SRQ Magazine | January 2022 | In Conversation with 2021 Top Doctors

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SHARE WITH OUR READERS A BIT ABOUT YOURSELF, YOUR PRACTICE, AND WHAT SERVICES YOU PROVIDE. JEHANZEB BILAL, MD: I am a nephrologist, or kidney disease specialist, a hypertension specialist, and I have a special interest in geriatric medicine and in ICU or critical care patients who have kidney-related issues. I have been practicing as a nephrologist since 2013. Originally from Pakistan, I moved to the US in 2007and to Sarasota in 2017. Renal Hypertension Center (RHC) is a specialized group of all nephrol-

ogists from Hudson down to Fort Myers. We are one of the biggest groups in the Tampa Bay area. I am part of the Venice and Sarasota offices. DANIELLE BABB, D.O. DABA, DABA-PM: I’m an interventional pain physician, part of the Ramos Interventional Pain and Functional Medicine practice. Our focus is primarily doing interventional new techniques to treat chronic and acute pain. And we also offer a way of other therapy options such as medication therapy, addiction treatment, psychotherapy options, and physical therapy.

AVANTIKA MISHRA, MD: I am a gastroenterologist with special interest in cancer prevention, reflux disorders, inflammatory bowel disease, women's health, liver disorders, and many other topics. I work with the Florida Digestive Health Specialists, a large gastroenterology organization serving a huge area in Florida, but there is a large presence here in the Sarasota and Lakewood Ranch area. WHAT ARE SOME OF THE PARTICULAR AILMENTS OR SPECIALTIES THAT ARE MOST

LIKELY TO BE SEEN WITHIN YOUR PRACTICE? MISHRA: Gastroenterology is very interesting because it's an all encompassing specialty. We deal with disorders starting from the mouth, swallowing in the esophagus, the stomach, the liver, the gallbladder, the pancreas, the small intestine and the large intestine. So anything related to digestive health is incorporated in gastroenterology. BILAL: Renal hypertension, which is due to a specific abnormality in the renal vasculature that leads to high blood pressure, is a specific field,


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and a name given to our practice to tell people that we are not just about kidneys, but an associated specialty called hypertension as well. When it comes to hypertension, people do not recognize that it is a specialty of a nephrologist as well as cardiologist, whereas we are the ones who deal with most of the difficult cases, of course, in coordination with cardiologists and other colleagues. IT’S ALWAYS INTERESTING FOR OUR READERS TO LEARN, WHAT IS IT THAT BROUGHT YOU TO BEING A PHYSICIAN AND THEN THIS SPECIALTY? BABB: Growing up, both of my parents were chronic pain patients. My mother injured herself at work as a nurse. She herniated a lumbar disc, and my father shortly thereafter injured himself at work, falling off a ladder, doing construction. So through my adolescence, I used to bring both of my parents to their chronic pain physician's office for interventional procedures and the pain physician they saw helped both of my parents recover significantly. So he was really a mentor toward me and kind of brought me to the specialty. MISHRA: I always knew I wanted to help people. But the way to approach that was very nuanced. I initially started off thinking I wanted to do health policy and work in diplomacy at the international level.

And ultimately I realized that I wanted, after going on medical missions and really dealing with patients in different countries and locally in the United States, that I felt the way I made the most impact was direct patient contact. And so ultimately, that helped stir me into medicine itself. And then GI was my calling ultimately, because I think basic happiness comes from enjoying simple pleasures. I think having a meal with loved ones, having shared experiences, being able to have good bowel movements, those are basic and simple pleasures that I think really impact people's quality of life and can really help people. BILAL: As a young man, our family physician, Dr. Zia Ullah, exposed me to the ways to talk to people, make them comfortable, and about the actual pathology. He improved my parents' life. They both have diabetes, they both have high blood pressure, and they both have acid reflux. So, I saw how he improved their quality of life by being their health coach. Nephrologists take pride in the fact that we are detectives. We want to look into more data so as to give a more accurate picture to the patient that, "Hey, this is what's going on with your kidneys, with your life in general, and that's where I can be helpful." So, I enjoy being that detective, doing that workup, being the first

person to inform a patient. It's a great feeling every day to help out these patients because you are changing lives in a big way. DR. BILAL, WHAT ARE THE NEW CHALLENGES AND/OR NEW TREATMENTS THAT YOU'RE SEEING FOR PEOPLE WITH RENAL CHALLENGES OR HYPERTENSIVE PEOPLE? BILAL: I think the biggest challenge that we all are facing, whether we're physicians or non-physicians is COVID-19, the way it has changed each and every physician's practice. And the challenge is to find a cure or a treatment that targets specifically that population, because the prevalence of kidney failure or kidney-related dysfunction or diseases is very high in people with COVID-19. And in fact, it is a sign of higher risk of death if they end up getting kidney failure, if they get admitted to a hospital with COVID-19. So, so far we are working on a lot of new strategies, but none of them have been proven or are ready for prime time. WHAT ARE SOME OF THE CUTTING EDGE TREATMENTS IN YOUR FIELDS? BABB: I really enjoy going through this algorithm with the patients, laying all the cards out on the table. These are the steps of everything I can offer you starting with the things that are least invasive, maybe just

therapy or a very directed form of physical therapy to medication therapy, if they're interested in using that as an adjuvant to more aggressive things like injections. Sometimes surgeries, minimally invasive surgery, sometimes implantable therapy...there's lots of different treatment options, depending on what's going on. We see orthopedic injuries from acute inflammatory conditions to chronic spine pathology, so there's not just one algorithm, but there are very effective and safe, minimally invasive techniques that are available and they're continuing to be developed. So it is an exciting time to be in interventional pain medicine. I think we're really making strides and helping patients. And getting patients back to doing what they love, whether that's golf or traveling with their spouse or significant other, spending time with their grandchildren. That's our goal. even more with it. BILAL: We have seen some tremendous developments, especially in the last 10 years or so. We've seen a lot of new medications that have revolutionized nephrology practice recently. The biggest, SGLT2 inhibitors, are medications that were initially brought on as diabetes medication, but we noticed they have profound benefits in reducing mortality in patients with kidney disease, heart disease, as well as diabetes.

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ABOUT THE PARTICIPANTS AVANTIKA MISHRA, MD, OF FLORIDA DIGESTIVE DISEASE SPECIALISTS is a board-certified gastroenterologist serving the Sarasota and Lakewood Ranch communities. She has a special interest in obesity and nutrition, cancer prevention, esophageal and reflux disorders and women’s health. She completed her internal medicine residency at Medstar Georgetown University Hospital in Washington, DC, then went on to Rutgers Robert Wood Johnson Medical School for her gastroenterology fellowship. Dr. Mishra provides care to patients who struggle with common to complex gastrointestinal and liver diseases. “Diagnosing gastrointestinal issues can be very nuanced and layered; it requires paying key a ention to patients’ symptoms while keeping in mind already diagnosed medical comorbidities. Patients need to know they’re heard and are working with someone that is invested in their care. An essential part of this doctor-patient relationship is continual patient education and engagement. As physicians, we need to constantly be talking to our patients about the importance of understanding symptoms and early screening. With this work, we can save lives.” Florida Digestive Disease Specialists – Lakewood Ranch 11505 Palmbrush Trail, Suite 200, Lakewood Ranch, FL 34202 Phone: (941) 361-1100

Congestive heart failure is a big problem in people with kidney disease and heart disease. These ailments are the biggest drivers of Medicare money and health expenditure, so the medication has huge implications there. We are in a great position to help a patient who could decline potentially by just having the old school treatments available to them. With this medication we've seen excellent results. MISHRA: Originally the guidelines used to say that at 50 years old you should get a colon cancer screening. But recently, the guidelines have been amended amongst all health societies to say screenings should begin at 45. Overall there have been large population studies done that help drive these screening guideline changes. And this happens in every field, whether it's in breast cancer screening or other disorders. But, ultimately there's just been a rising incidence of colorectal cancer in patients at a younger age. These days I'm seeing colon cancer, personally myself, younger and younger. And I've diagnosed it as young as someone in their early thirties most recently. And so ultimately, while we don't perform screening on everyone who has symptoms, these generalized studies for the population have really triggered all societies to amend their previous recommendations.

"There's just been a rising incidence of colorectal cancer in patients at a younger age. These days I'm seeing colon cancer, personally myself, younger and younger. And I've diagnosed it as young as someone in their early thirties most recently." — Dr. Avantika Mishra

AS A PHYSICIAN, HOW HARD IS IT TO WORK WITH PEOPLE ON BEHAVIOR AND LIFESTYLE CHANGES? BILAL: I feel very privileged being their health coach from a nephrology standpoint, because nephrology is a very cross-sectional kind of field of medicine—we see patients with all kinds of disorders that involve heart, gastroenterology, liver, lung, immune system, cancers. When a middle-aged or elderly person comes in they are already motivated to change their lifestyle and are looking for the right advice. Younger patients are not as open to getting our input because, first, they need to be convinced that there's something wrong or abnormal. I start with the dietary

modifications. We all are what we eat, we all are what we consume. Everything else is secondary. And our role as health coach is important because we're not here just to give them medication. We have a great network of dietitians and my goal, I feel, is to educate them, so they can then change their lifestyle. MISHRA: There are very basic things that we can do in our own life that can promote our own health. I think ultimately, hydration is key for prevention. So if you're drinking your 64 ounces of water per day, drink up. A plant-based diet, which is very crucial to your digestive health, but also your cardiac health, amongst other organ system healths, is very important. And then, for digestive disease prevention, a high fiber diet is very crucial, especially for things like colon cancer prevention. I do my best to abide by these practices myself. But I'm only human as well. And I also enjoy the occasional pleasure, whether it's a glass of wine or the occasional high-sugar dessert. But ultimately, I think you have to practice what you preach. And we just do our best, but we understand where others are coming from. CHANGING GEARS JUST A LITTLE BIT. DRS. BABB AND MISHRA, WHAT IS IT LIKE BEING A FEMALE PHYSICIAN? DOES THAT INFLUENCE YOUR EXPERIENCE AND YOUR

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PROFESSIONAL JOURNEY? AND DO YOU FEEL THAT FEMALE PATIENTS WILL SEEK YOU OUT BECAUSE YOU ARE A FEMALE PRACTITIONER? BABB: I think being a female gives me an understanding for certain pathological states like female pelvic pain or just some conditions that some of my male colleagues are just not as well versed in naturally. So I think it gives me a different perspective. I find it challenging and stimulating. But I receive complete support from my male colleagues. Pelvic pain is something that is uncomfortable, not just from the pain perspective, but just dealing with the social anxiety and kind of emotional stress related to that. And so I have many patients that are seeking a female physician for comfort. Some of the other specific requests for a female physician are ethical like religious patients that prefer a female physician to discuss their medical problems with. But beyond that, I have male and female patients. I'm actually not the only female physician in my practice. There's also Dr. Lindsay Schroer who has been practicing a long time in this community and she's wonderful. And we have discussed some of these patients we see and we share some of these patients together. We may be two of the few female pain physicians in this community, but we're able to provide that to patients.

MISHRA: I think in the field of gastroenterology, particularly when I was in training, there was a little bit of a lack of mentorship. Because at that point, less than 10% of gastroenterologists were females. In the past several years, there's been a lot of momentum. And actually, medicine is changing in the sense that there's a lot more females entering medical

"Pelvic pain is something that is uncomfortable, not just from the pain perspective, but just dealing with the social anxiety and kind of emotional stress related to that. " — Dr. Danielle Babb

school than males at this point. And I think people who are out in practice now, whether they're in academics or private, especially in the field of GI, we acknowledge that dramatic mentorship is needed. So I myself have taken on roles of mentorship to help people behind me because that was something that I didn't receive. And so I've had to pave my way a little bit. But now I'm trying to pay it back because I think ultimately that would've

made my experience rising in this field a lot more positive. I think it definitely helps having a female perspective. Ultimately, because of my own independent experience, but I think empathy goes a huge way because you have a personal understanding. And so yes, I see a lot of female patients with ailments that are not quite diagnosed. And I think ultimately, being able to relate and also acknowledge that there are some perplexing diseases and disorders that are very particular to the female body versus the male body. I think it helps. And I think it all goes back to patients wanting to feel seen and heard.

WHAT IS IT LIKE FOR YOU TO SEE A PATIENT WHO PERHAPS HAS TRIED EVERYTHING AND IS READY TO GIVE UP HOPE COME TO REDISCOVER HEALTH? BILAL: Nephrologists are the gatekeepers of a life-saving therapy called hemodialysis, or dialysis in general. And so, we provide a life-saving therapy, but also a life-preserving therapy. Starting someone on dialysis is a big deal for any person, they feel it's the end of the world. We see a lot of these people actually starting dialysis for days, weeks, sometimes months, or even a year, and then recovering their kidney function. So, that is like a life-changing experience. BABB: It’s like instant almost at times

DANIELLE E. BABB, D.O. DABA, DABA-PM, OF RAMOS CENTER FOR INTERVENTIONAL AND FUNCTIONAL PAIN MEDICINE is an interventional pain physician who completed her Bachelor of Science from the University of South Florida Tampa campus in 2012. In 2016 she graduated from Medical School, locally, at the Lake Erie College of Osteopathic Medicine in Bradenton. Following medical school, she relocated to Miami, Florida where she completed her residency and internship at Jackson Memorial Hospital/University of Miami. During her time in south Florida, Dr. Babb was selected to participate in research focused on patient safety and quality improvement. During this study she designed and developed surveys that helped measure patient outcomes and responses to interventional treatment. In 2020, Dr. Babb made the move to Lexington, Kentucky for her Fellowship in Interventional Pain Management at the University of Kentucky. Upon completion of her fellowship, she knew she wanted to return to the sunshine state—she is a native of Fort Myers. Dr. Babb was inspired at a young age to go into the field of pain medicine when she witnessed how chronic pain directly impacted a family member. Ramos Center for Interventional and Functional Pain Medicine: Sarasota Location: 2540 S. Tamiami Trail Sarasota, FL 34239.New Patients: 941213-8752. Existing Patients: 941-708-9555. Locations: Bradenton, Sarasota, St. Petersburg, Dunedin

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ABOUT THE PARTICIPANTS JEHANZEB “JB” BILAL, MD, graduated from Allama Iqbal Medical College in Lahore, Pakistan. He completed his residency in Internal Medicine from Cooper University Hospital, Camden, NJ. He joined University of Michigan, Ann Arbor where he completed a Geriatrics Fellowship. He subsequently completed a Nephrology Fellowship at Cooper University Hospital. At Emory University, he completed a Mini Fellowship in Renal ultrasound. Dr. Bilal is Board Certified in Internal Medicine and Nephrology. He is a CertifiedClinical Hypertension Specialist. Dr. Bilal has a special interest in Kidney Ultrasound, Kidney disease of the Elderly and Critical care Nephrology. Dr. Bilal served as a Nephrologist in Rural West Virginia for 4 years before joining Renal Hypertension Center. He served as the Medical Director of Grundy Dialysis unit, VA and Home Dialysis Medical Director at Eastern Kentucky Dialysis unit in Pikeville, KY. Sarasota Location: 3801 Bee Ridge Rd., Ste. 1 Sarasota, FL 34233 Phone: (941) 922-4498 Fax: (941) 922-4571 Venice Location: 517 Riviera Street Suite B Venice, FL 34285 Phone: 941-488-2881 Fax 941-486-8305

" We see a lot of these people actually starting dialysis for days, weeks, sometimes months, or even a year, and then recovering their kidney function." — Dr. Jehanzeb "JB" Bilal

when we do a procedure and we can tell that's the nerve or that's the spot. And the patients have this sense of ease and relief over their face that's just almost immediate. And it's so satisfying for a physician to say, well, we know what the problem is now. So we can further investigate this and focus our treatment here. But for the patients, to take their pain that's a 10 out of 10 limiting their ability to live their life down to a one out of 10 or zero out of 10, for some patients, that's life changing. And to see our patients that are debilitated, unable to walk, unable to go to the grocery store now, traveling, going to Europe, it's incredible. I love what I do and I wouldn't do anything else. MISHRA: I think ultimately, if you really sit down with patients and try to get down to the root symptoms originally, that you can actually provide a lot of benefit for them. I also think there's a

huge component of the patient physician relationship that is very crucial in this interaction as well. And so I think if you ultimately spend a few minutes just to take a break and listen to the patient, rather than interjecting your own beliefs, I think that goes a huge way with helping diagnose someone who's tried it all, but really, maybe just hasn't been heard. DR. BILAL, IS THERE ANYTHING ABOUT YOU AS AN IMMIGRANT, SOMEONE COMING FROM PAKISTAN, THAT HAS BEEN INFLUENTIAL TO YOU IN HOW YOU'VE BEEN CARING FOR PATIENTS? BILAL: Here in the United States, almost everyone who gets on dialysis gets Medicare to cover the cost. So that's a huge, huge thing, which most of the other countries don't. In Pakistan, you don't have that privilege. So kidney disease is like a death sentence to them because most of the people live under the poverty line. They don't have the money, they don't have the resources. I tell my patients that back in my country, people are dying because they can't afford a single dialysis session. And here people are living 10, 15, 20 years after starting dialysis, just because it's so easily available here. Medication, life-saving medication in general, the testing, the doctors, everything that is available here is like a dream in so many other countries. SRQ

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