February 22, 2019

Western Tidewater Free Clinic

Anthony J. DiStasio, II, MD, Board-certified Orthopaedic Surgeon, Sports Medicine & Orthopaedic Center – Suffolk

 

The patients who Dr. Anthony DiStasio treats during his volunteer hours at the Western Tidewater Free Clinic often work multiple jobs yet struggle to support their families. They cannot afford commercial health insurance and many do not qualify for employers’ health plans as part-time employees.

Many have suffered from painful and debilitating orthopaedic conditions for months, if not years, from carpal tunnel syndrome to arthritis in their hips or knees. 

“These are people who have truly slipped through the cracks,” Dr. DiStasio says. “They’re not looking for a handout. They’re simply looking for a little help to get back to their regular jobs and home life.” 

Dr. DiStasio volunteers several hours a month at the Suffolk-based clinic, which is open five days a week to serve uninsured and underinsured patients in Suffolk, Franklin, and Isle of Wight and Southampton counties. If patients need surgery, he also performs those for free on a second day.   

Western Tidewater offers non-emergency healthcare to patients ages 19 to 64 who live at or below 200 percent of the federal poverty level ($50,200 for a family of four, for example). As the only free clinic in a 1,400-square-mile service area, the bustling operation is one of the fastest-growing clinics in the region. 

Clinic staff and volunteers provide medical, dental, vision, women’s health and mental health care; pharmacy consultation and assistance programs; and laboratory and diagnostic testing services. Patients also gain access to surgeries and specialists through clinical partnerships. 

Since opening in 2007, the clinic has cared for a diverse group of more than 5,300 patients during 150,000-plus visits. Staff focuses on primary care and continuous education on chronic conditions such as diabetes and high blood pressure, both in individual appointments and group counseling. 

Not surprisingly, volunteers are critical. In fact, medical professionals from a wide variety of specialties have donated more than 125,000 hours to date, a nearly $4 million market value. 

Dr. DiStasio handles injuries and overuse or degenerative conditions in the shoulders, hips, knees, ankles and hands. He typically does five to six follow-up surgeries a month at Sentara Obici Hospital, such as carpal tunnel releases, knee and shoulder arthroscopies and fracture repairs. “It’s gratifying to be able to help so many people with fairly simple procedures,” he says. 

Most total joint replacement patients get a referral to a larger surgical program at Virginia Commonwealth University, he adds: “I see some very advanced pathology on our X-rays. You know a joint replacement is going to be absolutely life-changing.” 

Both medicine and community service have appealed to Dr. DiStasio since early childhood. As a football, rugby and track athlete, he suffered multiple injuries and was grateful when his orthopaedists recognized his eagerness to return to action. 

“They taught me how to take care of a whole person, not just a body part or problem,” he says. “I was also raised in a family that always emphasized giving back.” 

Dr. DiStasio, a graduate of Georgetown University School of Medicine, served for 13 years in the Navy before transitioning to private practice in 1995. Prior to joining SMOC, he completed a fellowship at the R Adams Cowley Shock Trauma Center in Baltimore and worked as Director of the Orthopaedic Traumatology Division at Naval Medical Center Portsmouth. He has lived in Hampton Roads for 30 years.  

The Western Tidewater Free Clinic is a real team effort, Dr. DiStasio stresses, based on core mission values of excellence, unity of purpose, respect, diversity, integrity and stewardship of all resources. 

“Access to health care is a huge problem in our country, and the staff is all in for these patients,” he says. “I’m happy to be a small part of its impact.”

To learn more about volunteering, visit wtfreeclinic.org, call (757) 923-1060 or send email to info@wtfreeclinic.org. 

John W. Boyd, MD

Riverside Gastroenterology Specialists – Newport News

 


Ask Dr. John Boyd about the most rewarding aspects of his specialty and longtime community practice, and you’ll get two very different answers. 

One covers the innovative technology and medicines that have allowed him to save and change so many more lives, such as emergency endoscopic interventions for bleeding ulcers. The other is about the impact he can make by taking the time to listen to his patients. 

“They’re going through difficult moments, and they need their doctor to be caring, to hold their hand and be someone who sticks by them,” Dr. Boyd says. “I’m often in my office past 8 p.m., calling patients back at home. Many tell me, ‘You’re the first doctor who did this for me.’ I’m not sure why, because to me that’s how medicine should always be.”  

Since 1999, Dr. Boyd has practiced with Peninsula Gastroenterology, PC, with hospital affiliation at Riverside Regional Medical Center. As he has built strong local roots, he has embraced a multitude of new treatments that have transformed care. 

Other than a cure for hepatitis C, one highlight has been biologic therapies for inflammatory bowel diseases. Delivered intravenously or subcutaneously, the treatments have been revolutionary for patients with ulcerative colitis and Crohn’s disease, who once had few options beyond Prednisone.  

“For years, there was so little I could do for them,” Dr. Boyd notes. “These therapies have a low side effect profile, and they have a great benefit in more than 70 percent of patients.” 

The continuous evolution of minimally invasive procedures also has been a game-changer. Endoscopic Retrograde Cholangio-Pancreatography (ERCP), for example, allows physicians to diagnose problems in the pancreatic and bile ducts via a flexible tube maneuvered through the mouth. In some cases, they can remove gallstones, tumors or cysts.  

Even more advanced endoscopic ultrasound equipment, meanwhile, can deliver needle biopsies of lesions via sound waves. And the Peroral Endoscopic Myotomy (POEM) procedure uses high-definition upper endoscopes to treat achalasia, which impairs swallowing, and certain spastic esophageal disorders, again with access only through the mouth.  

“Every few months, there seems to be a major advancement,” Dr. Boyd says. “There is now talk of taking out a gallbladder through the mouth, without a single exterior incision.”  

Medicine drew Dr. Boyd in early, for a variety of reasons. He was born in a small town near Manteo, N.C., where his grandparents had a farm. While his military family moved frequently, including a posting to Japan, he was mainly raised in a community of solid, hardworking farmers and fishermen. Every summer, he pitched in on the family farm. 

“I can plant a straight row of soybeans or corn, and drive a combine,” he laughs. “Most importantly, I learned the value of working a long and honest day.” 

Dr. Boyd enjoyed science and anatomy in school and was fascinated by how different machines work, from the engines and transmissions he picked apart on farm equipment to the far more complex human body. He earned money for medical school by building houses with his father. 

Dr. Boyd’s dad was a decorated Vietnam veteran who became Army hospital administrator and often brought his son along to interact with physicians. As a young teenager, Dr. Boyd also developed great respect for a family doctor named Dr. Liverman, who served his entire North Carolina county. A kind and revered figure, Dr. Liverman handled everything from delivering babies to managing diabetes in older patients, including Dr. Boyd’s grandmother. 

When Dr. Boyd started medical school at East Carolina University – where he had earned a bachelor’s degree in biology and a master’s in biochemistry, with a thesis on fetal alcohol syndrome – he assumed he would go into family medicine, too. However, he soon decided to narrow his focus and was particularly captivated by both video endoscopy and the complexities of the liver. 

“It was remarkable to be able to see inside a stomach on a television,” he recalls. “Then there was the incredible liver, with its thousands of enzymes that create energy for the entire body.” 

Diving into internal medicine, Dr. Boyd completed an internship at Richland Memorial Hospital in South Carolina and a residency at Sentara Norfolk General Hospital; he also was a chief resident at DePaul Medical Center. He followed those with a two-year gastroenterology fellowship and a year-long pancreaticobiliary fellowship at Medical College of Virginia.  

Dr. Boyd moved to the Peninsula to serve what was then an underserved community in terms of GI specialists. Two decades later, he sometimes finds himself caring for three generations of patients. “For all the diplomas on the wall, nothing is more rewarding than knowing a family trusts me with their health,” he says. 

In many cases, in fact, Dr. Boyd becomes more than a gastroenterologist. If an older patient seems depressed and lonely, for instance, he might research volunteer opportunities or contact a pastor at his or her church. “Patients shouldn’t ever feel rushed when I’m with them,” he says. “My philosophy is that’s an important piece to helping them.” 

So not surprisingly, during the same conversation in which he touches on the future promise of gene therapies, Dr. Boyd takes delight in discussing his “simple” hobbies: carpentry, home repair, mechanical work and painting. 

“I like to see the real, tangible results of my efforts,” he says. “I want to be proud of what I’ve built or accomplished. It’s a joy that I discovered as a child, and it has influenced me throughout my career.”

Pramod Malik, MD, FACG, FASGE, AGAF, CPI

President and Lead Physician, Virginia Gastroenterology Institute, Suffolk

 


Dr. Pramod Malik has never hesitated to think outside the box. He’s not afraid of taking risks that he and his patients decide on together, as a team. 

In his years of training as a surgeon before he decided to go into gastroenterology, Dr. Malik developed unique insights and innovative approaches in his specialty that have allowed for remarkable recoveries in patients with highly complex situations. 

Dr. Malik, who has practiced in Virginia since 2002 and is now the President of Virginia Gastroenterology Institute, likes to share stories of his memorable patients. 

One of his most satisfying cases was that of an otherwise healthy man in his early 50s with complete obstruction of the esophagus from previous radiation for cancer. He could not swallow even his saliva and was fed with a tube in his stomach.  

“He would have continued on like that forever,” Dr. Malik relates. “I believed we could reconnect the esophagus for him. I had never done this before, but I knew of a technique that had been reported. I consulted with that physician in Texas and shared the plan with the patient and his wife. We all took risks and I was able to reconnect his esophagus that was separated by about an inch. It changed his life.” Since then, Dr. Malik has helped several other patients with similar problems.

Another major success story involved a woman who had undergone a vertical banded gastroplasty in which the band had stenosed. For nearly a decade, she had vomited almost all solid foods, yet surgeons did not want to operate. Dr. Malik inserted a stent inside her banded stomach to expand it and break down tissue around the band, so it was no longer embedded in her stomach and he could remove it. 

Like many of his peers, Dr. Malik embraces emerging technologies in his specialty, often participating in trials to test them. 

One potential game-changer in Crohn’s disease, for example, is a new camera pill that may avoid the need for a colonoscopy for disease assessment. Flexible endorobotic systems now provide 3D views and access to areas of the body that couldn’t be reached before. Gene therapy and smarter drugs are revolutionizing treatments for diseases that have been quite challenging. 

Minimally invasive procedures, stents and the creative use of trans-specialty techniques are standard in Dr. Malik’s practice. He works with experts in other specialties to offer combined techniques that help patients avoid more traumatic and expensive treatments. He has been an early adopter of therapeutic endoscopy to drain pancreatic fluid collections, as well as the use of clips, endoscopic mucosal resection, and trans-gastric ERCP in patients who have had a gastric bypass surgery.

Yet Dr. Malik is equally committed to the “old school” value of building strong bonds with patients via thorough, honest conversations about their diseases, concerns and treatment options. “We are partners in managing their health,” he notes. “This, to me, is how medicine should always be practiced – never compromising quality, compassion and integrity.” 

Dr. Malik also is a team player who believes in “closed loop” communication with patients, staff and other physicians involved in care to minimize misunderstandings. “The medical field is too complex for one person to know all that is needed to know to provide comprehensive care,” he says. To this end, Malik teaches nurses and techs in the area during various courses, as well as encourages them to be active participators in the endoscopy suite.

Growing up in India, Dr. Malik decided early on to pursue a career as a physician. After his medical education and a general surgery residency at M.S. University of Baroda in India, he debated between choosing trauma or cardiothoracic surgery as he searched for a challenging specialty that required advanced skills and quick thinking in critical situations. 

Once Dr. Malik and his wife had emigrated to the United States in 1992, he did a medicine residency at Christ Hospital in Chicago, where a gastroenterologist introduced him to GI medicine and endoscopy. “I immediately saw in this specialty the things that attracted me to surgery,” he recalls. 

Dr. Malik went on to complete a fellowship in gastroenterology at the University of Illinois at Chicago. He spent three years at Sturgis Hospital in Michigan and joined a GI group based in Norfolk, Chesapeake and Virginia Beach in 2002, where he was a partner until 2014. In 2015, he moved to Suffolk to be closer to his home; he started in his practice in 2016.  

Dr. Malik has won numerous awards as a physician and has served in leadership roles ranging from chairman of hospital committees to an eight-year term as a board member of the Virginia Gastroenterological Society, including two years as the society’s president. 

A father of two, Dr. Malik is grateful that his specialty gives him a good work-life balance, which he also feels makes him a better physician. His daughter is a junior pre-med student at the University of Virginia, while his son is a senior at Norfolk Academy. In his free time, he enjoys community service, biking, hiking, and backpacking trips with his friends. 

In life, as in medicine, Dr. Malik never wants to take a route just because it’s easy. “To help people most and contribute most to society, you must evolve and be positive,” he says. “You don’t want to abandon things that work well, but innovations in care require a curious mind and calculated risk taking.”

Michael J. Ryan, MD, FACP

Gastroenterologist/Hepatologist and Co-Director of Research, Digestive & Liver Disease Specialists, Norfolk; Professor of Medicine, Eastern Virginia Medical School

 

For more than three decades, Dr. Michael Ryan has been a fixture in the fields of gastroenterology and hepatology in Hampton Roads, as a dedicated physician, leading professor and nationally prominent researcher. 

Dr. Ryan, who co-founded the Norfolk-based Digestive & Liver Disease Specialists in 1987, has both built a major medical practice and contributed to several medical breakthroughs that have transformed his specialty, most notably a cure for hepatitis C. 

Today, his goal is to write similar success stories for other chronic liver and digestive diseases, including hepatitis B, nonalcoholic fatty liver disease, primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC), Crohn’s disease, ulcerative colitis and more. 

At any given time, Digestive & Liver Disease Specialists’ research department has 30 to 40 ongoing clinical trials, often working in partnership with major pharmaceutical companies such as Gilead, GlaxoSmithKline, Merck and Pfizer. The non-alcoholic steatohepatitis (NASH) team alone has three research coordinators.   

“We solved hepatitis C, and we’re not stopping there,” Dr. Ryan says. “Conditions such as NASH will be more difficult because they have many different molecular pathways. There are, however, many possibilities for treatments in development. It will take several years for FDA-approved medication to become available, but we will get there. We are making constant progress. I expect the first wave of medications to be approved in late 2019.”   

Dr. Ryan, who is Fellowship-trained in his specialty and Board-certified in internal medicine, gastroenterology and transplant hepatology, has longtime privileges at Sentara Leigh and Sentara Norfolk General hospitals. He is an award-winning clinical professor at Eastern Virginia Medical School and a frequent lecturer locally and nationwide. Recent honors include the Sentara Southgate Leigh Outstanding Physician Award for 2017 and the 2018 Mason Edwards Award, given to “the medical staff member who has made a significant contribution to education both in the hospitals and the community.”  

As a researcher, Dr. Ryan has authored or co-authored numerous articles in prominent medical journals, starting with his fellowship study on the once-doubted notion of reversing hepatic fibrosis. His practice of eight physicians, which operates as a division of Gastrointestinal & Liver Specialists of Tidewater, PLLC, also is heavily involved in preventative care, including promoting colonoscopies and helping to develop Cologuard, the non-invasive prescription screen. 

After running several trials on the direct-acting antivirals that now can erase hepatitis C in 99.7 percent of cases, Dr. Ryan is passionate about educating primary care physicians on the critical need to screen patients and, if necessary, oversee the simple 8- to 12-week treatment protocol. He has served as Co-Director of the American Gastroenterological Association awareness committee on hepatitis C, acting as an advisor to the CDC.    

“The problem is that 50 percent of people who have hepatitis C in the United States still don’t know it,” he notes. “In addition, the majority of patients identified with it are not being treated. It has resulted in more deaths than HIV over the past decade and increases the risk for non-liver disease such as cardiovascular and renal disease as well.”   

A New York City native, Dr. Ryan was interested in science and medicine by late elementary school. By the time he was a freshman at Fordham University, he was teaching high school biology students in summer programs. 

At the Johns Hopkins School of Medicine, Dr. Ryan originally planned to go into orthopaedics. However, he found himself drawn to the university’s liver and gastroenterology specialists, particularly Dr. Willis Maddrey, who would direct him to Yale New Haven Hospital for his combined GI/Hepatology fellowship. 

NASH, which affects an estimated 8 percent of the America population, is an obvious research focus today. Largely due to rising obesity rates and unhealthy American diets, fatty liver diseases are soon to become the No. 1 cause of liver failure and transplants. They also cause primary cancer of the liver (hepatocellular carcinoma), which has now become the fifth-leading cause of cancer deaths in men and the eighth in women in the United States. 

“I am optimistic that we will have effective medications in the next couple of years, as there are numerous compounds in development,” Dr. Ryan says. Probiotics also could play an important role in treatment, he adds.  

New therapies have come on the market for PBC as well, he notes, while some animal models have produced positive results for trial PSC medications. In gastroenterology, the JAK Inhibitor shows promise for inflammatory bowel disease; Tofacitinib, sold under the brand name Xelijanz, has been approved for ulcerative colitis and may be an option for Crohn’s disease. So could the drug Filgotinib. 

“It’s truly an exciting time in the field, with a lot of reasons to be confident that we are making headway against these devastating illnesses,” Dr. Ryan says.  

Dr. Ryan is equally committed to educating the next generation of physicians, continuously working with internal medicine and family practice students at EVMS and teaching a monthly gastroenterology elective. As a provider, he is regularly named on best-of lists for regional physicians. 

“Back 30 years ago, we really had almost no treatments for liver disease,” he says. “We have made so many advances since then, but we still have a great deal of research to do.”

Shannon D. Burris, RN, MSN, FNP-BC

Congratulations, it is an Honor to Feature Shannon D. Burris, RN, MSN, FNP-BC
Family Nurse Practitioner, Sentara Family Medicine Physicians, Gloucester

 

For 21 years, Shannon Burris has cared for families in Gloucester and Mathews counties. She now sometimes treats the children of patients she first met as children. An advanced nursing student completing a rotation in her practice was her patient as a pre-teen. 

Burris knows much more about her patients than their names and faces. She has heard about their families, hobbies, vacations and life highs and lows. She prides herself on listening, which to her is the most important part of being a nurse practitioner. 

“Especially in a small community, people don’t want to just be a chart – they want to be a person,” Burris says. “They know me as a person, too, and what has worked for me with health, diet or exercise. Even if I’m rushed and busy, I don’t want them to see that. I want them to feel important. To me, that’s the best way to really make an impact on their health care and the decisions they make.” 

Burris has worked at Sentara Family Medicine Physicians since 2010, following 13 years at Sentara’s Mathews Family Medicine. She has lived in Gloucester since 1997, where her husband, Brian, is an Associate Pastor at a local church; they also have raised two teenagers in the community. 

“I’m always running into my patients around town,” Burris laughs. “I go into Walmart and my kids joke that it takes forever to leave because I must know everyone in town. I am really grateful to practice in a place where I can build those kinds of relationships.”  

Burris, 50, grew up in Kentucky and originally planned on becoming a dentist. In college at Transylvania University in Lexington, she pivoted to a psychology major before deciding the variety of nursing appealed to her more. 

After moving to Virginia Beach with her family in 1990, Burris earned a nursing degree from DePaul Medical Center School of Nursing in Norfolk in 1993 and spent a year as a staff nurse in the Medical-Surgical Unit at Chesapeake General Hospital, with a subspecialty in oncology. 

Working with cancer patients taught Burris the value and rewards of getting to know families on a more long-term basis. “I wanted to do even more – to develop even more of these deeper relationships with patients,” she recalls. “That’s what I like most about being a nurse practitioner, along with the range of cases. You never know who or what is going to walk through the door each day.” 

Burris earned a master’s degree in Nursing and a Family Nurse Practitioner Certificate at the Medical University of South Carolina in Charleston in 1997. In addition to the extensive experience she has built caring for patients of all ages since then, she still draws on her general psychology background in conversations with patients struggling with mental health issues such as depression and anxiety.

“There’s such a shortage of mental health specialists around the country, and especially in smaller communities like ours, that we are having to manage medications and provide some counseling on a daily basis in primary care,” she notes.  

Burris, a member of the Virginia Council of Nurse Practitioners, has no plans to leave Gloucester, where she enjoys volunteering with her church and spending time with family and friends. Her daughter Caitlyn, 18, works as a dental assistant – her mom’s once-planned-upon career – and her son Chase, 14, is a freshman in high school. 

“My life is here, and my patients are an important part of that life,” she says. “I feel very loyal to them, and while not every day is easy, I do feel like I am making a difference.” 

We are grateful for local Nurse Practitioners and Physician Assistants who serve our local health care community! Please let us know if there is an NP or PA you would like to see honored in a future edition. holly@hrphysician.com

Virtual Exam Room

How telemedicine is changing medicine — and the obstacles the technology still faces

By Kasey Fuqua

 

Healthcare in the United States is facing a slew of challenges: from increasing costs to a shortage of health professionals and lack of access to care. While there’s no silver bullet for these issues, telemedicine services show promise as cost-effective care. Even as healthcare systems grapple with drawbacks of telemedicine technology, the use of these services continues to grow—and in Hampton Roads patients may be seeing the benefits.

Increased Access to Specialty Care
Telemedicine services began as consultation services like teleneurology and teleradiology. These services, largely offered at remote facilities, give patients quicker access to more physicians. Riverside Health System has been using telemedicine consultations for about 15 years at their hospitals and skilled nursing facilities in Tappahannock, the Eastern Shore and Gloucester.

Liz Martin

“We’re providing a specialist to a site that needs that specialty coverage,” says Liz Martin, Senior Vice President for Care Management and Telemedicine at Riverside. 

At Chesapeake Regional Medical Center, teleneurology allows for quick assessment of acute stroke patients in the emergency department. 

Lewis Siegel, MD

“It’s a reality that it has become more of a challenge to have physician consultants available for patients at all times,” says Lewis Siegel, MD, Chief of Department of Emergency Medicine and Medical Director of the Emergency Department at Chesapeake Regional. “Telemedicine gives us the ability to have the patients seen in a timely manner and keeps open the options for rapid treatment of stroke.”

Faster consults can help emergency departments meet their door-to-needle goals for stroke care, though it’s not an ideal solution for physician shortages in rural areas.

“I don’t think you can replace having physicians be there in person,” says Dr. Siegel, “but in situations where you don’t have that option, it allows a lot of input and more expeditious care.”

Meeting the Demand for Mental Health Services

Telemedicine is also giving more patients greater access to mental health services. Nearly all health systems in Hampton Roads also offer some telepsychiatry programs, whether in emergency departments or at skilled nursing facilities. These programs cut down on physician travel time by allowing them to offer care at many locations from one office. With less travel time, they can provide more patient care.

To meet the growing demand for pediatric mental health services, Children’s Hospital of The King’s Daughters offered tele-mental health as its first telemedicine service line. The program has grown quickly thanks to positive patient response.

Ody Granados

“In mental health telemedicine sessions, there is a self-reported increased level of comfort and sharing,” says Ody Granados, Director of Telemedicine Services at CHKD. “Telemedicine provides a medium where patients feel more able to divulge things they may not talk about in a face-to-face encounter.”

CHKD has established telemedicine “endpoints” at multiple practices, consisting of a private room with seating for patients and parents, a large screen, and a camera. Through a secure connection, patients can receive mental health services and assessments.

“If a pediatrician determines during a well-child check that a child needs a mental health assessment, they can offer the possibility of that appointment right then via telemedicine,” says  Granados “It really provides convenience for the family and it’s proved to be a very popular service.”

Faster, More Convenient Primary Care
Virtual visits or e-visits with primary care providers are also saving patients time. Multiple hospital systems in Hampton Roads offer the visits for minor conditions like rashes, acne, or urinary tract infections.

Since January 2018, Sentara has been rolling out telemedicine primary care visits. Unlike services like MDLive or Amwell, patients meet with actual Sentara medical group physicians via their smartphone, tablet or laptop. 

The visits are integrated into the EPIC electronic medical record, making it easier for physicians to offer this service. Any physician from their medical group with a webcam can see patients via telemedicine. Even documentation is easier and faster thanks to smart phrases that can be used in the moment.

Mark Haggerty, DO

Mark Haggerty, DO, medical director for Sentara Virtual Care Services and primary care provider in Virginia Beach, says telemedicine could help primary care physicians manage well controlled chronic conditions that don’t require in person care as frequently. Telemedicine may also help patients who have difficulty traveling to the office due to their health or transportation needs.  

“With virtual care at my disposal, I have another form of access, which can alleviate primary care visit congestion thus allowing me to take care of more acute needs” says Dr. Haggerty. “While the face-to-face time with patients may not change, I am taking up less of their overall time and reducing rooming time and documentation required by my staff.”

Education for Patients and Providers
Patient care isn’t the only possible use for telemedicine services. Riverside uses their telemedicine infrastructure as much as possible, including as a cost-effective method to provide patient and provider education.

“We use our technology to collaborate across the system,” says Martin. “We’ve used it for meetings, clinical collaborations, and to educate future healthcare workers on the uses of telemedicine.”

For patients, they are now providing education both before and after procedures. For example, patients no longer need to come in for a visit before a colonoscopy. Instead, they can learn about prep through a video in the patient portal and a nurse visit via telemedicine.

For patients who are remotely monitored, telemedicine provides an opportunity for real-time education. These patients use special scales, blood pressure cuffs, or other devices to send health information to their providers. Nurses can quickly spot problems and call the patient to teach them what to do.

“Remote monitoring helps us manage the patient’s condition and teach them how to self-manage,” says Martin. “The goal is that patients wouldn’t be on monitoring forever, because we can help them understand how to ask for support and what to do when they can see their vital signs going out of range.”

Reimbursement Still a Roadblock
Though providers see the value in telemedicine care, poor reimbursement continues to be an obstacle for the growth of telehealth services. Currently, Medicare does not reimburse for acute care services unless they are offered to remote areas. Some private companies will cover telemedicine services, but it varies from payor to payor.

Virginia has been a more progressive state when it comes to telehealth reimbursement. Medicaid does reimburse for certain services, such as remote monitoring of patients with diabetes, live video psychiatric care or live video speech therapy. Consultation services, such as teleradiology, are also covered.

Dr. Haggerty says that Centers for Medicare and Medicaid Services (CMS) are making changes to reimbursements that favor telemedicine. For instance, in 2019, prolonged preventive health services will be covered. They are also lifting some location limitations so that certain services, like teleneurology, can be covered anywhere, not just in rural areas.

“If that trend continues, telemedicine will make a lot more sense from a revenue and overhead perspective,” says Dr. Haggerty. “But right now, we still want our patient population to be well served. If this program advantages them, we still want to take care of them whether or not this will be covered.”

CHKD faces unique challenges in the rollout of its telemedicine programs. While Medicare reimburses for adult care, Medicaid often does not reimburse for the same pediatric services. 

Granados says he expects Virginia Department of Medical Assistance Services to update telemedicine reimbursement regulations within the next two years and is hopeful that pediatric services will receive better coverage.

Riverside Health System has found alternative ways of making telemedicine more financially sound. As part of the Bay Rivers Telehealth Alliance, the health system has received grants to provide services to populations on the Northern Neck, Middle Peninsula and Eastern Shore. Services include mental health care at nursing homes or other facilities and school-based health programs.

Martin says the data Riverside collects through its telemedicine services may also play a role in improving reimbursement. As evidence reveals that telemedicine education and remote monitoring help patients avoid ER visits and hospitalization, insurance companies may be more likely to see the benefit of covering such services.

Physician Reluctance Slows Growth
Though reimbursement for telemedicine services is only likely to expand, many physicians have real concerns about how technology affects patient care. Telemedicine may prevent physicians and patients from developing a strong relationship. Lack of information about a patient, like heart rate or bowel sounds, may lead to incorrect diagnoses.

“My concern with telemedicine in general is that there may be a tendency to potentially overtreat with medications, especially antibiotics,” says Dr. Siegel. 

Still, in its current forms, most telemedicine manages to avoid these possible problems, and physician support is growing. Martin says that many physicians who experience telemedicine through specialty coverage are more open to other telemedicine services. As more physicians are exposed to the technology and its efficiency, the adoption rate is becoming quicker.

As technology becomes easier to use, physicians are also more likely to buy in to telemedicine. Integration into the EMR is just one step toward making telemedicine part of routine care.

At Sentara, Dr. Haggerty and his team are working to facilitate training for interested practices and help them establish an appropriate workflow for telemedicine services.

“While there are a long list of things that can’t be done by virtual care, there’s also a long list of things that can,” Dr. Haggerty says. “Providers may want to use this technology differently to optimize their practice and satisfy their patients. People are going to use this in a variety of interesting and different ways.”

Patient Demand Climbing
Whatever the benefits or downfalls of telemedicine, it’s clear that patient demand is growing. Dr. Haggerty believes that the Millennial population may feel more comfortable with telemedicine care because of their reliance on technology. They may also be more comfortable selecting a physician who offers telemedicine.

“I think the patient as the customer will be driving a lot of growth in telemedicine,” Dr. Haggerty says. “Already we are seeing patients’ expectations turn towards easier, less hassle care. It’s possible that patients may not go to doctors who don’t provide at least some telemedicine services.” 

Granados agrees, citing a study by Deloitte that all other things being equal, patients would rather have a doctor who offers telemedicine services than one who didn’t. Parents of pediatric patients (today’s Millennials) were also more open to telemedicine services than older patients. 

“This is not going to decrease in use, only going to increase in use,” says Granados. “The writing is on the wall. This is what our patients want.”

As demand grows, reimbursement changes, and more physicians come on board, telemedicine is likely to be widespread across the country. 

 “It’s going to improve access,” says Martin. “It will reduce costs and improve outcomes of care. As we see those things happen, telemedicine will become just another exam room.”

 

How Technology has changed women’s health care

By Kasey Fuqua

 

Over the last 40 years, advances in technology have changed the way women get pregnant, deliver babies and receive treatment for conditions ranging from cancer to endometriosis. Gynecologic care has become more effective with fewer side effects, allowing women to experience a high quality of life whether they experience infertility, fibroids or pregnancy.

Minimally Invasive Surgery
Minimally invasive surgery is arguably the largest and most important innovation in gynecologic care. The first minimally invasive hysterectomy was performed in 1989. Throughout the 1970s and 1980s, laparoscopy became safer and more effective, thanks in large part to the work of gynecologists across the globe. By 2016, more than 15 million laparoscopic procedures were performed worldwide each year.

Rachel Lee, MD

“Anything that moves us toward a smaller incision is an advancement because it allows people to have a faster recovery, less risk of infection, and shorter hospital stays,” says Rachel Lee, MD, a gynecologist with Monarch Women’s Wellness, a Bayview Physicians Group practice. 

Dr. Lee primarily performs robotic surgeries as opposed to laparoscopic procedures. She believes the robot is just one more tool to help ensure women can receive laparoscopic procedures and has seen benefits in its use.

“Before I was using the robot, I would have to convert more people to open procedures,” says Dr. Lee. “Part of it is that you have a lot of magnification to see things clearly. Also, the robot rotates just like your wrist does and allows you to maneuver in spaces that may be more challenging for conventional laparoscopy.”

Robotic surgery, which has only been FDA approved for laparoscopy since 2000, is evolving rapidly. Recently, a urologist at the Cleveland Clinic performed a procedure using a new approved single incision robotic platform that could revolutionize single incision surgery.

Still, it’s not clear that robotic surgery has any advantages over conventional laparoscopy. 

Joseph Hudgens, MD

“I don’t know if there ever will be an answer between robotics and laparoscopy,” says Joseph Hudgens, MD, gynecologist with EVMS Medical Group. “Data supports that both robotics and laparoscopic surgery are superior to conventional open surgery, but there’s not conclusive data that exists that one is superior to the other.”

Dr. Hudgens and Dr. Lee agree that the right approach surgery depends on the surgeon and their experience. With either minimally invasive approach, experienced surgeons offer excellent results.

Robotic surgery is not the only technology improving gynecologic care. Dr. Lee says new devices, such as hysteroscopes that allow for the use of tools inside the uterus, have improved treatment for many conditions. 

One device, called Myosure®, allows for quick and accurate removal of fibroids and polyps. The device contains both a hysteroscope and a small vacuum device to remove the polyp. 

Dr. Hudgens served as one of the principal investigators for the recently FDA-approved device called Sonata to treat uterine fibroids transcervically with radiofrequency ablation. The breakthrough procedure treats painful fibroids while sparing the uterus and avoiding hysterectomy. 

While all these advances benefit patients, they can put a strain on gynecologists who have to keep up with the latest technology. 

“Coming out of training now, it’s very hard to keep up with the amount of information and the latest treatment without being focused,” says Dr. Hudgens. “The trend nationally is becoming specialized in treating a particular disease or subspecialty.”

Dr. Hudgens says many OB/GYNs now seek advanced training and sub-specialization in the treatment of certain conditions. This can lead to an increased quality of care for patients, especially those with complex conditions, as surgeons become more comfortable with technology.

“We have come such a long way so fast,” says Dr. Hudgens. “If you look at all aspects of society, technology has revolutionized the way we live. Medicine is probably behind some other industries in adoption of technology, but as our healthcare system evolves, we’re going to get even more specialized.”

Reproductive Medicine
Reproductive medicine is one area of sub-specialization in gynecology that has developed quickly over the past four decades. Since the first successful in-vitro fertilization procedure was performed at the EVMS Jones Institute for Reproductive Medicine 37 years ago, assisted reproduction technologies have changed dramatically. The physicians and scientists at the Jones Institute have helped spur those changes, resulting in the births of more than 4,000 babies.

Laurel Stadtmauer, MD, PhD

“Drs. Howard and Georgeanna Jones at EVMS were the first to use fertility medication that stimulates the ovaries for in-vitro fertilization, increasing the number of eggs obtained from a single cycle,” says Dr. Laurel Stadtmauer, MD, PhD, of the Jones Institute. “The first IVF treatment actually used no fertility medication. The patient’s eggs were retrieved from a natural cycle.”

Dr. Stadtmauer says the first lab was like a small closet with little technology. IVF treatment focused on women who had blocked or missing Fallopian tubes. Now, the Jones Institute hosts multiple labs and uses IVF and other procedures to treat both male and female factor infertility.

Dr. Stadtmauer says new technology, from intracytoplasmic sperm injection (ICSI) to embryoscopes, has tremendously improved IVF success rates. While success rates in the 1980s were around 10 percent per attempt, they are now between 30 and 50 percent depending on the patient’s age and other factors.

Laboratory technology is key to this increased success. Embryos spend a longer time in the lab, five days as opposed to two or three, giving embryologists more time to determine which are healthy. In the past, an embryologist would check on the embryos about once per day. Now at the Jones Institute, the specialists use an embryoscope to take about 2,000 pictures of embryos over the five days they remain in the lab. They can then select embryos that are growing and dividing normally and have a better chance of survival and implantation after embryo transfer. 

The extended time in the lab also allows for pre-implantation genetic testing. This testing may be especially important for women over age 38 who have a higher rate of miscarriage due to chromosomal abnormalities.

“Genetic testing for aneuploidy and for genetic diseases has been a big advancement,” Dr. Stadtmauer says. “About 25 percent of our patients choose to do genetic testing prior to transferring embryos.”

The Jones Institute was the first center to perform pre-implantation genetic testing for Tay Sachs disease in 1994. Today, they can perform genetic testing for dozens of diseases. Between increased monitoring and testing, embryologists can now select the embryos most likely to develop successfully and have the normal numbers of chromosomes, and avoid an affected child in cases where the patients are known carriers of a specific disease. Instead of transferring four of five embryos, physicians today transfer a maximum of two, and a single embryo in many cases, which greatly reduces the multiple birth rate after IVF.

 “Another big advancement is the process used to freeze embryos,” says Dr. Stadtmauer. “It used to be inefficient, and maybe 60 percent of embryos would survive. Now with a technique called vitrification, which is a rapid cooling technique, 90 to 95 percent of embryos survive.”

Thanks to vitrification, transfer of frozen embryos is now more common. The break between harvesting eggs and transferring embryos allows patients to achieve an optimal endometrial lining and ideal hormone levels to increase success rates. It also has reduced a patient’s risk for ovarian hyperstimulation syndrome.

Freezing is not limited to just embryos. Physicians can also freeze eggs, providing fertility preservation options for cancer patients. Even ovarian tissue can be frozen and transplanted back after cancer treatment to allow patients to ovulate and conceive naturally. As technology advances and IVF success rates rise, more women will have the opportunity to experience pregnancy and motherhood.

Obstetrics
Once women have achieved pregnancy, they can receive more information about their developing child than ever thanks to advancements in technology and knowledge.

Laura Cordes, MD, OB/GYN

“Genetic screening has really changed in the last decade, allowing for noninvasive prenatal testing,” says Laura Cordes, MD, OB/GYN at Tidewater Physicians Multispecialty Group. “Fetal chromosome analysis from maternal blood sample in early first trimester opens up genetic testing to more women and also opens options for management of pregnancy.”

This early, noninvasive testing has far fewer risks than amniocentesis. It also improves the safety of treatment for women who choose to end their pregnancy after the discovery of a lethal genetic abnormality. 

“It’s not yet standard of care for 100 percent of women via American College of Obstetrics and Gynecology guidelines, but it’s available to everybody,” says Dr. Cordes. “Certainly for those women in high risk categories, it’s a recommendation.”

In some ways, women are opting to leave technology out of the labor and delivery room. Dr. Cordes says that at her practice, midwives work closely with OB/GYNs to offer personalized and safe care for expectant mothers. 

“Midwifery care has really grown in the last decade,” says Dr. Cordes. “Our practice really integrates the midwifery model into the obstetric model. Our six midwives probably do 90 percent of our natural vaginal deliveries.”

This model of care allows patients to receive the care they want and even allows high risk-patients, who normally wouldn’t be appropriate for midwifery care, to still have the pregnancy experience they want. It also frees up OB/GYNs to specialize further in gynecologic surgery.

Whether or not women opt to take advantage of technology, it allows them the opportunity for more personalized care throughout every stage of their life. As new devices, surgical tools, and laboratory techniques are developed, women should expect a continued increase in both their quality of care and their quality of life.

Western Tidewater Free Clinic

Anthony J. DiStasio, II, MD, Board-certified Orthopaedic Surgeon, Sports Medicine & Orthopaedic Center – Suffolk

 

The patients who Dr. Anthony DiStasio treats during his volunteer hours at the Western Tidewater Free Clinic often work multiple jobs yet struggle to support their families. They cannot afford commercial health insurance and many do not qualify for employers’ health plans as part-time employees.

Many have suffered from painful and debilitating orthopaedic conditions for months, if not years, from carpal tunnel syndrome to arthritis in their hips or knees. 

“These are people who have truly slipped through the cracks,” Dr. DiStasio says. “They’re not looking for a handout. They’re simply looking for a little help to get back to their regular jobs and home life.” 

Dr. DiStasio volunteers several hours a month at the Suffolk-based clinic, which is open five days a week to serve uninsured and underinsured patients in Suffolk, Franklin, and Isle of Wight and Southampton counties. If patients need surgery, he also performs those for free on a second day.   

Western Tidewater offers non-emergency healthcare to patients ages 19 to 64 who live at or below 200 percent of the federal poverty level ($50,200 for a family of four, for example). As the only free clinic in a 1,400-square-mile service area, the bustling operation is one of the fastest-growing clinics in the region. 

Clinic staff and volunteers provide medical, dental, vision, women’s health and mental health care; pharmacy consultation and assistance programs; and laboratory and diagnostic testing services. Patients also gain access to surgeries and specialists through clinical partnerships. 

Since opening in 2007, the clinic has cared for a diverse group of more than 5,300 patients during 150,000-plus visits. Staff focuses on primary care and continuous education on chronic conditions such as diabetes and high blood pressure, both in individual appointments and group counseling. 

Not surprisingly, volunteers are critical. In fact, medical professionals from a wide variety of specialties have donated more than 125,000 hours to date, a nearly $4 million market value. 

Dr. DiStasio handles injuries and overuse or degenerative conditions in the shoulders, hips, knees, ankles and hands. He typically does five to six follow-up surgeries a month at Sentara Obici Hospital, such as carpal tunnel releases, knee and shoulder arthroscopies and fracture repairs. “It’s gratifying to be able to help so many people with fairly simple procedures,” he says. 

Most total joint replacement patients get a referral to a larger surgical program at Virginia Commonwealth University, he adds: “I see some very advanced pathology on our X-rays. You know a joint replacement is going to be absolutely life-changing.” 

Both medicine and community service have appealed to Dr. DiStasio since early childhood. As a football, rugby and track athlete, he suffered multiple injuries and was grateful when his orthopaedists recognized his eagerness to return to action. 

“They taught me how to take care of a whole person, not just a body part or problem,” he says. “I was also raised in a family that always emphasized giving back.” 

Dr. DiStasio, a graduate of Georgetown University School of Medicine, served for 13 years in the Navy before transitioning to private practice in 1995. Prior to joining SMOC, he completed a fellowship at the R Adams Cowley Shock Trauma Center in Baltimore and worked as Director of the Orthopaedic Traumatology Division at Naval Medical Center Portsmouth. He has lived in Hampton Roads for 30 years.  

The Western Tidewater Free Clinic is a real team effort, Dr. DiStasio stresses, based on core mission values of excellence, unity of purpose, respect, diversity, integrity and stewardship of all resources. 

“Access to health care is a huge problem in our country, and the staff is all in for these patients,” he says. “I’m happy to be a small part of its impact.”

To learn more about volunteering, visit wtfreeclinic.org, call (757) 923-1060 or send email to info@wtfreeclinic.org. 

TIME = VISION

By Alan L Wagner MD, FACS, FICS

 

Stop, Drop, and Roll. Apply direct pressure to a wound. Thirty chest compressions before two rescue breaths. Sixty minutes “door to needle” within 240 minutes of symptoms with an ischemic stroke.

Here’s another rule everyone should know: 97 minutes until irrevocable loss of vision with a Central Retinal Artery Occlusion (CRAO). Blindness at six hours!

The retina, highly specialized brain tissue, is one of the most metabolically active parts of our body. Most think of changes in vision as non-emergent, or something that goes along with age.

Yet we recently received a “semi-urgent” referral of a 72-year-old female with an acute loss of vision for three hours in her non-dominant left eye. A painless change, without systemic complaints. She carried the diagnosis of a possible retinal detachment. Could we please see her later in the afternoon, or tomorrow?

We had her come in directly. She had a CRAO. An evolving ischemic stroke of the eye! Our emergent intervention restored blood flow, and she got her sight back. Few are as fortunate.

A CRAO usually presents as painless, acute and with profound loss of vision (visual acuity of barely counting fingers to no light perception). The U.S. incidence of a CRAO is 1.9/100,000.

The cause of the CRAO is usually a thromboembolus. It lodges where the central retinal artery, a division of the internal carotid artery, enters the optic nerve adjacent to the globe. Only if the thrombus/embolus can be dislodged, or lysed, will vision recover. Retinal recovery depends upon age and pre-existing conditions.CRAOs may be associated with: carotid artery disease, atherosclerosis, valvular heart disease, myxoma, atrial fibrillation, hypertension, smoking, IV drug abuse, oral contraceptives, sickle cell disease, homocystinuria and pregnancy. Most patients are in their 60s, with men at greater risk than women. Arteritic causes are rare (<5%).  

A macular cilioretinal artery is present in 15 to 30 percent of the general population. It spares the central 5º– 10° of the visual field, maintaining its flow during a CRAO. These fortunate patients experience an acute loss of their peripheral vision. If a CRAO develops in the non-dominant eye possessing a cilioretinal artery, a constrained “tunnel vision” is discovered when the dominant eye is covered.

 If a CRAO is suspected, immediate referral to an eye surgeon is crucial, because time equals sight!

There is no definitive treatment for a CRAO. Removing fluid from the eye, vasodilators, and lytic therapy are options. Reducing intraocular pressure abruptly allows the systemic blood pressure to better push the embolus “downstream”, sparing more retina. Similarly, drops or systemic mannitol can be employed. Thrombolytic therapy and vasodilators have had mixed results. Carotid ultrasound, echocardiogram and Holter monitor are standards of care for primary testing, identifying the most likely origin of the thromboembolus.  A CRAO, or branch retinal artery occlusion, BRAO, can be associated with increased mortality.  The American Academy of Ophthalmology recommends emergent referral to the emergency room, and the Neurology service, following initial treatment for CRAO/BRAO. The highest window for risk of a stroke is within seven days of presentation of a CRAO/BRAO. That risk remains elevated for the first 30 days.Close follow-up by both the surgeon and medical team is of paramount importance to optimize the patient’s success and survival, and to avoid complications.  

Remain suspicious of, and sensitive to, reported vision loss.

Alan L. Wagner, MD, FACS founded the Wagner Macula & Retina Center in 1987. A Board-certified ophthalmologist specializing in vitreoretinal surgery, Dr. Wagner received his medical degree from Vanderbilt University School of Medicine. He completed his residency in Ophthalmology at EVMS, and furthered his training as the Dyson Fellow in vitreoretinal disease and surgery at Weill Cornell University Medical Center.  wagnerretina.com

The Story of Alpha-gal: Allergy to Red Meat after a Tick Bite

By Christina Funari Ortiz, MD, MPH

 

Ticks are often implicated in infectious disease, but rarely, if ever, has the allergy community considered ticks important in the spread of food allergy – until recently. 

One such tick-associated food allergy is referred to as “alpha-gal,” which is an allergy to red meat. This was first reported in the 1990s; however, advances in research, augmented by epidemiologic insight, lead to a full description by University of Virginia researchers in 2009.

Alpha-gal is a delayed food allergy to mammalian meat. It is spread by the Lone Star tick, which is found largely in the southeastern United States and is very common in Hampton Roads. The Lone Star tick bites both humans and animals, and in the event of a mammalian bite, it ingests a complex sugar called galactose-alpha-1,3-galactose, or alpha-gal. This sugar is a component of the cell membrane in most mammals but is not found in humans, a distinction important to the nature of how the allergy is transmitted. When the tick bites a human, it subsequently transfers the sugar ingested from a previous mammalian bite and activates the immune system to make allergic antibodies to alpha-gal.  

People with these allergic antibodies mount a delayed reaction after ingestion. The time-frame for reaction is about three to six hours after ingesting mammalian meats, including beef, pork, lamb, and sometimes even milk or butter. Reactions vary in severity and may involve hives or progression to anaphylaxis. Symptoms can include swelling, difficulty breathing or swallowing, nausea/vomiting and, at times, a decrease in blood pressure. 

Alpha-gal can be difficult to diagnosis as, in many cases, patients do not associate the meat they have eaten with the reaction due to the time span between the two events. This is a serious and potentially life-threatening condition, and patients have reported waking in the middle of the night with severe hives or even anaphylaxis that requires administration of epinephrine.  

If you or your patient suspect an alpha-gal allergy, evaluation by an allergist is recommended. If indicated, this allergy is diagnosed after a thorough consultation and blood testing. The current treatment recommendation is a strict avoidance diet of all mammalian meats and, at times, mammalian products, which can include the gelatin found in various medications. Interestingly, certain vaccine products also contain gelatin, and alpha-gal has been implicated in anaphylactic reactions to both the Zoster and MMR vaccines. Although rare, a minority of alpha-gal patients may react to vaccines or medications, but it is not yet possible to test for this reactivity. 

In addition to the strict avoidance of red meat, patients diagnosed with an alpha-gal meat allergy are prescribed an EpiPen and monitored closely each year, as the allergy can dissipate over time. There is a possibility of re-introducing mammalian meats into the diet as the allergy changes; however, it is not yet clear how often or how likely this is the case. Re-introduction should only be performed in a supervised setting with emergency medical equipment and trained personnel close by.

Dr. Christina Funari Ortiz is a fellowship trained allergy specialist at TPMG Coastal Allergy in Chesapeake and Virginia Beach. www.mytpmg.com