June 18, 2018

Side Summer 18

Summer 2018 Issue
Family and Internal Medicine
To View the Summer 2018 issue
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Physician Spotlight 

 

James G. Dixon, MD
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Margaret M. Gaglione, MD, FACP
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J. Matthew Halverson, DO, FAAFP
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Good Deeds

John D. Sheppard, MD, MMSc
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Advanced Practice Provider

Tonia Yocum, PA-C
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James G. Dixon, MD

Associate Professor of Internal Medicine and Vice Chair for Clinical Affairs, Department of Internal Medicine, Eastern Virginia Medical School

To James G. Dixon, good medicine is – at its heart – about listening skills and empathy. 

Over a long and influential career at Eastern Virginia Medical School, Dr. Dixon has never stopped listening and learning, whether from colleagues at EVMS and Sentara Healthcare, medical students or the many underserved patients he treats through community outreach programs.

“You have to spend the time to really understand the person in front of you,” he says. “You will also rely on science and technology, of course, but you need to hear about a patient’s history and life and what that person values. That’s what gives you an opportunity to make an enormous difference.”  

While maintaining a large primary care practice at EVMS, Dr. Dixon has founded a training program, developed innovative classes, held important leadership positions, nurtured joint initiatives with Sentara and garnered numerous awards as a physician and professor. Thanks to his interest in women’s health, he also joins with a colleague, Dr. Jennifer Ryal, and EVMS internal medicine residents in the “Every Woman’s Life” preventive care program for low-income patients. 

An ability to adapt over time has shaped Dr. Dixon’s career. In 1995, amidst a push for community-based medical schools to train more primary care physicians, he founded a combined Family Medicine/Internal Medicine Residency Program that he would direct for 23 years. The initiative caught the attention of talented residents from around the country. 

“We attracted adventurous, motivated students who wanted to tackle a challenging and experimental program,” Dr. Dixon notes. The combined program ends this year, due to a complex mix of funding issues and diverging training paths for the two specialties. 

In response, Dr. Dixon re-embraced an earlier focus on women’s health, hoping to again contribute to the EVMS curriculum. Last year, he implemented an elective for fourth-year medical students to delve into recent research on breast cancer risk, heart disease, hormone replacement, osteoporosis and other important issues. Two students were in the first class; six have signed up for next year’s edition. 

“Professionally, that class was the best thing I did all year,” Dr. Dixon reports. “These two bright young women shared so much with me about what they’ve observed and learned.” His students and residents continuously push him to become a better physician, he adds: “They challenge me. They give me energy. They make it much easier to stay up at night reading up on a variety of topics.”

Reaching low-income patients is another passion for Dr. Dixon, whether they’re hospitalized or part of outpatient initiatives such as Every Woman’s Life. That program, funded by the Centers for Disease Control and Prevention, provides free breast and cervical screening tests. 

Concern for the vulnerable came early to Dr. Dixon. Although the Hampton native earned undergraduate and master’s degrees in mechanical engineering from the University of Virginia, he believes the seed for his medical career was planted at age 12 when an older sister, then 16, was diagnosed with serious depression. She struggled with mental illness for much of her life before passing away several years ago. 

Dr. Dixon and his oldest sister – who became a wound care nurse – watched during their teenage years as doctors and hospitals fought to help their sibling, while learning the devastating effect a disease could have on a patient and a family. “She was the most talented of all of us,” he says. “I gained a lot of perspective and compassion.” 

Even as an engineering student, Dr. Dixon made time to volunteer at nearby hospitals, including a stint on the female-dominated “Pink Lady” team at Riverside Regional Medical Center. “They didn’t make me wear a pink dress, but my badge did have a fair amount of pink in it,” he laughs. 

Once he pivoted full-time to medicine, Dr. Dixon completed his medical degree at EVMS and an internship and residency in family medicine at Riverside. He then spent two years practicing with Eastern Shore Rural Health in Northampton County to fulfill an obligation to the National Health Service Corps and repay his student loans. The center served people from all walks of life and income levels; one favorite patient was a 90-year-old woman whose father had been born a slave. 

Dr. Dixon returned to EVMS for good in 1986, completing an internal medicine residency before beginning his teaching career. “During training I flirted with a few specialties, but I always pictured myself as a primary care provider,” he recalls. Ever since, he has mentored hundreds of learners in hospital and ambulatory settings – many now practicing clinicians in Hampton Roads – while serving on and chairing multiple high-profile committees. 

Additionally, Dr. Dixon has held several leadership posts at Sentara Norfolk General, where he is a longtime staff member. He served a term as Medical Staff President, remains on the hospital’s Peer Review Committee and regularly bolsters collaborations between the hospital and EVMS. 

Outside work, Dr. Dixon most enjoys family time with his wife Marybeth, a gynecologist, their two children and his rescue Labrador retriever, Tahoe. He also likes to mess around on his old guitar, read history books and attempt to stay healthy with elliptical machine workouts.  

As for the future of primary care medicine, Dr. Dixon is optimistic. He predicts a computer-savvy generation of doctors will improve technology – including cumbersome electronic medical record systems – so they can focus more on delivering value-based care.   

“This is such a rewarding field,” he says. “No matter what else changes, that’s never going to change.”

Margaret M. Gaglione, MD, FACP

Internist and Bariatrician, Tidewater Physicians Multispecialty Group; Assistant Professor of Clinical Internal Medicine, Eastern Virginia Medical School

Two basic principles underlie Dr. Margaret Gaglione’s success with patients struggling to lose weight. The first is that obesity is a chronic disease, with complex behavioral and physiological factors. The second is that maintaining a healthy weight is a skill – and one that many patients need to be taught. 

“They need active and direct management,” Dr. Gaglione says. “You don’t see a cancer patient and give them treatment guidance and then say, ‘Okay, I’ll see you next year.’ Some of the lifestyle changes I recommend may seem ‘simple’, but to someone without this skill set, they’re not so simple.” 

Dr. Gaglione’s intense, personalized and multifaceted treatment of obesity is the same approach that she takes for all her patients’ health concerns. At Coastal Internal Medicine and Tidewater Bariatrics in Chesapeake, her practice is about 70 percent general internal medicine and 30 percent bariatric medicine. Other specialty areas include diabetes, hypertension and hyperlipidemia management. 

Bariatrics was a focus that Dr. Gaglione discovered 18 years ago. With a team of health educators, she has developed education, treatment and maintenance programs to attack the problems that impede each individual’s progress. Most patients start with weekly or biweekly appointments before gradually moving to a bimonthly schedule. 

“You can have people who are incredibly skilled in other areas of life, personally and professionally, but not at this,” she notes. “We need active engagement on their part and my part, as we would with any chronic disease.” 

Prescribed changes might include meal replacement plans, medication, nutritional supplements or a range of diet and exercise fixes such as bringing lunch to work, scheduling daily walks, buying a standing desk or watching less television. Dr. Gaglione also will recommend bariatric surgery as part of a larger plan if necessary, although many patients who seek her out wish to avoid that.  

Patients often can wean off medications while becoming more active, social and self-confident. “Obesity is a very isolating disease,” Dr. Gaglione says. “It’s very gratifying to see people rediscover things they haven’t been able to do in years. It’s also shocking to see how quickly dietary changes can reverse serious health issues such as hyperglycemia.” 

Dr. Gaglione takes a data-driven, down-to-earth approach. After precisely calculating each patient’s daily calorie needs based on laboratory tests, body composition analyses and lifestyles, she outlines specific choices that will achieve desired results – along with memorable one-liners. 

“I might tell them, ‘I’d like to be 6 feet tall and muscular, but I’m 5-foot-4 and petite,” she laughs. “So, I only need about 1,300 calories to maintain my weight. If I chose to eat what I want, when I want, regardless of boundaries, I will not maintain my weight. Many of my patients eat enough in one day that they would need to be over 7-foot-tall athletes for that to be a ‘normative’ number of calories.”

In Dr. Gaglione’s experience, meal replacements can be highly effective because they ensure patients will eat healthfully most times of a day. She uses Health Management Resources, or HMR, products that are high in protein and low in simple carbohydrates and fat. “If you’re replacing 14 of the 21 meals that someone eats weekly, you’re cutting out two-thirds of the danger zone,” she says. “As patients learn how to eat, they only have to focus on a single meal.” 

Any surgery, she adds, should be just one tool in the toolbox – much like a cancer patient wouldn’t stop seeing an oncologist after a surgical procedure.  

Originally from Queens Village, N.Y., Dr. Gaglione had a grandmother who was a nurse and encouraged her early dreams of becoming a doctor. After receiving her Bachelor of Science degree from Le Moyne College in Syracuse, she completed a medical degree from Pennsylvania State College of Medicine and a residency in Internal Medicine at Naval Medical Center Portsmouth. 

“I love this specialty because I like to think broadly and really get to know my patients – their challenges, living environments, families and how I can empower them,” she says. 

For six years after medical school, Dr. Gaglione proudly served on active duty as a Lieutenant Commander in the U.S. Navy. She was a staff internist at Naval Medical Center for 20 years and was in private practice with Tidewater Bariatrics from 2007 to 2015 before moving to TPMG. 

Committed to lifelong learning, Dr. Gaglione is a prolific author, popular lecturer and instructor and winner of multiple awards for her service. She is a diplomate of the American Board of Internal Medicine and the American Board of Obesity Medicine, as well as a member of the Clinical Faculty at the Edward Via College of Osteopathic Medicine.   

Personally, Dr. Gaglione stays healthy by taking regular walks and bike rides, never skipping meals, cooking often at home and eating plenty of fish, fruits and vegetables. She and her husband, Capt. David Collins, have four children between them. 

Dr. Gaglione’s patients – some of whom she has treated for 25-plus years – also have become like family, which makes her happy to go the extra mile for them. In the future, in fact, she hopes to offer more virtual appointments. 

“I want to meet people where they are, whether that’s at home, at work or in my office,” she says. “I want them to know how much I care about their lives. My job is to be by their side.”

J. Matthew Halverson, DO, FAAFP

Founder, James River Family Practice, LLC

For an independent medical practice, celebrating a 20th birthday is a major milestone. James River Family Practice in Newport News will do just that come October, thanks largely to the dedication and innovation of its founder, J. Matthew Halverson. 

And the practice isn’t going anywhere. 

“We are deeply committed to this community,” Dr. Halverson says of himself, his partner of 10 years, Tammy Beavers, MD, and their two full-time Family Nurse Practitioners. “We have worked very hard to always give our patients the high-quality, compassionate care they deserve – on the same day they need it. That’s how we can stand out amidst all the big competitors around us.”

Dr. Halverson is a proud osteopathic physician, emphasizing proactive preventive care and wellness education. He’s also a self-described “comprehensivist” – he prefers that to “specialist” – who enjoys staying current on effective, evidence-based treatments for a wide variety of health issues.

Competing as a small independent practice has never been easy. Dr. Halverson relies on multiple strategies: 24/7 access to care for patients; comprehensive annual exams with in-depth discussions of healthy lifestyle choices; intensive chronic care management programs; and the quick embrace of emerging technology such as electronic medical records and patient portals. 

“Our goal is to be a five-star practice, much like a concierge setup but without the annual fees,” he says. “Being accessible to patients is simply good medical care.” As an independent business, he’s also able to accept all insurances and has more flexibility in selecting the best specialists for patients, he adds.  

A natural extrovert, Dr. Halverson dreamed of becoming a doctor while growing up in Annandale, Va. Yet despite graduating with distinction with a chemistry degree from the University of Virginia, he initially didn’t get into medical school. He ventured into education instead, earning a master’s in education at Virginia and teaching chemistry and physics in Fairfax County public schools for four years. 

Looking back, Dr. Halverson wouldn’t trade those years for a direct journey into medicine. He learned to work with all ages and personality types, from teenage students to veteran administrators, while honing his scientific research skills. He also got to coach basketball, his favorite sport.

“I’m absolutely a better doctor because of that time,” he says. “The importance of education has carried over to my practice as well. I’m passionate about teaching my patients how to be responsible for their own health, because I consider that an integral part of my duty to them.”

It was a relative of Dr. Halverson’s, a colorectal surgeon, who first told him about the field of osteopathic medicine. Fascinated, Dr. Halverson went to study at the Kirksville College of Osteopathic Medicine in Missouri, the first such program in the country. “It’s a wonderful philosophy, to focus on supporting the body’s amazing innate healing mechanisms and healthy functions,” he says. 

After his 1992 graduation as a member of Kirksville’s 100th class, Dr. Halverson completed a family medicine residency at Riverside Regional Medical Center in 1995. He remained on active staff at Riverside until 2017, including 12 years as an attending emergency room physician and three years as chair of the hospital’s Department of Family Medicine. He and Dr. Beavers were among the last community physicians to defer care of hospitalized patients to hospitalists, which they did last fall. 

In 1998, Dr. Halverson decided to found his own practice. Since then, he has never wavered from his emphasis on prevention over intervention – in fact, it has only grown. Since relinquishing his hospital duties, he is even more laser-focused on outpatient care. 

Conversations about critical issues such as weight loss, smoking cessation, blood pressure control, depression symptoms and alcohol use take precedence during wellness appointments. Patients often leave with both advice and a handful of educational pamphlets. “I firmly believe that this is how we can have the biggest impact on an individual’s health,” Dr. Halverson explains.   

The practice recently added a Chronic Care Management program for its Medicare patients, a proactive and personalized approach for older patients with two or more such conditions. The system requires at least 20 minutes of out-of-office monitoring per month, such as phone calls to check on medication compliance, at-home equipment or progress toward health goals. 

Dr. Halverson’s community ties have won him numerous honors, both as a physician and an instructor for medical students, residents, nurse practitioners and physician assistant students. He also is a past president of the Hampton Roads Academy of Family Medicine.  

The father of two grown daughters with one grandson, Dr. Halverson practices what he preaches when it comes to healthy living. Once a college JV basketball walk-on – “I was slow and too short, but I had a good shot,” he recalls – he has traded hoops for the more joint-friendly sport of golf. 

His career, Dr. Halverson says, has been a challenging but joyful journey of lifelong learning. He is quick to credit his practice’s 20-member team for its success, from his fellow care providers to office staff who handle complicated billing and paperwork. 

At 58, Dr. Halverson has no plans to retire anytime soon. “Some of my biggest role models practiced into their 80s, and I don’t see any reason for me not to do the same,” he says. “I’m happy. I’m healthy. I love my patients – and I think people still value having a doctor who really, truly knows them.”  

Plus, he has that 20th birthday party to plan. <

Tonia Yocum, PA-C

Orthopaedic Physician Assistant, Orthopaedic & Spine Center

For Tonia Yocum, a 30-minute lunch break is a rare luxury. Far more often, she grabs microwaved leftovers or some yogurt and a handful of nuts while she’s at her computer between patients. 

Yocum wouldn’t have it any other way. 

“It’s so rewarding to be able to help people become functional and happier again, and I don’t mind working hard to do so,” she says. “Our patients all deserve to have excellent care, which includes someone to help them understand what is happening to their body and the treatment they need.” 

Since 2002, Yocum has practiced alongside Dr. Jeffery R. Carlson, a fellowship-trained spine surgeon at Orthopaedic & Sports Center. They operate as an efficient team both at Dr. Carlson’s Newport News office and his two busy operating rooms at Mary Immaculate Hospital. 

During her 12-hour days, Yocum’s work might include taking X-rays, giving injections, stitching and bandaging surgical patients, reviewing medications, ordering tests or physical therapy, doing post-operative hospital rounds, dictating notes, consulting with multiple physicians and simply listening. “Sometimes, patients just need to talk about their pain and know someone hears them,” she explains.  

During in-office days, Yocum generally does her hospital rounds at 7 a.m. before starting patient appointments at 8. On surgery days, she often arrives by 6:30 a.m. to prepare orders and check equipment for 7:30 cases. She most enjoys the “construction” aspect of surgery: placing the screws, plates, rods and prosthetics that can restore strength and stability to patients who frequently have struggled with pain, deformities and mobility issues for years. 

Dr. Carlson handles many complex cases, such as adult scoliosis patients who require multi-level spine reconstruction. “They go from being severely hunched to standing up straight and looking you in the face, free of pain,” Yocum marvels. “It’s such an amazing feeling to change someone’s life like that, and to hear the heartfelt thanks from them and their families.” 

Growing up in West Virginia, Yocum decided on a medical career after hearing stories from her mother, an operating room nurse manager. “Some were funny and some were poignant, but they all taught me how meaningful this type of work could be,” Yocum recalls. 

After initially studying physical therapy after high school, Yocum gravitated toward the PA specialty during an early job at her mother’s hospital, Thomas Memorial in Charleston. She earned bachelor’s degrees in both Medical Science and Sports Medicine at nearby Alderson-Broaddus College. 

In 1996, Yocum started at a multi-specialty surgical practice in Alexandria, where for three years she helped with general surgery, plastic surgery, orthopaedics and some spine cases, most often lumbar laminectomies. While her colleagues shied away from spinal surgeries, Yocum was fascinated by them and quickly became the “go-to” assistant on them.  

After a three-year interlude spent living in Japan with her Army husband, Yocum jumped at the opportunity to partner with Dr. Carlson once her family moved to Hampton Roads. Today, more than 90 percent of her caseload involves spine care, a job that requires compassion, flexibility, organization, meticulous record-keeping and constant communication with Dr. Carlson.   

In her off time, Yocum enjoys hiking, golf, fishing and attending her 17-year-old son’s baseball games where – not surprisingly – she is the well-prepared mom with extra drinks and snacks, first aid supplies, sunscreen and bug spray to share.  

Yocum is excited about the future of orthopaedics, especially given ongoing improvements in surgical hardware and equipment, along with minimally-invasive techniques that have allowed for more outpatient procedures.   

“Our goal is always to get people back to their homes – and their lives – as quickly as possible,” she says. “That’s where the joy of this job comes from. It’s very demanding and time-consuming, but it’s the career I chose and which I love.”  

John D. Sheppard, MD, MMSc

 

President and Founding Partner, Virginia Eye Consultants; Professor of Ophthalmology, Microbiology and Molecular Biology, Eastern Virginia Medical School

A plumber with a painful corneal ulcer who, despite working 80 hours a week to support his family, couldn’t afford health insurance. A 22-year-old woman who was blinded at age 7 in a school assault, when part of a pencil broke off in her eye; she grew up hiding the injury behind her hair. People who have lost their jobs or the ability to drive, all due to treatable vision problems. 

Every year, Dr. Sheppard and colleagues at Virginia Eye Consultants select about 50 such people from a pool of 200-plus applicants. All are uninsured, underinsured or financially unable to pay for care that often could save their sight – and transform their lives.

“This work never ceases to be rewarding,” says Dr. Sheppard, who leads VEC’s team of 18 specialty providers and 210 staff. “Most of these patients are the working poor who simply don’t have good access to health care. They are tremendously deserving of our help.”

Since 2013, more than 250 local patients have received upward of $500,000 in donated care, including corneal transplants; cataract, glaucoma, retinal and laser surgeries; and ongoing management of diabetes-related vision concerns. The plumber has a functional eye again, minus what would have been $50,000 in medical bills. The young woman has a custom-fit glass eye and has shared her story at VEC charity fundraisers. “Her self-esteem has skyrocketed,” Dr. Sheppard notes. 

Community service has long been important to Dr. Sheppard, an acclaimed researcher, author and instructor who has held his post at VEC for nearly 30 years. He also serves as president of the Virginia Eye Foundation, which raises money for individual patients; delivers grants and optical equipment to free clinics; offers workshops on medical advances to local providers; and awards college scholarships to gifted high school students interested in medical careers.

Growing up in Pittsburgh, Dr. Sheppard himself decided to become a doctor in fifth grade after writing a report on the human heart. He also had a neighborhood friend whose father was an ophthalmologist and lined up a summer job for him at a nearby hospital. By age 18, Dr. Sheppard had assisted a glaucoma specialist with research and observed several eye surgeries, including one memorable procedure on a patient blinded in a lawnmower accident. 

“After that, I didn’t want to do anything else but immerse myself in hospitals and labs,” he recalls.

Ophthalmology also drew on Dr. Sheppard’s interest and skill in the visual arts, including drawing and architecture. “The first time I saw an eye – an iris – through a slit-lamp biomicroscope, I was fascinated by the intricacy and beauty of its muscular architecture,” he notes.   

Dr. Sheppard earned undergraduate, medical and master’s degrees from Brown University on a full Armed Forces Health Professions Scholarship. During four years in the Navy, his posts included 6th Fleet Medical Officer, where he gained valuable experience in trauma surgery. He then completed an ophthalmology residency at the University of Pittsburgh Eye and Ear Institute and a 30-month fellowship in corneal diseases and uveitis at the Proctor Foundation for Research in Ophthalmology at the University of California San Francisco. 

At VEC, Dr. Sheppard has been principal investigator in more than 120 clinical research trials for major pharmaceutical companies and the FDA. He also has presented 700-plus invited lectures worldwide and served as a volunteer faculty member at Eastern Virginia Medical School since 1989. 

No matter how busy he gets, however, giving back remains a priority. “I’ll do this as long as I’m in practice,” he says, “and I hope this program continues long after I’m gone.”

Riverside Vascular Specialists – Staying on the Cutting Edge of Technology

…surgical team looks forward to bringing the first hybrid OR to the Peninsula

 

When vascular surgeons Dr. Joseph Piotrowski and Dr. Russell Campbell joined Riverside Health System a dozen years ago, they brought with them years of experience in performing complex and intricate endovascular procedures.  “In fact,” Dr. Piotrowski remembers, “we did the first endovascular aneurysm repair ever performed at the hospital.”  

Both Board certified and fellowship trained in vascular surgery, Drs. Piotrowski and Campbell handled all of the endovascular procedures at Riverside for greater than five years, taking call every night and every other weekend.  As word of their expertise spread and more patients were referred, it became clear they would need to expand, and Riverside approved the addition of two fellowship trained surgeons at the same time: Dr. Todd Jenkins and Dr. Ernest Zichal.  When Dr. Campbell retired, Dr. Adam Sagarwala was recruited to join the team.  These surgeons, supported by Megan Cobb, PA and Kristin Dehoux, NP, constitute the endovascular surgical department at Riverside.  

Today, the team treats the wide variety of vascular conditions, which include diseases of the peripheral and carotid arteries, venous disease, aortic aneurysms, blood clotting disorders and lymphedema.  “In other words,” says Dr. Sagarwala, “we treat almost every artery and vein in the body: anything involving the descending aorta, the abdominal aorta, the arteries from that point down the legs – so iliacs, femorals, aneurysmal disease and atherosclerotic vascular disease, including renal artery stents.  We treat venous reflux, varicose veins, DVTs, pulmonary embolism, and placing IVC filters.”

By ‘almost’ every artery and vein, Dr. Sagarwala means that intracranial cases are handled by neurosurgeons and neurointerventionalists, while coronary arteries and cases involving the ascending aorta are done by cardiothoracic surgeons.  “The rest are ours,” he says.  

There’s one area of overlap, Dr. Jenkins explains: “The aortic arch is kind of a hybrid between vascular surgeons and cardiothoracic surgeons.  The arch travels backward, so it ultimately runs to the left of the trachea.  We work together, employing a multidisciplinary approach for these procedures.”

All of the work is intricate and exacting.  Surgeries are intense, requiring extraordinary skill and exceptional visualization.  The skill has been there, and now, the surgeons are preparing to open a suite that will match that skill with the latest technology. 

After a nearly six-year process, which involved tremendous research and negotiations among surgeons, administrators and planners, Riverside is excited to announce that the hospital is pursuing the implementation of a hybrid cardiovascular operating room – the first on the Peninsula. 

The need was obvious: traditionally, diagnostic procedures like MRI, CT or angiography, and even some interventional procedures like balloon angioplasty and stenting, have been performed in an Interventional Radiology (IR) and Cardiac Catheterization suite, where the most precise images are provided by large, highest quality, fixed equipment.  Unlike operating rooms, IR suites are not as suitable for complex and high risk cardiac cases.  Conversely operating rooms, with their need for surgical equipment and anesthesia, have been unable to accommodate the larger imaging technology.  Surgeons have relied on smaller mobile C-arms, which produce images of lesser quality than the newer, fixed technology.  The high x-ray power of fixed imaging allows clear visualization of devices, even in obese patients and in a lateral position; and 3D guidance can be supported by fusing preoperative 3D images with fluoroscopy. 

“This hybrid operating room will allow us to simultaneously reach a diagnosis and provide treatment in real time, during surgical interventions,” Dr. Piotrowski says.  “It will let us treat patients with highly complex anatomies, many of whom we’ve had to send elsewhere for the care they need.  It will offer patients the most sophisticated care, without having to leave the community.”

Dr. Sagarwala explains: “For example, if we’re dealing with a very complicated case like a bypass of the leg, but we also need to do angiograms of the iliac or the aorta, we’ll have the highest quality imaging right in the OR itself, and be able to accomplish the combination procedure in the sterile environment.”  

Similarly, Dr. Jenkins emphasizes, with the anticipation of the addition of the hybrid room and its superior imaging quality, the surgeons can expand to adding branch devices for the aortic arch.  “We’ll be able to do fenestrated endovascular aneurysm repair (FEVARs) and thoracoabdominal aneurysm repair (TEVARs) as well.  We’ll be able to expand the amount of disease and complexity of disease that we’re seeing now, and be able to treat it in house; and again, patients won’t have to incur the extra expense and stress of having to travel for care.”

Outfitting a Hybrid OR
Because operating rooms have generally been built on a small scale, the addition of very large imaging equipment to an already crowded space presented a challenge.  Dr. Zichal, who took the lead on behalf of the vascular surgeons, worked with hospital planners to identify a useable, appropriate space.  Smaller areas within the operating department itself were reconfigured to accommodate the larger space, which will house the main piece of equipment: a Siemens hybrid vascular system with a floor mounted fixed C-arm.  “We chose the floor mounted system, as opposed to a ceiling mount, because of its clear advantage in an OR environment.  With no ceiling component, there’s only minimal impact on the laminar airflow.”

This system will be supported by new surgical lights and gasses, video integration, a pressure injector, anesthesia and hemodynamic carts and information systems technology.  “We’ll also acquire a specially designed bed for the hybrid room,” Dr. Zichal adds, explaining that “most regular OR beds are made of metal, so we can’t use the fluoroscope because we can’t see through metal.  With the special bed, we can see straight through it.”

It’s not just the physical space that must be reconfigured, Dr. Zichal adds: “The personnel who staff an IR lab have different training than those who work in operating rooms.  They have different vocabularies and different skill sets.  They know their specific equipment and environment, but not necessarily those of the other team.  So there will of necessity be a lot of staff cross-training before we’re fully operational.”  

The Benefits of the Hybrid OR are Far Reaching
Because so many more procedures will be available in the hybrid OR, many more patients can be treated.  “With the number of patients we see increasing every year, having the hybrid room in addition to our standard ORs and the IR lab will enable us to do multiple cases at a time,” Dr. Sagarwala says.  “And when the hybrid room isn’t required for the complex vascular surgeries, it can still be used as a regular OR for more routine cases, so it will rarely be vacant.”

Another benefit is the reduction in radiation.  “Our OR techs, nurses, staff and patients as well will have less radiation exposure,” Dr. Zichal says.  “We’ll be able to offer the same high level of vascular care that’s available in larger academic settings for more patients, more effectively and in a safer environment.  Their hospital stays will be shorter, and recovery in their own homes more comfortable.”

“This hybrid room will be a game-changer for the people of the Peninsula and the Eastern Shore,” Dr. Piotrowski says.  “And it will be implemented through the Riverside Care Difference.  As surgeons, we never forget that while we have this wonderful technology, we’re still doctors.  We’re still the ones talking to patients about life and death issues.  We know it’s the personal touch that makes the difference.”

Riverside Vascular Specialists

Three offices serving the Hampton Roads area

Peninsula – 757-534-5340

Gloucester – 757-534-5340

Williamsburg – 757-229-7939

Todd Jenkins, MD
Dr. Jenkins earned his medical degree from Eastern Virginia Medical School, Norfolk, Virginia. He completed his general surgical residency at The Carilion Clinic in Roanoke and his fellowship in Vascular Surgery at the University of Tennessee Health Sciences Center. He is Board certified in Vascular Surgery.

Dr. Jenkins is fellowship trained for the whole spectrum of vascular care. He has a special interest in the management and treatment of carotid disease and in minimally invasive procedures. He sees patients in the Peninsula office and in Williamsburg.

 

Joseph Piotrowski, MD, FACS
Dr. Piotrowski earned his medical degree at Hahnemann School of Medicine in Pennsylvania. He completed a general surgery residency program at the University of Colorado and a vascular surgery residency program at the University of Arizona, where he also completed his vascular surgery fellowship. 

Dr. Piotrowski has expertise in big open surgeries.  He is Board certified by the American Board of General and Vascular Surgery and a Fellow in the American College of Surgeons.

 

 

Adam Sagarwala, DO
After earning a master’s degree in biomedical engineering at the University of Texas, Dr. Sagarwala received his medical degree from the Texas College of Osteopathic Medicine at the University of North Texas Health Science Center. He completed a general surgery internship at St. Barnabas Hospital in the Bronx, New York and a general surgery residency at the Ohio University Heritage College of Osteopathic Medicine Doctors Hospital. He subsequently completed a fellowship in vascular surgery at St. Barnabas Hospital and Beth Israel Hospital in Newark, New Jersey. 

Dr. Sagarwala is Board certified in general surgery and board eligible in vascular surgery.

He specializes in complex aortic disease, including open and endovascular repair options, as well as cutting-edge, non-invasive treatment of peripheral arterial disease. 

Ernest Zichal, DO
Dr. Zichal earned his medical degree at Kansas City University of Medicine and Biosciences. He completed his surgical residencies at Palms West Hospital in Florida and at Saint Barnabas Hospital in the Bronx, NY, where he was chief surgical resident. Dr. Zichal completed a Vascular Surgery Fellowship at the Deborah Heart and Lung Center. He is Board certified by the American Osteopathic Board of Surgery in general and vascular surgery.

Dr. Zichal specializes in the treatment and management of arterial disease. He has a special interest in using minimally invasive procedures to re-establish blood flow in areas of need. 

Breakthroughs in Immunotherapy: New Treatments are Benefiting More Cancer Patients Than Ever

By Kasey Fuqua

 

Though immunotherapy is one of the fastest growing areas of cancer treatment, this area of cancer treatment got its start in 1893 when physician William Coley first used bacteria to treat sarcomas. After more than a century of research, new immunotherapy drugs are now gaining FDA approval on almost a monthly basis. 

Aisha Zaidi, MD

“This is an exciting time because we see approvals left and right,” says Dr. Aisha Zaidi, medical oncologist with Riverside Medical Group. “It’s amazing how many immunotherapy drugs in combination with chemotherapy drugs are out there in the pipeline.”

The modern breakthroughs in immunotherapy began in 2001 when researchers identified the PDL1 immune checkpoint pathway that made many of today’s treatments possible. By 2011, a new treatment for metastatic melanoma extended patient survival time significantly, marking a huge breakthrough in immunotherapy.

“No cancer patient should give up before a dose of immunotherapy,” says Ligeng Tian, MD, PhD, medical oncologist at Virginia Oncology Associates. “We really see miracles in what immunotherapy has done for people.”  

Physicians and researchers are achieving breakthroughs in every type of immunotherapy treatment, including:

Checkpoint Inhibitors
Checkpoint inhibitors are showing huge promise for cancers that previously had few effective treatment options, including patients with stage 3 lung cancer and stage 4 melanoma.

In 2017, more patients than ever gained access to checkpoint inhibitors. The FDA approved pembrolizumab to treat any type of solid tumor—from colon cancer to kidney cancer—in adults and children, as long as the cancer cells are deficient in mismatch repair (MMR) or have high microsatellite instability. These cancer cells tend to have a higher number of DNA mutations, meaning they have more abnormal antigens.

Ligeng Tian, MD

This is the first type of cancer treatment to be approved based on the cancer’s molecular features instead of its specific site of development. It gives patients with many different types of cancer a new treatment option and new hope.

“In the clinical trial, they included patients with cancers of many types, and patients showed an excellent response rate,” says Dr. Tian. “It doesn’t matter any more what type of cancer you have or what treatments you do or do not quality for; as long as you have these characteristics demonstrated in cancer tissues, you can use this drug and you may have a chance. This is revolutionary.” 

Both Dr. Zaidi and Dr. Tian encourage patients and physicians to look at the response rate of immunotherapy drugs before pinning their hopes on these new therapies. While checkpoint inhibitors can be incredibly effective, they may only work in a small group of patients.

“A lot of people think these are miracle drugs, and they are, but only in those where they work,” says Dr. Zaidi. “In patients with metastatic melanoma, there’s roughly a 20 percent response rate, but those people are alive beyond 10 years, which is remarkable and unheard of just a few years ago.”

Unfortunately, checkpoint inhibitors have not shown as much promise in pediatric patients as adults. 

“There are a number of theories on why checkpoint inhibitors aren’t as effective,” says Eric Lowe, MD, pediatric oncologist at Children’s Hospital of The King’s Daughters. “Some of it has to do with the genetics of cancer and the different types of cancer in children. We are definitely trying them in clinical trials, but they haven’t shown as much potential as in adult diseases.”

Chimeric Antigen Receptor (CAR) T-Cell Therapy
Though checkpoint inhibitors are not as effective in children currently, chimeric antigen receptor (CAR) T-cell therapy has been a much larger success in children with lymphoma and leukemia. 

Eric Lowe, MD

Because of the complicated equipment and expertise required to manufacture the CAR T-cells, the therapy is only available in around 10 to 20 locations around the country. Patients from Hampton Roads needing these therapies must travel to The National Institute of Health in Maryland or to Duke Medical Center in North Carolina.

“T cell therapy has worked wonders in some diseases in kids, specifically in acute lymphoblastic leukemia,” says Dr. Lowe. “We have sent patients to receive CAR T-cell therapy and seen benefits for these kids.”

Monoclonal Antibodies
One of the oldest forms of immunotherapy, monoclonal antibodies still play a huge role in cancer treatment today. At CHKD, Dr. Lowe and his fellow oncologists enroll patients in clinical trials for bispecific monoclonal antibodies.

“The idea of these treatments is to get T-cells in proximity to the cancer cell, then activate them to attack the cancer,” says Dr. Lowe. 

Other studies are examining how monoclonal antibodies work in combination with other immunotherapy agents, chemotherapy or radiation therapy. These drugs remain one of the most common immunotherapy treatments available.

The Future of Immunotherapy and Medical Oncology
In many ways, today’s treatments reflect the future of cancer care. While immunotherapy will play a large role, treatments like chemotherapy or radiation therapy won’t be going away. 

“Don’t disregard traditional chemotherapy,” says Dr. Zaidi. “We have seen in patients that have undergone radiation therapy and chemotherapy, when we monitor their T-cell response, that response went up. When we gave immunotherapy to those patients, they did much better.”

Dr. Tian also believes new agents may target different immune cell molecules. Though trials targeting these molecules are currently ongoing, none are close to market yet and some may never make it to patient’s bedsides.

“Because immunotherapy is so promising and toxicity is so tolerable and is becoming so effective, new immunotherapy drugs are really what everybody is looking for,” says Dr. Tian. “Still, a crucial part of cancer treatment is and will continue to be targeted therapy.”

The biggest difference between current and future treatments may be an increase in the number of targeted therapies available. Physicians and scientists are constantly learning more about the molecular make-up of cancer tumors. Dr. Zaidi believes this understanding of the microenvironment and genetic make-up of cancer tumors will be the future of treatment, helping identify why some patients respond to treatment and others don’t.

“When we talk about personalized medicine or targeted therapy, we should be able to map that pathway that’s causing people to be resistant to immunotherapy,” says Dr. Zaidi. “I think that’s really where the cure is going to be, if we are able to identify those roadblocks to effective treatment.”

Dr. Lowe agrees that the ability to understand the genetics and molecular drivers of cancer is the key to the future of cancer treatment. 

“If we can really get down to what is driving the cancer in the first place, I think we are going to get better at treating cancer and curing it,” says Dr. Lowe. “If we can’t cure it, we should be able to make it like a chronic disease where we can use medicines that keep you alive until you are 70 or older.” 

Dr. Tian also predicts that patients will spend less time in cancer centers. Already immunotherapy has shorter infusion times than chemotherapy. She also believes medical oncology treatments will consist of more injections and pills instead of IV infusions, a benefit of targeted therapy some of her lung cancer patients already enjoy today. 

“I have patients coming in for targeted therapy who have never had a port put in,” says Dr. Tian. “They have never sat in the infusion room. They just come in for a check.”

The ultimate goal in immunotherapy treatment in Dr. Lowe’s mind would be a vaccine that prevents cancer development or recurrence. 

 “The very distant future of cancer treatment is hopefully vaccines so cancer doesn’t occur in the first place,” says Dr. Lowe. “Will that happen in my lifetime? Probably for a disease or two, but not for all cancers.” 

Whether as a pill, infusion or vaccine, immunotherapy is quickly expanding the range of treatment options for cancer patients. As new treatments continue to gain approval throughout 2018 and beyond, patients are more likely to experience longer survival times, and in some cases, a cure for their cancer.

Insuring Patients Ensures Healthier Communities

By Kasey Fuqua

 

718,000 Virginians have no health insurance, according to the Virginia Health Care Foundation. While hospitals provide charity care for these uninsured patients, the lack of insurance can have profound effects on their health—and the health of Virginia’s communities. 

Fortunately, Medicaid expansion and improved access to health insurance provides hope. These newly passed measures may remove challenges in caring for patients and provide benefits to all members of the Hampton Roads community. 

    

Raymond McCue, MD

The Challenges of Caring for the Uninsured
In Virginia, hospitals spend more than $600 million per year providing charity care or financial assistance to underserved patients, according to a report from the Virginia Hospital & Healthcare Association (VHHA). They spend another $347 million on community programs that support health. From medication programs to community gardens to health screenings, hospitals strain to care for the health needs of the underserved while continuing to operate on a positive margin. 

“I think more and more, you’re finding that your hospitals and healthcare systems have become a safety net for patients,” says Raymond McCue, MD, Chief Medical Officer for Chesapeake Regional Healthcare. “I think that’s the obligation of society at large to provide that safety net for these underserved and important members of our community.”

The weight of providing unreimbursed care has taken its toll on hospitals across Virginia. In the same report, the VHHA states that 23 percent of Virginia’s hospitals have negative operating margins. The new Medicaid expansion may help reduce this cost and provide patients with greater access to both the physicians and medications they need.

“The real challenge in caring for uninsured patients is continuity after they leave the hospital,” says Dr. McCue. “We have to use a lot of resources to care for patients when they are ready to go back home or back into their communities.”

Emily Lieb, MD

Emily Lieb, MD, medical director for the Bon Secours Care-A-Van, agrees, saying that finding the right specialist for patients who need more advanced care can be difficult. 

“Bon Secours specialists do see patients without insurance, but there are still some specialists not included in the Bon Secours systems,” says Dr. Lieb. “We still have a really hard time getting those specialists to see uninsured patients.”

While Dr. Lieb provides primary care to uninsured patients on the Care-A-Van, she has difficulty meeting all of their preventive care needs. She and her staff strive to get patients access to recommended screenings like colonoscopies or screenings for diabetic eye diseases. Her patients can also have trouble obtaining medicines for chronic conditions such as hypertension or diabetes.

 “We have real problems with medication compliance,” says Dr. Lieb. “Patients often go periods of time where they are not able to take high blood pressure medicine or they are not taking it as prescribed, putting them at risks for strokes and heart attacks.”

 At Chesapeake Regional Healthcare, healthcare providers often provide patients with medications before they leave the hospital to help them get started on recovery. Its transitional care clinic strives to fill in gaps with both medicines and follow-ups for these patients. But for many, preventive care is still out of reach.

 “When you are dealing with daily struggles of food, clothing and shelter, your healthcare drops pretty far down on that list of concerns,” says Dr. McCue. “This population is missing out on the benefits of preventative care.”

Hospitals aren’t alone in their efforts to fill in care gaps for these patients. Physicians often care for the health of the community in both their professional and personal lives. 

“Physicians play an important role beyond inpatient care,,” says Dr. McCue. “The support from community physicians is extraordinary, not only as individuals, but as part of the various professional organizations they belong to.”

Physicians often provide charitable care in their private practices, following up with patients who have had an acute health crisis. Physicians also staff free clinics, serve on the boards of outreach programs, provide expert consultation for community health initiatives and donate money to community charities. 

For patients, physicians can also serve as a vital link to resources like Every Woman’s Life, which provides free mammograms, or prescription assistance programs through pharmaceutical companies. But even with all this work from hospitals, physicians and community organizations, many community members still lack the access to care they need. 

How Medicaid Expansion Can Help the Hampton Roads Community
Medicaid expansion may provide the boost in access that patients need to achieve better health. 

“In Virginia, the group that will benefit the most from Medicaid expansion are the folks that are poor enough that they have not been able to afford care through the exchanges that were put in place with Affordable Care Act,” says Dr. Lieb. 

However, these patients were not quite poor enough to qualify for Medicaid until recently. Up to 400,000 working Virginians fell into this coverage gap, including the majority of the patients who seek care on the Care-A-Van. This number includes working adults under the age of 65 with no children. No matter how little these adults make, they did not qualify for Medicaid. Now, adults who make less than $16,643 per year have access to coverage.

Many families also fell into the coverage gap. Families of four who make as little as $9,516 living in Norfolk did not qualify for Medicaid before, but also couldn’t afford to purchase health insurance off the marketplace, even with help from subsidies. 

“These are families,” says Dr. McCue. “They are doing everything they can for their kids. The least we can do is make sure we can cover their basic health needs.”

Medicaid expansion may help cover these families. Under expansion, a family of four could make up to $34,638 and still qualify for coverage. These patients will soon have new access to a variety of preventive care services that could reduce healthcare costs.

Dr. Lieb says costs for both hospitals and patients may be reduced through multiple factors, such as reduced ER utilization and prevention of health complications through reliable, regular care. 

With more patients covered by health insurance, hospitals could see millions of dollars added to their annual budgets through reduced costs and improved reimbursement, leaving room for new equipment and services that benefit all community members.

“Certainly Bon Secours as a health system has a large amount of money they don’t collect because they do have a mission to take care of the uninsured,” says Dr. Lieb. “If those patients suddenly became insured, there would be a huge financial benefit.”

Expanding services also means an expanding staff. The VHHA estimates that, had Medicaid been expanded in 2013, it would have generated 30,000 new healthcare jobs by 2018 and added more than $2 billion to the state’s economy through both new jobs and a healthier, more productive community. 

“If fewer people are having strokes because they can afford their diabetes medicines, that’s good for society as a whole because then you retain more productive members of society,” says Dr. Lieb. “I certainly think that over time Medicaid expansion makes sense just for the health of community.”

Challenges Remain After Medicaid Expansion
Though Medicaid expansion supports the entire community, obstacles to care remain. 

”It will take time to see the full benefit of a healthier community,” says Dr. Lieb. “There are still other barriers that are not going to go away with Medicaid expansion, like transportation barriers and other challenges people face.”

Dr. Lieb says many patients have no access to reliable transportation, preventing them from getting to a doctor’s office for appointments or follow-ups. Physician shortages can also mean it’s hard for patients to make an appointment, even if they gain coverage. 

Still, physicians are optimistic about the benefits of expansion.
“I believe with better coverage, patients will take advantage of the access and we’ll have a healthier population,” says Dr. McCue.

What to Know as You Prepare to Enter the Possible Realm of Homeownership

By J. Mansisidor

With the current climate for qualifying to purchase a home quickly changing, there are some key elements to be aware of, not only in choosing the product/program that fits your needs the best, but also in finding the right lender that equally meets your expectations.  

Make no mistake, there will be some stress accompanying this process, but managing that stress throughout and not letting it spiral out of control is the key. Enter the Loan Officer.   

Where to start your search?  Ask friends, family, colleagues, or Realtors preferred or favorite lenders are.  Keep in mind that just because other people like them or feel they did a great job, it doesn’t mean that they are the right fit for you and your family.  

Interview your prospective loan officers. Find out how many years of experience each one has working with medical professionals.  Make sure he offers the products you need.  Make sure he can work around your unique schedule.  Ask him how quickly they can process your loan and get it to closing.  Finally, does he have testimonials you can read?  A good to great Loan Officer will make your home buying experience one to remember for all the right reasons.  A bad Loan Officer will make this a memorable one for all the wrong reasons, including possibly losing out on your home of your dreams.  

Stage One:  The Loan Application and Qualifying is a simple process.  A loan application will be taken by your loan officer or their assistant either by telephone, online, or in person.  Typical information needed would be your name, date of birth, Social Security number, two years of residence history, tax returns and W2s, pay stubs, K1s if you have any ownership of a business, (School transcripts in lieu of for medical students), and assets accounts that will be used to show funds sufficient to cover any down payment, as well as closing costs. 

Stage Two:  Once you have a ratified contract, the loan officer can lock in your interest rate, order your title and order your appraisal.  The Loan Processor will contact you for any additional items (if needed) before forwarding your file to underwriting.  The underwriter will validate the findings and all documentation received.  They will review and sign off on the appraisal and any final conditions needed for final approval.  Once that is done your processor will do a verification of employment along with a couple of standard checks and clear your loan to close.  The closing department will clear the title and send the closing package to the settlement agent, and you are now ready for the final stage closing day.  

Stage Three:  Closing day.  Your attorney or settlement company will provide a closer to go over your closing package and all the forms you are signing.  Once you have gone over the package and are comfortable signing it, you are now a new home owner, congratulations.  

Until next time, happy house hunting!

J. Mansisidor is a Senior Loan Officer with Fulton Mortgage Company, a division of Fulton Bank, NA.  www.fultonmortgagecompany.com