Hampton Roads Physician Summer 2017 by Hampton Roads Physician Magazine

Summer 2017

Top L to R: Jeffrey R. Carlson, MD, Antonio Quidgley- Nevares, MD, H. Sheldon St. Clair, MD Bottom L to R: J. Abbott Byrd, III, MD, Dean B. Kostov, MD, Mark B. Kerner, MD

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Quality patient care for our community. Meet some of the members of our Quality Team. They’re working to optimize the healthcare experience for our patients and referring physicians by: • • • •

Focusing on “best” Quality data Improving CAHPS survey data Improving transitions of care Coordinated care management for CHF, COPD, Diabetes and Heart Failure patients

• • •

Increasing electronic messaging with patients and electronic referrals to and from referring physicians Expanding patient access through timely and efficient communication and office visit availability Medicare Wellness Visits

Teams of physicians, residents, nurses and health professionals are working together to encourage preventive care, coordinate transitions of care and maintain overall quality of life. EVMS Medical Group’s mission of improving the healthcare of the patients that we serve means better health for Hampton Roads. Standing Left to Right: Richard Bikowski, MD Chief Quality Officer, James Lind, CEO, Lambros Viennas, MD, James Dixon, MD, Cynthia Ferguson, PA. Sitting Left to Right: Allison Gray, RN Nursing Clinical Quality Coordinator, Danya Lewis, MD

For more information, contact Dr. Richard Bikowski, EVMS Medical Group Chief Quality Officer at 757-451-6200.

Learn more at EVMSMedicalGroup.com.

contents Summer2017 VOLUME V, ISSUE III

39 Advance Directives – A Safe Haven when Making Medical Decisions 8

40 Maintaining Vision for Geriatric Patients 10

41 News from the AMA 42 How to Ensure that Your Real Estate Closing Happens on Time DEPARTMENTS 4 Publisher’s Letter 14 Advanced Practice Providers: Donna Talbott, NP

FEATURES 6 Oh, My Aching Back!

8 J. Abbott Byrd, III, MD, FAAOS 9 Jeffrey R. Carlson, MD 10 Mark B. Kerner, MD 11 Dean B. Kostov, MD 12 Antonio Quidgley-Nevares, MD 13 H. Sheldon St. Clair, MD

15 Sports Medicine & Orthopaedic Center 18 For Back Pain, Physical Therapy Plays Key Role in Prevention and Rehabilitation

16 Good Deeds: Angela Marie Galdini, MD 30 Medical Update: Geriatrics and Palliative Medicine 43 Physician Advisory Board 44 In the News 50 Welcome to the Community 54 Awards and Accolades 14

20 The Evolving Use and Benefits of Cementless Total Knee Replacements 22 Riverside Neurological & Spine Institute

“My doctors said my options were surgery or regular radiation; they didn’t mention proton therapy. I did my own research and decided proton therapy was right for me. I feel great. I didn’t miss a day of work and had no side effects afterward. I want to thank the Hampton University Proton Therapy Institute for the wonderful treatment I received.”

- Stuart Goodman

• Non-invasive • Precisesly targets tumor • Healthy tissue spared • Reduced side effects • Treatment times less than 2 minutes

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26 Advanced Therapeutics for Overactive Bladder

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Summer 2017 Hampton Roads Physician | 3

WELCOME TO THE SUMMER 2017 ISSUE Holly Barlow

Bobbie Fisher Editor

Publisher

s legendary American dancer and choreographer Martha Graham once said, “the spine is the tree of life.” It’s impossible to overstate the importance of the spine, and we are especially pleased in this issue to honor six local orthopaedic and neurosurgeons who treat individuals who experience illness or injury to this vital structure. Our medical feature is an update on geriatrics and palliative care, topics that are very much of concern not just to the aging population, but as the article reveals, to individuals of every age. These topics were suggested by our Physician Advisory Board. If you’re new to the area and therefore to this publication, a word about Hampton Roads Physician: it’s our belief that the medical care available to the people of Hampton Roads is on a par with that in larger metropolitan areas. Hampton Roads Physician was designed to showcase that care, and to recognize the achievements of the local medical community. The magazine is mailed to local physicians, area hospitals, and to nurse practitioners and physician assistants as well. Our cover stories concentrate on a specific branch of medicine – with a specific focus on the exceptional physicians providing care to Hampton Roads. Featured physicians are chosen through a nomination process involving fellow physicians and public relations directors from local hospitals and large practice systems. These nominations are reviewed by our Physician Advisory Board, which then determines which physicians will be profiled.

Physician H

A publication for

Summer 2017 Volume V, Issue III

Recognizing the achievements of the local medical community Publisher: Holly Barlow Editor: Bobbie Fisher Cover photos by Abejon Photography Physician Advisory Board (see page 45)

Published by Publishing, LLC Emeritus and Voting Board Alfred Abuhamad, MD O.T. Adcock, Jr., RPh, MD Jon M. Adleberg, MD

4 | www.hrphysician.com

Holly Barlow, Publisher: 757.237.1106 holly@hrphysician.com Bobbie Fisher, Editor: 757.773.7550 bobbie@hrphysician.com Fax: 757.222.1345 hrphysician.com

and about the local medical community

Magazine Layout and Design Desert Moon Graphics

The Board serves for a period of one year, or four issues (you can meet the 2017 Board on page 43), and we’re now actively recruiting for our 2018 Board. Service on the Board consists of offering topics for our cover stories and medical updates, as well as reviewing and voting on nominations. There are no meetings and all communication is done through email. At the end of their service year, members of our Physician Advisory Board are included in our emeritus Board, and if they wish, offered the opportunity to review and vote on subsequent nominations. If you’re a physician, and would like to serve on our Advisory Board, please let us know by contacting our publisher, Holly Barlow, at 757.237.1106. To all physicians, whether new to Hampton Roads or of longstanding in the community: we welcome your ideas, comments and thoughts!

John W. Aldridge, MD, FAAOS 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 Mark W. McFarland, D.O. Jennifer Miles-Thomas, MD, FPM-RS Jerry L. Nadler, MD, FAHA, MACP, FACE Paa-Kofi Obeng, DO Jennifer F. Pagador, MD Richard G. Rento II, MD Michael M Romash MD Michael Schwartz MD John M. Shutack, MD I. Phillip Snider, DO Deepak Talreja, MD, FACC, FSCAI Jyoti Upadhyay, MD, FAAP, FACS Christopher J. Walshe, MD, FACOG, FACS, FPMRS Elizabeth Yeu, MD

Contact Information 757-237-1106 holly@hrphysician.com Hampton Roads Physician is published by DocDirect Publishing, LLC, 1263 Manchester Ave., Norfolk, VA 23508 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

OH, MY ACHING BACK.... Treating Conditions of the Spine in the 21st Century

n February of 2013, news outlets across the world ran stories about a remarkable archeological find: the skeleton of one of the most famous hunchbacks in history – King Richard III of England. After radiocarbon dating and comparison of his mitochondrial DNA with two matrilineal descendants, British scientists declared themselves “convinced beyond reasonable doubt” that the skeleton found in central England in August 2012 was indeed that of the former king, who died on Bosworth Field in 1485. As a May 20, 2014 CNN report stated, “When Shakespeare described Richard III as a ‘bunchback’d toad,’ he didn’t have the benefit of actually seeing the king, who had died in the previous century.” The 21st century physicians who subsequently examined the skeleton made a more informed diagnosis: scoliosis. We don’t know whether Richard actually considered himself, as Shakespeare wrote, so “deform’d, unfinish’d, sent before my time into this breathing world scarce half made up, so lame and unfashionable that dogs bark at me as I halt by them…” What we do know is that had the King lived in the 21st century, he could have received careful and 6 | www.hrphysician.com

By Bobbie Fisher

highly advanced treatment that could have straightened his spine and relieved both the physical and emotional pain of his condition. And if he lived in today’s Hampton Roads, he would have access to orthopaedic and neurosurgical expertise comparable to that found in the world’s finest medical centers and university hospitals. Scoliosis is but one of the many illnesses and injuries that can beset the intricate and complex human spine. Back pain is ubiquitous – virtually no one is exempt. Whether cervical, thoracic, lumbar or sacral in nature, spine pain affects nearly everyone. As the National Institutes of Health states, 80 percent of all people will experience back pain at some point in their lives. So when Hampton Roads Physician announced the topic of this issue – treating conditions of the spine – we weren’t surprised by the number of nominations for physicians and surgeons who treat the symptoms and causes of back pain. It created a huge task for our Physician Advisory Board to review all of these nominations, and narrow it down to three to feature on our cover. In fact, there were so many spine physicians nominated, with such outstanding qualifications – and so many ties among the voting Board – that we wanted to expand that number; thus, six doctors appear on the cover of this issue, and are profiled within these pages. These physicians and surgeons, whether practicing orthopaedics or neurosurgery, don’t only treat spine patients. They also research; they invent, they teach, they write and publish their findings to share with current and future generations of doctors who will treat spine patients. Their expertise and dedication are yet further proof that patients in Hampton Roads need not travel to find world class medical care. 

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J. ABBOTT BYRD, III, MD, FAAOS Orthopaedic Spine Surgery Atlantic Orthopaedic Specialists

hen Dr. Abbott Byrd began practicing orthopaedic surgery in Hampton Roads in 1987, he was one of the few spine surgeons treating adult spinal deformity. Since the earliest days of his spinal surgery career in 1984, he has maintained a strong interest in research and innovation: that same year, with Dr. Randy Puno and Dr. Robert Winter, he developed the PWB spinal implant system to treat spinal deformity, a pedicle screw system that led to the “555” patent, describing the first variable angle pedicle screw in the world. Today, that device is on display at the Kansas University Spine and Orthopedic Historical Collections, and is credited as the first variable angled pedicle screw in the world. Dr. Byrd also invented one of the first, standalone, spinal cages used to treat discogenic lumbar and cervical pain. These inventions are still in use today. A graduate of Medical College of Virginia, Dr. Byrd studied general surgery at Emory University, and completed a four-year residency in orthopaedic surgery at Duke, followed by a fellowship in spinal surgery at Minneapolis’ Twin Cities Scoliosis Center. Dr. Byrd served as Chair of the Department of Orthopaedic Surgery at Sentara Norfolk hospitals in the 1990s, and for the last 16 years, has been the President of Atlantic Orthopaedic Specialists. During his tenure, the group has grown to include 23 physicians, supported by a staff of nearly 200 in six locations throughout South Hampton Roads. He has held leadership roles in the Scoliosis Research Society, the leading spinal deformity organization in the world. He has served as a member of the Society’s Board of Directors on two separate occasions and was recently elected Treasurer. With his wife, Dr. Allison D. Byrd, an internal medicine physician, Dr. Byrd endowed a chair in orthopaedic surgery at Medical College of Virginia, providing funding for orthopaedic research well into the future. “Research is the key to future advances to improve the care of orthopaedic patients,” Dr. Byrd says. “Research has been the focus of my professional giving.” His philanthropy also includes leadership gifts to the Research, Education & Outreach Fund of the Scoliosis Research Society and to the Shand Circle, which was established by the Orthopedic Research and Education Foundation to provide long-term funding for independent, peer-reviewed research and education initiatives. His contributions to treatment of these deformities are most evident in the operating room, and particularly on behalf of patients with sagittal plane deformity. As he explains, “The removal of bone (laminectomy) to decompress the nerves may weaken the spine and allow it to fall forward. Also, fusing the lumbar spine in a flattened position causes a loss of lumbar lordosis, which prevents the patient from standing erect, thus causing sagittal plane deformity. Other less frequent causes of sagittal plane deformity include fracture, infection or tumor. “The more severe cases often require surgery to realign the spine, which usually consists of removing a portion of the spine to loosen the spine, followed by the placement of screws and rods to correct the sagittal plane deformity and restore normal lumbar lordosis. After this, the spine is fused in the corrected position to hold it permanently in place.” For the most severe deformities, Dr. Byrd performs a pedicle subtraction osteotomy, a technically demanding procedure that requires a deft hand for the delicate spine work, and mechanical expertise to realign the spine. This surgery significantly reduces pain and restores function to suffering patients. In 2016, Dr. J. Abbott Byrd received the Virginia Orthopaedic Career Award from the Virginia Orthopaedic Society.  8 | www.hrphysician.com

JEFFREY R. CARLSON, MD Spine Surgery Orthopaedic and Spine Center

hen Dr. Jeffrey Carlson joined Orthopaedic and Spine Center in 1999, he was the first fellowship trained spine surgeon on the Virginia Peninsula, having completed a fellowship in Orthopaedic Trauma at Massachusetts General Hospital, and a combined Neurosurgical and Orthopaedic fellowship in Spine Surgery at Harvard’s Brigham and Women’s Hospital in Boston. Arriving in Hampton Roads, he learned that simple discectomies were lasting an hour and a half, and disc surgeries on the neck were taking as much as two and a half hours – and both being done as inpatient procedures. “The thinking used to be that we had to keep these patients in the hospital,” Dr. Carlson says. “But we don’t have to, and they don’t want to stay. There are risks associated with being in the hospital – bacteria, viruses and the like – and nobody really wants to be in the hospital. Patients would much rather be at home in their own environment.” One of his first orders of business was to establish a program to teach area nurses and hospitals about micro-discectomy outpatient spine surgery, which is performed using smaller incisions, causing minor injury to soft tissue and bone, and resulting in less patient pain and a much quicker recovery. These procedures are performed in a shorter amount of time, which lessens the patient’s time under anesthesia. Today, the majority of simple discectomy surgeries in Hampton Roads are performed as outpatient procedures, many of them in out-patient surgery centers. Virtually all of Dr. Carlson’s cervical spine fusion cases are done as outpatient procedures, and he is now innovating outpatient lumbar fusions. “We take the disc out as an outpatient, but what about those patients that need a fusion? The thought process has always been that if we put in screws and rods, that’s a much more painful surgery, so those patients really did have to stay in the hospital,” he says. “But we can use the same incision to get the screws and rods in that we use to get the disc out, so we’re not moving muscle and tendon and irritating the soft tissue any more than with the outpatient micro-disc procedure.” The procedure involves putting the hardware in at a different angle that grasps stronger bone. “By only touching what needs to be fixed, we can avoid having to do the painful wide dissections that have been done at the past,” he explains, “and they’re more stable.” “We’ve done several hundred of these operations as outpatient procedures,” Dr. Carlson says, “and patients are now starting to demand it. They’re asking why they should undergo a four-hour surgery requiring a two-night stay in the hospital, when they can have the same procedure done in 90 minutes, and go home the same day.” Dr. Carlson believes that for many surgeons, it’s as much a question of changing their mind set as it is in adopting new technologies that make these procedures actionable. “It’s a question of thinking outside of old training techniques,” he says. “It’s a question of using the best method to fix our patients’ problems as quickly and efficiently as possible, reconstructing the spine, and getting them back to doing what they want to do, in as short a period of time and with as little pain as possible.” Dr. Carlson finds as he teaches these techniques in the US and around the world that “Surgeons are adopting these techniques because they result in less injury, less pain for the patient and a shorter recovery time.”  Summer 2017 Hampton Roads Physician | 9

MARK B.

KERNER, MD Bon Secours The Spine Center of Hampton Roads

o most, it would seem a far distance from the Federal Reserve Bank of New York to a Bon Secours operating room in Hampton Roads, but for spine surgeon Mark Kerner, it was merely a matter of leaving his career as a Systems Analyst to enroll in medical school. “I didn’t like the goals of banking,” Dr. Kerner says. “I wanted to take care of people.” At Albert Einstein College of Medicine in New York, Dr. Kerner developed a love for the musculoskeletal system, and as an orthopaedic resident at the College’s Montefiore Medical Center, a passion for working with spine patients. During his fellowship with Dr. Arthur White at San Francisco Spine Institute, he developed a philosophy of practice that he has maintained throughout the 21 years he has practiced in Hampton Roads. “I came to orthopaedic surgery because it has relatively concrete results,” Dr. Kerner says, “and in residency, our spine patients had both a different type and a different level of complexity than other conditions. They tended 10 | www.hrphysician.com

to have more life-changing, career-changing issues that dealt with pain and deformity and function. They had problems that were riskier to operate on, and I found myself drawn to it.” He had very firm ideas about how spine care and treatment should be managed for each individual patient, and how a spine practice should be organized around that care. Moving to Hampton Roads, Dr. Kerner says he was fortunate to find a medical group that allowed him to put his philosophy into practice. Then known as Orthopaedic Surgery Centers in Portsmouth and Suffolk, the practice soon became part of the Bon Secours Health System. He remains a Bon Secours employee today, as Medical Director of the Spine Center of Hampton Roads, where his staff of physiatrists, physical therapists and others work with him in true partnership for the benefit of each patient. His philosophy focuses finding the right diagnosis. “Classically,” he says, “most spine injuries don’t require surgical intervention. Most humans will get back or neck pain at some point in their lives, and most often it gets better on its own, or through conservative treatment.” Unfortunately, Americans tend to demand surgery when they’re in pain. “You can’t turn on the television without someone saying how miraculous their back surgery was,” he says. “Patients are being marketed to, and we have to counter market with the reality of their particular injury, especially those patients who think they’re being undervalued if surgery isn’t the first line of treatment.” He understands: “When patients are in pain – the type of pain where their brains say they need surgery – they’re very vulnerable to an early decision for surgical resolution. But when we show them what the entire course of treatment can be, both surgical and nonsurgical options, and they understand we’re not judging their pain as unworthy of surgery, they’re more willing to be patient to allow us to try to get them better without cutting them.” But when surgery is indicated, Dr. Kerner’s patients know that he utilizes the latest proven, least invasive techniques to hasten their recovery and maximize their outcome. A significant portion of those patients have been referred to him after previous failed surgeries. “It’s often that their expectations weren’t properly managed,” he says. “In these cases, as in every case, our goal is to get to know each patient, to figure out what their expectations really are, and whether we can truly achieve them. It involves a lot of time, but it’s better for the patient in the long run.” 

“Few specialists have the luxury of such a diverse and exciting practice. I never have a boring day at work. It’s thrilling, it’s exciting. ”

DEAN B. KOSTOV, MD Riverside Neurosurgery Center Neurosurgeon, Neurointerventional Specialist

hen Dean Kostov was a student at University of Pittsburgh Medical School, his original intention was to become a cardiac surgeon. However, as he was doing extensive research, he discovered he had a passion for neurosurgery, and with the approval and encouragement of his mentors, he decided to pursue that field. He did, and upon graduation, Dr. Kostov remained at University of Pittsburgh for an internship in general surgery, a six-year residency in neurological surgery, and a fellowship in endovascular surgery. He was invited to stay on at the University of Pittsburgh, but declined the offer. “If you stay in academia, you tend to super-specialize,” he says. “And I had spent nearly a decade learning different leading-edge procedures from the tremendous mentors I’d had. I wanted to put the breadth and depth of knowledge and skill I had acquired into practice on patients who needed that level of care.” Thus, he came to Hampton Roads when Riverside Health System offered him the opportunity to do just that. Today, while his practice focuses on complex spine problems, he routinely does a variety of neurosurgical procedures: “radiosurgery, biopsies (including awake biopsies), craniotomy

for tumors, trigeminal neuralgias. In fact,” he says, “I trained where that particular operation was invented.” But he feels his unique specialty is knowing the right treatment for each individual patient. “I tell each patient, I don’t operate on their pictures – I operate on them. You have to tailor your operation to the symptoms the patient is having, not exclusively to what the pictures show. Too often, the pictures don’t tell the story – but the symptoms do.” He adds, “Our understanding of the nervous system, spine, bones around nerves, have changed – with the instrumentation now available, our techniques have grown and matured, so that when the right patient is selected and the right surgery is performed, that patient has the right outcome.” For the majority of the patients he does take to the operating room, he performs minimally invasive, instrumented operations with the goal of restoring their quality of life. With the support of a sophisticated system of computer assisted navigation for both cranial and spinal surgery, as well as ultrasound, MRI and CT-assisted image guidance, Dr. Kostov believes the care he’s able to provide is equivalent to the care his patients could get at larger, more metropolitan university centers. “We conduct weekly neurosciences conferences, tumor boards,” he says. “We treat patients with a multidisciplinary approach. And while that level of research is standard in a university hospital, it’s par for the course for Riverside. We meet with the radiologists, neurologists, pathologists, neurosurgeons. We present cases and discuss them and figure out what’s the best thing for each individual patient. It provides all of us steady learning opportunities.” Dr. Kostov recalls another thing one of his mentors told him about caring for patients. “In addition to being exquisitely trained and skilled, he told me a surgeon should be available, able and affable,” he says. “I’ve never forgotten that lesson.” Finally, he says, “Few specialists have the luxury of such a diverse and exciting practice. I never have a boring day at work. It’s thrilling, it’s exciting. And neurosurgery is the most humbling profession, because just when you’re patting yourself on the back, you get humbled real quick. It’s a reality check every single day.”  Summer 2017 Hampton Roads Physician | 11

ANTONIO QUIDGLEY-NEVARES, MD Eastern Virginia Medical School Lydia Meyer Endowed Chair and Associate Professor of Physical Medicine and Rehabilitation

n 2004, when then-Department Chair Dr. Jean Shelton recognized the need to establish a spine center at EVMS, it was Dr. Antonio Quidgley-Nevares whom she recruited to accomplish that task – although he is quick to point out that Dr. Jennifer Reed had already begun making connections and starting referral patterns. “The first building blocks were there,” Dr. Quidgley-Nevares says, “and that made things easier.” Thirteen years later, Dr. Quidgley-Nevares is directing a center that boasts seven physicians, one psychologist, a residency program and a pain management fellowship. He completed medical school at the University of Puerto Rico School of Medicine, and did his residency training in Physical Medicine and Rehabilitation at the University of Virginia. In 2003, he completed a fellowship in Pain Management from Medical College of Virginia/VCU. Dr. Quidgley-Nevares founded and serves as director of the Pain Fellowship Program at EVMS, and as Medical Director of the Pain Consult Service at Sentara Norfolk General Hospital, Medical Director of Lake Taylor Transitional Care Hospital and Medical Director for @ Heart Hospice Care. As a physician dealing with all aspects of pain management in addition to the spine, Dr. Quidgley-Nevares is keenly aware of the opioid crisis in the Hampton Roads, and co-developed the Opioid Agreement Protocol that has become widely adopted for use throughout EVMS. “The way we approach spine pain has changed,” he says. “Over the years, we’ve been trying to prescribe more things like physical therapy, staying away from opiates as much as possible. The role for opiates is now considered more for function, rather than pain relief. Most of what we’re doing now focuses on non-opiate alternatives.” Among those alternatives are epidural injections as well as spinal cord stimulators, implanted devices that block pain signals from the spinal or peripheral nerve injury, delivering an electrical current to the spinal cord. And with more than 200 patients being actively treated with intrathecal pain pumps, Dr. Quidgley-Nevares has considerable expertise in that means of controlling chronic spine pain in patients who have failed conservative treatment and would not benefit from additional surgery. He explains: “The surgeon implants a device about the size of a hockey puck in the abdomen, underneath the skin but above the muscle. The device has a catheter that goes underneath the skin and inside the spine in the intrathecal space. Medication is slowly dispersed around the spinal cord and the brain.” The surgery is image-guided, and performed under fluoroscopy, avoiding the respiratory centers. The benefits of the intrathecal pain pump, in addition to effective pain relief, include providing greater ability to function normally and reducing side effects associated with oral medications. “In the case of morphine, for every 300 mg a patient would need to take by mouth, the pump only needs to deliver one mg,” Dr. Quidgley-Nevares explains. “There’s still the risk because it’s still an opiate, but it’s much less of an opiate load to the patient.” Because compliance is vital to the success of any modality dealing with chronic pain, Dr. Quidgley-Nevares considers patient selection crucial. “Despite being safer, these treatments aren’t totally without risk,” he says. “Thus every pain patient undergoes a psychological evaluation before embarking on the therapy, to avoid the consequences of not following the prescribed regimen.” Dr. Quidgley-Nevares continues to research and publish articles on a wide variety of topics in Pain Evaluation and Management, and serves on several committees at EVMS, including Resident Education, Clinical Advisory/Quality Assurance, Pain Management and Rehabilitation Research, and the Dean’s Council of Chairs.  12 | www.hrphysician.com

H. SHELDON ST. CLAIR, MD Pediatric Orthopedic Surgeon Children’s Hospital of The King’s Daughters

aving practiced in Hampton Roads for more than thirty years, Dr. Sheldon St. Clair is no stranger to treating the children of former patients. These days, he notes with pride, he’s treating their grandchildren. Following a fellowship in pediatric orthopedics at Tufts-New England Medical Center Hospital, Dr. St. Clair came to Hampton Roads in 1984 and practiced with Vann-Atlantic Orthopedics Specialists until 1999, when he joined the staff of Children’s Hospital of The King’s Daughters. Throughout his career, Dr. St. Clair has seen extraordinary advances in the treatment of pediatric spine deformities like scoliosis, from the Harrington rod to Luque wires and combinations of those two modalities, to Cotrel-Doubusset instrumentation and later, pedicle screw fixation. He has not only seen these advances, he has made significant contributions to the evolution of the modalities and techniques used in the care of patients as young as neonates, and into their early 20s. He began working with the spinal implant industry in the 1990s, his first efforts being in the development of growth rod systems for children with early onset scoliosis, who weren’t responding to conservative management like casting or bracing. He later worked on the team that developed the Arsenal AIS system, which offers a unique solution to address complex deformities in both children and adults with scoliosis. The latest iteration of the Arsenal was launched in January of 2017, and is considered the best available on the market today. Dr. St. Clair has served in many leadership roles at CHKD, including chief of the department of orthopedics, surgical director of orthopedics, vice president of Children’s Health Network, vice president of surgical affairs, and president of the CHKD professional staff. He is a member of the clinical faculty of Eastern Virginia Medical School as assistant professor of orthopedics and serves as the program director of pediatric orthopedic residency training at CHKD. Dr. St. Clair helped develop CHKD’s spasticity management program, a multidisciplinary clinic designed to treat cerebral palsy patients. He also has served as the orthopedic surgery attending at the spina bifida clinic. Most recently as Orthopedic Director of the spine program, Dr. St. Clair has been instrumental in developing the spine program at CHKD to standardize care, develop protocols and use a team approach for both conservative and operative treatment of all pediatric spine deformity. The team consists of pediatric trained neurosurgeons, orthopedic surgeons, nurses, physical therapists, orthotists, office staff and the perioperative team. This comprehensive program has implemented the principles of quality, safety, value, and expertise to the program, which has resulted in decreased blood loss, shortened hospital length of stay, decrease in SSI and an increase in patient/family satisfaction. He’s particularly excited about a research project he’s currently doing in collaboration with the computer simulation/mechanical engineering departments at Old Dominion University. With a grant from Children’s Health Foundation, the team is developing computer simulation models that describe spine deformities like scoliosis. Studies on cadavers to identify surrounding ligaments will enable the team to accurately place those ligaments into the computer simulation model, which will in turn show how much force would be necessary to put on the spine to result in the needed correction. “It’s never been done,” Dr. St. Clair says. “In the past, we’ve had to estimate the level of force by our own experience and knowledge. There’s been no science behind it. This research project is trying to answer some of those questions.” 

Summer 2017 Hampton Roads Physician | 13

A D VA N C E D P R A C T I C E PROVIDERS

It is an honor to highlight local Nurse Practitioners and Physician Assistants as they are increasingly invaluable members of the healthcare industry. We congratulate Donna Talbott.

DONNA TALBOTT, NP

Bon Secours Oncology Survivorship Nurse Practitioner

s modern medicine has increasingly made it possible to treat cancer as a chronic disease, the need has arisen for medical professionals specially trained and skilled in caring for survivors. As Donna Talbott,

Oncology Survivorship Nurse Practitioner, notes: “There are more than 14 million cancer survivors in America right now, and that number grows every day.” She adds, “In the early 1960s, when Danny Thomas founded St. Jude’s, 95 percent of all children with leukemia

died. Today, 95 percent of children with leukemia live. That has turned around completely in just one generation.” Indeed, it is statistics like those that inspire survivorship nurse practitioners like Talbott every day. She’s been a nurse for 37 years, having earned her Bachelor’s of Science in Nursing from the University of Akron in 1980. In 2001, she received a Family Nurse Practitioner Master’s Degree from Franciscan University in Steubenville, Ohio. When she began working with oncology patients, she says, she wasn’t convinced she’d enjoy the work, but it was only a short period of time before she knew she was exactly where she belonged: “I felt like I had come home.” When her family moved from Ohio to Virginia, she took a job working in hospice care until a position in oncology became available. That opportunity came when she saw a Bon Secours ad for ‘Oncology Survivorship Nurse Practitioner.’ She applied and was hired, happy to be back with oncology patients. “It was a challenge,” she says, “because at the time, they didn’t really have a formal survivorship program in place. So we were tasked with developing it.” Using guidelines and requirements established by the Commission on Cancer, Talbott and her team set to work, and today, all Bon Secours cancer survivorship programs in Hampton Roads are fully accredited. Much of the work Talbott does on a daily basis involves developing individualized survivorship care plans for patients who have completed their cancer treat-

ment. These plans are comprehensive, and include a list of each physician who has treated the patient for any aspect of cancer care. “The second part of the plan is the patient’s cancer story,” Talbott says, “including when they were diagnosed, what kind of cancer they have, what their pathology report showed, what treatment they had and when.” The third part of the plan describes follow-up care – what and when. “This is an extremely critical element,” Talbott says, “because some studies show that some cancer survivors fail to follow up regularly. It can be for lack of transportation, not knowing who should be scheduling follow-ups, or simply lack of communication among members of the team. I help them understand how important it is.” The plan also helps patients understand side effects, and addresses emotional, physical and financial problems they may be having. Finally, the plans emphasize wellness, especially changes these patients can make to reduce the risk of cancer in the future. Donna Talbott is passionate about caring for cancer patients, but even more passionate about teaching patients how to reduce the risk of cancer: “When people tell me they’ve never had a colonoscopy or a mammogram or a PSA test, I get upset. Some of these diseases – like colon cancer – are almost 100 percent preventable. We have grants to educate people, like the 80% by 2018 colon cancer screening. I cannot say it often enough: get screened. And if your doctor doesn’t talk to you about it, bring it up yourself!” 

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. 14 | www.hrphysician.com

SPORTS MEDICINE & ORTHOPAEDIC CENTER …surgical and non-surgical solutions for complex conditions of the spine

t has long been a hallmark of Sports Medicine & Orthopaedic Center that the practice has continued to grow with the communities it serves – both in terms of expanding availability to patients and mastery of the latest technologies and treatment options for the most complex orthopaedic conditions. That is especially true in the case of SMOC’s two Spine Centers. In two locations throughout Southeast Hampton Roads, two spine surgeons, a non-surgical spine specialist and two interventional pain medicine specialists – all Board certified – provide state-ofthe-art care for patients suffering the acute and chronic pain associated with spine conditions of every etiology. Fellowship-trained spine surgeon David G. Goss, MD treats all aspects of spinal disorders and injuries, including degenerative and traumatic disorders of the cervical, thoracic, and lumbar spine, scoliosis, infection, and spinal deformity.

“We’re increasingly better able to field referrals from emergency departments, family doctors and even patients themselves, in a time frame that makes our patients happy.” and Eileen Scott, PA-C, all of whom have been certified by the National Commission on Certification of Physician Assistants. In addition, physical and occupational therapists are available to assist patients who need them. Working as a cohesive team, these SMOC professionals have the knowledge, training and experience to offer real solutions for their spine patients. Both Spine Center locations feature sophisticated surgical equipment and technology, including fluoroscopy units and digital radiography.

And they are constantly alert to advances in both surgical and nonFellowship-trained spine surgeon surgical treatment of spine patients, Bryan A. Fox, MD is an expert in and in some cases, at the forefront. minimally invasive spine surgery Dr. Goss recently participated techniques, having performed in an international cervical disc thousands of spinal surgeries and replacement trial. “The purpose of taught several types of highly the trial was to design and implant effective and innovative spine disc replacements in the cervical surgery procedures. spine in an effort to determine whether or not short term and long Non-surgical spine specialist term cervical disc replacement was Richard Guinand, DO offers as good as, if not better than, the gold diagnosis and treatment of standard treatment for cervical disc general orthopaedic injuries, acute herniation, which had been a cervical and chronic back pain, workman’s fusion,” Dr. Goss says. “The Spine compensation injuries, and (L-R, back row): Richard D. Guinand, DO; Michael Ingraham, MD Center At Chesapeake was one of the non-surgical management (L-R, front row): Bryan A. Fox, MD; David G. Goss, MD; Victor W. Tseng, DO US research centers. The trial went of spinal pathology. well; the patients were by and large happy with cervical disc replacement as a treatment option for cervical Victor W. Tseng, DO, Board certified in Physical Medicine, disc herniations, and as time has gone by, more and more insurers have Rehabilitation and Pain Management, treats patients with a holistic recognized that that is a good long term surgical treatment for cervical approach, utilizing injections, interventional procedures and therapies. disc herniations and cervical radiculopathy.” Michael J. Ingraham, MD, a Board certified Physical Medicine & Among the biggest points of pride for this team of spine specialists is Rehabilitation Specialist, uses his knowledge to diagnose the cause their ability to serve more patients, more quickly – and to offer the latest of his patient’s pain or functional limitations, and helps alleviate pain and medical and technological advances – in efficient, welcoming offices. restore vitality. As Dr. Goss says, “We’re increasingly better able to field referrals from emergency departments, family doctors and even patients themselves, in These highly trained physicians are supported by Timothy Winkler, PA-C, a time frame that makes our patients happy.” Deniz Goss, PA-C, Scott Clingan, PA-C, Michael Mitchell, PA-C, Spine Center of Chesapeake | 501 Discovery Drive • Spine Center of Suffolk | 150 Burnett’s Way Spine Center of North Suffolk | 3920A Bridge Rd • 757-547-5145 | smoc-pt.com Summer 2017 Hampton Roads Physician | 15

GOOD DEEDS

Throughout Hampton Roads, there are physicians who regularly volunteer their time, knowledge, training and experience to individuals and organizations in this community, in the nation and throughout the world. They do so quietly, without fanfare, and often without reward or recognition of any kind. Hampton Roads Physician is pleased to acknowledge these physicians by sharing their good deeds with our readers.

IN MEMORIAM:

Angela Marie Galdini, MD September 22, 1956 - May 19,2017

ne of the pleasures of publishing Hampton Roads Physician over the past four years is the opportunity it has given us to highlight physicians who regularly volunteer their time and talent to individuals and causes in their communities, in the Commonwealth, in the nation and the world – and who do so quietly, without fanfare and often without recognition or acknowledgement of any kind. This month, it is much less a pleasure and much more an honor to feature Dr. Angela Marie Galdini.

Angie Galdini died unexpectedly on May 19th of this year. She was a brilliant, skilled, and widely respected physician, with specialty certification in both family practice and geriatrics. She earned her A.B. from Franklin and Marshall College and her medical degree from Thomas Jefferson University. She trained as an intern in Cooperstown, New York, and as a resident at the Blackstone Family Practice Center with the Medical College of Virginia, Virginia Commonwealth University. Dr. Galdini practiced in an underserved community in Alabama before she was recruited by (now retired) family practitioner Dr. Bonnie Waldrop to join First Care PC in Portsmouth. “Angie was intuitive, kind and generous,” Dr. Waldrop remembers, “and an excellent doctor.” Dr. Galdini also served on the family practice medical staff of Bon Secours Maryview Hospital. Throughout the years, she became known not just for her medical skill, but for her unwavering devotion to the uninsured and underserved members of her community. Always without judgment and frequently without payment, Dr. Galdini cared for these patients out of a genuine concern for their health. It was part of her personal mission, which was informed by

a deep and abiding Christian faith. She was specific about her mission. Among the words she wrote in the Bible that was never far from her side, are these: Mission: to seek to stand hour by hour in the conscious presence of God, from whom my mission is derived… To do what I can, moment by moment, day by day, step by step, to make this world a better place… To know God, to love Him, and to serve… God calls us to the place where my deep gladness and the world’s deep hunger meet… When Angie Galdini could feed that hunger, she did. When she could heal wounds, both seen and unseen, she did. She did so unhesitatingly, both out of that sense of mission and out of the pure joy of helping make the world a better place. A friend since they were both in school, Dr. Kelly Stern, a family practice physician with Patient First, knew about the extra hours Dr. Galdini spent seeing the patients who came to her for care. “She couldn’t bear to turn anyone away,” Dr. Stern remembers. “She had a genuine servant’s heart, and was a true healer. She’s missed by so many – friends, colleagues, her church and family – but most of all, by her patients.” Dr. Galdini is survived by her brother, Reynold G. Galdini, her niece Peggy and husband Vincent Votta, and by her nephew, Reynold B. Galdini.

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. 16 | www.hrphysician.com

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FOR BACK PAIN, Physical Therapy Plays Key Role in Prevention and Rehabilitation By Brian Hoy, PT, CMP, FMS-C

he goal of any physical therapist is straightforward: to help patients gain or regain the highest degree of quality of life. Meeting this goal involves both prevention and rehabilitation. And while our human body is both fragile and resilient, one area that’s frequently a source of discomfort is the back. In addition to discomfort and frustration, back pain also brings high financial cost and is a significant cause of missed work. A University of North Carolina study found that “that more than 80 percent of Americans will experience an episode of low back pain at some time in their lives and that total costs of the condition are estimated at greater than $100 billion annually, with two-thirds of that due to decreased wages and productivity.” Further, according to the American Physical Therapy Association (APTA): • 61% of Americans experience low back pain. • In a survey, 69% of respondents indicated that low back pain affects their daily lives. Most affected: exercise, sleep, and work.

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• Three out of four women take over-the-counter or prescription medication to treat the symptoms. • 31% of men and 20% of women report that low back pain affects their ability to work.

So what role can physical therapy play in helping address this global epidemic? The first is cost: the APTA states, “Early physical therapy can be cost-effective treatment for low back pain,” adding that “a recent study suggests there’s no reason to delay physical therapy that might relieve pain.”

Another benefit of physical therapy is the avoidance of medication and opioids. A study published in JAMA Internal Medicine (“Worsening Trends in the Management and Treatment of Back Pain”) indicates that “physicians often over-treat back pain, with increases in use of imaging, narcotics, and referrals to other physicians. The overtreatment leads to unnecessary expenses,” according to the APTA. Of course, sometimes back and spine problems persist and a doctor may advise that surgery is required. Even these individuals, though, can benefit from physical therapy – before the surgery occurs. A study published in the journal Spine (Preoperative pain neuroscience education for lumbar radiculopathy), followed a group of individuals who were undergoing surgery of the lumbar spine. “Prior to surgery, half of the participants received typical pre-surgical care. The other half received specialized education from a physical therapist on the neuroscience of pain. The researchers followed up with the participants one year after surgery and found the group who received a single, educational session from a physical therapist viewed their surgical experience much more favorably, and utilized 45% less health care expenditure following surgery.” Of course, physical therapy cannot solve all back pain issues. However, given the number of people this problem afflicts – and given associated costs, missed work, and frustration – inquiring about the role PT can play in both prevention and rehabilitation can pay significant dividends.  Brian Hoy, PT, CMP, FMS-C serves as Vice President of Clinical Services and Director of the Clinical Excellence Team at Pivot Physical Therapy. www.PivotPhysicalTherapy.com

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C The Evolving Use and Benefits of Cementless Total Knee Replacements By Jon H. Swenson, MD, FAAOS, Hampton Roads Orthopaedics & Sports Medicine

20 | www.hrphysician.com

ementless total knee replacements have gained popularity in the past five years, thanks to improved technology that allows for even more precise fit and enduring adhesion. Using advanced 3D printing systems and lasers, we are able to shape titanium powder into rough, porous metal surfaces. The metal surface has a rough texture which helps it to “stick” to the bone when impacted. A patient’s natural bone then can grow into those microscopic, sponge-like holes on the prosthetic’s coating over time, creating a strong, long-term bond. As is the case with cemented joints, surgeons also carefully shape natural bone so the prosthetic fits snugly. In addition, four pegs and a central stem anchor the implant in place during bone growth into its complexly patterned surface, which generally occurs over about six weeks. The basic difference is this: cemented bonds, which affix with a fast-drying acrylic polymer, are strongest immediately after surgery, but they often break down and weaken after a decade or two. Non-cemented joints – also referred to as

Using advanced 3D printing systems and lasers, we are able to shape titanium powder into rough, porous metal surfaces. press-fit implants – are designed to gain strength over time and ultimately form a more permanent bond. While data is still emerging, research to date has shown success rates at least equal to – and possibly greater than – cemented prostheses. A 2012 study, for example, found 96 percent survivorship after 18 years, longer than the 10- to 15-year rate generally quoted to our knee replacement patients. That can be particularly beneficial for younger or more active patients. Cementless prostheses often reduce time in the operating room by 15 or 20 minutes, as surgeons don’t need to wait for bone cement to set. That can potentially trim costs and reduce uncommon complications such as blood loss and infection. The non-cemented approach also tends to involve less bone loss should a patient ever require revision surgery, as any cement debris in surrounding tissues must be removed to prevent irritation and inflammation. All that said, cemented joint replacements have been used successfully for many years, and they do remain the best choice for about 10 percent of my patients. Most of those have bones weakened by osteopenia, osteoporosis, vitamin D deficiency, rheumatoid arthritis or some other form of connective tissue disease. In these cases, which frequently involve more elderly patients, natural bone likely would not effectively affix to, or grow into, the artificial joint. Bone cement, on the other hand, can immediately anchor deficient bones to the prosthesis. In my experience, post-operative pain levels and recovery time are similar for patients who receive both types of replacement joints. Surgeons also are developing hybrid solutions that use both cementless and cemented components in different parts of the knee joint. I expect the use of cementless knee replacements to continue to expand as improved fixation methods. The same is true of hip, shoulder and possibly other types of total joint surgeries. Over time, we also will gain better insights into long-term results, along with more specific indications and contraindications, for these promising technologies. Dr. Swenson has practiced orthopaedic surgery on the Peninsula since 1991. He completed orthopaedic surgery training at the world-renowned Campbell Clinic in Memphis, Tenn., and specializes in sports medicine and minimally invasive joint replacement of the knee, hip and shoulder. www.hrosm.com.

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(L-R) Jackson B. Salvant, Jr, MD; William McAllister, IV, MD; Dean Kostov, MD; Javier Amadeo, MD and Brian Farrell, MD, PhD

A multidisciplinary program focusing on complex conditions of the brain and spine.

he relationship between the brain and spine is undeniably one of the most delicate and complex in the human body. The smallest misalignment in the spine or misfire in the brain – unless identified and treated by the most well trained and highly skilled neurosurgeon – can cause excruciating pain, debilitating loss of function and even death. The surgeons of Riverside’s Neurological and Spine Institute have the knowledge, training and skill to treat these potentially devastating conditions with exquisite precision. Their combined years of surgical experience and mastery of 21st century technologies prove once again that Riverside Health System is providing the highest level of health care to the people of the Virginia Peninsula and beyond. Despite their surgical expertise, these five neurosurgeons agree that surgery should always be the last resort. “Our job is to try to keep patients out of the operating room,” says Dr. Dean B. Kostov, “so that by the time the patient and I decide together to proceed with surgery, we know there’s nothing else that could have been done, and we know that the benefits will outweigh the risks.” 22 | www.hrphysician.com

No surgery is without risk, but when conservative treatment fails or is inappropriate, or when patients no longer respond to medical therapies, surgery can be the correct choice. With the aid of the latest three-dimensional image guided, computer assisted navigation , these surgeons are able to perform complex and delicate, minimally invasive procedures for the most complicated cases, with results equivalent to those found in major university medical centers.

Unprecedented precision when micro-measurements count. The use of a bi-plane digital x-ray in treating brain aneurysms is one example. Because in their earliest stages, aneurysms are asymptomatic, often the first sign of trouble is when they rupture. Between 30 and 50 percent of patients with a ruptured aneurysm die, or are left with significant disability; but when patients receive timely treatment, they can survive and even thrive. Timely treatment used to mean craniotomy. Today, utilizing the bi-plane digital xray for guidance, Riverside surgeons insert a flexible catheter into the femoral artery, and thread it up through the neck into the brain; they can then insert a smaller catheter into the aneurysm through which progressively smaller platinum coils can be introduced until the aneurysm is tightly packed, thus depriving the aneurysm of its blood supply. The patient,

headache and symptom free, goes home the next day. The extraordinary high-resolution visualization of the brain’s vascular network made possible by the imaging technology is assisting surgeons in managing stroke cases as well.

Stereotactic radiosurgery – still the gold standard for brain tumors and abnormalities. The concept of stereotactic radiosurgery, introduced in 1951 by Dr. Lars Leksell, has an impressive track record in treating brain tumors and other abnormalities. No other non-invasive treatment method in the field has greater clinical acceptance anywhere in the world. Riverside’s Neurological and Spine Institute employs two modalities that deliver stereotactic radiosurgery, both of which focus very high beams of radiation on a small part of the body.

Gamma Knife – from the 4C to the Perfexion™ In 2015, after successfully utilizing the 4C model for nearly a decade, Riverside’s joint venture with University of Virginia and Chesapeake Regional acquired the latest iteration of the Gamma Knife: the Perfexion, then one of only 300 in the world. The Gamma Knife delivers a single, finely focused, high dose of radiation to its target within the brain, causing little or no damage to surrounding tissue. The 4C allowed the surgeons to treat abnormalities measuring less than three centimeters, or one inch in diameter. The Perfexion system expands the treatable volume through an automated, multi-source collimator, and dramatically streamlines workflow. System benefits include faster set-up and treatment delivery to one or more tumors in a single session. The Perfexion’s unique collimator is a permanent device divided into moveable sectors, ensuring superior conformity, accuracy and dosimetry while reducing

Bi-plane technology – 3D imaging of the brain used to treat aneurysms

residual dose to unintended areas. Integrated and intuitive treatment planning software facilitates creation of even the most complex plans (e.g., a donut-shaped dose distribution) by configuring composite shots that avoid overexposure to critical structures. Perfexion offers 98 percent reliability and unrivalled accuracy, guaranteed to 0.50mm. “When the Gamma knife was invented, it was really meant to treat the center of the head, deep in the brain,” says Dr. William H. McAllister. “As it’s evolved, it’s become more of a primary modality for dealing with metastatic brain tumors. The problem with the design of the original unit was a lot of metastatic brain tumors occur right out on the periphery of the head, so if you had a tumor on the left and another on the right, with the old unit you could have a hard time getting to both of them: moving the head, you would actually bump into the actual machine and there would be an actual direct physical limitation as to how far you could move the patient to one side or the other in order to treat these tumors in multiple locations. The Perfexion was designed with that in mind.” With years of experience behind them, Riverside surgeons are always finding ways to fine tune these procedures, making them more patient friendly. They have recently developed a new technique that allows them to preplan the treatment, using the patient’s diagnostic MRI. “We’re now able to do all the planning before the patient even comes to the Gamma Knife unit,” Dr. McAllister says. “where we used to have to put the head frame on the patient and sit at the computer for a half hour to plan, that’s no longer the case. The time the patient has to wait to begin the procedure is reduced, which in turn reduces anxiety.”

Gamma Knife Perfexion – treatment for tumors in the brain

Summer 2017 Hampton Roads Physician | 23

Synergy S

Further, with the Perfexion, the risks associated with open surgery are eliminated; because no incisions are required, the procedure can be performed using only local anesthesia. Treatment can be planned and programmed within a matter of an hour or two, requiring fewer MRI sequences. Treatment time is significantly less than conventional radiation and other delivery systems – often just one or two sessions – and because it’s most often done on an out-patient basis, most patients return to normal activity within 24-hours.

From Synergy-S to Varian – improved radiotherapy delivery. For cancers of the spine (as well as neck, chest, lung, prostate, pancreas and liver) and for tumors in the brain not accessible to the Gamma Knife, Riverside neurosurgeons have had remarkable success with the Synergy-S delivery system, which combined a linear accelerator with an on-board CT scanner to visualize internal structures, including boney and soft tissues, in three dimensions prior to treatment. However, advances in administering radiotherapy to these areas have enabled improvements in technologies, and Riverside has kept up, always seeking a safer, faster, more efficient delivery. The Neurological and Spine Institute is in the process of upgrading the Synergy-S to an entirely new and different system: as this is being written, the vault is being built to house the Varian EdgeTM system. The new Edge system has a real-time system architecture that enables a high level of synchronization between treatment planning, imaging, patient positioning, motion management, beam shaping, and dose delivery. The Edge will allow for tighter radiation dose gradients, resulting in better targeting and dose conformity of tumors with less radiation dose to normal tissues. Patient imaging and tumor tracking are also improved. The new upgraded Varian Edge system will continue to improve the success the neurosurgeons have seen over the past decade for intracranial and spine tumors.

Safer and more effective modalities to treat an aching back. Among the reasons back surgery has such a negative reputation are the traditional methods of performing it. As open procedures, such operations required a long incision in the back that would allow the surgeon to cut down to the fascia and then peel away 24 | www.hrphysician.com

the muscles of the spine on both sides to expose the area needing surgical intervention. The unfortunate sequelae of open surgery were muscular damage and reduced circulation. Patient recovery was lengthy and exhausting. “The challenge with any spine surgery is you’re trying to achieve two seemingly contradictory goals,” says Dr. Brian T. Farrell, the newest member of Riverside’s Neurological team. “You’re trying to decompress, and get the tissue out of the way of nerves that are pinched or disc material. And you have to do that in a way that preserves stability – so we’re always working on techniques that try to accomplish both.” He adds, “As a matter of our standard training, neurosurgeons spend a minimum of seven years learning and performing spine surgeries – including surgeries of the lumbar, cervical and thoracic spine.” No matter how complicated the procedure nor how well trained the surgeon, precision is absolutely critical to a safe and effective result when operating on the spine. In today’s minimally invasive spine surgery, Riverside neurosurgeons localize the target area with intraoperative x-rays, allowing them to insert a dilator, a small tube that gently nudges the muscle fibers out of their way. Riverside Neurological and Spine Institute remains the only facility on the Peninsula with the capability to use both fluoroscopic and CT-based images intraoperatively. This capability, known as StealthStation, is a computer program that allows surgeons to build and visualize a 3-D model based on images obtained either from intraoperative x-rays obtained from a C-arm, or when indicated by the complexity of the pathology being treated, by intraoperative CT scans obtained from the O-arm. Because these 3-D images are more accurate than the traditional two-dimensional x-ray, the result is a quicker and more accurate operation. “The O-arm and StealthStation work together; they’re intimately linked,” says Dr. Javier Amadeo. “They allow us to navigate instruments, very precisely, particularly for placing screws and rods in the spine.”

Minimally invasive spinal fusions. For example, Dr. Amadeo explains, this technology allows him to perform procedures like the midline interbody lumbar fusion – Midlif, for short – with greater ease and precision: “When we do these fusions, we use something called pedicle screws that very securely anchor one vertebra to another vertebra through an intervening rod,” he says. “These screws have to be put in very precisely through the pedicle, a relatively narrow tubular structure that links the front part of the spine to the posterior. When you can thread a robust screw through there and into the front part of the spine, it’s a good way of providing fixation.” He continues: “Doing this the traditional way, where the screw head is further out laterally and the tip of the screw points inward, we had to make a long incision and dissect the tissues out quite a bit laterally, about three and a half centimeters. In a Midlif, instead of using a lateral starting point, we start closer to the midline and angle the screw outward, thus we don’t have the same anatomical landmarks that we traditionally use that kind of give us a tactile feel for where the screw is going. The way we can do that by StealthStation guidance linked to the O-arm: that is, we get an O-arm set of images that are downloaded to the Stealth computer

and the Stealth gives us a virtual image of the spine and a virtual image of the screw, and the drill we use to create the pilot hole. We know exactly where that screw is going, so it’s a novel technique for doing a standard traditional procedure in a less invasive way.”

Deep brain stimulation and movement disorders. Many of the conditions that affect the nervous system are relatively free of observable symptoms, while others produce unmistakable signs of the disease within. Two such conditions are essential tremor and Parkinson’s disease. And because the symptoms are so similar and so overtly recognizable, many people believe they’re the same condition. But despite their seemingly similar manifestations, they are in fact very different, notes Dr. Jackson B. Salvant, a neurosurgeon who works with these patients. No matter the etiology of the condition, patients with these conditions tend to suffer social anxiety, which especially in the case of essential tremor can exacerbate symptoms. While there is no cure for either condition, there are treatment options and techniques that can greatly improve the qualify of life of these patients. Riverside has the only facility on the Peninsula that offers a unique treatment option to patients with either condition, Dr. Salvant says: “Deep brain stimulation, a modality that has shown significant results in controlling tremors. Prior to administering the stimulation, we give the patient mild sedation, and then under local anesthesia, we fit the patient with a frame similar to the Leksell frame used in Gamma Knife procedures. Once the frame is secure, the patient is awake, alert and responding to commands – so I’m able to test and measure the effects of the stimulation.” Using MRI imaging and stereotactic techniques, the surgeon guides an electrical stimulation lead to a target deep within the brain in the area of the thalamus. The target areas for Essential Tremor and Parkinson’s are in relatively close proximity within the brain, but they are decidedly different in their functions and in the effects of treatment. Thus precision in reaching the appropriate target is critical. Once a stimulating lead is precisely placed to obtain the ideal results, it is later connected to an implanted pulse generator similar to a pacemaker. The device then transmits painless electrical pulses to interrupt signals from the thalamus that may cause the tremors.

interactions with a member of the medical community, could preclude some patients.”

Patient selection. Just as critical to outcomes is the art of patient selection. Not every Neurological procedure is indicated for every patient with symptoms. The Riverside neurosurgeons, working with their colleagues at Riverside Neurological & Spine Institute – neurologists, neurovascular experts and neuroradiologists - insist on reserving the specialized treatment options considered herein for only those patients who will benefit the most. Each case is thoughtfully reviewed, and each procedure performed under the strictest criteria, done in coordination with other specialists. Riverside Neurological and Spine Institute surgeons pride themselves on doing the right surgery at the right time for the right patient, says Dr. Farrell, and by carefully managing expectations. “We maintain a high standard as far as knowing when, and for whom, to recommend surgery.” As he counsels his patients, Dr. Kostov tells them, “We don’t operate on pictures; we operate on patients.”

What lies ahead. “We’ve continued to evolve,” Dr. Kostov says. “We’ve pushed the technology and used it to make procedures safer. We’re utilizing robots more and more, and three-dimensional images acquired intraoperatively to tailor each procedure to each patient’s pathology.” As for the future, he says, “Neurosurgery has always been on the cutting edge, because our imaging has always been improving, and we’re pushing it to be even better. We’re able to see tumors and nerve fibers better and better. What’s exciting about neurosurgery is that there’s always something new on the horizon that allows us to preserve neurological function while treating our patients for back and spine problems.”  Riverside Hampton Roads Neurosurgical & Spine Specialists 12200 Warwick Blvd., Ste 410, Newport News (757)534-5200 120 Kings Way, Suite 3500, Williamsburg (757)220-6823

Awake brain tumor surgery with brain mapping. Dr. Salvant also offers a unique surgical intervention for patients who have difficult brain tumors in locations where, if those patients were under general anesthesia, there is a higher potential for new neurological problems. “By doing the surgery with the patient awake and mapping the surface of the brain during surgery,” he says, “we can choose the safest avenue to perform the procedure, while getting real time monitoring of the patient’s condition. It allows us to avoid new neurological problems ensuing from the surgery.” The awake procedure is highly effective, Dr. Salvant continues, but cautions: “We have to be very careful about who we offer that option to, because there are patients who are confused or disoriented, or who might have some underlying medical condition, like severe anxiety, for whom the procedure would not be appropriate. Even a significant fear of needles, or a history of poor

Bi-plane being used on a patient to treat aneurysms

Summer 2017 Hampton Roads Physician | 25

ADVANCED THERAPEUTICS FOR OVERACTIVE BLADDER …third line therapy for men and women of all ages By Jennifer Miles-Thomas, MD and Jessica DeLong, MD Jennifer Miles-Thomas, MD

he American Urological Association estimates that about 33 million Americans suffer from overactive bladder (OAB) – 30 percent of all men and 40 percent of women. It’s one of the vexing conditions associated with aging, but OAB is prevalent in the general population as well. A significant amount of OAB is never diagnosed or treated because many patients are embarrassed to reveal their symptoms to their family physician. Symptoms of an overactive bladder can be caused by any number of conditions, including neurological disorders, diabetes, urinary tract infections, certain foods or drinks, or tumors. In men, OAB can be caused by an enlarged prostate. No matter the etiology of the condition, OAB can have a tremendous negative impact on quality of life. In the past, large surgeries like augmentation cystoplasty were

Jessica DeLong, MD

performed to increase the capacity of the bladder when patients failed conventional treatments such as anticholinergic medications. Today, however, advances in third line therapies are providing relief for patients of all ages, and those surgeries are less frequently performed. • OnabotulinumtoxinA (Botox) – The same substance that is used by cosmetic and plastic surgeons to smooth facial lines and wrinkles is injected directly into the bladder muscle, where it calms the nerves, helping block the signals that trigger overactive bladder. Once relaxed, the bladder can hold more urine and is less overactive, eliminating the need for multiple trips to the bathroom. Each Botox treatment lasts on average six months. • Percutaneous (or posterior) tibial nerve stimulation (PTNS) – Understood by patients as similar to acupuncture, PTNS is the least invasive form of neurostimulation. The procedure targets the sacral plexus, which regulates bladder function, through an electrical pulse delivered via the tibial nerve. The low electrical current calms down the bladder and allows it to retain more urine. Initial PTNS generally consists of 12 quick, weekly treatments. Patients then require less frequent maintenance treatments to maintain efficacy. • InterStim – After an in-office test of a temporary system to determine efficacy, this treatment involves the implantation of a neurostimulator next to the sacral nerves just above the tail bone. The patient can adjust the stimulator as needed with a remote, applying personal programs, and can control the level of the stimulation by holding the programmer over the neurostimulator.

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.

Studies have shown that these therapies are greater than 80 percent effective, and are offering new hope to patients with the sequelae of overactive bladder. As the technology continues to improve, patients who were afraid to leave the proximity of their home bathrooms are increasingly able to enjoy a more normal lifestyle.  Jessica DeLong, MD and Jennifer MilesThomas, MD are co-directors of the Center for Health and Wellness at Urology of Virginia. www.urologyofva.net

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A surgery team just for kids. 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.

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MEDICAL U P D A T E

GERIATRICS AND PALLIATIVE MEDICINE Two Sides of the Same Coin

hen our Physician Advisory Board suggested topics for our 2017 publication year, an update on geriatrics/palliative medicine was among the most frequently requested. At first, it seemed there was enough difference between the two specialties to warrant a separate article for each – but as we got into the research, and began interviewing experts, the more it became apparent that as distinct as they are, they are also inextricably linked. As it turns out, one of the most striking connections between geriatrics and palliative medicine is the local and indeed national shortage of physicians trained in these disciplines. In 2011, the Baby Boomers began turning 65, and that trend isn’t anticipated to abate for some time. “By 2030, 30 | www.hrphysician.com

it’ll reach maximum impact,” says Marissa Galicia-Castillo, MD, Professor of Geriatrics and Section Head of Palliative Medicine at EVMS. “The number of geriatricians is nowhere near the number needed to take care of all those patients.” An article in the January 25, 2016 edition of The New York Times supports that assertion: “According to projections based on census data, by the year 2030, roughly 31 million Americans will be older than 75, the largest such population in American history. There are about 7,000 geriatricians in practice today in the United States. The American Geriatrics Society estimates that to meet the demand, medical schools would have to train at least 6,250 additional geriatricians between now and 2030, or about 450 more a year than the current rate.”

There’s not always an easy way to suggest to patients that they have become geriatric, or indeed, even an agreed upon age in which someone becomes a geriatric patient.

The same holds true in palliative medicine, says Laura Cunnington, MD, a hospice and palliative medicine specialist with Riverside Health System: “There are simply not enough of us to do all the palliative care that needs – and will need – to be done.” An August 20, 2015 article in The New England Journal of Medicine, sets out the numbers: “… the number of palliative care specialists falls far short of what is necessary to serve the Marissa Galicia-Castillo, MD Laura Cunnington, MD population in need. A 2010 demand.” At Eastern Virginia Medical School, Dr. Castillo says, study estimated that 6000 to 18,000 “We’re teaching geriatric concepts to everyone. We’re still trying additional physicians are needed to meet to grow geriatricians, but the big focus now is to train other the current demand in the inpatient physicians to care for older patients. There is now a required setting alone.” geriatrics rotation students go through in their third year, and Unfortunately, these statistics are there are geriatrics electives in the fourth year.” In addition, unlikely to improve. It’s understandable: both geriatrics and internal medicine residents do a month with Dr. Castillo and palliative medicine are among the lowest-paying specialties her colleagues, and EVMS welcomes residents from the Naval in medicine. And since geriatric patients are covered for Medical Center at Portsmouth to participate as well. the most part by Medicare, that program’s low (and slow) For students at EVMS, Dr. Castillo says, there are six sessions reimbursement rates make sustaining a practice difficult. offered throughout the third year, one two-hour session every Thus, many of the practitioners in these fields consider eight weeks, on a variety of topics. Her next session will the rewards of long-term, rich relationships with patients an concentrate on how physicians deal with patient loss. “It’s not incentive. And in fact, many physicians come to geriatrics and/ in the textbooks,” she says, “but it’s something these students or palliative care medicine after practicing in other areas for are going to have to deal with.” many years and experiencing these long term relationships, explains Steven Griswold, MD, a geriatrician and palliative “Who You Calling Old?” medicine physician with Bon Secours. “We’re trained in There’s not always an easy way to suggest to patients that medical school basically to think that all problems are fixable they have become geriatric, or indeed, even an agreed upon with the right medications and treatment,” he says, “but the age in which someone becomes a geriatric patient. “Everyone longer we’re in practice, the more we learn that that’s not the would probably say 65,” says Daniel Dickinson, MD, Medical case, so that’s one of the reasons people with more experience Director of Clinical Integration with Sentara Medical Group, tend to gravitate to these fields.” “but there are plenty of 65-year olds who are healthy, and there And, he adds, “It may not be that there’s so much a lack of are some younger than 65 who have functional or cognitive interest as a lack of training spots to train people to meet the Summer 2017 Hampton Roads Physician | 31

Daniel Dickinson, MD

Nakeisha R. Rodgers, MD

challenges. So age is less a criterion than behavioral or functional capability.” Nakeisha R. Rodgers, MD, is an internal medicine physician with JenCare Senior Medical Center in Norfolk. She sees her 400+ patients on a regular basis, far more often than the twoor-three times a year typical of many practices. “Caring for geriatric patients isn’t a one-size-fits-all situation,” Dr. Rodgers says. “You can’t approach all seniors with the same mindset.

I have 80-year old patients who can run circles around some of my 65-year olds.” There are key elements to aging, however, to which Dr. Rodgers is keenly attuned. “Dementia, falls, incontinence, these are more common in geriatric patients,” she says. While dementia gets a lot of attention, she feels one of the biggest problems of all for this age group is polypharmacy: “Some of these patients are taking so many medications, it’s like their own little pharmacy in their medicine cabinets. The prescriptions may be years old, or may have been borrowed from a friend – often they don’t know why they’re taking the pills.” Dr. Castillo agrees: “Some of these patients are taking as many as 40 different prescriptions. Their entire day is nothing but taking medicine.” An example of a seemingly innocuous medication – “safe, because it’s over the counter” – is Benadryl. “Most people don’t realize it can cause delirium, confusion, urinary retention and other side effects.” The highest incidence of polypharmacy is found in nursing homes, according to the National Institutes of Health, which also found that “the burden of taking multiple medications has been associated with greater health care costs and an increased risk of adverse drug events, drug-interactions, medication

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sure she’s comprehending, or will remember it well enough to tell it back to you, let alone a family member,” she says. “So I’ll often call the caregiver and relay the information at the same time.” When the patient has no such support system, Dr. Rodgers relies on the social worker JenCare retains on staff, or to Social Services. “There are many resources available to these patients, and to the physicians who care for them, but they aren’t always well known,” she says. “Social Services is one of these vital resources.” Dr. Dickinson agrees wholeheartedly. “One of my wishes is that over time, we have stronger systems in place to communicate and collaborate across our medical neighborhoods Steven Griswold, MD David Murray, Executive Director of the coalition for geriatric patients, so we not only have PCPs and geriatricians co-managing our patients’ needs, but also non-adherence, reduced functional capacity and multiple connecting them with other services and professionals— geriatric syndromes.” medical and non-medical—within the community,” he Yet one of the most difficult conversations a physician can says, adding, “Our Clinically Integrated Network, Sentara have with geriatric patients is trying to convince them to Quality Care Network, is one such vehicle for that type of relinquish these unnecessary and sometimes harmful drugs. collaboration, as it connects independent/private practice In these instances, and many others in dealing with aging and employed physicians and a hospital or health system to patients, Dr. Rodgers tries to enlist the help of a caregiver. improve the quality and delivery of health care services for “When you’re talking to an 80-year old patient, giving her a patients.” list of things to do and when to do them, you can’t always be

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Talking to patients about palliative care.

was offered to inpatients in the main hospital. Today, that care is available at Riverside hospital locations, as well as its nursing homes and complex care centers throughout the middle and upper peninsula. Still, these doctors all agree, primary care physicians and specialists alike aren’t aware of what palliative medicine can bring to patient care. “In the hospital, doctors who’ve seen the value of what we do, like to send patients home with home-based palliative care,” says Dr. Cunnington, “but out in the community, it’s been slower to catch on, mostly because these other doctors don’t have that level of experience with palliative care.”

One of the biggest misconceptions about palliative care is that it’s the same as hospice, Dr. Griswold says, and it’s important to assure patients that this isn’t the case. “Palliative care is broader, in that we can apply the same principles of improving symptoms, maximizing comfort and quality of life to patients at any stage of a serious illness.” Some physicians and other health care providers, and most patients, still don’t fully understand all the elements of palliative medicine, Dr. Cunnington believes. “We’re still the newest medical specialty,” she says, with Board certification only since 2008. “But there are significant differences between palliative care, comfort care and hospice.” Hospice, Dr. Cunnington says, is fairly well understood by both physicians and laypeople: system-based care for patients within the last six months of their lives. It’s quality-of-life, not curative, treatment. She explains: “Comfort care is like hospice, but patients don’t have to be on hospice to receive comfort care. We can provide comfort care to patients who decide they don’t want any more active Are you looking for a satisfying career and a life outside of work? treatment. Palliative care is broader – it can be provided at any point in the disease Enjoy both to the fullest at Patient First. Opportunities are available process. From the time of the diagnosis of in Virginia, Maryland, Pennsylvania, and New Jersey. the illness, the patient can have palliative care, even if that patient is going to get Open 8 am to 10 pm, 365 days a year, Patient better. And when the illness is over, and the First is the leading urgent care and primary care majority of the patient’s symptoms have provider in the mid-Atlantic with 70 locations and abated, there are residual symptoms that growing throughout Virginia, Maryland, Pennsylvania, can be helped with palliative care.” Palliative care can be rendered in the and New Jersey. Patient First was founded by hospital, in a nursing facility, at home or a physician and we understand the flexibility in an outpatient center like the Outpatient and freedom you want in both your career and Palliative Care Clinic, which opened in personal life. If you are ready for a career with To learn more about fantastic career December 2016 at Bon Secours Mary opportunities at Patient First, contact Immaculate Hospital in Newport News. Patient First, please contact us. Recruitment Coordinator Eleanor “Outpatient care is probably the area of Dowdy at (804) 822-4478 or palliative medicine that’s expanding most Each physician enjoys: eleanor.dowdy@patientfirst.com or rapidly,” Dr. Griswold says, “in attempt • Competitive Compensation visit prcareers.patientfirst.com. to serve those patients who aren’t at the • Flexible Schedules end of their lives, but who are living with chronic illness or being actively • Personalized Benefits Packages treated for a life-limiting disease, who • Generous Vacation & CME Allowances can benefit from better care coordination • Malpractice Insurance Coverage and symptom management while they’re receiving these other services in the • Team-Oriented Workplace outpatient setting.” • Career Advancement Opportunities When Dr. Cunnington joined the staff of Riverside Health System, palliative care

Summer 2017 Hampton Roads Physician | 35

And because there aren’t enough palliative medicine specialists to provide all the care that’s needed, “our focus is on education, to ensure that all of our students have a basic understanding,” Dr. Castillo says. “That’s why every EVMS student is exposed to both geriatrics and palliative care before they graduate.” “One of the goals for our specialty is to serve as a resource to train people to do primary palliative care in terms of better symptom management, better ability to conduct goals-for-care discussions,” Dr. Griswold says. And that, he emphasizes, is the most basic level of primary palliative care: a candid, thoughtful discussion with patients about their goals for care. The question is, when should that discussion begin? “No doctor has a crystal ball,” Dr. Rodgers says. “We don’t always know how long our patients will live. Thus, initiating that discussion before they are in crisis is far superior to waiting until there’s an admission to the emergency room or the hospital.” And, she says, there are resources to help physicians with the discussion, which many find challenging or uncomfortable.

As You Wish – a unique community resource for physicians, caregivers and patients alike. Students aren’t trained to have these discussions in medical school, so it’s no wonder they can seem difficult or even uncomfortable to physicians. In a typical 15-minute visit, when there are multiple medical issues to be dealt with (more with aging patients), introducing a sensitive topic like a patient’s wishes and goals for 36 | www.hrphysician.com

treatment when illness or infirmity strike down the road is impractical, even impossible. And until January of 2016, these conversations weren’t reimbursed by Medicare. In 2011, the four major hospital systems in Hampton Roads – Bon Secours, Chesapeake Regional Healthcare, Riverside Health System and Sentara – recognized that the majority of advance care discussions occurred when the patients were in crisis. In a remarkably visionary step, these four competing systems came together to look for a community partner to engage the public in a variety of platforms to introduce the importance, steps and benefits of advance care planning. After years of strategic planning, the Advance Care Planning Coalition of Eastern Virginia was established in 2014. The Coalition launched the As You Wish Advance Care Planning program as the unified community education brand later that year. The As You Wish initiative also serves as an extension for area physicians who have neither the time nor the training to initiate these discussions, and may not have office staff certified to conduct them. “As You Wish has the joint goal with practitioners of educating patients and easing the burden on the care providers,” says David Murray, Executive Director of the coalition. “Unfortunately, many area practitioners aren’t yet aware of the resources the coalition can offer.”

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The As You Wish initiative also serves as an extension for area physicians who have neither the time nor the training to initiate these discussions, and may not have office staff certified to conduct them. The program is not a substitute for physician-patient discussions, but rather a complement to the need to have these discussions – early and often. “Crisis isn’t the time to understand the planning steps leading to the fact that one day, we’re all going to die,” Murray says. “Modern medicine is about curing, healing and fixing. In 2011, it typically didn’t include discussions about that time when curing, healing and fixing weren’t possible.” Murray is candid about the challenge: “People don’t want to talk about end-of-life issues. Medicine today is about living longer and better. We’ve taken death out of the picture. People aren’t taking the time to consider their personal goals and wishes about the care they’ll receive. “That’s the irony,” he says. “As independent and control-oriented as we become as adults, we abdicate that independence at this time of life.” So he takes the message about advance care planning to people where they are: at community centers, in their homes, in a comfortable setting like a restaurant, if necessary, in a hospital – wherever they’re receptive to learning. He talks

38 | www.hrphysician.com

about the ways in which having an advance care directive can help them maintain their dignity, and ensure that they receive only the care they want. He explains how it can protect fragile relationships. And he notes that currently, fewer than three out of every 10 adults has an advance care directive. In the first year of the coalition, the goal of a three percent increase was achieved – a goal As You Wish hopes to replicate. In addition to having the directive, Murray stresses, it’s important that it’s in the patient’s chart where every physician, caregiver and hospital have access to it. But, he emphasizes, “Our focus is always on the importance of starting – and finishing – the conversation before the allimportant documentation becomes necessary.” If there’s a common thread that ties geriatrics and palliative medicine together, it’s the need for honest, candid conversation between doctor and patient, and between patient and caregivers. As Dr. Rodgers says, there are many resources available to anyone dealing with these issues.  For more information about the resources and services As You Wish provides, visit asyouwishvirginia.org.

Advance Directives A Safe Haven when Making Medical Decisions By William Charters and Jeffrey Kiser

William Charters

Jeffrey Kiser

dvance Medical Directives are the most prevalent guidance documents seen by hospitals and medical professionals nationwide. In 1990, Congress passed the Patient Self-Determination Act, requiring healthcare providers to inform patients of their right to make predetermined decisions regarding their medical care. Since then, advance directives have consistently increased in popularity and are accepted in all fifty states. Between 2000 and 2010, patients 60 years or older who died with an Advance Directive rose from 47 to 72 percent. Often, healthcare professionals are tasked with interpreting and implementing a course of action based on incomplete or misunderstood parameters contained in a “legal document”. Unfortunately, many of these directives were drafted by individuals without a thorough understanding of the medical, or legal, implications of the verbiage they have chosen – resulting in documents that are subject to misinterpretation or simply ineffective. Among the first hurdles healthcare professionals face are conflicting laws between states, since not each follows the same processes or mandates the same requirements for a directive. It is important, therefore, for healthcare providers to be cognizant of their own state’s laws regarding acceptance and enforcement of foreign directives. While the predominant standard is to honor a validly executed directive from another state, not all states follow this protocol. Equally as impactful is the difference as to the powers that may be granted to the Healthcare Proxy. Virginia, for example, does not recognize the

Death with Dignity Act (or any other physician-assisted end of life program), but nearby Washington DC does. Validly executed Advance Directives can not only provide evidence of a patient’s intent, but also lessen the degree of family/physician uncertainty when difficult decisions need to be made. Proactively making end of life decisions can relieve family members of guilt and prevent intrafamilial conflict. The provisions of a valid Advance Directive are virtually unassailable by family or physician and provide a safe haven for the decision-making process. While these rules and the rest of the Health Care Decisions Act offer aid and guidance, they are most effective when implemented proactively. The time to inquire about the status of a patient’s Advance Directive or to provide resources for such a discussion with friends and family is early in the process, even as soon as the initial intake. The time to educate yourself and your practice on the many facets of Advance Directives and establish a protocol for how you will determine if an Advance Directive exists for a given patient and how to insure it is valid and enforceable, is now. Next time: What if you, as a treating physician, believe that the treatment demanded by patient or decision maker is inappropriate?  William Charters, a member of Goodman Allen Donnelly, focuses his practice on providing advice, risk and litigation support to healthcare. Jeffrey Kiser, an Associate with GAD, provides detailed and targeted guidance to individuals and groups for their end of life and asset protection plans. goodmanallen.com Summer 2017 Hampton Roads Physician | 39

MAINTAINING VISION FOR GERIATRIC PATIENTS By Kapil G. Kapoor, MD

aintaining vision for geriatric patients is a component of their very basic health. As a retinal provider, I admit to ample bias in suggesting that visual health is truly integral; in spite of my confessed partiality, the data does in fact support this! Aging patients with severe vision loss have significantly increased risk of falls and fractures, increasing the likelihood of hospital or nursing home admissions and/or disability. Basic activities critical to daily health can become challenging with even moderate visual impairment, including identifying medications, bathing, dressing, or safely navigating familiar areas like the home or the grocery store. It’s easy to see why there is significant increase in depression associated with visual impairment with aging. Of the vision problems that beset older patients, agerelated macular degeneration (AMD) is by far the most prevalent, and the greatest threat to these patients. AMD affects more than 10 million people in the US, and as our population ages, that number is expected to increase significantly. Establishing a basic familiarity with this condition will enable all of us to protect our patients. AMD deteriorates the macula, which is responsible for central vision and focusing on fine detail. Visual decline corresponds to the stages of dry AMD that often progress slowly, but can convert unpredictably to the potentially more devastating wet AMD. In early dry AMD, characterized by small drusen (small yellow deposits made of lipids), patients may experience slight blurry vision centrally, or metamorphopsia (noticing small wavy lines when trying to focus on a straight line.) In intermediate dry AMD, these symptoms become more pronounced, with many patients experiencing fatigue when reading, often closing one eye due to a slight asymmetry of disease. In advanced AMD, patients develop atrophy, typically where drusen developed. Histologically, this corresponds to cell death, and functionally translates to gaps in vision. In the earliest stages of atrophy, patients experience loss of contrast, increased glare, and often describe skipping letters when reading. In the most advanced stage, atrophy becomes confluent 40 | www.hrphysician.com

throughout the central macula and patients can become legally blind. The typical progression through the stages of dry AMD is slow, occurring over several years to decades. However, approximately 10-15 percent of patients with dry AMD can convert to the wet form of AMD, where a new vessel forms right in the center of vision, potentially leading to severe vision loss over weeks or even overnight. Our best understanding supports that chronic oxidative stress in this aging macula creates a feedback demand for more oxygen, which engenders this harmful vessel to recruit more oxygen. Rather than actually recruiting any oxygen, this new vessel just bleeds and starts making a blind spot in the central visual field. Fortunately, we have developed treatments in the form of intravitrael injections of anti-VEGF for the

wet form of macular degeneration. These treatments play superb defense – with over 95 percent of patients avoiding further severe vision loss after timely treatment. These treatments also play better and better offense, with approximately half of patients enjoying a significant improvement in vision after converting to the wet form of AMD.  Kapil G. Kapoor, MD is a Board certified ophthalmologist specializing in vitreoretinal surgery. wagnerretina.com

News from the AMA

Responding to Physician Burnout, AMA Adopts Policy to Improve Physician and Medical Student Access to Mental Health Care

HICAGO - With increasing evidence that physicians and physicians-in-training are facing increased burnout, depression and suicide, the AMA adopted policy today aimed at improving physician and medical student access to mental health care. The new policy would help reduce stigma associated with mental health illness that could unfairly impact a physician’s ability to obtain a medical license and impede physicians and medical students from receiving care. “We are concerned that many physicians and physicians-in-training are dealing with burnout, depression and even suicidal thoughts, and we find it especially concerning that physicians have a higher rate of suicide than the general population. In fact, in March the AMA partnered with leading CEOs in the health care industry and declared that physician burnout is becoming a public health crisis that needs to be addressed,” said AMA Board Member and resident Omar Z. Maniya, M.D. “Today’s policy builds on the AMA’s current efforts to prevent physician burnout and improve wellness. We are committed to supporting physicians throughout their career journey to ensure they have more meaningful and rewarding professional experiences and provide the best possible care to their patients.” The policy calls on state medical boards to evaluate a physician’s mental and physical health similarly, ensuring that a previously diagnosed mental health illness is not automatically considered as a current impairment to practice. Additional policy calls for researching and identifying the risk factors for and rates of depression, burnout and suicide among medical students, including encouraging medical schools to confidentially gather and release this information from its students who authorize consent. Through the AMA’s Professional Satisfaction and Practice Sustainability initiative launched in 2013, the AMA is partnering with physicians, leaders, and policymakers to reduce the complexity and costs of practicing medicine so physicians can continue to put patients

first. As part of this work, the AMA’s Steps Forward program offers a series of practice transformation modules designed to improve the health and well-being of patients by improving the health and wellbeing of physicians and their practices. The AMA has also adopted numerous policies over the past several years to reduce physician burnout and create the

medical school of the future to ensure a healthier practice environment for physicians and close the gaps that exist in medical education to improve the health of the nation.  This press release was sent to us on 6/14/17 from the American Medical Association

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Summer 2017 Hampton Roads Physician | 41

How to Insure Your Real Estate Closing Happens on Time By J. Mansisidor

ith all the new regulations in today’s mortgage industry, closing on time has become more challenging than ever and more costly to the consumer. Consider some of the examples below and how they can affect you and your wallet. · Lost work or vacation time. Taking additional days off to attend a rescheduled closing can cause financial and professional headaches. · Increased moving expense. The moving truck may be all packed up and ready to unload - but if the closing is delayed, you may have to pay additional days of storage on that truck. · Storage expenses. If you’re moving over a holiday weekend, you may not be able to keep your household items on the same truck. You may have to rent a temporary storage unit and/or find another company to complete the move on the new schedule. · Increased temporary lodging expense. Imagine you’ve just sold your house and moved out, but your closing is delayed.

You may find yourself with an unexpected hotel bill. · Frustration. Rescheduling child care, furniture or appliance deliveries, contractor services (flooring, painting, etc.) and utility activation are but a few examples of the hassles that delayed closings cause. The above scenarios may seem extreme, but they happen all the time. So how do you avoid these situations? It starts with having a knowledgeable, experienced, ethical and diligent Loan Officer. When you begin shopping lenders and interviewing loan officers, ask how they will ensure that your loan closes on time. Lenders aren’t permitted to require supporting documentation from an applicant during the pre-qualification stage. However, providing your supporting documentation will allow the Loan Officer to reference that vital information on your Pre-Qual Letter. The following are standard requirements: · Most recent (two years) tax returns (personal and business, if applicable) · Most recent (two years) W2’s, 1099’s, K1s (if applicable) · Most recent two months paystubs (or employment contract, if applicable) · Most recent (two months) checking/savings/retirement/ investments statements (all pages) · Photo ID If you’re a Non-Permanent Resident Alien, be sure to ask if your qualification is still valid. And if you’re a first time home buyer, don’t forget to ask about any programs available to you. The more questions you ask or the Loan Officer brings up at the beginning of the process, the more likely you will close on time – and the more likely you’ll avoid any of those unpleasant scenarios!  J. Mansisidor is a Senior Loan Officer with Fulton Mortgage Company, a division of Fulton Bank, NA. www. fultonmortgagecompany.com

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B O A R D A D V I S O R Y P H Y S I C I A N

2017 ADVISORY BOARD Anthony T. Carter, MD, FAAOS

Steven Pearman, MD

Orthopaedic Surgeon Board certified orthopaedic surgeon with Hampton Roads Orthopaedics & Sports Medicine. Dr. Carter specializes in minimally invasive joint replacement surgery of the hip and knee.

Family Medicine As a Board certified family medicine physician, Dr. Pearman practices at Sentara Family Medicine Physicians in Virginia Beach and also serves as Vice President & Senior Medical Director of Primary Care & Ambulatory Services of Sentara Medical Group.

Jessica DeLong, MD

Robin Poe-Zeigler, MD, FACOG

Reconstructive Urology Dr. DeLong practices in Virginia Beach at the Devine-Jordan Center for Reconstructive Surgery and Pelvic Health, a Division of Urology of Virginia. She is Board certified in Urology and Fellowship trained in Adult and Pediatric Reconstructive Urology.

Reproductive Endocrinology and Infertility Practicing REI physician in Hampton Roads since 1993 and has owned her own practice since 1997. Currently serves as the Medical Director at the New Hope Center for Reproductive Medicine.

Susan B. Girois, MD, MPH, FACP

Merfake Semret, MD

Primary Care Board certified in Internal Medicine in practice in Hampton Roads for five years. Currently serves as Chief Medical Officer for JenCare Senior Medical Centers in Tidewater.

Nephrology Dr. Semret is a Board certified internist and nephrologist. Practices nephrology with Peninsula Kidney Associates in our Hampton, Newport News and Williamsburg offices. He also serves as the medical director at Davita Langley dialysis unit.

David Goss, MD

Barry Strasnick, MD

Orthopaedic Spine Surgery Dr. Goss practices at The Spine Center at Chesapeake, a Division of Sports Medicine and Orthopaedic Center. He is Board certified in Orthopaedic Surgery and Fellowship trained in Spinal Surgery.

Otolaryngology Board certified in Otolaryngology: Neurotology. Dr. Strasnick is Chair of EVMS Otolaryngology-Head & Neck Surgery, a physician leader in his specialty and past Medical Director of EVMS Medical Group

Robert R. Harding, MD

Raj N. Sureja, MD

Internal Medicine Board certified in Internal Medicine. He practices as a hospitalist at Riverside Doctorsâ&#x20AC;&#x2122; Hospital Williamsburg and serves as Chair of the Riverside Medical Group Board.

Pain Management Board certified and Fellowship-Trained Interventional Pain Management Physician, in practice since 2008. Senior Pain Management Partner at Orthopaedic & Spine Center in Newport News, VA.

Lauren James, MD

Richard Wertheimer, MD

Family Medicine Dr. James is the Lead Physician at Portsmouth Medical Associates of Bon Secours Maryview Medical Center. She is Board certified in Family Medicine.

Neurologist Dr. Wertheimer practices at Neurological Associates of Hampton Roads, Chesapeake Regional Medical Group. He is Board certified in neurology and electrodiagnosis, and fellowship trained in neuromuscular disease.

Summer 2017 Hampton Roads Physician | 43

IN THE NEWS Associates in Dermatology is now offering online visits for patients through a new partnership with DermatologistOnCall®, a national telemedicine product with secure desktop and mobile apps available 24 hours a day. Patients can consult with board-certified dermatologists, upload photos and receive a diagnosis, treatment plan, needed prescriptions or a referral for in-office care, typically within a day’s time.

Beach Eye Care now offers The Raindrop Near Vision Inlay, a treatment to reshape the central curvature of the eye for a long-term solution to presbyopia. The inlay, placed during a 10-minute procedure, is transparent and tiny – about the size of a pinhead – and mimics the properties of the natural cornea to improve age-related near vision loss.

Associates in Dermatology, Inc., and William L. Coker, Jr., MD, are proud to announce that this summer they are celebrating their 47th anniversary of serving the families of Hampton Roads!

Atlantic Orthopaedic Specialists (AOS) opened a third OrthoNow facility in Norfolk conveniently located near the Kempsville and Newtown Road areas. People can walk in with possible fractures, sprains and strains, and other sports- and work-related injuries, or sudden onset back and leg pain and receive specialty orthopaedic care. Bayview Physicians Group became one of the first healthcare providers in Virginia to embed NarxCare into its electronic health record system this past spring, in order to help curb prescription drug misuse and abuse. In January, Gov. Terry McAuliffe made the fight against opioid abuse a priority by announcing that Virginia had received a $3.1 million grant to help pay for NarxCare technology. The program links all doctors to their patients’ prescription history and assesses the risk of addiction.

Bon Secours Mary Immaculate Hospital celebrated 65 years of service to the community in May. Newport News’ first hospital, Elizabeth Buxton Hospital, was originally established in 1906 by Dr. James Buxton. The 17-bed hospital eventually grew to a 114-bed facility that the Bernardine Franciscan Sisters purchased on May 1, 1952, and renamed Mary Immaculate Hospital. The hospital opened in its current Denbigh location in 1980, became a member of Bon Secours Health System in 1996 and has undergone numerous expansions and renovations over the years. Its rich history of “firsts” in the region includes the integration of patient rooms (1952) and the addition of natural childbirth classes (1971), kidney dialysis services (1973) and a robotic surgical system for knee replacement operations (2012). Bon Secours DePaul Medical Center and Bon Secours Maryview Medical have received the American Heart Association/American Stroke Association’s Get With The Guidelines®-Stroke Gold Plus Achievement Award with Target: StrokeSM Honor Roll Elite Plus. The award recognizes a commitment to providing the most appropriate stroke treatment according to the latest nationallyrecognized, research-based guidelines.

Bon Secours Hampton Roads has received a one-year March of Dimes community grant from Anthem Blue Cross and Blue Shield Foundation to establish a Centering Pregnancy program, which is a team approach that actively engages expectant mothers in goal setting, skill-building and peer support. Its group prenatal care model helps participants to bond with others going through similar experiences and achieve healthy, full-term pregnancies. Groups will be offered monthly at Bon Secours DePaul Medical Center and Bon Secours Maryview Medical Center. 44 | www.hrphysician.com

Bon Secours Hampton Roads Health System is pleased to announce that the Bon Secours In Motion diabetes education program has been accredited by the American Association of Diabetes Educators (AADE). The diabetes self-management education program incorporates group and individual education in all areas of self-care, including nutrition and also reviewing medications, monitoring of blood glucose, the importance of being active and ways to reduce risks posed by the chronic disease. Bon Secours Mary Immaculate Hospital’s orthopedic services recently earned The Joint Commission’s Gold Seal of Approval for Certification for Total Hip and Total Knee Replacement. The hospital earned this prestigious designation by demonstrating compliance with national standards for health care quality and safety in disease-specific care, both through an onsite visit and an intensive survey process.

Bon Secours Vein and Vascular Specialists has merged its Chesapeake and Portsmouth offices into a new office on the campus of Bon Secours Health Center at Harbour View in Suffolk. The new, more efficient space allows for the office and vascular lab to be in the same location. Bon Secours Virginia Health System has hired its first veterans through the Military Medics and Corpsmen (MMAC) Program, which affords service members with specialized training opportunities for employment and pathways to licensure and long-term medical careers. To date, five veterans have been hired by the health system to work as clinical care technicians in the Richmond and Hampton Roads areas. The MMAC program, authorized by legislation passed unanimously in the Virginia General Assembly and signed by Governor Terry McAuliffe, focuses on a solution to health care staffing shortages while boosting veteran hiring. Chesapeake Regional Healthcare (CRH) recently earned a total of six 2017 Healthgrades® Quality Achievement Awards including five-star ratings for performance in Bariatric Surgery, Hip Fracture Treatment and Spinal Fusion Surgery and excellence awards in Bariatric Surgery, Patient Safety and Spine. These achievements are part of new findings and data released by Healthgrades and are featured in the Healthgrades 2017 Report to the Nation.

Chesapeake Regional Healthcare (CRH) has received the American College of Cardiology’s NCDR ACTION Registry Silver Performance Achievement Award for 2017. CRH is one of only 105 hospitals nationwide to receive the honor. The award recognizes CRH’s commitment and success in implementing a higher standard of care for heart attack patients and signifies that CRH has reached an aggressive goal of treating these patients to standard levels of care as outlined by the American College of Cardiology/American Heart Association clinical guidelines and recommendations. As the Principal Investigator, Dr. L.D. Britt, the Henry Ford Professor and Edward Brickhouse Chairman of the Department of Surgery at Eastern Virginia Medical School, was recently awarded a multimillion-dollar NIH (National Institutes of Health) research grant to develop specific strategies to address healthcare disparities in the various surgical specialties. The NIH R01 grants are the most competitive awards in all of research. Dr. Britt has assembled a talented research team, with the leading experts in the field. These investigators are from the nation’s top medical organizations and academic institutions, including the American College of Surgeons, Harvard Medical School, and UCLA.

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IN THE NEWS Chesapeake Regional Healthcare (CRH) now offers 3D Whole Breast Ultrasound with Hitachi’s SOFIA equipment. This system is designed to make patients with dense breasts comfortable while receiving additional images following a screening mammogram. The images delivered by the system allow radiologists to view a high quality larger field-of-view, thus shortening review times. EVMS Ghent and Portsmouth Family Medicine practices were recently re-certified by The National Committee for Quality Assurance (NCQA) as a Patient-Centered Medical Home. This three-year national recognition highlights both practices for their use of patient-centered processes and their focus on highly coordinated care and long-term, participative relationships.

Children’s Hospital of The King’s Daughters welcomed New York-based artist Ryan McGinness in June to celebrate the installation of a mural he designed for the CHKD Health Center at Landstown. McGinness, a Virginia Beach native, created the colorful work – entitled “Energy” – with the support of RxArt, a nonprofit whose mission is to use visual art to help children heal. CHKD uses art throughout the health system to provide important distractions during stressful experiences and create environments that help children feel safe and positive.

Wilford K. Gibson, MD, a surgeon at Atlantic Orthopaedic Specialists in Virginia Beach, was named chair of the American Association of Orthopaedic Surgeons (AAOS) Council on Advocacy. The Council plans, organizes, directs and evaluates the Association’s legislative, regulatory and health policy programs and initiatives. Dr. Gibson specializes in orthopaedic hip, knee and shoulder reconstruction and replacement and orthopaedic sports medicine.

(L-R) Michael K. Kerner, CEO, Bon Secours Hampton Roads; The Honorable William D. Sessoms, Jr., Mayor, City of Virginia Beach; James P. McNamara, Vice President, Bon Secours Virginia; Christine S. Webb, CBS; Warren D. Harris, Director, City of Virginia Beach Economic Development; Marne Naas, Administrative Director, Rehabilitation Services, Bon Secours Virginia; and Bert Crawford.

Bon Secours in Motion Physical Therapy, along with Bon Secours Sports Performance, celebrated the opening of their new building, Bon Secours Town Center, in Virginia Beach. Bon Secours Town Center is a two-story, 25,000-square-foot medical plaza that was recently redesigned from retail space to medical. Physical therapy operations began in late March and the relocation increased space for services by 25 percent with its approximately 12,500 square feet on the second floor of the building. 46 | www.hrphysician.com

Hampton Roads Orthopaedics & Sports Medicine (HROSM) has opened a new division, Hampton Roads Urgent Care, adjacent to its main office in Newport News. HROSM is partnering on the project with Dr. Michael Baddar, a local specialist in Workers’ Compensation and Occupational Medicine. With extended hours and a comprehensive X-ray facility, HRUC will be equipped to treat orthopaedic, sports and work-related injuries such as bone fractures or tissue tears. It also can handle all the general health concerns that send people to an urgent care and will treat patients ages two and older. Pivot Physical Therapy, a leading provider of physical therapy, sports medicine and aquatic therapy services, announced an expansion of its services and locations with the acquisition of Tidewater Physical Therapy, a local outpatient practice. The increase of more than 30 locations across Virginia – including five Aquatic Therapy Centers and three Performance Centers – adds to the resources of the largest independent provider in the region, with more than 50 locations in Virginia and nearly 250 locations throughout the East Coast. The deal closed in the fourth quarter of 2016.

Dr. Vahagn Nazaryan, Executive Director of HUPTI (left) and) Delegate David Yancey

Hampton University’s Proton Therapy Institute is celebrating the Virginia General Assembly’s recent passage of a bill that makes it illegal for insurance companies to hold proton therapy to a different standard than other forms of cancer treatment. The bill was sponsored by Del. David Yancey, R-Newport News, and passed after the legislature heard the call of patients who have struggled to get coverage. The institute currently treats prostate, breast, lung, head and neck, gastrointestinal, brain, spine and pediatric cancers. The New Hope Center for Reproductive Medicine now offers INVOcell as a new form of fertility treatment, becoming one of 29 certified centers in the country. INVOcell is a patented medical device that enables egg fertilization and early embryo development to take place in a woman’s body, rather than in a laboratory.

Farm Fresh has made a $75,000 grant on behalf of the SUPERVALU Foundation to Children’s Hospital of The King’s Daughters to help meet the region’s growing demand for pediatric behavioral health services. SUPERVALU, the parent company of Farm Fresh Food & Pharmacy, now has contributed a total of $175,000 through two grants for the initiative. The money will help provide advanced training in pediatric behavioral health for 35 CHKD Medical Group pediatricians, allowing them to better recognize common problems such as ADHD, depression, anxiety and eating disorders for quicker intervention.

Summer 2017 Hampton Roads Physician | 47

IN THE NEWS all primary site categories, as well as one of highest increases since 2005. Prostate and lung cancer incidents also rose sharply. Collectively, breast, lung and prostate cancers represented 65 percent of all cancers treated at Riverside facilities in 2015.

Lake Taylor Hospital celebrated the grand opening of its newly renovated and expanded Recreation Room with an Open House on June 15. The expanded facility includes an outside deck area, interior reading spaces, large multipurpose room, kitchen, hair salon for residents/ patients and offices for Rec staff. Riverside Health System is now offering the latest in brachytherapy and linear accelerator technologies. The new, highly precise radiation oncology offerings from Elekta, available in Riverside’s Cancer Care Center, make treatments quicker and more comfortable for patients while delivering excellent results. Brachytherapy is an advanced treatment in which a radioactive source is placed inside or near a tumor; Riverside has now added a new type of localized therapy for certain forms of skin cancer. The health system also continues to invest in other noninvasive radiotherapy options. Riverside Health System published its 2016 Cancer Care Annual Report in June, which highlighted key statistics, new advancements in local treatment capability and success stories from patients and providers. The report revealed a marked increase in the number of cancer diagnoses over the last 10 years in the southeastern Virginia service area. Cases of breast cancer had the highest total count across

Riverside Tappahannock Hospital recently honored area First Responders with a special photographic tribute for EMS Week. The images highlighted the men and women of law enforcement, fire and rescue groups and also captured the unique character and beauty of each of the counties the hospital serves: the Tappahannock area of Essex, King & Queen and King William; and the Northern Neck counties of Richmond, Westmoreland, Northumberland and Lancaster. Sentara Hospice Services welcomes Carol A. Maikisch, RN, BSN, MBA, as the Hospice Administrator for the Southside Hampton Roads area. Carol comes to Sentara from New Jersey where she was a Clinical Director as well as a Business Development and Clinical Initiatives Director with VNA Health Group.

Farm Fresh made a $166,683 donation to Children’s Hospital of The King’s Daughters to help local kids fighting cancer, the result of its 17th annual Round Up campaign. The June 2 presentation took place in the Children’s Cancer and Blood Disorders Center at CHKD, which was built with the help of funds raised and donated by Farm Fresh. Round Up is an annual in-store fundraising drive held at every Farm Fresh location that encourages customers to round up the total of their bill to an even dollar amount, or to add additional dollars to benefit the hospital. To date, the grocer has donated more than $8.2 million.

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Urology of Virginia has acquired a high resolution micro-ultrasound system, called ExactVu, for targeted prostate biopsies. The state-of-theart technology from Exact Imaging offers a 300 percent improvement in resolution over conventional ultrasound. That will allow urologists to visualize areas of interest in the prostate and specifically target biopsies at those suspicious areas – rather than relying on more blind biopsies – as well as perform systemic ultrasound biopsy procedures. Urology of Virginia announced that the practice has been designated as a UroLift® Center of Excellence. The designation recognizes that Gregg R. Eure, MD has achieved a high level of training and experience with the UroLift System and demonstrated a commitment to exemplary care for men suffering from symptoms associated with Benign Prostatic Hyperplasia, or BPH. The UroLift System is a minimally invasive treatment that typically takes less than an hour and can offer multiple benefits for men with enlarged prostate, with minimal side effects.

Virginia Dermatology and Skin Cancer Center is expanding its office in Suffolk. The practice’s new, 9,000-square-foot facility on Centerbrook Lane in Suffolk is due to open in August and will offer patient care services in General Dermatology, Mohs Surgery and Cosmetics.

If you have News you would like to share with our readers in the Fall 2017 edition, please contact the publisher at 757-237-1106 or email: holly@hrphysician.com • Deadline for submissions is September 26h.

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Summer 2017 Hampton Roads Physician | 49

WELCOME TO THE COMMUNITY

HoRohit Adyanthaya, MD has joined Virginia Eye Consultants. Dr. Adyanthaya is a Board certified ophthalmologist who is also fellowship trained in vitreo-retinal surgery. He earned his medical degree from MGM Medical College and Hospital in Mumbai, India, where he also completed an Ophthalmology Residency at King Edward Memorial Hospital and a Master of Surgery at the University of Mumbai. Dr. Adyanthaya was a Clinical Fellow in the Department of Pediatric Ophthalmology and Adult Strabismus, Wilmer Eye Institute at the Johns Hopkins University. Nicolai B. Baecher, MD has joined Sports Medicine & Orthopaedic Center. Dr. Baecher earned his medical degree at Georgetown University School of Medicine. He completed his residency at Georgetown University Hospital and completed a Hand Surgery Fellowship at the University of Pittsburgh Medical Center Hamot, Erie PA. He is specializing in upper extremity orthopaedic care. James Brennan, MD has joined Sentara Neurosurgery Specialists in Virginia Beach. Dr. Brennan earned his medical degree from Albany Medical College. He completed his spine surgery fellowship at Washington University School of Medicine and his neurosurgery residency at University of Oklahoma Health Sciences Center.

Lei Chen, MD has joined Peninsula Kidney Associates. Dr. Chen received his medical degree from China Medical University and earned a doctorate in Molecular and Developmental Biology from the University of Cincinnati. He also completed an internal medicine residency at East Tennessee State University and a nephrology fellowship at University of Texas Southwestern Medical Center in Dallas. Albert Y. Cheung, MD has joined Virginia Eye Consultants. Dr. Cheung is a fellowship-trained anterior segment/cornea specialist. He earned his medical degree at Penn State University College of Medicine and completed an internship and ophthalmology residency at Beaumont Health System in Michigan, where he served as Chief Resident. He then completed his cornea and external disease fellowship at the Cincinnati Eye institute in Ohio. Keith Claussen, DO has joined EVMS Ghent Family Medicine; he also serves as the Director for HOPES clinic and Western Tidewater Free Clinic. Recently retired from the U.S. Navy, Dr. Claussen is Board certified in family medicine. He earned his degree in Osteopathic Medicine from Kansas City University and was a Senior Medical Officer at the Naval Hospital in Okinawa, Japan.

50 | www.hrphysician.com

Rachel Ellis, MD has joined Integrated Dermatology of Tidewater. Dr. Ellis completed her medical degree at Eastern Virginia Medical School in Norfolk and did her residency at the University of Texas Health Science Center at Houston.

Kristin Kreider, MD has joined The Group for Women. Dr. Kreider is a Board certified OB/GYN physician and a Fellow of the American College of Obstetrics and Gynecology. She attended Eastern Virginia Medical School, where she was a part of the Health Professionals Scholarship Program and joined the US Army. She completed her internship and residency at San Antonio Uniformed Services Health Education Consortium. Pallavi Kuppireddy, MD has joined Sentara Hospital Medicine Physicians at Sentara Leigh Hospital. Dr. Kuppireddy earned her medical degree from Ahmadu Bello University and completed her internal medicine residency at Canton Medical Education Foundation.

Rachel Lock, DO is a new care team member at Sentara Family Medicine Physicians in Virginia Beach. She earned her medical degree from Lake Erie College of Osteopathic Medicine and completed her residency at Washington Health System Family Medicine.

Peter LoFaso, MD has joined the care team at Sentara Family & Internal Medicine Physicians in Elizabeth City. He earned his medical degree from Kansas City University of Medicine and Biosciences and completed her residency at Sun Coast Osteopathic Hospital.

Emily Malgor, MD has joined Sentara Vascular Specialists in Virginia Beach. Dr. Malgor earned her medical degree from New York Medical College. She completed her vascular surgery fellowship at Mayo Clinic and her general surgery residency at Stony Brook University Medical Center.

Aleea Maye, MD has joined Greenbrier Medical Associates, a primary care practice of Bon Secours Hampton Roads Health System. Dr. Maye is a double Board certified internist and adult psychiatrist. She earned her medical degree from Meharry Medical College in Nashville TN, and completed a combined internal medicine and psychiatry residency at the University of California Davis Medical Center. Michele Nedelka, MD has joined Bon Secours Oncology Specialists. Dr. Nedelka is a Board certified radiation oncologist who received her medical degree from Eastern Virginia Medical School. She completed a residency in radiation oncology at Massey Cancer Center Department of Radiation Oncology at Virginia Commonwealth University.

Manoj Patel, MD has joined Chesapeake Pulmonary & Critical Care Medicine, a division of Bayview Physicians Group. Dr. Patel is Board certified in Pulmonary Medicine and Critical Care Medicine. He received his medical degree from Shree Pramukh Swami Medical College in India and completed his Primary Care and Internal Medicine residency at the University of Connecticut Health Science Center. He completed a fellowship in Pulmonary and Critical Care Medicine at the UVA Medical Center. Frederick N. Quarles, MD has joined Virginia Dermatology and Skin Cancer Center in Norfolk and Suffolk-Harborview. Dr. Quarles earned his medical degree from Howard University College of Medicine and completed his dermatology residency at Howard University Hospital. Previous to this move, he privately practiced dermatology in the Hampton Roads area for more than 27 years.

Faustino Reniva, MD has joined Sentara Internal Medicine Physicians in Chesapeake. He earned his medical degree from Far Eastern University and completed his residency at Cabrini Medical Center.

Malena Taylor, DO has joined the care team at Sentara Family Medicine Physicians in Virginia Beach. She earned her medical degree from Edward Via Virginia College of Osteopathic Medicine and completed her residency at VCU/Riverside Regional Medical Center.

Christopher Zamani, MD is now practicing at Ghent Station Medical Associates, a practice of Bon Secours Hampton Roads Health System. Dr. Zamani is a Board certified family medicine physician. He earned his medical degree from Meharry Medical College in Tennessee and completed his residency training at Contra Costa Family Medicine Residency in California.

Send your Welcome announcements for the Fall 2017 edition to holly@hrphysician.com by September 26.

Taking Nominations for the Fall 2017 edition We are looking for physician leaders who specialize in

Reconstructive Plastic Surgery Deadline for Nomination Submissions

Reconstructive Plastic Surgery

August 23

Nomination forms are available on www.hrphysician.com (click nominate tab) or by emailing a request to holly@hrphysician.com Summer 2017 Hampton Roads Physician | 51

WELCOME TO THE COMMUNITY

Welcome NPs and PAs

Kelly Barriualt, PA-C Virginia Dermatology and Skin Cancer Center

Mila Brenner, NP Sentara Palliative Care Specialists in Norfolk

Keshia Brown, NP Sentara Urgent Care at Little Neck

Erin Casey, NP Sentara Vascular Specialists in Williamsburg

Kevin Charles, PA-C Integrated Dermatology of Tidewater

Amy M. Clements, MSN, AGCNS/Ed., FNP-C Cardiovascular Associates, Bayview Physicians Group

Lauren Copely, PA-C Orthopaedic & Spine Center

Cynthia D. Ferguson, MHS, PA-C Integrated Dermatology of Tidewater

Michelle Frickanisce, MSN, BSN, RN, NP-C Eagle Harbor Primary Care

Janelle Galbriath, FNP Virginia Beach Obstetrics and Gynecology

Meredith Giroux, PA Sentara Cardiology Specialists in Norfolk

Denise Harbin, NP Sentara Palliative Care Specialists in Williamsburg

Amy Harrelson, PA-C Sentara Internal Medicine Physicians in Williamsburg

LaShawna Heflin, FNP Sentara Internal Medicine Physicians in Woodbridge

Jennifer Henson, NP Sentara Pulmonary, Critical Care & Sleep Specialists in Norfolk

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Mary Elizabeth Lane, WHNP Virginia Beach Obstetrics and Gynecology

Amie Lank, PA Sentara Pediatric Physicians in Virginia Beach

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Kelly Thompson, PA-C Pulmonary Medicine of Virginia Beach, Bayview Physicians Group

Lisa Tisch, MSN, RN, FNP-C Roosevelt Family Medicine, Bayview Physicians Group

Heidi Walblay, NP Sentara Hospital Medicine Physicians at Sentara Princess Anne Hospital

Nicole Watson, MSN, FNP-C Bayview Primary and Urgent Care team, Bayview Physicians Group

Anne Weinhold, PA Sentara Cardiology Specialists in Suffolk

Ashley Witt, NP Sentara Cardiology Specialists in Suffolk

Rebecca Zinn, PA-C NowCare Urgent Care, Bayview Physicians Group

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Summer 2017 Hampton Roads Physician | 53

Awards Accolades

Celebrating the Accomplishments of Physicians Who have Received Major Honors

Francis L. Counselman, MD, CPE, FACEP, Distinguished Professor of Emergency Medicine and Chairman of the Department of Emergency Medicine at Eastern Virginia Medical School, has received the award for Outstanding Contribution in Education from the American College of Emergency Physicians (ACEP). The prestigious prize, one of ACEP’s 2017 Leadership and Excellence Awards, is presented to a member who has made an outstanding contribution to academic emergency medicine.

David Darrow, MD was recently named Physician of the Year by the Vascular Birthmarks Foundation (VBF), an international nonprofit organization serving families affected by vascular birthmarks. Dr. Darrow is the founder and co-director of the CHKD Center for Hemangiomas and Vascular Birthmarks and served for 13 years on the executive committee of the American Academy of Pediatrics section on otolaryngology – head and neck surgery, including terms as its chair and program chair. He will be honored at the VBF 2017 Annual Conference and Clinics in California this fall.

Bradley Prestidge, MD, MS, FABS, Regional Medical Director of Radiation Oncology for Bon Secours and radiation oncologist with Bon Secours Oncology Specialists, was awarded the Dr. Thom Shanahan Distinguished Brachytherapy Educator Award from the American Brachytherapy Society. Dr. Prestidge is only the second physician to receive this award, which recognizes his work to educate physicians and students worldwide on brachytherapy. The specialized form of radiation therapy delivers highly targeted radiation through small seeds or devices inside the body.

Elizabeth Yeu, MD a corneal, cataract and refractive surgery specialist at Virginia Eye Consultants, was recognized as one of the most influential people in ophthalmology by being voted onto the international 2017 Power List. This list recognizes thought leaders and inspirational talents in ophthalmology. Being ranked in The Power List is an acknowledgment of Dr. Yeu’s achievements and prowess in the field of ophthalmology

54 | www.hrphysician.com

MEE T OUR

Spine and Interventional Pain Management Team

Pictured (L-R, back row): Michael A. Mitchell, PA-C; Timothy S. Winkler, PA-C; Richard D. Guinand, DO; Michael Ingraham, MD; Scott Clingan, MSHS, PA-C (L-R, front row): Eileen Scott, PA-C; Bryan A. Fox, MD; David G. Goss, MD; Victor W. Tseng, DO; Deniz O. Goss, PA-C

Directed by highly trained and experienced spinal surgeons, the SMOC Spine Center finds most back pain patients can be treated non-operatively. Featuring an on-site fluoroscopy suite and alternative treatments such as acupuncture, the Spine Center makes treatment more convenient and effective for SMOC patients suffering from back pain.

CALL US TODAY TO SCHEDULE AN APPOINTMENT

757-547-5145

Chesapeake | Suffolk | North Suffolk smoc-pt.com

Orthopaedic Care | Spine Care | Physical Therapy | Interventional Pain Medicine

S AY “ Y ES” TO

LIFE WITHOUT LIMITS

Tre has always been such a joy and blessing to our family! He is a resilient young man, and he handled this challenging situation so well. We are grateful to Dr. Goss and all of the team at The Spine Center for helping Tre get back to enjoying his life, without back pain! TRE LEWIS - Spine Patient (as told by his parents, Marcy and Terry Lewis)

Read more about Tre Lewis’ success story at http://smoc-pt.com/about-us/patient-stories

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Bon Secours Mary Immaculate Hospital Earns National Certification for Total Hip and Knee Replacement

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O R T H O P E D I C S

The first certification of its kind in Hampton Roads, Bon Secours Mary Immaculate Hospital Orthopedics recently earned the prestigious Gold Seal of Approval for Certification for Total Hip and Total Knee Replacement from the nation’s oldest and largest accrediting body in health care. The Joint Commission’s Disease-Specific Care Certification evaluates three core areas, including compliance with national standards, evidence-based care models and strategic performance measurement programs. The certification reinforces Mary Immaculate Hospital’s commitment to providing comprehensive, compassionate care to patients undergoing total hip or knee replacements.

Mary Immaculate Hospital 2 Bernardine Drive Newport News, VA 23602 757-886-6000

bonsecours.com/ortho