Carilion MedicineSPRING/SUMMER 2018 In partnership with the Virginia Tech Carilion School of Medicine and Research Institute

THE QUALITY ISSUE contents CARILION MEDICINE SPRING/SUMMER 2018 Departments 2 FROM THE CMO 3 IN BRIEF Nancy Agee takes the helm of the American Hospital Association; reflections on history and the future 7 GRAND ROUNDS Education initiatives both classic and with a twist 44 THE ART OF MEDICINE: A CONTAGION IN LAUGHTER The medical school’s most recent art show honors a beloved Roanoke physician. 46 CHEERS FOR PEERS 30 Carilion clinicians achieve recognition DOUBLE STANDARDS: Roanoke City, which has one of the lowest health 48 BACKSTORY: THE RESILIENCY CODE rankings in Virginia, is enclosed within To do their jobs well, physicians must be able Roanoke County, whose health ranking is to open themselves up to pain—and then one of the highest. That discrepancy has caused Carilion Clinic to look beyond the figure out how to bounce back. traditional boundaries of health care. BY GARY R. SIMONDS, M.D.

SPECIAL REPORT The Quality Issue Features 10 12 18 24 30 36 40 INTRODUCTION: CHASING THE HUMAN PLAYING A TALE OF ADJUSTING KEEP CALM TO ERR IS HUMAN ZERO FACTOR THE PATIENT TWO CITIES FOR GROWTH AND CARRY ON Stakes in the medical world are In its efforts to eliminate A team of experts at Carilion The Virginia Tech Carilion Carilion Clinic partners As the demand for care grows, Virginia Tech Carilion Research high for patients and clinicians patient harm, Carilion Clinic is Clinic are researching School of Medicine’s with local organizations Carilion Clinic is expanding Institute scientists record the alike. The need for speed amid demonstrating that medical perfection in health care— standardized patients help to find innovative ways the role of advanced clinical first clear evidence of the inter- uncertainty can trigger human errors are not as inevitable as and implementing their medical students sharpen to help medically under- practitioners to improve play between serotonin and error, yet a just culture can offer once believed. findings in real time. their clinical skills. served communities. patient access to quality care. dopamine in humans. divine forgiveness. BY DAVID BUMKE BY CHARLES SLACK BY CATHERINE DOSS BY JESSICA CERRETANI BY VERONICA MEADE-KELLY BY ASHLEY WENNERSHERRON

COVER ILLUSTRATION: NEIL STEVENS; ILLUSTRATION: GRACIA LAM (ABOVE) a recent study reported that medical errors are the third leading cause of death in Carilion Medicine the United States, ranking just behind heart President and Chief Executive Officer disease and cancer. While much has been Nancy Howell Agee On the pulse of the done to reduce medical errors and improve Chief Medical Officer and Carilion Clinic community patient safety, mistakes can still happen. Executive Vice President Often circumstances beyond anyone’s Patrice M. Weiss, M.D. control render a bad outcome inevitable. Editorial Advisory Panel in brief Patients and their families—the first Nathaniel L. Bishop, D.Min.; Cesar Bravo, M.D.; victims—aren’t the only ones affected. John Burton, M.D.; Kimberly Carter, R.N., Ph.D., Clinicians are too, and the effects of being a R.N.; Julie DeLoia, Ph.D.; Kimberly Dunsmore, M.D.; Evelyn Garcia, M.D.; Mark Greenawald, ASSUMING THE MANTLE “second victim” can be devastating. M.D.; Daniel Harrington, M.D.; Cynda Johnson, Years ago, I knew of a young intern caring M.D., M.B.A; Donald Kees, M.D.; Wilton Kennedy, It was a hike with her Girl Scout troop for a pregnant woman with severe preeclampsia and insulin-dependent D.H.Sc., P.A.-C.; Michael Nussbaum, M.D.; John that led Nancy Howell Agee to a career diabetes. The mother was being induced under the care of the attending Pastor; Paul Skolnik, M.D.; Robert Trestman, M.D., that most recently culminated in being Ph.D.; Fidel Valea, M.D. physician and the intern. The attending left the room, with the expectation the top elected official of the American that the intern would be closely following the patient. When the attending Chief Administrative Officer Hospital Association. Jeanne Armentrout returned, she could see multiple subtle decelerations in the fetal heart rate, Agee, then 15, tripped and slid down indicating decreased oxygenation. The baby was delivered by emergency Vice President a small mountain. Although the clinicians Mike Dame at the emergency department found no C-section and whisked away to the NICU. broken bones, they did diagnose a tumor I want you to consider two possible outcomes for the intern. First, his Executive Editor Linda Staley in her knee. It was the care she received superiors could have blamed and reprimanded him. Or they could have over the next two years that inspired her given him support, recognizing that he could be emotionally affected by his Editor to become a nurse—and an impassioned Paula Byron oversight and encouraging him to learn from the experience. advocate for patients. Throughout my career, I’ve witnessed adverse events, some more serious Art Director Decades later, Agee, president and Laura McFadden PLEDGE TO SERVE: “Our commitment to excellence demands our continual focus on than others. And I’ve learned a great deal about what it means to be a chief executive officer of Carilion Clinic, making care better and more affordable for our patients,” said Nancy Howell Agee in her second victim. Special Thanks assumed the chairmanship of the investiture ceremony. “They are the reason we are here and why we do what we do.” It turns out that more than 40 percent of providers are second victims Joe Castiglioni, Mark Lambert, Josh Laukaitis, American Hospital Association’s Board Alison Matthiessen, Karen McNew McGuire, of Trustees. Although she began her “The doctors and nurses who cared In her role as chair, Agee will work to and about one-third of them experience emotional distress, placing them at Laura Mitchell, Anne Shaver risk for depression, burnout, and feelings of guilt and shame that can be long tenure in January, her official investiture for me then inspired me, and the work of advance health care nationally and to be an lasting. They may also experience shock and hopelessness, sleep disturbance, CARILION CLINIC ceremony took place at the association’s caregivers all across this country inspires agent for change in health care. During her 1906 Belleview Avenue Annual Membership Meeting in May. me now—inspires me to make a differ- address, Agee spoke about the association’s social avoidance, intrusive thoughts, and nightmares. Interestingly, these P.O. Box 13727 Agee opened her investiture address ence to the patients who put their trust in Value Initiative, which provides thought emotions and reactions can be similar to those of post-traumatic stress Roanoke, VA 24036 by describing her experiences as a teen- us,” Agee said. “In my opinion, there’s not leadership on the issue of affordability. She disorder. Recovery can take years, and some clinicians never rebound. CarilionClinic.org 800-422-4842 age patient. much that’s more important.” also touched on the association’s commit- Hospital systems’ internal review processes for medical errors often ment to drive excellence. compound the problem. They can too easily devolve into a “name, blame, “We cannot sit on the sidelines as shame game.” We need to move beyond that to a just culture, one that meeting health care changes around us,” Agee said. differentiates between competent professionals who make mistakes and Carilion Medicine is published twice a year at: “We must lead—for all our patients. We those who behave recklessly and should be punished. 213 McClanahan Street, Suite 200 Medical School to Host International Conference must lead for our teams, the caregivers and staff who demonstrate care and compas- We physicians all pledge to avoid harm, and we are often held to standards Roanoke, VA 24014 The Virginia Tech Carilion School of Medicine will host the 23rd Annual Meeting of Phone: 540-266-6586 Fax: 540-266-6608 sion every day. Together, with open ears of perfection by society, peers, and, above all, ourselves. Yet we are only the International Association of Medical Science Educators (IAMSE). Set for June 7–11, Email: [email protected] and eyes and hearts, we will be the catalyst human. We deserve empathy and support after a stressful outcome or event. 2019, the meeting is expected to draw more than 500 basic science and clinical educa- Web: CarilionClinic.org/carilionmedicine for change in a sector that is ripe for it.” When we put on our white coats, let’s not turn off our hearts. tors from across the globe to Roanoke, Virginia. Agee, who has served as Carilion’s Carilion Clinic is a nationally ranked integrated health “The event organizers saw the school successfully hosted a large conference a president and CEO since 2011, joined the care system headquartered in Roanoke, Virginia. Its few years ago, the 2015 Collaborating Across Borders conference, which attracted flagship, Carilion Roanoke Memorial Hospital, is the American Hospital Association’s Board of nearly 700 health care professionals from across North America to Roanoke, and clinical affiliate of the Virginia Tech Carilion School of Trustees in 2015, serving on its Executive, Medicine and Jefferson College of Health Sciences. they felt confident we could accommodate this annual meeting,” said lead orga- Operations and Audit Committees. She has nizer Richard Vari, Ph.D., senior dean for academic affairs at the medical school and Patrice M. Weiss, M.D. © Copyright 2018 by Carilion Clinic. No part of this also served on the association’s Health Care publication may be reproduced or transmitted the current president of IAMSE. Chief Medical Officer and Executive Vice President Systems Governing Council and represent- in any form or by any means without written “I look forward to bringing my peers to the place I’ve called home for the last Carilion Clinic permission from Carilion Clinic. All editorial rights ed the association as a commissioner on decade,” Dr. Vari said. reserved. Opinions expressed herein may or may not The Joint Commission Board. reflect the views of Carilion Clinic. CarilionClinic.org/carilionmedicine

2 CARILION MEDICINE | SPRING/SUMMER 2018 PHOTO: JARED LADIA PHOTO: STEPHANIE KLEIN-DAVIS, COPYRIGHT, THE ROANOKE TIMES, REPRINTED BY PERMISSION CARILION MEDICINE | SPRING/SUMMER 2018 3 tribute

Students Founding Medical Dean to Retire practicing VETERANS UNDER PRESSURE briefings disaster After more than a decade at the helm, “That presented its own set of challenges scenarios. Fireworks on nights other than the diagnosed with PTSD, while others were CYNDA JOHNSON, M.D., M.B.A., founding and opportunities, but her hard work has Fourth of July and New Year’s Eve might not. In the functional MRI, participants dean of the Virginia Tech Carilion School of paid off in numerous ways,” said Agee. “The suggest nothing more than inconsiderate played a gambling game, in which they Medicine, has announced plans to retire. extraordinary success that the school has Jefferson College of neighbors, but for veterans with post- learned to associate certain choices with She will stay in her position while a search seen under Cynda’s leadership isn’t a sur- traumatic stress disorder (PTSD), the monetary gains or losses. for her replacement is under way. prise to anyone who knows her. I’m proud Health Sciences to shock of noise and light may trigger a “Computer science and mathematics “Being founding dean of the Virginia to have had the opportunity to work with Explore Partnership deeply learned expectation of danger. have given us new tools to understand Tech Carilion School of Medicine and creat- such a leader.” Scientists at the Virginia Tech Carilion how the brain learns,” Dr. Chiu said. “We ing a school from scratch has been an amaz- The school received more than 1,600 Jefferson College of Health Sciences, a Research Institute have found that people used these tools to study whether and how Small Wonder ing experience,” said Dr. Johnson. “From the applications for its charter class; in each of longtime teaching affiliate of Carilion with PTSD have an increased learning learning might play a role in PTSD. These Carilion has opened a new unique, patient-centered curriculum that we the last two years, it received more than Clinic, is exploring a public-private part- response to surprising events. While most results suggest that people with PTSD mini-clinic at Carilion Roanoke created, to the high-caliber students 4,000 applications for just 42 spots. nership with Radford University, a com- everyone reacts to surprise, people with don’t necessarily have a disrupted response Community Hospital. The first of and graduates and faculty “One of the amazing prehensive public university in south- PTSD tend to pay even more attention to to unexpected outcomes, rather they pay its kind in the area, the clinic seeks who deeply care about things about starting a western Virginia. The partnership, the unexpected. more attention to these surprises.” to enhance the role of academic teaching and mentoring, new school was we slated for 2020, would create the second The study was published in January The researchers found that people nursing in the community clinic leading this school has could look at the largest nursing program in the state. 2018 in eLife, an open-access journal with PTSD had significantly more activity network and to allow nursing exceeded my expecta- trends and see what “Jefferson College already enjoys a published by the Howard Hughes Medical in the parts of their brains associated students the opportunity to learn tions in every way.” the next generation wonderful relationship with Radford Institute, the Max Planck Society, and the with how much attention they paid to about community-based practice. In 2007, Carilion of physicians will University,” said Nathaniel L. Bishop, Wellcome Trust. surprising events when the learning task The clinic also helps increase Clinic, Virginia Tech, need to be successful, D.Min., president of Jefferson Col- “Disproportionate reactions to unex- threw an unexpected curve ball their way. access to care for uninsured and and the governor of such as training in Johnson lege. “We’re combining forces to cre- pected stimuli in the environment are a “Fireworks unexpectedly going off underinsured patients. Virginia announced plans interprofessionalism ate something even bigger and better core symptom of PTSD,” said Pearl Chiu, after a person has exchanged fire in the for the Virginia Tech Carilion and research to improve for the entire commonwealth.” Ph.D., associate professor at the research field can trigger an over-estimation of School of Medicine and Re- patient outcomes, and build In its 35-year history as an accred- institute and the lead author on the danger,” said Brooks King-Casas, Ph.D., search Institute. Dr. Johnson arrived in the curriculum to meet those needs. ited institution, Jefferson College has study. “These results point to a specific associate professor at the Virginia Tech Roanoke a year later to oversee the creation That is harder to do in well-established grown from 200 students to more disruption in learning that helps to Carilion Research Institute who co-led of the new allopathic medical school. schools,” said Dr. Johnson. “We also built than 1,150. One of the region’s lead- explain why these reactions occur.” the study. “Particularly for individuals The school welcomed its first class in Au- the curriculum to remain flexible so we ing producers of nursing and allied Dr. Chiu and her team used functional with PTSD, unexpected surprising gust 2010 and received full Liaison Commit- can continually adapt and ensure we can health professionals, the college is magnetic resonance imaging to scan the events—noise or otherwise—could tee for Medical Education accreditation after meet our mission to develop the next gen- listed among the top 10 in Virginia. brains of 74 veterans, all of whom had be a matter of life or death. The study Partnership to Focus the charter class graduated in May 2014. eration of physician thought leaders.” “Carilion Clinic is proud to have experienced trauma while serving at shows that while everyone is affected During Dr. Johnson’s tenure, four class- Under Dr. Johnson’s tenure, the nurtured Jefferson’s growth, as it es- least one combat tour in Afghanistan or by unexpected events, in PTSD extra on Brain Injury es of students have graduated. Each class medical school has been an independently tablished a reputation for developing Iraq. Some of the study participants were attention is given to these surprises.” How can you accurately diagnose has exceeded the national mean score accredited private school; in July 1, it will be ethical, knowledgeable, competent, a mild traumatic brain injury that on Step 1 and Step 2 licensing exams and integrated into Virginia Tech as the univer- and caring health care professionals,” has subtle or no physical signs yet has earned a 100 percent match rate to sity’s ninth college, with Carilion Clinic as a said Nancy Howell Agee, president and can cause long-term damage? residency programs. partner providing faculty and the clinical chief executive officer of Carilion. “Join- Carilion clinicians are teaming up “Not too many people these days can experience for students. ing the Radford University family is a with Virginia Tech Carilion Research say they built a medical school from the “Thanks to Cynda’s tireless work, the wonderful opportunity for Jefferson Particularly for Institute scientists, University of ground up, particularly one with such a Virginia Tech Carilion School of Medicine is College. And now is the right time as the Virginia researchers and clinicians, stellar reputation,” said Nancy Howell Agee, one of the top research-intensive medical vision for a health sciences and technol- individuals with and experts from the biotechnology president and CEO of Carilion Clinic. “We schools in the country,” said Timothy Sands, ogy campus in Roanoke comes to life.” “ company BRAINBox Solutions to aid knew we needed someone special for the president of Virginia Tech. “Her leadership PTSD, unexpected Students from both Radford and in the diagnosis and management job, and Cynda surpassed expectations— over the past decade will support the Jefferson College would have access to of mild traumatic brain injuries. not only ours, but the community’s—at success of its students, faculty, and staff for surprising events enhanced educational opportunities, By studying patients’ cognitive every step of the way.” decades to come, and has established the including clinical rotations and intern- could be a matter performances during advanced Dr. Johnson built the school under school as a driving force in the development ships, and Radford would continue to brain imaging, the team will a still-unique public-private partnership of the Virginia Tech Carilion Health Sciences partner with Carilion in sharing facili- of life or death. determine the accuracy of a blood- between Virginia Tech and Carilion Clinic. and Technology Campus.” ties and research resources. based test that can be administered CarilionClinic.org/carilionmedicine directly at the point of care.

4 CARILION MEDICINE | SPRING/SUMMER 2018 PHOTOS: DAVID HUNGATE ILLUSTRATION: DAVIDE BONAZZI; PHOTOS: MARK LAMBERT,” TOP RIGHT; DAVID HUNGATE, RIGHT CARILION MEDICINE | SPRING/SUMMER 2018 5 a moment in history BREATHS OF RELIEF: A patient in the early 1950s receives lifesaving support from an iron lung, a mechanical respirator used to combat the paralysis that can compromise polio patients’ breathing. grand rounds Education at Carilion Clinic and its affiliates

STUDENTS RECEIVE PRESTIGIOUS SUPPORT Two students in Virginia Tech’s Translational Biology, Medicine, and Health doctoral program have won National Institutes of Health fellowships for research aimed at protecting people with cardiac problems. Tristan Raisch and Carissa James will each receive a Ruth L. Kirschstein National Research Service Award Individual Predoc- toral Fellowship, a highly selective honor ALL IN: Kevin Mensah-Biney conferred on top U.S. graduate students in enjoyed his clinical rotations so health science–related fields. much that he found choosing a specialty to be challenging. Under the mentorship of Steven Poelzing, Ph.D., associate professor at the Virginia Tech Carilion Research Institute and co-director of the doctoral program, A Passion for Medicine Raisch seeks to resolve a controversy about the roles that extracellular spaces Kevin Mensah-Biney is known among his To have his research recognized on a next to gap junctions play in the conduc- fellow students at the Virginia Tech Caril- national level, Mensah-Biney says, speaks tion of electrical signals across the heart. ion School of Medicine as a trivia buff. to the rigor and quality of the school’s re- While James also studies gap junc- “Not really trivia,” he says with a grin, search program. Since 2010, when the Vir- tions, she focuses on alterations in the “more like random facts.” ginia Tech Carilion School of Medicine wel- assembly of these structures, which allow THE LITTLE HOSPITAL THAT COULD His talent for storing and retrieving comed its first class, 53 of the students have heart cells to communicate with each At the height of the polio epidemic, Roanoke did the impossible to save countless young lives. information has served him well academ- had research published in national journals. other. With mentor Jamie Smyth, Ph.D., as- ically. Mensah-Biney, the son of Ghanaian Students have also presented 234 posters sistant professor at the research institute, parents, grew up in Asheville, North Car- and 39 oral presentations at regional, na- James seeks to expand understanding of The summer of 1950 was a scorcher in southwestern Virginia, and not the nurses or doctors, the physical therapists, the engineers olina, where he showed an aptitude—and tional, and international meetings. how proteins are synthesized and play a power surges were common. The moment the electricity failed, who oversaw the transport of patients in iron lungs, or the student zest—for science at an early age. “Having research experience is some- role in healthy cellular communication. Memorial and Crippled Children’s Hospital employees—from orderlies nurses who rocked the beds of patients struggling to breathe— One element of his medical school thing that keeps us competitive as we apply to cooks, maids, and office workers—would rush to the polio ward. questioned whether they would be infected. They just pitched experience he found particularly helpful for residencies and later when we go into There they pumped iron lungs by hand until the power returned. in, and the entire community rallied in support, from donating was the intensive research requirement. practice,” Mensah-Biney says. “I can’t imag- The little hospital on the hill—which would eventually grow theatre ticket sales to equipping moving vans and rail cars with His project, under the mentorship of ine going through medical school and not into Carilion Roanoke Memorial Hospital—could reasonably care generators to accommodate patients in iron lungs. Sandy Fogel, M.D., associate professor of having the research requirement.” for 40 polio patients. That year, the hospital treated an estimated “There was so little we could do,” Dr. Ripley said. “It was devas- surgery, looked at patients transferred Mensah-Biney also found his clinical 450, with patients in iron lungs even lining the hallways. tating. Everyone worked their hearts out.” to Carilion Roanoke Memorial Hospi- rotations invaluable—and enjoyable. “It was awful,” one of the hospital’s physicians, the late Louis Years later, after the introduction of the Salk vaccine, the Polio tal for emergency surgery to determine “They made it hard for me to choose a Ripley, M.D., recalled decades later. “Whole floors of the hospital Foundation would feature the hospital’s response to the epidemic the effects of distance and time on their specialty,” said Mensah-Biney, who even- were full of patients, infants to adults. And many died.” in a movie shown nationally as part of a March of Dimes campaign. outcomes. The research was published in tually settled on surgery. All this experi- At the height of the nation’s polio epidemic, the hospital be- “Those iron lungs never missed a beat,” Dr. Ripley said. “Every- The American Surgeon last year, and Men- ence, he says, has prepared him well for came a regional magnet for those stricken with the virus. No one— one just worked together to get it done. It was amazing.” CM sah-Biney presented a poster at the 2017 future years of service. Annual Scientific Meeting Southeastern “Making an impact on others,” he says, From left: Dr. Steven Poelzing, Tristan Surgical Congress. “is something I’ve always wanted to do.” Raisch, Carissa James, and Dr. Jamie Smyth

6 CARILION MEDICINE | SPRING/SUMMER 2018 PHOTO: CARILION CLINIC ARCHIVES PHOTOS: DAVID HUNGATE CARILION MEDICINE | SPRING/SUMMER 2018 7 DOCTORAL PROGRAM A NEW VISION FOR SMOKERS GRADUATES FIRST STUDENTS The research project of Perisa Ruhi, a member of the Virginia Tech Carilion School of Med- When NithyaPriya Ramalingam and Kevin icine’s Class of 2018, offers new findings to Pridham donned caps and gowns for Virginia help change smoking behaviors. Ruhi found that smok- Dr. Aubrey Knight, senior dean for student Two students take advantage of the A medical student expresses her glee A student coyly tests the opacity of his Tech’s recent commencement, they made affairs, plays the Mad Hatter. option to match as a couple. upon getting her first-choice residency. envelope before the strike of noon. ers were more likely to value a future without cigarettes history as the first two graduates of the Translational when envisioning future events with smoking-related Biology, Medicine, and Health doctoral program. Yet illness symptoms, such as lung cancer. their impact extends far beyond a ceremony. Previous research has found that cigarette smokers LocationLocation of of residency, medical including school preliminary discount or devalue future rewards at a higher rate than Location of residency, following preliminary Location of university student will transfer to in one year nonsmokers, a tendency called delay discounting. Using an online crowdsourcing platform, Ruhi re- cruited and randomly assigned 199 smokers to one of four groups: those who imagined positive future events, those who added symptoms of smoking-re- lated illness to their imagined positive future events, and two control groups for validity. Ruhi’s study showed cigarette craving diminished significantly in both groups assigned to imagine the Ramalingam future. “But when we measured delay discounting, and Pridham things got even more interesting,” she said. Ruhi found that participants who envisioned posi- “These students represent the breadth of the tive future events were less likely to devalue the future research focus areas available through the program,” and, unexpectedly, participants who envisioned them- said Michael Friedlander, Ph.D., executive director selves with a smoking-related illness showed the oppo- of the Virginia Tech Carilion Research Institute and site effect: It led them to devalue the future more. Yet vice president for health sciences and technology at for both groups, episodic future thinking seems to pro- Virginia Tech. “Nithya is highly focused on health tect against circumstances that increase impulsivity. implementation to improve quality of life for the elderly, Ruhi conducted the study under the mentorship as well as preventing obesity, while Kevin is dedicated to of Warren Bickel, Ph.D., director of the Addiction Re- understanding and correcting the molecular processes covery Research Center at the Virginia Tech Carilion that underlie the deadliest form of brain cancer, Research Institute, and Jeff Stein, Ph.D., research assis- glioblastoma multiforme. They are on the cusp of tant professor at the center. promising careers as biomedical and health scientists.” The Virginia Tech Carilion School of Medicine is one of only a few medical schools in the country that requires an intensive longitudinal research project, a EPILEPSY IN NIGERIA fact that heavily influenced Ruhi’s decision to go there. Nigeria has few trained neurologists spotlight “I’ve been able to conduct a research project from in a country of nearly 200 million. the ground up,” she said. “I wouldn’t have gotten this “Sadly, due to cultural beliefs, most opportunity anywhere else.” patients with epilepsy are stigma- A Perfect Match tized, as it is generally believed that When the suspense ended, all 41 members of the Virginia Tech Carilion their condition is due to a spiritu- School of Medicine’s Class of 2018 matched. It was the school’s fifth Match MOST POPULAR SPECIALTIES, BY THE NUMBERS al attack or fetish practices,” says Day—and the fifth time that its match rate was 100 percent. Anyanwu Chinekwu Anyanwu, M.D., medi- During Match Day 2018, themed “March Match Madness,” members General Surgery Diagnostic Radiology cal director of Carilion’s EEG laboratory. In January, of the graduating class learned where they would be spending their 5 5 Dr. Anyanwu spearheaded a two-day conference in residencies. Beginning at noon, students at the Virginia Tech Carilion School 5 Internal Medicine 3 Neurology Enugu, Nigeria, on epilepsy and EEG in clinical practice, of Medicine—as well as students in medical schools across the country— Obstetrics–Gynecology Psychiatry for primary care physicians, pediatricians, and neurol- opened envelopes to see where their next chapter would unfold. Members of 5 3 ogists. A community walk followed the conference, to the class will go into programs representing 15 specialties in 16 states. raise awareness and help dispel myths about epilepsy. Ruhi CarilionClinic.org/carilionmedicine

8 CARILION MEDICINE | SPRING/SUMMER 2018 PHOTOS, THIS SPREAD: DAVID HUNGATE AND JARED LADIA (DR. ANYANWU) CARILION MEDICINE | SPRING/SUMMER 2018 9 THE QUALITYQ ISSUE In The Checklist Manifesto, writer and surgeon Atul Gawande, M.D., M.P.H., paints by numbers the world of clinical care: more than 13,000 different diseases, syndromes, and types of injuries; at least 6,000 drugs; more than 4,000 medical and surgical procedures, each with a range of requirements, risks, and protocols. Dr. Gawande concludes his portrayal of the complexity of medicine with an understatement: “It is a lot to get right.” The stakes in medicine are enormously high. When an error occurs, the consequences for patients can be life altering or even life ending. The impact on the caregivers involved—the “second victims”—can be dramatic as well. While to err may be human and forgiveness of clinical missteps divine, health care systems can adopt a range of strategies to ensure impeccable care.

10 CARILION MEDICINE | SPRING/SUMMER 2018 ILLUSTRATION: NEIL STEVENS CARILION MEDICINE | SPRING/SUMMER 2018 11 THE QQUALITY ISSUE

chasing

CarilionZER Clinic is striving to eliminate patient harm completely. BY DAVID BUMKE CATHETER-ACQUIRED URINARY TRACT INFECTIONS ARE A MAJOR PROBLEM FOR HOSPITALS. They can happen whenever patients need to have a urinary catheter inserted into their blad- ders, which is a common procedure, particularly after surgery. These infections, also known as CAUTIs, account for 75 percent of all urinary tract infections in hospitals, and health care professionals have been trying for years to find ways to make them less commonplace. So when Carilion Clinic and its affiliated hospitals decided to address the problem, many observers were skeptical. “People said we couldn’t do it,” said Nancy Agee, president and chief executive officer of Carilion and the current chair of the American Hospital As- sociation, in a recent address to the National Quality Forum. Led by Thomas Kerkering, M.D., medical director of hospital infection control, Carilion introduced protocol changes that have been remarkably effective. With 99 percent

12 CARILION MEDICINE | SPRING/SUMMER 2018 13 compliance from providers, who have embraced a better “You can’t teach your way to safety,” Dr. Gleason says. “Safety approach to something that had been part of their routine for must be built.” The focus needs to be on working with people years, CAUTIs dropped from 101 per year to 77, and Carilion who are already driven to be excellent to improve the systems is currently on track for a 30 to 40 percent reduction again in that may facilitate or even lead to mistakes. 2018. Carilion took a systematic and holistic approach that Carilion has developed a Four Pillars Model for meaningful included introducing transparency about infections. improvement: safety culture, analytics, process improvement, “Our goal was to eliminate all preventable CAUTIs,” and human factors. says Dr. Kerkering, “and we are very close to that with our “We rely on engaged staff to identify opportunities and current numbers.” participate in change,” Dr. Gleason says. “We use analytics to Carilion’s efforts to reduce CAUTIs are part of an aggres- understand our opportunities, performance improvement to sive push to limit harm of any kind. Other initiatives have also redesign care, and human factors and simulation to ensure that borne fruit. By adjusting systems and expanding resources, our care redesign will result in the desired outcome when applied Carilion Roanoke Memorial Hospital has reduced acute inpa- to patients in the environment of care.” tient mortality by 15 percent and surgical site infections after This approach was recognized by the Next Generation common procedures by more than half. The overall Patient Innovator program at the prestigious National Quality Forum Safety Index has improved, and Clostridium difficile infections in March 2018. Carilion is the only health system to have been have fallen to well below national averages. recognized with this honor. Yet Carilion’s goal is to eliminate not just some mistakes, “Modern health care is a complex human-machine interac- but all of them. tion,” Dr. Gleason says. “This gives us the opportunity to build a “In five years, I want Carilion to be recognized as a global clinical operating system that is more likely to achieve the results leader of quality and continuous improvement in health care,” we seek. We use behavioral economics, process improvement, and Agee announced in an address at the International Health human factors design to build better and safer health care.” Forum in Taipei, Taiwan. “Chasing zero is a part of that.” That approach may involve redesigning a test-ordering protocol to reduce infection rates and overtreatment, using artificial intelligence to better identify patients who are at risk Refining the System for being readmitted to the hospital, or systematizing a method Traditionally in health care, when patient safety problems for conversations about end-of-life care. arose, the default response was either to punish the providers “At Carilion, CAPS has taken on a life of its own,” says Dr. Glea- involved or to provide them with more education, says Jonathan son. “For all of us, this is about starting by saying we’re really good Gleason, M.D., vice president of clinical advancement and at what we do. Now, let’s be exceptional. And let’s bring together patient safety (CAPS). Yet as important as it can be to provide all of the resources we have to make that happen. Together, we information and tools to those on the frontlines of medical have to build safety. We’re fortunate to have considerable resourc- Gleason care, that approach wrongly implies that a lack of education is es in quality, analytics, process improvement, human factors, and what leads to errors in the first place. our new Center for Simulation, Research, and Patient Safety.” the gift of the THE NUMBERS ARE DROPPING Carilion Clinic’s aggressive push to limit harm of any kind continues to bear fruit Occurrence 100 NEAR MISS Catheter-Associated Urinary Tract Infections 0 arilion Clinic’s interventional radiology group is trained in both to issues noted in SafeWatch, recognized a trend that called for a system 40 radiology and interventional therapy, two fields that have response. Closer analysis revealed that the error rate during the complex 20 come together as doctors combine imaging and minimally ordering process for certain procedures was 66 percent. “This problem Central Line–Associated Bloodstream Infections C 0 invasive tools to diagnose and treat patients. In 2017, when performing never resulted in harm,” Hall says, “because we have excellent staff who CT-guided procedures, this group experienced a series of near misses. were diligent in identifying any problems in the ordering process.” 200 No patients were hurt, but the potential for harm had been real. Working together, the quality leader, the human factors and process

100 “One of the greatest gifts we get in medicine is a near miss,” says improvement teams, and the interventional radiology department Clostridium Difficile Infections 0 Patrice M. Weiss, Carilion’s chief medical officer and executive vice redesigned the process for ordering the tests. In a matter of weeks, president. “How we respond to it defines our organizational culture.” the error rate dropped from 66 percent to 1 percent.

20 In keeping with the culture of learning and understanding rather “This case illustrates our Four Pillars Model at work,” says Jonathan than blaming, the near misses—reported through SafeWatch, Caril- Gleason, M.D., vice president of clinical advancement and patient 10 Surgical Site Infections After Colorectal Surgery ion’s event-reporting software—were seen as an opportunity. Joseph safety. “These factors—safety culture, analytics, process improvement, 0 DATA: NATIONAL HEALTHCARE SAFETY NETWORK 2015 2016 2017 2018 Hughes, M.D., and Leslie Hall, R.T.R., the team responsible for responding and human factors—seek to achieve safe and reliable health care.”

14 CARILION MEDICINE | SPRING/SUMMER 2018 PHOTO: JARED LADIA CARILION MEDICINE | SPRING/SUMMER 2018 15 “To our knowledge, we are the only health system that has built a mechanism for provider support directly into their event reporting system,” says Dr. Gleason. “For literally every reported “Our ultimate event that occurs in our health system, we have forced ourselves to ask the question, ‘does this provider need support?’” goal is that The TRUST Team reaches out to each second victim by phone or email just to ask how the person is doing. our patients “Everyone gets some kind of contact,” says Neely Conner, L.C.S.W., the practice manager for Carilion Employee Assistance. receive the highest “In working with those second victims, we look at sleep, appetite, support systems, concentration, and focus. We’re probing for quality care each and symptoms of acute distress. Based on that assessment, we may recommend additional support.” every day, that means “This isn’t only about doing the right thing for the people we help,” Conner adds. “It’s also about mitigating further risk.” we can’t just do things Working with a clinician who has been involved in a medical error or adverse event can help relieve stress or other problems the way we were that could affect patient care. It’s all part of developing what Con- taught in school.” ner calls “a culture of safety and compassion and respect.” The response of one doctor, who had undergone a particularly —KIMBERLY CARTER, R.N., PH.D., SENIOR DIRECTOR OF NURSING harrowing experience, has stuck with Conner. RESEARCH AND EVIDENCE-BASED PRACTICE “She was very, very seasoned and had served in capacities that certainly weren’t a walk in the park,” Conner says. “When we got in touch with her, she was so grateful. She said, ‘No one has ever cared enough to reach out and check on me after an event.’ I think was a hook-loop front closure. “Frontline nurses questioned that will stay with me for a while.” whether this was the best bra,” says Dr. Carter. So Kimberly Bolling and Takako Long, nurses at Carilion Ro- “But this isn’t only about doing the right anoke Memorial Hospital, designed a study to compare the stan- Finding Answers on the Frontlines dard of care bra with other options. They found that the hook-loop thing for the people we help. It’s also very In the quest to avoid mistakes, improve care, and enhance patient front closure led to irritation and rubbing, and some patients sim- much about mitigating further risk.” safety, the people who provide that care are in an ideal position ply stopped wearing it. The study, which compared that bra with to notice potential problems and suggest solutions. One grant- two others, discovered a strong preference among postop patients —NEELY CONNER, L.C.S.W., PRACTICE MANAGER FOR CARILION EMPLOYEE ASSISTANCE funded Nursing Research Study, for example, looked at the for a more comfortable bra with a hook-eye closure. They wore it pneumococcal immunization rate for at-risk adults visiting walk- more consistently and reported improved satisfaction. in clinics. The research led to changes that almost doubled the “The result of this study led to a practice change, and patients percentage of patients receiving the vaccination, from 32 percent who have a sternotomy are now given the evidence-based bra put One Carilion priority—improving diagnostic stewardship— fer. At Carilion, the TRUST Team focuses on helping those second to 56.8 percent, thus reducing their risk for the serious health on right in the operating room,” says Dr. Carter. involves managing the high rate of medical testing. The goal isn’t victims, who may experience emotional and physical symptoms. effects of pneumococcal pneumonia. Dr. Carter believes that the research fellowship program both necessarily to do fewer tests but to identify the right tests. TRUST stands for “Treatment that is just, Respect, Under- The Nursing Research Fellowship, run by Kimberly Carter, leads to changes that benefit patients and fosters a culture of ex- “It’s about being very deliberate and systematic about how we standing and compassion, Supportive care, and Transparency and R.N., Ph.D., senior director of nursing research and evidence-based cellence and curiosity that is essential for a thriving, dynamic staff. use certain diagnostic tests,” Dr. Gleason says, “and creating mech- opportunity to contribute.” The TRUST Team’s principal goal is practice, also capitalizes on nurses’ frontline perspective, offering Giving nurses the support to lead their own research projects of- anisms to help our system right-size our testing.” twofold—to identify second victims who may need support and them support in designing, implementing, and disseminating fers yet another way to get to a higher level of patient care. Testing for Clostridium difficile, known as C. diff, shows how counseling, and then to provide that support, including from col- studies that move swiftly from question to research to action. “Our ultimate goal is to provide our patients with the high- that can be done. Diagnostic issues arise when patients who test leagues who may have been in similar situations, as well as from To apply for the yearlong program, nurses must have a est quality care each and every day,” Dr. Carter says. “That means positive for C. diff do not actually have an infection, but are col- mental health professionals and other health care professionals. well-developed idea grounded in a literature review, as well as a we can’t just do things the way we were taught in school. Patient onized with the bacterium. Changes were made to the ordering During its first two years, the TRUST Team received only methodology for testing their hypothesis. Those who are chosen needs, nursing practices, and the resources available are always process and the lab that dramatically reduced testing and over- a handful of referrals of second victims. Since then, the team receive the support of a mentor, take relevant classes, and can take changing. It’s essential to keep asking whether we’re doing some- treatment of C. diff. Similar adjustments in other areas have also has focused on developing systemwide communication about time off from patient care to complete the work. thing a particular way because that’s what we were taught, or be- promoted diagnostic stewardship. the second victim phenomenon and the TRUST Team, as well Many studies in the fellowship program have already had cause it’s the best way to help patients.” as creating referral mechanisms to help ensure all health care a direct outcome on patient care. One initiative compared As the broader health care community continues to pursue im- team members experiencing distress related to an adverse pa- bras for female patients who have undergone a sternotomy, provements in patient care and safety, Carilion aims to go further, Helping Second Victims tient event receive support. in which the sternum is “cracked” open during surgery. With- using every means at its disposal—technology, data, dedicated When a medical episode involves inadvertent error or simply has In April 2017, the Team began using SafeWatch, Carilion’s out proper breast support during recovery, women face sev- staff, support systems, and research. a poor outcome, the primary concern is always for the patient— electronic event-reporting software, which tracks “events” that eral postoperative complications. So, after surgery, patients “We do have an outrageous goal to be the global leader in the first victim. But recent research underscores the damage that might involve second victims, to trigger referrals. That led to 112 must wear a supportive bra for 20 to 24 hours a day. Before quality and patient safety,” says Dr. Gleason. “I think we’re well “second victims”—the medical personnel involved—may also suf- referrals that year, and another 63 in 2018 through mid-March. the study, the only bra that nurses had available for patients on our way. And we’re going to get there.” CM

16 CARILION MEDICINE | SPRING/SUMMER 2018 PHOTOS, THIS SPREAD: JARED LADIA CARILION MEDICINE | SPRING/SUMMER 2018 17 THE QUALITY ISSUE IN GOOD COMPANY: Q Dr. Bryan Collier, (top left), chief of trauma surgery at Carilion Roanoke Memo- rial Hospital, performs a tracheostomy. The human factors research team at Carilion studies the high stakes of teamwork in surgical suites.

A team of experts at Carilion Clinic are researching perfection in health care—and implementing their findings in real time. BY CHARLES SLACK human the factor T’S LATE AT NIGHT IN THE CARDIAC CARE UNIT OF A BUSY hospital. A cardiologist asks the on-duty nurse to administer heparin, a common blood thinner, to a patient at risk for clot- ting. Nearing the end of a long shift, the nurse retrieves a vial from a drawer in the medicine cart and, despite checking the label, mistakenly prepares to administer not heparin but a po- tentially harmful dose of lidocaine, a local anesthetic. What might first appear a clear and unambiguous case of nurse error is actually something more complex. The nurse entered the proper information into the cart’s com- puterized screen and pulled the medicine from the drawer where the heparin is always stocked. Although she checked the label, the nurse saw what she expected to see: heparin, not lidocaine. Did a colleague also err by stocking drawers with the wrong medicines? And while he could have been more careful, did the workers who packed the medicines for the pharmacy err by mislabeling the boxes they came in? Other questions arise: Were the containers of heparin and lidocaine shaped too similarly? Could larger fonts or bolder colors on the labels help distinguish one drug from another? Could the computerized carts be designed and programmed to better detect and prevent mix-ups?

18 CARILION MEDICINE | SPRING/SUMMER 2018 PHOTO: DAVID HUNGATE CARILION MEDICINE | SPRING/SUMMER 2018 19 Considering the hectic, always-on environment of the twen- liberate and tactical in the use of antibiotics, for example, the ty-first century, U.S. hospitals are, by and large, marvels of ef- team has helped Carilion reduce hospital-acquired infections. ficiency. Yet mistakes happen, and in an industry where lives The human factors team is one part of Carilion’s overall com- are at stake, preventable errors are unacceptable. And, as this mitment to advancing patient safety and improving the already hypothetical case illustrate, the problem often reflects not one high standards of care across the system’s seven hospitals and large error but a series of smaller ones that might have been 13,000 employees. Jonathan Gleason, M.D., who oversees these prevented through improvements in processes, training, or efforts as vice president of clinical advancement and patient safe- equipment. The nurse administering the wrong medication is ty, describes them as fully collaborative pursuits. “We’re helping our at the tip of a much larger iceberg of issues hidden beneath the “The goal is for all of us to get better,” Dr. Gleason says. “Pro- caregivers have the surface. Following the many and multifaceted trails, identifying cess improvements start with forming strong relationships with trouble spots, and recommending solutions is the province of staff and building on the idea that we’re really good, but we can right tools, the right an emerging health care field known as human factors. be better. That’s something everyone can get behind.” “Nobody, particularly health care workers, comes to work not decisions, and the right to do their best,” says Sarah Henrickson Parker, Ph.D., director of human factors research at Carilion Clinic and a research assistant Origins of Human Factors filters in place so they professor at the Virginia Tech Carilion Research Institute. “The cli- The study of human factors as a distinct field, though relatively can be in that direct nicians and staff we work with on a daily basis are just incredible.” new to medicine, goes back decades in other high-stress, A human factors approach, then, is not about pointing fin- high-stakes industries. In aviation, for example, human- patient care role more gers or finding fault with specific workers, she adds. Rather, it’s factors research has led to such improvements as better dreds or thousands of employees perform countless daily tasks, about understanding human capabilities and limitations and communication between pilots and crews, enhanced each of which may affect a patient’s safety or comfort. effectively.” designing processes that “make it easier to do the right thing, backup systems to guard against human errors, and more “You’re not only asked to use your skills and training as a nurse — MATTHEW JESSO, HUMAN FACTORS SPECIALIST and harder—ideally impossible—to do the wrong thing.” ergonomically designed cockpit instruments. or physician, you’re also asked to be engaged, one human to anoth- Safely flying a civilian jetliner to its destination and complet- er,” Dr. Parker adds. “This is about people taking care of people.” ing a successful mission at the controls of an advanced military Laurie Wolf, Ph.D., director of human factors implementa- Carilion Takes a Lead Role helicopter are undeniably complex tasks requiring precise use of tion, joined Carilion last October. She had started her career in Carilion has emerged as one of a few health care systems national- instruments, multiple decisions, and accurate communication. ergonomics more than 20 years ago, helping design safer inte- periodic pauses can help health care workers maintain peak effi- ly with a dedicated human factors team, including two Ph.D.-level Health care adds new levels of complexity, Dr. Parker says. Un- riors for automobiles and ergonomic control panels for military ciency. Subjects perform simulated yet stressful tasks. Some are scientists—overseeing studies into making processes, equipment, like the confined environment of a cockpit containing a finite helicopters and tanks. instructed to stop and take a deep breath—to “reset the brain,” and work environments better adapted to the ways that people in number of crew, a hospital is essentially a small city where hun- In health care, Dr. Wolf says, human-factors work was orig- as Dr. Parker puts it—at moments of peak stress. Others pause stressful jobs think and react to rapidly changing events. inally about reducing accidents in order to limit workers com- at random intervals, while still others take no breaks. Under- Launched just over two years ago, the human factors initia- pensation. In the last decade or so, the trend has shifted increas- standing which approach results in the best performance could tive is already having a tangible impact. By helping clinicians ingly to a focus on patient safety. one day help clinicians in a trauma situation or operating room improve placement and care of catheters and become more de- Dr. Wolf adds that she was attracted to Carilion not only by stay at their sharpest during the most demanding procedures. Human factors its clear commitment to researching human factors and devis- Another study investigates the extent to which surgical teams ing ways to apply those findings to improve care, but also by the benefit from prior experience working together. While logic dic- research is not about open culture and eagerness on the part of clinicians and others tates that well-oiled teamwork helps any endeavor, the research- DREAM TEAM: pointing fingers; it’s to identify improvements. ers are mining Carilion’s vast database of process metrics (such as Dr. Sarah “I’ve been impressed with the dedication and expertise of room turnover time) and outcomes (such as duration of surgery Henrickson about understanding people here, and their willingness to share without defensive- and length of stay) from past procedures to examine which spe- Parker (left) and ness,” she says. “People really take this to heart.” cific pairings of operating-room team members—such as surgeon Dr. Laurie Wolf human capabilities and scrubber, or surgeon and circulator—and which types of pro- cedures—whether knee replacement or heart surgery—gain the and limitations and Laying the Fundamentals most when staff members have familiarity with one another. designing processes A centerpiece of the efforts is the Parker Lab, which operates as The idea, Dr. Parker says, is not to evaluate individuals; in part of both Carilion and the Virginia Tech Carilion Research In- fact, in all studies, clinicians are completely anonymized. In- that make it easier to stitute. The lab is devoted to ongoing research into how workers stead, the goal is to gain a deeper understanding that could one behave and respond in stressful situations requiring quick de- day help Carilion and other health care systems deploy staff do the right thing. cisions, multitasking, and teamwork. Some projects are aimed more effectively and with better results for patients. at contributing to our basic understanding of human behavior. — SARAH HENRICKSON PARKER, PH.D., DIRECTOR OF HUMAN FACTORS RESEARCH AT CARILION CLINIC The research combines elements of computational model- ing, organizational psychology, and observation of individuals Found in Translation and teams in highly realistic simulated situations in Carilion’s As those long-term studies produce findings that may pay div- new Center for Simulation, Research, and Patient Safety. idends down the road, the Carilion team is finding ways to im- In one study funded by the Agency for Healthcare Research prove procedures in real time. and Quality, for example, doctoral candidates at the Virginia “Carilion is unique in its dedication to translational human Tech Carilion Research Institute are researching whether brief, factors,” says Dr. Wolf. “What I mean by that is taking concepts

20 CARILION MEDICINE | SPRING/SUMMER 2018 PHOTOS, THIS SPREAD: JARED LADIA CARILION MEDICINE | SPRING/SUMMER 2018 21 in the SIM LAB practice pursues perfect As today’s students become tomorrow’s reproducing just about any hospital situa- both its capabilities and the context in tion. The center, which opened in February, which it is being used.” clinicians, they’re learning replaced the previous 800-square-foot lab. Simulation is increasingly critical in training “Before, we had essentially one room to medical students and residents, says Daniel more and more how to work out of,” Dr. Fortuna says. “Now we have Harrington, M.D., vice dean of the Virginia Tech four. In one room we can be teaching resi- Carilion School of Medicine. “In years past, take care of patients in dents. In another we can be teaching medical students and residents learned how to do pro- from academic studies or laboratories and putting them into an a safer fashion. students, and in still another, nurses.” cedures such as starting IVs or placing central actual hospital setting—bringing them alive, in the real world.” The Sim Lab provides a dual benefit of lines by doing on them on patients,” he says. As director of human factors implementation, Dr. Wolf is tasked — DANIEL HARRINGTON, M.D., VICE DEAN, VIRGINIA TECH CARILION SCHOOL OF MEDICINE training medical teams for their current jobs “Now they learn through simulation.” with evaluating processes at Carilion and working with individ- hen a patient suffers a cardiac and helping Carilion’s human factors specialists And in the Sim Lab, the learning doesn’t ual departments on possible improvements. arrest, it requires fast action learn by watching them. In addition to basic stop with students and residents. Experienced As one example, Dr. Wolf and Matthew Jesso, a human factors W by clinicians trained for such research into how medical workers function in surgeons prepare for situations they hope specialist, have been observing Carilion workers such as nurses By watching teams test equipment under simulated situa- an emergency. Although cardiac arrests are their stressful tasks, the human factors team, they’ll never see, such as a nicked artery that and emergency vehicle dispatchers whose jobs include tracking tions such as this, Dr. Parker says, “We’re actually getting closer most often seen in the emergency depart- led by Sarah Henrickson Parker, Ph.D., uses the could result in potentially fatal bleeding. information on multiple computer screens. Dr. Wolf and Jesso are to the context in which work is actually done.” ment and intensive care units, they can occur Sim Lab to test technologies. “It’s not something that happens often, working on recommendations that could help streamline the in- anywhere in the hospital. “While technologies are great, they’re thankfully, but if it does, it’s a very high-risk formation and potentially reduce the number of monitors. Therein lies a challenge: How can Carilion not always designed for frontline caregivers’ event, and you want to be proficient in it,” “We’re helping our caregivers have the right tools, the right Educating the Next Generation Clinic help ensure that physicians and nurses use,” says Dr. Parker, who serves as senior Dr. Fortuna says. “In the Sim Lab, we can decisions, and the right filters in place,” says Jesso, “so they can With the human factors field evolving so rapidly, specialists in other units, where heart attacks are rela- director of the Sim Lab. “To have the best reproduce those scenarios at any time.” be in that direct patient care role more effectively.” such as Dr. Parker believe its greatest payoffs lie ahead. At the tively rare, are also fully prepared to help a technology in place, we have to understand CarilionClinic.org/carilionmedicine Sometimes, reducing the possibility of error involves some- Virginia Tech Carilion School of Medicine, human factors and patient in need? Enter Carilion’s new Center thing as seemingly straightforward as revising a form. In one patient safety are increasingly a part of the curriculum. Rather for Simulation, Research, and Patient Safety— instance, hospital staff members were having trouble transcrib- than teaching human factors as a separate course, Dr. Parker also known as the Sim Lab­­—which enables ing information provided by outpatient clinics that referred says, the school is incorporating new ideas about teamwork and clinicians to “revive” sophisticated manne- patients to Carilion for treatments. Jesso worked closely with better communication with other clinicians and patients into quins in a highly realistic setting. Carilion’s process improvement experts to better understand everything the medical students learn. Mannequins are more than just patient the problem and develop interventions. That’s an idea that fits perfectly with the school’s innovative, proxies; they are advanced computers that “Each clinic had its own forms, so Carilion staff could be case-based teaching method, says Daniel Harrington, M.D., can blink, breathe, move, and even mimic looking for specific information in the top right or in the middle the school’s vice dean. Instead of focusing just on basic science appropriate physiological responses to clinical of a form, or find it buried in tiny text, or on the third page of a during the first two years, as at many medical schools, Virginia interventions. They can also present a range of document,” Jesso says. “The information wasn’t presented in a Tech Carilion students delve deeply into patient cases and then clinical conditions. standardized way.” teach their peers what they’ve learned. Increasingly, issues of “Repeated practice on these mannequins Beyond straining already busy workers, the process escalat- safety and human factors inform those discussions. has really improved how a range of clinicians ed the possibility of errors or omissions. The solution? A stan- “After hearing about quality and safety, students are able respond to cardiac arrests,” says Timothy dard, one-page cover sheet containing essential information in to go home and do investigations on their own, and then come Fortuna, D.O., the Sim Lab’s medical director. easily identifiable locations. back and teach their classmates,” says Dr. Harrington, a psy- Centrally located in an historic Roanoke Also key for the human factors team are usability studies, chiatrist at Carilion, where he also serves as vice president for building known as the Trolley Barn, which which help them evaluate new technologies or equipment that academic affairs. “When the students enter the clinical phase once housed streetcars undergoing repairs, Carilion is considering acquiring to help ensure that they work of their education, their clerkships have stated goals and objec- the 12,000-square foot Sim Lab features four well with existing systems and that hospital workers won’t find tives about quality and safety.” advanced simulation rooms—including a trau- them burdensome to use. Although a new defibrillator may be As today’s students become tomorrow’s clinicians, Dr. Har- ma bay, an operating room, and two patient a wonder of engineering, if a nurse who does not often use the rington adds, “We’re learning more and more how to take care rooms. And mannequins, while virtually synon- machine misunderstands the indicators on the control panel of patients in a better and safer way than what we had before. ymous with simulation, are just the start. THEY’RE NO DUMMIES: Carilion’s new simulation center offers a range of learning opportunities and accidentally turns the machine off at the wrong time, the There are many great advances coming down the road for Computer rooms, a skills lab, and debrief from advanced mannequins, including a female whose abdomen adjusts to different birthing impact on a patient in distress could be disastrous. Carilion and, most important, for our patients.” CM rooms complete a holistic facility capable of scenarios (top left) and a male programmable for multiple medical emergencies (above).

22 CARILION MEDICINE | SPRING/SUMMER 2018 PHOTOS, THIS SPREAD: JARED LADIA CARILION MEDICINE | SPRING/SUMMER 2018 23 THE QQUALITY ISSUE

The Virginia Tech Carilion School of Medicine’s standardized patient program employs masters of deception to help medical students sharpen their clinical skills. BY CATHERINE DOSS PHOTOS BY JARED LADIA

playing the patient

FTER A QUICK KNOCK ON THE DOOR, A WHITE-COATED YOUNG WOMAN enters the room. “Good afternoon, Ms. Water,” she says. “My name is Lisa Crisalli, and I’ll be taking care of you. What’s brought you in today?” It sounds like the start of a typical doctor’s appointment, but it’s a centerpiece to the clinical training students receive at the Virginia Tech Carilion School of Medicine. The medical school has ten identical rooms, each set up like a typical exam room at a doctor’s office. Yet if you look up, you’ll no- tice two cameras mounted on the walls. The rooms are where med- ical students learn how to conduct clinical exams, and the cameras provide a means for evaluating their patient encounters. Students have on average one required standardized patient en- counter every week through the first two years of school, with oth- er opportunities for practice sessions and further training in years three and four. “Our program is longitudinal,” says Heidi Lane, Ed.D., senior director for clinical skills assessment and education at the medi- cal school. “We try to correlate the simulated medical conditions with what students are studying elsewhere in the curriculum at any given time.” 24 CARILION MEDICINE | SPRING/SUMMER 2018 a CARILION MEDICINE | SPRING/SUMMER 2018 25 the stage The Virginia Tech Carilion School of Medicine has ten fully equipped examination rooms in which medical students can practice their skills on standardized patients in a controlled, risk-free environment.

the actors

Standardized patients help medical students learn to think critically. The “patients” begin with a back story—a complete medical history—and a script. They also learn how to move their body like a patient with their assigned complaint would and how to react to the physical examination in character. Left: First-year student Ryan Perry performs an exam on standardized patient Linda Dane. Below: A medical student performs an eye exam on standardized patient Jeff Edwards, while student Dixon Lee watches.

“The feedback from standardized patients is one of the best parts of the program,” she says. “They act not only as convincing patients, but also as educa- tors, providing insights into process and technique. They are attentive, encourag- ing practice of a skill until it is perfected.” Tarin Schmidt-Dalton, M.D., associ- Carilion School of Medicine is one of the Dr. Lane’s program employs a tightknit Students thrive on the training, prac- ate dean for clinical science years 1 and 2, most comprehensive. group of dedicated professionals who em- tice, and evaluation. Beginning with its says integration of the school’s standard- In addition to the usual cadre of stan- body the concept of quality assurance in first class, the school has an unbroken ized patient program into its curriculum dardized patients are ones who have been everything they do. In addition to regu- record of a 100-percent pass rate on the blocks provides a powerful learning tool. certified as physical teaching associates lar encounters, students are offered prac- USMLE Step 2 Clinical Skills exam. “Early exposure to patient scenarios by undertaking additional intensive phys- tice times with standardized patients and Zakk Walterschied, a member of the is critical for developing effective, ical exam training based on the guide- physical teaching associates. Video record- Class of 2018, recalls the moment that patient-centered communication and lines from which the students themselves ings of patient encounters are painstak- made him realize what an important physical examination skills,” she says. learn. After mastering the art of teaching ingly reviewed, and feedback and remedia- part of his education standardized pa- “It also helps students integrate content physical exam methods, these associates tion are offered. In addition, standardized tients had been. “When I went for my from the basic science disciplines, such teach, assess, and give feedback on details patients are active in giving feedback. Step 2 exam, I saw medical students who as physiology and anatomy, and apply such as the exact spot to palpate and the Crisalli, a member of the school’s had never worked with a standardized their knowledge in a fun, clinically correct amount of pressure to use. Their Class of 2020, says standardized patients patient before,” he says. “That was so engaging environment.” work allows faculty members to teach the help students improve their clinical tech- foreign to me. Our Fridays consisted of Although most medical schools have implications of findings and special types nique, especially with minor yet critical working with standardized patients.” a standardized patient program, Dr. Lane of physical exam maneuvers. It’s a win- adjustments that might be difficult to “We are teaching our students how to says the program at the Virginia Tech ning solution for all. coach on the clinical units. think critically,” Dr. Lane says. “By the

26 CARILION MEDICINE | SPRING/SUMMER 2018 CARILION MEDICINE | SPRING/SUMMER 2018 27 end of a physical exam, they need to be to work as a team to treat the patients, able to say, ‘This is what I know from the who offer real challenges in real time, such exam, this is what I don’t know, and this as unrecognized internal bleeding. is what I need to know to rule out or con- The methodology of using standard- firm diagnosis.’” ized patients began about 40 years ago as Dr. Lane added that even though stu- a means to counteract the difficulty of -ac dents learn theoretical underpinnings in quiring real patients who had the type of lecture sessions, applying those princi- medical issues a student needed to learn ples to a real person can be different. at any given time. With standardized pa- “They may know how to do a physi- tients, every student is able to learn the cal exam when they’re practicing with a same medical condition that is consis- friend, but when they get someone they tently portrayed. don’t know, and they have to think on “A standardized patient program al- their feet, sometimes it just flies out of lows students to make mistakes in a safe their head,” she says. “This is why we’re environment,” Dr. Lane says. “They can here to evaluate how they did and offer ask questions and perform physical exam help if they need it.” maneuvers incorrectly without their fac- The Virginia Tech Carilion School of ulty member watching them.” Medicine’s standardized patient program Dr. Lane, herself, is internationally is also unique in its close involvement known for her expertise in establishing with the school’s interprofessional cur- and managing standardized patient pro- riculum. Interprofessionalism—one of grams. She arrived at Virginia Tech Car- the school’s four value domains, along ilion with an impressive breadth of expe- with basic science, clinical science, and rience as a senior standardized patient research—emphasizes service learning trainer. She was actively involved on the and team-building activities that involve task force for standardized patients with medical students and students in a range the National Board of Medical Examin- of academic programs at Jefferson College ers to set up training and implementa- of Health Sciences—including nursing, tion protocols as they were developing physician assistant, respiratory therapy, the USMLE Step 2 exam. emergency services, and public health. In 2013, Dr. Lane was recognized by Ka- One highlight each spring is a daylong zan State Medical University in Russia for disaster training drill that uses standard- her work developing a standardized patient ized patients in intense, high-energy sce- program as part of that school’s curricu- narios. During the drill, the students have lum. Established in 2000 by Lane and Beth

behind the scenes The examination rooms at the Virginia Tech Carilion School of Medicine allow live monitoring of student encounters with standardized patients, as well as recordings of sessions, to allow students to perfect their interactions. Clockwise from top: In the nerve center, Elizabeth Briere, left, standardized patient trainer, and Taylor Lynch, clinical skills manager, watch and take evaluation notes on a clinical encounter; Sharita Brown, left, clinical skills coordinator, demonstrates proper palpation technique for Jeff Edwards, physical teaching associate, on standardized patient Linda Dane; and, from left, medical students Morgan Julian, Dixon Lee, and Keri Godbe practice clinical skills on a standardized patient.

Ipock, MA.Ed., M.S.W., director of clinical Dr. Lane says many of the school’s she finds the job the perfect post-retire- skills assessment and education, with ad- standardized patients play the part as a ment solution. ministrators at Kazan, it was the first such way to give back because they appreciate “I love being in a medical environment, program at any Russian medical school. the local medical community. and I love being around young people who The partnership quickly evolved into an Others, like Linda Waters, who has are striving to become good doctors,” she international rotation exchange program been in the role for seven years, want to says. “It’s interesting, mentally stimulat- between the Virginia Tech Carilion School remain busy and active. After 35 years ing, and fun. And I feel like I’m an ambas- of Medicine and its Russian counterpart. working as a physical therapist, she says sador for the medical school.” CM

28 CARILION MEDICINE | SPRING/SUMMER 2018 CARILION MEDICINE | SPRING/SUMMER 2018 29 A T A L C I T I E S Carilion reach ANI ILLUSTRATIONS BY GRACIA es be E RET LAM yond clin O SICA CER ic ES wall O BY J s to p W ties. a F ni rt T u ner mm with local o erserved co rganizations in helping medic ally und

CARILION MEDICINE | SPRING/SUMMER 2018 31 A PRESCRIPTION FOR CHANGE It’s something most of us take for granted, whether To help improve Roanoke’s diet, Carilion Clinic, in we’re simply relying on it for fuel or enjoying a partnership with Healthy Roanoke Valley, offers its t the top of Mill Mountain, the illuminated Roanoke Star casts delicious meal. Yet for many people, accessing fresh, Fresh Foods Prescription Program in two locations. wholesome food is an everyday struggle. According to The program targets overweight and obese adults at a bright neon gleam over the city below. Though the icon has some estimates, more than 1.7 million Virginians live in risk for diabetes and includes weekly health education overlooked Roanoke City for nearly 70 years, these days, the food deserts, areas where residents tend to have low classes as well as prescriptions and cash vouchers to glow seems a little more auspicious—especially to those who incomes, lack transportation, and live more than one buy fresh food at the practices’ weekly mobile markets. are working hard to ensure that the area’s residents have the mile away from a supermarket. With poor access to So far, the results are promising: More than 60 per- same opportunities for good health as their neighbors. good food, families may rely on convenience store and cent of participants have decreased their body-mass fast food offerings, which can contribute to obesity, index and hemoglobin A1C measures, while half have Despite their proximity, Roanoke City and such as income, education, neighborhood safety, diabetes, and other chronic conditions. lowered their blood pressure. Roanoke County have vastly different characteristics. and access to food and stable housing have a strong As recently as 2015, the former was ranked 123 out influence on overall health and life expectancy. of 133 in the Robert Wood Johnson Foundation’s According to one meta-analysis of nearly 50 annual health rankings for the state of Virginia. Yet studies, social determinants of health account for Roanoke County was considered one of the healthier about one-third of total deaths in the United States areas with a rank of 12. each year. The difference between longevity and pre- It’s a discrepancy that doesn’t sit well with the mature death can stem from problems as diverse as Carilion Clinic community, says Shirley Holland, a lack of transportation to medical appointments, a vice president of planning and community de- dearth of safe walking areas in neighborhoods, velopment at Carilion. A 5 percent and limited access to fresh, wholesome food. “These two areas border each other,” reduction in the Prevention plays a key role, too. she explains. “Within the shadow of incidence of hypertension— Recent statistics from the U.S. Sur- our largest hospital, we have a zip geon General underscore the impact code where almost 40 percent of through lifestyle measures of taking a proactive approach to residents live below the federal pov- such as decreasing dietary health, on both quality of life and erty level, in what’s deemed a ‘medi- sodium—could save the health expenditures: For instance, cally underserved area.’ Are we okay just a 5 percent reduction in the in- with that?” country an estimated cidence of hypertension—through The answer, it turns out, is “no”— $25 billion in lifestyle measures such as decreasing and that refusal to accept such health five years. dietary sodium—could save our coun- disparities as normal has led Carilion to try an estimated $25 billion in five years. look beyond its walls, reaching out to the sur- Likewise, increasing physical activity has been rounding communities. shown to reduce the risk of developing type 2 dia- “The acute care we provide—in the hospital, betes by 58 percent, potentially leading to tremen- in the emergency department, in urgent care cen- dous savings in a country where one of every five ters—is and will continue to be important,” says health care dollars is spent on diabetes care. Holland. “But is it enough?” “We’re increasingly recognizing that many dif- ferent factors contribute to health,” says Holland. “It’s time for us to invest more in our communi- Beyond Clinical Care ties—in prevention and wellness—so we’re ad- It’s clear that clinical care is just one of many fac- dressing these factors long before people come to tors that determine good health. Indeed, elements the hospital.”

32 CARILION MEDICINE | SPRING/SUMMER 2018 CARILION MEDICINE | SPRING/SUMMER 2018 33 Inspired Solutions tine health screenings, immunizations, and even says Robert Trestman, M.D., Ph.D., chair of psy- With so many intertwining aspects of health, a chronic disease management. chiatry and behavioral medicine at Carilion and multipronged approach is necessary, says Kimber- EXPERT INSIGHTS “We see this as an opportunity to reinvent co-chair of the task force. “As clinicians, we’ve ly Dunsmore, M.D., Carilion’s chair of pediatrics. school nursing programs,” says Dr. Dunsmore. unwittingly contributed to the problem by over- “No one institution can fix very complex issues “As clinicians, we’ve Although the proposed program is still in prescribing these drugs. Now we believe it’s partly like these,” she explains. “The really lovely Increasing the early planning stages, supporters are our responsibility to help solve it.” unwittingly contributed to thing about Roanoke is that the popula- optimistic that Carilion and other po- On the task force’s agenda: creating a the problem by overpre- tion is so diverse—we look like Amer- physical activity tential partners will support its cre- multidisciplinary approach to pain management, ica—and Carilion can leverage many has been shown to reduce scribing these drugs. Now ation. By tackling diseases that start using electronic health records to guide different resources that allow us we believe that it’s partly the risk of type 2 diabetes in childhood, they hope to stem the prescribing practices, educating patients and all to work together for innovative tide of chronic conditions affecting providers about the problem, and embarking on our responsibility to help change.” by 58 percent, potentially Roanoke adults. For instance, Dr. research into innovative approaches to addiction. solve it.” One such example involves the leading to savings where Dunsmore envisions regular screen- Over time, Dr. Trestman explains, residents —ROBERT TRESTMAN, M.D., PH.D., CHAIR OF PSYCHIATRY AND BEHAVIORAL MEDICINE AT deployment of community health one of every five dollars ing programs for respiratory health struggling with opioid dependency can begin to CARILION AND CO-CHAIR OF THE OPIOID TASK FORCE workers to Southeast and North- is spent on diabetes and blood pressure, which might help expect better integration of medical management west Roanoke, which are designat- ward off emergency room visits for asth- and psychotherapy and improved access to social ed as medically underserved areas. In care. ma attacks and future cardiovascular disease. support agencies. partnership with Healthy Roanoke Valley, a “We’ve been asked by the Roanoke City “We need to help them get through their im- community coalition housed under United Way, “The really lovely thing school system to have a more vibrant interaction mediate challenges,” he says. “Then there’s a lot of Carilion helps place these specially trained pro- with them,” Dr. Dunsmore explains. “We see this hope for people.” about Roanoke is that the fessionals, who encourage patients to advocate idea as an opportunity to provide kids with proac- population is so diverse— for their health and wellness. That can mean help- tive interventions before they become ill.” ing patients get insurance or job training, finding Signs of Progress we look like America—and transportation to medical appointments, or con- Today, there’s also a change in the air: the Robert Carilion can leverage necting them with primary care providers to cut Collaboration and Coordination Wood Johnson Foundation’s health rankings for many different resources down on emergency room visits, for instance. Other initiatives are aimed at addressing issues 2018 place Roanoke City further up the list at 112. that allow us all to work The Virginia Health Care Foundation funded an such as substance abuse, which can also have an It’s a slow yet promising climb: “It took decades for together for innovative change.” 18-month pilot study of this coordination-of-care impact on physical health. In 2016, the Gover- us to get here, and it’s going to be a long road out,” program, and the results suggest that its impact nor’s Office declared the Virginia opioid addiction admits Dr. Dunsmore. “But these small improve- —KIMBERLY DUNSMORE, M.D., CHAIR OF PEDIATRICS AT CARILION can be significant. Of the 245 patients served, crisis a public health emergency. For Carilion, the ments speak to the progress being made.” emergency room visits decreased by more than 60 crisis has hit close to home: About 15 percent of She’s hopeful that the future holds even more percent, while charity care costs dropped by about Roanoke City’s population has admitted to recent good news for Roanoke patients, as long as Car- $500,000. Based on these promising outcomes, heroin use, and Southwest Virginia has the state’s ilion continues to collaborate within and outside “We’re increasingly says Holland, the program plans to expand to in- highest overdose mortality rates. its walls. “Solving such a complex set of prob- recognizing that many dif- clude additional community health workers. That grim scenario has spurred Carilion’s lead- lems requires different skills sets, from medicine A similar strategy is in the works to bring ership to assemble a comprehensive Opioid Task to community development to government,” she ferent factors contribute preventive care to children and families in the Force to confront opioid abuse from multiple an- says. “In this case, it doesn’t just take a village to to health. It’s time Roanoke City school system. While Carilion al- gles. Clinicians and other experts from specialties effect change—it takes a city, and the Star City is for us to invest more in ready provides nurses to these schools, their as diverse as emergency medicine, pain, psychia- the perfect place to do that.” our communities—in pre- current role is largely limited to caring for kids try, research, information technology, and public Holland agrees. “We’re learning how important with acute illness—a stomachache or fever, for policy are banding together to provide an orga- real partnerships are,” she says. “We can’t just go vention and wellness—so example. Holland and Dr. Dunsmore have a much nized response to the epidemic. into the community and change people’s health. It we’re addressing these factors broader vision: They hope to establish schools as “Carilion had already been doing a lot of good has to be a collaborative effort. It takes everyone long before people come to the hospital.” wellness hubs, where students and their families work in this area, yet the groups involved weren’t together to make a difference—and that starts —SHIRLEY HOLLAND, VICE PRESIDENT OF PLANNING AND COMMUNITY DEVELOPMENT have access to a variety of resources, such as rou- necessarily approaching it in a coordinated way,” with each one of us.” CM AT CARILION

34 CARILION MEDICINE | SPRING/SUMMER 2018 PHOTOS: JARED LADIA (DRS. TRESTMAN AND DUNSMORE) AND DARRYLE ARNOLD (HOLLAND) CARILION MEDICINE | SPRING/SUMMER 2018 35 EXTENDING THE TEAM: Physician assistant Joel Bashore oversees the development of advanced clinical practitioners in Carilion Clinic’s emergency department.

WITH BABY BOOMERS AGING AND THE Affordable Care Act extending health care coverage to many of the previously uninsured, demand for clinical care in the United States is at an all-time high. More patients mean more office visits— and physicians alone cannot meet the in- creasing need. It’s a problem that taxes our health care system—and could over- whelm it were it not for an important group of players on the clinical care team: advanced clinical practitioners, or ACPs. ACPs are licensed medical profes- sionals—primarily physician assistants and nurse practitioners—who hold ad- vanced degrees and typically practice medicine in collaboration with physi- cians. Under the Affordable Care Act, ACPs have been recognized as prima- ry care providers, and they’re becom- ing increasingly responsible for routine office visits and frontline care. In some states, including Virginia, they even main- tain their own, separate panel of patients.

Adjusting for growth// AS THE DEMAND FOR CARE GROWS, CARILION IS EXPANDING THE ROLE OF ADVANCED CLINICAL PRACTITIONERS TO IMPROVE PATIENT ACCESS TO QUALITY CARE. BY VERONICA MEADE-KELLY

CARILION MEDICINE | SPRING/SUMMER 2018 37 At Carilion, the number of ACPs has grown roughly 40 percent al departments, and fellows work clinical shifts under the close over the past five years to roughly 350. Collectively, ACPs han- Building the Talent Pool supervision and tutelage of senior, experienced clinicians in that Trusted Partners dled greater than 20 percent of the nearly 400,000 patient en- In giving this once-ancillary group of caregivers a more central specialty. Like a physician’s clinical rotations or postgraduate fel- The elevation of ACPs has also led to their inclusion in deci- counters at Carilion Clinic last year alone. role in patient care, this new model also tacitly calls for more lowship, the ACP fellowships are compressed training experiences sion-making bodies across the Carilion system. “We have ACPs in pretty much all medical and surgical ar- and more specially trained medical professionals. that provide a more intense, structured, and focused learning op- In 2014, Howell, Bashore, and others helped form Car- eas of Carilion,” says Patrice Weiss, M.D., Carilion’s chief med- Traditionally, ACPs have learned on the job after leaving portunity than a new ACP would regularly receive on the job over ilion’s first ACP Council, made up of ACPs across specialties ical officer. “They are vital members of the health care team, graduate school. For any given specialty, that could mean an several years. And, there’s an opportunity for trainees to stay on and institutions. As a body, the council provides a forum for and they’ve heightened our ability to provide our patients ac- ACP might work two to four years, depending on assignments at Carilion after the completion of the program. discussion and development of policy initiatives important cess to care.” and job responsibilities, before feeling comfort- “It benefits both the system and the candidate: if the trainee to ACP scopes of practice. The council also offers an advisory Once viewed more as support staff, ACPs able enough to work autonomously. At Carilion, is contemplating staying, the fellowship serves essentially as a channel to executive administration about ACP practice and have taken on added responsibilities in recent a series of fellowship programs is changing that. one-year job interview,” Bashore says. “Trainees are a known role development systemwide. years and now enjoy what could be described In 2012, Howell and colleague Joel Bashore, quantity to the staff and, if the fellows are a good fit and choose ACPs have been added to committees and advisory boards as collaborative autonomy, shouldering more P.A.-C., the ACP manager for Carilion’s Depart- to stay, they are in position to make the transition seamlessly.” such as the Medical Education Committee and the Carilion of the day-to-day decision-making in the clin- ment of Emergency Medicine, proposed a novel Perhaps the most novel facet of the fellowships is that Centralized Credentialing Committee. At Carilion New Riv- ic as they work alongside physicians and other program that would offer ACP trainees a year of they are open to both physician assistants and nurse practi- er Valley Medical Center, ACPs are now voting members of health care providers. intense, specialized training—in their case, in tioners—groups whose training has traditionally remained the medical staff and, throughout Carilion, ACPs are finding “At Carilion, physicians view ACPs as part- emergency medicine—to more efficiently and -ef separate. The decision recognizes the reality that, in the clini- themselves in more leadership and management positions ners,” Dr. Weiss says. “It’s very much a team fectively prepare them to be autonomous health cal setting, physician assistant and nurse practitioner respon- than they did in the past. concept for health care delivery.” care providers in their medical area of interest. sibilities are similar in the patient care context. “It’s a recognition that ACPs bring a great deal to the table That model, argues J. Randy Howell, The department welcomed its first three fel- “Clinically speaking, in our emergency department, be- as health care professionals,” Bashore says. “We aren’t just an- D.H.Sc., P.A.-C., an emergency medicine phy- “We aren’t just lows in 2013, and soon the model caught on. In cause of the identical roles they fill, the only way you can re- cillary staff anymore. ACPs are dedicated, hard-working pro- sician assistant at Carilion, epitomizes the ancillary staff just five years, Carilion has expanded the pro- ally tell the difference between physician assistants and nurse fessionals who truly care about our patients, our community, oft-cited ideal of “patient-centered care.” anymore. ACPs gram to include ACP fellowships in orthopaedic practitioners is to get close enough to read their badges,” says and the success of our organization. Our inclusion in institu- “Gone are the days of the solo physician are dedicated, surgery, urgent care and rural health, acute care Howell, who, in addition to co-founding the ACP fellowship tional decision-making says that we deserve as much of a voice practicing out on their own,” Howell says. “To hard-working surgery, and wilderness medicine. program, is director of Carilion’s emergency medicine fellow- as anyone on the team.” fill the unmet health care needs in this country, professionals who While the fellowships coordinate some basic ship for ACPs. “Physician assistants and nurse practitioners For their part, Dr. Weiss and other Carilion leaders believe what you’re seeing at Carilion and other hospital training and share a common start- and end-date, do essentially the same work—and they do many of the things that the success of the organization and the success of ACPs systems is this team approach, with patients at truly care about each fellow is immersed in his or her specialty that physicians do.” are very much interdependent. the center of this large group of health care pro- our patients, our and completes rotations in various subspecialties Recognizing that overlap, Howell argues, reflects Carilion’s “As the population ages and as it continues to grow, health fessionals—physicians, nurses, physician assis- community, and throughout the year. The orthopaedic surgery dedication to interprofessional practice and the “team” view needs are increasing throughout the country,” Dr. Weiss says. tants, nurse practitioners, nurse midwives, cer- the success of our fellow, for instance, might rotate between hand of health care delivery. “As we expand the number and roles of ACPs at Carilion, we’re tified registered nurse anesthetists, and many organization.” surgery, sports medicine, and joint replacement “Our goal is to provide excellent care for patients, so any- going to remove some of the barriers that would otherwise others—all working together to optimize quali- at various points in the fellowship. thing that we can do to get rid of barriers between our respec- limit patients’ access to care. Our care providers will take care —JOEL BASHORE, P.A.-C., MANAGER OF ty and access to care. Patients really benefit from ACPS, CARILION DEPARTMENT What is common to all the programs is the gen- tive professions is incredibly important,” he says. “We want of more patients, and the quality of care will continue to im- this collaborative, interprofessional approach.” OF EMERGENCY MEDICINE eral structure: the programs are run by individu- our team to work collaboratively to enhance patient care.” prove as we work together to treat patients as a team.” CM Assistance, please THE ROLE OF ADVANCED CLINICAL PRACTITIONERS IN THE UNITED STATES HAS GROWN ALONGSIDE THE HEALTH NEEDS OF AMERICANS THROUGHOUT THE COUNTRY’S HISTORY.

he story of advanced clinical physician assistants, are many and varied. In hills and hollows of Kentucky with midwives. Many credit that formalization to Eugene than a decade later, he created a “physician’s practitioners in the United States the military, there were Navy hospital mates There were also hospital aides, such as Vivien Stead, Jr., M.D., who, after using medical assistant” program at Duke University to is rooted in need: whether on modeled after the 19th-century “loblolly Thomas, a surgical technician renowned for students and residents to staff Atlanta’s employ medically-trained military corpsmen. the frontier, in the wilderness, on boys” who assisted physicians in the British his pioneering techniques in cardiac surgery. Grady Hospital during World War II, became The first nurse practitioner training program the battlefield, or in remote, rural Royal Navy, as well as field medics, the real- Advanced clinical practitioners weren’t convinced that trained support staff could was recognized two years later, when a regions, these medical care pro- life equivalent of such cinematic characters formally recognized professionally in the fill gaps in health care delivery public health nurse, Loretta Ford, and a Tviders have, throughout history, stepped in as Corporal Irvin Wade in Saving Private Ryan. United States until the latter half of the In 1957, Dr. Stead partnered with resident pediatrician, Henry Silver, M.D., founded a to help wherever and whenever there were On the home front, there were groups twentieth century, though, when demand nurse Thelma Ingles, R.N., to develop the program at the University of Colorado. not enough doctors to go around. like the Frontier Nursing Service, which for health care rapidly outstripped the first master’s degree program for nurse The role and recognition of advanced MISSION CRITICAL: The Second World War Antecedents to modern advanced clinical nurse-midwife Mary Breckinridge founded supply of trained medical doctors following clinicians. Although the program was denied clinical practitioners has continued to helped demonstrate the wisdom of using practitioners, such as nurse practitioners and in 1925 to provide expectant women in the the institution of Medicaid and Medicare. accreditation, he remained undeterred. Less expand ever since. medics with different backgrounds.

38 CARILION MEDICINE | SPRING/SUMMER 2018 PHOTOS: JARED LADIA, PREVIOUS SPREAD; MARK LAMBERT, ABOVE PHOTO: COURTESY OF THE NATIONAL ARCHIVES CARILION MEDICINE | SPRING/SUMMER 2018 39 KEEP A M

AND C L C A R R Y ON

Virginia Tech Carilion Research Institute scientists record the first clear evidence of the interplay between serotonin and dopamine in humans. BY ASHLEY WENNERSHERRON

40 CARILION MEDICINE | SPRING/SUMMER 2018 CARILIONCARILION MEDICINEMEDICINE | SPRING/SUMMER 2018 41 CIENTISTS AT THE VIRGINIA scious human subject. The analysis pro- Dr. Kishida, now an assistant pro- “Serotonin acts in a way that reminds sistant professor of surgery at the Virginia Tech Carilion Research vides new understanding of serotonin’s fessor in the departments of Physiology us to pay attention and learn from bad Tech Carilion School of Medicine. Institute have begun role in regulating human choice and how and Pharmacology, as well as Neurosur- things, and to promote behaviors that The work is critical. According to the to unravel how sero- it operates alongside dopamine, a neu- gery, at Wake Forest School of Medicine, are less risk seeking but also less risk National Institute of Mental Health, S tonin acts, based on data rotransmitter long associated with re- is developing this work with larger pa- averse,” Dr. Moran says. “When there’s more than 10 million adults in the collected in a first-of-its- ward and its reinforcement. tient cohorts and increasingly realistic an imbalance of serotonin, you might United States have suffered at least one kind experiment that used electrochem- “This is the first clear evidence, in any environments. hide in a corner or run toward the fire, major depressive episode. About half ical probes implanted into the brains of species, that the serotonergic system As the research subjects played the when you should really be doing some- of those people take antidepressants, awake human beings. acts as an opponent to dopamine signal- investment game, serotonin appeared to thing in between.” which primarily consist of selective se- The neurotransmitter serotonin is ing,” says Read Montague, Ph.D., senior act as a caution signal to prevent them The researchers refer to this middle-of- rotonin reuptake inhibitors. The drugs associated with mood and helps shape author on the paper and director of the from overreacting to an outcome. As the the-road behavior promotion as a “keep are designed to keep serotonin at ele- the decisions we make. Human Neuroimaging Laboratory and neurotransmitter is implicated in preva- calm and carry on” motif. Here, serotonin vated levels in the brain by limiting the The readings were collected during the Computational Psychiatry Unit, both lent neuropsychiatric disorders, includ- appears to temper excitement over posi- neurotransmitter’s reabsorption. brain surgery as patients played an invest- at the Virginia Tech Carilion Research ing depression, the researchers aim to tive outcomes while softening the poten- “People take drugs to manipulate their ment game before receiving deep brain Institute. “If a person didn’t expect a uncover how the chemical aids humans tial disappointment of negative outcomes. serotonin when they have such low levels stimulation as a treatment to try to allevi- positive outcome in the game but they in developing adaptive actions. This process can go awry when the neu- they can’t work or they may even be a sui- ate symptoms of Parkinson’s disease. received one, dopamine goes up while se- “We found that serotonin is highly ac- rotransmitter levels aren’t in balance. cide threat,” Dr. Montague says, noting The study, conducted in collaboration rotonin goes down.” tive in the part of the brain that helps us The research team will soon begin that prior to his team’s work, the best with Wake Forest School of Medicine, Kenneth Kishida, Ph.D., co-first au- to navigate bad outcomes in a way that data collection at Carilion Clinic, through measurement tool for serotonin was pos- appears in the May 2018 issue of Neuro- thor on the paper and a research scien- ensures we don’t overreact to them,” says collaboration with Mark Witcher, M.D., itron emission tomography, or PET, scan- psychopharmacology, a publication in the tist at the institute at the time of data Rosalyn Moran, Ph.D., now a reader at a functional neurosurgeon. Dr. Witcher, ning, which measures one point every two Nature family of journals. collection, worked directly with neuro- the Institute for Psychiatry, Psychology, who is also an author on the paper, be- minutes. “Now, we can measure a point The research provides the first-ever surgeons at Wake Forest School of Med- and Neuroscience in King’s College Lon- came a collaborator on the project when ON THE BRAIN: Dr. Read Montague every 100 milliseconds. It’s a completely focuses his work principally in the field of recordings of simultaneous sub-second icine to take measurements of patients don. At the time of the data collection, he was the chief surgery resident at Wake computational psychiatry, which offers different ballgame in terms of the time re- fluctuations in dopamine and serotonin undergoing deep brain stimulation who Dr. Moran was an assistant professor at the Forest School of Medicine. He is now an a new, mathematically based lexicon for gime that we’re in and the implications for during active decision-making in a con- volunteered to take part in the study. Virginia Tech Carilion Research Institute. attending physician at Carilion and an as- understanding mental disorders. understanding human behavior.” CM

Measure for Measure To record dopamine and, more recently, serotonin signals in “We analyzed the dataset of about a thousand pulses of neurons appear to track whether something could have been better “We married two known computational models into something sub-second fluctuations for the first time took decades of prepa- dopamine, and it was flat,” says Dr. Montague. “The signals did not or worse, and this information is encoded by the rapid changes in do- new,” Dr. Montague says. “In doing so, we found dopamine tracking ration—and ingenuity. The research team that achieved those distinguish between a positive reaction and a negative one.” pamine release. These findings may start to reveal, in computational and combining two streams of information into one chemical pulse.” landmark readings had to develop extremely sensitive methods. The scientists used fast-scan cyclic voltammetry to measure the terms, what’s missing in the dopamine system of Parkinson’s patients.” Now that researchers have measured multiple contributions to Led by Read Montague, Ph.D., director of pulses of dopamine in the patients’ brains. This The findings have been more than 20 years in the making, since the individual dopamine signals, they have even more pathways the Human Neuroimaging Laboratory and the electrochemical technique allows for near-con- Dr. Montague’s first computational studies examining the mecha- to explore the human brain’s learning systems in health and disease. Computational Psychiatry Unit, both at the Vir- tinuous measurements of chemical activity in nisms of dopamine signaling. Since their initial sub-second recordings of dopamine in 2015, ginia Tech Carilion Research Institute, the team the brain. In this case, it was used to measure “Dopamine encodes what are called reward-prediction errors— Dr. Montague and his colleagues have worked to understand modified a carbon fiber electrode previously the dopamine signaling 10 times each second, the ongoing difference between reward expectations and the actual whether their discovery applies to people who don’t have Par- used to measure dopamine fluctuations in ro- for several minutes, while patients made finan- rewards experienced,” Dr. Montague says. “From just dopamine signals, kinson’s. The scientists’ prior research, using functional magnetic dents. They adapted the electrode to interface cially risky decisions. we can see when a person expects a reward and whether the person resonance imaging, suggested that the new model should hold with the surgical needs of the clinical proce- Once the researchers had the measure- receives the reward. But we found this earlier model of reward-predic- true in healthy individuals as well. Yet the previous work lacked the dure in humans, to reduce the risks and surgical ments, they started to analyze what the tion error to be incomplete. Rather, dopamine pulses appear to com- precision of the team’s new measurements. time for the patients. Surgeons then placed the dopamine was actually signaling. They used bine information about what might have happened with information “Dr. Montague’s innovations in recording dopamine and serotonin electrode in each patient’s striatum, near the center of the brain. new machine-learning methods, which employ several computation- about what actually happened. This is an entirely new way of viewing signals offer a breakthrough, and I don’t use that word lightly,” says The researchers took readings of ultra-quick dopamine pulses al tools that help scientists dive deeper into data and emerge with the role of dopamine signaling in the human brain.” Michael Friedlander, Ph.D., executive director of the Virginia Tech as conscious patients played an investment game. The scientists more nuanced information. The idea that “what could have been” is part of how people evaluate Carilion Research Institute. “Being able to take precise, real-time expected to see dopamine responses in direct relation to expected “We found that dopamine tracks two factors—what happened actual outcomes is not new. Yet no one expected that dopamine would measurements in the living human brain will help us understand the rewards and actual outcomes. They didn’t. and what could have happened,” Dr. Montague says. “Our dopamine be doing the job of combining this information in the human brain. mechanisms of decision-making in health and disease.”

42 CARILION MEDICINE | SPRING/SUMMER 2018 IMAGES: ISTOCK (LEFT); DAVID HUNGATE (ABOVE) CARILION MEDICINE | SPRING/SUMMER 2018 43 the art of medicine A MESSAGE OF MIRTH The “Laughter Is the Best Medicine” art show included selections from photographer Alejandra Moral’s “We the Women,” a series of images of women expressing joy. Through these portraits, Moral seeks to empower future generations of women, to inspire them to chase their dreams and to remind them that together they can shape a new society A CONTAGION free of gender norms and stereotypes. “I create photographs that speak beyond the image,” she writes, “beyond the standardized beauty of women, and tell stories of growth, IN LAUGHTER embrace, and celebration.” The medical school’s most recent art show honors a beloved Roanoke physician. BY CATHERINE DOSS

THE SPRING ART SHOW AT THE Virginia Tech Carilion School of Medicine pays tribute to Julien H. Meyer Jr., M.D., a Roanoke phy- sician who passed away last year. The show, “Laughter Is the Best Medicine,” which will run through mid-July, features works by nearly 60 local artists and is inspired by two of Dr. Meyer’s passions: art and humor. A Roanoke native, Dr. Meyer was an obstetrician and gynecologist for 43 years at Physicians to Women, Inc. Throughout his career, he was renowned for his skill in incorporating humor into his work. “There is a contagion in laughter,” Dr. Meyer said in 2016, while accepting the Robert L.A. Keeley Healing Arts Award for his service to the medical community of the Roanoke Valley. “It is a social glue, and it helps pa- tients feel more at ease. Humor and a sunny presence make for good bedside manner.” Dr. Meyer went on to note that patients had told him they never thought a gynecologic visit could be such fun. “Joking was only a small part of Julien’s upbeat and humorous personality,” said Lynn Meyer, his wife of 28 years. “He truly loved being a physician and looked for- ward to going to work each day. He often said he had a captive audience akin to show business.” Dr. Meyer took special interest in mentoring Virgin- ia Tech Carilion School of Medicine students. He also embodied many of the school’s core values, especially patient-centered care and community involvement. “My father was always joking with his patients,” said Jeff Vespa, Dr. Meyer’s youngest son, who contrib- uted to the art show some of his humorous portraits of Hollywood actors. “He would wear a red foam clown nose or put a large plastic cockroach on the exam table to make people laugh. I miss him every day and know the community does too.” CM

44 CARILION MEDICINE | SPRING/SUMMER 2018 PHOTOS: ALEJANDRA MORAL CARILION MEDICINE | SPRING/SUMMER 2018 45 cheers for peers

American Board of Preventive Psychiatry MARIA HIRSCH, petition in Richmond. HANNAH to study complex biological Medicine. TRACEY CRISS, C.R.N.A., WORIAX, M.D., presented “Is the machinery, including the M.D., a psychia- director of face an airbag for the brain and formation of breast cancer. PATRICE M. WEISS, M.D., chief trist and vice certified registered torso? The potential protective medical officer and executive president of nurse anesthetists effects of severe midface frac- This spring, READ MONTAGUE, vice president, was named to medical staff for Carilion tures.” ASHLEY GERRISH, M.D., PH.D., director of the Human the “100 Hospital and Health and credential- Roanoke Memorial Hospital, is a presented “Post Discharge Mor- Neuroimaging Laboratory System CMOs to Know 2018” ing, was awarded the Nancy member of a national research tality after Geriatric Low Level at the Virginia Tech Carilion list of Becker’s Hospital Review. C.A. Roeske M.D., Certificate of team that was recognized by the Falls: A Five Year Analysis.” Research Institute, became The list features national Recognition for Excellence in American Association of Nurse the 41st person to present physician leaders dedicated to Medical Student Education by Anesthetists with the John F. the annual Dorcas Cummings strengthening their organiza- the American Psychiatric Garde Researcher of the Year Affiliated Institutions Memorial Lecture at the Cold tions through physician lead- Association. The annual award Award. She also was elected Spring Harbor Laboratory ership development, patient is given to association treasurer for the Council on The Virginia Symposium on Quantitative safety initiatives and quality members who have made Accreditation of Nurse Anesthesia Hospital and Biology, Brains and Behavior: improvement. outstanding and sustaining Programs and she served as an Healthcare Order and Disorder in the Emergency Medicine The Teaching Excellence Obstetrics contributions to medical editor for the sixth edition of Association has Nervous System. Six Nobel Academy for Collaborative and Gynecology student education. Nurse Anesthesia, published by recognized Prize laureates have previously MATTHEW BORLOZ, M.D., medi- Healthcare (TEACH)—a Orthopaedics Elsevier- Saunders. NATHANIEL L. given the lecture, including cal director for Emergency Med- collaboration between EDUARDO BISHOP, D.MIN., president of Francis Crick, one of three win- icine at Carilion New River Valley Carilion, the Virginia Tech LARA-TORRE, JONATHAN CARMOUCHE, Radiology Jefferson College of Health ners of the prize in physiology Medical Center, was named by Carilion School of Medicine, M.D., vice chair of M.D., section chief for Residency and Sciences, with its Meritorius or medicine for the discovery Annals of Emergency Medicine as and Jefferson College of Academics and Orthopaedic Spine, was DANIEL KAROLYI, M.D., PH.D., Fellowship Programs Service Award for significant of the structure of DNA. a Top 50 Reviewer and a Distin- Health Sciences—recently section chief of named a Spine Surgeon Lead- vice chair of Imaging, taught contributions to the health care guished Senior Reviewer. announced the first annual General Obstetrics er to Know by Becker’s Spine a three-day body MRI course ALEXANDRA NASSIF, P.A.-C., field through commitment to RICHARD VARI, PH.D., TEACH Awards. Recipients and Gynecology, was named Review. Dr. Carmouche was in Sydney as a joint venture advanced clinical practitioner service and leadership. senior dean for academic included CLAUDIA KROKER- president-elect of the North also chosen to receive one between the Royal Australian fellow with Urgent Care Medi- affairs at the Virginia Tech Family Medicine BODE, M.D., PH.D., who American Society for Pediatric of the first Research Domain and New Zealand College of cine, coauthored a case report, The Roanoke- Carilion School of Medicine, received the Innovative and Adolescent Gynecology, Mentors Award given by the Radiologists and the American “Medication-Induced Pruritius Blacksburg has been appointed president MARK GREENAWALD, M.D., vice Teaching Award, and P. J. which is dedicated to providing Virginia Tech Carilion School College of Radiology. From Direct Oral Anticoagu- Technology of the International Associa- chair for Academic Affairs for WHALEN, M.D., a pediatric multidisciplinary leadership in of Medicine, along with ZHI lants, ” published in the Decem- Council honored tion of Medical Science Edu- Family and Community Medi- hospitalist who received the education, research, and SHENG, PH.D., an assistant ber issue of Federal Practitioner. DEBORAH KELLY, cators (IAMSE). His two-year cine, was the plenary speaker at Faculty Feedback Award. gynecologic care to improve the professor at the Virginia Tech Surgery PH.D., with its term began in January. IAMSE the American Academy of Family LUKAS LOSCHNER, M.D., a reproductive health of youth. Carilion Research Institute. Two fourth-year Surgery resi- Innovator of the Year Award. Dr. is an international nonprofit Physicians’ 2018 Residency Edu- physician with Pulmonary Dr. Lara-Torre’s term began in Recipients were nominated by CHARLES HARRIS, M.D., was dents presented at the Virgin- Kelly, an associate professor at professional development cation Symposium in late March. Medicine, and BRADLEY April 2018. the school’s current students recently elected president of ia Chapter of the American the Virginia Tech Carilion society focused on promoting His presentation was titled ICARD, D.O., a fellow in Pul- and alumni. the Virginia Chapter of the College of Surgeons’ Committee Research Institute, focuses on excellence in health profes- “Calibrating the Leader: Being monary/Critical Care, were FIDEL VALEA, M.D., chair of American College of Surgeons. on Trauma Resident Paper Com- developing new methodologies sions education. Well While Leading Well.” members of a team that was Obstetrics and Gynecology, has T.K. MILLER, M.D., section awarded a Research Eureka been named to the Board of chief of Sports Medicine, was Accelerator Program (REAP) Directors of the American Board named a principal reviewer for Internal Medicine grant from the Edward Via of Obstetrics and Gynecology. the American Journal of Sports College of Osteopathic Med- His three-year term as director Medicine. The peer-reviewed Provider Excellence STEVEN KATOR, icine to work on a proposal of gynecologic oncology will scientific journal is the official The Carilion Clinic Provider Excellence Awards recognize CALEB PAGLIASOTTI, M.D., a resident with Psychiatry and M.D., a hospitalist to develop a point-of-care begin this year. publication of the American providers who demonstrate dedication and exceptional care Behavioral Medicine, received the Provider Excellence Award for with Carilion diagnostic kit for bacterial Orthopaedic Society for to patients, families, staff, and fellow providers. This year’s Residents and Fellows. Stonewall Jackson and viral pneumonia. KIMBERLY Sports Medicine. awardees are: Hospital, was SIMCOX, D.O., LAURA JONES, N.P., a hospitalist at Carilion Roanoke Memorial named a PAUL YEATON, M.D., section was named a JOSEPH MOSKAL, M.D., chair of KIMBERLY SIMCOX, D.O., a physician with Obstetrics and Gyne- Hospital, received the Provider Excellence Award for Advanced Diplomate in Clinical Informatics chief for Gastroenterology, was Diplomate in Orthopaedics, was named an cology, received the Provider Excellence Award for Physicians. Clinical Practitioners. by the American Board of named a GI Leader to Know by Addiction Orthopaedic Surgeon to Know Preventive Medicine. Becker’s GI and Endoscopy. Medicine by the by Becker’s Orthopedic Review.

46 CARILION MEDICINE | SPRING/SUMMER 2018 PHOTO, TOP LEFT: JARED LADIA CARILION MEDICINE | SPRING/SUMMER 2018 47 backstory

THE RESILIENCY CODE To do their jobs well, physicians must be able to open themselves up to pain— and then figure out how to bounce back. BY GARY R. SIMONDS, M.D. PATIENTS

T’S EARLY EVENING WHEN MY CALL PAGER ironies. It’s neither the volume nor the ferocity of it all sounds. It’s a 15-year-old with a gunshot wound that gets in. I trained for a long, long time to be as im- The Heart of Innovation. to the head; he’s already beyond saving. As I con- penetrable as possible, to not feel, to be able to focus on sole a room packed with loved ones, a half doz- the problem at hand. I have to: I’m a brain surgeon, for TAVR is an innovative cardiac procedure that uses a en other calls stack up. Some are simple: a blood goodness sake. pressure medicine here, a new CT scan there. For me, it’s speaking with the families in the very minimally invasive approach, benefiting patients with IOthers, though, are complex and worst of scenarios. I’m good at severe aortic stenosis by offering faster recovery times. emotionally wrought: a 38-year- it, and it oddly brings me fulfill- old mother of three in a coma, a ment—I sometimes cannot help postop aneurysm patient who’s the patient, yet I can help his or We congratulate and thank the physicians and clinical looking fragile. her loved ones. To do it well, to staff whose teamwork and dedication made this Within two hours, another do it really well, I think we have teenager comes in with a trau- to open ourselves up to feeling. milestone in surgical heart valve replacement possible, matic brain injury; he’ll probably We must feel and process their survive. An elderly woman with pain and anxiety. We must walk and who continue to position Carilion as the region’s a hemorrhagic stroke has a good for a short time in their shoes, leader in heart care. Most importantly, we thank our prognosis as well. Yet a 43-year- to help them along the path. old with a broken back and pa- And once the shields go down, patients for entrusting us with their care. ralysis in the legs needs to go to “it” gets in, it all gets in. Stack up surgery, stat. I speak with sever- several in short order, and our CarilionClinic.org al families and tackle four more shields are in disarray. emergency room consults and Different stressors affect dif- nine more floor calls. ferent providers in different ways. It’s nearly midnight, and now None of us is truly impervious, it’s a 48-year-old with what is a however. likely a malignant brain tumor; My colleagues and I, along with it doesn’t look good. A few more renowned physician resilience patients with spine fractures expert Wayne Sotile, have spent that should heal in braces. More the past five years exploring how families. Then a 32-year-old with and why “it” gets in, the damage a massive subdural hematoma “it” can do, and how we can build sends me back to surgery. When I emerge, the waiting resilience against “its” effects. Many talks, a podcast, room is filled with people. and two books—Building Resilience in Neurosurgical Res- And so it goes. It’s a bad night, though not atypical: idents and The Thriving Physician—have followed. many desperately ill people, many grieving and anxious Care providers, take the time to reflect and care for families, a great deal of tragedy. No promise of sleep— yourself. Because “it” always gets in. CM or even rest—until tomorrow evening. It isn’t the tragedies themselves. It’s not the hor- Gary R. Simonds, M.D., is chief of neurosurgery at rible injuries, the deaths, or the sometimes sickening Carilion Clinic.

48 CARILION MEDICINE | SPRING/SUMMER 2018 ILLUSTRATION: BRETT RYDER

G220485 Cardiac TAVR OurHealth FP.indd 1 4/17/18 1:18 PM CARILION CLINIC P.O. BOX 13727 NON-PROFIT ORG. ROANOKE, VA 24036-3727 U.S. POSTAGE PAID ROANOKE, VA PERMIT NO. 247

LEADERSHIP IN ACTION The investiture of Nancy Agee as chair of the American Hospital Association’s Board of Trustees inspired reflection on the national state of health care.

online exclusives

Practice With Purpose Vanishing a Stigma In Good Company Carilion Clinic’s new simulation center A Carilion Clinic team is collaborating Jefferson College of Health Sciences places a focus on enhancing patient safety, with colleagues in Nigeria to teach clinical explores what it would mean to merge medical education, and innovation. techniques and raise awareness of epilepsy. with Radford University.

Please visit us at CarilionClinic.org/carilionmedicine. If you would like a complimentary subscription to Carilion Medicine, please email us at [email protected].