maryland physician magazine mayjune 2013 issue

CELEBRATING MARYLAND WOMEN IN MEDICINE:EXCEPTIONAL CHARACTER & COMMITMENT

NEW HOPE FOR MENOPAUSAL WOMEN

MANAGING CONCUSSIONS

TELEHEALTH: BEYOND OFFICE WALLS

CELEBRATING MARYLAND WOMEN IN MEDICINE:EXCEPTIONAL CHARACTER & COMMITMENT

NEW HOPE FOR MENOPAUSAL WOMEN

MANAGING CONCUSSIONS

TELEHEALTH: BEYOND OFFICE WALLS

VOLUME 3: ISSUE 3 MAY/JUNE 2013VOLUME 3: ISSUE 3 MAY/JUNE 2013

Physic i an Physic i anYOUR PRACTICE. YOUR LIFE.

www.mdphysicianmag.comwww.mdphysicianmag.com

YOUR PRACTICE. YOUR LIFE.

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12 Exceptional Character and Commitment

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F E A T U R E S

D E P A R T M E N T S

ContentsVOLUME 3: ISSUE 3 MAY/JUNE 2013

2412 34

Cases | 7 | Superficial Venous Thrombophlebitis: New Practice Guidelines

Compliance | 9 | How HIPAA Rule Changes May Affect EHR Relationships

Healthcare IT | 29 | Telehealth Expands Care Beyond Office Walls

Policy | 32 | Coordinated Healthcare Reform in Maryland

Living | 34 | The Game of Golf: Learn It, Love It

Solutions | 37 | Reputation Management – To Do or Not To Do?

Good Deeds | 38 | House of Ruth Creates Safe Haven For Victims of Domestic Violence

On the Cover: Regina Hampton, M.D., FACS, breast surgeon, medical director of Comprehensive Breast Care Center at Doctors Community Hospital

4 | WWW.MDPHYSICIANMAG.COM

JACQUIE COHEN ROTHPUBLISHER/EXECUTIVE EDITOR

[email protected]

LINDA HARDER, MANAGING [email protected]

MANAGER OF DIGITAL CONTENT AND SOCIAL MEDIA

Jackie [email protected]

CONTRIBUTING WRITERTracy Fitzgerald

PROOFREADEREllen Kinsella

PHOTOGRAPHYTracey Brown, Papercamera Photography

Melissa Grimes-Guy, Location Photography, Inc.Kevin J. Parks, Mercy Medical Center

Randy Sager, Randy Sager Photography, Inc.

DIRECTOR OF FINANCE & OPERATIONSKyle Marisa Roth

BUSINESS DEVELOPMENTEileen Nonemaker

[email protected]

Maryland Physician Magazine – Your Practice. Your Life.™ is published bimonthly by Mojo Media, LLC. a certified MinorityBusiness Enterprise (MBE).

Mojo Media, LLCPO Box 949Annapolis, MD 21404443-837-6948www.mojomedia.biz

Subscription information: Maryland Physician Magazineis mailed free to Maryland licensed and practicing physicians and a select audience of Maryland healthcare executives and stakeholders. Subscriptions are available for the annual cost of $52.00. To be added to the circulation list, call 443-837-6948.

Reprints: Reproduction of any content is strictly prohibited and protected by copyright laws. To order reprints of articles or back issues, please call 443-837-6948 or email [email protected].

Maryland Physician Magazine Advisory Board: An advisory board comprised of medical practitioners and businessleaders in diverse practice, business and geographic scopesprovides editorial counsel to Maryland Physician. Advisoryboard members include:

KAREN COUSINS-BROWN, D.O.Maryland General Hospital

PATRICIA CZAPP, M.D.Anne Arundel Medical Center

HOLLY DAHLMAN, M.D.Greenspring Valley Internal Medicine, LLC

PAUL W. DAVIES, M.D., FACSKURE Pain Management

MICHAEL EPSTEIN, M.D.Digestive Disorders Associates

STACY D. FISHER, M.D.University of Maryland Medical Center

REGINA HAMPTON, M.D. FACSSignature Breast Care

DANILO ESPINOLA, M.D.Advanced Radiology

GENE RANSOM, J.D., CEOMedChi

CHRISTOPHER L. RUNZ, D.O.Shore Health Comprehensive Urology

JAMES YORK, M.D. Chesapeake Orthopaedic & Sports Medicine Center

Although every precaution is taken to ensure accuracy of published materials, Maryland Physician and Mojo Media, LLCcannot be held responsible for opinions expressed or facts supplied by authors and resources.

To ‘lean in’ – the term coined byFacebook COO Sheryl Sandberg thatencourages women to not hold themselvesback in their professional advancement – is theperfect theme for this issue. In the following

pages, we celebrate four Maryland female physicians who most certainly have beentrailblazers and ‘leaned in.’ Each of their stories shares the underlying qualities ofcharacter, compassion, commitment, mentorship and family.

Early this spring, I cherished the gift of celebrating my dad’s 87th birthday withhim. As a child, I used to love to pick his handsome face out from his medical schoolgraduating class. Having been raised without boundaries about what I could do andwho I could be, I was always surprised that there were only two women in that 60-year-old medical school photo. Now I realize that those two women were most certainlypioneers who were ‘leaning in’ long before that phrase was in the lexicon.

This issue also celebrates the second anniversary of the launch of MarylandPhysician Magazine. As a young girl, I was always asked if I wanted to grow up and be anurse to help my dad, the doctor. That was the mindset of the 60s and early 70s. Myanswer was always the same, “No, I want to be a doctor and his boss,” (an inkling ofmy rationale in naming my company ‘Mojo’?). Although when I started college I wastaking a pre-med curriculum, my professional and personal journey ultimately took meaway from a medical career. However, the route I took eventually brought me back tomy intellectual passion - medicine and wellness.

Over the last two years, the staff of Mojo Media and Maryland Physician has grownand now boasts two mother-daughter teams – one of them being one of my threedaughters and myself. I’m proud to have built a team of very smart, creative anddriven people, all of whom happen to be women who share the goal of being able tobalance family and professional life. We’re actively ‘leaning in’ and, I hope, leading byexample.

Since the inception of Maryland Physician, our advisory board has helped to guideus in content development and our advertisers have enabled us to get that content out to you. When you’re making the business decisions that support your practice, no matter the size, please consider our advertisers. Without them, our stories ofcommitment, dedication and inspiration - all with a focus on improving the quality ofpatient care throughout Maryland - wouldn’t get to you.

To life!

Jacquie Cohen RothPublisher/Executive Editor [email protected]

@mdphysicianmag

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DISCUSSION Superficial Thrombo-phlebitis (SVT) refers to a clot in asuperficial vein associated withsurrounding inflammation. The usualclinical presentation is pain, tenderness,induration or erythema along a superficialvein. It is usually treated with NSAIDS(Ibuprofen, etc), compression stockingsand warm compresses.

SVT is associated with varicose veins,malignancy, pregnancy, estrogen therapy,travel and history of prior leg clots.

Although SVT is less studied thandeep venous thrombosis (DVT), it is seen more commonly in the generalpopulation. The incidence of SVT isabout 3-11%, compared to DVT, which is about 1%. It may involve the greatsaphenous vein in 2/3 of the patients. It is generally considered a benign, self-limited disorder, but it may becomplicated by extension of thrombus in the deep venous system.

The aim of treatment is not only torelieve local symptoms but also toprevent thromboembolic complications.But the role of anticoagulation iscontroversial. Most studies have beensmall and have shown benefit overplacebo, but the evidence was of lowquality. The CALISTO Study(Comparison of Arixtra in Lower LimbSuperficial Thrombophlebitis withPlacebo) was recently published whichshowed benefit of Fondaparinux (Arixtra2.5mg/d for 45 days) over placebo in 3000 patients with lower limb SVT >5cm, with lowered incidence of venousthromboembolism, recurrent SVT andextension of SVT.

Based on these studies, the AmericanCollege of Chest Physicians issued newguidelines in February 2012,recommending anticoagulation for

patients with SVT who are at increasedrisk for venous thromboembolism(SVT>5cm, proximity to deep veins<5cm, positive medical risk factors).Positive medical risk factors include priorclots, cancer, surgery, thrombophilia,estrogen therapy or prolonged travel.Fondaparinux 2.5mg daily or enoxaparin40 mg daily for a period of 4 weeks isrecommended. If DVT is present, thepatient should be fully anticoagulated.

Ligation of the great or smallsaphenous vein may be considered forpatients in whom anticoagulation iscontraindicated. Otherwise, surgery forSVT was found to be associated with ahigher risk for thromboembolism.

Patients with isolated SVT and noassociated risk factors may be diagnosedby physical exam and treated withNSAIDS, compression stockings andambulation. Repeat physical exam should be done in 7-10 days to evaluatefor extension or resolution. Duplexultrasound should be done in patientswith SVT >5cm, involvement of GSV or SSV, presence of phlebitis above the knee, or extension of phlebitis onserial exam.Sanjiv Lakhanpal M.D., FACS, is President/CEO

of Maryland-based Center for Vein Restoration.

www.centerforvein.com

REFERENCES:Decousus H, Quéré I, Presles E, et al. Superficial venousthrombosis and venous thromboembolism: a large, prospectiveepidemiologic study. Ann Intern Med 2010; 152:218.Di Nisio M, Wichers IM, Middeldorp S. Treatment for superfi-cial thrombophlebitis of the leg. Cochrane Database Syst Rev2007; :CD004982.Decousus H, Prandoni P, Mismetti P, et al. Fondaparinux forthe treatment of superficial-vein thrombosis in the legs. NEngl J Med 2010; 363:1222. Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapyfor VTE disease: Antithrombotic Therapy and Prevention ofThrombosis, 9th ed: American College of Chest PhysiciansEvidence-Based Clinical Practice Guidelines. Chest 2012;141:e419S.

Cases

Superficial Venous Thrombophlebitis:New Practice Guidelines

CASE: LM, a 78-year old female,was seen in the emergency roomwith leg pain and localizedswelling in the calf. The patienthad no significant past medicalhistory except for varicose veins,no history of prior leg clots orfamily history of clottingdisorders. On physical exam, atender, reddened, indurated areaover the lower thigh and medialcalf was seen. Ultrasound of theleft leg, done in the EmergencyDepartment, showed a superficialthrombophlebitis involving thesuperficial calf veins and the greatsaphenous vein.The patient presented for

further evaluation in the officeand her pain and redness had improved with mild residual induration. Repeat ultrasound inthe office showed extension ofgreat saphenous venous thrombusinto the common femoral vein.She started treatment with

Lovenox and continued onCoumadin for 3 months. Follow-up ultrasound in three monthsshowed reflux in the great saphe-nous vein and resolution of thedeep venous thrombosis. Patientunderwent radiofrequency closureof the great saphenous vein as an outpatient procedure withoutcomplications. Coumadin wasstopped after the follow-up.

Sanjiv Lakhanpal M.D., FACS

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MAY/JUNE 2013 | 9

HE HITECH ACT IN 2009 SET INmotion a series of changes to the HIPAA rules that govern the use,disclosure and protection of protectedhealth information (PHI). TheDepartment of Health and HumanServices (HHS) subsequently issuedinterim regulations in response to thesechanges in the law, and this year issued a final regulation as of March 26, 2013that requires compliance by coveredentities and business associates within180 days. These final regulations make anumber of important changes that mayimpact your relationship with thevendors that provide electronic healthrecord (EHR) licensing and support.

First, prior to HiTech, businessassociates of covered entities were notrequired to comply with the securityrules and standards set forth in theHIPAA security regulations. HiTechchanged the applicability of the securityregulations to include businessassociates. The final regulation from

HHS implements this provision of theHiTech Act, but with a twist:subcontractors to business associates are also defined as business associateswithin the final regulation. What thismeans is that EHR vendors and theirsubcontractors must fully comply withthe HIPAA security rules, not just with“reasonable” security measures.

Second, prior to HiTech, there was nofederal requirement that a covered entityor business associate report a securitybreach that resulted in the disclosure ofprotected health information (PHI).

HHS subsequently issued interimregulations to implement thesenotification requirements, and as ofMarch 26, 2013, HHS issued finalregulations that alter the assumptionsand exceptions to what constitutes a“breach” under HIPAA. In addition,business associates and subcontractorsare obligated to report security breachesto covered entities.

Providers selecting an EHR vendorshould have an attorney review anyproposed contract between yourorganization and the vendor to ensurethat the business associate provisionscomply with the final regulations. If youalready have an existing relationship,work with your attorney to ensure thatthe contract in place complies with thefinal regulatory requirements. Allbusiness associate agreements must comeinto compliance with the finalregulations by September 2014.

In recent years, some EHR vendorshave moved to cloud-based data storage

and access solutions for their clients.These cloud systems store data collectedby the EHR at a remote data center, andmake it available over an Internetconnection with the provider. Some EHRvendors subcontract with a third partyto provide the cloud data storage. Morelikely than not, that subcontractor isnow a business associate under the finalregulations and takes on the sameobligations as the EHR vendor withregards to your data. The finalregulations require a covered entity’scontract with their business associate to

include subcontractor compliance withthe final security regulations.

Beyond compliance issues, providersshould evaluate whether an EHR vendorthat hosts your data in the cloud hassufficient security provisions. Such anevaluation makes good business sensebecause of the incredibly negativeconsequences of any security breach thatresults in a loss of PHI for a healthcareprovider. For example, does the vendorcomply with a recognized, nationalsecurity standard like NIST? Is the EHRvendor, or the data center it uses forstoring your data, audited against anSAS standard like SAS-70? What are thesecurity practices and security devices inplace at the EHR vendor to protect yourdata? If the vendor will host your data,what are its disaster recovery and databackup procedures? Are thoseprocedures regularly tested?

Providers and their counsel shouldalso evaluate what, if any, additionalprovisions should be negotiated into anyfinal agreements to require the EHRvendor’s compliance with a securitystandard, commitment to securityprocedures, and related obligations (suchas maintaining appropriate encryptionfor data during its transmission).

The changes in HIPAA compliancemean that providers cannot simply relyon the EHR vendor’s representations thatthey know best regarding security.Further, because the scope of HIPAA nowcovers most subcontractors of businessassociates that handle PHI, more entitiesrisk substantial fines for failing to complywith the applicable security standards. Allproviders should work with their counselto analyze and address compliance withthe final regulations. Tim Faith is an attorney with a private practice

focused on technology issues that intersect

with legal ones. www.faithlaw.com

Compliance

By Tim Faith

THow HIPAA Rule Changes MayAffect EHR Relationships

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“If you already have an existing relationship, workwith your attorney to ensure that the contract in placecomplies with the final regulatory requirements.”

– Tim Faith


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Combining Robotic-Assisted Surgery, Communicationand Multidisciplinary Care for Superb Outcomes

Saint Agnes Hospital’s ComprehensiveThoracic Program

Gavin Henry, M.D.,director of thoracicsurgical oncology,and his partner, Riny Karras, M.D.,thoracic surgeon.

MAY/JUNE 2013 | 11

HE THORACIC SURGEONSat Saint Agnes Hospital havecompleted their 100th thoracic

surgery case using the da Vinci SurgicalSystem, a state-of-the-art robotictechnology that is the most advancedsurgical equipment available. As proud asGavin Henry, M.D., director of thoracicsurgical oncology, and his partner, RinyKarras, M.D., thoracic surgeon, are ofthat milestone, they are even more proudof the multidisciplinary process they’vebuilt. With an emphasis on speed andaccuracy, patients and referring physiciansreceive not only a diagnosis but also acomprehensive treatment plan in a matterof days, not weeks.

At Saint Agnes Hospital, treatmentplans are created through a multi-disciplinary team that includes specialistssuch as medical oncologists, radiationoncologists and thoracic surgeons. The team meets weekly, ensuring acomprehensive plan with input from all appropriate disciplines.

Patient Education and PhysicianCommunication are EmphasizedDr. Henry, Dr. Karras and the rest of the thoracic team go to great lengths to ensure that patients thoroughlyunderstand their diagnosis and treatmentoptions and to communicate withreferring physicians to ensure that thecontinuum of care is never broken.

“We work closely with referringphysicians, updating them after ourinitial consult. We then keep theminformed as the patient progresses,” Dr.Karras says. “We always have patientsreturn to their physician afterwards fortheir ongoing care.”

Dr. Henry adds, “We spend an hour or more with each new patient to makecertain they have a clear idea of theirdiagnosis and appropriate tests. Theyleave with an understanding of their lungcancer stage, if appropriate. We encouragethem to call us with any questions.”

Experienced Robotic-Assisted SurgeryDr. Henry remarks, “We perform morerobotic surgeries than any other hospitalin Maryland. We use the robot toperform minimally invasive lobectomiesas well as other procedures such asthymectomies and mediastinum massresections. The robotic-assistedprocedure is appropriate chiefly for Stage 1 and 2 lung cancers. It allows usto use ¼ to ½ inch incisions, significantlyimproves our depth perception with a3D view and provides better angles sowe can reach more tumors with greaterdexterity. Patients leave the hospital assoon as one to two days post-op.”

As early as the evening of theirprocedure, patients can sit up and eatwithout pain, and they can even walk.On the second day following surgery,most patients are released from thehospital, an average of two days earlierthan patients undergoing an openlobectomy. “It makes a huge differenceto our patients that they can return to work or normal life so quickly. And, where appropriate, they can begin adjuvant chemotherapy sooner,”Dr. Henry says.

“When tumors approach 3 - 4 cm,there’s a higher likelihood of regionallymph node involvement,” notes Dr.Karras. “The robotic-assisted lobectomyprovides us with a greater ability to

dissect out the nodes and helps withstaging and post-op treatment. Previous studies have indicated that a lymph node biopsy was sufficient, but more recent data has found thatdissection is better. The roboticprocedure helps us achieve that.”

Dr. Henry comments, “Our robotic-assisted mortality and morbidity ratesare comparable to, and in some casesbetter than, our open lobectomy rates.However, not all patients are appropriatefor a minimally invasive procedure.Depending on the size and location of the tumor, and whether the patienthas had prior chemotherapy or radiationtherapy, we may perform an openprocedure. The key is giving patients a safe experience and the mostappropriate oncologic surgery.”

“The robot is a nice tool in ourtoolbox, but we’re very cautious aboutwhat we do,” Dr. Henry adds. “Wecontinue to do chest wall resections as an open procedure, for example.”

New Pulmonary Nodule Clinic Enhances Benign CareIn May 2013, Saint Agnes began offering a pulmonary nodule clinic that provides a comprehensive way todiagnose lung nodules. With the opening of this new service, benignnodules benefit from the same rapid,multidisciplinary approach thatmalignant nodules have received.

For more information about SaintAgnes’ new Cancer Institute, robotic-assisted thoracic procedures and theother advanced thoracic services at Saint Agnes Hospital, call 410-368-2910or visit www.stagnes.org.

We work closely with referring physicians, updating them after our initial consult. We then keep them informed as the patient progresses.” – Riny Karras, M.D.

TRACEY BROWN T

“


LINDA HARDER • PHOTOGRAPHY BY TRACEY BROWN

CHARACTER ANDCOMMITMENT

Continuing our yearly tradition, Maryland Physicianinterviewed female physicians we admire for their exceptional

commitment to leadership. They remind us of the importance ofmentors, family support and following your passion.

Exceptional

Using Epidemiology To Control CancerAs a child, Kathy Helzlsouer, M.D., MHS,director, The Prevention and ResearchCenter at Mercy Medical Center, hadBroadway dreams, but with a mother who was a nurse and a father who was aphysician, the odds were probably stackedin favor of a health career. She recalls, “My interest in medicine was a gradualthing. It wasn’t until I was a sophomore in college that I began to get interested inthe possibility of medicine as a career.Because I went to a small college, it washarder to get into medical school but I wasfortunate to be accepted at the Universityof Pittsburgh School of Medicine. There I had my first exposure to epidemiologyand eventually got a Masters degree whiletraining in oncology.”

Facing and Fighting DiscriminationFemale physicians of Dr. Helzlsouer’s generation still had to fight to be

accepted. Women comprised only 20% of her medical class. “If a woman saidsomething, then a male physician said thesame thing, he got the credit,” she recalls.“I even had a male colleague tell me that I had an abstract accepted just because Iwas a woman. Today, discrimination in the work place is still there, but it’s moresubtle and harder to detect. It’s particularlychallenging for women who are starting out to achieve any work-life balance. Wewere expected to work 60 to 80 hours aweek even after residency.”

Achieving Balance“I have a wonderful husband – he gave up his career path to support mine. As aconsultant, he’s more flexible. My priorityis to work hard but family always comesfirst. Men want that work-life balance now,too. Interestingly, though, it wasn’t until a male doctor came to a meeting with his young son in a backpack carrier thatHopkins finally got onsite childcare.

MAY/JUNE 2013 | 13

Kathy Helzlsouer, M.D., MHS, director, The Prevention and Research Center at Mercy Medical Center

KEVIN J. PARKS, MERCY MEDICAL CENTER


The women wouldn’t dream of showing upat a meeting with their children!”

In academia, balancing career goalswith caring is another tightrope that manyfemale physicians walk. “It truly is publishor perish. Women have a harder timesaying ‘no’ to committees and other servicework that can take away from that.”

Cancer Prevention and SurvivorshipIronically, Dr. Helzlsouer has experiencedthe tragic impact of cancer first hand, losingher one-year old daughter to leukemia.This has influenced her research path. She joined Mercy in 2004 to spearhead itsclinical research and programs in cancerrisk assessment and cancer survivorship.She has chaired or served on numerouscancer committees throughout her careerand was an associate editor for the Journalof the National Cancer Institute. As aresult of her contributions to the field, sheis the recent recipient of the Martin D.Abeloff Award for Excellence in PublicHealth and Cancer Control. Much of hercurrent work involves prevention andcounseling. “We conduct a geneticcounseling assessment for women who’vehad cancer or a strong family history ofcolon, breast or ovarian cancer.” Dr. Helzlsouer has also focused her

considerable talents on improving life after

cancer. When she came to Mercy, shestarted the Mind/Body Program, based on the one at Harvard. “Breast cancer can be very traumatic and lead to persistent fatigue. The Mind/Bodyapproach can reduce fatigue by 40%without medications. Complementarymedicine is so important and soundervalued. We need to think aboutcancer rehab in the same way that we do

cardiac rehab. Improving quality of lifereally motivates me. I hope to expand theresearch and programs to help all cancerpatients, especially women with ovariancancer. We’ve researched the underlyingcauses of aromatase inhibitors, whichincrease joint pain, and how we canprevent or minimize the problem,” sheadds. “Our survivorship program is critical for cancer patients, who otherwisewould fall through the cracks. Medicalprofessionals tend to be too focused on the cancer the patient had and not enoughon the ones that they’re at risk for in the future.”

Dr. Helzlsouer has passed on hercommitment to those she has trained. “I enjoy teaching. It’s rewarding to realizethat some of the leaders in the field todaytrained with me. My advice to youngphysicians is to find a great mentor. I had some wonderful mentors who helpedme find research work that makes adifference.”

Quality, Comfort, Dignity At The EndLakshmi Vaidyanathan, M.D., medicaldirector of the Shore Health SystemPalliative Care Program and Shore HomeCare Hospice, was destined to become aphysician. “Even as a child, I play-actedthe care taker, never tiring of pretending I was a doctor. I was the first in our familyto become a doctor, with my cousin and brother closely following suit. Myparents, who truly honor medicine as a‘noble profession,’ were always there tolend encouragement. They sacrificedgenerously to help me see my career goals through.”

Fortunately, she encountered littlegender discrimination in her training.

“When I completed medical school inMumbai, India in the late 1990s, half of myclassmates were women. While most of theprofessors were male, I felt womenstudents were treated equally to men.”

As did many women physician leaders,Dr. Vaidyanathan enjoyed the support ofexcellent mentors during her residency inPittsburgh. “My mentors not only wereexcellent clinicians but also humane,

dynamic physicians who believed in closeinteraction with their patients. One whowas particularly inspiring spearheaded arobust palliative care program that wasahead of its time. His vision was a greatexample for me.”

That experience influenced her pursuitof certification by the American Academyof Hospice and Palliative Medicine.During her tenure as Chief of Staff atShore Hospital System, she started thepalliative care service with the blessings ofsenior leadership. Initially located at theMemorial Hospital, Easton, the programhas expanded to Dorchester GeneralHospital and has grown threefold. Herefforts to launch this program wererecognized when she received the 2012Arthur B. Cecil, Jr., M.D. Award forExcellence in Healthcare Improvement.

“Palliative care is not about death anddying – it’s about living your best life inthe time you have left,” observes Dr.Vaidyanathan. “We strive to maximizepatient well being, and tailor their care towhat serves their needs best underdifficult circumstances. We minimizeexcessive testing and intervention thatmay do more harm than good, but wedon’t give up on them – our multi-disciplinary team approach seeks to do the right thing at the right time.”

She acknowledges, “Physicians nowrecognize the value of requesting apalliative care consult. Most palliative careprograms start in the inpatient setting, butas they grow, they expand to outpatient andhome settings because we want to providetimely interventions instead of waiting untilpatients need emergency care.”

The Cecil Award honor has helped toraise the profile of Shore Health’s palliativecare program. She comments, “That’s been

Lakshmi Vaidyanathan, M.D., medical directorof the Shore Health System Palliative CareProgram and Shore Home Care Hospice

“The best advice I ever got was not to choose my career path based on aconcern about lifestyle implications.”

— Regina Hampton, M.D.

MELISSA GRIMES-GUY, LOCATION PHOTOGRAPHY, INC.

a fantastic boost to our efforts. One of ourgoals for the coming year is to raise publicawareness so that patients and theirfamilies know to ask for palliative care.”

A Family Juggling ActBeing married to a urologist and cominghome every evening to care for two youngchildren is challenging but also a great joy.“My husband is one of my inspirations,”she enthuses. “Maybe because he’s retiredArmy, he just rolls up his sleeves to pitch inwhen he comes home to ‘accomplish themission’ as he puts it. We strive to spendquality time with our children and are veryinvolved in their school. I believe the oldcliché, ‘it takes a village.’ This ringsespecially true in our busy household as we balance raising our children andmaintaining a healthy home and career.”

Sports Medicine Picked Me It’s not surprising that Leigh Ann Curl,M.D., who helped the Baltimore Ravenswin their second Super Bowl this yearwhile being a mother to two youngchildren, has always been a high achiever.“I’ve always gotten by with little sleep,”she notes. “I’m up by 5 am most morningsafter six hours of sleep. It takes a lot of self discipline and I have always pushed

myself personally and professionally.”The second oldest of six children in

a close-knit family, Dr. Curl, who is anorthopaedic surgeon at the Center forSports Medicine and Shoulder Surgery atMedStar Harbor Hospital and the HeadOrthopaedic Surgeon for the Ravens, hadan early morning paper route as a child.She was the first in her family to earn acollege degree and was class valedictorianat the University of Connecticut. However,she nearly missed a key deadline to declarefor medical school. “I made a final decisionto apply about four weeks before most ofthe deadlines. In medical school at JohnsHopkins, I had an immediate positivereaction to orthopaedics. You could say thatsports medicine picked me. The positiveshave to outweigh the negatives of what youchoose and it’s easy to work hard when youenjoy what you do.”

Times Have ChangedWhen Dr. Curl interviewed for herorthopaedic residency, she encountered noother females during the interview process.“I was fortunate to have some excellentmentors and faculty at Hopkins whofostered my interest in orthopaedicsdespite it being a nontraditional career pathfor women at the time,” she recalls.

“I realized early on that the surgicalattendings were most interested in howwell you did your job, but I may have hadless margin for error than the men.” Shenever sensed blatant discrimination duringher training at Hopkins, but she does recallthat she was asked some inappropriatequestions in her residency interviews atother institutions, such as whether she wasplanning to have children or if she couldphysically handle the job. She laughs, “I was probably physically more capablethan some of the interviewers.”

A Long Sports CareerServing the Ravens is the culmination of a long sports career with top-notch teams.Dr. Curl was herself a Division I basketballstar at the University of Connecticut. After becoming an orthopaedic surgeon,she served in various capacities as teamphysician for the University of MarylandTerrapins, New York Mets, BaltimoreOrioles, USA Women’s Basketball, USA Women’s Rugby, Johns HopkinsUniversity and St. John’s University inNew York teams.

“My initial team physician experiencewas with the Mets and St. Johns during my fellowship training before returning to a faculty position at Hopkins,” she

MAY/JUNE 2013 | 15

Leigh Ann Curl, M.D., orthopaedic surgeon,MedStar SportsHealth at Harbor Hospital,and head orthopaedic surgeon for the Baltimore Ravens

remembers. “Then I was recruited toUniversity of Maryland to help start theirsports medicine program and work withthe Ravens and College Park. You just chipaway at the barriers.”

Her initial reluctance to be in thelocker room with male athletes vanished inher time with the Mets. “An equipmentguy directed me back to the locker roomtraining area after practice, jokingly tellingme the guys didn’t have anything I hadn’tseen already. Today, it’s not a big deal. Iused to be acutely aware of being a woman,but now there are growing numbers offemale sports physicians and trainers.”

Football is a Year-Round Commitment“It’s really a year-round job that consumeswhat would otherwise be mostly freetime,” notes Dr. Curl when describing herjob with the Ravens. A new season “starts”with preparation for the draft at the NFLCombine each February. “We do physicalson over 300 potential draft picks and areburied in the bowels of the stadiumlooking at MRIs and other test results.There’s the draft, free agency, off seasonworkouts and then the true start of theseason in July. Football probably occupies30 weekends a year on average, and theSuper Bowl makes it an especially longseason. But I love what I do.”

Follow Your Passion And Be Part Of The SolutionRegina Hampton, M.D., FACS, breastsurgeon, medical director ofComprehensive Breast Care Center atDoctors Community Hospital, didn’tfollow a traditional route to becoming asurgeon. After graduating from college,where she wasn’t interested in takingtraditional pre-med classes, she worked fortwo years as a radiation therapist.Fortunately, the Medical College ofPennsylvania took non-traditional students.“I was a little more focused than those whowent straight through,” she recalls.”

Her love of surgery came as a surprise.“I thought I would like family practice orpediatrics, but I didn’t. I was surprised tofind that I loved my surgical rotation. But Iworried that I wouldn’t be able to have afamily if I was a woman in surgery. Aftertalking with lots of female surgeons,though, including one who took a full dayoff each week to be with her children, Irealized I could do it.”

She started her career as a generalsurgeon, but began receiving adisproportionate share of breast cases. “In the last four years, I’ve focused

exclusively on breast surgery,” she says.“It’s very gratifying to focus on this ever-changing field that is moving tocustomized treatment for each woman.And today, most of my patients will survive their cancer.”

Nipple Sparing Breast SurgeryOne of the most significant advances inbreast surgery is nipple-sparing surgery. “If the woman has a small tumor, we leavethe nipple and the skin fold. We fill in the breast with an implant or abdominaltissue (TRAM) and hide the scar under the breast so it looks normal.”

Dr. Hampton is also enthusiastic abouthaving more treatment options. “Everypatient can make the choice that’s best forthem. We’re learning that breast cancer isdifferent in every person. A small tumorcan spread quickly, while some largetumors will not. Young women often don’twant to have to get a mammogram everysix months for the rest of their life – theywant to go back to the peace of mind theyhad before they were diagnosed. Theymay opt for bilateral mastectomies andbenefit from our ability to give them greatcosmetic results.”

Family SupportAs with so many other female physicianleaders, Dr. Hampton credits her husbandand in-laws with allowing her to have ayoung child while managing a busypractice. “Their support really helps,” shestates. “It’s allowed me to run and grow my practice, and even to do speakingengagements or participate in weekendhealth fairs.”

She encourages female physicians intraining to follow their passion. “The best

advice I ever got was not to choose mycareer path based on a concern about its lifestyle implications. You can adaptyour career to your lifestyle and find aspouse that understands the demands of your career.”

Leadership and Legislative InvolvementDr. Hampton is a past president of thePrince George’s Chapter of MedChi whereshe was involved in supporting relevantlegislation. “I always had the attitude thatit is better to be part of the process,” shesays. Prior to her MedChi work, she hadserved on several hospital committees,including the Operating Room andMedical Executive committees. “I want tobe at the table for things that are relevant.You can’t just sit back and complain – youneed to be part of the solution.”


Leigh Ann Curl, M.D., orthopaedic

surgeon, MedStar SportsHealth at

Harbor Hospital, and head orthopaedic

surgeon for the Baltimore Ravens

Kathy Helzlsouer, M.D., MHS, director,

The Prevention and Research Center,

Mercy Medical Center and adjunct

professor of Epidemiology at the Johns

Hopkins University Bloomberg School

of Public Health

Lakshmi Vaidyanathan, M.D., medical

director of the Shore Health System

Palliative Care Program and Shore Home

Care Hospice

Regina Hampton, M.D., FACS,

breast surgeon, medical director of

Comprehensive Breast Care Center

at Doctors Community Hospital

Regina Hampton, M.D., FACS, medical director of Comprehensive Breast Care Center at Doctors Community Hospital

MAY/JUNE 2013 | 17

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 28,000 member physicians have qualified

for a monetary award when they retire from the practice of medicine. More than 1,800 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. Call (866) 990-3001 or visit www.thedoctors.com/tribute.

We do what no other medical malpractice 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.

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.

www.thedoctors.com

Menopausal Women

Clearing Up the Controversies


ABDOMINALLY PLACED PELVIC MESH IS SAFE An estimated 3.3 million U.S. women have pelvicprolapse, and that number is expected to grow by about 50% in the next few decades as womenlive longer. Victoria Handa, M.D., FACOG,professor of Obstetrics/Gynecology and director,Advanced Training Program in Female PelvicMedicine and Reconstructive Surgery at JohnsHopkins Bayview Medical Center, hopes toclarify several critical misconceptions aboutpelvic prolapse and how to best treat it.“Sometimes even among OB/GYNs who don’tsee many women with prolapse, there’s amisunderstanding about what prolapse is, and a tendency to confuse it with bowel and bladderfunction issues. Women often have more thanone issue and when they call me saying they have a dropped bladder, they mean they have a non-functioning bladder. They may or may not have pelvic prolapse.”

In the past, pelvic support defects were labeledby the organ that was prolapsed (e.g., enteroceleor cystocele). The current convention is toclassify the prolapse based on where it is and how severe it is. Anterior and posteriorcompartment prolapses herniate toward the front and back of the vagina, respectively, whilein apical compartment prolapses, the top of thevagina (and sometimes uterus) fall down. Insevere pelvic prolapse, the uterus protrudesoutside the vaginal entrance.

EvaluationThe primary assessment for pelvic prolapse is ahistory and physical exam. If bowel and bladderissues coexist, the physician may also evaluatethose. “Patients occasionally, but not normally,need imaging. We can usually deduce the type of prolapse from the physical exam,” explainsDr. Handa.

Treatment OptionsNon-surgical approaches for pelvic prolapsegenerally consist of pelvic muscle strengtheningexercises and/or a pessary. Dr. Handa notes, “I tell patients that the pessary is a supportivedevice. Like contact lenses, it doesn’t make theproblem go away, but it can relieve yoursymptoms. Some women use the pessary untilsurgery, while others may use it long term.”

Pelvic muscle exercises typically involve weeklyphysical therapy for about two months. “Usually,if a woman doesn’t have a benefit within threemonths, we discontinue it.” Surgery can beperformed vaginally, with an abdominal incision,laparoscopically or robotically.

“In the past few years, our thinking haschanged and we focus more on apical prolapse,pulling the top of the vagina up. Surgical repairsthat don’t provide support to the vaginal apexare not as successful in the long term. The goodnews is that, over the past 10 to 15 years, we’veaccumulated good scientific data to guide us.Sacropexy is considered the gold standard.”

MAY/JUNE 2013 | 19

Maryland Physician spoke with women’s health experts to provide the latest medical information

on common issues in middle-aged women – osteoporosis, hormone replacement therapy and

pelvic prolapse. Here is their advice.

BY LINDA HARDER

PHOTOGRAPHY BY TRACEY BROWN


If the patient has bowel and bladderissues for which surgery is appropriate,surgeons can address those in the sameprocedure.

Misunderstandings About Mesh Dr. Handa is dismayed by inaccurateperceptions about the safety of meshused in prolapse repair that have resultedfrom recent FDA advisories concerning a specific class of surgeries that includetransvaginal implantation of mesh.

In 2009, the FDA issued an advisorythat reported increased complicationsfrom transvaginal mesh products. In2012, they issued a second advisory.“However, the advisory only pertains to a very narrow class of mesh that isplaced transvaginally to treat prolapse, which I’ve never used. It does not pertainto mesh placed abdominally or totreatment for stress incontinence,”underscores Dr. Handa. “Unfortunately,the FDA advisory keeps many womenfrom coming in and makes themunnecessarily afraid to have any type of surgery for their prolapse. Physiciansneed to help address this misconception

with accurate information such as that at the FDA website (www.FDA.gov).”

New FPMRS Subspecialty BoardAnother positive development inprolapse treatment is that there are agrowing number of specialists in FemalePelvic Medicine and ReconstructiveSurgery (FPMRS). This year for the firsttime, urologists and gynecologists whohave specialized training can pass arigorous exam to become boarded in this subspecialty.

“Until now, it’s been hard to knowwhat credentials to look for,” Dr. Handastates. “This certification will helpreferring physicians and patients knowwho has the expertise. Over time,hospitals will change their credentialingprocess accordingly.”

OSTEOPOROSIS: WHOSHOULD BE TREATED ANDWHEN? Surprisingly, far more women haveosteoporotic fractures than new strokes,heart attacks or invasive breast cancercombined. The National Osteoporosis

Foundation (NOF) estimates that morethan 10 million Americans have thiscondition, and nearly half of allCaucasian women and about 20% ofmen will have an osteoporotic fracture in their lifetime. While fractures havedeclined in the past few decades, lessthan one third of osteoporosis cases have been diagnosed and only oneseventh of U.S. women with osteoporosisreceive treatment.

DXA RecommendationsThe NOF recommends that all men over50 and all post-menopausal women beevaluated clinically for their osteoporosisrisk; those at higher risk should receivedual-energy X-ray absorptiometry (DXA) prior to age 65; women not atrisk should receive DXA at age 65 (men at age 70), and typically every two years thereafter.

“Two to three years post menopause iswhen the greatest bone loss occurs,” saysJames Mersey, M.D., an endocrinologistat GBMC. “Age, sex, weight, family andpersonal history of fracture, smoking,drinking, certain diseases such as

Victoria Handa, M.D., FACOG, director, Advanced TrainingProgram in Female Pelvic Medicine and ReconstructiveSurgery at Johns Hopkins Bayview Medical Center

MAY/JUNE 2013 | 21

rheumatoid arthritis and corticosteroiduse are among the key risk factors.”

Dr. Mersey says, “The average 70 yearold female has osteoporosis, and anyonewith osteoporosis is at increased risk offracture. Anyone who has lost height, ison steroids, has hyperthyroidism,

smokes or drinks, or who has a familyhistory, should get a DXA. Diabetes alsoincreases the risk. If on therapy, theDXA should be repeated yearly. Aftertwo normal DXA scans, getting scannedevery three to five years is reasonable.”

DiagnosisDXA generates a T-score that comparesthe patient’s bone density to the optimalbone density for others of the same sexand ethnic group. A T-score greater than -1 is considered normal. A score of -1 to -2.5 implies a higher risk ofdeveloping osteoporosis, and a score of -2.5 is diagnostic.

The 10-year risk of a fracture can bemeasured using a fracture riskassessment (FRAX) tool developed bythe World Health Organization. It uses a computer algorithm that takes intoaccount age, sex, weight and height, and other variables. Patients cancalculate their approximate risk onlineeven without having their bone mineraldensity (BMD) tested.

TreatmentIf the FRAX score indicates osteoporosis,the patient is typically referred to anendocrinologist or rheumatologist fortreatment. A metabolic work-up providesinformation about the underlying causeof the disease, measuring thyroidhormones, serum CTX, urine calcium,Vitamin D levels and more. “Currently,there is no indication for Vitamin Dsupplements other than bone health,”notes Dr. Mersey.

“Before you treat osteoporosis, youshould measure 25 hydroxy vitamin Dand if necessary, restore vitamin D levels to the normal range. If not most

therapies run the risk of causingsustained low calcium levels, or at leastbeing ineffective,” Dr. Mersey advises.“We typically provide 50kl units perweek for six or more weeks, and thentake a second level to see if we need to continue it.”

The use of bisphosphonates (BPs) has been controversial in recent years,but research data supports its use inwomen with:z Hip or vertebral fracturez BMD <-2.5 at the lumbar spine or

femoral neckz Low BMD and 10-year risk of hip

fracture >3%

The data also demonstrate that serious side effects with BPs areuncommon. Dr. Mersey comments, “I’ve treated 5000 patients withFosamax and have never seen anyonedevelop osteonecrosis and have only seenone patient with an atypical femoralfracture. We still don’t know how longit’s ideal to use BPs, however. At fiveyears, we give a break in treatment if

the bone density is improved. If it is stilllow and at high risk for fracture, wecontinue treatment. In 2013, the choicesfor therapy haven’t broadened, but wehave better data about what works.”

The key issue with oral BPs (e.g.,alendronate, risedronate) is lowadherence – typically, half of patients arenot taking them appropriately. Dr.Mersey often recommends a yearlyinjection of parenteral therapy (e.g.,zoledronic acid) or a semiannualinjection of Prolia to ensure that patientsget the appropriate dose.

Other commonly prescribedmedications include Forteo, the onlyanabolic therapy for bone loss -appropriate for many patients for twoyears. After bone density has increased,physicians switch their patients to othertherapies to maintain bone density.

Prolia, a monoclonal antibody, is apowerful anti-resorptive agent injectedevery six months for women who cannottake BPs. Dr. Mersey explains, “We wantit to wear off so the bone turnover rate is not zero, creating more flexible bone.There’s a slight risk of dermatitis, butthere are no immediate side effects andeven dialysis patients can be on thistherapy. Patients must have adequateVitamin D levels, however.”

He concludes, “A commonmisunderstanding about osteoporosistreatment is that older women don’tneed it. But it can reduce the risk ofanother spinal fracture by 70% and a hip fracture by 25% in one year,preventing many women from

“Currently, there is no indication for Vitamin D supplements other thanbone health.” – James Mersey, M.D.

James Mersey, M.D., endocrinologist at GBMC


hospitalization and a downward healthspiral. It’s the quality of life, not howlong it prolongs life, that’s important.”

HORMONE REPLACEMENT:SAFE AFTER ALL? The Women’s Health Initiative study (a 15-year research study launched in1991) raised significant questions aboutthe safety of hormone replacementtherapy (HRT) for older women. Sincethe study was discontinued in 2002,however, researchers have reassessed thedata from that study and determinedthat HRT can be a safe and eveninvaluable aid to many women in theperi-menopausal and early menopauseyears. Several major professionalsocieties now consider HRT to be themost effective available treatment.

Darryn Band, M.D., OB/GYN withCapital Women’s Care and an associateclinical professor at George WashingtonUniversity, says, “The WHI study founda slightly higher risk of stroke, coronaryartery disease and breast cancer, but the average patient in their study washeavier, aged 65 or older and many weresmokers, so it was not a fair comparison.These effects were limited to those

participants taking combination oralHRT. The estrogen-only group (thosewho had had hysterectomies) did nothave an increased risk of breast cancer.”

Women who have an intact uterusmust take progesterone along withestrogen to prevent hyperplasia and the risk of uterine cancer. Dr. Bandcontinues, “The study scared women tothe extent that the percent of peri-menopausal or menopausal womenusing HRT has declined from about50% in 2002 to 25 - 30% today. Today,many experts feel there are significanthealth benefits to women who beginHRT at the onset of menopause. A clear benefit is the relief of vasomotor

symptoms and urogenital health,including urinary urgency, possibledecrease in recurrent UTIs and relief of vaginal atrophy. In addition, HRT has been shown to reduce the risk ofcolon cancer and improve bone health.

“Our goal is to improve quality of life and provide therapy for symptom

relief for as short a time as possible,” he adds. “Many GYNs feel we’ve done a disservice to women. The pendulum is definitely swinging back. In fact, more GYNs are starting to use estrogenand progesterone to alleviate symptomsof peri-menopause, which includeirregular vaginal bleeding and moodlability. These symptoms result fromrapid fluctuation in hormoneproduction, which settle down followingmenopause.”

The key is the route of administrationand using the lowest dose for theshortest possible time. “Some havesuggested that transdermal andtransvaginal administration may reduce

some of these risk factors by bypassingthe liver.”

There are other options for those not interested in hormones. Newproducts such as IsoRel, a soy isoflavonesupplement, help with mild to moderatehot flashes. However, black cohosh andfish oil have not been proven effective.

A group that includes prematureovarian failure prior to the average age of 51, spontaneous or postoopherectomy, may benefit fromhormone replacement therapy. It hasbeen shown that these women havehigher morbidity and mortality thanwomen with normal hormonalproduction.

Dr. Band concludes, “HRT should be used for those women that are havingsevere vasomotor symptoms, issues ofwell-being or urogenital issues. It shouldnot be used for primary prevention ofheart disease or osteoporosis.”

Victoria Handa, M.D., FACOG, professor

of Obstetrics/Gynecology and director,

Advanced Training Program in Female

Pelvic Medicine and Reconstructive Sur-

gery at Johns Hopkins Bayview Medical

Center

James Mersey, M.D., endocrinologist,

GBMC

Darryn Band, M.D., OB/GYN with Capital

Women’s Care and an associate clinical

professor at George Washington Univer-

sity

“The pendulum is definitely swingingback... more GYNs are starting to useestrogen and progesterone to alleviatesymptoms of peri-menopause.”– Darryn Band, M.D.

Darryn Band, M.D., OB/GYNwith Capital Women’s Care

RANDY SAGER PHOTOGRAPHY, INC


MANAGINGCONCUSSIONS

And Choosing Wisely

Maryland children are benefiting from national and local initiatives that promote

better treatment of concussions and that limit unnecessary tests and procedures.

Our Maryland medical experts explain.

BETTER MANAGEMENT OF CONCUSSIONS IN THE YOUNGAs the medical community becomesincreasingly aware of the possibleeffects of even minor trauma to thebrain, and as Maryland became the18th state to pass laws addressingconcussion management in 2011,programs to treat concussions aremushrooming. The KennedyKrieger Institute now offers onesuch center, the NeurorehabilitationConcussion Clinic, as the newestarm of their Pediatric Brain InjuryProgram, which now addresses thefull spectrum of brain injury severity.

Stacy Suskauer, M.D., thecenter’s medical director, also wasappointed by the Centers forDisease Control and Prevention(CDC) to a work group developingnational clinical diagnosis andmanagement guidelines forconcussions in children and teens.She explains, “Our program atKennedy Krieger is unique – everychild sees both a neuropsychologistand physician at every visit. Thephysician may be a pediatricneurologist, physiatrist, or pediatricsports medicine physician,depending on the child’s needs. For example, those with co-existingcervical injuries may be directed to the pediatric sports medicinespecialist.”

The clinic treats patients agedthree to 18; not surprisingly, morethan half are athletes, and themajority are teens. Perhaps lessobvious, however, is that a minorityof these children have lostconsciousness. Also surprising isthat experts now know thathelmets may do little to protectagainst some concussions, ashelmets don’t stop the rotationalforces that cause most concussions.

“We know that pediatriciansmay not have time in their busyschedules to manage thesepatients,” Dr. Suskauer says.“That’s why we’re here.”

DiagnosisNo one diagnostic test can evaluateconcussions. Dr. Suskauer states,“MRIs are not typically ordered.Neurocognitive tests are useful ifthere’s a history of trauma, whetheror not symptoms are notedimmediately after injury. If parentsthink the child’s memory is not quiteright, or if a straight A student issuddenly performing as an averagestudent, that’s cause for evaluation.”

All of those evaluated by theclinic receive neuropsychologicaltesting, and the clinic providersreach out to the child’s school with recommendations foraccommodations.

MAY/JUNE 2013 | 25

“If parents think the child’s memory is not quite right, or if a straight A student is suddenlyperforming as an average student,that’s cause for evaluation.”

– Stacy Suskauer, M.D.

Stacy Suskauer, M.D., medical director, Neurorehabilitation Concussion Clinic at Kennedy Krieger Institute


Current Treatment ApproachesDr. Suskauer notes, “Cognitive rest is a hot topic now. Is rest best?Yes, at least for the first few days.We avoid an approach of strictconfinement until the child is 100% better, because that can leadto additional stress and moodconcerns. Instead, we take asymptom-based approach andminimize whatever aggravates thechild. Texting, television and otheractivities can be undertaken to the child’s tolerance. Some childrenlike to listen to, rather than watch,television.

“We try to keep the child movingahead without slowing theirrecovery,” she continues. “Familiesoften don’t realize that, during thefirst few days, symptoms can evolverather than improve. In the first two weeks, there is a metabolicmismatch; the brain needs moreglucose but glucose delivery isimpaired. Data suggests that DHA(docosahexaenoic acid) can behelpful for brain injury recovery. We recommend a moderate dosebased on weight.”

After about three to four weeks,many children are ready for asecond phase of treatment, withincreased safe physical activity. Dr.Suskauer recommends, “Start withjust five minutes of walking, andstop before or as symptoms emerge.

Especially in athletes, safe exercisemay be a critical intervention toimprove cerebral blood flow.”

Children with cognitive deficitsmay also benefit from amantadine.It increases dopamine, which dropsafter brain injury, and blocks theNMDA receptor, a memoryfunction. “We don’t know yet whichof these mechanisms is helpful,”observes Dr. Suskauer. “We alsomay prescribe melatonin if thepatient’s sleep is disrupted, as sleepis vital for recovery.”

Dr. Suskauer concludes, “Oneproblem physicians should be aware of is that teens underreportsymptoms because they feelpressured to be on the field. The

bottom line is – when in doubt, sit itout. If there’s any question, that’swhy we’re here.”

CHOOSING WISELY: WHEN MORE IS LESSAn initiative launched by theAmerican Board of InternalMedicine (ABIM) Foundation in 2012 called Choosing Wisely®

encourages conversations betweenphysicians and patients to promoteappropriate testing. The foundationstates that its goal is to help patientschoose care that is:- Supported by evidence- Not duplicative of

tests/procedures already received- Free from harm- Truly necessary

The initiative aims to keep themessage succinct and simple enoughto be useful to patients. To that end,each medical society that participateshas been asked to develop a list of“Five Things Physicians and PatientsShould Question.” In April 2012,nine medical societies participated inthe first release of these lists. InFebruary 2013, another 18 societiesadded their lists, including TheAmerican Academy of Pediatrics(AAP), the American Academy ofFamily Physicians (AAFP) and theSociety of Hospital Medicine –Pediatric Hospital Medicine. TheAAFP’s list does not contain anyitems pertaining to pediatrics,however.

Neil Siegel, M.D., clinicalassistant professor of Family andCommunity Medicine at University

Five Things Pediatricians and PatientsShould Question1. Antibiotics should not be used for apparent viral respiratory illnesses

(sinusitis, pharyngitis, bronchitis).

2. Cough and cold medicines should not be prescribed or recommended forrespiratory illnesses in children under four years of age.

3. CT scans are not necessary in the immediate evaluation of minor headinjuries; clinical observation/Pediatric Emergency Care Applied Research

Network (PECARN) criteria should be used to determine whether imaging

is indicated.

4. Neuroimaging is not necessary in a child with simple febrile seizure.5. CT scans are not necessary in the routine evaluation of abdominal pain.Adapted from the American Academy of Pediatrics Choosing Wisely® list.

Neil Siegel, M.D., medical director of UniversityCare

of Maryland School of Medicine,observes, “I’ve been attuned to this conservative mode of practicesince my residency training, butChoosing Wisely is giving meadditional tools to use when talkingto my patients. It also helps to startconversations with my colleagues or anyone who is suspicious thatyou have an ulterior motive if youdon’t recommend undertaking aprocedure or test. It helps make thecase that you’re not trying to cutcosts or save money.”

He adds, “I can use this list to tell my patients that I’m doing thisto keep them safer. Doing more isnot always better. Sometimes extratests don’t help, and sometimes theyeven cause harm. For example,antibiotics can cause an allergicreaction, or unnecessary imagingtests emit radiation that can beharmful when it accumulates.”

Dr. Siegel describes the widevariability of pre-op testingpractices among hospitals andphysicians. “One hospital will sendme evidence-based guidelines, whereonly certain patients need an EKG,for example. Other hospitals willrequire ordering everything on thepre-op list, regardless of thepatient’s age and health. It’s moreconvenient for the doctor to geteverything because they know therewon’t be a delay. But it can lead tounnecessary testing.”

Another major area of concern in recent years is the overuse ofantibiotics. Recent guidelines have been issued to discourageprescribing antibiotics for many ear infections or sinus infections, for example.

“My advice to doctors,” says Dr. Siegel “is to become familiarwith your own specialty’s list. Makesure you’re implementing thoserecommendations in your ownpractice. Also review the lists fromany related specialties. Really ownyour own society’s measures andbecome familiar with the broadercampaign. All of us serve as publichealth information sources for ourneighbors, family and friends. When they ask us, we should tellthem that sometimes less is better.Our specialty societies also have an obligation to publicize the

campaign in their medical meetings.Hopefully, media attention will help to generate awareness among consumers.”

We have a TV screen in ourwaiting room that we can use for educational purposes such asthis Choosing Wisely campaign,” he continues. “We prefer tocustomize our messages, though, so that patients only get messagesappropriate to their personalsituation.”

Consumer Reports also is helpingto educate consumers, with a seriesof reports and eventually a series of videos on Choosing Wisely. TheAARP, the Leapfrog Group, theNational Partnership for Women & Families, Wikipedia and others,are among a long list of otherorganizations working to educatethe general public about theseguidelines. Visit www.choosingwisely.org for more information.

The AAP’s list of five things toquestion is shown in the sidebar onpage 26. Other societies’ lists alsoinclude various pediatric tests andprocedures to question, such as:

z DON’T diagnose or manageasthma without spirometry.(American Academy of Asthma,Allergy and Immunology)

z DON’T prescribe oral antibioticsfor uncomplicated acute externalotitis. (American Academy ofOtolaryngology)

z DON’T do CT for the evaluationof suspected appendicitis inchildren until after ultrasoundhas been considered as an option.(American College of Radiology)

z DON’T perform ultrasound on

boys with cryptorchidism.(American Urologic Association)

z DON’T order chest X-rays inchildren with uncomplicatedasthma or bronchiolitis.

z DON’T routinely use broncho-dilators in children withbronchiolitis.

z DON’T use systemiccorticosteroids in children under2 years of age with anuncomplicated lower respiratorytract infection.

z DON’T routinely treatgastroesophageal reflux in infantswith acid suppression therapy.

z DON’T use continuous pulseoximetry routinely in childrenwith acute respiratory illnessunless they are on supplementaloxygen. (the last five are from theSociety of Hospital Medicine)

MAY/JUNE 2013 | 27

Stacy Suskauer, M.D., medical

director, Neurorehabilitation

Concussion Clinic at Kennedy

Krieger Institute and assistant

professor of physical medicine and

rehabilitation at the Johns Hopkins

University School of Medicine. Dr.

Suskauer is a member of a CDC

work group where she is

developing national clinical

diagnosis and management

guidelines for concussions in

children and teens.

Neil Siegel, M.D., assistant

professor of Family Medicine at

University of Maryland School of

Medicine, medical director of

UniversityCare and physician at

UniversityCare at Edmondson

Village

AMERICAN ACADEMY OF NEUROLOGY GUIDELINES

> Athletes suspected of sustaining a concussion should immediately beremoved from play to minimize further injury.

> Before returning to play, athletes should be assessed by a professionaltrained in diagnosing and managing concussions.

> Athletes high school-age and younger who have a concussion shouldbe managed more conservatively.

Maryland Wellness Magazine is for discerning healthcare consumers makinghealth and wellness choices for themselves and their families.

For Advertising Information Contact:Jacquie Cohen Roth

President/CEO, mojo media, llc443.837.6948 | [email protected]

www.mojomedia.biz

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Maryland Wellness Magazine – Your health. Your life.™

Fall 2013

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VOLUME 1: ISSUE 1 FALL 2013

MA RY L A N D

YOUR HEALTH. YOUR LIFE.

Wellness

MAY/JUNE 2013 | 29

Healthcare IT

TELEHEALTHBY LINDA HARDER

S TECHNOLOGYimproves and reimbursement trends toglobal or performance-based pay,telehealth is becoming a more importantway to deliver care. Maryland Physicianspoke with early adopters to learn howlegislation is reducing barriers and howthis technology is being used in practice.

Legislative InitiativesH. Neal Reynolds, M.D., associateprofessor at the University of MarylandSchool of Medicine, and director ofProgram Development for the MarylandCritical Care Network, was a member of the state telemedicine task force twoyears ago. This year, in concert with theMaryland State Medical Society (MedChi) and others, he fought forsignificant legislative reform. Dr. Reynolds says, “There are three mainbarriers to the expansion of telemedicine:1) reimbursement, 2) the burden of

duplicative credentialing in multiplehospitals and 3) interstate licensure. Legislation requiring private insurers toreimburse telemedicine passed last year,but Medicaid was given a mandate tojustify non-participation. Legislationintroduced this year (HB 931/SB 496)aimed to enhance State of MarylandMedicaid reimbursement for telemedicineservices. Unfortunately, the bill thatpassed will dramatically limit Medicaidreimbursement for telehealth to selectconditions in the emergency department.”He continues, “Credentialing was

another push this year – The JointCommission and the Centers for Medicare and Medicaid Services (CMS)agreed that the originating hospital(defined as where the patient is located)can accept a consulting physician’scredentials from the hospital providingtelemedicine, but Maryland is the onlystate that has a Code of MarylandRegulations (COMAR) regulation thatrequires ‘primary source’ credentialing of every telemedicine consultant.”SB 798/HB 1042 (Hospitals –

Credentialing and Privileging Process –Telemedicine) reduces the credentialingburden of a telemedicine consultant bypermitting “proxy privileging.” MedChiamendments were negotiated with theMaryland Hospital Association and requirethe telemedicine consultant to be aMaryland licensed physician and thecredentialing and privileging decision tobe approved by hospital medical staff.“This legislation is a big step,” notes

Dr. Reynolds. “Telehealth will be cheaperand doctors will be more likely toparticipate in telemedicine programsthanks to this legislation. For physicians,the burden of multiple hospital privilegingpackets can be totally overwhelming.” Another bill (HB 934, SB 776) that aims

to reconvene and fund the telemedicinetask force passed both houses easily; itaddressed its structure, linking to CRISP(Maryland’s initiative to connect providerselectronically), setting up a state registryand other operational issues. A fourth bill(SB 494/HB 937) that sought to enhancethe security of Personal Health

EXPANDS CARE BEYOND OFFICE WALLS

A

Information (PHI) via a cooperative andknowledge-sharing relationship with theMaryland Cyber Security Commission did not pass.

Extending Primary CareWhile this year’s legislative battles ensued,Seth Eaton, M.D, MPH, medical directorof MedPeds in Laurel, took advantage ofthe new reimbursement for telehealth tooffer this service to patients. Launched in March 2013, Dr. Eaton and his fourphysician partners and three nursepractitioners use telehealth to provideafter-hours urgent care to their patients.They also use telehealth to provide somemental health visits and follow-up careafter discharge. “There are two issues where primary

care telemedicine is needed – first, toexpand availability when the office is notopen and second, to improve coordinationbetween hospitals and primary care afterdischarge,” notes Dr. Eaton. “The latter is now possible thanks to new Medicarerules allowing reimbursement and theprivate carriers will likely follow. Primarycare providers can use the new billing codeto coordinate care following discharge.”Since MedPeds participates in CRISP,

they have access to real-time data abouttheir patients following discharge from the hospital. Their participation in thestate’s Patient Centered Medical Home(PCMH) program enables their carecoordinator to reach out to the patient athome. Patients need high-speed Internetaccess plus a computer that includes acamera and microphone.Of course, any telemedicine visit must

be HIPAA compliant, which the practicesolves by using ExamMed, a specialinternet-driven software platform that’s aconsiderable step up from Skype. Patientsregister for the telemedicine service byclicking on a link on MedPeds’ website,which takes them to the ExamMed site to register securely for an appointment.Dr. Eaton concludes, “Some patients

initially may be reluctant to use telehealth,but that’s changing and I’m confidentthey’ll see the value. It’s an opportunity to increase quality and decrease costs.”

Filling Gaps in Behavioral HealthRadiology and behavioral health aregenerally more advanced in the provisionof telehealth than primary care. For years,radiologists have used teleradiology to read

imaging studies remotely. In behavioralhealth, however, availability has not alwaysequaled use.

“Telepsychiatry has been available foryears,” says David Pruitt, M.D., director of the Division of Child and AdolescentPsychiatry at the University of Maryland.“It’s critically important for children andadolescent psychiatry, as nearly half ofpsychiatric disorders start in childhood and we have a major shortage of pediatricspecialists. And the shortfalls will deepen

with the Affordable Care Act, which is expected to bring in 600,000 newMedicaid recipients, 40% of whom will be children.”Dr. Pruitt adds, “We have to extend our

reach if we’re to be relevant. We’re tryingto develop new collaborative care modelswith primary care physicians, schools andthe Medical Home model. Telehealthprovides a partial solution. Technologicaladvances have made it viable and it offers significant benefits for both patientsand providers.According to Dr. Pruitt, the DHMH has

advocated for telehealth for roughly thepast decade. “Hopkins, University ofMaryland and the health departments inGarrett and Somerset Counties operateseveral pilot sites, and the medical centersare linked with school teams in PrinceGeorges County and Baltimore City.”One of the barriers is the need for

providers to be at the other end, eitherwith the patient or receiving consultativeinput. “It’s an added cost that needs to bebuilt in,” Dr. Pruitt observes. “We’re notthere yet, but as we move to outcomes-based reimbursement, this model will bemore viable. The COMAR does a goodjob of regulating equipment and encrypteddata to avoid privacy violations.” On the receiving end, Mountain Laurel

Medical Center, a small federally qualifiedhealth center (FQHC) in the GarrettCounty town of Oakland, is expandingtelehealth beyond the local healthdepartment. The center is also starting itsthird year in the state PCMH program.

“The health department has a partnershipfor pediatric psychiatric telehealth withthe University of Maryland,” commentsDon Richter, M.D., medical director of thecenter and family practitioner/geriatrician. “There is only one full-time adult

psychiatrist in the county and there’s nopediatric psychiatrist,” notes Dr. Richter.“Our closest referral system to the east isCumberland and to the west isMorgantown, and it’s hard to cross statelines. While we also need access to

consultative services with medicalspecialists in areas such as rheumatologyand endocrinology; mental health, andespecially pediatric mental health, is oneof the area’s biggest needs. Telehealth willhelp to fill that gap.”With some funding from the DHMH,

the partners provided a consultative rolerather than direct care – helping providershandle behavioral issues in children withADHD, for example, and teaching themhow to approach the child’s parents aboutmanaging their disorder. The newtelehealth program will allow them toprovide direct care as well. “The LearningCollaborative has been helpful in gettingthis program underway,” Dr. Richter adds.

Thanks to the telehealth legislationpassed this year, Maryland has made iteasier for physicians to reach out topatients beyond the walls of their practice.


Healthcare IT

H. Neal Reynolds, M.D., associate

professor at the University of Maryland

School of Medicine, and director of

Program Development for the Maryland

Critical Care Network

Seth Eaton, M.D., MPH, medical director

of MedPeds in Laurel

David Pruitt, M.D., director of the

Division of Child and Adolescent

Psychiatry at the University of Maryland

Don Richter, M.D., medical director of

Mountain Laurel Medical Center and

family practitioner/geriatrician

“There are two issues where primary care telemedicineis needed – first, to expand availability when theoffice is not open and second, to improve coordinationbetween hospitals and primary care after discharge.”

– Seth Eaton, M.D.

MAY/JUNE 2013 | 31

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What is the role of your office and howdo you support federal healthcare re-form? In May 2011, the Governor createdthe Office of Health Care Reform to leadand coordinate Maryland's implementa-tion of the federal Patient Protection andAffordable Care Act (ACA) of 2010. Essentially, my office has a coordinatingrole/oversight function with respect tohealthcare reform efforts in the state.Maryland Lieutenant Governor AnthonyG. Brown has taken a hands-on leadershiprole, so we work closely with his office.

It’s a complicated process. In the firstyear, together with our partners in theGeneral Assembly, we enacted legislationto set up the governance structure andframework of the Maryland HealthBenefit Exchange. Maryland has been atthe forefront among states in launchingthe health insurance marketplaces, orexchanges, required by the ACA. Thisyear, in our third and final big legislativepush, we are putting in place the lastpieces, which include Medicaidexpansion, a funding stream for the

Exchange, and policies to ensurecontinuity of care for Marylandersmoving between Medicaid andcommercial insurance, or betweendifferent insurance policies. We areworking closely with a terrific team fromthe Exchange, the Department of Healthand Mental Hygiene, and the MarylandInsurance Administration.

We will have the legislation in place bythe end of the session. Marylanders canbegin enrolling in qualified health plansstarting October 1, 2013, with coveragestarting January 1, 2014. The goal is tomake health insurance affordable andaccessible for all Maryland residents,including the approximately 750,000who are currently uninsured. By the endof the decade, we hope to cut thisnumber in half.

How will the Exchange Work? The Exchange, which will be known as theMaryland Health Connection, will offerinsurance to individuals and small busi-nesses. Small businesses purchasing

Policy

Coordinated Healthcare Reform in Maryland

Coordinating thecomponents of thestate’s healthcare reforminitiatives is a big job.Fortunately, CarolynQuattrocki, executivedirector of theGovernor’s Office ofHealth Care Reform, is up to the task.Maryland Physicianspoke with her near the close of the 2013General Assemblysession to learn whather office hasaccomplished and what is planned.

TRACEY BROWN

A Conversation With Carolyn Quattrocki

MAY/JUNE 2013 | 33

through the Exchange will qualify for a tax credit of up to 50% of their contri-bution to their employees’ premium.They also will be able to offer employeesgreater choice among plans tailored totheir individual needs and greater insur-ance portability if they change jobs. Inaddition, individuals with incomes below400% of federal poverty guidelines willreceive federal subsidies for coverage.

Establishing the Exchange andbuilding the IT system to support it is anenormous and complicated undertaking.We have received $157 million in federalgrants to fund this development and tosupport operations through 2014. Adynamic, nine-person board oversees this effort, and the Exchange now has aterrific staff. We are also developing arobust consumer assistance program thatwill help enroll and support people inthe Exchange.

This education and outreach campaignwill be a key to the Exchange’s success inreaching the people who can benefitmost. The Maryland Health Connectionwill divide the state into six regions, withone umbrella “Connector” entityresponsible for enrollment in eachregion. The Connector entities will hirestaff and partner with other communityorganizations to get the word out topeople in every corner of their region.They will need to make special efforts totarget specific populations thathistorically have had cultural, linguistic,or other barriers to obtaining insurance.

All insurance carriers currently doingbusiness in Maryland have expressedtheir intent to participate in theExchange, and we are also pleased tohave a few new entrants into the market.The ACA also established ConsumerOperated and Oriented Plans (CO-OPs),and at least one, the Evergreen HealthCooperative in Howard County, intendsto operate in the Exchange.

Interested parties can visit the following websites for information:z Exchange stakeholders –

www.marylandhbe.comz Office of Healthcare Reform –

www.healthreform.maryland.govz Individuals and small businesses –

www.marylandhealthconnection.gov

What are some of the key challengesyou face? Ongoing challenges remain,

the most immediate of which is thesprint from here to October when theExchange must “turn the lights on.” AsI said, though, we have a great team thatis making every day count.

Over the longer term, we need tocontinue to find ways to decrease theunderlying costs of healthcare. Asubcommittee of the Health CareReform Coordinating Council is lookingat new and promising models for caredelivery such as Patient CenteredMedical Homes (PCMH) andAccountable Care Organizations (ACO).

What are your goals for this year andbeyond? My immediate goals are to en-sure passage of the Maryland HealthProgress Act and to help the team at theExchange be ready to begin operations

on October 1st. Over the longer term,we want to focus on workforce develop-ment. As we get more people into cover-age, we need to ensure that we have theright professionals in the right place tomeet their healthcare needs. In Mary-land, we have decent ratios of providersto patients, but we still have problemswith access and distribution.

Thus, we are exploring ways toincrease access to primary care and toaddress other shortages, like the lack ofbehavioral health practitioners on theEastern Shore. The Health EnterpriseZones, through which communities mayseek grants and other financial incentivesto attract and retain the allied healthprofessionals necessary to address healthdisparities, is one promising initiative.(see Maryland Physician’s interview withLt. Governor Brown from Jan/Feb 2012Volume 2: Issue 1).

Another exciting initiative is theGovernor’s EARN program (HB 227 -Employment Advancement Right Now)legislation passed this year, whichprovides grant dollars to matchMarylanders seeking new or better jobswith the workforce needs of stateemployers. The program will bring

together businesses, government, andeducational institutions to create trainingprograms that help prepare people forjobs in high-demand fields. While notlimited to the healthcare sector, thisprogram will help address healthworkforce needs.

What have been your office’s greatestsuccesses? While some people have saidthe ACA is too prescriptive, it actuallygives states a lot of tools and discretionto implement reform in a way thatworks for us. So I’m proud of involvingthe full panoply of stakeholders – physi-cians, insurance carriers, hospitals, con-sumer advocates, unions, insurancebrokers and small businesses – in thisprocess. We recognized early on that weneeded the input and expertise of every-

one who would be affected by reform inorder to implement it most effectively.Our efforts have been inclusive and col-laborative, and I believe this has beenkey to our success.

This issue celebrates Maryland womenin medicine. What unique skills haveyou brought and what challenges haveyou faced as a woman in today’shealthcare environment? My legalbackground has been helpful in draftingand shepherding bills through the GeneralAssembly, and in negotiating thecompromises that are critical to successfullegislation. My work in policydevelopment under Joe Curran,Maryland’s former Attorney General, wasalso important. Most of all, I’ve beenlucky to have had wonderful mentors,several of which were ahead of their timein recognizing the challenges women faceand helping me succeed while I wasraising four children. Beginning withAttorney General Curran and his deputies,and now working for the Governor andLieutenant Governor, I am extremelygrateful for the importance they haveplaced on making women integral andsuccessful members of their team.

TRACEY BROWN

“The goal is to make health insuranceaffordable and accessible for all Marylandresidents, including the approximately750,000 who are currently uninsured.”

– Carolyn Quattrocki

OME CALL IT A FAVORITEpastime. Others call it a hobby, a passionor perhaps just a good reason to breakaway from the “every-day grind” to getoutside and enjoy the sunshine along withsome good company. It’s one of the fewactivities that can be relaxing, peaceful,challenging and rewarding all at the sametime; it’s the game of golf. Today, morepeople than ever before are taking to thegreens across the state of Maryland.

“People love the game because it canbe so rewarding and is the ultimate testfrom a mental perspective,” said ChadCraft, PGA head golf professional at theHyatt Regency Chesapeake Bay GolfResort on the eastern shore town ofCambridge. “It’s a great way to enjoyambience, nature and relaxation after along day at the office.”

Craft and his team at the Hyatt’s River Marsh Golf Club see about 21,000golfers on an annual basis, who are drawn to the 18-hole Keith Foster award-winning facility, complete with a20-station practice putting green. Whilemore accomplished golfers will appreciatethe challenges presented by the course’sPar 3 gold tees, private instruction,afternoon family golf programs and aspecialized “Starting New at Golf Course”are also offered, to accommodate golfersof all levels of experience and interest.

“Because professional golf is on TV,people think it is much easier to pick upand learn than it truly is,” said Craft. “Thetruth is that it takes patience, effort and asolid work ethic.”

John Anderes, director of Golf andGrounds at Queenstown Harbor Golf,explains how a lot of his customers hit the green for a unique environmentalexperience. The facility features two 18-hole championship courses as well as a practice facility with a driving range,

two putting greens, practice bunkers and adesignated short-game area. The course isdistinguished for its surrounding sceneryand wildlife, as well as its commitment toenvironmental conservation. In fact,Queenstown Harbor earned the national2012 Environmental Leader in GolfAward, recognizing its leadership in waterand energy conservation along withwildlife preservation and management.

“Golf is a great game that you can play for a lifetime in some of the mostbeautiful surroundings you can access,”expressed Anderes, who sees roughly55,000 golfers each year at QueenstownHarbor. “Come play the back nine of ourRiver course one evening as the sun isdropping slowly over the Chesapeake Bayand the deer are emerging from the treelines, and then let me know if you arebreathing any easier. Our courses are uniquebecause they are very casual and serene.”

Nestled between Baltimore andAnnapolis, Compass Pointe Golf offers yetanother premier public golf facility. With36 championship-caliber holes consumingmore than 800 acres in Pasadena, thecourse’s “four nines” – North, South, Eastand West, offer diversity and variety forgolfers of all levels of experience. In

addition, a wide range of amenities arefeatured on-site to help those who arehoping to learn or improve their game.The facilities include a putting green,chipping green and driving range withgrass and matted tees. Compass Pointeoffers a number of golf leagues and clinicswith programs for men, women, co-eds,beginners and those in need of some“refresher” tips.


Living

The Game of Golf:Learn It, Love It By Tracy M. Fitzgerald

S

Rounding back to the clubhouse at Mountain Branch Golf Club.

A Choptank River view from Queenstown Harbor Golf.

MAY/JUNE 2013 | 35

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For those who live, work or travel in a more “northbound” direction,Mountain Branch Golf Club offers auniquely challenging course, along withthe breathtaking views of HarfordCounty’s rolling greens – an added bonusfor any golfer. Best known as a publiccourse with private club amenities andconditions, Mountain Branch offers men’sand women’s golf leagues, a specializedladies clinic as well as private instructionfor those who crave to improve their game.Carol McCarthy, general manager anddirector of Sales and Marketing forMountain Branch, says that the golfindustry as a whole is starting to see somemajor shifts in terms of who is playingthese days.

“One misperception that people haveis that golf is expensive and that it’s an‘older man’s game.’ Women are the biggestgrowth area in golf, followed by teenagers,”said McCarthy. “There are great,inexpensive golf courses out there andprograms available for every age. Golf canbe played any time of day, from one houron the range to five hours on the course.”

Marylanders who golf or plan to startgolfing are fortunate, as there is no lack of options in terms of where to play.According to golflink.com, the state boasts aselection of 231 courses. While many offercourse options for the most novice to the most advanced golfers, those whohave committed to the game and are insearch of the state’s more challengingcourses may want to explore WakefieldValley Golf in Westminster, Caves ValleyGolf Club in Owings Mills, WoodholmeCounty Club in Pikesville, Maryland Golfand Country Club in Bel Air, or Bulle Rockin Havre de Grace which are recognized assome of the top most challenging golfcourses in the Baltimore area.

“What I love most about my job is thatI have the chance to see people enjoy thegreat game of golf,” admitted Craft. “Itcan be a great lifelong experience.”

To search for a golf course or drivingrange by location, visit golflink.com.

Clinical FeaturesMaryland Physician focuses on the latest cancer

developments. We talk with top Maryland specialists to

get their take on the effectiveness of the latest treatments

for prostate, breast and blood cancers.

Healthcare ITIn every issue, Maryland Physician explores a different

facet of the race to implement EHRs to meet Meaningful

Use and other e-health government incentives. Don’t be

left behind – read what Maryland physicians and health-

care IT experts have to say that eases the pain of transition

to an electronic world.

In Every Issue and OnlineCases x Solutions x Compliance x Medical Beat x Policy

Jacquie Cohen Roth x Publisher/Executive Editor443-837-6948 x [email protected]

www.mdphysicianmag.com


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Solutions

Reputation Management –To Do or Not To Do?

By Brenda Brouillette

HE REPUTATION MANAGE-ment buzz in the healthcare industry, andmore specifically surrounding physicians,is growing at tremendous speed.Physicians must understand what isnecessary to portray and maintain asolid image to build their practice. Sowhat is Reputation Management? It isyour online image being monitored,managed, and promoted.

In the past, physicians were at thecenter of control of their image andreputation. However, with the explosiveemergence of real time communication,social media and an empoweredconsumer, this control has shifted. Atpresent, consumers can instantly review,reflect, and report their opinions andreactions. In the future, online rating andgrading sites are projected to either makeor break a physician’s reputation. Amajor concern is that no internetregulations regarding these sites exist.

The chief contributors to the challenges of reputation management are the lack of:

z Physician interestz Knowing what to doz Regulations in internet marketing

The key to successfully deal with thisparadigm is to strategically plan andexecute a reputation managementprogram. Taking a proactive andpositive approach will help a practicedeal with its online presence andembrace opportunities to engage insocial media.

Fear and Lack of InterestFear has been a major obstacle forphysicians to embrace reputationmanagement. Physicians shouldunderstand that a small percentage ofposts are negative, and if dealt withcorrectly, they present an opportunity to

improve an internal process or toeducate the consumer.

As reported in the Journal of GeneralInternal Medicine, “Dr. Lagu andcolleagues examined online reviews of300 physicians on 33 different physicianrating sites and found that nearly 90%of the reviews were positive. Thenegative comments were mostlyactionable criticisms that physicianscould address immediately withoutcompromising patient confidentiality.”

Some 35% of patients leave aphysician’s practice due to issues withstaff and office processes rather than thephysicians themselves. According to theJournal of General Internal Medicine,“Most negative comments are made onthe management of the practice itselfwith wait times (61%) as well as officestaff and appointment access being themost common.”

Knowing What to DoThe first step is to monitor your onlinepresence. One free, but limited solution isto sign up for www.googlealert.com. Abetter solution is to invest in a programthat will thoroughly monitor, analyze,and assist with positive social media. Anoptimal choice is to select one companythat offers comprehensive services thatinclude monitoring and digital marketinginitiatives to include patient and referringphysician engagement. Such services cancost from $150 to $1000 per month.

The best way to address the onlinenegative review is to first acknowledge itwith a simple, professional messagewithout attacking the reviewer. Next,take the discussion off line by invitingthem to contact your office. Mostimportantly, to protect you from apotential HIPPA violation, NEVERacknowledge that the reviewer is apatient or divulge any patientinformation. Crafting a scripted responsecan positively portray the practice as

caring and patient-focused, deflecting thenegativity. If the reviewer includes aname, the office should follow up withsome good old-fashioned servicerecovery tactics.

While it may not be wise for a practiceto address certain negative posts, it isusually better not to ignore them, whichcan make you seen as aloof, thus addingfuel to the fire.

The best tactic is to implement astrong, aggressive campaign for postingpositive comments and reviews toovershadow the negative ones, incombination with addressing negativeposts. This tactic should be followedwith lots of online educationalinformation and communication toestablish the practice as a thought leaderand medical expert.

Developing a ProgramImplementing a program can be done inincrements. A number of tactics can beutilized in each phase to create an overallprogram that will help to communicate,educate, develop relationships, andultimately grow a practice.

z Listen – Actively monitor and captureconversations to understand theperception

z Participate – Proactively post andpublish content on social mediaplatforms as a one-way conversation

z Engage – Actively interact withconversations

Do not hesitate to embrace reputationmanagement, as it has become anecessity for any practicing physician. Brenda Brouillette, RN, BS, is principal of

Savvy Marketing Solution, a healthcare

consulting firm.

Editors Note: For a list of Top Grading Sites

and Online Profile Pages go to our website:

www.mdphysicianmag.com/solutions

T


House of Ruth Creates Safe HavenFor Victims of Domestic Violence

HE STATISTICS ARE SIMPLYstaggering: research consistently showsthat one in every four women will be ina physically abusive relationship in her life-time. Of the 35,000 individuals who tookpart in the survey conducted by the CDC,89% of the women interviewed claimedto have been subject to verbal abuse.

Recognizing that women in dangerousor even life-threatening situationssometimes have no place or person toturn to, the House of Ruth was foundedin 1977 to provide a “safe haven” forvictims of domestic violence. Whatstarted at that time as a small shelterstaffed by one, has evolved and grownten-fold. Today, the Baltimore-basedorganization is recognized as one of the nation’s leading domestic violencecenters, providing a comprehensive lineof services and support to women andchildren who want and need a place togo, or perhaps a helping hand as theystrive for a fresh start.

“We are known for our emergencyshelter services but this is just one pieceof what we do,” said Sandi Timmins,Executive Director of the House of Ruth.“We help women who can’t go homefind transitional housing or apartments,and provide resources and support tohelp them become independent overtime. We also manage a legal clinic,staffed by 20 local attorneys who work pro bono to help women obtainprotective or peace orders, as well as a

team of counselors andtherapists, who work with moms and theirchildren who haveendured trauma.”

While they may notcome with any visiblescars or bruises, womenwho suffer verbal andemotional abuse are alsoable to take advantage ofthe full spectrum of services offered bythe House of Ruth. According to EllynLoy, Director of Clinical Services, thiskind of abuse can range from yelling andscreaming, to intentional manipulationand diminishment of someone’s feelings,with the abuser’s need for control beinga key factor.

“The abuser will try to control thevictim by attacking their self-esteem,isolating them or threatening them,” saidLoy. “In many cases the abuser will denythat he is being verbally or emotionally

abusive, and this makes it harder for thevictim to find her reality.”

In 2012, Timmins, Loy and their teamof 120 staff members and over 300 localvolunteers provided support and servicesto approximately 15,000 women andchildren. “If a woman is on a path toleaving, on average she will come and go seven times before she will make itpermanent,” Timmins said. “Our role isnever to tell her what to do, but insteadto provide her with information,

acknowledge her choices and make sure she knows we are here for her.”

Women who are seeking support arenot the only people the House of Ruth is working hard to educate. Raisingcommunity awareness about theprevalence of domestic violence, and theteaching people how to identify the signsthat can indicate someone else is introuble, is another priority for Timminsand her staff. Often, what is happeningin the workplace can be a key indicator.

“You have to remember that bothvictims and abusers are oftenemployed,” Timmins explained. “Wehave a program called ‘When IntimatePartner Violence Comes to Work’ andthe goal is to meet with human resourcesteams, managers and supervisors, to helpthem understand what do to, when theyare working with someone who mayneed help.”

To learn more about the House ofRuth’s workplace education program, orfor a schedule of upcoming fundraisingevents that you can attend, which willsupport the organization’s mission,please visit www.hruth.org.

Good Deeds

T

“Our role is never to tell her what to do, but instead to provide her with information, acknowledge her choices and make sure she knows we are here for her.”

– Sandi Timmins, executive director of the House of Ruth

By Tracy M. Fitzgerald

Founded in 1977, Baltimore's House of Ruth provides a "safehaven" for victims of domestic violence.

Maryland Physician would like to hear about your “Good Deeds.” Please share your ideas with us at [email protected].

Good intentions or bad judgment?

There are times we do crazy, misguided things; feats that shouldn’t be possible,and sometimes aren’t. So when you push yourself past your limits, it’s nice toknow there’s a place like the Rubin Institute for Advanced Orthopedics – where doctors perform more total hip and knee replacements and progressive procedureslike hip resurfacing – all combined with the latest rehabilitation services.

Nice work knees and hips – the dynamic duo – when we ask too much of you!www.lifebridgehealth.org

maryland physician magazine mayjune 2013 issue

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