the digestive and liver center of florida€¦ · 4-color reprints to use as brochure inserts,...

The Digestive and Liver Center of FloridaFocusing on Preventing Colon Cancer by

Providing Compassionate, Caring, and Sophisticated Medical Care

JULY/AUGUST 2019 • COVERING THE I-4 CORRIDOR

Connected care. Superior outcomes. HealthSouth Corporation and Encompass Home Health & Hospice have combined our post-acute strengths into Encompass Health. As part of a nationwide network, we are redefining expectations for how providers work together to create better patient experiences and deliver unparalleled outcomes. As a coordinated care team, we set the standard for the future of rehabilitation.

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FLORIDA MD - JULY/AUGUST 2019 1

Connected care. Superior outcomes. HealthSouth Corporation and Encompass Home Health & Hospice have combined our post-acute strengths into Encompass Health. As part of a nationwide network, we are redefining expectations for how providers work together to create better patient experiences and deliver unparalleled outcomes. As a coordinated care team, we set the standard for the future of rehabilitation.

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FLORIDA MD - JULY/AUGUST 20192

ADVERTISE IN FLORIDA MDFor more information on advertising in Florida MD, call Publisher Donald Rauhofer at(407) 417-7400,fax (407) 977-7773 or [email protected]

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PREMIUM REPRINTSReprints of cover articles or feature stories in Florida MD are ideal for promoting your company, practice, services and medical products. Increase your brand exposure with high quality, 4-color reprints to use as brochure inserts, promotional flyers, direct mail pieces, and trade show handouts. Call Florida MD for printing estimates.

FROM THE PUBLISHER

Publisher: Donald RauhoferPhotographer: Donald Rauhofer / Florida MDContributing Writers: PPam Ruben, John “Lucky” Meisenheimer, M.D., Rajesh M. Nair, MD, Sam Pratt, Pharm D, Christopher L. Reeves, DPM, Jennifer Thompson, Julie Tyk, JD, Michael Patterson NHA, OTR/L, CEAS, Juan Lopez, Pharm D, John Meisenheimer, VIIArt Director/Designer: Ana EspinosaFlorida MD is published by Sea Notes Media,LLC, P.O. Box 621856, Oviedo, FL 32762. Call (407) 417-7400 for more information. Advertising rates upon request. Postmaster: Please send notices on Form 3579 to P.O. Box 621856, Oviedo, FL 32762.Although every precaution is taken to ensure accuracy of published materials, Florida MD cannot be held responsible for opinions expressed or facts expressed by its authors. Copyright 2019, Sea Notes Media. All rights reserved. Reproduction in whole or in part without written permission is prohibited. Annual subscription rate $45.

I am pleased to bring you another issue of Florida MD. Sometimes a patient may have the opportunity to participate in a clinical trial. Sometimes a patient may need specialized treatment that is not available in Central Florida. And sometimes there’s no money for that patient to get

to those places. Fortunately there is Angel Flight Southeast to get those patients where they need to go. I asked them to tell us about their organization and how you, as physicians, can help. Please join me in supporting this truly wonderful organization..

Best regards,

Donald B. RauhoferPublisher

ANGELS ON EARTH HELP PATIENTS GET TO LIFESAVING MEDICAL TREATMENTEveryone knows angels have wings! But did you know in Florida and many parts of the nation they have engines

and tails with dedicated volunteers who donate lifesaving services every day? Leesburg, Fla.-based Angel Flight Southeast is a network of approximately 650 pilots who volunteer their time, personal airplanes and fuel to help passengers get to far-from-home medical care. A member of the national Air Charity Network, Angel Flight Southeast has been flying passengers since 1993.

Almost all of its passengers are chronic-needs patients who require multiple, sometimes 25-50 treatments. Passengers may be participating in clinical trials, may require post-transplant medical attention or are getting specialized treatment that is not available near home. Each passenger is vetted to confirm medical and financial need and is often referred to Angel Flight Southeast by medical personnel and social workers.

Angel Flight Southeast “Care Traffic Controllers” arrange flights 24 hours a day, 365 days a year. In the event of a transplant procedure, the Care Traffic Controllers have precious minutes to reach out to its list of volunteer pilots who have agreed to be prepared on a moment’s notice to fly a patient to receive his or her potentially lifesaving organ.

The organization is completely funded through donations by individuals and organizations. A typical Angel Flight Southeast pilot donates $400 to $500 in services-per-trip. In fact, Angel Flight Southeast has earned the Independent Charities of America Seal of Approval as a good steward of the funds it generates from the public. Each $1 donated generates more than $10 worth of contributed services by Angel Flight Southeast.

The charity always seeks prospective passengers, volunteer pilots and donations. For additional information, please visit https://www.angelflightse.org or call 1-888-744.8263.

Check out our website at www.floridamd.com!


contents JULY/AUGUST 2019COVERING THE I-4 CORRIDOR

4 COVER STORY

DEPARTMENTS

Digestive and Liver Center of Florida (DLCFL) is proud to announce the opening of their compre-hensive Digestive Health Center of excellence in Kissimmee in the first quarter of 2020. The Digestive Health Center will provide comprehensive gastroenterology and hepatology services for residents of Kissimmee and surrounding areas, offering diagnostics, testing services, and treatment all under one roof. Practice co-founder, Dr. Harinath Sheela comments, “The new center will continue our prac-tice’s unique medical culture, continuing our excellent patient care provided by a highly skilled medi-cal staff that regularly improves itself through continuing medical education, while using use the latest technologies.” The new center will be located at 737 West Oak Street in Kissimmee, supplementing the three current practices located in East Orlando, Downtown Orlando, and Altamonte Springs. The state-of-the-art East Orlando facility, on Dean Road, includes the Endo-Surgical Center of Florida where patients can have colonoscopy, endoscopy or hemorrhoid procedures.

The experienced medical staff of DLCFL, Dr. Seela, Dr. Sheela, and Dr. Atiq, are recognized au-thorities in the field of gastroenterology and colorectal, conducting research, publishing findings, and teaching other physicians to advance the field. The practice’s expert gastro and liver doctors offer a wide array of services, treating the entire range of liver and gastrointestinal conditions and performing most diagnostic procedures including colonoscopy, endoscopy, as well as more advanced tests. The practice also includes world-renowned colorectal surgeons, Dr. Sergio Larach and Dr. Sam Atallah, who have garnered international recognition with their cutting-edge surgical treatment options.

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ON THE COVER: Basher Atiquzzaman, MD “Dr. Atiq”

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12 THC FROM CANNABIS DOES NOT INCREASE TRAFFIC ACCIDENTS

16 NEW OPTIONS FOR ANKLE PAIN

2 FROM THE PUBLISHER

7 CANCER

8 MARKETING YOUR PRACTICE

9 DERMATOLOGY

10 HEALTHCARE LAW

14 PHARMACY UPDATE


COVER STORY

The Digestive and Liver Center of Florida (DLCFL) is proud to announce the opening of their comprehensive Digestive Health Center of excellence in Kissimmee. The Digestive Health Center provides comprehensive gastroenterology and hepatol-ogy services for residents of Kissimmee and surrounding areas, offering diagnostics, testing services, and treatment all under one roof. Practice co-founder, Dr. Harinath Sheela comments, “The new center will continue our practice’s unique medical culture, continuing our excellent patient care provided by a highly skilled medical staff that regularly improves itself through continuing medical education, while using use the latest technologies.” The new center will be located at 737 West Oak Street in Kissimmee, supplementing the three current practices located in East Orlan-do, Downtown Orlando, and Altamonte Springs. The state-of-the-art East Orlando facility, on Dean Road, includes the Endo-Surgical Center of Florida where patients can have colonoscopy, endoscopy or hemorrhoid procedures.

The experienced medical staff of DLCFL, Dr. Seela, Dr. Sheela, and Dr. Atiq, are recognized authorities in the field of gastroenterology and colorectal, conducting research, publish-ing findings, and teaching other physicians to advance the field. The practice’s expert gastro and liver doctors offer a wide array of services, treating the entire range of liver and gastrointestinal conditions and performing most diagnostic procedures includ-ing colonoscopy, endoscopy, as well as more advanced tests. The practice also includes world-renowned colorectal surgeons, Dr. Sergio Larach and Dr. Sam Atallah, who have garnered inter-national recognition with their cutting-edge surgical treatment options.

Basher Atiquzzaman MD, best known as “Dr. Atiq” to pa-tients, is happy to be returning to the Kissimmee area in advance of the opening. He is currently seeing clients on a weekly basis, as he prepares to direct the Digestive Health Center. Practic-ing in the Kissimmee area for almost half of his medical career,

Providing personalized care is our every day mission.

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The Digestive and Liver Center of Florida – Focusing on Preventing Colon Cancer by Providing Compassionate, Caring, and Sophisticated Medical Care

By Pamela Ruben


COVER STORY

Dr. Atiq enjoys treating patients in the Kissimmee-St. Cloud-Hunter’s Creek-Lake Buena Vista area because of its wide-rang-ing population and need for compassion-ate and sophisticated care. He comments, “Fifteen years ago, when I began practicing medicine in the Kissimmee area, it was a little village, very quiet, without much-advanced GI support. Today it is an area of maximum growth with a need for complete care from diagnosis through treatment.”

Internal medicine practitioners have ea-gerly awaited Dr. Atiq’s return to South Orlando. “His exceptional level of expertise in the treatment of diseases and disorders that affect the stomach, colon, intestines, liver, pancreas, and esophagus have gained the respect of primary care physicians who are already referring their patients, ”com-mented Dr. Sheela.

Dr. Atiq is “very passionate” about the entire range of liver and gastrointestinal conditions, including the treatment of heartburn, which affects almost 30% of Americans. He comments, “Heartburn is such a common com-plaint, and patients deserve to understand it better. After ruling out heart-related issues, we need to find out what really is caus-ing the symptoms of reflux.”

Dr. Atiq diagnoses heartburn using endoscopy as well as func-tional testing, with a microchip that measures acid reflux over 72 hours. He explains that the chip transmits data to a smartphone-type device, with the patient also recording symptoms. From the data collected, the doctor discerns which patients need acid reducers and which require other treatments like hiatal hernia repair. He also screens for Barrett’s esophagus, a pre-cancerous condition. Dr. Atiq comments, “Patients of the Heartburn Cen-ter will be treated by experienced physicians using advanced technology.”

As an Assistant Professor at the University of Central Florida Medical School, Dr. Atiq is motivated to teach the next genera-tion of young doctors. He educates incoming doctors by training medical school students in the same treatments and techniques being utilized within his own practice. He remarks, “Touching the life of a student is part of the process, as is sharing expertise.”

The gastro doctor recalls one particular student who was in her first month of residency when she came under his charge. The student, a recent refugee from Syria, initially found the hands-on teaching style in America to be very different. However, the resident developed a significant interest in GI and liver disease after following several patients under Dr. Atiq’s care. During that time, Dr. Atiq admitted a young patient with a failing liver who turned out to have a rare condition, Wilson’s Disease. The pa-tient ultimately received a liver transplant, with Dr. Atiq follow-ing his case all the way through the process. Following the case from beginning to end, the student became passionate about

liver disease and entered a hepatology fellowship. Dr. Atiq is grateful to a teacher of his own during his fel-

lowship at Stony Brook University. “Dr. Grossman was a good teacher who made a difference in my own life. Teaching is a re-warding part of a practice.”

Dr. Atiq completed two fellowships, the first in gastroenterol-ogy and the second in geriatrics. He comments, “When I fin-ished my residency, I chose to do a geriatric fellowship. With the senior population growing, I wanted to learn about their unique set of symptomology.”

Well-known for his endoscopy skills, Dr. Atiq checks for esophageal abnormalities during the procedure. He is skillful in tumor ablation, as well as in stretching or dilating the esopha-gus. He also checks for growths or Barrett’s esophagus, a pre-cancerous condition. A skilled physician at both ends, Dr. Atiq regularly performs colonoscopies to diagnose abnormal growths and ulcers, and to look for early signs of cancer in the colon and rectum. He also looks for causes of unexplained changes in bowel habits and to evaluate symptoms like abdominal pain, rectal bleeding, and weight loss.

A family lineage of doctors led him to pursue medicine; his wife, sister, brother-in-law, and in-laws are all physicians. This year his daughter was accepted into an eight-year medical pro-gram at Nova Southeastern University.

Practice co-founder, Dr. Harinath Sheela also hales from a family of doctors. Dr. Sheela, along with his brother, Dr. Srini-vas Seela, are founding partners of Digestive and Liver Center of Florida. The pair completed both medical school and residencies together. Following the completion of prestigious fellowships at Yale University, in 2005 the brothers opened their practice in

We believe in trust and relationships based on communication between the patients and the physician

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COVER STORY

Orlando. Dr. Seela’s interests include advanced and therapeu-tic endoscopic procedures, colorectal cancer screening, Gastro Esophageal Reflux Disease (GERD), metabolic and other liver disorders.

Like Dr. Atiq, Dr. Sheela enthusiastically awaits the opening of the Digestive Health Center, which will better accommodate the practice’s expansive patient base, which ranges from Polk and Osceola Counties to North Lake County. The former head of GI at Florida Hospital from 2012-2016 notes that patients will get a “Mayo Clinic type experience with GI, liver, and colorectal problems treated from beginning to end at the care center.” He remarks, “We not only remedy symptoms but find their causes and follow up with treatments and cures.” Additionally, Diges-tive and Liver Center of Florida is the only practice with colorec-tal surgeons in-house.

Compassionate care is at the heart of Dr. Sheela’s practice, and the doctor and staff members of DLCFL give back to the com-munity by donating time to Shepperd’s Hope, a free and chari-table clinic located in Longwood. Teaching is also an active com-ponent of the practice. In addition to his Assistant Professorship at the University of Central Florida School of Medicine, Dr. Sheela is also a teaching attending physician at both the Florida Hospital Internal Medicine Residency and Family Practice Resi-dence (MD and DO) programs. He comments, “The younger generation needs to learn not only about the latest technologies but the importance of empathy in medicine.” The experienced GI doctor is an active member of the Orange County Medical Society and sits on the Board of Directors. He is also a mem-ber of the American Gastroenterological Association (AGA), the American Society for Gastrointestinal Endoscopy (ASGE), the American Association for the Study of Liver Diseases (AASLD),

and Crohn’s Colitis Foundation (CCF).Dr. Sheela shares. ”Ours is one of the of few practices that see

its own patients in the hospital. We have long-term relationships with our patients, we know their histories, and they trust us.” He recalls one particular patient who began seeing doctors in the practice when she was a UCF student at the age of nineteen to help manage her Crohn’s disease. The patient enjoyed the con-tinuity of care and continued to see DLCFL doctors through her young adulthood. Now 28 and married, she relies on the practice to help manage her symptoms as she tries to become pregnant.

Double board certified in internal medicine and gastroen-terology, Dr. Sheela is equipped to understand how the whole body works together. With a passion for preventive medicine, Dr. Sheela and the staff of Digestive and Liver Center of Florida created a sophisticated medical practice that emphasized in equal parts state-of-the-art medical care along with a warm and caring environment for patients.

To refer patients to any of the Digestive and Liver Center of Florida locations, including the new Digestive Health Center in Kissimmee call 407-384-7388. Visit their website www.dlcfl.com.

ORLANDO•ALTAMONTE SPRINGS DOWNTOWN•KISSIMMEE

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CANCER

Innovative Treatment for GI Cancers By Rajesh M. Nair, MD

Some cancers — such as those in the abdominal area — can be challenging to treat. That is especially true for cancer of the peritoneum, the tissue that lines the abdominal wall. This type of cancer often is caused by the spread of diseased cells from pre-existing cancers in the appendix, colon, rectum, pancreas, ovaries and stomach. It also can be caused by peritoneal mesothelioma

In the space between the organs in the abdomen, there is a nat-urally occurring membrane called the peritoneum. This mem-brane forms a barrier between the bloodstream and the peritoneal space, making it hard to get chemotherapy drugs to the site of the tumor at a sufficient concentration to be effective.

Hyperthermic intraperitoneal chemoperfusion, or HIPEC, is an innovative treatment that enables “delivery of a high concen-tration of effective medication to the tumor itself and minimizes the toxicity that would be associated with using these doses de-livered traditionally by IV,” says Rajesh M. Nair, MD, an oncol-ogy surgeon specializing in gastrointestinal surgery at Orlando Health UF Health Cancer Center.

HIPEC consists of two phases that are both performed on the same day. The first phase is tumor debulking, also known as cyto-reductive surgery (CRS). This process removes all visible tumors from the abdomen. Sometimes it involves simply removing the lining of the abdominal cavity, but it also may require removing organs such as the gallbladder, spleen, or part of the large or small intestine. The more complete the cytoreduction, the more effec-tive the HIPEC phase is.

Once the cytoreductive phase of the surgery is completed, a heated solution of chemotherapy is circulated throughout the peritoneal cavity for 90 to 120 minutes. After this, the chemo-therapy solution is removed and the abdomen is closed.

HIPEC is most effective in treating certain tumors of the gastrointestinal tract as well as peritoneal-based tumors such as mesothelioma. Within the GI tract, the most widespread use is for treatment of tumors of the appendix, which occur along a spectrum. At one end are tumors that produce a thick, mucus-like substance that distributes widely throughout the peritoneal cavity. This condition is called pseudomyxoma peritonei. On the other end of the spectrum is a more traditional type of appendix cancer. While HIPEC can be used in this situation, it is far more effective in patients with pseudomyxoma peritonei. HIPEC also can be used in selected patients with peritoneal involvement from colon cancer.

“Many things go into deciding whether the patient is a good candidate for cytoreductive surgery and HIPEC,” says Dr. Nair. “The surgeries tend to be long (8 to 14 hours) and hospital stays may last 10 to 14 days. Good overall health and fitness is an important consideration. Organ function and nutritional param-eters are also important, and we assess both closely before making

a decision regarding candidacy.”

Two other important factors are the type of tumor present and the amount of disease that exists. “HIPEC is far more effective with certain cell types,” says Dr. Nair. “The treatment is only truly effec-tive if a complete cytoreduction can be performed. We use these two factors to ultimately determine whether someone is a good candidate. For example, we would be more willing to perform the procedure on a patient with a large amount of disease if their tumor type is favorable.

“In contrast, if the tumor type is less favorable,” Dr. Nair con-tinues, “we aim to select patients with a low volume of disease, where we have a strong belief that a complete cytoreduction is achievable.”

Rajesh M. Nair, MD, is an oncology surgeon, is a member of the Department of Surgery at Orlando Health UF Health Cancer Center and a member of Orlando Health’s Graduate Medical Education team. He has been a principal investi-gator in multiple research projects and has presented at na-tional and regional medical and surgical meetings. Dr. Nair has particular clinical interest in melanoma, advanced gas-trointestinal malignancies and regional cancer therapy for peritoneal carcinomatosis (HIPEC).


MARKETING YOUR PRACTICE

How to Deliver Customer Service Like the Ritz CarltonI recently took a unique 8-hour course called the Ritz Carlton

Leadership Center Excellence in the Patient Experience.

As one of the most successful hotel chains in the world, Ritz Carlton has achieved unparalleled levels of success, profitability, and customer services standards and is often hired by hospital groups to evaluate, train, and revamp their customer service de-partments.

How do they do it? And how can your medical practice emulate it (for pennies on the dollar)?

The Ritz Carlton business model is founded on three pillars of success: employee engagement, customer satisfaction, and profit-ability. They know that behind every great product or service are great people, and in their business model, they put their employ-ees before everything else. By investing in their employees from day one, instilling an understanding of organizational standards and the WHY, the other two pillars naturally fall into place.

EMPLOYEE ENGAGEMENTWhen we’re caught up in the day-to-day grind checking things

off the list, we sometimes forget to ask ourselves why we’re do-ing what we’re doing. It’s critical to slow down, consider the why and make sure we’re focused on the things that actually matter. If your goal is to treat your patients with the utmost professionalism, show them empathy, and get them in and out as quickly and as smoothly as possible, then you’ve defined your ‘why.’

By providing your employees with a rigorous training and on-boarding program, your expectations will be crystal clear from day one. You’ll weed out those potential employees looking for an easy paycheck with little responsibility and attract people who can de-liver wow-moments to your patients. You can reinforce your stan-dards and practice culture by instituting a ten-minute stand-up meeting (another Ritz Carlton innovation) every day before work to share best practices and get everyone on the same page before greeting patients.

Ritz Carlton empowers every employee to deliver exceptional moments by giving them up to $2,000 per person to create an unforgettable experience. We’re not saying you should allow your employees to give out money! However, you could tell them, “Look if the waiting time is beyond 30 minutes, you’re empow-ered to go and hand out cookies, a bottle of water, or a $10 Star-bucks gift card.”

CUSTOMER ENGAGEMENTIt’s not rocket science: when your employees are fully engaged,

they will automatically deliver excellent customer service. And the most critical aspect of patient customer service is consistency.

You need to deliver an excellent patient experience all the time consistently. That means greeting every patient by their first or last name, smiling at patients when they walk in and looking them in the eye. From your website to your front desk and lobby, to the physician’s bedside manner, your standards should be consistent

across the board, all the time.

PROFITABILITYThe third pillar of success, profitability,

follows from the first two. When you focus on your employees 100%, those employ-ees deliver excellent customer experiences. That, in turn, makes you profitable and enables your organization to function smoothly and efficiently.

Healthcare nowadays is very transactional. Patients have a myr-iad of choices when it comes to physicians and are more in con-trol of their healthcare destiny than ever before. By focusing on enhancing the patient experience at every turn, the better off your practice will be in the long run.

By making small, incremental changes in how you go about delivering patient customer service, your medical practice can achieve Ritz Carlton-like patient care standards, employee engage-ment, and profitability.

For a full breakdown of how Ritz Carlton achieves industry-best customer service standards, check out our podcast here: https://insightmg.com/ep-183-deliver-customer-service-like-the-ritz-carlton/

Jennifer Thompson is the President of Insight Marketing

Group and Insight Training Solutions and can be reached

at 321.228.9686 or [email protected].

By Jennifer Thompson


DERMATOLOGY

Dermatology MythsMYTH #1 MELANOMAS ARE ALWAYS BLACK.

Although I think most physicians realize melanomas come in different morphologic patterns, it is still surprising to find out how many believe that melanomas must be dark pigmented. It is true that most melanomas are pigmented but rest assured not all are. Melanomas lacking pigment are called amelanotic melano-mas, and they are typically diagnosed at a more advanced stage than pigmented melanomas. It is believed more than 2% of mela-nomas are amelanotic and the survival curve is worse for these cancers as they are detected later. The take-home message is that a suspicious lesion is a suspicious lesion and should be biopsied. Don’t “follow” a lesion that is suspicious; biopsy it.

MYTH #2 TOPICAL ANTIBIOTICS PREVENT INFECTIONS IN SKIN BIOPSY SITES.

The first take-home message is that topical antibiotics don’t seem to prevent infection any more than plain Jane white Vaseline.

The second message is that neomycin (one of the main ingre-dients in over the counter topical antibiotics such as Neosporin) is one of the most common contact allergens in the U.S. with approximately 10% of the population sensitized. Decades ago recommendations changed from using Neosporin to using Baci-tracin which had a much lower sensitization rate. Fast forward a few decades, and now we have sensitized about 8 percent of the population to Bacitracin as well. Oops! Our bad.

If you perform lots of skin biopsies and you use topical antibi-otic you will notice many return patients complaining of biopsy site infections, but the vast majority of these end up being allergic reactions. When I was using topical antibiotics, I used to see return allergic reactions almost on a daily basis. When I switched to white Vaseline the only “infections” I see now are those from folks that did not follow my instructions and used a topical anti-biotic. Ditch the antibiotic and use the petrolatum.

MYTH #3 INFLAMED CYSTS NEED ANTIBIOTICS.

When I am referring to inflamed cysts, I am talking specifically of epithelial inclusion cysts (many physicians call these sebaceous cysts, epidermal cysts, epidermoid cysts or keratin cysts). These are common and can occur just about anywhere on the skin. An invagination of the epithelial tissue forms the cyst wall which fills

with cheesy keratin debris. They grow slowly, are typically asymptomatic, and are not cancerous. Occasionally these cysts rupture, leaking keratin contents through the cyst wall into the skin which results in a massive inflammatory reac-tion.

In a few hours, they can swell several times their normal size, turn red, and become extremely painful. At this point many are diagnosed as “infected cysts,” but infection is not the cause, and the treatment is not antibiotics but incision and drainage. If you don’t drain the cyst, the pain will persist until nature expels the contents for you. Ultimately, the inflammation will break through the skin and drainage will occur.

When you drain an inflamed cyst, a little squeeze won’t do the trick. You need to get in and remove all the contents, including the cyst wall. It’s a messy, smelly procedure, but the patient will appreciate your work in the end. I also frequently inject low doses of steroids into the site to combat the inflammation and pack the cavity with iodoform gauze for the night. Generally, the inflam-mation and swelling is 80 to 90 percent better the next morning when you remove the packing. No antibiotics needed.

MYTH #4 RASHES ARE NOT CANCER.I have seen basal cell carcinomas, squamous cell carcinomas

and even lentigo maligna melanomas treated as benign rashes. Even more common is seeing mycosis fungoides (Cutaneous T cell lymphoma) misdiagnosed as contact dermatitis or nummular eczema. Physicians that are not aware that skin cancers can clini-cally look like rashes are destined to miss early treatment oppor-tunities. In the case of cutaneous T-cell lymphoma, the average duration from the first appearance to the correct diagnosis is five years. Always consider cancer in a chronic eruption that does not respond to reasonable therapy.

Lucky Meisenheimer, M.D. is a board-certified derma-tologist specializing in Mohs Surgery. He is the director of the Meisenheimer Clinic - Dermatology and Mohs Surgery. John Meisenheimer, VII is a medical student at USF.

By John “Lucky” Meisenheimer, MD and John Meisenheimer, VII

Melanomas don’t have to be black or have any pigment at all. “Conventional wisdom is the worst wisdom of all” quoted from “The Immune.”

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lymphoma) usu-ally presents as

an asymptomatic rash that is often confused with ec-zema. Rashes can

be malignant.

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A positive patch test result for neomycin. Topical

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HEALTHCARE LAW

Understanding Exculpatory ClausesAn exculpatory clause purports to deny an injured party the

right to recover damages from a person negligently causing his injury. Cain v. Banka, 932 So. 2d 575 (Fla. 5th DCA 2006). They are disfavored in the law because they relieve one party of the obligation to use due care and shift the risk of injury to the party who is probably least equipped to take the necessary pre-cautions to avoid injury and bear the risk of loss. Applegate v. Cable Water Ski, L.C., 974 So. 2d 1112, 1114 (Fla. 5th DCA 2008). Such clauses are strictly construed against the party seek-ing to be relieved of liability. Sunny Isles Marina, Inc. v. Adulami, 706 So. 2d 920 (Fla. 3d DCA 1998). Thus, exculpatory clauses are enforceable, only where, and to the extent, that the intention to be relieved from liability is made clear and unequivocal. Tat-man v. Space Coast Kennel Club, Inc., 27 So. 3d 108, 110 (Fla. 5th DCA 2009). The wording must be so clear and understand-able that “an ordinary and knowledgeable person will know what he is contracting away.” Id. (quoting Gayon v. Bally’s Total Fitness Corp., 802 So. 2d 420 (Fla. 3d DCA 2001)).

The seminal Florida case on exculpatory clauses is the Florida Supreme Court case of Sanislo v. Give Kids The World, Inc., 157 So. 3d 256 (Fla. 2015). Give Kids the World, Inc. (“GKTW”) provided free vacations to seriously ill children and their families. When applying for the vacation, the Sanislos executed a “wish request” form that contained a waiver of liability, also known as an exculpatory clause. When the parents arrived at the resort vil-lage they again signed a liability release form, also an exculpatory clause. The language of the exculpatory clause is reprinted below for reference:

I/we hereby release Give Kids the World, Inc. and all of its agents, officers, directors, servants, and employees from any liability whatsoever in connection with the preparation, execution, and fulfillment of said wish, on behalf of our-selves, the above named wish child and all other participants. The scope of this release shall include, but not be limited to, damages or losses or injuries encountered in connection with transportation, food, lodging, medical concerns (physi-cal and emotional), entertainment, photographs and physi-cal injury of any kind....

I/we further agree to hold harmless and to release Give Kids the World, Inc. from and against any and all claims and causes of action of every kind arising from any and all physical or emotional injuries and/or damages which may happen to me/us....

Sanislo at 258-259.While participating in a horse-drawn wagon ride, a rear pneu-

matic lift designed to allow those in wheelchairs to participate failed, and Ms. Sanislo was injured. The Sanislos brought suit and GKTW filed a motion for summary judgment arguing that the signed releases precluded an action for negligence. The Sanislos filed a motion for partial summary judgment against GKTW’s affirmative defense of release. The trial court granted the Sanislo’s

motion and denied GKTW’s motion. The jury found for the Sanislos and GKTW appealed. Id.

The Fifth District reversed, finding the lower court erred in denying GK-TW’s motion for summary judgment because the release signed by the Sanislos was unambiguous and did not contravene public policy. It ruled the exculpatory clause barred the negligence action despite the lack of a specific refer-ence to “negligence” or “negligent acts” in the exculpatory clause.

The Fifth District reasoned that exculpatory clauses are effec-tive if the wording of the exculpatory clause is clear and under-standable so that an ordinary and knowledgeable person would know what he or she is contracting away, and that the court had previously rejected “‘the need for express language referring to release of the defendant for “negligence” or “negligent acts” in order to render a release effective to bar a negligence action.’ ” On the public policy argument, the Court said the relative bargain-ing power of the parties should not be considered because it was outside of the public utility or public function context and the Sanislos were not required to request a vacation with GKTW or go on the vacation. Id.

In affirming the Fifth District’s decision, the Supreme Court wrote that the conflict for the Court’s resolution was “whether an exculpatory clause is ambiguous and thus ineffective to bar a negligence action due to the absence of express language releas-ing a party from its own negligence or negligent acts.” Id. at 260.

The Florida Supreme Court wrote:

.... we are reluctant to hold that all exculpatory clauses that are devoid of the terms “negligence” or “negligent acts” are ineffective to bar a negligence action despite otherwise clear and unambiguous language indicating an intent to be relieved from liability in such circumstances. Application of such a bright-line and rigid rule would tend to not effectuate the intent of the parties and render such contracts otherwise meaningless.

Id. at 270.

The Court found that the GKTW liability release form re-leased GKTW and all of its agents, officers, directors, servants and employees from “any liability whatsoever in connection with the preparation, execution and fulfillment of said wish…” The release then provided that the scope of the agreement included “damages or losses or injuries encountered in connection with transportation, food, lodging, medical concerns (physical and emotional), entertainment, photographs and physical injury of any kind . . . .” The Court found that the release clearly conveyed that GKTW would be released from any liability, including negli-gence, for damages, losses, or injuries due to transportation, food, lodging, entertainment and photographs. Id.

The determination of whether an exculpatory clause is en-

By Julie A. Tyk, JD.


HEALTHCARE LAW

forceable will be determined by the Judge as the enforceability of a pre-injury release is a question of law. The enforceability there-fore, will depend on the Judge assigned to the matter. Physicians should not assume that because a patient signed a liability release form the patient does not have a viable cause of action. Physicians should consult with an experienced attorney who can examine the facts of the case and help you determine the best path for-ward. The Health Care Practice Group at Pearson Doyle Mohre and Pastis, LLP is committed to assisting Clients in navigating and defending medical malpractice claims. For more informa-tion and assistance, please contact David Doyle and Julie Tyk at Pearson Doyle Mohre & Pastis, LLP.

Julie A. Tyk, JD, is a Partner with Pearson Doyle Mohre

& Pastis, LLP. Julie concentrates her practice in medical

practice defense litigation, insurance defense litigation and

health care law. She has represented physicians, hospitals,

ambulatory surgical centers, nurses and other health care

providers across the state of Florida. She may be contacted

by calling (407) 951-8523; [email protected]..

Check out our newly redesigned website at www.floridamd.com!


One of the topics that prohibitionists gravitate towards when it comes to cannabis legalization (in any form), is the threat of people driving around “stoned” causing accidents and being a detriment to society. The premise is that if cannabis is legal, ev-eryone will run out and get “high” and drive around and get into accidents. However, a new clinical study published in the May 2019 edition of Addiction magazine concludes that there is no increase in accident rates for drivers with THC, the psychoactive cannabinoid in cannabis, in their system. https://www.ncbi.nlm.nih.gov/pubmed/31106494

Researchers from the University of British Columbia ana-lyzed over 3000 medical reports and blood samples taken from injured drivers in British Columbia, Canada between 2010 to 2016. From the data, it was found that alcohol was detected in 14.4% of drivers, THC in 8.3%, other drugs in 8.9%, and sedat-ing medications in 19.8%.

The researchers reported that they “found no increase in crash risk, after adjustment for age, sex, and use of other impairing substances, in drivers with THC less than 5 nanograms. For driv-ers with THC greater than 5ng there may be an increased risk

THC from Cannabis Does Not Increase Traffic Accidents By Michael Patterson, NHA, OTR/L, CEAS

of crash responsibility, but this result was statistically non-significant and further study is required.” However, there was a significant increase in trauma for patients who had alcohol in their system above .08% as well as drivers with sedating medication in their system.

“There was a significantly increased risk for drivers who used alcohol, sedating medications, or recreational drugs other than cannabis,” the researchers wrote. The study also found that drivers who tested positive for both THC and alcohol were more likely to cause an accident than drivers who tested positive for alcohol alone.

The results of this study show similar results to other recent studies performed on impaired driving relating to cannabis. In 2018, the Frontiers of Pharmacology journal also found no sig-nificant link between cannabis-intoxicated drivers and traffic ac-cidents. Furthermore, a study published in the American Journal of Public Health in 2017, compared the rate of traffic accident deaths in adult-use states with prohibition states, and found no significant association between legal weed and increased motor vehicle fatality rates.

These studies are promising to show that cannabis does not in-crease the chance of a motor vehicle accident. However, for any of your patients who are taking Medical Marijuana (MMJ), or con-sidering getting a recommendation for MMJ, ensure they know how they will react to the medicine (just as they would any other medication), prior to getting behind the wheel.

Michael Patterson NHA, OTR/L, CEAS is CEO of US

Cannabis Pharmaceutical Research and Development

LLC. (uscprd.com). Mr. Patterson is a healthcare executive

with over 25 years experience in the following areas: Can-

nabis-Hemp investment, Law, Regulation, Compliance,

Operations, and Management, Skilled Nursing, Phar-

macy, Laboratory, Assisted Living, Home Healthcare, and

Healthcare Analytics. Michael is a subject matter expert

in the Global Cannabis and Hemp Industry with Gerson

Lehrman Group (glg.it) and Guidepoint. Mr. Patterson

is an editorial board member of the American Journal of

Medical Cannabis, licensed Nursing Home Administrator,

and licensed Occupational Therapist in 4 states.

Patient Assistance Resource CenterTo make sure people with CF have the support, information and access to resources they need to take advantage of the best treatments available, the CF Foundation has developed a network of access to care programs called the Patient Assistance Resource Center.

• CF Patient Assistance Foundation (CFPAF) helps patients meet their co-pay requirements and provides financial assistance to those in need.

• CF Social Security Project provides support for patients applying for SSI or SSDI.

• Case Management helps patients, their families and CF care centers understand and navigate insurance and reimbursement terms and coverage. It also provides guidance with coordination of benefits, prior authorizations, appeals and network exceptions.

• CF Legal Information Hotline serves as a free information resource about the laws that protect the rights of individuals with CF.

• Mutation Analysis Program (MAP) offers free genetic testing to people with a CF diagnosis who do not know both of their mutations.

• Patient Assistance Resource Library (PARL) is a self-service online resource with up-to-date materials on coverage and care for patients, their families and CF care providers.

• CoverMyMeds assists health care providers expedite and streamline the submission of prior authorization requests.

Patient Assistance Resource [email protected]/AssistanceResources

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AdventHeAltH CAnCer InstItute’s

REGISTER TODAY

Formerly known as Florida Hospital Cancer Institute

Formerly known as Best of ASCO®

AUGUST 24 & 25, 2019 – ORLANDO, FLORIDAtHe rItz-CArlton orlAndo, GrAnde lAkes

AdventHealth Cancer Institute is proud to bring the highlights of the 2019 ASCO Annual Meeting to you through its licensed ASCO Direct™ Highlights. The ASCO scientific committee selects the highest rated abstracts from the Annual Meeting to be available for licensed ASCO Direct™ Highlights meetings around the world.

Highly Requested Meet the Professor | Breakout Sessions

Round Table Discussions* Lunch Provided · RSVP Required · Limited Seating

*Physician Participation Only at Round Table

Intended Audience: Physicians, Fellows, Residents, Medical Students, Oncology Nurse Practitioners, Oncology Nurses and other Oncology Allied Health Care Professionals.

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The Ritz-Carlton Orlando, Grande Lakes 4012 Central Florida Parkway | Orlando, FL 32837Hotel Reservation Line: 800-266-9432For more information or to register:

AdventHealthCancerInstitute.com/ClinicianEventsAH.ORL.CI.Registration@AdventHealth.com407-303-1945 or 800-375-7761

AdventHealth Orlando is accredited by the Florida Medical Association to provide Continuing Medical Education for physicians.

AdventHealth Orlando designates this live activity for a maximum of 9 AMA PRA Category 1 Credit(s)™ and Sunday, Breakout session 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in this activity.

Up to 1.5 Nursing Continuing Education Credit Hours have been applied for Saturday, August 24th and 5.5 Nursing Continuing Education Credit Hours have been applied for Sunday, August 25th through the Florida State Board of Nursing Provider Number NCE2012/CEBroker Provider Number #50-724.

Physicians:

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PHARMACY UPDATE

Personalized Medicine and the Pharmacy Consult

“100 patients a day are easy and fun to see.”

I saw this sign hanging in a physician’s office once. Honestly, I don’t believe it. I’ve seen how tired and hurried practitioners can get. How could it be easy and fun to spend one-on-one time with 100 different patients in one day? How can you share with

By Sam Pratt, RPh, FIACP & Juan Lopez, PharmD, FIACP

them the benefit of your education, knowledge and experience? You do this all day and then are expected to go home and pour over journals and research so that you can offer your patients the best of what is available. I’m exhausted just thinking about it. I know with man-

aged care you do not have much of a choice, but I doubt that this is what many of you had in mind when you entered medicine.

Pharmacy Specialists’- “Pharmacy Con-sult” is a tool that can ease the demands on your time and improve patient satisfaction. We have had the privilege of working with many area physicians in this manner. By us-ing the “Pharmacy Consult”, you are invit-ing your colleague, the pharmacist, to enter into relationship with you and your patient to assist you in researching and choosing medications for difficult to treat patients. These patients may have been seen by one of your colleagues and can be challenging. You have limited time and limited com-mercial preparations to choose from. It can take two weeks, a month or more before you find out whether the course of treatment has been helpful or if the patient is still suf-fering. The “Pharmacy Consult” increases patient satisfaction by providing quicker time to a positive outcome. This helps your practice by producing good will between the patient and the physician. It can also make you aware of personalized medicine options, which produces a uniqueness of practice for you.

Using the Pharmacy Consult is easy. Write “Pharmacy Consult” on one of your existing prescription pads and have your patient con-tact our pharmacy to schedule an appoint-ment. If the consult is for pain the pharma-cist can evaluate several topical medications to see which one works best. This saves the patient time and money often lost in try-ing multiple medications. Another area we are frequently called in to consult on is bio-identical hormone replacement. The “Phar-macy Consult” focuses on these women’s concerns and helps them enter a treatment program approved by you and satisfying to them. We have also been called in to con-


COVER STORY

sult on wound healing, radiation burns, limb preservation, sexual dysfunction, dermatologic conditions, nutritional genetics, and so on. In all cases, the pharmacist will contact you, most often via fax, with recommendations and requesting your authorization to a course of treatment.

Early intervention is often the key to successful healing. If we can see a shingles patient in the rash or blister stage, we have a better chance of keeping it from advancing to post herpetic neuralgia. Early intervention in hormone therapy can be aimed at holding ground in regards to bone loss, sexual function, and moods as opposed to having to fight the battle of restoring the quality of someone’s life. Enemas to prevent or alleviate burns as-sociated with radiation therapy produce best results when used sooner rather than later.

We are happy to partner along side of you and your practice, assisting you in bringing health and satisfaction to your most diffi-cult patients. In the process we can lighten your load by spending the time necessary to satisfy your most challenging patients. Our goal as personalized medicine pharmacists is to provide practitioners with therapy op-tions that meet the unique needs of those they care for.

References available upon request.

For more information on how our pharmacists can help, please call 407-260-7002.

Sam Pratt, RPh and Juan Lopez,

PharmD are personalized medicine

pharmacist with Pharmacy Specialists

Compounding Pharmacy in Altamonte

Springs, FL. Currently, they are the only

Full Fellows of the International Acad-

emy of Compounding Pharmacists prac-

ticing in the Orlando area.

Juan Lopez, PharmD, FIACP is a

personalized medicine pharmacist with

Pharmacy Specialists Compounding

Pharmacy in Altamonte Springs, FL.

For more information on how personal-

ized medicine can help you, please call

407-260-7002 or email us at Info@

MakeRx.com.

PHARMACY UPDATE

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New Options for Ankle PainBy Christopher L. Reeves, DPM, FACFAS

We know arthritic hips and knees are replaced all the time—but did you know that arthritic ankles could also be replaced? In fact, ankle replacements in the U.S. more than doubled last year, thanks in part to technological advances in ankle implants. An-kle replacements as well as other new surgical techniques includ-ing arthroscopic ankle surgery and bone or cartilage replacement are offering hope for those wanting to remain active. This is good news for active adults who are plagued with painful ankles.

End-stage ankle arthritis is a painful condition and most of-ten occurs after a traumatic injury, history of chronic sprains, or in patients with diseases such as rheumatoid arthritis and is one of the leading causes of chronic disability in North America. Todays patient, especially those near or past retirement age are more active than ever and don’t want to be held back by painful arthritis. Historically, ankle fusions were the gold standard for care and while it is successful in pain relief, the resulting restric-tion in motion can shift motion stresses to adjacent foot joints, which in time also become arthritic.

Total ankle replacement surgery—also called ankle arthro-plasty—involves replacing the damaged joint with an artificial joint. Recent studies have demonstrated that the safety profile

of ankle replacement surgery is equivalent to that experienced with ankle fusion. Patients undergoing ankle replacement are typically in their 50s through 70s, although older in-dividuals who are “physiologically young” may also be good candidates. We have performed the procedure on individuals ranging in age from 45 to 83 years of age with great success, despite the age differences.

Not everyone is a candidate for an ankle replacement. For exam-ple, people with poor circulation (peripheral arterial disease), loss of sensation (neuropathy), or significant congenital deformity, or serious medical illness may not be a candidate.

Though still evolving, the quality and design of the implants have drastically improved over the years. Implants are now even more customized to the patient’s size, gender and uniqueness of their ar-thritis; it’s no longer a-one-size-fits-all world. This is especially im-portant for maintaining functionality and range of motion in the ankle.

Today, because of the medical advancements and new surgical techniques, patients of all ages suffering from arthritis have ad-

ditional, viable treatment options to keep them on their feet and enjoying their active lifestyle.

Dr. Christopher Reeves is the Presi-

dent of the American College of Foot

and Ankle Surgeons and practices at

Orlando Foot and Ankle Clinics. The

Orlando Foot & Ankle Clinic is the

largest and oldest Podiatry practice in

Central Florida, with Podiatric offices

in 18 locations throughout Central

Florida. Their 16 Clinical Podiatrists

have over 100 years of combined expe-

rience and work with patients to un-

derstand their needs and provide the

best treatment for their foot and ankle

issues. For more information about

Orlando Foot & Ankle Clinics please

visit www.orlandofootandankle.com

or call 407-423-1234.


2019 Florida MD is a four-color monthly medical/business magazine for physicians in the Central Florida market.

Florida MD goes to physicians at their offices, in the thirteen-county area of Orange, Seminole, Volusia, Osceola, Polk, Flagler, Lake, Marion, Sumter, Hardee, Highlands, Hillsborough and Pasco counties. Cover stories spotlight extraordinary physicians affiliated with local clinics and hospitals. Special feature stories focus on new hospital programs or facilities, and other professional and healthcare related business topics. Local physician specialists and other professionals, affiliated with local businesses and organizations, write all other columns or articles about their respective specialty or profession. This local informative and interesting format is the main reason physicians take the time to read Florida MD.

It is hard to be aware of everything happening in the rapidly changing medical profession and doctors want to know more about new medical developments and technology, procedures, techniques, case studies, research, etc. in the different specialties. Especially when the information comes from a local physician specialist who they can call and discuss the column with or refer a patient. They also want to read about wealth management, financial issues, healthcare law, insurance issues and real estate opportunities. Again, they prefer it when that information comes from a local professional they can call and do business with. All advertisers have the opportunity to have a column or article related to their specialty or profession.

JANUARY – Digestive Disorders Diabetes

FEBRUARY – Cardiology Heart Disease & Stroke

MARCH – Orthopaedics Men’s Health APRIL – Surgery Scoliosis

MAY – Women’s Health Advances in Cosmetic Surgery

JUNE – Allergies Pulmonary & Sleep Disorders

JULY – Neurology / Neuroscience Advances in Rehabilitation

AUGUST – Sports Medicine Robotic Surgery

SEPTEMBER – Pediatrics & Advances in NICU’s Autism

OCTOBER – Cancer Dermatology

NOVEMBER – Urology Geriatric Medicine / Glaucoma

DECEMBER – Pain Management Occupational Therapy

Please call 407.417.7400 for additional materials or information.

EDITORIALCALENDAR

the digestive and liver center of florida€¦ · 4-color reprints to use as brochure inserts,...

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