Thoracic Group, P.A. Jean-Philippe Bocage, M.D., and Robert J. Caccavale, M.D.

Transcription

1 Central New Jersey Edition November 2007 VOL. 4, NO. 11 Thoracic Group, P.A. Jean-Philippe Bocage, M.D., and Robert J. Caccavale, M.D. At the Forefront of Video-Assisted Thoracic Surgery Choosing a Retirement Plan for Your Practice Some Light at the End of the Tunnel, Dealing with Frivolous Lawsuits Autism: The Evolving Role of a Physician

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3 from the publisher Dear Readers, Welcome to the November issue of M.D. News, the voice of New Jersey physicians. We have an especially interesting issue for you this month. We are currently working on selecting our cover story candidates for Iris and I are doing our best to locate the most interesting, unique and special practices to offer you, we welcome your suggestions. Drs. Jean-Philippe Bocage and Robert J. Caccavale of the Thoracic Group are featured on our cover this month. These two docs have developed a unique team approach in pioneering and advancing VATS (Video Assisted Thoracic Surgery). Their practice, one of the first nationally to utilize this technique and the largest provider of general thoracic surgical services in the state utilizes VATS in 99% of their procedures which allows them to perform surgery on patients who might otherwise be ineligible due to the patient s significant risk factors. They operate together in all surgical situations and it is unique to see two surgeons who know each other so well that their actions have become intuitive. The generation of baby boomers is approaching retirement and most of us have begun to think of the preparations that are necessary to ensure our comfort. Hopefully, these thoughts took place some time ago, not at the last minute. Don Cowan, principal of Cowan Gunteski shares his insight into how to properly set up your practice s retirement program. A recent court decision may have put the brakes on some of the frivolous lawsuits that may come the way of your practice. The New Jersey Appellate Division recently awarded penalties and court/legal expenses to a victim of such a suit. Steve Kern of Kern Augustine, Conroy and Schoppmann shares how this case may help your practice. In a rebuke to New Jersey doctors, the NJ Medical Availability Task Force has decided there should be no limitations on non-economic damages for medical malpractice judgments, no change in the current statute of limitations regarding medical malpractice, no changes in pre-suit procedures and no requirement for mediation or screening of frivolous lawsuits. Jay Heddon of NJ Physicians shows just where this task force has gotten it wrong. As I sit here writing this letter, and closing the November issue, it is 80 degrees in New Jersey and I m beginning to think I will never get a chance to tap into the newly stacked cord of wood I ordered. I don t know if the globe is warming but here in New Jersey I still have to keep my A/C on. Have a safe, healthy and wonderful month! With my best regards, Michael Goldberg Publisher and Editorial Director M.D. News New Jersey Central New Jersey Edition Publisher and New Jersey Editorial Director: Michael Goldberg Associate Publisher: Iris Goldberg Photographer: Ken Alswang, At Home Studios Contributing writers: Iris Goldberg, Brian Kern, Donald A. Cowan, Steven I. Kern, Jay Heddon, Timothy Downs M.D. News is published by Sunshine Media, Inc N. Hayden Rd., Ste 220 Scottsdale, AZ (480) sunshinemedia.com President/CEO: Jim Martin Founder: Robert J. Brennan Chief Financial Officer: Rob Pearson Editor-in-Chief: Liz Meszaros Marketing Director: Andrea Hood Marketing Specialist: Kristine Aldrin Director of Publisher Development: Howard LaGraffe Recruiting Specialists: Teri Burke, Jennifer Young, Megan McCabe Manager of Sales Administration: Cindy Maestas Creative Services Director: Tyler Hardekopf Production Director/Managing Editor: Keli Quinn Creative Services: Josh Bergmann, Rob Bonilla, David Drew, Gerry Dunlap, Breanna Fellows, Joanna Galuszka, Kristen Gantler, Amelia Gates, Brenda Holzworth, Tess Kane, Tanna Kempe, Lana May, Ryan Mills, Jodi Nielsen, Shannon Wisbon Financial Services: Malia Collins, Lori Elliott, Allison Jeffrey, Sharon Lardeo, Christian Williams, Cheng Wan Zheng Circulation Director: Holly Carnahan Circulation Manager: Beth Lalim Manager of Human Resources: Carrie Hildreth Manager of Information Technology: Eric Hibbs Printed by Sunshine Media Printing William H. Hibbs, General Manager Subscription rates: $36.00 per year; $62.00 two years; $3.50 single copy. Advertising rates on request. Bulk third class mail paid in Tucson, AZ. Although every precaution is taken to ensure accuracy of published materials, M.D. News cannot be held responsible for opinions expressed or facts supplied by its authors. Copyright 2007, Sunshine Media, Inc. All rights reserved. Reproduction in whole or in part without written permission is prohibited. Advertise in M.D. News For more information on advertising in the M.D. News New Jersey edition, call Publisher Michael Goldberg at (973) or fax (973) mgoldberg@mdnews.com Contact Information Send press releases and all other information related to this local edition of M.D. News c/o: 22 Burnet Hill Road Livingston, NJ Postmaster: Please send notices on Form 3579 to P.O. Box 27427, Tucson, AZ

4 contents VOL. 4, NO. 11 NOVEMBER COVER STORY THORACIC GROUP, P.A. JEAN-PHILIPPE BOCAGE, M.D., AND ROBERT J. CACCAVALE, M.D. Drs. Jean-Philippe Bocage and Robert J. Caccavale of the Thoracic Group have developed a unique team approach in pioneering and advancing Video Assisted Thoracic Surgery (VATS). Their practice, the largest provider of general thoracic surgical services in New Jersey utilizes VATS in 99% of their procedures including those patients with significant risk factors who would be ineligible for conventional open surgery. DEPARTMENTS 12 hospital rounds 18 financial matters 20 legal issues 24 food for thought ON THE COVER Drs. Jean-Philippe Bocage and Robert J. Caccavale of the Thoracic Group, the largest provider of general thoracic surgical services in New Jersey. PHOTO BY KEN ALSWANG, AT HOME STUDIOS 10 The Facts Behind a Negative Ad Campaign 4 23 Autism: The Evolving Role of a Physician 24 2 NEW JERSEY M.D. NEWS NOVEMBER 2007

5 Whatyouneedis arelationshipwitha malpracticeinsurer, notanagent. Malpractice insurance agents are not our biggest fans. That s because, as a direct writer of medical malpractice insurance, we don t need them. Which means they don t make any money from us. Which also means, if you ask them what they think of us, they don t throw around a lot of compliments. So we thought we d say a few nice things about ourselves. We re NJ PURE, a financially stable medical malpractice insurance carrier that insures doctors throughout New Jersey. Here s the first nice thing: we haven t had a rate increase since 2004, and even then, it was only 10%. Second nice thing: we re a reciprocal exchange, which means all unused premiums build the surplus, or are paid back as dividends to insured doctors. Guess what? This year, we paid back a dividend to all subscribers with us in the 2003 calender year. These are things insurance agents know about us, but won t tell. For good reason. You d drop them immediately. We know that by all the calls we get from doctors switching to us. Our number is NJ-PURE or visit us at njpure.com. We d love to hear from you as well New Jersey Physicians United Reciprocal Exchange

6 cover story Thoracic Group, P.A. Jean-Philippe Bocage, M.D., and Robert J. Caccavale, M.D. At the Forefront of Video-Assisted Thoracic Surgery By Iris Goldberg PHOTO BY KEN ALSWANG, AT HOME STUDIOS Anytime a referring physician sends a patient for a surgical consultation, he or she undoubtedly understands that surgery is a major event in any patient s life. Medical clearance must be obtained to certify that the patient is an appropriate surgical candidate, capable of withstanding anesthesia and the trauma of the procedure itself. Open surgeries, in particular, which utilize large incisions, heavy sedation and take many hours to complete, can be associated with numerous risk factors, especially in the elderly and those with compromised health. Additionally, the recovery period is often painful and prolonged. Fortunately, there is a growing trend in many surgical specialties to perform more and more procedures with a minimally invasive approach, significantly reducing the possibility of complications and allowing for a less painful and speedier recovery. One specialty, however, which still seems to utilize the standard open procedure much of the time, is that of thoracic surgery. It is most interest-worthy, therefore, to profile a practice that is pioneering a revolution in the approach to chest surgery, which dramatically increases the number of suitable thoracic surgical candidates and virtually eliminates much of the trauma associated with the open procedure. Thoracic Group, P.A., which is centrally located in Somerset and is affiliated with Somerset Medical Center, St. Peter s University Hospital and Robert Wood Johnson University Hospital, specializes in video-assisted thoracic surgery (VATS). After many years of performing thoracic surgery through a standard thoracotomy (open New patients are evaluated by both doctors, who work as a team to provide the best possible care to their patients. chest with rib removal), the surgeons at Thoracic Group embraced the VATS procedure, which allowed them to enter the chest cavity in a less invasive and certainly less traumatic manner. Robert J. Caccavale, M.D. and Jean-Philippe Bocage, M.D. have developed a unique team approach in which they work together in all aspects of each patient s care. This begins with the initial consultation and preoperative evaluation and continues into the operating room where Drs. Caccavale and Bocage perform all surgical procedures together. They share the philosophy that this approach provides their patients with the best possible outcome. The traditional open surgical approach utilizes one large single incision that is placed between the patient s ribs. The ribs are then spread apart, allowing the surgeon to look directly into the chest cavity. The surgery is then performed via this single large opening. Although relatively safe for medically cleared candidates, this procedure is quite invasive and traumatic, even for those patients who are otherwise in good health. A patient undergoing the open procedure must obviously be heavily sedated and therefore subjected to the side effects of the anesthesia which may take some time to diminish. There is considerable post-operative pain and patients usually require time in the ICU, followed by a lengthy hospital stay. Those patients with significant risk factors such as chronic obstructive pulmonary disease (COPD) or heart disease, for example, are often deemed ineligible to undergo this procedure at all, even though it could provide a cure or greatly improve their situation. The morbidity of the operation is not about what we do inside, explains Dr. Caccavale. It s what s involved in getting there. VATS is performed using a small video camera that is introduced into the patient s chest via a scope. This device, called a thoracoscope, transmits images of the operative area onto computer monitors that are strategically positioned in the operating suite. During VATS, Dr. Bocage and Dr. Caccavale generally make four one-inch incisions as compared to one 10 to 14-inch incision with the open procedure. Surgical instruments and the thoracoscope are inserted through these small incisions or ports. Once in 4 NEW JERSEY M.D. NEWS NOVEMBER 2007

7 place, the thoracoscope allows the surgical team to visualize all of the structures in the chest displayed and magnified on the video monitors. Quite often, this is a better view than would be possible using traditional thoracotomy (open) techniques. Because VATS does not require a large incision, patients have less blood loss, fewer complications and do not suffer from severe chronic chest wall pain, which is a common problem with the open thoracotomy. Most VATS patients do not require intensive care services and are usually able to eat and walk on the day of surgery. Additionally, hospital stays and recovery times are reduced by more than 80% with VATS. Obviously, insurance companies benefit as well, with substantially lower costs The monitors provide a clear view of the surgical field, allowing the surgeons to perform their procedure without a larger, open incision and removal of a rib. The minimally invasive VATS procedures begin with four small incisions to accommodate the instruments and the camera. Once the camera is in place, the surgeons proceed using the monitors to view the surgical site. for VATS as compared with open surgery. It is interesting to note that although VATS was not performed as recently as twenty years ago, thoracoscopic procedures have existed for close to one hundred years. In 1910, Hans Christian Jacobaeus, a Swedish physician, theorized that a cystoscope could be placed into the thoracic cavity to aid in the treatment of pulmonary tuberculosis, which was an extremely common disease at the time. By lysing adhesions in the lung, doctors could force the lung to collapse, cutting off the oxygen supply to the bacterial organism. He also reported on the use of thoracoscopy to localize and diagnose benign and malignant lesions of the pleura and pulmonary parenchyma. Although Jacobaeus work was known in the United States and some thoracoscopic procedures were performed, the techniques were not widely embraced, especially because of the availability of antibiotic therapy. It was not until the development of the charged coupling device, a silicon chip that is light-sensitive and led to the sufficient miniaturization of a video camera which could be attached to a fiber optic telescope, that the videothoracoscope was introduced. This technology, which produces a well-defined, magnified image on a video monitor, frees the surgeon from holding the thoracoscope and looking into it as he or she works. Additionally, the entire operating room team can also view the proceedings. With the monitors in place, NEW JERSEY M.D. NEWS NOVEMBER PHOTOS BY KEN ALSWANG, AT HOME STUDIOS

8 PHOTOS BY KEN ALSWANG, AT HOME STUDIOS A lobectomy is performed. We can see the lobe through the thoracoscope on the monitors. there is now the capability of two surgeons and four hands actually working together, enabling significantly more complex procedures to be performed. This monumental development was enthusiastically studied and incorporated by Drs. Caccavale and Bocage, who have since been performing VATS together. They have continuously been perfecting and expanding the VATS procedures they offer in order to treat the entire gamut of thoracic disorders and to be able to do so for most patients that come to them, even those who would not be appropriate candidates for an open procedure. The Thoracic Group is the largest provider of general thoracic surgical services in New Jersey. Drs. Bocage and Caccavale can now use VATS more than 99% of the time to perform surgical procedures on the lung, mediastinum, pleura and esophagus in order to treat diseases such as cancer, pneumothorax, infections, emphysema, cysts, as well as other thoracic disorders. Some of the procedures routinely performed by the Thoracic Group utilizing the VATS procedure include lobectomy, wedge resection, lung biopsy, drainage of pleural effusions and mediastinal and thymus thoracoscopic procedures. In 1990, the practice was among the first in the world to perform VATS and since then has successfully performed more than 5,000 procedures. Because of their vast experience and skill, Drs. Caccavale and Bocage are considered to be among the best in the performance of VATS. In fact, they have both lectured nationally and internationally and many established surgeons from across the United States and abroad regularly visit the Thoracic Group to learn this technique. With an estimated one million new lung cancer cases per year among males and 400,000 cases per year among females, lung cancer is the most common cancer worldwide and the leading cause of cancer-related death. Perhaps the most significant impact made by VATS has been in the definitive management of a patient with an indeterminate lung nodule. In the past this involved open thoracotomy with its associated morbidity or a transthoracic needle biopsy in the attempt to establish a diagnosis without the need for thoracotomy. At the Thoracic Group, patients can now proceed directly from diagnosis The thoracoscope clearly shows the instruments separating the lobe of the lung. to a VATS excision in most cases. Since many lung cancer patients are elderly, this is particularly beneficial. VATS offers the opportunity to both definitively make a diagnosis and treat many of these lesions, even in compromised patients. Once the diagnosis of lung cancer has been established, Drs. Bocage and Caccavale can treat the disease with a video-assisted lobectomy, which is the removal of a large section of the lung, or if necessary, the entire lung can be removed during a VATS procedure. A video-assisted wedge resection, which is the removal of a wedge-shaped portion of tissue from the lung and is usually used for the diagnosis and treatment of small lung nodules, is another option. By using VATS to treat lung cancer, the surgeons can eliminate the need for cancer patients to wait weeks or months until they are sufficiently recovered in order to undergo chemotherapy and/or radiation, if indicated. VATS is also used by Drs. Caccavale and Bocage to diagnose cancer of the pleura. The pleura is a two-layer membrane that lines the chest cavity and surrounds both lungs. Mesothelioma is a rare cancer of the pleura, which can be diagnosed with a VATS biopsy. Although mesothelioma is incurable, during VATS, the cancerous pleura can be removed endoscopically, to prolong and improve the quality of life for these patients. With mesothelioma and pleural diseases such as emphysema, or following chest trauma or surgery, patients can develop pneumothorax or hydropneumothorax, which is a collection of air or fluid or both in the pleural cavity, causing the lung to collapse. Drs. Bocage and Caccavale use VATS to evacuate the pleural space of air or fluid. VATS allows the surgeons to repair the lung and prevent future collapses without an open procedure. Pleural effusions, which are abnormal collections of fluid in the pleura and cause shortness of breath, can also be caused by trauma or disease. Excess fluid which is removed may then be analyzed to indicate possible causes such as infection or cancer. In cases of severe recurrent pleural effusions, the surgeons at the Thoracic Group can then perform pleurectomy and pleurodesis, which is a procedure that causes the membranes around the lung to stick together and prevents the build-up of fluid in the 6 NEW JERSEY M.D. NEWS NOVEMBER 2007

9 The separated lobe is removed from the chest cavity through the incision. space between the lung and the chest wall. During the procedure, an irritant, such as talc powder, is instilled inside the space between the pleura in order to create inflammatory adhesions which tack the pleura together. This obliterates the space and prevents the reaccumulation of fluid. In patients with mesothelioma, for example, pleurectomy with pleurodesis provides tremendous relief from discomfort. For patients who have primary cancers that originated elsewhere in the body and have metastasized to the chest, Drs. Caccavale and Bocage can perform VATS to maintain and improve the quality of life. Patients with malignant pleural effusions, for example, are very uncomfortable, with severe shortness of breath. Most of these patients could not be cleared medically for an open procedure to drain this fluid and would not want to spend whatever time was left to them being subjected to the tremendous discomfort and lengthy incapacitation caused by an open thoracotomy. Attempting to drain pleural effusions with a chest tube prove to be minimally effective and cause discomfort and inconvenience which impacts on the quality of the time left to these patients. With VATS, however, tumors in the lung and/or fluid surrounding, can be removed during a short, minimally invasive procedure that can provide long term relief. Dr. Bocage explains, You can do a complete drainage within 20 minutes and the patient goes home breathing comfortably, without drains that need to be emptied. People need to know that this is available. At the Thoracic Group, the surgeons can also use VATS to diagnose lymphomas (cancers originating in the lymph nodes). They can endoscopically remove samples of abnormal lymph nodes to determine the type and location of the lymphoma. Once this has been established, the information obtained is shared with an oncologist, who can then initiate appropriate treatment almost immediately. Interstitial lung disease (ILD) is a general term that includes a variety of chronic lung disorders. When a person has ILD, the lung is affected in three ways. First, the lung tissue is damaged in some known or unknown way. Second, the walls of the air sacs become inflamed. Finally, scarring or fibrosis begins in the interstitium (tissue between the air sacs) and the lung becomes stiff. For theses patients, Drs. Bocage and Caccavale employ VATS to obtain pieces of lung in order to ascertain a diagnosis and thereby help pulmonologists to make treatment decisions. Inflammatory or infectious processes can easily be evaluated and treated using VATS as well. For example, an empyema is a collection of pus and fluid that develops from a lung infection such as pneumonia. At the Thoracic Group, VATS is performed to drain the excess fluid and allow the lung to re-expand. Sometimes masses of inflamed tissue can develop in the lungs from other underlying conditions. Drs. Caccavale and Bocage use VATS to remove these in order to ascertain their cause. Besides diseases affecting the lungs, the Thoracic Group also treats other thoracic disorders. The mediastinum is the area in the middle of the chest between the lungs. VATS is performed to evaluate and remove cysts, tumors or abnormal glands in the mediastinum. The thymus is a small organ located in the upper/front portion of the chest, extending from the base of the throat to the front of the heart. The cells of the thymus form a part of the body s normal immune system. Early in life, the thymus plays an important role in its development. In addition to using VATS to examine the mediastinum and thymus, remove tissue samples and surgically remove cancerous growths, Drs. Bocage and Caccavale can perform VATS to improve the quality of life The lobe is shown after removal, prior to going to pathology. PHOTOS BY KEN ALSWANG, AT HOME STUDIOS NEW JERSEY M.D. NEWS NOVEMBER

10 PHOTO BY KEN ALSWANG, AT HOME STUDIOS The staff, gathered here with Dr. Bocage and Dr. Caccavale, act as patient advocates. for those with chronic diseases originating in these areas. For example, myasthenia gravis is a neuromuscular disorder that is characterized by variable weakness of voluntary muscles. This condition is caused by an abnormal immune response. There is no cure for myasthenia gravis. At the Thoracic Group, patients with myasthenia gravis can undergo VATS to remove the thymus. A thymectomy can result in a permanent remission or at the very least, significant improvement and less need for medications. When this is performed without an open procedure, many more patients with myasthenia gravis can take advantage of the benefits associated with undergoing a thymectomy. Other thoracic disorders that can be treated with VATS at the Thoracic Group include nervous system disorders such as palmar hyperhidrosis (excessive sweating of hands and feet), which is related to certain nerves in the chest. This disorder causes patients a great deal of dysfunction and embarrassment. The simple task of writing, for example, becomes almost impossible with hands that are soaking wet and the handshake or hand-holding is something to be dreaded. During a VATS procedure, the sympathetic nerve is severed, thereby eliminating perspiration in the extremities and greatly improving the quality of life for these patients. Dr. Bocage and Dr. Caccavale pride themselves on the fact that virtually any thoracic surgical procedure performed elsewhere in the traditional open manner, can be successfully performed at the Thoracic Group with video-assisted thoracic surgery. VATS is a technique which they have perfected together for more than ten years. These physicians are true partners in every respect. They perform all surgeries together and share the philosophy that their team approach, constantly backing each other up, will benefit each and every patient. Office manager, Tracey Seibert, talks about how well they work together. They have an open and honest communication with each other, she says. This follows them into the operating room where they combine their skills and expertise to work quite efficiently together, ensuring that each procedure they perform has the most positive outcome possible. Dr. Caccavale proudly shares, When you see an 88 year old person after undergoing a lobectomy, up and walking, the same day of surgery, with the chest tube having been taken out in the recovery room, that s pretty amazing. That s what we do. Dr. Bocage adds, We have worked on this technique for years and as it continues to evolve, we continue getting better at it. Dr. Caccavale is Chief of the Division of Thoracic Surgery at Somerset Medical Center and Dr. Bocage is Chief of the Division of Thoracic Surgery at Saint Peter s University Hospital. Both doctors are certified by the American Board of Thoracic Surgery. They are co-directors of the Thoracic Oncology Program at the Steeplechase Cancer Center and are affiliated with the Cancer Institute of New Jersey. Additionally, both are Clinical Associate Professors at University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School and at Drexel University College of Medicine. Patients who come to the Thoracic Group for treatment, even those who are seriously ill, usually leave with a more positive and optimistic attitude than they had before their initial office visit. Of course most are relieved to learn that their problem can be effectively treated without the need for an open surgical procedure. Beyond that obvious advantage to being treated by Drs. Bocage and Caccavale, is the overall experience patients have at the Thoracic Group. From the moment they enter the attractive office space, purposefully designed so that the staff is immediately accessible, patients are put at ease. During the consultation, the surgeons take whatever amount of time is necessary to thoroughly explain the patient s disorder and the procedure which will be performed. Staff members act as patient advocates, facilitating everything from scheduling imaging appointments and dealing with all insurance issues, to arranging transportation. Although undergoing a surgical procedure of any kind still evokes a certain amount of trepidation for most, it is rather comforting to know that there are options which can minimize the physical as well as the emotional trauma involved. With skilled and compassionate surgeons like Dr. Caccavale and Dr. Bocage leading the way, VATS will, undoubtedly, soon become the standard of care for the surgical treatment of thoracic disorders. The Thoracic Group, P.A. 35 Clyde Road, Suite 104 Somerset, NJ (732) NEW JERSEY M.D. NEWS NOVEMBER 2007

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12 The Facts Behind a Negative Ad Campaign By Brian Kern, Esq. A family-run medical malpractice company formed in 2003 as a direct writer, seems to be blaming independent insurance agents for its slow growth in its latest ad campaign. NJ PURE initially projected that by the end of 2004, it would insure 1,000 physicians, but it is now projecting that same 1,000-physician goal by the end of NJ PURE wants physicians to believe that agents are not recommending it because of some ill will, but facts about the company paint a far different picture, and reveal some important perspective behind the company s campaign. NJ PURE continuously claims that it is able to keep costs down by not employing agents or brokers, but the cost of agency commissions to an insurance company is ordinarily far less than the cost of dealing directly with physicians. NJ PURE provides perhaps the best example, as it reported an expense ratio of 36.01% in 2006, 35.58% in 2005, and 38.6% in This translates into NJ PURE spending, on average, nearly thirty-seven cents of every dollar it collects in premiums on expenses entirely unrelated to risk. Many of these expenses are for services that would ordinarily be handled by agents. A comparison of NJ PURE s expense ratio to other carriers further illustrates the point. AM Best A-rated carrier The ProMutual Group has a far lower expense ratio, just 18.6% (in 2006) of its premium dollars, which includes all commissions paid to its agency force (ProMutual works exclusively through its agency force in NJ). Princeton Insurance Company, the largest medical malpractice insurance writer and oldest company writing consistently in NJ, has an expense ratio of just 17.26% (2006), and has embraced the agent model as well. Princeton works almost exclusively through agents. Some of NJ PURE s other claims, including some made in a letter sent to members of a medical organization on July 18, 2007, and are discussed below: 1. Due to favorable financial results NJ PURE has recently announced its first dividend to be paid to its physician policyholders However, according to mandatory filings with The NJ Department of Banking and Insurance (DOBI), NJ PURE reported a negative net income in 2004, 2005 and At year-end 2006, NJ PURE reported total admitted assets of $32,830,048, $21,334,754 of which was deemed to be its liabilities, leaving its entire surplus at $11,495, NJ PURE has not taken a rate increase in more than three years. Its last rate increase was 10% on 1/1/04 and they have no rate increases currently pending NJ PURE started writing business on 1/1/03 yet compares its increases to some carriers that have been around far longer represented the apex of the medical malpractice insurance crisis, nationally, and most companies were believed to be under pricing policies. These carriers were thus forced to significantly increase rates in order to return stability and solvency to the marketplace. It follows that carriers formed using adjusted rates would not need to take similar increases, though, as reported, NJ PURE imposed a 10% increase in NJ PURE purchases reinsurance for claim losses in excess of $250,000 up to the policy limits through AM Best A rated Lloyd s of London. While NJ PURE may be reinsured through an AM Best A-rated company, it can claim no similar rating for itself. To the contrary, NJ PURE carries an AM BEST rating of NR-5 (not formally followed), and Weiss gives it a rating of D+ (weak), which adds that, In 2006, the two year reserve development was 48% deficient. Entering into reinsurance treaties with a financially strong company does not amount to independent financial stability. NJ PURE does boast that it has received a favorable rating from a company called Standard Analytic Services (SAS). Interestingly, efforts to Google SAS reveal little about this company. The only successful hits were from three other companies touting a similar favorable rating. In fact, SAS does not even have a website, and efforts to contact the company were unsuccessful. 4. NJ PURE offers both the occurrence-type and claims-made policy forms. Occurrence coverage is historically the preferred type of policy in NJ, but decisions on coverage type should incorporate an analysis of whether a malpractice carrier is financially strong enough to be there in the future. Otherwise, the extra upfront investment for an occurrence policy could not only prove worthless, but could also effectively prevent the transfer to a well-financed company in the event of insolvency. 1 0 NEW JERSEY M.D. NEWS NOVEMBER 2007

13 From the perspective of the physician, the value of an independent agent cannot be overstated. That is why the vast majority of NJ physicians work through agents. New Jersey physicians are forced to navigate one of the most turbulent insurance markets, in one of the most turbulent states in the nation. They need to carefully analyze their options and costs. The complexity of this process explains why only a handful of agencies have contracts with medical malpractice insurance carriers in New Jersey, and why only a select few of those have access to most of the major markets. The NJ tort system, and its relationship to medical malpractice insurance is the subject of countless court decisions. For example, claims-made policies require the purchase of extended reporting coverage (a tail ), which is generally unlimited in duration. NJ PURE however, offers extending reporting coverage which expires after just two-years, leaving a physician personally liable to a claim at dollar one. How can NJ PURE justify this two-year tail, knowing a physician can be fully exposed when those two years expire? More importantly, why would a physician accept only a twoyear tail? Indeed, when DOBI questioned its filing, the company cited in an Explanatory Memorandum NJ s two-year statute of limitations for filing a medical malpractice claim. This statute though, is known as a discovery statute, meaning that the two-year time limit does not begin to run until a patient learns of or discovers that negligence was committed. One NJ physician faced this reality when he settled a lawsuit for $1 million after the NJ Supreme Court allowed a plaintiff to add him into a lawsuit four years after the alleged incident occurred. The only thing this physician can be thankful for is that he did not have a two-year tail, From the perspective of the physician, the value of an independent agent cannot be overstated. That is why the vast majority of NJ physicians work through agents. something his agent would have never recommended. What does the future hold for NJ PURE and its insureds? NJ PURE is now faced with a much more challenging battle than the one it chose to wage against agents and brokers. The medical malpractice insurance market is softening, which means that more companies are looking to write more business in New Jersey. As the market becomes more crowded, competition will increase, and weaker companies may not have the resources to remain in business. A++ rated carriers are already entering or looking to expand their presence in NJ, and are offering very competitive rates. Given the choice between one of these companies and a company like NJ PURE, physicians may not be inclined to choose the latter. Of course, without the help of an independent agent, the physician may never be given the choice. Brian S. Kern, Esq., is a principal with McLachlan Kane Insurance Agency, Inc., and can be reached at bsk@insuranceagent.com This article was provided by Brian Kern and is printed without opinion by M.D. News. NEW JERSEY M.D. NEWS NOVEMBER

14 SCREENING TOOL REDUCES NEED FOR BREAST BIOPSIES Screening for breast cancer with magnetic resonance imaging (MRI) is significantly more effective at identifying suspicious breast lesions than other existing screening methods such as mammography and ultrasound. The limitation is that MRI screening is not always accurate in distinguishing between cancerous and noncancerous breast lesions a fact that leads to a number of unnecessary and invasive biopsies. However, a recent study conducted at Memorial Sloan-Kettering Cancer Center found that combining MRI screening with a scanning tool known as magnetic resonance (MR) spectroscopy can help radiologists in diagnosing breast cancer by producing fewer false-positive results and reducing the number of avoidable biopsies. MRI AND MR SPECTROSCOPY MRI is a diagnostic procedure that uses a magnetic field to provide three-dimensional images of body structures, including the breast. MRI breast screening can detect both lumps and what are known as non-mass lesions, which are sections of breast tissue that are neither a mass nor a lump. Non-mass lesions can occur either as a result of benign, noncancerous, changes in hormone levels, or they may be a sign of malignancy. A biopsy is normally used to distinguish between cancerous and noncancerous lesions. Chemical substances known as choline compounds, which are produced by cancerous breast tumors. MR spectroscopy helps radiologists to differentiate between benign and malignant tumors while adding only an additional ten minutes to the screening time. This ability to differentiate between tumor types is especially important in premenopausal women, who sometimes develop benign non-mass lesions as a result of variations in their hormone levels. MRI + MR SPECTROSCOPY STUDY In the study, conducted at Memorial Sloan- Kettering and published in the October issue of Radiology, 32 women, ages 20 to 63, with MRI-identified non-mass breast lesions were screened with MR spectroscopy. Of these women, 25 had lesions that the 1 2 NEW JERSEY M.D. NEWS NOVEMBER 2007 radiologist performing the MRI had labeled as suspicious. The remaining seven women had already had their cancer confirmed by biopsy as part of a diagnostic MRI used to assess the extent of their cancer. The results of the MR spectroscopy revealed that 15 of the 32 lesions had elevated choline levels. Of those 15, 12 were confirmed by tissue sample tests to be cancer while the remaining three were benign indicating that MRI screening combined with MR spectroscopy is 100 percent accurate at detecting cancer and 85 percent accurate at detecting malignant non-mass lesions. (Tissue sample tests were performed on each of the 32 lesions to determine malignancy.) The study s authors point out that if only those lesions with elevated choline levels detected by MR spectroscopy were biopsied, 17 out of 25 women might have been spared unnecessary biopsies, with no cancers missed. Consequently, the study suggests that MR spectroscopy combined with MRI screening can eliminate some of the false-positive results and unnecessary biopsies that occur when a woman is screened with only MRI. Breast MR spectroscopy is an exciting tool that may make breast cancer diagnosis much more specific, so that a woman does not have to undergo biopsy for a benign condition, says Elizabeth Morris, Director of Breast MRI at Memorial Sloan-Kettering and one of the study s authors. We are excited and hopeful that the technology will improve women s health. ATLANTICARE REGIONAL MEDICAL CENTER CITY CAMPUS OPENS $128 MILLION EXPANSION NEW EMERGENCY CENTER OPENS AtlantiCare Regional Medical Center (ARMC) City campus Emergency Center physicians and staff treated 157 patients, including eight trauma patients when the center opened 6 a.m. Monday, October 15. The first trauma patient arrived by helicopter at 6:45 a.m. The Emergency Center is the first of seven floors to open in the $128 million expansion the George F. Lynn hospital rounds Harmony Pavilion, the largest expansion in the 109 year history of the hospital. The opening of the new Emergency Center marks Phase II of ARMC City campus s expansion. AtlantiCare officially broke ground on the 198,000 square-foot expansion September 7, Phase I was completed in May 2007 with the opening of a new rooftop trauma helipad and trauma stabilization bays at the Harrah s Regional Trauma Center at ARMC. The expansion also includes a new pedestrian walkway from the Caesar s Atlantic City garage to the George F. Lynn Harmony Pavilion and renovation to 23,000 square feet of existing hospital space expected to be completed by mid The new Emergency Center, more than double the size of the original, is designed to handle more than 60,000 annual patient visits. Specialized and comprehensive emergency care areas for children, women s health, trauma and critical care resuscitation, behavioral health and general emergency care will contribute to patient privacy and comfort. The expansion will also include a new radiology department with separate inpatient and outpatient suites. New intensive care units (ICU) will feature 26 private rooms, four treatment bays in the Harrah s Regional Trauma Center and four private rooms in a Fast Track treatment area; consultation space and three separate waiting areas. Four new medical surgical floors will each have 30 private inpatient suites. A multi-phased opening of the remaining floors will take place through the first quarter of The George F. Lynn Harmony Pavilion will feature all private rooms, decentralized nursing stations, wireless technology, natural light, access to nature, family space and other features designed to contribute to privacy, comfort and quality care. What s going to be really powerful about this building is that it will have the fingerprints of our community and staff all over it, said David Tilton, president and CEO, AtlantiCare. Our physicians and staff have been actively involved in the design of the new building because they know best the needs of patients and how to meet those needs.

15 ARMC and architects Granary Associates of Philadelphia, Pennsylvania and New York used evidence-based design to ensure that the approximately 198 thousand squarefoot building allows for the highest level of safety, clinical care and comfort for patients. ARMC studied what are considered some of the best medical facilities in the country and incorporated the successful elements of those facilities into its design. All patient suites in the George F. Lynn Harmony Pavilion are private and have windows to allow natural light into the rooms. Patient rooms were designed for environmental comfort and control allowing patients to control temperature, lighting and sound on their own. Diagnosis and treatment technology maximizes safety and efficiency. Work from more than 60 artists from New Jersey and the Philadelphia, Pennsylvania region is in each patient suite, waiting area, nursing station and corridor. The nearly 500 pieces of art are part of AtlantiCare s commitment to designating one percent of all building costs to the arts. The new George F. Lynn Harmony Pavilion features the latest advancements in medical technology and equipment throughout the emergency center, radiology department and on patient care floors. Among the highlights are: digital mammography, medical gas booms in patient rooms, 64-slice computed tomography (CT) scanner, integrated monitoring system and voice-activated staff communication. Patient booms that have all medical gases, outlets and call buttons everything that the care team needs will be in all ICU rooms, said Larisa Goganzer, director of Special Projects for AtlantiCare. The booms are in the middle of the room so we can care for the patient in 360 degrees all around the bed instead of just having the patient in the current head/wall position. A fully-integrated patient monitoring system will allow physicians to access patient information from any computer. The Emergency Center staff will wear handsfree, voice-activated communication devices to communicate seamlessly throughout the hospital. There will be 120 private patient suites in the George F. Lynn Harmony Pavilion. Each will have a computer for staff to chart at the bedside. A hands-free sink in every room, in Jaime Pitner, MICP, RN, and Tom Brabson, DO tour the rooms of the new facility addition to the sink in the patient lavatory, will contribute to patient and staff safety. Suites will be spacious with accommodations for a family member. Standardized supply cabinets in each room will contribute to efficiency of care. Comfortable conference rooms will allow the patient, family and care team to meet outside the patient room if desired or necessary. Members of the community played a vital role in the expansion project. Many have served on one of three committees: the Healing Arts Committee, the Project Oversight Committee and the Community Advisory Committee. Each group contributed to decisions about the design of many patient and public areas and the enhancement of ARMC services. ARMC opened a new Emergency Department and Center for Childbirth at its Mainland campus in Pomona in It also has private rooms, healing arts and other features the George F. Lynn Pavilion will offer. We thank our community for its support of, and contributions to opening the George F. Lynn Harmony Pavilion, said Margaret Belfield, vice president and administrator, ARMC City campus. We thank AtlantiCare s Board members, physicians and staff for their commitment to helping our community access the care it needs and deserves, and congratulate them for building a world-class facility to deliver that care. NOTED HEART SURGEON JOINS ENGLEWOOD HOSPITAL AND MEDICAL CENTER Jock Nash McCullough, MD, a cardiothoracic surgeon and one of the area s leading heart surgeons, has joined the cardiac surgery team at Englewood Hospital and Medical Center. Dr. McCullough has spent the past 7 years performing complex cardiac surgeries and procedures at Hackensack University Medical Center where he performed more than 450 operations over the last two and one-half years with an overall hospital survival rate of 99%. Dr. McCullough joins mentor and former partner M. Arisan Ergin, MD, Chief of Cardiothoracic Surgery, and former colleague James Klein, MD, Director of Cardiac Surgery Services, at the Medical Center s Heart and Vascular Institute of New Jersey. The three surgeons routinely performed cardiac procedures together while at Mount Sinai Medical Center in New York from 1993 to We re fortunate to have Dr. McCullough join our team at Englewood, said Dr. Ergin. He brings a wealth of expertise in heart surgery, particularly in the area of minimally invasive mitral valve repair. I am excited to work once again with Dr. Ergin and Dr. Klein, said Dr. McCullough. I am confident that we can continue to build on the tremendous results already achieved at Englewood Hospital. At Englewood Hospital, the cardiothoracic team focuses on the diagnosis and treatment of all cardiac and vascular diseases, 80% of which are performed without the use of blood or blood products, and on mitral valve repair, an open-heart procedure to treat regurgitation (leakage) of the heart valve. Englewood Hospital s cardiac program has the lowest risk-adjusted mortality rate (0%) following coronary artery bypass grafting in New Jersey according to the state s Department of Health and Senior Services, a distinction achieved in three of the last four cardiac surgery reports. Dr. McCullough is Board Certified in General Surgery and Thoracic Surgery. He received his medical degree from the University of Medicine and Dentistry of New Jersey (UMDNJ) and completed his cardiothoracic surgery fellowship at the Mount Sinai Medical Center where he was a member of the Faculty as an attending cardiac surgeon in the Department of Cardiothoracic Surgery for four years before moving to Hackensack University Medical Center. There he developed a very successful private practice in Cardiac Surgery. NEW JERSEY M.D. NEWS NOVEMBER

16 ST. JOSEPH S WAYNE HOSPITAL FOUNDATION WILL HONOR HARVEY COOPER, M.D. AT ANNUAL CHARITY BALL Harvey Cooper, M.D., a member of the St. Joseph s Wayne Hospital Professional Staff for more than 40 years, will receive the Distinguished Physician Award at the St. Joseph s Wayne Hospital Foundation s Charity Ball on Saturday, December 8, 2007 at the Glenpointe Marriott. Dr. Cooper will be honored for his commitment to clinical excellence, devotion to his patients, leadership on a variety of hospital committees and outstanding commitment to the hospital. Dr Cooper has dedicated his entire professional career to our patients and hospital, has been a tireless advocate for the continuous improvement of clinical services and has served as a role model and mentor for generations of young physicians, commented Paula Nevoso, Executive Director of the St. Joseph s Wayne Hospital Foundation. We are thrilled that Dr. Cooper has agreed to be our only honoree at the Ball and our entire hospital community, his colleagues, patients, family members and friends look forward to paying tribute to him. Dr. Cooper has practiced internal medicine and hematology/oncology in Wayne since In addition to fulfilling his patient care responsibilities, Dr. Cooper serves on the St. Joseph s Healthcare System Board, was a member of the Bioethics Committee and chairs the Healthcare System s Quality Committee. He has also served as President of the St. Joseph s Wayne Hospital Medical Board and Chairman of the Department of Medicine. A graduate of New York Medical College, Dr. Cooper was a National Institutes of Health Postdoctoral Fellow in Hematology. He was Chairman of the Judicial Committee of the Passaic County Medical Society and is a member of the American Society of Hematology, the Medical Society of New Jersey and the American Society of Internal Medicine. He also served as Medical Director of Passaic Valley Hospice for eight years, at its inception. Dr. Cooper and his wife Lynn live in Wayne. Their son Jonathan, daughter-in-law Dianne and grandchildren, Alex and Jaimee, live in Davie, Florida. Their daughter, Loren, lives in Brussels. Dr. and Mrs. Cooper are members of Temple Beth Tikvah in Wayne. Proceeds from the Charity Ball will benefit patient care services at St. Joseph s Wayne Hospital. The evening will feature elegant dining and dancing to the music of Sax and Sounds as well as a champagne bonus auction. For further information on the Charity Ball, please call the St. Joseph s Wayne Hospital Foundation at (973) JOHN VICTOR MACHUGA FOUNDATION DONATES $100,000 TO ST. JOSEPH S WAYNE HOSPITAL CARDIAC CATHETERIZATION LABORATORY The John Victor Machuga Foundation has donated $100,000 to benefit services provided to patients in the Cardiac Catheterization Laboratory at St. Joseph s Wayne Hospital. Machuga Foundation Trustees Albert Dahab and Joseph M. Makoujy recently visited the hospital and presented the contribution to William McDonald, President and CEO of the St. Joseph s Healthcare System and Rex Ghassemi, M.D., Medical Director of the Cardiac Catheterization Laboratory. We are extremely grateful to the Machuga Foundation for their generous support of the Cardiac Catheterization Laboratory, Dr. Ghassemi said. These funds will enable us to expand and enhance the clinical services provided to patients with coronary disease through the purchase of valuable, state-ofthe-art equipment. We will also purchase a wide range of educational materials that will enable our patients to better understand their cardiac condition and the cardiac catheterization or other procedures that are offered. This contribution will improve both patient care and patient comfort, Dr. Ghassemi added. O p ene d i n 20 03, t he C a rd iac Catheterization Laboratory at St. Joseph s Wayne Hospital is a $1.6 million state-ofthe-art facility that features advanced digital and imaging technology that enables cardiologists to assess the strength and functioning of the heart muscle and provide immediate, life-saving treatment. In 2005, Dr. Ghassemi performed the first carotid stenting procedure, using a neuron-protection device, in Passaic County. Approximately 4,000 interventional procedures have been performed in the St. Joseph s Wayne Hospital Cardiac Catheterization Laboratory. The John Victor Machuga Foundation has been a generous supporter of clinical programs at St. Joseph s Wayne Hospital. The Foundation provided funds for the Diabetes Education Program and for the purchase of the latest CAT Scan technology for the Radiology Department. HIGH INCIDENCE OF AUTISM FOUND IN NEW JERSEY SCHOOL The Deirdre Imus Environmental Center for Pediatric Oncology held a press briefing today at Hackensack University Medical Center regarding the reported high incidence of autism and other learning disorders among children born to teachers working at St. Anthony s School, located in Northvale, NJ. Findings of the initial investigation of children with professionally diagnosed developmental disorders, born to teachers working at St. Anthony s School have confirmed a statistically significantly higher rate of autism and other neurodevelopmental disorders in comparison to a control group of children born to teachers at another Northvale public elementary school. In addition, the Phase I data found the rate to be higher than state and national prevalence statistics. The St. Anthony s Task Force, initiated by the Deirdre Imus Environmental Center for Pediatric Oncology, at Hackensack University Medical Center (HUMC), a 501(c) 3 not-for-profit corporation, was established following a series of June news reports. The Environmental Center represents one of the first hospital-based programs, whose specific mission is to identify, control, and ultimately prevent exposures to environmental factors that may cause adult, and especially pediatric cancer, as well as other health problems with our children. Our first priority in the first phase of this investigation was to determine if the number of affected children born to the St. Anthony s staff truly represented a significant increase above what would be expected, said Lawrence D. Rosen, M.D., Medical Advisor, The Deirdre Imus Environmental Center for Pediatric Oncology; Chief, Pediatric Integrative Medicine; Hackensack University Medical Center, and lead investigator. The results indicate that this is, in fact, the case. 1 4 NEW JERSEY M.D. NEWS NOVEMBER 2007

17 While we cannot yet determine the cause of these findings, we can say for certain today, that the prevalence of autism and other neurodevelopmental disorders in this cohort is statistically significantly higher. There is initial evidence of a cluster of autism cases at Northvale School, said Michael Brimacombe, Ph.D., Associate Professor, Biostatistics and Epidemiology, Vice Chairman, Biostatistics, Director Biostatistics Core Facility, NJMS, Department of Preventative Medicine, New Jersey Medical School and School of Public Health University of Medicine and Dentistry of New Jersey. Further study, both to investigate potential causes of autism and prevent future cases at the school would seem warranted. We are concerned about these children, their families, and our community, said children s health advocate Deirdre Imus. New Jersey has the highest autism rates in the country affecting 1 in 94 children. Having concluded the St. Anthony s cluster to be legitimate, the center will now enter Phase II of the project, which will include environmental testing, with the objective of attempting to identify what factors may have contributed to the increase of developmental disorders in this small population. This is in keeping with the center s mission. Joining the investigative research team will be Philip J. Landrigan, M.D., MS.c, Professor of Pediatrics, Director, Center for Children s Health and the Environment at Mount Sinai School of Medicine. Dr. Landrigan is a nationally recognized environmental health expert who will assume the responsibilities of Chairman of the St. Anthony s Project Advisory Board. There is no question these initial findings represent an important first step. We must now begin the difficult work of investigating what these results mean, said Dr. Landrigan. Questions about the ongoing investigation can be directed to Dr. Landrigan at HACKENSACK UNIVERSITY MEDICAL CENTER INTRODUCES MOBILE EMERGENCY RESPONSE PROTOTYPE THE NEXT GENERATION IN MEDICAL PREPAREDNESS The first Emergency Mobile Trauma Unit and several support vehicles have been delivered to Hackensack University Medical Center (HUMC) and are ready for field testing and deployment. In less than a year after Congressman Steve Rothman (D-NJ) and United States Senators Frank Lautenberg (D-NJ) and Robert Menendez (D-NJ) announced the allocation of $3.2 million in federal funding to HUMC to develop the first-ever mobile hospital, the units are now ready and available for use in responding to bioterror attacks and other mass casualty incidents in urban areas. MACH-1 (Mobile Emergency Trauma Department: a 43-foot box truck with expandable sides is fully outfitted with seven critical care beds having monitor-defibrillator capability, portable digital X-ray unit, telemedicine capability, portable field laboratory, small pharmaceutical cache, overhead medical procedure lighting and onboard medical gases. It is a rapidly deployable fully functional mobile ETD, staffed by HUMC emergency physicians, nurses and operations personnel. It is able to respond to large-scale incidents that result in the need for an on-site ETD and can be pre-deployed to expected events like hurricanes or other expected events based on intelligence. It is self sufficient for 72 hours. T he MCALSV (Mass Casualty Advanced Life Support Vehicle) is designed and constructed to carry support equipment for the MACH-1 by providing on-scene communications and links back to the medical center as well as the NJ Health Command Center, Office of Emergency Management and the Medical Coordination Centers. It contains additional supplies for the MACH-1 and is staffed by operations personnel. A third vehicle, the BIRV (Biological Incident Response Vehicle), staffed by operations personnel, carries specialized testing and monitoring equipment such as HUMC s BIO Veris M1M Analyzer and other vital communication equipment that will be able to go directly into the incident site for rapid identification of a biological agents. These units provide our communities with the best on-site trauma care possible. Instead of bringing disaster victims to the hospital, these mobile units bring the hospital to them, said Senator Lautenberg. With these vehicles, New Jersey will be better prepared to handle emergencies and disaster response. Every day, in our fight to protect our nation, we strive to be as prepared as we possibly can, and to respond with every tool that we have. I am proud to have worked to obtain federal funding for this vehicle, which will undoubtedly change the nature of emergency medical response; it will change the response our emergency personnel are able to provide in the moments after an event; and it will change the lives of those in need of immediate and comprehensive medical attention, said Senator Menendez. We have Congressman Rothman, Senators Lautenberg and Menendez, and the U.S. Department of Defense to thank for helping Hackensack University Medical Center bring the next generation in medical preparedness to northern New Jersey and the entire tri-state area, said Robert L. Torre of Hackensack, executive vice president of the HUMC Foundation. The delivery of these vehicles is a milestone development for a project that will save lives and minimize harm. The mobile trauma unit that we unveil today will enable emergency responders to provide advanced, on-the-scene medical care in the event of a terrorist attack or large-scale disaster. Its compact design, which enables movement through tightly packed areas, is especially important because in the event that we can t get victims to a hospital for care, we will bring a hospital to the victims, said Congressman Rothman. As a member of the House Appropriations Committee, I consider it a privilege to fight to bring federal funding for such cutting edge, life-saving equipment to our community. Not only will the development of this trauma theatre benefit New Jerseyans, but the Defense Department plans to replicate it in urban and suburban areas all across the country. We now have a unit that will be an invaluable asset to our region should we need to respond to a large scale incident that requires an on-site Emergency Department, said Joseph Feldman, M.D., of New York, chairman of the Department of Emergency Medicine at HUMC. I am confident that it will substantially improve the capability for on-scene treatment at major incidents over what is currently available only through NEW JERSEY M.D. NEWS NOVEMBER

18 local Emergency Medical Service units, and hopefully we can dramatically decrease the number of casualties suffered in any given disaster. Dr. Feldman explained the medical center continues to work with the U.S. Department of Defense in developing and establishing the HUMC Regional Biodefense Response Program. The introduction of the first Emergency Mobile Trauma Unit and several support vehicles is the first phase of a three part program. The second phase of the HUMC Regional Biodefense Response Program is developing and constructing a Mobile Operating Theatre that interlocks and attaches to the ETU. This will allow life saving surgical procedures to be performed while the victim is still at the scene. The third phase focuses on additional supportive vehicles for decontamination, pharmacy and equipment as well as the development of a Disaster Institute to support a regional training center. In addition to hospital staff, training would be provided for civilian police, fire, and EMS services. PHYSICIAN/RESEARCHER JOINS TEAM OF INTERNATIONAL LEADERS IN MULTIPLE MYELOMA TREATMENT AND RESEARCH AT THE CANCER CENTER AT HACKENSACK UNIVERSITY MEDICAL CENTER Nikoletta Lendvai, M.D., Ph.D., a physician and researcher who specializes in the blood cancer multiple myeloma, has joined the internationally renowned team of David S. Siegel, M.D., Ph.D., chief of the Division of Multiple Myeloma, at The Cancer Center at Hackensack University Medical Center. Dr. Siegel is recognized worldwide for his treatment and research into multiple myeloma, including the breakthrough clinical trials that led to approval by the U.S. Food and Drug Administration of Velcade and Revlimid, two chemotherapeutic drugs that slow and halt the progression of the deadly disease. We are excited that a promising clinician and researcher such as Dr. Lendvai has elected to join our outstanding multiple myeloma team, says Andrew L. Pecora, M.D., chairman and executive administrative director of The Cancer Center. Through her clinical research in multiple myeloma, we hope to better understand how the disease works and how we can best fight it. Multiple myeloma occurs when the blood s plasma cells which normally produce antibodies that help fight infection grow out of control and overproduce a particular antibody. Patients may experience pain in areas where the tumors press on bone, and fractures can result from plasma cells accumulating in and weakening the bones. Multiple myeloma can also cause problems with the blood, including anemia, leading to fatigue. Myeloma patients also have a lowered resistance to infections, such as pneumonia, and are susceptible to kidney problems. Dr. Lendvai joins Dr. Siegel in diagnosing and treating both inpatients and outpatients with multiple myeloma at The Cancer Center. She is conducting immunotherapy research in collaboration with the NYU School of Medicine, where she recently completed a fellowship in hematology/oncology and is now an adjunct assistant professor of medicine. Dr. Lendvai s research will focus on developing vaccines that induce an immune response in patients with multiple myeloma. Our aim is to someday be able to manipulate the patient s immune system to target abnormal multiple myeloma cells and then set off a cascade of events that will eventually eliminate these cancer cells, she explains. There are proteins that are expressed on multiple myeloma cells but not normal cells, which makes them ideal targets for the vaccines. Current therapies work well, but they do not get rid of the multiple myeloma entirely, says Dr. Lendvai. However, there is good evidence that the disease is sensitive to attack by cells of the immune system, she explains. One example of this is the so-called graft-versus-tumor effect seen in patients who underwent an allogeneic stem cell transplant. The immune cells derived from the donated stem cells are able to attack and, in some cases, eliminate the multiple myeloma cells. My goal at The Cancer Center is to develop an immunotherapy program for multiple myeloma and to design therapies that piggy-back off therapies that we already know help patients, such as stem cell transplantation. Currently, the most effective treatment available for multiple myeloma is allogeneic stem cell transplantation, which uses donated stem cells from a relative or unrelated donor whose stem cells match the patients. Hackensack University Medical Center s Adult Blood and Marrow Stem Cell Transplantation Program is one of the top 10 programs in the United States, where each year 250 transplants are completed. Transplant strategies for multiple myeloma incorporate some of the recently approved myeloma drugs, including Velcade and Revlimid. Dr. Lendvai was born in Budapest, Hungary. She follows a family tradition in medicine. Her father is a psychiatrist on Staten Island. She earned a bachelor of arts degree in neuroscience at Macalester College in St. Paul, Minn., during which she worked at the Mayo Clinic. She completed a master of science degree, doctoral degree, and medical degree at Albert Einstein College of Medicine in the Bronx, N.Y. While working in a hospital in Paris during medical school, she became fascinated with hematology and stem cell transplantation. She went on to complete an internship and residency in internal medicine at UMDNJ-Robert Wood Johnson Medical School in New Brunswick, N.J. She did her three-year fellowship in hematology/oncology at NYU School of Medicine, where she worked with Hearn J. Cho, M.D., Ph.D., a researcher in multiple myeloma vaccines. Multiple myeloma has an intriguing biology, and it affects patients over a long period of time, says Dr. Lendvai. This gives me the opportunity to build relationships with patients as we diagnose and treat them with today s most promising therapies. She says two Cancer Center faculty members Dr. Siegel and Tatyana Feldman, M.D., whom she had studied under during her fellowship at NYU were the leading factors that drew her to Hackensack University Medical Center. To be able to work with Dr. Siegel, who is an international leader in multiple myeloma, was an exceptional opportunity I couldn t pass up, she says. In addition, Dr. Feldman was highly respected at NYU, and through her I learned about the exciting work being done in multiple myeloma at Hackensack 1 6 NEW JERSEY M.D. NEWS NOVEMBER 2007

19 University Medical Center. This is a dynamic place to work and a major referral center for patients with multiple myeloma. Dr. Lendvai is board-certified in internal medicine and is board-eligible in hematology/oncology. She is a member of the American Society of Clinical Oncology, the American Society of Hematology, and the American Medical Association. Throughout her training, she was honored several times for her scholarship. She was awarded a full merit-based scholarship and the Cleveland E. Dodge scholarship for academic achievement at Macalester College, the Howard Hughes Undergraduate Summer Research Fellowship at the University of Chicago, a Corporate Sponsor Student Travel Grant from the American Society for Microbiology, and Hematology Fellow of the Year Award at NYU. She has presented her research at annual meetings of the American Society of Hematology, the Infectious Diseases Society of America, and the Interscience Conference on Antimicrobial Agents and Chemotherapy. Her research has been published in several peer-reviewed medical journals. ONCOLOGIST OFFERS TREATMENT OF WOMEN S CANCERS USING ADVANCED ROBOTIC SURGICAL APPROACHES The Cancer Center at Hackensack University Medical Center welcomes gynecologic oncologist Babak Litkouhi, M.D., of Ridgewood, who has undergone extensive training in traditional open, laparoscopic, and robotic surgical procedures for the diagnosis and treatment of women s cancers. Dr. Litkouhi, a full-time attending in the Division of Gynecologic Oncology, completed his three-year fellowship at the gynecologic oncology program of the Brigham and Women s Hospital/Harvard Medical School in Boston. The addition of Dr. Litkouhi to our gynecologic oncology team will enable us to expand our cutting-edge program in the use of robotic surgery to treat some gynecologic cancers, which is the wave of the future in this specialty, says Andrew L. Pecora, M.D., chairman and executive administrative director of The Cancer Center at Hackensack University Medical Center. He brings exciting research and clinical skills to our center that will broaden our reach in fighting devastating gynecologic cancers. Dr. Litkouhi says he looks forward to working with the chief of the Division of Gynecologic Oncology, Daniel H. Smith, M.D., in expanding The Cancer Center s treatment capabilities in the areas of complex ovarian cancer and minimally invasive procedures, including robotic surgery for endometrial, cervical, and early ovarian cancers. Hackensack University Medical Center is a leader in robotic technology on the East Coast. he says. I was attracted to the potential that exists here to take robotic surgery in gynecologic oncology to the next level. Dr. Litkouhi grew up in the area says he is glad to be back in New Jersey after completing his fellowship in Boston. He graduated summa cum laude with a degree in mechanical engineering from The Cooper Union in New York City, received his medical degree with distinction in research from Mount Sinai School of Medicine, and was a resident and chief administrative resident in obstetrics/gynecology at Yale-New Haven Hospital/Yale School of Medicine. Many gynecologic surgeries for the staging and treatment of women s cancers can be accomplished today using minimally invasive techniques with the laparoscope or the robotic da Vinci Surgical System. Dr. Litkouhi is skilled in using these technologies to stage endometrial (uterine) and early ovarian cancer and to treat cervical and endometrial cancers. His expertise also includes performing complex open surgery for the treatment of advanced and widely metastatic ovarian cancer and a variety of non-cancerous complex gynecologic conditions, such as large fibroids or advanced endometriosis, which can greatly alter normal anatomic structures and compromise the female reproductive system. During his fellowship at Brigham and Women s Hospital in Boston, Dr. Litkouhi also trained extensively in the treatment of gestational trophoblastic disease at the renowned New England Trophoblastic Disease Center, one of the leading national referral centers for this type of cancer. Gestational trophoblastic disease arises during early pregnancy from tissues that develop into the placenta. The tumor can be benign or malignant and spread outside the uterus. Dr. Litkouhi is also experienced in administering chemotherapy for the treatment of gynecologic cancers, including intraperitoneal (IP) chemotherapy to treat advanced ovarian cancer. IP chemotherapy which places the chemotherapeutic drugs directly into the abdomen (peritoneal cavity) to treat the area after cancer has been removed surgically is now being used to treat women with stage III and stage IV ovarian cancer. I enjoy performing the surgeries and the treatments some women require after surgery, he says. I also like the challenges of handling the complex issues involved with treating gynecologic cancers and the relationships I build with my patients. In the field of prevention, Dr. Litkouhi will be involved with The Cancer Center s Maureen Fund for Ovarian Cancer, a screening and counseling program that aims to reduce the incidence of ovarian cancer through early detection and treatment. After graduating from The Cooper Union with a degree in mechanical engineering, Dr. Litkouhi says he expected he would go into orthopedics after medical school. But instead, the field of obstetrics/gynecology beckoned, and he was later inspired by one of his attending physicians at Yale to pursue gynecologic oncology. During college and medical school, Dr. Litkouhi was involved in research in orthopedics and cryopreservation technology for oocyte (female egg) banking. During his residency and fellowship, he concentrated on basic and clinical research in ovarian cancer. He has been published in Neoplasia, Cryo-letters, and Cryobiology. His research has been presented at meetings of the American Society of Clinical Oncology, the Society of Gynecologic Oncologists, and the American Orthopaedic Association. He was honored with the Meehan-Miller Award for Academic Scholarship and as Resident with Special Excellence in Endoscopic Procedures from the Department of OB/ GYN at Yale-New Haven Hospital. He is a member of the Society of Gynecologic Oncologists and the American College of Obstetrics and Gynecology. NEW JERSEY M.D. NEWS NOVEMBER

20 Choosing a Retirement Plan for Your Practice What Options Do You Have? By Donald A. Cowan, CPA, CFP, Managing Director, Cowan, Gunteski & Co., P.A. financial matters What type of retirement plan should you choose for you and your staff? There are so many options available today for retirement planning that it can be very difficult for physicians to know which one is best for their practice. To make an informed decision, you need to evaluate the various alternatives and their potential tax advantages. You also need to define what your ultimate goal is in establishing the plan and how much or how little you can afford to or are willing to contribute as the employer. For example, is your most important goal to offer highly competitive benefits in order to attract and retain key employees, or is it to minimize your costs, or to encourage retirement in older staff? Once your goals and objectives are determined, it will be easier to decide which plan is best for your practice. There are two broad types of employersponsored retirement plans: nonqualified and qualified. NONQUALIFIED RETIREMENT PLANS Nonqualified retirement plans are plans that do not meet the income tax qualification requirements of Internal Revenue Code Section 401(a) or the Employee Retirement Income Security Act of 1974 (ERISA). These plans are funded by employers and are more flexible but are not eligible for the tax benefits that qualified plans offer. They may be discriminatory in their application and are typically used to provide deferred compensation to key personnel. Benefits are paid at retirement age in the form of annuities, which are taxed as ordinary income, or in lump sum payments, which can be transferred into an Individual Retirement Account (IRA) to defer taxes. QUALIFIED RETIREMENT PLANS Qualified retirement plans receive greater tax advantages than nonqualified plans but are subject to stricter government regulations, meeting the requirements of both the IRC Section 401(a) as well as ERISA. These plans must be for the exclusive benefit of employees or their beneficiaries, and they provide several tax benefits. As an employer, you can deduct allowable contributions in the year they were made on behalf of your plan s participants. Contributions and earnings on those contributions are tax-deferred until withdrawn for each participant. In addition, the plan s earnings grow tax-free, and participants and/or beneficiaries can further delay taxation on the plan s benefits by transferring those amounts into another tax-deferred vehicle such as an IRA. Qualified retirement plans can be a defined benefit plan, a defined contribution plan or a hybrid plan that combines various attributes of both. Under a defined benefit plan (traditional pension plan), the benefit is defined so that employees know the amount of the benefit that they will receive at retirement, based on their salary history and years of service. The employer bears the investment risk; the employee, the employer, or both may make contributions. Defined benefit plans do not maintain an individual account for each participant. Instead, the assets are pooled together and the employer promises that the plan will pay a defined benefit to each employee. In order to ensure sufficient funds are contributed to and accumulated within the plan to pay the required benefits, the services of an actuary are required. Defined benefit plans include the following: Cash Balance Plans In this type of defined benefit plan, the employer guarantees principal and interest rate. The participant s account is credited each year with a pay credit (dependent upon the participant s salary) and an interest credit (a fixed rate or variable rate usually linked to an index such as the one-year Treasury bill rate.) The plan is based on the end benefit, but it is accounted for like a defined contribution plan. Because cash balance plans do not take longevity or age into account, they are more favorable for younger employees and those with fewer years of service than the traditional defined benefit plan. Keogh Plans These plans can be defined benefit or defined contribution. Keogh plans are retirement plans for the self-employed professional (law partnerships, medical practices and family businesses) with ten or fewer highly compensated employees. Defined benefit Keogh plans are complex, and the employer is responsible for administration and investment choices. Defined contribution Keoghs enable employees to make their own investment decisions, with the amount of the retirement benefit dependent on the amount of annual contributions and earnings. A defined contribution plan is a qualified retirement plan in which the contribution is defined, but the ultimate benefit to be paid is not. These plans allow the employer and/or employee to make contributions. An individual account must be set up for each participant in the plan, and employees themselves choose from a number of investment options. The benefit at retirement depends on the amounts contributed and on the investment performance of the account through the years. These plans take many forms and are known by various names such as profit sharing, money purchase, 401(k), or 403(b) plans. Defined contribution plans include: Profit-Sharing Plans Contributions in these retirement plans are made solely by the employer. The employer has the flexibility to contribute and deduct up to 25% of a participant s eligible compensation each year. The 1 8 NEW JERSEY M.D. NEWS NOVEMBER 2007

21 employer invests the money, and employees pay taxes only when the money is distributed, generally upon retirement. Profit-sharing plans are a good option for small businesses, like medical practices, because they offer the greatest flexibility; an employer can contribute to the plan in profitable years and not contribute in lean years. Profit-sharing plans are also relatively easy to administer. They allow employers to contribute to an employee s account and offer tax-deferred savings and business tax deductions. Money Purchase Plans These are similar to profit-sharing plans, except annual fixed-percentage employer contributions are mandatory as prescribed in the terms of the plan. This means an employer must contribute to the plan even when it does not have a profitable year. Employee Stock Ownership Plans (ESOP) An ESOP is a type of employee benefit plan, similar in some ways to a profit-sharing plan. In an ESOP, a company sets up a trust fund, into which it contributes new shares of its own stock or cash to buy existing shares. The shares of the company stock have to vest before a participant receives them. Company contributions to the trust are tax-deductible, within certain limits. Shares in the trust are allocated to individual employee accounts. Traditional 401(k) Plans For any type or size employer, traditional 401(k) plans enable an employee to defer up to $15,500 in 2007 with a $5,000 catch-up contribution (for individuals age 50 and older). There are no employer limitations (such as number of employees) and there is no required contribution on the employer s part. If employers do make a matching contribution, vesting occurs on a graduated scale. Participants are allowed to borrow money from their accounts. These plans are subject to nondiscrimination testing and top heavy rules. Safe Harbor 401(k) Plans For any size employer, this plan is similar to the traditional 401(k) with several major differences. With this plan, employers are required to make contributions, which participants are 100% vested in at all times. Also, these plans are not subject to nondiscrimination testing and are generally not subject to top heavy rules. Simple 401(k) Plan With this plan, the employee maximum deferral amount is $10,50 0 with a $2,50 0 catch-up contribution in The business cannot have more than 100 employees earning over $5,000, and there cannot be any other plans covering the same employees. Employers are required to make a contribution which participants are 100% vested in at all times. Participants can borrow from their account, and the plan is not subject to nondiscrimination testing or top heavy rules. Simple IRA For small businesses with 100 employees or fewer, this plan is similar to the Simple 401(k) plan except that plan loans are not allowed. The plan is funded by mandatory employer and optional employee contributions. SEP IRA This plan is for self-employed and small businesses with fewer than 25 employees. Funded by employer contributions only, the SEP IRA may be supplemented with another retirement plan. Once you thoroughly evaluate the type of retirement plan that will best meet your objectives (with the advice of a tax professional), you then need to take the necessary steps to establish the plan within your practice. Many of these plans must be established and communicated to employees under strict timelines. Depending on the type of plan you select, you may need to arrange a fund for its assets, adopt a written policy, notify eligible employees and develop a tracking system. You will financial matters also have to ensure you are covering eligible employees, making the appropriate contributions, adhering to changes in retirement law, managing the plan assets, communicating to plan participants and distributing the appropriate benefits. In conclusion, it is important to note that there are many different regulations today that govern retirement plans as well as certain exceptions and/or additional details to some of the items discussed in this article. Therefore, it is important to involve a tax advisor and financial planning expert familiar with retirement plans to help you design a plan to meet your practice goals and objectives. As one of the leading accounting and consulting firms for physician practices, Cowan, Gunteski & Co., P.A. is well-versed in helping physicians choose an appropriate retirement plan for their practice and take advantage of any tax-related savings. To find out more, contact Don Cowan, CPA, CFP, Managing Director, at (732) extension 122 or dcowan@cowangunteski.com. As a diversified certified public accounting firm, Cowan, Gunteski & Co., P.A. is committed to being an active partner in its clients growth by delivering value beyond accounting, innovative solutions and consistent exceptional service. Visit com for more information on the services available to meet the unique needs of physician practices. NEW JERSEY M.D. NEWS NOVEMBER