Winter / Spring 2017 1 2 the Stethoscope the Stethoscope Medical Bulletin of the Volusia County Medical Society P.O. Box 9595 • Daytona Beach, FL 32120 Published Quarterly Steve Sevigny, MD...... Editor Table of Contents Sami Bay...... Managing Editor President’s Message...... 4 2017 Executive Committee Agent Orange...... 6 Delicia M Haynes, MD...... President FSU College of Medicine Pathographies...... 8 Scott Kiloze, MD...... Immediate Past President Food for Thought...... 17 Andria Kiloze, MD, FACP...... President-Elect Heart Disease: Volusia County’s Challenge...... 19 Stephen Sevigny, MD...... Secretary Welcome Commander Jacqueline Bernard, MD...... 21 Andrew Gamenthaler, MD...... Treasurer The Hidden Cost of Quality Reporting...... 22 Scott Kiloze, MD ...... FMAPAC Ketul Patel, MD...... Public & Professional Relations Marjorie Bhogal, MD...... Membership Kimberly Keller, MD...... Young Physicians About the Cover Sarah Henry, MD...... East Volusia Representative Marty Prado, MD...... West Volusia Representative The Stethoscope is a compilation of artwork and articles submitted by physician members, friends of the society, Lauren Powell, MD...... HH Resident Representative and community partners. The cover of the magazine always Michael Young, MD...... HH Resident Representative showcases a person, place or event. Over the years, we’ve had Lauren Jeck...... FSU Student Representative award-winning photographers, designers, and painters share their work with you. This cover is a sampling of the work that Bruce Ferraro...... FSU Student Representative graced the covers of 2016 & 2017 editions. Thank you to all our Kathryn Barbon...... FSU Student Representative contributors over the years - past, present and future! Samara Bay...... Executive Director

Cover photographs and stories for the Stethoscope are gladly accepted from members of the Volusia County Medical Society. If you are interested in submitting a cover photograph or article, please contact Sami Bay, Executive Director, 386-255-3321. The opinions expressed in the Stethoscope are those of the individual authors and do not necessarily reflect policies of the Volusia County Medical Society, its committees or members. The Stethoscope reserves the right to edit all contributions for clarity and length, as well as reject any submitted material. We greatly appreciate our advertisers, however the inclusion of an advertisement does not imply endorsement.

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Winter / Spring 2017 3 President’s Message - Delicia M. Haynes, MD The Who, What, Where, When & Why of How We Choose Medicine

When was the last time you thought The doctor looked at me over his out to my colleagues for mentorship, and about why you chose medicine as your glasses and said “take off your top.” for their guidance and support I am still livelihood and your life? Was it when For a moment, I sat in stunned silence; very grateful. It was a struggle but after you were fed up entering information and then looked over at my mom. She several long and laborious semesters at the into a computer instead of having a nodded that it was okay and I took of school-of-hard-knocks, I built a reputable meaningful, eye-to-eye conversation my blouse. He walked over and started and financially profitable solo family with a patient? Or maybe it was when pressing on my chest with ice cold hands. medical practice. We gave meaning to you delivered a life-changing diagnosis Then he stepped back, started writing meaningful use. We learned to navigate to a patient – for the better! So why did in his chart and said “it’s probably just the unnecessary complexities of medical you go into medicine? Do you remember a benign fibroadenoma but we won’t billing. We had finally arrived…or so I what your first experience at a doctor’s know for sure until we have it surgically thought. office was like? removed. Due to the location, the scar In the fall of 2014 I received an Mine was memorable. When I was in will be minimal so if you want to be a insurance contract in the mail with the 7th grade I felt a lump in my breast stripper when you grow up that will be what equated to a 40% reimbursement while taking a shower. At first I thought fine.” And he walked out the door. reduction to some services. When I that maybe I would finally get some My mom was a Baptist deaconess finally learned the game, the rules had volume in the breast department and if so needless to say, that did not go over changed. I realized when a third party there was a lump on the other side I’d be well with her. I was devastated. I didn’t could make a decision that almost put evened out. know what benign meant or what a me out of business, I wasn’t working for But that thought was fleeting and fibroadenoma was, but I knew what myself. I wasn’t working for my patients. immediately turned to fear. But I didn’t surgery was and I looked at my mom I was working for the insurance company. tell anyone right away. Why? Because with tears streaming down my face and The harsh reality of it all was that I had being a 12-year old girl, I knew I would said “mom they’re going to cut me.” come to the proverbial fork in the road literally have to bear my chest to get My mom simply said, “Delicia put and had some hard and fast choices to anything done about it. So, I waited your shirt on”, and she went out the make: sign the contract, which would and I hoped it would go away. It didn’t. door to find the doctor. He was already have required me to double my patient More than two months passed before I in another exam room and wouldn’t talk load while cutting staff to make it work confessed to my mother. Off we went to with us. financially (and become the type of see a doctor. In retrospect, our interaction that day doctor I never wanted to be in the first We waited for nearly two hours in a moved me to action. As I slipped my place); sell to a larger organization with small waiting room before being escorted blouse over my head, I made the decision unquestionably better negotiating power back to a room with peeling blue paint, that I WOULD be a doctor and I WOULD but perhaps practice medicine with where we spent another hour of waiting be the type of doctor that I wish I would values that may not be aligned with my time. I remember the environment as have had that day. I would be the type of own; shift to only doing the aesthetic side cold but thankfully, my thoughts didn’t doctor who doesn’t make you wait hours of my practice; leave medicine and go dwell on the immediate situation but for a seven-minute visit; the type of back to being a decorating consultant; or rather on the future. Crazy as it sounds, doctor who explains things in words you take a calculated leap of faith and change I was excited because, up to that very can understand; the type of doctor that my entire business model. moment in time, I was convinced my helps you make good decisions and who I chose the latter and in 2015 became future vocation would be as a doctor, or you know how to care ofyour health. Volusia County’s first Direct Primary a teacher, or a lawyer and I realized if So, I set out with my idealistic self to Care clinic. The main idea behind direct I became a doctor I could do all three. do just that. I went to under grad at the primary care is this: 80% of what most I was about to meet my mentor! As a University of Louisville; medical school people go to the doctor for is primary doctor, I could teach my patients (the at the University of Kentucky; completed care. Direct primary care provides educator in me); I could advocate for my my Family Medicine Residency at comprehensive primary care for an patients (the lawyer in me); and I could Halifax Hospital; and in 2009 started a affordable flat monthly fee. heal people (obviously, the doctor in me). solo family medical clinic straight out of Unlike traditional concierge medical Another hour passed as we sat in the residency with zero business background practices which bill insurance and charge blue room and finally, in walked the or sense. a fee for services above and beyond what doctor. With all the enthusiasm of a 7th I couldn’t afford an office manager at insurance covers, direct primary care is a grader who had just figured out what first so I studied what other offices did direct payment relationship between the she wanted to be when she grew up, I and made friends with office managers so doctor and patient. No copays, deductibles squealed, “I want to be a doctor too.” I could get help when needed. I reached or insurance hassles. It works like a gym 4 the Stethoscope membership: for a predictable monthly insurance to cover things that would be In 2016, Family First Health Center investment, patients get a defined set of financially devastating to our families. was awarded the Small Business of primary care services such as same or Then why are we using health insurance the Year award by the Daytona Beach next day appointments, longer 1:1 time for primary care? Does it really make Chamber of Commerce. with the doctor, convenient virtual visits sense to file an insurance claim for I love what I do now and I love how I for healthcare while traveling, and our every sinus infection, chronic disease do it. Better yet, I get to help others to do membership even includes basic labs. visit, or preventive visit? Why don’t the same. Medicine is an apprenticeship Prices are completely transparent and we use our health insurance like every profession. The business of medicine is the patient-doctor relationship is always other insurance product and keep a too. at the forefront. When patients need to maintenance plan in place for more Today, when I look in the mirror and see a specialist, they can either use their routine things? see the woman that the scared 7th grader insurance or we negotiate to secure As a small business owner, I realize grew up to be, I know that I AM the prompt-pay discounts for our patients that my employees are one of my doctor I always wanted to be. who pay the specialist up front at the company’s best assets. That’s why I offer I wish each of you the same as you time of service. We actively partner with primary care memberships to other small move forward this year and always. doctors seeking a simpler direct patient- business owners who are interested in doctor relationship. reducing their total healthcare costs, Coupled with high deductible attracting and retaining talented team Sincerely, insurance plans or a health care cost members, reducing absenteeism, and sharing ministry, our patients have creating a healthy work force. Delicia M. Haynes, MD reduced their total health care costs Business models will come and go. The President, VCMS while experiencing an improved level alphabet soup of regulatory challenges of service plus they don’t have to worry and opportunities will too. At the end of about ACA penalties. the day the patient-doctor relationship Think of it this way. You wouldn’t is, has been, and must always remain at use your car insurance for an oil the heart of healthcare. Let’s never lose change or claim a broken window on sight of that. Stand up for yourself, your your homeowner’s insurance. We keep profession, and your patients. TUESDAY, MARCH 28TH | 6:30 PM Volusia County Medical Society’s Physician General Meeting & Social MASERATI ALFA ROMEO OF DAYTONA DAYTONA AUTOMALL || 1450 N. TOMOKA FARMS RD DAYTONA BEACH, FL 32124

• VCMS 2017 General Meeting followed by an evening of physician fellowship

• Hors D’Oeuvres, Cocktails & Beverages, Door Prizes

• Meet Your Orlando Medical News Team

• ‘Experience’ the all-new 2017 models, including the Alfa Romeo Guilia

RSVP No Later than Monday, March 27th at 386.255.3321 or [email protected]

Winter / Spring 2017 5 Agent Orange By Sam Cromartie, M.D., FACS Doctor Cromartie served as a physician in the inland waterways or docked in the cause. in the US Army at the 93rd Evacuation Vietnam with the soldier going ashore. Spina Bifida is a birth defect recognized Hospital in Long Binh, the 18th Surgery • Served in certain areas of Korea as caused by Agent Orange in a child Hospital in Quang Tri, and the 91st between 1 April 1968 and 31 August conceived after a male or female Evacuation Hospital in Chu Lai in 1971. 1971. soldier entered Vietnam or the Korean • Served at certain air bases and in demilitarized zone. That is the only Of the three million American soldiers certain occupations in Thailand. birth defect recognized by the VA for who served in Vietnam, many were male veterans. Multiple birth defects are exposed to Agent Orange, an herbicide The following table list conditions recognized for children of female veterans. used extensively to defoliate forests that the VA presumes are caused by Veterans, male and female, may still apply and to destroy crops between 1961 and Agent Orange exposure and for which for compensation for other birth defects 1971 in Vietnam, Laos, and to a small compensation is likely. not listed. extent in Cambodia. Agent Orange Exposure to TCDD can cause elevations contained the toxic chemical 2,3,7,8– Table II. Diseases Recognized by the of serum TCDD, which diminish slowly tetrachlorodibenzo-p-dioxin (TCDD). VA as Presumptive for Agent Orange over many years. With men, the median The US Air Force delivered over ninety- Exposure. half-life is about seven years, whereas five percent of the herbicides as aerial • AL Amyloidosis women exhibit a half-life of about nine spray in Operation Ranch Hand with the • Chronic B-cell Leukemias years. • Chloracne remainder being applied by Americans The VA maintains a registry of veterans • Diabetes Mellitus Type 2 in other branches of the military or by who may have been exposed to Agent • Hodgkin’s Disease RVN soldiers using spray trucks, hand Orange. Registering for this involves • Ischemic Heart Disease sprayers, boats, and helicopters. Spraying • Multiple Myeloma questions about military service, exposure was also performed in the demilitarized • Non-Hodgkin’s Lymphoma history, medical history, and tests for zone between North and South Korea • Parkinson’s Disease various diseases associated with Agent and around some US Air Force bases in • Peripheral Neuropathy, Orange including blood chemistries, chest Thailand. Early-Onset X-ray, urinalysis and a physical exam. Since the war, veterans have developed • Porphyria Cutanea Tarda The closest facility for this process is the a number of diseases and malignancies • Prostate Cancer Orlando VA Medical Center (telephone # which may be related to this exposure • Respiratory Cancers (Cancers of the 407 646 5544). and which may entitle the veteran for Lung, Larynx, Trachea, and Bronchus) Enrolling in the AO Registry does compensation if he meets conditions • Soft Tissue Sarcomas (excluding not serve as a claim for compensation. shown in Table I. osteosarcoma, chrondosarcoma, Veterans who wish to make a claim may Kaposi’s Sarcoma, & Mesothelioma find it helpful to consult with the director Table I. of Volusia County Veterans Services in • Served in Vietnam between 9 January Veterans with other diseases or Deland (telephone # 386 740 5102). 1962 and 7 May 1975. neoplasms may still apply for disability • Served on a boat or a ship that operated and make the case that Agent Orange was Dennis A. Fried, M.D., J.D. Licensing, Discipline & Peer Review Defense for All Medical Professionals in Florida

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352-732-7218 www.bmaklaw.com 6 the Stethoscope Radiology Associates would like to officially welcome A native of Montgomery County Pennsylvania, also in Jacksonville. She completed residency CDR Bernard graduated Villanova University in Radiology at the Naval Medical Center with a degree in General Science and was Portsmouth, Virginia in 2008 and returned to commissioned an Ensign in May 1985 through the Naval Hospital Jacksonville, FL as a staff the Naval Reserve Officer Training Corps. radiologist. CDR Bernard began her Navy career in Naval She was selected for fellowship training in Aviation as a Naval Flight Officer receiving her Breast Imaging in 2011 and was subsequently wings in 1986. She was one of only four women assigned to the Walter Reed National Military chosen that year to fly jets and after completing Medical Center as the Division Officer of the Electronic Warfare School in 1987 she was Breast Imaging Center. Under her leadership assigned to Electronic Warfare Squadron Thirty Walter Reed became the first DOD center to Three in Key West, Florida where she flew EA- implement tomosynthesis (3-D mammography) 4’s and subsequently EA-7’s. At the completion technology and the Breast Imaging Center of this operational tour, she was selected became the first DOD treatment facility to receive to attend the Naval Postgraduate School in the American College of Radiology designation Monterey, California leading to a Master’s Commander Jacqueline Bernard, MD as a “Breast Imaging Center of Excellence”. Degree in Technical Intelligence in 1991. Dr. Bernard returned to the Naval Hospital Follow on tours as the Assistant Administrative Dr. Bernard excelled in her new specialty and Jacksonville in 2015. Under her leadership the Officer at the Enlisted Aircrew School Naval was inducted into the National Medical Honor Breast MRI imaging and biopsy program was Schools Command Pensacola, Florida and Society, Alpha Omega Alpha, in 1998 and was successfully implemented, the first such Navy as the NROTC Scholarship recruiter for Naval awarded the Naval Surgeon General Award at program outside a tertiary care facility. Recruiting District Jacksonville, Florida allowed her graduation in 1999. Commander Bernard has been awarded her to complete her medical school requirements Dr. Bernard completed an Internship in Family Joint Service Commendation Medal, three and in 1995 she was selected to attend the Practice at the Naval Hospital Jacksonville, Navy Commendation medals and two Navy and Uniformed Services University of the Health Florida followed by an operational tour as a Marine Corps Achievement Medals. Sciences in Bethesda, Maryland. Flight Surgeon with Patron Squadron Thirty

William H. Johnson, III, M.D., F.A.C.S. John B. Holt, M.D., F.A.C.S.

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Winter / Spring 2017 7 Florida State University College of Medicine - Pathographies (Students’ essays on one of their patients from their Longitudinal clinic or other rotation. All patient names are fictitious.)

“Have you ever had mouth for me okay?” she asks. twenty minutes straight. I feel my heart thoughts of wanting to I inhale, and I exhale. The room is silent as slow and my face cool as I unwind and commit suicide?” the student listens and my mother focuses even laugh with this stranger. She asks me Thirty seconds went by in so intently I can tell she is hoping to a few more questions and just I as think I without an answer but hear whatever the student hears from her am past the subject of my wrists she asks: the clock in my head chair. Systematically the student moves “Have you ever had thoughts of wanting to ticked off what felt like to my heart. I feel it pound heavier. The commit suicide?” thirty minutes of unbearable silence. student smiles at me again. Thirty seconds of silence pass but it only I considered how much easier the “Sounds good Elizabeth, do you mind if takes me one second to think the word questions were at the beginning of my I check your pulses?” she asks. I hesitate yes. I am screaming it loud in my head. scheduled doctor’s appointment… but then rest my hands face up on my lap. YES! I have tried before actually. I cut. I “How often have you needed to use your She places her fingers over my wrist. I have used razors, scissors, and the edge inhaler?” the interning medical student can tell she notices the bright red tracks of a broken locket my grandmother gave asks as she flips through my chart and across my forearm. The student does not me. Yes, there have been days I do not jots down some notes. react but I wonder if she is counting the want to live anymore. “I’ve probably been using it daily. My mom marks, tallying every sad thought I have “Not recently,” I tell her. thinks my asthma has been worse over the had over the last ten years. “When was the last time you felt that way?” last couple of months but I do not really “Okay, we are all done,” she says. She she asks, her tone more serious. think it is that big of a deal,” I tell her. turns to address my mother, “If you do not I think about how my mom told me three I am sixteen years old and I have only ever mind Mrs. Green I would like to ask your weeks ago that we are moving back to been plagued by asthma and the inability daughter a few more questions in private Pennsylvania because of finances; moving to read my teacher’s whiteboard from the and then I will call you back in.” My back to my old Alma mater, my old three- back of the classroom. mother looks as if the Queen of England bedroomed house, and my old fears. I “Any nighttime symptoms?” the student has just been asked to dine at Burger spent ten years being bullied by the same continues. My mother jumps in for me and King, but she is too polite to make a scene group of relentless boys. Whatever love I informs her of my shortness of breath with and respectfully leaves the room. had for myself was extinguished by daily a frantic desperation. It truly has not been I know what she is about to ask and I can verbal assaults; whatever strength I wore that much of a bother but in my mother’s feel my heartbeat quicken and the skin was torn away physically in ways I have account I might as well be a middle-aged on my face get warm. “Can you tell me yet to share with my closest friends. I hate coal miner dying from the black lung. about the marks on your arm Elizabeth?” them, and if I believed in God I think he The student continues with her questions she asks. would hate them too. and I do not bother racing my mom to an I try to formulate the sanest sounding “I have not felt that way since we moved elaborate, mostly exaggerated telling of explanation but the best I could come up here from Pennsylvania six months ago” my symptoms. with is, “Just some old scars from a year I tell her. The student does not seem less “I think I have enough information for now. ago.” I look down because I am afraid she concerned. I explain to her that I know How about you hop up on the table and I will think I am lying. Everyone always I am loved by my overbearing mother, do a quick physical exam?” the student thinks I am lying because I am a teenager father, and two-year-old little brother, and asks warmly. and apparently, that is what we do. The they are reasons I try to be happy. I reluctantly move my way to the table and student does not challenge my answer but “Do you feel happy today?” she asks. slump on. The student starts with a smile continues to ask me about my home life I realize I am not sure how to respond. and narrates her actions as she works. and what kind of friends I have at school. The doctor in Pennsylvania once told my “I am going to place my stethoscope on She asks me what I would like to study mother I was depressed because I stopped your back and I would like for you to take once I am done with high school and we hanging out with my friends. I slept all some deep breaths in and out of your proceed to talk about Marine Biology for day on the weekends and I lost some 8 the Stethoscope weight because I did not always want cancer, and tomorrow, we will be putting OB/GYN for a routine pap smear, and the dinner. I hardly thought that warranted our cat, Patches, to sleep because he too next thing you know, you wake up with no a medical diagnosis of depression. I bet has cancer. “Honey, I’m scared” I said to hair. Your body so weak you can barely that doctor would have felt the same way him as we waited for the doctor to come move. The mouth sores preventing you if he felt alone and pathetic. Maybe I was in. “You’re a strong woman and we’ll get from having an appetite, the uninvited depressed, but I am not really convinced a through all of this,” he replied softly. diarrhea making social outings a fear. Yes, doctor can help with that anyways. We could hear the medical student I beat cancer once, but the toll those toxins “I do not feel sad and afraid here, but it’s presenting my information to the doctor took on my body is nothing like anyone like a totally long story,” I tell her, hoping on the other side of the door. “This is a could imagine. And just because I’ve been that made me seem positive. healthy 59-year old female referred to cancer free for almost twenty years doesn’t “Well, I am glad you do not feel sad and us because she was found to have a mean it won’t come knocking back at my afraid here, maybe you can tell me about 5.5 centimeter incidental left hilar mass door. I’ve lived with anxiety for years, this long story in two weeks when you on CT scan. Today, she complains of and prayed that day would never come. follow-up?” she asks hopefully. left upper back pain that is focal, non- My husband, so supportive and loving I appreciate her not pushing the subject. radiating and dull. She has no coughing, through it all, now fighting the battle She would probably just roll her eyes at wheezing, or shortness of breath. No himself. Our marriage has had its ups my teenage problems anyways. Tell me fevers, chills, night sweats, hemoptysis, and downs. It’s difficult to communicate everyone is bullied and I should get over or recent unintentional weight loss. She sometimes when you’re swimming in a it. She would probably think it is normal has been smoking one pack per day for pool of medical bills. But we’ve pulled to not want to live sometimes. But maybe, more than 30 years and is currently trying through. Painting has been one of my only I guess I could tell her more next time if to quit. She has had a decorative painting reprieves. she brings it up. business for over ten years, and she There was a knock at the door. “Good “Yeah, we can talk next time” I say. She does a lot of plastering and is exposed to afternoon. Sorry for the wait, but thank squeezes my shoulder and walks out to several chemicals…” you for being patient.” The doctor and get my mom. Could it be true? Could my life’s passion of medical student entered the room and painting have put me here in this doctor’s after a few minutes of reviewing the scans -Joelle Kane office today? Awaiting a diagnosis of and results, I felt an intense blow to my cancer? “Find a job you love and you’ll stomach as if I had been sucker punched These walls are so dim. never work a day in your life,” they said. in the gut. “We still need to confirm, but They could definitely But they never told me I would have to I am ninety nine percent positive this is use some color. Maybe pay for my pleasure by coming face to cancer,” explained the doctor. “I’m going a nice Venetian Blue face with cancer itself. My husband and to order a PET scan and we’ll then proceed would do the trick. Or I moved to Florida 25 years ago from with a CT-guided biopsy.” perhaps an Adriatic upstate New York. Why? The weather. So here we are. Sitting in this cold room Mist to provide a soft After so many years of kneeling down with unpleasantly painted walls. My life background for all of these medical fixing crooked baseboards installed by rudely invaded by the dreadful return of posters on the wall. We’ve got to get commercial businesses, and climbing up what once almost took my life. Cancer home to Patches. He’s been alone all ladders to ensure precisely painted edges now knocking on my door, yet again, and day and needs to be fed. I can’t forget to at the confluence of wall and ceiling, these I wish I had never answered. Biopsies, call Mr. Williams back about the house. knees of mine couldn’t handle that cold scans, surgery, chemotherapy, radiation. I’m sure he’s wondering why his dining weather, especially not now. I have always These words of my future reality back to room wall was left half painted. I hope loved to paint, and I finally mustered up haunt me again. Should I fight this battle I remembered to wash that paintbrush the courage to start my own painting once more? Or throw in the towel? I’m out so it doesn’t get ruined. The car! My business. only 59 years young. My husband says goodness the car. I’ve got to take it in so “Past medical history is significant for I’m strong. I know he needs me. And that we can figure out why it won’t start. My hypertension controlled with medications, dining room wall! I have to go back to Mr. racing thoughts were broken as I felt my and cervical cancer in 1993 treated Williams’ house and finish painting that husband’s hand gently touch my back. He with radiation, chemotherapy, and total wall! It’s funny the things that run through looked at me and gave a tender smile. It’s hysterectomy…” your mind when you’re confronted with been a long week. Last Friday I found out Man, was that hell. Going through death… my husband was diagnosed with colon chemotherapy. A simple office visit to my My attention was brought back to the

Winter / Spring 2017 9 exam room by the doctor’s voice. “We’ll found the taste of alcohol unappealing. Her family members have been very get those tests done as soon as possible. Mrs. H. is a quiet person, but enjoys supportive and have helped tremendously Please come back and see me later this conversations with the clinical staff. In with her transportation needs. In addition week so we can discuss the results. You addition to being followed by this primary to her transportation limitations, her are a healthy woman and we need to be care office, she is having regular visits finances have been greatly impacted with aggressive because you have many more to an oncology office. Regular visits is her increasing medical problems. years ahead of you, and I think we can an understatement. She has to undergo Like many people in her age group, Mrs. cure this.” blood work every two weeks due to her H. collects Social Security. Her monthly “Thank you so much for your help, multiple myeloma. Her arthritis, type two income has been financially limiting when doctor.” I never imagined being diagnosed diabetes mellitus, hypertension, and stage accounting for her personal finances and with cancer. Not to mention twice. Have II chronic kidney disease do not help her medical bills. She spoke of her current you ever heard the saying, “When it situation either. When I pry further into predicament regarding her foot pain. She rains, it pours”? Or, “Bad things happen her past medical history, I learn she was was previously diagnosed with peripheral in threes”? I never believed it myself. diagnosed with multiple myeloma in 2014 neuropathy, which could be caused But here we go. Round two. Along with and has been carefully followed by her by her diabetes, multiple myeloma, or my husband and Patches. Despite the oncologist ever since. Multiple myeloma a combination between the two. She apprehension I felt, I also had a sense of is a cancer formed by malignant plasma unenthusiastically states her previous confidence because of the faith my doctor cells, an important component of the peripheral neuropathy medications had in me and his positive attitude for my immune system, within a person’s bone cause her “to be in the fog” while she treatment and recovery. I shook his hand, marrow. Within the first few minutes of the points with her index finger toward her and as I began to walk out of the room, I encounter and with further history taking, temple. Additionally, her last prescribed quickly turned back to the doctor to make it is clear that Mrs. H. is an educated, medication was too expensive for her to mention of something very important. well-spoken woman who is meticulous purchase each month. This medication “By the way doc, here’s my business card. when answering my questions. was the last of an exhaustive list of If you ever need these walls painted in Mrs. H. earned her Associates and medications that her physicians have here, just let me know!” Bachelors degrees in Jamaica and her recommended as a possible treatment for Masters of Education in the United States. her neuropathy. With the lack of possible -Angelina Malamo Before retiring, she was a deacon of treatments, Mrs. H. is concerned that she the Episcopal Church and a university may have to live with the pain. The chief complaint is professor within a Department of Fine In Mrs. H’s perspective, the peripheral the first step in history Arts. Her eagerness to mentor others led neuropathy and the financial cost of the taking that every her to these supportive roles within her medication are the most concerning and physician follows. It is community. She clearly has accomplished stressful components of her cancer. She the concise statement many achievements in her life; in addition, understands her oncologist is continually highlighting she lived during the time of the Second assessing her kidney function and the reason for the World War and in the era when Jamaica checking her “blood components.” She medical encounter. Today’s first chief finally gained independence. Throughout feels her current knowledge about her complaint is “my feet hurt.” As a third her entire life, her faith and active multiple myeloma is adequate for her year medical student, my mind begins participation within her local church has and she trusts her oncologist’s choices racing with thoughts of plantar fasciitis, been a constant component of who she regarding her treatment and workup. The stress fractures, tarsal tunnel syndrome, is. She participates in her church services constant surveillance of her cancer has and other medical problems to list in my at least once per week. This has become become an integral component within her differential diagnosis. The chief complaint increasingly more difficult to accomplish life. is useless without context; therefore, I due to her financial and transportation Mrs. H. has “learned to live with the begin gathering more history from the limitations. multiple myeloma” to the best of her patient to know her story. Within the past few years, Mrs. H. ability. She is still eager to do everything I have the pleasure to meet Mrs. H. She has relied on her family members for that makes her happy, such as going is an 83-year-old black female who was transportation, especially to church and to church and spending time with her born in Jamaica. When asking for her age, doctors’ appointments. She refrains husband and son. This encounter was she explains the secret to her longevity. from driving due to her lower and upper my initial interaction with Mrs. H. and I She never used a cigarette in her life and extremity arthritis and limited mobility. have had the privilege to see her multiple

10 the Stethoscope times during my Chronic Care Clerkship. I stage IV chronic kidney disease) and RV from one destination to the next. My personally learned from Mrs. H. the value my kidneys are no longer responding to sons each took a leave of absence from of trying to make the most out of a bad Lasix. I developed clots in both of my legs work and my wife and I are retired. With situation. She is a reminder to continue from the fluid that built up, which made the most recent decline in my health, we to value the aspects and people in our it difficult to get up and walk around on all know my days are limited. So, with lives that bring us happiness, while not my own. I went home on oxygen, new what little precious time I have left, I continuously dwelling on the negative medication, and was weaker when I left will be spending it with the family I love circumstance surrounding a medical than when I first got to the hospital two crossing off as much of the remaining condition. weeks prior. I can no longer sleep in the items on my bucket list as I can. There is same bed as my wife. I can no longer help nothing that has put what my last wishes -Anthony Miller her around the house. I can no longer do are on this earth into perspective for me many things that I used to do, but this like the thought of dying. As someone Breathe in. Breathe out. latest experience has shown me what I once said, death is the great equalizer. You Breathing is something want to do – spend the rest of my time I can’t take anything with you when you go, that we often take have left with my family, making it as easy but the memories you’ve made. So, I have for granted until we on them as possible. decided to breathe in and breathe out my consciously have to This is why I am here at my doctor’s office own personal life’s breath – my time with work on it. For most, today. I need to fill out some forms – a family. Although it is the physiological it is as automatic as DNR form and an Advanced Directives function of my body that keeps me here blinking, or the unconscious beating of form. My family and I previously wanted for the time being, I have learned it is the one’s heart. My name is JR and for me, all lifesaving procedures to be utilized; love of my family that makes me who I am breathing is something akin to drowning anything that could be medically done to at my very core. So, until I take my last on dry land. I have metastatic bladder prolong my life. Over the last two weeks, breathe, I will continue my goal of taking cancer and congestive heart failure, I have had the unlucky fortune to not only each moment one breath at a time. attributed to my vice as a young man suffer the constant hustle and bustle of when I came home from the Vietnam War the ICU in the hospital, but to also see -Kristen Noud – smoking. Some of the people I’ve met how it affected my family emotionally since I’ve become so sick have labeled and financially. I do not want to spend Coming of Age me by my plight - “that’s the guy with an the rest of my life in and out of hospitals, The television chatters exacerbation of CHF and bladder cancer constantly making myself only slightly softly in the corner of the mets in room 416,” someone once said. better (with no chance of a real cure). waiting room and I listen For me, however, I am much more than After much discussion with my family, we absent -mindedly as the my disease. I am a husband of forty-six all have agreed on what’s truly important local news anchors years. I am a father of two healthy, adult – time. It is not the quantity of time, but discuss the weather and children. I am a veteran of the Vietnam the quality of time I have left to spend it morning traffic patterns. The office is still War. I am an American citizen. Yes, I am with those I love the most, which is key. In quiet, aside from an elderly couple seated a former smoker now dealing with the the case of my Advanced Directives, I do at the opposite side of the room, bickering repercussions of smoking thirty plus not want any life sustaining measures to about where to eat breakfast. It’s time years later, but I am so much more than be taken in the event I can no longer eat, for my Welcome to Medicare visit, and I that. drink, breathe, or have a heartbeat of my arrived promptly to fill out my mountain I finally got discharged home from the own. These are my new wishes. of paperwork. Yet another reminder of hospital five days ago after being there, During our many lengthy discussions my advancing age and the unfortunate this time, for almost two weeks. My wife about the DNR and Advanced Directives consequences that tend to come with it. and children are understandably upset – I forms I wanted to fill out, my family and I I can no longer read without glasses. My went in for a round of chemotherapy to try made a list of the activities we wanted to tennis game has suffered. I ache in places to halt the progression of my cancer, but do together with the time I have left. Over I didn’t even know were possible. But, I developed shortness of breath and built the course of many years, we’ve always woke up again this morning. I’m alive. My up more fluid in my legs and in my lungs. put off traveling to see Yellowstone and mind is sound. Those are some things to This is what landed me in the hospital for Yosemite National Parks, to dip our toes be grateful for. my latest stay. While there, I was told my in the Pacific Ocean, and to do so by I’m ushered back into an exam room and kidney function had gotten worse (I have traveling across the United States in an left in solitude for several minutes until

Winter / Spring 2017 11 a young woman in a white coat finally visit when I can, almost weekly. The guilt, grandchild. I tell her about my wife’s enters. She informs me that she is a however, remains. passing almost two months ago. She was medical student working with my family The young woman leaves and returns with at home in her own bed, surrounded by the doctor and asks how I’m doing. “Never my doctor. We’ve known each other for people who loved her. I ensure her that I’m been better,” I respond with a smile and as many years. He’s a member of our church coping well, and it helps to know that my much conviction as I can muster. A little and took care of our two daughters until wife is no longer suffering. I’ve reluctantly white lie never hurt anyone. We exchange they left home for college. Unfortunately, joined a support group, and was surprised pleasantries and I ask her a little bit about he knows me well enough to read through at how much I’m truly enjoying our weekly herself, anything to distract her from the jokes and dismissive answers. He can meetings. I’ve actually made quite a few asking certain questions I’m not ready to tell that I’m barely holding on by a thread. friends there. My mother is adapting well answer. We discuss my general health and He asks about my mother and how she’s to her new home, and seems to get along I sprinkle in a joke here and there, getting adjusting to her new home. He doesn’t well with the residents and staff. I visit her polite laughs before moving on to the push me when my voice cracks as I talk every Monday to have lunch and watch next item on the agenda. I have no new about my wife’s disappointing prognosis. old western movies. The student asks complaints and I assure her that I’m doing Eventually, my regrets, anxieties, and if I’ve been taking the time to do things well - still hearing, walking and urinating fears flow out of my mouth as if I haven’t I enjoy. I laugh and tell her that I now without difficulty. spoken to another human being in weeks. feel like an old man with too much time “How are you sleeping?” He listens intently and compassionately, on his hands. It’s been a long time since “Oh, just fine.” only interjecting when he knows I have I didn’t have the responsibility of caring I’m sure she doesn’t need to hear that I said all I needed to say. We talk in for another, and I’m slowly beginning to have spent many nights on the bathroom detail about end of life planning and the discover new things that bring joy into floor, comforting my wife as she expels benefits of hospice. He reassures me my life. It’s been strange getting used to the contents of her stomach after another about my decision to move my mother making my health a priority again. I might round of chemotherapy. Her hair is now into a long-term care facility. I’m provided be able to predict the weekend forecast gone, her limbs thin and frail, her face with resources for support groups and from an achy hip, and a cheeseburger only a shadow of what it once was. The bereavement counselors, and he refills my does much more damage than it used to. doctor tells us that the cancer has now cholesterol medication, orders follow-up But, I woke up again this morning. I’m spread to other parts of her body, and it’s bloodwork and urges me to take the time alive. My mind is sound. Those are some probably time to consider hospice care. I to take care of myself. I know the lobby is things to be grateful for. have no choice but to put on a happy face no longer empty and there are now several and be strong for her. Tears and pity will patients waiting to be seen, but I never -Emily Ost do no good for her now. once feel as if my problems are a trouble “How is your mood? In the last two weeks, or inconvenience. They matter to him as “So Ms. B, tell me what have you felt down or depressed?” well, and that offers me great comfort. I you do for fun. What’s a “No. I have stresses in life like anyone leave his office today feeling a little lighter day in your life like?” else, but nothing I can’t handle.” and reassured. My heart is still heavy, but “Umm nothing. I don’t I don’t divulge the overwhelming guilt I I know I’m now a little better prepared for do much. I stay at home. feel for moving my mother into a nursing the difficult decisions that will be madein I am happy.” home. She lived with us for almost a the coming weeks. Surely she must have year after her Alzheimer’s diagnosis. I A few months later, I return for my follow- been exaggerating. I mean, who could live was able to juggle doctors’ appointments up appointment. The young medical like that? and radiation and chemotherapy visits student and I have now met on multiple “No, it’s true. I leave the house when I for several months, but knew I could no occasions, as I’ve accompanied my wife have to for groceries or doctor visits and longer offer her the care that she needed. and mother to their regular check-ups as stuff… but I spend my days alone at I made the final decision when we found well. home. That’s how it has always been.” her wandering a half mile from our house She asks how the family is doing, and I To say this was how it had always been one night. She had awoken while we were proudly inform her that Charlotte, my was not entirely true. She lived what most sleeping, dressed up in her Sunday best, daughter, is expecting a baby in the spring. would consider to be a normal life until and walked right out the front door. Now, She and her family are moving back here her early 20’s. Born and raised locally, she she shares a 250-square foot room with a from Virginia, and I’m looking forward to lived at home with her parents. After school, woman who thinks she’s Amelia Earhart. I all of the opportunities to spoil my new she and her friends would take their bikes

12 the Stethoscope and ride around the neighborhood until more than others. To her, as long as there just grabbed for her, I perused through her someone’s parent would come outside was sound and moving pictures she could paper chart. I noticed she had failed to get yelling, “about homework or something.” stare at it all day. Aside from a small sofa, any of her requested labs done for the past In the summer her father would treat her there really was not much else in terms of 6 months. to ice cream once a week and then they furnishings in her place. Well, there was, “Well, did you learn anything from a crazy would go to beach. Sometimes they would but the majority of her belongings were person today?” go to people watch. Most of the time they still in boxes that she had not touched for At that moment I could only think about would just walk and chase birds around. over a year. She would not dare to unpack; the fact that Ms. B. may be experiencing On occasion her father would impart something about unfinished business adverse effects from her lithium treatment. lessons of life that he had “learned the provided her with a peace of mind. Ms. B. In retrospect, I am not sure how much of hard way”. To her amazement, no two days was not much of a cook either, or even an my conversation with Ms. B. was true to at the beach were ever the same, “Each eater for that matter. Eating was too much her definition of happiness. Nonetheless, time it felt new to me.” work she explained. She had a microwave, each time I ask a patient how they choose The day Ms. B. ran away from home “… but you have to plug it in and push to enjoy life I think about her. to a nearby motel was the day her life buttons.” When she does get hungry she changed. Her parents reported her makes herself a PB&J; sometimes tuna -Mueez Qureshi missing and after a frantic week she depending on her appetite. If she felt was eventually caught on a golf course the need to be around people she could I stare out the window at lighting portable bathrooms on fire. “That always take a walk outside and observe the pool in the backyard was my first episode. That was when others from afar; rarely did she have to of our Florida home. everything became different.” That was resort to this. Another hot, stagnant when Ms. B. and her family learned she “I pick my own clothes. I decide what I get day is trudging along. had bipolar disorder. Unfortunately for to do. No one bothers me and I can just My days repeat. I wish Ms. B., there was a poor understanding be myself.” I was working. My on the severity of her condition and she As Ms. B. went on to explain her right shoulder forced me into retirement. lacked adequate follow-up care. The end satisfaction I realized her solitude had Swinging a hammer for 40 years takes a result was a stepwise deterioration of her become her most valuable possession. toll. My wife awakens me from my daze mental being. Over the next decade, she Yes, she lived in isolation, but she had and asks if I’ll run to the pharmacy and would go on to lose all of her meaningful accepted this state with open arms and pick up my mother-in-law’s prescriptions. relationships in her life. Unable to work taken full advantage of the opportunity. She’s been staying with us for the last for a living, a significant portion of Obviously, I understood that Ms. B’s eight months. It’s been 10 months since her adulthood was spent in and out of thought process was a byproduct of her I retired from the carpentry business homeless shelters. In fact, her impairment disorder. It was unfortunate to hear how I owned in Maryland. My father, too, became so intolerable to others that the much her life had changed because of was a carpenter. As a child, I worked most significant relationship she could her condition, but if there was one silver with him. We would build anything and name today was her landlord who would lining, it was that Ms. B. did not fill her everything—from cabinets to tables. I come to check up on her and the property days with regret. Whether due to ignorance found solace in hard work. At the end of every few weeks. or not, she was happy, she was content. each day, I’d be exhausted. A good night’s “I realize that my life is the way it is More than anything my conversation with rest came easily. Stress and nervousness, because of my bipolar. I don’t get other her made me cognizant of the fact that for the most part, were fleeting. That all people as much or my disease, but I get my definition of happiness is not always changed when I traded my hammer in for myself and what makes me happy.” going to be the same as my patient’s. How a fishing pole at my wife’s insistence to Ms. B. had a daily routine but she did not could it be when I have not gone through retire in Florida. adhere to any schedule. She went to bed the same experiences as them? Now my life feels monotonous and when she pleased and got up when she “How are you not burning up? I’m so meaningless. Each day seems much like desired. Sometimes she would sleep in thirsty.” the last, with the important exception bed for upwards of 15 hours. She loved This was about the fourth-time Ms. B. that the panic attacks are becoming more her TV set and the days she spent outside had commented about her dry mouth. I frequent and intolerable. I’ve dealt with of her bedroom were enjoyed in the living did not think anything of it at first but she this before. As a newlywed in my early room. She was not able to name a favorite was really starting to look uncomfortable. twenties, I found myself spiraling out of show or a specific genre that she enjoyed As she finished the bottle of water I had control. Trying to meet the demands of

Winter / Spring 2017 13 my new wife and beginning a family was tightens around my left arm. She tells me combination of therapy and medicine. I’m an upheaval of my previous routine. The it’s a bit high. Of course it is. She asks if not a guy to go to counseling; I politely stress and angst lapped at my neck, often anything has changed since my last visit. decline the offer. rising higher, overtaking my ability to “No,” I tell her. And that’s the problem. Oddly, having just disclosed my breathe. It finally passed after a year. Now, “Did you get your lab work done?” she embarrassing struggle to a complete I fear this time it won’t. asks. I lie and tell her I didn’t know I had stranger, I feel immensely better. Soon, As I grab my keys, thankful for a task, I see any to complete. She leaves the room. my regular physician and the student the reminder on the refrigerator. I have a My doctor is going to rebuke me for the return. He agrees with the thought to doctor’s appointment tomorrow morning. absence of labs. I hear a knock at the door. try a different means of confronting my I’ve been dreading it for three months I try desperately to still my nerves. problem. He still criticizes me for not since my last visit. I was told to have labs It’s not my doctor. A young woman with having completed the lab work, but done. I haven’t. I’m worried what they could brown hair and matching horn-rimmed tackling the underlying issue brings me a show. My cholesterol is usually high. glasses greets me with a smile. She tells new sense of peace. Somehow, now, I feel I wish I could cancel, but I desperately me she is a medical student and would a new leaf is about to be turned. I schedule need a refill on my anxiety medication. I like to interview me before my doctor. another appointment on my way out for ran out three days ago. The panic attacks I agree. She asks how I am doing. “I’m one month from now. I feel encouraged are becoming more insufferable. alright.” I assume she’ll brush past the that next time, I’ll be better and prepared, That night, like most nights, the battle unenthusiastic response and start asking with lab work completed. Maybe then, I’ll ensues. The fear of not being able to fall about the blood pressure readings I’m finally be beginning to enjoy the swim. asleep begins early in the evening. By the supposed to check at home, but she time my wife is in bed, I know I should doesn’t. -Stacy Ranson start the ritual of trying to make myself She returns my response with a go to sleep. The mere act of undressing thoughtful look, and a query to tell her Nearly 25 years ago, begins the cascade. My mind races with more. I hesitate, debating on how much Danny traded in his frantic thoughts of what my appointment to divulge. I relent. I explain the attacks harsh Midwestern will bring tomorrow. What should I say that come daily now. How they rise and winters for the year- about the absent lab work? I’m sure my escalate and soon I’m in over my head. I round sun in Daytona blood pressure will be high. I just have to relay to her the fight it was this morning, Beach. He had just been get in and get out with my prescriptions. just driving to the appointment. She laid off and heard he In and out. The red analog clock on my listens carefully. Not taking notes, not could find work at a hotel that would also night stand reads 10:30…midnight…1 looking into the computer screen, but provide living arrangements. AM. giving me full attention. I tell her I’m out of With a suitcase and a bus ticket, he I wake at 5:30 AM. I may have gotten four my anxiety medicine and she asks if it has hugged his mother goodbye and waved hours of sleep at the most. I shower and been helping; if I’m improving. I concede to his father, who replied with a tip of his dress. I make coffee and try to read the that it seems I’m getting worse. whiskey glass. When Danny arrived in newspaper. My stress is building. I get She asks if I’d be willing to try a daily Florida, he could taste the salt in the air. into the car and the angst begins rolling medicine that could, over time, help He headed to the beach, feeling entirely into an excruciatingly loud crescendo in bring the sea of anxiety from the level of warm and free once his toes hit the water, my mind. The traffic and red lights are my neck down to my waist and maybe and knew he would not need much more sending me over the edge. I can tell my further—like equipping me with a life than this. blood pressure is high. My heart rate jacket instead of rescuing me at the point Misfortune has a way of finding people quickens. I feel my chest rising and falling of nearly drowning. I wonder about this. in threes, the saying goes. Danny’s job faster than it should. I pull into the parking It’s something different. I fear potential prospects never did come through, so he lot and try to cool down. side effects. She tells me this medication moved in with a couple of guys who were I walk to the front desk and sign in. I sit, would modulate the chemicals in my in a similar point in their careers, that is fidgeting in the cold waiting area. My brain, to help prevent my nervousness to say, in between. Shortly after, Danny’s stomach lurches when the nurse calls my from building, to help prevent the attacks parents passed away; they were killed in name. She politely greets me and seats instead of treating them after they’ve a car accident on their way home from me in the exam room. I try desperately to already begun. This actually makes perfect a dinner at the local Moose Lodge. The take slow measured breaths, willing my sense to me. She continues to tell me the police suspected alcohol was involved. pulse to slow as the blood pressure cuff most effective means of treatment is a Judy, his only sister, said she would

14 the Stethoscope never forgive Danny for not coming to he thought he must be getting help and he know me very well. God did not intend for the funeral. He was too ashamed to tell fell asleep. man to witness such things, yet everyone her that he was broke and missed his Several times he was awoken with a gentle was given a choice and everyone chose bus because he was drunk. Danny was shake and an unfamiliar face demanding to stay. I laid there while you acted like drunk for most of his days after that. He answers from him. He was cold and things were “par for the course”, but I was decided he didn’t mind living paycheck hurting, and could only breathe with an “albatross”. That was the beginning of to paycheck, especially if he could bike short shallow breaths. Danny was worried a formidable journey; I was never going to down to the beach and enjoy a beer with that he was getting worse, but he was so be the same. the sunset. Years of living in the elements tired he couldn’t say anything. Some time I met you again; this time I was aware. You can change a person. Danny enjoyed his passed before he was being jostled around seemed so out of place next to the mature alternative lifestyle; no one demanded and moved to another bed. He thought healer who has seen it all. Even he would anything from him- no rent, no showing up something was being done to help; maybe learn something from me in the time to on time, no responsibilities. The trade-off he needed surgery or an x-ray. Danny come. Moving from bed to floor and from was sometimes going hungry or having to decided to let the professionals do their floor to window, my goal was to get back hide from the police, but overall, it was a job and he fell asleep. to a normal life. You came to understand simple life drenched in sunshine and salty The day was drawing to a close, but Danny my world when you met my wife, my humidity. Most days Danny spent the few did not know. He was trying to sleep away sister, my nephew and my daughter. Her handfuls of cash solicited from tourists on the pain as he had done various times next occupation became something of a game. snacks and beer and made rounds to the to his pile of belongings on the ground. We all played and it kept spirits up. I was local soup kitchens for main meals. He He didn’t hear the statements of disgust, nearly there, as if the seasons changing in kept to himself and after years of silently fear, and pity directed at him, but even if the window was a foreshadowing for my roaming, most people thought he was he had, it would not have been anything imminent discharge. Then, seemingly in sullen and too drunk to notice much of he had not heard before on the streets. He an instant, I found myself moving from anything. The truth is, he didn’t get drunk didn’t know he was at a different hospital the window to the bed. I already knew much these days. He drank out of habit, now. He didn’t feel the tube go in his chest, by looking at his face; I could see what and perhaps because of a deep genetic the stitches on his head, the monitors and was coming next. Your face was neutral calling. He kept to himself because he catheters all over his body. He didn’t feel because you did not know. realized it was usually safer- the streets the tubes go in his throat or the wires in We met again without me knowing. It did had a way of swallowing people up and his skull. But it was too late and now he not seem much different from the first time. he had seen it with his own eyes. Alone, was giving up. He couldn’t answer any I am sure you were probably thinking, Danny lived day to day tied to existence by questions if he tried. He thought about his “It couldn’t get any worse.” I already a thin thread of comforts. sister, such a distant memory and yet he explained this - “you have never seen a A few times Danny had gotten a cold, could hear her laughing when they had a patient like me.” His experienced hands or had been scratched by some sharp snowball fight. He could feel his mother’s worked magic again although things were object, but overall he felt healthy and arms squeezing him after he brought her not perfect. This time, there was a different had not sought medical attention in a bowl of black berries, picked from just room with a different window. What had many years. That changed on a spring down the road. In the end, Danny thought been “goals”, changed to “hopes” and day near the intersection of Granada and about his first days in Florida and with his “prayers”. I was no longer focused on the Beach Streets. Just after dawn, Danny was toes in the water he felt warm and free one window; I just hoped that I did not have riding his bicycle to the store for breakfast last time to leave the room again. You came to when he was hit by a car. Danny was say “goodbye” every night and I prayed I motionless but the car was in a hurry to -Rachel L. Rider would live to see the morning. The most get away. He laid there and could feel his advanced contraption on the planet and chest throbbing, his head spinning, and A Tale of Meetings I will be damned if a little fluid is going his stomach grumbling. He doesn’t know The first time we met, to take it down – “over my dead body!” how much time passed before he was I did not know it. The events to come would put this to the surrounded by people who were lifting There is no question test. You were not there this time. What him into an ambulance. He didn’t hear as to why you were so happened to me does not seem possible; any words; just loud voices coming at anxious; it is obvious what a story this will be! I just have to get him with various tones. Finally, he heard you have never seen out of this bed first. someone say he was at a hospital and so a patient like me. Yet, you would get to You made your first of your multiple visits

Winter / Spring 2017 15 for the day. It had been many weeks since even think the doctors are sure. Between have an illness. I think I do now. I can we first met and you were different. You all the medications and diagnoses that hear the voices that started a couple of did not flinch when you saw what they have changed over the years, I guess you years ago, and I believe him when he says had done. Though you would say later, could say I’ve had a little bit of everything. they are not normal. And I do believe the “something like that should not exist But for the most part now it’s the voices medications are helping. I just wish that outside of the operating room. I cannot that I notice the most. They’re saying there was a medication to help me improve believe it”. He would tell you “bottom line, nice things about you now in case you’re the one thing I care about most. Surfing is this doesn’t happen every day”. We hoped wondering. the only thing that I really get motivated for something would change, but it did not. I guess before all of this started, I had anymore. The doctor says I should focus I remember thinking “Please tell me this is a relatively normal childhood. I was the on some volunteering, maybe a part-time the last time we will meet like this.” If there youngest of four brothers growing up in job that interests me. The only problem was any reason to hope, it was lost on me. Virginia. I eventually moved to Florida for me is I just don’t feel any urge to. And At least this one was quick. Gas exchange after my dad got stationed here for the that’s okay with me. I’m perfectly content is important to keep things in balance, military. Things were smooth-sailing with the way life is right now. I don’t really especially in such an advance piece of through the time I was in community need much money, and I get all of my food machinery like this. It seems odd that this college. Sure, I smoked and drank my fair through a weekly stipend from the mental little piece of plastic is all I needed. There share. I don’t think I ever really thought health clinic. was improvement, but something was still twice about it when it was offered. Between Life is good. missing. In my core, it felt as if there was a that and my surfing, I would occasionally All in all, I feel like I have made peace with gaping void that would never close. There go to class when I could remember. Life my current situation. I have seen how far were other machines to fix that. was good for a while. And then, everything gone some of the other patients are in The sun feels so good. I have not seen changed. A lot of it is a haze in my mind, this mental health clinic. Many of them it since before we first met. It is hard to so all I can tell you is what I was told won’t admit that they have anything wrong explain my appreciation for this bright after the fact. For some reason, I started with them. Some are even paranoid that heat. Though, I gather that after such an believing out of nowhere that I was Jesus. the staff is out to get them. Thanks to ordeal, my appreciation for many things You heard that right, and I couldn’t tell you the medical care and counseling that will be difficult to explain. You have why. Not long after, I stopped going to I’ve received through this program, I’ve changed and so have I; so has my entire classes completely. In addition, I pretty been fortunate enough to get my life back world. I am on the other side of the window much broke off all contact with my family together in some sense. I know that I now but I will have to return to my room. and friends that were closest to me. After will probably never completely get rid of I am sure I will see you one last time. You some searching, my parents said they mental illness, but I embrace the hand that have undoubtedly learned something from found me in the beach dunes acting like a I have been dealt in life. Now if you don’t me; that is my gift to you. God, if I did not maniac. I was immediately hospitalized in mind, I’m going to catch a wave. learn how lucky I am to be alive. the psych ward. All it took was one shot of medication and I miraculously came back -Theo Strom -Thomas Shakar to reality for the first time in a long time. I’ve been back and forth between different Maybe the Voices Aren’t doctors and treatment adjustments since So Bad then. Some regimens were rougher than “Can you trust him? others, but overall they’ve helped me turn He’s watching you. Be a huge corner in terms of my overall well- careful what you tell being. him.” When it comes A lot of my time has been spent thinking to the voices, I can’t turn about the things that I said and did back them off. Some days are certainly worse then. For a while I was literally convinced than others, and today is an average one. I would be judged before God for what But they’re always there in the background. was going through my head. The doctor Overall, I don’t think I can complain much. says though that it was my illness that I’m doing better now than I was before, was putting those thoughts together. I that’s for sure. I wish I could tell you suppose that gives me some relief. He the exact condition I have, but I don’t asks me every time I see him if I think I

16 the Stethoscope Richard Rhodes, M.D.

SINATRA’S L’ALDILA

Cautiously making our way down the misty darkened back roads of downtown Cassadaga we suddenly found ourselves staring at the famous landmark of the town itself. Brightly lit, the Hotel Cassadaga stands proud and prominent among the surrounding antiquated edifices incorporating the 100 or so known spiritualists the town is famous for. Since 1894 Cassadaga has been known as the Psychic Center of the South. The Hotel itself was rebuilt in a Spanish revival motif after it burnt down. Since 1928 it has hosted many who have come to talk to their dead relatives in séances, palm readings, tarot readings, and attend spiritualist classes. Upon entering the front door we noticed a sign that read, “Séance in progress, do not disturb”. The restaurant was off to the other side of the building. As we entered, we could here the talented music of a pianist playing and singing songs of the ‘60s and ‘70s. Several people were singing along with him. Our waiter Merle led us to our table surrounded by windows and wall decorations that exuded a funky charm. Merle then told us about Chef Mathew C Odett who hails from New England where he was master chef at a catering hall. He has since moved to Florida in April 2016 where he revamped the menu at Sinatra’s. Joining Lisa and me tonight included friends from Deland and Orlando. Sinatra’s was therefore a great place to meet up. Sinatra’s is primarily an Italian restaurant. They do have a full bar available including wine, beer, and (no pun intended) spirits. After some of our guests had cocktails, we ordered several appetizers to share. The calamari was done quite nicely with a marinara and Cajun seasoning with pepper rings. The delectable bruschetta was done with a watermelon base and finished with a balsamic reduction served on toasted French bread. My favorite appetizer was the Shrimp I-Thai- Gano that is a fabulous and definitely mouthwatering, lightly fried and breaded large white shrimp tossed in a not too spicy but creamy Thai chili sauce and served over a bed of homemade sesame pasta salad. To go with our appetizers and meal I ordered a nice drinkable red 2013 Argentinian Malbec called Tamari. It proved to pair well with our meals.

Shrimp-I-Thai-Gano Bruschetta Calamari

Winter / Spring 2017 17 Our meals came with a standard Caesar salad with homemade dressing. These proved to be a decent intermezzo for our main courses. The main dishes were quite diverse and you could even create your own pasta bowl. You simply pick your choice of any homemade pasta: spaghetti, fettuccini, tortellini, cavatappi, or farfalle; add a style of sauces such as marinara, vodka, aioli, Mediterranean, Alfredo, diavolo, carbonaro or creamy pesto. Last of all choose your protein: chicken, meatballs, vegetarian, Italian sausage, calamari, shrimp, salmon or mahi. One of us chose simple spaghetti and meatballs with marinara. This was quite tasty. I opted for the Vitello Amatriciana, containing a wonderful conglomeration of cream, cheese, garlic and amaretto all sautéed to perfection. This was served over a nice al dente risotto. Lisa ordered veal with fig and mushroom served with a sweet brown marsala containing sweet mission figs, cremini mushrooms and locally grown red onion. Our friend who loves hot foods ordered a very spicy Italian Jambalaya. This contained scallops, shrimp, chicken, roasted red peppers, onions and risotto in a spicy chicken broth. He loved it. The braised short ribs Italiano were roasted perfectly and served with a Parmesan risotto. They were quite good but were served too cold for our guest and needed rewarming before eating. Deserts are not homemade but are still quite good. We split a very savory five layer chocolate cake and a mouthwatering Tuxedo Bomb chocolate mousse which contained several layers including white and milk chocolate. By evening’s end we became caught up in the entertainment and enjoyed singing along with the pianist. They do have live entertainment Wednesday through Saturday and even have dueling pianos twice a month. Our total bill for the evening was very reasonable. My entrée was the most expensive: $19.00. Not bad at all. We enjoyed ourselves immensely and do plan on returning for dueling pianos. I give this fine establishment 4 stethoscopes for its funky ambience, 5 stethoscopes for value, 4 stethoscopes for quality, and 4.5 stethoscopes for service.

Address : 355 Cassadaga Rd 32744 Open daily for lunch and dinner except Sunday dinner. Full service bar.

Short Ribs

Veal Amatriciana Spaghetti and Meatballs Tuxedo Bomb

Ambience: Value: Quality: Service:

18 the Stethoscope Heart Disease: Volusia County’s Challenge Ethan Johnson, MPH and Patricia Boswell, MPH

The Centers for Disease Control and Prevention Age-adjusted Heart Disease Death Rate by Race (CDC) lists heart disease as the top cause of death in Volusia County, 2011-2015 the U.S. since the early 1900’s. More than 600,000 deaths were due to heart disease in 2014, a rate of 192.7 per 100,000 population. In Volusia County, heart disease accounted for 23.3% of all deaths in 2015 with a rate of 176.4 per 100,000 population. This rate was 9.2% lower than the nation but 15.4% higher than Florida at 152.9. Risk factors associated with heart disease such as obesity, high cholesterol and hypertension are common chronic illnesses in our community. The 2013 Florida Behavioral Risk Factor Surveillance Geographic Distribution Survey reported that over half of adults in Volusia Volusia County is partitioned into four geographic County (58.1%) were obese or overweight, 39.3% quadrants (northwest, northeast, southwest, and were told they had high cholesterol and 40% were southeast), constructed from zip codes, to assess told they had hypertension. population health at the sub-county level. The Emergency department (ED) visits rates for heart northwest quadrant had highest average heart disease disease increased from 590.5 to 668.6 (13.2%) death rate (175.3) from 2011-2015; yet it logged from 2011 to 2015. Heart disease hospitalizations the only downward trend among the quadrants. decreased 4.0% from 1010.3 to 969.9 during that Heart disease death rates among the quadrants have period. Volusia County heart disease death rates for increased over the years. The lowest heart disease 2011-2015, on average, were 20 points higher than death rate in 2011 was 149.5. The lowest rate in Florida rates. While the Florida heart disease death 2015 was 168.9, a difference of 19.4 points. While rates remained nearly unchanged (less than 1%) from other chronic diseases show a high rate of disparities 2011 to 2015, the rates in Volusia County grew from across quadrants, heart disease has become more 163.4 to 176.4 (7.9%). evenly distributed from 2011-2015. Key to understanding the impact of heart disease is an assessment of its distribution across racial groups Financial Burden and geographic boundaries in Volusia County. Over half (50.4%) of emergency department (ED) Racial Distribution visits with heart disease in Volusia County were patients who were 65 and older. In contrast, only According to the CDC, heart disease is the leading 23% of the county population was 65 and older. cause of death for most racial/ethnic groups in the Northeast quadrant residents had the highest number U.S. Similar patterns occurred in Volusia County of ED visits in 2015, but southwest quadrant had the as non-Hispanic black residents had a higher heart highest amount in total charges. The total charges disease death rate than other racial/ethnic groups for heart disease in 2015 were $27,463,943, a 28.7% (223.5) in 2015 in Volusia County. Hispanic residents increase from 2014. consistently had lower rates of heart disease deaths Health care costs have increased nationally and among all racial/ethnic groups but like their fellow Volusia County was no exception. In 2015, there residents their heart disease death rates trended were 55 fewer ED visits for heart disease. Although upward and represented the largest percent increase ED visits for heart disease decreased, the average (39.7%) from 2011 to 2015. Winter / Spring 2017 19 Average Charge per Emergency Department Visit with Heart Disease in Volusia County, 2015

Volusia Quadrants 2015 County Northwest Northeast Southwest Southeast Ed Visits 4477 675 1478 1063 1194

Total Charges $27,463,943 $4,752,099 $7,485,815 $8,072,012 $6,277,221

Average Charge Per Visit $6,134.45 $7,040.00 $5,064.83 $7,593.61 $5,630.00 charge per visit rose 23% from 2014 ($4,709) to 2015 • Assessments of patients’ risk for developing ($6,134). The chart below depicts the steady upward cardiovascular disease trend with the average charge per ED visit for heart • Recommendations for evidence-based treatments disease increasing by 104% from 2011 to 2015. to prevent cardiovascular disease • Recommendations for health behavior changes to Average Charge per Emergency Department Visit with discuss with patients Heart Disease, Volusia County, 2011- 2015 • Patient alerts when indicators for cardiovascular disease risk factors are concerning

And when combined with other effective strategies such as culturally competent healthcare, team- based care, or other infrastructural improvements to facilitate the delivery of evidence-based care, this has been proven to reduce patients’ risk for cardiovascular disease.

Conclusions Heart disease impacts our community on many levels. Eliminating barriers to care is critical to prevention and treatment. Barriers to efficient healthcare delivery exist at multiple levels including financial, community, patient, provider and organizational. The manner in which patients and providers interact during a visit must foster productive patient-provider relationships. A system of care is designed to assist Sources: providers in cardiovascular disease prevention may Florida Department of Health, Bureau of Vital Statistics, include one or more of the following: Volusia County Deaths, 2011-2015 Florida Agency for Health Care Administration (AHCA), Volusia County Hospitalizations & Emergency Department, • Reminders for overdue cardiovascular disease 2011-2015 preventive services, including screening for CVD Centers for Disease Control and Prevention, Heart Disease, risk factors https://www.cdc.gov/heartdisease/

20 the Stethoscope Maserati Alfa Romeo of Daytona 1450 N. Tomoka Farms Rd. Daytona Beach, FL 32124 888-741-7170

Winter / Spring 2017 21 The Hidden Cost of Quality Reporting By Steve Miles, M.D.

The Medicare Access and CHIP consuming task for physicians and their the American Medical Association, must Reauthorization Act of 2015 (MACRA) practices. U.S. physician practices in four form a strong coalition and present this passed in 2015 as a fix to the Sustainable common specialties spent, on average, evidence to the RVU (Relative Value Units) Growth Rate (SGR) Physician Fee Schedule 12.5 hours of physician’s staff time per Advisory Board. We should demand the issue stopping proposed draconian cuts week entering information into the medical RVU Commission add a specific expense to the Physician Fee Schedule in favor of record for the sole purpose of reporting for EHR/Quality implementation. a 0.5% increase. Hidden from most of us, quality and measures for external entities. The way a physician payment is buried within this 1,000 page document, There is also a hidden cost of EHR use in calculated is a simple formula. The was Medicare’s movement from a payer to hospitals. A 2010 study by the UC Davis payment equals the RVU for work times a purchaser of service. This process started Graduate School of Medical Management a Geographic Pricing Cost Index (GPCI), in 2012 when Medicare commissioned a revealed a 25-35% decrease in productivity plus RVU expense times a GPCI expense, study on the quality of Medicare reimbursed in the clinic outpatient section. In 2012, an plus RVU malpractice insurance cost times health care in the United States. Out of this HIT Consultant Survey indicated that more the GPCI for malpractice cost, times the commission grew the idea that Medicare than 26% of physicians reported decreased conversion factor currently of 35.8043 should start focusing on value and not productivity and 50% were not happy with cents. A simple way to mitigate some of the volume. the EMRs. Only 23% of the physicians cost of implementation of EHR and quality What Medicare did was provide a carrot – responding said that EHR made them more metrics is for the RVU Commission to add a 1.5% increase in physician fee schedules efficient. In 2014, Medical Economics an RVU/ EHR expense into the conversion beginning in 2015 for use of a compliant published an article stating that 65% of factor. electronic medical record (EMR), reporting respondents reported EHR use resulted in Payment = [(RVU work x GPCI work) of quality measures, e-prescribing, etc. financial losses to their practice. + (RVU expense x GPCI expense) + (RVU Beginning in mid-2016, this carrot There have been multiple and very EHR/Quality X GPCI EHR Quality cost) + became a stick with an increasingly larger visible failures of EHR implementations in (RVU malpractice insurance cost x GPCI percentage of deductions from physician hospital systems. The University of Texas malpractice insurance cost)] x conversion professional fees for not meeting these M.D. Anderson Cancer Center reported factor of $35.8043 (Jan. 1-Dec. 31, 2016). “goals“. A 0.5% increase in physician fee a 56.6% decrease in adjusted income in The 0.5% stabilization to our fee schedules now resides with an escalating a seven-month period related to an EMR schedules on the professional side pales decrease in fee schedules, up to a minus 9% implementation. Boston-based Partner’s in comparison to the amount of money if quality goals are not met. Health Care reported an operating income and time spent in implementation of these Bottom line: Quality reporting costs loss of $74 million for a quarter partly due products. both time and money and there is now to its Epic implementation. Also, Brigham Until organized medicine wakes up voluminous data showing how much. and Women’s Hospital in Boston reported and shines the light on this hidden cost of Researchers at Weill Cornell Medical its first budget shortfall in more than “quality” mandates, including the promises College teamed up with the Medical Group 15 years partly due to unexpected costs made for Health Information Exchanges Management Association (MGMA) to put associated with its EHR transition. (HIE), patient care will continue to suffer. a price tag on the time providers spend Similar findings are noted in California. Physicians will become less efficient inputting quality data into an electronic Jeff Sprague, CFO of Sutter Health Care in and information will remain siloed into health record (EHR). This group also Sacramento, attributed a 31.5% decrease in fragmented electronic databases that do not studied the time required to input these operating income from a onetime only EHR communicate with each other. newly introduced measures and protocols implementation cost. of tracking and reporting them. There was also an article published in the http://hitconsultant.net/2012/10/30/80- Globally, this answer according to Weill Annals of Internal Medicine, September mind-blowing-emr-and-meaningful-use- Cornell is approximately $15.4 billion 2016, with a conclusion that for every statistics-trends/ a year. This study was published in the hour physicians provide direct clinical face http://www.healthcareitnews.com/ March 7, 2016 Health Affairs. The 2016 time to patients, two additional hours are news/study-emrs-effect-docs-productivity- MGMA survey reports revealed health spent on EHR deskwork within the clinical depends-needs-workflow care technology costs have now topped day. Outside of office hours, physicians http://medicaleconomics. $32,500.00 for physicians. Dr. Fisher spend another 1-2 hours of personal time modernmedicine.com/medical-economics/ Wright, MGMA President and CEO, each night doing additional computer and content/tags/ehr/physician-outcry-ehr- opined, “We remain concerned that far clinical work. functionality-cost-will-shake-health- too much of a practice’s IT investment is The small amount of money that informa tied directly to complying with the ever Medicare added to the beginning of this Ann Intern Med. Published online 6 increasing number of federal requirements process pales in comparison to the cost of September 2016 doi:10.7326/M16-0961© to provide better care.” implementation of these measures. 2016 American College of Physicians Health Affairs also reported that quality What can be done to stop this bureaucratic metrics is becoming an increasingly time mess? Organized medicine, including 22 the Stethoscope Winter / Spring 2017 23 PRESRT STD U.S. POSTAGE PAID PERMIT #178 DAYTONA BEACH, FL P.O. Box 9595 Daytona Beach, FL 32120-9595