In Health Management SPECIAL SECTION: OBESITY PAGE 12 THIS ISSUE in a WORD Down, and Whatever You Say Will Be Clouded by His Weighty: Embarrassment

+++++++++++++ +++++++++++++ +++++++++++++ +++++++++++++ [ ] +++++++++++++ ISSUE 2, 2014 +++++++++++++ A PHYSICIAN PUBLICATION FROM +++++++++++++ +++++++++++++ THE NORTH SHORE-LIJ HEALTH SYSTEM +++++++++++++ +++++++++++++ +++++++++++++ +++++++++++++ +++++++++++++ +++++++++++++ +++++++++++++ +++++++++++++

REBUILDING RESIDENT CONNECTIONS PAGE 7

A PHOTOGRAPHIC PHYSICIAN PAGE 29

Q&A: OPINIONS ABOUT ICD-10 PAGE 33

in Health Management SPECIAL SECTION: OBESITY PAGE 12 THIS ISSUE IN A WORD down, and whatever you say will be clouded by his weighty: embarrassment. You will not be an effective doctor. heavy; of great Your job is to be sophisticated and importance or introspective enough to understand and consequence neutralize your prejudices. Mind you, the aforementioned attitude is pervasive in all walks of medicine, health care and our society. It is up to you to stop the stares, the jokes and the insensitivity that too often emerge during treatment of the overweight. Understand appetite and energy metabolism. Bring something smart to the table. Do not assume obese patients are simply out-of- DEAR COLLEAGUES, control eaters. And if they are (which you need to ask about sensitively), assume that it is the A doctor enters the examination room underlying biology — or a mix of things — and the patient, terribly uncomfortable driving them to that next plate. in every way, struggles to close his cotton We must treat obesity without stigma. Our robe. He is obese. He can’t climb onto the minds must be set on helping overweight exam table without help. Thoughts swirl patients understand how weight contributes to around unstopped in the doctor’s head, and disease. We must work with them — or refer although nothing is said aloud, the patient them out — to help with weight loss gets the message: “You are fat. You have and exercise. no self-control. You are killing yourself, and The stigma will end one doctor at a time. now you’ve come to me with your long list of For three years now, I have met with the medical problems.” students and faculty of the Hofstra North Physician, heal thyself. Stop blaming Shore-LIJ School of Medicine for a lecture patients for their girth. There is now enough and discussion about obesity-related diseases. data to show that obesity is a complex You will see from several articles in this issue and multifactorial problem. It is a disease, that the North Shore-LIJ Health System takes according the American Medical Association. obesity seriously and has designed many ways If you are ever going to help your overweight to address the problem among our patients and obese patients, you must stop blaming and in our communities. We are also teaching them (even silently) and do your own work medical students and residents healthy cooking to educate them. methods so that they can better understand It is clear that fighting obesity is infinitely the messages they deliver to their patients. more complex than simply reining in eating habits. The minute you become judgmental Lawrence Smith, MD LEADERSHIP MESSAGE LEADERSHIP toward your patient, trust is gone. He may PHYSICIAN-IN-CHIEF, NORTH SHORE-LIJ HEALTH SYSTEM not be out the door, but his mind will shut DEAN, HOFSTRA NORTH SHORE-LIJ SCHOOL OF MEDICINE

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DOCTORING DR. CONTENTS ISSUE 2, 2014

GADGETS & GEAR 10.... Complex Care, Simplified 22.... Cooking Up Health 04.... Misconception Solutions ...... Scoping the Body ART & SCIENCE ...... Tiny Tech SPECIAL SECTION: OBESITY 26.... The Stage Doc 14.... Tipping the Scales CULTURE RESIDENT PROFILE Against Obesity 29.... A Developing Passion 05.... Inspired by Illness 17.... Leading by Example OUTREACH 20.... A Battle of the Bulge FIRST PERSON 07.... Calling All Alumni Veteran Offers a Plan 33.... Q&A: ICD-10 of Attack

ON THE COVER: FAT CELLS, SEEN AT A MICROSCOPIC LEVEL IN THIS ILLUSTRATION, CAN EXPAND TO AS LARGE AS 1,000 TIMES THEIR ORIGINAL SIZE.

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ISSUE 2, 2014: DOCTORING G gadgets & gear > A ROUNDUP OF PRODUCTS AND DEVELOPMENTS OF INTEREST TO PHYSICIANS by Jamie Talan

1 2

Scoping the Body [GI IMAGING]

Swallow this camera and call me in the morning. Early this year, the US Food and Drug Administration approved PillCam COLON, a pill- sized video camera that can be swallowed, allowing it to travel through the gastrointestinal tract to the Misconception colon. There, the PillCam captures images that are READ MORE [FICTION-WRITING PHYSICIAN] transmitted to a data recorder worn on the patient’s belt. The device typically remains in the body for about 10 hours before it is eliminated as waste. Avner Hershlag, MD, has spent his career Doctors retrieve images from the data recorder bringing babies into the world who might not to inspect inconclusive yet suspicious polyps or otherwise have been born. Chief of the North adenomas following a standard colonoscopy — Shore-LIJ Center for Human Reproduction, offering an effective option for completing the Dr. Hershlag is also the author of an intricate approximately 750,000 incomplete colonoscopies novel based on the modern state of affairs in that require further testing in the US each year. reproductive medicine and genetics. The medical thriller Misconception delivers the right amount of fear and joy that comes with the prospect of conception. But what Tiny Tech [NANOMOTORS] happens when the new technology is 3 threatened and scientists have the tools to “poach” an embryo and alter the mix of genes? Scientists in the Mallouk Lab at Eberly What happens when a child is born grossly College of Science, Pennsylvania State deformed after in vitro fertilization? How did a University in University Park recently young woman (a senator’s daughter) who has introduced nanomotors — a technology being been in a coma for years become pregnant? developed to damage or kill abnormal cells Are embryos made in a laboratory safe from — into human systems. They were able to evil forces that want to alter humankind? steer these miniature “rocket-shaped metal As a fertility specialist, Dr. Hershlag has particles” through the anatomy to deliver been grappling with such questions for ultrasonic waves that can target and destroy decades. Now, he struts his writing stuff in specific malignant cells. a great read. Misconception can be ordered In the Penn State study, scientists targeted from amazon.com. human cervical cancer HeLa cells, which have READ MORE been widely used in scientific research due to their durability and propensity to proliferate. READ MORE The hope is that nanomotors could travel OR ORDER inside the body and perform various kinds of YOUR COPY diagnostics and therapy.

DOCTORING : ISSUE 2, 2014 5 RESIDENT PROFILE RESIDENT

Inspired by Illnessby Jamie Talan

FOR ONE LENOX HILL HOSPITAL RESIDENT, THE JOURNEY INTO MEDICINE HAS LONG BEEN GUIDED BY PERSONAL MEDICAL EXPERIENCES.

ISSUE 2, 2014: DOCTORING 6 RESIDENT PROFILE RESIDENT

ichard Adamski was about five years old when might have another autoimmune disease. Tests revealed he began to understand that his mother he had rheumatoid arthritis. The unrelenting exhaustion couldn’t walk on her own because she was sick. scared him, but tenacity fueled him. His driving goal was R He was used to seeing other moms out and to become a doctor. He was only a few years away, and about — but the woman he loved was always home, and nothing was going to get in his way. most of the time she was lying in bed. Well, almost nothing. In college, he became interested Multiple sclerosis was the in toxicology, worked in a lab ghost that kept his mother and decided to pursue a doctor- down. He hadn’t even entered ate. But he was more interested elementary school when he found in the clinical experience and his calling. He told his father and later opted to turn back to medi- grandmother: “I want to make my cine. After medical school at St. mommy better.” George’s University in Grenada An only child, Richard spent — to which he was led by a cous- much of his youth surrounded by in — he applied for a fellowship doctors. He was as comfortable in rheumatology. At this point, around white coats as he was he was a second-year resident at around toy soldiers. Lenox Hill Hospital. Before his mother became ill, “I have never felt sorry for she, too, had dreams. She wanted myself, and I understand what it’s to become a nurse. But the first like to be a patient,” Dr. Adamski troubling signs appeared when said. “I don’t view this aspect she was 22. of my life as a hardship, but as She also wanted love, marriage something that strengthens me and a child — all of which became and contributes to a stronger Richard Adamski, MD, right, pictured with his father, hers, but not without challenges. mother and son bond with my patients. I think The medicine she took for multi- that these experiences help me ple sclerosis — and the disease itself — made it difficult when I interact with patients. It gives us common ground.” to get pregnant. She was already spending much of her As a teenager, he worked in a program to help educate life in a wheelchair and considerable time with doctors children newly diagnosed with diabetes. He’s also helped and nurses at her local hospital. She finally gave birth to deliver medical care to his mother throughout her life. her son when she was 33. “I am now on the other side of the fence. I am finally Then, the Adamski family took another medical hit. on the doctor side of the relationship, and it is humbling,” One day at age 11, Richard woke up thirsty and nause- Dr. Adamski said. ated, and he couldn’t shake the symptoms. He looked He lost his mother to pneumonia last December. them up in a medical textbook, and they spelled out Type She was 67. It is now clear to the young man that his 1 diabetes. mother — even from her wheelchair and hospital bed “I don’t have that,” he told himself. — took care of him in big ways. He was often called By that night, he was so exhausted and dehydrated upon to assist in medical duties surrounding her care, that his father rushed him to a local emergency but they cared for one another. department, where clinicians confirmed what Richard “She was very proud that I am a doctor,” he said. “She had read in the textbook. He had Type 1 diabetes. His taught me compassion. I understand the difficulties of body was depleted of islet cells. He spent more than a managing a chronic illness and of dealing with pain and week in intensive care. medications that can have severe side effects.” The diagnosis only solidified Richard’s obsession Dr. Adamski, who will practice internal medicine, takes with medicine. Before he graduated from high school, time with his patients because he knows, he remembers, he had experienced symptoms his classmates were not and he will never forget. likely to encounter for decades: His joints ached, he felt “Because of these experiences, I have truly been moved exhausted, his hands swelled. His doctor thought he by what medicine can do for my patients,” he said.

DOCTORING : ISSUE 2, 2014 7 OUTREACH

CALLING ALUMNIby Jamie Talan A NEW PROGRAM AIMS TO REBUILD CONNECTIONS WITH FORMER RESIDENTS.

ISSUE 2, 2014: DOCTORING 8

PHOTO BY ALAN ORLING NORTH SHORE-LIJ ARCHIVE OUTREACH

David Rosen, MD, right/front, former chair of ophthalmology at LIJ Medical Edward Meilman, MD, second from left, LIJ Medical Center’s first chief of Center, explains a sample on a teaching microscope to the department’s medicine, discusses a case with a group of residents in this photo, circa 1975. residents in this photo, circa 1986.

1958, four years after North Shore University “Our feeling is that they trained here, so they are the best Hospital opened, Kanti Rai, MD, arrived to interview candidates for open positions,” said Andrew Yacht, MD, the In for a chief residency in pediatrics. At the time, he health system’s chief academic officer. recalls, there was no such thing as job matching to determine Cheryl Spence, manager of alumni affairs and GME physician the best person suited to a particular role. Only one other doctor recruitment in the Office of Academic Affairs, has been working interviewed for the position. to identify resident alumni from all North Shore-LIJ hospitals. Dr. Rai, then 26, got the post and showed up at the beginning Sometimes it’s a matter of tracking down a handwritten scrawl of the summer. At the end of a busy day, he would make his way on the back of an old black-and-white photo. Back when Dr. Rai back to a little room in the Colony House Hotel at Grace Avenue was chief resident, there may have been a handful of doctors and Bond Street in Great Neck. His only goal was to learn in training at North Shore University Hospital. Today, 500 enough about taking care of children to enable him to return doctors a year finish training in the health system. to rural India and get down to the business of treating them. A new Web site for the alumni effort recently launched with But his career path quickly took an unexpected turn. He hopes that former residents will add their names to the growing diagnosed acute leukemia in a toddler from Port Washington. database. Ms. Spence and her team hosted an alumni reception There was no treatment. He watched the young girl die and in the spring and are also creating an alumni newsletter. made an unspoken promise that he would help figure out vexing “Our residents are a community of people proud of where they cancers. He never returned to India to take care of that country’s came from,” said Ms. Spence. children. Instead, he transitioned from pediatric to adult hematology and moved his research and practice to LIJ Medical COMMITTED TO TEACHING Center. He stayed put on Long Island — and is still practicing Howard Kerpen, MD, a nephrologist and internist who medicine. Today, he is 82. completed his residency at LIJ Medical Center in the 1970s, grew up knowing he would follow his grandfather into medicine. LEARNING FROM OTHERS Doctors were scattered across many generations in his family, Dr. Rai credits his mentors for what he learned about the and his grandmother saw it as her role to turn every young practice of medicine and has offered a similar teaching philosophy person into a doctor. to his residents. He’s trained around 150 fellows during his 56- Following medical school, he memorized The Washington year tenure. Manual of Medical Therapeutics so that he would know the answer “You develop lifelong relationships with your mentors and to any question that might come his way during an interview. mentees,” he said. “It is always a privilege.” His first chance to exhibit his studying skills was at Montefiore Leaders within the North Shore-LIJ Health System agree, Medical Center in the Bronx. But he found himself ill-prepared and they recently set up an alumni program for residents. The to answer the first question posed to him: “Why do you want goals are to foster relationships with residents and fellows and to come to Montefiore?” He remembers that he paused and develop ways to keep them connected to the health system — stammered something about the excitement of the hospital and to maintain the bond that began when they started training. its affiliation with Cornell University. Unfortunately, the hospital The health system is also providing CME-credit opportunities had no affiliation with Cornell, and Dr. Kerpen subsequently had and will be able to tap into this well-educated pool for physician no chance of an affiliation with Montefiore. recruitment efforts. “That’s how I ended up at LIJ [Medical Center],” Dr. Kerpen said.

DOCTORING : ISSUE 2, 2014 9

We want to serve our alumni OUTREACH community as we grow as a health system. As part of that effort, we are looking for physician volunteers to help. — Andrew Yacht, MD, chief academic officer for the North Shore-LIJ Health System

Dr. Rai and Edward Meilman, MD, LIJ’s first chief of medicine, LASTING RELATIONSHIPS were his mentors. Like Dr. Rai, he never left. Dr. Kerpen has been Ira Udell, MD, now the chair of ophthalmology for the North furthering the continuing medical education of residents, staff and Shore-LIJ Health System, recalled his early years of residency at LIJ community doctors through the Bette and Jerome Lorber Center for Medical Center. He grew up on Long Island before he went to Tulane the Advancement of Medical Education at LIJ Medical Center. University School of Medicine in New Orleans. He came back to New Dr. Kerpen remembers his heady days of residency, when there York and took a series of odd doctoring jobs — medical officer on was a mandate to “experience what the patient feels,” he said, add- Riker’s Island, then on to a similar role (with different clientele) at ing: “So many of our projects are carried out with a goal to instill this the New York Stock Exchange. He was set to head south again when core value that we must understand our patients and make them he received an offer for a residency at LIJ Medical Center. After feel better on many levels.” his residency, he served as a fellow at Harvard Medical School’s Dr. Kerpen was presented with the 2014 Outstanding Volunteer Massachusetts Eye and Ear Infirmary, then returned to LIJ in 1981 Clinical Teacher Award by the American College of Physicians. That to accept its first full-time position in ophthalmology. organization searches the country for a physician who embodies a Dr. Udell remembers the day before he began his residency. He was consistent commitment to teach medical students and residents. in the library at LIJ Medical Center when a gentleman approached The aim is to identify a doctor — a role model and mentor — whose and introduced himself. efforts epitomize care and compassion at the bedside and strong “You look like you are starting your residency tomorrow,” the one-on-one relationships with patients. The organization found man said. “You look a little nervous. Don’t worry, I will make sure Dr. Kerpen, who has practiced well what his mentors taught him as everything is O.K.” a resident. That man was Dr. Kerpen, a year ahead of him in training. During the last four decades, things have changed in residency Dr. Udell’s department has kept detailed records of every resident programs. In Dr. Kerpen’s day, residents could spend more time who has been through its program. It publishes an ophthalmology with their patients. They didn’t need to manage the heavy adminis- alumni newsletter. trative load that exists now. Today, resident hours are limited, and “I think it is important for residents to stay connected,” Dr. Udell they have more patients to see. said. “This is where they learned how to be specialists. Residency “It is more difficult to instill that feeling of dedication, but that is prepares us to establish long-term relationships with our patients our daily goal,” Dr. Kerpen said. and with each other.”

Anyone interested in contributing to the alumni program can contact Cheryl Spence at We need you! 516-465-3251 or [email protected].

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10 OUTREACH

COMPLEX CARE,by Colin Stayton Simplified Solutions THE NORTH SHORE-LIJ HEALTH SYSTEM’S NEW CARE MANAGEMENT ORGANIZATION WORKS TO OPTIMIZE ALTERNATIVE REIMBURSEMENT CONTRACTS FOR PHYSICIANS BY CLEARING THE WAY TO EFFECTIVE ADMINISTRATION OF COMPLEX PATIENT CARE.

orth Shore-LIJ Care Solutions launched earlier this “Most of our reimbursement still comes from fee-for-service con- year as a complement to the health system’s new tracts, but we’re in the middle of a transition period,” Mr. Schulman insurance company, North Shore-LIJ CareConnect. said. “Those fee-for-service arrangements are quickly evolving into N Care Solutions is a bridge between the health system’s either modified risk arrangements or fully capitated contracts.” business initiatives and care delivery services. The care management In today’s environment of rapid reform in the health care field, organization will help smooth collaborative efforts among all a care management organization such as Care Solutions can have involved parties, including the health system, the North Shore-LIJ substantial effects on a health system’s finances. CareConnect Insurance Company, outside insurance companies “The pace of change in the commercial market is far outpacing and North Shore-LIJ physicians. what’s happening in Medicare,” said Dr. Smith. “Medicare and the “Care Solutions bears responsibility for the implementation, Affordable Care Act unleash permission for insurance companies performance and value-based outcomes of all our alternative re- to move quickly and share in higher quality and lower costs. In imbursement contracts and programs across the health system,” two to four years, North Shore-LIJ will have a substantial amount said Joseph Schulman, executive director of Care Solutions. “Our of revenue tied to our ability to manage populations across the alternative reimbursement portfolio is growing rapidly, and we be- continuum of care.” lieve Care Solutions will fully prepare us to handle the complex care needs of our patients.” BY PHYSICIANS, FOR PHYSICIANS As Mr. Schulman notes, Care Solutions is interwoven with the TEMPERING THE TRANSITION fabric and culture of the health system’s physicians. For example, Mr. Schulman, who previously served as executive director of Care Solutions is organizationally centered on the office of David The Zucker Hillside Hospital, and Kristofer Smith, MD, medi- Battinelli, MD, North Shore-LIJ’s chief medical officer. cal director of Care Solutions, will oversee North Shore-LIJ’s care “It’s really important to observe Care Solutions’ strong connection management strategy for Care Solutions. Dominant factors in that to physicians, because it shows that North Shore-LIJ’s approach strategy, Mr. Schulman said, include staying abreast of the evolv- differs from those of other health systems,” Dr. Smith said. “It also ing insurance markets and helping physicians meet the demands of speaks to one of the core values of the organization — something alternative reimbursement. Mr. Schulman and I personally believe in — which is to support

DOCTORING : ISSUE 2, 2014

11 OUTREACH

and amplify the ability of our providers to be One of the opportunities good partners and stewards to their patients. We know our providers want to deliver higher quality care at a lower cost. We’re here inherent in starting an to figure out how to help physicians do that as they move through this transition period insurance company within a from volume to value.” Dr. Smith is familiar with value-based population management. As vice president health system is that you can and medical director for advanced illness management at North Shore-LIJ, he oversaw the medical components of leverage the expertise of both complex patient care and brought the health system’s Advanced Illness Program the insurance company and to national prominence. In his new role with Care Solutions, Dr. Smith will report to Dr. Battinelli and work closely with the provider network. Through CareConnect to interface with providers on a patient-care level. Care Solutions will deploy team members to help physicians Care Solutions, we aim to play navigate specialty services and programs for high-risk patients. to the strengths of both sides “Physicians’ offices must consistently sat- isfy guideline-recommended best practices to maximize reimbursement,” Dr. Smith of the equation. said. “We will work directly with physicians and their staffs to help doctors’ offices fulfill the prescribed best practices and maintain — Kristofer Smith, MD, medical director of Care Solutions the highest possible revenue stream.”

BETTER CARE MADE SIMPLE Enabling physicians to deliver care in a consistent, measurable way will make pay- for-performance arrangements through both North Shore-LIJ CareConnect and third-party payors more lucrative and less resource-consuming for small practices, Support for Complicated Cases said Mr. Schulman. “Our priority is to educate our providers North Shore-LIJ Care Solutions’ physician-facing services include: about the changing landscape,” Mr. Schulman »» Coordinating smoother care transitions between inpatient and outpatient said. “We want to make sure they have settings for patients with chronic illnesses everything they need to optimize patient »» Educating community physicians about effective population management care in light of changing incentives.” »» Helping physicians connect high-risk patients with key risk-reduction programs »» Helping physicians implement more efficient workflows and care protocols »» Leveraging North Shore-LIJ’s centers of clinical excellence and other assets For more information about North Shore-LIJ to better manage complex patient populations CareConnect, call 855-706-7545 or visit »» More fully integrating practices into both the North Shore-LIJ Health System nslijcareconnect.com. and North Shore-LIJ CareConnect

ISSUE 2, 2014: DOCTORING 12

OBESITY Special Section

SPECIAL SECTION:

ACCORDING TO THE CENTERS FOR DISEASE CONTROL AND PREVENTION, MORE THAN ONE-THIRD OF AMERICAN ADULTS ARE CONSIDERED OBESE. AS OBESITY RATES CONTINUE TO RISE IN OUR REGION AND NATION — AND ASSOCIATED HEALTH ISSUES BECOME MORE PREVALENT THROUGHOUT OUR HEALTH SYSTEM AND OTHERS — THE NORTH SHORE-LIJ HEALTH SYSTEM AND ITS ASSOCIATES ARE FACING THE GROWING PROBLEM HEAD-ON.

OBESITY Special Section TIPPING THE SCALES Against

Obesityby Jamie Talan

BY THE TIME ANNA HIT he extra weight was showing itself in ways that went beyond her appearance. Her blood pressure was up. Her HER 50s, SHE’D SPENT sugars were high. And her cholesterol numbers were well THE BETTER PART OF T above normal. That 35 pounds had to go. But how many HER LIFE BATTLING times had she made that promise to herself, dieted, lost the weight, then gained it all right back? THE SCALES. “This time has to be different,” she told herself.

OBESITY Special Section She signed on with the Center for Weight Management may also be recommended for certain patients. (To qualify for at Syosset Hospital and, for the first time in decades, began bariatric surgery, patients must go through six months of a the behind-the-pounds work to understand what led to her medically supervised weight-management program and meet weight gain. During her initial visits, she worked with a team other requirements.) — endocrinologist Maria Peña, MD; Christine Santori, RDN, At the Center for Weight Management, patients see members program manager at the Center for Weight Management; and of the team weekly for the first four weeks and then meet psychologist Willo Wisotsky, PhD — to identify her bingeing monthly with Dr. Peña. They can always meet with any of the triggers and develop a realistic diet and exercise plan. It seems to team members to address any challenges. Patients can also attend be a plan that works. She’s already lost 20 pounds, and all of her weekly classes while in the program, which spans a year. blood work is heading in the right direction. The center launched last July, and its patients have collectively lost more than a thousand pounds. Many patients have been able A WEIGHTY PROBLEM to lower intake of their cholesterol and diabetes medications. And With obesity rates at an all-time high, North Shore-LIJ Health more importantly, Dr. Peña said, “they are making changes that System physicians are dealing with an increasing number of positively affect their medical problems.” obesity-related medical problems, including heart disease, type 2 diabetes, inflammation, cancer and stroke. The Syosset Hospital SYSTEM-WIDE EFFORTS weight management program was established last year as a Other initiatives within the health system are also helping resource for health professionals who might not have the time or patients lose weight: expertise to help their patients lose weight. About 80 patients are COOKING DEMONSTRATIONS AT SOUTHSIDE now part of the program. HOSPITAL: Southside Hospital has a Healthy Community As Dr. Peña sees it, “there’s a lot of insensitivity toward obese Cooking Program that provides instruction on how to prepare patients from the moment they step into a waiting room.” The healthier meals. The free program combines nutrition instruction chairs are too small; the exam table is too narrow. Patients often with cooking demonstrations (complete with feasting) for tip the scales during the exam. community members and organizations. Leah Pasquarella, RD, “The stigma is palpable,” Dr. Peña said. “Many health care Southside Hospital’s chief clinical dietitian, coordinates the providers think their obese patients are lazy and lacking in self- program with skilled culinary food service team members. control. They don’t know how to help them beyond the obvious The classes cover nutrition and wellness topics like the healthy advice: Lose weight and exercise.” lunchbox, fighting fatigue, gluten-free diets and vegetarian Dr. Peña trained in endocrinology and finished her residency eating. After a successful cooking demonstration for the Southside in 2013. She was drawn to the challenge of helping her diabetic Hospital Stroke Support Group last year, Ms. Pasquarella and patients lose weight, and she signed on to direct the new Center her colleagues now offer similar presentations to other support for Weight Management. Dr. Peña is board certified in obesity groups for brain injury, heart and diabetes patients. medicine, one of roughly 500 such physicians in the country. GUIDANCE FOR THE PROS AT LENOX HILL HOSPITAL: The program begins with a medical assessment to identify any Lenox Hill Hospital has implemented a cooking program for potential hormonal causes of obesity, conduct metabolic testing doctors and other health professionals. See page 22 to read about and screen for vitamin deficiencies. Once any medical issues are internist Robert Graham’s work transforming the way residents established, the dietitian reviews the patient’s food intake and and other health professionals think about food as medicine. provides detailed information about the nutritional value of HEALTH SYSTEM TACKLING DIABETES: More than one- common foods. Ms. Santori, who is also a certified personal trainer, third of American adults tip the scales at an unhealthy weight. tailors a realistic meal plan and helps outline an exercise plan. This obesity epidemic has gone hand-in-hand with a rise in Dr. Wisotsky, the health psychologist, then conducts an metabolic syndromes, including Type 2 diabetes. assessment that focuses on identifying behavioral issues According to Tracy Breen, MD, chief of endocrinology and associated with unhealthy overeating. She helps the patient director of diabetes care for the North Shore-LIJ Health System, identify the cues that trigger food intake and offers strategies her team recently launched the Diabetes Wellness Program, for stress management. which offers courses on healthy eating, exercise, medication “True lifestyle modification occurs when a change in food management and weight control. The team is also collaborating intake and physical activity takes place as a result of changes in with New York State on implementing a Diabetes Prevention attitude, knowledge and emotions,” Dr. Peña said. Program, and it has been working to educate medical staff to pay The team monitors weight loss and any complications that attention to risk factors that lead to diabetes. might result, including gallstones and gout. If patients have “When patients are overweight, even a small amount of weight difficulty losing weight through behavioral interventions, the loss — around 10 percent — can improve how their bodies use team may decide to prescribe weight-loss drugs. Bariatric surgery insulin,” Dr. Breen said.

Special Section In chart reviews conducted on 603 children and adolescents between the ages of six and 18 who had been hospitalized at Cohen Children’s Medical Center during a six-month period in 2012, 1 in 5 CHILDREN WERE OBESE.

KATZ INSTITUTE FOCUSES ON PREVENTION: The Katz records to see whether their health care providers had documented Institute for Women’s Health is committed to helping patients get the problem of obesity. healthier through proper fitness and nutrition. They conducted chart reviews on 603 children and adolescents be- “Every prevention initiative should focus on the whole woman,” tween the ages of six and 18 who had been hospitalized during a six- said Stacey Rosen, MD, vice president for women’s health at the month period in 2012. They collected data on gender, height, weight, institute, located on the LIJ Medical Center campus. body mass index, discharge diagnosis and the admitting specialty. The institute’s nutritionist works with doctors and patients on “One-third of our patients were overweight or obese,” said strategies for preventing a number of medical conditions, including Dr. Feinstein. “One in five children met the national guidelines for obe- Dr. Rosen’s specialty: heart disease. sity. And most of our residents don’t know anything about nutrition.” “It’s clear that lifestyle changes offer the best way to prevent Additionally, physicians were mostly ignoring the heft of the heart disease and diabetes,” she added. kid in the room. Only 0.9 percent of overweight or obese patients COMMUNITY COLLABORATION: The health system works had a documented discharge diagnosis of overweight or obesity, with a low-income community in Manhasset to help residents make Dr. Feinstein said. And only 13.2 percent had documentation of healthier food choices and exercise more. In addition to starting a increased weight status noted elsewhere in their medical record. walking group, the initiative collaborated with local churches and The chart analysis also suggested that none of the patients were Head Start to open a farmer’s market. More than 2,000 people referred for weight counseling during their hospitalization. attended the weekly market between July and October last year. In an initiative addressing the findings of Dr. Feinstein’s “We are starting to make progress in changing behavior,” said study, Henry Bernstein, DO, Pamela Reichert-Anderson, RD, Nancy Copperman, the health system’s corporate director of public and their team at Cohen Children’s are partnering with primary health initiatives in the Office of Community and Public Health. care pediatric practices at Staten Island University Hospital and “It is a process.” the Suffolk County Department of Health to improve providers’ A health survey conducted across Long Island identified a major screening, identification and treatment of pediatric overweight unmet need: treatment for obese patients with chronic medical and obesity. This initiative is supported by a grant from the problems. This led to the health system offering a seven-week New York State Department of Health. course on chronic disease self-management. Through this program, Child obesity is worrisome on many levels, Dr. Feinstein added. hospitals in the health system are targeting young patients who are showing up with conditions once only seen in adults. APPROXIMATELY 50 TO 77 TARGETING CHILDHOOD OBESITY: Ronald Feinstein, MD, PERCENT OF OBESE CHILDREN medical director of the Weight Management Program in Adolescent Medicine at Cohen Children’s Medical Center of New York, has also AND ADOLESCENTS BECOME taken on the challenge of childhood obesity. He and a few of his PERSISTENTLY OBESE ADULTS. Cohen Children’s colleagues — Devora Azhdam, MD, pediatrician; Iris Reyhan, MD, pediatrician; Jamilah Grant-Guimaraes, MD, Education and weight management programs can work, but pediatrician; and Carly Mayer, PhD, psychologist — set out to exactly what works best is still not known. Dr. Feinstein said that look at the prevalence of obesity among children and adolescents he is working to implement a comprehensive treatment program at admitted to the hospital and to evaluate the children’s medical Cohen Children’s.

OBESITY Special Section

Leading By EXAMPLE by Jamie Talan

A GROWING GROUP OF FITNESS-MINDED NORTH SHORE-LIJ PROFESSIONALS IS TAKING THE OLD SAYING “PRACTICE WHAT YOU PREACH” TO NEW LEVELS. HERE, WE TAKE A LOOK AT TWO HEALTH SYSTEM PHYSICIANS WHO ARE GOING WELL BEYOND WALKING THE WALK. Photo by Sportograf

Alessandro Bellucci, MD, is among a number of health system employees who compete in cycling races together.

udo” means “the gentle way” in Japanese — and to The work he puts into sports has taught him humility and Paul Wright, MD, director of clinical performance im- respect for the team. provement at Cushing Neuroscience Institute, there “We are all in the same game together,” Dr. Wright said. “J is something soothing about being taken down to the “You get to the end by helping people and allowing people to ground by an opponent and finding the motivation within to help you.” get up again. That is why he was drawn to judo as a child. Dr. Wright is also among a growing number of health care The passion for martial arts that began at a young age professionals who are competitive cyclists, runners and stayed with him through his college years at Cornell Univer- swimmers. Dozens of them have joined forces to create a sity, where he was part of the judo team, and into his doctor- North Shore-LIJ triathlon team. Through their athletic ing years, when he took up kendo, a Japanese martial art that endeavors, they often raise money for worthy causes and, more incorporates bamboo swords and protective gear. importantly, raise awareness so that people can be healthier.

/////////// SPECIAL SECTION: OBESITY /////////// SPECIAL SECTION: OBESITY /////////// SPECIAL SECTION: OBESITY /////////// SPECIAL SECTION: OBESITY /////////// SPECIAL SECTION: OBESITY /////////// SPECIAL SECTION: OBESITY //////// ISSUE 2, 2014: DOCTORING Special Section DOCTORING :ISSUE2,2014 18 18 OBESITY athletes from more travel 75countries than to Israel to compete fourthe Maccabiah Games years, 9,000Jewish inIsrael. Every Dr.and Alzheimer’s competed in associations. also has Wright problems. He’sneurological raised more $20,000for than stroke mind,” Dr. for example “Iwant said. agood to my set Wright patients.” hisbody. hismind allhelpshimclear andit strengthen — The steady pace, himself pushing theof thechallenge movement, and endurance ateam you without pushing toward the finishline. could follow to atriathlete. becoming doing allthree. there And he started decision, was it —apath he and like inwhat nowasplit-second seems and running, swimming ways.in other Since he could remember, he had loved cycling, andraising he wanted —and mind to—moving hisbody kids, get moresomething to stay He inshape. was workinglongs hours and exercise.of practice Life Island. in the way got on Long and aneurology joined afamily started Medicine.at He of Mount School Sinai married, inthe game. heart —to to not work disappoint hardhe learned hishead and keep and years, school hismedical judo team during competition-winning at Facultyschool the Sackler Medicine in Tel of Aviv. a of part As inthe Israeli before Army goingyears to old medical and served DRIVEN TO INSPIRE He to competitions raise uses for money patients with me focused, motivated keeps my and“It in tune with and body Training for races to led has even more life lessons: commitment wasn’tIt Dr. until wasto inhis30sthat he decided do Wright In 1996, Dr. moved to Wright New York his residency and began Dr. moved to inScotland, up grew Israel Wright whenhe was 16

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THE FIRST STEP IS TO SUPPORT GOING OUTSIDE AND TAKING A WALK, JUMPING ON A BIKE OR GOING FOR A SWIM. IT WILL MAKE ALL THE DIFFERENCE IN THE SPECIAL SECTION: WORLD. tells them hisstory. He listens to He theirs. educates. He advises. todoor aconversation exercise. healthierthrough getting about He apatient the the pictures, as it says about he uses something When room inaction. His exam isreplete scenic photos cyclists with of He’ssion for sports. and swimming. had patients take cycling up patients. Anyone Dr. who knows heard has his pas Wright about all the difference inthe world.” jumping on abike or going make for will awalk, It taking aswim. at prevention. outside good going and The first issupport step to Work Day. Your thesystem health includethrough aBring will to Bike He to the push hopes promoteAlzheimer’s Association. exercise the NewAlzheimer’s, of an initiative York chapter the of City was time,” Dr. said. Wright Dr. to decided enter the New Wright York Ironman Triathlon. City ishaving time.” agood wheneveryone “I amhappy four more before competitions the year isout. marathonin a half He Island. to up participate issigned on Long year, competed heinanIronman has and Triathlon inNew Orleans to which around. he plans time entercompetition, the next This he found the trip, that out there group. in hisage During isajudo 47, Dr.of 62 andcame inninthout the triathlon finished Wright the “Jewish called in what been has Olympics.” year, Last at age That difference seen in the ofhis some be of facesbodies can and “Physicians are at fixingthings,” good we aresaid. “But he not He raisingmade through, it for money Athletes to End and I had always“My thisrace, friends talked about and now it trainingIn 2012,after triathlon and adecaderacing, of really I amnot “I like to competitive,” compete, although he said. OBESITY ///////////

–Paul Wright, MD, director of clinical

Cushing Neuroscience Institute

performance improvement at SPECIAL SECTION:

OBESITY -

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OBESITY Special Section His gentleness and enthusiasm are often just enough to get them race, which has roots in Italy, had arrived in New York only a thinking — and start them doing. few years earlier, running from the George Washington Bridge One patient was carrying more than a hundred pounds of extra to Bear Mountain and back. They raised $15,000 for the That weight, which had led to spinal cord compression. He had just en- Others May Live Foundation, which provides financial aid and tered his fifth decade and was already having problems walking. Af- other support to families of US Air Force Rescue Airmen who ter neurosurgery to decompress his spine, he turned his life around. died in the line of duty. He lost the weight. He is no longer hypertensive or diabetic. And “That was the start of something big,” Dr. Bellucci said. “We every once in a while, Dr. Wright will see him at a race — in the wanted to introduce people to the sport.” race — and nod, smile and feel the magic of being out on the road. Last year, the group competed in several races, including a return to the Gran Fondo. Dr. Bellucci, who was 63 in 2013, CENTERED ON TWO WHEELS finished fifth in his age group. But his favorite race of the year was Alessandro “Sandro” Bellucci, MD, executive director of North a 56-mile ride in the Italian Alps. He wore his North Shore-LIJ Shore University Hospital, is also a triathlete. As a young boy grow- cycling kit. ing up in Florence, Italy, Sandro would spend summers with his sis- Keeping fit is part of Dr. Bellucci’s professional life, too. As a ter and their 21 cousins playing soccer and cycling. nephrologist, he sees a lot of people with high blood pressure Bicycles were his first love. Before he ever balanced himself on and kidney disease. two wheels, he’d watch his father, a general practitioner, cycle with “Una mente sana in corpo sano,” he says, quoting a phrase he friends. One of them was Gino Bartali, who would later win the Giro heard over and again as a child. “‘A sound mind in a healthy d’Italia (Tour of Italy) three times and the Tour de France twice and body’ — it’s very important. We teach our patients how to who, during World War II, helped Jews who were being persecuted exercise and take good care of their minds and bodies.” by the Nazis and carried messages and documents to the Italian Re- sistance on his bicycle. The North Shore University Hospital Department of Medicine What the young boy — and later the doctor — loved about just published a magazine highlighting a dozen health system cycling is that once you are on wheels, it doesn’t matter what you athletes. To get more information on the triathlon team, contact do in life. Jonathan Meyer at [email protected]. “It is a great equalizer,” he said. For the Bellucci men, bicycling was replete with life lessons. You grabbed your bike knowing that you would be pushed to exhaustion. You would be cramped and hungry, and still you would ride on. “We understood that riding was a way to learn how to balance challenges and stay in control,” Dr. Bellucci said. “Bicicletta maestra di vita,” his father would say. (“The bicycle is a teacher of life.”) In 1976, after medical school, Dr. Bellucci left Florence for the United States. When he moved to Long Island for a nephrology fellowship at North Shore University Hospital in 1979, he couldn’t believe his cycling luck. He’d been in the city, where it was hard to ride, for three years. But the North Shore of Long Island had a cycling tradition, and soon he was taking to the back roads on a daily basis. He found colleagues at the hospital who shared his passion. Dr. Bellucci loved a good race, but mostly he just wanted to ride. In 2011, he found another cycling companion in Luis Rivera, an ad- ministrator in the hospital’s Department of Medicine. Mr. Rivera had a mountain bike. Within months of establishing the new friendship, he bought a road bike. Around that time, the health system was sponsoring the Walk to Paris fitness challenge, and Mr. Rivera had the idea of forming a sports team of staff members from the health system hospitals. It was in keeping with promoting wellness, and Mr. Rivera knew enough interested cyclists to get started. About a dozen North Shore University Hospital Department of Medicine employees met to discuss an inaugural race. They decided on the Campagnolo Gran Fondo New York 2012. The 100-mile bike Paul Wright, MD

OBESITY Special Section

PLANby Justin Rosati OF ATTACK

JUSTIN ROSATI, A MEDICAL STUDENT AT THE HOFSTRA NORTH SHORE-LIJ SCHOOL OF MEDICINE, DISCUSSES HIS BATTLE WITH — AND TRIUMPH OVER — OBESITY.

submitted my application to medical school more the bunch and carried the extra than two years ago. While my goal was to make weight in more ways than one. sick people better, I was anything but the picture of I was no longer the norm. Others in I health. With a BMI of 35, I had long ago surpassed my home and school life reinforced Courtesy of Justin Rosati what a physician would call a healthy weight. Yet there that I was now different. From then I was, pursuing a career in which I would tell others on, it just seemed to snowball. By the time I reached college, how to be healthy. I knew there was something inher- I had put on the “freshman 15” and then some. ently wrong with the situation, and I felt it every time a In addition to being unhealthy, carrying the extra school requested my picture in advance of an interview weight prevented me from being taken seriously in or when I talked with other applying students. I believed many avenues and being able to do many things I want- they had an advantage over me simply because they did ed to do. By my senior year of college, I was complacent. not look like me, because they knew how to stay healthy. I figured my weight was at its set point. I told myself, Trust me when I say my weight problem did not hap- “I am who I am,” and accepted it as something I would pen overnight. As a child, my mom always said I was deal with for life. But I was also afraid. I feared that my “skinny as a twig.” At five years old, I was underweight, weight would keep me from doing the one thing I had active and a picky eater. But things changed. By the wanted to do since childhood — become a doctor. time I reached middle school, I was the heavy kid in During my first medical school interview, I was

Let’s consider a different approach. Maybe we should treat weight loss as we treat diabetes. A BATTLE OF THE BULGE VETERAN OFFERS A

DOCTORING : ISSUE 2, 2014 /////////// SPECIAL SECTION: OBESITY /////////// SPECIAL SECTION: OBESITY /////////// SPECIAL SECTION: OBESITY /////////// SPECIAL SECTION: OBESITY /////////// SPECIAL SECTION: OBESITY /////////// SPECIAL SECTION: OBESITY //////// 21 OBESITY PLAN OF ATTACK Special Section extremely self-conscious. Everyone in the room was on modifications are the first line of treatment for many an equal playing field intellectually, but I stood apart metabolic diseases. Patients receive pamphlets on proper aesthetically. I knew that if I were going to care for diet and exercise and are asked to follow up in a few patients, I had to do something about my own health. months. When the patient returns, weight unchanged, a That was when I decided to make a change. natural assumption is that the patient was noncompliant with the doctor’s suggestions. BEGINNING A NEW WAY OF LIFE I speak from experience when I say, more often than It was my last semester of college, but I wouldn’t not, this is not the case. Chances are that the patient tried be coasting. Instead, I vowed that I would accomplish more than once to bring the weight down but became something I had failed to achieve so many times before. frustrated and hopeless at some point on the journey, I changed my diet and began exercising much more. My and physician reactions to failed weight-loss attempts goal? By the time medical school started, I wanted to were not reassuring. be in charge of my own health. I lost 30 pounds by the As physicians (and physicians-to-be), we are often un- start of my first class. It was a huge accomplishment, aware of the extent to which becoming healthy and losing but I still felt out of place at orientation. Clinically, I was excess weight can be burdensome for patients. Sure, diet still obese. and exercise will help with weight loss — but are patients I planned to maintain my new and improved lifestyle, aware of exactly how much their lifestyles need to change but the rigor and routine of medical school made it tough. to start seeing results? When physicians tell obese people I lost another five pounds during the first few months of to get 30 minutes of exercise three to four times a week school, but I had difficulty managing my time or take 10,000 steps a day, do they really know what they and stress and soon found myself slipping are asking? back into old patterns. I was regaining weight If you are like me, you will be surprised to learn that by Christmas. walking 30 minutes at least three or four times a week will It was only after taking a course get you nowhere near the recommended 70,000 weekly about nutrition, metabolism and steps. Yet a patient will try walking a few times a week weight management that I was able and, seeing no real results, become frustrated and give up. to get back on track. I started manag- This is not for a lack of trying on the patient’s part. ing my time more effectively Radical diets are also likely to fail. New calorie Let’s consider a and adhering to the routine restrictions — limiting portions, cutting out fat and that was so effective in the past. sweets — may seem doable to the physician but require different approach. One year later, I have lost 50 more quite a large shift for many patients. The patient may Maybe we should pounds. My BMI is 23. restrict his or her diet for a few days or even weeks at the treat weight loss as My experience gives me a unique physician’s direction, but soon exposure to foods that are perspective when talking to patients not on the plan begins to take a toll. we treat diabetes.about medical problems directly related to their Let’s consider a different approach. Maybe we should girth. I understand. And with this knowledge, I treat weight loss as we treat diabetes. When patients first can begin the talk and help them on their own roads to come in with elevated A1C results, we look to control good health. their disease with one medication, then another, then additional options as necessary. The same can be done A NEW KIND OF PRESCRIPTION with a diet plan. Physicians can suggest first cutting out An increasing number of Americans are facing the “you sugary drinks, then, after a few weeks, replacing breads should really try to eat healthier and exercise more” conver- with whole grains and eventually substituting for red sation when they visit their physicians. Patients have meat with more lean proteins. grown to expect this conversation during their annual From a medical student who once struggled as physicals and, if they are anything like me, they dread a patient, here is the prescription I endorse: Ask hearing those words every time. patients to eat healthier and exercise more — and Weight loss is often seen as a simple solution to offer praise for those incremental steps along a complex problem. For many physicians, lifestyle the way.

OBESITY Special Section

Robert Graham, MD, spearheaded an initiative to create rooftop gardens at Lenox Hill Hospital.

Photos by Christian Johnston and Julie Graham

OBESITY Special Section COOKING UP

HEALTH by Jamie Talan

Rooftop farms are taking this concept a step forward. The green roof movement has made its way here to New York City, and Lenox Hill Hospital is a leader in the movement. —Robert Graham, MD

OBESITY Special Section FOR ONE LENOX HILL HOSPITAL INTERNIST, WELLNESS STARTS IN THE KITCHEN — WHERE ALL DOCTORS COULD LEARN A THING OR TWO.

obert Graham, MD, the Lenox Hill staff internal urban farmer. This spring, Lenox Hill Hospital chefs began medicine physician who directs integrative health gardening and picking the herbs, fruits and vegetables. They and therapies at the hospital, also holds vegetarian showcase them at a local farm stand and use them in their R cooking classes for residents, coordinates yoga recipes at the hospital. and meditation programs for hospital employees, and has “Rooftop gardens have a long history in health care — fashioned a hospital rooftop garden filled with vegetables and especially in Europe — of providing employees and patients herbs for use in meals prepared by Lenox Hill Hospital chefs. with a tranquil place to reflect and recover,” Dr. Graham said. His ultimate goal: rooftop to bedside. “Rooftop farms are taking this concept a step forward. The “Nutrition is marginalized in medicine, even though every green roof movement has made its way here to New York talk with our patients starts with questions about diet and City, and Lenox Hill Hospital is a leader in the movement. exercise,” said Dr. Graham, who along with his wife keeps a “At Lenox Hill, we pride ourselves on taking steps vegetarian home. “Nutrition plays a major role in the treatment to help alleviate healthcare ‘burnout,’ which has real- of existing diseases and in staving off new problems.” life consequences for our patients,” he added. “Through Dr. Graham has been cooking up ideas ever since he initiatives such as the Lenox Hill meditation and yoga arrived at Lenox Hill Hospital in 2008. Each year, he invites programs and healthy cooking classes, we have been at the 13 Lenox Hill Hospital residents to join a class where he forefront of wellness.” teaches them healthy cooking. Geared toward a plant- Dr. Graham’s vision brought two closed rooftops at based diet and hosted by the Natural Gourmet Institute, Lenox Hill Hospital to life last summer. Collectively dubbed the program includes weekly lectures on nutrition. Last “Victory Greens,” one garden is located on a fourth-floor year, under Dr. Graham’s direction, top chefs from all of rooftop at the hospital, the other on a seventh-floor rooftop the North Shore-LIJ Health System’s kitchens mastered of the multilevel hospital complex. The gardens have since techniques to incorporate plant-based foods into their been featured by numerous news outlets, including NY1, daily patient menus. NBC 4 New York and Fox 5 News. Dr. Graham recently took his nutritional pursuits to new Both offer tranquil seating and fertile beds planted heights. Inspired by several rooftop gardens in New York with tomatoes, zucchini, kale, lemongrass, other herbs City, he saw a barren space on the roof of Lenox Hill Hos- and spices. With Ms. Monji’s help, hospital employees and pital and imagined a place rich in soil, rooted plants and volunteers water and maintain the gardens daily. walking gardens. He headed down to his office to draft his As for the program’s future, Dr. Graham envisions doctors, plan and later handed it to hospital administrators. They nurses, staff and volunteer farmers growing produce and ate it up. Last summer, Lenox Hill Hospital created the first running an educational rooftop farm. Here, he hopes to see hospital-based rooftop garden in New York City. hospital representatives teach community groups, schools, businesses and individuals how to create and maintain their NEW IDEAS TAKING ROOT own urban gardens, as well as share information about the Dr. Graham’s wife, who offers yoga and meditation benefits of local, organic food production and medicinal classes for Lenox Hill Hospital staff members, met plants and herbs. The food will go from the garden to the organic gardener Kristin Monji at New York City’s Urban cafeteria and into local community-supported agriculture Agriculture Conference, and the idea for the rooftop garden (CSA) programs. Expanding on his current efforts, he hopes took form. Dr. Graham brought in Ms. Monji, an expert on to someday have teaching kitchens all over the city to help all things organic, to help with the garden and serve as the patients learn how to eat better.

OBESITY Special Section

TABLET-EXCLUSIVE PHOTOGRAPHY TABLET-EXCLUSIVE VIDEO

Photos by Christian Johnston and Julie Graham

The Stage Doc Physician/Playwright Makes Albert Einstein

Sing by Jamie Talan

MEDICINE IS MY LAWFUL WIFE AND LITERATURE MY MISTRESS.

— RUSSIAN PHYSICIAN AND WRITER ANTON CHEKHOV

DOCTORING : ISSUE 2, 2014 2727 ART & SCIENCE ART

BURT ROCHELSON WAS A KID WITH A VOICE. NOT A GREAT VOICE, MIND YOU, BUT A GOOD ONE THAT HE BELTED OUT FROM CENTER STAGE DURING HIGH SCHOOL PLAYS AND REGIONAL THEATER PRODUCTIONS.

he Brooklyn boy took to directing and writing lyrics for so concerned about school musicals. He joined a large band of New York City- his friend’s well- area high school students who participated in an annual being that he wrote T student-run musical production — SING! — with a his- to the board of the tory of giving voice to the likes of Carole King, Barbra Streisand and Netherlands’ Leiden Paul Simon. University, where Today, decades later, Burt Rochelson, MD, chief of obstetrics Ehrenfest served as and maternal/fetal medicine for North Shore University Hospital, a professor, to has written The Rule of Disorder, a play that went into workshop suggest a reduced production in March as part of the New Musicals Project at the workload might Patchogue Theatre for the Performing Arts. take pressure off his The idea for the play was sparked one moment in 1990 during a friend’s psyche. visit to his aunt’s small Brooklyn apartment. “I remember thinking But it wasn’t only the time was right to get back to writing and I would write about the the pressure of work first thing I saw,” Dr. Rochelson said. That turned out to be a thick affecting Ehrenfest. book with red cloth binding in his aunt’s packed bookcase. It was a Life for Jews in Eu- biography of Albert Einstein. In it was a small paragraph about the rope became increas- tragic life of another theoretical physicist, Paul Ehrenfest. ingly uncertain in the period leading AN UNFINISHED STORY up to Adolf Hitler’s Intrigued, Dr. Rochelson dug deeper. He read Paul Ehrenfest: The ascension to Ger- Burt Rochelson, MD, has written a play that went into workshop production in March. Making of a Theoretical Physicist: Volume One, which covered the rich man chancellor in and heady story of the Vienna-born physicist up to 1920, when a January 1933. And with Nazi power and anti-Jewish sentiment then-40-year-old Ehrenfest was making his mark. Written by Yale spreading throughout Europe, Ehrenfest feared what the Nazis University science historian Martin Klein and filled with examples might ultimately do to someone as helpless as his boy with Down of moving correspondence between Einstein and Ehrenfest, the syndrome. In late September, a despondent Ehrenfest took his son’s book also covered the lesser-known physicist’s life with his wife, life and then turned a gun on himself. Russian mathematician Tatyana Afanasyeva. She was Ehrenfest’s The tragic story resonated with Dr. Rochelson, whose physician collaborator in work and in homeschooling their four children, father, a Holocaust survivor, immigrated to the United States at including a son with Down syndrome. age 40 after he lost his first family to war. While re-establishing From the moment he read the Ehrenfest bio, Dr. Rochelson was his practice, his father instilled in his two American-born children hooked. He closed the volume, wanting more, but couldn’t find a a passion for Russian playwrights and the conviction that man can volume two. He penned a note to the author and received a lengthy survive anything. by Jamie Talan letter back. “Sadly,” Mr. Klein wrote, “there is no second volume. It was not written. The story is too sad.” INSPIRATION FOUND Dr. Rochelson would soon discover why. A decade after the Dr. Rochelson knew he had the makings of a powerful play, events described in Mr. Klein’s first volume, correspondence but it had been more than a decade since he’d found the time between Ehrenfest and his friends revealed that the physicist and inspiration to write. He reminded himself of the high school had become deeply depressed. By August 1932, Einstein had become summer he spent studying theater at Georgetown University, his

ISSUE 2, 2014: DOCTORING 28 ART & SCIENCE ART

acting in local theater productions during college at Columbia are envious of each other — one the great family man but University and writing his first play during medical school comparatively limited thinker, the other the great thinker but a at the University of Michigan. Soon, he began writing again. limited father and husband, despite his love.” He enlisted his cousin Jonathan Glickman, an aerospace As the story unfolds, the characters reveal their thoughts engineer at the Goddard Space Flight Center and composer about the imminent war and the oppression of the Jewish who shares a love for music and theater, to write the musical people. We learn that Einstein is rejected in Germany as a score, and The Rule of Disorder was born. traitor, and the validity of his work is questioned. Ehrenfest’s “The play opens in the patent office in Bern, Switzerland, son is born with Down syndrome, and he feels devastated in 1909. The setting and characters are introduced by Jules, by this development. Einstein divorces his wife, and his two a master clockmaker,” Dr. Rochelson said, offering a synopsis sons shun him. The play portrays a close friendship between of the musical. “Jules is in charge of the ‘Bern Clock,’ set high two men who share a love for physics but differ markedly in above the patent office. The Bern Clock is the clock by which how they show love, admiration and commitment to their all clocks are set; it is the standard. Jules provides a running families. The Ehrenfests spend nearly everything they have narration throughout the play from a walkway beneath the to care for their disabled son. clock, high above the stage.” “Ehrenfest can no longer afford to pay for tutors for his Albert Einstein is at his first job in the patent office, other children,” Dr. Rochelson said. “He is afraid of the onset where he puts to music his heady thoughts about how the of fascism and fears what they will do to his son. Active in world works. getting prominent physicists out of Europe, he himself cannot “He sings of his obsession with figuring out how light, leave. Despondent and helpless, he sings ‘I Am What I Could time and space interact — theories scoffed at by most,” Have Been.’ He makes a decision. Desperate and without Dr. Rochelson said. hope, he shoots his son and then himself.” Later, Einstein visits his friend Paul Ehrenfest in Holland, In the final two scenes of the musical, Einstein is walking where he finds a happy home that offers sharp contrast to the on a beach toward his favorite place on Earth: a lighthouse. quietness of the Einstein home. The death of his friend has shattered him. Einstein is mindful “Music plays, students come in and out, people drop of Ehrenfest’s great body of work, which led him to conclude by for dinner,” Dr. Rochelson said. “Known as a great that all things tend to disorder. Einstein is about to set sail for teacher and physics professor, Ehrenfest cannot compare America, once again finding order in the chaos of life. his achievements with those of his brilliant and powerful “I am so excited by this production,” said Howard friends. He is, however, the consummate family man. He Beckerman, the producer and artistic director of the New desperately loves his two girls, Tanitschka and Anna, and his Musicals Project. He met Dr. Rochelson in 2000, when he wife, Tatyana, who is pregnant with their third child. created a contest for Long Island playwrights. Dr. Rochelson’s “His children are his life,” Dr. Rochelson said. “He proudly play won. shows them off to Einstein, in the song ‘They Love Music. Readings for Dr. Rochelson’s full-length play were They Love Math. They Love Me.’ He then suggests to Einstein presented in San Francisco and Los Angeles. It has been that they retire to the music room and play a duet on piano performed at the Stage One theater in St. James and at the and violin. There, they sing ‘I Wish I Were Him,’ in which both Huntington Town Hall.

TABLET-EXCLUSIVE VIDEO

DOCTORING : ISSUE 2, 2014 29 CULTURE

A Developing

Passion by Jamie Talan

age 17, in the company of his family, Alan Sloyer Dr. Sloyer takes his travels seriously. He, his wife and their friends took his first vacation abroad. He took along a go for the exotic and remote — and breathtaking has to be in the At Kodak Instamatic camera. The culture, the people mix, too. Sometimes, the time he spends snapping away can bring a and the landscape of Italy captivated the young man and sigh from his travel companions, but when they get home and see the marked the beginning of a lifetime of journeying to foreign photos, they understand. “Were we on that trip?” they’ve asked. countries, with cameras in tow. “I never considered myself a photographer,” Dr. Sloyer said. “I Forty years later, Dr. Sloyer, a gastroenterologist at North take pictures to remind me of a place or experience.” Shore Gastroenterology Associates, Glen Cove Hospital and Then, he realized he had an eye for both nature and human North Shore University Hospital, has captured beautiful nature — the land and the humans who inhabit it. pictures of subjects as diverse as ships, villagers and blazing A few years ago, he went to Bhutan and was captivated by a sunsets from 70 far-flung countries. Sophisticated Nikons have monastery perched on a sheer cliff some 900 meters above the replaced his easy-load Instamatic. Paro Valley. He fell in love with the ancient culture and its color- His photographs have appeared in The New York Times, fully dressed people, who impressed him as happy and quiet. The New England Journal of Medicine, Annals of Internal Dr. Sloyer and his entourage have toured India, Chile, the Medicine, Chronos and Eclat. His work has been shown at wine country of Argentina, Botswana, Morocco, Cambodia and several galleries on Long Island, with proceeds donated to a up and down the Andes. number of charities. Dr. Sloyer, a triathlete, also put together On a recent trip to Cuba, he spotted a vintage, sky-blue the annual Spin-a-thon fundraiser for colorectal cancer Chevy parked outside a church. He excused himself from his awareness and prevention that has generated more than present company — his son and brother — to capture images $150,000 for several charities, including the Ralph Lauren of the beautiful metal beast. Center for Cancer Care and Prevention and, most recently, Every one of his photographs tells a story, which is how it Michael’s Mission. should be. Next stop: Mongolia.

ISSUE 2, 2014: DOCTORING 30 CULTURE

CULTURE TABLET-EXCLUSIVE PHOTOGRAPHY

DR. SLOYER’S PHOTOS HAVE APPEARED IN PAST ISSUES OF NARRATEUR: REFLECTIONS ON CARING, AN ANNUAL LITERARY JOURNAL PUBLISHED BY THE HOFSTRA NORTH SHORE-LIJ SCHOOL OF MEDICINE. TO SEE MORE ORIGINAL WORKS OF FICTION, NONFICTION, POETRY, PHOTOGRAPHY OR ILLUSTRATION, VISIT NARRATEUR.ORG.

DOCTORING : ISSUE 2, 2014 3333 FIRST PERSON FIRST Q&A

by Ally Bunin

THIS PAST SPRING, CONGRESS PASSED A LAW THAT DELAYS ICD-10 IMPLEMENTATION UNTIL OCTOBER 2015 AS PART OF A BROADER BILL THAT PREVENTS MEDICARE REIMBURSEMENT CUTS TO PHYSICIANS UNDER THE SUSTAINABLE GROWTH RATE.

espite the delay, the health care industry in the United States remains in turmoil amid growing concerns over how to effectively and seamlessly D implement ICD-10. In particular, physicians face unique challenges to incorporate the granular documentation and coding standards into their practices. While the law prohibits the US Department of Health and Human Services (HHS) from adopting the ICD-10 code sets prior to Oct. 1, 2015, the North Shore-LIJ Health System continues to prepare for the eventual arrival of ICD-10. The health system will require all providers to complete education before the transition. In their own words, these physicians — from both the administrative and practice sides of the health system — frame the ICD-10 conundrum.

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THE PHYSICIANS FIRST PERSON FIRST 1

John Chelico, MD, DOCTORING: WILL THE ICD-10 DOCUMENTATION STANDARDS chief medical informatics — REGARDLESS OF THE EFFORT IT WILL TAKE FOR US TO officer IMPLEMENT THEM — DELIVER BETTER PATIENT CARE IN THE LONG RUN? DR. CHELICO: Clearly, ICD-10 documentation standards will lead to better and more specific clinical documentation of patient diagnosis. However, it is hard to translate this to how it will help deliver better patient care. DR. KEBER: Yes. With much more specific information in the chart, such as laterality and episode of care, there will be better communication among the providers caring for the patient. Eventually, this should lead to improved patient safety. The improved documentation should also eventually lead to Inderpal Chhabra, MD, better data collection and more accurate research in health care, which will director of physician result in improved care with better evidence for guidelines. education for clinical DR. LASER: I believe delivering value in patient care is the true spirit of documentation improvement ICD-10. Unfortunately, the value of the ICD system has been lost and is frequently attributed to payment, but the true spirit is data. As we progress into new payment models, having granular, high-quality data will enable us to make the decisions needed to deliver value-based care. Of the 100-plus countries currently using ICD-10, only a handful use it for reimbursement or resource allocation, and at least for the United States, it seems to have diluted the opportunity the ICD-10 system can provide. DR. NASH: Depends how long the run. For an individual provider on the front lines, it is hard to see how ICD-10 documentation standards will have Barbara Keber, MD, chair of family medicine much direct or immediate impact on patient care. On the other hand, better at Glen Cove Hospital documentation may allow for better understanding of patterns of care, which can lead to systematic improvements in how we organize and deliver care.

DOCTORING: DOES DOCUMENTING WITH GREATER SPECIFICITY HAVE BENEFITS? IF SO, FOR WHOM? DR. CHHABRA: Absolutely no question about it — all practicing physicians could docu- ment better. ICD-10 is not new medicine. It is a true reflection of our patients’ real clinical conditions. When has being more thorough and detailed been an issue? DR. KEBER: The patient benefit will be related to improved communication and patient Jordan Laser, MD, safety resulting from the medical team all speaking the same language associate medical director, North Shore-LIJ Laboratories and giving the same information. DR. LASER: The greater specificity of ICD-10 should be viewed as a business analytical tool, enabling the analysis of high- volume/high-quality data to uncover opportunities for improved health care delivery. Too frequently, there are massive efforts to improve health care delivery without adequate data. If ICD-10 simply enabled us to identify the best opportunities to invest in, it would be a tremen- dous success. DR. NASH: This has clearly been of great benefit to the Ira Nash, MD, senior vice president and executive army of consultants and pundits who have made a career out 2 director of the North of the ICD-10 conversion. Shore-LIJ Medical Group

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DOCTORING: ARE YOU FAMILIAR WITH THE AMERICAN MEDICAL PERSON FIRST ASSOCIATION’S RECENT EFFORTS TO DELAY ICD-10 IMPLEMENTATION — WHEREBY IT TOUTED A RESEARCH STUDY ESTIMATING THE COST FOR PHYSICIANS TO TRANSITION TO ICD-10 IN THEIR PRACTICE IS WELL INTO SIX FIGURES, THUS MAKING IT A POTENTIAL FINANCIAL DISASTER? WHAT ARE YOUR THOUGHTS? DR. CHELICO: They are not off base with their estimates. Upgrading to these new systems can cost a physician practice dearly, with most practices needing to upgrade at least three to four applications. It would be even more if they do not already have electronic health records in their practice. Hospitals — including those of 3 North Shore-LIJ — are spending staggering amounts of money to get the new ICD-10 standards implemented in their systems, and this does not take into consideration the potential loss of productivity to these individual practices and hospital systems. DR. CHHABRA: It depends on the practice. If one looks at the details of the study, it calls for a cost of around $3,000 to update superbills. Is that truly your cost? To me, all it involves is looking up the codes online and changing ICD-9 codes to ICD-10 codes. And by the way, why use a superbill at all if you are on an EMR? The other major cost shared in the study is around vendors charging an arm and a leg to be ICD-10 compliant. If your vendor is gouging you like that, perhaps it’s time for a change. Something else to note here is if you are employed by the North Shore-LIJ Medical Group, then this is being done for you by the health system anyway. DR. LASER: I am not sure about the estimated costs for implementation. However, I believe the fact that payment is tied to ICD-10 implementation has increased the total expenditure. If not tied to payment, it would behoove a provider (particularly large providers and health systems) to ensure adequate and proper implementation. This would give a competitive advantage for those who embraced it. In the current model, the country is gearing up to reduce denials and delayed payments but in the process is missing the opportunity that ICD-10 can deliver. DR. NASH: While I have not studied the methodology used in the study — to be fair, the AMA did not do the study. It commissioned an independent research group to do it. When is the last time an independently commissioned study didn’t come to exactly the same conclusion that the folks paying the bills hoped it would?

DOCTORING: IF GIVEN THE CHOICE, WOULD YOU SUPPORT ANOTHER CMS DELAY OF ICD-10, OR WOULD YOU SUGGEST WE GET ON WITH IT NOW? DR. CHELICO: I would delay it if they could find a better system to use for billing diagnosis codes in the United States. A delay will give providers and hospital systems more time to update their systems and educate staff members. DR. CHHABRA: I would not delay. A lot of individuals and corporations have already spent too much money and resources to turn back now. A delay will create unnecessary confusion, and we will be shortchanging ourselves in the long run. Personally, to use the analogy of a test, I would rather take the test and be done with it than have it postponed. DR. KEBER: I would not delay it again. Physicians often need the pressure of a deadline 4 to complete things. I believe that we should go forward, especially since there have now been a large number of resources devoted to education of providers and to the all- important IT aspect of this project, which affects almost all systems within health care. To delay again at this point in the process would likely cause more harm than good. DR. LASER: If we were to remove the “negative reimbursement link” and distill ICD-10 down to a business analytical tool to help health care organizations provide superior value, TABLET-EXCLUSIVE VIDEO then I think we should not delay any longer. DR. NASH: Let’s get on with it. It is never going to get easier or more fun to do this.

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