Carilion MedicineFALL 2017 In partnership with the Virginia Tech Carilion School of Medicine and Research Institute

CARING FOR ONE’S OWN Carilion Clinic is using targeted Eugene Yopp is a patient programs to meet the health at Carilion’s family medicine practice in pastoral needs of rural residents Shawsville, Virginia contents CARILION MEDICINE FALL 2017 Departments 2 FROM THE CMO 3 IN BRIEF Major biomedical research expansion; national recognition; leadership past and present 7 GRAND ROUNDS Education initiatives both classic and with a twist 42 THE ART OF MEDICINE: HEALING ART IN THE BLUE RIDGE Carilion celebrates the power of art to create 16 moments of respite for patients and caregivers. ROUGH AND READY: 45 CHEERS FOR PEERS As he was growing up in Recognition for Carilion clinicians small-town Virginia, Adam Tate watched his physician father care for patients with 48 BACKSTORY: WOMEN a range of ailments. “In rural family medicine,” the IN HEALTH CARE younger Tate, now a medical Getting a seat at the executive table often student, says, “you have means sticking your neck out. to be ready for whatever BY NANCY HOWELL AGEE comes in the door.”

SPECIAL REPORT Rural Outreach Features 10 16 22 24 28 32 38 CLOSING THE ROAD THE RURAL STRONG THE THE COSMOS ROOM WITH THE GAP LESS TRAVELED ROUTE MEDICINE AFTERMATH OF OUR CELLS A VIEW For Carilion Clinic, meeting Carilion training programs are The terrain and wildlife of Once just a hospital-owned Law-enforcement officers Scientists are using cryo- A day in the life of the the health needs of rural preparing medical students, southwestern Virginia and the athletic club, Carilion Wellness aren’t the only witnesses to electron microscopy at neuroangiography suite at residents is more than just a physicians, and advanced lifestyles of its residents create has transformed itself into an violence; health care providers unprecedented resolutions to Carilion Roanoke Memorial medical challenge. It’s about clinical practitioners to meet challenges beyond those of active partner in the Carilion often find themselves on the witness the self-destruction of Hospital provides glimpses caring for one’s own. the needs of rural populations. mere remoteness. care team. front lines as well. mutated breast cancer proteins. into high-tech miracles. BY CHARLES SLACK BY DAVID BUMKE BY PAULA BYRON BY VERONICA MEADE-KELLY BY JESSICA CERRETANI BY ASHLEY WENNERSHERRON BY JARED LADIA

PHOTOS: JARED LADIA, COVER AND ABOVE; ILLUSTRATION: MIKE LEMANSKI my hometown of brodheadsville, Pennsylvania, was once rural farmland. Our Carilion Medicine town in the Poconos was small. The closest President and Chief Executive Officer hospital was 20 miles away, a distance I recall Nancy Howell Agee On the pulse of the well when, as a four-year-old, I was rushed Chief Medical Officer and Carilion Clinic community there with a compound-fractured arm. I still Executive Vice President vividly remember another day there, years Patrice M. Weiss, M.D. later, when I had an appendectomy. It was, Editorial Advisory Panel in brief after all, the day Elvis died. Nathaniel L. Bishop, D.Min.; Cesar Bravo, M.D.; I guess you could say my experience in rural John Burton, M.D.; Kimberly Carter, Ph.D., medicine began at an early age. R.N.; Kimberly Dunsmore, M.D.; Evelyn Garcia, M.D.; Mark Greenawald, M.D.; Daniel Harrington, As the youngest of four, I was my father’s M.D.; Cynda Johnson, M.D., M.B.A; Donald Kees, GROUNDBREAKING FOR last hope for continuing the family plumbing, M.D.; Wilton Kennedy, D.H.Sc., P.A.-C.; Michael RESEARCH EXPANSION heating, and remodeling business. Then, one day in college, I finally Nussbaum, M.D.; John Pastor; Paul Skolnik, M.D.; admitted: I wanted to become a doctor. Robert Trestman, M.D., Ph.D.; Fidel Valea, M.D. Carilion Clinic and Virginia Tech ofcials I went on to medical school in Philadelphia and trained to become an Chief Administrative Officer symbolically broke ground in October to OB/GYN in the Lehigh Valley at a large tertiary care center. It was only 45 Jeanne Armentrout begin construction on a new facility to minutes from Brodheadsville, but it seemed a world away. Vice President expand biomedical research and provide Later, as an OB/GYN resident, I was asked to go by helicopter to pick up Mike Dame enhanced experiential learning opportu- nities to students at all levels. a woman in labor with pre-term twins. As I climbed aboard, the pilot asked Executive Editor Known as the Virginia Tech Carilion whether I’d ever been to the Poconos. I couldn’t help but chuckle and reply, Linda Staley Biomedical Research Expansion, the “Never by helicopter!” Editor 139,000-square-foot building will rise on We landed near Pocono Community Hospital, the same place I was born Paula Byron the Virginia Tech Carilion Health Sciences and the same place I’d had surgery the day Elvis died. The twins received Art Director and Technology Campus in Roanoke. An the care they needed in our NICU. The event was big news, and we made the Laura McFadden elevated walkway will connect the struc- front page of the local paper: “Local hero returns home to save twins.” Special Thanks ture to the Virginia Tech Carilion School Now, as chief medical officer of Carilion Clinic, I once again find myself Catherine Doss, Mark Lambert, Steven Mackay, of Medicine and Research Institute. dealing with the challenges of caring for patients in some of our country’s Alison Matthiessen, Laura Mitchell, Anne Shaver The $90-million building, expected to THE FUTURE IS NOW: The new biomedical research expansion will be built at the heart of open in the spring of 2020, will be a phys- the Virginia Tech Carilion Health Sciences and Technology Campus in Roanoke. The building remotest areas. Our 20-county, mostly rural service area stretches from CARILION CLINIC will be organized around highly interactive research themes. central and southwestern Virginia to southern West Virginia, with 230 miles 1906 Belleview Avenue ical manifestation of the success of the separating our furthermost practices. Times have changed, but we still face P.O. Box 13727 Virginia Tech Carilion Research Institute. Roanoke, VA 24036 The expansion will enable additional state- Ph.D., Virginia Tech president; Nancy How- “In the frst 10 years of the Virginia challenges of geography and health disparity. People who live far from our CarilionClinic.org of-the-art laboratories organized around ell Agee, Carilion president and chief exec- Tech–Carilion Clinic partnership, we cre- cities often lack access to health care. 800-422-4842 interactive research themes, from neurosci- utive ofcer; Michael Friedlander, Ph.D., ated a research institute that makes a huge For some people, the nearest family physician may be hours away and ence to cardiovascular science, metabolism Virginia Tech Carilion Research Institute impact for its size, and we created what is they must travel even longer distances at signifcant cost for specialty care. and obesity research, and biomaterials and executive director; and Patrice M. Weiss, regarded as one of the best research-ori- People living in rural areas are more likely than those in cities to die from body–device interfaces. M.D., Carilion chief medical ofcer and ex- ented medical schools in the country,” heart disease, cancer, unintentional injuries, stroke, and chronic lower Carilion Medicine is published twice a year at: During the groundbreaking event, the ecutive vice president—all talked about ris- Dr. Sands said. “More faculty members and respiratory disease. 213 McClanahan Street, Suite 200 project leaders—including Timothy Sands, ing expectations for the partnership. students from Virginia Tech’s colleges will Carilion is confronting the challenges in the same way it has since its Roanoke, VA 24014 be involved in this next phase.” founding more than a hundred years ago as a scrappy little hospital for Phone: 540-266-6586 Fax: 540-266-6608 Ofcials said the new building will be immigrant railroad workers: with a spirit of self-reliance. We continue to Email: [email protected] Rising in the Ranks of Hospitals the next—yet not the last—product to push ourselves to find creative, new ways to bridge the gaps between patients Web: CarilionClinic.org/carilionmedicine spring from the partnership. In 2017, Carilion Clinic’s flagship hospital rose to its highest and providers. “Looking back more than 10 years ago, Carilion Clinic is a nationally ranked integrated health ranking ever in U.S. News & World Report’s annual assessments two aspirational conversations were hap- The solutions aren’t easy, but they’re vital. All our patients deserve the care system headquartered in Roanoke, Virginia. Its of hospitals. Out of nearly 130 hospitals in Virginia, Carilion pening in parallel—one at Carilion Clinic, chance to go home again—or to stay in the home they love. flagship, Carilion Roanoke Memorial Hospital, is the clinical affiliate of the Virginia Tech Carilion School of Roanoke Memorial Hospital was named the third best hospital one at Virginia Tech,” Agee said. “We began Medicine and Jefferson College of Health Sciences. in the state. to think, ‘Wow, what if we do something © Copyright 2017 by Carilion Clinic. No part of this The hospital was also one of 48 hospitals nationally—and together? And what might that look like?’ publication may be reproduced or transmitted in any form or by any means without written the only one in Virginia—to be rated “high performing” in all And I think that was the launch of some- Patrice M. Weiss, M.D. permission from Carilion Clinic. All editorial rights nine chronic conditions and surgical procedures the magazine thing phenomenal. What we’ve gained Chief Medical Officer and Executive Vice President reserved. Opinions expressed herein may or may not reviewed, an achievement that placed it in the top 1 percent of from it is truly exponential, and the biggest reflect the views of Carilion Clinic. Carilion Clinic the more than 4,500 hospitals evaluated. gains in terms of growth and service to the community are still ahead of us.”

2 CARILION MEDICINE | FALL 2017 PHOTO: JARED LADIA RENDERING: AECOM CARILION MEDICINE | FALL 2017 3 honors

VTC Innovation Fund FORMER CARILION PRESIDENT REMEMBERED briefings The Virginia Tech Foundation and Carilion at Virginia Tech, many in collaboration with EDWARD MURPHY, M.D., former president Charles Steger, then president of Virginia Clinic have formed a $15-million VTC Innova- Carilion Clinic.” and chief executive ofcer of Carilion Clinic, Tech, the vision for—and creation of— tion Fund focused on investing in life scienc- The VTC Innovation Fund is just one of died of cancer on October 15 at the age of 61. the Virginia Tech Carilion School of es and disruptive technology opportunities. the latest collaborative efforts in the partner- A native of upstate New York, Dr. Mur- Medicine and Research Institute. The private fund will support late-seed ship between Carilion and Virginia Tech. phy received his bachelor’s degree from At the groundbreaking event for a and growth-stage companies in efforts to “We know how important our efforts the University of Albany and his medi- $90-million expansion of the Virginia commercialize groundbreaking research as are to our region’s future and we take that cal degree from Harvard Medical School. Tech Carilion biomedical research cam- well as innovative products and solutions. responsibility very seriously,” said Nancy Rather than entering full-time medical pus in Roanoke less than two weeks af- Chairman Honored “The fund will invest in promising new Howell Agee, president and chief executive practice, he chose health care research ter Dr. Murphy’s death, Timothy Sands, JAMES HARTLEY, chairman of companies and bring innovations to the officer of Carilion. “As we move forward, we and administration. Early in his career, he Ph.D., the current president of Virginia Carilion Clinic’s Board of Directors, marketplace,” said John Dooley, Ph.D., chief want to make sure infrastructure is in place served as a clinical professor at the Uni- Tech, paid tribute to him. has received the 2017 Excellence in executive officer of the Virginia Tech Founda- to make game-changing new achievements versity of Albany School of Public Health “Because of Dr. Murphy’s original vision Governance Award from the Virginia tion. “It aims to help commercialize viable life in health, medicine, and technology.” and adjunct assistant professor at Rensse- and his close working relationship with Hospital & Healthcare Association. sciences or accelerate general technology Growth-stage companies in a university Agee laer Polytechnic Institute’s President Steger,” Dr. Sands The award honors those in assets and attract corporate or venture cap- and research environment often depend on School of Management, said, “we have made many governance roles who have a ital. The investments may lead to real-world sources of capital such as the VTC Innovation based in Troy, New York. great accomplishments and history of making significant applications for the high-quality research Fund to drive proven ideas from the research MAKING THE LISTS He assumed the presidency are positioned very well for contributions to the health care coming out of Virginia Tech, Carilion Clinic, bench to the marketplace, said Michael For the second year in row, NANCY HOWELL of Leonard Hospital, also the future.” field through commitment to and other sources with strong connections Friedlander, Ph.D., executive director of the AGEE, president and chief executive in Troy, in 1989. He later Upon leaving Carilion service and leadership. to the Commonwealth of Virginia.” Virginia Tech Carilion Research Institute. ofcer of Carilion Clinic, has been negotiated the creation of in 2011, Dr. Murphy went Hartley joined the Board Many of the companies will be within “Intellectual property is developed named to Modern Healthcare’s list Seton Health System, an into health care consulting of Directors of Carilion Giles 150 miles of Roanoke or have a strong con- across Virginia Tech and in collaborative re- of the 100 Most Influential People integrated health care sys- in Connecticut, including, Memorial Hospital in 1980 and, nection to Carilion or Virginia Tech. search partnerships with Carilion Clinic,” said in Healthcare. Her ranking for 2017 tem, for which he served as most recently, as executive nine years later, the Board of “We have extremely gifted faculty Dr. Friedlander, who also serves as Virginia rose to number 23 on the list. president and chief execu- chairman of Management Directors of what was then Carilion and students,” said Timothy Sands, Ph.D., Tech’s vice president for health sciences and “This honor recognizes Nancy’s tive ofcer. Murphy Health Solutions. Through- Health System. president of Virginia Tech. “By providing technology. “Investors are needed to take tireless efforts in our own community, In 1998, Dr. Murphy out that time, he continued “James’ dynamic leadership, opportunities for our own startup compa- the work being done in the lab to the market in addition to the substantial joined Carilion Health System as exec- to serve his community by accepting lead- sound judgment, and humility nies to take their ideas into the marketplace, because you can’t use research grant money contributions she makes to local, utive vice president and chief operating ership roles in numerous nonproft orga- made him an ideal candidate for we are helping fulfill our land-grant mission or university money for those purposes. It regional, and national conversations ofcer. Three years later, he assumed Car- nizations dedicated to education, health this prestigious honor,” said to transfer technology and economic takes private investment capital to take an on health care,” said James Hartley, ilion’s top position, which he held for 11 care improvement, and quality of life. He Nancy Howell Agee, president opportunity to the people of Virginia and the idea to the next stage and build a virtuous Carilion’s chairman of the board. “We in years. During that time, he presided over also served on the board of the Virginia and chief executive officer of world. Some of the most innovative ideas in cycle of discovery, innovation, translation, southwestern Virginia have long known some of the most dynamic moments in Tech Carilion School of Medicine. Carilion. “It is truly a privilege to science and technology are being developed application, and commercialization.” that Nancy is a strong, competent the organization’s history, including the Dr. Murphy is survived by his wife, work alongside such a dedicated leader. It seems the rest of world may transition from a system of hospitals to Arlene Murphy, and daughters, Sarah and passionate leader.” now be catching on.” a physician-led clinic model. At the time, Elizabeth Murphy and Emily Anne Murphy. Hartley noted that as proud of this he likened his vision for Carilion with “Ed will be missed by the many honor as Agee should be, he was certain that of Mayo Clinic, noting, “It’s not a who worked with him,” said Nancy Leader in her greatest pride lay in Carilion’s team hospital business that owns doctors. It’s Howell Agee, Dr. Murphy’s successor as Patient Care of professionals. a physician business that has hospitals.” president and chief executive ofcer of Carilion Roanoke Memorial Hospital “Nancy’s—and Carilion’s—star is One accomplishment he was most Carilion. “His imprint on our community has once again been recognized on rising on the national stage,” Hartley lauded for was, in collaboration with will be felt for generations to come.” Becker’s Hospital Review’s 2017 List said. “The work that Carilion’s compas- of 100 Great Hospitals in America. sionate and talented professionals do The hospitals included on each day continues to be recognized in the list are all acknowledged the industry. That reputation has en- It’s not a hospital business that industry leaders in innovation, abled the organization to continue to quality patient care, and clinical build strong partnerships.” owns doctors. It’s a physician research, and they have received DISCOVERY CHANNELS: The VTC Innovation Fund is the latest collaborative effort in Earlier in the year, Agee was also recognition across a range of the expanding partnership between Carilion Clinic and Virginia Tech. named to Modern Healthcare’s list of Top “ business that has hospitals. publications and accrediting 25 Women in Healthcare. organizations. 4 CARILION MEDICINE | FALL 2017 PHOTOS: DAVID HUNGATE (LEFT); JARED LADIA (TOP) PHOTOS: DARRYLE ARNOLD ” CARILION MEDICINE | FALL 2017 5 award

The curriculum was later recognized RICHARD VARI WINS PRESTIGIOUS NATIONAL by the Carnegie Foundation in the AWARD FOR MEDICAL STUDENT EDUCATION Flexner II Report as an exemplary medical education program. grand rounds When Dr. Johnson was named dean of so many students from VTC have enjoyed the Virginia Tech Carilion School of Med- success is truly a testament to the type of icine, leadership had envisioned a prob- man he is. Dr. Vari is deserving of the high- lem-based learning curriculum. She knew SURGERY FELLOWSHIPS est honor in teaching, and I couldn’t be hap- she needed Dr. Vari to make it a reality. pier for a mentor and a friend.” “There was no individual in this country Carilion Clinic’s Department of Dr. Vari has been involved in medical with credentials better suited to be our Surgery is now offering a post- education for more than 30 years. As a col- founding associate dean of medical edu- graduate Advanced Clinical lege student, he was planning to become a cation,” she said. Practitioner Fellowship in Surgery aimed physician until work in a physiology labo- Dr. Johnson hired Dr. Vari to lead at preparing physician assistants and Vari ratory convinced him to pursue research efforts and build the curriculum from nurse practitioners for careers in general rather than medicine. scratch. “Starting a new school meant we and acute care surgery. The fellowship is The Association of American Medical At the same time, Dr. Vari found him- didn’t have anything to tear apart so we intended to be a complement to Carilion’s Colleges has honored RICHARD C. VARI, self more involved in the development could essentially do what we wanted to established general surgery residency. Ph.D., senior dean for academic affairs at of medical education curricula. While at do,” Dr. Vari said. the Virginia Tech Carilion School of Medi- the University of North Dakota School In addition to problem-based learning, BEYOND TEXTBOOKS: cine, with the Alpha Omega Alpha Robert J. of Medicine and Health Sciences, he was Dr. Vari helped establish two important Students taking the Clinical EXPANDED RESIDENCIES Glaser Distinguished Teacher Award. asked to serve on a council tasked with curricular elements—research and inter- Neuroscience in Practice The Virginia Department of course are able to watch The prestigious award provides na- recommending a new curriculum. He and professionalism—and embed them into Medical Assistance Services neurosurgical procedures live. tional recognition to faculty members his fellow council members ended up rec- each year of the four-year curriculum. The has awarded Carilion Clinic a who have distinguished themselves in ommending adoption of a problem-based curriculum now helps attract competitive $2-million grant to add six internal medicine medical student education. Each Liaison learning curriculum. students from across the country. residency slots a year for three years. The Committee on Medical Education–accred- “I had been teaching medical students “We managed to pull something off From Classroom to Operating Room principal goal will be to provide both Medic- ited medical school in the United States for 10 years or so and had never seen them that’s pretty phenomenal here,” Dr. Vari aid and self-paying patients in southwestern and Canada may nominate only one facul- so engaged and excited about learning,” said. “We have a lot of wonderful faculty, The Clinical Neuroscience in Practice course sible for students to learn by the side of Virginia with better access to primary care. ty member each year for the honor. he said. “There was something about it; I a lot of people who really care about the in Virginia Tech’s School of Neuroscience is neurosurgeons in a hospital setting. “Getting this award is the pinnacle didn’t know what it was, but if we could school. Our students have been incred- no ordinary class. It offers undergraduates “It is such a fantastic opportunity to be of my career and such an honor,” said capture it, that’s what we wanted to do.” ible. The work has been very gratifying.” the opportunity to experience the world of around the people at Tech and, we hope, RESEARCH AWARD Dr. Vari. neurosurgeons in both the classroom and they feel the same way about us and this Oscar Alcoreza, a third-year “Rick is one of the most energetic, en- the operating room. creates that bridge,” Dr. Simonds said. “For Virginia Tech Carilion School gaging, and effective teachers I have ever After receiving lectures from surgical us, and particularly for our residents, we most wired of Medicine student, has been seen,” said Cynda Johnson, M.D., M.B.A., residents and attending physicians, the feel that the better physicians are as educa- awarded a highly competitive Howard founding dean of the Virginia Tech Car- students enter operating rooms of Carilion tors, the better they are as physicians.” Hughes Medical Institute fellowship, which ilion School of Medicine. “He is one of a Making Numbers Work for Patients Roanoke Memorial Hospital—scrubs on, Among the students who took the will allow him to spend a year at the Virginia kind. He teaches his students from his notebooks in hand—to watch brain and class in the spring of 2017 was Amy Wells, For the 14th time—and the ninth year in a row—Carilion Clinic has received Health Care’s Tech Carilion Research Institute conducting heart, his passion for his work is infec- spine surgeries. a senior double majoring in psychology Most Wired designation from the American Hospital Association’s Health Forum. mentored biomedical research on epilepsy. tious, he leads his faculty by example, and According to the stated criteria for the designation, Most Wired hospitals transform care The experiences are one of a kind. and neuroscience in the Virginia Tech Col- he is revered by the students.” delivery through knowledge gained from data and analytics. They invest in analytics to “I keep telling the students every single lege of Science. Wells watched a neurosur- “I always thought that Dr. Vari was in- support new delivery models and effective decision-making, and they train clinicians to use time we come here, this is not normal, you gery team led by Carilion neurosurgeon fluential in my ending up at VTC, because analytics to improve quality, provide access, and control costs. are seeing a neurosurgery team opening Lisa Apfel, M.D., who is also an assistant I remember feeling a connection with him “We are constantly evaluating ways to improve the experience of our patients,” said their world to undergraduates,” said Harald professor of surgery at the Virginia Tech when I interviewed,” said Christopher Keith Perry, senior vice president and chief information officer for Carilion. “The Most Wired Sontheimer, Ph.D., executive director of the Carilion School of Medicine. Before the Vieau, M.D., a graduate of the school’s designation is a nice affirmation of the work we are doing every day.” School of Neuroscience. surgery, Dr. Apfel briefed the students on charter class and now a family medicine The course is a collaboration between the patient’s history and what would hap- physician at Union Family Practice in Car- Virginia Tech and Carilion Clinic. Gary pen during and after the surgery. olinas HealthCare System. “He inspired Simonds, M.D., chief of neurosurgery at “I am a very visual learner,” Wells confdence in me that this school would be Carilion, joined Dr. Sontheimer in design- said, “and to see the cases and see what successful, even though on that day, there ing the course to be all encompassing. It is happening, that is a very big learning Oscar Alcoreza (center) with Dr. Susan were no books and no physical school. That was Dr. Simonds, in fact, who made it pos- tool for me.” Campbell and Dr. Harald Sontheimer.

6 CARILION MEDICINE | FALL 2017 PHOTOS: JIM STROUP (FAR LEFT); STEVEN MACKAY (ABOVE); DAVID HUNGATE (RIGHT) CARILION MEDICINE | FALL 2017 7 landmark

JEFFERSON COLLEGE OF HEALTH SCIENCES TURNS 35

In October, Jefferson College of Health Sciences celebrat- Roanoke Valley College of Health Sciences was established, c. 1916 ed its 35th anniversary as a degree-granting institution. becoming the frst hospital-based college in Virginia. During a gala with more than 250 guests, Nancy Since then, Agee said, Roanoke’s only downtown col- The Early Days Howell Agee, president and chief executive ofcer of lege has helped revitalize the area. Today, the college ed- The earliest iteration of Jefferson Carilion Clinic, spoke about the history ucates a range of health care professionals College of Health Sciences opened of its college. She noted that the college at the associate, bachelor’s, master’s and as a nursing school in 1914, with a grand total of six students. traces its earliest roots to 1914, when doctoral levels, and its record number of the Jefferson Hospital School of Nursing students represent 35 states and territories. 1982 opened with six students. “The accomplishments of the various Between 1914 and 1965—when it iterations of our college over the past few Capping It Off joined with the Lewis-Gale School of Nurs- decades have laid the foundation of a proud In 1980, the school’s then adminis- ing to form the Community Hospital of tradition upon which to build the health trator, William Reid, commissioned Roanoke Valley School of Nursing—the care of the future,” said Nathaniel L. Bishop, a task force to investigate the feasibi- lity of establishing a hospital-based school trained 658 new nurses. D.Min., the college’s president since 2010. college that could grant two-year In 1981, the Community Hospital Board “Today, Jefferson College of Health Sciences degrees in nursing and allied health. of Trustees agreed to turn the school into a hospital-based sits at the intersection of education and health care, where A year later, the Community Hospital Board of Trustees made a commit- college that could grant two-year degrees in nursing and it prepares ethical, knowledgeable, competent, and caring ment to such a school, and in 1982 allied health. A year later, the Community Hospital of health care professionals.” the Community Hospital of Roanoke Valley College of Health Sciences was established.

1988 Tradition of Caring As the decades passed, the college expanded not only its student class, but also the numbers and levels of educational programs available. By 1988, the college had 200 students and three programs; in 2017, it has 1,200 students and 23 programs.

2012 Founder’s Circle The true founder of the modern version of Jefferson College of Health Sciences is considered to be William Reid (right), pictured with the current president of the college, Dr. Nathaniel L. Bishop. Reid still sits on the college’s Board of Directors.

2017 35th Anniversary Celebration Nancy Howell Agee, Carilion’s president and chief executive officer, and Dr. Nathaniel L. Bishop celebrate at the college’s 35th anniversary gala, held in October.

8 CARILION MEDICINE | FALL 2017 PHOTOS: COURTESY OF JEFFERSON COLLEGE OF HEALTH SCIENCES CARILION MEDICINE | FALL 2017 9 CLOSING THE GAP

For Carilion Clinic, meeting the health needs of rural residents is more than just a medical challenge. It’s about caring for one’s own. BY CHARLES SLACK

IN A RURAL COUNTY MILES FROM ROANOKE, A WOMAN IN HER LATE 50S calls 911 to say she’s not feeling well. Just minutes after the EMS team arrives at her home, she goes into cardiac arrest, setting SPECIAL DELIVERY: in motion a series of intricately coordinated and—ultimately—life- Retired roofer Eugene saving actions. Yopp, shown in front of an outbuilding on his 25-acre First, the EMS team restores a steady pulse. Instead of the famil- property in rural Shawsville, iar hands-on-chest method, they use an advanced portable device Virginia, receives his medical care at the local Carilion capable of continuing CPR even while the patient is being moved. family medicine practice. But that calls up a crucial question: where to? Recognizing the

10 CARILION MEDICINE | FALL 2017 CARILION MEDICINE | FALL 2017 11 severity of the woman’s condition, the EMS team— the rapid response team frst in Carilion’s emergen- Still, the challenges are stark. According to the ral health education programs encouraging medical specially trained and authorized to make such deci- cy department and then in the cath lab and coronary County Health Rankings, while a number of coun- students to experience the rewards of rural medi- sions—bypasses the local hospital in favor of Car- care unit, I’m not sure she would have survived.” ties in the region are showing improvement in health cine (see “The Road Less Traveled,” page 16). ilion Roanoke Memorial Hospital. Though farther It was for just such emergencies that Dr. Frantz status, others—most notably in far southwestern away, it has an advanced cardiac catheterization lab and several other Carilion cardiologists and cardio- Virginia—actually declined from 2016 to 2017. Con- and a coronary care unit capable of handling the thoracic surgeons started HeartNet of the Virgini- tributing factors range from economic and wage stag- Community Health and Outreach most life-threatening emergencies. as back in 1989. Since then, the program has saved nation to persistent tobacco use, poor diets, diabetes, As vice president of planning and community devel- As the crew races toward Roanoke, workers at untold lives that might have been lost to the tricky and a rise in addictive drugs that reaches deep into opment, Shirley Holland oversees Carilion’s efforts Carilion’s Transfer and Communications Center are navigation of the region’s beautiful yet rugged and rural communities. to assess community needs and plan responses. ready. Within minutes they have alerted the emer- sparsely populated terrain. As a nonproft, community-owned institution, “Our role is to understand the health status of gency room, the cath lab, and the coronary care unit Carilion has a special sense of mission when it comes our region, the communities in which we are in- about the woman’s condition and imminent arrival to fnding solutions. volved, and how we as an organization can convene and arranged for admission. A Widespread Challenge “We’re charged with providing leadership in care community partners and resources to help,” Hol- After arriving at Carilion, the woman suffers a However dramatic, such emergencies represent just for patients throughout our area,” says Dr. Frantz. land says. “Strong collaborations in the community second and third cardiac arrest. With no time to one of the many challenges of providing health care “That means care that is healthy not just to the clin- can get us so much further than anything we can do spare, coronary specialists insert a stent that opens to rural residents. Nationally, rural areas have fewer ic’s bottom line, but the entire spectrum. That takes by ourselves.” a severely blocked artery. Her brain is kept artif- than 40 primary care physicians per 100,000 peo- a hospital that’s not only willing to provide that To that end, Carilion partners with some 50 cially cool to protect it from damage. Hours later, ple, compared with more than 53 in urban areas, care, but is large enough to do it.” national, state, and local organizations, including though still in serious condition, she’s stabilized according to the National Rural Health Association. And because rural health care is a multipronged the United Way, Virginia’s Department of Health, and expected to recover. Noting that some 70 rural hospitals have closed in challenge, Carilion clinicians and administrators are community associations, food banks, libraries, law At any stage of this odyssey, a misstep, delay, or just the past seven years, the association projects a working simultaneously on a variety of fronts—from enforcement, and volunteer organizations. Every breakdown in communication might have spelled shortage of 45,000 doctors by 2020. educating local populations about healthy lifestyles three years Carilion coordinates exhaustive, coun- disaster, says Paul Frantz, M.D., Carilion’s medical And access to physicians and quality health care, to encouraging clinicians to follow the less-traveled ty-by-county Community Health Assessments, director of cardiac services. “If it hadn’t been for the though vital, accounts for just 20 percent of an but hugely rewarding path of rural medicine. drawing on insights from these and other groups, EMS training, access to the compression device, and area’s overall health, according to the County Health as well as surveys of local residents, aimed at deter- Rankings, a national research project by the Robert mining where the needs are greatest. In most recent Wood Johnson Foundation and the University of The Human Factor reports, residents cited alcohol and drugs, obesi- Wisconsin Population Health Institute. Other fac- For Christopher Mertes, M.D., who serves patients ty, mental health issues, limited access to healthy tors presenting outsized risks for rural residents in- out of Carilion’s family medicine clinic in Blacks- foods, and diabetes as the top challenges to health clude social and economic issues such as education, burg, Virginia, the decision to focus on primary care in the community. employment, and income (40 percent); behaviors and rural populations was not so much a process of Part of the response goes beyond screenings and such as smoking, poor diets, and lack of exercise (30 elimination as one of inclusion. flu shots to provide creative community education percent); and environmental factors such as water “I went into medical school thinking I would be- programming, such as Be a Quitter, a smoking cessa- and air quality and housing (10 percent). come a surgeon,” he says. “But I began to realize I tion program; a peer-to-peer recovery support initia- While some national health observers have framed really liked the separate subareas, whether it was tive; Healthy Walks and Talks; Wellness Workshops; rural health care as a newly emerging crisis, it’s a chal- pediatrics, internal medicine, general surgery, or- and A Matter of Balance, a falls prevention program. lenge that Carilion—by nature, history, and disposi- thopaedics, or oncology. It dawned on me that fam- An urban farm and a network of community gardens tion—has been addressing for generations. Far from ily medicine was a perfect opportunity to take care have also been established. closing down rural facilities, Carilion in the past decade of the whole person. That entire spectrum of care is “We’re putting more value on preventive care has doubled down on its longstanding commitment what appealed to me; it integrates right into family and health literacy,” Holland says. “Helping people to family and community medicine throughout its medicine and it’s what Carilion stands for.” understand how their behavior affects their overall 20-county, mostly rural service area stretching from A native of Chicago, Dr. Mertes says one of the health is critical. Many still don’t know, for example, central and southwestern Virginia to southern West things he fnds most appealing about treating rural the role that diet and exercise play in the onset of Virginia. A key to that commitment has been the patients is the human connection sometimes lack- type 2 diabetes.” transformation over the past decade of a health system ing in more densely populated areas. Sometimes, it’s not so much about scarcity of re- into a clinic model that emphasizes primary care. “In Chicago,” he says, “I recall people thinking, ‘I sources as educating people that the resources are would never want to go to a doctor who knows who there. Holland adds, “Oftentimes the community I am. I would be embarrassed. I want to see a strang- isn’t aware of the services available to them or how er.’” But after experiences training in rural medicine to access them. So coordination of care is a big op- “I CAME TO in Illinois and North Carolina, “I came to realize that portunity.” once you get to know these people, they don’t want Health care is one of the few industries dedicated REALIZE THAT once you get to know these people, they don’t want anyone to take care of them other than the person to its own demise, in the sense that perfect health they know cares about them and they can trust.” would obviate the need for hospitals, clinics, physi- anyone to take care of them other than the person they know cares about them To encourage more young physicians to follow cians, and nurses. While no one envisions that fu- in the path of Dr. Mertes and others, the Virginia ture, much of Carilion’s outreach with local partners —Dr. Christopher Mertes (pictured above with a patient) and they can trust.” Tech Carilion School of Medicine has launched ru- involves education and shaping behavior to lessen

12 CARILION MEDICINE | FALL 2017 PHOTOS, THIS STORY: JARED LADIA CARILION MEDICINE | FALL 2017 13 ALTHOUGH TELEMEDICINE is not a replacement for more intensive therapy, after a brief consultation with a patient a psychiatrist can often make key recommendations INSIDE THE NERVE CENTER about medications and further treatments. When a medical emergency arises in Roanoke or surrounding them refer to the helicopter crew as angels swooping down Milam, M.D., a member of Carilion’s psychiatry and counties, there may be no busier room in all of southwestern from above and bringing them life.” behavioral medicine team. “Many people with se- Virginia than the Transfer and Communications Center at One man, badly injured in a motorcycle accident on a rural vere mental illness or substance abuse issues have Carilion Clinic. road more than a decade ago, regularly reaches out to Morris not been properly diagnosed, and many don’t have With rows of workers wearing headphones and staring after all these years to thank her for her role in saving his life. access to insurance,” Dr. Milam says. Although the intently at large, ever-changing screens, the center has the In other cases, it’s about saving lives at the very outset, commonwealth took a step forward in April 2017 by look and feel of an air tra c control room. Yet while air and such as providing emergency neonatal intensive care. “We’ve approving Medicaid payments for substance abuse ground tra c is part of the job—Carilion counts three state- got a specialty neonatal transport team that we can send to treatments, many rural residents lack both access to of-the-art rescue helicopters and 40 ambulances in its eet— transport those babies,” Morris says. psychiatrists in their communities and the means to the true mission is about more than transportation. It’s about Beyond directing patients to the appropriate care, the travel to cities where services are more plentiful. saving lives. center’s electronic patient care records system ensures that Three years ago, Dr. Milam launched a pilot When the center receives a call from an emergency clinicians receive vital patient information in real time. program in rural Giles County to help fll that gap medical services unit, a rural hospital, or an accident scene, “This interconnectedness is really important,” says Paul remotely by offering telepsychiatry—secure, conf- “As soon as they call and tell us what kind of patient it is, we’re Frantz, M.D., Carilion’s medical director of cardiac services. dential video conferencing—between Carilion psy- connecting them to the appropriate doctor, we’re scanning “It keeps us from having to repeat tasks and trying to locate chiatrists in Roanoke and patients in Giles. Working our bed board to determine whether that type of bed is avail- somebody by telephone. Everything is at our ngertips.” with the eight-member staff from Carilion’s family able,” says Melanie Morris, R.N., the center’s senior director. medicine practice in Giles, Dr. Milam developed a “And while the doctors are talking about the patient, we’re system that was inexpensive, mobile, and flexible, simultaneously sitting right next to the people who dispatch requiring only a pair of iPads for teleconferencing. the helicopters and ambulances,” Morris adds. “So before When a Giles patient needs psychiatric consulta- the physicians even hang up the phone, we’re telling them JUST A CLICK AWAY: Using his computer in Roanoke, Dr. Robert Trestman, tion, the staff sends Dr. Milam a message requesting whether we can take their patient, and, by the way, we’ve got Carilion’s chair of psychiatry, consults with a family physician, Dr. Robert Devereaux, a meeting. a helicopter that can be to you in 15 minutes, or an ambu- 70 miles away in Pearisburg, a small town in rural Giles County, Virginia. Although telemedicine is not a replacement for lance that can be to you in 20 minutes.” more intensive therapy, after a brief consultation A native of the area, Morris gained her rst experience the need for emergency department visits and help with a patient a psychiatrist can often make key at Carilion in the 1980s as a teenaged candy striper. She people avoid the hospital. recommendations about medications and further returned in the 1990s as an inpatient nurse before getting “It’s not just the hospital where health care is deliv- treatments. Just as important, the calls allow pa- her “dream job” as a ight nurse on one of Carilion’s res- ered anymore,” Holland says. “We’re starting much ear- tients unaccustomed to seeking medical help to de- cue helicopters. Beyond the excitement of the job was the lier by connecting with people in their communities.” velop a sense of treatment continuity. Indeed, while satisfaction of the immediate dierence she was making in people’s lives. 35 percent of Giles County residents said they would LIFESAVER: Melanie Morris works with a team of consult friends and family to discuss a mental health “We’re intersecting with people who may be awaiting a dispatchers who connect patients with appropriate doctors, Possibilities in Telemedicine or substance abuse problem, and 15 percent their lifesaving intervention or treatment,” Morris says. “I’ve heard arrange transport, and secure bed placements. Carilion is also using technology to try to ameliorate church, just 10 percent would consult a psychiatrist. the geographic challenges of rural health. Telemedicine also shows promise in educating “We’re seeing issues related to social isolation the staff at the local clinic on handling such cases. and depression,” Holland says. “When you can’t “It’s really a collaborative effort between the psy- get around, when you can’t take care of your home, chiatric specialist and the primary care clinicians,” We’ll include mental health and substance abuse fulfill its mission to rural residents, then, Carilion when you have limited transportation and the Dr. Milam says. “They feel empowered, they deep- treatment from the beginning. It won’t be an after- must keep one eye on the future and the other on nearest grocery store is 15 miles away, these are en their knowledge base, and they’re reassured that thought; it won’t be an embarrassing thing to bring the here and now, responding to sudden illnesses very real issues in rural areas.” Indeed, the need we’re there to back them up.” up to your family doctor. It will be something that and accidents and changing lives for the better. for psychiatric care in rural settings has never been Building on the promise of Giles, Carilion recent- every patient who presents is screened for, because For Carilion staff, the call to serve rural and urban higher, thanks in part to rising use of opioids and ly received a $435,000 grant from the U.S. Depart- now they have the access.” residents alike is as personal as it is professional, other drugs of abuse, and the addiction problems ment of Agriculture to help expand the idea to 15 Holland says. that go hand in hand. rural clinics throughout Carilion’s service area. “Carilion started in the late 1800s,” she says. In Virginia, as around the country, traditional re- Although telemedicine remains in its infancy, A Call to Serve “Our roots are here. Our 13,000 employees don’t sources for treating psychiatric patients have been Dr. Milam sees the approach as helping usher in Even as these long-term efforts evolve, life’s emer- just work here; we live here. The community’s is- overwhelmed in recent years, according to Thomas “a new era of how we envision rural health care. gencies will continue to unfold in real time. To sues are ours as well.” CM

14 CARILION MEDICINE | FALL 2017 CARILION MEDICINE | FALL 2017 15 COUNTRY ROADS: The site of his four-week rural family medicine rotation—the small town of Shawsville, Virginia— reminded medical THE student Adam Tate of his rural hometown of Laurel Fork, Virginia. ROAD LESS

BY DAVID BUMKE TRAVELED

Carilion training programs are preparing medical students, physicians, and advanced clinical practitioners to meet the unique health needs of rural populations.

IT WAS A WELL-MEANING EFFORT THAT FELL VICTIM TO unintended consequences. Local communities in Kansas, trying to encourage physicians to put down roots in small towns and rural outposts, created a program that paid medical residents to commit to practicing there as family doctors. Once the physicians agreed to stick around, they faced a steep fnancial penalty for pulling out. Although the program succeeded at frst, with- in a few years a widening gulf between primary care salaries and much higher compensation for specialists led more and more young physicians to buy themselves out and leave. That swelled the

16 CARILION MEDICINE | FALL 2017 CARILION MEDICINE | FALL 2017 17 “WHAT DO

program’s coffers—“it had gobs of money,” says national graduating class of more than 19,000, that STUDENTS NEED to help them face the challenges of rural practice? Cynda Johnson, M.D., M.B.A., founding dean and adds up to about 350 doctors—seven per state. president of the Virginia Tech Carilion School of Among many efforts to improve on those num- They need experience, they need to understand rural communities, and they Medicine—but it folded because it couldn’t fnd bers, Carilion Clinic and the Virginia Tech Carilion need to have some way to feel they’re not alone.” —Dr. Cynda Johnson enough residents willing to take the cash. School of Medicine have launched initiatives to Dr. Johnson, after training in California, had re- help expose medical students and residents to the turned to her Kansas roots, and she saw frsthand a life of a rural doctor, and to prepare them for the problem that persists to this day. Stark disparities clinical needs of rural populations. An additional exist between the care most rural residents receive program focuses on physician assistants and nurse and what people in more populated areas can ex- practitioners, who can provide the essential care pect. Farmers and others who can scarcely spare that many patients might otherwise not receive. the time may need to drive hours to see a doctor, “What do students need to help them face the and getting to specialists or the nearest hospital challenges of rural practice?” asks Dr. Johnson. takes longer still. Death rates are higher in rural “They need experience, they need to understand ru- areas than in the cities and suburbs, and so is the ral communities, and they need to have some way to percentage of people without health insurance. By feel they’re not alone.” Carilion programs approach just about any statistical yardstick, the situation is all of those issues from several crucial angles. in serious need of improvement. “It’s not a sudden crisis, because the problem has persisted for as long as I can remember,” says Lessons in a Rural Environment Dr. Johnson. “But there is an urgency in the need The Virginia Tech Carilion School of Medicine’s to keep physicians in rural areas.” four-week elective in rural family medicine seeks to Despite fnancial incentives, so few doctors immerse students in both the challenges of primary coming out of medical school intend to practice in care in such settings, as well as the unique relation- remote places that their numbers barely register in ships clinicians develop with rural patients. surveys such as the annual Medical School Gradua- For fourth-year medical student Adam Tate, tak- ACCESS FOR tion Questionnaire from the Association of Amer- ing the elective last summer recalled his upbringing EVERYONE: ican Medical Colleges. In 2017, just 1.8 percent of in Laurel Fork, Virginia, a town of about 1,200 people Under the super- new physicians said they planned to work in a rural near the North Carolina border, where he watched his vision of Dr. Julia area or a town with fewer than 2,500 people. In a physician father take care of patients with wide-rang- Hemphill, medical ing maladies. He understood that in such places, even student Adam Tate takes a biopsy today, a physician may resemble a doctor in a Norman from patient Rockwell painting, a revered fgure everyone knows Eugene Yopp at and runs into on a daily basis. the Carilion Clinic “You’re part of the community,” Tate says, and he Family Medicine notes that living among your patients can also confer practice in rural Shawsville, Virginia. signifcant clinical benefts. “You really get to know the people who come to see you on a personal level—you see how to interact with them, and the best ways to get them on board with the care plan you have for them.” In his previous medical rotations, the physi- to all kinds of care, and it’s all applicable in terms of That reality, in turn, may help shape the plan for a cians Tate observed and worked with in the hospi- taking care of patients yourself or, if it’s something particular patient. “If you know your patients can’t af- tal and in urban practices could take advantage of you can’t do, knowing whom and where to refer to.” ford things or you think they might be less likely to go cutting-edge technology and the easy availability of Even when a referral may be the best option, see someone else for whatever reason—that’s some- other physicians for consultations or referrals—lux- however, Tate understands that many rural patients thing you need to be prepared for in a rural practice,” uries not available to most rural doctors. Yet Tate will choose to be treated right then and there. Tate says. “Then you can make sure you’re providing feels those rotations were excellent preparation for That happened all the time when Dr. Johnson care that’s actually helpful to them and that they can anyone considering hanging a shingle far from ur- treated patients in small-town Kansas. “They just follow through on.” ban and suburban resources. wanted me to sew up whatever cuts they had, and it Tate, who holds a master’s degree in public health, “In rural family medicine, you have to be ready didn’t matter if I told them we had a plastic surgeon often thinks about what it may take to improve medi- SPECIAL DELIVERY: As a family medicine physician, for whatever comes in the door,” Tate says. “In our available,” she says. “‘Could you just do it for me, Doc?’ cal access and care for rural patients—and technol- Dr. Cynda Johnson appreciates the value of rural medicine. third year of medical school we get broad exposure they’d say. ‘I’m a farmer. I have to be back in the felds.’” ogy is high on his list. As the clarity of audio and

18 CARILION MEDICINE | FALL 2017 PHOTOS: JARED LADIA, PREVIOUS SPREAD; DAVID HUNGATE, LEFT PHOTO: JARED LADIA CARILION MEDICINE | FALL 2017 19 “IF YOU CAN

video used in telemedicine improves, it gets easi- dents who opt for the elective in the second or third GET A TEAM together—a family doctor, a pharmacist, and er to link patients with physicians and specialists year of their three-year residency normally don’t across long distances. relocate to Martinsville, Virginia, where the rural ro- a nurse practitioner, say—you can cover many patients while “It’s especially helpful to have telemedicine tation is based, but rather split their time between giving each other relief and support.” —Dr. Cynda Johnson available for psychiatric and psychological counsel- there and Roanoke or Salem. “They still follow their ing,” Tate says. “In my community, there’s not much continuity patients here at our practices,” she says, access to those, and mental health is a big issue.” “but they spend much of the week in Martinsville.” Yet even the parts of family medicine training In all of the small towns in which he has prac- fessional trained to deliver essential medical care as that take place in Carilion clinics and hospitals pre- ticed—in his medical school elective, in rural rotations part of a multidisciplinary team. Doctors for All Seasons pare physicians for rural practice. during his residency, and now in his new permanent “Interprofessionalism is very important to what With his clear afnity for rural medicine, Tate hopes “Everything you do in the residency, while not position—Dr. Vieau has been warmly embraced by pa- we do,” says Dr. Johnson, in describing the educational one day to be able to practice in an area where the skills specifcally targeted to whether you’re going to prac- tients and doctors. And already, in the early days in his approach of the Virginia Tech Carilion School of Med- he has developed during medical school can be put to tice rural medicine, still trains you for that,” says new practice, he has been reminded of what he consid- icine. “Our medical students do projects with nursing good use. And although plans for his upcoming resi- Dr. Misicko. “When you do your regular rotation in ers one of the most important attributes for anyone students and physician assistants in training, they dency are still being formulated, he and others who adult or pediatric emergency medicine or in critical going into medical practice, regardless of the setting. learn about each other’s professions, and they work want to continue preparing themselves for a profes- care or on the family medicine inpatient service, all “Patience is a virtue,” he says. “In a rural situa- in teams—all great preparation for a rural practice, sional life far from population centers could consider of those help you learn how to care for patients in tion, as in any other kind of practice, you have to where it really helps to have colleagues. If you can get the Virginia Tech Carilion Family Medicine Residency, any setting. They help you learn how to be a critical build a relationship with your patients, and that a team together—a family doctor, a pharmacist, and a which includes a third-year elective in rural medicine. thinker for patients with acute care problems.” takes time. But if your patients learn they can trust nurse practitioner, say—you can cover many patients “When people go into family medicine, they often Of course, not everyone who chooses the rural elec- you, you’re going to have better outcomes.” while giving each other relief and support.” want to help underserved populations,” says Nancy E. tive will go on to practice far from the madding crowd. Dr. Nichols, meanwhile, is only the second phy- Toward that end, Carilion’s Department of Fam- Misicko, M.D., M.P.H., program director of the resi- Understanding the particular challenges of treating ru- sician to undertake Carilion’s recently established ily and Community Medicine offers an advanced dency. “The rural rotation within our program adds ral populations, however, can be invaluable wherever one-year Wilderness Medicine Fellowship. Trav- practice fellowship for physician assistants and another layer to their knowledge and skills. For those someone chooses to be a doctor. “In rural settings, you eling to remote mountain trails and deep into the nurse practitioners in urgent care and rural health. who do go out and practice in outlying areas, it’s ex- see things you won’t necessarily encounter in your typ- woods to provide whatever care may be needed, In a one-year fellowship, designed to mirror family citing, because you feel like you’re helping patients ical training,” says Dr. Misicko. You may be called on to often without the beneft of modern medical tech- medicine residency training for physicians, physi- who may not have had anybody before.” treat victims of a tractor accident, for example. Or you nology close at hand, is one more way to hone skills cian assistants and nurse practitioners acquire the The rural elective is part and parcel of the broad- may realize that something that’s routine in the hospi- that are needed every day in rural medicine. specialized skills and knowledge they would need er family medicine program, Dr. Misicko says. Resi- tal is much more complicated when you’re working in “You see the possibilities for practicing in aus- in a rural practice. That focus is a logical extension a small ofce on your own. “You have to learn to think tere environments with minimum resources,” says of Carilion’s long-time commitment to training on your feet,” she says. Dr. Nichols. “In rural practice, you can be confronted nurses and other professionals through its afliat- “To me,” she adds, “our goal has always been to ed- with situations where you just don’t have the right ed Jefferson College of Health Sciences. ucate people to be well-trained physicians, so they can materials. This fellowship prepares you to keep your Dr. Johnson notes that the mission of the Virgin- go wherever their interests take them, to serve what- mind flexible in coming up with different solutions. ia Tech Carilion School of Medicine isn’t rural health ever community they choose to be a part of.” Stabilizing fractures, evaluating airways, checking care—“it’s to educate physician thought leaders breathing and circulation, treating environmental through inquiry, research, and discovery,” she says. injuries, such as hypothermia and heat stroke—you “Often, in rural areas, doctors ask themselves, ‘Am I Into the Real World, Rural or Not treat the patient as well as you can immediately, and doing a good job? Am I practicing up-to-date medi- Christopher Vieau, M.D., and Joshua Nichols, M.D., then get them to defnitive care.” cine?’” Students who come out of the medical school illustrate Dr. Misicko’s point. Both young physi- Dr. Nichols notes, too, the critical importance of do clinical research with their own patient popula- cians attended the Virginia Tech Carilion School of community education. “We try to prevent accidents tions—a focus that is sorely needed, Dr. Johnson Medicine, and both have had experience in treating from even happening,” he says, “by teaching people says, because so much research looks at hospitalized rural populations. Their career paths now under- how to be safe when they go into the wilderness.” patients mostly in cities and suburbs. score the flexibility of their education and training. Dr. Johnson notes that being able to contribute Dr. Vieau is from Syracuse, New York, and went to new research that more accurately reflects the to college in New York City, so rural medicine was Sharing the Load broader population is one more way in which com- not in his DNA. Yet as a family physician, he knew Dr. Nichols plans to work in rural medicine, and mitting to a life as a rural practitioner can be pro- he wanted to be where he could help patients get ac- he looks forward to meeting just those kinds of fessionally and intellectually fulflling while bringing cess to the care they needed, and he says the rural challenges—and to settling into a community af- enormous benefts to an underserved community. BACK ROADS: Dr. Joshua Nichols, shown on a hike near the Blue Ridge Parkway, rotation he did in medical school was “deeply influ- ter a dozen years of higher education and training. “To me, as a family doctor,” says Dr. Johnson, has learned that wilderness medicine encompasses more than rescuing errant ential” in his decision last summer to enter a private Chances are good that he’ll practice alongside a “that’s the way to give students more confdence to adventurers; it also requires educating the public. practice in rural Union County, North Carolina. nurse practitioner or a physician assistant, a pro- practice in rural areas.” CM

20 CARILION MEDICINE | FALL 2017 PHOTO: JARED LADIA CARILION MEDICINE | FALL 2017 21 81

64 Carilion Stonewall THE RURAL ROUTE Jackson Hospital Carilion Clinic encounters scenic beauty and special challenges Lexington

THE TERRAIN AND WILDLIFE OF SOUTHWESTERN VIRGINIA—AND THE LIFESTYLES OF ITS residents—can create challenges for clinical care beyond those of mere remoteness. For years now Carilion Clinic has been forging solutions to ensure the nearly one million residents in its service area have access to quality care as well as emergency services ranging from air ambulances to a regionwide cardiac response network. 81 These services—together with Carilion’s network of other resources, including community hospitals, primary care and urgent care sites, and telemedicine initia- 501 tives—prove that rural isolation does not need to mean clinical abandonment. 460 Lynchburg Carilion Roanoke 581 Community Hospital Carilion Giles Community Hospital lue ie Virginia Tech Carilion School of 460 aray Medicine and Research Institute 460 Pearisburg Blacksburg Jefferson College of Roanoke 460 Health Sciences Carilion Tazewell Virginia Tech Bedford Community Hospital Carilion Roanoke Memorial Hospital Carilion Children’s Hospital 81 Tazewell Radford University Primary Care Carilion New River Valley Medical Center Urgent Care Carilion Clinic Saint Albans Hospital mith ountain Home Care and/ ae or Hospice Hospital Rocky 220 Mount Educational Institution 122 (Carilion Affiliate or Partner)

81 Carilion Franklin Life-Guard Air Memorial Hospital Ambulance Base 77

Terrain Outdoor Sports Wildlife Hunting Limited Access to Care Diet and Exercise Opioid Abuse Tobacco Use The beautiful yet rugged terrain The region’s growing popularity Celebrated for its abundant Hunting can prove dangerous Nationally, rural areas have far Lifestyle choices have led to high Substance abuse has reached People in rural areas have up to of southwestern Virginia often as a destination for outdoor wildlife, the area also faces for hunters as well as the hunted, fewer primary care physicians rates of obesity, which in turn epidemic proportions in the 20 percent higher lung cancer exacerbates the challenges of adventurers has led to a dangers from critters, including with tree-stand falls and shooting than urban areas. In southwestern have fueled a diabetes epidemic. region, with southwestern rates than those in cities. People rescuing injured and ill people, spike in mountain biking, snakebites, collisions with deer accidents accounting for a Virginia, relatively low incomes Poor diet and exercise have Virginia confronting the state’s in Appalachia also have a greater from Appalachian Trail hikers to hiking, swimming, rock climbing, and, more recently, Lyme disease significant portion of emergency and employment rates further also contributed to some of the highest mortality rate from risk of hospitalization for chronic those living in remote areas. and boating accidents. and other tick-borne illnesses. department visits. hinder access to care. nation’s highest rates of stroke. opioid overdoses. obstructive pulmonary disease.

22 CARILION MEDICINE | FALL 2017 ILLUSTRATION: MIKE LEMANSKI Note: Map is for illustration purposes only; icons of perils are intended to be representative of the region rather than specific localities. CARILION MEDICINE | FALL 2017 23 S T OR GN MedicineOnce just a hospital-owned athletic facility, the Roanoke Athletic Club—now Carilion Wellness—has transformed itself into an active partner in the Carilion care team. BY VERONICA MEADE-KELLY

IT’S BEEN TWO YEARS SINCE THE ROANOKE ATHLETIC CLUB and its fellow Carilion-owned ftness centers, Botetourt Ath- letic Club and RAC Express, were rebranded as “Carilion Well- ness” centers. And while the new moniker might not roll off the tongue as easily as “the RAC and the BAC,” as the clubs were once affectionately known, there’s a consensus that “Carilion Wellness” descriptively captures the shift in culture and mis- sion that has taken root in these facilities. Bud Grey, vice president of wellness for Carilion Clinic, trac- es the transformation back fve years. At the time, the clubs served Carilion’s then roughly 12,000 employees, along with members of the local communities, using a ftness-club mem- bership model that is common nationwide. “But then we had an epiphany,” Grey explains. “We realized so many physicians in the Carilion system were recommending exer- cise for their patients. But it was clear they didn’t necessarily know where to send those patients after making that recommendation.” The realization inspired staff at thef tness club to create “Fit Rx,” a 60-day prescription exercise program that gives pa- tients referred by physicians access to one-on-one personal training sessions with a nationally certifed trainer. The train- ers, in turn, exchanged feedback with the prescribing clinicians. The program took off. Nearly 7,000 participants have com- CALL TO ACTION: Les Perdue never worried pleted the program since its inception—and its appeal hasn’t about his health—until the day he had a stroke. been limited to ftness fanatics. His prognosis was grim, with the specter that “What was interesting was that, for the frst time, we were he may never walk again. Then he received a prescription for a supervised fitness program reaching sedentary people who had either never exercised or at Carilion Wellness. Since then, he and his wife, hadn’t done so in years—and we were reaching them with Pat, pictured at right, both focus on staying physically fit in retirement.

24 CARILION MEDICINE | FALL 2017 CARILION MEDICINE | FALL 2017 25 remarkable success,” Grey says, noting that this once-sed- son’s patients, as studies suggest exercise improves many entary group has accounted for about 75 percent of Fit Rx symptoms that would otherwise be difficult to treat. participants. “It was an exciting breakthrough for us.” “Motor symptoms often respond well to exercise, and so can a variety of nonmotor features, including sleep, mood, energy levels, and cognition,” Dr. Ferrara says, Just What the Doctor Ordered adding that there is also some evidence that aerobic ex- In the age of desk jobs and screen-time, so-called “exer- ercise may slow disease progression. “The goals of every cise prescriptions” are fairly common. Many people live patient embarking on therapy are a little different, as are sedentary lifestyles, and the lack of exercise increases the the outcomes, but I have seen meaningful improvements risk of muscle atrophy and other physical impairments. in gait, and many of my patients report improvements in It also invites obesity, which now affects over a third of their function, safety, and quality of life.” American adults and is a leading risk factor for condi- Pat Grisetti has experienced the benefits firsthand. tions such as diabetes, hypertension, and heart disease. The retired law enforcement coordinator from Boones Clinicians routinely recommend exercise to minimize Mill, Virginia, was diagnosed with Parkinson’s last year. these long-term health risks. They also prescribe exercise to She said that, even more than the motor challenges stave off recurring injuries and even to mitigate debilitating posed by the disease, she was moved to join the Carilion symptoms that accompany chronic disease. It’s all part of a Wellness program because of the illness’s associated risk growing clinical focus on preventive care. And it’s here, Grey of dementia. says, that the missions of the fitness clubs and the broader “The thought of one day not recognizing my husband, Karen Anderson (left), Carilion system align: both believe in the power of exercise to children, and two precious grandsons frightens me to director of Take Control improve the wellness of the communities they serve. death,” she says. “I asked my doctor, ‘What medications Rx, helps patient Valerie The recognition of this shared mission—and the suc- can I take? What foods do I need to eat? Are there any Church fill her exercise prescription. cess of Fit Rx—inspired the fitness center leadership to experimental treatments?’ His response was, ‘Exercise, broaden its clinical approach, and the focus of the centers exercise, exercise. You can’t do enough.’” turned to “wellness” rather than memberships. Grisetti says she’s more than willing to put in the With that shift came new programs. One, Recovery Rx, physical work if it can help keep her mind sharp. When is a physician-referred program designed for people re- her current 12-week program ends, she says she’ll join M O O RT covering from injury, pre- and post-surgery. It’s meant to a bicycle spinning class that Carilion Wellness offers to fill the care gap left at a particularly vulnerable time—af- those who have completed the program. ter insurance-covered physical therapy ends, but before “Parkinson’s disease is making it difficult for me to do often respond well to exercise, symptomsand so can a variety of nonmotor patients are back to their pre-injury selves. many things I used to take for granted, but I know this Other programs are aimed at people with chronic dis- program is helping me both physically and mentally,” she features, including sleep, mood, energy levels, and cognition.” ease. So far, Carilion Wellness offers classes for people with says, noting that the camaraderie and support of other —Dr. Joseph Ferrara Parkinson’s disease and multiple sclerosis, with programs program participants with Parkinson’s have also helped being developed for people with cancer. All programs are boost her spirits. priced to make them as accessible as possible, with fees Karen Anderson, director of Take Control Rx, says comparable to copayments that the participants would that along with the program’s cardiovascular and social Paving a Better Road to Wellness And Grey is quick to note that this clinical approach isn’t have paid for physical therapy. Limited-income patients are benefits come improvements to mobility, stability, and In her native Australia and elsewhere, Anderson says, limited to prescription-exercise programs: all Carilion em- eligible for financial assistance; the Carilion Clinic Foun- body mechanics that enhance quality of life. programs that use ftness and functional training to help ployees and Carilion Wellness members beneft. The cen- dation offers assistance for people with multiple sclerosis While traditional group exercise classes such as cycling manage and prevent illness—like those now offered at Car- ters—which now include two other Virginia branches, in and, in alliance with the foundation, a community donor and boxing are available to people diagnosed with Parkin- ilion Wellness—are relatively common. Not only are they Blacksburg and at Smith Mountain Lake—offer education provides support for people with Parkinson’s disease. son’s disease or multiple sclerosis, the primary focus of Take thought to improve quality of life for participants, but they classes that cover everything from yoga to painting. These Control Rx is functional training. Twenty-four hundred have also been shown to lower systemic medical costs from centers also host “Healthy Happy Hours” both at their facili- square feet formerly reserved for racquetball courts have medication, hospital visits, and long-term care. Yet the pro- ties and out in the community, where people can eat, social- Much-Needed and Welcome Support been converted to a functional training studio where classes grams remain difcult to fnd in the United States. In fact, ize, and talk to experts about a range of health topics. The The development of the chronic disease programs, now focus on developing the core muscles, balance, and flexibility when Grey was looking for models to emulate while devis- Carilion Wellness team even offers such services as mammo- known as Take Control Rx, reflects a growing apprecia- needed to carry out the routine activities of daily life, from ing the Carilion programs, he came up empty-handed. gram signups and biometric screenings at these events. tion in the medical community for the pivotal role exer- carrying groceries and caring for children, to climbing steps, “I didn’t want to reinvent the wheel,” he says, “but It’s all part of the Carilion Wellness focus on preven- cise can play in maintaining the health of the chronically driving, or swinging a golf club. when I reached out to colleagues, many said they’d been tive care, which is not only about physical ftness, but ill. These programs also reflect the reality that certain “These exercises aren’t about maximizing one’s bench looking into it but hadn’t yet developed any programs.” also on building a healthy mind and body to increase en- health factors, such as symptoms that affect balance and press,” Anderson says. “There’s a reason behind the exer- Grey says that Carilion was fortunate to hire Ander- joyment of life. coordination, require the type of monitoring and assis- cise we do with the participants. Our ultimate goals are son, a chronic disease specialist and accredited exercise “Wellness is about so much more than caloric expendi- tance during exercise that only physical therapy or pro- keeping these people independent and out of the hospi- physiologist with experience in the feld. With the help of ture,” Grey says of the centers’ new mission. “There’s a role grams like those at Carilion Wellness can provide. tal, reducing their medications, and giving their caregiv- her expertise, Carilion Wellness has become one of only for wellness in everyone’s life regardless of age or physical Joseph Ferrara, M.D., a Carilion neurologist, recom- ers support by trying to limit the physical ailments that a few centers on the East Coast to defne itself by this condition, and centers like ours should be there to help you mends regular exercise for the vast majority of his Parkin- participants and their families have to contend with.” preventive care model. do whatever it is that makes your life more fulflling.” CM

26 CARILION MEDICINE | FALL 2017 PHOTO, PREVIOUS SPREAD: DARRYLE ARNOLD PHOTO: JARED LADIA CARILION MEDICINE | FALL 2017 27 THE by Jessica Cerretani AFTERMATH LAW-ENFORCEMENT OFFICERS AREN’T THE ONLY ONES WHO ROUTINELY WITNESS THE EFFECTS OF VIOLENCE; HEALTH CARE PROVIDERS ARE OFTEN ON THE FRONT LINES AS WELL. CARILION IS HELPING IN EFFORTS TO PROTECT THE VULNERABLE.

ILLUSTRATIONS: BRIAN STAUFFER CARILION MEDICINE | FALL 2017 29 T’S BEEN A LONG DAY IN THE EMERGENCY DEPARTMENT, knows that’s unlikely. Aidan’s femur is broken—and he’s only and it’s about to get even longer. Amid the typical flurry of two months old. patients with chest pain or sprained ankles, a nurse spots As the doctor asks more questions, the story starts to something unusual. At frst blush, little Aidan* isn’t much change. “I think he fell off the couch,” his father offers haltingly. IN THE IMMEDIATE AFTERMATH OF VIOLENCE, THE PRINCIPAL FOCUS OF CLINICIANS different from other kids in the emergency department: Yet that account doesn’t make sense either. IS ALWAYS ON TREATING INJURIES AND SAVING LIVES. BUT THEY’RE ALSO COGNIZANT His parents have brought him here, worried that he’s hurt “The basis of the medical relationship is trust, and we his leg. But as pediatrician Donald Kees, M.D., begins to ex- should never jump to conclusions,” Dr. Kees, who has been OF THE INVISIBLE SCARS THAT CAN LINGER LONG AFTER A CAST COMES OFF OR amine him, some red flags appear. brought in to consult on the case, explains later. “But in some “I don’t know what happened,” his mother says. “He just cases, the history given by the parents just doesn’t match the STITCHES ARE REMOVED. seemed fussy and then his leg started to swell.” But Dr. Kees baby’s injuries.”

FORENSIC NURSES: Uncovering the Crime, Aiding the Victims Dr. Kees gently informs Aidan’s parents that his suspicions vice chair of Carilion’s Department of Pediatrics. “We all work require him to call Child Protective Services. As a pediatric together as a team to help vulnerable patients.” In the examination room, the nurse carefully inserts a spec- “We see patients from the moment they enter the hospital hospitalist at Carilion Children’s Hospital, Dr. Kees is well Recently, Carilion expanded its support when a Community ulum into the patient and swabs her genital area. But this until they’re discharged—and sometimes afterward, for versed in detecting possible cases of child abuse. Yet he’s just Health Assessment identified mental health services as a top isn’t a typical gynecologic exam, nor is she a typical nurse. follow-up examinations in the emergency department,” says one of a cadre of clinicians at Carilion dedicated to helping priority for patients. Since issues like sexual assault and child Instead, the act is one component of a sexual assault forensic Melissa Harper, M.S.N., a founding member of Carilion’s Forensic care for Virginia patients in the wake of sexual assault, child abuse can negatively affect mental health—and people with evidence kit, colloquially known as a rape kit. And the clinician Nurse Examiner Program. “It’s a very intense form of nursing.” abuse, and other forms of violence. The clinic’s designation as mental illness are significantly more likely to experience trau- is a forensic nurse examiner who provides specialized care for In such situations, when emotions are understandably a Level I trauma center makes its position on the front lines ma—clinic leadership has begun funding valuable programs patients who have experienced violence. running high, forensic nurses say they must focus on the im- of post-trauma medical and psychological care a natural one. aimed at stemming the tide of violence in the community. Since 1995, Carilion Clinic’s team of forensic nurse examin- portance of stepping away from snap judgments and staying “So many patients suffering from violent injuries land on our This year, Carilion committed to provide financial support ers has offered a full spectrum of care to calm—especially in cases of child abuse doorstep,” says Dr. Kees. “It’s our responsibility to help them.” to the Southern Virginia Child Advocacy Center, which offers a trauma patients—a service that’s been and domestic violence, where the perpe- comprehensive and coordinated response to criminal and civil described as the intersection of health trator may be right at the victim’s bedside. cases of child abuse and neglect in the region. Similarly, the clinic care and the legal arena. Although “We have to be as methodical and Strength in Community stepped in to help keep doors open at Sabrina’s Place, the area’s sexual assaults comprise most of these meticulous as possible, without condemn- In the immediate aftermath of violence, the principal focus of only secure supervised visitation and safe exchange program for cases, forensic nurses see a range of ing or showing any bias,” explains Harper. clinicians is always on treating injuries and saving lives. But families affected by domestic and dating violence, sexual violence, patients, including those who are victims “If they think we’re judging them, they they’re also cognizant of the invisible scars that can linger long stalking, and child abuse. or perpetrators of child abuse, intimate may clam up and not share important in- after a cast comes off or stitches are removed. “Carilion has been really supportive of helping clinicians ad- partner violence, elder abuse, trafficking, formation. People’s lives depend on what There’s little doubt that violence can have lasting effects. dress the causes and effects of violence, not just within the hospi- and attempted murder. we say and how we act, not just on what Survivors can experience serious mental health problems, in- tal, but where our patients live and work,” says Harper. “Whatever hits the emergency depart- evidence we find.” cluding depression, anxiety, and post-traumatic stress disorder. ment, our forensic nurses are there to pro- Yet such vital programs are not the They are also at higher risk for developing chronic conditions vide support,” explains Janet Young, M.D., norm: According to the International As- such as cardiovascular disease, asthma, and cancer—perhaps The Long View medical director of the program. “Even sociation of Forensic Nurses, just one of 10 because, as research suggests, they are more likely to smoke, Back in the emergency department, Dr. Kees tries to keep every- beyond the emergency department, they hospitals in the United States has a forensic make unhealthy food choices, and abuse alcohol or drugs after one’s emotions in check—including his own. give medical treatment, social support, nurse examiner program, and even fewer experiencing a violent crime. Although he suspects the baby’s injuries were intentional, and legal support, acting almost as physi- have comprehensive programs that address “This is a major health care issue, but not everyone realizes he’s still Aidan’s doctor, and that means he’ll need to con- cian extenders. These nurses have a unique niche in health care crimes beyond sexual assault. For this reason, Carilion provides that,” says Melissa Harper, M.S.N., a founding member of Car- tinue to work with the family and care for the little boy, re- that no other profession provides.” forensic nurse services for agencies across its service area. ilion’s Forensic Nurse Examiner Program. “It’s been gratifying gardless of the legal outcome. Even with the call to protective In addition to treating patients’ injuries, forensic nurse Now in its 22nd year, Carilion’s Forensic Nurse Examiner Pro- to see our leadership acknowledge that violence is a true public services, Aidan won’t necessarily be taken from his family. examiners test and provide prophylaxes for possible sexually gram has six full-time forensic nurses. Sensitive to the issue of pro- health problem that extends beyond hospital walls.” Depending on the investigation, he may eventually go to live transmitted infections, provide emergency contraception, and vider burnout, Dr. Young conducts regular debriefing meetings Indeed, Carilion has long partnered with community pro- with a relative, enter foster care, or even return to his par- collect evidence that may later be used by law enforcement that allow the nurses to discuss recent cases, gain new insights, grams to ensure that patients who have suffered abuse, sexual ents once they have received appropriate preventive resourc- officials. They also offer emotional support, provide domestic and, sometimes, vent. The program is also in the early stages of assault, and other types of violence have access to the resources es and interventions. violence victims with safety planning and safe shelter referrals, developing a more routine system of mental health counseling for they need after they leave the hospital. By maintaining working Everyone’s goal is to ensure that abuse doesn’t happen report to social services and law enforcement as appropriate, the nurses. In the meantime, some of the greatest support comes relationships with a range of community programs—such as the again—which is why Dr. Kees and his colleagues provide a and refer patients to child advocacy groups, counseling, and from the team itself, and from recognizing they aren’t alone. Children’s Advocacy Center, which is part of Children’s Trust; range of services beyond standard care, whether that’s helping follow-up medical care. Later on, they may provide medical “It takes many talented people to make this program work,” the Domestic Violence Council; and Turning Point, the Salvation connect parents with educational programs and social work- testimony in court. Along with pediatricians, forensic nurses says Harper. “We work closely with our physicians, as well as Army’s domestic violence shelter—emergency clinicians can feel ers, testifying at trials, or reviewing previous cases to glean also serve on case-review teams to understand why violence with police and social services. Forensic nursing is just one more confident that their patients have options rather than being useful insights. Above all, the focus is on the patient. happens and how to prevent it. small piece of the puzzle.” forced to return to a potentially dangerous home environment. “It’s not my place to say who committed the abuse,” says “The hospital’s involvement with these groups has been Dr. Kees. “It’s my job to help keep children safe and to give the somewhat of a natural evolution,” says Dr. Kees, who is also vulnerable a voice.” CM

30 CARILION MEDICINE | FALL 2017 *Name and details have been changed to protect patient confidentiality. CARILION MEDICINE | FALL 2017 31 The Cosmos of Our Cells A Virginia Tech Carilion Research Institute scientist sees cancer with new vision. BY ASHLEY WENNERSHERRON

Breast cancer vexes Deborah Kelly. “Cancer is merciless,” she says. “It doesn’t discriminate.” Dr. Kelly, an associate professor at the Virginia Tech Carilion Research Institute, wants to eradicate breast cancer for the same noble reason others study the dis- ease—to rid the world of a threat that’s expected to kill more than 40,000 women in the United States and 500,000 worldwide this year alone. “That’s always the ultimate goal, to improve human health,” she says. “But there’s something else here. Breast cancer cells move around in ways they shouldn’t. They outsmart other cells.” The strangeness challenges her to think about cancer differently.

PHOTOS: DSCIENCE SOURCE CARILION MEDICINE | FALL 2017 33 “Our goal is to see the BRCA1 protein in its most pristine condition at the atomic scale,” Dr. Kelly says. “The electron microscope affords us that opportunity.”

“Cancer cells don’t ft a natural pat- The image could be a topographic map can make a person’s body build mutated tern,” Dr. Kelly says. of the moon; it’s reminiscent of the frst BRCA1 proteins. And she likes a good pattern. She frst photos taken by a lunar rover in 1966, Dr. Kelly learned about the inner noticed natural patterns when she was in with dark peaks and valleys, populated workings of proteins while an under- elementary school. by small dots. graduate; by then, she had traded her “I’d seek out pictures of space, this The molecules on the screen are breast telescope for a microscope to study the strange place that looked so different cancer–susceptibility proteins, known as cosmos of our cells. At frst, she was fo- from anything I knew,” says Dr. Kelly. BRCA1. They’re the health enforcers of cused on gene regulation, trying to un- “But I noticed a familiarity in the images: our cells. Found in every cell throughout derstand how proteins are made and how colors and shapes repeated throughout the body, not just breast tissue, BRCA1 that process can go awry, a subject she the galaxy, including on Earth.” proteins work to repair DNA damage and continued to study in graduate school. She recognized the same patternsHI-RESOLUTION in prevent the out-of-control FIGURE cellular PROOFpro- “When she decided to join my lab, I of- biology: The symmetries and fractal im- cesses that lead to cancer. fered her a project that was pretty much a ages she saw in space were mirrored in The proteins can break, however. Risk sure bet to work, and an alternative project SUPER COOL: Researchers in the Kelly Lab use liquid nitrogen to freeze breast cancer proteins for high-resolution imaging. Members of the our very being. factors, such as smoking or genetics, that would have higher impact, but might team include, from left, Dr. William Dearnaley, Brian Gilmore, Yanping Liang, Dr. Deborah Kelly, Cameron Varano, and Nicholas Alden. “Natural patterns consistently repeat,” she says, “from planets down to atoms.” But breast cancer doesn’t ft any known pattern. The broken symmetry THE BUMPY ROAD TO UNDERSTANDING BREAST CANCER not work,” says Kenneth Taylor, Ph.D., a scope affords us that opportunity. It’s un- support and freedom to pursue her re- bothered Dr. Kelly—so much so that she Dr. Deborah Kelly led a research team to see the breast cancer–susceptibility professor of biological science at Florida biased and tells you the observable truth.” search questions. built her research program on under- protein for the first time. By visualizing the protein in health, as shown below, State University who advised Dr. Kelly as Dr. Kelly was specifically interested in “We were extremely fortunate to standing the secrets of these dangerous they were able to see how mutated proteins had a specific bump in what she earned her doctorate in molecular bio- seeing BRCA1 and learning more about its recruit Dr. Kelly as one of the original researchers call the modification hotspot zone. cells. The frst step? physics. “She chose the project with the collaborations with other molecules in the institute research team leaders,” said “To solve a problem,” she says, “you greater impact. I have met few students as cell. It proved a difficult task. If the sample Dr. Friedlander, who is also Virginia need to see the culprit.” ready to take up a new technique and put preparation didn’t inactivate the protein, Tech’s vice president for health sciences in the effort to master it once they deter- the electron beam certainly did. and technology. “Debbie has exceeded mined that it could facilitate their desire to “Imaging optics were improving,” our expectations, developing a premier The Observable Truth solve a particular problem. I admire her for Dr. Kelly says, “but we still couldn’t see structural biology research enterprise There’s a click, barely audible above the venturing into the unknown.” the things we wanted to see, in the way we and applying powerful molecular imag- hum of machines unknown. The room is As Dr. Kelly worked in Dr. Taylor’s lab needed to see them.” ing and computational approaches to dark, with only the glow of a computer and attended conferences, she made a star- Her team began developing better bio- develop new insights into cancer.” monitor lighting half of Dr. Kelly’s face. tling discovery about the state of research chemical techniques to isolate the proteins According to Dr. Kelly, there’s a spirit of She peers down an eyepiece. Without on the breast cancer–susceptibility protein. from human cells without damaging the innovative collaboration at the institute, shifting her gaze, her hand dances across “BRCA1 is a prime suspect implicated proteins. She then turned her attention to especially when it comes to developing and a control panel. She taps a button and in breast cancer, and no one knew what improving upon the substrates traditional- improving the tools needed for avant-garde tweaks a knob. When she lifts her head, it looked like,” Dr. Kelly says. “How could ly used in electron microscopy. scientific pursuits. she’s smiling. She presses another but- that be? It’s so important!” By this time, Dr. Kelly had complet- “I’ve been lucky with my research team ton, eliciting a small whine from the ma- Researchers were limited by the exist- ed a postdoctoral fellowship at Harvard as well,” says Dr. Kelly, who is also an as- chine towering over her. ing technology, so Dr. Kelly and her team Medical School and moved to Roanoke to sociate professor of biological sciences in Dr. Kelly turns her attention to the changed the technology. set up her lab at the Virginia Tech Caril- Virginia Tech’s College of Science. “We have computer screen to the right. She palms ion Research Institute. a talented team of both early-career and the mouse and clicks a few times. A “There are unlimited possibilities for more seasoned scientists.” grainy black-and-white image appears. Seeing the Unseen growing a research program at the insti- Dr. Kelly began to collaborate with Pro- “That’s it,” she says, admiring the fea- “Our goal is to see the BRCA1 protein in tute,” says Dr. Kelly. She credits Michael tochips, Inc., a North Carolina company tures on the screen. “My version of space its most pristine condition at the atomic Friedlander, Ph.D., the institute’s found- specializing in electron microscopy. Work- exploration.” scale,” Dr. Kelly says. “The electron micro- ing executive director, for providing the ing with engineers at the company, she de-

34 CARILION MEDICINE | FALL 2017 IMAGE: COURTESY OF THE KELLY LAB PHOTO: DAVID HUNGATE CARILION MEDICINE | FALL 2017 35 “We can rotate their 3-D structures on a computer screen and examine them from different angles. This information reveals how BRCA1 interacts with other factors in cells.”

SPOTTING THE HOTSPOT veloped improved preparation approaches, croscope to take a grainy black-and-white reveals how BRCA1 interacts with other Cameron Varano, a doctoral student in Virginia Tech’s Translational Biology, as well as better substrates to attract bio- photo of thousands of BRCA1 proteins. factors in cells.” Medicine, and Health Program, is a member of the Kelly Lab. She prepares the logical samples to the microchip surfaces “The use of this approach was a major samples of the mutated BRCA1 protein for imaging, from which Dr. Deborah Kelly’s to enable examination. step forward in seeing cancer proteins team found a structural bump in the mid-section of the protein that leads to self-destruction in the cell. The techniques involve carefully pre- for the frst time,” Dr. Kelly says. “But the Second Sight paring cellular samples to separate out the images alone aren’t enough. We have to Dr. Kelly struggles to capture the magni- desired biological specimen. Dr. Kelly and analyze the images statistically to gather tude of that moment, years in the making, Protochips engineers developed special- meaningful information.” when she frst saw the protein’s full struc- ized microchips coated with antibodies to With modern computing algorithms ture. She borrows from Marcel Proust’s In attract and trap the prepared samples. The developed by other colleagues in the feld, Search of Lost Time to better explain. antibodies can be changed to create broad- Dr. Kelly and her team used their collected “‘The real voyage of discovery consists ly “tunable” devices on which the desired data to calculate the frst three-dimension- not in seeking new lands, but seeing with The mutated BRCA1 protein is impli- research subjects have an afnity for the al view of BRCA1 proteins, in both healthy new eyes,’” Dr. Kelly says, her own eyes cated specifcally in triple-negative breast chip’s coating. and genetically damaged states. lighting up. “It was worth it. I love the com- cancer. This type of cancer lacks the three The antibody layer attracts BRCA1 pro- “Finally, we can really see these natu- plexity of research—seeing things for the receptors—estrogen, progesterone, and tein assemblies—the cancer-related cul- rally occurring cancer proteins,” Dr. Kelly frst time and working toward discoveries.” human growth factor receptor 2 (HER2)— prits—directly viewable with the electron says. “We can rotate their 3-D structures Dr. Kelly began to see differences be- that clinicians may be able to use for target- microscope. The result is that Dr. Kelly can on a computer screen and examine them tween the healthy and mutated BRCA1 ed treatments. Triple-negative breast can- tap a button to the left of her electron mi- from different angles. This information proteins formed in breast cancer cells. cer has the highest rate of recurrence for pair system. Eventually, the unrepaired Scientists are still years away from a all breast cancer types, meaning that while DNA damage leads to cancer. restorative or preventative treatment for treatments like chemotherapy may be able breast cancer, according to Dr. Kelly, but to push the cancer into remission, the like- the ability to see BRCA1 come to life in its lihood that the cancer will return is greater. An Extra Bump entirety is providing new insights for ratio- Even mutated BRCA1 proteins retain In Dr. Kelly’s feld of work, which she’s nal drug design. The BRCA1 protein looks some ability to repair DNA damage, yet dubbed “structural oncology,” she saw normal, so now it might function normally. cancer still occurs. Dr. Kelly set out to that the mutated BRCA1 proteins looked Should Dr. Kelly’s hypotheses prove correct, understand the compromised protein’s physically different from healthy proteins. people with a known mutation might one defciencies in the cell. “The mutated protein has an extra lit- day be able to avoid a cancer recurrence by “We found that the cancer cells signal tle bump,” Dr. Kelly says. “We refer to the undergoing a treatment that restores their the mutated BRCA1 proteins to self-de- site on BRCA1 that receives the bump as mutated proteins to a healthy structure. struct, on the path to forming tumors,” the ‘hotspot.’” “There’s a lot of potential here,” Dr. Kelly Dr. Kelly says. “We wanted to see why The presence of the bump in the hotspot says. “BRCA1 is associated with breast can- this process occurred and then try to in- zone alerts the cell to the fact that BRCA1 cer because that’s where the genetic inheri- tervene in this self-destruction.” isn’t healthy, so the cell triggers a cascade tance component was frst understood. Yet In the repair process, BRCA1 inter- of events to destroy BRCA1. The research- we have BRCA1 in every cell in our bodies. acts with a molecular partner to form a ers theorized that they could restore the What if these proteins play an equally criti- clamp-like structure. The molecules work structural properties of mutated BRCA1 by cal role in other cancer types? Could BRCA1 together to relay the message of damage simply removing the self-destruction signal be restored in other tissues in the same to other proteins in the nucleus. It’s a from the hotspot region. manner? Is this the pattern we’ve been barn raising for genetic damage—all the “These experiments worked beautiful- searching for with cancer cells?” FROM TELESCOPE TO MICROSCOPE: Dr. Deborah required proteins jump in and help re- ly—upon treatment, the mutated BRCA1 Dr. Kelly, still driven by the uniqueness Kelly redirected her attention from the stars to struc- build the broken molecules. protein looked perfectly normal, no of cancer cells, hopes to fnd more answers. tural oncology, a field of research made possible When BRCA1 is mutated, the cell si- bump,” Dr. Kelly says. “We’re now testing “We’re just beginning to understand by the electron microscope. She uses cryo-electron lences this protein warning system. The whether the normal duties of BRCA1 can how breast cancer–related proteins look microscopy to study frozen biological samples and determine their structures. cell initiates the degradation of BRCA1 also be restored in cells using the same and work and how things can go wrong,” and loses a critical component of its re- treatment idea.” she says. “We still have much more to do.” CM

36 CARILION MEDICINE | FALL 2017 PHOTO: JIM STROUP PHOTO: DAVID HUNGATE; IMAGE: COURTESY OF THE KELLY LAB CARILION MEDICINE | FALL 2017 37 photo essay

with a

A day in the life of the neuroangiography suite at Carilion Roanoke Memorial Hospital PHOTO ESSAY BY JARED LADIA

INSIDE THE WALLS OF CARILION ROANOKE MEMORIAL HOSPITAL’S biplane neuroangiography suite, neurointerventional radiologists perform nearly 1,000 procedures each year. Technological advances are enabling the doctors to deliver stents, coils, flow diverters, and clot retrievers to affected vessels with precision and a high degree of success for treatment of brain aneurysms and ischemic strokes. Guided by high-resolution, three-dimensional images displayed on a 60-inch flat screen, doctors deftly thread tiny catheters through blood vessels in the groin or arm directly into the problem area. The neurointerventional radiologists and endovascular neurosurgeons can then deliver interventions through holes as tiny as pinpricks, re- sulting in good outcomes and shortened recovery times for patients. The results can be dramatic, such as during a “Stroke Alert,” when clinicians race the clock to remove a blood clot from a patient’s brain mid-stroke, often restoring normal function almost immediately. “Patients who used to spend months in rehabilitation, often with SEEING THE BIG PICTURE: Dr. Andrew Nicholson, a neurointerventional signifcant residual disability, can now go home feeling totally nor- radiologist at Carilion Clinic, uses mal,” says Andrew Nicholson, M.D., a neurointerventional radiolo- three-dimensional images to guide gist at Carilion. “Sometimes they can go home the very next day.” a tiny catheter through arteries to a patient’s brain aneurysm. 38 CARILION MEDICINE | FALL 2017 CARILION MEDICINE | FALL 2017 39 POINTS OF VIEW Clockwise from top right: Radiologic technologists Randy Shrewsbury and Patricia Smith help fifth-year neurosurgery resident Cara Rogers, D.O., get prepped for a procedure; Andrew Nicholson, M.D., and Dr. Rogers look at a patient’s brain to evaluate it for aneurysm coiling; Dr. Nicholson examines a patient’s diagnostic imaging to plan for the procedure; a radiologic technologist prepares a catheter to be inserted through arteries to a patient’s brain aneurysm for treatment; Dr. Nicholson stands at the monitor to teach Dr. Rogers during a procedure. Dr. Rogers, like all neurosurgery residents, is undertaking a rotation on the neuroendovascular service as part of her training.

AMPLE SAMPLE Biraj M. Patel, M.D., chief of neuroendovascular radiology, verifies that a spine biopsy has yielded an adequate sample for testing. The sample was obtained using biplane fluoroscopy guidance to insert a needle with precision through a tiny nick in the skin and into the spinal bone.

40 CARILION MEDICINE | FALL 2017 CARILION MEDICINE | FALL 2017 41 the art of medicine ART THERAPY This artwork is just a small sample of area artists’ pieces that line the hallways of Carilion Clinic and provide visitors with views of life in the Blue Ridge.

A. Tina McConchie, “Untitled” B. Patricia Placona, “Sunday in the Park” C. Nancy Stellhorn, “Late August Palette” D. Mary Boxley Bullington, “Untitled” E. Sharon Strite, HEALING ART IN “Evening Splendor” F. Helen Hublar, “Mother” THE BLUE RIDGE Carilion celebrates the power of art to C create moments of respite for patients and caregivers alike. BY PAULA BYRON

AIN IS OFTEN AN INVISIBLE SPECTER LURKING in the corridors of places of healing. Sometimes the pain is physical or psychiatric; other times it may take the shape of grieving, or the anxiety of an unfolding medical drama. POver the years, Carilion Clinic’s recognition of the role of art in soothing pain has resulted in the collec- tion of more than 1,000 original works of art. Many of these pieces—which span a range of mediums, from sculpture to oil painting, photography, and watercolor— brighten spaces in Carilion’s hospitals, physician’s ofc- es, and other places of healing. “More than decoration, the works adorning our A B D interiors create pockets of respite for patients, families, visitors, and staff,” says Nancy Howell Agee, president and chief executive ofcer of Carilion. “We’ve long known the power of art to enhance the healing process.” Carilion has now assembled representative works of its collection in a curated book, Healing Art in the Blue Ridge. With so many of the artists capturing the landscapes they live in, the art has been organized into several regions: the history-steeped Shenandoah Valley; the Roanoke Valley, home to Carilion’s flagship “little hospital on the hill”; and the rugged terrain and natural resources—including one of the world’s oldest rivers— of the New River Valley and beyond. “Our devotion to landscape and community has led us to focus on works that reflect the natural beauty and cultural diversity of our area,” says Agee. “Through the work of so many talented artists, we’ve woven our surroundings throughout our places of healing, just as Carilion has been woven through the decades into the fabric of the communities we serve.”

The Carilion art collection represents generous contributions, special acquisitions, and the work of the Carilion Clinic F E Foundation for the Dr. Robert L.A. Keeley Healing Arts Program.

42 CARILION MEDICINE | FALL 2017 PHOTOS OF ARTWORK: KEVIN HURLEY CARILION MEDICINE | FALL 2017 43 cheers for peers

Family Medicine

MARK GREENAWALD, M.D., vice chair of academic affairs and professional development, was a co-presenter for several Chief H Resident Leadership Develop- ment Program workshops of the American Academy of Family Physicians. Topics included the fourth aim, team building, nego- G. Walter Biggs, “Reverie” H. Eric Fitzpatrick, “Autumn” tiation, leadership, and emotion- I. Dorothy Blackwell, “Plank Road” J. P. Buckley Moss, “Fire and al intelligence. Dr. Greenawald Ice” K. Robert E. Tuckwiller, “The Seasons of Life “ (detail) also coauthored an article titled “Coaching in Healthcare” for the G magazine TD at Work.

ROGER HOFFORD, M.D., published information on cryptosporidiosis in Essential Evidence Plus, an evidence- based, point-of-care clinical decision support system pub- lished by Wiley. at the American Osteopathic anterior hip ultrasound, perfor- ERIC CHEN, M.D., and medical PRISCILLA TU, D.O., program di- Association of Sports Medicine mance-enhancing drugs, knee resident KEVIN COOKE, M.D., were rector of osteopathic medicine, Preconference on Musculoskel- procedures, and anterior hip co-presenters for a session on gave several oral presentations etal Ultrasound. Topics included surgeries. wellness at the Society of Teachers

spotlight on Michael Nussbaum, M.D. was program director for the Advanced Gastrointestinal/Mini- A nationally recognized expert in the mally Invasive Surgery Fellowship. I J areas of gastrointestinal, endocrine, Prior to that, he played many roles at the University of Cin- and minimally invasive surgery has cinnati, including interim chair of the Department of Surgery joined Carilion Clinic as chair of its and program director of the surgery residency. Department of Surgery. Dr. Nussbaum, who now also serves as chair of surgery for MICHAEL NUSSBAUM, M.D., arrived the Virginia Tech Carilion School of Medicine, brings an exten- in Roanoke by way of the University sive background in surgical education and leadership. He has of Florida College of Medicine–Jack- held leadership positions with numerous national professional sonville, where he was an endowed professor and chief of the organizations and is currently a senior director for the Ameri- Division of General Surgery. There he had earlier served as chair can Board of Surgery. of the Department of Surgery, surgeon-in-chief of the Univer- Dr. Nussbaum received his bachelor’s degree from North- sity of Florida Health Jacksonville, and program director for the western University and his medical degree from the Perelman surgery residency. School of Medicine at the University of Pennsylvania. He com- Dr. Nussbaum was instrumental in starting a surgical robot- pleted his residency at the University of Cincinnati Hospital, ics program at the University of Florida Health Jacksonville and where he was a faculty member for 22 years. K

44 CARILION MEDICINE | FALL 2017 PHOTOS OF ARTWORK: KEVIN HURLEY PHOTOS: JARED LADIA (ABOVE); DARRYLE ARNOLD (TOP RIGHT) CARILION MEDICINE | FALL 2017 45 cheers for peers

of Family Medicine Annual Spring ectomy project to the National Recovery in Emergency Cases spotlight on Conference. MARY BETH SWEET, Improvement Challenge on Protect Against Post-Operative spotlight on Kimberly Dunsmore, M.D. M.D., co-presented a poster titled Prevention of Surgical Site Infec- Pneumonia and Lower the Rate Robert Trestman, M.D., Ph.D. “Do You See What I See? Compar- tions in Major Gynecologic Sur- of Re-Intubation?” The paper will KIMBERLY DUNSMORE, M.D., a ing Faculty Evaluations of Resi- gery. The project was reviewed also be published in Surgery, the A nationally He serves on the American Psychiatric nationally recognized expert in pe- dents” at the same conference. by the Council on Patient Safety o cial journal of the Society of recognized expert Association Council of Psychiatry and the diatric hematology and oncology, in Women’s Health Care and tied University Surgeons, the Central in psychiatry and Law, on the Data Safety Monitoring Board has joined Carilion Clinic as chair of for first place. Surgical Association, and the population health of the National Institute of Mental Health, as its Department of Pediatrics. Internal Medicine American Association of Endo- has joined Carilion board secretary for the Academic Consor- Most recently, Dr. Dunsmore crine Surgeons. Clinic as chair of tium for Criminal Justice Health, and as chair served as the associate chair for PAUL DALLAS, M.D., and Psychiatry its Department of of the Research Committee for the American clinical program development MICHAEL WIID, M.D., associate Psychiatry. Academy of Psychiatry and the Law Institute and the Karen Jargowsky Endowed Chair for Pediatric program director for Internal WILLIAM REA, M.D., vice chair Residency and ROBERT TRESTMAN, M.D., Ph.D., joined for Education and Research. He also serves Hematology/Oncology at the University of Virginia Chil- Medicine, served as co-leaders of Psychiatry, was the keynote Fellowship Programs Carilion from the University of Connecticut on the editorial boards of two academic dren’s Hospital. for the precourse “Point-of-Care speaker at the Opioid Epidemic School of Medicine, where he was a profes- journals and is a referee for many others. While with the University of Virginia Health System, Ultrasound for Internists and in Rural Virginia conference in CARA ROGERS, D.O., a sor of medicine and psychiatry with a joint Dr. Trestman received his bachelor’s Dr. Dunsmore was the primary investigator for the Chil- Hospitalists” at the American February. The conference was PGY-5 neurosurgery resident, appointment as a professor of nursing. degree from Carnegie-Mellon University dren’s Oncology Group. She sat on the Acute Leukemia College of Physicians meeting. sponsored by the Virginia Rural was selected as a Council of While at the University of Connecticut, and his doctoral and medical degrees from Committee and was the international primary investi- Health Association. State Neurosurgical Societies Dr. Trestman served as executive director gator for the T-Cell ALL Treatment Protocol Committee. JON SWEET, M.D., co-presented Socioeconomic Fellow. The of Correctional Managed Health Care, a She also served as director and primary investigator the concluding talk at the fellowship was created as an division of the University of Connecticut for the University of Virginia Health System’s Compre- American College of Physicians Radiology educational opportunity for Health Center, where he led a program that Dr. Trestman is interested hensive Pediatric Sickle Cell Program and Hemophilia annual meeting. The talk was ti- neurosurgical residents interest- provided health care to all inmates within in the treatment of Treatment Center. She also founded the first pediatric tled “Internal Medicine Meeting EVELYN GARCIA, M.D., chair ed in socioeconomic education. the state’s Department of Corrections. Un- people with severe mood hospice program at the University of Virginia. 2017 Highlights and Doctors’ of Radiology, was the keynote It provides fellows with broad der Dr. Trestman’s leadership, the program Her research interests are in the areas of T-cell im- Dilemma: The Finals.” speaker at the 11th World exposure to pertinent neurosur- went from having budget and regulatory and personality disorders. mune dysregulation, T-cell leukemia, clinical trials in pe- Congress on Neurology and gical socioeconomic issues and concerns to being a national leader in cor- diatric oncology, innovative Therapeutics in Madrid, Spain. an introduction to the world of rectional health care. therapeutics for pediatric Obstetrics Her keynote speech was titled organized neurosurgery. Just 12 Dr. Trestman now also serves as chair of the University of Tennessee. He completed cancers, and pediatric and Gynecology “Comprehensive Stroke Care fellows are chosen from across psychiatry for the Virginia Tech Carilion his internship and residency at Mount Sinai Dr. Dunsmore hemophilia. in the Rural Setting.” She also the United States each year. School of Medicine. His research interests Medical Center in New York City, followed focuses much Dr. Dunsmore, who now PATRICE M. WEISS, M.D., chief gave a topic speech on struc- Dr. Rogers’ faculty mentor for include mental health services and the by training as a research psychiatrist at the of her research also serves as chair of pedi- medical officer and executive vice tural heart disease, minimally the fellowship is GARY SIMONDS, neurobiology and treatment of people with Bronx Veterans Aairs Medical Center and atrics for the Virginia Tech president, and JONATHAN GLEA- invasive procedures, and the M.D., chief and program director severe mood and personality disorders. Mount Sinai Medical Center. on innovative Carilion School of Medicine, SON, M.D., chief of urogynecology relationship to thromboembolic for Neurosurgery. therapies for has authored or co-au- and vice president for clinical cerebral disease. children with thored numerous articles advancement and patient safety, in peer-reviewed journals presented at the Becker’s 8th cancer. and book chapters and has Annual Meeting. The presentation Surgery noteworthy been an invited presenter was titled “Carilion Clinic: Forma- at a number of national and tion and Transactions—Physician SANDY FOGEL, M.D., associ- international conferences. She has received awards for Leadership and Its Impact on ate program director for the Orthopaedic Surgeon Returns both teaching and clinical excellence. Liability, Engagement, Competi- General Surgery Residency, and Dr. Dunsmore received her bachelor’s degree from tion and Production.” JING CHEN, Ph.D., a student at to His Athletic Past the University of Tennessee and her medical degree from the Virginia Tech Carilion School THOMAS K. MILLER, M.D., vice chair for Orthopaedic Surgery at Emory University School of Medicine. She completed her JANET OSBORNE, M.D., chief of Medicine, participated in the Carilion, was named assistant medical director for the Ironman World pediatrics residency and a fellowship in pediatric hema- of Gynecologic Oncology, scientific session at the annual Championships. He was also elected chair of the Ironman Global Medical tology/oncology at Duke University Medical Center. submitted Carilion’s multidis- meeting of the Central Surgical Advisory Board. ciplinary Enhanced Recovery Association. Dr. Chen presented Dr. Miller, who serves as chief of Sports Medicine at Carilion, After Surgery (ERAS)—Hyster- their research, “Can Enhanced participated in the Ironman World Championship in 1996.

46 CARILION MEDICINE | FALL 2017 PHOTOS: JARED LADIA TOP LEFT AND ABOVE; DAVID HUNGATE RIGHT CARILION MEDICINE | FALL 2017 47 backstory

WOMEN IN HEALTH CARE Top 1% in the Nation. Getting a seat at the executive table often means sticking your neck out. Of 4,500 hospitals evaluated by U.S. News & World Report, Carilion Clinic’s flagship facility NANCY HOWELL AGEE was one of only 48 in the nation to earn top ratings in all nine surgeries and conditions. A leader in innovative, collaborative care, Carilion Roanoke Memorial Hospital works every day

AO’S APHORISM IS WELL KNOWN: “WOMEN It takes courage to lead. It also takes courage to inno- to advance our mission: Improve the health of the communities we serve. hold up half the sky.” In health care, you’d vate—to take risks without recklessness. A leader must better add the sun and the moon! be intentional, thoughtful, and purposeful. Women drive the engine of health care, Leadership is learning. It’s engaging. It’s growing holding 75 percent of all health care jobs. yourself and growing others. It’s about putting people Yet women occupy only 26 percent of chief frst. And, though it sounds corny, a servant leader leads Mexecutive ofcer positions. In this, health care organiza- with heart. People know when you are undisciplined, in- tions mirror Fortune 500 companies, where women hold sincere, or motivated by money or advancement. Lead- a similar percentage of executive and board positions. ing with heart draws on the most basic and important Clearly, opportunities exist for human values: trust, empathy, women in leadership positions. forgiveness, understanding, love. When I grew up, women were And servant leadership is not expected to become execu- not just about the present. It’s tives, board members, or even also about the future—bring- physicians. My career began as ing along the next generation of a nurse at one of Carilion Clin- leaders. Including more women ic’s hospitals—the very same in senior leadership is critical for hospital in which I was born. As the same reason any diversity I moved through management, initiative is important—hos- I thought hard about what kind pitals and health systems are of leader I wanted to be. And I more effective when they are decided that leadership works representative of the communi- best when it flows not from the ties they serve. Diversity in the top down, but from the bottom boardroom leads to richer con- up. It wasn’t until some years versations and better decisions. later that I learned my convic- For women to have a seat at tion was actually a well-estab- the executive table, we need to lished philosophy. venture out and speak up. On Robert K. Greenleaf founded the modern-day my desk, I keep a small brass turtle fgurine. It’s my dai- servant-leadership movement with his 1970 essay, ly reminder that a turtle gets nowhere until she sticks “The Servant as Leader.” her neck out. With commitment to diversity, develop- The proof of a servant leader, Greenleaf wrote, mani- ment of others, and the fostering of workplace cultures fests in those led: “Do those served grow as persons? Do that allow all to thrive, I’m confdent in the future of they…become healthier, wiser, freer, more autonomous? health care in this country. CM And, what is the effect on the least privileged in society? Will they beneft—or at least not be further deprived?” Nancy Howell Agee is president and chief executive officer Servant leaders listen, assess, and identify and re- of Carilion Clinic and chair-elect of the American Hospital move barriers so those they lead—in our case, phy- Association. Modern Healthcare has recognized her as one sicians, nurses, technologists, therapists, and many of the nation’s 100 Most Influential People in Healthcare for others—can focus on the magical moments between the past two years—most recently ranked at 23—as well as caregiver and patient. among the Top 25 Women in Healthcare.

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28 | THE AFTERMATH Law-enforcement officers aren’t the only ones who witness violence; health care providers are often on the front lines as well. Carilion is helping in efforts to protect the vulnerable. online exclusives

Class Operation Strong Medicine Room with a View Virginia Tech students have the rare A 12-week exercise course is making all Carilion’s neuroangiography suite opportunity to witness live surgeries. the difference for Parkinson’s patients. allows instant clinical successes.

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