SRQ Magazine | In Conversation with Medical Experts January 2021

JANUARY 2021 EDITION

IN CONVERSATION WITH THREE LOCAL 2020 TOP DOCTOR HONOREES ON TRENDS IN MEDICINE, HEALTH AND WELLNESS. INTERVIEW BY WES ROBERTS

DR. DANIEL M. COOPER MD, FACC

COULD YOU EACH DESCRIBE YOUR PRACTICE AND WHAT SERVICES YOU OFFER? Dr. Fabian A. Ramos of Ramos Center: I service patients in chronic pain. Pain can be devastating. It can change your life, the life of your loved ones. Normally these patients that come to our practice are patients that have been neglected for a long time.

We try to tell them from the beginning; we understand you're in pain, and we have so many things that we can offer to them, from medical management, from mental health counseling to an addiction medicine specialist so

DR. FABIAN A. RAMOS FIPP, DABA, DABIPP, DABPM

we can help take some patients off opioids. The primary focus of what I do is offer the interventional tools to change the pain-to diagnose the generators of pain and change them. Our specialty has evolved in amazing ways over the last twenty years. We're able to offer patients implantables that are very minimally invasive, that can change your ability to function significantly; fusions that we do are almost like injecting glue into some of the open joints. We have stimulators that we put in the spine to change the perception of pain. We have the ability to go into the vertebra and make a very

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RONALD TORRANCE, II DO

precise cut of the specific nerves that carry that pain signal. We're very, very happy that, for the most part, the majority of patients that come to our offices in pain will have some improvement in their pain and improvement of their function. Dr. Daniel M. Cooper of Cooper Concierge Cardiology and Internal Medicine: So about five years ago, what we did is we converted a practice from a conventional general cardiology and electrophysiology sub-specialty practice into a full concierge model. We provide, which is unique, an all in one kind of private practice because I've maintained my board

certification in internal medicine.

So my practice now includes internal medicine, general medicine, general cardiology, and electrophysiology, which is a subspecialty of cardiology that deals with electrical problems of the heart.

I'm your doctor, whether you have a sore throat or a cardiac arrest.

And because we a private practice, I contract directly with the client, not with their insurance company.

Dr. Ronald Torrance of Regenexx Tampa Bay: I specialize in sports medicine. My practice is Regenexx Tampa Bay. We have offices in Sarasota, St. Pete and, Tampa. Our practice specializes in regenerative

ENGAGING READERS THROUGH STORYTELLING.

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ABOUT THE PARTICIPANTS DR. DANIEL M. COOPER, MD, FACC, COOPER CONCIERGE CARDIOLOGY AND INTERNAL MEDICINE Highly trained in Cardiology, Electrophysiology and Pacing by the Cleveland Clinic, the number #1 Heart Hospital in the USA, Dr. Cooper is Board Certified in Cardiology and Internal Medicine, having trained at Buffalo General Hospital, the flagship Internal Medicine program of the State University of New York. He has attended the Harvard Medical School Internal Medicine Recertification. Dr. Cooper is the Associate Professor of Cardiology and Medicine, FSU College of Medicine. Over the past two decades Dr Cooper has cared for a wide range of outpatient ailments from common infections, diabetes, cholesterol, hypertension; to complex hospital medical and heart emergencies.

DR. FABIAN A. RAMOS, FIPP, DABA, DABIPP, DABPM, RAMOS CENTER Dr. Fabian A. Ramos, FIPP, DABA, DABIPP, DABPM is triple board certified by the American Board of Interventional Pain Physicians, American Board of Pain Medicine, and the American Board of Anesthesiology, where he ranked in the 99th Percentile Nationwide. As the recipient of the 2018 Champion of Prevention in Healthcare Award by Drug Free Manatee and the 2018 Community Health Advocacy Award from the Sarasota Medical Alliance Foundation & Society, Dr. Ramos is recognized for his impact in preventing and reducing substance abuse within our community. As of 2019, Castle Connolly Ltd. has formally included Dr. Ramos in their prestigious Top Doctor Database.

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medicine-platelet, rich plasma, bone marrow aspirate concentrate. We get our bone marrow derived from stem cells. We offer a non-surgical alternative to orthopedics, and that's why we're aligned with Regenexx. It gives us the ability to bring the highest quality regenerative products to our patients. Our mission is to get patients back to what they love to do. And that's what we love to do-we love to treat our patients. We offer a comprehensive approach— Dr. Ramos has that same comprehensive approach in his practice.

TELL US ABOUT THE HISTORY BEHIND REGENERATIVE MEDICINE. Dr. Torrance: The last 30 years are where regenerative medicine was really pioneered. But you can go back further to Dr. George Hackett and prolotherapy, which was first established in the 1930s. Prolotherapy is kind of the basis for thinking about how platelet-rich plasma and bone marrow can drive stem cells. We're causing new inflammation that causes healing.

For a time, medical thinking was that steroids and cortisone were these amazing discoveries, but with more knowledge, we can see that often steroids actually cause more harm than good in the long run. Innovators in the field really advanced regenerative medicine, about 30 years ago where they started looking at AVN or avascular necrosis where you're having bone die and you’re trying to figure out a way to stimulate that bone to essentially regenerate. Now we can treat that with bone marrow-derived stem cells now. Our company has been doing this in the United States for about 15 years, and we have a university-style lab. We have 40 locations throughout the United States that really specialize in this, and it is really bringing regenerative medicine to the forefront of orthopedic care.

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IT MUST BE AMAZING TO HAVE THAT HUMAN EXPERIENCE WITH A PATIENT—OF SEEING THEM COME IN SICK, MEETING THEM AND GETTING TO KNOW THEIR GOALS, AND THEN TO SEE THEM, LATER, IMPROVED AND REACHING FOR THOSE GOALS. Dr. Cooper: One of the things that I tried to teach my medical students is that for the majority of patients, you first need to sit down and listen to what they have to tell you. Then, you can ask the right questions. And I teach the old practice of the stethoscope.

With a stethoscope and a good physical exam, faster even than it would take you to just order an echocardiogram or an ultrasound, you already know what the answer is probably going to be. You learn to hear what a murmur sounds like, what other issues sound like.

I hear from patients a lot, "the doctor didn't even touch me, but he ordered ten exams; a cat scan and an MRI." The doctors don't have the time. You also incorporate the latest tests; more and more the insurance companies are limiting how many you can do, and it's always possible you will be practicing in an underdeveloped country where the power can go out or in another nation that won't OK the test; like the English National Health System where they won't pay for the tests, WE WOULD LIKE TO HEAR FROM EACH OF YOU ABOUT THE PATIENTS THAT COME INTO YOUR PRACTICES AND HOW YOU WORK WITH THEM IN WAYS THAT ARE UNIQUE TO YOUR PRACTICE. Dr. Ramos: My typical story is that there is a grandmother or grandfather that wants to travel and wants to have their two or three weeks of vacation, they want to play with the grandchildren, and they are in pain. The misery of the restriction is not being able

to be independent. As a human being, they are looking forward to those moments. I remembered a well-known priest that came to us with cancer of the spine.

The cancer had not responded to treatment. The priest knew he was going to die. But the only thing he still wanted to do was to preach. He wanted to stand and preach. He came in a wheelchair, and I was able to do a de-bulking of the tumors in the spine. We worked on five of the vertebra that had solid tumors. The pain went away in two, three hours, and it gave him almost two more years where he was able to continue walking, and of course, standing and preaching. That was an unbelievable result. Dr. Torrance: I'm thinking of a patient as well.

I can still see her being wheeled through the door. Her husband, who she was separated from, but who was still helping care for her, was pushing her wheelchair, and he was at stage four cancer and in bad shape as well. She had terrible knee arthritis in both knees. She's overweight. She's been told by multiple orthopedic surgeons that they really don't recommend a knee replacement at her size.

Even sitting, she was at a ten for pain in the right knee. I proposed to her that we do a bone marrow-derived STEM cell treatment for her knee. Her goal was to lose 20 pounds and then get up and go line dancing. Well, we perform the treatment, and, maybe six months later, she's emailing me that her knees are now maybe a two or three out of ten. She's line dancing three nights a week. She's lost weight, and has finished the beginner line dancing class, and moved on to the intermediate line dancing class. The ex-husband who was caring for her had passed away from his cancer, and it's easy to imagine how poorly her life would have been going without continued on page 80

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ABOUT THE PARTICIPANTS DR. RONALD TORRANCE II, DO, REGENEXX TAMPA BAY Ronald Torrance II, DO, is a non-surgical orthopedic physician specializing in Sports Medicine at Regenexx Tampa Bay. He graduated from Lake Erie College of Osteopathic Medicine and is board certified in Family Medicine and Sports Medicine. He has published in peer-reviewed journals and is an invited speaker at national medical conferences. Dr. Torrance’s practice focuses on interventional regenerative orthopedics, specializing in Regenexx procedures, which are patented stem cell and platelet treatments for injuries and arthritis using advanced image guidance. Regenexx has published nearly half of all orthopedic-stem-cell research and completed 111,350+ procedures.

reading the ability to care for herself and enjoy herself. Dr. Cooper: The age of my patients can vary all the way from my youngest patient at 25 years to my oldest at 102. I also have a large group of patients that are the middle-aged patients, high thirties, forties, fifties, that don't have much in terms of symptoms, but they have a very, very busy lifestyle. Perhaps they are an executive with a busy workload, and a regular practice just does not cut it for them. They can't go to a waiting room and sit for an hour. With me, they can schedule their appointments either the day before or the same day. We are not rushed; we may meet for an hour if the patient needs it. That's one of the advantages of concierge care that you can limit the number of patients

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and fully dedicate yourself to each and every patient as much as they need. My farthest away experience was with one of our patients that decided on his bucket list to go to Antarctica. And I got this, you know, crystal clear call from, from the ship and this doctor who obviously was French-speaking in broken English, trying to explain.

Well, I speak many languages, French, Spanish, Portuguese, and others, and that has helped me help patients around the world. I was able to speak with this doctor in French. There was an orthopedic surgeon that he was trying to treat that a hypertensive crisis on this patient, and I was able to give him recommendations for the situation and for my particular client. Then I was able to call ahead to their destiantion port so as soon as the ship arrived, they could continue to deal with that accelerated uncontrolled hypertension.

So these are some of the things that you just won't be able to get in a conventional practice because you don't have that accessibility.

The doctors don't have the time.

WHY DID YOU CHOOSE YOUR FIELD? Dr. Cooper: A lot of times in cardiology, when that was my focus, we would already get patients well into their acute heart emergency, not having had the chance to do that prevention.

We could have been implementing a medical strategy before the emergency situation happened.

So one of the things that I find in my practice at this point is that I can modify things or have patients access me before we realize that their first heart attack has happened. One of the rewarding things is for them to come up to me and say, "you know, I'm in my fifties, but my dad had a heart attack at age 50, and I'm getting to that age, and I'm not sure if I'm doing everything right." You might assess them and find that they have silent heart disease that was

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previously unrecognized. So it's that it is actually quite rewarding for me to be able to get ahead of the problems. And that wasn't possible in a practice that was dependent on insurance plans.

Dr. Ramos: Well, in my case, it was an emergent sub-specialty.

That made it very attractive, very exciting. It's near my background, which is anesthesia. I liked that I was going to be in contact with the patient, which is something very different from anesthesia. There is a book, "The Fight Against Pain," that I read, and it described the evolution of anesthesia as a field and how it connects to the fight against pain. I love this field. Dr. Torrance: I was lucky to be visiting family in Sarasota and attending a conference at the same time when I ran into the founder of my practice center, James Lieber. He invited me to come by the office and see what he was doing with the new techniques. This was over Thanksgiving Break, and a visit became an interview, which became a job offer. Now, after four years, I can say I love it. Just like Dr. Ramos say, you get to put your hands on patients, and you get to get them back to doing the things they love. That's really our mission, to help people get out of pain in the best way. Often people we see have been offered very extensive surgeries or procedures, and those surgeries or procedures have risks, and they may have been offered a 50/50 chance of seeing improvement.

So they're coming to us, looking for a non-surgical alternative for an orthopedic condition.

YOU ALL SEEM TO BE DOCTORS THAT THRIVE ON CHANGE. Dr. Ramos: Well, I personally love, love change. I glad that that's my element. I preach that into the office every single time. Change is an opportunity to grow and to serve in a better way. Big insti-

tutions can be slow to bring new techniques in, and we are able to lead in that. We are trying right now to get one of our area hospitals credentialed for a new procedure. Once it's done, that will be another new treatment option for our community, and we will be the first to bring it here. The newest treatments evolve from different institutions and different parts of the world. It's still a field with so much new discovery that there maybe two or three important emerging discoveries a the same time around the world.

The good thing is that, through the years, your hands are already trained. The only thing that you need to do is to learn the steps, the equipment, and then you can do it. Dr. Torrance: I think that all physicians are lifetime learners - inquisitive and curious. That has brought the doctors here to the forefront of what we're doing, like Dr. Ramos, for those of us on the frontier of medicine. For our practice, that's helping people find non-surgical alternatives.

The exiting orthopedic model is a little bit archaic. It's a "hardware" model where you put things back together. Instead, we are looking at how the body has an innate ability to heal itself. For many needs, we are trying to utilize the body's healing cells to help it heal itself. That's what really appeals to patients and to us as physicians. Dr. Cooper: And I think that's a good way of putting it. One of the things that we love is when we have a challenge. And, if we have the time, what we are supposed to do as physicians is to research the possibilities. Sometimes the research helps not only the patient in front of you but the rest of your practice. At the beginning of the COVID situation, February and March, none of us knew what we were dealing with. But through colleagues and through Cleaveland Clinic alumni, I was able to find out from physicians in

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Italy that the situation was really dire-before it hit the news. As a personal example, I was already telling my son, who lives in New York City, to wear masks and not take the elevator, even when the initial recommendations were that masks were not necessary.

I heard from a doctor in Korea that he disagreed with the initial recommendations. I reached out to see if hydroxychloroquine was working or not. We have a couple of close colleagues in Israel, early on I was contacting them trying to find out what were they seeing?

One is the chief of radiology in Ashkelon, and the other a professor at Tel Aviv University. So all this curiosity enhances your delivery of care and also your capability of teaching as well.

DESCRIBE THE EXPERIENCE THAT A NEW PATIENT WILL HAVE ON ARRIVING AT YOUR OFFICES. Dr. Ramos: First, our new patient scheduler gathers all the information from the patient.

We request records before the patient comes, the patient fills out a questionnaire, so before they even set foot in the door, we have begun to analyze which patients we are likely going to be able to help or not. Normally 80 to 75% of the applicants continue through to become patients.

We have a selection process, but once the patient is here, we know so much about them, we have all their records, and then we can walk the patient through the different modalities that are indicated for that particular patient. It's not a cookie-cutter type of approach. So the comfort of the patient is that as soon as you walk into the office, we are here to treat you as an individual.

Dr. Cooper: We take our time. We have the capability of spending an hour and a half, sometimes even two hours with them reviewing all the medical records, a good general medical exam and a good,

very focused cardiology exam. I combine what an internist would do and what a cardiologist would do into a single exam. We do all our non-invasive heart evaluation in our office as part of the package. So we do the stress test, we do the ultrasound, I have all the equipment also to assess all the electrical problems of the heart.

For the first month, we're a bit busier with the patient, and after that, we start seeing patients on a regular visit, whether it's every three months, if it's routine or let's say a patient that's unstable, we could be seeing them every week until they stabilized. Dr. Torrance: For our practice, there is a 60-minute evaluation with the physician also gathering all the information from their past evaluations, past treatments, their history, we do a physical, but we also do a diagnostic ultrasound on all of our patients to take a look at what's going on in the inside. Whether they have a rotator cuff tear or a knee meniscus tear, or an ACL tear, we really want to get to the root cause of the problem. Once we are treating certain conditions, we may platelet-rich plasma that we do with a blood draw. If we are using the patient's bone marrow-derived stem cells, then we use image guidance. That's really what the Regenexx brand is all about. It's about image, guidance, superior, quality products, and high-quality physicians. With the patient, we discuss the best options that we can offer. We discuss whether they're a candidate, number one.

Are you a poor candidate, a fair candidate, or a good candidate for one of our procedures? Or do we need to send to somebody like Dr. Ramos or to an orthopedic surgeon-not everybody's a candidate for a regenerate procedure? We want you to have the best option possible for the best outcome possible.

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DO PEOPLE WAIT LONGER THAN THEY SHOULD TO GET HELP? Dr. Ramos: Pain is very associated with your lifestyle.

Genes play a role, but a significant amount of pain is self-inflicted.

Patients may have made lifestyle choices that have played a significant role in their condition.

It's not easy. Normally the patient has had ten doctors telling them exactly the same thing. We want to help with the pain, but the lifestyle conversation is always on the table. Dr. Cooper: Let's put it this way, patients that understand what we are trying to do for them, as opposed to just giving them a prescription, say, take this twice a day. That's less effective than spending a few minutes teaching about their disease or problem and about the forms of treatment. Dr. Torrance: Pain can be devastating. I had a bone marrow-derived stem cell treatment for my shoulder. It was a nagging pain for a long time, and then one day, the call to action was asking myself, "are you going to let that pain control you? The thing that owns you and doesn't allow you to do what you want to do, or are you going to step up and find some sort of solution to get you out of that pain? I would say that pain is the thief of joy in life; it takes away from some of the things that you take for granted on a day-to-day basis-taking a walk outside, taking a walk stroll with your spouse around the block, doing anything. Dr. Ramos and I see patients in this kind of chronic pain conundrum. I'm grateful that, especially in the past three to five years, people aren't taking chronic medications as much. We're really finding now that alternative medicine is becoming the mainstream medicine, and that's what Dr. Ramos and myself practice. We're helping you get back to doing the things you love without pain so that you can enjoy life again.

HOW DO YOU FIND OR DEFINE SUCCESS IN TREATING A PATIENT? Dr. Cooper: For me, the private model and personalized care have brought us back to being a diagnostician like the old doctors used to be. You have to have time to think about a patient to come up with a differential diagnosis. That's what I teach to medical students. Your initial assessment is very important. So shortness of breath-it could be a heart problem, it could be a lung problem, it could be a metabolic problem. You have to line up all your thoughts and, in your mind, assess. If you are in a rush, you will go for the most obvious diagnosis in the room. I call that the "shotgun approach," so it's "OK, we think he may have a heart problem, we're going to do A, B, C, D E exams, and let's see him in a month and see what happens."

Now, with time to assess, we can determine which exams we do and don't need. Maybe we do check-in areas that could be causing the problems but aren't obvious. To be successful in your treatment, you need time, and you need a clear head, a clear thought process to be able to formulate the prevention and the treatment. Dr. Ramos: The assessment of pain is often described as a measurement of intensity, you know, pain on a ten-point scale, but the function is something different. If you are a three in pain, but it's made you sedentary at home, and on many medications, then that three is quite important. We want to take the patient in pain, diagnose, treat, and make you functional. Is the pain affecting mental health?

Are you fearful of doing certain things? The pain can give people depression. That's why the specialty of man treatment is a joyful one for me; I not only want to treat your pain but also as a human being. Dr. Torrance: I agree that it's about the whole person. I've

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looked a lot at functional medicine. I did a year-long training course with Chris Kresser. He's an acupuncturist who specializes in really looking for the root cause of conditions and issues. Most times, the root cause of our problems is inflammation. It really is the basis for a lot of the chronic pain that people are in. So when a patient sees me, I'm also looking at their dietary habits, their exercise habits, their sleep habits, everything that could be contributing to their condition. Sometimes patients don't realize that they're really causing a vicious cycle of chronic pain by eating processed foods, eating tons of sugar. If we can address the root cause, and then we can begin to influence the other things in their lives that can be contributing to that root cause. Dr. Ramos: There is a frequent conversation. If a patient, for example, with degeneration type of pain in the spine or joints, we always encourage the patient to eat with a balanced, correct diet. If you eat too much sugar too much, un-balanced omega-six versus omega three, you are going to end up with an inflammatory condition. Now, it doesn't mean that everybody's going to follow. I said earlier that it is not an easy conversation, and other doctors have already told them the same. Something has to click for the patients.

WHAT ARE SOME OF THE MOST EXCITING NEW TREATMENTS IN YOUR FIELD? Dr. Torrance: The innovations that we're really pioneering are looking at percutaneous ways to repair partial tears of the rotator cuff, and partial tears of the ACL where you don't have to go through arthroscopic surgery. We have two randomized control trials on each, showing that we can percutaneously help regenerate these injuries. So you don't have to necessarily have to go to surgery to get these areas

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to heal. Our CEO has a mission for Regenix that our innovations reduce the number of elective orthopedic surgeries by 70% by 2030. I feel with the new modalities coming for the people, it's a certainly attainable mission.

Dr. Ramos: In my area, there are many new techniques that will improve life for my patients. For example, a person with spinal stenosis and the inability to walk because of leg numbness due to the pressure on the nerves—the old technique involved removing bone from the spine through a laminectomy, a major surgery.

Now we have a procedure where we can install a small device that simply prevents the vertebra from flexing in the one spot and that stops the compression. It's a fifteen-minute deployment.

So many emerging techniques-for joints, for degenerative discs, for chronic abdominal pain. Pain that used to be very hard to treat is often now something we can reduce or even resolve.

WHAT ABOUT THE EFFECT OF PSYCHOLOGICAL ISSUES ON HEALTH? Dr. Cooper: You know, a lot of times, an illness or an ailment could be simply a reactive depression. I mean, it's a significant psychological issue that's been going on that is masquerading under the surface. You know that can confuse doctors that don't have a chance to interview the patient and understand the patient. So sometimes the intervention needed is to take care of their reactive depression.

That can solve a lot of problems.

From aches and pains to feeling weak, psychological problems can be manifested in many ways in patients. Some patients react through their skin. Some patients are GI sensitive. Some patients will manifest themselves as heart symptoms; palpitations, anxiety, chest pain. So once again, having

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the capability to get to know your patients, as a cardiologist, I could be testing and then ask, "wait for a second, I just did a stress test.

I just did an echocardiogram and EKG. I don't see any evidence of structural heart disease. Why is he having palpitations?" And you will end up finding out that the basal heart rate is higher because of a psychological issue. This is just that issue of finding root causes.

Whether you are in orthopedics or dealing with back pain, you have to look at all the factors to come to a conclusion.

THERE MUST BE PEOPLE WHO ARE LIVING WITH PAIN TODAY BECAUSE THE DIAGNOSIS AND TREATMENT THEY WERE GIVEN TEN YEARS AGO SEEMED RISKY AND INVASIVE, BUT THEY ARE NOT AWARE THAT THERE ARE NEW, SIMPLER OPTIONS. Dr. Torrance: I think that's the call to action; there's no need to live in pain. And if you didn't like the solutions offered in the past, there are other solutions out there, such as regenerative treatments, which consist of platelet-rich plasma, prolotherapy, a bone marrow aspirate concentrate, and fat micronized fat. Fat has done fantastic things for knees. We're asking all the patients out there who are living in some sort of acute or chronic pain and have been told they need a surgical intervention that seems very invasive; you don't need to live in pain. I treat others the way I want to be treated and how I'd want my family members treated. And I really, I believe that our practice personifies exactly what that means. I've treated my mother, I've treated my father, and they both have had good outcomes. I'm going to treat you like family. That's really the biggest thing. I'm going to give them the best recommendation I can, and if I can't help them, I'm going to give them a referral to somebody who

can. Dr. Ramos: It's necessary to have a complete comprehensive diagnosis. Once you have the correct diagnosis and if you are disabled, looking at pain as intensity, functionality, and medications, then make the next step.

Can you treat the cause? There's no point in treating the symptom if the treatments or therapies are going to be successful. From my perspective, we're going to treat you as the human being that you are; we're going to understand your pain. We're going to offer to you only the best advice that we can have-fairness; and honesty are good principles that should give you reassurance as a patient.

PEOPLE OFTEN, AND DISPROPORTIONATELY MEN, PUT OFF TAKING CARE OF ISSUES THEY KNOW ARE GETTING WORSE Dr. Cooper: If you're having a problem, you're my patient. We can work on a plan based on the testing we do on our new patients to avoid issues, and when issues do arise, then, well, I'm the attending physician for them at Sarasota Memorial, meaning I don't delegate them to a hospitalist. You call me if it's chest pain, I'll meet you in an emergency room, I'll admit you, I will be the quarterback organizing whatever specialists you may need. If you need to be admitted to the intensive care unit, I'm your cardiologist; I'm your internist. If needed, I'll consult you with a pulmonologist or surgeon. I remain the quarterback of your medical care as opposed to the punter of your medical care.

And that's very important. And you gotta be able to be the patient advocate whether the issue is right now, or if it's a consultation with a neurologist that may not happen for three months. SRQ