June 24, 2017

Treating Chronic Pain Patients

By Michael J. Ingraham, MD

When most people hear the words “pain management,” they think of medications and procedures to fix existing problems. However, another important side to the field is preventive medicine – therapies that can guard against recurring pain or future injuries and improve overall health.

As an Interventional Pain Medicine physician, a major goal is to help patients avoid long-term reliance on narcotics and invasive surgeries whenever possible. We often can ease discomfort and restore function and range of motion with therapeutic injections, in-office physical therapy, at-home exercises and stretches, and structured medication regimens.

The bulk of our patients struggle with neck or lower back pain; some have suffered for years, if not decades. In many cases, non-surgical interventions can provide months and sometimes years of relief without significant side effects, lengthy recovery times or risk of painkiller addiction.

Once patients are feeling better and moving more, they also tend to improve on other important wellness indicators such as heart health, core strength and flexibility, mental outlook and sleep quality.

For chronic pain patients who don’t respond to conservative therapies or in some cases surgery, or who aren’t surgical candidates, we can try two other procedures: radiofrequency ablation, or RFA, and a spinal cord stimulator, or SCS.

RFA uses an electrical current to heat and destroy specific areas of nerve tissue, thereby reducing pain signals. The current is delivered via a small needle to a spot targeted by X-ray images, test blocks and patient feedback. The most common indications are neck, back or knee pain. The goal is at least six months of pain relief, but some patients feel better for as long as 18 months.

The SCS, a technology similar to a pacemaker or defibrillator, is a battery-powered device placed under the skin in an outpatient surgery. The stimulator delivers mild electrical currents to nerve fibers in the back, creating a tingling sensation and interrupting pain signals to the brain. Patients can turn the current on, off or up with a handheld remote control. This relatively minor surgery can provide incredible pain relief.

Before committing to any surgery, SCS patients first undergo a temporary trial to determine if a stimulator is a good option. Over a five-day period with trial leads – temporarily placed through hollow needles as an outpatient procedure with a local anesthetic – we can measure improvements in pain and the precise stimulation that was most effective. If a permanent SCS is implanted, batteries last about seven years and can be replaced easily.

With such a variety of treatment options, we are able to tackle complex chronic pain issues and prevent continuing health declines in more patients than ever. Watching people return to overall wellness is extremely rewarding.

 

Dr. Ingraham is a fellowship trained Interventional Spine Specialist and Board certified Physical Medicine & Rehabilitation physician based at SMOC’s Suffolk and North Suffolk locations. He completed a fellowship in Pain Medicine at the University of Virginia School of Medicine. www.smoc-pt.com

Understanding Your Patient

… the second in a series

Dr. Anthony Bevilacqua

In 2014, the National Institutes of Health noted, “Over the past 20 years, patient satisfaction surveys have gained increasing attention as meaningful and essential sources of information for identifying gaps and developing an effective action plan for quality improvement in healthcare organizations.”  It’s become as much an economic imperative as a good will one: as reported in our last issue, “…payers are more and more tying a portion of reimbursement to patient satisfaction scores.”

So how do patients measure their satisfaction?  Certainly when they feel their concerns have been addressed, when they believe they’ve been listened to and heard – when they feel they’ve been understood.  But how can a physician – with a standing-room-only waiting room and a call-back list a yard long – get to really know and understand each patient?

It can be something as complicated as reviewing Medicare records (see our Winter 2017 issue), or as minor as a simple ergonomic shift.  “If you’re not ergonomically designed to prevent it,” says Dr. Anthony Bevilacqua of Sports Medicine and Orthopaedic Center, “you’ll end up looking at the computer when you should be looking at the patient.”

He explains: “We had some room configuration issues in our old offices, and it could be very challenging to face our patients.  When we moved, we bought computers on wheels, so we could look directly at the patient, rather than the computer screen.”  That’s important, he says, because actually looking at patients provides so much information – “body language tells us a lot about the problem(s) they’re having, as much or more than they’re articulating.”

“To me,” Dr. Bevilacqua adds, “the treatment I prescribe has everything to do with who’s sitting in the chair.  A patient thinks because his pain is similar to his friend’s, he’ll get the same treatment; people think medicine’s a cookbook thing: you come in with knee pain, so I prescribe X.  But I’ve got 50 treatments for knee pain, and I have to figure out which one will work for the patient in the chair, whether or not his symptoms mirror someone else’s.  And now, with computers so omnipresent, if we’re focused on a screen, we can lose many of the vital visual cues we had before.”  And, unfortunately, the necessity to populate the EMR can overtake the need to learn about the individual patient, he says, if everyone’s looking at the computer all the time.

Dr. Bevilacqua resolves the issue by not touching the computer while he’s with patients.  A tech sits across the room entering data, while he sits directly across from each patient, making eye contact, asking questions and taking notes.  “I try to establish a personal connection with each patient,” he says, “and then I can add notes that will make that patient unique, which I can bring up at the next visit.”

It takes longer to document the care he renders, Dr. Bevilacqua concedes, but it helps patients trust that he’s treating them, not their chart.  And that kind of trust goes a long way toward building patient satisfaction.

How to Interview Lenders

By J. Mansisidor

Making an informed decision about mortgage products relies on asking the right questions.  The same holds true when selecting a loan officer.  Some topics you may want to explore with prospective loan officers:

Product Knowledge: How knowledgeable is the loan officer about “Doctor Loans” or “Medical Professional” loan programs?  Does the loan officer specialize in working with medical professionals and really understand the unique circumstances that they face, or is the Doctor Loan just a product the loan officer has access to and sells as a novelty when circumstances fit?

Experience:  How long has the loan officer specialized in loans for medical professionals?

References:  Does the loan officer have references available?  Written testimonials are valuable when assessing how past clients feel about the loan officer.

Attention to Detail:  Does the loan officer take time to review your credit, research the area into which you’ll be moving, obtain accurate estimates for fees and insurance up-front, and then offer a quote that is truly customized to you? Relying on a quote that’s not based on accurate information is like trusting a diagnosis that’s not supported by lab work or imaging.

Closings:  Having your loan officer present doesn’t guarantee the closing will go smoothly, but it may be worth asking prospective loan officers how often they typically attend closings.

Product Highlights:  How well does each loan officer explain the relevance of loan products’ features to your situation?  Does the loan officer seem to push the need for a down payment, or weigh the pros and cons of making a down payment?

Availability and Communication:  How easy was it to get in touch with the loan officer?  How responsive was the loan officer?  Can you reach the loan officer and get answers to questions after hours or on weekends?

Differences You Notice:  It’s a good idea to interview a few lenders – both to get an idea of the physician loan programs available and to get a sense for which loan officers seem most knowledgeable and willing to answer your questions.

Be Vigilant:  Notice what different loan officers mention and what they gloss over; if a particular point seems like it’s being overlooked or portrayed as unimportant, you may want to ask for additional explanation or greater specificity.  Take note of the questions the loan officers ask you, and gauge for yourself whether they truly understand your situation and goals.

The old adage caveat emptor – buyer beware – applies to the mortgage industry just like any other.  Research your prospective loan officer: you can check the status of loan officers on line by looking up their NMLS numbers and verifying they are in good standing.  You can use Google or other search engines to check on what customers have to say about loan officers. And, you can ask loan officers about the sites where they’re listed as preferred lenders.

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

Responding to requests for records and/or testimony

…in the age of electronic information, some things a treating physician should consider
By C. Thea Pitzen, Goodman Allen Donnelly

At some point in their careers, many physicians – especially those who treat patients allegedly injured as the result of another’s negligence – will be called upon to provide copies of medical records, and possibly give testimony in a deposition or a court proceeding.

In this age of electronic charting and communications, there are several things treating physicians should be cognizant of, chief among them that such requests for records include not just the chart itself, but also many electronic communications relating to the patient.  This can include emails, texts and transcripts or summaries of conversations as well, whether between the physician and the patient or the physician and other consulting providers.  All of this material is discoverable, subject to pertinent HIPAA considerations.

Physicians should also be aware that in this age of electronic record-keeping, electronic medical records (EMR) contain substantial non-medical information; that is, metadata that shows any time the record is accessed, any time the record is altered or changed in any fashion, and how many times the record has been reviewed.  Physicians should be aware that they might be questioned about why they accessed a certain record so frequently, as well as why and how it was edited.  This metadata is stored and becomes part of the permanent medical record.  It is, of course, important to maintain accurate and thorough medical records at the time of treatment.

More broadly, it’s important to understand that social media is also subject to discovery.  If a party maintains a Facebook page, Twitter account or other social media presence, to the extent that any posting is relevant to a case in litigation, that posting may have to be produced.  For example, in the interest of time, a physician might send a quick text or instant message to a colleague about a particular patient’s care.  Such communications, however brief, may be subject to production in a subsequent legal matter.

It’s a wise old adage – made even more relevant in this new age of electronic communication – that you shouldn’t put anything in writing that you wouldn’t want to see on the front page of tomorrow’s newspaper.  Today, that writing doesn’t have to be on paper – it can exist as an email, a text, or anywhere on the Internet.

When treating physicians are asked to give depositions – pre-trial testimony – they should immediately seek out the risk manager of their practice or hospital to discuss the matter.  It’s also wise to consult an attorney, and when appropriate, to have that attorney attend the deposition as well.  It’s rare that anything contentious arises in these instances, but an attorney can ensure the deposition proceeds in strict accordance to applicable rules.

Thea Pitzen joined Goodman Allen Donnelly in 2016, and focuses her practice on the defense of hospitals, physicians, dentists, nurses, nursing homes, and other health care providers.  She is a graduate of Emory University School of Law, and previously served as judicial law clerk to U.S. District Judge William C. O’Kelley, Northern District of Georgia.  www.goodmanallen.com

For Total Hip or Knee Replacements, Think ‘Prehabilitation,’ Not Just Rehabilitation

By Steve Howell, PT, M.Ed.

Doctors and nurses talk every day with patients about rehabilitation, and especially patients who need total hip or knee replacements because that is when the real work begins.  It is general knowledge that physical therapy guides in the recovery process, but a comprehensive “prehabilitation,” program can be the key to a quick and full recovery.

Medical providers and patients alike are now beginning to understand the benefits of early intervention with preoperative physical therapy programs including:

• One to two sessions for patient education in a home exercise program;

• Gait training with a walker and cane, proper utilization of elevation and ice and pain control strategies;

• Setting realistic post-surgical expectations for typical recovery periods and return to normal life activities;

• Education in signs and symptoms of complications such as fever, severe pain, excessive drainage;

• Faster recovery, less pain, and more confident patients who are compliant with exercise programs;

• Less need for pain medications;

• Decreased odds of readmission to the hospital.

Beyond helping recovery, published studies have also focused on another key factor: cost reductions for patients.

The APTA post sites an October 2014 study published in the Journal of Bone & Joint Surgery titled, “Associations Between Preoperative Physical Therapy and Post-Acute Care Utilization Patterns and Cost in Total Joint Replacement.” The study “looked at hip- and knee-replacement cases within a 39-county Medicare hospital referral cluster,” and concluded that “the use of preoperative physical therapy was associated with a 29 percent decrease in the use of any post-acute care services.” The APTA reports that “this translated, after adjusting for demographic variabilities and comorbidities, into cost reductions of $1,215—‘driven largely,’ the authors wrote, ‘by reduced payments for skilled nursing facility and home health agency care.’”

The benefits of prehabilitation are seen in more than outpatient orthopaedic patients, too.  Positive results have also been seen when implemented with cancer patients.

The APTA post notes that in Nov. 2014, the Journal Anesthesiology published “Prehabilitation Versus Rehabilitation: A Randomized Control Trial in Patients Undergoing Colorectal Resection for Cancer.” Authors investigated “the impact of prehabilitation on recovery of functional exercise capacity was thus studied in patients undergoing colorectal resection for cancer.” Their conclusion: “Meaningful changes in postoperative functional exercise capacity can be achieved with a prehabilitation program,” add, “the preoperative period (prehabilitation) may represent a more appropriate time than the postoperative period to implement an intervention.”

Prehabilitation programs are an excellent time to empower patients to commit to their return to health through exercise and education in the recovery process.  These early visits with their physical therapist set the mental and physical tone for the coaching that is to come and their new productive lives.

Steve Howell, PT, M.Ed. is a partner and practicing physical therapist with Pivot Physical Therapy, formerly Tidewater Physical Therapy.  With almost 30 years of providing outpatient orthopedic care and a knee replacement in 2008, Steve knows the recovery process well.

Prevention of Orthopaedic Conditions

By Boyd W. Haynes III, MD

Prevention of illness is an important part of our work with the patients we serve.  Many of the mostly common and costly conditions that are seen today can often be prevented, such as adult onset diabetes, hypertension, obesity, heart disease, high cholesterol, etc.  When we ask patients to eat a nutritious balanced diet, maintain a healthy weight and get sufficient aerobic and weight lifting exercise for their hypertension, heart health or diabetes, the same steps can be taken to avert common orthopaedic conditions, such as osteoarthritis (especially in the knees and hips) or osteoporosis.

Recommending a healthful diet can help your patients’ bones and joints in many ways.  A diet, such as the Mediterranean diet, rich in vegetables, olive oil, fresh seafood and low in sugar, has been shown to reduce systemic inflammation, which may aid in the prevention of OA.  Calcium and vitamin D rich foods aid the body in keeping bones strong and dense, warding off osteoporosis.  A multivitamin, tested by an independent lab for quality and purity, may also provide essential vitamins and minerals that may be missing but are necessary for good bone and joint health.

I can’t put enough emphasis on the role that weight-management plays in helping prevent OA of the knees and hips.  Healthy weight maintenance alone would help eliminate many of the joint replacements we must perform due to the wear and tear on joints caused by obesity. Losing weight is also a treatment for OA, and greatly relieves the associated pain and discomfort.  Oddly, it is rarely mentioned to patients as a treatment outside of an orthopaedist’s office.  Instead, physicians tend to recommend anti-inflammatory medications, physical therapy and even surgery, before weight loss.

Exercise is also a very important part of any OA and osteoporosis prevention regimen.  I have a saying that I often tell my patients: “Motion is life.”  I truly believe that staying active and in motion can prevent or ease much of the pain, stiffness and inflammation caused by OA.  I also know that staying active and fit reduces the chance patients have of injury when participating in sports or other activities.  As a sports medicine specialist, I can attest to the difference in performance and resistance to injury my fit and active patients have compared to less fit, less active individuals.

Weight bearing exercise and weight lifting, where the patient must work against gravity, are proven to help prevent osteoporosis or can assist the patient in rebuilding some of the bone density they may have lost.  When bones are “stressed” against gravity, the resulting forces stimulate the bone to remodel.  When the attached ligaments and tendons are stretched, this puts an additional strain on the bone, further intensifying this effect.  Jumping and running are the best exercises for remodeling bone; however, benefits can be seen from any exercise that involves impact with the ground. Weight lifting enhances this effect and is recommended for maximum bone remodeling efficacy.

Dr. Haynes is an orthopaedic surgeon and the Senior Partner at Orthopaedic & Spine Center in Newport News, VA.  He is fellowship trained and Board certified in Sports Medicine and Orthopaedic Surgery. www.osc-ortho.com

A Leap Forward in Diagnosing Prostate Cancer

By Raman Unnikrishnan, MD

Detecting prostate cancer can be notoriously difficult, as can deciding whether to treat or simply monitor confirmed or suspected malignancies.

Thankfully, a new diagnostic technology called fusion-guided biopsy is improving our ability to find the more aggressive cancers that do require early intervention. Unlike older screening tools, the UroNav Fusion Biopsy System offers detailed, real-time maps of the soft tissues of the prostate by combining MRI and ultrasound images.

Our hope is to reduce unnecessary surgeries, repeated biopsies and other therapies that can cause troubling side effects like erectile dysfunction, urinary incontinence and anxiety for patients who may have a slow-growing, non-lethal tumor – or no cancer at all.

Before the 1980s, prostate cancer screening involved digital rectal exam alone, and the disease often went undetected until presenting in advanced stages. Since then, the prostate specific antigen blood test, or PSA, has caught significantly more cases, including many low-risk malignancies that may not need treatment.

These tools have other significant diagnostic limits. Rectal exams only allow for access to part of the gland and may miss anterior tumors. As for the PSA, other medical conditions such as inflammation and benign prostatic hyperplasia can cause elevated levels of the same protein that increase with cancer.

Ultrasound-guided biopsies require multiple needles to sample mapped out areas of the prostate in hopes that if a tumor is present, one of the needles will pierce it. MRI images are much more distinct, allowing radiologists to mark suspicious areas for further examination with an ultrasound probe. The “fusion” software overlays US and MRI images during the procedure, providing a live, three-dimensional view and critical guidance to direct biopsy needles to precise points.

Fusion-guided biopsy can still miss tumors, but they tend to be the clinically insignificant ones – which is good news. The technology has 85 to 95 percent sensitivity for intermediate- and high-risk cancers that are more likely to metastasize and become life-threatening.

We currently are targeting fusion biopsy to two groups of men: patients with worrisome PSA levels who’ve previously had a negative biopsy who might otherwise have to go undergo another standard biopsy; and patients who are on active surveillance for prostate cancer for what we believe, but would like to confirm, are only low-risk tumors.

This spreading technology is already a great leap forward in the quest to reduce hundreds of thousands of unnecessary interventions each year – and to catch the dangerous cancers that do matter to survival.

Dr. Unnikrishnan is based at Urology of Virginia’s Portsmouth and Virginia Beach locations and is a member of the American Urological Association. He completed a residency in urology at the Cleveland Clinic and specializes in robotic-assisted and minimally invasive surgery, stone disease and benign and malignant conditions of the bladder, prostate and kidney.  www.urologyofva.net

Bon Secours

ENHANCING AND EXPANDING CANCER CARE IN HAMPTON ROADS
… the Bon Secours Cancer Institute at Harbour View

In 2014, the Bon Secours Cancer Institute at DePaul opened its doors, a $20 million investment heralded as offering “a comprehensive continuum of interdisciplinary care and treatment to cancer patients in Hampton Roads.” The Institute, which includes a team of radiation oncologists, surgeons and other cancer specialists, was the first step in Bon Secours’ strategic plan to address the high incidence of cancer and mortality rates throughout Southeastern Virginia.

Christopher McCann, DO

It was a highly ambitious and successful endeavor, but Bon Secours had just begun.  Recognizing that cancer rates run even higher in Western Hampton Roads than other local and national averages, Bon Secours invested another $20 million to build the state-of-the-art Bon Secours Cancer Institute at Harbour View in Suffolk, which began treating its first patients in late 2016.

Gregory B. Franz, MD

Offering innovative treatments like external beam radiation therapy, advanced brachytherapy, mobile PET/CT and chemotherapy services, the Bon Secours Cancer Institute at Harbour View is focused on the mission of reducing death rates for individuals with a diagnosis of cancer, and is on target to provide more than 8,000 radiation therapy treatments for its patients each year.

The Cancer Institute is located at Bon Secours Health Center at Harbour View, a premier outpatient destination serving Western Hampton Roads.  The addition of the radiation therapy and infusion therapy services provides cancer patients with access to diagnostic testing, outpatient surgery, and cancer specialists on the same campus.

Bon Secours is increasingly recognized as a leader in cancer treatment and innovation. A large part of that reputation is owed to its ability to attract physicians of the highest caliber, who come from across the country to join the health system.  Both the DePaul and Harbour View Cancer Institutes have recently welcomed specialists.

Christopher McCann, DO received his doctor of osteopathic medicine degree from the University of New England. He completed his residency in obstetrics and gynecology at Saint Francis Hospital and Medical Center in Hartford, Connecticut and his fellowship in gynecologic oncology at Massachusetts General Hospital in Boston, MA.

He previously served as an instructor in obstetrics, gynecology and reproductive biology at Harvard Medical School. He is a member of the American Congress of Obstetricians and Gynecologists, American Association of Gynecologic Laparoscopists and the Society of Gynecologic Oncology.

Dr. McCann practices gynecologic oncology and performs major gynecologic surgeries, focusing on medical and surgical management of patients with ovarian, endometrial and cervical cancer with an emphasis on minimally invasive techniques, including laparoscopy and robotic-assisted laparoscopy to enhance traditional gynecologic oncology procedures.

Gregory B. Franz, MD is a board certified medical oncologist and hematologist.  He attended medical school at the University of Rochester in Rochester, New York and completed his internship at New York Hospital Queens (Cornell Medical School Program). After completing his internal medicine training, he went on to complete a fellowship in hematology and medical oncology at the University of Tennessee Health Sciences Center-National Comprehensive Cancer Network affiliated training site in Memphis, Tennessee.

Dr. Franz served as a director at a regional hospital-based oncology practice in Southeastern Georgia and as medical director for a regional hospice program. Additionally, he has practiced at a large Memphis hospital-based oncology practice, where he primarily focused on treating breast cancer patients and served as an investigator and participated in several clinical trials. More recently, he worked in private practice at the Piedmont Cancer Institute in Atlanta, Georgia.

Together with the multidisciplinary teams at the Bon Secours Cancer Institutes at DePaul and Harbour View, Dr. McCann and Dr. Franz continue to elevate and expand cancer care and treatment to the people of southeastern Virginia.  Visit BonSecours.com for more information or to refer a patient.

Robert Lancey, MD

Heart Health Academy at Bon Secours

When cardiothoracic surgeon Dr. Robert Lancey joined Bon Secours Heart & Vascular Institute in 2013, he brought with him an innovative program that had its roots two decades earlier at the University of Massachusetts Medical Center.  “I was teaching off-pump cardiac surgery to classrooms of visiting surgeons, operating with a camera to demonstrate how to perform the operation.”  Around that time, the University was routinely inviting high school students to tour the medical facilities, and it was suggested that Dr. Lancey allow them to observe him operating as well.

“The students were fascinated,” he says, “and they liked being able to ask questions while we were operating.  Someone inevitably asked why the patient needed the surgery, and as I explained that heart disease is caused by lifestyle choices – smoking, poor diets, and lack of exercise – it struck me what a great opportunity I had to show, rather than tell them, the results of those choices.”

This led him to subsequently set up an educational class for area seventh graders while at Bassett Medical Center in Cooperstown, NY, and over the first eight years of the program, over 10,000 students participated.  “The original program was about teaching them not to smoke, to exercise, and to eat healthy,” he says, “but it changed and evolved as I saw what worked and how the students responded.”

When he began practicing at Maryview Medical Center, he adapted the program for Hampton Roads – where more than 30 percent of adults and 15 percent of children are obese – and renamed it the Heart Health Academy at Bon Secours – HHA@BS.

The HHA@BS is a three-hour program featuring interactive demonstrations and discussions, videos of open-heart surgery and of lungs damaged by smoking, taken right from the operating room.

“We know heart disease begins at an early age,” Dr. Lancey says, “and many kids are offered their first cigarette at 13.  We’ve targeted the program to the age when they’re beginning to make lifestyle choices.  We start out talking about healthy decision making: seventh graders are smart enough to know what’s right and what’s wrong, so we talk to them about how fast food and tobacco marketing tries to influence their decisions.  We also hook them up to a heart monitor and have them run around the room, so they can see what exercise does for their heart.”

No cute cartoon drawings or animated clips for these students: they’re seeing an open chest, a beating heart, and smoke damaged lungs.  They’re seeing buildups of fat and cholesterol blocking blood vessels.  They’re seeing surgeons opening up these vessels, stabilizing the heart.

“We hit them pretty hard,” Dr. Lancey says of the students.  “We treat them like adults.  We don’t just give them facts; we show them reality.  And we impress on them that they’re the ones who are in control of their health, that they can make their own decisions, but need to make the right ones.”

In its first year, seven area schools participated in HHA@BS; this year Dr. Lancey anticipates the number will grow to twelve.  The service is provided to the schools free of charge.  In addition to teaching seventh graders, Dr. Lancey has also devised similar programs based on the age of the students – from second grade to high school.

He also envisions a robust HHA@BS online presence, providing a different heart-health related topic each week.  The site could allow students to log in, record their exercise, and even more fully participate.

“I give the students a chance to see what it takes to get on my operating table,” Dr. Lancey says,   “so that hopefully they never get there.”

Medical Update Spring 2017

The Many Facets of Preventive Medicine

A January 19, 2017 article on the website of the American College of Preventive Medicine ran with the headline, Preventive Medicine’s Identity Crisis.  Authors Dr. Boris Lushniak and Dr. Paul Jung posed this question: “What is preventive medicine?  Specifically, what is the specialty of preventive medicine, and how should it best be described?”

The physicians explained: “The specialty of preventive medicine is poorly understood, not only by the medical profession and the general public, but even among some of its practitioners. Currently, there is no unifying, vernacular explanation of the specialty of preventive medicine, to its detriment.”

The confusion isn’t so difficult to understand; within the term ‘preventive medicine’ care are a number of specialties and subspecialties.

From the American Board of Preventive Medicine:

• Preventive Medicine is the specialty of medical practice that focuses on the health of individuals, communities, and defined populations. Its goal is to protect, promote, and maintain health and well-being and to prevent disease, disability, and death.

Preventive medicine has three specialty areas with common core knowledge, skills, and competencies that emphasize different populations, environments, or practice settings: aerospace medicine, occupational medicine, and public health and general preventive medicine.

• Public health and general preventive medicine focuses on promoting health, preventing disease, and managing the health of communities and defined populations. These practitioners combine population-based public health skills with knowledge of primary, secondary, and tertiary prevention-oriented clinical practice in a wide variety of settings.

• Occupational medicine focuses on the health of workers, including the ability to perform work; the physical, chemical, biological, and social environments of the workplace; and the health outcomes of environmental exposures.

• Aerospace medicine focuses on the clinical care, research, and operational support of the health, safety, and performance of crewmembers and passengers of air and space vehicles, together with the support personnel who assist operation of such vehicles.

Additionally, the ABPM has traditionally identified three subspecialties within preventive medicine:  Clinical Informatics, Medical Toxicology and Undersea/Hyperbaric Medicine.  In March 2016, the American Board of Medical Specialties announced the recognition of Addiction Medicine as a new subspecialty under the APBM.

So it’s small wonder that preventive medicine might be suffering an identity crisis.  With so many individuals, populations and communities falling under one or more of these categories, the lines between and among specialties can be blurred.

Dr. Christine Matson

On a recent Monday morning on the campus of Eastern Virginia Medical School, Dr. Christine Matson, professor and chair of the Department of Family and Community Medicine, was talking to a class of third-year medical students about prevention.  The class was reviewing a series of scenarios previously given to them, in which they were asked to identify preventions, sources they relied on, principles of preventive medicine, and whether the scenario involved primary, secondary or tertiary prevention.

One case involved a 9-month old infant.  The responding student addressed the issue of injuries, and listed preventions that included installing rear-facing car seats, installing smoke detectors in the home, and importantly, ensuring babies sleep on their back, with all objects removed from the bed.  Her source was the Academy of Family Physicians.  The scenario involved primary preventive medicine.

While the students considered several other scenarios, Dr. Matson emphasized the tendency of some people to think that the reason others get sick (other than genetics), is because they aren’t doing the right things, or they don’t know the right things.  “Educational deficits is certainly part of it,” Dr. Matson told them, “and having a good education and being health literate correlates well with improved health for the future – but education isn’t enough.  The fact is that too many of our dollars go to treatment rather than to prevention.”

Dr. Michael Levine

Dr. Michael Levine, a preventive medicine specialist in Williamsburg, Virginia, agrees.  “The goal of primary prevention is to prevent new disease by reducing risk factors, or to prevent the onset of preventable conditions.  Not smoking significantly reduces the risk of developing lung cancer.  Eating well avoids diabetes.  Fluoride in the water prevents caries.  The problem is, nobody wants to pay for prevention.  It’s hard to sell and very easy to defund.”

In secondary prevention, Dr. Levine continues, “disease is at its incipient stage, when it’s possible to walk it back completely, or at the least, make the outcome better.  Losing excess weight can slow or stop diabetes.  In the case of noise-induced hearing loss, for example, we may not be able to reverse it, but we can prevent further loss.”  Screening procedures are often the first step in secondary prevention.

Tertiary prevention’s goal is to reduce the damage caused by symptomatic disease, and to prevent further pain and damage, halt progression and complications from disease, and to the extent possible, restore the health of patients affected by disease.  Still, “It’s not surprising that so many of our health care dollars go to treatment rather than to prevention,” Dr. Levine says, “despite the fact that primary prevention would probably save a lot more money than any curative activity.”

Dr. Shannon Blackmer, LCDR

Both Dr. Shannon Blackmer, LCDR, a preventive medicine physician with the US Navy and Marine Corps Public Health Center in Portsmouth, and Dr. Donald Hastings, a primary care physician with Bon Secours Patient Choice Oceana in Virginia Beach, have seen first hand what happens in the absence of strong preventive medicine.

Dr. Blackmer assists a team with planning Global Health Engagements in Central and South America.  In the summer of 2015, she deployed in support of Southern Partnership Station, an annual series of US Navy deployments focused on subject matter expert exchanges with partner nation militaries and civilian medical personnel in Central and South America and the Caribbean. She continues to plan engagements for this mission.  US military teams work with partner nation forces during naval-focused training exercises, military-to-military engagements and community relations projects in an effort to enhance partnerships with regional maritime activities and improve the operational readiness of participants.  “We’re trying to build our partner countries’ capacity to improve their health, to teach them things they can teach others in their country to improve their overall health structure.”

She describes the conditions she found: “We went to a very small clinic and met the local medical staff.  They were in the middle of a vaccination drive.  I asked how they were able to keep track of the children who had been vaccinated.  One of the nurses pulled out a very large, very old book, and showed me page after page on which the children’s names had been handwritten.  This was their only record.”

Dr. Donald Hastings

Dr. Hastings has seen similar circumstances.  “I’ve done a lot of overseas work, in Africa, where our hospital was filled with patients who had preventable illnesses – like diarrheal illnesses caused by unclear water,” he says.  “We saw tuberculosis, malaria, meningitis – the same patients with the same conditions over and over, conditions that could have been prevented through simple changes like adding bed nets and spraying.”

Dr. Hastings spent time in China, as well, which he says was doing better than Africa, but still lagged far behind the US.  “We were in an area with a great deal of HIV infection,” he says, so we did public health training as well as treating patients.”

In daily practice as primary care physicians, Dr. Hastings says, “We’re at the forefront of taking care of patients, and preventive medicine is the key.  A big part of our job is being sure that patients are up to date on preventive screenings.” For a primary or family care practitioner, it can be frustrating, Dr. Hastings says, “because every specialty has its own academy with its own guidelines, and they can sometimes conflict with others.”

Dr. O. T. Adcock

Dr. O. T. Adcock, an administrator and family medicine physician with the Riverside Health System, agrees: “Many different societies publish recommendations, and they’re often in agreement or very similar.  But occasionally there’s disagreement – for instance, at what age should women start getting mammograms and how often?  It’s the same with the PSA test – some guidelines say stop doing at 75, but if I have a patient who’s that age or older, who’s otherwise very healthy and likely to live a decade or more longer, I’ll certainly order the test.  A lot depends on the individual patient.  That’s when we prove that medicine is as much an art as a science.”

Both Dr. Adcock and Dr. Hastings rely heavily on the guidelines set forth by the United States Public Health Service Task Force.

Establishing the guidelines under which primary care physicians operate is the bailiwick of preventive medicine specialists like Dr. Levine, whose practice takes him to several locations each week: a federal agency one day where he’s the onsite occupational medicine doctor, or a clinic in Williamsburg where he evaluates employees to determine whether they can safely perform their assigned jobs.  He performs medical qualification exams, commonly done on employees with safety sensitive jobs: police officers, firefighters.  Additionally, he looks at workplace settings of employees with specific medical conditions, and helps find ergonomic solutions that make that workplace work for them.

“We really focus on function,” Dr. Levine explains.  “I can clear a bus driver in his eighties for a short duration, while denying clearance to a 40-year old with a disqualifying condition.  If we’re doing our job correctly, we’re setting the stage for workers to remain on the job safely, without injury, for as long as they want to be there.”

Workers can perform their jobs in the air or under water, as well as on the ground.  As a former flight surgeon, Dr. Blackmer ensured that pilots were safe to fly, without injury or illness, and not taking any form of medication that could interfere with their ability to be in the cockpit.  When incidents did occur, she participated in accident investigations as well.

A New Definition for the 21st Century
Dr. Lambert Parker, who maintains a private practice in Virginia Beach and also serves as Medical Director of Integrative Longevity Institute of Virginia, takes an ecological approach to preventive medicine, and genetics plays a large role.  He is a proponent of the Human Biome Project, which was established in 2008.  “The HBP is the collection of all of the microorganisms living in association with the human body,” Dr. Parker says, “and because of our newfound and ever expanding knowledge of genomics and microgenomics, new cognitive tools are letting us see the world and biology in a different way.

Dr. Lambert Parker

“We can’t continue to prevent problems by giving a shot. People are getting more obese every day, while there’s a gym on every corner,” Dr. Parker says.  “We’ve beaten the things that were catastrophes for our forefathers – malaria, typhoid, leprosy – but human beings aren’t healthier and more productive.  We’re living longer, but sicker.  We have to address these problems from a 21st century perspective.”

Dr. Matson agrees.  “We need to think about primary prevention and the ways we’ve designed our environment that have greatly increased the incidence of chronic diseases in our population.   We still don’t have all the information we need, and all you have to do is open the Internet to see all the products being advertised as tonics and cure-alls, to know that there’s a huge number of dollars being spent on pills, because people are looking for an easy way to be healthy.”

“We’re making some progress,” says Dr. Adcock.  “But people are still drinking sugary drinks, still smoking, still not exercising.  These are the basics.”

Changing those three things might well be the health care revolution the country needs.