Planning for Market Leadership

How Dermatology Associates of Kentucky became one of the largest freestanding practices in the US.

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LEXINGTON Imagine UofL’s Papa John’s Cardinal Stadium filled to capacity or UK’s Commonwealth Stadium with all but the corners filled and you can picture the annual volume of Lexington-based Dermatology Associates of Kentucky (DAK), which boasts 55,000 patient visits a year.

DAK’s eight physicians, three PAs, and 89 employees work in one of the largest free-standing dermatology centers in the United States, built in 2002 with over 45,000 square feet on three levels, including its own AAAHC and Medicare accredited ambulatory surgery center. In October 2011, DAK opened a facility in the Beaumont area to accommodate patients on the west side of Lexington, and they also have a Frankfort location.

Current managing partner Laurie R. Massa, MD, attributes the growth of DAK to a simple practice philosophy of an emphasis on patient care throughout the entire staff. “We treat each patient as we would want our family member to be treated,” states Massa.

DAK has embraced the evolution of dermatology practices and now incorporates general dermatology with outpatient surgery, including Mohs micrographic surgical techniques, clinical dermapathology, immunodermatopathology, and cosmetic dermatology. “We treat much more than warts and acne,” says Massa. “Often we can diagnose systemic illnesses by complete physical exams of the skin.”

Off-label use of medications is a common occurrence in dermatology because some of the skin’s more unusual diseases will not generate sufficient pharmaceutical research and development to create the necessary drugs. Massa has seen such off-label use in her own practice, using Enbrel, the psoriasis and rheumatoid arthritis tumor necrosis factor inhibitor, to treat a patient with multicentric reticulohistocytosis.

Skin cancer prevention by routine full-body examinations is a growing part of general dermatology that Massa has seen in recent years. “We are now seeing patients in their 30s and 40s who are looking to prevent skin cancer, not waiting for melanomas to develop,” states Massa. Cancer prevention exams plus cosmetic dermatology have fueled the practice’s growth and are a trend Massa expects to continue.

Massa and April Ramsey, MD, share the cosmetic dermatology duties at DAK’s Bellege Medispa. Other physician members of the practice are Mary Guiglia, MD, a double-boarded internist and general dermatologist; Charlie Becknell, MD, a double-boarded internist and general dermatologist who performs cutaneous and laser surgery; and Todd Clark, MD a general dermatologist and cutaneous surgeon.

The certified physician assistants at DAK are Sherri Baer, Braeye Rueff, and Victoria Falconer.

Mohs Micrographic Surgery

The current gold standard of micrographic surgical techniques for the removal of malignant cancer cells while the patient is in surgery was created by Dr. Frederic Mohs. It allows the surgeon to microscopically examine the tissue specimens in three dimensions and obtain complete circumferential peripheral margin control. The cited cure rates with Mohs surgery are 98 to 99% for basal cell carcinoma. Mohs surgical technique is the preferred method for removal of skin cancers in anatomical and cosmetically important areas such as eyelid, nose, and lips.

Anir Dhir, MD, is the Mohs surgery specialist at DAK, performing over 2200 Mohs surgeries each year since he joined DAK in 1999. Dhir admits that his high volume of surgeries “may sound dramatic,” but it’s achievable because surgery is all he does. “I can do surgeries five or six days a week only because my partners conduct the clinics. Our extenders hold the screenings and do the follow-up care.”

Dhir received his medical degree from Baylor College of Medicine and took residency in dermatology at Emory University, followed by a fellowship in Mohs micrographic surgery, facial reconstruction, and cosmetic surgery at Dermatology Associates with Dr. Gary Monheit in Birmingham, Alabama.

Mohs surgery is more expensive and can be more time-consuming, but Dhir is passionate that the advantages outweigh the negatives. Using the Mohs technique, Dhir says he can chase a tumor in the three dimensional field, not in a “bread loaf slice,” in real time before the patient is stitched and leaves the operating room. The advantage being that Dhir is both surgeon and pathologist. “The buck stops with one person,” says Dhir, “the surgeon.” Dhir’s cure rate is “over 99.5%,” based on 13 years of follow-up care with thousands of patients.

Mohs surgery is also a tissue saving procedure and is ideal for patients who are at risk for general anesthesia surgery. All anesthesia is local, says Dhir. Patients are sedated but awake. “It’s like a trip to the dentist,” says Dhir.

Dhir is equally passionate about uncovering the underlying dangers of skin cancer. “What you see on the surface has very little bearing on what’s below the surface,” the surgeon says. He has treated many tumors that look like a surface pimple but the cancer cells run deeply through the muscle fibers and even to the nerves. “Like pulling out a weed,” Dhir says, “you have to get out the root.”

Dermapathology & Immunodermatopathology

It’s not unusual for a dermatology practice to have a dermatopathologist and immunodermatopathologist in the practice, but it is not that common either. Fernando R. de Castro, MD, is double board-certified in medical and surgical dermatology and clinical and laboratory dermatological immunology. He is fellowship trained at the Mayo Clinic in Rochester, Minnesota, in Dermatology, Dermatopathology & Immunodermatopathology, where he studied under the renowned Dr. Richard Winklemann, a founding member of the American Society of Dermatopathologists, before joining DAK in 1995.

His fellowship training is an asset to DAK, says de Castro because it allows him to bring more focus to the work up and therapies of the skin diseases presented by patients. While skin cancer, sun damaged skin, and common skin disorders are the majority of the DAK patient population, occasionally a patient will present an uncommon condition such as bullous pemphigoid, in which the patient’s body has become sensitized to a protein in the skin. In such a case de Castro will prescribe systemic corticosteroids and steroid sparing immunosuppressive drugs including rituximab. De Castro is also encouraged by new psoriasis treatments such as TNF alpha inhibitors and IL 12/23.

The success of DAK is the result of a combination of factors, says de Castro. “We, the physicians, all get along in a very communal and professional way,” he says. “We have a shared vision, the goal to be the best practice of medicine for our patients and the best at practicing the business of medicine.”

DAK Legacy

The roots of DAK go back 61 years to 1951 and the founding partner, Ullin W. Leavell, Jr., MD. Current senior partner, Ira P. Mersack, MD, joined Leavell in 1972. W. Patrick Davey, MD, joined Leavell and Mersack in 1987. In 1988 Mersack was managing partner and saw the growth potential beyond Lexington and changed the practice name to Dermatology Associates of Kentucky. “We were already seeing many patients from southern and eastern Kentucky,” says Mersack, “so we knew the potential was there for expansion. And I didn’t want our practice to sound like a law firm,” says Mersack.

Mersack recently celebrated his 40 year anniversary with the practice. At the celebration, he humorously recalled the early years of visiting doctor’s offices in eastern and southeastern Kentucky to introduce himself. He drove the Kentucky back roads with a plentiful supply of chocolate pinwheels that rarely lasted the entire trip. “It was effective,” Mersack recalls, “I think we got a lot of referrals from those pinwheels, but boy did my waistline suffer.”

Mersack arrived in Lexington in 1972 with wife Anita after completing military service in the US Army, serving as “a battlefield surgeon” in Vietnam during the most intensive combat arena, the Tet Offensive in January 1968. It is hard to imagine the soft spoken and gentle Mersack today as a captain in an Army infantry unit performing battlefield triage, but he recalls vividly his time in Southeast Asia.

In 1988 Mersack began his involvement with thoroughbreds. His first equine acquisition was Persian Gold, which he bought as a yearling at Keeneland. Persian Gold went on to become a three times stakes winner and earner of $270,803, and Mersack was hooked. Fueled by his own admitted “delusions of grandeur,” Mersack, with his farm manager and partner Steve Johnson, purchased the J.T. Lundy Farm near Midway, Kentucky. The farm was renamed Margaux Farm and continues to operate as a successful breeding and training facility for stakes winners.

Louisville dermatologist Dr. Joe Fowler [Editor’s note: See story on Fowler on pg 24], who created the International Physicians Thoroughbred Owners Society (IPTOS) and wife Lynn Fowler, RN, BSN, joined Mersack as co-owners of Margaux Farm. Together they have introduced many physicians to the highs and lows of the horse industry.

Throughout his long and varied career as doctor, businessman, and entrepreneur, Mersack views himself as a physician first. “I receive great pleasure in making another person’s life better. That’s what keeps me going,” he says. He notes that the success of DAK is derived from many factors, including the vast majority of patients that are referred by the friends and family members of other patients.

Mersack recalls what his mentor Leavell told him many years ago, “Take care of your patients and they will take care of you.”

We treat much more than warts and acne. Often we can diagnose systemic illnesses by complete physical exams of the skin.– Dr. Laurie R. Massa

Among its many positive attributes, Mohs surgery is a tissue saving procedure and is ideal for patients who are at risk for general anesthesia surgery.