Maryland Physician Magazine September/October 2012 Issue

M A RY L A N D

Physician YOUR PRACTICE. YOUR LIFE.

CANCER TREATMENT AND SURVIVOR TRENDS PHYSICIAN ADVOCATE CONGRESSMAN JOHN SARBANES HELPING PATIENTS WITH MOOD DISORDERS

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VOLUME 2: ISSUE 3 SEPT/OCT 2012

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Contents 10

VOLUME 2: ISSUE 3 SEPT/OCT 2012

F E AT U R E S

9 Amyvid: A Window into Alzheimerâ&#x20AC;&#x2122;s 10 Cancer: Treatment Trends and Help for Survivors 16 Better Mental Health Diagnosis and Care Mood and anxiety disorders are among the most common issues that bring patients to primary care offices

20 Physician Bane or Benefit? Six Reasons to Use Social Media

D E PA R T M E N T S

Cases

| 7 | Your Patient Just Said She's Suicidal: What Do You Do?

Living

| 24 | Rockfishing: A Different Way to Break Away

Policy

| 26 | A Conversation with Congressman John Sarbanes

Solutions

| 29 | The Marketing Plan: A Protocol for Success

Good Deeds

| 30 | Healing Hands, Giving Spirit: Carole Miller, M.D.

On the Cover: Hopkins colorectal surgeon, Jonathan Efron, M.D.

SEPTEMBER/OCTOBER 2012

JACQUIE ROTH, PUBLISHER/EXECUTIVE EDITOR jroth@mdphysicianmag.com LINDA HARDER, MANAGING EDITOR lharder@mdphysicianmag.com CONTRIBUTING WRITERS Tracy Fitzgerald Jackie Kinsella

HIRTY YEARS AGO, I HAD THE BEST INTRODUCTION TO MARYLAND as part of the 1982 reelection campaign for Senator Paul Sarbanes. My experience ranged from knocking on doors as I walked through Baltimore’s immigrant-flavored neighborhoods, to holding placards on street corners and waving at drivers, to one magical night enjoying pizza with the campaign staff, the Senator and his lovely late wife Christine, watching the Baltimore Orioles in contention for 1982 World Series. Even lounging on the floor surrounded by a frazzled campaign staff and pizza boxes, the Senator’s ease, intellect and gentlemanly qualities were not lost on me. That year, it was a particular nasty campaign, with the first large and powerful PAC unsuccessfully gunning for the Senator’s seat. What an honor it was to have the opportunity to sit with his son, Congressman John Sarbanes, thirty years later and discuss the impact of the Supreme Court’s ruling on the Affordable Care Act (ACA). While this issue goes to press, we’re at the very early stages of what is sure to be the ugliest and most expensive presidential campaign in American history. This fall is going to make the 1982 NCPAC (National Conservative Political Action Committee) look like pablum. We have another Sarbanes leading our country with ideals focused on what he believes to truly best for our country – comprehensive healthcare for all Americans. The coverage will not necessarily translate into care for all – we already suffer from a shortage of providers and Maryland providers are some of the most reimbursement-challenged in the country. Read Congressman Sarbanes’ thoughts on the future and solutions for providers and reimbursements in Policy, page 26. The state plans to call on primary care physicians to help manage the influx of mental health patients expected as part of the ACA’s expansion of insurance coverage for mental health. In this issue, we have two editorial pieces that offer information and resources to help you care for your patients, see Cases (page 7) and our feature, Better Mental Health Diagnosis and Care (page 16). The issue’s cover story (page 10) spotlights new trends and treatments in cancer, including survivorship programs. Most unfortunately, Maryland stacks up high in both cancer diagnoses and deaths when compared to other states. Most fortunately, we have some of the country’s leading-edge cancer diagnosticians and clinicians. More patients are surviving cancer, and they and their loved ones have traveled incredible journeys on their way to remission, but with that comes a new set of issues. Now a required component of accreditation from the Commission on Cancer of the American College of Surgeons, health professionals are recognizing that cancer survivors need better coordination of their ongoing post-treatment care. Primary care physicians play a critical role in that coordination. I was personally touched twice by cancer deaths – my mother and my sister. Their care, deaths, my grieving and healing led me to Hospice of the Chesapeake. I’ve taken to heart an adage that I learned from my experience, “The greatest cure for grief is action.” I’ve taken action as chair of Hospice of the Chesapeake’s Annual Golf Tournament – celebrating our 10th year on October 4th. Please join me on the course or raise funds and awareness on your own. There are incredible organizations throughout Maryland working for you, your patients and your families, see Good Deeds (page 30). Be inspired. To life!

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Jacquie Roth Publisher/Executive Editor jroth@mdphysicianmag.com

CONTRIBUTING PHOTOGRAPHY Tracey Brown, Papercamera Photography www.papercamera.com Mark Molesky, Moleskey Photography www.moleskyphotography.com ADMINISTRATION Ginger Jenkins EXECUTIVE ASSISTANT/WEBMASTER Jackie Kinsella Maryland Physician Magazine™ is published bimonthly by Mojo Media, LLC. a certified Minority Business Enterprise (MBE). Mojo Media, LLC PO Box 1663 Millersville, MD 21108 443-837-6948 www.mojomedia.biz Subscription information: Maryland Physician Magazine is 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 contact is strictly prohibited and protected by copyright laws. To order reprints of articles or back issues, please call 443-837-6948 or email jroth@ mdphysicianmag.com. Maryland Physician Magazine Advisory Board: An advisory board comprised of medical practitioners and business leaders in diverse practice, business and geographic scopes provides editorial counsel to Maryland Physician. Advisory board 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., FACS KURE Pain Management MICHAEL EPSTEIN, M.D. Digestive Disorders Associates STACY D. FISHER, M.D. University of Maryland Medical Center REGINA HAMPTON, M.D. FACS Signature Breast Care DANILO ESPINOLA, M.D. Advanced Radiology GENE RANSOM, J.D., CEO MedChi Although every precaution is taken to ensure accuracy of published materials, Maryland Physician and Mojo Media, LLC cannot be held responsible for opinions expressed or facts supplied by authors and resources.

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Cases

Your Patient Just Said She’s Suicidal: What Do You Do? Mark S. Komrad, M.D

CASE: Claire, a patient you’ve known for years, has just told you that she is so depressed that she wants to die. If you’re not a psychiatrist, you might think, ‘it’s been a long time since I had that rotation in med school.’ Surprisingly, patients are far more apt to discuss mental health issues with their primary care provider than they are to call a psychiatrist. It’s one thing to manage a typical depressed patient, but a patient who shares suicidal thoughts is something else. What do you do? DISCUSSION Start with the understanding that your patient told you because she wants your help. Express appreciation that she trusted you enough to share these feelings. This implies that you accept her empowerment of you as a trusted helper and guide in this situation. Ask a few straightforward questions at this point; asking them will not make things worse, or plant thoughts that aren’t already in her mind: For how long and how persistently have you been having these thoughts? Is dying a “wish” or “hope,” or is it a plan? If it’s a plan, what’s the plan and how much has been implemented so far (e.g. bought a hose or bullets for a gun)?

These factors indicate “reflected intent,” useful predictors of risk that feelings might turn into action. Let’s divide your possible responses into three speeds, based on your clinical assessment of the situation: slow, medium, and fast. Compare it to a cardiac situation: tachycardia that is sinus, supra-ventricular, or ventricular; each calls for a different level of urgency. SLOW Just as you have a cardiologist to whom you refer people, it’s important to have an established relationship with a psychiatrist, who will give priority to your referrals. Transferring the empowerment Claire has given you to a colleague psychiatrist, you might tell Claire “I have great confidence in Dr. X, whose expertise in situations like this has been so valuable to me in the past.” Notice you are implying that even you need help in a situation like this, and this is the professional you trust to help you. Have your office make the appointment for Claire. Also, try to convince her to let you contact a support person about the situation and appointment with Dr. X. A staff member should call Claire every day until that appointment occurs, to keep the umbilical cord of help connected until Dr. X takes over. MEDIUM Perhaps you’re not sure that she can safely go home and wait for an appointment, or suspect that she needs inpatient treatment. Try to get Dr. X on the phone to consult with you personally. Meanwhile, ask a staff member to sit with Claire, who may share additional information while you are waiting for Dr. X to call back. Let Claire know you have a call in to Dr. X to consult. Patients feel very cared for when they know that you are taking time out of your busy day to call another doctor about them. This can strengthen Claire’s trust in you. Dr. X can help you assess Claire further and determine what to do next. You might even be able to send Claire right over to

X’s clinic or office to be seen now. Or Dr. X may know of an urgent assessment clinic that can provide fairly immediate evaluations in the community. Again, try to involve a family member. FAST Prepare in advance to mobilize the fast route, if you have concluded that Claire is very serious, and is in imminent danger. In this path, the patient needs to go to an ER, where she can receive an acute suicidal evaluation. ER physicians have options such as referring Claire for outpatient treatment or inpatient hospitalization (involuntarily, if necessary). Optimally, mobilize a family member or friend to bring Claire to an ER right away; don’t trust Claire to drive herself there. If Claire refuses, and the situation is dire, you can complete an Emergency Petition (EP) (available at www.courts.state. md.us/courtforms/joint/ccdc013.pdf) to initiate involuntary hospitalization. Contact the police to take Claire and the completed EP to an ER for evaluation. Explain to her how important her safety is to you, that you are very worried, and that you will follow up. Find out what happens to her in the ER. If she is hospitalized, and you make rounds at that hospital, be sure to stop in. Knowing the patient’s healthiest baseline is a critical aspect of evaluating the credibility of their suicidal intent. As a primary care provider, you are in a particularly good position to have learned that baseline and developed trust in a longstanding relationship with patients like Claire. That is why I advise people who are worried about a loved-one’s mental health to contact that person’s primary doctor. An established relationship provides a more felicitous way to approach a psychiatric concern than going to a mental health professional for the first time. However, if you need us, psychiatrists are here to help. You just have to make the call. Mark Komrad, M.D., is the author of You Need Help: A Step-by-Step Guide to Convince a Loved One to Get Counseling (Hazelden Press, 2012) SEPTEMBER/OCTOBER 2012

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Amyvid™ > > > > >

A Window into Alzheimer’s

Amyvid ™ is the latest radioactive tracer used with PET scans to detect, and better characterize, commercially. Approved by the FDA in Alzheimer’s disease. April 2012, Amyvid uses an F-18 labeled with a longer half-life; three Maryland Physician compound other products with this compound await spoke with a FDA approval. Studies to date found that the tracer has a median sensitivity of 92% local nuclear and specificity of 95% for detection of amyloid plaques. medicine specialist Appropriate Patients to learn more. Ethan Spiegler, M.D., chief of nuclear Ethan Spiegler, M.D.

Some 5.4 million Americans (one in eight age 65 and older) have Alzheimer’s today and the annual incidence is expected to double by 2050 to nearly one million cases. Already, the disease is the sixth leading cause of death in the U.S., fueling the search for better ways to detect and treat it. The ground for creating Amyvid (Florbetapir F 18) was laid when Pittsburgh Compound B (PiB), a compound labeled with Carbon 11, was developed several years ago to tag beta-amyloid neuritic proteins in the brain. With a half-life of only 20 minutes, that compound was not viable for use

medicine at Advanced Radiology, says, “Appropriate patients are those who have memory impairment and have already undergone multiple blood

the brain. We don’t know if they are the cause or the byproduct of the disease, but if few or no amyloid plaques are present, it’s extremely unlikely that the patient currently is suffering from Alzheimer’s. Unfortunately, the flip side is not true – positive findings do not definitively establish the diagnosis, as some other conditions may also have amyloid deposits.” In other words, Amyvid is more helpful to rule out than to diagnose Alzheimer’s disease. An additional issue is the dearth of effective treatments. “There are no good therapies out there yet,” acknowledges Dr. Spiegler. “Some are helpful initially but they typically wear off after a few months. However, identifying the disease earlier can ensure that there aren’t other reversible causes of dementia to pursue. In addition, early detection may help with family planning.” Radiologists must take a course to become certified and only certified readers should interpret Amyvid results. Amyvid has a half-life of two hours. As a result, it must be distributed directly to imaging centers from the specialized radiopharmacies that produce it. Presently, Amyvid is an expensive option, though the goal is to obtain reimbursement and increase availability. “The dose itself may cost $3000 and it’s not currently reimbursable,” adds Dr.

“…if few or no amyloid plaques are present, it’s extremely unlikely that the patient currently is suffering from Alzheimer’s.” Ethan Spiegler, M.D. tests and MRI with atypical imaging results. If you’re already 99% certain that the patient has Alzheimer’s, you may not need PET/CT evaluation with Amyvid.” He continues, “The key is that we’re looking for amyloid deposits in

Spiegler. “Advanced Radiology will receive some doses in the next few months, and will do perhaps five to 10 free cases so that we can validate that the parameters we use are correct.” Ethan Spiegler, M.D., a radiologist, is chief of nuclear medicine at Advanced Radiology.

SEPTEMBER/OCTOBER 2012

Jonathan Efron, M.D.

CANCER TREATMENT TRENDS AND HELP FOR SURVIVORS In this issue, ďŹ ve Maryland physicians describe advances in treating rectal, peritoneal and skin cancers and the role of cancer survivorship programs in caring for those who survive cancer. BY LINDA HARDER PHOTOG RAPHY BY TRACEY BROWN

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Trends in Treating Rectal Cancer Over the decades, physicians have learned much about how to best treat rectal cancer. Hopkins colorectal surgeon, Jonathan Efron, M.D., and his team are investigating the efficacy of laparoscopic and robotic procedures, endorectal brachytherapy and other state-of-the-art treatments for this disease. “In the past, we gave radiation therapy after surgery,” recalls Dr. Efron. “Then, in the 1990s, large randomized European trials showed a better response when patients were given adjuvant therapies before surgery and American surgeons subsequently found it decreased recurrence rates. Today, most patients with rectal cancer get neoadjuvant therapy prior to surgery.” Multidisciplinary Approach Dr. Efron explains, “We’re using a multi-disciplinary approach. Our rectal cancer center is composed of radiation oncologists, medical oncologists, surgical oncologists, colorectal surgeons, nuclear medicine specialists, pathologists and others. Typically, patients come to us after having had a colonoscopy or sigmoido-scopy that identifies rectal cancer. “We evaluate rectal cancer using a battery of radiology tests, usually MRI of the pelvis or CT of the abdomen and pelvis,” Dr. Efron continues. “On the same or next day, the patient can see the surgeon, radiation oncologist and medical oncologist. We can coordinate with the patient’s medical and radiation oncologist back home or provide those therapies here. The vast majority of patients proceed with surgical intervention about eight weeks later. About 20% of patients – those for whom radiation and chemotherapy have apparently completely eradicated their cancer and those who are too sick to undergo surgery – will receive watchful waiting instead.” Laparoscopic and Robotic Approaches “With colon cancer, we know that laparoscopic and robotic surgery results are comparable to open excisions, but we’re not yet sure that is true for rectal surgery,” Dr. Efron notes. “Hopkins is involved in a large, randomized trial across the country, but we won’t know the results for another three to four years.” Total Mesorectal Excision (TME) Surgery Studies have shown that total excision of the mesorectum, fatty tissue directly adjacent to the rectum that contains blood vessels and lymph nodes, provides superior outcomes and has more than halved the recurrence rate. TME is appropriate for patients with tumors in the middle or lower two thirds of the rectum.

Dr. Efron comments, “In the older technique, the lateral aspects of the rectum were divided and left in. Now, we excise everything. The five to 10 year recurrence rate has decreased to 5-10%. “In the 1980s, a tumor anywhere in this area would have required a colostomy,” he continues. ‘Now, using pre-op radiation therapy, many people are candidates for the preservation procedure. We can often shrink large tumors to alter our operational plan and keep the anal muscles intact. Patients typically get a temporary colostomy but can avoid a permanent one. Less than 1% of patients experience some urinary continence and sexual dysfunction issues as a result of nerve damage.” High-Dose-Rate Endorectal Brachytherapy (HDRBT) Hopkins is conducting a pilot study of HDRBT for patients with clinical stage T2N1 or T3N0-1 resectable rectal cancer. This approach, first pioneered in Montreal, uses an anal probe to deliver brachytherapy over a four-day period in lieu of five weeks of external beam radiation therapy. The trial started in early 2012 and results won’t be known for several years. “We’ve had excellent results with 10 patients to date, and we plan to test it on about 20 more,” concludes Dr. Efron.

Cytoreductive Surgery and HIPEC For years, the only treatment for patients with peritoneal dissemination of cancer was chemotherapy, which has poor results. Then, in the 1990s, a few surgeons began performing cytoreductive surgery and intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) at the completion of surgery to destroy remaining cancer cells in the abdomen. This is a lengthy procedure taking seven to 12 hours that requires a highly experienced surgical team. Cytoreductive surgery refers to the complete removal of all visible cancer or only leaving cancer nodules less than 2.5 mm in size. This is followed in the same setting by HIPEC to destroy remaining cancer cells in the abdomen. Colorectal cancer with peritoneal dissemination is the most common carcinoma treated by cytoreduction with HIPEC. Others include appendix, ovarian, gastric, primary peritoneal, sarcoma Armando Sardi, M.D. and mesothelioma.

SEPTEMBER/OCTOBER 2012

| 11

MOHS SURGERY INDICATIONS Basal cell carcinoma, squamous cell carcinoma and other skin cancers that:

Develop on areas where preserving cosmetic appearance and function are important Have recurred after previous treatment or are likely to recur Are located in scar tissue Are large Have edges that are ill-deﬁned Are aggressive and rapid-growing

Refer Early, Before Chemo Unfortunately, patients are often referred late, after they’ve received chemotherapy and multiple surgeries. Armando Sardi, M.D., director of the Institute for Cancer Care at Mercy, states, “As soon as patients are diagnosed by CT or surgery with peritoneal spread, they should be referred. Chemotherapy makes the patient debilitated.” Dr. Sardi says, “The surgeon has to be prepared to perform an extensive surgery, which may require the removal of several organs at one time. Most of the patients I perform this surgery on have extensive disease and this is their last hope. However, there’s so much data in the literature now that supports cytoreductive surgery with HIPEC, and thanks to the Internet, patients are getting to us earlier.” Media coverage is misleading, according to Dr. Sardi. “A New York Times article* described it as a horrendous surgery but it’s not.” Insurance is another barrier. “Medicare doesn’t want to recognize this procedure,” he adds. The Procedure “In the procedure, surgeons remove all of the visible tumors and attempt to preserve as many organs as possible,” Dr. Sardi continues. “Some 85% of the time, we remove all visible tumors of 2.5mm or greater. Then, the peritoneal area is bathed in a heated chemotherapy solution, which is the most effective way to kill remaining cancer cells. Patients with colon, rectal and ovarian cancer often need follow-up chemotherapy, which we coordinate closely with medical oncologists.” However, there is

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Lisa Renfro, M.D.

no data that all patients with cancer of the appendix or mesothelioma benefit from follow-up chemotherapy.” Following the procedure, patients spend about 12 days in the hospital, start eating after about one week and take two months to fully recuperate. Most patients are 40 to 50 years old, but some are in their 20s or 80s. Outcomes The mortality rate for an experienced surgeon is surprisingly low. Dr. Sardi comments, “In about 400 procedures, we had only one mortality and that was in 1998. Very few treatments have as good outcomes as HIPEC, yet it remains underutilized.” A study in the Journal of Clinical Oncology found that merely 4% of patients with colorectal cancer and peritoneal dissemination who were given only chemotherapy were alive after five years. A prospective randomized trial in patients with colon cancer using HIPEC in addition to chemotherapy showed a 45% survival at 5 years if the cancer was completely removed. “For patients with Stage IV cancers that have spread to the peritoneum, very few treatments have outcomes as good as HIPEC. In fact, a patient I treated in 1994 is still alive today,” concludes Dr. Sardi.

Mohs Surgery: A 99% Cure Rate Annapolis dermatological surgeon Lisa Renfro, M.D., has performed more than 15,000 surgical excisions and 10,000 Mohs surgical procedures in her nearly 20 years in practice. Even for a dermatologic surgeon, it’s an astounding indication of the prevalence of skin cancers. With 3.5 million skin cancers diagnosed annually, it is the most common cancer in the U.S.,

affecting more people each year than breast, prostate, lung and colon cancers. Mohs surgery uses microscopic examination of skin cells to trace the skin cancer and completely remove it. Performed under local anesthesia, the tumor is excised with a narrow margin and immediately processed in an on-site histological lab. There, it is color coded with dyes and the tissue is precisely mapped. Under the microscope, the tissue is analyzed for remaining cancerous cells; when indicated, a second thin layer of tissue is removed from the exact site that contains cancerous tissue. Most patients only need one stage; rarely a second or third stage is necessary to achieve cancer-free margins.

Cancer Survivorship Programs With more people surviving cancer than ever before – estimated at over 80% – health professionals are recognizing that cancer survivors need better coordination of their ongoing post-treatment care than has been available to date. That has led to the onset of Cancer Survivorship Programs, now a required component of accreditation from the Commission on Cancer of the American College of Surgeons. Barry Meisenberg, M.D., director of the Cancer Institute at Anne Arundel Medical Center, observes, “Cancer patients have medical, social and psychological issues that aren’t being well addressed.

Mohs surgery, by conserving tissue, allows the best cosmetic and functional outcome. Lisa Renfro, M.D. The removal of each tissue layer takes about 15 minutes, but each tissue analysis requires one to two hours due to histologic processing. In most cases, the dermatologic surgeon performs reconstruction of the surgical defect. The Mohs procedure offers the highest success rate of all skin cancer treatments – greater than 99% for new cancers and 95% for recurrent carcinoma – and preserves the maximal amount of normal tissue. Dr. Renfro remarks, “Mohs surgery, by conserving tissue, allows the best cosmetic and functional outcome. Since many skin cancers are on the face, that’s an important advantage.”

There are gaps in communication between the oncologist, primary care physician, other providers and the patient. A plan for follow-up care is not always clear. Physicians worry they don’t have enough information on the patient’s treatment. Patients may be caught in between and don’t know where to go for screening for other medical problems. For example, who does the follow-up for back pain and how do you treat it in a patient with cancer?” AAMC’s initial survivorship program was created for those with breast cancer, but it is expanding to patients with prostate, head and neck, lung and other cancers.

Advice for PCPs “When evaluating skin lesions, primary care physicians should be vigilant for new or changing lesions,,” Dr. Renfro advises. “Be on the lookout for any skin lesion that is pink, scaly, or pearly, and is enlarging or bleeding. Melanomas, although usually pigmented, may be subtle in appearance and occasionally do not reveal any pigment. Any unusual lesion should be biopsied.” Dr. Renfro also urges primary care physicians to check patients’ Vitamin D levels and to encourage patients to protect themselves from even small doses of sun exposure. “The American Academy of Dermatology’s position is that people should get any additional Vitamin D from diet and supplements, not sun exposure,” she says.

Survivorship Care Plan Aids Coordination “The survivorship program at Anne Arundel Hospital develops a detailed Survivorship Care Plan with the patient and sends it to the primary care doctors,” says Ravin Garg, M.D., medical oncologist with Annapolis Oncology Center. “It describes the various treatments the patient has undergone and the possible long-term side effects. For example,

Mohs Advances and Future Applications Dr. Renfro comments, “While it’s controversial, some surgeons are using Mohs for melanoma in situ, employing special immunostains. MART-1 is the stain of choice for this type of skin cancer. Immunostaining is used in addition to H & E staining. Cytokeratin stains are used for large, advanced, recurrent cancers.” In the future, Mohs is expected to have applications for locally invasive tumors with contiguous growth patterns in the prostate, cervix and larynx.

Ravin Garg, M.D. and Barry Meisenberg, M.D.

SEPTEMBER/OCTOBER 2012

| 13

with a breast cancer patient, it details when a patient should receive a mammogram and other follow-up tests. All the details of the patientâ&#x20AC;&#x2122;s therapies, including dates and types of therapies, lymph node involvement, where the radiation was directed, what medications the patient is taking, etc., are contained in a single document.â&#x20AC;? Dr. Garg remarks, â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s incredible what cancer patients go through â&#x20AC;&#x201C; typically surgery, radiation, sometimes chemotherapy and anti-estrogen therapy. Each has short and long term side effects, such as lymphedema after breast cancer excision. To patients and their loved ones, it can feel overwhelming. â&#x20AC;&#x153;Primary care physicians should be aware of the risks of blood draws and blood pressure readings on the arm with lymphedema, but also be informed that sometimes certain exercises are no longer contraindicated for these patients,â&#x20AC;? he continues. â&#x20AC;&#x153;Physicians also need to be aware of what a low white or red blood cell count could mean in a cancer patient (myelodysplasia from chemotherapy exposure).â&#x20AC;? Psychosocial aspects are also part of the survivorship assessment and followup. Dr. Garg notes, â&#x20AC;&#x153;Depression and anxiety are under-diagnosed in survivors. It can be difficult to address the psychosocial issues in a 20-minute visit with the oncologists, so it is important that this aspect of a patientâ&#x20AC;&#x2122;s longitudinal care is not forgotten. â&#x20AC;&#x153;Nutrition is another critical and often overlooked aspect of recovery,â&#x20AC;? he states. â&#x20AC;&#x153;I tell people to eat a healthy diet, drink lots of water and try get 150 minutes of moderate exercise every week rather than overdoing it with supplements.â&#x20AC;? * Pollack, A. (2011, August 11). Hot Chemotherapy Bath: Patients See Hope, Critics Hold Doubts. The New York Times.

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Armando Sardi, M.D., surgical oncologist, is director of The Institute for Cancer Care and director of Surgical Oncology at Mercy Medical Center. Jonathan Efron, M.D., colorectal surgeon, is an associate professor of surgery and chief of Ravitch Service, Johns Hopkins Medicine. Lisa Renfro, M.D., is a dermatologic surgeon at Annapolis Dermatology Associates and an attending physician at Anne Arundel Medical Center. Barry R. Meisenberg, M.D., hematologist/oncologist, is director of the Cancer Institute at Anne Arundel Medical Center. Ravin Garg, M.D. is a hematologist/ oncologist at Annapolis Oncology Center.

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BETTER

MENTAL HEALTH DI AGNOS I S AND CARE

Mood and anxiety disorders are among the most common issues that bring patients to primary care offices. Maryland experts describe how to assess these conditions quickly and the most effective treatments. WRITTEN BY LINDA HARDER

16 | WWW.MDPHYSICIANMAG.COM

M-3: Quick Assessment Tool

Despite society’s growing awareness and acceptance, depression and other mood/anxiety disorders continue to be significantly under-diagnosed and undertreated. Primary care physicians’ time constraints make it challenging to accurately assess and track these conditions. That’s a key reason that Robert Post, M.D., clinical professor of Psychiatry, George Washington University, and other psychiatrists developed a 27-item online selfassessment tool for patients to complete and share with their doctor. The free anonymous tool, My Mood Monitor (M-3), which became available in 2010, helps physicians quickly assess depression, and bipolar, anxiety, and posttraumatic stress disorders (PTSD). Dr. Post observes, “It has a pretty comprehensive screen for these four disorders. The key is that patients fill it out then share it with their physician. Users have found it helpful and easy to complete.” The responses trigger a risk assessment page that can be accessed securely online, or faxed or emailed to the physician. There’s even a mobile app. Dr. Post says, “We know that primary care physicians don’t have much time. It facilitates communication so the doctors don’t have to ask lots of questions. Doctors can even bill for it.” He continues, “The PHQ-9 (part of the Personal Health Questionnaire), is another good tool, but it only deals with depression. The M-3 includes four questions related to bipolar disorder, which is critical to assess because antidepressants can push these patients into a full-blown mania.”

Inadequate Treatment Risks

Dr. Post is an advocate for ensuring adequate long-term treatment of depression, especially given the risk of concomitant medical disorders. “We know that depression is a risk factor for many major illnesses – those affected are twice as likely to have a heart attack, and the risk for cognitive impairment and diabetes increases,” he says. “Two studies have demonstrated that stroke patients who are treated with selective serotonin reuptake inhibitors (SSRIs) recover better.” He adds, “The media don’t address the long-term preventive effects of antidepressants. Meta-analyses show huge preventive effects with long-term

use among populations that have had several prior depressive episodes. Physicians would never think about taking patients off high blood pressure medication – they should approach antidepressant use in the same way. And these drugs have relatively few serious side effects, even compared to aspirin or statins.” Dr. Post also notes that antidepressants may benefit cognitive function. “They increase brain-derived neurotrophic factor (BDNF) and prevent depressions, which decrease BDNF. An American Journal of Psychiatry study found that women with depression who had taken anti-depressants for a longer time did not have decreases in their hippocampal volume. New data suggest that even the mood stabilizer lithium increases BDNF and has brain protective effects. Most remarkably a preliminary study in The British Journal of Psychiatry found that a very small dose (150 mg/day) of lithium for one year compared to placebo helped to decrease the rate of cognitive decline in non-mood disorder patients with mild cognitive impairment.”

Depression in Adolescents Jack Vaeth, M.D., an adult and adolescent psychiatrist, has an irrepressibly cheerful personality that contrasts with the mood of many of his patients. “If you have depression, you have a lot of company,” he says. “Your odds of being diagnosed rise from one in eight as a teen to one in TRACEY BROWN

“We ask if the person has a family history of bipolar illness and whether they have ever had increased energy and decreased need for sleep in a period. Some two-thirds of women with hypomania have dysphoric hypomania, in which they experience irritability and anxiety rather than euphoria during manic periods, but clearly have increased energy and decreased need for sleep. If we can properly identify the disorder, we can get them started sooner on the right treatment.” The M-3 tool includes a graph of the patient’s progress and educational materials. Says Dr. Post, “Another benefit of the M-3 is that it provides longitudinal follow-up mechanisms so that physicians can readily monitor patients over time.”

Jack Vaeth, M.D.

SEPTEMBER/OCTOBER 2012

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six as an older adult, with more women at risk than men.” He adds, “After declining throughout the 1990s, teen depression, suicide and substance abuse have been on the upswing for the past five years. One theory is that our society is more open about suicide and depression. My theory is that the FDA’s 2001 black box warning about suicidal thinking scared many physicians from prescribing medications for teens and children.” SIGECAPS

“Primary care physicians see more depression than psychiatrists and prescribe more antidepressants than we do due to the sheer volume of patients they see,” notes Dr. Vaeth. He recommends that his primary care colleagues employ the acronym – SIGECAPS – to remember to screen for behaviors that can indicate depression. The acronym stands for:

S leep I nterest Guilt S ynergy C oncentration Appetite Psychomotor Changes S uicidal thinking/sex drive/somatization He adds, “Dysfunction in school or work is a common symptom. Another area I ask about is family. Children are more likely to have problems when parents are fighting or separating, have an inconsistent approach, or are too dictatorial or permissive.” The teen’s romantic/sexual and spiritual/religious life is also important. “Those who have suffered a recent break up or who question their sexual orientation are more likely to have a mood disorder,” he comments. There is a strong link between ADHD, anxiety, eating disorders, depression and substance abuse. “Children born with ADHD are at higher risk for anxiety disorders,” he says. “When they’re more anxious, they become more run down and depressed. They may abuse substances to feel better 18 | WWW.MDPHYSICIANMAG.COM

temporarily. For many children, if I treat their ADHD, their depression goes away. I screen everyone for all of these conditions.” Effective Treatments

A 10-year NIMH-funded study, Treatment of Adolescents with Depression (TADS), found that talk therapy helped improve depression in 40% of participants, medication improved it in 60% and using both combined improved depression in 72% of participants. Statistically, cognitive behavioral therapy works for all age ranges. Dr. Vaeth observes, “It’s straightforward and structured and we give them homework. I hold my patients accountable and it works.” “You need to think outside the box of therapy and medication alone, though,” he says. “I ask about the child’s hobbies and interests. What do they do for fun? Parents should encourage and even force kids at a young age to pursue hobbies, because it gives them an opportunity for an ego boost.” “The benefits of exercise also cannot be underrated,” he continues. “Studies show that when people work out three to five days a week, many of them benefit to the extent that they can reduce or even eliminate their antidepressants. Work, nutrition and exercise are all important. People who don’t set an alarm clock every morning concern me the most, because this is a signal that they lack structure and are not needed anywhere, anytime.” Unfortunately, the research and development pipeline for new drugs has nearly dried up. In 2011, VIIBRYD® (Vilazodone), an SSRI plus 5HT1A receptor partial agonist, was the only psychiatric drug approved by the FDA. This drug and other newer drugs such as Pristiq, a serotonin-norepinephrine reuptake inhibitor (SNRI), are not so closely associated with weight gain or sexual side effects. Nicotine and melatonin agonists showed promise, but trials have been halted. Another treatment found effective for many who don’t respond to antidepressants is transcranial magnetic stimulation (TMS). However, reimbursement is a barrier for most. “TMS is seldom reimbursed by insurance even though it has 40% to 50% effectiveness,” Dr. Vaeth laments. “It costs $5000 - $7000 or more for the

treatment course.” Finally, ketamine and scopolamine injections are on the treatment horizon. Dr. Vaeth notes, “Scopolamine injections have shown great promise in treating depression. Ketamine also is promising.” A recent study in Biological Psychology found that a single dose of ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, could rapidly decrease depression in 79% of those with bipolar disorder.

PTSD PTSD, a type of anxiety disorder, can be challenging to detect despite its prevalence; nearly 8% of the U.S. population will experience it at some point in their lives. It can be caused by experiences such as childhood neglect; physical, verbal or sexual abuse; rape or combat exposure. Acute stress disorder (ASD) refers to those suffering symptoms for less than 30 days, while PTSD lasts longer than 30 days. Lora Vaughan, MA, LCPC, specializes in seeing patients who have been traumatized or who have borderline personality disorder. “Identifying PTSD, especially with sex abuse and rape, can be hard because patients often have so much shame that they avoid talking about it. Physicians can ask patients how they are feeling to help open the door,” she suggests. Those with PTSD often suffer from the following: Re-experiencing the trauma – through intrusive thoughts, images, flashbacks, nightmares, etc. Avoidance of the trauma – avoiding thoughts and feelings related to the trauma, talking about it, or places and people that remind them of it. Inability to recall an important aspect of the trauma, withdrawal from usual activities, feelings of detachment. Increased arousal – difficulty sleeping, irritability, anger outbursts, poor concentration, startle easily, etc. “In men, trauma often exhibits as anger, whereas women are more likely to implode than explode,” explains Ms. Vaughan. “One of the few outwardly visible symptoms of PTSD is an exaggerated startle response. Those who have experienced long periods of abuse as a child may become attuned to certain sounds, such as footsteps coming down the hall, and that carries into adulthood.”

Treatment

Robert Post, M.D., is a psychiatrist in private practice, clinical professor of Psychiatry,George Washington University, and head of the Bipolar Collaborative Network in Bethesda. Jack Vaeth, M.D. is an adolescent & adult psychiatrist in private practice. He is an ECT physician at Sheppard Pratt, a consultant to the Baltimore City Public Safety Infirmary and the college psychiatrist at the Maryland Institute College of Art. Lora Vaughan, M.A., L.C.P.C., is a licensed clinical professional counselor in private practice specializing in the treatment of trauma and borderline personality disorders.

TRACEY BROWN

Medications that act on the nervous system can reduce anxiety and other symptoms of PTSD. Antidepressants, including SSRIs, can be effective, as well as anti-anxiety and sleep medications. However, the chief treatment approach involves working with a skilled therapist. Cognitive behavioral therapy (CBT) and prolonged exposure (PE) therapy are considered the most effective approaches. The latter has been empirically tested over 20 years and produces clinically significant improvement in about 80% of patients with chronic PTSD. It focuses on both imaginal exposure (revisiting and processing the traumatic memory) and in vivo exposure (repeatedly confronting situations that cause distress but are not dangerous). Ms. Vaughan cautions, â&#x20AC;&#x153;This therapy has a high drop-out rate because initial sessions are emotionally difficult. Trust in the therapist is critical because the patientâ&#x20AC;&#x2122;s instinct is to avoid revisiting the trauma.â&#x20AC;? â&#x20AC;&#x153;CBT helps people identify their thinking patterns and emotions, and learn to interrupt the cycle,â&#x20AC;? she says. â&#x20AC;&#x153;A specific form of CBT called Dialectical Behavior Therapy (DBT) works on acceptance, acknowledgement and then change. Itâ&#x20AC;&#x2122;s a bit slower, but effective.â&#x20AC;? Treatment can be short-term or longterm, depending on the type, duration, and severity of the trauma. Some people find their symptoms of PTSD remit after one course of PE (approximately 10-12 sessions). â&#x20AC;&#x153;For people who have experienced severe and long-standing trauma, it can take several sessions a week for five to 10 years to get better,â&#x20AC;? Ms. Vaughan concludes.

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Healthcare IT

PHYSICIAN BANE or BENEFIT? SIX Reasons to Use Social Media BY LINDA HA RDER

While some physicians have embraced social media, many still fear, misunderstand, or underuse it. Two Maryland physicians and Kevin Pho, M.D., a social media guru, discuss how physicians can make social media work to their beneďŹ t. 20 | WWW.MDPHYSICIANMAG.COM

A DEFINITION What is social media? According to Chris Boyer, director of digital marketing at Inova Health System, social media is user-generated content, twoway participation that is transparent. “I use social media to build trust. It’s how we connect, not why we connect.” The vehicles used in social media are growing and morphing continuously, but the best-known ones include Facebook, Twitter, LinkedIn, YouTube, Google Plus, blogs, and now Pinterest. Like email, billboards and print ads, social media is simply another communication vehicle. Yet what distinguishes it is its participatory and inclusive nature that creates a two-way conversation. In social media, physicians cannot prevent negative feedback and they cannot use an overt sales approach. Social media can be time consuming, overwhelming and not intuitive for many medical professionals. However, it can also save time and facilitate information sharing. Our experts suggest six ways to use social media to your benefit.

1. Online Reputation Management Kevin Pho, M.D., author of the blog KevinMD (www.kevinmd.com) and arguably one of the best-known physicians in the social media arena, says, “Physicians are reluctant to use social media because they’re hesitant to be online. Eric Topol, M.D., notes that it took 20 years for the stethoscope to be used after it was invented. Start slow and be comfortable online. Every doctor has to go at his or her own pace. “Physicians need to take control of their online presence and manage what comes up

when someone ‘Googles’ their name. Doctors are afraid of negative reviews,” he continues. “As a start, I recommend that they take 15 minutes to create a simple LinkedIn profile. It puts them in control and typically comes up first in a Google search.”

2. Continuing Medical Education LinkedIn groups and Twitter are two key ways to stay abreast of the tsunami of available medical information. Dr. Pho notes, “Twitter can help physicians keep up with the medical literature. It’s a fantastic tool for filtering and curating data. Physicians should follow the thought leaders.” Christopher L. Runz, D.O., urologist at Shore Comprehensive Urology, agrees. “I use Twitter to make sense of what I do and keep up to date in urology. In addition to reading journals, I use Twitter and a number of mobile apps on my iPad. I can access the latest information quickly. On Twitter, no one will follow you if you’re not relevant. Your tweets have to provide value. I retweet things that are pertinent and valuable, adding comments. If you’re cautious, start with a private account and approve who follows you, though that slows your learning curve.” “I think Twitter is easier than Facebook to catch up on and follow because it’s concise,” contributes Steve R. Daviss, M.D., DFAPA, chair of psychiatry at Baltimore Washington Medical Center. “I first heard about the Celexa warnings that way. It’s bite sized so it’s easy to read, and there’s usually a link to follow. I also use Google Plus, which is a good way to build networks with targeted groups. It’s almost like a list serve.” Dr. Runz advocates that

physicians, “Just listen at first. Follow a few accounts such as Eric Topol, M.D., Kevin Pho, M.D., and well-known physicians in your specialty. Learn what hash tags are. Then you’ll begin to understand how you can join the conversation.” He joined doximity.com, a HIPPA-compliant, encrypted social media site for physicians. “They perform background checks and doctors can comment on healthcare information, discuss challenging cases and receive feedback from other physicians. It’s a blend of Twitter and Facebook.”

I use social media to learn, stay current and disseminate valuable information. Christopher Runz, D.O.

Christopher L. Runz, D.O.

Dr. Daviss is more cautious about using doximity (www.doximity.com)—a professional networking tool exclusively for physicians and healthcare professionals. “I used it when it first came out but was taken aback by the fact that they built their lists via medical school yearbooks. I use LinkedIn, where you can establish a private group. For example, the American Psychiatric Association has nearly 2000 members in its LinkedIn group. Members discuss everything from clinical issues to social medicine and healthcare reform.” Physicians can also join Twitter chats. Visit SEPTEMBER/OCTOBER 2012

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Healthcare IT

Kevin Pho, M.D.

www.syymplur.com to view a schedule of upcoming chats.

As a start, I recommend that [physicians] take 15 minutes to create a simple LinkedIn profile. It puts them in control. Kevin Pho, M.D.

22 | WWW.MDPHYSICIANMAG.COM

3. Healthcare Policy Advocacy These physicians believe that social media can help doctors advocate for appropriate healthcare policy and be heard above the noise. “Social media is a launch pad for me to be heard by the general media,” comments Dr. Pho. Dr. Daviss concurs. “I use social media to educate myself about new laws such as the ACA and determine how they affect my practice. It’s a good way for physicians to get involved in the health policy debate. If we don’t, the decisions get made by non-physicians.” 4. Patient Education “We know patients are using social media,” says Dr. Pho. “It’s a great way to dispel myths and guide patients to appropriate data online. Social media amplifies the opportunity for sharing reputable healthcare information.” Ed Bennett, director, Web and Communications Technology at University of Maryland Medical System, agrees. “Studies show that patients want more social media. They’re comfortable with having physicians on social media, but

doctors think they aren’t. A recent survey showed that 61% of consumers trust physician information online, and they’re using social media to seek a second opinion or cope with a chronic condition.” “As a doctor in 2012 with dramatic changes occurring, it’s critical we use technology to engage patients,” Dr. Runz adds. “CMS has essentially said to doctors that we have to provide high quality care that has value by engaging our patients. Social media is one way to do that effectively. I recently put a video on active surveillance for low-grade prostate cancer on our practice’s Facebook site that convinced an older patient to reconsider his treatment options. Better informed patients are easier to take care of.” Podcasts have proven to be a fun and effective way for Dr. Daviss and two colleagues to disseminate mental health information to both professionals and the lay public. “We get together for three hours and record a podcast called My Three Shrinks (mythreeshrinks.com) instead of hanging out at a restaurant. For us it’s fun and we get good feedback. You have to hit people in a way that’s interesting and relevant.” Some physicians are making “hip” online videos as a way to actively engage people in their health. An example is Z Dogg MD (www.zdoggmd.com), a physician who has created multiple videos, including one that promotes testicular selfexams using humorous lyrics to the tune of Man in the Mirror. That tongue-in-cheek approach may not work for most doctors, but it’s more likely to engage young men than a dry article.

5. Patient Support Groups Private online support groups, often based on Facebook, are springing up to help people with a wide variety of diseases.

Dr. Runz is starting a support group for patients newly diagnosed with prostate cancer, to help them share treatment side effects, experiences and more. “They don’t have to wait for a monthly meeting,” he states. “It’s another tool to connect with other patients experiencing the same issues. Another example is a private Facebook site Ed Bennett created for UMMC trauma patients, where they can open up to each other about their experiences and recovery.”

6. Practice Marketing Social media does not typically lend itself to an old-school advertising approach. “However, physicians who use it wisely can get new patients,” notes Dr. Daviss. “Howard Luks, an orthopedic surgeon who has created numerous online educational videos, now gets about half of his referrals through social media. But that evolved because he repeatedly provided useful information to patients, not because he was selling anything.” Dr. Runz sums up the rationale for learning to use this new tool. “Social media now pervades everything. Think of Amazon and its product reviews. I use social media to learn, stay current and disseminate valuable information.” Steven R. Daviss, M.D., DFAPA, is chair, department of psychiatry, Baltimore Washington Medical Center and author of the blog Shrink Rap. Kevin Pho, M.D. is author of the blog KevinMD, www.kevinmd.com, a frequent national speaker and one of the best-known physician users of social media. Christopher L. Runz, D.O., is a urologist at Shore Comprehensive Urology.

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Living

Rockfishing: A Different Way to Break Away By Tracy M. Fitzgerald

Pictured after a recent rockfishing expedition (left to right) are: Michael Kerr, M.D., president of the medical staff and director of the emergency department at MedStar Montgomery Medical Center; Gary Fennel, surgical physician assistant from Washington Adventist Hospital; and Glen Harper, M.D., neurologist from Washington Adventist Hospital. Also pictured (far right) is Jerry Murry, senior manager of Donohoe Construction.

FEW TIMES A YEAR, Gary Fennel rounds up a small group of colleagues and friends to charter a fishing boat and set sail for a day of fun on the Chesapeake Bay. The goal is typically two-fold, but quite simple: take a break from the everyday stresses that go along with working in the patient care environment, and come back to the marina with rockfish that will be the centerpiece for that night’s dinner. “It’s a great sporting fish but also a great table fish,” said Fennel, a surgical physician assistant at Washington Adventist Hospital, who is often joined on the water by some of the physicians he works with day in and day out. “It’s relaxing to spend a day out on the water, 24 | WWW.MDPHYSICIANMAG.COM

but is also very exciting to bring one in and prepare it.” Rockfish, also known as striped bass, is a schooling fish that can live for up to 40 years in the ocean, freshwater bays and rivers. Recognized as Maryland’s state fish, and with the potential to grow to a weight upwards of 60 to 70 pounds, there is a particular interest in this catch along Maryland’s water ways. And according to Fred Donovan, owner of the Chesapeake Beach Resort and Spa, the opportunities are abundant for those who have easy access to the Chesapeake Bay. “In the 1980’s, the Maryland Department of Natural Resources instituted a moratorium that prevented fisherman from keeping their catches for

about five years, and ever since then, we have had a very good and sustainable fishery,” said Donovan. “Today, the midbay area is truly a world-class fishery and several state records have been set here for fish weight and length.” Since 1978, Donovan has owned and managed the Chesapeake Beach Resort and Spa, which also serves as a marina for approximately 25 independently-owned and operated charter boats. Captains who work out of this marina accommodate groups of people ranging from avid fishermen to novices just looking for something different to do for a day. While rockfishing opportunities are available throughout the year, the best time to go really depends on what each individual

fisherman is looking for. “The best times of year to catch bigger fish are late April to mid May, and then again in late October to early December,” Donovan said. “During these times, it’s common to see fish in the 40-inch range. But we also realized that

as a “nursery” for rockfish, thus sustaining and nurturing the growth of the species across the state. Each fisherman’s goal drives not only the right timing to hit the waterways, but also the catch method for the day. Some prefer trolling, which means traveling at a

“Today, the mid-bay area is truly a world-class fishery and several state records have been set here for fish weight and length.” Fred Donovan, owner of Chesapeake Beach Resort and Spa

not everyone is after a single big fish. Some just want to have fun and enjoy being out on the water, and that is okay too.” Those going out in the spring, also known as the “trophy season” for rockfishers, can keep only one fish, and it must be a minimum length of 28 inches. The rest of the year, two fish can be kept, but only one can be over 28 inches in length. These regulations are part of the Maryland Department of Natural Resources’ ongoing efforts to assure the Chesapeake Bay will continue to function

slow speed with fishing rods out, baited with lures (artificial bait) that keep spools of fish coming up to and grabbing at the surface. Those who want to anchor off in a specific location may opt for chumming, which brings fish up to the surface using grinded natural bait that creates a “slick” across a length of water. Jigging involves moving a spoon up and down vertically in the water, to catch fish. Steve Goss, an eastern shore resident and avid rockfisherman, says that working with an experienced captain is the key to having a fun and also successful fishing adventure.

“You don’t need any experience to catch fish on the Chesapeake Bay, but being out on the water with someone who knows what they are doing and who can guide you will help a lot,” said Goss. “It’s not rocket science but it takes time to learn about wind, tides and barometric pressure; all things that will effect when and how you should fish.” If sailing out of Baltimore’s Inner Harbor is appealing, Baltimore Fishing Adventures is another resource for those who want to experience rockfishing. The company’s owner, Captain Don Marani, offers an eight-hour rockfishing tour out of the Marina at Henderson’s Wharf in Fells Point. He takes pride in his ability to give his customer’s a one-of-a-kind experience, based on his knowledge of Maryland’s waterways. “I know the bay. I know where the fish are, and their patterns,” Marani said. “I have always worked on the water and do this every day, so when I take a charter out, fish will be coming up almost the entire time. When something does come up, everyone celebrates. It’s a good way to get away from your everyday world for a while.”

Travels with Eli

JACQUIE ROTH

he Infiniti M® Hybrid– it’s a car I most certainly did not want to give back to Sheehy Infiniti of Annapolis after a week-long test drive. Eli was just as excited as I was to jump into the four-door, top-of-the-line luxury performance hybrid. As I sat behind the wheel admiring the sexy lines of the car’s inside and outside design, Eli was clearly at ease, resting his head on the back seat, gazing out the window and ready for wherever we were headed. The only goal of our Sunday morning drive was to test the M and bring home some of the bounty of Eastern Shore farm stands, including a stop at Holly’s Restaurant & Hotel – “the meeting place of the Eastern Shore.” Holly’s serves breakfast, lunch and dinner to Eastern Shore folks, Marylanders and travelers lucky to have a sense of adventure to stop and enjoy it. We were certainly not disappointed by the great people-watching opportunities, with folks who indeed look like they’ve been going to Holly’s ever since it opened its doors in 1955. Our server had a warm smile while she brought us full breakfast plates loaded up her arm. It was cool enough that Eli was content to hang out, languishing on wheat-colored leather, while we fueled up for some farm-stand stops. The M’s handling down Route 50 East was highlighted by its balance and superb body control. Very mindful of the state troopers lying in wait, it took lots of self control to resist putting its inspired engine to the test. That drive came later in the week, when I could experience the engine’s progressive technology that takes it from an eco-friendly purr to a roar of exhilaration. Throughout the workweek, Maryland’s beltway frustrations were totally lost on me while I enjoyed the M’s smooth, quiet and extremely comfortable drive. The Bose Surround system was mighty impressive, when I sampled DVD audio, my iPod and satellite radio. With a base price of about $53,000, the M is most certainly a car to keep in mind if you’re looking for an exhilarating luxury sedan with some eco-friendly elements. –Jacquie Roth

SEPTEMBER/OCTOBER 2012

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Policy

Supreme Court Ruling Should Spur Physician Leadership A Conversation with Congressman John Sarbanes LINDA HARDER • PHOTOGRAPHY BY TRACEY BROWN

In Maryland Physician’s recent interview with Maryland Congressman John Sarbanes, he offers his take on the Supreme Court’s ruling June 28th on the Affordable Care Act (ACA) and describes his efforts to increase physician availability. His recent reinstatement to the Energy and Commerce Committee, which has legislative oversight on many healthrelated matters, puts him in a position to advocate for physicians.

charge. By increasing the risk pool, ACA provides insurance companies with an incentive to offer comprehensive health coverage to all individuals.

How effective will the Republican challenge to the ACA be and what role should physicians play in implementing it?

Their efforts to impede the legislation started at the beginning of this legislative

How will the ACA affect the insurance industry?

Congressman John Sarbanes

If you want to enforce new rules and regulations on the commercial insurance industry, the individual mandate was important because having everyone opt in is the best insurance pool design you can have. Without the mandate, insurers would reject many of the important measures put into place by ACA, such as ending discrimination against individuals with pre-existing conditions or covering preventive care services at no additional

session. They’ll continue to make runs at it, but as the healthcare industry begins to invest in making the changes required by the reform law, it will become more difficult to pull it apart. Physicians have a tremendous leadership role to play now that the Supreme Court has ruled the law is constitutional. Physicians can explain the new benefits of ACA to their patients and also address some of the myths.

26 | WWW.MDPHYSICIANMAG.COM

They can also explain that we are trying to turn the system towards prevention and better management of patient care. For example, ACA closes the prescription drug “donut hole,” which will directly impact the health of millions of America's seniors. Currently, physicians see patients who cannot afford the drug regimen they've been prescribed to keep them healthy. By closing this gap in coverage and providing a 50 percent discount on brand name drugs, physicians

can have more confidence in the care they provide. At the same time, working with their colleagues, physicians are in a position to embrace those components of the ACA that create more efficiencies and better care management, and help their colleagues explore the potential for electronic medical records and the use of online resources and data. Within the ACA, there are meaningful, structural

opportunities to better manage care going forward, such as with Accountable Care Organizations (ACOs). Physicians can now have a higher level of confidence, and as a result, they can play a leadership role to help us move toward a more rational healthcare system that leans in the direction of prevention.

How will your legislation, the Physician Re-Entry Demonstration Program, help increase physicians in the workforce?

Primary care physicians, in particular, have a critical role to play in keeping people healthy and the shortages in this field are alarming – the shortage will reach 40,000 in the next ten years and is expected to grow to nearly 160,000 by 2025. We have to think about how to bolster the supply of physicians. We can do that in the traditional fashion, but we also have to think out of the box about where to find new physicians. We’ve looked at all kinds of ways of doing that – more quickly assimilating returning army medics and things of that nature. I found that one topic that kept coming up was physician re-entry. There are a fair number of physicians who leave medicine for early retirement or family obligations, such as caring for a young child or an aging parent. When they want to return, they encounter a variety of financial and logistical obstacles. I looked at some of the physician reentry programs around the country. My proposal, which I’ve introduced and the American Medical Association supports, sets up a demonstration project with 10 sites across the country. The sites would train physicians and provide financial assistance for stipends, salaries, and so on and it wouldn’t be limited to those previously in primary care. There are some specialty areas where you would have been certified as an internist as part of the process, so the universe of potential candidates is actually quite large. Physicians who complete the process would be placed in a public health environment – community health centers, VA medical centers or schoolbased health centers – places where we have the most shortages. It’s designed to address some of the most significant inhibitors to returning to

practice, such as providing malpractice insurance through the Federal Tort Claims Act, and the costs associated with the program aren’t significant when you consider what the return would be. We’ll also have a streamlined, customized training program and financial support. I think that will be very inviting to physicians. I’m hopeful I’ll get support from both sides of the aisle on this because it’s the first time these ideas have been put together into one piece of legislation.

What’s the future of Medicare reimbursement and the waiver in Maryland?

We have this continuing frustration around the sustainable growth rate [SGR]. I experienced that when I was chair of the health care practice at Venable [a Baltimore-based law firm] representing non-profit hospitals and senior living providers, so I remember this period of time in December every year – everyone’s running around in a panic because you didn’t know whether the reimbursement was coming through – even when the cuts were only 6 or 7%.

What Role will the Energy and Commerce Committee play as the ACA moves forward?

Even if the ACA and all its components remain in place as we now expect, we will need to monitor various parts of the law. Any reform of that magnitude needs constant attention to make sure it’s doing well and the committee will have a very active role in evaluating the implementation of the law as well as potential improvements or changes that may need to be made.

Will you discuss the Public Service Loan Forgiveness (PSLF) Program?

I worked hard to pass this legislation and I’m proud we’ve done something to address the huge financial burden students face when they finish their degrees. Often times these students owe loan payments that could never be covered by public-sector salaries. This federal program provides critical loan reduction for people who pursue careers in public service and forgives the balance of their debt after 10 years.

It’s designed to address some of the most significant inhibitors to returning to practice, such as providing malpractice insurance... Now the stakes are even higher. Physicians are facing double-digit cuts and the cost to repeal the SGR is over $300 billion, but it’s critical that we find a long-term or, preferably, a permanent solution. In terms of the waiver, I’m hopeful that Maryland can find a new way to morph the waiver that allows the Rate Setting Commission to be on the cutting edge and be compatible with the ACA. Joshua Sharfstein, John Colmers [Secretary and former Secretary, respectively, of the Maryland Department of Health and Mental Hygiene], and others are wrestling with what the next generation of the waiver will look like. It’s allowed Maryland to do some creative things; if we can find a way to sustain that innovation with CMS and HHS through a waiver approach, we ought to fully explore that.

I’ve spoken to medical students who are anticipating $100,000 or more in student loans and want to go work at a non-profit health clinic. With the loan forgiveness option, if you work for 10 years at that clinic, then your loans are completely forgiven. We’ve got to get the word out about this program because it will be especially helpful for medical students. All of the information and forms you need are now on the web at www.ibrinfo.org. It’s another way to get people into positions they might not otherwise be able to afford to do and is very relevant to an aspiring group of young physicians. Congressman John Sarbanes (D) has served in the U.S. Congress since 2007, representing Maryland's Third Congressional District. Sarbanes previously served as the chair of Venable, LLP’s healthcare practice from 2000 to 2006.

SEPTEMBER/OCTOBER 2012

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Solutions

The Marketing Plan: A Protocol for Success

By Constance W. Helms

N TODAY’S COMPLEX AND competitive health care marketplace, marketing is essential for a physician practice to succeed. While the majority of physicians realize the importance of marketing their practices, most are at a loss as to where to start. When many people hear the word marketing, they think of marketing tactics…things like advertising, brochures, websites and now, social media. These are all important tools used in marketing, but marketing is far more than tactics. Marketing is presenting your practice in a way that gets and retains patients. It involves everything that consumers encounter regarding your practice, from advertising, to what they hear from neighbors, to the service they receive from the front office staff, to the followup care you provide.

that differentiate you from your competitors. This is probably the most important step in developing a marketing plan.

The good news is that marketing doesn’t have to be expensive or complicated to be effective. You just need a plan—a protocol, if you will, for marketing your practice. If you don’t have a marketing plan, here are some tips to get you started that should help you think more strategically about your practice.

Identify Your Target Audiences You are going to have several target audiences. First there are prospective patients. Who do you want to attract to your practice and where are they? If you are a primary care physician, chances are your target market is going to be geographically smaller and more local than if you are a specialist who practices within a “center of excellence.” You also need to understand the demographic make-up of the patients you want to attract, such as age, education and income. This information is essential in terms of focusing your marketing dollars where they are going to have the most impact. Your target audiences should include individuals and organizations that can help you attract new patients as well. Word of mouth has always been a big part of physician practice success. So your current patients may be the most powerful marketing tool you have. Make them the focus of your initial efforts. If you treat your current patients right, their recommendations to family and friends may do more to build your practice than anything else. Don’t forget about your fellow physicians. Their potential for referring patients makes them another important audience.

Define Your Practice What is your practice all about? What do you want people to think about when they hear the name of your practice? In defining who you are, you will be better able to communicate to your patient base why they should feel confident and comfortable in your care. Define the elements of your practice

Develop Your Marketing Strategies and Tactics Based on this information, you now know more about the possibilities of your market. You are ready to start developing strategies and tactics for marketing to each of your target audiences. The challenge is identifying the most effective ways for reaching them.

The good news is that marketing doesn’t have to be expensive or complicated to be effective.

This will take some creative thinking and some research. Involve your staff members. They have different perspectives than you. Have a brain-storming session. Get everyone in a room and start listing ways to communicate with each of the various target audiences you’ve identified. Once you’ve got some ideas on paper, you can start looking into costs (some may not involve any!) and determine what your practice can realistically afford. Implement Your Plan A well-developed marketing plan will guide decision-making throughout the year and ensure that all marketing initiatives are intentional and cohesive. To get the most out of your plan, you should assign tasks to specific staff in your practice according to workload and responsibilities. Timelines should be included in the mix as well so that marketing does not become a “to-do” that never gets done. Also be realistic about your own capabilities and those of your staff. Implementing a marketing plan with specific strategies to reach each segment may take outside help. But it may be a worthwhile investment in terms of increased patients and revenue. Evaluate Your Results Finally, set goals for each specific strategy and then monitor the results. If a particular strategy isn’t paying off within a reasonable amount of time, discontinue or modify it. Don’t throw good money after bad. And be sure to ask your new patients how they found out about your practice! Constance W. Helms, MBA, APR, is immediate past president of the Maryland Society for Healthcare Strategy and Market Development and president of Whittington Helms & Associates, LLC, a consulting firm that specializes in marketing communications, public relations and freelance writing services.

SEPTEMBER/OCTOBER 2012

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Good Deeds

Healing Hands, Giving Spirit Dr. Carole Miller: Oncologist, Philanthropist and Community Activist

By Tracy M. Fitzgerald

OUR YEARS AGO, IN CELEBRATION of her fiftieth birthday, Carole Miller, M.D. pledged to raise $50,000 in support of the Leukemia and Lymphoma Society, an organization whose mission lies near and dear to her heart. Over a period of ten weeks, Miller rallied for support and donations, inviting her friends and colleagues to parties, casino nights, silent auctions and bingo fundraisers to support her goal. She served as a keynote speaker at several physician events, contributing each honorarium stipend to her cause. When all was said and done, Miller far exceeded her initial goal, raising a total of

community citizens. “Working in a hospital, I really see the needs that exist,” Miller said. “There are worse things than having cancer. There are people who have cancer and no health insurance. There are those who have cancer and also happen to live in a homeless shelter. I feel that it is my responsibility to get involved and help people in different ways outside of the hospital walls.” In addition to her involvement with United Way, for three years, Miller held leadership roles in planning and coordinating “Bridesmaid Bingo,” an

“It’s fun to get out of the hospital and build something outside of medicine.” Carole Miller, M.D., Director of the Cancer Institute at Saint Agnes Hospital

$112,000 in what she considers her first “real” philanthropic effort, and leading to her selection as the Leukemia and Lymphoma Society’s 2008 “National Woman of the Year.” And, she was hooked. From that point forward, Miller knew that philanthropy and the idea of giving back to her community would remain a key priority in her life. Since then, Miller, who serves as director of the Cancer Institute at Saint Agnes Hospital, has gotten involved with several local non-profit and charitable organizations, donating her time, talent and money to worthwhile causes that strive to help create better, strong communities across the state of Maryland. She is an active leader within United Way of Central Maryland’s Women’s Leadership Council, comprised of a network of approximately 150 women who make an annual financial contribution of at least $10,000, and who work to continuously build programs geared toward meeting the basic needs of 30 | WWW.MDPHYSICIANMAG.COM

annual event sponsored by Catholic Charities to benefit “My Sister’s Place,” a homeless shelter for women in downtown Baltimore. She has also supported the American Red Cross, serving as a loyal financial donor and volunteer spokesperson for the importance of emergency preparedness. “It’s fun to get out of the hospital and build something outside of medicine,” said Miller. “Being part of these organizations has been a good creative outlet for me and has also given me the opportunity to work with great mentors who have done so much good for the city of Baltimore.” As a result of her involvement, Miller has networked and built strong relationships with groups of people representing various industries and professions. One of her personal goals is to promote community activism within Maryland’s medical community, and encourage more physicians to take part in local philanthropic and volunteer efforts. “It’s important for those who have the

Carole Miller, M.D., Director of the Cancer Institute at Saint Agnes Hospital, makes it a priority to give back to her community by serving as an active volunteer and philanthropist for various charitable and non-profitable organizations.

means to give back,” she said. “The money that is raised by these organizations is put to good use and makes a positive impact on so many people. I really want to see more doctors getting involved and giving to these causes.”

FOLLOW IN DR. MILLER’S FOOTSTEPS Get involved today. For further information about the charitable organizations she is involved with, and encourages you to join, please visit the following web sites: United Way of Central Maryland www.uwcm.org American Red Cross, Chesapeake Region www.redcross-cmd.org Catholic Charities of Baltimore www.catholiccharities-md.org Leukemia and Lymphoma Society, Maryland Chapter www.lls.org/md

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