AN EXHAUSTING BUT PRODUCTIVE THE HIDDEN DANGERS OF MILD LOW-DOSE SCANS SAVE LIVES DAY WITH A TRAUMA SURGEON TRAUMATIC BRAIN INJURIES OF THOSE AT RISK FOR CANCER
FALL 2016 Carilion Medicine
TIMING IS EVERYTHING From fertility assistance to teen pregnancy prevention, physicians are helping patients achieve their dreams contents CARILION MEDICINE FALL 2016
Departments 2 FROM THE CMO 3 IN BRIEF New Health Sciences and Technology Innovation District; other milestones 6 GRAND ROUNDS Education initiatives both classic and with a twist 36 THE ART OF MEDICINE The Burden Boat helps patients and families lighten their hearts. 38 CHEERS FOR PEERS Carilion physicians receive recognition for a range of achievements. 40 BACKSTORY: 16 THE QUALITY IMPERATIVE Physicians need to embrace transparency A SPOONFUL OF SUGAR: Carilion Children’s seeks to bring joy into in the quest for safe, high-quality care. kid’s lives as part of healing. BY RALPH WHATLEY, M.D.
SPECIAL SECTION Timing Is Everything Features 8 12 16 18 22 26 30 IN DUE TIME ACROSS THE WONDER BRAIN FOUNTAIN SMOKE A DAY IN THE LIFE Carilion forged an STATE LINES YEARS STRAIN OF YOUTH SCREEN OF BRYAN COLLIER enduring partnership with local schools to help A fertility expert redraws Carilion Children’s care Experts cross disciplines Pediatricians help ensure A new lung-cancer Twenty-four exhausting reduce the state’s highest borders to give her extends beyond clinic walls to tease out the dangers clean water to improve screening holds out hope but productive hours with teen pregnancy rate and patients their best to capture imaginations of mild traumatic maternal and child health for long-time smokers who Carilion Clinic’s chief of keep futures bright. chance at pregnancy. and encourage healing. brain injuries. in Malawi. might otherwise have died. trauma surgery. BY JESSICA CERRETANI BY PAULA BYRON BY PAULA BYRON BY CHARLES SLACK BY VERONICA MEADEKELLY BY CHARLES SLACK BY DAVID HUNGATE
PHOTOS: MARK HOOPER COVER; ERIC SOLLINGER TOP; SHUTTERSTOCK BOTTOM timing is everything. I was reminded of this simple yet powerful Carilion Medicine truth in June, when one of my role models President and Chief Executive Officer On the pulse of the Nancy Howell Agee passed away. Pat Summitt was an incredible Carilion Clinic community coach, leading the University of Tennessee Lady Chief Medical Officer and Executive Vice President Vols to 1,098 wins—the most of any coach in Patrice M. Weiss, M.D. women’s college basketball history. Pat was a Editorial Advisory Panel leader off the court as well. She raised the profile Nathaniel L. Bishop, D.Min.; Cesar Bravo, M.D.; of women’s basketball. She authored books. John Burton, M.D.; Hugh Craft, M.D.; Mahtab in brief Foroozesh, M.D.; Evelyn Garcia, M.D.; Mark Happy 200th Perhaps most important, she was a mentor who Greenawald, M.D.; Daniel Harrington, M.D.; Hal graduated 100 percent of her four-year athletes. Irvin, Ph.D.; Cynda Johnson, M.D.; Claudia Kroker- NEW INNOVATION HUB Bode, M.D., Ph.D.; Eduardo Lara-Torre, M.D.; Bruce Valve Replacement She also raised awareness about Alzheimer’s disease, which took her life Long, M.D.; William Rea, M.D.; David Sane, M.D.; Virginia Tech and Carilion Clinic have staked at the age of 64. Pat was one of my inspirations, and her death stopped me in Gary Simonds, M.D.; Jon Sweet, M.D. a new claim in the world of health sciences In March, a team of Carilion cardiologists, cardiothoracic surgeons, and radiologists hit a surgical Chief Administrative Officer through a strong public-private partnership my tracks. It was especially tough because for years my mother has struggled milestone when they treated their 200th patient Jeanne Armentrout and a major vote of confidence from the with the same disease. with transcatheter aortic valve replacement, or TAVR, Commonwealth of Virginia. That vote of Vice President making them the first in Southwest Virginia to do so. R. Wayne Gandee, M.D., a Carilion hero and leader, also died this year. He confidence—in the form of an estimated Mike Dame This surgery offers hope to patients considered too served as Carilion’s chair of radiology from 2006 to 2011 and then as chief $46.7-million allocation to be matched by high at risk for traditional treatment. Executive Editor $21 million from Virginia Tech and Carilion medical officer until illness led to his retirement in 2014. He was my boss during Linda Staley “We are leading the nation with our minimally Clinic—will result in the construction of invasive approach to TAVR, replacing heart valves that time, and I was proud to call him a friend as well. Wayne was never afraid to Editor a 105,000-square-foot facility to expand while patients are only lightly sedated to avoid the say what he felt and to tell the people around him that he loved them. Paula Byron health sciences and technology research perils of general anesthesia,” said Jason Foerst, M.D., an The strongest of the strong, the best of the best—we are all vulnerable. It can Art Director and training in Roanoke. interventional and structural cardiologist at Carilion. be hard to grasp that time is finite, even for those we regard as superheroes. Laura McFadden “We are building a foundation for “This strategy has allowed us to discharge many of Timing matters, in life and in medicine. Special Thanks biotechnology and medical research that our patients as soon as the next day. We’ve since been Catherine Doss, John Griessmayer, will establish Virginia as a hotbed for fortunate to present our approach and outcomes at For a trauma patient, five minutes at a Level 1 trauma center can mean the Laura Mitchell, Betsy Parkins, Anne Shaver, companies who want to be shoulder-to- three major national cardiology conferences.” difference between life and death. For a woman undergoing fertility treatments, Ashley WennersHerron shoulder with world-class collaborators five days can affect a potential pregnancy. For a baby born five months too early, CARILION CLINIC and a highly trained technical workforce,” access to a Level 1 neonatal intensive care unit is critical. For a teenage girl, 1906 Belleview Avenue said Virginia Governor Terry McAuliffe, Health Sciences and Technology Innovation Nancy Howell Agee, president and P.O. Box 13367 who signed a bond authorizing the District in Roanoke, with Michael Fried- chief executive officer of Carilion, delaying pregnancy by at least five years can improve her own life—and the lives Roanoke, VA 24033 building in May. “This is a cornerstone of lander, Ph.D., executive director of the remembers looking out from her office of her future children. CarilionClinic.org a new Virginia economy and will position Virginia Tech Carilion Research Institute, window at Carilion Roanoke Memorial 800-422-4842 Pat Summitt once said, “I won 1,098 games and eight national championships, the commonwealth as a national leader named the university’s inaugural Hospital less than a decade ago and and coached in four different decades. But what I see are not the numbers. I see in advanced research.” vice president for health sciences and seeing a deserted landscape. The initiative will enable the recruit- technology. “Now there’s a medical school, a their faces.” ment of an additional 25 research teams The innovation district will bring research institute, and a beautiful park As physicians, we spend only moments with our patients, but our impact Carilion Medicine is published twice a year at: to the Virginia Tech Carilion Research faculty members, students, and other where there once was only a brownfield,” transcends those moments. What we do affects our patients’ future selves and 213 McClanahan Street, Suite 200 Institute, raising the total number of trainees together with Carilion clinicians in she said. “This is a moment when we their families. The people—the faces—are why we are here. Roanoke, VA 24014 teams conducting scientific investigations biomedical and health sciences laboratories can take stock of all that has been Phone: 540-266-6586 Fax: 540-266-6608 in Roanoke to about 55. to do research in a real-world context, accomplished and build on it to create I invite you to read this second edition of Carilion Medicine, which focuses on Email: [email protected] Virginia Tech had earlier announced transcending disciplinary boundaries to an even more remarkable medical and time. In the end, it is our most precious commodity. a plan for the development of a far-reaching solve complex health problems. educational resource for our region.” Carilion Clinic is a nationally ranked integrated health care system headquartered in Roanoke, Virginia. Its flagship, Carilion Roanoke Memorial Hospital, is the clinical affiliate of the Virginia Tech Carilion School of Medicine and Jefferson College “This is a cornerstone of a new Virginia economy and of Health Sciences. will position the commonwealth as a national leader in © Copyright 2016 by Carilion Clinic. No part of this Patrice M. Weiss, M.D. publication may be reproduced or transmitted Chief Medical Officer and Executive Vice President in any form or by any means without written advanced research.” Carilion Clinic permission from Carilion Clinic. All editorial rights — Terry McAuliffe, governor of Virginia, in signing a bill authorizing reserved. Opinions expressed herein may or may a significant expansion of the Virginia Tech Carilion Research Institute not reflect the views of Carilion Clinic.
2 CARILION MEDICINE | FALL 2016 PHOTO: DARRYLE ARNOLD PHOTOS: SHUTTERSTOCK TOP; DAVID HUNGATE/VIRGINIA TECH BOTTOM CARILION MEDICINE | FALL 2016 3 honors Research Institute Faculty Members briefings Honored with Endowed Professorships FORMER CHIEF MEDICAL OFFICER REMEMBERED Life-Guard Milestone R. Wayne Gandee, M.D., CMO at Carilion Upon his retirement, Dr. Gandee told Two Virginia Tech Carilion Research Institute cost to society,” said Michael Friedlander, Clinic until his retirement in 2014, died in The Roanoke Times how cherished his faculty members were honored with Ph.D., the institute’s executive director. “He January 2016 at the age of 70. time with Carilion had been. “It’s been a endowed professorships in March. Warren is extending his original research to try to Dr. Gandee, who was also president blessing,” he said. “I’m proud that they Bickel, Ph.D., director of the institute’s Addic- modify these maladaptive behaviors such of Carilion Clinic Physicians, earned his even let me walk among them.” tion Recovery Research Center, became the that individuals may be able to recapture medical degree from West Vir- Dr. Gandee is survived by first Virginia Tech Carilion Behavioral Health their full functional brain capacity.” ginia University School of Med- his wife, Marianne; sons, Rich- Research Professor, while Read Montague, Dr. Montague pioneered an entirely icine and undertook a radiology ard and Braden Gandee; and In June, Carilion Clinic celebrated Ph.D., director of the institute’s Human new field of science—computational residency at the University of daughter, Kristen Dicks. the 35th anniversary of the found- Neuroimaging Laboratory, became the first psychiatry—and is credited with a range of NANCY HOWELL AGEE Virginia before relocating to “Dr. Gandee was beloved ing of Life-Guard, Virginia’s first air Virginia Tech Carilion Vernon Mountcastle notable research achievements, including Roanoke in 1981 to start a pri- and respected by those who ambulance program. Research Professor. the discovery of the brain’s prediction error TO CHAIR AMERICAN vate radiology practice. worked with him,” said Nancy When the first helicopter flew Dr. Bickel has made seminal discover- reward signals, the invention of technology HOSPITAL ASSOCIATION A native of West Virginia, Howell Agee, president and chief in 1981, it could accommodate ies on how addiction hijacks the human that allows real-time interactive functional Dr. Gandee spent 26 years in executive officer of Carilion. “His only one pilot, one paramedic, and brain. His work on how the brain values brain imaging on a worldwide scale, and The American Hospital Association’s that practice before joining Carilion in enthusiasm for his job was a large part of one patient at a time, for an annu- and discounts future events is recognized the invention and implementation of a Board of Trustees has elected Nancy 2006 as chair of the radiology depart- what made him so special to all of us. He will al rescue of 200 to 300 patients. throughout the scientific and medical com- technology that precisely measures the Howell Agee, president and chief execu- ment. He was promoted to chief medical be greatly missed by so many whose lives and Now, with the addition of helicop- munities as a key component of addictive release of key chemical neurotransmitters tive officer of Carilion Clinic, as its chair- officer five years later. careers he touched.” ters, flight crews, and bases, that behavior. Bickel founded the International in the brains of living patients with such elect designate. Agee will assume the number is closer to 1,500. Since its Quit & Recovery Registry, a worldwide disorders as Parkinson’s disease. chairmanship in 2018, becoming the top inception, Life-Guard has rescued program that seeks to further scientific The name for Dr. Montague’s professor- elected official of the national organiza- an estimated 25,000 critically ill or understanding of recovery and to inspire ship comes from Vernon Mountcastle, M.D., tion, which represents nearly 5,000 U.S. chronic pain injured patients. those struggling with addiction. a Roanoke native who is often called the hospitals and health systems and works “Dr. Bickel has taken on one of the father of modern neuroscience. to advance health among Americans. Outpatient Joint Replacements Near to the Heart greatest societal problems of our life- “Dr. Montague’s work is of the Currently a member of the association’s In January, Philip time—substance abuse and addiction— magnitude of Dr. Mountcastle’s—truly Executive Committee and Operations Shiner, M.D., retired The possibility of being able to recover at and brought the sciences of behavior, transformational and certain to leave its Committee, Agee is a past member of the after more than 45 home sold Steven Pittman on outpatient hip computation, economics, and neurosci- mark on the world and future generations,” association’s Health Care Systems Govern- years in cardiology replacement surgery. The 48-year-old had ence together to converge on a potentially Dr. Friedlander said. “His research addresses ing Council and Regional Policy Board 3. practice in Roanoke. been having pain in his knee, shin, and hip unifying theory that may explain a wide fundamental problems and challenges in Agee has long been a leader in profes- Dr. Shiner’s principal affiliation on his left side for six years. After a range of range of dysfunctional behaviors that human brain health and behavior in ways sional and community activities, serving was with Carilion Roanoke remedies failed to provide any relief, he tried have immense health consequences and not even imaginable just a decade ago.” as an American Hospital Association Memorial Hospital. There he to live with the pain as best he could. But in commissioner on The Joint Commission performed Carilion’s first heart the fall of 2015, he learned he needed a total board and on the boards of the Virginia catheterization and first angioplasty. hip replacement. Hospital and Healthcare Association, the He also founded the catheterization Pittman was referred to Benjamin Coalition to Protect America’s Health- laboratory, which was renamed Coobs, M.D., a Carilion orthopaedic care, the Virginia Tech Carilion School of the Philip Thompson Shiner, M.D., surgeon and joint replacement specialist, Medicine, the Virginia Business Council, Cardiac Catheterization Laboratory. who believed that the patient’s age and and Healthcare Realty Trust. At the event at which the good health made him an excellent “America’s hospitals are leading a renaming was announced, Joseph candidate for outpatient hip replacement transformation in health care, and as Austin, M.D., Carilion’s medical surgery. The procedure went smoothly, and chair I look forward to helping my col- director for cardiac rehabilitation, Pittman was headed home by dinnertime. leagues as they work to improve the thanked Dr. Shiner for being an “Before I was in pain 24/7 and I limped all health of their communities,” said Agee. innovator, a leader, and a role model. of the time,” says Pittman. “I know it sounds Agee began her career as a nurse. She “Thanks,” he said, “for being the a little silly, but now I can finally do simple holds degrees with honors from the Uni- type of physician that makes others things without pain, like walking across the versity of Virginia and Emory Universi- proud to be in your profession.” yard or bending down to tie my shoes.” GIFTED RESEARCHERS: Dr. Warren Bickel, left, works internationally in addiction ty and undertook postgraduate studies The Roanoke Valley Academy of studies, while Dr. Read Montague has pioneered the field of computational psychiatry. at Northwestern University’s Kellogg Medicine gave Dr. Shiner a lifetime School of Business. achievement award in 2013.
4 CARILION MEDICINE | FALL 2016 PHOTOS: DAVID HUNGATE/VIRGINIA TECH FAR LEFT; JIM STROUP/VIRGINIA TECH LEFT; JARED LADIA TOP PHOTOS, CLOCKWISE FROM TOP LEFT: DARRYLE ARNOLD; ALISA MOODY; DARRYLE ARNOLD; SHUTTERSTOCK CARILION MEDICINE | FALL 2016 5 Education at Carilion Clinic and its affiliates grand rounds EMS FELLOWSHIP Emergency medical services is the newest subspecialty recognized within the field MANAGING MEDICINE of emergency medicine, and an increasing The Virginia Tech Carilion School of number of governments now require local EMS Medicine has teamed up with Virginia LocationLocation of of residency, medica lincluding school preliminary systems to have a medical director on staff to better Tech’s Pamplin College of Business to allow LocationLocation of of residency, university following student preliminary will transfer to in one year manage the operation from a medical perspective. In students pursuing a doctorate in medicine to earn a response, Carilion has launched a two-year Virginia master of business administration at the same time. Tech Carilion Emergency Medical Services Fellowship. “By partnering with the Pamplin College of This program combines EMS instruction with real- Business to offer an M.B.A. progam, we continue to world, hands-on experience and a concurrent online increase the attractiveness of our own medical curric- master’s of business administration program offered ulum,” said Cynda Johnson, M.D., M.B.A., dean of the through Virginia Tech’s Pamplin College of Business. Virginia Tech Carilion School of Medicine. “Students who take advantage of the program will be uniquely qualified as physician thought leaders, as they’ll have NEUROLOGY RESIDENCY a set of skills that will allow them to navigate many Carilion Clinic has developed an Adult challenges in health-care management.” Neurology Residency Training Program. Program administrators expect to enroll the first Approved by the Accreditation Council for students in the fall of 2016. The program will initially Graduate Medical Education last year, this four-year target current and future students at the Virginia Tech program now enrolls three trainees each year. Carilion School of Medicine. For later cohorts, it will “Although new, the program offers many advantages seek to recruit prospective students at other medical to its trainees,” said residency director Jay Ferrara, M.D. schools in Virginia and beyond. “Our size allows the house staff and faculty to work Johnson earned her M.B.A. later in her career hand-in-hand in a range of clinical settings at both to prepare for taking on academic administrative Carilion and the Salem Veterans Affairs Medical Center. roles. “I got more out of earning an M.B.A. than I Our faculty have many years of teaching experience at ever imagined I would,” she said. “Courses in finance, university medical centers and a proven track record in organizational behavior, and manufacturing efficiency mentoring residents. Finally, our clinics serve diverse continue to serve me today.” urban and rural communities, and our patients present challenges that are both complex and inspiring.” ORTHOPAEDIC FELLOWSHIP spotlight In February, Carilion Clinic began offering an Advanced Clinical Practitioner Fellowship in orthopaedic surgery. The one-year pro- Match Day 2016 MOST POPULAR SPECIALTIES, BY NUMBER OF RESIDENTS gram—which provides specialized postgraduate train- The Class of 2016 proved the third time’s a charm when, for the third time in ing for physician assistants and nurse practitioners—is 6 Emergency Medicine 3 Internal Medicine its three-year history of participating in the national residency match, the 5 2 one of only four such fellowships in the country. Fellows Virginia Tech Carilion School of Medicine achieved a 100-percent match rate. Pediatrics Medicine–Pediatrics work as part of an interdisciplinary team that includes The 41 graduates are now pursuing 21 specialties in 34 programs dispersed across residents and attending physicians. The curriculum 4 Family Medicine 2 Neurology or Child Neurology 19 states. “Our third straight year of having a 100-percent match rate speaks 4 2 mirrors residency training and provides orientation to volumes about the caliber of our students,” said Aubrey Knight, M.D., the school’s General Surgery Obstetrics–Gynecology the Epic electronic health record, as well as classroom associate dean for student affairs. “These students are well trained and more than instruction and clinical rotations in such subspecialties 3 Diagnostic Radiology 2 Orthopaedic Surgery DOCTORINTRAINING: Recent graduate Catherine ready to start the next phase of their journey.” as foot and ankle, hand and upper extremity, pediat- Gambale is pursuing a family medicine residency at rics, sports medicine, total joint replacement, spine, Carolinas Medical Center in Charlotte, North Carolina. trauma, and emergency medicine.
6 CARILION MEDICINE | FALL 2016 PHOTO: DAVID HUNGATE/VIRGINIA TECH CARILION MEDICINE | FALL 2016 7 DueIn Time THE TENTH GRADERS WATCH THE TV SCREEN INTENTLY, CAUGHT up in the drama of the MTV program Teen Mom. But this isn’t a lazy Saturday morning at home. Instead, it’s a school day, and the reality show clip is just one part of a key lesson in their health class. Using this and other pop culture offerings such as the film TIMING IS Juno, adolescent health educator Brooks Michael draws the stu- EVERYTHING dents’ attention—and then introduces some sobering statistics. “Did you know that six out of 10 teen mothers won’t finish high school?” she asks them. “Or that only two out of 10 teen dads will marry the mother of their child? Parenting is hard enough when you’re in your thirties and forties.”
Carilion Clinic forged an enduring partnership with a local school system to help reduce the state’s highest teen pregnancy rate and keep futures bright. by Jessica Cerretani
8 CARILION MEDICINE | FALL 2016 CARILIONCAARRIILLIIONON MMEDICINEEDDICCINNE | FAFALLLLL 20162010 6 9 Michael’s lesson, and the resourc- known as the Adolescent and Student es that accompany it, has its roots in a Health Services program. program that began 25 years ago—well “It took a lot of thinking outside the before current high school sophomores box by Carilion leadership and the Roa- were even born. What initially started as noke Health Department,” says R. Allen a response to Roanoke’s adolescent health Blackwood, M.D., co-medical director of needs has blossomed into a lasting part- the program and past president of the nership between Carilion Clinic and the partnership. “But the local hospitals city’s public school system. And, as recent and public school system really came research shows, this inspired approach to together to address teen pregnancy.” teen health is reaping great rewards. The partnership realized the best approach to the issue was prevention: Many teens, Dr. Blackwood says, had BRINGING UP BABY gotten lost in the shuffle of preventive It’s usually an advantage to achieve top care. The solution? A cutting-edge pro- ranking—but not when it comes to teen gram that embeds adolescent health pregnancy. Yet that was the very situation clinics in the two area high schools with facing Roanoke City in the early 1990s, the highest pregnancy rates. when the area had the highest teen preg- These clinics aim to bridge gaps in nancy rates in Virginia. The statistics were care, says Jeri Lantz, M.D., Carilion’s nothing to boast about: For every thou- division chief of adolescent medicine sand pregnancies, 176 occurred in ado- and, with Dr. Blackwood, co-medical lescents aged 15 to 19. The numbers were director of the Adolescent and Student troubling, if not exactly shocking. Even Health Services program. “Even today, today, teen pregnancy rates in the United we lose about 60 percent of our patients States remain substantially higher than from pediatric practice after about those in other developed countries. age 12,” she explains. “Teenagers can That’s a concern because teen preg- nancy has been identified as a root cause of poverty. Teens who become pregnant often struggle financially and even be- For every thousand come dependent on community services. Their vulnerability—and that of their ba- pregnancies, 176 bies—persists long after the pregnancy, even after adjusting for the factors that occurred in adolescents increased their risk of pregnancy in the first place, such as growing up in pover- aged 15 to 19. ty or in a single-parent family, having on funding from the Commonwealth of often embarrassing topics, ranging from Dana Abney, Erinn Hokanson, and Suzanne parents with low levels of education, and Virginia. But when budget cuts threated puberty to birth control. Barron—staff the clinics, providing con- performing poorly in school. to eliminate the partnership, Carilion “I make it clear right away that I’m not sistency and services ranging from pre- Teen pregnancy affects more than have obvious barriers to care, like an The results have been stunning: In stepped up to the plate. In 2011, the or- there to tell them not to have sex,” she ventive care to diagnosing and treating young parents and their babies. According inability to get to appointments, but there 1995, nearly 73 of every 1,000 preg- ganization took over responsibility for says. “But I do share that the majority of acute illnesses. The in-school clinics also to the Centers for Disease Control and are also subtler obstacles. Teens often need nancies occurred in girls under age 19. the three in-school and community teen teens I’ve spoken with do say they regret offer confidential screening for sexually Prevention, teen pregnancy and childbirth time to warm up to adults and trust them.” By 2010, that number had dropped to health clinics in Roanoke, ensuring that it, so they should consider waiting.” transmitted diseases. account for at least $9.4 billion in costs to That makes it challenging to discuss 43 adolescent pregnancies. The most this critical program would remain in With an hour and a half too scant a Such approaches continue to pay off, U.S. taxpayers for increased health care sensitive topics like pregnancy in a 20-min- dramatic drop, 32 percent, occurred be- place for future generations. time to cover all aspects of sexual health, both for Roanoke’s adolescent popula- and foster care, higher incarceration rates ute office visit. The in-school clinics, which tween 2009 and 2010. And Roanoke fell Today, the Adolescent and Student Michael gives students a way to contact tion and for the community itself. In among children of teen parents, and lost offer basic health care, counseling, and ac- out of the top 10 ranking of localities Health Services program operates as her and ask questions after the session 2014, the city’s formerly sky-high rate tax revenue from teen mothers’ lower cess to inexpensive contraception, fill this with the highest teen pregnancy rates part of Carilion Children’s—and is more ends. In addition to class time, she vis- hit an all-time low, with just 27 teen educational attainment and income. need—and on teens’ own terms. for ages 15 to 19 for the first time since successful than ever. For the past five its afterschool and community programs pregnancies per every thousand. It’s an Recognizing the serious consequences “Being in schools is key,” says Dr. Lantz. the partnership was founded. years, adolescent health educator Michael throughout the Roanoke area, talking to accomplishment that’s merely part of the of what can be a complicated issue, Caril- “It allows us to deliver services directly to has visited Roanoke’s tenth-grade teens and parents alike. ongoing bid to make Virginia shine. ion has been at the forefront of teen preg- young people where they already are.” The classrooms, sharing vital information Michael’s educational efforts aren’t all “When it comes to teen pregnancy, nancy prevention since 1992. It was then program also includes a third, community- ALL IN GOOD TIME about sexual health and wellness with that Adolescent and Student Health Ser- Carilion and the school system are on the that the clinic helped formed the Roa- based clinic for teens who aren’t students For more than a decade, the Roanoke some 1,200 students a year. In just one vices provides the Roanoke community. same page,” says Dr. Lantz. “We all want to noke Adolescent Health Partnership, now at the two high schools. Adolescent Health Partnership survived 90-minute session, she tackles tough, Three full-time nurse practitioners— help develop smart, healthy adults.” CM
10 CARILION MEDICINE | FALL 2016 PHOTOS, PREVIOUS SPREAD: METTUS/SHUTTERSTOCK LEFT; JOEY KOTFICA/GETTY IMAGES PHOTO, THIS PAGE: MAX KEGFIRE/SHUTTERSTOCK CARILION MEDICINE | FALL 2016 11 TRAVELING DOCTOR: Dr. Emily Evans-Hoeker goes the extra mile for her patients—literally. She drives to North Carolina several times a year to enable her patients to take advantage of an established embryology laboratory in Raleigh while at the same time receiving Across continuity of care. State Lines A fertility expert redraws borders to give her patients their best chance at pregnancy. by Paula Byron
MEGAN* HAD JUST TURNED 30 WHEN SHE AND HER HUSBAND decided they were ready to start a family. But when she stopped taking birth-control pills, her normal cycle failed to resume. After several increasingly anxiety-filled months of testing, she learned she had undergone premature menopause. TIMING IS EVERYTHING “I felt my world crashing around me,” Megan says. “I’d always wanted to be a mother. Now I could barely summon enough energy to drag myself to work and back.” In what they considered a last-ditch effort, Megan and her husband consulted with Emily Evans-Hoeker, M.D., Carilion Clinic’s chief of reproductive endocrinology. “She was so optimistic and compassionate, and she spent several hours answering our questions,” Megan says. “She assured us that, even though my eggs were no longer viable, I could still bear a child. That’s when my depression began to shift.”
12 CARILION MEDICINE | FALL 2016 *NAME CHANGED TO PROTECT PRIVACY CARILION MEDICINE | FALL 2016 13 With Dr. Evans-Hoeker’s encourage- hours not only for the extraction of eggs “What we do is not your typical medi- eggs from one and, days later, implanted an A Private Pain ment, Carilion formed an IVF partnership and implantation of embryos, but also for cine,” says Dr. Evans-Hoeker. “It’s very per- embryo in the other. All’s Well An estimated one in eight couples— with UNC Fertility, an established embry- their consultations, workups, and other sonal and very emotional. Our partnership Megan was at work one day when her or 12 percent of the reproductive-age ology laboratory in Raleigh, North Caro- procedures. Now, through the new part- with UNC Fertility allows me to perform cell phone rang. When she glanced at population—have trouble getting pregnant lina. The laboratory is affiliated with the nership, they have to travel only twice. every step of the IVF process, rather than Take Good Care the screen, her breath caught; it was or sustaining a pregnancy. More than University of North Carolina at Chapel Hill, Dr. Evans-Hoeker literally goes the sending our patients to physicians they Dr. Evans-Hoeker had wanted to be a Dr. Evans-Hoeker’s number. The irony 7 million women in the United States have where Dr. Evans-Hoeker underwent her extra mile for her patients. Through the don’t know to perform parts of the cycle.” cardiologist since the age of seven. But of receiving the most memorable call received services for infertility, defined as advanced training. partnership, she performs most steps of Carilion’s initial target was to treat an obstetrics/gynecology rotation in of her life, she says, is that she remem- the inability to conceive after one year of Patients seeking IVF treatments in the IVF cycle in Roanoke; then, four times 25 IVF patients each year within three medical school changed her mind. bers nothing beyond hearing two words: unprotected intercourse for women under Southwest Virginia used to travel for a year, she travels to the embryology lab to five years of the program’s launch; “I witnessed the connection you You’re pregnant. in Raleigh. There she conducts egg re- Dr. Evans-Hoeker achieved that goal make with families at one of the most Megan and her husband are now the trievals and embryo transfers on several within the first year. important moments of their lives,” she elated parents of a baby girl. patients each time she travels. says. “I loved being able to help people Still active in infertility support Most IVF cycles require two proce- when they were feeling their most groups, Megan enjoys giving encour- dures, which Dr. Evans-Hoeker performs Frozen: A Sisterly Devotion desperate, even hopeless.” agement to other women struggling to One in eight couples in Raleigh anywhere from three to five As Megan and her husband began Dr. Evans-Hoeker adds that no become pregnant. days apart. She is able to perform the exploring options, they received an woman ever wants to visit her office for “I tell them, if deep down in your have trouble getting procedures on her patients herself be- unexpected offer—and one tenderly the first time. heart you know you want to be a mother, cause she holds an adjunct faculty posi- made. Megan’s sister wanted to help in “No one dreams of seeing a fertility don’t run from it,” she says, with emo- pregnant or sustaining tion at UNC Fertility. any way she could, whether it would be doctor to start a family,” Dr. Evans- tion still raw in her voice. “Don’t think Dr. Evans-Hoeker points out the to act as surrogate or to donate eggs. Hoeker says. “By the time my patients it can’t happen. It’s going to be hard, but a pregnancy. advantages of continuity for her patients. “They need to be parents,” the sister see me, they’ve been trying to get don’t give up. There are so many ways told Megan’s mother. “They would be pregnant for so long and it’s such an to become a mother, including surroga- wonderful.” emotional journey, they want to know cy and adoption. And if you choose IVF, Using an egg from an anonymous donor someone is taking care of them.” find the best doctor you can to help you is expensive, but using an egg from some- Her care of patients includes— through it.” 35 and six months for women 35 or older, one you know entails a long, painstaking poignantly—a dose of empathy. Megan’s own doctor continues to or the inability to carry a pregnancy to live process. Anonymous egg donors have al- It was while she was completing her achieve remarkable success. Since birth. What those numbers fail to capture ready waived their rights; known donors, fellowship in reproductive endocrino- Dr. Evans-Hoeker launched Carilion’s IVF is the emotionally wrenching challenge although they cannot receive remunera- that infertility usually represents. tion, represent tremendous complexity. “The infertility journey is a profound Megan’s sister had to undergo extensive one,” says Dr. Evans-Hoeker. “For wom- medical and psychological screening to en, the dream of becoming a mother ensure she was a fit donor, and then she, “What we do is not often begins during childhood, and Megan, and Megan’s husband all had to the reality can be painful. When you’re work with a counselor to talk through your typical medicine. struggling to become pregnant, it seems all contingencies. Who had the rights to women everywhere are pregnant—your the eggs? Who would own any resultant It’s very personal and friends, your colleagues, every woman embryos? What if the sister later struggled passing you on the sidewalk.” with infertility and wanted to use a frozen very emotional.” An estimated 85 to 90 percent of embryo? Would Megan and her husband couples who experience infertility are eventually tell any children about their treated with drug therapy or surgical aunt’s role in their conception? procedures. Megan and her husband As donor eggs are considered proper- found themselves joining the less than ty, the couple and the sister needed sepa- logy and infertility at the University of program in 2015, many of her patients 3 percent whose only remedy would be rate lawyers, who captured their answers North Carolina that Dr. Evans-Hoeker have conceived and delivered babies. advanced reproductive technologies, in a legal document. Finally, their case discovered she too would need to undergo And they’re not the only ones such as in vitro fertilization (IVF). had to be reviewed and approved by the fertility treatments to conceive a child. celebrating motherhood. Thanks to the IVF ethics committee. “It’s so difficult talking about infertil- same types of treatments she provides With the hurdles finally cleared, the ity all day with patients, and then going her patients, Dr. Evans-Hoeker is now Close to Home sisters, in different regions of the country, home in the evening and agonizing about expecting her second child. When Dr. Evans-Hoeker joined Carilion’s began taking hormonal shots—one to your own,” she says. “Now, with my pa- “I’ve known all too well how Reproductive Medicine and Fertility Clinic stimulate her ovaries, the other to prepare tients, I’m open about my own struggles. emotional and frustrating the infertility in 2014, it was with the goal of building her body for pregnancy. I tell them, I know exactly what you’re journey can be for my patients,” she an IVF program that would help couples STRONG MEDICINE: Dr. Emily Evans-Hoeker was drawn to reproductive endocrinology and The sisters then convened in North Car- going through; I get it. It makes them says. “And now I understand their joy start their families closer to home. infertility because of the opportunity to restore hope to patients wanting to become mothers. olina, where Dr. Evans-Hoeker extracted feel better.” as well.” CM
14 CARILION MEDICINE | FALL 2016 PHOTOS, THIS PAGE AND PREVIOUS SPREAD: JARED LADIA CARILION MEDICINE | FALL 2016 15 MY LITTLE PONY: A young patient enjoys her hippotherapy session, which allows her therapy team to collaborate with a horse from Healing Strides, The Wonder Years a center for equine-assisted therapeutic riding. Carilion Children’s care extends beyond clinic walls to capture imaginations and encourage healing. by Paula Byron
orses can be wonderful therapists. their canters ers especially, because one leg might end are soothing; their broad backs inviting. And their warm up shorter than the other.” The quest to make care as child friendly and wordless presence offer irresistible lifelines for their as possible has led Carilion to forge creative riders, especially children with physical, emotional, and solutions that go beyond medical and sur- cognitive challenges. gical problem-solving, Dr. Ackerman adds. Several pediatric specialties—including Carilion Children’s takes advantage of at each age and stage of development. cardiology, gastroenterology and endocri- Hthe healing qualities of horses by offer- You also need to consider their mental nology—take care closer to children living ing its patients hippotherapy. Derived and emotional development.” at a distance by providing outreach clinics from hippos, the Greek word for horses, Health care providers always allow for that travel to several cities in the region. hippotherapy capitalizes on the move- differences across individuals, Dr. Acker- Carilion Children’s also hosts periodic ment and cadence of horses to encourage man adds. But with children, those differ- clinics that bring children and families to- and motivate patients to reach physical, ences can have both broad and long-term gether with rehabilitation therapists and speech, or occupational therapy goals. impact. Children grow at varying rates assistive device manufacturers. In those Carilion’s partnership with Healing and achieve developmental milestones clinics, the therapists work with the man- Strides, a nonprofit that offers equine- at their own pace. In addition, treatment ufacturers to custom fit wheelchairs and assisted therapeutic riding, is just one decisions need to take into account chil- other equipment for individual patients. of many programs that acknowledge dren’s continued growth. Dr. Ackerman notes that Carilion that caring for children often entails Dr. Ackerman offers the example of a Children’s unifies all pediatric services, complexities beyond adult care. broken femur. “If a patient is in her mid-20s, no matter where they’re offered. “For us, “To provide children with excellent the healing tends to be straightforward, Carilion Children’s is a promise to children medical care,” says Alice Ackerman, M.D., as her growth plate is fully formed,” she and to their families,” she says. “We want to Carilion’s chair of pediatrics, “you need says. “But you have to make allowances give every child the best possible chance to to understand how their bodies change for how you treat infants and preschool- grow and thrive.” CM
Pediatric Specialties at Carilion Children’s Children, like adults, need a broad range of medical, surgical, and therapeutic specialties.
Q Adolescent Medicine Q Gastroenterology Q Occupational Therapy Q Allergy Q Genetic Counseling Q Orthopaedics Q Behavioral Medicine QHematology/Oncology Q Otolaryngology Q Physical Therapy Q Cardiology Q Medicine QPediatric and Adolescent Q Pulmonology Gynecology Q Child Development Clinic Q Nephrology Q Speech Therapy QPediatric and Adolescent Q Dentistry Q Neurology Q Spine Surgery Psychiatry Q Endocrinology Q Neurosurgery Q Surgery
16 CARILION MEDICINE | FALL 2016 PHOTO: JARED LADIA CARILION MEDICINE | FALL 2016 17 BRAIN STRAIN
EXPERTS CROSS DISCIPLINES TO TEASE OUT THE DANGERS OF MILD TRAUMATIC BRAIN INJURIES. by Charles Slack
ON A COLLEGE SOCCER FIELD IN SOUTHWEST VIRGINIA, A 20YEAROLD MIDFIELDER leaps for a header, desperately seeking to break a tie. But instead of striking the ball, her head smacks an opponent’s elbow, sending her to the turf. The action stops. Hoping to tough it out, she rolls her eyes as the team doctor insists she visit the emergency room to get checked out. It’s the responsible thing to do, but the emergency physician finds the young woman alert and fully responsive. After a few days sidelined, just to be safe, she returns to action, filing the episode away on that long list of bangs and bruises that turn out, thankfully, to be nothing. That scene might be wholly unremarkable, except that on that same afternoon, on a nearby college field, another 20-year-old athlete endures an almost identical knock on the head. She, too, feels fine, and the emergency room assessment
18 CARILION MEDICINE | FALL 2016 ILLUSTRATION: STUART BRADFORD CARILION MEDICINE | FALL 2016 19 PATIENTS IN DANGER MAY RETURN TO NORMAL ACTIVITY TOO SOON, BLITHELY UNAWARE
THAT THEIR INJURED BRAINS NEED TIME TO REST AND HEAL. likewise reveals no apparent consequences. That knowledge could help researchers Yet back at her dorm late that night, she abundant caution. More ominously, others in mid-thought. Blood flow relates direct- develop treatments that would speed the wakes from a deep sleep with a splitting may return to normal activity too soon, ly to thought patterns, Dr. LaConte says, process of returning to normal—if that’s headache and vomiting. For her, it’s the blithely unaware that their injured brains Such an understanding might yield two motor coordination. Yet that term, while because “When the neurons are firing, what happens during recovery—or, alter- start of an ordeal that may last months, need time to rest and heal. important breakthroughs. The first would clinically relevant, can be misleading to the the vascular system increases flow to feed natively, help the brain compensate more including difficulty sleeping, severe grog- be the ability to detect, through a quick and lay public. Even a mild brain injury is a vio- those neural cells.” quickly and completely. giness upon waking, poor concentration in painless fMRI scan, whether an injured per- lent physical event in which the soft brain Patients who enroll in the study (50 For Dr. Kuehl and his colleagues, an class, mood swings, and even depression. Shared Expertise son is likely to develop serious symptoms. tissue slams against the hard wall of a skull so far, and counting) return for three fol- even more immediate payoff of the research To help unlock that puzzle and give doc- The second would be new methods of treat- brought to a sudden stop. In a few hundred low-up fMRIs over the next year. Simulta- might be the ability to evaluate brain injury tors those needed tools, Dr. Kuehl has ing and caring for people who have suffered milliseconds, the brain bounces back and neous with those tests, Dr. Kuehl and his cases in real time, with an fMRI machine The Great Unknown teamed with Stephen LaConte, Ph.D., an such injuries. forth, often bruising or stretching the cel- emergency department colleagues conduct not in a research lab but in the emergency For patients, families, and the physi- associate professor at the Virginia Tech lular machinery. In addition to the physical detailed clinical evaluations to determine department. By comparing a patient’s re- cians who handle such cases, classified Carilion Research Institute and a lead- jarring, brain injury can disrupt the electri- whether the patient has experienced on- sults with patterns of both normal and as mild traumatic brain injuries, perhaps ing innovator in novel applications of When “Mild” Is Serious cal signals within and between the neurons going symptoms, such as headaches, mood injured brains, doctors could determine the greatest frustration is how little is functional magnetic resonance imaging Traumatic brain injuries are among the that dictate thoughts and actions. changes, and difficulty sleeping. whether a specific individual can resume known about what’s really going on, and (fMRI), whose detailed dynamic imaging most common causes of emergency room “When you see someone wobbling off The process is painstaking—com- usual activities, or needs an extended rest. why two people involved in the same approach captures patterns of thought, visits—more than one million each year the field after a hard hit,” Dr. Kuehl says, plicated by the fact that Dr. Kuehl and Dr. Kuehl uses football as an example. type of accident can experience such rad- as measured by minute changes in blood nationwide, and 2,000 at Carilion Roanoke “it’s because their brain can’t communicate Dr. LaConte cannot know precisely what “Someday, when the next Peyton Manning ically different outcomes. flow in the living human brain. Memorial Hospital alone. The causes are as the appropriate balance to their feet.” patterns they’re looking for, since those or Tom Brady gets his bell rung on Sunday,” “These are some of the most vexing For the past two years, Drs. Kuehl and varied as human activity—a child falling Because such symptoms may be fleet- patterns have never been measured. Dr. Kuehl says, “we can give him an fMRI and challenging things to diagnose,” says LaConte have studied patients who visit backward in a school chair while horsing ing or even unnoticeable, parents or coach- “It’s more nuanced than anybody and tell his coach whether he should play Damon Kuehl, M.D., director of Carilion the Carilion emergency department to be around; a sharp tackle on the football field; es—or even well-meaning physicians—who would like,” says Dr. LaConte. “Every- the next week.” Clinic’s emergency medical residency pro- examined for mild head injuries. The idea is a fistfight; a slip while hiking. And while would never let a linebacker play on a broken body’s different, and the images are quite gram. “Outside of taking a CT scan to look that by combining Dr. Kuehl’s clinical exper- incidents spike in the summer when more leg might allow a teen with an elusive brain subtle. It’s not easy to drop down into the for bleeding, and doing a basic assessment tise with Dr. LaConte’s deep dive into the people are outdoors, they can happen any injury to return to action prematurely. individual case and say what’s happening.” The Power of Partnerships of their ability to function at the time they workings of the brain at the level of local cel- time, any place, to people of any age. The ability to conduct research directly present, we still don’t have really good diag- lular networks, the pair might detect brain About three-quarters of these inju- with clinicians such as Dr. Kuehl was, for nostic tools to find out which patients will activity patterns that are distinctive both ries are classified as “mild,” to distinguish Measuring Thought Potential Breakthroughs Dr. LaConte, one of the draws to Roanoke do poorly and which will be fine.” for those whose head injuries produce few from catastrophic cases when a patient is These days, when patients present with By combining their results, the two in 2011. “Carilion’s size is ideal for finding As a result, patients who are not in dan- if any lasting effects, and those who develop knocked out for an extended period and a mild traumatic brain injury at Carilion researchers are gradually developing a clinicians who are eager to collaborate,” he ger may be kept away from activities out of serious symptoms. suffers clear disruption of thought and Roanoke Memorial Hospital, Dr. Kuehl unique and potentially invaluable data- says. “For me, that’s fantastic.” and other emergency physicians encour- base matching blood flow patterns with Dr. Kuehl shares those sentiments. He age them to enroll in the study, which individual patients over time—those arrived at Carilion in 2007, attracted by starts with a visit to Dr. LaConte’s labora- who experience no symptoms or swift “the opportunity for getting involved at the tory down the street at the Virginia Tech recoveries, as well as those whose symp- ground floor of a new medical school and re- Carilion Research Institute, to play games toms become more serious. search institute, and ultimately starting an of a different sort. For Dr. LaConte, one of the primary emergency medical training program here.” There Dr. LaConte gives them a Multi- goals is to get a better understanding of Both men praise leaders such as John Source Interference Task, which asks them exactly what “recovery” means. “We want Burton, M.D., chair of Carilion’s Depart- for quick responses to number puzzles of to know what’s going on in the prefrontal ment of Emergency Medicine, and Michael varying difficulty. While they do so, the MRI area of the brain over time,” he says. “The Friedlander, Ph.D., executive director of the scanner captures images of blood flow pat- big question for any neurologic injury is, Virginia Tech Carilion Research Institute, terns in the brain. The researchers focus on what does recovery look like?” for encouraging cross-disciplinary research. the patterns in the prefrontal part of the ce- Specifically, he’s hoping to determine “We’re getting close to some pretty ex- rebral cortex, which plays a role in executive whether, in a patient no longer suffering citing findings,” Dr. Kuehl says. “It’s one thought, such as decision-making. ill effects from an injury, the brain has re- of the best things I could imagine, having Essential to the process is an innova- turned to its fully normal, pre-injury state, the opportunity to collaborate this close- tion that Dr. LaConte developed, known or has found ways to work around the inju- ly with someone like Dr. LaConte. When as “temporally adaptive brain states,” or ry by compensating—just as a person who you put clinicians in with researchers, TABs, which uses three-dimensional vid- has lost a finger compensates by gaining and let them work together, you start JOINING FORCES: Dr. Stephen LaConte and Dr. Damon Kuehl are putting their heads together to understand mild traumatic brain injuries. eo images of the brain to detect changes greater dexterity with the remaining digits. arriving at unique solutions.” CM
20 CARILION MEDICINE | FALL 2016 PHOTOS: JIM STROUP/VIRGINIA TECH LEFT; ERIC SOLLINGER CARILION MEDICINE | FALL 2016 21 FROM CLEAN AND CLEAR: In Malawi, communitiesHEAD just outside city limitsTO are ATER IS SO ESSENTIAL TO LIFE THAT IT’S especially susceptibleTOE to easy to take for granted. But access water contamination, as they to clean, drinkable water is far from tend to draw from shared, guaranteed. In some countries, public taps or from backyard W wells not always adequately such as the East African nation of protected from sewage. Malawi, water can even pose an unrec- ognized threat, harboring unseen contamination— parasites and poisons that add to the health burden of an already struggling economy. For children especially, the lack of safe drinking water can be devastating. Penelope (“Penny”) Muelenaer, M.D., M.P.H., an assistant professor of pediatrics at the Virginia Tech Carilion School of Medicine, witnessed this devastation firsthand while visiting Malawi in the mid-2000s. A pediatric infectious disease and pub- lic health specialist, Dr. Muelenaer was volunteer- ing for the aid organization CitiHope International, treating children and educating Malawians about maternal-to-fetal transmission of HIV. She quickly realized, though, that her patients were facing more fundamental health needs. Children were dying, often before any HIV infection or other underlying conditions could be diagnosed. Malnutrition was costing lives, and so were diarrheal diseas- es triggered by the bacteria and parasites in the chronically contaminated water supply. In Malawi, a low-income country where the average family subsists on the equivalent of roughly US$900 a year, infrastructure is scant. Access to reliable plumbing and treated water is DEEP-BRAINuncommon and, STIMULATIONin a country where few advanceHELPS CONTROL MOVEMENT DISORDERS. By Veronica Meade-Kelly »
Carilion pediatricians are leading a program that uses affordable of technology to improve water quality and children’s health in Malawi. FOUNTAIN YOU TH BY VERONICA MEADE-KELLY
22PHOTO:22 CARILION CARILION © UNICEF/UN189754/ MEDICINE MEDICINEGILBERTSON | |FALL VIIWINTER PHOTO 2016 2016 PHOTO: SHUTTERSTOCK CARILIONCARILION MEDICINE | FALL 2016 23 past an elementary-level education, the and engineer, McGill had spent much of systems to determine how practical relationship between bacteria and disease his life in Malawi, working with locals on and efficacious they might be in the “ YOU CAN DELIVER ALL THE MEDICATION YOU WANT, BUT IF YOU goes unappreciated. sanitation projects. And he wasn’t hard communities just outside the city limits. Waterborne illness contributes heavily to find; in a serendipitous turn of events, Such communities were primed for wa- DON’T LOOK AT THE WATER AND SANITATION, IT’S JUST A DROP to the startling mortality rate of children. Andy Muelenaer bumped into McGill not ter contamination—heavily populated by “As a physician trained in the U.S., I 20 minutes after the phone conversation Malawians drawn to the city’s amenities, IN THE BUCKET.” —Dr. Penelope Muelenaer, assistant professor of pediatrics, Virginia Tech Carilion School of Medicine found it frustrating,” Dr. Muelenaer says. with his wife. but beyond the reach of city infrastructure. “I was very aware that many children were The meeting led to a tour of McGill’s wa- In these areas, households obtained water dying of preventable diseases, but I didn’t ter and sanitation center. As he observed all from shared, public taps or from backyard to look beyond the data to know what How the Tulip Works valuable resources—student talent—and have access to the medications and lab re- the gadgets McGill’s team had assembled to wells that weren’t always adequately pro- truly worked, and why. brought it to bear on health quandaries sources I would have had at home. Over dig wells and build latrines, Andy Muelen- tected from sewage. Both methods risked Through surveys and conversations, in Malawi. time I realized that if I wanted to make an aer saw both need and opportunity. As part additional contamination during storage; they learned that the ceramic systems “Many students are interested in impact, it had to be through prevention.” of Virginia Tech’s Mechatronics Lab, he had most families stored water in open buck- produced natural-tasting water, while applying their skills to address important worked for years with engineers on biomed- ets, exposed to the elements, unwashed chlorine and boiling—which was done challenges, and they come up with ical devices, and he routinely collaborated hands, and unsanitized utensils. over coal or wood—left a taste the partic- Upper bucket fantastic solutions we may not think of,” A WATERSHED MOMENT with engineering faculty and students. He For these families, a system for puri- ipants disliked, making it less likely they’d Andy Muelenaer says. In 2013, Penny Muelenaer’s husband, proposed bringing engineers to Malawi to fying the water supply might significantly keep using those systems. The team also Ceramic Since the initial trip with the filter Andre (“Andy”) Muelenaer Jr., M.D., a help tackle pressing challenges. reduce risk of disease. learned that after boiling, water was still Scieneering students, the Muelenaers Carilion Clinic pediatric pulmonologist The next summer, the Muelenaers stored in open buckets, leaving it exposed have returned to Malawi regularly to test, and an associate professor of pediatrics were back in Malawi, this time with a to further contamination. Dirty refine, and build upon Meador’s initial at the Virginia Tech Carilion School of small group of Virginia Tech students who DRAWING FROM Penny Muelenaer’s team made a point water prototype. In that time, students have Medicine, took his own turn volunteering were part of Scieneering, a program that to report back to the community, to graduated and others have taken their in Malawi. Working with the Coca- encourages students in the life sciences THE SOURCE explain the findings and discuss what still place, each lending their own talents as Cola Africa Foundation, he was in the and engineering to find interdisciplinary The Muelenaers say community has been needed be done to improve water quality. the project evolved. country assessing health care needs and solutions to complex problems. key to their success. Tasked with testing They also launched a poster campaign to In response to feedback from health Water storage distributing medical supplies. One day, “My marching orders for the under- water filtration systems in an unfamil- educate people about the benefits of such workers in Malawi, the project has en route to the northern city of Mzuzu, graduates was to visit hospitals, look into iar community, Penny Muelenaer relied hygiene practices as handwashing. branched in new directions. The team has he called his wife back home in Virginia. water and sanitation, and identify needs on McGill’s network: local leaders—a Dubbed community-based participato- Clean been asked to adapt the device to scan As he recounted his efforts, Penny we might be able to help address,” Andy teacher, a businessman, the community’s ry research, this approach allows research- water for schistosomiasis—a disease caused Muelenaer’s long-simmering frustrations Muelenaer says. headman, and the headman’s wife—who ers to get beyond what they think should by a fresh-water parasite that can lead bubbled to the surface. The students would also help Penny were convinced of her good intentions work to find solutions that are sustain- to chronic and fatal organ damage—and “You can deliver all the medication you Muelenaer with her research. Through and the potential benefits of her study. able—those the community is more likely tuberculosis. The former effort requires want, but if you don’t look at the water and McGill, the Muelenaers had connected Their involvement was essential for to embrace. the device to spot parasites moving sanitation, it’s just a drop in the bucket,” with Rochelle Holm, manager of Mzuzu recruiting and communicating with par- in liquid samples; the latter involves she said. “You need to find Jim McGill.” University’s Centre of Excellence in Water ticipants. When only a handful of those The Tulip tabletop system cleans adapting the device to “see” and scan The Muelenaers had met McGill pre- and Sanitation. She offered the team a participants showed up for a demonstra- A RENEWABLE RESOURCE water by filtering out dirt and slides through a microscope lens. viously through CitiHope. A missionary project: Test in-home water purification tion of the water purification systems Andy Muelenaer once asked Malawi’s bacteria through small pores in a Such challenges are now being met by that would be used in the study, for in- health minister to identify the biggest silver-impregnated ceramic material. a growing number of invested faculty and stance, it was the headman’s wife who obstacle to the ministry’s work. The im- This portable technology is ideal for students. The Muelenaers’ early efforts scrambled door-to-door to remind them. mediate response: “Human resources.” households in low-income settings, as have evolved into TEAM Malawi (Technolo- But the Muelenaers would be the first This became evident when Penny each filter can clean up to 7,000 liters gy-Education-Advocacy-Medicine Malawi), of water. to admit that the support of community Muelenaer’s team had to test the water a joint program with Virginia Tech’s School members isn’t enough; their input is also samples. The test involved counting colo- of Education and Radford University’s Col- essential. An error many outside organi- nies of E. coli, a common intestinal bacteri- hours staring at plates, we had an auto- lege of Education and Human Development. zations make, the Muelenaers contend, um and clear sign of fecal contamination, mated, affordable process we could use in The program now offers summer work- is making assumptions about the type of on plates cultured from the participants’ the field,” Penny Muelenaer says. study opportunities in Malawi with a aid that’s required without understanding water supply. The colonies appeared as She put the challenge to her husband, focus on health, wellness, and communi- the needs and context of the culture. The blue spots alongside dots of red, which who had just been approached by a Vir- ty participation. Muelenaers are careful to solicit input and were colonies of less pernicious bacteria. ginia Tech engineering student who was “Over a decade ago I was working in feedback from those they aim to help. The task was burdensome; team members interested in studying computer vision. The a Malawi hospital, frustrated because I For instance, Penny Muelenaer’s had to count the colonies manually, one- student, Ben Meador, quickly tackled the couldn’t save all those children,” Penny COMMUNITY IS KEY: Dr. Penelope data revealed that two of the water by-one, a process made more challenging problem. He programmed a Raspberry Pi, a Muelenaer says. “Now we have students Muelenaer (above, right) and Dr. Andre purification systems—a ceramic filter and when the electricity—and lights—would small computer that retails for only $35, to applying what they’re learning to help cre- Muelenaer Jr. (right) have learned that community members are critical in chlorine treatment—greatly improved go out intermittently. “see” and count the blue and red colonies. ate real-world solutions to problems in the ensuring that remedies are proposed in water quality. Boiling water also showed “I remember thinking how much better It’s an example of how the Muelenaers communities around Mzuzu. I’m excited full cultural context. modest improvement. But the team had it would be if, rather than people spending have mined one of Virginia Tech’s most about the direction we’re taking.” CM
24 CARILION MEDICINE | FALL 2016 PHOTOS: COURTESY OF PENELOPE MUELENAER AND ANDRE MUELENAER JR. INFOGRAPHIC: COMPLEX STORIES CARILION MEDICINE | FALL 2016 25 SMOKE SCREEN
LIKE THE STATE HE’S CALLED HOME FOR ALL of his 71 years, Lewis Mitchell’s life is in many ways a story of tobacco. For a young man in Southwest Virginia in the 1960s, lighting up for the first time was less a matter choice than a rite of passage, like driving a car or cashing a first paycheck. For 45 years, as Mitchell married, raised a family, and built a successful career in the heat- BY CHARLES SLACK ing and air conditioning business, cigarettes were his constant companions. They helped him get started in the morning, relieve tension at work, and unwind at the end of the day. By the time Mitchell quit his two-to-three- pack-a-day habit in 2005 (and the occasional cigar a few years later), tobacco had already exacted a heavy price for that companionship. Suffering from chronic obstructive pulmonary disease and emphysema, he spent his first de- cade of retirement worrying about the most dreaded possibility, cancer. He says, “I guess
A NEW LUNG-CANCER SCREENING HOLDS OUT A NEW LUNG-CANCER SCREENING HOLDS OUT HOPE FOR LONG-TIME SMOKERS WHO MIGHT DIED. OTHERWISE HAVE we’re all scared of that word.”
26 CARILION MEDICINE | FALL 2016 ILLUSTRATION: CRISTIANA COUCEIRO CARILION MEDICINE | FALL 2016 27 tutes of Health that the study was terminated early and LDCT The Chance to Survive screening put into action. Even though his fears were ultimately confirmed, Mitchell’s sto- “That study validated what we had suspected all along,” STATISTIC ry diverges from the vast majority of lung cancer patients, for Dr. Nakat says. “The findings were significant and reliable, and SMOKING HAS DROPPED SINCE 2005, WHEN NEARLY whom diagnosis amounts to a virtual death sentence. Thanks the benefits were obvious. We’re at the forefront of a new medi- to an innovative new screening exam he underwent at Carilion cal breakthrough and a screening tool that saves lives.” 21 PERCENT OF AMERICANS SMOKED, BUT IS STILL HIGH ENOUGH Clinic earlier this year, doctors were able to detect a nodule of Implementation has been swift. The U.S. Preventive Services TO CAUSE 480,000 SMOKING-RELATED DEATHS EACH YEAR. cancerous cells while it was still too small to appear on a con- Task Force added LDCT to its list of recommended screens, and ventional x-ray. Prompt surgery to remove the upper lobe of his in early 2015 Medicare began covering it. right lung, where the nodule appeared, has offered him the pos- In the past year, Carilion has performed about 120 screen- sibility of many more years. ings—an average of 10 a month—a number Dr. Nakat hopes composing the Roanoke Valley, all but Botetourt County meet Subjects may simply be advised to have yearly follow-ups. The two-year-old screening method, known as low-dose will grow substantially as word of the benefits spreads among or surpass Virginia’s higher-than-national average of 18 percent Indeed, Mitchell’s first scan, in 2014, was negative. It was a fol- computed tomography, or LDCT, captures the entire lung area physicians, longtime smokers, and family members. of adults who smoke. low-up screening in 2016, suggested by his Carilion pulmonolo- in one-millimeter slices. This up-close view enables radiologists gist, Sameh Aziz, M.D., that revealed the problem. such as Sam Salim Nakat, M.D., chief of diagnostic sections at Carilion, to detect pulmonary nodules as small as two millime- Smoking Is Down, But Not Out Who Should Be Screened? ters wide. That’s about the size of a grain of rice. An x-ray, by Nearly 17 percent of U.S. adults smoke, according to the Cen- Screening is a painless procedure that requires no advance Mostly Benign comparison, detects masses the size of a dime or larger. ters for Disease Control and Prevention. That’s well down from preparation and takes only a few minutes of the patient’s lying In some cases, the screening will reveal a finding that warrants a That difference is crucial: By the time a mass is visible on an 2005, when nearly 21 percent of Americans smoked, but still immobile on a table. closer look—whether another CT follow-up or a biopsy. But the x-ray, the cancer may already be inoperable. high enough to cause 480,000 smoking-related deaths each year “It takes almost no time,” says Mitchell. “I was amazed how presence of a nodule doesn’t mean malignancy, Dr. Nakat says. and relegate more than 16 million people to living with a smok- quick it was.” Most of the nodules are benign and may result from infection, ing-related disease. The screening is recommended for people at relatively high fibrosis, or inflammation. If a biopsy reveals the nodule to A Hidden Killer For Virginia clinicians, there’s an added sense of urgency risk of developing lung cancer. That includes those who are 55 to be malignant, doctors may perform a lobectomy—surgically “Lung cancer is the leading cause of death from cancer for both based on the state’s long history of residents farming, manufac- 80 years old and have smoked an average of a pack a day for 30 removing the lobe of the lung where the nodule was found. men and women,” Dr. Nakat says. “More people die annually turing, and using tobacco. years, even if they’ve quit within the past 15 years. Mitchell’s lobectomy was performed by David Wyatt, M.D., a from lung cancer than from breast, colon, and prostate cancer “This is tobacco country,” Dr. Nakat says. In Southwest Subjects should have no symptoms of lung cancer and have Carilion cardiothoracic surgeon. combined. And while we have screening tools for those other Virginia, among the four counties and two independent cities had no other types of cancer within the past five years. People “I can’t say enough about Dr. Wyatt and Dr. Aziz,” Mitchell types of cancer, we’ve never had one for lung cancer.” should also consider getting screened if they are over 50 and says. “They’re great doctors.” Adding to those challenges, Dr. Nakat says, is the fact that have smoked for 20 years—if they also have been exposed to It was serious surgery, to be sure. Mitchell had to be tested patients often don’t experience symptoms until the disease “has EARLY DETECTION: radon or chemicals in the workplace, have a family history of in advance to make certain, among other things, that he had already progressed to the point where life expectancy and the For high-risk smokers lung cancer, or have experienced chronic obstructive pulmonary sufficient lung function to compensate for the missing lobe. possibility of cure are fairly minimal.” like Lewis Mitchell, disease or pulmonary fibrosis. The aftermath has involved rehabilitation, and he’ll need to be Padmaja Mallidi, M.D., an oncology and hematology special- early screening can watched closely for the next five years to ensure he’s cancer free. ist at Carilion, knows full well the pain that late-stage diagnosis literally mean the Yet because the cancer was caught so early, Mitchell didn’t need of lung cancer brings. difference between Overcoming Resistance chemotherapy or radiation. “It’s tremendously frustrating,” Dr. Mallidi says. “Patients look life and death. For all its lifesaving potential, real success for LDCT screening And compared with the alternative, he says, “I feel at us and say, ‘I want my cancer cured.’ But there’s not a whole lot depends on overcoming resistance to getting screened. For extremely lucky.” we can do in that regard. We do what we can to improve the qual- some longtime smokers, reluctance amounts to simple iner- ity and quantity of their life, but it’s beyond the point of cure.” tia—they feel fine, so why bother with a medical examination? Others may be leery of subjecting themselves to radiation. Yet The Ultimate “Cure” while radiation is certainly a factor that any patient should Of course, the LDCT scan, even when it saves a life, is not the Birth of a Breakthrough take into account, the low-dose CT, as the name implies, emits ultimate weapon in the battle against smoking-related lung can- Hope came with a broadly accepted implementation of low-dose around one-and-a-half millisieverts for an average scan, com- cer. The disease, unlike so many whose origins remain a mys- CT scan technology. pared to seven for a conventional CT. tery, is among the most readily preventable by stopping smok- “For years, radiologists have been well aware of both the “That’s about what you’d get from seven to 10 chest x-rays ing or—better yet—never starting. limitations of chest x-rays and the potential for CT scans,” or six months of background natural radiation,” Dr. Nakat says. “The best thing is prevention,” Dr. Mallidi says. “The next Dr. Nakat says. “You’d see a patient’s x-ray and it would look com- One of the most persistent concerns, ironically, is that the best thing is early detection.” pletely normal. Then, for whatever reason, he’d have a CT scan and scan will work too well, delivering news people don’t want to Yet overcoming centuries of history doesn’t happen in a you’d see abnormal findings that weren’t visible on the x-ray.” hear. Given the profusion of information linking smoking not flash—in Virginia or around the world. While rates are drop- But clinicians needed a solid study that could back up just to lung cancer but also to high blood pressure, emphyse- ping, smoking remains stubbornly difficult to overcome. In the those observations. ma, circulatory problems, and a host of other conditions, most meantime, for generations already smoking, LDCT holds out a That came in 2011, when a National Institutes of Health– smokers recognize at some level that they are tempting medi- measure of hope for surviving the unsurvivable. funded study of more than 53,000 subjects showed that LDCT cal fate. Thus they may see LDCT as speeding a process that is “For most people I’ve known who have gotten lung cancer, screening reduced mortality by a whopping 20 percent. The pos- bound to come eventually—so why rush things? it’s pretty much over,” Mitchell says. Instead, he’s full of hope sibility that, of 100 lung cancer patients who would otherwise Dr. Nakat stresses that in most cases, LDCT screenings for more years to spend with his seven grandchildren and six have died, 20 might survive, so impressed the National Insti- reveal no cancer. great-grandchildren. “This is just a great thing.” CM
28 CARILION MEDICINE | FALL 2016 PHOTO: DARRYLE ARNOLD CARILION MEDICINE | FALL 2016 29 photo essay
Bryan Collier 24 exhausting but productive hours with the chief of trauma surgery at Carilion Roanoke Memorial Hospital. PHOTO ESSAY BY DAVID HUNGATE
PATIENTS WITH TRAUMATIC INJURIES HAVE A 25 percent better chance at surviving at Levels 1 and 2 trauma centers than at other facilities. “Our hospital covers people across more than 15,000 square miles, including two major interstates and thousands of acres of national forest,” says MORNING SURGERY Bryan Collier, D.O., chief of trauma surgery at Carilion Roanoke Bryan Collier, D.O., Memorial Hospital, the region’s only certified Level 1 trauma center prepares a patient for since 1983. “That means we have to be ready for all emergencies, all a skin graft to close an abdominal wound. the time.” While “patient care comes first,” Dr. Collier adds, teaching Dr. Collier had treated the is also important. “Because I work with surgical residents, every day patient two weeks earlier is a series of teaching moments,” he says. “Not all doctors want to after a car accident. work with residents; I can’t imagine myself not doing so.”
30 CARILION MEDICINE | FALL 2016 CARILION MEDICINE | FALL 2016 31 THE DOCTOR IS IN
Dr. Collier and Daniel Freeman, R.N., discuss an administrative issue (top right, this page); Dr. Collier prepares for a skin graft (middle right); resident Allison Farris, M.D., joins him in performing a tracheostomy on a patient with a traumatic brain injury (bottom right and left); he explains a critical care patient’s condition to family members (middle left).
A TEACHING MOMENT
Dr. Collier and Michael McKee, M.D., a resident at Carilion Roanoke Memorial Hospital, prepare for a tracheostomy on a patient.
32 CARILION MEDICINE | FALL 2016 CARILION MEDICINE | FALL 2016 33 ACTION FIGURE
Dr. Collier consults with a specialist about a patient’s condition (top right, this page); residents John Ortolani, M.D., and John Rudderow, D.O., learn from Dr. Collier while performing a difficult bowel resection (middle right); after completing a tracheostomy, Dr. Collier explains a detail of the procedure to resident Allison Farris, M.D. (bottom right); with CT technologist Molly Krupa, Dr. Collier performs a scan on a patient (bottom left); he reviews a CT scan in the emergency department at Carilion Roanoke Memorial Hospital (middle left).
PRIDE IN JOY
Dr. Collier and Matthew Joy, M.D., a plastic surgery resident at Carilion Roanoke Memorial Hospital, share a lighthearted moment between surgeries.
34 CARILION MEDICINE | FALL 2016 CARILION MEDICINE | FALL 2016 35 B the art of medicine
BURDENS LIFTED IN RITUAL The Burden Boat, created in response to the Virginia Tech tragedy, finds a home in Carilion’s healing arts program. A BY PAULA BYRON
HE BURDEN BOAT, A TWELVEFOOT ceramic-and-wood sculpture, is also a cer- emonial vessel intended to foster healing. “The idea was to create a container that would allow people to release their personal T burdens,” said artist Kurt Steger. “I wanted to create a sculpture that would come alive with the interaction of those participating in the ritual.” The Burden Boat, a permanent installation in Carilion Clinic’s Dr. Robert L.A. Keeley Healing Arts Program, offers members of the public the oppor- tunity to capture their burdens on scraps of paper and place them in the boat’s hull, eventually to be released in a burden-burning ceremony. “This is an uplifting event and a time for reflection A and celebration, of moving forward in our lives and becoming wiser from our experiences,” said Steger. “Through the ceremony, the Burden Boat brings people together; it creates common bonds on a deep level and fosters compassion, empathy, and trust.” The first Burden Boat ceremony took place in 2009, as part of an exhibition of Steger’s sculptures RELEASING BURDENS LIFTS THE SPIRIT at Virginia Tech. The university was still in mourning A. Artist Kurt Steger (right) prepares for a ceremonial lighting over the April 16, 2007, shooting, during which while Carilion artist-in-residence Pedro Szalay places in the 32 people were murdered. Steger felt compelled to Burden Boat slips of paper capturing the pain people have held create a work of art that would help the community for moments, years, or even a lifetime. B. The ignited burdens heal. With the blessing of the university’s newly provide light in the darkness of night. C. During a ceremony held formed Center for Peace Studies and Violence in front of Carilion Roanoke Memorial Hospital in November 2014, Prevention, Steger created the sculpture. participants found warmth from both community and the blazing Before joining Carilion’s permanent collection in burdens. D. The fire incinerates more than burdens; it also burns 2014, the Burden Boat was used in ceremonies at other the string holding burden bags, allowing them to fall away both locations, including the Smithsonian National Portrait literally and figuratively. In all the ceremonies, including the one Gallery in Washington, D.C., as part of the tenth pictured here, at Carilion’s Dr. Robert L.A. Keeley Healing Garden, anniversary of the September 11 terrorist attacks. In the bags contain hallowed ground from Virginia Tech’s campus. that ceremony, the burdens wereE removed with a water D D C cleansing ritual rather than with fire. CM
36 CARILION MEDICINE | FALL 2016 PHOTOS: JARED LADIA CARILION MEDICINE | FALL 2016 37 cheers for peers
Dermatology Pediatrics School of Medicine spotlight on Paul Skolnik, M.D. DOUGLAS GRIDER, M.D., and ALICE ACKERMAN, M.D., chair CYNDA JOHNSON, M.D., first-year dermatology resident of the Department of Pediatrics, M.B.A., dean of the Virginia In May, PAUL SKOLNIK, M.D., a ALEX HOLLIDAY, M.D., had a received a Golden Halo Award Tech Carilion School of nationally prominent infectious case report—”Tinea Versicolor from Children’s Trust. The Gold- Medicine, was the 2016 diseases specialist and academician, Masquerading as Vitiligo”— en Halo Awards recognize and recipient of the Society of joined both Carilion Clinic as chair accepted into the New England honor outstanding contribu- Teachers of Family Medicine of its Department of Medicine and Journal of Medicine’s Images of tions to the cause of child abuse Foundation’s F. Marian the Virginia Tech Carilion School of Clinical Medicine series. prevention, intervention, and Bishop Leadership Award. advocacy in the Roanoke Valley. Established in 1990, the Medicine as chair of its Department award honors individuals of Internal Medicine. Family Medicine who have significantly Dr. Skolnik brings more than 30 Psychiatry enhanced the credibility of years of experience in medicine, across patient care, educa- RANDALL RHEA, M.D., received family medicine through tion, and research, especially in the field of infectious diseases. Rhodes College’s Algernon THOMAS MILAM, M.D., interim a sustained, long-term He was the founding director of the Center for HIV/AIDS Care Sydney Sullivan Award, which co-chair of the Department of commitment to family and Research and chief of infectious diseases at Boston Uni- honors individuals who demon- Psychiatry, received the Leonard medicine in academic versity Medical Center. He has served as principal investigator strate nobility of character Tow Humanism in Medicine settings. or co-investigator on dozens of HIV and immunovirology through service. Award for 2016. This award is research projects. given each year by the Gold Dr. Johnson also received the Dr. Skolnik most recently served as chairman of the Depart- Foundation to a faculty member American Board of Medical ment of Medicine at the University of Connecticut Health Center Internal Medicine at the Virginia Tech Carilion Specialties Distinguished and as the James E. C. Walker, M.D., Professor of Medicine at the School of Medicine who best Service Award for extraordinary University of Connecticut School of Medicine. He received his CHAD DEMOTT, M.D., received demonstrates outstanding, contributions to the medical bachelor’s degree in music from Yale University and his medical the Academic Teaching Award compassionate delivery of care. specialty certification process. degree from the University of Pennsylvania School of Medicine. from the Virginia Chapter of the She has served in a number of He undertook his internship and residency in medicine at the American College of Physicians Dr. Milam was also inducted into capacities in the organization, Hospital of the University of Pennsylvania and then served as at the annual meeting in March. medicine over a broad, effective, population health and succeeding esis via Intramedullary Nail? A both the Alpha Omega Alpha including both chair and first a clinical and research fellow in the Infectious Disease Unit of and productive career. in the new physician payment Multicenter Evaluation,” which Honor Medical Society and the woman president. Massachusetts General Hospital. Dr. Skolnik is a fellow of the CLAUDIA KROKERBODE, M.D., models taking effect in 2019. was published in the Journal of Gold Humanism Honor Society. American College of Physicians and a fellow of the Infectious PH.D., program director for the Foot and Ankle Surgery. Diseases Society of America. Internal Medicine residency, Obstetrics and Gynecology AMANDA MURCHISON, M.D, Surgery During his career, Dr. Skolnik has received numerous awards and DARIEN WANG, M.D., chief was inducted into the Alpha THOMAS K. MILLER, M.D., Residency Programs and recognition for his clinical work, teaching, and research. resident for Internal Medicine, JONATHAN GLEASON, M.D., Omega Alpha Honor Medical section chief for Sports Medi- CAROL GILBERT, M.D., attended the 2016 Chief Resi- chief of Urogynecology, Society, the oldest academic cine, was named to the Becker’s Nine resident physicians were was inducted into the Gold He has served on several editorial boards and as a reviewer for dent Immersion Training (CRIT) coauthored “Nonantimuscarinic medical honor society in the ASC Review list of 164 Physician inducted into the Gold Human- Humanism Honor Society. numerous medical journals. He authored or coauthored dozens Program in Addiction Medicine: Treatment for Overactive United States. The society Leaders to Know in the ambula- ism Honor Society. The residents The society is composed of of publications in peer-reviewed journals and has been an Improving Clinical and Teaching Bladder: A Systematic Review” recognizes scholarship and high tory surgery industry for 2016. were MASON AYOBELLO, individuals who have been invited lecturer at numerous conferences and events. He has Skills for Generalists. in the American Journal of moral standards and encourag- M.D.; MATTHEW CAUCHI, recognized for practicing also taught and mentored many residents, fellows, physicians, Obstetrics & Gynecology. es students and physicians to be JOSEPH MOSKAL, M.D., D.O.; RICHARD HA, D.O.; JOHN patient-centered care by and researchers. JON SWEET, M.D., received “worthy to serve the suffering.” chair of the Department of JEFFRIES, M.D.; MATTHEW modeling the qualities “Dr. Skolnik’s clinical talents, experience, and passion for the Laureate Award from the Dr. Gleason and KATHLEEN Orthopaedic Surgery, received JOY, M.D.; KRISTIN LIEBRECHT, of integrity, excellence, education will benefit Carilion and the School of Medicine in Virginia Chapter of the Ameri- BAUDREAU, vice president for the 2016 Achievement Award M.D.; JONATHAN NOGUIERA, compassion, altruism, respect, many ways,” said Patrice M. Weiss, M.D., chief medical officer can College of Physicians at its clinical risk management and Orthopaedics from the American Academy of D.O.; JENNIFER WELLS, M.D.; and empathy. of Carilion. “In addition, his research skills will enable him annual meeting in March. The interactive patient care, were Orthopaedic Surgeons for his and MIDHUNA WILLIAM, M.D. to be an important collaborator in translational and other Laureate Award, the chapter’s accepted into an American J. RANDOLPH CLEMENTS, D.P.M., volunteer efforts supporting MARK HAMILL, M.D., chief of research efforts at Carilion and with the Virginia Tech Carilion highest honor, is given to physi- Hospital Association–American coauthored “Is Subtalar Joint patients, colleagues, the ASHLEY GERRISH, M.D., was surgical critical care, was inducted Research Institute.” cians who dedicate themselves Medical Group Association learning Cartilage Resection Necessary academy, and the orthopaedic inducted into the Alpha Omega as a fellow in the American to the practice and teaching of fellowship focused on managing for Tibiotalocalcaneal Arthrod- profession. Alpha Honor Medical Society. College of Critical Care.
38 CARILION MEDICINE | FALL 2016 PHOTOS: EDWARD HAMILTON LEFT; JARED LADIA CARILION MEDICINE | FALL 2016 39 backstory IT ALL HAPPENS If truly caring for patients and XBOUJOHUPNBLF a difference in UIFcommunity BSF the reasonT THE QUALITY IMPERATIVE ZPVbecame a doctor, then join us JO Physicians need to embrace transparency in the quest for safe, high-quality care. Virginia’s Blue Ridge Mountains. BY RALPH WHATLEY, M.D. You’ll feel right at home here with us.
HEN WE CARE FOR OUR PATIENTS This is not easy; our patients’ diseases don’t Paired with our innovative and their families, one of our unwritten always read the rulebooks—and that complicates our approach to health care, the commitments is that the care we pro- efforts. Infections may not respond to appropriate vide will be safe and effective. That has antibiotics; patients may have unforeseen reactions region features a low cost of living, certainly been the expectation of those to medications. Despite our best efforts, procedures exceptional schools, outdoor fun, seeking our help at some of the most may have complications. And caring for patients W and Brich array of arts and culture. vulnerable and challenging times in their lives. Despite with lingering illnesses at the end of their lives is this commitment, in the past, the complex business of extraordinarily challenging. medicine has too often relegated quality and safety to Sometimes, the complexity of care trumps our best Our flagship hospital, Carilion lower priorities for providers with conflicting demands efforts at standardizing processes. What is considered on their time and attention. “evidence based” changes Roanoke Memorial (pictured), is During the past two de- over time as new knowl- a 700-bed, nationally recognized cades, several forces have edge accrues. Often, change teaching/tertiary referral center led to a strengthening of to a value-based approach our commitment to qual- requires a fundamental cul- with a Level 1 trauma center. ity. First, our profession tural shift, one that is not 8FUFBDI theOFYUHFOFSBUJPOPG acknowledged our respon- only difficult, but must also sibility to place safety at be continuously reinforced physicians atUIF7JSHJOJB5FDI the forefront of practice, and monitored. CarilionSchool of Medicine. with the 1999 Institute In addition, we must de- of Medicine Report To Err velop comfort with openly Is Human: Building a Safer sharing our efforts and our Reach out to us at 800-856-5206 Healthcare System setting results. At Carilion Clinic, or visit CarilionClinic.org/careers. the stage. our embrace of transpar- We offer BSBOHFPG employment This was followed by ency is evident in a quality an increasing recognition website we launched ear- opportunitiesGPSQSJNBSZDBSF by payers—Medicare and lier this year. The data we QIZTJDJBOTBOEspecialistsBMJLF health insurers—and pro- post there are intended to viders that pay should be be more accurate, informa- BUCPUIPVSGMBHTIJQNFEJDBMDFOUFS linked to the quality rather tive, and timely than those BOEDPNNVOJUZIPTQJUBMT. than volume of care. The acceptance of pay for perfor- found in the many online “ratings.” We will continue to mance as a valuable paradigm continues to transform expand our efforts to be transparent. the U.S. health care system. These trends have forced us to challenge our tra- Lastly and perhaps most important, our patients ditional approaches to providing care. Fortunately, have changed; they have become health care physicians, nurses, and other caregivers have a re- “consumers” with an increasing expectation—even markable, nearly universal characteristic: We find our demand—that the care they seek will be readily efforts to provide safer, high-quality care to be incred- available, safe, and effective. ibly exciting and gratifying. CM These compelling and converging forces are dramatically changing the health care system. As Ralph Whatley, M.D., is chief quality officer of Carilion Clinic. providers, we continue striving to deliver high-quality, A professor of internal medicine at the Virginia Tech Carilion safe, and cost-effective care, the kind we would expect School of Medicine, Whatley is also a member of the for ourselves and our family members. Carilion Clinic Board of Governors.
40 CARILION MEDICINE | FALL 2016 CARILION MEDICINE | FALL 2016 41 ILLUSTRATION: BRIAN STAUFFER/THEISPOT 7 hospitals | 680+ physicians | 70+ specialties | 240 practice sites| 24 GME programs Equal Opportunity Employer - Minorities • Females • Protected Veterans • Individuals with Disabilities • Sexual Orientation • Gender Identity CARILION CLINIC P.O. BOX 13727 NON-PROFIT ORG. ROANOKE, VA 24036-3727 U.S. POSTAGE PAID ROANOKE, VA PERMIT NO. 247
DOCTOR IN THE HOUSE: Bryan Collier, D.O., chief of trauma surgery at Carilion Roanoke Memorial Hospital, checks with his team on a patient’s recovery.
ONLINE EXCLUSIVES Photo Gallery of a Day in the Life of a Trauma Surgeon Weather and Time Are Critical for Carilion Clinic’s Life-Guard Crews Cochlear Implants Allow a Playful Kindergartner to Hear Close to Home: Perspectives from Pediatrician Alice Ackerman
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