LouisviLLe Medicine - Greater Louisville Medical Society

Louisville

GREATER LOUISVILLE MEDICAL SOCIETY

Medicine VOL. 61 NO. 8 January 2014

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GLMS Board of Governors Russell A. Williams, MD, board chair James Patrick Murphy, MD, MMM, president Bruce A. Scott, MD, president-elect and AMA delegate Heather L. Harmon, MD, vice president Robert H. Couch, MD, treasurer Robert A. Zaring, MD, MMM, secretary and AMA alternate delegate Rosemary Ouseph, MD, at-large Tracy L. Ragland, MD, at-large Jeffrey L. Reynolds, MD, at-large Neal J. Richmond, MD, at-large John L. Roberts, MD, at-large Wayne B. Tuckson, MD, at-large Fred A. Williams Jr., MD, KMA president Randy Schrodt Jr., MD, KMA 5th district trustee David R. Watkins, MD, KMA 5th district alternate trustee K. Thomas Reichard, MD, GLMS Foundation president Stephen S. Kirzinger, MD, Medical Society Professional Services president Toni M. Ganzel, MD, MBA, dean, U of L School of Medicine LaQuandra S. Nesbitt, MD, MPH, director, Louisville Metro Department of Public Health & Wellness Karyn Hascal, The Healing Place president Ilene Bosscher, GLMS Alliance president Louisville Medicine Editorial Board Editor: Mary G. Barry, MD Elizabeth A. Amin, MD Waqar C. Aziz, MD Deborah Ann Ballard, MD, MPH R. Caleb Buege, MD Arun K. Gadre, MD Stanley A. Gall, MD Larry P. Griffin, MD Kenneth C. Henderson, MD Jonathan E. Hodes, MD, MS Martin Huecker, MD Teresita Bacani-Oropilla, MD Tracy L. Ragland, MD Ben Rogers M. Saleem Seyal, MD Dave Langdon, Louisville Metro Department of Public Health & Wellness Russell A. Williams, MD, board chair James Patrick Murphy, MD, MMM, president Bruce A. Scott, MD, president-elect Lelan K. Woodmansee, CAE, executive director Bert Guinn, MBA, CAE, associate executive director Kate Allen, communications designer Advertising Cheri K. McGuire, director of marketing 736.6336, [email protected] Follow us on Linkedin, Facebook, Twitter, YouTube and Vimeo

Louisville Medicine is published monthly by the Greater Louisville Medical Society, 101 W. Chestnut St. Louisville, Ky. 40202 (502) 589-2001, Fax 581-9022, www.glms.org. Articles to be submitted for publication in LM must be received on electronic file on the first day of the month, two months preceding publication. Opinions expressed herein are those of individual contributors and do not necessarily reflect the position of the Greater Louisville Medical Society. LM reminds readers this is not a peer reviewed scientific journal. LM reserves the right to make the final decision on all content and advertisements. Circulation: 4,000

Louisville

Medicine

Greater Louisville Medical Society

Vol. 61 No. 8 January 2014

feature articles 12

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What are You Afraid To MIss: Part 2 Stephen Wright, MD, FAAP

Evolution of Our Diets Martin Huecker, MD

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Students’ Lounge Righting The Ship Ben Rogers Medical Mentors: To Be Changed For Good Sarah Fisher

DEPARTMENTS 5 From the President: How Will You Define Yourself James Patrick Murphy, MD, MMM

7 In Remembrance: Louis O. Giesel, Jr, MD Mary A. Smith, MD 8 In Remembrance: Harold E. Kleinert, MD Randy Schrodt, MD 10 Reflections: The Super Storm Teresita Bacani-Oropilla, MD 17 Restaurant Review Guaca Mole M. Saleem Seyal, MD, FACC, FACP 21 Alliance News Ilene Bosscher, MA, MDiv, LMFT, LPCC 26 Book Review Forget a Mentor, Find a Sponsor: The New Way to FastTrack Your Career Elizabeth A. Amin, MD

28 Physicians in Print 29 We Welcome You 31 Doctors’ Lounge Is This The Party To Whom I am Speaking Mary G. Barry, MD 32 From the Blogosphere A NAIL IN THE PATIENT-PHYSICIAN RELATIONSHIP COFFIN Kathy Neider, MD Bad news/travel fast! Amanda Zhang, MD Your Diagnosis is? Matthew Allinder, MD Summer Penile Syndrome Megan Bertke, MD Look Past Your NosE Doug Kelly, MD On the cover: Images of bridge by Nick Roberts www.SpeedDemon2. com, skyline by Jacob Zimmer www. zymage.com, GLMS clock tower by M. Stephen Bassett

GLMS Mission Promote the science, art and profession of medicine; Protect the integrity of the patient-physician relationship; Advocate for the health and well-being of the community; Unite physicians regardless of practice setting to achieve these ends.

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Let’s Connect

From the

President JAMES Patrick Murphy, MD, MMM GLMS President [email protected]

How Will You Define Yourself? I am a doctor, but a doctor is not what I am. - penned in my spiral notebook, circa May 1985 Despite a medical career’s insatiable hunger for attention, my chosen path does not define me, but it has provided glimpses of who I am. For example, during my internship at Balboa Naval Hospital I was occasionally assigned to draw blood for labs. One such afternoon, my blood-rounding brought me to a diminutive, bent, hairless, elderly man sitting quietly in his bed on the open bay ward. After a brief exchange of pleasantries, he offered an atrophied left upper extremity for blood acquisition. Upon completion he warmly thanked me and even complimented me on being a “good needle-sticker.” Later, I learned that the diminutive octogenarian was a retired two-star admiral who was admitted to this ward because he had refused any special treatment in deference to his lofty rank. If a no-privacy open bay ward was good enough for his sickly comrades, it was good enough for him too. Besides an amazing lesson in leadership, my encounter with the admiral taught me that, regardless of how powerful, wealthy, famous, weak, poor, or humble one might be, we each travel a path to the same destination. In days past, simply rumor that he was onboard ship would have created an air of anxious hyper-attention. But in his life’s final chapter he was humbly grateful that the apprentice doctor sent to draw his blood didn’t botch the needle stick. What defined this person: his accomplishments? his failures? his youthful conquests? his final chapter? Are we defined by life’s moments? Perhaps the sum of life’s moments? Is one’s present moment - or even one’s final moment - life’s truest summation? I have my doubts. Despite our yearnings to the contrary, our present evaporates and becomes our past - no different than a dream. And we are not defined

by our dreams - nor our past. So, if not the past, are we defined by the present? I have more doubts. The brain does not work at the speed of light - not even close. In fact, every conscious thought results from a chain of chemical reactions initiated by sensory stimuli. Therefore, awareness of a moment in time can only occur after the stimulating event. Awareness of the present is really just a memory. So does the present even exist? Yes it does; in theory (i.e. the theoretical present). But I can’t prove it. During a deposition I gave years ago, with the lawyer’s argument hinging upon proving the medical record to be comprehensive, she asked, “Isn’t it true that if it wasn’t documented, it didn’t happen?” My response was, “If it wasn’t documented it simply means it wasn’t documented.” I still stand by that. Like the medical record, your perception of the present moment is legitimate documentation that your present moment exists. But that’s all it is - documentation. Not proof. Again, awareness of the present is really just a memory. I have lots of memories - especially of my patients. And being a physician to a significant number of elderly patients, I deal with loss on a regular basis. While it is never easy to say goodbye, I usually find solace in knowing that I tried to provide comfort in a patient’s latter steps along life’s journey. Obituaries, written to summarize these journeys, usually pique my curiosity. Some are just a few lines. Some are novellas. Some offer comparison photos of the youthful and the elderly visage. Regardless of length, obituaries cannot define a life. For example, by the time you read my article, the iconic Nelson Mandela will have been laid to rest - after perhaps the most extensive obituary in the history of the media - and still the world will have only gotten an infinitesimal account of

Email me at [email protected]. Follow me on Twitter @ jamespmurphymd. Connect with me on LinkedIn. Sign up for, visit and comment on the GLMS blog. Download the GLMS mobile app. Or just give me a call. My number is in the GLMS “mug book” and the mobile app.

his life. At the end of it all, will we have defined the man? Not a chance. About a year ago, I read the obituary of a local doctor, P. Patrick Hess, M.D. He was eloquently described as: “A dedicated pediatrician, gifted artist, collector of oddities, beloved husband, father, grandfather, voracious reader, with a quick wit - Patrick Hess had an obsessive curiosity and a driving desire to unravel the mysteries of the world.” It went on to mention his family, accomplishments, education, and professional endeavors - all lovely. But I felt there was more to this man’s life. Then I read his poem and felt something had indeed been defined. All physicians are artists, not always in disguise. Our way of looking at a patient, allowing our minds to roam all over those perceptions of our previous life, often forgotten, to scan these memories and pull something from our unconscious mind - all with the purpose of creating something. Something to help the patient. This creation is, itself, a work of art. Every imperceptible moment that passes is not only a new reality; it is rebirth, renewal, and redefinition. Therefore, like the theoretical present, we can only be theoretically defined. How will I define myself? I guess this will have to do: I am a doctor, but a doctor is not what I am. - circa January 2014 How will you define yourself? L

M

Note: Dr. Murphy, board-certified in Anesthesiology, Pain Medicine and Addiction Medicine, is the president and medical director of Murphy Pain Center. He is an assistant clinical professor at the University of Louisville School of Medicine and serves on the board of the International Association of Pain and Chemical Dependency.

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In Remembrance Louis O. Giesel, Jr., MD (1927-2013)

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he Louisville medical community lost a fine pediatrician and a true gentleman on September 27, 2013, when Louis O. Giesel, Jr., MD, passed away at age 86. Louis grew up on Western Parkway (now Northwestern Parkway) in Louisville and developed an early love for gardening by helping his father with a large vegetable garden and chicken coop behind their house. Louis was a graduate of duPont Manual High School, Class of 1944. He did his undergraduate studies at the University of Louisville and was a member of the University of Louisville School of Medicine, Class of 1950, graduating at age 23. While at UofL, Louis was a member of the Woodcock Society, the Tau Kappa Epsilon fraternity, and the Phi Chi fraternity. After medical school, Louis served in the Public Health Service in Lawton, Oklahoma, working with the Native Americans. I recall Louis telling us all about how he and his new bride, Norma, became such friends with the Kiowa Indians that the tribal leaders invited them to a pow-wow under the Oklahoma stars. Louis and Norma were the only attendees who were not members of the Kiowa tribe. Louis and Norma then moved to New Haven, Connecticut, where Louis took a fellowship with the Child Study Center at Yale University. Louis and Norma returned to Louisville in 1956. Louis hung out his shingle in Hikes Point, where he served as a pediatrician in solo private practice for over 30 years. He and Dr. Fred Pipkin and Dr. Tom Courtenay, two other pediatricians with solo practices, covered for each other for time away from the office. Louis also covered for Dr. Owen

Ogden. As a result of these informal alliances, Louis was well-known and loved not only by his own patients but also by many patients of these other doctors. Though busy with a thriving practice and four children, Louis also served many years at the Kentucky Children’s Home and as president of the Louisville Pediatric Society. He was an elder of the Presbyterian Church, USA, and served as moderator of the Synod of the Mid-South and as board chairman of St. Matthews Area Ministries. Louis closed his practice in 1991 in an effort to focus on traveling with Norma and enjoying the grandchildren, eventually totaling nine, who had begun to arrive. Although Louis’s mobility declined in later years, he served as an inspiration to others to keep going and doing even when the going and doing was difficult. Louis could often be seen with his walker or wheelchair at a lecture, a concert, or a worthy political or charitable dinner. Two of Louis’s children followed him into medicine -- one in pediatrics and one in ophthalmology. Louis’s patients remember him with gratitude and affection. His family and friends remember him as a kind and giving person who cared deeply about each and every one of them. LM - Mary A. Smith, MD

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In Remembrance Harold E. Kleinert, MD (1921-2013)

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s the story is told, and there are many told, Harold Kleinert was born in a chicken coop on the family ranch outside Sunburst, Montana, not far south of the Canadian border. His studies led him east, through Ann Arbor, Philadelphia, and Detroit, with full intention of returning to his home state to practice general surgery. There is a second, well-told tale of a chance encounter and a beer shared in a hotel bar, and the detour to Louisville with his young family for just another year of general hospital surgery, before going home. Of course, as we now know, Louisville and Southern Indiana became his new and permanent home. Between those early days as a young attending in the Department of Surgery, and his burial at Cave Hill on the day he would have been 92 this past October, Harold was a colorful, distinguished figure in the Louisville medical community. It

can conservatively be stated that Harold, and the talented team of colleagues he surrounded himself with, transformed the practice of hand and microsurgery. His pioneering developments in surgical instruments and techniques modernized the treatment of hand injuries. The private practice he established drew patients who injured their hands on nearby farms and in local factories, as well as from around the world. Perhaps his proudest accomplishment, more than the many national and international awards he received, was the over 1300 surgeons, from more than 50 countries, who completed the hand surgery fellowship he founded, named in honor of his mother. Family, friends, colleagues, and patients are often eager to tell their own stories of a favorite, memorable encounter with Harold. He was quick-witted, playful, and irreverent. His hard work, long days, and late nights were legendary. To the medical community of Louisville, his work as a physician, a healer, will remain a benchmark of excellence. LM - Randy Schrodt, MD

The garden level of the Old Medical School Building was the location of Dr. Kleinert’s first laboratory in Louisville. Through the continued efforts of the GLMS Foundation to preserve this historic gem, Dr. Kleinert’s wife, Sharon, his family and associates contributed to the remodeling of “the old coal bin” and dedicated it to him in March 2010. The Kleinert Lounge features a kitchenette and comfy chairs to serve as a relaxing spot for physicians attending meetings at the building and GLMS staff.

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REFLECTIONS THE SUPER STORM Teresita Bacani-Oropilla, MD

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t was billed as a super storm. One that strong had not touched down on earth in recent memory. It gathered strength and momentum over the great Pacific Ocean, meteorologists following its course as it barreled its way west, towards the Philippine Islands and beyond. When it did touch down on November 8, 2013 on Tacloban, capital of Leyte province in the Philippines, the efforts made to prepare for it were too puny to withstand its ferocity. Buildings, infrastructure, 16th century churches that had withstood past assaults; modern arenas, palatial homes and small huts; carefully tended parks, piers and man-made structures were literally lifted up, bashed around, and scattered to the winds. The sea rose up and deposited big ships inland while it made twiddle sticks of fishing boats. Then it receded and swept anything in its path into the deep sea, including a schoolhouse filled with children placed there for safety. Devastation completed, Haiyan (called Yolanda in Asia) then continued its path and wrecked other populated islands before exiting into the South China Sea, and ended as a tropical storm on the Vietnam side of that sea. The world, linked by satellites, heard of the destruction and mobilized to help. Despite many responding with alacrity and compassion, the initial work was slow. To get to the afflicted people, areas had to be cleared to land planes and helicopters, places had to be found to anchor boats, supply vehicles had to be flown in to carry goods, and roads repaired and connected by temporary bridges. Survivors had to desalinize seawater to drink, but first had to have electricity for power and light. The need for machines to remove debris and recover bodies was becoming more imperative by the hour. A bereaved person could look on his beloved beneath a collapsed roof, but not have access to him. The reachable dead were lined up on the ground, many unclaimed. People were either relieved or dismayed after a head count of those who were presumed dead and those who survived. Grief was palpable and heartbreaking. As a word of caution, some initial supplies were hijacked and

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looted by desperate and lawless elements, thus the need for peace officers nearby to ensure the safety of responders and victims alike. Well-intentioned rescuers including medical personnel had to be sure they had a support system with transportation, food, and accommodations lest they get stranded themselves, and end up being statistics in a very unhealthy environment. Once the beneficent helpers got organized however, they became very effective in meeting the immediate needs of the grateful victims. Tragedies such as this bring out the best and sometimes the worst in people. The great outpouring of help, spiritual and material, from all over the world is gratifying. Donors gave regardless of creed, political affiliations or material wealth. It was a true example of humans helping humans. Instances of looting and hijacking of food in the initial stages of the tragedy, however, also showed that self-preservation and selfishness can rear their ugly heads, anytime and anywhere. After the initial goal of taking care of the immediate basics of water, food, shelter, and establishing communication was accomplished , comes the question of what the future holds. How do you reconstitute families? When do you stop hoping the lost one will show up? Where and how do you rebuild livelihoods? There is a future, no doubt, but what will it be like? It may look bleak for now, and it may take years to recover, but humans have always shown they can survive disasters. With indomitable will , courage, and hope, they always find ways to solve problems and even improve on the past. And so, the people affected by this super storm , will do it again. We who are blessed with plenty in this land and safe from harm, can only be thankful and cherish our good fortune. We hope that when we, too, are faced with our local natural disasters, we will rally to help our own just as we helped others. Humans helping humans: that should be our goal every time and every day of our lives. LM Note: Dr. Oropilla is a retired psychiatrist.

What are you afraid to miss? Part 2 An ongoing series from the Partnership to Eliminate Child Abuse Stephen Wright, MD, FAAP Childhood Sexual Abuse Implications for Adults

Given that 90% of childhood sexual abuse goes unreported, it is fair to say that 90% of CSA victims do not get the proper intervention they need and deserve in childhood. It is important to note that while not everyone who reports a history of childhood sexual abuse develops health problems, many live with a variety of chronic physical, behavioral, and psychological problems that bring them into frequent contact with health care practitioners. Because health care practitioners do not routinely inquire about childhood sexual abuse, its long-term effects are under recognized, its related health problems are misdiagnosed, and it is often not met with a sensitive, integrated treatment response.1 Indeed, childhood sexual abuse can have a devastating impact on adults’ lives, often resulting in adult experiences of shame, powerlessness, flashbacks, nightmares, severe anxiety, depression, alcohol and drug use, feelings of humiliation and unworthiness, ugliness, and profound terror.2 They frequently have difficulty with intimate relationships and parenting, may suffer from the symptoms of post traumatic stress disorder, and may isolate themselves from their community and peers.3 Victims of childhood sexual abuse are also often repeat victims of domestic violence and adult sexual assault, with over 30% of women who reported a completed rape as a child also experiencing rape as an adult.4 The American Medical Association estimates that one in five adult survivors of childhood sexual abuse suffers from severe, lifelong psychological problems.5 Too often, these presenting symptoms are not connected to their root cause – a history of childhood sexual abuse – and these patients are not receiving the specialized services they need.6

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CSA as Major Women’s and Men’s Health Issue

The impact of CSA on women’s health warrants specific highlight. As girls are more likely than boys to be sexually abused by a family member,7 they are less likely to report the abuse and more likely to be encased in family loyalty, secrecy and denial, referred to as “entrapment” and “forced silence,” preventing them from accessing healing services as a girl or woman, for fear of what may happen to the offending family member.8 These specific familial and cultural conditions surrounding CSA and incest for girls, then, puts them in particularly vulnerable positions to both experience abuse and to be denied appropriate healing well into their adulthood. Moreover, because an experience of CSA in childhood has direct implication for an adolescent girl or woman to be revictimized through intimate partner violence (IPV) and adult sexual assault, resulting in unplanned pregnancies, increased exposure to STD’s, cervical cancer, and domestic violence, it is particularly vital that girls and women understand the ways their lives and reproductive health may be negatively impacted by CSA and that their healthcare providers and potential counselors understand this connection, as well.9 Certainly, the need to screen for, identify and treat CSA trauma due to its high occurrence for girls and women, then, makes CSA a major women’s health issue. To be sure, however, CSA is also an equally significant men’s health issue. Indeed, men are impacted in ways similar to women, while they may experience challenges and face barriers in seeking help that are specific to their gender. The statistics on the number of boys who experience CSA (1 in 6) are only slightly lower than that of girls (1 in 4). In both cases, due to the challenges associated with disclosing CSA, many leaders in the field believe the statistics could be much higher. Because of the restrictive stereotypes surrounding masculinity in our culture, men often face extensive barriers in recognizing the impact of CSA trauma on their lives and seeking help.

For example, our cultural attitudes about being male dictate that men are expected to be strong and in control, sexually dominant, and unemotional. As boys may have experienced CSA trauma at the hands of trusted men in their lives (though statistics show that boys and girls are abused by women, as well), they may grow up with deep feelings of shame and unworthiness, causing them to feel “unmanly” and/ or to have questions about their sexuality, which is also stigmatized in our culture.10 Providing supportive and encouraging resources to address male survivors’ needs is, therefore, a prime concern within the broader umbrella of CSA intervention. The following table indicates major health implications of childhood sexual abuse trauma for women and men:

TABLE 111

Correlates of childhood sexual abuse and measures of health and function: A selected list of findings from research studies In females, a history of childhood sexual abuse is correlated with: • poorer physical and mental health and a lower healthrelated quality of life than non-traumatized individuals • chronic pelvic pain • gastrointestinal disorders • intractable low back pain • chronic headache • greater functional disability, more physical symptoms, more physician-coded diagnoses and more health risk behaviors, including driving while intoxicated, unsafe sex and obesity • ischemic heart disease, cancer, chronic lung disease, skeletal fractures and liver disease • high levels of dental fear • greater use of medical services • drug and alcohol use, self-mutilation, suicide and disordered eating • adult onset of 14 mood, anxiety and substance use disorders • higher rates of childhood mental disorders, personality disorders, anxiety disorders and major affective disorders, but not schizophrenia • diagnosis of Borderline Personality Disorder In males, a history of childhood sexual abuse is correlated with: • anxiety, low self-esteem, guilt and shame, depression, post-traumatic stress disorder, withdrawal and isolation, flashbacks, dissociative identity disorder, emotional numbing, anger and aggressiveness, hypervigilance, passivity and an anxious need to please others • adult onset of five mood, anxiety and substance use disorders • substance abuse, self-injury, suicide, depression, rage, strained relationships, problems with self-concept and identity and a discomfort with sex • increased risk of HIV5 • anxiety and confusion about sexual identity and sexual orientation • increased risk of “acting out” aggressively • contact with criminal justice system

The ACE Study – Adverse Childhood Experiences

Some of the consequences of CSA are intuitive such as depression and psychological and behavioral disorders. However, what is not so intuitive and recognized are the many physical ailments that are directly proportional to the number of adverse childhood experiences. These include: • Early death • COPD • Ischemic heart disease • Liver disease • Fetal death • Lung cancer • Obesity The long-term impact of childhood sexual abuse trauma is finally being documented by leaders in the medical field. Researchers connected with the Center for Disease Control and Prevention and Kaiser Permanente are many years into the Adverse Childhood Experiences (ACE) Study, one of the largest investigations ever conducted to assess associations between childhood maltreatment and later-life health and well-being. Their findings suggest that certain experiences are major risk factors for the leading causes of illness and death, as well as poor quality of life, in the United States – chief among them, a history of childhood sexual abuse. When the lead researcher of the ACE Study, Dr. Vincent Felitti stumbled upon the high occurrence of CSA in adult participants of his study, he was shocked and perplexed. “It was very disturbing,” he said. “It seemed that every other person was providing information about childhood sexual abuse. I thought, ‘This can’t be true. Someone would have told me in medical school.”12 Dr. Felitti’s initial reaction and ongoing findings through the ACE Study clearly indicate the very real and disastrous implications of the invisible and silent aspects of childhood sexual abuse trauma we have been missing. We are treating CSA trauma symptoms without treating the root cause. This dynamic must change.

Proper

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Detection, Referrals and Treatment – for Adults

Misinformation and misdirection by the counseling and medical communities about the impact of CSA trauma and the need for specialized intervention pose real threats to adult survivors’ ability to recover and therefore greatly impacts their long-term health. It is essential that healthcare providers adopt trauma-informed care practices to screen for a history of childhood sexual abuse and that proper referrals are offered to patients who need them. Many adults, and many healthcare providers upon whom adults rely for care, do not know these intervention services exist – or that, as victims of the crime of childhood sexual abuse – adult survivors of CSA have rights to those specialized services. As healthcare providers, we have a responsibility to inform patients of the ways their health may be harmed by unresolved CSA trauma, and we have the responsibility to honor the rights of these patients and refer them for appropriate resources designed to help them heal.

Kentucky Association of Sexual Assault Programs

In Kentucky, referrals for adults needing services for having been sexually abused as children can be made through the Kentucky Association of Sexual Assault Programs (KASAP.org), which consists of thirteen centers statewide designed to provide the proper intervention for adults who have experienced sexual violence. In Kentucky, using 2012 population estimates, there are approximately 422,000 females and 281,000 males who experienced CSA trauma13. Because society in general, as well as the medical community, has not focused significantly on CSA trauma as a major health risk factor, it is fair to assume that the vast majority of these individuals living with CSA trauma have not received the services they need. The cost to their lives and health is astronomical; the cost to our society and state is incredibly high, as well. It is estimated that childhood sexual abuse costs the U.S. $35 billion annually.14

Breaking Down Stereotypes and Improving Access to Services for All Involved

Indeed, as health practitioners and community members alike, we must honestly examine the cultural and even professional denial about the high occurrence of childhood sexual abuse in our society so we may begin to design services to help child, adolescent and adult victims heal.

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Moreover, we need to thoughtfully and critically examine the complex factors leading to the perpetuation of this silent health pandemic and explore appropriate prevention and treatment options for all individuals who are part of the abuse dynamic. Too often, CSA is a family system problem, so we need to explore prevention and intervention models that address this difficult reality. Recognizing that child sexual abuse happens “in ‘good’ families and ‘trusted’ institutions, at all socioeconomic levels, and among all racial and ethnic groups”15 is essential in avoiding stereotypes that reduce CSA to something that happens to and by “bad” people. This stereotype is damaging and does not help prompt solutions that will bring about the change our culture needs.

Conclusions and Complexities

Childhood sexual abuse is clearly a public health problem with far-reaching consequences that are far too often unrecognized. It is one of the most common adverse childhood experiences. Clinicians of all disciplines should probe for these underlying issues which produce emotional, psychological and, yes, physical impairments.

Additional resources: Prevention: stopitnow.org/ d2l.org

Adult Survivors: Wingsfound.org 1in6.org malesurvivor.org rainn.org

Prevention/Intervention, including for those who have sexually abused a child: http://www.safersociety.org/ Kentucky: KACAC.org KASAP.org

References

1 Schachter, C.L., et al. (2009). Handbook on sensitive practice for health care practitioner: Lessons from adult survivors of childhood sexual abuse. Ottawa: Public Health Agency of Canada. 2 Harris, T.R., et. al. (1997). Childhood sexual abuse and women’s substance abuse: National survey findings. Journal of Studies on Alcohol and Drugs. 3 Mullen, P. & Fleming, J. (1998). Long-term effects of child sexual abuse. Issues in child abuse prevention (9). Australia: National Child Protection Clearing House. 4 Black, M.C., et al. (2011). The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 Summary Report. Atlanta, GA: National Center for

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As skilled and dedicated as Elmcroft nurses are, what really sets them apart is their compassion for the patients they serve. The result: faster recoveries, shorter stays and better outcomes. Call any of our six Louisville communities to find out more. January 2014

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Themes:

Practicing/life physician category: “Current Practice: Realities and Controversies” $1,500 cash prize Physician-in-training/medical student category: “What Patients Have Taught Me” $750 cash prize

Length:

800 to 2,000 words

Format:

Do not put your name on your essay! Judges are blinded to authors. Instead, include a separate cover letter with name, entry category, essay title and contact information.

Medical Writing for the Public Award:

In addition to the essay contest, GLMS offers a Medical Writing for the Public Award. You may enter an article of any length, written on a medically related topic for readers in the general public, that was published in a newspaper, magazine or book anytime during 2013. The submission may not be a self-published work. Include a copy of the article along with a cover letter with the name and date of the publication and your contact information. The award for this category is non-monetary.

Deadline:

Monday, March 3, 2014

Submission:

Send via email as an attachment to Kate Williams at [email protected]. Email submissions are highly preferred, but if not possible, send entry by fax to 502-736-6339 or by mail to 101 W. Chestnut St., Louisville, KY 40202. You must be a GLMS physician member (practicing or retired), GLMS in-training member or University of Louisville medical student to enter. 16

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Injury Prevention and Control, Centers for Disease Control and Prevention. 5 WINGS Foundation Inc. JD Vale Grant Application, 2013. 6 Cobia, D. C., Sobansky, R. R., & Ingram, M., (2004). Female survivors of childhood sexual abuse: Implications for couples’ therapists. The Family Journal, 12 (3), 312-318. 7 “What is child sexual abuse?” American Psychological Association. Retrieved July 14, 2013 from http://www.apa.org/pi/families/ resources/child-sexual-abuse.aspx. 8 Courtois, C. A. (1988). Healing the incest wound: adult survivors in therapy. New York: Norton. 9 Chamberlain, L. (2010, October 11). When It’s Not Her Choice: Reproductive Health and Violence. Presentation at University of Louisville Women’s and Gender Studies Department/Kentucky Domestic Violence Association Training Institute, Louisville, KY. 10 “Myths and Facts.” 1in6. Retrieved July 15, 2013 from https://1in6.org/men/myths/. 11 Schachter, et. al., 1. 12 “Toxic stress from childhood trauma causes obesity too.” (2012, May 23). AcesTooHigh. Retrieved July 15, 2013 from http:// acestoohigh.com/2012/05/23/toxic-stress-from-childhood-traumacauses-obesity-too/. 13 “Kentucky.” U.S. Census Bureau. Retrieved April 20, 2013 from http://quickfacts.census.gov/qfd/states/21000.html. 14 “The Economic Impact of Child Sexual Abuse.” Darkness to Light. Retrieved August 22, 2013 from http://www.d2l.org/site/ c.4dICIJOkGcISE/b.6069261/k.E915/The_Economic_Impact_of_ Child_Sexual_Abuse.htm. 15 Schachter, et. al., 5. LM

Co-authored by: Jennifer Stith, MAT, MA Interim Executive Director for the WINGS Foundation Stephen P. Wright, MD, FAAP Medical Director, Kosair Children’s Hospital Professor and Academic Advisory Dean University of Louisville School of Medicine Lisa Pfitzer, MD Associate Professor University of Louisville School of Medicine Fellowship Director Kosair Charities Division of Pediatric Forensic Medicine Note: Dr. Wright is medical director of Kosair Children’s Hospital. He is a professor and academic advisory dean at the University of Louisville School of Medicine, Department of Pediatrics. GLMS is an ally in the Partnership to Eliminate Child Abuse chaired by Dr. Wright.

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uaca Mole, a new addition to an expanding number of ethnic restaurants in Louisville, opened its doors in the spring of 2012. It is billed as a Cocina Mexicana, but in reality it is much more than that. It can aptly be described as a Fusion Latino restaurant because of varied Hispanic culinary influences. It is located in an area of North Hurstbourne Parkway across the street from UPS headquarters and flanked by many other corporate offices in a location that used to be the site of an Applebee’s restaurant. The décor is warm and inviting with brilliant tropical colors; walls are painted with green, lime, orange and yellow colors. An Aztec calendar graces one wall along with sculptures of tree frogs and other Latin artifacts scattered about the restaurant. Next to the bar are life-size skeletons in party regalia commemorating the Day of the Dead (Dia de Los Muertos), reminding us to enjoy and relish each day of our brief lives fully (viva la vida). Fernando Martinez, his wife, Christina Martinez, and his cousin Yaniel Martinez are the brains behind the day-to-day activities at the restaurant. Their story is an amazing success story of immigrants to the United States who have the willingness, entrepreneurial spirit and wherewithal to attain their dreams in this land of opportunity. Born and raised in Cuba, they drew inspiration and looked forward to their grandmother’s Sunday dinners and learned cooking techniques by watching her intently in her kitchen. Fernando came to the United States in 1994 on a self-built raft with his family but was stopped by the Coast Guard near Key West. After spending a year in Guantanamo Bay, his asylum application was approved and a permanent visa granted. He came to Louisville and worked at Ernesto’s and later opened his own highly successful restaurants, Havana Rumba in 2002 and Mojito’s in 2007. After a decade, Yaniel had joined him at his businesses. Wanderlust for exploring new opportunities and learning new culinary techniques compelled Fernando to sell his two restaurants in 2009. He traveled to Paris to study at the Le Cordon Bleu College, moved to Venezuela to start a new hotel/ restaurant venture (local politics squashed that dream, however), went to Peru and Oaxaca,

Mexico, and Florida to explore New World cuisine with Hispanic influence. After several stints as a regarded chef at some fine establishments in Florida, he decided to move back to Louisville and opened a unique restaurant, Guaca Mole. Guacamole is a ubiquitous dip in Mexican restaurants (and also in some Mediterranean restaurants like Grape Leaf on Frankfort Avenue), with mashed ripe avocados, onions, cilantro, tomato, garlic, peppers and lime juice. Guacamole at the namesake restaurant comes in three different renditions. We have faithfully stuck with the traditional guacamole, but two others called Yucateco (with grilled corn and roasted poblanos) and Con Chicharron (with pumpkin seeds, radish and pork rinds) or a sampler of all three are available. Corn chips with three kinds of salsas are unique to Guaca Mole, and the cost of $1.99 is most certainly worth it. Ceviches are seafood dishes that are marinated in lime juice and other condiments and include salmon, mussels, calamari and scallops. The lunch menu includes several sandwiches with generous portions and includes smoked fish, adobo chicken, carne asada (beef tips) and vegetarian. Fries can be had with dark chocolate-based mole sauce and cheese. I have always enjoyed the presentation of their varied dishes. Many customers can be seen taking pictures of the dishes with their handy smartphones. I particularly like the Short Ribs Enfrijoladas, braised beef ribs delightfully tender and savory with black bean sauce and rice, and Salmon Pibil, pan-roasted fish steak with rice, plantains and poblano cream sauce. My wife, Sally, has enjoyed (and I have sampled) the Carne Asada, grilled skirt steak with garlic thyme marinade and corn tortillas, and Pepian Verde, seared scallops with toasted pumpkin seeds, pickled fennel and orange salad. One can make a meal out of the tapas, including appetizers (fish tacos, for example), sopes (small corn shells with toppings like short ribs, chicken tinga) or one of various salads. Dining at Guaca Mole is a fulfilling experience with superb service, friendly waiting staff and expertly prepared and beautifully presented unique Fusion Latino fare. LM Note: Dr. Seyal practices Cardiovascular Diseases with Floyd Memorial Medical Group-River Cities Cardiology.

RESTAURANT REVIEW Guaca Mole 9921 Ormsby Station Road Louisville, KY 40223 502-365-4822 http://on.fb.me/guaca-mole

Reviewed by M. Saleem

Seyal, MD, FACC, FACP January 2014

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Evolutionof Our Diets Y

Martin Huecker, MD

ou are feeling pretty good about yourself. You have a diverse diet: 35-40% as carbohydrates (mostly fiber), 20-35% as fat, 15-30% as protein. You have no vitamin deficiencies and no constipation with your 100 grams of fiber daily. You are not at risk of famine and hardly think about infectious diseases. You have never heard of cancer or heart disease, have no family history of type 2 diabetes. You gather fruits and vegetables and hunt meat with as much fat as you can find. The biggest treat is smoking out bees from a hive to bring a honeycomb back to camp. You walk about seven miles per day, sometimes chasing animals and climbing mountains. This hunter-gatherer lifestyle is the culmination of millions of years of evolution on the human body. Then comes farming, possibly the “worst mistake in the history of the human race.” Add the industrial revolution and now in the last 300 generations we have roughly one million new mutations, 86% of which are believed to have negative effects. Now humans are getting shorter, fatter, lazier; getting cancer and diabetes; and we are now full of plaque (in our mouths and arteries). We have transitioned to the wrong kind of cabbage. This is not propaganda for the Paleo diet, but we cannot ignore our genetics. We may be creating a dysevolution of our species by challenging our biology with foods we did not evolve to eat. Daniel Lieberman, Professor of Human Evolutionary Biology at Harvard, proposes these and many other concepts in “The Story of the Human Body.” He makes a strong case for the perversion of the human diet (and lifestyle) by the industrialization of populations and nutrition. A dangerous epidemic of “mismatch diseases” faces the human race. Lieberman uses the example of a Zebra transplanted from the African savanna to New England. The zebra would no longer have to run from lions, but he would be mismatched for life in his new habitat, likely starving for lack of grass to eat and freezing in the cold winter. The human body we all possess evolved for a different habitat and diet than the one we find so convenient now. Many changes in what we consume are likely harming us. We spray pesticides, eat meat from corn-fed livestock, pollute our waters, inhale smoke and smog, and breed our produce to be higher in sugar and starch. The biggest challenge to our physiologic balance could be in macronutrient ratios. Our carbohydrate / fat / protein proportions are far different from

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the hunter-gatherer’s above (now more like 52%/33%/15%). That hard-earned honey helped simple sugars make up two percent of the hunter-gatherer diet. In 2013 we eat 15-30% of our diet as fructose and glucose and have gone from 100 grams of fiber a day to ten. Authors, journalists and nutrition scientists are making a strong case against carbohydrates. The pure weight loss merits of low-carb and very-low-carb diets appear to be well-founded, though the duration of success has been questioned. Journalist Gary Taubes (Why We Get Fat) and Cardiologist William Davis (Wheat Belly) have written well-researched books to suggest that almost complete elimination of dietary carbohydrate causes weight loss and other health benefits. By placing the blame on hormones rather than the lack of willpower of obese people, Taubes explains how to shift from fat storage mode to fat breakdown (bottom line – insulin is the enemy). William Davis agrees but takes a specific aim at wheat and gluten, implicating this dietary staple in diseases from acne and arthritis to diabetes and coronary disease. Jeff Volek, a dietitian, and Steve Phinney, a physician, have written many scientific articles and a few books about the benefits and apparent lack of ill effects related to carbohydrate restriction. All four authors have composed rigorous but readable books detailing the benefit of low carb lifestyles, intending to have more than a transient yo-yo diet effect on readers (our patients and …us). These are not new ideas. Many physicians remember the initially ostracized Dr. Atkins who used valid but underappreciated data to successfully convince millions of people with his first book in 1972. I have recently adopted the attainable goal of less than fifty grams of carbohydrate per day. Having lost ten pounds, I must say I feel great, do not crave starch and sugar all day, and still enjoy food as much as ever: anecdotal support for the low carb lifestyle -check. Instead of examining and describing the literature regarding weight benefits of carbohydrate elimination, I wanted to focus on whether these dietary changes would help us live longer and have less (mismatch) diseases. The authors mentioned above use the scientific literature to state their cases for health benefits beyond obesity. These can be broken up into body composition of the three major molecules: protein, fat, carbohydrate.

tabolism in general clearly benefits from carbohydrate restriction. Though genetic differences can allow some people to indefinitely consume large amounts of refined carbohydrate with no adverse effects, a great deal of our patients will eventually develop what has been aptly referred to as carbohydrate intolerance. Evolution has not yet selected genes allowing the pancreas to pump out insulin for 80 years without fail. This carb intolerance is a spectrum, as we know from definitions of prediabetes to type 2 diabetes to insulin dependent type two diabetes. The physiology and the literature support low carbohydrate intake to manage diabetes in any form, and I am excited to read about a possible role in disease prevention. Improved lipid metabolism may present one of the most surprising, exciting, but potentially misleading benefits of carbohydrate restriction. Most low carb recommendations involve quite high proportions of fat. This activates an unfounded fear in us. Many populations (usually low carb eaters) have done well for generations on fat content as high as 80% of diet. Most studies cited in the above-mentioned books, and on my search, show a reliable decrease in fasting triglycerides and increase in HDL. Both reductions would predict favorable impact on patientoriented outcomes such as myocardial infarction and death. The convincing AtoZ study in JAMA, a randomized controlled trial, compared the following diets: Atkins (very low carb), Ornish (high carb, very low fat), Zone (low carb) and LEARN (similar to national guidelines). HDL and fasting triglycerides improved the most in the Atkins arm. (Also best in the Atkins arm were improvements in weight, body fat, waist circumference, insulin level, serum glucose, and blood pressure). LDL levels present a possible speed bump for the very low carb diets. LDL is known to correlate with cardiovascular events, and the benefits of statin drugs may be related to LDL lowering effects. Most studies show no change or a slight increase in total LDL level with a low carb diet. Of note, a few studies show overall decrease in LDL when continued for 12-23 months or longer than 24 months. However, the above books and the literature do show an interesting finding. The subclasses of LDL particles are favorably changed (continued on page 20)

I did not find an overwhelming benefit of low carb diets in protein and hence muscle metabolism. The literature warns that patients should maintain a moderate protein intake, rather than excessive amounts of dietary protein. Supplements such as branch chain amino acids, along with adequate fat intake, can help the low carb diet patient to maintain lean muscle mass. Overall I do not see a major difference in lean body mass preservation comparing low carb to low fat or any other diet. Your patient’s carbohydrate meJanuary 2014

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(continued from page 19) by carbohydrate restriction. The atherosclerosis-inducing small, dense LDL particles tend to decrease with carb restriction, while the less dangerous large LDL particles are in greater amount. So a patient whose LDL goes from 110 to 120 while on a low carb diet might have less chance of MI due to a decrease in small LDL. More information will be elucidated in future studies, but the LDL increase as Kryptonite for the very low carb diet may be unfounded. On to what really matters to health care professionals: cardiovascular risk and mortality. This is where my self-satisfaction with my own change in lifestyle began to waver. The biggest blow is the Jan 2013 meta-analysis by Noto et al. In this review of albeit limited observational studies, the authors conclude “low-carbohydrate diets were associated with a significantly higher risk of all-cause mortality.” Moreover, low carb diets apparently had no positive or negative effect on cardiovascular disease incidence and mortality. Most of the remaining literature comments on effects of carbohydrate restriction on cardiovascular risk factors, surrogate markers rather than events and mortality. We cannot ignore that the most common cause of death in our patients is cardiovascular - and diabetes, hypertension and lipids appear to contribute. It is up to us as health care providers to synthesize the data, be it from popular science books, talk show guests, scientific literature, and our own experience. We are in a position to appreciate the diversity of patient response to dietary measures. I believe we cannot blindly accept government agency recommendations for large quantities of healthy whole grains and we should not propagate the fear of dietary fat present in America for decades. We also want happy patients. Dr. Mary Barry recommends that her patients have only one flour food a day. In my snapshot encounters with emergency department patients, I encourage a low carb approach and point out the processing perversion of our food by the industry. The key to success for our patients seems to be adapting a lifestyle, rather than a diet. And of course - we must predict which 50% of all of these data will be proven wrong in the next 50 years.

References Lieberman, Daniel. The Story of the Human Body: Evolution, Health, and Disease. Random House 2013. Taubes, Gary. Why We Get Fat: And What to do About It. Random House 2010. Davis, William MD. Wheat Belly: Lose the Wheat, Lose the Weight, and Find Your Path Back To Health. Rodale Books. 2011. Phinney, Stephen, Volek, Jeff. The Art and Science of Low Carbohydrate Living: An Expert Guide to Making the Life-Saving Benefits of Carbohydrate Restriction Sustainable and Enjoyable. Beyond Obesity. 2011. Gardner CD, Kiazand A, Alhassan S, Kim S, Stafford RS, Balise RR, Kraemer HC, King AC. Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women: the A TO Z Weight Loss Study: a randomized trial. JAMA. 2007 Mar 7;297(9):969-77.

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Rees K, Dyakova M, Ward K, Thorogood M, Brunner E.Dietary advice for reducing cardiovascular risk. Cochrane Database Syst Rev. 2013 Mar 28;3:CD002128. Santesso N, Akl EA, Bianchi M, Mente A, Mustafa R, Heels-Ansdell D, Schünemann HJ. Effects of higher- versus lower-protein diets on health outcomes: a systematic review and meta-analysis. Eur J Clin Nutr. 2012 Jul;66(7):780-8. doi: 10.1038/ejcn.2012.37. Epub 2012 Apr 18. Bravata DM, Sanders L, Huang J, Krumholz HM, Olkin I, Gardner CD, Bravata DM. Efficacy and safety of low-carbohydrate diets: a systematic review. JAMA. 2003 Apr 9;289(14):1837-50. Sharman MJ, Kraemer WJ, Love DM, Avery NG, Gómez AL, Scheett TP, Volek JS. A ketogenic diet favorably affects serum biomarkers for cardiovascular disease in normal-weight men. J Nutr. 2002 Jul;132(7):1879-85. Westman EC, Yancy WS Jr, Olsen MK, Dudley T, Guyton JR. Effect of a low-carbohydrate, ketogenic diet program compared to a low-fat diet on fasting lipoprotein subclasses. Int J Cardiol. 2006 Jun 16;110(2):2126. Epub 2005 Nov 16. Santos FL, Esteves SS, da Costa Pereira A, Yancy WS Jr, Nunes JP. Systematic review and meta-analysis of clinical trials of the effects of low carbohydrate diets on cardiovascular risk factors. Obes Rev. 2012 Nov;13(11):1048-66. doi: 10.1111/j.1467-789X.2012.01021.x. Epub 2012 Aug 21 Nordmann AJ, Nordmann A, Briel M, Keller U, Yancy WS Jr, Brehm BJ, Bucher HC. Effects of low-carbohydrate vs low-fat diets on weight loss and cardiovascular risk factors: a meta-analysis of randomized controlled trials. Arch Intern Med. 2006 Feb 13;166(3):285-93. Appel LJ, Sacks FM, Carey VJ, Obarzanek E, Swain JF, Miller ER 3rd, Conlin PR, Erlinger TP, Rosner BA, Laranjo NM, Charleston J, McCarron P, Bishop LM; OmniHeart Collaborative Research Group. Effects of protein, monounsaturated fat, and carbohydrate intake on blood pressure and serum lipids: results of the OmniHeart randomized trial. JAMA. 2005 Nov 16;294(19):2455-64. Noto H, Goto A, Tsujimoto T, Noda M. Low-carbohydrate diets and allcause mortality: a systematic review and meta-analysis of observational studies. PLoS One. 2013;8(1):e55030. doi: 10.1371/journal.pone.0055030. Epub 2013 Jan 25. LM

Note: Dr. Huecker practices Emergency Medicine with Physicians in Emergency Medicine. He serves as gratis faculty for the University of Louisville School of Medicine, Department of Emergency Medicine.

Alliance News Ilene Bosscher, MA, MDiv, LMFT, LPCC GLMSA President [email protected]

T

he Alliance will ring in the New Year on January 31, 2014 - the Chinese New Year of 4712, the year of the Horse that is! As Chinese legend explains, Buddha asked all the animals to meet him on New Year’s Day and named a year after each of the twelve animals that came. The animals in the Chinese calendar are the dog, pig/boar, rat, ox, tiger, rabbit, dragon, snake, horse, sheep, monkey, and rooster. Also according to legend, people born in each animal’s year have some of that animal’s personality traits. To celebrate this holiday we will gather at August Moon: Chinese Bistro (2269 Lexington Road) at 6:30 p.m. for cocktails and be treated to a four course dinner beginning at 7 p.m. Please mark your calendars and plan on joining us for an exciting evening. For more information or to RSVP for this event, please send an email to [email protected] The next day we will have our January Outreach, Shop and Share, which will take place on February 1, 2014. This event is held on ‘Superbowl Saturday’ every year to benefit the domestic violence centers across our state. This will be the second year we have participated in this event. We are planning on going to the Kroger that we are assigned and helping collect the can goods from the Shop and Share Wish List and cash donations. Please reserve some time to volunteer or shop for this outreach or donate some cash to this worthy cause. To sign up to volunteer or pledge a donation for this outreach, email the Alliance at [email protected] December was quite busy for the Alliance as we traveled to Lexington on December 3rd to attend their Annual Christmas Bazaar. We had a lovely lunch and enjoyed meeting others from the Lexington Alliance. The proceeds of their event will go for health grants for students who are seeking a career in a health care field. The December outreach was held for the benefit of the Center for Women and Families. We collected cash donations and gifts cards for the Center’s Christmas event totaling over $700.00. I had the pleasure of meeting The Center’s President and CEO Marta

GLMS Alliance Upcoming Events January 23 – Book Club January 31 –Chinese New Year February 1 - Outreach, Shop & Share

Miranda who is very inspiring, very talented, and has the background experience that makes her such a wonderful asset to lead the Center. I also met Jeanine Triplett, Vice President for Development & Communications, there who explained that we could also benefit the Center by designating our Goodwill donations with CWF. Triplett explained that The Center would receive credit from Goodwill in the form of Goodwill Vouchers. The Center can then in turn give these Goodwill Vouchers to their clients to shop at Goodwill Stores. This is a great way we can benefit others with our year end donations to Goodwill! The best is yet to be! Looking ahead, the rest of our year is full of events you won’t want to miss! From the Technology Coffee and the Gilda’s Club Outreach in February, our Annual Opening Night at the Track in April to benefit our own Health Grant Fund, the Annual Doctor’s Day in March where we honor all the doctors of Jefferson County and one in particular, Our Annual Meeting in May, to the events of the AMAA Southern Regional Meeting at the Brown Hotel in March - we have lots to look forward do. It is not too early to RSVP for these events as well at [email protected]. Clubs: The January meeting of the Book Club will take place on Thursday, January 23 at 10:30 a.m. at Heine Brothers on 119 Chenoweth Lane. The book to be discussed will be Lean In by Sheryl Sandberg. Contact Carol Lambert for more information at [email protected]. For information on the Bridge Club please contact Arlene Redinger at (502) 775-9109 and for Health and Wellness Club information please contact Dominique Hendren at (502) 592-6067. LM

GLMSA President Ilene Bosscher, KMAA President Rhonda Rhodes, and Lexington Medical Alliance President Jessica Ragland at the Annual Christmas Bazaar

(left to right) Millicent Evans, Jenny Jacob, Ilene Bosscher, Dominique Hendren, Rhonda Rhodes, Barbara Cox, Karin Sonnier, Frazia Kamber, and Chitra Kayerker at the Annual Christmas Bazaar

Note: Contact Ilene Bosscher at alliance@ glms.org or (502) 552-7319. To contact the Men in the Alliance Committee, email [email protected]. Ilene Bosscher presenting Marta Miranda, President and CEO of the Center for Women and Families, with donations from GLMSA

January 2014

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Students’ Lounge A monthly feature written by the students of U of L Medical School 22

righting the ship Ben Rogers

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was rotating through a local hospital the afternoon its Electronic Medical Record (EMR) went live. My resident was technologically savvy, so as we saw patients I asked questions and she entered the information into the new electronic chart. However, whereas my evaluation had formerly been sufficient, the system often wanted superfluous information. This left my resident asking a series of questions that left even our patient confused as to why they were pertinent. At one point, my resident seeing this emotion in a patient’s face said, “Sorry, I just do what the computer tells me to.” Physicians are facing a virtual landslide of technological innovations. Within this year alone I’ve seen advertisements for a machine that is meant to scan for melanomas, one that is supposed to be a safe alternative to anesthesia in low risk surgical procedures, and several more for various forms of robotic physicians. So, when I sit in a preceptor’s office and he tells me that his single greatest piece of advice is to never sit and stare at a computer screen while I’m seeing a patient, it is impossible to not feel a disconnect. Taking EMR as an example, it’s clear that it will provide improvements in our patient’s medical lives. Formerly, a community practitioner might see a patient and his or her entire family throughout a lifetime, keeping notes on family history, allergies, prior surgeries, and so on. However, our patient populations are more mobile now and interventions more numerous and diverse, so naturally it is becoming more difficult to manage all their personal data. EMR offers interesting solutions. Not only would a unified medical record keep information from slipping through the cracks, it allows incredible opportunity for the analysis of large amounts of data. Much of medicine is pattern recognition, and physiciandirected interpretations of trends found through EMR are going to play a big role in the future of disease control, prevention, and discovery. Remote links help rural patients and doctors connect to urban specialists. The portability of medical records is greatly enhanced for patients. There are good things happening. However, the data from a survey of over 10,000 patients performed by JD Power and Associates was released in September of last year and the results showed far and away that interpersonal skills of staff were a much more important factor in determining satisfaction than facilities or equipment. Satisfaction may be an important marker of future adherence and medical literacy,

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ignoring the more obvious way it is related to general comfort with a practitioner. Further, retrospective analyses of former technological innovations have shown that often-unexpected negative consequences may result from our best-intended practices. We have all seen side effects from antibiotics and the numbers on the cost of unnecessary CT scans in our country, so I believe that it goes without saying that any technologies we produce will only generate the same sort of issues. Additionally, studies have shown that adoption of advanced medical technologies accounts for the largest percentage of growth in health care spending in the United States when compared with other developed countries.1 Ignoring patient satisfaction and negative outcomes, this one fact alone should be enough for us to take pause and consider where our profession’s technological future lies. Of course, technology doesn’t just refer to medical records or machines. Lab tests and online resources and thousands of other developments compete for our attention from every direction. It will be essential that physicians develop ways to navigate the new terrain. In coming years there will likely be a nationally standardized resource that physicians will be able to reference as new faculties become available. In the meantime it is imperative that as a profession we demand objective data regarding each new product, test, or treatment we intend to employ. Further, we must be ever conscious of how changes we plan to implement will affect cost burden to the system. It seems likely the future will also be one in which our patients have access to benefit, cost, and outcomes data regarding our treatments and it behooves us to help lead the way to transparency. Technological changes will afford us tremendous opportunities to advance the art of medicine. However, only if we analyze each implementation rigorously will we be able to ensure that the unintended negative effects don’t intrude on the physicianpatient relationship. In short, we must be the captains of this ship or else all our advancements will be for naught. LM References: 1 http://www.ncbi.nlm.nih.gov/pubmed/23404417 Note: Ben Rogers is a fourth-year medical student at the University of Louisville. He is currently interviewing for internal medicine residency programs.

A

wise man once told me, “Your life should be about influencing others in a positive way, to make a difference for good. It’s not about academic or monetary accomplishments, but how you live your life and treat others.” This wise man, my own father, was influenced by his medical mentors and has subsequently influenced me. When talking to other physicians about their medical mentors, it was never the wealthiest or the most medaled physician who made the cut. Rather, the medical mentors who are most remembered are the ones who influenced more than academic and clinical knowledge. Instead, they struck to the very heart of the caregiver to change for good.

rural health campus in Madisonville, including teaching firstyear medical students. Although I was initially terrified, I grew into my position and enjoyed explaining embryology to eager students. On the last day of my teaching, my mentor said to me, “You have a real career in academic medicine.” I was blown away – I had never given any thought to anything other than practicing medicine. The more I thought about it, the more I loved the idea of teaching medical students and others who were interested about medicine. A huge responsibility of medical mentors is recognizing talent that the individual cannot see for herself, and fostering that gift. Were it not for these opportunities, I’m not sure I would have recognized my desire to teach and or knew that it was possible in my small town. This doctor has truly affected my career, a change for good.

From an early age, I have found myself mentored, not always by a physician, but always by someone one step ahead of me on my path to medical school. When I was a freshman in college, it was a college junior who was applying; she continued to mentor me, even as she entered medical school. To this day, I still reference her when talking about medical school admission. As a senior in college, I had difficulty being accepted to a medical school. I had become deeply discouraged and as some would say, “faint of heart.” She sent me an email, stating that she had heard of my struggles, and she told me something I will never forget. She wrote, “I am going to school with over 100 people who will assuredly become physicians. But you are the one I want to be my doctor. You have the heart of a doctor.” Her words came to my mind during a particularly difficult admissions interview at the University of Louisville, and have stayed with me as encouragement. Her mentoring changed my perspective of where I stood. Her words were humbling – despite my so-called failures, she still believed in me and my abilities to achieve my dream. A huge part of mentoring is being encouraging. Because of my mentor’s kind words, I believed in myself and I was changed for good.

All throughout my life, I have had my best mentor right under my nose: my father, a practicing physician, has influenced me in every scope of my life. As a young girl, I started working in his medical office, doing basic secretarial work and odd cleaning jobs, working my way up to just under the nurses. He taught me about hard work, taking pride in what I do, and doing only the very best because that was all he accepted. He taught me about treating others well and loving the seemingly unlovable, not through words but through actions. I would watch him take care of the poorest patients as if they were the wealthiest. He has never been fazed by the superficial, making him loved by people from all walks of life. I was also able to witness for myself the relationships he has with nurses and other staff at our local hospital; he is courteous and respectful, never degrading them based on their status. Being a curious girl and now a medical student, I ask so many questions. He never has become aggravated and answers each one with confidence, explaining difficult concepts. He may be one of the smartest physicians I know, but he is never boastful and he always knows when to ask for advice from others. His medical mentorship has shaped my approach of medicine to one of a team-player attitude, and how to care for every patient in an honest and hearty way.

As I progressed through multiple rural health programs based at the satellites of U of L, I was introduced to another important medical mentor. This physician fostered my love of medicine and rural health. Through his challenging cases, I was allowed to go above and beyond what was expected in order to feed my thirst, and I think he more than picked up on it. As I returned for subsequent undergraduate and medical summer programs, I was given more and more responsibilities and challenges to grow as a leader. This past summer, I did a lot of work with the

My father’s way of practicing medicine has also carried over to our home life. This is perhaps what makes his medical mentoring so effective – his professional actions mirror his personal life. He is a caring father, always inspiring my sister and me to be our very best, and he encourages us to put our whole heart into our goals. I was taught about hard jobs on hot summer days in our garden, pulling weeds and planting seeds. He is the spiritual (continued on page 25) January 2014

A monthly feature written by the students of U of L Medical School

Sarah Fisher

Students’ Lounge

Medical Mentors: To Be Changed for Good

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(continued from page 23) leader of our household, and always concentrated on the fact that “medicine is not an avocation, but a vocation,” reminding me that medicine is a calling to heal. His actions have truly spoken louder than his words, showing me how to treat everyone, including patients, a change I believe is for good. Being mentored is not the end of the line, however. Just as medical students are mentored, we in turn must pass it on. This act is essential to continue to foster the love of medicine that we all carry. The amazing part is that it doesn’t have to begin when we are practicing in a clinic; mentoring can start as soon as a need is recognized. I know that I would not be where I am today without the help of so many other people, and I am diligent about trying to ensure the success of others. It can be as simple as a Facebook message, dinner, or a Skype conversation. For me, mentoring others serves as a reminder of where I have been, which helps me to keep humble about where I am going and where my unbridled future will take me.

for they “speak louder than words.” Medical students are not looking for someone to tell them how to treat patients; we are looking for a physician to show us how to care, to lead by example. That’s what medicine, and particularly medical mentoring, is about. Just as lecturing a patient about weight management is ineffective after he’s watched you eat a Big Mac, teaching medical students to be humble and caring falls on deaf ears when the physician is destructive, rude, and apathetic. The actions of our medical mentors are what change us for good. LM Note: Sarah Fisher is a third-year medical student on the rural track at the University of Louisville.

A medical mentor is not just about influencing future careers; it is more importantly about influencing future lives through actions,

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January 2014

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Book review Forget a Mentor, Find a Sponsor: The New Way to Fast-Track Your Career Sylvia Ann Hewlett

Harvard Business Review Press, Boston, Massachusetts, September 2013 Reviewed by

Elizabeth A. Amin, MD

S

ylvia Ann Hewlett is an economist who received her BA degree from Girton College, Cambridge and her PhD from London University. She is the founding president of the Center for Talent Innovation, a Manhattan-based think tank, where she currently chairs the Task Force for Talent Innovation. In this role she leads a private sector consortium of some seventy-five global companies committed to changing the face of leadership around the world. She holds academic positions at Columbia University where, since 2004, she has directed the Gender and Policy Program at the School of International and Public Affairs. She is also co-director of the women’s Leadership Program at the Columbia Business School. She is a former Kennedy Fellow, a member of the Council on Foreign Relations, and the Century Association. In the 1980s she was the first woman to head the Economic Policy Council - a nonprofit composed of 125 business and labor leaders. She is the author of 10 critically acclaimed books as well as numerous articles in the Harvard Business Review, the New York Times, the Financial Times, Foreign Affairs and the International Herald Tribune. She is currently ranked #11 on the Thinkers50 list of the world’s most influential business gurus. Ms. Hewlett held a book launch for Forget a Mentor, Find a Sponsor in early September 2013 at the New York Stock Exchange. In her own words this was the third of her books to be launched there. The launch was broadcast on Book TV (C-SPAN 2) which is where I first saw and heard her personal presentation. I was fascinated by her accent and her general demeanor and I downloaded her book to my iPad later the same day. Forget a Mentor, Find a Sponsor appears to be a collaborative work 26

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based on research conducted by the members of the Task Force for Talent Innovation. The research is based on “surveys underwritten and shaped by the senior executives” of many of the companies which are represented by the Task Force. There is no other specification or methodology cited. To my mind this immediately screamed tautology and seemed very self-serving, but I plodded on. As the book’s sole author Ms. Hewlett uses the results of the research to support the “stories” that are actually the main content of the book. As noted in the acknowledgement pages and introduction all the “stories” represent the actual interviews of successful and less successful executives and senior management employees of the Task Force affiliated companies (such as American Express, AT&T, General Electric, Bristol-Myers Squibb, Booz-Allen-Hamilton). All of these interviews were conducted by the author herself. All are used to illustrate the various aspects of sponsorship and the hard work and ingenuity required of a protégé. The author’s stated purpose is to improve the opportunities in the workforce for women and minority employees by fostering an environment where talent is recognized and nurtured. By this means employees may rise through the ranks to the highest echelons within their companies (the corner or C-suites), and conversely the companies benefit by attracting to their workforce employees with drive and vision who will strengthen the “brand.” The target readership of this book is, I believe, female but is inclusive of all ethnicities. The book does cite research figures related to minority groups and males; however the interviews by the author of African-American and Caucasian males are very few. The book contains several tables comparing and contrasting the key terms, particularly mentor/mentee and sponsor/protégé. I

am sure the various definitions and comparisons can be attributed largely to the author but she is generous, although non-specific, in her acknowledgements of all those who contributed to the book in its final form.

enough; three is the ideal number. (Pity the poor protégé.) Three is also the number of serious pitfalls in the sponsor/protégé relationship. The author devotes an entire chapter to each of these: Chapter 10 Sex; Chapter 11 Distrust; Chapter 12 Executive Presence.

Much of this book is in fact autobiographical and herein lies the fascination for me. The sub-title of the introduction is: My Story. The first line of the introduction is as follows:

The author rounds out the book with an epilogue subtitled Castles. This is the continuation of her autobiographical underpinning of why sponsorship works and why it is necessary. In broad terms she attributes all her successes (her ability to build her castles) to sponsorship and her failures to lack of sponsorship. There is a great irony in one of her statements. “Sponsorship vaulted me from academia into public policy.” The reality behind this statement is evident in her original introduction toward the end of which she states, “Post-Harvard and post-London University (where I earned my PhD), I landed a sought-after first job as assistant professor of economics at Barnard College, Columbia University, and began to forge what should have been a promising career in academe.” We learn that seven years later she was denied tenure despite being an acclaimed teacher and having published a book. She attributes the decision of the Appointments, Promotion and Tenure Committee of Columbia University to many things including the fact that she had no-one on the committee pulling for her (lack of a sponsor) rather than the fact that she had done no research and had no publications in peer-reviewed journals.

“My understanding of the power of sponsorship is rooted in my childhood.” The author then tells us that she grew up as one of six sisters in a small rather bleak mining town in Wales in the 1960s. Unemployment hovered at 28 percent and as a girl child the future was devoid of any great opportunity. “Maybe you could marry an unemployed miner? You could always do that.” The author never tells us where she ranked in age relative to her sisters nor does she tell us which, if any, of her sisters has met with the kind of success she has. She tells us simply that her father, “very much the working-class bloke,” had plans for his daughters. At the age of thirteen Ms. Hewlett and her father boarded the bus for England; the destination was Cambridge with its “dreaming spires.” Thus inspired and very likely anxious to please her father she embarked on a course of study previously unheard of in her local school and community. Four years later she was indeed accepted to Cambridge’s Girton College (although rejected by Oxford) and realized that she owed an enormous debt of gratitude to one of her teachers in school; a Miss Gwen Jones who had spent all her free time tutoring the young Ms. Hewlett and reviewing with her the material related to years and years of prior Oxford/Cambridge Entrance Exams. Only much later, in retrospect, did she also realize the importance of British politics at the time; specifically the role played by Barbara Castle, a female member of Parliament and minister in Harold Wilson’s government, who had advocated relentlessly for equal opportunity for women in both education and employment. As the author says, “Oxbridge admissions committees were newly in the business of leaning over backwards to see potential in candidates like me.” From this realization was born the conviction that lies at the heart of Forget a Mentor, Find a Sponsor: that no amount of hard work will get anyone into the elite C-suite in any organization unless someone WITH THE POWER pushes for it to happen. The person with the power is the sponsor and the protégé is the one who sees her/his opportunity linked with or even dependent upon the actions of the sponsor. Sponsorship doesn’t come cheap and it demands sacrifice and loyalty from the protégé. The requirements and responsibilities of both parties are repeatedly emphasized throughout the book. In a nutshell the main task of the protégé is to enhance the function of the sponsor who - ideally- will finally propel said protégé into the desired orbit. One sees immediately that one’s career could also be ruined by targeting the wrong sponsor. It is obvious that the sponsor could simply leave the firm with no provision made for the protégé or the protégé could be tainted by the sponsor’s malfeasance and dismissal. Our author therefore proposes that one sponsor is not

Soon to be fired, the author turned to the one person she hoped would be able to find her another job. His name was Harvey Picker who at the time was dean of the School of International Affairs at Columbia University. Harvey Picker had become a friend of the author and his significance for her was his network of contacts in the outside world. That network had been largely developed after 1945 when Harvey became president of the Picker X-ray Corporation, the company founded by his father James and to which Harvey himself contributed significantly during WWII by his development of the mobile x-ray machine. Harvey knew that the “top slot” at the Economic Policy Council was open and since he also knew the chairman of the board of the EPC he wondered if he might have permission to put the author’s name forward for that position. We already know the answer to that question and it would be meanspirited to point out that Harvey was not a sponsor as defined by the author herself in this book. Nor had she fulfilled the obligations of protégé. She was lucky and perhaps in recognition of this decided to “pay it forward” and devote her career to improving the workplace for women and minority groups. I do not know if her sponsorship protocols can work for a significant number of individuals in the work force. I had hoped to find a nugget or two in the book that might be applicable to young women in the medical profession - particularly those in danger of leaving. I didn’t find that but I did find sincerity - as outrageous as some of the paragraphs read. I also discovered an incredibly driven individual who is her own self-fulfilling prophecy. I would like to meet her, talk to her and will very likely read some of her other books. LM Note: Dr. Amin is a retired diagnostic radiologist.

January 2014

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Physicians in Print Kaufman CL, Ouseph R, Marvin MR, Manon-Matos Y, Blair B, Kutz JE. Monitoring and long-term outcomes in vascularized composite allotransplantation. Curr Opin Organ Transplant. 2013 Dec;18(6):652-8. PubMed PMID: 24220047.

Philips P, Hays D, Martin RC. Irreversible Electroporation Ablation (IRE) of Unresectable Soft Tissue Tumors: Learning Curve Evaluation in the First 150 Patients Treated. PLoS One. 2013 Nov 1;8(11):e76260. PubMed PMID: 24223700.

Kind T, Patel PD, Lie D. Opting in to Online Professionalism: Social Media and Pediatrics, Pediatrics, November 2013, Vol. 132, No. 5.

Xiang D, Zhang B, Doll D, Shen K, Kloecker G, Freter C. Lung cancer screening: from imaging to biomarker. Biomark Res. 2013 Jan 16;1(1):4. PubMed PMID: 24252206.

Kind T, Patel PD, Lie D, Chretien K. Twelve Tips for Using Social Media as a Medical Educator, Medical Teacher, 2013 Nov 21. PubMed PMID: 24261897. Miller KH, Hermann C, Jones VF, Ostapchuk M, Patel PD, Rowland M. Maximizing Co-Training Opportunities on a Traditional Health Sciences Campus, Journal of Nursing Education and Practice, 2013, Vol. 3, No. 12. ISSN 1925-4040.

NOTE: GLMS members’ names appear in boldface type. Most of the references have been obtained through the use of a MEDLINE computer search which is provided by Norton Healthcare Medical Library. If you have a recent reference that did not appear and would like to have it published in our next issue, please send it to Kate Williams by fax (502-736-6341) or email ([email protected]). LM

Motiwala FB, Siscoe KS, El-Mallakh RS. Review of depot aripiprazole for schizophrenia. Patient Prefer Adherence. 2013 Nov 13;7:1181-1187. Review. PubMed PMID: 24265550.

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Subscriptions to Vital Signs are available as a benefit to all active and associate members at no cost. To receive Vital Signs at your practice contact Membership Coordinator Jennifer Howard at [email protected] or 502-736-6362.

Candidates Elected to Provisional Active Membership Alkhalil, Bassel (31025) Rasha Hamouda 550 S Jackson St Fl 3 40202 502-813-6500 Internal Medicine 08 U of Damascus 04

Overbey, Evelyn Louisa (3449) James Perry 231 E Chestnut St 40202 Anesthesiology 97 U of Louisville 92

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would like to welcome and

Alrefai, Hisham Afa (11696) Gusoon Mhesin 2355 Poplar Level Rd Ste 301 40217 636-0406 Endocrinology 01,11 Internal Medicine 99,10 Damascus Med School 90

Cha, Yong I (32230) Michelle Brooks 676 S Floyd St 40202 502-629-4555 Radiation Oncology Vanderbilt U 08

Saad, Mohamed A (4039) 401 East Chestnut St Ste 310 40202 502-813-6500 Pulmonary Diseases 01,11 Critical Care Medicine 04 Sleep Medicine 11 Internal Medicine 96,06 Alexandria Med School 89

Schwendau, Leo A (1335) 400 Blankenbaker Pkwy Ste 200 40243 502-244-6373 Pediatrics 94,02 U of Louisville 89

congratulate the following physicians who have been elected by Judicial Council as provisional members. During the next 30 days, GLMS members have the right to submit written comments pertinent to these new members. All comments received will be forwarded to Judicial Council for review. Provisional membership shall last for a period of two years or until the member’s first hospital reappointment. Provisional members shall become full members upon completion of this

Candidates Elected to Provisional Associate Membership

time period and favorable review by Judicial Council. LM

Lingreen, Richard A (11793) Karen Lingreen 279 Kings Daughters Dr Ste 100 Frankfort KY 40601 502-352-2530 Anesthesiology 92 Pain Management 01,12 U of Kansas Medical 86

January 2014

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Speak Your Mind If you would like to respond to an article in this issue, please submit an article or letter to the editor.

Contributions may be sent to [email protected] or may be submitted online at www.glms.org. The GLMS Editorial Board reserves the right to choose what will be published. Please note that the views expressed in Doctors’ Lounge or any other article in this publication are not those of the Greater Louisville Medical Society or Louisville Medicine.

IS THIS THE PARTY TO WHOM I AM SPEAKING? Mary G. Barry, MD

I

Louisville Medicine Editor [email protected]

hear Lily Tomlin in my head whenever I am subjected, as are all employed physicians, to the spume of corporate admonishments. Often it is merely annoying, but generally the dull barrage of verbiage from the Head Office is simply a front for, “We sort of deign to talk to you, but not really.” Recently we have endured the four -hour safety testing and annual corporate compliance time-wasters. Currently we are disputing recent mandates to have full office hours on Christmas Eve and Oaks Day, having just fought a battle about the day after Thanksgiving. The main billing office is hungrier than ever for new code-able visits. Apparently, family togetherness and beloved holiday traditions matter far less in management world than big budgets, big debts, and big plans to buy every hospital on the shelf. Of course, the NGoodHealth folks spout a smokescreen of advice on “improving work/ life balance” on our annual Health Assessment forms. Despite the fact that fulfilling the NGoodHealth edicts does earn employees a financial credit for health insurance, it’s all just lip service. At the grunt level we who do all the patient care are being held upside down to shake the hours from our pockets. But in business-speak it is “maximizing productivity” instead of “We buy, you pay.” And from what I hear from my compatriots at some of the other hospital brands in this city, things are exactly the same there too.

Some sort of brainwashing must go on in MBA programs. People go in speaking English and come out speaking Camouflage. The USMC (who look good in camo) like all branches of the military, speaks in acronyms. They say “RIP/TOA” and mean “Relief in Place/Transfer of Authority” when one unit relieves another at a duty post. But they also say, “KIA, ” leaving no bones about it. However, management types, faced with a fatal wound to a budget, manage to kill off lots of jobs without ever using the word “fired.” Witness this statement from Mr. Bob Graziano, the head of Ford in Australia: To better position the company to compete in a highly fragmented and competitive market, Ford will cease local manufacturing in October 2016. All entitlements are protected for the 1200 employees whose jobs are affected, and the company will work through the next three years to provide support. I suppose he could have said “downsizing” or “rightsizing” or “detransitioning,” other euphemisms for You’re Fired. “Affected” is so sterile a term, removing any hint of the violent blow of losing one’s livelihood. He does not say, “We’ve decided to dispense with your job instead of mine,” or “Our decisions to date have maybe been disastrous.” Instead, he explains: Ford is transforming its Australian business by accelerating the introduction of new products for Australian customers,

enhancing the sales and service experience, and improving its business efficiency and profitability. This is perfect Camo-speak – a paragraph of a sentence that yields zero facts or meaning. Imagine the junior medical student presenting her jaundiced, septic, hypotensive, anuric patient to her boss in Camo-speak: “He is, at the end of the day, not going forward or optimizing his core competencies. To drill down, he has issues with key metrics and is not leveraging his throughput. Current projections are for sunsetting – he might be taking this offline.” So far as “brand alignment initiatives, “what some hospital outfits in this city have done this fall is to rip big holes in doctorpatient relationships by holding employees’ wallets hostage for keeping a doctor not “in network.” All of the independent doctors whose specialties are represented inside a hospital’s network will face financial competition from the employed physicians in those specialties, to a greater or lesser degree depending on the system. The same sorts of office visits and procedures “kept in” the Norton system for a Norton employee will cost patients a smaller copay than if that employee chooses a non-Norton specialist. But “crossing Chestnut Street” can up the ante for Norton employees. Especially for those with the high-deductible plans, people who choose doctors not Norton-owned face additional costs going up into the thousands (continued on page 36) January 2014

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From the Blogosphere A NAIL IN THE PATIENT-PHYSICIAN RELATIONSHIP COFFIN Kathy Neider, MD

B

renda works as a nurse at the other big health care system in town. She is a bit of a stoic. During our 25+ year relationship there were times I thought she didn’t like me until I realized what a nononsense personality she possesses. Thus it was upsetting to see distress in her face and hear her frustrated tone as she said, “You’ve been my doctor a long time, but I have been told that I can only see doctors in our system for my visits to be covered on my insurance.” This came as no surprise to me. Just a few weeks earlier our hospital president made the same announcement to our employees. It is infuriating to hear relationships destroyed with a flippant “We have good doctors here. There is no reason for our employees to see doctors in other systems.” First of all, a 25-year relationship with someone makes for a damn good reason to continue to see them. And yes, we have great doctors in our system. But sometimes better talent is in another hospital. I want my patient to benefit from the best talent available. And sometimes a better physician with a bedside manner that engenders patient trust trumps a “best” physician. Trust goes a long way in helping patients heal.[1,2,3] Creating more silos for our patients is not the answer to improving care but in these days of tightening budgets regardless of how much “patient engagement” rhetoric is thrown about, the bottom line is what is most on the hearts and minds of the system CEOs. As administration continues its attempt to be transparent, I may scream on hearing one more “faith-based platitude”. I do not believe that putting dollars before patient care is a religious value. On the competition’s side their mission statement urges quality health care in a manner that responds to the needs of the community and also honors a faith heritage. Regardless of the faith heritage,  shattered trust is not a community need. In the aforementioned meeting, our hospital president also stated that discussions to join with the competition for supply volume discounts were in process. How about negotiating the salvation of patient-doctor relationships with them as well? Systems can continue to insist on patients using the facilities where they work

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for testing and procedures but this strategy could encourage doctors, regardless of where they work, to continue to have privileges in BOTH systems. Then we have a win-win for patient employees, their doctors and the systems. As hospital networks struggle to balance their budgets in this competitive marketplace, here is my prediction: health care systems will survive based on the level of care they give the patients they serve, not by destroying the trust that patients put into those systems and their physicians. As Karma will have it, what goes around, comes around. Or if you prefer, in your faith-based work culture: Proverbs 26:27 - Who so diggeth a pit shall fall therein: and he that rolleth a stone, it will return upon him. LM Note: Dr. Nieder practices Family Medicine with Baptist Medical Associates-St. Matthews. She blogs at http://familypractice2.blogspot.com. This was posted on November 4, 2013.

GLMS members are welcome to submit recent blog posts for possible publication in this space by emailing [email protected].

From the Blogosphere Editor’s note: Emergency Medicine residents and faculty at the University of Louisville have a private blog called Room9ER.com. With permission, we share four of their posts with Louisville Medicine readers.

Bad news/travel fast! Amanda Zhang, MD

= BAD BAD BAD

In the setting of Acute Coronary Syndrome, ST elevation in aVR is a sign for Left Main or LAD occlusion. Most of us don’t even look at aVR - it’s the “forgotten lead.” But it should receive more attention -- ST elevation in aVR

58 yo woman comes in with chest pain. 12-lead ECG shows diffuse ST depression, AND there is ST elevation in lead aVR. A lot of people would just focus on the ST depression and call this Unstable Angina/NSTEMI. She would get admitted, started on ACS protocol, but the cath lab would probably not be emergently acti-

vated. But, since she has ST elevation in aVR in the setting of ACS, this is indicative of a LMCA occlusion, and the cath labs needs to be activated! Or if you’re in a rural ED, you need to be on the phone for transfer and consider thrombolytics though they may be of less value in these patients. Here’s an article focusing on the importance of a VR, not just in diagnosing STEMIs but also some other diagnoses, like PEs, pericarditis, etc. www.ncbi.nlm.nih.gov/pmc/articles/PMC2898534/. LM Note: Dr. Zhang is a second-year resident in Emergency Medicine at the University of Louisville.

Your Diagnosis is? Matthew Allinder, MD

P

t. is a 53 yo M who presented intially to First Care (fast track) for shortness of breath. Transferred to the main ER for worsening symptoms. Intial evaluation showed a patient with labored breathing, stridorous, and a hoarse muffled voice. Pt. tachycardic, 93% on 2L, 102F. Transferred to room 9 with film above . What are your initial thoughts? Diagnosis and treatment?

Note: Dr. Allinder is a second-year resident in Emergency Medicine at the University of Louisville.

(Answer in next issue) LM

Summer Penile Syndrome Megan Bertke, MD

A

5 yo male presented with penile swelling and irritation for 4 days. His parents say that he has pain in the area, but he has not had any fevers or complained of pain with urination. On exam he looks well with normal vitals. On GU exam he has mild penile swelling with some skin breakdown beginning on the anterior scrotum. He also has multiple erythematous papular lesions in the inguinal region and at the base of the penis. The rest of his exam was normal. When I presented to the attending she asked if I had heard of

summer penile syndrome. Since neither I nor any of the other residents seemed to know what she was talking about, I thought this would be a good case to share. Apparently this is a condition that occurs typically in younger children who play outside a lot in the summer. It appears to be caused by chigger bites to the inguinal region. We sent him home with prescriptions for hydrocortisone cream and benadryl. (Eewwww poor kid.) LM Note: Dr. Bertke is a second-year resident in Emergency Medicine at the University of Louisville

January 2014

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From the Blogosphere Look Past Your NosE Doug Kelly, MD

P

t is a 55 year old gentleman with history of chronic alcoholism and previous head injury brought to the ED by EMS for assault. Upon questioning the patient, he would only say, “I got hit.” Per EMT’s the patient was push/shoved/hit to the ground in an alleged assault resulting in a large stellate scalp laceration complicated by alcohol intoxication. En route patient was boarded and collared. Pt was alert, following commands, and complained only about headache with repetitive demands to remove the c-collar and backboard. History limited by slurred speech. PHYSICAL EXAM Vitals: HR 99 BP 115/62 RR 16 Temp 97.5 Oral General: Disheveled, in obvious discomfort. Alert, but disoriented to place and time. Speech is slurred, breath smells of ETOH. Wrists in soft restraints secondary to attempts to remove c-collar and IV. Head: 3.0cm stellate scalp laceration, hemostatic at presentation. Tenderness over right parietal skull in the area of the laceration without evidence of crepitus or deformity. No raccoon eyes / Battle’s sign. Small abrasion over right zygomatic arch with mild tenderness. Eyes: PERRL, EOMI ENT: No obvious dental injury. No hemorrhage/malocclusion/ TMs ok Neck: Non-tender over vertebral prominences. ROM not tested /collared Cardiac: Reg rate/ no m/ Strong pulses present x 4 extremities. Lung: No signs of respiratory distress. Lungs clear Abdomen: No visible injury, soft, non-tender in all four quadrants. Back: No visible injury. Non-tender over vertebral prominences. Extremities: Moves all extremities spontaneously. No visible injury or deformity. All bones palpated without tenderness. NVI distally with 5/5 strength. INITIAL IMPRESSION Presentation and examination was initially consistent with typical night of drinking culminating with a “fall down, go boom.” Patient did not appear to have any major injury. Intervention: Dilaudid, Ativan, IVF with Thiamine, Continued physical restraint CBC: Unremarkable CMP: AST/ALT 194/125, TProt 5.0, Alb 3.1 S Tox: EtOH 265, otherwise negative PT/PTT: 15.8/32.6 (wnl) 34

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CT Head w/o: Left subdural hematoma causing edema and mass effect with midline shift measured 4mm. Subarachnoid hemorrhage at cranial vertex, left temporal lobe, and anterior middle cranial fossae. Evidence of fracture in the squamous portion of the right temporal bone. Acute impacted fracture of right zygomatic arch. Air fluid levels in the sphenoid sinus. Large scalp contusion over right parietal region. CT C-Spine: Acute fracture of C7 vertebra including left superior articulating facet and left pedicle. Acute fractures of right transverse processes in C6, C7, T1, and T2. REASSESSMENT By this time the patient’s wife had made it to the bedside. She stated that though she was not there she had spoken with witnesses who told her he was actually struck by a vehicle. Although the original history and physical seems to fit with an intoxicated assault, the radiographic results certainly supported a more significant mechanism of injury. Trauma surgery called for admission. Neurosurgery, and ENT were called for consultation of respective fractures. Additional studies were indicated with the new history and significant findings thus far. Interventions: Keppra started, Scalp laceration repaired, additional IVF (rally bag per NES), NO MORE ATIVAN (per NES) CT Chest: Redemonstration of fractures in C6, C7, T1, and T2. Callous formation at left 5th through 8th ribs consistent with nonacute fracture. Two 4mm pulmonary nodules in left upper lobe. CT T-Spine: Redemonstration of T1, T2 transverse process fractures. CT L-Spine, Abdomen, Pelvis: No evidence of acute injury or pathology. L Foot 3-view: Distal fractures of the 3rd and 4th metatarsals. Discussion I chose to present this patient because I had noticed that after only two months as an intern I had quickly been numbed by the constant flow of EtOH and other intoxications through the ED. I approached this case with what I felt was an open mind, realized that I had a normal-ish physical exam and zeroed in on a simple case of drunken fall with possible assault. I really expected that this guy would get a couple sutures in the scalp, a sober re-eval several hours later, and a sandwich on the way out the door. It was a reminder that regardless of how routine a workup appears, the EP needs to be vigilant for things that just don’t jive and to err on the side of an over-cautious workup versus minimalism. Thanks for reading. LM Note: Dr. Kelly is a third-year resident in Emergency Medicine at the University of Louisville.

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Doctors’ Lounge (continued from page 31) of dollars. However, for the KentuckyOne Health employees with the standard plan, choosing Norton-owned doctors costs only a higher copay, with the exception of some “preventive visits,” especially for women’s health, which are covered at 100%. So employees who have high-deductible plans have significantly higher out of network costs on both sides of Chestnut St., but Norton-owned doctors are still considered “in network” for those who work at Jewish. Going east, people who work for Baptist Health face no punitive price hikes now. They have only an increased copay - as little as $25 - $30 more - for seeing non-Baptist owned physicians.

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LOUISVILLE MEDICINE

In Camo-speak, keeping visits in-network while penalizing out of network choices would be called “reducing revenue leakage” or “dollarizing the deliverables” and, I suspect, “ controlling the message.” (I get a whisper of goose-stepping off in the wings.) Doctors and patients, however, see this as losing the person who has stuck with them through trials and troubles, knows something about their strengths and weaknesses, and understands and respects them. As always, the people on the shortest end of the financial stick get hurt the most, not being able to pay a higher price for choosing certain doctors, while the rifle butt can come down on the heads of spe-

cialists of the wrong stripe. Loyalty, trust, and simple caring between doctors and patients are human values (like being home with your family on Christmas Eve). But God forbid that human values should interfere with “stakeholding.” Scrooge, thy name is legion. LM Note: Dr. Barry practices Internal Medicine with Norton Community Medical Associates-Barret. She is a clinical associate professor at the University of Louisville School of Medicine, Department of Medicine.

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