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Archive for July, 2018

Solving Physician Burnout

Monday, July 30th, 2018

Operational improvements are more important than resiliency.

By Rob Schreiner, M.D.

Dr. Carl Goolsby remembers those days. No matter how early he’d arrive at the office to prepare his charts for the day’s patients or remain in the office after the patients and staff had left, he couldn’t stay ahead of the workload.

Carl Goolsby, MD, Family Medicine, WellStar Medical Group

He was well-trained, with a disciplined work ethic that attested to his military background, yet the workload of his family medicine practice in east Paulding County seemed insatiable. Moreover, the proportion of his time devoted to the work that only he could do (medical reasoning to reach the right diagnosis in the least amount of time, balancing multiple medications for multiple conditions and managing the patient’s wellness longitudinally) had given way to clerical work, despite every member of his team working hard every day, including his three Advanced Practice Professionals (APPs).

Dr. Goolsby began to feel emotional exhaustion, depersonalization toward his patients and that he was no longer making a difference in the lives of his patients – the telltale triad of physician burnout. He was offered enrollment in a Physician Resilience Retreat. While that experience might have left him better equipped to tolerate the chaos of the workday, it wouldn’t actually improve the chaos of the workday.

Ivy Spencer, MN, RN, FNP-BC, Chief Nursing Of cer, WellStar Medical Group

The Solution
At the same time, 20 miles away, Ivy Spencer, chief nursing officer of the WellStar Health System, envisioned a better office flow for primary care offices, one that combined better teaming, optimal EMR use and top-of-scope practice for all team members. But she needed a willing physician partner to refine her design and test its deployment. She found that partner in Dr. Goolsby.

Before I tell you how they did what they did, let me tell you the results of that intervention, sustained for each of the eight consecutive months since roll-out of the office changes:

• Dr. Goolsby’s symptoms of physician burnout resolved. He was starting and ending the day on time, with much less after-hours chart completion in the EMR (closing more of his charts during the day). He was spending more time with his patients. He was eating lunch daily with his staff, discussing the session’s patients and office flow, rather than finishing charts in his office alone.

• Quality metrics improved. Rates of pneumococcal vaccination, colorectal cancer screening, depression screening, fall-risk reduction – all improved 9-35 percentage points

• Patient’s perception of clinician-patient communication (cg-CAHPS Physician Communication Composite) improved by 12 percentage points and continues to rise

• No office staff have left since the intervention (zero turnover in 8 months, front-office or back-office, whereas turnover rates prior to the intervention, while low, were not zero)

Alright. Here’s how they achieved that turnaround.

Elevate Everyone’s Proficiency on the EMR. A team of three clinical informatics nurses spent two weeks in the office training the entire team beyond the basics. (Medical assistants, nurses, APPs and Dr. Goolsby all learned how to make patient flow check-in to check-out quicker with more complete documentation, using menus of ordering preferences, and more efficient patient outreach and resulting of tests.) Specialty-specific physician advisors taught Dr. Goolsby and the APPs better use of time-saving EMR functionality. All too often EMR training is treated as a “one-and- done” at the time of deployment, yet we physicians are, or ought to be, continuous learners in everything we do, including how to best use the current and evolving functionality within the EMR.

Optimize the Staffing Ratio. In an attempt to be as lean as possible, Dr. Goolsby had reduced his staffing to one CMA devoted to his day, with a portion of a shared RN. Adding two LPNs to the practice of four clinicians (Dr. Goolsby plus 3 APPs; 0.5 LPN per clinician) to give injections, do patient education, close care gaps, clean out the InBasket and handle patient paperwork, substantially offloaded clerical duties from the clinicians, enabling them to spend more time with patients and families, with more time to think.

Deliberately Improve Teaming Attitudes and Behaviors. For two decades now, a great deal has been published regarding the benefits of teaming in healthcare, yet we as a profession have not adopted nor spread those teaming best-practices as widely as we should. AHRQ’s Team- STEPPS training was used as a template for Dr. Goolsby’s and Ms Spencer’s cultural enhancement on the team. Teaming can be taught for the betterment of patients, colleagues and staff.

This Solution Works for the Majority of Practice Settings. Dr. Goolsby’s and Spencer’s success at improving office work flow, thus reducing clinician and nurse burnout, can’t be considered unique. But the point is that their three operational enhancements described above are more effective than physician resiliency training. And interventions such as theirs that (1) improve office flow for all, (2) optimize everyone’s use of the EMR and (3) restore time and space for the physician to do what she/he is best- equipped to do (e.g., medical reasoning and interacting with patients and families) are evidence-based.

We should deploy those operational interventions more reliably. I’ve got nothing against taking personal accountability for one’s happiness and using well-facilitated time away from the office to enhance self-insight, self-awareness and self-control. Indeed, my personal and professional maturity have benefited from insight gained with Covey, Myers-Briggs, Herman Brain Dominance Inventory, StrengthFinders, TKI and more. But the idea that physicians are the cause of their burnout (“they just don’t make ‘em like they used to”) is inaccurate and harmful.


For more information about how we physician leaders ought to be changing operational flow for the betterment of our colleagues and the patients and families they serve, consider any of the following recent papers:

Erickson SM, et al. Putting patients first by reducing administrative tasks in health care: a position paper of the ACP. Ann Intern Med 2017;166:659-661.

Olson KD. Physician burnout – a leading indicator of health system performance. Mayo Clin Proc Nov 2017;92(11):1608-1611.

Sternberg S. Do Electronic medical records breed burnout? US News and World Report: diagnosis burnout. 2017. Pages 12-13.

Dr. Schreiner thanks Dr. Carl Goolsby and Ms. Ivy Spencer for allowing him to tell their story.


Rob Schreiner, MD, FACP, FCCP

Dr. Schreiner is president of WellStar Medical Group. He is a pulmonary and critical care physician and a past president of the Medical Association of Atlanta.

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Hernia Repair: Current Diagnosis and Management for Abdominal Wall Hernia Repair

Monday, July 30th, 2018

By Mark B. Wilkiemeyer, M.D., FACS

Abdominal wall hernia, simply defined as a space or gap in the abdominal wall, is one of the most common complaints seen by the practicing general surgeon. Literature tends to focus on management of hernia once it is identified and classified, but this ignores the necessary diagnostic steps to correctly classify the location of the hernia. The history and physical examination provides many of the clues necessary for proper hernia identification and subsequent classification and management.

History: Use the OLD CARTS Mnemonic
Onset can provide context for hernia identification and management. The sudden appearance of a bulge or the gradual “coming and going” of vague pain will help guide the physician towards an accurate diagnosis and help triage the patient. Sudden unrelenting painful bulges would prompt much more rapid assessment and surgical treatment than the slow, gradual onset of discomfort.

Location is an important component for hernia management. The patient’s subjective reporting of location of pain and/or a bulge provides the starting point for hernia identification. Incisional, umbilical and inguinal/groin hernias can be quickly localized by patient complaint.

Duration is less specific for hernia identification. As hernias can have long durations and gradually become more symptomatic, the duration of the hernia rarely is the most important factor in classification or management strategies.

Character of the pain can give clues to the hernia contents (bowel more crampy, preperitoneal fat sharp localized pain, omentum sharp but more generalized in location). As hernias can be painless but still bothersome, the character of the hernia symptoms should be noted but are not essential to initial diagnosis. It may prompt further diagnostic workup or more urgent management.

Aggravating factors and relieving factors will generally be related to abdominal wall musculature utilization and rest. Increases in intra-abdominal pressure through coughing, sneezing or exercise will commonly exacerbate discomfort.

Radiation of pain can provide additional clues as to the contents of the hernia.

Timing or temporal factors will sometimes help with hernia diagnosis and management but are often associated with aggravating factors and won’t often distinguish hernias alone.

Severity of symptoms will prompt urgent or elective management but rarely give additional information about the hernia itself. However, severe unrelenting crampy pain can point to a strangulated hernia containing ischemic or compromised bowel.

Physical Exam: Experience Counts
The comprehensive physical exam remains critical to assessment and management of the patient with a hernia complaint. Experience with examination improves diagnostic accuracy and likely reduces the use of imaging.

Generally, the hernia should be classified as “reducible” or “incarcerated”; this will assist in determining timing of repair if needed. Incarcerated hernias, or hernias thought to contain compromised viscera, will generally be explored and repaired as a surgical emergency. Conversely, the reducible hernia is often managed on an elective basis. Chronically incarcerated but minimally symptomatic umbilical or incisional hernias are exceptions to this rule, where severity of symptoms will help us make recommendations for urgency of surgical treatment.

Examination will include multiple positions (standing and supine) along with multiple degrees of intra-abdominal pressure. A relaxed abdominal wall can allow the physician to palpate the fascial edges of the hernia defect; a Valsalva maneuver provides “proof” of hernia bulge and possibly clues as to the contents.

Thorough inspection of overlying skin incisions and anatomic landmarks help improve accuracy of diagnosis and management; for example, umbilical hernias and incisional hernias at the umbilicus can provide vastly different challenges during surgical management.

Partial thickness abdominal wall hernias can provide diagnostic confusion; if no “hole” is present in the most superficial fascial layer, then a vague bulge may be identified but a focal fascial defect may be absent. We see this with lateral trocar site incisional hernias and lower lateral abdominal wall Spigelian hernias; generally, hernias in or near the midline will not cause this confusion.

One common point of confusion is the presence of rectus diastasis. This is not a true hernia but is the separation of the rectus muscles due to chronic abdominal distention. This separation is commonly secondary to truncal obesity or multiple pregnancies. This presents as a vertical abdominal bulge above the umbilicus which appears when doing a sit up. This does not represent a true hernia and therefore does not require repair unless there are cosmetic concerns.

Imaging When Necessary
Cross-sectional imaging of the abdomen and pelvis can provide assistance when history and physical examination are not sufficient to confirm diagnosis and accurate localization of an abdominal wall hernia. They are not necessary to make a diagnosis or recommendation for surgery, and can sometimes cloud the issue if there is no obvious hernia seen but history and physical are clearly pointing towards surgical management.

Cross-sectional imaging of the abdomen and pelvis can incidentally identify abdominal wall defects. When identified these should be evaluated by an experienced surgeon.

Surgical Management of Abdominal Wall Hernias
In general, symptomatic hernias will be repaired in suitable surgical candidates. Regional anesthesia is available to reduce anesthesia risk, but care should be given to prioritize the ability of the surgeon to produce a durable repair. If regional anesthesia alone is insufficient for reduction and proper repair of the hernia, then the surgical risk outweighs benefit and the procedure should be carefully reconsidered.

The main surgical principals of hernia repair are reduction of the hernia contents, clear identification of the borders of the defect, followed by closure of the defect with as little tension as possible. Mesh is commonly used to reinforce and add durability to the repair. The location of the mesh reinforcement has changed over the years. Current trends in hernia repair place the mesh within the layers of the abdominal wall as opposed to inside the peritoneal cavity or above the fascia.

Minimally invasive surgical techniques for abdominal wall hernias include laparoscopic and robotic approaches. Traditional repairs are done with open incisions. Each of these has benefits and drawbacks; nonetheless, the patient is well served by meeting with surgeons who can offer a wide variety of treatment options.

Mesh is used to reduce the risk of recurrence. In some cases mesh is required to “bridge” a defect that cannot be closed with suture, although this is less than ideal. The use of mesh can increase the risk of complications, but its value in adding durability to the repair generally outweighs these concerns.

Common materials used to manufacture synthetic mesh include polypropylene and polyester. In recent years biologic meshes have become common with porcine- and bovine-derived materials being used in certain complicated and high-risk situations. Generally these biologic materials are thought to carry less risk of chronic infection but are much more expensive than synthetic mesh and are commonly perceived as a less durable over the long term.

The ideal hernia repair continues to be an evolving science. Advances in technique and options for abdominal reinforcement create an exciting and changing landscape for patients and general surgeons.


Mark Wilkiemeyer, M.D., FACS

Dr. Wilkiemeyer grew up in Atlanta and attended Vanderbilt University, then went on to attend Tulane University School of Medicine in New Orleans, where he graduated Alpha Omega Alpha in 1998 as a Doctor of Medicine. He trained in General Surgery at University of Texas Southwestern, subsequently completing a fellowship in laparoscopic surgery at the Duke University Medical Center. He lives in
Atlanta with his wife, Claire Dudley Wilkiemeyer, M.D., and their two children.

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EyeSouth Partners Develop Physician Advisory Board

Friday, July 27th, 2018

EyeSouth Partners — a network of integrated eye care practices located throughout the Southeast — announced the formation of its Physician Advisory Board. Its responsibilities will include overseeing clinical policies and procedures, continuing education initiatives, new equipment and modalities, and quality assurance programs.

Practices affiliated with EyeSouth Partners include Gainesville Eye Associates, Georgia Eye Partners, Georgia Ophthalmology Associates, Georgia Retina, Opal Aesthetics, and South Georgia-North Florida Eye Partners.

Dr. Parul Khator, a board-certified ophthalmologist and EyeSouth Partners’ VP of Medical Affairs, serves as co-chair of the Physician Advisory Board. Dr. Khator said the board will further strengthen the practice’s clinical and patient care services.

The initial physician advisory board members include:
• Parul Khator: Georgia Eye Partners (co-chair)
• Stephanie Vanderveldt: Georgia Retina (co-chair)
• Jack Chapman: Gainesville Eye Associates
• Scott Petermann: South Georgia Eye Partners
• Eugene Gabianelli, EyeSouth Partners Chief Medical Officer

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The Swan Center for Plastic Surgery Welcomes Dr. Cristen Catignani

Friday, July 27th, 2018

The Swan Center for Plastic Surgery announced that board certified plastic surgeon Dr. Cristen Catignani has joined the Alpharetta cosmetic surgery practice.

Dr. Catignani, or “Dr. Cat” as she is known by her patients, has quickly developed a reputation for her meticulous surgical skill and ability to understand a patient’s goals for their appearance and achieve naturally appealing results that match those desires.

A fellowship-trained, board certified plastic surgeon and breast & body contouring specialist Dr. Catignani graduated from Florida State University and earned her Doctor of Medicine from the University of Tennessee College of Medicine. She completed her general surgery and plastic surgery residency training at the University of Alabama at Birmingham, where she also completed a Clinical Research Fellowship in Reconstructive Breast and Microsurgery. She is board certified by the American Board of Plastic Surgery and the American Board of Surgery.

At The Swan Center, Dr. Catignani specializes in cosmetic plastic surgery for the breast and body. Procedures she offers include:
• Breast augmentation
• Breast lift
• Breast reduction
• Breast implant removal and replacement
• Tummy tuck (abdominoplasty)
• Mommy makeover surgery
• Labiaplasty & vaginal rejuvenation
• Post-weight loss body contouring

She joins Dr. Joseph Bauer and Dr. Dean Fardo as the third plastic surgeon at The Swan Center.

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Northside Hospital CEO Robert Quattrocchi named Top CEO

Friday, July 27th, 2018

Northside Hospital CEO Robert Quattrocchi

Northside Hospital health system CEO Robert Quattrocchi has been named a winner of the sixth annual Glassdoor Employees’ Choice Award, ranking no. 32 on the list of 100 top CEOs in the United States.

Mr. Quattrocchi was one of only two Georgia-based CEOs named in the rankings, which are calculated from Glassdoor’s employee reviews of more than 700,000 companies around the world.

He also was among more than a dozen health care CEOs named in the top 100, which included the leaders of MD Anderson Cancer Center, Memorial Sloan Kettering, and St. Jude’s Children’s Hospital.

Among chief executives recognized by employees in the United States, Mr. Quattrocchi received an impressive 95 percent approval rating, which is based on anonymous and voluntary reviews shared by Northside Hospital employees on Glassdoor in the past 12 months.

“This recognition is possible only because of the people of Northside Hospital,” said Mr. Quattrocchi, who has been with the Atlanta-based health care system for more than 30 years. “The strength and dedication of Northside’s physicians and employees is unsurpassed – I haven’t seen anything like it in my career.”

Mr. Quattrocchi has been a part of the senior management team at Northside Hospital since 1987. Prior to taking the helm, he served as chief operating officer and executive vice president of finance and administration, chief financial officer and director of fiscal services.

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Georgia’s First Mobile Stroke Unit Unveiled

Friday, July 27th, 2018

Grady CEO John Haupert, Marcus Stroke Network Director Dr. Michael Frankel, Bruce Inverso, Senior Vice President, American Heart Association and Dr. Jon Lewin, CEO Emory Healthcare, cut the ribbon to officially launch Georgia’s first Mobile Stroke Unit.

Grady Health System, Emory University School of Medicine and the American Heart Association/American Stroke Association Monday unveiled Georgia’s first mobile stroke unit – an ambulance designed to take cutting edge stroke care directly to patients. The mobile stroke unit is part of the recently launched Marcus Stroke Network, made possible through the generosity of The Marcus Foundation. The Marcus Stroke Network is a coordinated and collaborative effort to help reduce stroke disability and death rates in the Southeastern United States.

The mobile stroke ambulance will operate in the city of Atlanta through Grady’s EMS system, linking the Network doctors directly to patients in the field by utilizing an on-board CT scanner to facilitate the earliest treatment possible.

“In a situation where every second counts, this specialized ambulance allows lifesaving treatment to begin for stroke patients before they reach the hospital,” said Bernie Marcus, founder of The Marcus Foundation.

The mobile stroke unit will be in operation Monday through Saturday and manned by an experienced team of medical professionals – an emergency medicine nurse, paramedic, advanced EMT and CT technologist. The team will perform a diagnostic scan, transmitting the image via telemedicine to Grady’s Marcus Stroke and Neuroscience Center. There, an Emory University School of Medicine vascular neurologist will evaluate the patient’s condition and advise the crew on next steps for patient care, which could include treatment with the clot-dissolving drug alteplase – this while the patient is en route to a stroke-ready hospital in Atlanta.

“Using a sophisticated telemedicine platform, our goal is to extend the vast experience and proven expertise of our stroke specialists to participating network hospitals, giving each and every stroke patient in the areas serviced by our network partners the best chance of survival and living an independent quality of life,” says Marcus Stroke Network director Michael Frankel, MD, professor & director of vascular neurology, Emory University School of Medicine, chief of neurology and director of Grady’s Marcus Stroke and Neuroscience Center.

The Marcus Stroke Network, endorsed by Georgia’s Department of Public Health, will also provide a 24/7 call center serving as Georgia’s first centralized resource for paramedics to assist with decisions about diagnosing stroke and indicating to the paramedic the location of the nearest appropriate hospital destination for treatment.

Hospitals participating in the Marcus Stroke Network will be guided by the science and expertise of the American Heart Association/American Stroke Association.

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Georgia Urology Brings Robotic Surgical Procedures to Braselton

Friday, July 27th, 2018

Dr. Brent Sharpe and Froylan Gonzalez recently debuted two new minimally-invasive robotic procedures at Northeast Georgia Medical Center in Braselton.

Georgia Urology, the largest urology practice in the Southeast, is known for providing innovative procedures to metro Atlanta. Dr. Brent Sharpe and Froylan Gonzalez recently widened that scope by debuting two new minimally-invasive robotic procedures at Northeast Georgia Medical Center in Braselton.

On June 27, the physicians combined their expertise to perform a nephrectomy and an adrenalectomy on one patient, and a prostatectomy on another. This marked the first time bilateral cancer operations were performed through the same minimally-invasive, robotic incisions on an individual. The second case was a simple robotic prostatectomy for an enlarged prostate, which traditionally is done through a large open incision.

Dr. Sharpe used the XI DaVinci System, the latest in advanced robotic surgical equipment, to perform the surgeries. During each procedure, the surgeon operates joystick-like controllers. The surgeon’s movements are transferred in real-time to the robotic device, which is positioned over the patient and has the actual surgical instruments attached.

“We use the robotic system to do minimally-invasive surgery with what have traditionally been maximally-invasive procedures,” said Sharpe, who has performed more than 700 robotic surgeries. “By using the robotic system we are able to drastically reduce surgical complications and patient recovery time. In these two patients, recovery time will be reduced six-to-12 weeks.”

The nephrectomy and adrenalectomy procedures are unique in and of themselves, and serve as a tangible example of Georgia Urology being on the forefront of technology. The doctors expect this robot-assisted surgery to have been curative. They first removed the cancerous right kidney, and then repositioned the patient and robot to remove the left adrenal gland where the cancer had spread. It’s unusual for this type of surgery to be performed on opposite sides of the same patient in one sitting. The fact that there is new, cutting-edge robotic equipment at this hospital allows for easier repositioning and cuts down on surgical time.

Georgia Urology physicians offer a volume of these procedures that other health care systems in North Georgia do not. A total of 10 Georgia Urology physicians are highly experienced robotic surgeons. Collectively, these doctors have performed more than 5,000 robotic surgeries.

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International Conference on Pharmaceutical Oncology

Wednesday, July 18th, 2018

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4th Annual Conference on Gynecologic Oncology, Reproductive Disorders, Maternal-Fetal Medicine & Obstetrics

Wednesday, July 18th, 2018

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3rd International Conference on Aging, Gerontology & Geriatric Nursing

Wednesday, July 18th, 2018

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