Monday, April 28, 2014

Children’s expanding, improving services for children treated for cleft palates and lips

By:Dr.John Grant with UAB and Children’s Hospital

During my first year at UAB and Children’s Hospital about 16 years ago, I performed about a half dozen operations to correct cleft lips and a couple of surgeries to correct cleft palates. Last year—along with my partner, Dr. Peter D. Ray—our team performed about 200 operations. This phenomenal growth in our clinic has been accompanied by improved quality.

We use advanced techniques along with a comprehensive team approach that provides care well beyond the operating room. For example, within the past decade, pediatric plastic surgeons have learned to correct underlying muscles in cleft lips and palates, thus providing a much more natural look and better speech for our patients. The face is dynamic, and these new techniques lead to a broader range of facial expressions and better speech control. Of course, we usually work with young patients, but there is an enormous opportunity to improve outcomes for older children and even adults who underwent cleft surgeries before these new techniques were widely used.

Due to our growth, Children’s now houses one of the nation’s busiest clinics for treating cleft lips and palates. We add about 150 new patients annually, and follow them through adolescence. We are excited about our upcoming move into larger quarters. The area that previously housed the emergency department in Children’s McWane Building has been renovated and will nearly double our space. We hope this makes us more efficient and enable us to shorten waits in our clinic for children and their families.

We already offer a full-service program that is staffed with experienced health care professionals, such as audiologists, speech-language pathologists and registered nurses as well as specialized physicians and dentists. They’ve seen hundreds of patients, and there’s a cumulative knowledge base. Our staff has realistic expectations about how children heal, how much pain they may or may not have and airway issues for babies versus adults.

We are excited about the launch of our new international fellowship program. For many years, American doctors have traveled to developing countries where they quickly perform operations for cleft palates and lips. Unfortunately, there is often a lack of follow-up care, and many patients go untreated. We want to educate doctors from these countries so they can establish their own full-service clinics that will provide more thorough and consistent care. The first fellow will be coming this summer from Ghana, West Africa, for 11 months of training, and another will come next year from Egypt. We are hopeful that they will become the teachers for the next generation of doctors in their countries and make it possible for children in those places to have full-time, quality follow-up and coherent planning, instead of care based on chance.

Additionally, we are improving our techniques for conditions other than cleft lips and palates. One service line we want to increase is a technique called tissue expansion. It’s been used a lot in secondary burn reconstruction. But we are also using it for children with giant congenital nevus, or dark patches of skin, often on the face or scalp. We surgically place flat balloons under adjacent, normal skin, and families are taught to slowly inflate these balloons over weeks so a child’s skin is stretched. Then, the patient returns to the hospital for an operation that utilizes the stretched skin to replace discolored skin, restoring normal tissue. We have enhanced this service line with the help of Dr. Bruce S. Bauer of Chicago, a pediatric plastic surgeon who is renowned for his refinement and application of this technique. It’s low risk for the patient and requires little time in the hospital.

All this work is extremely rewarding for our team. Seeing families get their babies back after a cleft operation is an occasion that many parents tell us is nearly as joyful as giving birth.

Dr. John Grant is a board certified plastic surgeon with more than 15 years of experience working with children. He is chief of pediatric plastic surgery and craniofacial surgery at Children’s of Alabama, and heads the UAB Cleft and Craniofacial Center. He holds the James C. Lee III endowed chair in pediatric plastic surgery and teaches nationally and internationally.

Thursday, April 24, 2014

“Are you sitting on a Gold Mine?”

By: Dick Richard, AIA, is Associate Principal in TRO Jung|Brannen’s Birmingham office

For healthcare facilities everywhere, your greatest asset is your people; doctors, nurses and various members of your staff. They represent your biggest investment, by far, so it’s clear that having the right people on staff is the foundation of success for any business or healthcare entity. Your physical facilities likely represent your second largest investment. How they are configured and how well they perform plays a major role in whether or not you are positioned to weather the economic and regulatory storms in today’s turbulent healthcare environment. While there is uncertainty about the future of healthcare reimbursement, regulations and market forces, one thing certain is that maximum utilization of all of your most valuable resources is a must for survival.

Princeton Baptist Medical Center in Birmingham, Alabama recognized the importance of making the most of their existing facilities several years ago as they explored many ways of expanding the hospital. The goal of the Princeton East Expansion project was to create new state of the art Surgical, Endoscopic and Instrument Processing facilities and to replace outdated & undersized 1960’s era OR’s. Studies were done to determine the comparative costs & benefits of simply building all new facilities to replace the old Surgical Suite, and the resulting analysis revealed that utilizing a combination of new construction and renovations of existing space would provide a more sustainable and cost effective solution. Consequently, the final design involved constructing 90,000 square feet of new space and repurposing over 60,000 square feet of existing space to maximize both the utilization of the existing plant and improve staffing & operational efficiencies. For example, the existing facility had thousands of square feet of existing surgical support space that could be utilized either “as is” or with minor renovations. The combined approach saved construction costs by preserving more of the $100/square foot existing/renovated space and constructing less of the $300/square foot new space.

There are obviously many factors to consider when embarking on a significant facility expansion or renovation project. First, experienced management of complex phasing is important. The East Expansion Project involved more than two dozen phases of construction and renovation, causing hospital departments such as Surgery Pre-op to be moved several times. In Princeton’s case, the staff members who were affected by these moves were more than willing to be inconvenienced temporarily, knowing they would have state of the art facilities when construction was complete. Second, experience with complex systems analysis is part of the mix. When considering the degree to which it made sense to repurpose and renovate existing facilities at Princeton, other factors such as structural grid, floor to floor heights, condition of the building’s HVAC, Plumbing and Electrical systems and Life Safety and Building Code deficiencies had to also be addressed and evaluated carefully. Third, experience offering a comprehensive solution and a focus on patients, staff, and the visiting public should be required. By commissioning the right team to evaluate your existing facilities, the most cost effective, sustainable and intelligent solutions for facility renovation and expansion projects can be determined and implemented, as at Princeton.

Construction of new facilities can be expensive, so why not take time to evaluate opportunities to make better use of the space you already have. More and more, with evolving trends in healthcare and with the need to operate efficiently in order to remain competitive, you may find great value in making more of the latent gold mine you already have in your existing facilities.

About the author – Dick Richard, AIA, is Associate Principal in TRO Jung|Brannen’s Birmingham office. The architects and staff with TRO JB have offered design services for projects, large and small, to healthcare clients in Alabama and the southeastern region for more than forty years. See more about TRO JB at Dick can be contacted at 205-324-6744, ext 248 or

Tuesday, April 22, 2014

Menopause: It’s time to turn on the air conditioning during your personal summer

By Virginia N. Winston, MD Obstetrics & Gynecology Trinity OB/GYN

Hot flashes, night sweats, weight gain, mood swings, sleep difficulties. While all these symptoms may sound like a bad dream, they are actually all very common symptoms that women experience during the menopausal transition. And while women of ages past believed they should “suffer in silence,” that is no longer an acceptable way to live for the more than 55 million women who are peri-menopausal or post-menopausal in the United States today.

  Menopause is defined by the absence of menstruation for one year. For 4-7 years surrounding menopause, women experience what is called the menopausal transition. During this transitional period, many of the following symptoms can be experienced:

• Hot flashes and night sweats
• Sleep disturbance
• Depression, irritability, mood swings
• Loss of concentration and memory
• Changes in length between periods and changes in bleeding amount during periods
• Vaginal dryness, decreased libido, and painful intercourse
• Headaches
• Dizziness
• Heart palpitations
• Joint aches

Hot flashes and night sweats are the most common complaints of peri-menopausal women. During these episodes extreme heat is felt in the upper body (face, neck, and chest). These symptoms are caused by changes in thermoregulation in the brain and by decreased estrogen levels and increased levels of follicle stimulating hormone (FSH). At the present time, there are multiple hormonal and non-hormonal treatments for these symptoms. Consultation with a trained gynecologist or women’s healthcare specialist could lead to drastic reduction in these symptoms and also improve sleep quality and mood which can be affected by these vasomotor symptoms.

A common unspoken complaint of peri-menopausal women is the constellation of vaginal dryness, painful intercourse, and decreased libido. These can alter quality of life and relationships severely and are often not communicated to practitioners because of embarrassment. Women are strongly encouraged to voice these complaints as treatments are available. Both hormonal and non-hormonal options can be considered and provide drastic relief.

Women should feel empowered that effective treatments are available for the treatment of menopausal symptoms. Many times it is as easy as simply speaking up and voicing complaints to your doctor who can, in-turn, provide valuable education and safe options for treatment.

References: American College of Obstetricians and Gynecologists. ACOG Practice Bulletin Number 141: Management of Menopausal Symptoms; January 2014.

Hoffman BL, Schorge JO, SchafferJI, Halvorson LM, Bradshaw KD, Cunningham FG: Williams Gynecology, 2cd Edition. New York: McGraw-Hill companies Inc; 2012

Monday, April 14, 2014

Is it really a good thing???

By: Richard Stroud, MBA FACMPE
Practice Manager at UAB Eye Care

As you read this, a few weeks will have passed since H.R. 4302 passed the Senate and was sent to President Obama for signature. While there were sighs of relief from some, there were also some teeth-gnashing by others. As an administrator, I can see the benefits for some, and I understand the frustration of others.

When you review this legislation, you will realize that while the bill addresses several items, there are two things that really make you wonder. First, the “doc fix” has been addressed in the usual manner – TEMPORARILY postponing the impending Medicare Cuts to the fee schedule for another year. Second, the implementation has been postponed until at least October 2105.

The “doc fix” is almost becoming comical. This is not a new issue, as there have been discussions for over ten years about the “flawed” Medicare fee formula. At the base of this flaw is the Sustainable Growth Rate (SGR), which was implemented in 1997 as a part of the Balanced Budget Act. The intent was to force Medicare expenditures to be “budget neutral”, or to limit the spending per Medicare beneficiary so that it does not exceed GDP growth. While this is a noble goal, the issue is really not about GDP growth, but rather, the growth of Medicare beneficiaries. And, as many will tell you, it is a good political tool for candidates to use for election (or re-election). The interesting thing about the discussions is there appears to be a universal recognition that the formula is flawed. A “fix” has been proposed several times, but then is caught up in the addendums and never happens. So, to prevent Medicare beneficiaries from potentially losing access, Congress will step in to “save Medicare”. Good political fuel for the campaign. Congress has stepped in 17 times so far, and will probably continue to do so in the future.

The postponement of ICD-10 is also interesting due to the rhetoric that has been bantered about for the past few months. Make no mistake, the implementation of ICD-10 is a major shift in healthcare, it’s not just about coding. To implement such a change, there have been millions of dollars spent to accommodate this initiative. Software companies have had to invest in substantial programming to meet the October 2014 deadline as well, redesigning their databases to accommodate the additional space required and to be able to transmit data to the payors – which takes months to develop. Physician practices (both private and public) have spent an incredible amount of time and resources to be trained on the new system, knowing that this was a long learning process that could not be implemented overnight. In February, Marilyn Tavenner, CMS Administrator, announced there would be no more delays in the implementation of ICD-10. With barely seven months to go until implementation, the pressure was on for the health care system to be ready. This was very concerning for many (AMA, MGMA, and others), as this new process was lacking in confirmation testing or “end to end testing”. Many anticipated a potentially tremendous financial issue for health care providers if the system did not work. With the recent debacle with registration for the health exchanges, the worry was probably valid.

So, what happens now? Maybe it is time for everyone to take a step back and look at the “big picture” and then be realistic. While Medicare has been a welcome benefit for many Americans, it has also contributed to a wasteful healthcare system. Millions of dollars have been spent to be “in compliance” which could have been used for actual patient care. Physicians have worked hard (going to medical school, residency and maybe fellowship) to become a healthcare provider, a career that guarantees long hours, unreasonable expectations from patients, and other frustrations. I do not think anyone begrudges a physician that makes a good living considering the work that is involved. After all, there are attorneys and other professionals that are just as prosperous. But, the political impact on healthcare may also be the demise of healthcare in the U.S. At what point will physicians decide they have had enough, and tell Medicare “no thanks”? At what point will physicians do something about it, instead of waiting for “reasonable people to make reasonable decisions”? After all, we are talking about the federal government!

The business of healthcare is probably very confusing to the public. It is also very confusing and frustrating for providers. When thinking about healthcare, sometimes the “care” is lost in the chaos of the business. Providing compassionate, effective, efficient care should not be such a burden – but it is. Much of this burden has been created by the government –which while having good intentions, knows very little or nothing about the reality of healthcare. Healthcare has evolved into a “right” for all Americans. But, there is a price for this “right”, which tends to be overlooked. Just like any other service provided by society, there is a cost, which must be paid, at a fair market rate. And those that make the rules should be accountable for the chaos and waste they create.

So, you have read my opinion. What’s yours?

Friday, April 11, 2014

Sebelius Resigns

Embattled Health and Human Services Secretary Kathleen Sebelius is resigning as the White House seeks to move past the political damage inflicted by the rocky rollout of President Barack Obama's signature health care law.

Sebelius' resignation comes just over a week after sign-ups closed for the first year of insurance coverage under the so-called Obamacare law. The opening weeks of the enrollment period were marred by widespread website woes, though the administration rebounded by enrolling 7.1 million people by the March 31 deadline, exceeding initial expectations.

Even with the late surge in sign-ups, the law remains unpopular with many Americans and Republicans have made it a centerpiece of their efforts to retake the Senate in the fall.

Sebelius' resignation could also set the stage for a contentious confirmation hearing to replace her. In a sign that the White House is seeking to avoid a nomination fight, the president was tapping Sylvia Mathews Burwell, the director of the Office of Management and Budget, to replace Sebelius. Burwell was unanimously confirmed by the Senate for her current post.

A White House official requested anonymity to confirm Sebelius' resignation and Burwell's nomination ahead of the formal announcement. Obama has not nominated anyone to replace Burwell as budget director.

Obama remained publicly supportive of Sebelius throughout the rough rollout, deflecting Republican calls for her resignation. But she was conspicuously not standing by his side last week when he heralded the sign-up surge during an event in the White House Rose Garden.

The official said the 65-year-old Sebelius approached Obama last month about stepping down, telling him that the sign-up deadline was a good opportunity for a transition and suggesting he would be better served by someone who was less of a political target.

A spokeswoman for Sen. Pat Roberts, a Republican from Sebelius' home state of Kansas, called the resignation "a prudent decision" given what she called the total failure of Obamacare implementation.
Sebelius dropped no hints about her resignation Thursday when she testified at a budget hearing. Instead, she received congratulations from Democratic senators on the sign-up surge.

Sebelius has been one of Obama's longest-serving Cabinet officials and his only HHS secretary. She was instrumental in shepherding the health care law through Congress and implementing its initial components.
But Sebelius' relationship with the White House frayed during the fall rollout of the insurance exchanges that are at the center of the sweeping overhaul. The president appeared caught off guard by the extent of the website woes.
After technical problems crippled online sign-ups after the Oct. 1 launch, the White House sent Obama adviser Jeffrey Zients to oversee a rescue operation that turned things around by the end of November. After taking helm of the project, Zients said management issues were partly to blame but did not point the finger at any individuals.

Sebelius took responsibility for the chaotic launch of the website and asked the HHS inspector general to conduct an investigation. That report is not expected for months.

In nominating the 48-year-old Burwell, Obama is tapping a Washington veteran with a low-profile and the respect of some Republicans on Capitol Hill. Burwell held several White House and Treasury posts during President Bill Clinton's administration.

Between her stints in the executive branch, Burwell served as president of Wal-Mart's charitable arm and head of the global development program at the Bill and Melinda Gates Foundation.

If confirmed, Burwell will have to contend with huge challenges related to the continued implementation of the health overhaul, as well as the divisive politics surrounding the law that show no sign of abating.

On the practical side, the administration has to improve customer service for millions of Americans trying to navigate the new system. There's also a concern that premiums may rise for 2015, since many younger, healthier people appear to have sat out open enrollment season.

On the political front, congressional Republicans remain implacably opposed to Obamacare, even as several GOP governors have accepted the law's expansion of Medicaid. GOP opposition means Republicans can be expected to continue to deny additional funds for implementation.

Senate Minority Leader Mitch McConnell., R-Ky., welcomed Sebelius' resignation but appeared to indicate an openness to a dialogue with Burwell, the new HHS nominee — even as he declared that "Obamacare has to go."

"I hope this is the start of a candid conversation about Obamacare's shortcomings and the need to protect Medicare," McConnell said.

Thursday, April 10, 2014

Responding to Online Negative Comments

By: Josh Hyatt, Senior Risk Management Specialist at NORCAL Group of companies

With the advent of social media and online marketing outlets, physicians, healthcare practitioners and facilities are experiencing, in a new medium, a not-so-new phenomenon — bad publicity. There are many online sites that allow patients to rate their physicians on various scales, and oftentimes they can leave narratives about their experiences.

As such websites increase in popularity, so does the significance of such ratings. Many patients are using the sites to report negative comments about physicians, and physicians often feel unable to defend themselves due to HIPAA and other privacy regulations. Negative reviews can come from angry patients, disgruntled employees, and sometimes even members of the public just trying to create unsubstantiated problems.

When these attacks occur, sometimes the physician wants to go into a defensive mode to preserve both integrity and reputation. But impulsive responses may do more harm than good.

Because negative online reviews can affect a physician and his or her practice, the issue warrants a two-fold plan of action that is both proactive and reactive in nature.

Proactive Steps
• Setup your own practice web page where you can control the content and message you want to share with the community. Work with your group administrator or medical director as necessary.
• Develop a social media plan for your practice. This could include Facebook or Twitter accounts where postings can be controlled.
• Periodically check websites for yourself or your practice to identify any specific issue or trends. You may want to explore setting up online alerts that advise when comments have been posted about you as a physician.
• Ask patients to go online and rate your services. Positive ratings will help to counter balance negative comments.
• Provide a patient complaint process so disgruntled patients can receive timely resolution.

Reactive Steps
• Don’t panic.
• Do not respond immediately or impulsively. Take time to consider the comment, to reflect on why the individual felt compelled to post, and to decide if it warrants a response. Not all negative comments are worthy of your time to respond. A response may start a chain reaction of negative slurs and comments, potentially leading to litigation.
• If you feel the information is “clearly false, inappropriate and solely inflammatory, contact the (Internet) site administrator.”1 Legitimate sites have content guidelines and will probably remove information that violates them.
• If you are considering suing a reviewer, there are many potential issues you need to be aware of to avoid pitfalls and countersuits. Consult with your attorney as soon as possible before taking any steps in that direction.
• Periodically follow up with positive information about your practice on the sites. NEVER post fake consumer reviews, as this may result in significant fines and penalties.
• If you choose to respond in writing, limit the response to general information, NEVER use patient identifiers or reveal any protected health information, and do not directly or personally attack the individual posting the comment.

1. California Medical Association. CMA On-Call, Document 0822: Online Consumer Review and Rating Sites,

This article has been adapted from “Responding to Online Negative Comments,” one of 100+ risk management articles, sample forms and sample policies available online to NORCAL Mutual Insurance Company policyholders. Josh Hyatt is a Risk Management Specialist with NORCAL Group of companies, which includes NORCAL Mutual Insurance Company, Medicus Insurance Company and PMSLIC Insurance Company. Copyright 2012.

Wednesday, April 9, 2014

LOW TESTOSTERONE (hypogonadism) (Clearing up the confusion)

By: Dr. Rodney L. Dennis with Urology Centers of Alabama
There has been a lot of media attention given to low testosterone levels in men. Initially, there was a strong market push by the makers of testosterone supplements to have testosterone levels checked by their doctor if a man had low energy, fatigue, erectile dysfunction or low libido.  As a Urologist, I have seen a huge surge in patients who come in requesting that their “T level” be checked, no matter what other urologic problem they were being seen for. 

Currently, we are now seeing this same marketing, but also an overlap of advertising by lawyers looking for men who may have been adversely affected by testosterone treatment.  This coincides with media coverage of two recent articles that seemed to show an increased incidence of cardiovascular disease or strokes in men taking testosterone. I now have men coming in to my clinic requesting to be taken off testosterone or requesting clarification of the situation.

So, let me try to break this down into some basic facts which may help relieve some anxiety and better understand hypogonadism. 

First of all, the two studies mentioned above appear to be somewhat misleading and possibly flawed. The studies evaluated patients who already had some cardiovascular disease. Many prior studies have shown that testosterone could possibly be helpful in avoiding cardiovascular disease in certain patients.  The FDA is now doing a study to better clarify this confusion. However, my recommendation at this time is that if a patient is truly hypogonadal (low testosterone) and, symptomatic (i.e. decreased libido, fatigue, erectile dysfunction) then the benefit of getting his testosterone level back into a normal range probably outweighs the possible risks, unless the patient is elderly or has known cardiovascular problems.

However, I think it is important for men to realize that most cases of fatigue  and erectile dysfunction may not be related to low testosterone, and some men with low testosterone may have no symptoms at all.

There are some potential risks of testosterone supplements and starting this medication is something that should not be taken too lightly by the patient or the doctor.  For instance, for a male who is interested in having a pregnancy in the future, testosterone will prevent that by drastically reducing the sperm count.  Also, if a male has microscopic or unknown prostate cancer, this could cause the cancer to flourish.  It can also worsen prostate enlargement symptoms and also prevent the testicles from producing their own testosterone and occasionally will cause testicular shrinkage.  Also, testosterone supplements may raise the red blood cell count or hematocrit which could possibly result in thickening of the blood or blood clots. (It is always important for men to have their red blood cell counts checked before and during therapy).

Low testosterone may not be just a testicular problem. Some men with low testosterone may have secondary hypogonadism, which is a problem with LH (luteinizing hormone) production by the pituitary gland in the brain.  The LH has to tell the testicles to produce testosterone. Low levels of LH may occur because of many things including:  depression, head trauma, iron overload, steroid use by body builders, diabetes, sleep deprivation, and kallmann syndrome (a genetic disorder).

As you can see, it is very important to know the LH level in addition to the testosterone level to help determine where the problem is.  If the problem is in the testicles, the testosterone level is low and the LH level is high.  If the problem is in the brain, the testosterone is low and the LH level is normal or low. 

If the problem is in the brain, then the male may not even need to receive testosterone supplements. He may respond to a medicine called Clomid  (clomiphene citrate) which is a relatively inexpensive pill taken once a day or every other day.   Or, there is an injection called HCG (human chorionic gonadotropin) which can be given twice per week as an IM or sub q delivery. (Most men usually opt for the pill). 

One important thing to remember is that one low testosterone level is not sufficient to make the diagnosis of hypogonadism.  There need to be two separate testosterone levels checked in the mornings, as this is when the levels are most accurate.  Based on current knowledge, my feeling is that a man should not be started on treatment for low testosterone unless two separate morning levels are low, and, the patient has symptoms of low testosterone.  Before starting treatment, my recommendation is to also obtain an LH and hematocrit levels.

I hope this information is helpful, but keep in mind that it is based on current knowledge and, based on the changes we have seen in the last two years, may very well change again in the future. 


Rodney L. Dennis, M.D.