Chesapeake Physician November/December 2015 Issue

ATTACKING ADDICTIONS

LEANA WEN, MD: BATTLING FOR BETTER HEALTH IN BALTIMORE

TAILORING CARE FOR SENIORS

ON THE ROAD TO ENTREPRENEURSHIP

Maryland/DC/Virginia PhysicianYOUR PRACTICE. YOUR LIFE.

VOLUME 5: ISSUE 6 NOVEMBER/DECEMBER 2015

chesphysician.com

C H E S A P E A K E

14 Addictions Under Attack

24 Tailoring Healthcare to Seniors

F E A T U R E S

D E P A R T M E N T S

ContentsVOLUME 5: ISSUE 6 NOVEMBER/DECEMBER 2015

248 20

Cases | 7 | Spinal Cord Stimulation: Alternative to Pain Medication

Policy | 8 | Fighting for Better Health: An Interview with Dr. Leana Wen

Solutions | 12 | Remedies for Physician Burnout

HIT | 20 | Lessons on the Road to Entrepreneurship

Our Bay | 30 | Celebration of the Chesapeake Bay

On the Cover: Leana Wen, MD, Commissioner at Baltimore City Health Department

PhysicianWhen a disease rapidly spreadsto many people, it becomes an epidemic. Sadly, the U.S. has an epidemic of opioid abusetoday, and doctors have been part of theproblem. According to IMS Health, a healthcareinformation company, more than 219 millionprescriptions for opioids were written in 2014 with sales of $8.85 billion. The Substance Abuse and Mental Health ServicesAdministration (SAMHSA) estimates that themarket for addiction treatment is about $35billion per year. The numbers are staggering and they don’t even reflect the wider impact ofaddiction on the individual’s friends, family andemployer. It’s an epidemic that is everywhere.

An epidemic usually does not stop without medical intervention and assistance.Every primary care physician in America spends at least 20 percent of their time dealingwith the consequences of substance abuse (see Addictions Under Attack page 14). The need to medicalize addiction and the mental health issues that often underlie theaddiction is our editorial theme throughout this issue. We spoke with some leadinghealthcare providers and stakeholders, spotlighting the key needs as well as thetreatments and advocacy work that we all, including physicians, can do to stop thisepidemic. We learned how we can change the way we think about and act on mentalhealth disease and addictions, including training more doctors in a new specialty –addiction medicine (Solutions page 12 and HIT page 20).

Many of us have a story about mental health disease and addiction to share, whetherit’s our own, a family member’s, a colleague’s or a patient’s. We all need to be agents ofchange to destigmatize mental health disease and addiction. Dr. Leana Wen, BaltimoreCity health commissioner, patients’ rights and community advocate, believes that everydoctor should think through what they’re doing, rather than being complacent. As shestates, “We have to say, over and over, that addiction is a medical illness and not a moralissue.” (Policy page 8).

The ACA’s parity law requires that coverage for mental health ailments must becomparable to coverage for physical ailments. This is an urgent need with an incrediblyslow pace of adoption. Busy ERs can be ill-equipped to manage patients requiringtreatment for a mental health crisis, and hospitals often lack beds to accommodatepatients. It can take weeks to secure an appointment with a psychiatrist for outpatientcare, then patients often must pay out-of-pocket for the visit. The cycle of self-medication with street and/or prescription drugs begins, and sometimes unfortunatelyends, with heartbreak for the families left in the wake of no treatment, a misdiagnosisand/or the “treat and street” approach to care.

When it’s time to change behaviors, there are basically two approaches: change your own thinking and hope this leads to new behavior, or change your behavior andhope this leads to new thinking. And, act.

Wishing you and yours a healthy and joyful holiday season,

Jacquie Cohen RothFounder/Publisher/Executive [email protected]

@chesphysician

4 | CHESPHYSICIAN.COM

JACQUIE COHEN ROTHFOUNDER/PUBLISHER/EXECUTIVE EDITOR

[email protected]

LINDA HARDER, MANAGING [email protected]

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MANAGERSOCIAL & DIGITAL MEDIA

Jackie [email protected]

COPY EDITOREllen Kinsella

BUSINESS DEVELOPMENTKristine Granata

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PHOTOGRAPHYTracey Brown, Papercamera Photography

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Chesapeake Physician — Your practice. Your life.Advisory Board: An advisory board comprised of medical practitioners and business leaders in diverse practice, business and geographicscopes provides editorial counsel to Chesapeake Physician. Advisory Board members include:

RANDY M. BECKER, MDAdvanced Radiology

HARRY BRANDT, MDSheppard Pratt Health Systems

PATRICIA CZAPP, MDAnne Arundel Medical Center

HOLLY DAHLMAN, MDGreen Spring Internal Medicine, LLC

MICHAEL EPSTEIN, MDDigestive Disorders Associates

STACY D. FISHER, MDUniversity of Maryland Medical Center

MICHAEL FREEDMAN, MDEvolve Medical Clinics

GENE RANSOM, JD, CEOMaryland Medical Society (MedChi)

CHRISTOPHER L. RUNZ, DOShore Health Comprehensive Urology

VINAY SATWAH, DO, FACOICenter for Vascular Medicine

THU TRAN, MD, FACOG Capital Women’s Care

Although every precaution is taken to ensure accuracy of published materials, Chesapeake Physician and Mojo Media,LLC cannot be held responsible for opinions expressed or facts supplied by authors and resources.

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JANUARY/FEBRUARYn Cover Story: Advances in Cardiovascular Care

n Feature: Diabetes & Co-morbidities

n HIT: Direct Primary Care Model —An Alternative to Fee-for-Service

MARCH/APRILn Cover Story: Digestive Disease Update

n Feature: 3D Printing & Prosthetics

n HIT: Connected Health

MAY/JUNEn Cover Story: Chesapeake Female Healthcare Innovators

n Feature: Women’s Health & Pediatric Care

n HIT: Independent Practice Models That Work

JULY/AUGUSTn Cover Story: Progress in Orthopaedics

n Feature: Podiatrists — Partners & Referrers

n HIT: Reputation Management in Social & Digital Media

SEPTEMBER/OCTOBERn Cover Story: Progress in Cancer Care

n Feature: Advances in Imagingn HIT: Telehealth — A New Standard of Care

NOVEMBER/DECEMBERn Cover Story: Brain Medicinen Feature: The Biology of Depression

n HIT: Integrated Care Delivery Platforms

2016 CLINICAL EDITORIAL CALENDAR

Maryland/DC/Virginia PhysicianYOUR PRACTICE. YOUR LIFE.

C H E S A P E A K E

IN EVERY ISSUE AND ONLINECases x Solutions x Compliance x Policy

Jacquie Cohen Roth Founder/Publisher/Executive Editor

[email protected]

DISCUSSION: The use of opioids can have a negativeeffect on the body and brain after long-term use.Physicians are always looking for long-term solutions to help treat their patients. SCS, which has beenavailable for therapeutic use for more than 40 years,continues to improve, and is one of those modalities thatcan treat pain permanently and safely. This implanteddevice sends electrical impulses to the spinal cord,transforming severe, neuropathic pain symptoms into a more pleasant, tingling sensation (paresthesia). Withthis device, the patient uses a wireless remote control to obtain total control over the intensity of thesepulses. While considered a permanent intervention, SCS is a reversible therapy in which the implanted parts can be turned off or removed, if desired.

The ideal candidates for the SCS are those sufferingfrom burning, throbbing or shooting pain. Thesesymptoms can be a result of failed back surgery,diabetes, disc herniations, neuropathy, radiculopathy,and/or complex regional pain syndrome (CRPS). Idealpatient candidates are those whose pain is not related to a malignancy, those who have failed conservativetreatment, or those who do not have medicalcontraindications such as a defibrillator.

For SCS candidates, the first step is to undergo athree- to five-day trial before anything is permanentlyimplanted. What is so unique about this surgery is thatpatients have the ability to ‘test drive’ it to make surethat it has the ability to provide relief for their individualtype of pain. If the patient experiences significant relieffrom the trial, the patient is then referred for thepermanent implantation with a surgeon. Permanentimplantation is minimally invasive and requires littlerecovery time. Once the device is implanted, the patientalso has the ability to re-program the device as their painpatterns may change over the course of time. As SCSallows for improved functionality, a decrease in opioiddependency in a sub-set of this population is beingrecognized.

As prescription drug abuse continues to plagueAmerican society, the medical community strives to find alternatives that provide long-lasting pain relief and improved functionality. SCS is one such modalitythat has the proven ability to provide a long-termsolution to chronic pain.Sudhir R. Rao, MD, an anesthesiologist who specializes in painmanagement, is the founder of Pain and Spine Specialists of MD

in Mount Airy, Md.

NOVEMBER/DECEMBER 2015 | 7

Spinal Cord Stimulation: Alternative to Pain Medication

By Sudhir R. Rao, MD

CASES

CASE: A 51-year-old woman presented withsevere lower-back and leg pain that had beentaking a toll on her life since she had fallendown a flight of stairs nearly five years earlier.Despite multiple treatments with NSAIDs,physical therapy and lumbar spine surgery, she continued to report intolerable pain. While under the care of our pain managementpractice, she underwent epidural steroidinjections and radio frequency ablation, whichonly provided temporary relief. The patientcomplained that her pain medication regimenwas not providing her adequate relief, and wascausing untoward side effects resulting inaltered cognition.Since multiple treatments had been tried

and failed, Spinal Cord Stimulation (SCS) wasdiscussed with her as the next appropriate plan of action. After consideration, the patient decided that since all options had been exhausted, she was willing to proceed with thetrial. After a four-day trial period, the patientfollowed up to report 90-percent relief frompain. She was immediately scheduled for a permanent SCS placement with a surgeon.Her relief as a result of the permanent SCS

was so remarkable that she no longer needs totake her pain medication, and has not beenprescribed opioids for nearly a year. After sur-gery in 2014, she has had to follow up onlytwice in the two months after her surgery. Sheis now able to continue her active lifestyle withher family without needing pain interventionor limitation in her daily activities. She is one of many patients who have reported significantrelief from the use of SCS.


BY LINDA HARDER • PHOTOGRAPHY BY TRACEY BROWN

Q: You note that a quote by Dr. Martin Luther King, Jr., explainsyour core vision: “Of all the forms of inequality, injustice in healthcare is the most shocking and mostinhumane.” What are the greatestinjustices in Baltimore healthcaretoday, and what do you see as thegreatest health challenges forresidents of Baltimore City? Baltimoreis a microcosm of other places across thecountry. When I first moved here, I did a listening tour of our key stakeholders –hospital CEOs, community members,faith leaders, people across the city,federally qualified health centers, etc.They identified three key needs:

z Youth health and wellness. If ourchildren aren’t born healthy, don’thave glasses to read, have such severedental pain they can’t concentrate, orhave undiagnosed and untreatedmental health problems, then how canwe help them grow, learn and excel?

z Substance abuse and mental health.It’s estimated that about 19,000people in the city use heroin, and that likely far more use prescriptiondrugs like opioids, benzodiazapines,alcohol or a combination thereof. It’s so important for us to focus onthis issue, and we can’t talk aboutemployment or crime without alsoaddressing this need. Nationwide,only 11 percent of those who areaddicted get treatment. We wouldnever accept this rate for thosesuffering from diseases such as cancer.

z Population health. In Maryland, withglobal budgeting, there is tremendousopportunity to align the goals ofhospitals and insurers, together with public health goals such asprevention. How can we make sure we’re taking care of the mostvulnerable while keeping everyonehealthy and saving taxpayers money?

POLICY

Fighting for Better Health

Caption.

Baltimore City Health Commissioner Leana Wen,MD, has a level of energy and passion matched only by her ability to tackle critical health issues.Chesapeake Physician recently asked her about hermany health initiatives and her views on everythingfrom medical education to prescribing naloxone.

An Interview with Dr. Leana Wen, Commissioner at Baltimore City Health Department


Q: You’ve advocated for betterprograms for drug-addicted andmentally ill people in Baltimore as one way to reduce incarceration rates. What are your specificrecommendations? Just recently, we brought insurers, hospital CEOs,foundation leaders, government officials, and other partners together to talk through the major challenges and opportunities. Specifically, wefocused on behavioral health issues.

We talked about care coordination.Every hospital has its own list of highutilizers, with the vast majority of thesepatients having underlying behavioralhealth concerns. We discussed creating a city-wide, high-utilizer dashboard,coming up with some wrap-aroundservices for these patients, and workingwith our fire department, which overseesthe EMS system, to address this issuetogether.

Another area that we’re working on is a Stabilization Center, also known as a Sobering Center. In the ED, we often see individuals who come in withthe same issues, to the point where wecan recognize not only the individual,but the same scars over and over. Wegive them naloxone but we know we’renot providing everything they need.

Instead of taking up a bed and careresources in the ED, these patients would be brought to a separate centerwith specialized resources includingsocial work and addiction counseling – a centralized, citywide facility. Wesecured $3.6 million from our statelegislature for capital costs, and nowwe’re looking to our hospitals for help.It’s in everyone’s best interest to helppeople get the best care possible, at the time they need it.

We don’t want to dis-incentivizepeople from getting needed care, but we can provide a very strict protocol todivert the right people, freeing up beds

for people with acute medical concerns,and getting these individuals the rightcare for them.

Q: What should physicians bedoing to address these problems?Three major things:

First, physicians need to ask thequestions. Let’s use violence as anexample. There is often a ‘Treat andStreet’ mentality, where someone has aviolent injury and you fix their problemand send them home, instead of askingwhat led them to be there in the firstplace. We’ve developed a number ofcampaigns, including “Words NotWeapons” that is asking physicians totake the time to ask a question, and toknow what resources they can turn to.

Second, we have to recognize thatprescription opioid abuse is somethingthat started with doctors and drug

companies. I never thought about myrole as being somehow complicit in this until I started realizing how we turn to opioids as first line for painrelief. We prescribe 250 million opioidsevery year in America — one for everyadult American. We’re five percent of the world’s population but over 85percent of its opioid prescriptions. Every doctor should think through what we’re doing and how we canchange our practice. Is it really necessaryto prescribe, for example, 100 Percocetfor a rotator-cuff tear?

Third, doctors have to speak up. We are the ones who interpret science,who are trusted advocates for ourpatients. We need to speak up tolegislators, to our community. We have a really powerful voice. There is suchstigma around mental health andsubstance abuse. There is suchmisunderstanding about the role ofdoctors and the challenges we face inorder to provide the best care possible.

We have to say, over and over, thataddiction is a medical illness and not a moral issue. We have to advocate forour profession and for our patients.

We become complacent when we asphysicians feel that there isn’t anythingwe can do. I understand that we’repressed for time, and that there are many other pressures on us, but thatlack of sense of control leads to burnout.Doctors can speak up at a dinner partyor the nail salon or the barbershop. Wecan say, ‘This is what I’ve experienced.This is the science. These are the facts.This is what we must do.’

And there are specific actions we cantake. We can be on the lookout for thosewho may have opioid disorders, or whouse prescription pain medications, andalso prescribe them naloxone. We wouldnever think twice about dischargingsomeone with a severe food allergy withan EpiPen, because they could die fromanaphylaxis, so why would we not dothat with naloxone? That’s somethingdoctors can do with every patient at risk.

Q: How do you think you can bestwork with your colleagues in thisregion to implement similar programs?DC and Virginia have different laws than Maryland, but all physicians,regardless of where we are, can co-prescribe naloxone with opioids. Thestanding order we created here inMaryland is so that I can give naloxoneto someone even when (s)he is not mypatient. I have issued a standing order to all pharmacies in Baltimore. Thisshould encourage all residents to train to use naloxone and they can carry it to save lives.

Q: With heroin overdose deathsincreasing nearly 50 percent from thefirst quarter of 2014 to 2015, you’vehad staff and volunteers demonstratehow to use naloxone and got themaker of Evzio, a convenient form of the drug, to donate 3,000 kits tothe city. You’ve also urged Baltimorephysicians to prescribe naloxonewhenever they prescribe opiates.Some doctors expressed concernabout liability and what message

We have to recognize that prescription opioidabuse is something that started with doctors and drug companies.

they’re sending their patients. How do you respond? And what impact on heroin deaths are your actionshaving? The issue of liability isdependent on best practices, and the best standard of care is that you shouldbe prescribing naloxone to patients. If we have said in Baltimore City thatthis is the best practice, and you don’tprescribe naloxone to a patient and theyoverdose, that is your liability. And if Iwere giving fentanyl to a patient in the

ED or the OR, I would always havenaloxone available — it would bemalpractice to not do that.

So why would we send a patient homewith dozens of opioids but withoutnaloxone? Or if someone has overdosedalready, they should get naloxone to go,and training to use it; that’s equivalent to sending someone who has hadanaphylaxis home with an Epi-Pen. It’s also very possible that, if you toldyour patient that they could overdose or become addicted to a narcotic, theywould decide to use another method of pain relief instead. It’s our job asdoctors to save lives and to provideeducation to our patients.

We are turning the tide in somerespects, because at least we’re talkingabout the problem. We know that thereare 25,000 deaths across the country

from overdoses. The fastest growingdemographic is white, middle-agedsuburban women. I’m glad we finallyhave traction and that we’re working on naloxone and that I’m now the so-called “prescriber in chief” becausewe’ve issued a standing order in myname, but we’re all just treading waterunless we get people into treatment. I’d love for all primary care providers to be trained for buprenorphine.

With methadone, you have to go to

the clinic every day to get your dose,which is not only inconvenient, butcould be stigmatizing to patients. On the other hand, if you getbuprenorphine, you can go to yourdoctor’s office, just as you would forhigh blood pressure or diabetes. Theproblem is that there’s federal legislationthat limits the number of patients anydoctor can have on buprenorphine. But every primary care physician couldbe trained through a one-day trainingcourse that provides CME credit.

Q: Describe your recent “Words,Not Weapons” campaign and whatrole physicians and other healthcareproviders can play in furthering thegoals of that campaign. WORD stands

for Walk away, Organize your thoughts,Reach out for help and Decide not tofight.

We’re just starting to give the WORDS cards to people in emergencydepartments, rec centers, youth groups –people throughout the city. This is notthe only solution by any means, but it’sone thing we can do.

My chief medical officer and I are bothED physicians who have worked in busy trauma centers. We understandthe pressures on a physician’s time. But we also understand that violence is a communicable disease and thatthere’s a cycle of violence. For example, I saw a 17-year-old who died of gunshotwounds, but he had been there onmultiple previous occasions with less-severe injuries. The perpetrators are oftenthe victims of violence, and vice versa.

We need to see every opportunity as a point of intervention. We may not beable to do everything that one time, butwe need to think about what we mighthave done that could work. Words NotWeapons encourages physicians andnurses to ask questions, and to refer toresources. We also encourage everyonein the community to speak up becausewe all play a role.

After a tragedy, we always look backand note that all the warning signs werethere. Why didn’t anyone speak upsooner? I want healthcare providers notto look back, but instead, to intervenebefore it’s too late.

We have a 24/7 crisis line that we juststarted. We want one source for anyoneto call, whether for mental health,addiction, violence or overdose. It’s beentoo complicated to have multiple


We have to say, over and over, that addiction is a medical illness and not a moral issue. We have to advocate for our profession and for our patients.


numbers that depend on time of day,insurance status, and other factors. Weconsolidated existing phone lines. Theseare staffed not just by an operator at theend of a phone, but also by addictioncounselors and social workers whophysically go out to see patients in crisis.

Q: You’ve noted that the WordsNot Weapons campaign will be runout of the city health department'sOffice of Youth Violence Prevention,which also operates such programs asthe recently expanded Safe Streets, to have outreach workers combatviolence in their own neighborhoods.Tell us more about that program.These are citizens who literally walk thestreets and mediate violence where itoccurs. There are only four sites thatserve a total of about 1.5 square miles.Just in those four sites alone, we havehad tremendous progress. Last year, ourworkers mediated 880 conflicts. Some 80 percent of those conflicts mediatedwere deemed to be “likely” or “verylikely” to result in gun violence, which is really remarkable. How many livessaved is that, how many injuriesprevented is that?

The sites were identified by certaincriteria to target the most vulnerableindividuals where they are. We justobtained a grant to develop a fifth sitethat will likely be in the Sandtown-Winchester area.

Q: What advice do you have forphysicians? First, focus on what you can do now, because you can often feeldisempowered when dealing with acomplex patient, such as someone who’shomeless with diabetes. But if you hadsomeone in front of you with cancer, you would never give up. Start whereyou can and do what you can now.

Second, advocate for your patient.You have a powerful voice and it needsto be heard.

Third, go back to the fundamentals.We entered medicine to help people, toheal. Studies show that 80 percent ofdiagnoses can be made just by listeningto patients. It also helps to alleviatephysician burnout by focusing on whywe went into medicine.

Q: Speaking of that, how can theissue of physician burnout andinsufficient numbers choosing primarycare be addressed? I see people losetheir sense of why they’re in medicine.Pre-med students get that they are hereto help people. But we are not fosteringthat in our medical training. I think theburnout has to go all the way back toour training, and we need to educatestudents that there is more to being a doctor than typing on a computer ordoing a procedure.

Medical students hear that they needto go into the highest paid professions,rather than working in underservedareas in primary care. If we give themthe opportunity to serve in the way thatthey should, that’s how we can avoidburnout. Medicine is a serviceprofession, and we have to keep thatorientation throughout the course of our training.

We’re only accepting one in three

qualified candidates in medical school.So we should choose the ones fromunderrepresented groups, who areinterested in primary care, and weshould improve the pipeline so that weare drawing from individuals who arecommitted to returning to thecommunities they come from. Ratherthan selecting students by test scores,select those who understand what itmeans to be a public servant.

I was part of a group that wrote areport calling for an overhaul in how we think of our medical education.Specifically, we wanted every medicalstudent to commit to one or two years of national service. If you’re usingfederally or state subsidized dollars foryour education, you have an obligationto give back. If you’re not willing to take on that obligation, you shouldconsider a different career.Leana Wen MD, Baltimore City health commissioner


SOLUTIONS

Remedies for Physician Burnout

HEN A PHYSICIANconsistently feels unenthusiastic orcynical about practicing medicine, ordriven to despair by the administrativeburdens of caring for patients, they may be suffering from burnout.

A 2012 article published in theArchives of Internal Medicine by T.D.Shanafelt, MD, et al., attempted tomeasure and report the rate of burnoutamong physicians. It noted that thenegative consequences of burnout mayerode the quality of care, increasemedical errors, contribute to earlyretirement and substance abuse, andadversely affect physicians’ personalrelationships and mental health.

A 2015 Medscape survey revealed that physician burnout rates today rangefrom 37 percent (in dermatology) to 53percent (in critical care medicine). Thehighest rates are typically among those in primary and emergency care, with halfor more of these physicians reportingburnout. A 2014 Physician Compensationreport from Medscape found that familyphysicians and internists were amongthose most likely to choose medicine as a profession again, but unlikely to choose primary care as their specialty.

Of no surprise to physicians is that thegrowing administrative burden theyshoulder is a key cause of burnout. “Toomany bureaucratic tasks” topped the listin both a 2015 and 2013 Medscapesurvey of the causes of physiciandissatisfaction, followed by “too manyhours at work,” “insufficient income”and “increasing computerization.” A

2013 RAND survey commissionedby the AMA found that doctorswere dissatisfied with current EHRsystems, but still believed in thepotential of electroniccommunications to improve care.

Physicians are taking differentapproaches to prevent andaddress burnout, described below.

Improve Existing PracticesImprovements in workingconditions, such as creating anenvironment in which physicianshave more decision-making autonomyand a better work-life balance, can help. Using stress-reductiontechniques can also help. A 2014Cochrane review found that cognitive-behavioral training and mental andphysical relaxation reduced stress inhealthcare workers.

Medical societies also are gettinginvolved. Launched in June 2015, theAMA’s STEPS Forward™ program, a partnership with MGMA, is designedto help physicians address some of the key causes of burnout that wereuncovered in a 2013 survey conductedby RAND. Physicians can access a

growing collection of interactive, online educational modules to helpaddress common practice challenges at STEPSforward.org while earningCME credit. By the end of 2015, theAMA expects to have 25 modules that include steps for implementation,case studies and downloadable videosand other resources.

Direct Primary Care, Concierge Medicine and PCMH Direct primary care is a practice model that is gaining momentum across the country.

Examples of this model, whichtypically charges a monthly fee andbypasses insurance, can allow physiciansto eliminate insurance headaches, spendmore time with patients and havegreater control over their medicalpractice, include Evolve Medical Clinicin Annapolis, Iora Health in Boston,Qliance in Seattle, and R-Health inPhiladelphia. Some are B-to-B whileothers are B-to-C models, and somecater to both. Look for moreinformation on this model inChesapeake Physician’s January/February 2016 issue.

The concierge medicine model alsohas been adopted by many physicianswho want to practice medicine outsidethe walls of insurance, allowing them toavoid many of the hassles of billing fortheir services and devote more time totheir patients. A disadvantage of thisapproach is the high monthly cost topatients. See “Alternative Care DeliveryModels” at chesphysician.com/2012/06/28/alternative-care-delivery-models/.

Many physicians who have adoptedthe Patient Centered Medical Home(PCMH) model also report feeling re-energized about practicing medicine.

Be intentional about making the space to workon your life. It’s okay to do what you want, butdon’t quit without a plan or putting your finan-cial house in order before you leave. – Jattu Senesie, MD

W

ISTOCK@SHAPECHARGE

This model, which emphasizes moreaccessible, coordinated care, is nowexpanding to encompass urgent carecenters and some specialties. Physicianstypically are assisted by carecoordinators and work with a team ofcaregivers that are performing at the ‘top of their paygrade’ to deliver care.See Chesapeake Physician’s articles,“The Medical Home Gets aNeighborhood” chesphysician.com/2015/07/01/the-medical-home-gets-a-neighborhood/ and “PCMHs and ACOs: Are They Working?”chesphysician.com/2014/06/30/pcmhs-and-acos-are-they-working/ for moreinformation on this model.

Changing CareersSome physicians are addressing theburnout issue by leaving their medicalpractices – if not abandoning helpingother people. Jattu Senesie, MD,FACOG, a former OB/GYN in privatepractice in the Washington, DC, area,found that she was unable to design a life she enjoyed while practicingmedicine, even after changing a numberof variables in both her professional and personal life. In 2008, she stopped

working for 100 days, then triedreducing her work-week to four days, to no avail. “I realized in retrospect that I did everything I was supposed to do,but still wasn’t happy, and I had no Plan B,” she admits.

The problem wasn’t that she didn’tlove helping patients or didn’t find OB interesting, it was the need to spend most of her day dealing withadministrative issues that she saidsucked the joy out of medicine. Sherecalls, “People always told methroughout my training that when I got to the next step – whether myclerkships, residency or private practice– it would get better. It did get better,but it was never good.”

Fortunately, being single and havingsavings allowed her to take thefrightening step to stop practicing in2010. Dr. Senesie hired a life coach tohelp her decide what to do next, andfound that she was attracted to coachingother physicians in self-care and well-being. After pursuing certification froman International Coaching Federation(ICF)-accredited coach-trainingprogram, she is now working with a master certified coach until she

completes 175 hours of supervisedtraining. To supplement her incomewhile her business is taking off, sheperforms medical chart reviews anddoes some speaking and workshops on the weekends.

Dr. Senesie believes that many doctorsdon’t value their own well-being as muchas they do the health of their patients.Her advice to other physicians is, “Ifyou’re really not happy, get over thebrainwashing from our medical trainingand recognize that it’s not normal to feelmiserable. Be intentional about makingthe space to work on your life. It’s okayto do what you want, but don’t quitwithout a plan or putting your financialhouse in order before you leave. Anddon’t be shy about reaching out topeople in other fields.”

She adds, "Have a clear vision of whatyou want to do that can get you throughthe hard days. Don't limit yourself towhat seems obvious and reasonable.Start with a broad vision and narrow it down.”Jattu Senesie, MD, FACOG, former OB/GYNand current personal trainer and professional

life coach at Essence of Strength, LLC, in the

greater Washington, DC, area



BY LINDA HARDER

ISTOCK@ARTTIM

UNDERATTACK

ADDICTIONS


DDICTIONStypically get their start in the teenageyears. According to CASAColumbia, anational nonprofit research and policyorganization dedicated to improving theunderstanding, prevention and treatmentof substance use and addiction, over 90percent of people with addiction begansmoking, drinking or using other drugsbefore age 18. Worse, one-quarter ofthose who start young become addicted,compared to only four percent of thosewho started using at age 21 or older.

The disease is overshadowing otherchronic conditions. In 2010, roughly 40million Americans had an addiction,compared to 27 million with heartdisease, 26 million with diabetes and 19

doesn’t have bells and whistles, it’s avery intimate specialty, where patient-physician and family-physicianrelationships are essential. It’s also veryrewarding to understand the trajectoryof the disease, and to see patients recoverwith the care of a knowledgeable andskilled physician. And thesesubspecialists become the teachers ofothers in medical school and incommunities, just as cardiologists orother subspecialists do.”

Shining Light on a Silent Problem“Medicine has become expert at treatingthe complications of substance abuse,but we need to do far more to treat theproblem. Society tends to focus on thedrug of the day or the decade,” Dr. Kunzcomplains. “We think it’s great to reduceabuse of a given drug over time, but inthe meantime, the abuse of other drugstakes off. We need instead to payattention to the whole scope ofsubstance abuse in our society, not justthe current drug of choice.”

“There’s no primary care physician inAmerica who doesn’t spend at least 20percent of their time dealing with theconsequences of substance use,” says Dr.Kunz. “And some 40 percent ofcardiovascular deaths involve alcohol orother drugs, such as nicotine. It’s thesame story for cancers, trauma and ahost of other conditions. We tend tothink of the problem clustering in citieslike Baltimore or Miami, but the truth isthat all cities have an epidemic. It’s anational problem and a silent one.Physicians must be part of the solution.”

He says, “Every physician needs toknow some basics about addiction so heor she can screen patients and knowwhere to refer them. Addiction can be aterminal disease if untreated, but wehave evidence-based treatments,including cognitive behavioral therapyand effective medications. Encouragingpatients to delay drug use is ideal.Physicians also need education on theproper prescription of opioids.”

Dr. Kunz concludes, “Becomingrecognized as a legitimate field ofmedical practice changes the world.We’re on the verge of that. And this will

million with cancer. An additional 80million Americans are considered riskysubstance users – those who use them ina way that threatens public health andsafety. Tobacco, alcohol and other drugsalso cause an estimated 580,000 deathsin the U.S. each year – nearly 20 percentof the total.

SUBSPECIALTY RECOGNITION ATTACKS ADDICTIONSThe rise of addiction in American societyunderscores the need for medicalprofessionals who are fully trained todiagnose and treat these disorders, andwho can serve as faculty and changeagents in addressing this chronic disease.No specialized medical trainingprograms existed until 2007, when theAmerican Board of Addiction Medicine(ABAM) was incorporated.

“The purpose of all medical boards isto review eligibility and bestowcertification in specialty or subspecialtyfields, and to have a process formaintaining certification at the higheststandards,” ABAM Executive VicePresident Kevin Kunz, MD, MPH,declares. “Within the next year, weanticipate the recognition of theaddiction medicine subspecialty by theAmerican Board of Medical Specialties,bringing attention to this disease withinmainstream medicine.”

Becoming certified in addictionmedicine presently requires passing acertification exam after either a)completing 1,920 hours of work as anattending physician in the field, or b)completing a one-year fellowship at aparticipating program. By the end of2015, some 37 programs across thecountry will offer this fellowship. A totalof 3,800 physicians have been certifiedby ABAM.

Dr. Kunz notes that making addictionmedicine a medical subspecialty shouldfocus more attention on the problem andcreate more resources to treat it. “Whatchanges the equation is recognition andaccreditation,” he explains. “You don’thave a “real” credential or get paid as aphysician unless the subspecialty isrecognized.”

He adds, “While addiction medicine

A

Physicians arebeginning to tacklethe growing addiction rates in our society bycreating a newmedical subspecialty,treating comorbidsubstance abuse inpatients with eatingdisorders, andavoiding opioids when treating

cause more physicians to sharpen theirknowledge and skills in dealing withAmerica’s most devastating disease.”

ADDICTIONS AND EATING DISORDERS LINKEDThe facts are startling: Half of thosewith eating disorders also abuse alcoholor drugs, and their risk of substanceabuse is five times that of the generalpopulation. Irene Rovira, PhD, directorof Psychology Postdoctoral Program,and Psychology coordinator at theInpatient/ Partial HospitalizationProgram, The Center for EatingDisorders at Sheppard Pratt, says, “Some 35 percent of those withsubstance abuse also have eatingpathology.”

A shared characteristic between both disorders is its development inearly-mid adolescence. The usual age of first drinking is 15, similar to that of dieting onset. In fact, early adolescentgirls who are worried about their weight are two times more likely to start drinking. Teens who start drinking

under age 15 are two-to-three timesmore likely to develop Alcohol UseDisorder. For this reason, earlyintervention for both eating disordersand substance abuse is key."

Dr. Rovira notes "Multiple factorshave been identified linking thesedisorders, including common brainchemistry, family history, social pressuresand personal risk factors, such as lowself esteem, depression, anxiety, trauma,and personality disorders. There isevidence that both groups share deficitsin expressing negative affect andcontrolling impulses. These illnesses,although destructive to the person, mayserve a purpose, such as coping withnegative affect."

The Role of NeurotransmittersA growing body of research isuncovering the role of neurotransmittersin the cycle of addiction. A review articlepublished in Neuropharmacology in July 2012 suggested that alterations in dopamine, acetylcholine and opioidsystems in reward-related brain areas

occur in response to binge-eating ofpalatable foods.

Dr. Rovira states, “Low dopamine is seen in individuals with substance abuse, bulimia, and binge eatingdisorder, while higher dopamine is seenin those with anorexia. Serotonin andnorepinephrine have been linked to bothdisorders as well. Having this knowledgecould translate to better prescription of appropriate medications.”

Treat Comorbid Conditions Concurrently “It’s surprising that many eating disorder programs won’t accept thosewho also abuse substances,” she adds.“Only a handful of programs in thecountry, including ours, will treat both.

We’ve expanded in the last years to include a substance abuse track within our eating disorders center. It’s important to treat both at the same time to avoid symptom-substitution,such as switching from drug abuse tobinging and purging.”

Continues Dr. Rovira, “We offer



behavior modification, cognitivebehavior therapy and an expressive artcomponent. You have to treat thesymptoms first in order to achievestability. This allows treatment to thenfocus on additional difficulties, such asbody image, mood intolerance, trauma,and self esteem."

A key component of successfultreatment is preparing patients to returnhome without resuming their addictivebehaviors. Dr. Rovira explains, “Toaddress these comorbid conditions oncethey’re in the ‘real world,’ we startplanning while they’re still inpatient orin our partial hospitalization program.For example, we’ll have them attend AAmeetings, find a sponsor, and eliminatedrugs and alcohol in their home or carbefore they leave our center.”

Advice for Primary Care PhysiciansDr. Rovira advises, "As our first line ofdefense in identification, primary carephysicians should ask patients veryspecific questions, such as what they ateyesterday from the time they woke upuntil they went to sleep, rather than ageneral question about their eatinghabits. While patients can be secretiveabout these disorders, asking directquestions are more likely to get a moreuseful answer. Don’t ask, ‘Do youdrink?’ instead ask, ‘How much alcoholdo you drink?’”

For those whose eating disorder andsubstance use disorder coexist, the datasuggests that patients with bulimiausually develop their eating disorderfirst, and then substance abuse. Thosewith anorexia tend to have substanceabuse problems before they develop aneating disorder. Individuals withanorexia often restrict food in order tosave calories for alcohol later.

As former U.S. Secretary of Health,Education and Welfare, Joseph A.Califano, Jr., said, “Where there’s thesmoke of eating disorders, look for thefire of substance abuse and vice versa.”Caffeine, tobacco and stimulants, suchas cocaine, can be used by those witheating disorders to control their appetite.Those with bulimia, compared toanorexia, tend to use a heavier andwider variety of drugs, includingamphetamines, barbiturates and heroin,reportedly to assist in vomiting."Primary care physicians should also beaware of 'atypical' substance abuse of

over-the-counter medications such asdiet pills, diuretics and laxatives, whichmay lead to dangerous abnormalelectrolytes. For example, low potassiumand high carbon dioxide levels mayindicate purging, and the physicianought to suspect self-induced vomitingor laxative abuse. Ordering lab reportsto test these values can help uncoverhidden eating disorder symptoms," Dr.Rovira notes.

DO OPIOIDS WORK? Some physicians might be surprised tolearn that high-quality studies on opioidsfor chronic pain management havefound little evidence of efficacycompared with other pain medications.Kurt Hegmann, MD, MPH, editor-in-chief for the ACOEM OccupationalPractice Guidelines published by ReedGroup, Ltd., and professor, University ofUtah, notes, “After a careful review of

Irene Rovira, PhD, director of Psychology Postdoctoral Program and Psychology coordinator atthe Inpatient/Partial Hospitalization Program, The Center for Eating Disorders at Sheppard Pratt

TRACEY BROWN

28 well-conducted studies, we cannotfind one showing that opioids aresuperior to anti-inflammatories,antidepressants or placebos. All of theopioid approaches decreased pain byonly one to two points on a scale of oneto 10 compared with placebo. Whileopioids obviously do have a limited rolein acute and post-operative pain, eventhen they do not work as well ascommonly thought. In one example,ketorolac outperforms the opioids foradverse effects while providingequivalent pain relief.”

He continues, “A study of chronic lowback pain found that giving patientsoxycodone 5mg managed pain no betterthan 250mg of naproxen, despitepotentially handicapping the naproxenat half the dose of a prescription. Giventhat our body adapts to opioids soquickly, with rapid dependency and doseescalation, and the risks involved, it’sclear that there are better things toprescribe than opioids. They have nodemonstrable role in non-terminalchronic pain management. Firstprescribe functional restoration via atailored, functional exercise programplus perhaps limited NSAIDs, anti-depressants or anti-convulsants.”

Avoid Opiates for Safety-Related JobsThe American College of Occupationaland Environmental Medicine (ACOEM)Practice Guidelines: Opioids and Safety-Sensitive Work, published in the Journalof Occupational & EnvironmentalMedicine in July 2014, recommendedavoiding acute or chronic opioid use forpatients who perform safety-sensitivejobs such as operating motor vehicles orother heavy equipment.

According to Dr. Hegmann, qualitystudies have shown that acute or chronicuse of opioids can double the risk oftraffic accidents. He says, “There’s anelevated risk, even with weak opioidssuch as codeine and tramadol.”

Regarding overdose and fatality risks,“We now have clear evidence that risksof overdoses and fatality are significantlyincreased at a 50mg morphine-equivalent dose. Prescriptions shouldn’tgo above that dose without ademonstrable increase in function. Evenstarting a patient on an opioid should beundertaken only on a trial basis. If youdon’t get functional benefits within twoto three weeks, stop. Further, manyprescribers don’t have good programs tomonitor these patients.”

In December 2014, ACOEM

published updated “Guidelines forOpioids for Treatment of Acute,Subacute, Chronic, and PostoperativePain” in its journal. After reviewing 157studies of high and moderate qualityaddressing pain treatment, it found noquality studies demonstrating thatopioids were superior to othertreatments for treating chronic non-cancer pain or improving functionaloutcomes long-term. Therecommendations also encouragedphysicians to use informed consent, get atreatment agreement, track functionalbenefits, use drug screenings, andattempt tapering of the dose if opioidsare prescribed.

Medical Education: Part of the ProblemDr. Hegmann believes that medicaleducation is a part of the problem. “Pain management is not well taught in medical education,” he says. “Somephysicians under-recognize the problemopioids cause, and their contribution tothe growing addiction rate. In a sense,we need to turn back the clock to theway we treated pain 30 years ago,perhaps supplementing anti-inflammatories with the use of opioidson a very limited basis. We should alsobe emphasizing functional restoration totreat chronic pain-related impairments.”

He adds, “Even though we haveprescription drug registries as a tool that’sfast and easy to use, many physicians stillaren’t using them. It would help if eachstate’s laws would allow medical assistantsto review a patient’s registry data for thephysician at the start of the clinicworkday, to provide organizationalstructure and save time.”

The fact that some 25 to 45 percent of patients misuse opioids is sobering.Clearly, it’s long overdue for physiciansto make sure they’re doing everythingpossible to be part of the solution toaddictions.

Irene Rovira, PhD, psychology coordinator, Inpatient/Partial

Hospitalization Program, The Center

for Eating Disorders at Sheppard Pratt,

Baltimore

Kevin Kunz, MD, MPH, president, American Board of Addiction Medicine

Kurt Hegmann, MD, MPH, editor-in-chief for the ACOEM Occupational Practice

Guidelines published by Reed Group, Ltd.,

and professor, University of Utah

‰ National Alliance on Mental Illness (NAMI)800.950.6264nami.org

‰ Baltimore Crisis Response410.433.5175bcresponse.org

‰ American Foundation for Suicide Prevention800.273.TALK (8255) www.afsp.org

‰ District of Columbia Department of Mental Health888.7WE.HELPdbh.dc.gov

‰ Bethesda Community Crisis Center 301.656.9161communitycrisis.org

‰ CrisisLink – Arlington, VA703.527.4077prsinc.org/crisislink

‰ ACTS Helpline Prince William County, VA703.368.4141actspwc.org/

Mental Health/Addiction Resources‰ Addiction Hotline Washington DC855.219.5600addictionhotlinewashingtondc.com

‰ Mental Health Association in Talbot County888.706.9902mhamdes.org

‰ Suicide Prevention Education Awareness for Kids410.377.7711speakforthem.org

‰ Mental Health Association of Maryland800.572.6426mhamd.org

‰ Naloxone Training (Baltimore City Health Department)410.637.1900dontdie.org

‰ Maryland Youth Crisis Hotline Network800.422.0009Help4MDYouth.org

More online at chesphysician.com



Clinical FeaturesIn each issue, Chesapeake Physician interviews some ofthe region’s top specialists to spotlight the latest clinical developments, including leading-edge diagnostic and treatment options.

Healthcare ITChesapeake Physician explores ongoing major healthcareIT developments and the new care delivery models thatdepend on them, from interoperability issues to the lateston Meaningful Use, ACOs, Medical Homes, mobile health,hospital employment, mega groups, and more. Don't be left behind — read what Chesapeake physicians andhealthcare IT experts have to say that keeps you abreast of the latest technology changes in every size and type of medical practice.

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443.837.6948 x [email protected]

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Maryland/DC/Virginia www.chesphysician.com


HEALTHCARE IT

A growing number of doctors find that being anentrepreneur can enrich theirlives. Two physicians whocontinued practicing medicinewhile founding a company,and one who decided to quit his day job as aninterventional cardiologist to consult on medical devices,share the lessons theylearned.

lessons on the road to

USING SMARTPHONES TO FILL APPOINTMENTSOn a cold gray day in February 2013,Brian Kaplan, MD, an otolaryngologistat Ear, Nose & Throat Associates atGBMC in Glen Burnie, Md., suddenlyrealized that one of his greatestfrustrations might present a business opportunity.

When a patient cancelled with only 30 minutes notice, he realized that hissmartphone might be able to solve this frequent last-minute drain on hisrevenues. Recognizing that some patientscancelled on short notice, while otherswaited weeks or months to get anappointment, Dr. Kaplan had the germof an idea that became Everseat.

“Most of your day as a physician is not under your control,” he says.“Government agencies, payers,corporations and often your patientscommand the structure and organizationof your practice. The only freedom youhave is how to structure your day toincrease your professional enjoyment.You can’t use differential pricing or dobalance billing to increase your revenue.But you can make better use of your day.That is the impetus behind Everseat.”

It took until May 2014 for his idea to become reality, when he and CEO Jeff Peres launched the app that notifiespatients seeking appointments that a slot has become available that day or thenext. The approach also works for otherbusinesses that book appointments,including hairdressers, physicaltherapists, acupuncturists and dentists.

“Until now, the appointment processhadn’t really changed in 50 years,”comments Dr. Kaplan. “Everseat letsphysicians and healthcare organizationssend a list of cancellations to people on their cell phones and usually within30 seconds we have at least one responseto fill that slot.”

“We charge our providers a flat fee for unlimited bookings, and the service is always free to their patients andcustomers,” he continues. “Patientsoften say, ‘I’ve been waiting for myphysician to do this.’ We even had onepatient in Baltimore who felt Everseatsaved her life by freeing up anappointment that found an aggressiveskin cancer.”

For Everseat to succeed in a practice,

entrepreneurshipBY LINDA HARDER

ISTOCK©BLOSSOMSTAR

Dr. Kaplan notes that patientengagement is critical. “If you don’t get the app into patients’ hands, itdoesn’t work. When patients make anappointment, Everseat sends out a noticeas if they are from the physician’s office.Staff can confirm that the patient has the free app before they leave the office,and use postcards, email blasts, mailers,digital newsletters and website postingsto spread the word. It doesn’t take a lotof time, but you have to build it intoyour workflow.”

THE BIRTH OF A COMPANYDr. Kaplan describes how Everseatevolved. “My parents both ownbusinesses in the Boston area andworked 80 hours a week – it was justwhat you did. And I have a business idea every three days. I had been friendswith Jeff for over 12 years. Luckily,when I approached him with my idea, it proved to be the right time for him to take on a new project. Lawyers nixedmy initially more grandiose plans, buteveryone recognized the inefficiencies inmedicine and the huge supply anddemand for this service.

“We funded the first year ourselves,and contracted the initial developmentand graphics work,” he recalls. “Thenwe raised the seed money to start thecompany. Next, we underwent a secondround of financing for growth, sales and development. We had to vet a lotthrough various attorneys and undergoseveral rounds of financing, with thelatest over $3 million round closing inthe fall of 2015.”

Today, Everseat is in 35 states withnearly 2,000 providers, including severallarge systems such as Baystate Health,The Centers for Advanced Orthopaedics(CAO) and LifeBridge Health.

ADVICE FOR PHYSICIAN ENTREPRENEURSDr. Kaplan notes that, “Every annoyanceis a business opportunity. If it’s causingyou a problem, it’s likely causingmillions of other people problems too.Uber was created by two guys whocouldn’t get a cab in San Francisco.”

He advises physicians to clearlyarticulate the simplest solution to theproblem and vet that idea, expecting itto take several iterations. “What you

think is intuitive may not be to otherpeople,” he cautions.

Finding a partner with complementaryskills – perhaps including a business orfinancial background – is also critical.“You need to show investors that you

will spend their dollars wisely, and havesomeone who can focus on the businessfull-time. Jeff works 18 hours a day on the company. We’re also different in almost every way – you want to find a compatible relationship, not a clone. I enjoy the strategic element of growingthe business the most, while Jeff alsofocuses on operations.”

“Fortunately, the Baltimore-DCcorridor is currently a hotbed for technicaldevelopment,” Dr. Kaplan believes.

ORTHOPAEDIC INVENTORLike Dr. Kaplan, Jeffrey Gelfand, MD,

is a practicing orthopaedic surgeon aswell as president and founder ofSuspension Orthopaedic Solutions. Hispath to entrepreneurship was a bit morelengthy and rocky than Dr. Kaplan’s,perhaps because his business idea

involved the more regulated field ofmedical devices. But like Dr. Kaplan, the idea for his company arose from a problem.

“In 2007, I had a patient with afracture of their distal clavicle,” heremembers. “A company had recentlydeveloped a new arthroscopic device to treat the more common shoulderinjury of AC [acromioclavicular]separation, and it occurred to me that I might try that device for my patient.Unfortunately, the AC device hadinsufficient mechanical support, so Ipaired it with another already-commonly-

You need to show investors that you will spendtheir dollars wisely, and have someone who canfocus on the business full-time. – Brian Kaplan, MD

top tips for Would-Be entrepreneurs

z Network, network, network – there’s something to be learned from

everyone you speak to

z It’s never too late to change your career

z Remember that you have a right to be happy and you don’t have to put

yourself second

z Find a partner that complements your skill set – e.g., one with business

experience if you don’t have it – and who’s compatible, not a clone

z Expect the process to take far more time and dollars – and legal advice

– than you originally thought

z Every annoyance is a business opportunity. Identify a problem that’s driving

you and/or your patients crazy – then find the simplest solution

z For new devices, seek advice from a patent company

z Fund as much of the initial development yourself as you can

z You don’t need an MBA or special credentials – being an MD buys

you credibility



used device, rigged the two together, and it worked for a problem that waschallenging to treat. We reported ourencouraging results in a small group of four patients and thought we mightbe onto something.”

Before presenting the results at anational meeting, Dr. Gelfand appliedfor a patent. He then called a majordevice company to determine theirinterest. They passed on his idea, but afriend urged him not to give up.

“I reached out to another orthopaedicentrepreneur in Florida who had been

down this road and had a successfulexit, and he put me in touch with amedical device design firm inConnecticut,” he explains. “Theyworked with me to refine the concept,determine the feasibility and make someinitial prototypes. I funded the initialstage with $150,000 of my own money.Then I partnered with an attorney,formed the company, created additionalprototypes and secured $4 million inoutside funding, chiefly for R&D. We received three FDA clearances andcommercialized three products with theinitial funding, which was remarkableconsidering the average cost to get aproduct through FDA clearance is about $25 million.

“I was naïve initially about how muchit would cost,” admits Dr. Gelfand. “Iexpected that initial investment to makeus cash-flow positive. We had greatclinical success and sold our initialinventory in six months, but we neededmore capital to continue funding thecompany. Until that point, everythinghad come surprisingly easily, but allstart-ups should expect to have issues. In late 2012, we were running out of cash, which forced us to undergosome restructuring. I was able topurchase all the assets of the company,allowing me to pursue the currentlicensing deal.”

ADVICE FOR ENTREPRENEURSDr. Gelfand’s advice? “Stick to it and take your idea as far as you can with your own resources ratherthan just presenting an initial idea toothers. That’s the only way to buildvalue in the company. Also think about your intellectual property in the broadest terms possible, to make it harder for larger companies to takeyour idea.”

He adds, “Understand the size of your market. For my initial device, there are about 19,000 potential usersannually, making it a somewhat smallermarket than some investors might findattractive. However, if it is a higher-costdevice, or more importantly, a devicewith a higher gross margin, it will havemore appeal to investors.”

Dr. Gelfand concurs with Dr. Kaplanthat finding complementary partners iskey. “Orthopaedic surgery remains mypassion. The only way for me to keepmy full-time practice was to find day-to-

Brian Kaplan, MD, an otolaryngologist at Ear, Nose & Throat Associates at GBMC, in Glen Burnie, Md., launched the app,Everseat, which notifies patients seeking appointments when a slot has become available that day or the next.

TRACEY BROWN

Brian Kaplan, MD, otolaryngologist at Ear, Nose & Throat Associates at

GBMC, and co-founder, Everseat

Jeffrey Gelfand, MD, orthopaedic surgeon and president and founder of

Suspension Orthopaedic Solutions

Steven Brooks, MD, MBA, FACC, VP of Regional Affairs and Health Economics,

Ablative Solutions, Inc., and senior advisor,

Popper & Company


day partnerships with reliable businesspartners with connections to bankersand investors.”

Although launching a company is timeconsuming, Dr. Gelfand managed topursue his dream while being married toanother busy orthopaedic surgeon andhaving four children. “I was pretty goodabout being physically present for all theimportant ‘non-work events’ but I wasoften distracted,” he recollects.

“I definitely have the entrepreneurialbug,” he exclaims. “It’s exciting to closethis new deal and I have begun work onsome other good opportunities. I

plan to stay in the innovation game.Many doctors today lament all of thechallenges with the changing healthcareenvironment and reform, but there arebillions of dollars being thrown athealthcare today and with more insuredpatients as a result of healthcare reform,the opportunities are out there. Doctorsknow best where the needs are.”

FROM MEDICINE TO MEDICAL DEVICESIn contrast, Steven Brooks, MD, MBA, FACC, a former interventionalcardiologist in the Baltimore area, took a path away from the daily practice of medicine. He recalls, “By 2007, I was miserable. I enjoyed the proceduralside of medicine and getting to know my patients, but I was tired of fightingwith insurance companies. I had a seriesof appeal letters to insurers and wasfeeling pressured to do tests andprocedures I thought were unnecessary,for fear of malpractice. I wasconservative in my practice whereas itseemed like referring physicians oftenwanted you to be aggressive. I also had three children I barely saw, so Istarted to ask, ‘What else can I do with my medical degree?’”

He adds, “It can be hard at first,because you mostly bump into otherpeople who’ve made the same careerchoices as you. But as you get furtherinto exploring the options forphysicians, you realize there are other ‘dropouts’ out there. I foundnetworking was key. One call leads to another and another. That’s not anatural instinct for most doctors,though.”

Dr. Brooks pursued an MBA fromJohns Hopkins University – CareySchool of Business, going to class onenight a week from 2007 to 2011.

“We had some incredible discussions,”he recalls. “Then an opportunity opened up at the FDA related to drug-coated stents. I read an essay by AndyFarb, a medical officer at FDA, aboutthe current stent thrombosis crisis, andFDA opinions past and present on thisissue. I googled him, and a week later I had a job. I took a significant pay cut,but I would make that decision 100times over again.”

While at the FDA, Dr. Brooks waspart of the Entrepreneur in Residenceprogram, which brought in healthcareexperts to find inefficiencies in the FDA process, exploring approaches to decreasing pre-market datarequirements to get products out earlierand test them in the real world.

He also was one of the chartermembers of the FDA’s ReimbursementTask Force. That task force connectedpayers with companies creating novelproducts. helping them to design theirclinical trials to ease the reimbursementprocess after market approval.

“Lots of companies go to Europe tohave their products CE marked first

because its EMEA has a ‘bar’ that’slower than the U.S. FDA,” he explains.“We’re currently lowering the bar herewhile maintaining the highest standardsin patient safety in a way that’s good,because the U.S. has often used first-generation devices while Europe is ontheir second or third generation. Oneproblem here is the huge liability issuegiven our legal system.”

Looking to build on his experienceand interests, Dr. Brooks left to join Sage Growth Partners and teach atJohns Hopkins. Today, he works with Ablative Solutions, Inc., whichfocuses on device-based approaches todecrease hypertension, and Popper &Co., a medical technology-orientedconsulting firm.

ADVICE FOR ENTREPRENEURS“If you don’t have a reimbursementscheme, the product will die on thevine,” Dr. Brooks cautions would-be entrepreneurs. “I also learned that FDA decisions were different than insurers’ decision-making process, butthat the common currency was data. A combined approach to identify the optimal market, regulatory pathway and the means to reimbursement is critical at the earliest stages of productdevelopment. Data must then be generated to support this path anddemonstrate the value propositions for all stakeholders.”

He concludes, “Remember that it’snever too late to change your career. A single conversation can take you in adifferent direction. I think most doctorshave an entrepreneurial bent becausethey’re trained to recognize problemsand look for the best solution.”

Stick to it and take your idea as far as you can with your own resources rather than just presenting an initial idea to others. That’s the only way to build value in the company.– Jeffrey Gelfand, MD


Stephanie Trifoglio, MD, internist and geriatrician atMaryland Geriatric Medicine,Greenbelt, Md.


Susan Peeler, MD, MBA, co-founderof the Comprehensive GynecologyCenter in Gambrills, Md.

Stephanie Trifoglio, MD, an internistand geriatrician at Maryland GeriatricMedicine, Greenbelt, Md., believes thatphysicians can help patients agesuccessfully by starting to work withthem in midlife. “You can help themtake steps now to be healthy and hikingin the Galapagos in their 90s,” sheexclaims. “People are now aging well.Prevention is a luxury and a new science that was never on a physician’shorizon in the past. However,Millennials are on a trajectory to ashorter lifespan than Baby-Boomers,

with a higher prevalence of diabetes and other chronic diseases.”

Active AgingThe Finnish Geriatric Intervention Study to Prevent Cognitive Impairmentand Disability (FINGER) studypublished online in March 2015 in the Lancet, reported the results of a two-year, multi-domain use of diet,exercise, cognitive training, and vascularrisk monitoring, compared to a controlgroup, to see if these interventions could prevent cognitive decline in at-risk elderly people. The findingsindicated that these actions couldimprove or maintain cognitivefunctioning in this group significantlymore than health education alone.

Dr. Trifoglio states, “Exercise is

the true fountain of youth. It helps to maintain bone density, range ofmotion and mental status, while delaying the onset of dementia anddecreasing osteoporosis. It also has been proven useful in reducing orpreventing multi-infarct dementia.

“Tai chi helps protect against falls,and swimming provides fabulous aerobic and muscle-tone benefits, even though it’s not weight-bearing,” she adds. “Women especially are guiltyof not focusing on themselves. It takesjust a little time to invest in oneself. For example, I have three-pound barbellsunder my desk. I encourage my patientsto stand and pace while on the phone or while thinking, or to take a five-minute break at work and run up thestairs. If you can incorporate exercise

BY LINDA HARDER • PHOTOGRAPHY BY TRACEY BROWN

TAILORINGHEALTHCARETO SENIORS

From primary care to specialized emergencydepartments and surgical screenings,

the healthcare industry is beginning to do a better job of recognizing the special needs

of seniors – in meaningful ways.

SUCCESSFUL AGING STARTS IN MIDLIFE

into your life and not make it a separateitem on your ‘to do’ list, you’re ahead.”

She counsels her patients againstwatching too much television. “It’spassive and doesn’t promote socialinteraction. Laughing and being withfriends, on the other hand, is ideal. Andreading or playing a board game arebetter for promoting brain activity.” Dr. Trifoglio also is a proponent oflearning a new musical instrument,dancing to improve motor coordination,or doing simple weight-bearing activities.

Dr. Trifoglio advocates for protectingeyesight by wearing sunglasses todecrease cataracts, and getting an eyeexam at least every two years to detectdry macular degeneration and otherdiseases. The National Eye Institute’sAge-Related Eye Disease Study (AREDS)found that high levels of antioxidantsand zinc can cut the risk of advancedage-related macular degeneration byone-quarter.

Protecting hearing by wearingearplugs at concerts, races, constructionsites and other noisy venues is anothersimple preventive measure she advocates.

Common Sense Approach to NutritionA systematic review of 12 eligible studies published in Epidemiology inJuly 2013 found that higher adherenceto a Mediterranean diet was associatedwith better cognitive function, lowerrates of cognitive decline, and reducedrisk of Alzheimer’s disease in nine of the studies, whereas results for MildCognitive Impairment (MCI) wereinconsistent. The authors recommendedfurther studies to explore the connectionbetween diet and MCI and vasculardementia.

Dr. Trifoglio recommends that herpatients get a wide variety of nutritiousfoods, and only take supplements if theyhave a targeted medical problem. Sheexplains, “The exception is vitamin D,which is not absorbed as well by the skinas people age. Taking supplements canhelp while we’re learning more. Thesalad bar can be a great resource,because they can get small quantities of a large array of fruits and vegetables.”

The NIH Office of DietarySupplements notes that older adults alsoare at higher risk for insufficient vitaminD levels because they spend more timeindoors and their diet may notincorporate foods containing the

vitamin. They estimate that some 50percent of U.S. adults with hip fracturesmay have inadequate serum vitamin Dlevels, at less than 12 ng/mL.

Help Patients Set ReasonableGoalsIt’s important for physicians to reviewthe risks and benefits of over-the-countermedications with their patients,” Dr.Trifoglio advises. “Avoiding NSAIDsmay help decrease the risk of peptic ulcer disease, while those at risk forcolorectal cancer may benefit from them.

Each patient needs individualizedrecommendations that fit their healthhistory. We’ve learned that it’s not somuch the physical itself, but the annualreview of individual risks and benefitsthat is valuable in improving patients’health. A good doctor should talk tooverweight and obese patients aboutlosing just 10 percent of their bodyweight, and help smokers quit. Helpingpatients set reasonable goals isimportant.”

What works varies, but she notes thatsimply getting a doctor’s ‘prescription’ toexercise more or stop smoking issurprisingly powerful.

A Community Geared to Aging in PlaceDr. Trifoglio feels fortunate to live inGreenbelt, Md., a community developedby Eleanor Roosevelt. A number offactors make it a great place for older

adults to age in place. “I can walk everywhere,” she

enthuses. “Young professionals move inbecause Goddard Space Center is nearby.GIVES, the Greenbelt IntergenerationalVolunteer Exchange Service, was createdto help those who need assistance to stayin their homes independently. You canearn a life chip, for example, for helpingsomeone clean their gutters. There’s asenior center across from the preschool,and the interaction for aging in place isamazing. Those who join can take orgive help, for everything from gettingtransportation for doctors’ visits tohousework, meals, pet care, computer,laundry, or yard work. The hundreds ofparticipants fill out an application,without paying any fee.”

AN ED DESIGNED FOR SENIORSEmergency departments (EDs) haven’tbeen senior-friendly, but that may bechanging. Take Saint Agnes Hospital’snew ED designed for seniors inBaltimore. After recognizing that not only were 10 percent of itsemergency patients seniors, but that half of the visits from that populationresulted in admissions, it decided tocreate a specialized area that could better meet the unique needs of thispopulation, while decreasing repeat visits and hospitalizations.

Fortunately, Trishena Jones, MD, anemergency medicine attending physicianat the hospital, was eager to play the roleof physician champion, and other EDemployees were equally enthusiastic. She notes, “We’re the 73rd geriatric EDin the country, the second in Maryland,and the only one in Baltimore.”

Susan Mathers, director of theEmergency Department at Saint Agnes,recalls, “Starting about a year before weopened, we engaged the Erickson Schoolat UMBC as consultants, and conducteda five-day, multidisciplinary teamplanning retreat. Erickson wasphenomenal; they’ve done a lot of thiswork across the country. It was sorewarding and enlightening for the teamto come together and focus on meetingour seniors’ needs. We brought in a largegroup up front that included registrars,radiologists, nurses, doctors, and others,to identify the barriers for older patients.Dr. Jones really took this project and ranwith it. She was very collaborative witheveryone from the beginning.”

“EDs are very busy, noisy places,”


Exercise is thetrue fountain ofyouth. It helps tomaintain bonedensity, range ofmotion and mentalstatus, while delaying the onsetof dementia and decreasingosteoporosis.– Stephanie Trifoglio, MD


acknowledges Dr. Jones, “and older adultscan be pushed aside. We looked at newways to provide excellent care to seniorswith their unique needs. We conductedfocus groups of our techs, nurses andregistrars to solicit their input.”

The ED team then met frequently tooperationalize their plans, and still meets on an ongoing basis to continuemaking changes.

Environmental ChangesDr. Jones explains, “We constructed aseparate zone with seven rooms, payingattention to lighting, flooring and soundproofing, along with hearing-assistivedevices for those who didn’t bring theirhearing aids, and white boards tofacilitate communication.”

Mathers adds, “We made changes that included installing handrails, using softer paint colors, and makingblanket warmers available. The quietenvironment and lighting really havemade a difference.”

Up-Front ScreeningsBeyond a more calming environmentthat promotes better communication, the

ED team took a comprehensive careapproach that addressed key issues upfront with a series of screening tools.“We use screening tests for ADL, fallsrisk, cognition, nutrition, depression,and polypharmacy,” notes Dr. Jones.“When our screening identifies a patientwho needs help at home, we can get acase manager, social worker and/orpharmacist involved up front. We don’twant to admit the person, then find outthat the same issues exist at discharge.”

Staff EducationA third critical component of the newsenior ED involved educating the entireteam. “All of the ED staff, not just theones in the senior unit, receivedadditional training to better meet theneeds of older adults,” notes Dr. Jones.“We helped them appreciate how muchanxiety being in the ED can create, andto become more aware that older adultssometimes can’t speak up as much asyounger patients.”

Mathers contributes, “As soon aspatients enter the ED, they’re greeted bya ‘quick look’ nurse who assesses themto determine if they’re appropriate for

the senior ED. We don’t put the moreacutely ill patients in this unit. As theproject progressed, our goal was also tomake all staff aware of ageism. Forexample, we educated them that ifsomeone can’t hear well, you don’t justyell louder. You want to instead adjustyour pitch to preserve their dignity.”

Early ResultsWhile the early results are anecdotal, Dr. Jones notes that feedback frompatients and their physicians is extremelypositive, and that seniors appreciate thecalm environment and increasedattention. “It’s been very successful,” she notes. “In the next few months, we’ll begin to get statistics through theSchumacher Group. I didn’t realize therecould be so many resources availablefrom the ED until we undertook thisinitiative.”

A GERIATRIC SURGERY CENTERIf there are only 70-some EDs geared toseniors across the country, the number of surgery centers tailored to their needs is far smaller, with Sinai’s Centerfor Geriatric Surgery in Baltimore,

Mark Katlic, MD, MMM, FACS, chief of the Department of Surgery and surgeon-in-chief atSinai Hospital, and director of theSinai Center for Geriatric Surgery


still the only one in the U.S. This centerwas started in the fall of 2012 by MarkKatlic, MD, MMM, FACS, chief of theDepartment of Surgery and surgeon-in-chief at Sinai Hospital, and director of the Sinai Center for Geriatric Surgery.Dr. Katlic, a thoracic surgeon, has had a 30-year interest in geriatric surgery.

“The principal behind our center isthat the conditions requiring surgery all increase in prevalence with age,”explains Dr. Katlic. “However, it ispossible to get identical surgicaloutcomes in the elderly population. We asked, ‘What can we teach everyoneso that we can do it better?’ We alsobuilt a computerized database.”

The center gives pre-op elderlypatients a comprehensive evaluation that involves:

z The Mini-Cog™ testz Timed Up and Go (TUG)™ testz Oral health screeningz Hearing screeningz A Caregiver Strain Index (CSI)z PRIME-MD PHQ (A two-question

depression screening)z Mini-Nutritional Assessment

(MNA)® – a brief nutrition screeningz BMI calculationz Falls risk assessmentz CAGE alcohol assessment z Frailty test including a handgrip

device

Dr. Katlic explains, “We evaluateanyone over age 75 who is scheduled for a surgical procedure, and we havescreened about 1,000 people to date. We want to show that it’s predictable to determine who is an appropriatecandidate.”

Available to patients of any surgeonperforming procedures at the hospital,the screening is completed in a standardpre-op testing area, supplementing thestandard heart and lung screenings thatare performed for all pre-op patients.

What if a prospective surgicalcandidate ‘fails’ some of the tests? Dr. Katlic states, “I don’t know thatanyone has cancelled surgery as a result,but they have modified it and institutedspecial post-op measures. For example,some 20 percent of patients fail the minicognitive test even though they have noapparent mental deficiencies when theywalk in. We know, however, that they’reat risk for post-operative delirium if they

fail this test, which increases their risk of complications, a long length of stayand even death.”

To prevent post-op complications, the center notifies all staff caring for the patient and institutes measures thatinclude:

z Allowing the patient to sleep through the night

z Permitting the family to be at the bedside

z Frequently orienting the patient to date/time

z Removing cathetersz Avoiding restraints wherever possiblez Getting them up and moving as

soon as possiblez Begin working immediately on rehab

plans rather than assuming thepatient can be discharged to home

He continues, “We can get good resultswith elective surgery in the elderly,whereas performing emergency surgeryin this group can endanger their health.For example, a patient with a largehernia that has been trapped should beoperated on before it becomes a crisis,because the elderly lack the reserves of a younger population. They can handlestress, but not severe stress, and theycan’t handle post-op complications well.The best centers are doing a thoroughevaluation of older adults and payinggreat attention to details.

“We put all of the information in a database, with a goal to develop astandardized test that’s predictive ofoutcomes.”

Educating Medical ProfessionalsThe second component of the Center

for Geriatric Surgery is an educationalone for healthcare providers. Along withnearly 50 other hospitals in Virginia,Maryland and DC, Sinai has beendesignated a NICHE (Nurses ImprovingCare for Healthsystem Elders) hospitalfor its quality care of older adults.

Dr. Katlic also has participated in the Chief Resident Immersion Trainingin the Care of Older Adult (CRIT),which provides case-based training ingeriatrics principles to chief residents to improve care coordination and qualityfor hospitalized, at-risk older adults.Further, he notes, “The AmericanCollege of Surgeons, with whom we’reworking, just received a $3 million grant from the Hartford Foundation to develop a standards and verificationprogram similar to the one used forcancer centers.”

Avoid AgeismDr. Katlic provides this advice tophysicians: “Don’t be an ageist. Don’tbase your treatment and surgicaldecisions on a patient’s chronologicalage, but on their functional age. I’vesuccessfully operated on a woman who was 104 years old and recentlyoperated on two 90-year-olds.”

He notes that studies have found that older adults are less likely to betaken to a dedicated trauma center or receive aggressive treatment thanyounger patients with the same level of injury. “They also are less likely toreceive surgery for breast cancer, forexample. Even if hypothetical patientsare presented to doctors, studies foundthat they had different referral patternscompared to younger patients. We need to be aware of our own potentialfor bias.”

Mark Katlic, MMM, FACS, chief of the Department of Surgery and surgeon-

in-chief at Sinai Hospital, and director

of the Sinai Center for Geriatric Surgery,

Baltimore

Trishena Jones, MD, attending emergency medicine physician at

Saint Agnes Hospital, Baltimore

Susan Mathers, RN, director of Emergency Services at Saint Agnes

Hospital, Baltimore

Stephanie Trifoglio, MD, internist/geriatrician, Maryland Geriatric

Medicine, Greenbelt, Md.

Don’t be anageist. Don’t baseyour treatmentand surgical decisions on a patient’s chrono-logical age. – Mark Katlic, MD, MMM, FACS


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Chesapeake Physician November/December 2015 Issue