the days get
shorter, many of us will enjoy reading a good book, perhaps in some cozy nook within reach of a warm cup of cocoa or in the company of good friends in the embrace of
heartfelt conversation. Sound good? Then please join our
book club on Tuesday, October 25, 10:30 a.m. at Heine
Brothers’ Coffee,
119 Chenoweth
Lane in St. Matthews. We will
be discussing the
highly acclaimed
The Thousand
Autumns of
Jacob de Zoet by
David Mitchell.
Used medical books are needed to fill these shelves at Waggener High School, as well as at Moore and Valley.
28
LOUISVILLE MEDICINE
(Left to right) Leah Petrokubi, Millicent Evans, Toni Linville and
Carol Lambert at a book club meeting.
Selections read by the GLMS Alliance book club.
As long as we are on the subject of books, I want to
remind everyone that the GLMS Alliance is teaming with
the Jefferson County Public Schools to collect used medical books for Moore, Valley and Waggener high school
students in the JCPS career and technical education
program for medicine, health and the environment. The
book drive offers a great impetus for us to finally get together some of those books that have been lying around
the house gathering dust and put them into the hands
of some scholars eager for knowledge and insight into
health care careers. Books can be dropped off with Meredith Dreher (KMA Alliance) at the KMA building, 4965 U.S.
Highway 42, Suite 2000, or with Mary Hess, administrative
assistant with the GLMS Foundation, at The Old Medical
School Building.
No tricks, just treats. Join us for some great fall fun in
October. Costumes are optional! LM
Note: Contact Adele Murphy at [email protected]
or 502-664-5925.
we W elcome you
GLMS would like to welcome and congratulate the
following physicians who have been elected by Judicial Council as provisional members. During the next
30 days, GLMS members have the right to submit
written comments pertinent to these new members.
All comments received will be forwarded to Judicial
Council for review. Provisional membership shall last
for a period of two years or until the member’s first
hospital reappointment. Provisional members shall
become full members upon completion of this time
period and favorable review by Judicial Council. LM
CANDIDATES ELECTED TO PROVISIONAL
ACTIVE MEMBERSHIP
Duffee, Andrew
Richard (12492)
Stephanie Duffee
101 Stonecrest Rd Ste 2
Shelbyville KY 40245
647-7708
Orthopaedic Surgery
U of Louisville 06
Hirsch, Glenn Aaron
(31190)
Leslie Hirsch
401 E Chestnut St
Unit 310 40202
584-8563
Cardiovascular
Diseases 03
Loyola U 97
Mayo, Michael Reid
(30774)
250 Alpine Dr
PO Box 136
Shelbyville KY 40065
633-5683
Psychiatry 98,08
U of Louisville 90
Shaps, Howard
(12205)
Shane O. Shaps
200 Abraham Flexner
Way 40202
587-4421
Emergency Medicine 03
Boston U 98
Whitmore, Nathan
David (31331)
Carolyn Whitmore
300 High Point Ct
Mount Washington KY
40047
955-6129
Internal Medicine
Pediatrics
Indiana U 08
Workman, Laura
(31198)
401 E Chestnut St
Unit 310 40202
589-6788
Internal Medicine
U of Louisville 08
CORRECTION
Because of an error on the photo disc GLMS received from the University of Louisville,
two in-training members had incorrect photos in the August 2012 issue. Here are the
correct photos.
Allinder, Matthew P
(31296)
UL Emergency
Medicine
530 S Jackson St
40202
Emergency
Medicine
U of Louisville 12
Bergset, Jon Martin
(31300)
UL Cardiology
530 S Jackson St
40202
Cardiovascular
Diseases
New York Medical
College 06
OCTOBER 2012
29
P HY S ICIAN S IN P RINT
Ahmad SA, Edwards MJ, Sutton JM,
Grewal SS, Hanseman DJ, Maithel SK,
Patel SH, Bentram DJ, Weber SM, Cho
CS, Winslow ER, Scoggins CR, Martin
RC, Kim HJ, Baker JJ, Merchant NB,
Parikh AA, Kooby DA. Factors Influencing Readmission After Pancreaticoduodenectomy: A Multi-Institutional
Study of 1302 Patients. Ann Surg.
2012 Sep;256(3):529-537. PubMed
PMID: 22868373.
Bozeman MC, Cannon RM, Trombold
JM, Smith JW, Franklin GA, Miller
FB, Richardson JD, Harbrecht BG.
Use of computed tomography findings and contrast extravasation in
predicting the need for embolization
with pelvic fractures. Am Surg. 2012
Aug;78(8):825-30. PubMed PMID:
22856486.
Callen JP. Consider drugs as a cause
or an exacerbating factor in patients
diagnosed with subacute cutaneous
lupus erythematosus! Br J Dermatol.
2012 Aug;167(2):227-8. PubMed PMID:
22835019.
Dewitt EM, Kimura Y, Beukelman
T, Nigrovic PA, Onel K, Prahalad S,
Schneider R, Stoll ML, Angeles-Han
S, Milojevic D, Schikler KN, Vehe RK,
Weiss JE, Weiss P, Ilowite NT, Wallace
CA; The Juvenile Idiopathic Arthritis
Disease-specific Research Committee
of the Childhood Arthritis Rheumatology and Research Alliance. Consensus treatment plans for new-onset
systemic juvenile idiopathic arthritis.
Arthritis Care Res (Hoboken). 2012
Jul;64(7):1001-1010. PubMed PMID:
22290637.
Garcia-Garcia A, Rodriguez-Rocha
H, Tseng MT, Montes de Oca-Luna
R, Zhou HS, McMasters KM, GomezGutierrez JG. E2F-1 lacking the transcriptional activity domain induces
autophagy. Cancer Biol Ther. 2012 Sep
1;13(11). PubMed PMID: 22825328.
Giridharan GA, Lee TJ, Ising M, Sobieski MA, Koenig SC, Gray LA, Slaughter
MS. Miniaturization of mechanical
circulatory support systems. Artif Or-
30
LOUISVILLE MEDICINE
gans. 2012 Aug;36(8):731-9. PubMed
PMID: 22882443.
Gum JL, Glassman SD, Douglas LR,
Carreon LY. Correlation between
cervical spine sagittal alignment and
clinical outcome after anterior cervical
discectomy and fusion. Am J Orthop
(Belle Mead NJ). 2012 Jun;41(6):E81-4.
PubMed PMID: 22837996.
Guo Y, Tukaye DN, Wu WJ, Zhu X,
Book M, Tan W, Jones SP, Rokosh G,
Narumiya S, Li Q, Bolli R. The COX-2/
PGI2 Receptor Axis Plays an Obligatory Role in Mediating the Cardioprotection Conferred by the Late Phase
of Ischemic Preconditioning. PLoS
One. 2012;7(7):e41178. PubMed PMID:
22844439.
Kanaan Z, Rai SN, Eichenberger MR,
Roberts H, Keskey B, Pan J, Galandiuk
S. Plasma MiR-21: A Potential Diagnostic Marker of Colorectal Cancer. Ann
Surg. 2012 Sep;256(3):544-51. PubMed
PMID: 22868372.
Kashikar-Zuck S, Ting TV, Arnold LM,
Bean J, Powers SW, Graham TB, Passo
MH, Schikler KN, Hashkes PJ, Spalding
S, Lynch-Jordan AM, Banez G, Richards
MM, Lovell DJ. Cognitive behavioral
therapy for the treatment of juvenile
fibromyalgia: a multisite, single-blind,
randomized, controlled clinical trial.
Arthritis Rheum. 2012 Jan;64(1):297305. PubMed PMID: 22108765.
Lee TJ, Martin RC 2nd. Readmission
rates after abdominal surgery: can
they be decreased to a minimum? Adv
Surg. 2012;46:155-70. PubMed PMID:
22873038.
Morishita K, Li SC, Muscal E, Spalding S, Guzman J, Uribe A, Abramson
L, Baszis K, Benseler S, Bowyer S,
Campillo S, Chira P, Hersh AO, Higgins
G, Eberhard A, Ede K, Imundo L, Jung
L, Kim S, Kingsbury DJ, Klein-Gitelman
M, Lawson EF, Lovell DJ, Mason T,
McCurdy D, Nanda K, Nassi L, O’Neil
KM, Rabinovich E, Ramsey SE, Reiff A,
Rosenkranz M, Schikler K, Stevens A,
Wahezi D, Cabral DA; ARChiVe Investi-
gators Network. Assessing the performance of the Birmingham Vasculitis
Activity Score at diagnosis for children
with antineutrophil cytoplasmic antibody-associated vasculitis in A Registry for Childhood Vasculitis (ARChiVe).
J Rheumatol. 2012 May;39(5):1088-94.
Schikler KN. Metabolic myopathy a cause of rhabdomyolysis in
adolescents. J Adolesc Health. 2011
Aug;49(2):225; author reply 225.
Ting TV, Hashkes PJ, Schikler K, Desai
AM, Spalding S, Kashikar-Zuck S. The
role of benign joint hypermobility
in the pain experience in Juvenile
Fibromyalgia: an observational study.
Pediatr Rheumatol Online J. 2012 Jun
15;10(1):16. [Epub ahead of print]
Uribe AG, Huber AM, Kim S, O’Neil
KM, Wahezi DM, Abramson L, Baszis
K, Benseler SM, Bowyer SL, Campillo
S, Chira P, Hersh AO, Higgins GC,
Eberhard A, Ede K, Imundo LF, Jung L,
Kingsbury DJ, Klein-Gitelman M, Lawson EF, Li SC, Lovell DJ, Mason T, McCurdy D, Muscal E, Nassi L, Rabinovich
E, Reiff A, Rosenkranz M, Schikler KN,
Singer NG, Spalding S, Stevens AM,
Cabral DA. Increased Sensitivity of the
European Medicines Agency Algorithm for Classification of Childhood
Granulomatosis with Polyangiitis. J
Rheumatol. 2012 May 15. [Epub ahead
of print] PubMed PMID: 22589257.
NOTE: GLMS members’ names appear
in boldface type. Most of the references have been obtained through the
use of a MEDLINE computer search
which is provided by Norton Healthcare Medical Library. If you have a
recent reference that did not appear
and would like to have it published in
our next issue, please send it to Alecia
Miller by fax (736-6363) or email ([email protected]). LM
We do what no other medical liability insurer does. We reward
loyalty at a level that is entirely unmatched. We honor years spent
practicing good medicine with the Tribute® Plan. We salute a great career
with an unrivaled monetary award. We give a standing ovation. We are your
biggest fans. We are The Doctors Company.
We created the Tribute Plan to provide doctors with more than just a little gratitude for a career spent practicing
good medicine. Now, the Tribute Plan has reached its five-year anniversary, and over 22,700 member physicians
have qualified for a monetary award when they retire from the practice of medicine. More than 1,300 Tribute awards
have already been distributed. So if you want an insurer that’s just as committed to honoring your career as it is to
relentlessly defending your reputation, request more information today. Our medical professional liability program is exclusively
endorsed by the Kentucky Medical Association. To learn more about our benefits for KMA members, including the Tribute Plan,
call Frank Buster or Gary Noel at (800) 338-7148 or e-mail [email protected].
Exclusively endorsed by
www.thedoctors.com
Tribute Plan projections are not a forecast of future events or a guarantee of future balance amounts. For additional details, see www.thedoctors.com/tribute.
3745_KY_LouisvilleMed_Oct2012.indd 1
8/13/12 10:04 AM
Attention all Internal Medicine, Family Practice and Endocrinology Physicians who
treat Diabetes patients: The GLMS Physicians Take AIM at Diabetes Program
invites YOU to participate in this exciting initiative.
By attaining the NCQA DRP Recognition you:
Demonstrate to your patients that you are providing excellence in diabetes care
Earn increased respect from your peers
The GLMS AIM Program provides at no charge:
DRP audit support
DRP practice administrative and educational
support services
Patient and physician tools
Contact: Jessica Williams, Manager of Physician Education and
Practice Support and AIM Program Director at 502-736-6368 or
[email protected]
32
LOUISVILLE MEDICINE
Speak Your Mind The views expressed in Doctors’ Lounge or any other article in this publication are not those of the
Greater Louisville Medical Society or Louisville Medicine. If you would like to respond to an article in this issue, please submit
an article or letter to the editor. Contributions may be sent to [email protected] or may be submitted online at www.glms.org.
The GLMS Editorial Board reserves the right to choose what will be published.
Mary G. Barry, MD
Louisville Medicine Editor
[email protected]
shortchange your patients this way? As for
Listing Badly
Recently the American Board of Internal
Medicine Foundation, working with
Consumer Reports, asked nine medical
specialty Colleges to come up with ways
to cut unnecessary health care spending.
In this initiative, “Choosing Wisely,” they
asked member boards to name five ways.
Some are good, some are bad, few are innovative. Here’s a sampling.
From the American Academy of Allergy,
Asthma and Immunology: “Don’t order
sinus CT or indiscriminately prescribe
antibiotics for uncomplicated acute
rhinosinusitis.” This reminds me of a badly
written test question, at which I have
shaken my fist in years past. Part A, the CT
part, is sensible, and the ENT folks agree.
As for Part B, how many of your patients
come in complaining of an “uncomplicated rhinosinusitis?” I’d say zero, unless
they write test questions for a living. If
they have a cold and are not wheezers,
then tea, sympathy and Tylenol Sudafed
are in order. But if they have some sort of
localized, ongoing, several days’ worth of
pain and blockage symptoms in one ear or
one sinus, in which case exam usually verifies their symptoms, then antibiotics plus
drainage meds and saline help. But if they
have a cold, AND they wheeze, they will
continue to wheeze and cough for weeks,
unless you cut to the chase with steroid
inhalers, macrolides, cough syrup and
drainage meds. Lying on the sofa drowning in self-pity helps, but only for 24 hours.
Hot toddies help everything.
From the American Academy of Family
Physicians: “Don’t perform Pap smears on
women younger than 21 or who have had
a hysterectomy for non-cancer disease.”
Clearly, they took the same test-writing
class as the allergists. Part A: and miss the
opportunity for reinforcing condom use,
discussing birth control, discussing the
connection between safe sex and selfesteem, and detecting early addictions
to tobacco and drugs? Why would you
Part B, re the hysterectomized: I applaud
heartily, if you are sure that the woman
never had dysplasia or has any reason to
continue vaginal smears.
From the American College of Cardiology: “Don’t perform stress cardiac imaging or advanced non-invasive imaging
as a preoperative assessment in patients
scheduled to undergo low-risk non-cardiac surgery.” Well, duh, unless you like your
over-40 patient to have an anesthetic with
his scalpel. Just try sliding that past your
average Anesthesia preop doc and you
will have a canceled case in no time. Our
considered opinions, internists’ or heart
docs’ alike, carry no weight in the plaintiffs’ bar. But tests offer some protection to
the poor anesthesiologist and her unconscionable malpractice premiums.
From the American College of Radiology: “Avoid admission or preoperative chest
X-rays for ambulatory patients with unremarkable history and physical exam.” Fine,
if your practice consists of healthy women
having GYN and cosmetic procedures,
and young guys having hernia repairs and
knee scopes. I rarely admit anyone with an
“unremarkable history and physical exam,”
but will gladly recall this advice for the few
who meet that standard.
From the American Gastroenterological
Association: “For pharmacological treatment of patients with GERD, long-term
acid suppression therapy (with PPIs or H-2
blockers) should be titrated to the lowest
effective dose needed to achieve therapeutic goals.” That’s a mouthful, but a
well-considered one. PPIs long-term carry
bone-thinning and other risks, including
(shudder) a weaker defense against C. Diff.
Zantac–type-meds taken for many many
years can increase the risk of dementia.
Stopping such drugs gives your patient a
chance to practice eating less and eating
earlier, getting up off the sofa after dinner,
losing weight and stopping smoking. Success in those efforts breeds more comfort
and health overall.
From the American Society of Nephrology: “Avoid NSAIDs in individuals with
hypertension or heart failure or chronic
kidney disease of all causes, including diabetes.” Talk about your lumpers! Do youall
want half my patient population (and 68
percent of adult Americans) to forego the
anti-aching, anti-dementia, anti-cancer
anti-inflammatories even if they control
their blood pressure, stay well-hydrated
and always take their meds with food?
How mean of you. I get it about the sick
kidney and the noncompliant and the
hypoxic etc. etc. As for the rest of us, you’ll
have to pry the Advil out of our cold dead
hands.
From my own American College of Physicians: “Don’t obtain imaging studies in
patients with non-specific low back pain.”
Fine, if they have a “this-is-muscular-pain”
history and exam, and get better with PT
or chiropractic, or meds and stretching,
no-impact exercise, common sense and
yoga. Useless, if you want them to have a
Spine MD consult or a Pain MD consult. No
patient can get his foot in the door of any
spine practice without a current MRI. They
just refuse. Most pain MDs need something to aim at, e.g. the L4-L5 nerve root
impingement that correlates with the back
pain going down the left leg, that you can
only see on an MRI. So unless you are an
omniscient internist with X-ray vision, you
order a lot of MRIs, because you need orthopedic help. Stethoscopes aren’t much
good with bones.
From the American Society of Clinical
Oncology: “Don’t perform surveillance
testing (biomarkers) or imaging (PET, CT
or bone scans) for asymptomatic patients
who have been treated for early breast
cancer with curative intent.” This is one of
the simplest and nicest ASCO directives
ever, so far as relieving the patient of the
annual worry over results, and making the
clinician pay attention to and ask about
new symptoms that might mean something cancerous is brewing. I still have to
reassure my oldest breast cancer survivors
that my seeming neglect of them is OK.
But I can point to everything they just told
OCTOBER 2012
33
me as evidence in their favor. It’s cheap,
old-fashioned and personal.
The American College of Rheumatology
has yet to produce its five maxims, but its
Dr. Karmela K. Chan, of Pawtucket, R.I., is
now On My List, which means no dessert
for her and curfew at 7. She answered the
survey her College sent out, and wrote
about it for the June 19 digital Internal
Medicine News. I quote: “I’ve heard talk of
a ‘Rheumatoid Panel’ in the nether world
of primary care.” Nether! I defy her to last
one day in our lives and see just who tops
whom in unnecessary test ordering, not to
mention diagnostic accuracy and clinical outcome. Being condescended to by
Yankees is simply galling. Stuff that in your
Tucket, Karmela, and have you checked
your referral base lately? LM
Note: Dr. Barry practices Internal Medicine
with Norton Community Medical Associates-Barret. She is a clinical associate professor at the University of Louisville School
of Medicine, Department of Medicine.
Todd S. Shanks, MD
Beware the
Subtle Signs
of Parkinson’s
Disease
Parkinson’s disease can sneak up
on its victims with vague signs that are
both subtle and misleading to patients
and many medical professionals. A slight
tremor in a patient’s hand or arm may be
benign, a diminished sense of smell may
be an anomaly, and impaired or slowed
movements may be related to simple
age progression. However, the culprit
may be Parkinson’s disease, a chronic
and progressive movement disorder with
symptoms that advance and worsen
over time. Because it is essential to begin
treatment for Parkinson’s disease as early
as possible, it is important to know its
quiet signals in advance of referring your
patient to a movement disorder specialist. Medical and surgical intervention
options can significantly enhance a PD
patient’s quality of life.
Throughout my practice, I have met
numerous patients who have endured
years of misdiagnosis or been told there
is nothing wrong with them other than
the results of natural aging. Many of
these individuals are ultimately handed
a Parkinson’s disease diagnosis and find
us seeking a way to live well with PD. In
many cases, it is frustrating knowing that
if some of these individuals had received
treatment in earlier stages of the disease,
their ability to live well with PD may have
been improved. By the time they arrive in
my office, a diagnosis is well-established
and a surgical treatment option (deep
brain stimulation) is under consideration.
At the center of Parkinson’s disease is a
malfunction of neurons within the brain
(particularly within the substantia nigra)
and decreasing levels of the brain chemical dopamine. Dopamine is produced by
certain neurons in the brain and is critical
to a person’s controlled movement and
coordination. When malfunctioning or
dying neurons produce less-than-normal
dopamine levels, Parkinson’s disease
develops and progresses. The result is a
person who is unable to control his or
her movements normally, along with
34
LOUISVILLE MEDICINE
a host of other chronic and troubling
symptoms. One of the keys to helping
people live well with Parkinson’s disease
is harnessing any amount of dopamine
a PD patient may have. This helps stall
the progression of the disease, along
with medication and other treatments
and therapies to improve outcomes. One
of the most common misperceptions
about PD is that it only affects elderly
people. While typically most prevalent in
older populations, adults from every age
group can have PD and may even notice
the earliest symptoms of the disease in
their 20s or 30s. This is called early-onset
Parkinson’s disease.
The specific set of symptoms an
individual with PD may experience varies
somewhat widely. A host of non-motor
symptoms may present early on in some
patients. This is due to the presence of
Lewy Bodies (clusters of a protein alphasynuclein) in additional areas of the brain
and intestine controlling certain non-motor functions. More common symptoms
may include decreased sense of smell,
drooling, constipation, depression, dementia, insomnia and urinary problems.
Primary motor signs of Parkinson’s
disease include the following:
• Tremor of the hands, arms,
legs, jaw and face
• Bradykinesia or slowness of
movement
• Rigidity or stiffness of the limbs
and trunk
• Postural instability or impaired
balance and coordination.
According to the Parkinson’s Disease
Foundation, approximately 1 million
people in the United States are living
with this disorder for which there is currently no cure. The Parkinson Support
Center of Kentuckiana claims an estimated 8,000 people in Louisville Metro
and 14,000 in Kentucky are living with
the disease. While theories abound, its
cause is unknown. Symptom management is the focus of PD treatment and
may include use of medications and
deep brain stimulation surgery for some
patients. Deep brain stimulation involves
implanting a device within an area of
the brain influencing significant tremor
in PD patients. It can be highly effective,
yet depending on the progression of the
disease and other factors, it may not be
suitable for all individuals.
I recommend a multi-pronged approach to my patients tackling the disease. Exercise has been clinically shown
to slow the progression of Parkinson’s.
This is highly important. Along with the
involvement of the Norton Neuroscience
Institute and Frazier Rehab Institute, the
Parkinson Support Center of Kentuckiana offers a wide variety of free exercise
classes and programs for PD patients
and their care partners. Some classes are
held at PSCKY’s Middletown offices and
others at various locations throughout
the region. I also urge people with PD to
get involved with a support group and
manage stress whenever possible.
If you are witnessing a host of baffling
or vague symptoms in one of your own
patients and suspect possible Parkinson’s
disease, time is of the essence. We have
the tools to help lessen the severity of
symptoms and increase quality of life.
Early intervention makes all the difference in many cases. Refer your patient to
a neurologist with expertise in movement disorders. I also encourage you to
refer all Parkinson’s patients to the Parkinson Support Center of Kentuckiana for
a wealth of free support programs and
information. The center may be reached
at 502-254-3388 or www.pscky.org.
Living Well with Parkinson’s Symposium
The Parkinson Support Center of
Kentuckiana is hosting its seventh annual
Living Well with Parkinson’s Symposium
on Monday, October 29, from 8:30 a.m.
to 4 p.m. at the University of Louisville
Shelbyhurst campus. People with PD and
their care partners are invited to register.
The program will feature expert speakers
on subjects such as gene diets, tai chi,
music therapy, clinical trials and elder law
and a Q&A with a neurologist. Dr. Clifford
Kuhn, also known as “The Laugh Doctor,”
will entertain attendees as the keynote
speaker. For more information, contact
PSCKY at 502-254-3388 or [email protected].
LM
Note: Dr. Shanks practices Neurological Surgery with Norton Neuroscience
Institute. He is the director of functional
neurosurgery at Norton Healthcare.
Passport Health Plan is America’s 13th best Medicaid health insurance plan.*
WE TAKE THE TIME TO CARE.
Perhaps it’s a health coach who checks in to make sure you take your medicine
or a compassionate care manager who meets you at the doctor’s office. Maybe
it’s just someone who answers questions over the phone. No matter whom you
work with at Passport Health Plan, we take the time to care.
Members: 1-800-578-0603
TDD/TTY: 1-800-691-5566
g
n
i
k
r
o
rw
o
f
s
e.
k
T h a n my sch ed u l
d
a rou n
Mi ss y
be
Me m
r si n c
8
e 200
AUGUST 2012
* National Committee for Quality Assurance
Medicaid Health Insurance Plan Rankings 2011-2012.
www.passporthealthplan.com
35
Charles C. Smith Jr., MD
A Fragment of
Medical
Economic
Ephemera
Revisited
Apropos of Dr.
Morris Weiss’
article in Louisville Medicine in July
2012, I submit further evidence
from simpler times in the “delivery”
of health care. This is the check my
father wrote for payment in full for
the home delivery of me in September 1930. Dr. Reynolds was the only
expense.
When he gave me the canceled
check, my dad advised that if I ever
became “puffed up” about myself, I
could always see my original worth! I
think that’s why he gave it to me.
Ironically, home deliveries were last
performed in med school at the
36
LOUISVILLE MEDICINE
University of Louisville by our Class
of 1955. We senior students did the
deliveries unsupervised, accompanied by a junior student who administered chloroform anesthesia. My!
Times have changed. LM
Note: Dr. Smith is a retired internist.
He is a member of the Innominate
Society, Louisville’s medical history
society.
JEFFERSON MANOR
HEALTH &
REHABILITATION
1801 Lynn Way
Louisville, KY
502.426.4513
JEFFERSON PLACE
HEALTH &
REHABILITATION
1705 Herr Lane
Louisville, KY
502.426.5600
MEADOWVIEW
HEALTH &
REHABILITATION
9701 Whipps Mill Road
Louisville, KY
502.426.2778
OAKLAWN
HEALTH &
REHABILITATION
300 Shelby Station Drive
Louisville, KY
502.254.0009
ROCKFORD
HEALTH &
REHABILITATION
4700 Quinn Drive
Louisville, KY
502.448.5850
SUMMERFIELD
HEALTH &
REHABILITATION
1877 Farnsley Road
Louisville, KY
502.448.8622
Working harder
to help patients
recover faster.
There’s a reason we’re able to treat our patients to
shorter stays and better rehab outcomes. It’s our
people, all handpicked for their skill as rehab experts
and their compassionate spirits. Call any of
our six Louisville communities to learn more.
Elmcroft.com/skillednursing
OCTOBER 2012
37
Jay P. Davidson
I would like to thank the members of
GLMS for your continuing support of The
Healing Place. Your generosity has been
instrumental to the men and women
struggling with addiction in our community for nearly 23 years. And thanks to
$122,000 in gifts and pledges from about
100 Greater Louisville Medical Society
members and the GLMS Foundation at
the end of 2011, we received a challenge
grant from the Kresge Foundation and
paid off all indebtedness on our Women’s
Community at 15th and Hill streets. More
importantly, your generosity has been instrumental to the men and women struggling with addiction in Louisville. Thanks
to GLMS, small miracles are happening in
the lives of even more of these individuals, positively impacting their families,
friends, employers and our community as
a whole.
More than 29 years ago, I had the opportunity to get sober. I have dedicated
almost 21 years to making that opportunity available to each man and woman
who has come to The Healing Place
struggling with addiction. It is because
of my profound gratitude, passion and
commitment that I ask you to make an
immediate, significant financial contribution to The Healing Place.
We have gone through many difficult
financial situations in our history, but
the prolonged economic downturn has
created a situation where public and
private support has declined and operating costs have increased, necessitating
that we drastically draw down our cash
reserves to near zero. We have reduced
costs where possible, outsourced services
for greater efficiency and eliminated staff
positions at all levels.
We cannot depend on our cash reserves any longer. In order to guarantee
the survival of the comprehensive recovery program, we need to raise an additional $1 million for this year’s budget.
Now I need to address the 2,300
GLMS active and life members who have
not yet participated in the Partners for
Hope Initiative. As the leader of The
Healing Place, I have to make difficult
decisions that will ensure that the men
and women struggling with addiction
will continue to be served as long as
there is a need. Unfortunately, without
raising additional funds, we will have to
eliminate our child development program, parenting program, continuing
care program, free medical clinic and
supporting infrastructure staff.
Sadly, the face of addiction continues
to get younger and younger. Prescription
drug addiction is becoming a heartbreaking epidemic, with our fastest-growing
population being 18- to 25-year-olds. If
we can reach these men and women in
their youth, we can help curb a lifetime
of joblessness, homelessness and broken
families as well as premature deaths. We
have a recovery program that works!
Each day, we help 600 alcoholic and addicted men and women develop the skills
to stay sober for the rest of their lives. Of
these men and women, 75 percent are
sober a year later, helping them become
the best sons, daughters, fathers, mothers, employees and community volunteers they have always wanted to be.
This was a hard letter to write, and I
am sure it is a hard letter to read. Please
help us to continue to save lives – lives of
sobriety, productivity and purpose. I am
asking with all my heart that you make a
donation for 2012. LM
Note: Jay Davidson is chairman of The
Healing Place. Donations can be made
online at www.thehealingplace.org/
donate.aspx.
Robert F. Sexton Jr., MD
Letter to the
Editor
The increasing
use of the “Harvard
School of Business”
model of administering medical practice has to a very large
measure supplanted the development of
a physician-patient professional relationship. As an aging artifact of “how medicine used to be,” it is not proper for me to
say whether this trend is good or bad.
However, two of the articles in the
August 2012 issue of Louisville Medicine
illustrate the evils that can emanate from
this business model.
Dr. James Patrick Murphy’s article on
House Bill 1 is an articulation of the of-
38
LOUISVILLE MEDICINE
ficial KMA objection. His conclusion that
fine-tuning is necessary to put the law’s
emphasis where it is needed is quite obvious. However, pill mills are a fact of life.
Prescription drugs in Kentucky in particular and the United States in general take
more lives than automobile accidents.
Roughly 1,000 Kentuckians a year die of
this epidemic. Those facts represent a
major public health issue. Trying to correct
the problem is the responsibility weighing
on the medical professionals, i.e. the doctors. To assume that HB 1 is too complicated for the doctor to understand is an insult
to our collective intelligence. Anyone with
a baccalaureate degree, a doctor’s degree
and years of postdoctoral education is
most assuredly intellectually capable of
dealing with HB 1. If that takes a little time,
too bad. What it does is limit the ease of
overall illicit distribution of deadly drugs.
Dr. Timir Banerjee’s article in the Doctors’ Lounge section concerning “Sinful
Operations on the Spine” is very much
to the point. These procedures consume
millions of taxpayers’ dollars in a symbiotic conspiracy of some doctors and
lawyers. Kentucky’s no-fault automobile
insurance laws are obviously in need of
revision. But professional honesty is also
useful. Dr. Banerjee is to be applauded for
having the “spine” to speak up about the
tip of that particular morass. L
M
Note: Dr. Sexton practices Neurological
Surgery and Pain Medicine in solo private
practice.
B U S INE S S CARD G A L L ERY
ADVERTI S ER S ’ INDE X
KMA Insurance Agency
www.kmainsurance.com
10
Passport Health Plan
35
www.passporthealthplan.com
Louisville Medical Federal Credit Union
25
9
37
www.lmedfcu.org
ProNational Insurance
www.pronational.com
12
ResCare
27
Family Allergy & Asthma
www.familyallergy.com
26
MAG Mutual Insurance Co
www.magmutual.com
24
State Volunteer Mutual Insurance Co
2
Hall Render Killian Heath
& Lyman
www.hallrender.com
23
Medical Society Employment Services
Merkley Kendrick Jewelers
39
The Doctors Company
www.thedoctors.com
32
Jewish Hospital St Mary’s HealthCare
IFC
Murphy Pain Center
4
The Pain Institute
OBC
John Kenyon Eye Center
10
16
The Physicians Billing Group
40
Kentuckiana ENT PSC
www.kentuckianaent.com
24
Nephrology Associates of Kentuckiana PSC
www.nephky.com
36
Kentuckiana Pain Specialists
19
Norton Healthcare Physicians
www.nortonhealthcare.com
7&
IBC
Van Zandt Emrich & Cary
www.vzecins.com
Wakefield Reutlinger (Ken Reutlinger)
40
Athena Health
31
Canfield Development
1
Elmcroft
www.athenahealth.com
www.canfielddevelopment.com
www.elmcroftseniorliving.com
www.jhsmh.org
www.johnkenyon.com
www.painstopshere.org
40
www.glms.org
www.mkjewelers.com
www.murphypaincenter.com
LOUISVILLE MEDICINE
www.rescare.com
www.svmic.com
www.thepaininstitute.com
www.thephysiciansbilling.com
www.wrrealtors.com
CoMPreHeNsIve CAre for
MoveMeNT DIsorDers
Norton Neuroscience Institute and the Cressman Center for Parkinson’s Disease
and Movement Disorders offer the region’s most comprehensive team of
fellowship-trained neurologists, neurosurgeons, neuropsychologists and physician
assistants. They strive to provide excellent care and improve the quality of life for
people living with Parkinson’s disease and other movement disorders.
To schedule a patient for an evaluation, call the Norton Healthcare Access Center
at (888) 4-U-NORTON/(888) 486-6786.
SpecialiSTS iN mOvemeNT diSORdeRS
Mohammad s. Alsorogi M.D., M.s., Neurology
Bradley s. folley, Ph.D., Neuropsychology
Angela M. Hardwick, M.D., Neurology
Todd s. shanks, M.D., Neurosurgery
David A. sun, M.D., Ph.D., Neurosurgery
Greater Louisville Medical Society
101 WEST CHESTNUT STREET
LOUISVILLE, KY 40202
PRSRT STD
U.S. POSTAGE
PAID
LOUISVILLE, KY
PERMIT NO. 6

LouisviLLe Medicine - Greater Louisville Medical Society

Transcription

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