Summer 2016
www.hrphysician.com
BRIAN L. JOHNSON, MD ABBY S. VAN VOORHEES, MD
WILLIAM L. COKER, JR., MD
Honoring Physicians Who Specialize In:
Patients will always remember how we make them feel. And at EVMS Medical Group we want to make them feel better. We understand that for so many patients, a trip to the doctor is stressful — especially when they’re sick or hurt, or worried about a potential diagnosis. So how can we make a positive change?
It begins with the patient experience. We are dedicating ourselves to improving quality of care across each and every point of patient contact, from the very first hello. We’re expanding the lines of communication, placing even more value on kindness and compassion. Yet it’s more than simply being nice. It’s a conscious focus on shifting our entire culture. By working together as a team, we can provide each patient with the best — and most personalized — healthcare experience. Because above all, we’re here to treat our patients well.
The knowledge to treat you better.
Learn more at EVMSMedicalGroup.com.
contents
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Summer 2016 VOLUME IV, ISSUE III
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42 Innovations in Breast Prostheses 53 Adding Hours, Adding Revenue DEPARTMENTS 4 Publisher’s letter 6 Physician Advisory Board 18 Good Deeds: Claude Louis, MD 20 Advanced Practice Providers: Kim Scott, FNP, AE-C, CORLN 22 Medical Update: Innovations in Radiology 44 In the News 50 Welcome to the Community 54 Awards and Accolades
FEATURES 8 Dermatology
PROMOTIONAL FEATURES 28 Chesapeake Regional, Riverside & UVA Radiosurgey Center Celebrates 10TH Anniversary
10 William L. Coker, Jr., MD and Leslie R. Coker, MD 12 Brian L. Johnson, MD 14 Abby S. Van Voorhees, MD
34 Dominion Pathology Laboratories-Dermatopathology is our Specialty
16 Ocular Melanoma 30 Percutaneous Fusion Technique is Relieving SI Pain in Post-Fusion Patients
40 Taking the Pain Out of the Real Estate Market 18
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32 Thinking BIG 36 Medical Consumerism, MRI Services and Your Patients 38 Evaluating Clinically Integrated Networks
Taking Nominations for the Fall 2016 edition
We are looking for physician leaders who specialize in
PULMONOLOGY Deadline for Nomination Submissions
Pulmonology
September 1
Nomination forms are available on www.hrphysician.com (click nominate tab) or by emailing a request to holly@hrphysician.com Summer 2016 Hampton Roads Physician | 3
WELCOME TO THE Holly Barlow
Bobbie Fisher
Publisher
Editor
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In this issue, we recognize four physicians in our community who care for the patients who suffer from any of the more than 3,000 diseases that can attack the body’s largest organ – the skin. As the American Academy of Dermatology website states, “Skin is your body’s coat. It protects you. It helps you stay warm when it’s cold, and cool when it’s hot. Your skin keeps all your insides in, from your heart and lungs to your blood and muscles. And unless it’s cut or damaged, it keeps stuff out, including germs and water. You also feel things through the nerves in your skin.” For many, it’s a canvas to reveal an outer expression of an inner creativity.
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Summer 2016, Volume IV/Issue III
Recognizing the achievements of the local medical community Publisher Holly Barlow Editor Bobbie Fisher Physician Advisory Board (see page 6) Magazine Layout and Design Desert Moon Graphics Published by Publishing, LLC
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For others, it’s a placard to announce a personal philosophy. And it may very well be the most abused of the organs: we paint it, we pierce it, we stitch it and ink it. We even (intentionally) expose it to the sun until it burns. So when it comes to caring for it, it requires an exceptional physician with highly specialized training. Our cover honorees – as always, chosen by our Physician Advisory Board from among nominations submitted – are representative of the exceptional quality of dermatologic care available in Hampton Roads, proving once again that no one need ever leave Hampton Roads to access world class medical care.
Emeritus and Voting Board Jon M. Adleberg, MD Anthony M. Bevilacqua, DO Silvina M. Bocca, MD, PhD, HCLD Mary A Burns, MD, FACOG, FPMRS Jeffrey R. Carlson, MD Kevaghn P. Fair, DO Bryan Fox, MD Margaret Gaglione, MD, FACP Emmeline C. Gasink MD, FAAFP, CMD Jerry L. Nadler, MD, FAHA, MACP, FACE Paa-Kofi Obeng, DO Michael J Petruschak MD Richard G. Rento II, MD Michael Schwartz MD JohnM. Shutack, MD I. Phillip Snider, DO Deepak Talreja, MD, FACC, FSCAI Jyoti Upadhyay, MD, FAAP, FACS Christopher J. Walshe, MD Elizabeth Yeu, MD
For the medical update for this issue, we spoke with five area specialists who practice in the area of radiology about remarkable advances they’ve seen in their field. We’ve included articles by a local orthopaedic surgeon about a new technique to treat SI joint pain, and from a vitreoretinal surgeon about treating ocular melanoma. In our next issue, we’ll feature physicians who work in the field of pulmonary; our medical feature is on building a successful ACO. Have a wonderful remainder of the summer, and as all of our cover docs would say, don’t forget the sunscreen!
Contact Information 757-237-1106 holly@hrphysician.com Hampton Roads Physician is published by DocDirect Publishing, LLC, 7445 N. Shore Rd., Norfolk, VA 23505 Phone: 757-237-1106. This publication may not be reproduced in part or in whole without the express written permission of DocDirect Publishing, LLC. Published four times a year, Hampton Roads Physician provides a wide variety of the most current, accurate and useful information busy doctors and health care providers want and need. Cover stories concentrate on one branch of medicine, featuring profiles of practitioners in that specialty. Featured physicians are chosen by the advisory board through a nomination process involving fellow physicians and public relations directors from local hospitals and practices. Although every precaution is taken to ensure accuracy of published materials, DocDirect Publishing, LLC cannot be held responsible for opinions expressed or facts supplied by its authors. Visit Us Online
B O A R D A D V I S O R Y P H Y S I C I A N
2016 ADVISORY BOARD
Their input will help guide the editorial content, format, and direction of the magazine. Along with our Emeritus Board, they will select our featured physicians. Alfred Abuhamad, MD Obstetrics & Gynecology Dr. Abuhamad serves as the Vice Dean for Clinical Affairs and the Mason C. Andrews Professor and Chair, Department of Obstetrics and Gynecology at EVMS. He is Board certified in Obstetrics & Gynecology and Maternal-Fetal Medicine. He is the current president of the Society of Ultrasound in Medical Education, and the National Council of Safety in Women’s Healthcare and past president of the American Institute of Ultrasound in Medicine.
O.T. Adcock, Jr., RPh, MD
Jennifer Miles-Thomas, MD, FPM-RS Urology Dr. Miles-Thomas is a urologist with The DevineJordan Center for Reconstructive Surgery and Pelvic Health-a division of Urology of Virginia, an Assistant Professor in the Department of Urology at EVMS, and the Medical Director for the Pelvic Health Center at Chesapeake Regional Medical Center. Dr. MilesThomas is Board certified and fellowship trained in urology. She is also Board certified in female pelvic medicine and reconstructive surgery.
Hesed Mugaisi, MD
Registered Pharmacist/Family Medicine Dr. Adcock is a Board certified Family Medicine physician in practice in Hampton for 32 years. He currently serves as Associate Medical Director and Service Line Chief for Primary Care and Access for Riverside Medical Group.
Dr. Mugaisi is a Board certified family medicine physician with Bon Secours Suffolk Primary Care. He acquired his bachelor of medicine and bachelor of surgery from the University of Nairobi in Nairobi, Kenya and completed his family medicine residency at Group Health Family Medicine Residency Program affiliated with University of Washington in Seattle, WA.
John W. Aldridge, MD, FAAOS
Jennifer F. Pagador, MD
Orthopaedic Surgeon Dr. John Aldridge is Board certified orthopaedic surgeon with Hampton Roads Orthopaedics & Sports Medicine. He specializes in minimally invasive muscle sparing spinal surgery and total joint replacement surgery. Dr. Aldridge practices at both the Newport News and Williamsburg office locations of HROSM. In addition to his many interests in the field of orthopaedics, he also serves as a Lieutenant Colonel in the United States Army Reserves.
Brian L. Johnson, MD
Family, Bariatric and Age Management Medicine Dr. Pagador is Medical Director of Seriously Weight Loss, LLC and Attending Physician at Revita Medical Wellness, specializing in medical weight loss and hormone optimization. Dr. Pagador is Board certified in family medicine.
Michael M. Romash, MD
Dermatology Dr. Johnson is the founder of The Virginia Dermatology & Skin Cancer Center. He is a Fellow of the American Academy of Dermatology, American College of Mohs Surgery, and the American Society of Dermatologic Surgery. His emphasis is on the treatment of skin cancer using the Mohs Micrographic surgical technique, an advanced surgical procedure for the treatment of skin cancers.
Orthopaedic Surgeon A Board certified lower extremity specialist practicing for over 30 years, Dr. Michael Romash is a Fellow of the prestigious American Orthopaedic Association and known as a pioneer in his field. Author of numerous medical journal articles and chapters in text books about foot and ankle surgery, he has developed treatments commonly used for various heel fractures.
Mark W. McFarland, DO
Lynne A. Skaryak, MD
Orthopaedic Spine Surgery Dr. McFarland practices at the Orthopaedic & Spine Center in Newport News and is Board certified In Orthopaedic Surgery and Fellowship trained in Spine Surgery.
Thoracic Surgery Dr. Skaryak is Director of Thoracic Surgery and Co-Director of Thoracic and Lung Health at Chesapeake Regional Medical Center. She is Board certified in Thoracic Surgery.
Visit our website to see all members of the Emeritus Board: hrphysician.com 6 | www.hrphysician.com
Established in 2002 and dedicated to patient care, Dominion Pathology Laboratories, (DPL) is an independent laboratory that offers expert diagnosis on biopsies performed in healthcare facilities throughout Hampton Roads and greater Richmond.
Robert A. Frazier, Jr., M.D.
Kevaghn P. Fair, D.O.
Michael T. Ryan, D.O.
• 24 Hour Turn-Around On Routine Specimens • Board Certified Pathologists With Over 70 Years Of Combined Experience • Immediate Access To Our Physicians Whenever You Need Them • Continuous Internal Quality Control Where Second Opinions Are Routinely Provided In The Diagnosis Of Unusual, Suspicious, Or Malignant Cases. 733 Boush Street, Suite 200 • Norfolk,VA 23510 Phone 757-664-7901• Fax 757-664-9122 www.dominionpathology.com
Skin is not only an envelope protecting the inner body, or a membrane that allows exchange between exterior and interior of the body. It also serves as a mingling point between the outer world and inner self, and between body and soul. — Miru Kim, American photographer and film maker
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hen Hamlet contemplated ‘the thousand natural shocks that flesh is heir to,’ he no doubt meant more than the envelope protecting the inner body that Miru Kim describes. But that outer envelope is heir to more than 3,000 different disorders – from acne to zoster, with all of the attendant stigma that has attached to diseases of the skin for centuries. From the earliest recorded histories, we know that individuals with skin diseases were cast out from society in ancient times, labeled unclean and ostracized. Often diagnosed with leprosy, they probably really suffered from other skin diseases, such as eczema and psoriasis. Leprosy is considered the oldest infectious disease among humans. The Bible mentions leprosy no fewer than 40 times, always insisting that the sufferer is unclean, both physically and spiritually. The disease was considered a curse, a punishment for sins committed. Individuals diagnosed with leprosy were not allowed to live in any community of their own people; in fact, among the sixty-one defilements of ancient Jewish laws, leprosy was second only to a dead body in seriousness. The disease was considered so revolting that lepers weren’t permitted within 150 feet of anyone when the wind was blowing. Lepers lived in communities with other lepers until their skin was healed or they died. So prevalent was leprosy (correctly diagnosed or otherwise) in ancient times that the disease has been the subject of artists throughout history. Renaissance painters often included detailed portrayals of these lesions in their work. Others throughout history were also misdiagnosed, and also suffered the indignity of being labeled unclean. Robert I of Scotland (1274 - 1329), also known as Robert the Bruce, ruled Scotland from 1306 until he died. He was diagnosed with what contemporary accounts described as “an unclean ailment,” the traditional view being that his death was caused by leprosy. In fact, according to a March 17, 2016 article in The Scotsman, 8 | www.hrphysician.com
the national newspaper of Scotland, “The propaganda machine was working against King Robert and the worst thing that you could have said about someone in those times is that he had leprosy. It is true that King Robert’s father had and died of the disease, but the King himself died peacefully in his bed in the modern day village of Renton, medieval Cardross at the age of 54 due to an illness.” Particularly after his exhumation and facial reconstruction, historians have suggested such varying contributing factors as eczema, tuberculosis, syphilis, motor neuron disease, cancer or stroke, or even his diet of rich court food. Even today, because skin is exposed for everyone to see, these diseases are often obvious and visible; and unfortunately, the stigma remains, imposing on patients the dual difficulty of having to deal with their skin condition as well as the disdainful glances and comments of others. Because the social stigma can be so insidious, diagnosis is frequently delayed, with sometimes severe consequences. In fact, skin diseases are very common, affecting nearly everyone at some point in their lives. with acne being the most common and melanoma the most deadly – and while treatments for these conditions have become much more effective, the biggest challenge these patients may face in the future may well be lack of access to dermatologic care. From the US National Library of Medicine, National Institutes of Health, comes this abstract from 2007: Since 1999, multiple surveys have documented a stable undersupply of dermatologic services in the United States. Factors contributing to the imbalance include changes in the demographics of the physician workforce, increased demand for services, and a limited number of training positions for new physicians. In response to the demand, there has also been a substantial influx of nonphysician clinicians into dermatology offices.
The statistics have not improved. As a January 2012 article in Dermatology Times reported, patient requests are exceeding the time slots available at dermatologists’ offices across the country. Some of the numbers are slowly changing, but wait times remain lengthy, and solutions are complicated. A 2013 report compiled by Harris Williams & Co., entitled Dermatology Market Overview, revealed that in that year there were an estimated 9,600 dermatologists and 7,800 dermatology practices in the United States. The report indicates that the current shortage is expected to persist for the foreseeable future. All this, at a time when there is an increasing demand for dermatological services, driven primarily by the rising occurrence of skin cancer, in particular melanoma, and the aging of the population. According to a 2015 One Key report prepared by Cegedim Relationship Management, dermatologists “represent a very small number of the total number of physicians in the US. There are currently 13,847 dermatologists practicing across the country. Most dermatologists focus on a single specialty; only 13.5 percent have a secondary specialty. The number of dermatologists has certainly not kept up with demand. Since 2010, there has only been about a 10 percent increase in the number of dermatologists.” Additionally, the report continues, the Affordable Care Act (ACA) has contributed to additional demand for dermatology
services - dermatologists are among the top five specialists booked by ACA patients. And it’s the southern states that have the highest concentration of dermatologists: a third of the country’s dermatologists practice in the south, outweighing the northern states by about 70 percent. The American Academy of Dermatology addressed the growing problem at its 74th annual meeting in March 2016, reporting that expansion of coverage under the ACA is expected to increase still further. The report noted: With projected GDP growth of 3% annually, the supply of dermatologists will be 24.4% short of the estimated demand for dermatologic care assuming current trends in dermatology resident training continue… The report concluded that the US faces “a substantial shortage of dermatologists in the next 30 years, which may reach 25% of anticipated demand.” While growth in the NP and PA workforce may help to partially alleviate the severity of these workforce shortages, highly trained dermatological specialists and subspecialists – like Dr. Brian L. Johnson, Dr. Abby S. VanVoorhees, Dr. Luke Coker and Dr. Leslie Coker, whose exceptional work in the field of dermatology is profiled in this issue of Hampton Roads Physician – will always be in demand.
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Summer 2016 Hampton Roads Physician | 9
WILLIAM L. COKER, JR, MD LESLIE R. COKER, MD Associates in Dermatology, Inc.
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orty-six years ago, a dermatology practice was established on the Virginia Peninsula by Dr. William L. Coker, Jr. He hadn’t planned to be a dermatologist, nor even a physician – he just wanted a career that would take him far away from the South Carolina tobacco farm on which he grew up. “My dad was also a school teacher, but I didn’t want to do that either,” Dr. Coker says. “I knew doctors were held in high esteem, so I thought I’d become a dentist.” When his father developed rheumatoid arthritis, he reckoned that inheriting the condition would bode badly for a dentist, so he went to medical school. His plan was to become a family doctor in a small town in South Carolina. But, as he says today, “Plans go astray.” ‘Astray’ for Dr. Coker meant being drafted during his internship and deferred under the Berry Plan. “I joined the
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Navy, and they asked me if I was interested in submarines,” he remembers, “so I said yes, thinking they’d send me information. Instead, they sent me a notice to report to sub school.” Two important things happened to Dr. Coker during this time: he met his future wife, the renowned artist Gloria Coker, and he worked in a dermatology clinic. “I’d had no dermatology rotation in med school,” he says, “and figured I’d need it to be a good family doctor. The dermatologist I worked with on the Base made it interesting and fun, and I knew that’s what I wanted to do.” After two years in dermatology at Baylor and one at Duke, he and his wife settled on Hampton Roads as their home. “It was a compromise,” Dr. Coker explains: “She was from Connecticut and I didn’t want to live there; and I was from South Carolina, and she didn’t want to live there. Hampton Roads was our happy medium.”
Dr. William Coker opened his first practice in 1970. That same year, Leslie Robin Coker was born. Growing up, she watched her father with his patients, sometimes accompanying him on after-hours calls. “He never grumbled about long days, or even about taking calls for other dermatologists,” she remembers. “It was always obvious that he loved his work, and even more obvious that he cared about his patients.” She thought off and on about becoming a physician, but that decision was confirmed when she was 16. “I got a speeding ticket,” she says. “My court appointed community service was working in the emergency department at Riverside Hospital. I was struck by the compassion of the doctors working there, and even more drawn to medicine. I didn’t know what specialty I wanted to pursue, but I knew I wanted to become a doctor.” It wasn’t until medical school that Dr. Leslie Coker – Lee to her friends and family – chose dermatology as her specialty. “I considered general surgery and even OB, but I wanted to be able to balance my career with family,” she recalls. “It was in my third year, after rotations in many other specialties, that I came to the realization that dermatology was where I belonged. I’m very visually oriented (a gift from her mother) and dexterous. It was a good fit from the start, and it allowed me to have a family as well as a career.” When Dr. Lee Coker went into practice with her father, she discovered what he had known along: in dermatology, your patients become like family. “It sounds corny,” Dr. Luke Coker says, “but after 46 years, it still doesn’t feel like going to work. My patients have become my dear friends. And I’ve had some of them for all of my 46 years. We’ve matured together.” Dr. Lee Coker is already experiencing that sense of family, both with some of her father’s long-standing patients as well as her own. Both Drs. Coker are enthusiastic about the advances they’ve seen in dermatology over the years – 46 for him and 13 for her. Dr. Luke Coker still recalls the excitement that accompanied the discovery of Accutane, which made such a huge difference in managing patients with severe acne. “There are so many better ways to treat skin problems today – things like biologics and the medications to treat psoriasis,” he says. “The technology is expensive, but it has helped our patients so much.” They’re both concerned about the prevalence of melanoma, which has been rising for the last 30 years. The American Cancer Society estimates that about 76,380 new melanomas will be diagnosed in 2016 in the US, and about 10,130 will die of the disease this year. “It’s not just the sun worshipers who flock to our beaches,” Dr. Lee Coker says. “Melanoma sufferers include farmers, golfers, boaters, commercial fishermen – anyone who spends time in the sun without adequate protection.” She is hopeful that some of the advances being made in immunologic drugs to treat melanoma can be built upon to develop even more effective treatments – including vaccines to treat melanoma, which are currently being studied in clinical trials. “I can’t say enough good things about my dad, both as a father and as a physician,” Dr. Lee Coker emphasizes. “The reason I’m as good as I am is because of him. He taught me what they don’t teach in medical school: how to treat the staff, how to deal with colleagues and especially, how to not just treat patients, but how to care for them. I try to emulate what I see in him.”
Summer 2016 Hampton Roads Physician | 11
BRIAN L. JOHNSON, MD
Virginia Dermatology & Skin Cancer Center
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r. Brian L. Johnson began his medical training at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. His Navy medical career included service aboard the USS Yellowstone, the Kearsarge and the Iwo Jima. He participated in major deployments and field assignments with the Seabees and Special Forces. He studied dermatology at Johns Hopkins, and completed a Mohs Surgery Fellowship at Northwestern Skin Cancer Institute in Chicago. He’s a Fellow of the American Academy of Dermatology, the American College of Mohs Surgery, and the American Society of Dermatologic Surgery. Dr. Johnson wanted to really make a difference in his patients’ lives. He soon realized that was dermatology: “I grew up with it,” he says. “My father, Dr. Bernett L. Johnson, was a renowned master dermatologist who subspecialized in dermatopathology, and I knew that there were cases – like melanoma – where I could literally save lives.” He also realized that dermatology was very diverse: his father’s specialty, dermatopathology, focuses on the study of cutaneous diseases and their causes at the microscopic level. Where Dr. Bernett Johnson enjoyed looking at samples under the microscope, his son preferred the hands-on approach of treating patients in the surgical setting. During his Mohs fellowship, Dr. Johnson knew he had found a niche. The ground-breaking surgical procedure for treating skin cancer lesions was developed by Frederic Mohs in the late 1930s. “He developed the technique of removing skin cancers and looking at the margins immediately,” Dr. Johnson explains, but relates that the procedure wasn’t adopted by general surgeons at the time because during those years, “skin was considered a non-issue. If you weren’t an internist or a general surgeon, you weren’t considered a real doctor,” he says. Dr. Mohs tried to publish his findings, but surgeons then weren’t comfortable learning skin pathology and laboratory techniques, while dermatologists, who are well versed in dermatopathology, and who routinely treated skin cancers, embraced the procedure. “Dermatologists picked up the technique and ran with it,” Dr. Johnson says, “and over the years, we’ve refined it to the point where we can use local 12 | www.hrphysician.com
anesthesia, remove the cancers and evaluate the margins under the microscope while the patient is waiting. It’s easier on the patient in many ways – notably, it completely eliminates the anxiety of having to wait days or even weeks for a biopsy report, or to have the wound repaired.” Dr. Johnson can perform as many as 10-15 surgeries in a typical day. When his patients arrive for their Mohs surgery, they expect to stay a while, because the entire process can take several hours. Some are there all day – which leads to one of the most fascinating non-medical aspects of Dr. Johnson’s practice: after their initial incision, patients are bandaged and sent to Dr. Johnson’s waiting room. While they wait for their tissue to be processed and read – a process that can take up to 90 minutes – they become part of a small fraternity. “Some patients are self-conscious about going into the waiting room with bandages on their face,” Dr. Johnson says, but adds their embarrassment is shortlived, because in his waiting room, everyone has bandages – on their ears, noses, cheeks: anywhere on their face or neck. “They don’t even think about it, because everybody is bandaged,” he says. “They may start out watching TV or reading – but they always wind up talking to each other. They trade stories about how they got their cancers, and conversation grows from there. It lessens the anxiety.” Some of his patients have been coming to him for years, and he sees them calming down some of the newer patients. “It’s incredible,” he says. “The waiting room evolves into a big support group.” “Mohs surgeons are really three doctors in one,” Dr. Johnson says. “We’re oncologists, cutting out cancers. We’re pathologists, reading the slides to make sure all the margins are clear. And we’re reconstructive surgeons. We perform all three functions.”
From the patients’ standpoint, that efficiency means everything is dealt with on the same day, so they’re spared the ordeal of waiting for pathology and follow-up appointments. The cost savings can be substantial, but many think the convenience and lessened anxiety are even more important. Dr. Johnson’s passion for surgery and providing a familyfriendly environment was an integral part of his motivation to build a 16,000 square foot, state-of-the art medical facility in Norfolk. The building was designed to provide patients with unparalleled convenience for general, surgical, and cosmetic dermatology services under one roof. The building is equipped with the latest technology to treat the diseases of the skin, hair, and nails. In addition, the facility offers an exclusive cosmetic dermatological suite with the most innovative technology for aesthetic and body contouring procedures. Dr. Johnson says, “We found it necessary to become a larger organization to help counteract the many negative changes in healthcare that inhibit a provider’s ability to adequately care for and treat patients – notably, insurance companie’s control of what procedures we can perform or what medications we can prescribe and pharmaceutical companie’s exorbitant pricing of prescriptions. “Many of my patients can’t afford to get the medications we feel are best to treat their condition,” he says. “I was absolutely horrified when a patient told me that she spent $800 out-of-pocket for a small tube of ointment because I recommended it. Things won’t change until physicians come together as a group and demand a change. The system does not run without us.” Dr. Johnson’s top priority remains to promote outstanding quality healthcare through education, and providing patients with the highest level of personalized care in a family-friendly environment. Summer 2016 Hampton Roads Physician | 13
ABBY S. VAN VOORHEES, MD Chair, Department of Dermatology Eastern Virginia Medical School
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hysicians go into medicine for as many diverse reasons as there are specialties to choose from. In the case of Dr. Abby Van Voorhees, Chair of the Department of Dermatology at EVMS, it was because her mother was diagnosed with breast cancer while she was in college. She wasn’t planning to go into medicine, but rather to pursue her love of the sciences. But when she saw the treatment her mother was receiving, she had an epiphany: “I knew I could do a lot better than what I was seeing happen.” She earned her medical degree at Yale, where she met Dr. Irwin Braverman, a Professor of Dermatology who developed a now iconic course incorporating Victorian paintings to help students improve their diagnostic and observational skills. “He became my mentor,” Dr. Van Voorhees says. “We had very few treatments in those days to take care of patients with psoriasis. It’s a terribly disabling disease, but even with such scarce resources, he was masterful. I learned so much from him, and knew I wanted to make dermatology my focus.” Her studies with Dr. Braverman were a contributing factor to her decision to specialize in treating patients with psoriasis, particularly those at the more severe end of the disease spectrum. “I really liked caring for these patients,” she says, “and it’s been nothing short of revolutionary in terms of what we can do now for patients with the ever more precise biologics that are available today.” She still remembers the standard of care for such patients during her years in and just out of medical school: a treatment she describes as left over from the 1920s, in which patients would submit to tar baths, coupled with tar applications to their skin for 23 hours daily in combination with ultraviolet light therapy. “The truth is, it can be highly effective,” Dr. Van Voorhees notes, “but it requires patients to essentially devote a month of their life to their skin, and your average working person would have a hard time making that commitment.” But as recently as a year ago, she successfully used the method for a patient who wasn’t an appropriate candidate for biologics. Fortunately, for most patients – even the most severe – there are at least 10 therapies she can prescribe, individually or tailored to each patient’s case, and more are being developed. “These drugs are getting increasingly more exact. We now have IL17 inhibitors and soon we’ll have IL23 inhibitors, which means they’re getting more effective all the time, without suppressing the entire immune system.” Not content merely to treat these patients, Dr. Van Voorhees has lectured and published extensively on various aspects of caring for them and the many sequelae of their disease, including an overlay of depression that can accompany it. In addition, she says, “we’re discovering that
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patients with psoriasis have increased risk of heart disease, diabetes, stroke – and they die younger than the average person. We’re thinking it’s a result of the amount of systemic inflammation they have in their whole body, and we’re coming to view the skin as almost like a weather vane, a sign of all the inflammation that’s inside their body.” Much of her own research has lately concentrated on education about the importance of knowing these patients are at risk, because “if physicians don’t know that, they can’t possibly think to screen for it. Since psoriasis is a disease that affects people when they’re teenagers, in many ways, the dermatologist is in the best position to serve as that early warning detection system.” She explains: “If I have patients I can identify as being at risk when they’re 18, think of the impact it could have if they’d start making changes to their lifestyle at that point, rather than at 60, when heart disease is discovered. So a lot of my work has been in educating people about the associated co-morbid diseases that travel with psoriasis.” As chair of the National Psoriasis Foundation’s Medical Board, she’s working with a team that is developing a treatto-target – establishing guidelines to determine the point at which a patient’s psoriasis can be considered in good control. “Along the way, we’ve created a lot of best practice standards for managing patients to minimize their risk of sequelae in the future,” Dr. Van Voorhees says. “We’re just working on that effort right now, so it’s very exciting. This will be the first time that will be in the dermatology literature.” Dr. Van Voorhees has held editorial positions on a number of national dermatology publications, including Practical Dermatology and The Journal of Psoriasis and Psoriatic Arthritis. As editor of Dermatology World, the magazine of the American Academy of Dermatology, she has written a great deal about all of the different sides of dermatology – the surgical side of the house, the medical and cosmetic sides. In medical school, she discovered “an overwhelming kind of inner compass that said what’s right for a patient will always be right.” That’s still true, to this day, any time decisions are being made about a patient’s treatment. “If it’s in the best interest of the patient, it’s always right,” Dr. Van Voorhees says. “The idea of ‘patient first’ has been a very recharging and inspiring motivation.”
Ocular Melanoma By Kapil G. Kapoor, MD, Wagner Macula & Retina Center
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eing able to determine how someone’s health is when “ABCDE” principles (asymmetry, border, color, diameter, and that someone is far away requires knowing what to evolution). The same is not achievable for ocular melanoma measure, how to measure it, and how to get that infor- – there is no way to self-monitor. In fact, many patients have mation where it needs to go. absolutely no symptoms despite having a melanoma growWhen we think of melanoma, we think primarily of melanoma affecting the skin. To be sure, By collaborating together, we can achieve our cutaneous melanoma remains the most serious mutual goals for patients in our community by type of skin cancer and can be lethal if it progresses saving sight and enhancing lives. undetected. Even though cancer affecting the eye is much less common, melanoma still remains the most common type of primary intraocular cancer. With early ing inside their eye. This is because just like melanocytes are detection, both cutaneous melanoma and ocular melanoma present in the entire external skin layer and plainly visible to have great cure rates. However, early detection of ocular us, these same cells also line the uvea, or middle layer of the melanoma has unique challenges. Cutaneous melanoma entire inside of the eye. If a melanoma develops within the permits self-monitoring and detection through the basic uveal layer away from the central vision area of the macula,
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patients may have no vision changes, or may have only subtle oncology team. By collaborating together, we can achieve our or vague symptoms of floaters or flashes of light. mutual goals for patients in our community by saving sight Further, while suspicious moles are easily biopsied or and enhancing lives. excised with cutaneous melanoma, biopsy or excision of a suspicious nevus in the eye can present significant risks that include threatening the patient’s sight or allowing a pathway Kapil G. Kapoor, MD completed medical school at Ohio State University, residency for extraocular spread of the tumor. at the University of Texas Medical BranchThus the realm of screening and detection of ocular tumors is Galveston and a fellowship at The Mayo entirely in the wheelhouse of the team of physicians. Clinicians Clinic. Dr. Kapoor is a Board certified ophthalmologist specializing in vitreoretinal need to keep their ears to the ground for symptoms in at-risk surgery. wagnerretina.com patients, particularly those of the Caucasian race with lightcolored irises, history of previous skin cancers or other inherited skin disorders, and history of significant ultraviolet light or tanning bed exposure. Dermatologists need to insist patients with cutaneous melanoma or other skin cancers pursue baseline screening to rule out the presence of suspicious choroidal nevi that may require monitoring. Oncologists need to ensure that all cancer patients who have any visual symptoms are screened for metastatic spread, since the uveal tract is at high risk for metastasis for cancers that spread hematogenously, given the high amount of blood flow per Are you looking for a satisfying career and a life outside of work? surface area required to maintain sight. Enjoy both to the fullest at Patient First. Opportunities are available While uveal malignant melanoma continues to increase in incidence, in Virginia, Maryland, Pennsylvania, and New Jersey. treatment methods have become progressively more sophisticated, with high Open 8 am to 10 pm, 365 days a year, Patient success rates in the setting of early deFirst is the leading urgent care and primary care tection. Years ago, detection of a uveal provider in the mid-Atlantic with over 60 locations melanoma spelled removal of the eye throughout Virginia, Maryland, Pennsylvania, by enucleation. Today, we typically employ a sight-saving centered approach and New Jersey. Patient First was founded by using radioactive plaque brachytherapy a physician and we understand the flexibility with I-125 plaques, often coupled with and freedom you want in both your career and biopsy and genetic testing at the time of treatment to understand a patient’s personal life. If you are ready for a career with To learn more about fantastic career risk of metastatic spread. Some smaller opportunities at Patient First, contact Patient First, please contact us. tumors are amenable to laser treatRecruitment Coordinator Eleanor ments with transpupillary thermotherDowdy at (804) 822-4478 or Each physician enjoys: apy, photodynamic therapy, or cryoeleanor.dowdy@patientfirst.com or • Competitive Compensation therapy. Our regionally unique ocular visit prcareers.patientfirst.com. oncology team includes an assembly of • Flexible Schedules two ocular oncologists, a team of radia• Personalized Benefits Packages tion oncologists, and a clinical team • Generous Vacation & CME Allowances that coordinates digital imaging, surgical planning, and systemic evaluation. • Malpractice Insurance Coverage We remain focused on creating indi• Team-Oriented Workplace vidualized patient-centered treatment paradigms and welcome your partner• Career Advancement Opportunities ship as part of our extended ocular Summer 2016 Hampton Roads Physician | 17
GOOD DEEDS Claude Louis, MD
medical student and a sports medicine physician, he established three mobile clinics in the mountains, caring for more than 100 patients each day – many of whom had never seen a physician. That’s not unusual. “The need in Haiti is so great,” Dr. Louis says. “In many areas, there’s only one physician for more than 50,000 people.” In 2008, he established Words in Action Haiti, a nonprofit organization, to fund his continuing efforts. In 2010, three years after graduating from medical school, Dr. Louis realized his goal of establishing a medical clinic in his father’s village. With a major donation from a Canadian philanthropist, Dr. Louis set up a clinic in a renovated building in Qui Croit – the only physician for miles around. In 2012, he came to the U.S. to pursue his residency in family medicine, but he was determined to keep the clinic open and to return to Haiti frequently. He recruited a capable Haitian nurse to see patients, and help them get to the Baptist Mission Hospital when advanced care was needed. Today, the clinic continues, staffed by a team of nurses, and Dr. Louis visits several times a year with other volunteer medical professionals. What started in a church building is now a newly built stand-alone medical clinic, featuring three consultation rooms, a pharmacy, a room dedicated to a lab, and two rooms for patient admission. Many of these patients have walked five miles or more to receive care. They come with hypertension, infections, GI issues, severe dehydration, pediatric malnutrition, asthma, labor complications – every symptom imaginable among people who have lacked medical attention. These diseases and ailments Dr. Louis and his team can handle. More difficult to treat are the superstitions that often accompany patients: “Many Haitians have a fatalistic perspective on illness,” he explains. “They often attribute disease and poor health to being cursed by voodoo.” Thus educating his patients is among the most challenging components of care at the Qui Croit clinic. He’s proud that WIA is helping children at Qui Croit achieve their potential through its school sponsorship program, and is planning programs in agriculture training, water sanitation, nutrition, infrastructure and eventually local micro-finance for more sustainable community development in the future. His goal is to train more people, so that “if something happens to me, the clinic will survive.”
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laude Louis grew up in Qui Croit, a small village in Haiti’s mountainous region. There was no infrastructure – no electricity or running water, no transportation, no local government. He never met his father, who died when Claude was just a month old: he grew up hearing stories about the man everyone in the village called “Doctor Leon.” “He wasn’t a doctor,” Dr. Louis says. “He only went to primary school, and then had some first aid training as a community health provider. But he was revered by the people in our village, and the more I heard about him, the more I wanted to be like him.” Dr. Louis attended primary school in his village, but had to leave home to pursue his education. He went to the Baptist Haiti Mission in Fermathe, where he lived and studied until he enrolled in medical school at the Université Notre Dame d’Haïti. There was never any question in Dr. Louis’ mind that he wanted to continue the work his father had started – he wanted to provide medical care to the people of Haiti. During his last year of medical school, he worked with a foreign medical team running mobile clinics in two different churches, seeing close to 200 patients a day. In 2005, with a generous gift of medications from friends in Canada, another
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If you know physicians who are performing good deeds – great or small – who you would like to see highlighted in this publication, please submit information on our website – www.hrphysician.com – or call our editor, Bobbie Fisher, at 757.773.7550.
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hen Kim Scott joined Eastern Virginia Ear, Nose & Throat Specialists eight years ago, the practice had never before had a nurse practitioner on staff. A Board certified Asthma Educator and Otorhinolaryngology Nurse, Scott came to Eastern Virginia ENT with a Bachelor of Nursing Degree from
Virginia Commonwealth University and a Master’s Degree as a Family Nurse Practitioner from the Medical University of South Carolina – and many years of experience as a Registered Nurse, working in the Cardiovascular Intensive Care Units of Beaufort General Hospital in South Carolina and Sentara Norfolk General Hospital. She had developed a strong affinity for otolaryngology while working with an allergy and asthma specialist in Fresno, Dr. Malik Baz, a partner of Dr. Winston Vaughan, the founder of the Stanford University Sinus Center, and later the California Sinus Centers. “It was an adjustment,” Scott says of the move to Virginia. “In California, I’d worked in a large, multiple-city practice with many midlevel providers, all of whom had a great deal of autonomy and independence. I wanted to establish that as the best working paradigm when I joined my new practice, then a four-physician group that had no experience with a Nurse Practitioner. I was incredibly fortunate,” she emphasizes, “as the physicians at Eastern Virginia ENT were very forward thinking and willing to trust my judgment and abilities.” She knew she had a high bar to set, feeling that if she didn’t do well, it could spell the end of midlevel providers for the group. She worked hard to establish the initiative, and the physicians quickly recognized the value she added to the practice, and to its patients. The practice has grown, today consisting of the original four physicians, herself, a Physician Assistant, and two other doctors. Scott’s service to the field of medicine has gone far beyond her contributions to the physicians and patients of Eastern Virginia Ear, Nose & Throat. She is recognized as an otolaryngology expert on the Board panel for the National American Nurses Credentialing Center. And it doesn’t end there. She explains: “When I first joined the ENT community and was researching protocols in otolaryngology and allergy for Nurse Practitioners and Physician Assistants, there was no book, no publication for a midlevel that would guide us, not even in prioritizing the specifics of taking a history and physical exam,” she says. “Otolaryngology is a separate and distinct specialty from allergy, because there are so many procedural-based diagnoses in otolaryngology.” Dr. Keyes was first to encourage her to prepare her own protocol book, a task she took on with focused enthusiasm. As she developed the protocols, it became clear to the physicians that such a compilation of methodology for midlevel providers would have value well beyond their practice. Adding contributions from Dr. Richard Debo, Dr. Keyes and Dr. David Leonard, Scott contracted with Springer Publishing Company, a leading source of health care books, textbooks and medical journals for medical professionals, professors and universities. Within a year, A Quick Reference for Otolaryngology: Guide for APRNs, PAs, and Other Health Care Practitioners, was published. The book is available from Springer, as well as Amazon and Barnes & Noble. “It’s not Harry Potter,” Scott laughs. Perhaps not, but to the patients she treats, the physicians she assists, and the medical professionals her book continues to guide and inspire, it can seem a great deal like magic.
If you work with or know a Physician Assistant or Nurse Practitioner you’d like us to consider, please visit our website – www.hrphysician.com – or call our editor, Bobbie Fisher, at 757.773.7550. 20 | www.hrphysician.com
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MEDICAL U P D A T E
By Bobbie Fisher
P
ractically every school child knows that the discoverer of the x-ray was Wilhelm Roentgen, more than 120 years ago. They may not know that within a year of publishing his discovery, Roentgen saw x-rays being used in diagnosis and therapy, as an established part of medical practice – earning the German physicist the title of Father of Diagnostic Radiology, as well as an honorary medical degree and the first Nobel Prize in Physics. Discoveries followed at a rapid pace, as physicists and researchers built on Roentgen’s work, marking every ensuing decade as one of innovation and application. It’s no less true in the first decade and-a-half of the 21st Century, and it’s nowhere more evident than in Hampton Roads. The area’s radiologists, whether diagnostic, therapeutic or interventional, are early adopters of the most recent technological and scientific advances, and especially excited about the promise these innovations hold for the future. Herewith five area specialists talk about some of the recent trends and advances in their particular fields, and how those fields can overlap.
Dennie T. Bartol, MD
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Diagnostic Radiology. “For the first 70 years of radiology, everything was more or less x-ray based,” says Jeffrey A. VandeSand, MD, a diagnostic radiologist with Tidewater Physicians Multispecialty Group. “A short time after Roentgen’s discovery, Edison developed fluoroscopy, but it wasn’t until about 30 or 40 years ago, that there was a sort of renaissance, where CT, MRI and ultrasound were developed, and those three modalities were quickly incorporated into our toolkit.” Over the past 30 years, since the 1980s, the advances in these modalities have been in the form of refining. “Today, we’re moving toward more of a merger between radiology and pathology,” Dr. VandeSand says. “We’re starting to move away from just imaging the anatomy of the body, and starting to incorporate more looking at tissue specific – things like perfusion, how tissues receive blood flow and how the blood interacts with those tissues. Another technique, diffusion, looks at how water molecules move through different tissues.” Traditionally, much of the imaging of the brain has been looking just at the anatomy. “We’d see a mass in the brain and say it was probably a tumor, or a potential tumor,” Dr. VandeSand
Dmitri E. Samoilov, MD
Mark Sinesi, MD
says. “Now we’re able to look at the anatomy of the tissue; but using MRI, we can also use these techniques – diffusion, perfusion and others – to better characterize what we see.” Diffusion imaging has traditionally been used in the brain to look at things like stroke or tumors, but diagnostic radiologists are now starting to use it in different parts of the body as well, and in other organs like the kidneys, the liver and the prostate. “As radiologists, we’re always excited about any kind of new imaging,” says Salvador Trinidad, MD, Chairman of Radiology at Chesapeake Regional Healthcare. “One of the biggest changes we’ve recently incorporated is 3D mammography, or tomosynthesis, which has been shown to increase the incidence of early detection by as much as 35 percent. And nearly equally as important to patients is the reduction in false positive findings, eliminating the need for callbacks and the anxiety that accompany them. “We’re introducing a new technique that will also relieve some of the anxiety women feel in the early diagnostic stages of breast cancer,” Dr. Trinidad explains. “Typically, after a positive biopsy, in order for the area to be removed surgically, this area had to be localized by a guide wire prior to surgical removal. Both localization and surgery are done in the same day, which prolongs the day for the patient.” “The Savi Scout® uses non-radioactive, electromagnetic wave technology to detect a sensor that we place into the patient’s breast as much as a week before surgery biopsy,” Dr. Trinidad explains. “The system gives surgeons a precise way to locate the sensor and thus, the tissue targeted for removal during lumpectomy/excisional biopsy procedures.” But now, the procedure can be done on two different days, maximizing convenience for both the patient and surgeon. It can eliminate surgical delays, improve patient satisfaction and optimize surgical planning.
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(757) 313-5420 Dr. Trinidad is also excited about the recent acquisition of a 256-slice CT scanner. With this new technology, 256 slices are created with every rotation, “so we can scan the whole chest in only a matter of seconds.” He equates the technology to the wand Dr. McCoy used to wave over his patients aboard the Enterprise, but adds, seriously, “We use it for our arteriography, such as to rule out pulmonary emboli in the lung and cornering arteriography, where we want to stop the heart motion so we can see the vessels clearly. It’s a game changer in terms of cardiac imaging.” “Advancements in technology have definitely improved diagnostic testing for the patient,” says Dennie T. Bartol, MD, Medical Director for Radiology at the Riverside Health System’s regional campus. An interventional radiologist, Dr. Bartol notes that both diagnostic and interventional radiology are evolving and changing, and in some cases, overlapping.
Salvador Trinidad, MD
Jeffrey A. VandeSand, MD
Summer 2016 Hampton Roads Physician | 23
Interventional Radiology. Dr. Bartol explains: “It used to be that if patients had problems with hypertension and needed to have their kidneys evaluated, or if they had blue toe and needed their legs evaluated, or having problems with TIA and needed their necks evaluated, we’d send them for a Doppler ultrasound, and then progress to an arteriogram. We’d stick a needle in the artery, take several images until we had what we needed, and then hold pressure on the leg. It could take as much as four to six hours from check-in to prep to procedure to recovery and discharge.” Today, he says, with CTA or MRA, the patient goes into the scanner, contrast is injected, and the images are processed, evaluated and reconstructed – and “we basically have a recapitulation of the arterial tree, based solely on the contrast injection, for a much smaller commitment of time for the patient.” Whereas Dr. Bartol used to do as many as eight diagnostic carotid arteriorgrams a week, that procedure is virtually a thing of the past. “The technology has simplified the process for both the physician and the patient,” he says. “This is definitely an exciting time in interventional radiology,” says Dmitri E. Samoilov, MD, who practices with Medical Center Radiologists. “The biggest development in interventional radiology is interventional oncology.” Interventional oncology is more specific for the delivery of therapy in a very precise fashion, directly where the cancer is located. The greatest advances in the targeted tumor therapies have developed in the liver predominantly.
“If a patient has either a primary cancer of the liver or metastatic disease that has spread to the liver, we now have techniques that allow us to deliver chemotherapy or radiotherapy using the pathways of the blood vessels, directly where tumors are,” Dr. Samoilov explains. “It’s done with image guidance, basically eliminating surgery. It allows us to control primary or metastatic liver disease locally, therefore prolonging the patient’s survival, downstaging disease for resection or bridging the patient to transplantation.” It requires quite a lot of effort on the part of medical oncologists or transplant physicians, because some of these tumors are either nonresponsive or not amenable to systemic therapy. For hepatocellular carcinoma, Dr. Samoilov adds, targeted therapy is sometimes the only option for patients, given significant tumor burden combined with advanced chronic liver disease. The current guidelines for transplantation require that the tumor has to be completely treated. “We can’t transplant a patient in the US today unless the tumor has been treated,” Dr. Samoilov notes, “and if there’s still active disease in the liver, we can’t transplant because of the very high incidence of recurrence. So these are life and death situations.” The above example is just the tip of the iceberg of what is possible. More targeted therapies are currently in development; for example, non-surgical treatment of benign prostatic hypertrophy is gaining a momentum in the US. “We’re extending these patients’ lives, and enhancing the quality of their lives,” he says.
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Dr. Mark Sinesi, MD, a radiation oncologist at Eastern Virginia Medical School, agrees. Also known as therapeutic radiology, radiation oncology uses radiation to control cancer in collaboration with diagnostic radiologists and interventional radiologists. “A stunning example of our collaboration is selective internal radiation, or SIRT,” says Dr. Sinesi. For patients whose cancers originated in or metastasized to the liver, and for whom surgery is not an option, SIRT provides an extra opportunity for extending life and quality of life. “These tumors represent the type of disease normally treated with chemotherapy,” Dr. Sinesi explains, “and when that happens, the malignant burden in these patients’ bodies is decreased and they may go off chemotherapy. Then the cancer starts growing back, and they may go back on chemo and again enjoy some improvement, but that’s at the cost of some side effects. And after two or three cycles of that, these patients are worn out; their bone marrow is worn out and they’re ready for hospice.” Dr. Sinesi doesn’t advocate vigorous, toxic therapy in a futile attempt to cure what cannot be cured. “Rather,” he says, “with SIRT, we offer gentle treatment that serves to enhance quantity and quality of life, a very minimal side-effect type of treatment that causes symptoms to go away and lets our patients enjoy a better quality of life. We can give them a high performance
status for as long as possible, to make every day as good as it can be.” With his colleagues in diagnostic and interventional radiology, “We do a contrast study to see where the tumor or tumors are in the liver, and then we inject radioactive microspheres directly into the tumor,” Dr. Sinesi explains. “These are very tiny glass or plastic resin spheres – so small that the bottle containing this medicine looks like a bottle of smoke.” The microspheres block off the blood vessel that feeds the cancer(s), and at the same time, allows the radioactive component to focus on the mass(es). It’s a well tolerated treatment, requiring only overnight stay in the hospital. “It’s not a permanent cure for many of these patients,” Dr. Sinesi notes, “but it offers them more functionality and quality during the life they have left.”
What lies ahead – radiology in the 21st Century. “These technologies are just the tip of the iceberg,” Dr. Samoilov says. “For patients with cancer who requires staging or tissue diagnosis, we can perform an image-guided biopsy by either CT or ultrasound,” he says. In addition, interventional radiologists are placing ports in patients for the delivery of embolic and/or therapeutic agents, without the necessity of general anesthesia and without significant complication, reducing the burden of travel for these patients as well as their stress levels.
also the stiffness of the tissue, which is especially helpful when dealing with certain diseases,” Dr. VandeSand notes. “About 15 years ago, the idea of PET-CT was incorporated into radiology, overlaying the metabolism we get from PET with the anatomy we get from CT. That’s helping us differentiate between a tumor and an infection or other process. Now we’re starting to move beyond that, and incorporating PET-MRI. MRI often has the potential to provide more biological and functional data than CT, and thus the PET and MRI images allow us to get an even more accurate picture of the disease process.” “We’re working with 3T MRI now,” says Dr. Trinidad. “It’s still pretty much the sweet spot. But we’re looking at still higher field strength magnets now, and in five or 10 years, magnets may well be developed that will image the body even better.” And he notes that while the Savi Scout system was approved by the FDA only last January, the manufacturer believes that the same technology will have application in areas besides the breast: “This is really just the beginning for this technology.”
“Evolving technologies like ultrasound elastography allow us to look not just at anatomy and blood flow, but
“We’re instituting a new way of giving accelerated partial breast irradiation,” says Dr. Sinesi. “It’s a shortened course of radiation that doesn’t require implantation in the breast itself, through a procedure similar to mammography. It’s gentle compression of the breast that directs the radiation beam directly on the surgical bed. It’s an entirely non-invasive procedure.”
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Another innovation for cancer patients is a treatment for retinal melanoma: a radioactive implant that is sutured onto the back of the eye, to stay there for a specified number of days before being removed after it delivers radiation directly to the retina. The implant, essentially a small gold plaque, is designed by the radiation oncologist, Dr. Sinesi explains, and then placed by a retinal surgeon. “Thirty-five or forty years ago, no radiologist of any subspecialty could have envisioned how precise MRI and CT images would be within just a few years. “It’s hard to predict,” says Dr. VandeSand. “A lot of it is going to be refining the techniques we already have. One such refinement is in phase-contrast x-ray imaging (PCI), which gives us a new way to use x-rays. It’s based on the refraction or bending of x-rays as they pass through tissues in the body, rather than the simple absorption that traditional x-ray exams are based on. PCI results in images with greatly improved soft tissue contrast, and although its clinical use is not currently widespread, it may hold future potential in the imaging of soft tissue, including of the breast.” “We haven’t begun to see the tip of the advancing technological iceberg in radiology,” Dr. Bartol says. “There are so many things that have been developed that have eliminated or superseded the
need for surgery, or that are supplementing surgical needs. More are being imagined and explored every day.” In fact, Dr. Bartol notes, at the last interventional radiology meeting he attended, one of the papers presented involved an innovative approach to weight loss surgery. “The interventional radiologist had gone in and embolized the left gastric arteries of a handful of patients, who then had incredible success at losing weight. It’s not going to happen right away,” Dr. Bartol emphasizes, “but he was pushing for a multicenter trial to look at this as an option. It could certainly complement or even serve as the first line methodology for difficult patients.” And of course, the work being done in neurointerventional radiology is helping reduce the risk of invasive surgical procedures on the brain. Rather than having to undergo brain surgery, many patients are being treated with vascular surgery, easing their stress substantially.” Every day is a process of discovery when dealing with people’s lives. Like their colleagues in radiology practices all across Greater Hampton Roads, these subspecialists remain enthusiastic about their chosen fields, and excited by the ever increasing and innovative opportunities they see every day in their ability to identify diseases and treat their patients.
We Are Seeing Patients In A Whole New Light. Chesapeake Regional Healthcare’s Imaging Services offer modern capabilities in comfortable surroundings with services available to fit your schedule. Our dedicated team of radiologists, technicians and nurses are here to provide you with individualized attention. We are nationally accredited by the American College of Radiology in MRI and ultrasound. The Breast Center at Chesapeake Regional Healthcare is an American College of Radiology Breast Center of Excellence and also received the Women’s Choice Award for America’s Best Breast Center three years in a row.
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7/5/16 8:41 AM
ONE PERSON DIES EVERY 52 MINUTES FROM MELANOMA Everyone is at Risk for Skin Cancer Regardless of Race or Ethnicity
Reggae artist Bob Marley died of skin cancer when he was just 36 years old. He had a sore under his toenail that wasn’t healing properly. Doctors found that Marley had an aggressive form of skin cancer known as acral lentiginous melanoma – the most common subtype of melanoma in people with darker skin. Acral lentiginous melanoma often presents itself on the palms of the hands, the soles of the feet, or under toenails or fingernails. It can spread quickly to other parts of the body if not detected and treated early. Marley’s doctors recommended he have his entire toe amputated, but he ignored their advice, opting to have only the toenail and a portion of the nail bed removed. This treatment option did not fully remove the skin cancer, and the melanoma spread to his lungs and brain.
Proper Care Could Have Saved Bob Marley’s Life! Virginia Dermatology & Skin Cancer Center has also expanded the cosmetic dermatology menu of services at its Harbourview and Norfolk locations. The practice now offers a wide range of aesthetic procedures, injectable services, innovative body contouring technology, and the miraDry™ procedure to treat Hyperhidrosis. Provider referrals will receive a complimentary cosmetic consultation.
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The Virginia Dermatology team,(L-R): Theresa C. Talens, D.N.P., Kenyatta Shannon, Hiromi Asaida, Brian L. Johnson, MD, Vielka Inman, and Guy Inman
PROMOTIONAL FEATURE
CHESAPEAKE REGIONAL, RIVERSIDE & UNIVERSITY OF VIRGINIA RADIOSURGERY CENTER CELEBRATES 10TH ANNIVERSARY
F
or more than a century, Riverside Health System has proDr. Kersh introduced the idea of partnering with the vided medical care to the people of the Virginia peninsula. University of Virginia – a partnership that would grant Riverside From humble beginnings as a 50-bed regional hospital, greater access to the University’s radiosurgery capabilities, as well Riverside has grown into a modern medical center with naas establishing a solid connection to a major academic center. tional and international expertise. A case in point is Chesapeake The University had begun doing radiosurgical procedures in Regional, Riverside & University of Virginia Radiosurgery Center, 1989, and had seen the platform transform the care available to which recently celebrated its 10th Anniversary. neurological and oncology patients. In 2003, Riverside radiation oncologist Dr. As of June 2016, the Radiosurgery Center had C. Ronald Kersh was sending as many as 30 patients to the University of Virginia for radiosurprovided 1,294 Gamma Knife® treatments and 6,500 gical intervention each year, with that number Synergy S® treatments, with outstanding results. growing annually. Dr. Kersh had studied at the University of Virginia under Dr. Ladislau Steiner, a colleague of Dr. Lars Leksell, the Swedish physician In February of 2004, Riverside representatives met with the who introduced the concept of stereotactic radiosurgery in 1951. neurosurgery team at UVA to discuss partnership opportunities From his work with Dr. Steiner, Dr. Kersh knew that Gamma that would help them better serve the Riverside community, not Knife® radiosurgery was then the gold standard treatment for just in neuro-oncology but in other neurosciences as well. A brain tumors, both benign and malignant, vascular abnormalities partnership was formed and Dr. Jason Sheehan, neurosurgeon and other functional disorders of the brain. from the University of Virginia and Riverside Medical Group
28 | www.hrphysician.com
neurosurgeon Dr. James Lesnick were named as Medical Directors of the Radiosurgery Center. On June 5, 2006, the first Gamma Knife® procedure was performed at the Chesapeake Regional, Riverside & University of Virginia Radiosurgery Center, located on the campus of Riverside Regional Medical Center, observed by partners from the University of Virginia, a neurosurgeon from the Czech Republic, and a physicist from London.
The Gamma Knife®. The first Gamma Knife® purchased for the Radiosurgery Center was the Leksell 4C, then the state-of-the-art option. It was used for patients with brain tumors and other conditions, such as arteriovenous malformations, trigeminal neuralgias or vestibular schwannomas. Its high-intensity cobalt radiation therapy concentrated the radiation over a small volume. The risks associated with open surgery were eliminated, including the risk of general anesthesia. Treatment could be planned and programmed within a matter of an hour or two. Treatment time was significantly less than conventional radiation and other delivery systems and because it’s more often done on an outpatient basis, most patients could return to normal activity within 24 hours.
Synergy S®. For cancers of the spine, neck, chest, lung, prostate, pancreas and liver – and for tumors in areas of the brain too large for the Gamma Knife® – the Synergy S® was chosen. A highly accurate non-invasive delivery system for stereotactic radiation, the Synergy S® combined a linear accelerator with the ability to visualize internal structure, including soft tissues, in three dimensions at the time of treatment. The radiation dose was precisely targeted at the tumor or lesion, resulting in less damage to surrounding healthy tissue. As with the Gamma Knife®, the benefits of the Synergy S® included no risk of blood loss, fewer complications, faster recovery and the ability to effectively treat patients who could no longer be treated by other methods of care. By March of 2012, Chesapeake Regional Medical Center affiliated with the partnership expanding the reach of the Radiosurgery Center to Virginia’s Southside region.
Innovation begat innovation.
As of June 2016, the Radiosurgery Center had provided 1,294 Gamma Knife® treatments and 6,500 Synergy S® treatments, with outstanding results. One of the Synergy S®’s assets is the greater protection it provides for the spinal cord. For years, it had been accepted that once an area of the body had been treated with standard external radiation, it could no longer receive radiation treatment. Convinced that the protection the Synergy S® provided to the spinal cord negated that protocol, the Center began re-treating a series of carefully selected patients, many of whom were Stage IV. At a recent meeting of the Radiosurgery Society, it was reported that these patients were experiencing an 87 percent response rate with minimal side effects – and patients with third line chemotherapy with a 10 percent response rate were realizing 70 and 80 percent with the Synergy S®. And yet, there is newer, more efficient extracranial radiosurgery equipment available, and the Radiosurgery Center is once again determined to acquire the most effective treatment for its patients. A team was designated to evaluate the new equipment, with installation to be completed in 2017.
The vitality of research. One of the hallmarks of the Radiosurgery Center has been its commitment to research, analysis, and most importantly, to sharing its findings with the national and international medical communities. The Radiosurgery Center has contributed significantly to the literature, presenting papers to The American Society of Radiation Oncology, The Radiosurgery Society, The American Radium Society, and to the international multicenter database for radiation oncology, and in publications like the International Journal of Radiation Oncology, the Radiation Oncology Journal, Oncology and others.
A change in paradigm. As with all medical advances, the more hands-on experience visionary experts attain, the more potential applications for existing technology become apparent. Such was the case with the Radiosurgery Center and the Synergy S®. Riverside neurosurgeons and radiation oncologists discovered that in many instances, they were able to control these patients’ tumors without having to do an open procedure – thereby relieving pain, arresting the growth of the tumor and causing it to regress. The Radiosurgery Center at Riverside has as much or more experience in treating spinal metastases than anyone in the world. The outcomes and clinical data the Center has shared have led to multicenter clinical trials, publications and presentations across the globe. The team has literally and dramatically revolutionized the way spinal metastasis is treated.
For nearly a decade, the two original modalities served the patients of the Radiosurgery Center well. But as the team’s experience with the Gamma Knife® grew, it began to reveal some of 4C’s limitations, specifically a design A true cause for celebration. element that didn’t anticipate treating multiple areas of When that first patient was treated in 2006, no one could the head at one time, or metastatic tumors on opposite imagine how the Center would evolve. Rather than merely a sides of the brain. solid radiosurgical program with a regional presence – in itself a The makers of the Gamma Knife® recognized that remarkable accomplishment – the Chesapeake Regional, Riverside need, and refined the technology. In July of 2015, with and University of Virginia Radiosurgery Center has grown into a nearly a thousand Gamma Knife® 4C treatments to its respected member of the international radiosurgical community, credit, the Radiosurgery Center at Riverside installed and has quite simply changed the way complex neuroscience and the next iteration of the technology: the Leksell cancer care is delivered. Gamma Knife® Perfexion™. The Perfexion has enabled neurosurgeons and radiation For more information go to Riversideonline.com/radiosurgery oncologists to treat multiple metastatic lesions or call 757-264-9911 to make a referral. at a time, no matter where they are located.
Summer 2016 Hampton Roads Physician | 29
PERCUTANEOUS
FUSION TECHNIQUE
is relieving SI pain in post-fusion patients. By John W. Aldridge, MD, FAAOS
E
very year in the United States, approximately 150,000 hip replacements are performed, and more than 350,000 knee replacements. By contrast, the number of spinal fusions done each year is a stunning 650,000, reflecting just how many Americans suffer from a seriously aching lower back. The overwhelming majority of these procedures are successful, reducing or substantially relieving pain and restoring the patients to comfortable, active lifestyles.
However, orthopaedic surgeons have long recognized – and recent studies have shown – that in some cases, fully a third of these patients experience significant sacroiliac joint problems following fusion. Additional studies have shown that the incidence of SI joint degeneration after lumbar fusion is 75 percent at five years post surgery. As arthritic patients, those who have suffered traumatic injuries, and even some pregnant women know well, SI joint pain can be debilitating, often resulting in discomfort equivalent to or even worse than that which brought them to our offices in the first place. It’s a commonplace but vexing problem for orthopaedic surgeons, because until recently we have had very little to offer them. About the only surgical option required a gigantic dissection to get down into the SI joint to put plates and screws in, and the destruction that caused actually made people feel worse than the SI joint did. That’s 30 | www.hrphysician.com
why virtually no surgeons were offering it. That’s changed within the last year or two with the introduction of the percutaneous fusion technique. It’s a simple but effective minimally invasive procedure that is substantially reducing and even eliminating the effects of SI pain, including in post-spinal fusion patients. In the operating room, the patient is positioned face down on the table, under either general or spinal anesthesia, depending on size, weight and presentation. Using live imaging, the surgeon employs a specially designed system that prepares the bone to receive implants that will stabilize and fuse the SI joint. One of two devices, either screws or pegs, depending on the quality of the bone, is used. Generally, no larger than a one-inch incision in the lateral buttock is required to place the device into which the implants are threaded and placed across the SI joint and positioned before fusing them. There are normally three implants, but again, that can vary depending on the patient. The procedure takes about an hour, is easily tolerated, and some patients can even go home right after the procedure, although most stay overnight. Patients use a walker for two or three weeks after the surgery, and they’re fully healed and out of pain after about six weeks. The procedure has been a real godsend for patients with SI joint pain, especially those who experience it after a spinal fusion. Multiple published studies have documented the benefits of this procedure. Nationally, fully 95 percent of patients say they’d do it again. In my own practice, I’ve seen dramatic results when debilitating pain is reduced.
Dr. John W. Aldridge is a Board certified orthopaedic surgeon with Hampton Roads Orthopaedic & Spine Center who has been specializing in minimally invasive muscle sparing spinal surgery and total joint replacement surgery in the Hampton Roads area since 2002. www.hrosm.com
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Summer 2016 Hampton Roads Physician | 31 nm0681
BIG Thinking
By Ken Morris, PT, DPT, CMTPT LSVT-Big and Sarah Zeisler, PT, DPT, LSVT-Big Tidewater Physical Therapy- Hidenwood
I
magine what it would be like to go from being an active fine motor skills. LSVT BIG treatment typically includes four person to someone who now takes 10 slow, deliberate steps sessions a week for four weeks. Exercises focus on creating big just to get out of the car, or five minutes to put a jacket on. postures, big hand movements, big steps and big fluid motions, And while navigating the aisles of the grocery store used to such as swinging or pivoting the arms or legs to exit a car or put be easy, these days it feels more like climbing Mount Everest. on a jacket. The goal is to help patients feel more comfortable These are just a few of the scenarios patients living with moving in a larger pattern and navigating different tasks using Parkinson’s disease can face as the neurological illness takes its those techniques. toll. Parkinson’s, which is a cluster of motor system disorders Success happens when a patient for whom it once took caused by a loss of dopamine in the brain, can create a 10 steps to get out of the car can now do so in one fluid debilitating tremor, rigidity in the limbs and trunk, a slowness movement. For others, improvement may mean a general of movement and a loss of balance or coordination. According boost in confidence when they feel reassured they can easily to the National Parkinson Foundation, there is no cure for stand up on their own and walk to the kitchen, bathroom or the disease and a doctor’s goal when treating Parkinson’s is to mailbox with ease. minimize symptoms through prescription medications. Over time, those big movements will come naturally, and Traditional physical therapy can play a part in assisting Parkinson’s patients can enjoy the art of moving comfortably Parkinson’s patients who are suffering from a loss of balance through their day. or chronic falls, but that type of treatment isn’t geared toward tackling the neurological Success happens when a patient for whom it once causes for those problems. However, in took 10 steps to get out of the car, can now do so recent years, a new type of physical therapy in one fluid movement. has emerged that focuses less on remedying musculoskeletal impairments, and instead helps patients think about the art of moving. The treatment, referred to as LSVT (Lee Silverman Voice Treatment) BIG, is based on another Parkinson’s related treatment that helps patients who have had a decline in speech due to a loss of vocal volume. While the voice treatment encourages patients to talk louder, LSVT BIG tasks patients with thinking big – big movements that is. In addition to causing a slowing of movement, Parkinson’s can distort a patient’s sense of movement, making him or her Ken Morris, PT, DPT, CMTPT,LSVT-Big currently serves as the Clinical feel like they’re moving at a regular pace, when in actuality they Director for Tidewater Physical Therapy’s Hidenwood Clinic. are making small, jerky motions. Training patients to make Sarah Zeisler, PT, DPT, LSVT-Big came to Tidewater Physical Therapy larger, more fluid movements can actually normalize their as a physical therapy student, before joining the Hidenwood Clinic full time as a physical therapist. Tidewater LSVT-Big therapy is offered in motions and make it safer for them to do things like exit a car or Williamsburg and Franklin clinics as well. walk through a crowded hallway. tpti.com So how does it work? It really is as simple as teaching patients larger movements as a mechanism to complete daily tasks. And the technique can help with either gross motor function or 32 | www.hrphysician.com
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Dermatopathology is our Specialty
I
t can be an excruciatingly long wait: for anyone having undergone a biopsy, the time between the procedure and the results can seem like an eternity – whether it’s two days or two weeks. It’s not unusual for patients to experience physical and emotional symptoms like lack of sleep, irritability or nervousness. It’s also not unnatural: fear and anxiety over the results can set the body’s nervous system on overdrive – releasing adrenaline and other stress chemicals into the bloodstream. Doctors understand that patients waiting for a biopsy result are in this apprehensive state, so they want to assure them a rapid and dependable diagnosis. In Hampton Roads, for many physicians – particularly those who treat conditions of the skin – that means utilizing the diagnostic services of Dominion Pathology Laboratories.
patient’s biopsy one minute; then discuss colon biopsies with a gastroenterologist next; then we’d talk to general surgeons about liver or pancreatic biopsies; or with gynecologists about their patients,” Dr. Frazier explains. “In the hospital setting a pathologist has to be proficient with the variety of problems in each specialty because they come up on a day to day basis.” Because of the ever expanding complexity and ongoing changes in every medical specialty, many pathologists choose to focus on and pursue additional training within the various subspecialties. Drs. Frazier and Fair, both fellowship trained in dermatopathology, opened Dominion Pathology Laboratories to allow them to put their specialized knowledge, training and experience to wider use. Their decision to form an independent laboratory was based on a shared mission of individualized service to area physicians who perform biopsies in their offices. These physicians are aggressively marketed by large-scale national laboratories for biopsy specimens but “because we are small and local we can provide accurate results quickly,” Dr. Frazier says, “and, more importantly, we can establish and maintain a more personal relationship with each physician and their office.” It’s a mission that helped DPL grow over the last decade. In 2008, Michael Robert A. Frazier, Jr., M.D. Kevaghn P. Fair, D.O. Michael T. Ryan, D.O. Ryan, DO, a fellowship trained dermatopathology, joined the practice. Such extensive training is important Founded in 2002 by Robert Frazier, MD and Kevaghn Fair, because of the nature of the work that dermatopathologists DO, Dominion Pathology Laboratories was at that time the do. “Malignant melanoma is what we all worry about the only independent surgical pathology laboratory based in the most,” Dr. Frazier says. “It’s one of the most lethal of all Tidewater area. Both doctors had well-established careers the cancers, and survival depends almost entirely upon in surgical pathology: Dr. Frazier at Virginia Beach General diagnosing and removing it early, before it can spread to Hospital and Dr. Fair at Riverside Hospital in Newport News. other parts of the body – most commonly lymph nodes, They were familiar with the myriad challenges faced by lungs and the liver.” pathologists working in busy hospitals, who must not only be But melanomas can be problematic to diagnose early familiar with the diseases of each organ system, but also able since many of them are relatively slow growing. While to communicate about them effectively with clinicians. more common skin cancers grow rapidly and noticeably from the beginning, some forms of melanoma are different. Pathology – the crossroads of all specialties. “Patients can literally have them for many years and hardly “As hospital-based pathologists, on any given day we would notice as they get almost imperceptibly larger,” Dr. Frazier converse with a pulmonologist about the results of his or her notes. “They’ll see a little blemish or mole from its inception 34 | www.hrphysician.com
and think it doesn’t look that bad, but over the years, more and more mutations happen, making that lesion more and more malignant – and then at some point it just starts growing like gangbusters.” It can also be a challenge to diagnose melanomas in their beginning stages since they can mimic benign moles, on the patient and under the microscope as well. There are numerous different criteria in the microscopic diagnosis of melanoma, Dr. Frazier explains, and obvious melanomas display nearly all of them. Less obvious melanocytic lesions will have some but not all– and then some may show only one or two; these cases can be the most difficult and frustrating because the stakes are so high. Malignant melanoma is responsible for more than 75 percent of all skin cancer deaths. And there isn’t one universal diagnostic criterion, such as a single gene mutation that positively identifies all melanomas. That’s why it takes a trained and experienced eye to interpret the intricate patterns in ambiguous cases, and where a dermatopathologist’s fellowship training comes into play. “Fellowship is such a good place to learn,” Dr. Frazier explains, “because as fellows, you’re doing a lot of footwork for the leaders in the field. You’re allowing them to do research while you’re observing first-hand a lot of unusual cases that are often sent in consultation from other pathologists because of their difficulty.” When a pathologist at DPL encounters such a problematic case, where the diagnostic criteria aren’t well represented or obvious, they confer with each other before reporting their findings. If a consensus of opinion can’t be reached, they consult experts elsewhere around the nation. “We’re on a par with the most sophisticated laboratories in the world,” Dr. Frazier says, “but at least once a month, we’ll need to send something to an acknowledged expert who has on-going research or is published on that particular problem” – simply because the stakes are so high. The bottom line in every case is, simply put, what is the best diagnosis.
But not all of their work involves potentially fatal skin disease. In a good number of cases that they interpret, the doctors at Dominion Pathology Laboratories see less lethal cancers – but they emphasize that although death rates from basal cell and
squamous cell carcinomas may be low compared to melanoma, these cancers can cause considerable damage and disfigurement if left untreated. In other cases, the problem is dermatitis: a rash; an inflammatory process that may represent an underlying systemic disease or doesn’t respond to traditional treatment; sometimes a bacterial or fungal skin infection. Rashes can be difficult to tell apart clinically but the appearance and pattern of inflammation under the microscope can help narrow down the process, if not diagnose it outright. Here again, accurate reading of any biopsy is critical. That’s why the doctors of Dominion Pathology Laboratories are excited about some of the advances in their field, particularly with regard to some of the newer techniques available now that more specifically confirm or eliminate potential diagnoses. They’re also observing research underway in academic medical centers with interest, such as in situ hybridization and other molecular biology techniques that can be performed on the very same specimen that the glass slides are made from, in order to identify certain gene mutations associated with Stage IV melanoma. “That technology will surely become more established in time, but it’s not yet ready for routine practice,” says Dr. Frazier, thankful that in Hampton Roads, a diagnosis of Stage IV melanoma is still relatively rare.
A consistent focus on service.
In the meantime, Drs. Frazier, Fair and Ryan focus on maintaining their reputation for unparalleled customer service. In an age when automated phone systems are the (exasperating) norm, callers are often surprised to be greeted by a pleasant, efficient human being who responds with the same care and professionalism that the pathologists do when they read slides. The doctors of Dominion Pathology Laboratories take pride in making themselves available to any physician who calls with a question or concern. After almost 15 years, they are unwavering in their mission to give the best service available to treating physicians. “We know how anxiously patients are waiting,” Dr. Frazier says, “so our goal is always to get those critical results to their physicians as fast and efficiently as possible.”
For more information, visit our website: dominionpathology.com 733 Boush Street, Suite 200, Norfolk, VA 23510 (757) 664-7901 Summer 2016 Hampton Roads Physician | 35
Medical Consumerism, MRI SERVICES AND YOUR PATIENTS Jeffrey R. Carlson, MD
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another aspect of patient treatment that deserves our attention: the fiscal well-being of our patients. With the rising costs of health care now being passed along to the consumer, patients are seeing their healthcare expenses skyrocket. For those who must pay for insurance either partially or entirely, a family of four can easily spend more than $1,000 a month just to get basic health insurance. Most have seen copayments double or even triple. Many annual deductibles are now over $5,000, and out-of-pocket expenses are going through the roof. An unintended consequence of the Affordable Health Care Act is that families are having to weigh the cost of having insurance against the cost of housing, food and other necessities. If a surgery will cost them, out-of-pocket, more than three months wages, how likely is it that surgery will be delayed or cancelled altogether? Having to pay a copayment or coinsurance could mean that the family canâ&#x20AC;&#x2122;t afford their electric bill or groceries. As physicians, do we work to ensure that the services we prescribe are in the best financial interest of those for whom we provide care? We need to add another factor when thinking about our treatment options, where we also engage our patients regarding how the care we recommend will financially impact them. Consider the MRI scan, a highly useful diagnostic imaging resource. The difference in payments to hospitals vs. freestanding MRI providers for this service is astounding, usually totaling thousands of dollars. With this shift to higher deductibles, the out-of-pocket cost to the patient can be enormous as well!
An unintended consequence of the Affordable Health Care Act is that families are having to weigh the cost of having insurance against the cost of housing, food and other necessities. Consider the recent case of a patient who wanted to have her MRI scan at a free-standing clinic. She was informed (by the insurance company) that the clinic was out-ofnetwork and that she would have to access MRI services at a local hospital, which her insurance company assured her was in-network. She followed the recommendation of her insurance company, assuming that she would receive the maximum coverage. Imagine her dismay when she received her bill and learned that her out-of-pocket responsibility for the MRI was $1,800, even when going to an in-network MRI provider. She felt cheated and was angry because no one told her she had any options. How could this scenario have played out differently? Her physician could have told her to compare prices and even to consider going out-of-network or self-pay for her MRI. Why? Because most free-standing MRI clinics charge an average of $700 - $1,000 for a self-pay MRI scan,
and less for an out-of-network scan. The cost savings for the patient would have been significant and their satisfaction during this encounter could have been greatly improved. Physicians do not often see financial issues to be a consideration when treating most patients’ acute illnesses. However, our patients would be more content with their overall healthcare experience and much better served if we started to do so.
Jeffrey R. Carlson, MD is the President and Managing Partner of Orthopaedic & Spine Center in Newport News, VA. He holds a fellowship in Orthopaedic Trauma surgery and a combined Neurosurgery-Orthopaedic fellowship in complex spine surgery from Brigham and Women’s Hospital in Boston. osc-ortho.com
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EVALUATING CLINICALLY INTEGRATED NETWORKS
What Should My Practice Consider Before Joining? By Wythe Michael, JD
W
ith the implementation of practitioners. CINs adopt protocols and the CIN – often on governing committees. the Affordable Care Act, policies to improve the quality, safety and It also requires participants to comply numerous Accountable cost effectiveness of the care delivered by with the protocols and policies of the Care Organizations (ACOs) practitioners. Although a hospital system CIN. Importantly, the agreement typihave been established – especially ACOs will often help set up the organization cally gives the CIN the right to negotiate focused on Medicare patients. More and will assist in the management and managed care agreements with third party recently, we have seen an payers, including the right expansion of clinically to negotiate - on behalf of With third-party payers continuing to integrated networks (CINs) participants – fee-for-service seek additional cost savings, we expect that include a focus on arrangements and sharedparticipation in CINs to continue to grow. contracting with nonsavings payments. governmental payers and For practitioners, the broader participation from practitioners. operation of the CIN, CINs should be led main benefit of participating in a CIN is CINs are groups of providers that by physicians. that it allows the practitioners to jointly have organized to manage care for Participants in a CIN enter into a negotiate and enter into contracts with specific patient populations. Participants participation agreement that governs the payers. With the expected cost savings and in CINs can include hospital systems, participant’s relationship with the CIN. enhanced quality achieved by the CIN, groups of practitioners employed by a The agreement requires individual practhis can result in higher reimbursement hospital, ACOs and independent local titioners to participate in the operation of rates. Participating in a CIN also ensures ORTHOTICS | DRY NEEDLING | BALANCE AND FALL PREVENTION | VESTIBULAR REHABILITATION | TEMPOROMANDIBULAR DISORDERS TREATMENT
THE ART OF MOVEMENT THERAPY CERTIFIED | WOMEN’S HEALTH SERVICES WORK CONDITIONING | FUNCTIONAL CAPACITY EVALUATION & IMPAIRMENT RATINGS | MCKENZIE THE SCIENCE OF HUMAN PERFORMANCE ORTHOPEDIC CERTIFIED SPECIALISTS | AQUATIC THERAPY | NEUROLOGICAL REHABILITATION | PEDIATRIC ORTHOPEDIC THERAPY | LYMPHEDEMA ®
TRAINER-LED FITNESS TRAINING AND SPORTS PERFORMANCE | HAND THERAPY | CUSTOM SPLINTING | ORTHOTICS | DRY NEEDLING BALANCE AND FALL PREVENTION | VESTIBULAR REHABILITATION | TEMPOROMANDIBULAR DISORDERS TREATMENT | ORTHOPEDIC CERTIFIED SPECIALISTS AQUATIC THERAPY | NEUROLOGICAL REHABILITATION | PEDIATRIC ORTHOPEDIC THERAPY | LYMPHEDEMA | WORK CONDITIONING | FUNCTIONAL CAPACITY EVALUATION & IMPAIRMENT RATINGS | MCKENZIE® THERAPY CERTIFIED | WOMEN’S HEALTH SERVICES | TRAINER-LED FITNESS TRAINING AND SPORTS PERFORMANCE | HAND THERAPY | CUSTOM SPLINTING | ORTHOTICS | DRY NEEDLING | BALANCE AND FALL PREVENTION | VESTIBULAR REHABILITATION | TEMPOROMANDIBULAR DISORDERS TREATMENT | ORTHOPEDIC CERTIFIED SPECIALISTS | AQUATIC THERAPY | NEUROLOGICAL REHABILITATION | PEDIATRIC ORTHOPEDIC THERAPY | LYMPHEDEMA | WORK CONDITIONING | FUNCTIONAL CAPACITY EVALUATION & IMPAIRMENT RATINGS | MCKENZIE® THERAPY CERTIFIED | WOMEN’S HEALTH SERVICES | TRAINER-LED FITNESS TRAINING AND SPORTS PERFORMANCE | HAND THERAPY
Comprehensive Physical Therapy Services
| CUSTOM SPLINTING | ORTHOTICS | DRY NEEDLING | BALANCE AND FALL PREVENTION | VESTIBULAR REHABILITATION | TEMPOROMANDIBULAR DISORDERS TREATMENT | ORTHOPEDIC CERTIFIED SPECIALISTS | AQUATIC THERAPY | NEUROLOGICAL REHABILITATION | PEDIATRIC ORTHOPEDIC THERAPY | LYMPHEDEMA | WORK CONDITIONING | FUNCTIONAL CAPACITY EVALUATION & IMPAIRMENT RATINGS | MCKENZIE® THERAPY CERTIFIED WOMEN’S HEALTH SERVICES | TRAINER-LED FITNESS TRAINING AND SPORTS PERFORMANCE | HAND THERAPY | CUSTOM SPLINTING
flixr tpti.com
35 clinics and growing! VIRGINIA BEACH–Red Mill, First Colonial | NORFOLK–Kempsville, Brambleton | FRANKLIN | SUFFOLK | SMITHFIELD CHESAPEAKE–Western Branch, Great Bridge, Battlefield | HAMPTON–Executive Drive, Magruder | NEWPORT NEWS–Oyster Point, Denbigh, Hidenwood
38 | www.hrphysician.com
that participants aren’t left out of important local provider networks. One disadvantage of a CIN is a perceived loss of independence. A second disadvantage is the potential cost of upgrading software and other EMR systems to work with the CIN’s system. A third disadvantage is the additional time practitioners must spend on CIN governance, operations and protocols. In deciding whether to join a CIN, practitioners should consider, among other things, the following:
Does the CIN require an upfront payment or capital contribution?
What are the EMR system requirements of the CIN?
With third-party payers continuing to seek additional cost savings, we expect participation in CINs to continue to
grow. Accordingly, practitioners should be prepared to proactively evaluate potential CIN options.
Wythe Michael, an attorney with Goodman Allen & Donnelly, focuses his practice on the representation of healthcare providers. Often acting as an outside general counsel, Wythe provides practical solutions to legal issues by working with practice groups and individual practitioners to understand and implement their business strategy. goodmanallen.com
What are the other participation requirements? Is the CIN physician led? Are the physician leaders independent or part of a group employed by the hospital? How is the board elected? Has the CIN adopted protocols? If not, what is the process and timing for developing protocols? What type of authority does the CIN have to negotiate payer contracts on behalf of participants? Are any such contracts already in place?
Does the CIN permit practitioners to participate in another CIN?
How will cost-savings and quality bonus payments be shared with participants?
Is the CIN a narrow-network or more broadly based?
• Custom compounding for individualized care • Medications for: skin care, hospice needs, pain management, hormone replacement therapy & more... • Superior facilities and staffing • Special dosage forms such as ointments, creams, gels, injections, suspensions, etc.
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4001 Virginia Beach Blvd., Suite 110 Virginia Beach, VA 23452 (757)934-0533 Toll Free: (877) 873-9564 Fax: (757) 228-3991 Other locations include: Jamestown, NY • Erie, PA Houston, TX • Greenville, SC
Will the CIN engage in promotional or marketing efforts? How can the CIN terminate participants? How can participants resign? Summer 2016 Hampton Roads Physician | 39
Promotional Feature
Taking the Pain Out of the
It starts with a Realtor who knows you don’t have time to waste
I
f any one personality trait could be said to define all physicians and health care workers, it would be this: they’re always busy. In fact, it’s probably fair to say that anyone who chooses a career in medicine is volunteering to rest very little. For those who dedicate their lives to caring for the sick, discretionary time is a precious and very rare resource, to be used judiciously and guarded with care. These professionals, of necessity, take a no-nonsense approach to life, and to business transactions of any kind – including the often time-consuming venture of buying (or selling) a home. It’s the successful Realtor who respects that, and knows how to get to the heart of the matter quickly. It’s the exceptional Realtor who also knows that medical professionals have specific requirements when it comes to investing in a home. And it’s the superior Realtor who knows the community so well that he was
40 | www.hrphysician.com
selected by one of Hampton Roads’ major medical organizations to be part of its recruitment process for incoming physicians. Greg Garrett, a Realtor with 39 years of experience, was chosen by the organization to take potential employees on comprehensive tours of the areas in which they will be located, often even before their interviews are scheduled. “There are 11 cities and counties in the Greater Hampton Roads region,” Garrett says, “and I’ve had the opportunity to get to know all of them well. I’m able to show these professionals the neighborhoods in closest proximity to medical complexes and hospitals, and to talk with them candidly about housing costs, proximity of schools, houses of worship and shopping areas – and even how to avoid heavy traffic areas.” By the time his tours are completed, these potential residents know that Hampton Roads is an exceptional and very desirable place to live. “It’s taken me years to get to know our entire community so well,” Garrett says. “I did it by not limiting myself to just two or three cities, as many realtors do. But this is such a diverse area that I wanted to know all of it. And I know that our region is truly remarkable. And I know why.” Greg Garrett not understands why Hampton Roads is remarkable, he has in his own way contributed to it. He’s been active at the executive level in civic and community organizations like the Hampton Roads Economic Development Alliance, which is solely focused on working together to bring more businesses to Hampton Roads. He serves on the Workforce Development Executive Board, also a public/private partnership of many Hampton Roads cities/counties. “We’re helping people realize the current and potential job opportunities that exist here,” he says, “and we helping them get trained for those opportunities.” He cites a number of individuals who have gone on to secure positions at the Shipyard after training, and many who have chosen careers in the military, and adds, “we have a strong medical presence here, which is making it easier to attract more world class physicians and health care professionals. We want to create a workforce that is ready to assume the critical support roles in administration and technology, as well as to go to medical school.” His commitment to the community extends beyond executive leadership, to a more personal level. He has for years been a board member & is currently a teacher and mentor for students at Youth Challenge, a non-profit ministry that works with citizens throughout Hampton Roads to help them get free of drug and alcohol addiction. “It’s an alternative to jail,” he explains. “Judges have the option in some cases to sentence these individuals to a year under the custody of Youth Challenge, which is committed to restoring their lives, rebuilding their character and helping them return to the community prepared to live productive lives of integrity.”
Real Estate Market He runs a Thursday night basketball program for youth and young adults, from 9pm to midnight, where he both plays, teaches and mentors at risk young men. It’s been so successful that he’s trying to get the program started in other localities – and working with some of his players to become mentors themselves. Greg Garrett’s heart for service to at-risk children and youth extends even beyond the limits of Greater Hampton Roads. In the year 2000, while he was supposed to be planning for a cruise to celebrate his 20th wedding anniversary, he was researching the plight of orphans in Central America. A trip to El Salvador became their gift to each other. After seeing firsthand the appalling conditions, they returned home determined to do something to help. He founded Orphan Helpers, and began partnering with individuals, businesses, churches and governments to provide for the physical, spiritual, emotional and educational needs of orphaned, abused and incarcerated children. The organization has grown, today serving about a thousand children each year in El Salvador and Honduras. Its success is a testament to the level of commitment Greg Garrett brings to all of his endeavors, be they charitable deeds or service to clients. He is simply undeterred by challenges. He puts so much of his heart and soul into serving his medical clients because he feels such an affinity for them and their needs. His godfather was a doctor, but it was an early personal affiliation with doctors that shaped his approach.
He was still in high school when his father was diagnosed with cancer, and doctors and other medical personnel became part of everyday life. He attended the University of Richmond (on a scholarship) for a year, coming home on weekends to help his mother with the family’s small real estate business. “It was a natural progression from there,” Garrett says. “Before long, I had forgone college to help my mother full time, later joining another practice, and ultimately starting my own company, where my clients included more and more physicians. It just grew organically, through word of mouth and referrals.” “I’m inspired by health care professionals and their work ethic,” Garrett says, “and I’m respectful of their time. I’m motivated to get the best possible result for them as quickly and efficiently as possible.”
Greg Garrett Realty
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Greg Garrett founded Orphan Helpers to provide for the physical, spiritual, emotional and educational needs of orphaned, abused and incarcerated children.
Summer 2016 Hampton Roads Physician | 41
in
breast prostheses
Innovations
By Teresa Kelly
F
or patients who do not choose breast reconstruction, or those with a failed reconstruction, breast prostheses can help recapture the look and feel a woman had prior to her lumpectomy, mastectomy, reduction or uneven reconstruction. Conventional off-the-shelf breast forms are made of silicone, foam or fiberfill, and come in many shapes and sizes. These forms tuck inside a special pocketed bra or camisole to keep the form in place. Some styles come with adhesive backing that attaches to the chest wall for a very natural look and feel. Custom breast forms can be fabricated to give a more natural appearance by matching the patient’s natural contours and skin color, resulting in a better fit and more symmetrical look.
Improved Fitting Results with 3D Laser Scanning. Advances in technology are bringing changes to the world of breast prostheses. One example is the FastScan system (http://fastscan.com), a portable 3D scanner that makes a digital scan of the chest in real time. This technology delivers great results for post-mastectomy fitting, as well as for lumpectomy and uneven/unbalanced reconstruction. 3D scanning gives precise imaging of the patient’s chest, as well as any remaining breast tissue. The back side of the custom prosthesis is tailored to the exact dimensions of the surgery site as digitized by the scanner, providing the best possible fit. This precise fit eliminates the need for a pocketed bra and gives women the freedom to wear off-theshelf bras and swimsuits. Custom Prostheses Give Patients More Color Options. There are many companies that specialize in custom breast prostheses, offering patients breast forms that are lighter than traditional silicone off-the-shelf forms and available in a multitude of colors. These manufacturers can provide as many as 30 skin tone colors to choose from, ensuring a prosthesis that can match (or very closely match) a woman’s natural skin tone. The results are a realistic appearance that is a unique duplicate of the patient’s natural breast. Another benefit of a custom prosthesis is the ability to custom contour nipples and areolas. These are fabricated to match the desired size, 42 | www.hrphysician.com
color and shape of the remaining nipple and areola. Semi-custom nipples and areolas can also be fabricated for post-bilateral reconstruction patients. What to Expect from Insurance. Insurance coverage can vary, but most typically cover: • A minimum of two, and up to 12, special mastectomy bras (with prostheses pockets) on a yearly basis • One light weight prosthesis every six months • A new, silicone prosthesis every one to two years Some insurance companies also provide benefits for custom breast prosthesis. The mastectomy practice will contact each patient’s insurer to determine her eligibility and allowances, as well as any out-of-pocket expenses. Most plans typically allow lifetime benefits, no matter the length of time since the surgery; patients should be advised to continue to utilize these benefits. More Choices = Happier Patients = Better Outcomes. Living with mastectomy or lumpectomy is challenging on many levels. Giving a woman a piece of her femininity back can provide huge rewards in her mental and physical health. Advances in technology are extending beyond the hospital walls to after care, bringing devices that can make life more enjoyable and meaningful for patients. This result is happier patients with better outcomes.
Teresa Kelly is the Manager of Silhouette Mastectomy Boutique for breast cancer patients, featuring undergarments for women who have undergone mastectomy, with or without reconstruction. silhouettemb.com
More pediatric surgeons for children. Children’s Hospital of The King’s Daughters offers the most comprehensive pediatric surgical care for children in Hampton Roads, northeastern North Carolina and Virginia’s Eastern Shore. In addition to general pediatric surgery, we offer care in five pediatric subspecialties including cardiac surgery, neurosurgery, orthopedic surgery, plastic surgery and urology. Our team also includes more than 20 pediatric anesthesiologists and dozens of OR nurses.
CHKD’s state-of-the art facilities include a new cardiac catheterization lab and cardiac operating suite at our main hospital in Norfolk and two CHKD Health and Surgery Centers in Newport News and Virginia Beach for outpatient surgery. More than 20 pediatric surgeons. More than 13,000 surgeries last year. And more than 50 years of experience in pediatric surgical care. That’s what makes CHKD more than a hospital.
Our surgeons have pioneered non-invasive techniques for the correction of chest wall abnormalities at our worldrenowned Nuss Center, and our craniofacial reconstruction program is proud to be the American home of the international charity Operation Smile. Our multidisciplinary spine team includes orthopedic and neurosurgeons and is a regional leader in spine surgery for children and adolescents.
Learn more at CHKD.org.
OUR SURGERY TEAM Cardiac Surgery Felix Tsai, MD
Neurosurgery
John Birknes, MD Joseph Dilustro, MD Gary Tye, MD
General Surgery
Frazier Frantz, MD Robert Kelly, MD Ann Kuhn, MD Michelle Lombardo, MD Robert Obermeyer, MD
Orthopedics/ Sports Medicine
Marc Cardelia, MD Allison Crepeau, MD Cara Novick, MD Jeremy Saller, MD Sheldon St. Clair, MD Carl St. Remy, MD Allison Tenfelde, MD
Plastic Surgery
George Hoerr, MD Jesus (Gil B.) Inciong, MD
Urology
Charles Horton, MD Jyoti Upadhyay, MD Louis Wojcik, MD
IN THE NEWS Bon Secours Maryview Medical Center recently installed a 1.5 T GE Optima MR450 W MRI unit. The new scanner offers patient comfort and exceptional images that allows the imaging team to provide the best information possible for the patient’s diagnosis, as well as several features that improve patient comfort.
Bradley Prestidge, MD
Bradley Prestidge, MD, regional medical director for radiation oncology at Bon Secours Oncology Specialists Hampton Roads, recently injected the first patient at Bon Secours DePaul Medical Center with SpaceOAR hydrogel. The FDA-cleared system temporarily positions the front rectal wall away from the prostate during radiotherapy for prostate cancer, creating space that reduces dose to and protects the rectum from damage.
Bon Secours Hampton Roads Health Systems CEO Michael K. Kerner and members of the Bon Secours team, along with the American Cancer Society and local gastroenterology groups joined together on June 10 to sign the “80% by 2018” pledge, a National Colorectal Cancer Roundtable initiative working toward the shared goal of 80% of adults aged 50 and older being regularly screened for colorectal cancer by 2018. See photo below.
The Bon Secours Cancer Institute at DePaul now offers stereotactic body radiotherapy (SBRT) as an option for the treatment of early to intermediate stages of prostate cancer. SBRT, also known as Stereotactic Ablative Radiotherapy (SABR) is a non-surgical treatment that delivers very targeted radiation with submillimeter accuracy, allowing higher doses of radiation to be delivered in fewer treatment sessions, with less radiation dose to surrounding tissues. Bon Secours DePaul Medical Center is pleased to announce that Yassar Youssef, MD, FACS, general surgeon specializing in robotic and minimally invasive surgery with Bon Secours Surgical Specialists, has been nationally recognized as an epicenter physician by Intuitive Surgical. His work on the forefront of advanced medical technology has led to Bon Secours DePaul being selected as one of the first da Vinci® Robotic epicenters for general Yassar Youssef, MD, FACS surgery in the mid-Atlantic region. DePaul will serve as a national destination and training site for robotic surgeons.
Marlene Capps, MD
Marlene Capps, MD has been recently named Chief Medical Officer for Bon Secours Mary Immaculate Hospital. Dr. Capps will be responsible for leading system-wide initiatives, such as care coordination, population health and quality management, informatics and information sharing, for Bon Secours Mary Immaculate. She is Board certified by the American Board of Family Practice and the American Board of Obesity Medicine.
Front row (L-R) Sharon Windell, BSN, RN, OCN, Bon Secours; Precious Jenkins, LPN, Bon Secours; Kathy Brooks, RTT, Bon Secours; Daniel Neumann, MD, GI and Liver Specialists of Tidewater; Lauren Westmoreland, LPN, Bon Secours; Michael K. Kerner, CEO, Bon Secours Hampton Roads; Robin Pearson-Boothe, RN, Bon Secours; Joseph Frenkel, MD, Bon Secours Surgical Specialists; Brain Sullivan, MD, Gastroenterology Associates of Tidewater; and Paola Pachon, Bon Secours Back row (L-R) Mary Beth Taylor, American Cancer Society; Marylou Anton, MSN, RN, OCN; Bon Secours; Bradley Prestidge, MD, MS, Bon Secours; Rene’ Rivera, MD, Gastroenterology Associates of Tidewater; Donna Robertson, Bon Secours; John Barrett, CEO, Bon Secours DePaul Medical Center; Raymond L. McCue, MD, MBA, Bon Secours; Lisa Metten, CEO, Gastroenterology Associates of Tidewater; Brooke Rexrode, Bon Secours; and Sue Jobe, Bon Secours
44 | www.hrphysician.com
The Sisters of Bon Secours Mary Immaculate Hospital have awarded a $22,000 grant to support a community room for nutritional education in Jim’s Local Market. Located in Newport News, the market is positioned to serve an economically depressed community in what is considered a food desert. Activities will include introducing customers to fruits and vegetables they may be unfamiliar with, teaching them how to cook new and familiar food in a healthy manner, as well as portion control, all in a culturally relevant manner. Bon Secours Hampton Roads Health System is pleased to announce that Mikey’s Camp, a part of the Kidz N Grief program, has received a generous donation of $75,000 from the JoAnn Webb Family Foundation. The funds will enable the program to continue providing support for children in the Hampton Roads area who have experienced the loss of a family member or friend. Bon Secours DePaul Medical Center has received the Get With The Guidelines®-Gold Plus Achievement Award as well as the Target Stroke Elite Honor Award recognition from the American Heart Association/American Stroke Association, recognizing DePaul’s commitment to providing the most appropriate and responsive stroke treatments according to nationally recognized research-based guidelines centered on the latest scientific evidence. See photo below Bon Secours Health System has earned a place on the 2016 Top 10 Hospitals and Health Systems ranking in DiversityInc’s annual survey, tracking the nation’s top companies when it comes to hiring, retaining and promoting women, minorities, people with disabilities, LGBT, and veterans. DiversityInc is the most rigorous, data-driven survey of its kind, gauging detailed demographics based on race/ethnicity and gender at some of the largest US employers.
The Women’s Imaging Center at Bon Secours DePaul Medical Center has been designated a Breast Imaging Center of Excellence by the American College of Radiology, indicating that the breast imaging services at the center are fully accredited in mammography, stereotactic breast biopsy, breast ultrasound and ultrasound-guided breast biopsy. Bon Secours Virginia Health System is proud to announce that Bon Secours Mary Immaculate Hospital has received a Partner for Change Award, and Bon Secours DePaul Medical Center and Bon Secours Maryview Medical Center received Emerald Partner for Change Awards from Practice Greenhealth. The health facilities are being recognized for their green initiatives. The Greenhealth Partner for Change Award recognizes health care facilities that continuously improve and expand upon their mercury elimination, waste reduction, recycling and source reduction programs. At a minimum, facilities applying for this award must be recycling 15 percent of their total waste, must have reduced regulated medical waste, are well along the way to mercury elimination, and have developed other successful pollution prevention programs in many different areas. Bon Secours Health System has received the 2016 Gallup Great Workplace Award, an award created by Gallup to recognize organizations for their extraordinary ability to create engaged workplace cultures that drive business outcomes. It is Bon Secours’ fifth consecutive year to receive the prestigious award. The health system also won Gallup’s Comeback Champion Award for its work and results with facilities that had performed in the bottom quartile of engagement in previous years. Children’s Hospital of The King’s Daughters is offering pediatric and adolescent gynecology services from Dr. Mariel Focseneanu through its adolescent medicine program. Dr. Focseneanu is a fellowship-trained specialist in pediatric and adolescent gynecology with Children’s Specialty Group. She will focus on evaluation, diagnosis and treatment of reproductive health issues of girls from birth through age 23. Pediatric and adolescent gynecology services will be offered at CHKD’s main hospital in Norfolk, the CHKD Health Center at Oyster Point in Newport News and the CHKD Health Center in Williamsburg.
Stroke Team
Summer 2016 Hampton Roads Physician | 45
IN THE NEWS Farm Fresh President Micky Nye presented a $100,000 grant from the SUPERVALU Foundation to Children’s Hospital of The King’s Daughters (CHKD) to help the hospital meet the region’s growing demand for pediatric behavioral health services. The grant will help offset the costs of training CHKD behavioral health counselors to provide parent-child interaction therapy, a proven treatment for children ages 2 to 7 with emotional and behavioral disorders. CHKD is now offering outpatient pediatric behavioral health treatment within its community health centers so children and families can access mental health services close to home and in the same place they receive trusted care for their physical health concerns.
Dr. Eric Lowe, CHKD medical director, hematology/oncology (left) Micky Nye, president of Farm Fresh, (back center) and Mark Theophelakes, vice president of operations for Farm Fresh (back right)
Farm Fresh President Micky Nye presented a $179,874 donation to Children’s Hospital of The King’s Daughters (CHKD) to help local children in their fight against childhood cancer. The presentation took place in CHKD’s outpatient cancer and blood disorders unit, which was built with the help of funds raised and donated by Farm Fresh. The gift was a result of Farm Fresh’s recent Round Up campaign, an annual in-store fundraising drive held at every Farm Fresh location encouraging customers to round up the total of their tab to an even dollar amount, or to add additional dollars to benefit CHKD.
Accepting the gift for CHKD were President and CEO Jim Dahling (center back); Amy Sampson, vice president of marketing, government/public relations and physician services (far left); and Stephanie Osler, director of social work (center left).
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Chesapeake Regional Healthcare’s Knee & Hip Replacement and Spine Surgery programs have each been named as a Blue Distinction Center+ by Anthem Blue Cross and Blue Shield, recognizing the programs for expertise and efficiency in delivering patient care, adding to Chesapeake Regional’s previous designation as a Blue Distinction Center for Bariatric Surgery. Blue distinction facilities are determined based on an evaluation of “the expertise of the medical team, the number of times the facility has performed the procedure and the facility’s track record for procedure results.” The status also evaluates the facility’s ability to meet cost measures that address patient needs for affordable health care. Chesapeake Regional Healthcare honored two outstanding nurses during its annual Nurse Exemplar Awards Presentation on Thursday, May 12, 2016. Melinda “Mindi” Tysor, R.N. is this year’s winner and Lourdes “Ludy” Hofilena, R.N. was selected as runner-up. They were chosen as the 2016 recipients from 117 nominees. Tysor is a charge
Melinda “Mindi” Tysor, RN (right) and Elaine Griffiths, CRH chief nursing officer.
Lourdes “Ludy” Hofilena, RN.
nurse in the emergency department; Hofilena is a charge nurse in the surgical/oncology unit and has been an employee since 1988. The awards were presented by the hospital’s Professional Nursing Council (PNC) to recognize excellence in nursing. Eastern Virginia Medical School has been chosen by IBM to join Watson Health initiative, one of 16 academic medical centers, health systems, ambulatory radiology providers and imaging technology companies participating in the new initiative. As part of this global effort, foundational members will engage IBM’s augmented intelligence platform, called Watson, to extract insight from a variety of data sources, such as medical images, electronic health records, radiology and pathology reports, lab results, doctors’ progress notes, medical journals, clinical care guidelines and published outcomes studies. Watson, a cognitive computing system, understands natural language, reasons and learns over time. Six EVMS faculty were accepted into a leadership development program sponsored by the Association of American Medical Colleges (AAMC). The AAMC’s Leadership and Management Foundations for Academic Medicine and Science, formerly known as the Executive Development Seminar for Aspiring Leaders, was held at AAMC headquarters in Washington in April. EVMS faculty taking part in the training include Beverly Roberts-Atwater, MD, Assistant Professor of Physical Medicine and Rehabilitation; Shivanjali Shankaran, MD, Assistant Professor of Internal Medicine; Kimberly Dempsey, MPA, PA-C, Associate Professor of Health Professions; Ian Chen, MD, Professor of Internal Medicine; Jason Grahame, MPA, PA-C, Associate Professor of Health Professions; and Jagdeesh Ullal, MD, Associate Professor of Internal Medicine.
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Summer 2016 Hampton Roads Physician | 47
IN THE NEWS Dr. Cecelia Koetting of Virginia Eye Consultants recently volunteered her time providing optometric services for a Remote Area Medical Clinic in Smyth County, Virginia. This pop-up health clinic provided free health care to nearly 1,000 people who could not otherwise afford it.
Dr. Cecelia Koetting
Mayor Paul Fraim has made the following appointments to the Hospital Authority of Norfolk, the body which oversees Lake Taylor Transitional Care Hospital. Sarah M. Bishop has been named to her first term as Commissioner, which will run through May, 2018. Mayor Fraim reappointed three current Board members for another six-year term: Anita O. Poston, currently Chairperson; Calvin A. Durham, DMin, Sarah Bishop presently Vice Chairperson; and Adam Casagrande. Other Commissioners include: William T. Greer, Jr., PhD, Board Secretary; Deborah B. Bauman, Treasurer; and Willette L. LeHew, MD, Immediate Past Chair; Edward L. Lilly, MD; Beverly Roberts-Atwater, DO, PhD; Michael L. Tucker, MD; and Ronald E. Keys.
48 | www.hrphysician.com
Dr. F. Cal Robinson, Medical Psychologist with Orthopaedic & Spine Center, will offer a third session of the MindfulnessBased Chronic Pain Management (MBCPMâ&#x201E;˘) Program starting Thursday, September 22nd. The program, developed by Canadian Pain Management Physician Dr. Jackie Garner-Nix, can help patients with chronic pain, sleep disorders, anxiety, stress and fibromyalgia. Dr. F. Cal Robinson
Riverside Walter Reed Hospital has been selected by Anthem Blue Cross and Blue Shield as a Blue Distinction Center for Knee and Hip Replacement, part of the Blue Distinction Specialty Care program. Blue Distinction Centers are nationally designated healthcare facilities shown to deliver improved patient safety and better health outcomes, based on objective measures that were developed by Blue Cross and Blue Shield companies with input from the medical community. Hospitals designated as Blue Distinction Centers for Knee and Hip Replacement demonstrate expertise in total knee and total hip replacement surgeries, resulting in fewer patient complications and hospital readmissions. Designated hospitals must also maintain national accreditation. Riverside Regional Medical Center opened a new labor and delivery suite featuring 12 newly renovated labor and delivery rooms, four ante-partum rooms (rooms for expectant moms who require hospital care prior to delivery), and three triage rooms, offering expectant mothers a highly personalized, family-centered birth experiences with
Virginia Eye Consultants CEO Karen J. Spencer has been appointed to the board of the Virginia Ambulatory Surgery Association (VASA). VASA represents Virginia’s ambulatory surgery industry through educational programs, legislative action and collaboration with other organizations on local and national issues of importance to the industry.
amenities such as tub therapy, in-room private iPod plug-ins in a very spacious labor and delivery room. The ribbon cutting ceremony was held on May 11th.
Karen J. Spencer
The Virginia Eye Consultants team recently raised over $13,000 for the Foundation Fighting Blindness Annual Vision Walk in Virginia Beach, winning the award for being the biggest fundraiser and the largest team. Sentara Princess Anne Hospital has received a Magnet Recognition Program® designation from the American Nurses Credentialing Center. The designation, granted to about seven percent of US hospitals, culminates a multi-year journey toward recognition for excellence in patient care, innovation in nursing practice and a supportive work environment for nurses. ANCC’s Magnet is the most distinguished award a hospital can receive for nursing care.
If you have News you would like to share with our readers in the Fall edition, please contact the publisher at 757-237-1106 or email: holly@hrphysician.com Deadline for submissions is September 27th.
You take care of your patients. Let us take care of you. Our clients trust Goodman Allen Donnelly with their credentialing matters, Board of Medicine complaints, internal audits and litigation matters. Let us help you with your broader legal needs. Wythe Michael and Duffy Myrtetus handle a wide range of business and commercial real estate transactions, financing, employment and non-compete agreements, and practitioner ownership purchases and sales. Learn more about our Business and Transactional Team at www.goodmanallen.com.
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Summer 2016 Hampton Roads Physician | 49
WELCOME TO THE COMMUNITY
Fred Bagares, DO has joined EVMS Sports Medicine. Dr. Bagares earned his medical degree at the Arizona College of Osteopathic Medicine and completed a Physical Medicine and Rehabilitation residency at Northwestern University, Feinberg School of Medicine in Chicago, Illinois. He completed a Sports Medicine fellowship at Spine and Sports Medicine in Elmhurst, Illinois. Jessica Bowers, MD has joined Bon Secours Tri-Cities Medical Associates. Dr. Bowers is Board certified in internal medicine. She earned her medical degree from Virginia Commonwealth University. Dr. Bowers continued her training by completing a Commonwealth Public Health Training Program and combined internal medicine and family medicine residency at Eastern Virginia Medical School. Jeanne Marie Busch, DO has joined Gynecology Specialists in Chesapeake. Dr. Busch earned her medical degree from NY College of Osteopathic Medicine and completed her residency in Obstetrics and Gynecology at Naval Medical Center in 2003. She is Board certified in Obstetrics and Gynecology. Mark Edang, MD works with the Sentara Hospital Medicine Physicians team at Sentara Norfolk General Hospital. Dr. Edang earned his medical degree from Cebu Institute of Medicine and completed his residency at Monmouth Medical Center.
Benjamin Goins, MD has joined Lakeview Pediatrics and Family Medicine in Suffolk. Dr. Goins received his medical degree from the Medical University of the Americas, and completed his Family Medicine internship and residency at Self Regional Healthcare.
Mark Hippenstiel, MD has joined Currituck Internal Medicine and Family Practice, an affiliate of Chesapeake Regional Medical Group. A Board certified family medicine physician, Hippenstiel received his medical degree from Jefferson Medical College in Philadelphia. He completed a residency in family and community medicine at U.C. Davis Medical Center in Sacramento, Calif., where he also served as chief resident. 50 | www.hrphysician.com
Christi Hughart, DO has joined Urology of Virginiaâ&#x20AC;&#x2122;s South Boston location. Dr. Hughart earned her medical degree from West Virginia School of Osteopathic Medicine, and completed three years of general surgery training at Doctors Hospital/Grant Medical Center in Columbus, Ohio. She completed her urology training through Michigan State College of Osteopathic Medicine, Detroit Campus, and is a Fellow of the American College of Osteopathic Surgeons. Rosa Javier, MD has joined Sentara Family Medicine Physicians. Dr. Javier earned her medical degree from the University of Santo Tomas Medical School and completed her residency at Memorial Medical Center
Eric M. Karlin, MD joined Allergy Partners of Hampton Roads in April 2016. Dr. Kaplan earned his medical degree at the University of Miami School of Medicine and completed his residency at Washingotn University in St. Louis. He completed a fellowship at Vanderbilt University.
Elizabeth Robledo, MD has joined Sentara Family Medicine Physicians. Dr. Robledo earned her medical degree from the University of Miami Miller School of Medicine and completed her residency at the Naval Hospital Jacksonville.
Barbara Sarris, MD has joined Bon Secours Internists of Churchland. Dr. Sarris earned her Doctor of Medicine from Mount Sinai School of Medicine in New York City and completed her internal medicine residency at Barnes-Jewish Hospital, Washington University School of Medicine in St. Louis, Missouri. She is Board certified in internal medicine.
Rozales Swanson, MD, a Cardiothoracic Surgeon, has joined Riverside Regional Medical Center. After earning his medical degree from the Howard University College of Medicine, Dr. Swanson completed surgical internships at Greenville Memorial Hospital and a surgical residency at the University of South Florida, Bay Pines and VA Hospital Systems. He completed fellowships in thoracic surgery at Carolinas Medical Center and advanced heart failure, transplant and TAVR at Tampa General Hospital. He is Board certified by the American Board of Thoracic Surgery,
Lysa Story, PA-C has joined Sentara Cardiology Specialists in Suffolk. She earned her Master of Physician Assistant Studies degree at Eastern Virginia Medical School.
Julia Hough, PA-C has joined Hampton Roads Orthopaedics & Sports Medicine in April and will be working with Dr. Kinjal Sohagia at the Interventional Pain Management office in Newport News.
Jibiao Huang, RPA-C has joined Sentara Neurosurgery Specialists at Sentara Norfolk General Hospital. He earned his Master of Physician Assistant Studies degree from University of Detroit Mercy.
Andrew Johansson, PA-C has joined Hampton Roads Orthopaedics & Sports Medicine in June and will be working with Dr. Nelson Keller at the Foot & Ankle Centers in Newport News and Yorktown.
We would like to welcome your new physicians, NP’s and PA’s Please contact us at 757-237-1106 or email: holly@hrphysician.com Deadline for submissions for the Fall edition is September 27th.
Detect Lung Cancer Early with CT Lung Screening
Shelley Reams, NP has Sentara Pediatric Physicians in Virginia Beach. She earned her Nursing Practitioner degree from Northern Illinois University.
Melissa Roberts, MSN, NP-C has joined Sentara Pediatric Physicians in Virginia Beach. She earned her Nursing Practitioner degree from Old Dominion University. Karen Fields-Sykes, NP has joined the staff at Bon Secours Internal Medicine of Portsmouth. She reeived her master of science in nursing from the University of Cincinnati in Cincinnati, Ohio.
Low-dose CT Lung Cancer Screenings—now covered by Medicare and most commercial health insurance—are saving lives for asymptomatic patients 55 years and older with a 30-pack-year smoking history. The Sentara Cancer Network provides doctors with an easy how-to guide to the required shared decision making visit, and offers patients convenient locations throughout Hampton Roads. • Chesapeake • Gloucester • Hampton
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• Suffolk • Virginia Beach • Williamsburg
For more information, call 1-855-EARLY-DX (1-855-327-5939). Sentara.com/ScreenMyLungs Your community, not-for-profit health partner
Summer 2016 Hampton Roads Physician | 51
WELCOME TO THE COMMUNITY
Tidewater Physical Therapy would like to Welcome
Aaron Brizuela, PTA, LPTA West Point
BUILDING A SUCCESSFUL
ACO
More and more physicians are creating doctor-led ACOs to comply with the CMS mandate to improve both population health and the patient experience, while managing costs at the same time.
Christian “ Tyler” Johnson , PTA Quintin Lewis PT, DPT, CMPT Suffolk Suffolk
Our Fall edition will include an Update on this topic.
Brittni Maurer, PTA Oyster Point
If you would be willing to share your practice’s experience in either participating in or creating an ACO, please contact our editor, Bobbie Fisher, at 757.773.7550, or by email to bobbie@hrphysician.com.
Stephanie “ Crysten”Moreland, PTA, CLT Williamsburg Hand Therapy Center
Physician H
Nicholas Ott, PTA Oyster Point
Giovanni Weber, PTA First Colonial
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More Sub-Specialty Care. When you need orthopedic treatment, it’s good to know an expert with a high level of training and skill is here to care for you. Some of our orthopedic sub-specialties include: • Total joint replacement • Shoulder • Hand
• Foot & ankle • Sports medicine • Trauma
Orthopedic Specialists
757-337-3366 riversideonline.com/ortho
EXPANDED OFFICE HOURS INCLUDES SATURDAY APPOINTMENTS 52 | www.hrphysician.com
S
ADDING HOURS,
Adding Revenue
Y
our practice may be considering adding office hours to accommodate patient requests for more convenient appointment times and to increase revenue. But before you do, you need to carefully weigh the pros and cons. Here are some issues to consider.
provider labor costs by having a physician assistant or nurse practitioner see the bulk of the patients.
Focus on Patient Convenience Too many practices maintain hours that force working patients to take time off from work to make their appointments. The traditional 8:30 a.m. to 5 p.m. hours may be fine for patients who are retired, work shift hours, or are full-time students, but they can be tough on those who work during the day. Opening your practice an hour or two earlier, staying open later four evenings a week, or offering weekend hours would be a huge convenience for many patients. It’s important that you determine whether you’ll have sufficient patient volume to absorb the additional hours you are open. One way to help increase patient volume is to promote your practice’s new hours through patient e-mails, website updates, office signage, and press releases to the local media.
David M. Limroth, CPA
R. Paul Speece, CPA
Nicole J. Wood-Sabo, CPA, MS
Copyright 2015 by DST. All rights reserved. The general information in this publication is not intended to be nor should it be treated as tax, legal, or accounting advice. Additional issues could exist that would affect the tax treatment of a specific transaction and, therefore, taxpayers should seek advice from an independent tax advisor based on their particular circumstances before acting on any information presented. This information is not intended to be nor can it be used by any taxpayer for the purpose of avoiding tax penalties
Look at the Economics Will it be financially worthwhile for you to extend office hours? We can help you run the numbers. For example, if practice overhead is $1,100 per work day and the average reimbursement per patient is $85, it takes about 13 patients per day to cover the overhead. For each additional patient, the practice incurs only variable costs before paying its providers. Once all costs are identified, a projection can be made of the potential profit associated with seeing more patients.
Evaluate Staffing Issues If the demand exists, it might make sense to add a part-time physician to see patients during your additional office hours. You could reduce
THANK YOU! The doctors and staff at Allergy & Asthma Specialists extend a
heartfelt thank you to all the physicians and staffs in Hampton Roads who refer their patients to us for allergy and asthma health care. We never lose sight of the fact that your referral is accompanied with a trust in us.
Dr. Gary Moss
Dr. Greg Pendell
Dr. Craig Koenig
Lisa Deafenbaugh PA-C
June Raehll FNP-BC
Kim Pham NP-C
We make it as easy as possible on the patient and referring physician by ACCEPTING MOST INSURANCES.
Virginia Beach (757) 481-4383 • Chesapeake (757) 547-7702 • Norfolk (757) 583-4382 www.allergydocs.net
Summer 2016 Hampton Roads Physician | 53
Awards Accolades
Celebrating the Accomplishments of Those Who have Received Major Honors Alfred Abuhamad, MD, Mason C. Andrews Chair in Obstetrics and Gynecology, Professor and Chair of Obstetrics and Gynecology, and Vice Dean for Clinical Affairs at EVMS, has been chosen to receive a key award from the American Institute for Ultrasound in Medicine (AIUM). Dr. Abuhamad received the Joseph H. Holmes Clinical Pioneer Award in recognition of his career achievements in education, patient care and research. Dr. Abuhamad is an internationally known expert in ultrasound. During his term as President of the AIUM, he oversaw a year-long initiative to encourage the widespread use of ultrasound. Paul Harrell, PhD, EVMS Assistant Professor of Pediatrics, is one of two researchers from around the world selected for the Journal of Substance Abuse Treatment (JSAT) Editorial Fellowship Program for 2016-17. JSAT is the leading scientific journal dedicated to addiction treatment services and implementation research. His experience in many aspects of addiction research, as well as his productive publication record, were the primary reasons for his selection. The other fellow selected is from Johns Hopkins University School of Medicine. David Johnson, MD, EVMS Professor of Internal Medicine and Chief of Gastroenterology and Hepatology has been honored by The American Gastroenterological Association (AGA), with the 2016 Distinguished Educator Award. The national honor was bestowed upon Dr. Johnson for his accomplishments over the last 25 years.
54 | www.hrphysician.com
Erin Lee, PA-C with Othroapaedic & Spine Center. was awarded the title of Woman of the Year for The Leukemia & Lymphoma Society on Saturday, May 21 at a gala held in Richmond. Due to her tireless efforts and those of many others, including OSC physicians and employees, her team raised over $104,000! Holly S. Puritz, MD, FACOG with The Group for Women in Norfolk, has been appointed to the Virginia Board of Health by Governor Terry McAuliffe. The appointees will join McAuliffeâ&#x20AC;&#x2122;s Administration focused on finding common ground with members of both parties on issues that will build a new Virginia economy and create more jobs across the Commonwealth.
Dr. Steven Scoper and Dr. Elizabeth Yeu, with Virginia Eye Consultants were both named among the Ocular Surgery News Premier Refractive Surgeons of 2016. Aaron Vinik, MD, PhD, the Murray Waitzer Endowed Chair in Diabetes Research and Professor of Internal Medicine at EVMS, received the Distinction in Endocrinology Award from the American Association of Clinical Endocrinologists. The award, presented in May, is one of the highest honors given by the organization for outstanding achievement.
MEET OUR TEAM
Whatever treatment is needed – whether surgical or non-surgical – SMOC is a comprehensive, caring “one-stop shop” for orthopaedic issues from head to toe. Orthopaedic Care | Spine Care | Physical Therapy | Pain Medicine
CALL US TODAY TO SCHEDULE AN APPOINTMENT
757-547-5145
Chesapeake | Suffolk | BelleHarbour
smoc-pt.com
S AY “ Y ES” TO
LIFE WITHOUT LIMITS
“I am happy to report I am still saying “YES” to more volunteering days at the Fire Department and living my life fully again.”
READ DR. JEAN PRAT T’S STORY AT SMOC-PT.COM
Jason Andre, MD
Marc Camacho, MD
Chad McKenzie, DO
HAMPTON ROADS VEIN & VASCULAR EXPERTS
At Bon Secours Vein and Vascular Specialists, our board-certified experts are dedicated to bringing state-of-the-art vein and vascular care to our community. Our team of specialists at our Chesapeake, Newport News and Portsmouth locations provides comprehensive services and minimally invasive treatments for a full range of vascular diseases, including aneurysms, peripheral arterial disease and deep vein thrombosis.
To learn more or to refer a patient, call or visit commonwealthveincare.com
VE IN AND VASC UL A R SP EC I A L I STS
757-397- 23 8 3