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Narrative Medicine – Letting our Patients Tell The Story

Tuesday, May 29th, 2018

Bob Climko, MD, MBA

By Bob Climko, MD, MBA

Many years ago, my medical school roommate invited me to dinner at the home of his mother and father, both of whom survived the horrors of Auschwitz. After a delicious meal, they began sharing stories about life in “the camp.”

I asked them later why they had opened up to me. Their response was that I was one of the few people they thought could bear to hear what had happened. I recognized their trust as a gift to be treasured. As a young medical student, it taught me that histories must be received, not taken.

The ability to listen, to empathize, to build trust – this is the basis of narrative medicine. Developed by Dr. Rita Charon, a professor at Columbia University College of Physicians and Surgeons, narrative medicine is a model of enhancing the patient-physician relationships through empathy, reflection and enhancing trust. It uses the skills of recognizing, absorbing, interpreting and being moved by the stories of illness.

Research reveals that most clinicians interrupt a patient within 18 seconds after the interview begins. Dr. Charon suggests we begin with “Tell me what you think I should know about your situation.”

After that simple question, Dr. Charon does her best “not to say a word, not to write, but to absorb all that he emits about himself-about his health concerns, his family, his work, his fears and his hopes. I listen not only for the content of his narrative but also for its form, its temporal course, its images, its associated subplots, its silences, how he chooses to begin telling about himself.”

Dr. Charon describes the effect this has on patients. “After a few moments, the patient stops talking and begins to weep. I ask him why he cries, and he says, ‘No one ever let me do this before.”

Our society is losing this ability to listen, to stay focused on one person or topic for extended periods of time. Communication has been reduced to short bursts of text, social media posts and emojis. As clinicians, we listen just long enough to figure out what test to order and type it into our EMR. We must – the next patient is already waiting, with dozens more before the day ends. Before long, we find ourselves in a field where burnout and a loss of spirit, joy, wonder and meaning are commonplace.

Altering our clinical approach can fundamentally change our patient care routine and offer a more healing approach. If our patients do not feel like we heard them, we may not gain acceptance of the care plan we offer. Dr. Charon states “…for the body will not bend to ministrations from someone who cannot recognize the self within it … the self, exposed to the new light of day by virtue of ruptures in its surface of health.”

“What expert listeners [clinicians] do is open the door to hearing stories that they feel others might not be willing to hear,” says Mary Marshall Clark, co-founder and director of the Columbia Center for Oral History Research at Columbia University. “We think of stories as gifts. We are the receptacles and containers that hold the person’s narrative.”

The approach works in every specialty, in practices of all sizes. My own medical group is beginning to offer Narrative Medicine Rounds, where we share our ‘parallel chart’ – written stories and reflections on patient encounters. Our goal is to help clinicians reconnect with their own healing spirits through fellowship with other healers. A similar process could be used in department meetings, staff huddles or even one-on-one.

The process of learning to genuinely listen may take some time. In one of my favorite stories, Margery Williams’ The Velveteen Rabbit, the Skin Horse describes how becoming “real” takes time … and can be painful.

“It’s a thing that happens to you. When a child really loves you for a long, long time, not just to play with, but REALLY loves you, then you become Real. …Generally, by the time you are Real, most of your hair has been loved off, and your eyes drop out and you get loose in the joints and very shabby. But these things don’t matter at all, because once you are Real you can’t be ugly, except to people who don’t understand.”

Yes, the healthcare field needs significant and meaningful systemic and operational changes. We can do our part by giving patients more hope and healing by adopting a narrative medicine approach to care. Doing so can enhance our ‘realness’ and help us reconnect with our inner healing selves.


5 Best Practices for Treating Your Muslim Patients

Friday, April 20th, 2018

By Lisa Perry-Gilkes, MD, FACS

With a Muslim population reported to be a quarter million and with 35 mosques in the metro area, Atlanta ranks as the city with the sixth largest Muslim population in the country. Cultural sensitivity in caring for the Muslim patients requires a basic understanding of Islam.

Islam, which in Arabic is derived from the word salam, or peace, is the second largest world religion with 1.57 billion Muslims worldwide. Encountering and caring for Muslim patients requires knowledge of and respect for cultural observances. Islam is based on five pillars:
1. Believing in Allah, Arabic for God, and Mohamed as his prophet (the last prophet in the lineage of prophets starting from Abraham).
2. Performing five daily prayers.
3. Fasting during the holy month of Ramadan.
4. Contributing to charity.
5. Performing the hajj or the pilgrimage to Mecca at least once.

When caring for a Muslim patient, being sensitive to the traditions and cultural norms can go a long way to forming a strong patient-physician relationship.

1: Approach Alcohol and Smoking Topics Sensitively
Islam strictly forbids alcohol consumption, however it is still important to inquire about alcohol use in patients with suspected head and neck cancer. Be sure to approach this topic with sensitivity. It should not be assumed that not drinking is strictly observed, and it may not be admitted to in the presence of family members.

Smoking is not encouraged, but smoking of cigarettes or the hookah is common in Islamic countries. A common belief is that since the smoke is passed through water, the smoke is filtered and made harmless. However, this form of tobacco consumption may even be worse than cigarette smoke.

It’s important to ask about chewing tobacco when discussing substance use history. Betel nut (Areca catechu) chewing is common in certain cultures such as Yemen or the Indian subcontinent. This practice has been associated with oral cancer.

2: Know When Ramadan Occurs
Ramadan is the ninth month in the Muslim calendar. Ramadan lasts for 30 days and is based on the Islamic lunar calendar, which is 10 to 12 days shorter than the solar calendar and starts at sunset. (In 2018, Ramadan starts May 15 and last through June 14.)

During this period, observant Muslims refrain from taking anything by mouth from sunrise to sunset. The fast is broken at sunset and resumes at sunrise. Islamic dietary laws can be forgiven when the individual is ill, hospitalized and required to take medication and nourishment. Islamic dietary laws allow Muslims to modify the laws to save lives. During this period you may see an increased incidence of sialadentis and sialolithiasis.

3: Understand the Islamic Dietary Code
Like many religions, Islam has a set of dietary guidelines for its believers to follow. The strict dietary code includes only eating meat that is appropriately slaughtered, similar to kosher foods in Orthodox Judaism. It is interesting to know that all kosher food is acceptable as halal, which means lawful or permitted. Halal covers more than you would expect. The term is primarily associated with food, but it also covers products that include ingredients derived from animals, such as soap, cosmetics or medicine. Things that are haram, i.e. forbidden, are:
• Swine/pork and its by-products
• Animals improperly slaughtered or dead before slaughtering
• Animals killed in the name of anyone other than Allah (God)
• Alcohol and intoxicants
• Carnivorous animals, birds of prey and land animals without external ears (i.e. bugs, snakes and lizards)
• Blood and blood by-products
• Foods contaminated with any of the above products

4: Respect the Modesty of your Muslim Patients
Modesty is one of the requirements of Islam. You may be familiar with the head covering known as the hijab. This garment, most commonly seen outside of Muslim countries, covers the head and neck with the face uncovered. Although seen in more devout members, it may cover from ankle to lower face.

It is also suggested that men are required to cover from navel to the knee, and some will wear a small head covering, called a kufi. Female patients may wear their head covering during hospitalization. A knock on the door before entering the room would give the patient a chance to cover her head.

Muslim patients will feel more comfortable with care practitioners of the same sex. At registration, the office staff should ask the patient if she is comfortable being seen by a male physician. Another way to make the patient more comfortable with a male physician is to include a female chaperone in the room, especially during a physical exam. Male patients may not feel comfortable with a female practitioner with the personal history and more commonly with the physical exam.

5: Let Your Muslim Patients Take the Lead With Shaking Hands
Some female patients will not shake hands with a male practitioner. Therefore, it is important to ask before offering a handshake, “Do you feel comfortable shaking hands?” This advice also holds true for a female physician with a male Muslim patient. Eye contact is also commonly avoided, especially in mixed-gender situations.

Accommodate Islamic Traditions About Hospitalization and End of Life
When hospital admission is required, accommodations should be made for daily prayers. This could mean a specific prayer room or making room in their hospital room. It is important for Muslims to face Mecca during prayer. For the bedridden patients who cannot fully prostrate themselves, it would show a great sign of respect to position the bed to face Mecca, which is southeast in the U.S.

Death and its preparation are very important parts of the Islamic life cycle. It is customary to perform special prays for the patient. In the case that the family members are not able to attend the hospitalized patient, the Imam (the worship leader of a mosque, similar to a priest or rabbi) should be notified of the patient’s condition to counsel and console the patient.

After death, traditionally the family and/or friends wash the body to prepare it for burial, which will occur as soon as possible. Embalming should be avoided unless required by civil law, and cremation is not allowed by Islamic law.

Atlanta has a very diverse population. We need to keep in mind that our Muslim community is not homogeneous. Our Muslim patients come from diverse and varied backgrounds, from the Indian subcontinent to those born in the United States.

Keeping this in mind, we should avoid stereotypes and assumptions. With all patients, the care should be crafted to fit the individual. Using a culturally sensitive approach to all of our patients is a best practice with improved, welldeserved, better outcomes.


Health Literacy: What You Don’t Know Could Hurt You

Wednesday, January 24th, 2018

By Lisa Perry-Gilkes, MD, FACS


To some of our patients, the above headline is how our documents are perceived. Unscrambled, it reads: What you don’t know could hurt you.

In keeping with the best practices to improve patient care, we need to take into consideration our patients’ ability to understand their treatment plan to be able to implement it.

Definition & Demographics
In 2004, the Institute of Medicine defined health literacy as “the ability to obtain, process and understand basic health information and services needed to make appropriate health decisions and follows instructions for treatment.”

However, a third of American adults (89 million) today lack sufficient health literacy to carry out medical treatment and preventive healthcare. Economic consequence is estimated to be $50 billion to $73 billion annually.

The Bureau of Labor Statistics reports that 1 in 6 Georgia citizens between the ages of 19 and 65 have a low literacy rate. This cost the state of Georgia $1.26 billion dollars annually in social services and lost tax revenue per the Literacy For All study of 2017.

The National Assessment of Adult Literacy (NAAL) study of 2003 found that in Georgia’s Atkinson County, 36 percent of its population lacked basic prose literacy, the highest in the state. Fayette and Forsyth counties had the lowest, at 8 percent.

Results of the NAAL study are reported in terms of the four literacy performance levels—Below Basic, Basic, Intermediate, and Proficient—with examples of the types of health literacy tasks that adults at each level may be able to perform. At-risk populations are patients who scored below basic. These groups are as follows with their percentage.

• Adults 65yrs and older (59 percent)
• People with less than or some high school education (76 percent)
• Hispanic (all groups) (66 percent)
• African American (58 percent)
• Medicaid patients (60 percent)
• Medicare patients (57 percent)

Years in school may not always indicate the level of health literacy. The NAAL study shows that 39 percent of people with a high school education had only basic reading skills, and 13 percent had skills below average.
But an unexpected population of people with a low health literacy are our educated seniors. A 2002 Gerontology study found that 30 percent of affluent individuals in geriatric retirement communities scored poorly in health literacy. A 2002 Fortune article covered the story of several billionaire executives who also had limited general literacy skills. What both groups had in common was highly developed coping mechanisms.

“Literacy is one of the strongest predictors of health status. In fact, all of the studies that investigated the issue report that literacy is a stronger predictor of an individual’s health status than income, employment status, education level, and racial or ethnic group,” according to Karen Weis essay on Community Based Education. (Karen Weis, 2009, p. 13)

Lack of health literacy leads to ineffective execution of medical treatment and preventive care. Studies have shown that the majority of low literacy patients with pulmonary disease can not properly demonstrate how to use their inhalers, and more than half of patients with diabetes and low literacy knew the symptoms of hypoglycemia.

Common words that patients with limited literacy may not understand include:
• Blood in the stool
• Bowel
• Polyp
• Colon
• Lesion
• Rectum
• Screening
• Lesion

Literacy and the Law
Safeguarding a clear and understandable plan of treatment is the priority of patient health care. This also significantly impacts quality of care, treatment outcome, patient safety and satisfaction.

Communication is essential for effective healthcare. It is one of a physician’s most powerful tools. However, there can be a mismatch between communication and comprehension.

The Joint Commission and The National Committee for Quality Assurance have adopted guidelines specifying the need for comprehensible patient education information and consent documentation to be written in a way that patients can understand. Our legal system recognizes the patient-physician relationship as a fiduciary relationship, which is the highest standard of duty implied by law.

Poor communication between doctor and patient accounts for 75 percent of lawsuits, according to a study printed in Archives of Internal Medicine. Courts consistently held that physicians have a duty to fully disclose the risks and benefits of medical intervention and procedures in good faith and terms that the patient can understand.
Lawsuits stem from inadequate explanation of diagnoses and treatment. When patients feel ignored, doctors fail to understand the perspective of the patients or family members. The patient may feel rushed or feel they or their family members’ views are devalued.

The Social Impact of Limited Health Literacy
Patients with limited health literacy may not be easily identified. These patients carry a significant burden, and for some of them a sense of shame as well. They live a dual life to try and hide their limitations. Their limited reading ability is kept a secret.
• 85 percent never told their co-works
• 75 percent never told their healthcare providers
• 68 percent never told their spouses
• 62 percent never told their friends
• 52 percent never told their children

How Best Practices Get Best Outcomes
Setting the tone in your office involves all personnel. Physician and staff need to be sensitive of nonverbal clues that the patients exhibit. Patients with limited literacy skills are more comfortable with short words and sentences. They do better with personal contact as opposed to electronic communication. Visual clues are important in understanding directions.

There are certain behaviors and responses that may give you and your staff a clue. They are as follows:

• Incomplete or inaccurate registration forms
• Frequently missed appointments
• Noncompliance with medications
• Lack of follow through with labs, referrals, imaging tests
• Patients says they are taking medications, but labs or physical findings don’t agree

Responses to written information
• “I forgot my glasses. I’ll read it when I get home.”
• “I forgot my glasses. Can you read it for me?”
• “Let me bring this home so I can discuss it with my family.”

Responses to medication regimes
• Unable to name medications
• Unable to explain what medications are for
• Unable to explain timing of medication doses

How Improving Practices Leads to Best Outcomes

The First Visit/Scheduling & Registration. Sensitivity starts at the time of scheduling the appointment. Human interaction across the phone are better than automated services. Information collected should consist solely of what is needed to process the appointment. Preferably the receptionist should be able to speak in the patient’s native tongue. First-time patients will need directions to the office.
Currently, patient portals provide a plethora of information transmitted electronically, but don’t assume that patients have access to high-speed internet. Sixteen percent of Georgians – 638,000 households – do not have access to high-speed internet.

The first visit can be stress-free by asking the patient to make a list of questions to ask the doctor and to bring all medications including vitamins. Remind them that they are welcome to bring someone with them to assist in making them more comfortable.

At time of check in, all new patients should be offered assistance with completing the new patient registration form. Health information questionnaires may be particularly challenging. Indications of difficulty include an inordinate amount of time to complete forms and protest that questions are too “personal.”

To prevent these slowdowns with the registration process, be sure forms are user friendly and collect only essential information. When possible, forms should be in the patient’s preferred language. There are many online translation services and apps.

According to, “All providers who receive federal funds from HHS for the provision of Medicaid/CHIP services are obligated to make language services available to those with Limited English Proficiency (LEP) under Title VI of the Civil Rights Act and Section 504 of the Rehab Act of 1973. Interpreters are not Medicaid qualified providers; however their services may be reimbursed when billed by a qualified provider rendering a Medicaid covered service. Interpreters may not be paid separately. As of February 2009, oral interpreter services can be claimed using billing code T-1013 code along with the CPT Code used for the regular medical encounter.” Reimbursement varies from state to state. This is a timed code which is billed in 15 minute increments.

Meet the Doctor/Communication. Lack of understanding causes medication errors, missed appointments, adverse medical outcome and even malpractice lawsuits. Yet there are simple steps to improve your communication with your patients.

By simply slowing down your conversation, comprehension will improve. Sit down even if it is for a brief period toward the end of the visit. This helps to build a patient- centered visit and improve the clinician-patient relationship. A 1997 JAMA study showed that by simply increasing the average encounter time from 15 minutes to 18 minutes, it signi cantly decreased the incidence of malpractice suits.

Start your visit with an orienting statement: “First I will ask you some questions, and then I will examine you.” At closing, ask if they have concerns that were not addressed.

Use non-medical verbiage. Language we use in average conversation may be foreign to our patients.

Common language alternatives to medical terms
• Analgesic: Pain killer
• Anti-inflammatory: Lessens swelling and irritation
• Benign: Not cancer
• Carcinoma: Cancer
• Cardiac problem: Heart problem
• Cellulitis: Skin infection
• Contraception: Birth control
• Enlarge: Get bigger
• Heart failure: Heart isn’t pumping well
• Hypertension: High blood pressure
• Infertility: Can’t get pregnant
• Lateral: Outside
• Lipids: Fats in the blood
• Menopause: Change of life, stopping periods
• Menses: Period
• Monitor: Keep track of, keep an eye on
• Oral: By mouth
• Osteoporosis: Soft breakable bones
• Referral: Send you to another doctor
• Terminal: Going to die
• Toxic: Poison

“The Brown Bag Medication Review”

Evaluating your patient at their first follow up appointment allows you to see if they understood the directions for medications that were given at their first appointment. At the visit, ask the patient to name each medication and explain what it is for and how it is taken. As the patient responds, note whether or not they identify the medications by reading the label, or do they look at the pills to identify them. Ask the patient to name each medication, explain what they are for and how they are taken. Inquire when the last two times they took the medication was.

It’s been said that a picture is worth 1,000 words. Visual aids such as pictures, models and take-home brochures aid in communication. These documents need to be simple. To many in-depth images may be confusing. Simply drawn pictures without clutter are best to send home with the patient. Drawing your own images can help you customize your treatment plan.

Limit the amount of information given at one sitting. This by no means suggests that you should withhold important medical information. After reviewing the treatment plan, it should be repeated at check out by staff and/or with handouts.

An effective method to assure patient comprehension is the simple “teach-back” technique.
1. Do not ask the patient, “Do you understand?”
2. Instead, ask patient to explain or demonstrate how they
will follow the recommendations and treatment plan.
3. If the patient cannot do this to your satisfaction, assume that you have not supplied adequate teaching. Repeat your directions using simpler terms or explain the treatment plan to a competent family member  or companion.

As reported in Archives of Internal Medicine (2003), the teach back technique is effective in improving patient understanding and outcomes.

Finally, creating a comfortable shame-free environment in your office goes miles. Patients should feel free to ask questions about anything they don’t understand. The Partnership for Clear Health Communication, which consists of the AMA and a consortium of professional organizations, developed “Ask- Me-3” questions the patient can use as a framework to participate in conversation with their physician. These consist of:
• What is my main problem?
• What do I need to do about the problem?
• Why is it important that I do that?

If at the end of the visit the patient can answer these questions, you can document that they have a good understanding of the agreed-upon treatment plan.

Written materials should be no higher than a 6th grade level. For some practices with patients at high risk of illiteracy, a 3rd-5th grade reading level may be more appropriate. Short words and short sentences are easier to comprehend.

Many healthcare professionals find it difficult to form text at this basic literacy level. However Microsoft Word has a grammar checking tool that uses the Flesch-Kincaid grade level formula, which can be helpful in creating documents that are more appropriate for this patient group.

Format can also be con gured to make understanding documents easier to comprehend. Densely written material and small fonts make documents harder to understand. Using all capital letters also makes it more difficult to comprehend the document.

Health literacy has a significant impact on treatment outcomes. It is imperative that we as physicians keep this in mind while caring for our patients. As pay-for-performance continues to be adopted, outcomes will have an increasing impact on our earnings. These outcomes can be easily improved by addressing health literacy.

Simply stated, patience, tolerance, awareness and the true desire to give better healthcare in a caring environment is all that is needed.


New Northside Hospital Cherokee to open May 6

Tuesday, March 21st, 2017

Northside Hospital Cherokee’s long-awaited replacement hospital will open for patients on Saturday, May 6, 2017.

The new hospital is located at 450 Northside Cherokee Boulevard in Canton, off I-575 at the Ga. Hwy 20 exit.

“This is a huge move forward for Cherokee county and the surrounding areas,” said Billy Hayes, CEO of Northside Hospital Cherokee. “Our new hospital is the culmination of a lot of hard work by many people over many years. The entire Northside Cherokee family is proud of what we’ve accomplished, and we look forward to a new era of health care service.”

northside hospital cherokee concept

Northside Hospital Cherokee Concept

Construction is complete on the new hospital, which will open with 105 inpatient beds and more than twice the square footage as the current hospital. Northside staff is now focused on training and education, while overseeing the installations of equipment and furniture.

A medical office building opened on the 50-acre campus in early January. Several physician practices and Northside Hospital Radiation Oncology have opened their offices and are seeing patients. Additional Northside services and physicians will move into the building over the next several months.

Northside is planning an open house for late April to give everyone a chance to tour the new hospital campus before patients are moved and accepted there on May 6.

For more information about the new hospital and to view videos of the construction, visit Northside Cherokee.


The Future of Healthcare

Sunday, January 22nd, 2017

By Helen K. Kelley

The landscape of healthcare in America is facing rapid change, from the way care is delivered to a renewed focus on the physician-patient relationship. Here, three Atlanta-area physicians weigh in on what they believe the future of healthcare holds for physicians and patients.

Shared decision-making, technology help drive healthy behaviors

Mary L. Wilson, M.D.

Mary L. Wilson, M.D.

According to Mary L. Wilson, M.D., president and executive medical director of Kaiser Permanente of Georgia, technology and involving patients in the decision-making about their own care are effective tools for better creating better outcomes, both for today and in the future.

“One of Kaiser Permanente’s primary tenets is finding methods that successfully encourage healthy behaviors in our patients. We look at every physician visit as an opportunity to talk about healthy habits with the patient, and we cue that conversation up through the patient’s EMR,” she said. “The EMR prompts the nurse and physician to ask probing questions about the patient’s lifestyle, including exercise and eating habits, to gauge whether or not the patient is open to discussing ways to improve their health. If the patient indicates interest in making changes and the physician intervenes at the right moment, there is a much higher rate of success.”

Wilson says that the EMR will continue to play a role in the future in patient satisfaction and better health.

“The EMR helps us link with patients so that we can ask the right questions and encourage them to share in decision-making,” she explained. “We find that patients are likely to have better outcomes if they play a part in designing their own healthcare. And the EMR is a tool that helps us help our patients achieve their goals.”

Wilson adds that Kaiser, in response to patients’ growing interest in and reliance on technology, is looking at ways to make medical records more accessible.

“Here in Georgia, we’re thinking about having open notes in patient charts so that the patient can access his or her whole medical record online any time they want,” she said.

Returning to a patient-centric system

Thomas E. Bat, M.D., president of the Medical Association of Atlanta and CEO of North Atlanta Primary Care, PC, says he believes the recent presidential election holds important ramifications for our current healthcare system.

“For years, I’ve said that regardless of who’s running the show in Washington, managed care would probably never go away. Now, all bets are off. I think it’s possible that Donald Trump could tear up healthcare as we know it and move us away from the current system,” he said. “The question is, how will he actually accomplish that?”

While he believes in an open market for healthcare insurance, Bat feels that the Affordable Care Act has ended up doing exactly

Thomas E. Bat, M.D.

Thomas E. Bat, M.D.

the opposite of what it was intended to do and that rising costs are beyond what the average American can afford. Ultimately, he feels that the future of healthcare lies in restoring the physician-patient relationship as the very core of the way care is delivered to every citizen.

“Our current protocol determines how long patients have to wait for treatment and limits how physicians evaluate their patients and prescribe treatment. We’re forced to deliver care that is determined by a government-based treatment plan rather than on what we know the individual patient needs. Additionally, most physicians go into medicine to actually be doctors, but they end up frustrated with the system that governs the way they deliver care,” he said. “The current administration says there are no other alternatives. But we need to go back to a world where a doctor is a doctor and a patient is a patient. If we don’t find a way to create a physician-patient-centric system to reward physicians for working hard and patients for taking care of themselves, we all lose.”

Patient-centered doctors to usher in new age of healthcare

James Sams, M.D.

James Sams, M.D.

James Sams, M.D. and CEO of Privia Medical Group Georgia also believes that the doctor-patient relationship will move to the forefront of how healthcare is managed in the future.

“I’m very excited and optimistic about the profession of medicine. I think the next Golden Age of Medicine is in front of us and within our grasp,” he said. “And I believe it will be ushered in by physicians who are truly capable of being patient-centered.”

Sams feels that physicians are faced with making an important choice right now that will determine their future and their success.

“In my opinion, the future value in practicing medicine, both professionally and economically, will be given to physicians who make the choice to be patient-centered,” he said. “Achieving better outcomes at lower costs will be their focus, thereby unlocking this new value.”

Sams adds that patient-centered physicians will always keep in mind that their greatest responsibility is to their patients.

“If we prescribe care that our patients cannot afford, we’re not being their advocates or doing them a service,” he said.



Social Media and Healthcare

Just about everyone in America, from children to seniors, uses some form of social media. So it’s not surprising that social media has changed the way that people seek out information. Social media has become a powerful marketing tool and one that will likely continue to influence decision-making, including the choices people make regarding their health.

Here are five interesting statistics that show how social media has impacted the healthcare system in America:

  1. Forty-one percent of people said social media would affect their choice of a specific doctor, hospital, or medical practice. (source: Demi & Cooper Advertising and DC Interactive Group)
  1. Sixty percent of physicians report that one of their most popular activities on social media is following what colleagues are sharing and discussing. (source: Health Care Communication)
  1. Parents are more likely to seek medical answers online: 22% use Facebook and 20% use YouTube. Of non-parents, 14% use Facebook and 12% use YouTube to search for health care related topics. (source: Mashable)
  1. Sixty percent of doctors say social media improves the quality of care delivered to patients. (source: Demi & Cooper Advertising and DC Interactive Group)
  1. Thirty percent of adults are likely to share information about their health on social media sites with other patients, 47% with doctors, 43% with hospitals, 38% with a health insurance company and 32% with a drug company. (source: Fluency Media)

Is a Workers’ Compensation Practice Right for You?

Friday, September 30th, 2016

What you need to know to develop a successful and rewarding practice

By Snehal Dalal, M.D.


Successfully diagnosing, treating and returning workers’ compensation (WC) patients can be a rewarding part of a physician’s practice. However, not all of us are meant to take care of these type of cases.

There must be a commitment on the part of the provider to give extra time, fill out paperwork and handle specific issues. One must be comfortable in treating not only clear-cut cases but also those patients with vague symptoms without a specific injury.

We are usually accustomed to dealing with only patients and their families. With workers’ comp cases, correspondence from adjusters, case managers and even attorneys must often be handled. Sometimes communication is required to resolve conflicts in opinions.

As professionals, we must not only treat but also educate employers, insurers and case managers as well as help prevent injury in the workplace.

For patients with a workers’ compensation-related medical issue, having to take time off due to injury is quite distressing. The fear of losing one’s job due to an inability to keep up with what the position demands can cause anxiety. It may also put the patient at risk of further harm in their attempts to continue working while injured.

As an orthopaedist and sports medicine physician, I approach the injured worker as an athlete. I want to return the patient back into the game as soon as possible. Getting a patient back to gainful employment can be equally rewarding as getting an athlete back to their sport.


As the Authorized Treating Physician (ATP) in Georgia, we must diagnose and present a treatment plan for the injured worker that determines:

Causation: Is the injury due to direct trauma or overuse from job duties?

Work status: Is it safe for the patient to return to full or restricted duty and how soon?

Treatment Course: What is the anticipated time frame to Maximal Medical Improvement (MMI)?

Legal issues: What is the anticipated permanent impairment and functional limitations once the patient is deemed to be at MMI?


As we establish the doctor-patient relationship, it is paramount to be impartial and ensure that you have the best interest of your patient. After all, you are the patient’s best advocate. It is important to emphasize active patient participation and set expectations from the beginning. One a treatment plan is devised, it is important to educate the patient, case manager, adjuster, attorney and your Workers Compensation Coordinator.

Closer follow-up is a good idea to ensure patient compliance and insurance approval. This also allows changes to job restrictions as the patient’s symptoms improve or regress. If the patient is not improving, reconsider treatment options and/or diagnosis. Keep in mind that the importance should be placed on injury healing for functional restoration over subjective pain relief. This is critical when determining surgical intervention.

Prior to deciding on a procedure, ask why and how you have come to the conclusion to intervene. It is very important that the mechanism of injury, history, symptoms and exam positively correlate.


When determining when an injured worker may return to their job, the provider should emphasize return to work, even with restrictions, within 2-3 weeks from injury or surgery. This will keep the patient in his/her routine. Patients can return to work even if in chronic pain as long as they are functional and the job duties do not increase risk of further injury. It has been shown that patients out of work more than 6 months are unlikely to return.

Understand the demands of the workplace or job of the patient. Show interest, evaluate the job description and familiarize yourself with in-house occupational health staff. The patient will appreciate that you understand their perspective and understand that you aren’t with the employer “just to get them back to work.”

Illness behavior resulting in secondary gain can lead to prolonged perceived disability by patient. To deter avoidance behavior, encourage normal behavior and function. Involve case management or consider secondary gain if patient does not progress as expected in a 6-12 week timeframe.

Be aware of the many factors that may cause the patient to fail to return to pre-injury work status:

  • Some legitimate patients cannot return to work safely due to the nature of injury or high demands of job
  • Employers are not willing to accommodate restrictions
  • Malingering/secondary gain
  • Psychological issues
  • Worker dissatisfaction with employer
  • Symptom magnification


Recognize that many injuries, particularly those that arise from “overuse” happen insidiously and only are recognized or manifested at work. These are not necessarily related to work.

The concept of contralateral injury due to ‘overcompensation’ is a red flag and should be approached with caution.


Give the patient benefit of the doubt. There is a tendency to find fault with the treating physician in the private pay sector and a tendency to find fault with the patient in the workers’ compensation arena. There are times that the physician may have had the wrong diagnosis, resulting in the patient having protracted symptoms. Leave judgement at the door, and keep an open mind when evaluating second opinions or IME.

Evaluate each patient thoroughly, objectively and honestly. Be impartial.


Documentation is more important here than anywhere else. Workers’ compensation cases are highly litigated, and you may be asked to give testimony based on your medical records.

In general, keep clean, concise documentation in your practice. Electronic medical records (EMR) can be cumbersome, but these are very helpful in keeping track of phone calls, visit status reports(VSR), and work status forms and other correspondence.

Be proactive in communication with the case managers and adjusters. Avoid situations where someone must read your mind because they have to rely solely on your clinic notes. Identify problem cases, and bring them to their attention. With early communication, case managers may help expedite the treatment process. Provide timely notes to the adjuster with work restrictions.

Getting the patient to MMI is helpful, as their functional status may improve after settling a case. Get out Permanent Partial Disability (PPD) ratings as soon as possible to facilitate this.


Market yourself to get yourself on panels. Panels can change quickly and often, so stay in touch with the insurance carriers and employers.

Use other peers on the panel for second opinions to help reinforce the treatment plan.

Never belittle or criticize other medical providers. This will only adversely affect your credibility.

Although Georgia law allows the authorized treating physician (ATP) to dictate treatment, it is good practice to seek pre-approval through the WC insurance provider. Also try to use the insurance-preferred providers. Of course always have the best interest of the patient, and deviate if necessary. Early and clear communication is important so you can present your case and the carrier can see why you have made specific recommendations.

Pain management may be helpful, but put a limit on the course of treatment to discourage chronic treatment.

As your WC practice grows, your time will become increasingly limited. Therefore, I recommend employing a Workers’ Compensation Coordinator to help streamline the treatment and communication process with all involved parties.

Many physicians shy away from a workers’ compensation-focused practice because the process is misunderstood or appears too time consuming. Realize that the vast majority of injured workers are eager to return to work and carry good outcomes.

With a little more understanding of the process and the willingness to put in the appropriate time, hopefully more highly qualified physicians will take on the task of helping our injured workers.


Medical Residency: Keeping Residents in Georgia

Wednesday, June 22nd, 2016

By Helen K. Kelley

Doctor shortages are critical throughout the country. To address this growing problem in Georgia, educational institutions, health systems, legislators and medical organizations are working to increase the number of residencies offered to medical school graduates.

More Opportunity

“Georgia is in a ‘world of hurt’ for having enough physicians. In fact, some counties have only one or no physicians,” says Waldon Garriss, M.D., who serves as the internal medicine director for WellStar Health System’s new residency program. “Georgia has traditionally been a net exporter of physicians. Newly graduated M.D.s and D.O.s have to leave Georgia to train because there is little opportunity here.

“What makes this situation particularly bad is that about 70 percent of physicians will end up practicing close to their last stop for training,” he adds. “If we’re sending our doctors elsewhere to train, they often don’t come back to Georgia.”

In answer to this need, WellStar has assembled a team of qualified clinicians and resources to achieve accreditation and begin a residency program that has already begun attracting applications from medical graduates. WellStar has completed its first interview season for its internal medicine and obstetrics/gynecology residencies, which will get underway this summer. The health system is currently working on accreditation for two additional residency programs in emergency medicine and surgery.

Garriss emphasizes the importance of reaching out to medical schools in Georgia and surrounding states to make them aware of these new residency opportunities.

“It’s obviously crucial and in keeping with our mission to have doctors who join WellStar and remain in our community, so it’s important for us to reach out to our state medical schools to make sure they know what we’re offering,” he says. “These are the students who already have some roots here in Georgia and the southeast because of school. They have the highest likelihood of staying.”

Patient Base, Specialty Programs Grow

James R. Zaidan, M.D., M.B.A., associate dean for graduate medical education (GME) at Emory University School of Medicine, says Emory’s residency programs, a great number of them established many decades ago, have continually expanded over the years in response to a growing patient base.

“There comes a point for most patients when they will need some form of specialized care. As our knowledge of different areas of medicine expands, little segments of those areas break away to become their own specialties, and we are constantly developing training programs for these new specialties,” he says. “When I started as the Associate Dean at Emory 16 years ago, I believe we offered about 67 accredited residency programs. Today, we offer more than 100.”

Zaidan emphasizes Emory’s ever-growing patient base as the driving force behind the growth of its residency program.

“This dramatic growth is directly attributable to the numbers and types of patients who come here. When a new need is identified, our GME faculty members, department chair and program directors will review the possibilities of creating a new program, asking questions like, ‘Does it make sense?,’ ‘Does Georgia need it?,’ ‘Do we think this program will do a lot of good?,’ and ‘Do we have a faculty member who will want to oversee it?’” he says. “If the answers are ‘yes,’ then we still have to undergo the rigorous accreditation process.”

Some of Emory’s newer residency programs, which will begin this summer, include epilepsy and medical biochemical genetics. Others, such as clinical informatics and interventional radiology, are undergoing the accreditation process.

“Georgia needs more physicians and certainly more primary care physicians. But we must keep in mind that primary care physicians will need experts to whom they can refer patients who require specialized care,” Zaidan says. “We need to have that specialized training here in Georgia.”

Scholarships Benefit Emory and Morehouse Students

 In an effort to increase the number of practicing physicians in Georgia, the Medical Association of Atlanta Board of Directors has created four $5,000 scholarships, to be split evenly between senior medical students at Emory University School of Medicine and Morehouse School of Medicine.

To qualify for one of these scholarships, a senior medical student must have matched and committed to a residency program located in Georgia. Preference will be given to those students who have joined the Medical Association of Atlanta and attended MAA events.

State Invests in Rural Practitioners

Gov. Nathan Deal recently announced that Georgia will invest an additional $70 million in two medical schools as a result of a settlement agreement offer from the Centers for Medicare and Medicaid Services. The recipients, Morehouse School of Medicine and Mercer University, were selected based on their continued efforts to place graduates in rural and underserved areas throughout the state.

“The state should receive these funds as a result of a healthcare lawsuit settlement regarding Medicaid reimbursements,” Deal says. “It is only fitting that we in turn invest this money in healthcare education programs, particularly those that prioritize placing primary care physician graduates in high-demand areas throughout the state. We look forward to continue working with these two medical schools to advance their healthcare training and delivery efforts.”

Dr. Valerie Montgomery Rice, president and dean of Morehouse School of Medicine, says the medical school will use the money to help expand classes and its residency programs, as well as recruit new staff. Mercer University President William Underwood says their portion of money will be used to assist students with a commitment to providing primary care in areas of the greatest need.


Patients Enrolled in HOPES Trial through Emory and Grady Partnership

Wednesday, January 13th, 2016

Faiz AhmadSome traumatic brain injury patients admitted to Grady Memorial Hospital may be eligible to participate in the Hypothermia for Patients requiring Evacuation of Subdural Hematoma (HOPES) Trial. The trial is a collaboration between Grady and its faculty physicians at Emory University School of Medicine.

Faiz Ahmad, MD, MCh, director of spinal neurosurgery and surgical neurotrauma at Grady, is principal investigator for the trial. Ahmad is also an assistant professor of neurosurgery at Emory University School of Medicine. David Wright, MD, director of the Emergency Neurosciences Section in Emory’s Department of Emergency Medicine, is co-principal investigator for the HOPES Trial.

“Traumatic brain injury is the number one cause of death in individuals younger than 44,” says Wright. “We have yet to find a treatment that improves the outcome of a brain-injured patient. There is some evidence that hypothermia may be able to slow the progression and improve the swelling that occurs after the injury, thereby providing hope for a treatment for traumatic brain injury.”

The trial seeks to prove the benefit of induced hypothermia. Cold, iced saline will be administered to randomly-selected patients during surgical evaluation and continued for a minimum of 48 hours and up to five days. The patients will be followed for six months to track outcomes.

Due to the emergency nature of traumatic brain injury and urgency to get these patients into the operating room, doctors will use Exception from Informed Consent (EFIC) to avoid delay of treatment. When appropriate, the patient or legally authorized representative will be given full written and verbal consent to continue participation in the research study.

“Grady Memorial Hospital, being one of the nation’s busiest trauma centers, is an ideal location for this study,” Ahmad says.

Traumatic brain injury resulting in subdural hematoma occurs in more than 40,000 Americans each year, with up to 70 percent of these injuries resulting in death or severe disability. The HOPES Trial aims to develop a therapy to improve outcomes for these patients. The study is being funded through the Vivian L. Smith Foundation for Neurologic Research at the University of Texas at Houston.


Children’s Healthcare of Atlanta Announces Two New Appointments

Wednesday, January 13th, 2016

Dr. RomeroChildren’s Healthcare of Atlanta has appointed René Romero, M.D., Medical Director of Pediatric Liver Transplant,  as Chief of Solid Organ Transplant Services. In his new role, effective Jan. 1, 2016, Dr. Romero will oversee Children’s pediatric kidney, liver and heart transplant programs.

Since 1999, Dr. Romero has served as the Medical Director of the Pediatric Liver Transplant Program at Children’s and the Clinical Director of Pediatric Hepatology at Emory University School of Medicine. Dr. Romero also serves as the Medical Director of the Intestinal Rehabilitation Program and as the Program Director of the Pediatric Transplant Hepatology Fellowship Program at Children’s.

“We are thankful to have Dr. Romero assume the role as Chief of Solid Organ Transplant Services,” said Mark Wulkan, M.D., Surgeon-in-Chief at Children’s. “He has been a great leader to the staff and the patients and families of our Pediatric Liver Transplant Program for more than 15 years, and I am excited he now has the opportunity to serve the staff and patient families of the kidney and heart program as well.”

As Clinical Director for Pediatric Hepatology, Dr. Romero helped recruit and organize a team of six pediatric hepatologists who are actively engaged in clinical and basic research. This team participates in all of the major NIH consortia looking at liver disease in children, including Childhood Liver Disease and Education Network, Cystic Fibrosis Liver Disease Network, Fatty Liver Disease Network, and the Pediatric Acute Liver Failure Study Group. They are also active in the Studies in Pediatric Liver Transplantation, and in industry trials establishing curative therapies for hepatitis C infection in children.

Dr. Romero received his M.D. from the University of Florida and completed a pediatric gastroenterology and nutrition clinical and research fellowship at Harvard Medical School/Children’s Hospital of Boston. He has served in multiple roles with national and international committees, including the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition and OPTN/UNOS.

Dr. TurgeonIn addition to Dr. Romero being named Chief of Solid Organ Transplant Services, Dr. Nicole Turgeon, Emory University Hospital, has been named Endowed Mason Chair of Children’s Transplant Program. Dr. Turgeon is currently an Associate Professor of Surgery in the Division of Transplantation at Emory University School of Medicine and serves as Medical Director of the Kidney Transplant Program at Children’s. She joined the Emory staff in 2007 from the University of Massachusetts, where she served as director of kidney and pancreas transplantation and where she received her research fellowship training, residency training, and medical degree.


Athens Regional Health System and Piedmont Healthcare to Enter Exclusive Discussions

Tuesday, December 15th, 2015

The Athens Regional Health System’s Board of Directors voted unanimously in favor of exploring a partnership with Piedmont Healthcare.

Officials with Athens Regional announced they would be seeking a strategic partner to best position the system for the future of healthcare and to create a stronger healthcare network in its region.

“Our organizations share a common vision and culture of high quality patient and family centered care,” Kevin Brown, president and CEO of Piedmont Healthcare, said. “Working together, there’s a clear opportunity for Athens Regional to be a larger, regional hub for healthcare, expanding our collective reach across the state.”

Athens Regionals’ decision authorizes the finalization of a non-binding Letter of Intent with Piedmont and the commencement of an exclusive negotiation period between the two organizations.

“Piedmont demonstrated to us that they have a culture and history of putting people first,” Dr. Charles Peck, president and CEO of Athens Regional, said. “Just like at Athens Regional, Piedmont places the patient at the center of everything they do.”



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